• Monitor collection, compilation, analysis and corrective and preventive actions for Quality Indicators as per Hospital accreditation Guidelines.
• Upkeep of NABH Policies, Procedures and Manuals w.r.t latest NABH Accreditation Standards.
• Design and develop Policies, Procedures and manuals w.r.t latest accreditation Standards.
• Integrate the NABH and the JCI policies.
• Control and maintain all operational formats used by various functions, as per requirement of NABH Accreditation Standards.
• To facilitate critical analysis of Emergency Alert Codes and to ensure closure of the identified gaps.
• Ensure that committee meetings are conducted as per the standard guidelines.
• Identification and training quality representatives across functions.
• Identification and development of internal auditors/NABH Assessors from amongst clinicians.
• To ensure adequate number of the internal audits are planned and executed in the hospital.
• To follow up on the corrective action of the various internal audits.
• To ensure the implementation of the NABH policies across the various departments of the hospital.
• Take patient rounds, ensure patient satisfaction and take Corrective & Preventive Action as and when required.
• Facilitate quality awareness training sessions during inductions, or otherwise, as required.
• Facilitating in implementation of CESC Score card.

• To implement score card based matrices to assess clinical quality and operational excellence resulting in standardized and measurable scorecards and establish a review process, including need based training sessions.
• To develop and implement the audit checklists for the various departments.
• To ensure Medical Audit across the various clinical departments of the hospital.
• To ensure medical records (Concurrent and Retrospective) audit across the clinical departments of the hospital.
• To liaison with NABH/NABL/JCI Secretariat for continuation of NABH/NABL Accreditation and application for other Accreditation /Certifications as per the needs of the organization.
• To identify, plan and initiate various quality improvement programs across the hospital.
• Perform any other duty that may be assigned from time to time.

Candidates must have good communication skills and have the ability to multitask and prioritize daily workload.

Candidates from Hospital Background is only preffered.