Quality Analyst

Role & responsibilities

Key Responsibilities

1. JCI & NABH Coordination

• Coordinate implementation and monitoring of applicable JCI and NABH standards across departments.
• Maintain accreditation-related documentation, records, policies, SOPs and evidence.
• Follow up with departments on pending accreditation requirements and compliance gaps.
• Keep the hospital continuously prepared for accreditation assessments and surveys.

2. Quality Monitoring

• Coordinate collection and compilation of Quality Indicators/KPIs from respective departments.
• Maintain quality dashboards, trackers and periodic reports.
• Identify gaps, deviations and recurring issues and bring them to the attention of the Quality Lead.
• Support Quality Improvement Projects and monitor their progress.

3. Audits & Tracers

• Assist in planning and conducting internal audits, documentation audits and tracer activities.
• Record observations/non-conformities and maintain audit reports.
• Coordinate follow-up and closure of Corrective and Preventive Actions (CAPA).
• Verify and document evidence of compliance/closure.

4. Patient Safety & Incident Reporting

• Coordinate the reporting and documentation of incidents, near misses and patient-safety events.
• Ensure incidents are appropriately routed to the concerned department/authority.
• Maintain incident trackers and follow up on corrective actions.
• Support patient-safety initiatives under the guidance of the Quality Lead.

5. Policy & SOP Management

• Maintain the master list of hospital policies, SOPs, forms and other controlled documents.
• Coordinate periodic review, revision, approval and circulation of documents.
• Ensure obsolete documents are appropriately withdrawn and current versions are available at the point of use.

6. Training & Awareness

• Coordinate staff training related to JCI/NABH standards, quality, patient safety and hospital policies.
• Maintain training schedules, attendance, competency records and supporting evidence.
• Assist in conducting accreditation awareness sessions and mock survey preparedness activities.

7. Survey & Assessment Readiness

• Assist the Quality Lead in preparing departments for JCI/NABH surveys, surveillance visits and assessments.
• Coordinate availability of required documents, records and evidence.
• Support mock tracers and readiness rounds.
• Maintain a tracker for survey observations and follow-up actions.

8. Departmental Coordination

• Act as the day-to-day coordination link between the Quality Department and various hospital departments.
• Follow up with process owners for timely submission of data, records and compliance evidence.
• Escalate delays, repeated non-compliance or critical gaps to the Quality Lead.

9. Quality Documentation & Reporting

• Maintain systematic records of audits, indicators, CAPA, incidents, meetings, training and accreditation activities.
• Prepare periodic reports and presentations as required.
• Ensure documents and evidence are readily retrievable during internal and external assessments.

10. Continuous Improvement

• Identify opportunities for improving processes, documentation and compliance.
• Support cross-functional quality initiatives aimed at improving patient safety, patient experience and operational efficiency.
• Promote awareness that quality and accreditation are part of everyday hospital operations.

Preferred candidate profile

• Timely collection and reporting of Quality Indicators.
• Completion of scheduled audits and tracer activities.
• Timely follow-up and closure of CAPAs.
• Accuracy and completeness of accreditation documentation/evidence.
• Timely review and updating of policies and SOPs.
• Departmental compliance with JCI/NABH requirements.
• Completion of planned quality and accreditation training.
• Survey readiness and timely closure of survey observations.
• Accuracy and availability of Quality MIS and trackers.