Key Responsibilities:
- Lead the hospital through NABH accreditation and re-accreditation processes.
- Ensure continuous “survey readiness” for scheduled and surprise external audits.
- Act as the primary liaison between the hospital and the NABH accreditation board.
- Conduct regular internal audits and mock drills (e.g., Code Blue, fire safety, disaster preparedness) to identify compliance gaps.
- Perform gap analysis and recommend corrective and preventive actions for quality improvement.
- Audit medical records, discharge summaries, prescriptions, and other clinical documentation for compliance and accuracy.
- Develop, review, and update Standard Operating Procedures, policies, and Quality Manuals across all departments.
- Ensure proper implementation and maintenance of NABH-required forms, formats, registers, and incident reporting systems.
- Collect, monitor, and analyse key quality indicators such as infection rates, medication errors, patient satisfaction, and clinical outcomes.
- Prepare monthly quality reports and performance dashboards for hospital management.
- Organise and conduct training programs for medical, nursing, and support staff on quality standards, patient safety, ethics, and NABH requirements.
- Investigate patient safety incidents, near-misses, and patient grievances, and implement preventive measures to avoid recurrence.
Skills & Competencies:
- Strong analytical and problem-solving abilities
- Excellent attention to detail and organisational skills
- Leadership and team management capabilities
- Strong communication and interpersonal skills
- Expertise in healthcare quality tools and accreditation standards
Experience:
- Minimum 3–5 years of experience in hospital quality management or accreditation-related roles
- Hands-on experience in NABH implementation is mandatory/preferred
Qualifications:
- Master’s degree in Hospital Administration (MHA), Healthcare Management, Nursing, or Quality Management
- NABH certification or quality-related certification preferred
Pay: ₹20,000.00 - ₹50,000.00 per month
Work Location: In person
