Quality - Cluster Manager
Even · Bengaluru, Karnataka, India
Apply & track with Apply EdgeJob DescriptionCluster Manager – Quality | Even HospitalsRole OverviewThe Cluster Manager – Quality will be responsible for driving and maintaining quality, patient safety, regulatory compliance, and continuous improvement across a Bangalore cluster of Even Hospitals.The role will work closely with Hospital Leadership, Clinical teams, Nursing, Operations, Medical Administration, HR, and other functional stakeholders to ensure consistent implementation of quality standards and processes across hospitals.The incumbent will act as the key quality custodian for the assigned cluster and will ensure that hospitals remain audit-ready, compliant, and aligned with NABH and applicable statutory/regulatory requirements.Key Responsibilities1. Quality Management & GovernanceDrive implementation of the Even Hospitals Quality Management System across the assigned cluster. Ensure standardisation of quality processes, policies, SOPs, checklists, and documentation across hospitals. Establish and monitor hospital-level quality KPIs and dashboards. Conduct regular quality reviews with Hospital Leadership and track action plans to closure. Identify gaps, risks, and opportunities for improvement and recommend corrective actions. NABH & Regulatory ComplianceDrive NABH preparedness, compliance, and continuous readiness across the assigned hospitals. Ensure compliance with NABH standards, statutory requirements, and applicable healthcare regulations. Coordinate internal assessments, mock audits, external audits, and accreditation-related activities. Track non-conformities, observations, and corrective/preventive actions (CAPA). Maintain appropriate evidence and documentation for accreditation and regulatory requirements. Ensure timely closure of audit findings and maintain audit-readiness throughout the year. Clinical Quality & Patient SafetyMonitor key clinical quality and patient safety indicators across hospitals. Work with Medical Administration, doctors, nursing, and clinical departments to identify quality and patient-safety risks. Drive implementation of incident reporting, investigation, RCA, and CAPA processes. Review clinical incidents, near misses, adverse events, and sentinel events and ensure appropriate corrective actions. Monitor compliance with clinical protocols, infection control practices, medication safety, documentation standards, and patient identification processes. Facilitate quality improvement projects based on identified clinical and operational risks. Quality Audits & Process ImprovementDevelop and execute an annual internal quality audit plan for the cluster. Conduct periodic audits covering clinical and non-clinical functions. Review patient records, nursing documentation, medication processes, infection control, OT, ICU, emergency, laboratory, radiology, pharmacy, CSSD, biomedical waste, and other critical areas. Identify process deviations and recommend sustainable improvements. Track audit scores and recurring non-conformities across hospitals. Benchmark quality performance between hospitals and promote best practices. Patient Experience & Service QualityPartner with Operations and Customer Experience teams to improve patient experience. Monitor patient complaints, grievances, feedback, and service recovery trends. Identify recurring issues and drive root-cause-based interventions. Monitor turnaround times and service-quality indicators across key patient touchpoints. Ensure patient rights, communication, consent, privacy, and dignity requirements are consistently followed. Infection Prevention & ControlWork closely with the Infection Control team to monitor compliance with infection prevention protocols. Review infection control indicators, hand hygiene compliance, HAI trends, antimicrobial stewardship practices, and infection control audits. Support implementation of corrective actions and improvement initiatives. Ensure appropriate documentation and reporting of infection control metrics. Data, MIS & Quality AnalyticsDevelop and maintain a cluster-level quality dashboard. Analyse quality indicators, audit findings, incidents, complaints, and compliance trends. Present quality performance and key risks to Hospital Leadership and Central Quality/Management. Identify trends and use data to drive preventive and corrective actions. Ensure timely and accurate submission of quality MIS. Training & Quality CultureConduct and coordinate quality-related training and awareness programs for hospital employees. Ensure employees understand relevant SOPs, policies, patient safety practices, and NABH requirements. Build a culture of quality, accountability, patient safety, and continuous improvement. Conduct quality sensitisation sessions for clinical and non-clinical teams. Cross-Functional CollaborationWork closely with Hospital CEOs/COOs, Medical Directors, Nursing Heads, Department Heads, HR, Operations, and Central Quality teams. Support hospital leadership in resolving quality and compliance-related issues. Collaborate with functional teams to ensure quality requirements are incorporated into new processes and hospital launches. Support quality readiness for new hospitals, departments, services, and expansions. Key Deliverables / KPIsNABH and regulatory compliance score Internal audit compliance and audit scores Timely closure of audit observations and CAPAs Patient safety incident reporting and closure Reduction in repeat/recurring non-conformities Clinical quality indicator performance Infection control compliance Hand hygiene and patient safety compliance Patient complaint and grievance closure TAT Quality training completion and effectiveness Hospital quality dashboard accuracy and timeliness Readiness for external/accreditation audits Successful implementation of quality improvement projects Standardisation of quality processes across the cluster QualificationBachelor's degree in Healthcare/Hospital Management, Nursing, Pharmacy, Life Sciences, or a related field. Master's degree in Hospital Administration (MHA), Healthcare Management, Quality Management, or equivalent preferred. Certification/training in NABH, Healthcare Quality, Patient Safety, or Quality Management preferred. Experience8–15 years of experience in hospital quality, healthcare quality management, NABH/accreditation, or hospital operations quality. Prior experience managing quality across multiple hospitals/units or a hospital cluster preferred. Strong exposure to NABH accreditation and hospital quality audits. Experience in clinical quality, patient safety, CAPA, RCA, incident management, and process improvement. Skills & CompetenciesStrong understanding of NABH standards and hospital quality systems. Excellent audit and process-review skills. Strong analytical and problem-solving abilities. Good understanding of clinical and hospital operations. Strong stakeholder management and influencing skills. Ability to work with senior clinical and hospital leadership. Strong documentation and reporting skills. Ability to identify systemic issues and drive closure. Strong communication, presentation, and training skills. Data-driven approach to quality improvement. High ownership, attention to detail, and execution orientation. ReportingReports To: Group Medical Director