Quality Executive

Key Responsibilities

1. Quality Management & Compliance

• Support implementation and monitoring of hospital quality policies, procedures, and standards.
• Ensure departmental processes are aligned with applicable healthcare quality standards.
• Monitor compliance with defined SOPs, policies, and quality indicators.
• Identify gaps and coordinate with departments for corrective and preventive actions (CAPA).
• Support continuous quality improvement initiatives across the organization.

2. NABH & Accreditation Support

• Assist in maintaining compliance with NABH standards and requirements.
• Prepare and maintain documentation required for NABH assessments and audits.
• Coordinate with departments for implementation of NABH-related policies and processes.
• Support internal and external audits and ensure timely closure of observations/non-conformities.
• Maintain records and evidence related to accreditation requirements.

3. Internal Audit & Monitoring

• Conduct/support regular internal quality audits across clinical and non-clinical departments.
• Prepare audit checklists, reports, and observation sheets.
• Identify process deviations and coordinate with concerned departments for corrective action.
• Track audit findings and monitor closure within defined timelines.
• Maintain audit documentation for review and management reporting.

4. Quality Indicators & Data Management

• Collect, compile, and monitor departmental quality indicators/KPIs.
• Prepare monthly quality reports and dashboards.
• Analyze quality data to identify trends, gaps, and improvement opportunities.
• Coordinate with departments to ensure timely submission of quality-related data.
• Maintain accurate and updated quality records.

5. Patient Safety & Quality Improvement

• Support implementation of patient safety initiatives.
• Monitor compliance with patient safety practices and hospital protocols.
• Assist in monitoring incidents, near misses, complaints, and adverse events.
• Support Root Cause Analysis (RCA) and CAPA processes.
• Participate in quality improvement projects and process improvement initiatives.

6. Documentation & SOP Management

• Maintain and update quality-related documents, SOPs, policies, formats, and checklists.
• Ensure proper version control and document availability.
• Coordinate with departments for timely review and revision of documents.
• Maintain records required for internal and accreditation audits.

7. Training & Awareness

• Support quality-related training and awareness programs for hospital staff.
• Assist in conducting sessions on SOPs, patient safety, infection control, documentation, and quality standards.
• Maintain training records and attendance documentation.
• Promote a culture of quality and continuous improvement among employees.

8. Coordination & Reporting

• Coordinate with clinical, nursing, administrative, and support departments regarding quality requirements.
• Follow up with department heads for pending quality actions and compliance.
• Prepare regular reports for the Quality Manager/Head – Quality.
• Escalate significant quality gaps or non-compliance issues to the reporting authority.

Required Knowledge & Skills

• Good understanding of hospital quality management systems.
• Knowledge of NABH standards and healthcare quality practices.
• Knowledge of internal audits, CAPA, RCA, and quality indicators.
• Good documentation and report-writing skills.
• Strong analytical and problem-solving abilities.
• Good knowledge of MS Excel, Word, and PowerPoint.
• Good communication and coordination skills.
• Strong attention to detail.
• Ability to work with multiple departments and follow up on compliance requirements.

Pay: Up to ₹25,000.00 per month

Work Location: In person