Quality Executive

Infinity Care Hospital; Varanasi; On-site; INR 600,000 - 900,000; Full time

Job summary

Infinity Care Hospital in India seeks a Quality Executive to support NABH accreditation, monitor departmental compliance and drive continuous quality improvements across OPD, IPD and clinical areas. You will maintain quality documentation, coordinate CAPA, prepare audit reports and promote a culture of patient safety with cross-functional teams in a busy hospital environment.

Strong analytical skills and proficiency in MS Excel and documentation are essential to manage indicators and dashboards

Qualifications

• Bachelor’s degree in any discipline; BHA/MHA preferred.
• Diploma or certificate in hospital quality management or NABH training preferred.
• Minimum 12 years of experience in hospital quality management or NABH documentation preferred.

Responsibilities

• Assist in NABH implementation and maintenance across departments.
• Coordinate with HODs for policy implementation and NABH documentation.
• Conduct internal audits and prepare audit reports.
• Monitor patient safety practices and incident reporting.
• Maintain quality indicators, dashboards and monthly reports.
• Coordinate training on NABH standards and quality management.

Skills

MS Excel

MS Word

PowerPoint

NABH knowledge

Education

Bachelor's degree

BHA/MHA preferred

Diploma/Certificate in Hospital Quality Management

Job description

Rol

1. Job Purpose

The Quality Executive shall be responsible for supporting the implementation, monitoring, maintenance and continuous improvement of the hospital's Quality Management System (QMS) in accordance with NABH standards, applicable statutory and regulatory requirements, and hospital policies.

The role involves monitoring departmental compliance, conducting internal audits, maintaining quality documentation, analysing quality indicators, identifying gaps, coordinating corrective and preventive actions (CAPA), and promoting a culture of patient safety and continuous quality improvement across all hospital departments.

2. Key Responsibilities

A. NABH Accreditation & Compliance

1. Assist in the implementation and maintenance of NABH standards across all hospital departments.
2. Ensure departmental compliance with applicable NABH requirements.
3. Coordinate with department heads for implementation of quality-related policies, SOPs, protocols and work instructions.
4. Maintain updated NABH documentation, including policies, manuals, SOPs, formats and registers.
5. Assist in preparation for NABH internal assessments, surveillance assessments and accreditation audits.
6. Monitor implementation of recommendations received during NABH assessments.
7. Ensure availability of updated controlled documents at relevant locations.

B. Internal Quality Audits

1. Conduct scheduled internal audits of clinical and non-clinical departments.
2. Verify compliance with approved policies, SOPs, checklists and hospital protocols.
3. Conduct departmental rounds to identify non-compliance and quality gaps.
4. Prepare audit reports and communicate observations to concerned HODs.
5. Follow up on audit observations until corrective actions are completed.
6. Maintain records of internal audits and compliance reports.

C. Patient Safety & Quality Improvement

1. Monitor patient safety practices across OPD, IPD, ICU, Emergency, OT and other clinical areas.
2. Monitor compliance with patient identification protocols.
3. Monitor implementation of hand hygiene and infection prevention practices in coordination with the Infection Control Team.
4. Coordinate reporting and analysis of incidents, near misses and adverse events.
5. Assist in root cause analysis (RCA) of major incidents and sentinel events.
6. Monitor corrective and preventive action plans.
7. Promote patient safety awareness among hospital employees.

D. Quality Indicators & Data Management

1. Collect and compile monthly quality indicators from respective departments.
2. Maintain departmental quality indicator records and dashboards.
3. Monitor trends in quality indicators and identify areas requiring improvement.
4. Coordinate with departments for timely submission of quality-related data.
5. Prepare monthly quality performance reports for the Quality Head.
6. Verify the accuracy and completeness of submitted data.

E. Patient Feedback & Grievance Monitoring

1. Monitor patient feedback and satisfaction records.
2. Coordinate with the concerned departments for resolution of patient complaints.
3. Analyse recurring complaints and identify improvement opportunities.
4. Monitor patient grievance closure timelines.
5. Maintain records of patient feedback, complaints and corrective actions.
6. Assist in improving patient experience and service delivery standards.

F. Training & Awareness

1. Coordinate quality-related training programmes for hospital employees.
2. Conduct awareness sessions on NABH standards, patient safety, quality indicators and hospital policies.
3. Maintain training attendance records and feedback forms.
4. Identify training gaps during audits and departmental rounds.
5. Coordinate with HR and department heads to ensure timely completion of mandatory quality trainings.

G. Documentation & Record Management

1. Maintain the master list of hospital policies, SOPs, formats and registers.
2. Ensure periodic review and revision of quality-related documents.
3. Maintain records of audits, CAPA, RCA, quality meetings and improvement projects.
4. Ensure proper documentation and traceability of quality records.
5. Monitor departmental maintenance of mandatory registers and checklists.
6. Ensure obsolete documents are withdrawn from use.

H. Departmental Coordination

1. Coordinate with all clinical and non-clinical departments for quality compliance.
2. Conduct regular departmental quality rounds.
3. Communicate non-compliance observations to respective HODs.
4. Follow up on pending quality-related activities.
5. Participate in Quality Committee meetings and prepare meeting minutes.
6. Coordinate with Infection Control, Nursing, Medical Administration, HR, Pharmacy, Laboratory, Radiology, OT and other departments.e & responsibilities

Preferred candidate profile

5. Educational Qualification & Experience

• Graduate in any discipline; preferably, BHA, MHA,
• Diploma/Certificate in Hospital Quality Management or NABH-related training preferred.
• Minimum 12 years of experience in hospital quality management or NABH documentation preferred.
• Knowledge of NABH accreditation standards and hospital processes.
• Computer proficiency, especially MS Excel, Word and PowerPoint.
• Knowledge of audit documentation, RCA, CAPA and quality indicators.

6. Skills & Competencies