Executive - Quality Assurance

1. NABH Compliance and Documentation

• Ensure adherence to NABH standards and guidelines across all departments.
• Maintain and update all NABH documentation including manuals, policies, SOPs, and registers.
• Coordinate preparation and review of hospital-wide policies and ensure version control.
• Conduct regular internal audits and share findings with concerned departments for corrective actions.

2. Quality Indicators Monitoring

• Track, analyze, and report departmental Quality Indicators (QIs) as per NABH norms.
• Ensure timely data collection and submission from all clinical and non-clinical departments.
• Identify trends and deviations in QIs and assist in root cause analysis and implementation of corrective measures.

3. Training & Capacity Building

• Organize and conduct NABH and quality-related training programs for staff.
• Ensure training records and competency assessments are maintained as per standard requirements.

4. Internal & External Audits

• Schedule, conduct, and document internal quality audits.
• Support during external audits (NABH assessment, surveillance, renewal audits, etc.).
• Ensure timely closure of non-conformities raised during audits.

5. Incident Reporting & RCA

• Monitor incident reporting mechanism in the hospital.
• Facilitate root cause analysis (RCA), documentation, and follow-up of corrective and preventive actions (CAPA).

6. Committee Support

• Act as coordinator or secretary for various quality-related hospital committees (e.g., Infection Control Committee, Quality Steering Committee, etc.).
• Prepare and circulate agenda, minutes, and follow-up action items.

7. Patient Safety & Feedback

• Support patient safety initiatives and promote a culture of safety.
• Analyze patient feedback, complaints, and satisfaction surveys; ensure actions are taken for improvement.

8. Continuous Quality Improvement (CQI)

• Identify improvement areas through audits, feedback, and data analysis.
• Assist in planning and executing CQI projects within departments.

9. Statutory Compliance

• Ensure hospital is compliant with statutory and regulatory requirements related to quality and patient safety.

10. Data Management and Reporting

• Maintain records and reports required for NABH and internal purposes.
• Generate periodic quality reports for senior management review.

Job Types: Full-time, Permanent, Fresher

Pay: ₹18,000.00 - ₹25,000.00 per year

Benefits:

• Health insurance
• Leave encashment
• Paid sick time
• Paid time off
• Provident Fund

Schedule:

• Day shift
• Morning shift
• Night shift
• Rotational shift

Supplemental Pay:

• Performance bonus

Work Location: In person