Quality Manager (NABH & Accreditation)

Contact 639865 2832 

Urgent Hiring – Quality Manager (NABH & Accreditation)

Location: Tezpur, Assam

Hospital Type: Multi-Speciality Hospital

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Position

Quality Manager – NABH & Accreditation

Qualification

• Master's Degree in Hospital Administration (MHA), Hospital Management (MHM), Healthcare Quality, Nursing, or a related Healthcare Discipline

• Certification/Formal Training in NABH Quality Management – Preferred

• Six Sigma, Lean Healthcare, or Patient Safety Certification – Added Advantage

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Experience

• Minimum 5–8 Years of experience in Hospital Quality Management

• At least 3 Years of Hands-on Experience managing NABH Accreditation activities

• Experience in policy formulation, quality audits, documentation, and regulatory compliance is mandatory

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Key Responsibilities

NABH Accreditation & Compliance

• Lead and coordinate NABH Entry Level, Progressive Level, Full Accreditation, and renewal activities

• Ensure continuous compliance with NABH standards and statutory regulations

• Coordinate internal and external NABH assessments and CAPA implementation

Quality Management System (QMS)

• Develop, implement, monitor, and continuously improve the Hospital Quality Management System

• Monitor quality indicators, dashboards, and Continuous Quality Improvement (CQI) initiatives

Policies, SOPs & Documentation

• Develop, review, standardize, and maintain hospital policies, SOPs, manuals, protocols, and quality documentation

• Ensure proper document control and periodic revisions

Internal Audits & Compliance

• Conduct quality audits across all departments

• Identify non-conformities and ensure timely corrective and preventive actions (CAPA)

Patient Safety & Risk Management

• Implement patient safety goals, incident reporting, Root Cause Analysis (RCA), and risk mitigation strategies

• Promote a culture of patient safety throughout the organization

Clinical Quality Monitoring

• Monitor clinical, nursing, laboratory, pharmacy, and support service quality indicators

• Prepare monthly quality reports and recommend improvement initiatives

Infection Prevention & Control

• Coordinate with the Infection Control Team to ensure compliance with infection prevention protocols and quality standards

Training & Staff Development

• Conduct induction programs and regular NABH, Quality, and Patient Safety training sessions for hospital staff

Regulatory Compliance

• Ensure compliance with healthcare laws, Biomedical Waste Management Rules, Fire Safety regulations, and other statutory requirements

Patient Experience

• Monitor patient feedback, complaints, and satisfaction scores, and implement quality improvement initiatives

Committee Coordination & Reporting

• Coordinate Quality Committee meetings, prepare reports, monitor action plans, and present quality performance to hospital leadership

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Required Skills

• Thorough knowledge of NABH standards and accreditation processes

• Strong understanding of Hospital Quality Management Systems

• Expertise in documentation, SOP drafting, audits, RCA, and CAPA

• Excellent analytical, leadership, communication, and training skills

• Strong organizational and problem-solving abilities

• Proficiency in Microsoft Office and Hospital Information Systems (HIS)

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Key Performance Indicators (KPIs)

• Continuous NABH compliance across all departments

• Successful NABH Accreditation and Surveillance Audits

• Timely completion of internal audits and CAPA closures

• Improvement in quality indicators and patient safety outcomes

• High staff training compliance

• Improved patient satisfaction scores

• Zero major regulatory non-conformities

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Job Type

• Full-Time

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Salary

Best in Industry (Negotiable based on qualification and experience)

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Benefits

• Opportunity to lead Quality & NABH Accreditation for a growing multi-speciality hospital

• Professional growth in hospital quality leadership

• Supportive management and multidisciplinary clinical environment

• Long-term career development opportunities

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Interested candidates may share their updated CV along with current salary, expected salary, notice period, and details of NABH accreditation projects handled. Immediate joiners will be preferred.