Senior executive Quality (Experienced in Hospital Industry)

Graphic Era; Dehradun; On-site; INR 1,200,000 - 1,900,000; Full time

Job summary

Graphic Era Institute of Medical Sciences (GEIMS) in Dehradun is seeking a Senior Executive (NABH, NABL, JCI, QCI Compliance) to lead NABH accreditation efforts and drive continuous quality improvement across hospital operations.

You will work with clinical and administrative teams, conduct audits, train staff, monitor patient safety, and ensure documentation is audit-ready for NABH assessments and future accreditations.

Qualifications

• Masters degree in Hospital Administration, Healthcare Management, or related field.
• Hands-on NABH accreditation experience.
• Thorough knowledge of NABH standards, quality control protocols, and healthcare regulatory frameworks.

Responsibilities

• Lead NABH accreditation processes across the hospital and ensure compliance with latest standards.
• Develop, implement, and monitor internal audit systems for continuous quality assurance.
• Conduct regular staff training on NABH standards and quality processes.

Skills

Leadership

Communication

Analytical skills

Education

Masters in Hospital Administration

Tools

NABH Standards

Job description

Job Title: Senior Executive (NABH , NABL, JCI, QCI Compliance)

Location: Graphic Era Institute of Medical Sciences, Dehradun

Position Summary

Will be responsible for overseeing the continuous improvement and quality management processes at GEIMS, ensuring compliance with NABH (National Accreditation Board for Hospitals & Healthcare Providers) standards across all levels. This role involves developing and maintaining quality systems, conducting audits, and driving initiatives to achieve and sustain NABH accreditation. The Manager will work closely with clinical and administrative teams to embed a culture of excellence and patient safety within the organization.

Key Responsibilities

NABH Accreditation & Compliance

• Lead and manage all NABH accreditation processes across the hospital, ensuring compliance with the latest standards and guidelines.
• Ensure continuous improvement and adherence to the requirements of NABH pre-accreditation, full accreditation, and re-accreditation.
• Regularly update hospital management on changes in NABH standards, ensuring all departments are aligned with new regulations.

Internal Audits and Quality Assurance

• Develop, implement, and monitor a robust internal audit system for continuous quality assurance.
• Plan and conduct regular audits across departments to ensure compliance with NABH standards, identifying gaps and driving corrective actions.
• Ensure documentation and record-keeping processes are compliant with NABH guidelines, maintaining accuracy and completeness at all levels.

Training and Capacity Building

• Conduct regular training sessions and workshops for staff, ensuring they are well-versed in NABH standards and quality processes.
• Foster a culture of continuous learning and improvement through capacity-building initiatives across all levels of staff, including doctors, nurses, and administrative teams.
• Create and maintain a training calendar for ongoing quality improvement programs.

Patient Safety and Care Quality

• Implement and monitor patient safety protocols in compliance with NABH standards, including infection control, patient rights, medication safety, and emergency preparedness.
• Lead initiatives aimed at improving the patient experience, clinical outcomes, and overall quality of care.
• Ensure that all patient safety incidents are recorded, reviewed, and addressed with corrective actions and root cause analysis.

Quality Improvement Projects

• Initiate and drive hospital-wide quality improvement projects to improve patient care, operational efficiency, and compliance with NABH standards.
• Implement clinical governance and risk management frameworks, ensuring accountability and transparency in decision-making processes.
• Work with department heads to develop and implement key performance indicators (KPIs) aligned with NABH standards.

Data Analysis and Reporting

• Monitor quality metrics, patient feedback, and audit results, preparing detailed reports for hospital leadership and regulatory bodies.
• Use data analytics to identify trends, strengths, and areas for improvement, ensuring continuous quality improvements are driven by data.
• Prepare reports for NABH assessments, audits, and inspections, ensuring all documentation is audit-ready.

Cross-functional Collaboration

• Collaborate closely with clinical departments, nursing, HR, housekeeping, and other teams to ensure seamless implementation of quality standards.
• Coordinate with IT and management to develop electronic systems and dashboards for quality monitoring and real-time data analysis.
• Ensure that quality processes and protocols are integrated into every aspect of hospital operations, from clinical care to administrative functions.

Risk Management & Incident Reporting

• Implement a hospital-wide risk management program, ensuring all incidents, near-misses, and non-compliance issues are recorded and addressed.
• Develop protocols for reporting, analyzing, and resolving adverse events in compliance with NABH safety guidelines.
• Regularly review risk assessment and mitigation plans to minimize hospital liabilities and enhance patient safety.

Continuous Quality Accreditation

• Develop long-term strategies to maintain NABH accreditation, ensuring that the hospital sustains the highest standards of care and operational excellence.
• Prepare for future accreditations, including JCI (Joint Commission International) and ISO, to expand the hospital's recognition on both national and international levels.

Qualifications and Skills

• Educational Background: Masters degree in Hospital Administration, Healthcare Management, or a related field.
• Experience: Hands-on experience in NABH accreditation processes.
• Technical Skills: Thorough knowledge of NABH standards, quality control protocols, and healthcare regulatory frameworks.
• Key Competencies: Strong leadership, communication, and analytical skills with the ability to lead cross-functional teams towards quality improvement goals.