Quality Head Hospital

Qualification: MBBS/BDS/BHMS/BAMS/Nursing with MHA / MPH / MBA (Healthcare/Quality) / Certified NABH AssessorExperience Required: 8+ Years in Hospital Quality / Accreditation ManagementDr. P.K. Saha Hospital is 183 bedded multispecialty Hospital in heart of the city of Cooch Behar. It is the largest private hospital in neighbouring few districts in West Bengal with all major departments and is an extremely busy hospital with state-of-the-art emergency care, Cathlab, Neurosurgical facilities, high-end diagnostic and laboratory services and excellent round-the-clock bed occupancy.________________________________________Job DescriptionWe are seeking a dynamic and experienced Quality Head to lead the hospital's quality assurance and accreditation functions.

The candidate will be responsible for planning, implementing, and maintaining quality systems and standards across all departments, ensuring compliance with NABH/JCI and other applicable healthcare norms. The role requires a proactive leader with strong analytical, coordination, and documentation skills.________________________________________Key ResponsibilitiesQuality Management System

• Develop, implement, and maintain the hospital's Quality Management System (QMS) in alignment with NABH, other relevant standards.
• Create and update Standard Operating Procedures (SOPs), clinical protocols, and work instructions across departments.
• Monitor Key Performance Indicators (KPIs), conduct audits, and ensure continuous quality improvement (CQI) initiatives.

Accreditation and Compliance

• Lead all processes related to NABH certification and reaccreditation.
• Ensure documentation, audits, training, and corrective actions are carried out as per accreditation guidelines.
• Coordinate with department heads and teams to close non-conformities and implement improvements.

Training and Capacity Building

• Conduct regular quality training, awareness programs, mock drills, and orientation for clinical and non-clinical staff.
• Build a quality-conscious culture within the hospital through regular coaching and mentoring.
• Organize fire safety, biomedical waste management, infection control, and patient safety training sessions.

Audit and Data Analysis

• Lead internal and external quality audits, root cause analyses, and implementation of CAPA (Corrective and Preventive Actions).
• Perform incident/near-miss analyses, adverse event reporting, and mortality/morbidity reviews.
• Manage data dashboards, incident logs, feedback mechanisms, and quality reports.

Risk and Patient Safety Management

• Implement and monitor patient safety goals, clinical risk management practices, and infection control protocols.
• Ensure adherence to hospital safety measures including medical error reporting, SOP compliance, and HAZMAT standards.
• Conduct Hospital Infection Control Committee (HICC) meetings and monitor hygiene audits.

Stakeholder Coordination

• Collaborate with department heads, nursing teams, and administrative staff to drive hospital-wide quality initiatives.
• Liaise with external assessors, healthcare regulators, insurance companies, and government health departments during audits and inspections.

Customer Feedback and Grievance Redressal

• Manage the hospital's patient feedback system, grievance redressal process, and implement service recovery strategies.
• Analyze trends from patient satisfaction surveys and recommend improvements.________________________________________Required Skills and Qualifications
• Graduate in Medicine (MBBS/BDS/BHMS/BAMS) or Nursing; Postgraduate degree/diploma in Hospital Administration, Quality, or Public Health.
• Minimum 8 years of experience in hospital quality assurance, with hands-on experience in NABH.
• Certified NABH Assessor (preferred) or trained in healthcare quality protocols.
• Strong analytical and documentation skills, with the ability to manage audits and accreditation cycles independently.
• Proficiency in data interpretation, Excel, PowerPoint, and hospital information systems (HIS).

________________________________________Preferred Attributes

• Experience in large multi-specialty or tertiary care hospitals.
• Expertise in patient safety, risk management, and quality assurance tools (FMEA, RCA, PDCA, Six Sigma, etc.).
• Strong communication and leadership qualities.
• Ability to work under pressure and manage multi-functional teams.