011 4165 3612; 4165 2117 | consult@sams.co.in

Job Description

Lead Quality

Leading CSR Foundation

Pune, Maharashtra

1. POSITION VACANT: Lead Quality, Leading CSR Foundation, Pune, Maharashtra




Our client is the CSR Foundation of a large, well-known corporate, and is doing stellar work for creating an equitable world, while ensuring support and care for every human life through different partnerships.


Our client works in close association with credible institutions, non-government organisations, government agencies and domain experts, to implement several high impact and publicly lauded social initiatives.


The Foundation supports terminally ill patients and has been running a world-class medical care facility and training centre for more than a decade.


The centre incorporates a unique family care model where the patient and caregiver are supported equally by a multi-disciplinary team of doctors, nurses, medical social workers.


The centre provides free-of-cost care through in-patient, homecare, out-patient, and teleconsultation services to a large number of patients.




Reporting to the Medical Director, the Lead Quality (LQ) shall be responsible for devising and establishing quality procedures, standards, and specifications for all departments of the organization’s medical facility and training centre in Pune. S/he will promote quality improvements to all processes and procedures at the centre, share necessary reports, and facilitate its readiness for NABH accreditation.


Key Job Responsibilities:


(A) Quality & Safety Program


(1) Assist all departments in developing and implementing quality and safety program SOPs, in coordination with various departmental heads;

(2) Identify gaps in the implementation of the SOPs, recording observations and suggesting corrective actions;

(3) Facilitate submission of the application for NABH, ensuring compliance with all certification requirements;

(4) Facilitate NABH inspection and surveillance audits.


(B) Incident Reporting & Patient Feedback


(1) Monitor implementation, with emphasis on compliance with incident reporting and feedback reporting system requirements. Conduct training of staff in incident reporting;

(2) Ensure that documentation pertaining to incident reporting and patient feedback are updated at all times.


(C) Quality Indicators


Compile the monthly HMIS quality indicator data, creating trend sheets and monitoring compliance with benchmarks.


(D) Departmental SOP’s & Manuals


(1) Ensure that the SOPs and manuals are updated, as and when changes are informed by the concerned Head of Departments. Also ensure the annual review of all SOPs and manuals;

(2) Maintain records and documentation for the Quality Assurance Department in designated formats.


(E) Committee Meetings


(1) Ensure that Committee Meetings are conducted at the prescribed frequency;

(2) Serve as Secretary for all Quality Assurance Committee Meetings, ensure that the same are conducted at the desired frequency. Also draft minutes for all meetings conducted and ensure their circulation to the Committee Members.


(F) Internal Audit


Conduct internal audits at the decided frequency, generating Audit Reports and ensuring closure and resolution of all audit findings.


(G) Mock Drills


Track compliance against the mock drills for all emergency codes as per the defined schedule and ensure corrective and preventive actions are implemented by concerned Departmental Heads.


(H) Forms / Formats


Provide inputs regarding additions, deletions and/or revisions of forms and formats being used at the Centre.


(I) Training


(1) Conduct defined quality and safety related training programs;

(2) Perform any other tasks assigned by the reporting HOD.





(1) Applicants must be MBBS/ Dental/ AYUSH/ Nursing/ Science Graduates, with a masters in Hospital Administration/ Health Management;
(2) Applicants possessing a Certificate in Accreditation and Certification processes, shall be at an advantage.


Relevant Experience:

(1) Minimum three to five years of relevant experience with a leading private or charitable hospital, of which one year must be in public health or hospital administration;
(2) Preference shall be given to candidates with experience in Health Care Quality or formal

quality processes of a quality system like NABH/ JCI, or equivalent.



(1) Excellent oral and written communication in English and Marathi;

(2) Effective Communication.

(3) Judgment;

(4) Adaptability;

(5) Teamwork.




Gross compensation budgeted for the position is attractive. Please note that the offer made to the selected candidate shall be commensurate with qualifications, experience, and salary history.








Strategic Alliance Management Services P Ltd.
1/1B, Choudhary Hetram House, Bharat Nagar 
New Friends Colony, New Delhi 110 025
Phone Nos.: 011- 4081 9900; 4165 3612




Eligible candidates interested in the position can apply using the link https://bit.ly/Apply-LQ-CSR by or before August 20, 2023.