Head of Department – Quality

KEM Hospital Pune; Pune District; On-site; INR 2,500,000 - 4,000,000; Full time

Job summary

KEM Hospital Pune is seeking a senior Quality Leader to architect and drive the hospital's Quality Management System in alignment with NABH standards and regulatory requirements. You will lead quality strategy, KPIs, and QIPs while ensuring ongoing readiness for accreditation and audits.

The role requires extensive experience in healthcare quality management, stakeholder coordination across departments, and the ability to foster a culture of continuous improvement for patient safety and care

Qualifications

• Lead the development, implementation and continuous improvement of the hospital's Quality Management System (QMS) in alignment with NABH and applicable statutory and regulatory requirements.
• Develop and monitor the hospital's Quality and Patient Safety strategy, annual quality plan, objectives and key performance indicators.
• Ensure continuous readiness for NABH accreditation, surveillance assessments and other external accreditation/audit requirements.
• Establish and monitor hospital-wide Quality Indicators (QIs) covering clinical, nursing, operational, patient safety and support services.
• Review quality data and dashboards with functional HODs and senior management and identify areas requiring corrective or preventive action.
• Lead Quality Improvement Projects (QIPs) using structured methodologies such as PDCA, RCA, CAPA and other appropriate improvement tools.
• Establish a robust framework for incident reporting, adverse event management, near-miss reporting, root cause analysis and corrective/preventive actions.
• Drive the hospital's patient safety programme, including identification of risks, implementation of safety practices and monitoring of safety indicators.
• Coordinate and oversee internal audits, clinical audits, departmental audits and compliance assessments.
• Ensure development, review, implementation and periodic evaluation of SOPs, protocols, clinical pathways and quality-related documentation.
• Work closely with Medical Administration, Nursing, Infection Control, HR, Pharmacy, Laboratory, Radiology, Biomedical Engineering and other departments to improve quality outcomes.
• Lead the Quality Committee and Patient Safety initiatives, including preparation of agendas, reports, dashboards and review of action points.
• Analyse trends related to patient complaints, incidents, medication errors, falls, infections, mortality, readmissions, turnaround times and other relevant quality indicators.
• Ensure timely closure and effectiveness assessment of CAPA arising from audits, incidents, complaints and accreditation observations.
• Promote a culture of quality, accountability, patient-centricity and continuous improvement across the organisation.
• Develop and conduct quality-related training and awareness programmes for doctors, nurses and other hospital employees.
• Benchmark hospital quality indicators and practices against relevant healthcare standards and industry best practices.
• Provide management with periodic Quality MIS, risk reports, compliance reports and strategic recommendations.
• Guide and mentor the Quality team and build organisational capability in quality management and patient safety.
• Support management in evaluating and implementing digital quality systems, dashboards, automation and data-driven quality monitoring.

Responsibilities

• Lead the development, implementation and continual improvement of the hospital's Quality Management System aligned with NABH and regulatory requirements.
• Develop and monitor the hospital's Quality and Patient Safety strategy, annual quality plan, and KPI framework.
• Ensure readiness for NABH accreditation and external assessments; drive compliant processes.
• Establish hospital-wide Quality Indicators across clinical and support services.
• Review quality data with HODs to identify corrective and preventive actions.
• Lead QIPs using PDCA, RCA, CAPA and other methodologies.
• Oversee incident and adverse event reporting systems and CAPA processes.
• Drive patient safety initiatives and monitor safety indicators.
• Coordinate internal and clinical audits and compliance assessments.

Skills

Quality management

Stakeholder management

Education

Master’s in Healthcare Administration / Healthcare Management

Certification in Healthcare Quality / NABH / Quality Management would be an added advantage

Job description

QUALIFICATION:

• Master’s in Healthcare Administration / Healthcare Management
• Certification in Healthcare Quality / NABH / Quality Management would be an added advantage

EXPERIENCE:

• 12 – 15 years

JOB RESPONSIBILITIES:

• Lead the development, implementation and continuous improvement of the hospital'sQuality Management System (QMS)in alignment with NABH and applicable statutory and regulatory requirements.
• Develop and monitor the hospital'sQuality and Patient Safety strategy, annual quality plan, objectives and key performance indicators.
• Ensure continuous readiness forNABH accreditation, surveillance assessments and other external accreditation/audit requirements.
• Establish and monitor hospital-wideQuality Indicators (QIs)covering clinical, nursing, operational, patient safety and support services.
• Review quality data and dashboards with functional HODs and senior management and identify areas requiring corrective or preventive action.
• LeadQuality Improvement Projects (QIPs)using structured methodologies such as PDCA, RCA, CAPA and other appropriate improvement tools.
• Establish a robust framework forincident reporting, adverse event management, near-miss reporting, root cause analysis and corrective/preventive actions.
• Drive the hospital'spatient safety programme, including identification of risks, implementation of safety practices and monitoring of safety indicators.
• Coordinate and oversee internal audits, clinical audits, departmental audits and compliance assessments.
• Ensure development, review, implementation and periodic evaluation of SOPs, protocols, clinical pathways and quality-related documentation.
• Work closely with Medical Administration, Nursing, Infection Control, HR, Pharmacy, Laboratory, Radiology, Biomedical Engineering and other departments to improve quality outcomes.
• Lead theQuality Committee and Patient Safety initiatives, including preparation of agendas, reports, dashboards and review of action points.
• Analyse trends related to patient complaints, incidents, medication errors, falls, infections, mortality, readmissions, turnaround times and other relevant quality indicators.
• Ensure timely closure and effectiveness assessment ofCAPA arising from audits, incidents, complaints and accreditation observations.
• Promote a culture ofquality, accountability, patient-centricity and continuous improvementacross the organisation.
• Develop and conduct quality-related training and awareness programmes for doctors, nurses and other hospital employees.
• Benchmark hospital quality indicators and practices against relevant healthcare standards and industry best practices.
• Provide management with periodicQuality MIS, risk reports, compliance reports and strategic recommendations.
• Guide and mentor the Quality team and build organisational capability in quality management and patient safety.
• Support management in evaluating and implementingdigital quality systems, dashboards, automation and data-driven quality monitoring

Any other work/responsibility assigned by the HOD/Management in the course of business/work whether within the same unit/dept or any other unit/dept from time to time