Quality Manager

Dr. Kamakshi Memorial Hospital Pvt Ltd; Chennai; On-site; INR 1,200,000 - 1,800,000; Full time

Job summary

Dr. Kamakshi Memorial Hospital Pvt Ltd in Chennai seeks a Quality Assurance lead to drive NABH 6th Edition compliance across departments. You will oversee audits, CAPA, and QA documentation while aligning with CAHO standards and regulatory requirements.

The role focuses on data-driven improvement of patient safety, infection control, medication management, and clinical documentation, with regular Quality Council meetings and management reporting.

Qualifications

• Strong knowledge of NABH 6th Edition standards and accreditation requirements.
• Working knowledge of CAHO standards and hospital accreditation processes.
• Understanding of QMS, CQI, CAPA, RCA, FMEA, and risk management.
• Knowledge of hospital processes and clinical/non-clinical workflows.
• Excellent audit documentation, data analysis, and reporting skills.
• Effective communication and training capabilities.

Responsibilities

• Lead implementation and monitoring of NABH 6th Edition across departments.
• Ensure compliance with NABH, CAHO, and regulatory requirements.
• Develop and update Quality Manuals, SOPs, and policies.
• Coordinate internal quality audits and tracer activities.
• Identify gaps and drive CAPA with HODs for closure.
• Monitor QIs, KPIs, patient safety indicators, and outcomes.
• Coordinate QIPs and assist departments in improvements.
• Prepare agendas, minutes, and follow-up for Quality Council meetings.
• Maintain records and timely submission of reports.

Skills

NABH knowledge

Quality Assurance

CAPA RCA

Audit planning

Data analysis

Training delivery

Communication

Tools

MS Excel

MS Word

PowerPoint

Job description

Key ResponsibilitiesLead implementation, monitoring, and continuous improvement of NABH 6th Edition standards across hospital departments.Ensure compliance with NABH, CAHO, and applicable statutory and regulatory requirements.Develop, review, and update Quality Manuals, SOPs, policies, protocols, formats, and quality documentation.Coordinate internal quality audits, mock audits, tracer activities, departmental audits, and accreditation assessments.Identify gaps in compliance and coordinate with respective HODs for Corrective and Preventive Actions (CAPA).Monitor and analyze Quality Indicators (QIs), Key Performance Indicators (KPIs), patient safety indicators, and clinical outcomes.Coordinate Quality Improvement Projects (QIPs) and support departments in implementing measurable improvement initiatives.Facilitate Quality Council / Quality Committee meetings and prepare agendas, minutes, action plans, and follow-up reports.Monitor compliance related to patient safety, infection prevention and control, medication management, clinical documentation, biomedical equipment, facility management, and patient rights.Conduct staff awareness and training programs on NABH standards, quality systems, patient safety, and hospital policies.Maintain accreditation-related records and ensure timely submission of required reports and documents.Coordinate with clinical and non-clinical departments to ensure consistent implementation of hospital policies and standards.Track audit observations, non-conformities, incident reports, complaints, and improvement actions until closure.Promote a culture of continuous quality improvement and patient safety throughout the organization.Prepare management reports, dashboards, presentations, and periodic quality performance summaries.Required Knowledge & SkillsStrong knowledge of NABH 6th Edition standards and accreditation requirements.Working knowledge of CAHO standards, quality frameworks, and hospital accreditation processes.Good understanding of Quality Management Systems (QMS), CQI, CAPA, RCA, FMEA, and risk management.Knowledge of clinical and non-clinical hospital processes.Strong skills in audit planning, documentation, data analysis, and quality reporting.Good communication, coordination, presentation, and training skills.Ability to work effectively with doctors, nurses, technicians, HODs, and management.Proficiency in MS Excel, Word, and PowerPoint.PreferredNABH Assessor / Internal Assessor training will be an added advantage.CAHO training/certification or hands-on experience with CAHO-related quality initiatives will be preferred.Experience in a NABH-accredited hospital or in preparing a hospital for NABH accreditation/re-accreditation.Experience handling NABH assessments, surveillance assessments, and mock accreditation audits.

• Quality Management | NABH 6th Edition | CAHO | Patient Safety | Accreditation | Internal Auditing | CAPA | RCA | Risk Management | Quality Indicators | Continuous Quality Improvement | Documentation | Training & Compliance