Quality Manager

DR.KAMAKSHI MEMORIAL HOSPITAL PVT. LTD., (Inst. Code - 381) CHENNAI; Chennai District; On-site; INR 900,000 - 1,300,000; Full time

Job summary

DR.KAMAKSHI MEMORIAL HOSPITAL PVT. LTD. in Chennai seeks a Quality Assurance Lead to implement and monitor NABH 6th Edition standards across departments. You will coordinate audits, CAPA actions, and quality improvement initiatives to ensure compliance and patient safety.

The role requires expertise in QMS, CAPA, RCA, FMEA, and strong data analysis, reporting, and training skills. Excellent collaboration with HODs and management is essential.

Qualifications

• Strong knowledge of NABH 6th Edition standards and accreditation requirements.
• Knowledge of CAHO standards and hospital accreditation processes.
• Understanding of QMS, CQI, CAPA, RCA, FMEA and risk management.

Responsibilities

• Lead implementation and monitoring of NABH 6th Edition standards across hospital departments.
• Coordinate internal quality audits, tracer activities, and accreditation assessments.
• Identify gaps and drive CAPA with HODs for corrective actions.
• Monitor Quality Indicators, KPIs, patient safety indicators, and clinical outcomes.
• Facilitate Quality Council meetings and prepare agendas, minutes, and action plans.
• Prepare management reports, dashboards, and quality performance summaries.

Skills

NABH 6th Edition

Quality Management Systems

Audits & QA

CAPA

RCA & FMEA

Quality Reporting

Data Analysis

MS Excel

Communication & Training

Job description

Job Description

Key Responsibilities Lead 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 & Skills Strong 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. Preferred NABH 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.