NABH Quality Manager

Gleneagles BGS Hospital Fortis Network Hospitals; Bengaluru; On-site; INR 800,000 - 1,200,000; Full time

Job summary

Gleneagles BGS Hospital Fortis Network Hospitals in Bengaluru is seeking a Quality & Accreditation Lead to oversee NABH accreditation activities, documentation, and compliance for the latest edition.

Role involves conducting internal audits, gap analysis, policy and SOP updates, and monitoring hospital quality indicators. You will drive patient safety initiatives, manage incident reporting and CAPA processes, and deliver staff training on NABH protocols to improve outcomes.

Qualifications

• NABH accreditation knowledge and standards.
• Experience with internal audits and gap closure.
• Ability to update and enforce SOPs across departments.

Responsibilities

• Drive preparation, documentation, and compliance for NABH standards (e.g., 5th Edition).
• Conduct regular internal audits, mock drills, and gap assessments; ensure closure of non-conformities.
• Update, review, and implement Standard Operating Procedures (SOPs) across all clinical and non-clinical departments.
• Track and analyze hospital quality indicators, KPIs, and MIS reports.
• Monitor incident reporting, RCA, CAPA, and infection control guidelines.
• Train hospital staff on NABH protocols and patient safety goals.

Skills

NABH Accreditation

Audit & Gap Analysis

Policy & SOP Control

KPI Monitoring

Patient Safety

Training & Education

Job description

Role & responsibilities

• Accreditation Management: Drive preparation, documentation, and compliance for NABH standards (such as the 5th Edition). [1, 2]
• Audits & Gap Analysis: Conduct regular internal audits, mock drills, and gap assessments; ensure closure of non-conformities. [1, 2]
• Policy & SOP Control: Update, review, and implement Standard Operating Procedures (SOPs) across all clinical and non-clinical departments. [1, 2, 3]
• Indicator Monitoring: Track and analyze hospital quality indicators, Key Performance Indicators (KPIs), and MIS reports. [1, 2, 3]
• Patient Safety & Risk Management: Monitor incident reporting, Root Cause Analysis (RCA), Corrective and Preventive Actions (CAPA), and infection control guidelines. [1, 2, 3, 4]
• Training & Education: Train hospital staff, department heads, and nurses on NABH protocols and patient safety goals. [1, 2, 3]

Preferred candidate profile