Masina Hospital Trust - Manager - Quality & Compliance

About the job

Position: Manager Quality & Compliance

Location: Masina Hospital Trust, Mumbai

Type: Full-time | 35 Years Experience Required

Masina Hospital Trust, a 120+ Years old historic multi-specialty 270 bedded Heritage Hospital in South Mumbai, ranked among the Top Hospitals as per leading surveys like Times of India & Midday & winner of various Best Hospital Awards is inviting applications for the position of Manager Quality & Compliance. This role will be responsible for managing NABH compliance, statutory coordination, quality audits, and DNB inspections.

Its a great opportunity for professionals with 35 years of experience who are looking to step into a more independent and strategic quality role within hospital operations.

Role & Responsibilities:

Quality & NABH Compliance

- Conduct internal audits across clinical, support, and non-clinical areas

- Perform gap analysis and support implementation of improvements

- Maintain documentation, reports, and checklists as per NABH guidelines

- Support continuous readiness for accreditation and re-accreditation

- Review patient records, infection control protocols, and equipment readiness in ICU, OT, wards, ER

- Ensure compliance in Pharmacy, Lab, and Radiology services

- Track housekeeping, HR documentation, and biomedical waste compliance

Incident & Risk Management

- Implement an incident reporting system in all departments

- Track and analyze incident trends

- Conduct root cause analyses and recommend corrective actions

Statutory & Regulatory Coordination

- Coordinate with BMC and other authorities for license documentation and renewals

- Maintain records of nursing home license, Fire NOC, and other statutory requirements

DNB Coordination

- Assist in DNB applications, inspections, and compliance reporting

Requirements

- 35 years of experience in hospital quality management

- Experience with NABH standards, audit processes, and documentation

- Familiarity with BMC liaison work and statutory licensing

- Hands-on involvement in DNB inspections preferred

- Strong organizational, documentation, and interdepartmental coordination skills