Quality Analyst

M&A Enterprises; Chandigarh; Presencial; INR 600 000 - 900 000; Tempo integral

Resumo da oferta

M&A Enterprises hospital is seeking a Quality Assurance professional to oversee JCI/NABH coordination, documentation, and continuous improvement. You will manage audits, CAPA closures, incident reporting, and training programs to ensure compliance and patient safety.

You will work across departments to maintain policies, SOPs, and quality dashboards, driving readiness for surveys and accreditation assessments. This role emphasizes cross-functional collaboration and meticulous record-keeping.

Qualificações

• 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.

Responsabilidades

• Coordinate implementation and monitoring of 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.
• Coordinate collection and compilation of Quality Indicators/KPIs from departments.
• Maintain quality dashboards, trackers and periodic reports.
• Identify gaps, deviations and recurring issues and bring to the Quality Lead.
• Support Quality Improvement Projects and monitor their progress.
• 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 CAPA.
• Verify and document evidence of compliance/closure.
• Coordinate the reporting and documentation of incidents, near misses and patient-safety events.
• Maintain incident trackers and follow up on corrective actions.
• Support patient-safety initiatives under the guidance of the Quality Lead.
• 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 withdrawn and current versions are available at point of use.
• 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 accreditation awareness sessions and mock survey preparedness activities.
• 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.
• Act as the day-to-day coordination link between Quality Department and 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.
• 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.
• 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.

Conhecimentos

Quality indicators

Audits & tracers

CAPA closure

Accreditation docs

Policy & SOP management

Training coordination

Survey readiness

Data accuracy

Interdepartmental coordination

Descrição da oferta de emprego

Role & responsibilities

Key Responsibilities

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.