Quality Lead

Job Purpose

To lead and oversee the hospital's Quality Management System, NABH accreditation compliance, patient safety initiatives, clinical governance programs, quality improvement projects, and regulatory requirements to ensure the delivery of safe, effective, patient-centered healthcare services.

Key Responsibilities

1. Quality Management & NABH Accreditation

• Lead NABH accreditation and re-accreditation activities.
• Ensure compliance with NABH standards, statutory regulations, and organizational policies.
• Conduct gap assessments and implement corrective action plans.
• Maintain accreditation documentation, policies, SOPs, and manuals.
• Coordinate external and internal NABH assessments.

2. Clinical Governance

• Drive hospital-wide clinical governance initiatives.
• Monitor quality indicators, KPIs, and benchmarking data.
• Facilitate mortality, morbidity, clinical audit, and peer review activities.
• Ensure implementation of quality improvement projects.

3. Patient Safety

• Lead patient safety programs and International Patient Safety Goals (IPSG).
• Monitor incident reporting systems and RCA (Root Cause Analysis).
• Ensure implementation of CAPA (Corrective and Preventive Actions).
• Promote a culture of safety throughout the organization.

4. Quality Audits

• Plan and conduct internal audits across all departments.
• Monitor compliance with hospital policies and NABH standards.
• Track audit findings and closure of non-conformities.
• Review department-wise quality performance.

5. Quality Indicators & Data Analytics

• Define, monitor, and analyze quality indicators.
• Prepare monthly, quarterly, and annual quality reports.
• Present dashboards and trend analyses to hospital leadership.
• Support data validation and quality reporting processes.

6. Committee Coordination

• Coordinate Quality Assurance Committee activities.
• Facilitate Medical Audit, Infection Control, Patient Safety, Ethics, and other NABH committees.
• Prepare agendas, MOMs, and Action Taken Reports (ATR).

7. Training & Awareness

• Conduct NABH awareness and quality training programs.
• Educate staff on patient safety, quality tools, and documentation standards.
• Develop quality champions across departments.

8. Regulatory & Compliance Management

• Ensure compliance with NABH, Biomedical Waste, Fire Safety, PCPNDT, and other healthcare regulations.
• Coordinate inspections and compliance audits.

9. Patient Experience

• Monitor patient feedback and complaint management systems.
• Analyze trends and implement service excellence initiatives.
• Improve patient satisfaction scores through quality interventions.

10. Leadership & Team Management

• Lead and mentor the quality department team.
• Collaborate with clinical, nursing, HR, operations, and support services.
• Support strategic quality initiatives and organizational goals.

Qualification

• Master's Degree in Hospital Administration / Healthcare Management / Quality Management / MBA Healthcare.