Quality and Patient Safety Manager

The Quality and Patient Safety Manager is responsible for the overall leadership, coordination, implementation, monitoring, and continuous improvement of the organization's quality management and patient safety program across Washington Healthcare PLC.

The position provides strategic and operational leadership to improve the quality, safety, effectiveness, efficiency, and patient-centeredness of healthcare services; reduce preventable harm and clinical risks; strengthen organizational systems and processes; and promote a strong culture of quality improvement, patient safety, accountability, and continuous learning.

The Quality and Patient Safety Manager develops, implements, and monitors the organization's quality management framework, patient safety systems, quality indicators, clinical and operational audits, incident and adverse-event reporting, risk management, root cause analysis, corrective and preventive actions, quality improvement projects, patient experience initiatives, accreditation readiness, and performance improvement programs.

The position works closely with physicians, nurses, laboratory professionals, pharmacists, allied health professionals, department heads, hospital administration, finance, human resources, information technology, facility management, and other stakeholders to ensure that healthcare services are delivered in accordance with organizational policies, national requirements, professional standards, evidence-based practices, and applicable accreditation standards.

 

 

KEY RESPONSIBILITIES

1. Quality Management and Patient Safety Program Management

•       Plan, organize, coordinate, implement, and oversee the organization's Quality Management and Patient Safety Program.

•       Develop and maintain a comprehensive annual quality and patient safety plan aligned with organizational strategy, clinical priorities, patient safety objectives, regulatory requirements, and applicable national and international standards.

•       Develop, review, and implement quality management policies, procedures, guidelines, protocols, standards, and work instructions.

•       Establish an integrated quality management framework covering clinical, diagnostic, pharmacy, administrative, support, and patient-facing services.

•       Establish clear quality and patient safety responsibilities and accountability at organizational, departmental, team, and individual staff levels.

•       Coordinate with clinical and non-clinical departments to integrate quality improvement and patient safety into routine service delivery.

•       Promote evidence-based, patient-centered, safe, effective, timely, equitable, and efficient healthcare practices.

•       Provide technical advice to hospital leadership and departments on quality management, patient safety, clinical governance, and performance improvement matters.

•       Support organizational leadership in establishing measurable quality and patient safety objectives and performance targets.

•       Monitor implementation of quality improvement initiatives and ensure that identified gaps are addressed within defined timelines.

 

2. Patient Safety Management

•       Develop and maintain a comprehensive patient safety program across the organization.

•       Establish systems for identification, reporting, assessment, investigation, monitoring, and prevention of patient safety incidents.

•       Promote a culture of patient safety, transparency, accountability, learning, and continuous improvement.

•       Monitor patient safety risks associated with clinical care, diagnostic services, medication use, procedures, communication, patient identification, transitions of care, and other healthcare processes.

•       Identify actual and potential sources of patient harm and coordinate appropriate risk-reduction interventions.

•       Promote implementation of evidence-based patient safety practices across clinical and support departments.

•       Monitor compliance with patient identification, communication, consent, documentation, medication safety, clinical handover, and other critical patient safety practices.

•       Coordinate patient safety improvement initiatives based on incident data, audit findings, risk assessments, patient complaints, and quality indicators.

•       Ensure significant patient safety risks are escalated promptly to senior management.

•       Participate in organizational emergency preparedness and response planning where patient safety considerations are relevant.

 

3. Clinical Quality and Clinical Governance

•       Support the development and strengthening of clinical governance systems across the organization.

•       Coordinate with clinical leadership to establish appropriate clinical quality standards and performance expectations.

•       Promote evidence-based clinical practice and adherence to approved clinical guidelines, protocols, pathways, and standards.

•       Monitor clinical performance indicators and identify areas requiring improvement.

•       Support clinical departments in reviewing clinical outcomes, complications, readmissions, mortality, adverse events, and other relevant quality measures.

•       Coordinate multidisciplinary clinical quality reviews where appropriate.

•       Support clinical case reviews, mortality and morbidity reviews, clinical audits, and other mechanisms for learning and improvement.

•       Identify variations in clinical practice and support appropriate interventions to improve consistency and quality of care.

•       Promote integration of clinical governance, patient safety, quality improvement, and evidence-based practice.

•       Provide technical support to clinical departments in developing and implementing quality improvement initiatives.

 

4. Quality Indicators and Performance Measurement

•       Establish and maintain a comprehensive system for monitoring organizational quality and patient safety indicators.

•       Develop standardized definitions, data collection methods, reporting procedures, and performance targets for key quality indicators.

•       Monitor clinical, operational, administrative, and patient experience indicators as appropriate.

•       Develop and monitor indicators related to patient safety, clinical outcomes, medication safety, diagnostic quality, waiting times, readmissions, mortality, patient complaints, documentation, patient experience, and other relevant areas.

•       Analyze performance trends and identify areas of concern, variation, and opportunity for improvement.

•       Prepare regular quality and patient safety performance reports for hospital management and relevant committees.

•       Establish departmental quality dashboards and performance monitoring mechanisms where appropriate.

•       Ensure quality data are accurate, timely, reliable, appropriately interpreted, and securely maintained.

•       Use quality data to support evidence-based decision-making, resource allocation, and improvement priorities.

 

5. Clinical and Operational Audit

•       Develop and implement an organization-wide clinical and operational audit program.

•       Develop standardized audit tools, methodologies, schedules, and reporting mechanisms.

•       Conduct or coordinate regular audits across clinical, diagnostic, pharmacy, administrative, and support departments.

•       Monitor compliance with approved policies, procedures, clinical guidelines, standards, and regulatory requirements.

•       Conduct focused audits based on identified risks, incidents, complaints, performance gaps, or emerging quality concerns.

•       Analyze audit findings and identify systemic and process-related deficiencies.

•       Prepare audit reports and communicate findings to relevant department heads and management.

•       Ensure departments develop appropriate corrective and improvement actions in response to audit findings.

•       Monitor implementation and effectiveness of actions arising from audits.

•       Maintain appropriate records of audit plans, findings, recommendations, corrective actions, and follow-up activities.

 

6. Incident, Adverse Event and Sentinel Event Management

•       Establish and maintain an effective incident and adverse-event reporting system.

•       Promote timely and appropriate reporting of patient safety incidents, near misses, adverse events, sentinel events, complaints, and other quality-related events.

•       Ensure incidents are appropriately classified, documented, investigated, analyzed, and followed up.

•       Coordinate investigation of serious incidents and adverse events in collaboration with relevant clinical and administrative departments.

•       Ensure appropriate escalation of serious or high-risk events to hospital leadership.

•       Conduct or coordinate root cause analysis and other structured investigation methodologies for significant events.

•       Identify system failures, contributing factors, and opportunities for prevention.

•       Develop corrective and preventive action plans following incident investigations.

•       Monitor implementation and effectiveness of actions arising from incident investigations.

•       Maintain appropriate confidentiality and security of incident and patient safety information.

•       Promote organizational learning from incidents, near misses, and adverse events without compromising professional accountability.

 

7. Root Cause Analysis and Corrective and Preventive Action

•       Lead or coordinate Root Cause Analysis (RCA) for serious patient safety events and significant quality failures.

•       Apply appropriate quality improvement and problem-solving methodologies to identify underlying causes of performance gaps.

•       Distinguish between individual errors, process failures, system weaknesses, communication failures, and organizational factors contributing to adverse events.

•       Develop evidence-based corrective and preventive action plans.

•       Establish clear responsibilities, timelines, performance indicators, and verification mechanisms for CAPA implementation.

•       Monitor completion and effectiveness of corrective and preventive actions.

•       Escalate overdue, ineffective, or high-risk corrective actions to senior management.

•       Conduct follow-up assessments to determine whether interventions have resulted in sustainable improvement.

•       Maintain a centralized CAPA tracking system and appropriate documentation.

 

8. Quality Improvement and Performance Improvement

•       Lead the development and implementation of continuous quality improvement initiatives across the organization.

•       Identify improvement opportunities using quality indicators, audits, patient feedback, incident reports, risk assessments, clinical outcomes, and operational data.

•       Support departments in developing structured quality improvement projects.

•       Promote use of appropriate quality improvement methodologies and tools, including Plan-Do-Study-Act (PDSA), process mapping, root cause analysis, and other appropriate approaches.

•       Establish measurable objectives, baselines, targets, interventions, and outcome measures for quality improvement projects.

•       Monitor progress and evaluate the effectiveness and sustainability of improvement initiatives.

•       Facilitate multidisciplinary quality improvement teams and improvement activities.

•       Document and communicate successful improvement practices and lessons learned.

•       Promote replication and standardization of successful interventions across relevant departments and facilities.

•       Support a culture in which staff are encouraged to identify problems and participate in solving them.

 

9. Risk Management and Patient Safety Risk Assessment

•       Establish and maintain an integrated healthcare quality and patient safety risk management system.

•       Conduct regular quality and patient safety risk assessments across clinical and non-clinical services.

•       Identify, assess, prioritize, and monitor actual and potential risks.

•       Develop risk registers and appropriate mitigation strategies for significant risks.

•       Coordinate with department heads to implement risk reduction measures.

•       Monitor high-risk processes, services, procedures, and patient populations.

•       Participate in investigation of quality-related complaints, incidents, adverse events, and safety concerns.

•       Evaluate the effectiveness of implemented risk controls.

•       Ensure significant and emerging risks are appropriately communicated and escalated to senior management.

•       Integrate risk management findings into organizational quality improvement and strategic planning.

 

10. Patient Experience, Satisfaction and Complaints Management

•       Develop and support systems for monitoring patient experience and satisfaction.

•       Establish mechanisms for collection, analysis, reporting, and use of patient feedback.

•       Monitor patient complaints, compliments, suggestions, and service concerns.

•       Analyze complaint trends and identify systemic quality and patient safety issues.

•       Coordinate with relevant departments to investigate and resolve quality-related patient complaints.

•       Ensure appropriate documentation, response, escalation, and follow-up of patient complaints.

•       Develop improvement initiatives based on patient experience data.

•       Monitor patient-centeredness, communication, responsiveness, dignity, privacy, accessibility, and continuity of care.

•       Promote respectful, compassionate, culturally appropriate, and patient-centered healthcare services.

•       Report significant patient experience trends and concerns to management and relevant committees.

 

11. Medication Safety

•       Collaborate with physicians, pharmacists, nurses, and other healthcare professionals to strengthen medication safety.

•       Support implementation and monitoring of medication safety policies and procedures.

•       Monitor high-risk medication practices and medication-related incidents.

•       Promote appropriate patient identification, prescribing, dispensing, administration, storage, reconciliation, and monitoring processes.

•       Review medication-related incidents, near misses, and adverse drug events and support appropriate corrective actions.

•       Participate in multidisciplinary medication safety reviews where appropriate.

•       Monitor medication safety indicators and trends.

•       Support implementation of strategies to reduce medication errors and preventable medication-related harm.

•       Collaborate with pharmacy and clinical departments to promote safe medication-use systems.

 

12. Diagnostic and Laboratory Quality

•       Collaborate with laboratory, radiology, pharmacy, and other diagnostic services to monitor quality and patient safety.

•       Monitor relevant diagnostic quality indicators, including turnaround time, reporting accuracy, specimen-related errors, critical-result communication, and other applicable measures.

•       Support systems for appropriate identification, documentation, communication, and follow-up of critical diagnostic results.

•       Participate in investigation of diagnostic errors, delays, discrepancies, and patient safety incidents.

•       Promote adherence to approved diagnostic procedures, quality standards, and applicable regulatory requirements.

•       Coordinate with relevant departments to develop corrective and preventive actions for identified diagnostic quality gaps.

 

13. Documentation, Medical Records and Information Quality

•       Monitor the quality, completeness, accuracy, timeliness, and accessibility of clinical documentation.

•       Collaborate with medical records, clinical departments, and information technology teams to strengthen documentation systems.

•       Conduct regular medical record audits based on approved standards and requirements.

•       Monitor documentation of patient identification, assessment, diagnosis, treatment, consent, medication, procedures, discharge, and follow-up.

•       Identify documentation deficiencies and coordinate corrective actions with responsible departments.

•       Promote standardized and accurate clinical documentation as a key component of patient safety and continuity of care.

•       Maintain appropriate confidentiality and security of quality and patient information.

 

14. Accreditation, Regulatory Compliance and Standards

•       Coordinate organizational readiness for applicable regulatory inspections, accreditation assessments, certification processes, and external quality evaluations.

•       Monitor compliance with applicable national healthcare regulations, professional standards, organizational policies, and recognized international quality and patient safety standards.

•       Develop and maintain an accreditation and regulatory compliance plan.

•       Coordinate preparation of policies, procedures, records, evidence, reports, and other documentation required for assessments.

•       Conduct internal readiness assessments and mock surveys.

•       Identify gaps against applicable standards and coordinate corrective actions.

•       Monitor implementation of recommendations arising from regulatory inspections, accreditation assessments, and external evaluations.

•       Maintain an organizational quality and accreditation evidence system.

•       Keep management informed of significant compliance risks and readiness gaps.

 

15. Quality and Patient Safety Committee

•       Coordinate and provide technical leadership to the Quality and Patient Safety Committee.

•       Prepare committee agendas, reports, data, presentations, and recommendations.

•       Present quality indicators, patient safety events, audit findings, complaints, risk assessments, RCA findings, CAPA progress, and improvement initiatives.

•       Follow up implementation of committee decisions and recommendations.

•       Maintain appropriate records and minutes of committee activities.

•       Ensure effective communication between the Quality and Patient Safety Committee and clinical and administrative departments.

•       Support multidisciplinary decision-making on quality, patient safety, clinical governance, and performance improvement matters.

•       Monitor committee action plans and report progress to senior management.

 

16. Quality Training, Capacity Building and Staff Engagement

•       Develop and implement quality management and patient safety education programs for healthcare workers and support staff.

•       Conduct induction and orientation training on quality and patient safety for newly employed staff.

•       Provide regular refresher training on patient safety, incident reporting, risk management, quality improvement, clinical documentation, medication safety, and other relevant topics.

•       Conduct department-specific training based on identified quality and performance gaps.

•       Develop educational materials, guidelines, tools, posters, and awareness campaigns.

•       Assess staff knowledge and competency related to quality and patient safety practices.

•       Promote staff participation in quality improvement projects and patient safety initiatives.

•       Provide coaching, mentorship, and technical support to departmental quality focal persons.

•       Maintain appropriate records of quality and patient safety training activities.

 

17. Staff Management and Supervision

•       Supervise and coordinate Quality and Patient Safety personnel and assigned staff.

•       Develop work plans, schedules, priorities, and performance objectives for quality management activities.

•       Monitor staff performance, attendance, competency, productivity, and professional conduct.

•       Conduct or coordinate competency assessments and identify training and development needs.

•       Provide technical leadership, mentorship, coaching, and support to quality and patient safety personnel.

•       Promote teamwork, accountability, professional ethics, effective communication, and continuous learning.

•       Address performance gaps and professional concerns in collaboration with Human Resources and senior management.

•       Ensure relevant staff maintain appropriate professional competencies and participate in continuing professional development.

 

18. Data Management, Analysis and Reporting

•       Establish systems for collection, validation, analysis, interpretation, and reporting of quality and patient safety data.

•       Develop regular quality and patient safety performance reports for hospital management and relevant committees.

•       Develop dashboards and performance monitoring tools for key organizational indicators.

•       Analyze trends, variations, correlations, and emerging risks within quality and patient safety data.

•       Ensure data are accurate, complete, timely, reliable, and appropriately protected.

•       Use data to support evidence-based decision-making and prioritization of improvement activities.

•       Monitor departmental performance against established quality targets.

•       Develop management reports highlighting achievements, risks, gaps, trends, and recommended actions.

•       Maintain appropriate quality databases, registers, records, and documentation systems.

 

19. Strategic Quality Development and Continuous Improvement

•       Develop and implement strategies to strengthen quality and patient safety across Washington Healthcare PLC.

•       Identify opportunities for modernization, innovation, digitalization, and improvement of quality management systems.

•       Participate in strategic planning related to patient safety, service expansion, new clinical services, technology implementation, and organizational development.

•       Evaluate emerging quality improvement and patient safety practices and recommend appropriate adoption.

•       Develop quality improvement projects based on organizational priorities, performance data, risk assessments, patient feedback, and identified service gaps.

•       Promote cost-effective, sustainable, and measurable quality improvement initiatives.

•       Benchmark organizational quality and patient safety performance against appropriate national and international standards where applicable.

•       Support the development of an organizational culture of quality, patient safety, accountability, learning, and continuous improvement.

 

20. Communication and Collaboration

•       Maintain effective communication with physicians, nurses, laboratory professionals, pharmacists, allied health professionals, department heads, administration, human resources, finance, information technology, facility management, and other stakeholders.

•       Provide timely technical advice on quality management, patient safety, risk management, and performance improvement matters.

•       Participate in multidisciplinary meetings, clinical governance forums, quality committees, and management meetings as assigned.

•       Communicate quality risks, performance concerns, and required improvement actions clearly and professionally.

•       Establish effective mechanisms for reporting and escalating quality and patient safety concerns.

•       Promote collaborative approaches to quality improvement across all levels of the organization.

•       Represent the organization in relevant professional, regulatory, accreditation, training, and quality improvement forums when assigned.

 

21. Other Duties

•       Perform other duties related to quality management, patient safety, clinical governance, risk management, and healthcare service improvement as assigned by the Chief Clinical Officer or senior management.

•       Support organizational emergency response and business continuity activities where quality and patient safety considerations are involved.

•       Maintain confidentiality and professional standards in all quality and patient safety activities.

•       Ensure all activities are conducted in accordance with Washington Healthcare PLC policies, applicable laws and regulations, professional ethical standards, and recognized quality management and patient safety principles.

REQUIRED MINIMUM REQUIREMENTS

•       Bachelor's degree in Nursing, Medicine, Public Health, Health Services Management, Medical Laboratory Science, Pharmacy, or another relevant healthcare field.

•       A postgraduate qualification in Healthcare Quality Management, Patient Safety, Public Health, Epidemiology, Healthcare Management, Health Services Management, or a related field is highly desirable.

•       Professional certification or formal training in healthcare quality, patient safety, risk management, clinical audit, or quality improvement is highly desirable.

•       Valid professional license/registration by the appropriate Ethiopian regulatory or professional body, as applicable.

•       Minimum of 5 years of demonstrable professional experience in healthcare quality management, patient safety, clinical governance, healthcare administration, public health, clinical practice, or a related healthcare setting.

•       Minimum of 2 years of supervisory, managerial, or program leadership experience in healthcare quality, patient safety, clinical governance, risk management, or a related healthcare environment.

•       Demonstrated experience in developing and implementing quality improvement programs, clinical audits, patient safety systems, risk assessments, incident investigations, and corrective and preventive action plans.

 

KNOWLEDGE, SKILLS AND ABILITIES

•       Strong knowledge of healthcare quality management principles, patient safety, clinical governance, risk management, and continuous quality improvement.

•       Strong understanding of healthcare quality indicators, performance measurement, clinical audit, patient safety indicators, and quality reporting systems.

•       Strong knowledge of incident reporting, adverse-event management, near-miss reporting, root cause analysis, and corrective and preventive action processes.

•       Demonstrated ability to analyze quality and patient safety data, identify trends and risks, and develop appropriate improvement interventions.

•       Strong knowledge of quality improvement methodologies, including PDSA and other structured improvement approaches.

•       Knowledge of healthcare accreditation standards, regulatory requirements, clinical standards, and quality management frameworks.

•       Demonstrated ability to develop and implement quality management policies, SOPs, guidelines, annual plans, audit tools, dashboards, training programs, and quality improvement initiatives.

•       Strong knowledge of patient-centered care, patient experience, complaints management, and mechanisms for improving patient satisfaction.

•       Knowledge of medication safety, diagnostic safety, clinical documentation, healthcare risk management, and other major patient safety domains.

•       Ability to conduct quality audits, patient safety investigations, risk assessments, process reviews, and compliance monitoring.

•       Ability to conduct or facilitate Root Cause Analysis and develop effective corrective and preventive action plans.

•       Strong analytical, problem-solving, decision-making, critical-thinking, and organizational skills.

•       Ability to translate quality data and audit findings into measurable and sustainable improvement actions.

•       Ability to lead, supervise, motivate, coach, and develop healthcare personnel and multidisciplinary quality improvement teams.

•       Excellent communication, presentation, report-writing, facilitation, negotiation, and interpersonal skills.

•       Demonstrated ability to work collaboratively with physicians, nurses, pharmacists, laboratory professionals, administrators, and other multidisciplinary teams.

•       Proficiency in using Microsoft Office and other relevant information systems for data analysis, reporting, documentation, and presentation.

•       Ability to manage confidential and sensitive patient safety, clinical, staff, and organizational information appropriately.

•       Demonstrated professionalism, integrity, accountability, confidentiality, leadership, and commitment to patient-centered care and patient safety.

•       Commitment to evidence-based practice, continuous learning, organizational improvement, and a strong culture of quality and safety.