Hospital Quality Manager

1 week ago

Ankleshwar, Gujarat, India RightStones Consultants Full time

A Reputed Hospital is looking for Hospital Quality Manager based at Ankleshwar , Gujarat location

Key Responsibilities:

  • Implement and monitor compliance with NABH standards.Do periodic Internal Audits for standard Compliance.
  • Coordinate periodic gap assessments and ensure timely closure of non-conformities.
  • Monitor KPIs and assist departments in achieving targets. Do trend Analysis for KPIs, Patient feedback, Active Audits etc..
  • Prepare and maintain documentation as per accreditation norms. Prepare, review, and manage SOPs, manuals, policies, and quality documentation.
  • Facilitate incident reporting system hospital-wide. Perform root cause analysis and support CAPA (Corrective and Preventive Action) implementation.
  • Maintain incident registers and report trends Conduct regular MRD audits, Analyze documentation gaps and follow up for timely correction.
  • Coordinate emergency mock drills (Code Blue, Red, etc.).
  • Document findings, perform effectiveness analysis, and report gaps. Ensure training and awareness among staff. Evaluate Committee effectiveness.
  • Coordinate with internal committees (Infection Control, PSQI, Safety, etc.), Prepare minutes of meetings (MoMs), follow up on action points, and maintain records.
  • Plan and coordinate training programs on quality, patient safety, infection control, and NABH standards.
  • Track attendance and maintain training records.
  • Plan and support Quality Improvement Projects (QIPs), Document project results and outcomes.
  • Assist in digital transformation of EMR. Coordinate with IT and software team for software modules.
  • Asses for NABH digital Certification , Plan and conduct clinical and nursing audits as per schedule.
  • Analyze findings and coordinate with departments for corrective actions.
  • Ensure SOPs, manuals, and policies are current and approved, Coordinate timely review and revision of documents.
  • Maintain centralized documentation system.
  • Make sure compliance for each documentation.
  • Conduct periodic gap assessments across departments.
  • Facilitate implementation of CAPA. Document compliance verification and follow-up actions.
  • Conduct quality checks and visits to outsourced vendors (e.g., laundry, diet, waste management).
  • Ensure compliance with service level agreements Collect, analyze, and report PROM data to measure patient satisfaction and outcomes.
  • Coordinate improvement measures based on PROM feedback.

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