Manager – Quality & Compliance

The Manager – Quality & Compliance will be responsible for developing, implementing, and monitoring quality management systems across the hospital. The includes ensuring compliance with NABH standards, regulatory requirements, and internal policies while driving patient safety initiatives, conducting audits, and supporting accreditation processes. The position requires strong leadership, analytical skills, and a deep understanding of healthcare quality frameworks.

Roles & Responsibilities

• Develop, implement, and maintain hospital-wide quality management and compliance systems.
• Ensure adherence to NABH standards, healthcare regulations, and statutory requirements.
• Design and monitor quality improvement initiatives across clinical and non-clinical departments.
• Conduct regular internal audits, risk assessments, and compliance reviews.
• entify gaps in processes and implement corrective and preventive actions (CAPA).
• Coordinate and support hospital accreditation and re-accreditation processes.
• Monitor key performance indicators (KPIs) related to quality and patient safety.
• Ensure proper documentation of quality processes, audits, and compliance reports.
• Lead patient safety programs and incident reporting systems.
• Investigate adverse events and ensure root cause analysis is conducted.
• Conduct training programs on quality standards, infection control, and compliance.
• Collaborate with department heads to ensure implementation of quality protocols.
• Prepare and present quality reports and dashboards to senior management.
• Ensure compliance with infection control policies and hospital safety standards.
• Oversee grievance handling and patient feedback management systems.
• Support continuous improvement initiatives to enhance patient experience.
• Monitor regulatory updates and ensure timely implementation of changes.
• Facilitate quality committee meetings and ensure follow-up of action points.
• Promote a culture of safety, accountability, and continuous improvement.
• Liaise with external auditors, regulatory bodies, and accreditation agencies.
• Ensure readiness for inspections, audits, and compliance evaluations.
• Maintain high standards of documentation and record-keeping.
• Contribute to strategic planning for quality enhancement across the hospital.

Masina Hospital Trust is a historic healthcare institution committed to delivering compassionate, affordable, and quality medical care. The hospital serves patients across multiple specialties while maintaining a strong focus on trust, ethics, and community service.

Our Legacy

Masina Hospital has a long-standing legacy in healthcare, built on decades of dedicated service to patients. Over the years, it has evolved into a trusted institution known for its commitment to humanitarian care, clinical excellence, and service to society.

The hospital continues to uphold its founding principles of providing accessible healthcare, especially to underserved communities, while maintaining high standards of medical practice.

Our Mission

• To provide affordable and quality healthcare services to all
• To deliver compassionate and ethical medical care
• To serve society with dedication and responsibility
• To ensure continuous improvement in healthcare delivery

Our Vision

To remain a trusted healthcare institution recognized for its commitment to compassionate care, medical excellence, and service to the community.

Our Services / What We Offer

Masina Hospital Trust provides a wide range of healthcare services, including:

• Multi-speciality medical care
• Emergency and critical care services
• Surgical and inpatient care
• Diagnostic and laboratory services
• Community health and outreach services

Why Choose Us

• Strong legacy of trust and service in healthcare
• Patient-first and compassionate approach
• Affordable and accessible healthcare services
• Experienced medical professionals and support staff
• Commitment to ethical medical practice

Our Team

The hospital is supported by a dedicated team of doctors, nurses, administrators, and healthcare professionals who work together to provide safe, effective, and compassionate care to patients.

Infrastructure / Technology

Masina Hospital Trust is equipped with essential modern medical infrastructure and diagnostic facilities to support effective treatment and patient care.

Our Commitment

Masina Hospital Trust is committed to continuing its legacy of service by delivering high-quality, ethical, and compassionate healthcare. The institution places strong emphasis on patient dignity, trust, and community welfare.