Quality Executive

3 days ago


Shivajinagar Pune Maharashtra, India Sancheti Hospital Full time

Lead the hospital’s accreditation process by ensuring all standards and requirements are met for national and international accreditation bodies (e.g., NABH, JCI, ISO).
- Prepare and submit all necessary documentation for accreditation surveys and audits.
- Coordinate the preparation and execution of hospital self-assessments and gap analyses related to accreditation standards.
- Maintain an up-to-date understanding of changes in accreditation standards and ensure compliance across all departments.
- Ensure continuous compliance with all regulatory standards, local healthcare regulations, and accreditation requirements.
- Monitor changes in healthcare laws and regulations that affect hospital accreditation and ensure timely adaptation to these changes.
- Prepare for and support external audits, inspections, and surveys from accreditation agencies.
- Collaborate with clinical and administrative teams to develop and implement quality improvement initiatives that align with accreditation standards.
- Track performance metrics and report on quality improvement progress as part of the accreditation process.
- Assist in creating and updating standard operating procedures (SOPs) to align with accreditation and regulatory requirements.
- Provide training to hospital staff on accreditation standards, quality practices, and compliance requirements.
- Organize workshops, seminars, and awareness programs on quality and accreditation to ensure that all departments are prepared for audits and assessments.
- Regularly update staff on new developments in accreditation standards and quality management systems.
- Maintain accurate and comprehensive records of accreditation-related documents, including policies, procedures, reports, and audit results.
- Ensure proper documentation of corrective actions taken in response to audit findings and follow up to ensure implementation.
- Develop and maintain an organized system for accreditation-related files for easy access and reference.
- Act as a liaison between the hospital and accreditation agencies, ensuring effective communication throughout the accreditation process.
- Collaborate with department heads and senior management to resolve any issues related to accreditation or quality compliance.
- Provide regular updates and reports to senior leadership regarding the status of accreditation efforts, compliance, and performance metrics.
- Assist in identifying and managing risks related to quality and accreditation.
- Implement systems for continuous monitoring and evaluation to ensure long-term compliance with quality standards.
- Report any non-compliance or quality concerns that could affect accreditation status and assist in corrective action planning.
- Generate regular reports on the hospital’s quality performance and accreditation status.
- Monitor performance indicators to ensure continued compliance with accreditation standards.
- Present findings to senior management, recommending improvements where necessary.

Pay: ₹25,000.00 - ₹30,000.00 per month

**Benefits**:

- Health insurance
- Provident Fund

**Experience**:

- Hospital: 3 years (required)

Work Location: In person


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