Quality Manager

DR.KAMAKSHI MEMORIAL HOSPITAL PVT. LTD., (Inst. Code - 381) CHENNAI; Tamil Nadu; On-site; INR 1,500,000 - 2,500,000; Full time

Job summary

DR.KAMAKSHI MEMORIAL HOSPITAL PVT. LTD., (Inst. Code - 381) CHENNAI is seeking a Quality Manager to lead NABH 6th Edition implementation across hospital departments, driving continuous quality improvement and patient safety.

You will coordinate audits, CAPA actions, and quality documentation while interfacing with HODs for policy adherence and governance. The role requires expertise in accreditation processes, QMS, and data-driven improvement initiatives, with emphasis on staff training,

Qualifications

• Extensive experience in NABH quality management and accreditation processes.
• Ability to lead internal quality audits and CAPA.
• Strong documentation and reporting skills.

Responsibilities

• Lead NABH 6th Edition implementation across hospital departments.
• Coordinate internal audits, tracers, and CAPA activities.
• Prepare agendas, minutes, action plans, and follow-up reports for Quality Council/Committee.
• Monitor quality indicators, patient safety metrics, and clinical outcomes.
• Develop and update quality manuals, SOPs, policies, and formats.
• Provide staff training on NABH standards and quality systems.

Skills

NABH 6th edition

Accreditation

QMS

CAPA

RCA

FMEA

Audit planning

Data analysis

Quality reporting

Training skills

Stakeholder coordination

Tools

MS Excel

MS Word

PowerPoint

Job description

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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.