General Manager Operations

Job Title: General Manager – Operations

Department: Hospital Operations / Administration

Reports To: CEO / Medical Director / Governing Body

Applicable Standard: NABH

Job Purpose (NABH Focused)

To ensure effective planning, implementation, monitoring, and continuous improvement of hospital operations in compliance with NABH standards, statutory requirements, patient safety goals, and quality indicators, while ensuring optimal resource utilization and patient satisfaction.

Key Responsibilities (As per NABH Standards)

1. Governance, Leadership & Accountability

Support hospital leadership in implementation of NABH standards across all departments.

Ensure roles, responsibilities, and accountability are clearly defined and communicated.

Participate in quality meetings, management review meetings, and NABH core committees.

1. Quality Improvement & Patient Safety (CQI & PS)

Ensure implementation and monitoring of Continuous Quality Improvement (CQI) programs.

Track quality indicators, incident reports, near misses, and sentinel events.

Promote patient safety culture and ensure corrective and preventive actions (CAPA).

1. Compliance with NABH Chapters

Ensure compliance and coordination across:

AAC – Access, Assessment & Continuity of Care

COP – Care of Patients

PRE – Patient Rights & Education

HIC – Hospital Infection Control

ROM – Responsibilities of Management

HRM – Human Resource Management

IMS – Information Management System

FMS – Facility Management & Safety

1. SOPs, Policies & Documentation

Ensure availability, implementation, and periodic review of SOPs and policies.

Maintain document control, versioning, and staff awareness as per NABH norms.

Ensure records are legible, updated, and traceable.

1. Human Resource Management (NABH-HRM)

Ensure staff credentialing, induction, training, and competency assessment.

Coordinate mandatory trainings (BLS, fire safety, infection control, patient safety).

Monitor duty rosters, leave management, and staff performance.

1. Patient Rights, Feedback & Grievance Redressal

Ensure patient rights are displayed, communicated, and respected.

Monitor patient feedback, complaints, and grievance resolution within defined TAT.

Ensure confidentiality and ethical practices.

1. Infection Control & Biomedical Waste Management

Ensure compliance with infection prevention protocols and audits.

Coordinate with HIC team for surveillance, hand hygiene, and isolation practices.

Ensure biomedical waste segregation and disposal as per statutory norms.

1. Facility Management & Safety (FMS)

Ensure safe hospital infrastructure, fire safety, and disaster management plans.

Monitor preventive maintenance, equipment calibration, and AMCs.

Conduct mock drills and safety audits.

1. Financial Oversight & Resource Optimization

Monitor operational budgets, cost containment, and utilization of resources.

Ensure billing transparency and ethical financial practices.

Support management in revenue optimization without compromising quality.

1. Data Management & Reporting (IMS)

Ensure accurate data collection, reporting, and analysis for NABH audits.

Maintain confidentiality and data security.

Prepare NABH-ready reports, dashboards, and audit evidence.

Qualifications

Master's Degree in Hospital Administration / Healthcare Management / MBA (Healthcare)

NABH Internal Assessor / Quality Training (Preferred)

Experience

10–15 years of hospital experience

Minimum 5 years in senior operations or leadership role

Hands-on experience in NABH accreditation / renewal

Core Competencies

Strong understanding of NABH standards

Leadership & team coordination

Quality & patient safety orientation

Documentation & audit preparedness

Crisis & risk management

Communication & stakeholder management