1. Job Purpose

To drive the Quality & Patient Safety program at Reliance Foundation Hospital by ensuring strict adherence to NABH/JCI standards, clinical governance frameworks, patient safety practices, and operational excellence across all clinical and non-clinical departments. The role ensures continuous quality improvement through audits, analytics, training, and cross-functional collaboration.

2. Accountabilities

1. Accreditation & Compliance Management

• Ensure continuous compliance with NABH, JCI, and statutory accreditation standards.
• Develop, update, and monitor hospital-wide SOPs, policies, and clinical protocols.
• Conduct internal audits, gap assessments, and drive corrective & preventive actions (CAPA).

2. Quality Assurance & Continuous Improvement

• Implement quality improvement initiatives, Lean/Six Sigma projects, and process optimization.
• Monitor quality indicators, patient outcomes, and performance dashboards.
• Lead RCAs, incident analysis, and clinical audits to enhance patient safety and care standards.

3. Patient Safety & Risk Management

• Oversee patient safety programs including incident reporting, near-miss reporting, and safety rounds.
• Facilitate FMEA, risk assessments, and safety audits across all critical care areas.
• Ensure adherence to infection control practices in collaboration with the ICN team.

4. Training & Capacity Building

• Conduct training on NABH/JCI standards, documentation practices, patient safety, and quality tools.
• Build quality champions across departments to enhance internal capability.
• Orient new employees on quality, safety, and compliance requirements.

5. Data Management & Reporting

• Compile, analyze, and publish monthly quality dashboards for management review.
• Track KPIs, quality indicators, audit scores, incident trends, and compliance metrics.
• Support departments with data interpretation and action planning.

6. Interdepartmental Coordination

• Work with Nursing, Operations, Clinical Heads, Diagnostics, Pharmacy, and Support Services to ensure quality benchmarks are met.
• Facilitate Management Review Meetings and Quality Council sessions.
• Collaborate with biomedical, engineering, and safety teams to ensure environment-of-care standards.

7. Patient Experience & Service Excellence

• Monitor patient feedback, complaints, and satisfaction survey results.
• Lead root-cause analysis for escalated complaints and ensure timely closure.
• Implement service excellence initiatives to improve patient experience.

3. Competencies

A. Core HNH Values

Patient First

Excellence

Accountability

Respect

Teamwork

Integrity

B. Function-Specific Competencies (Technical / Functional)

• In-depth knowledge of NABH/JCI standards
• Clinical quality & patient safety
• Audit management & root cause analysis
• Data analytics and dashboard reporting
• Process improvement (Lean/Six Sigma preferred)
• Strong communication & stakeholder management
• Policy writing & documentation skills
• Proficiency in MS Office and hospital information systems

4. Experience & Educational Requirements

EDUCATIONAL QUALIFICATIONS:

Necessary: Graduation in Healthcare / Life Sciences / Nursing / Allied Health

Desirable: MHA / MBA Healthcare / PG Diploma in Quality Management / Six Sigma Certification

RELEVANT EXPERIENCE:

Necessary: 6–10 years of experience in Quality & Patient Safety in a multi-specialty hospital

Desirable: Experience in NABH/JCI-accredited hospitals; exposure to clinical audits; Lean Six Sigma projects; experience in handling accreditation independently