Quality and Compliance Manager

The Quality and Compliance Manager is responsible for developing, implementing, monitoring, and continuously improving the organization's quality management and compliance systems. The role ensures that clinical and non-clinical operations comply with applicable Ethiopian laws, healthcare regulations, licensing requirements, organizational policies, quality standards, and accreditation requirements.

The Quality and Compliance Manager works closely with clinical, administrative, pharmacy, laboratory, nursing, facility, procurement, finance, HR, and other departments to identify risks, monitor performance, investigate incidents, implement corrective and preventive actions, and promote a culture of quality, patient safety, accountability, and continuous improvement.

KEY RESPONSIBILITIES:

Quality Management and Improvement Duties:

• Develop, implement, and maintain the organization's quality management framework, policies, procedures, and quality-improvement programs.
• Establish quality objectives, performance indicators, standards, and monitoring mechanisms in collaboration with relevant departments.
• Coordinate organization-wide quality improvement initiatives and monitor their implementation.
• Conduct regular quality assessments, audits, inspections, and compliance reviews.
• Analyze quality performance data and identify trends, gaps, risks, and opportunities for improvement.
• Prepare quality reports, dashboards, and recommendations for management review.
• Promote continuous improvement and evidence-based quality management practices across the organization.

Compliance and Regulatory Duties:

• Monitor compliance with applicable Ethiopian healthcare laws, regulations, standards, licensing requirements, and organizational policies.
• Maintain a compliance register and monitor regulatory obligations applicable to the organization.
• Coordinate preparation for regulatory inspections, licensing requirements, accreditation assessments, and external audits.
• Ensure departments understand and comply with applicable policies, procedures, standards, and regulatory requirements.
• Identify compliance gaps and coordinate appropriate corrective and preventive actions.
• Maintain accurate compliance records, licenses, certificates, permits, reports, and supporting documentation.
• Escalate significant compliance risks and breaches to senior management in a timely manner.

Accreditation and Standards Management Duties:

• Coordinate organizational readiness for healthcare accreditation and certification programs.
• Develop and maintain standards, policies, procedures, guidelines, and supporting documentation required for accreditation.
• Conduct internal assessments against applicable accreditation and quality standards.
• Coordinate departmental action plans to address identified gaps.
• Monitor implementation of accreditation-related corrective actions and improvement plans.
• Maintain evidence and documentation required for surveys, inspections, and accreditation assessments.
• Promote a culture of continuous readiness rather than compliance only during external assessments.

Clinical Quality and Patient Safety Duties:

• Work with clinical departments to monitor patient safety, quality indicators, and clinical service standards.
• Coordinate systems for reporting, documenting, reviewing, and learning from incidents, adverse events, complaints, and near misses.
• Support root-cause analysis of significant incidents and coordinate corrective and preventive actions.
• Monitor implementation and effectiveness of patient-safety improvement initiatives.
• Collaborate with Infection Prevention and Control, Pharmacy, Laboratory, Nursing, Medical, and other relevant teams on quality and safety issues.
• Promote patient-centered care, service quality, confidentiality, ethical practices, and patient rights.

Risk Management and Internal Audit Duties:

• Develop and maintain a quality and compliance risk register.
• Identify operational, regulatory, clinical, reputational, and patient-safety risks in collaboration with relevant departments.
• Coordinate internal quality and compliance audits based on risk and organizational priorities.
• Document audit findings and monitor implementation of corrective actions.
• Follow up on recurring non-conformities and identify systemic causes.
• Provide management with timely reports on significant risks, audit findings, and unresolved compliance issues.

Policy, SOP and Documentation Management Duties:

• Coordinate development, review, approval, implementation, and periodic updating of organizational policies, procedures, guidelines, and SOPs.
• Ensure controlled documents are appropriately approved, communicated, distributed, and maintained.
• Establish document-control mechanisms to prevent the use of obsolete policies and procedures.
• Coordinate departmental review of policies and procedures to ensure continued relevance and compliance.
• Maintain appropriate quality and compliance documentation and records.

Complaints, Incidents and Corrective Action Duties:

• Establish and monitor systems for receiving, documenting, investigating, and resolving patient and service-related complaints.
• Analyze complaints and incident trends to identify systemic quality issues.
• Coordinate investigations and root-cause analyses for significant incidents and non-conformities.
• Develop and monitor corrective and preventive action plans.
• Verify the effectiveness of corrective actions and ensure closure of identified findings.
• Escalate unresolved or high-risk issues to senior management.

Training and Quality Culture Duties:

• Develop and coordinate quality, compliance, patient-safety, and policy-awareness training programs.
• Ensure employees understand relevant organizational policies, procedures, standards, and regulatory requirements.
• Promote staff awareness of quality indicators, incident reporting, risk management, and continuous improvement.
• Work with HR and department heads to integrate quality and compliance requirements into staff orientation and ongoing training.
• Encourage a culture of accountability, transparency, ethical conduct, and patient-centered service.

Performance Monitoring and Reporting Duties:

• Develop quality and compliance dashboards and key performance indicators.
• Collect, validate, analyze, and interpret quality and compliance data.
• Monitor departmental performance against approved standards and targets.
• Prepare periodic quality and compliance reports for senior management.
• Present significant findings, risks, trends, and improvement recommendations to management.
• Maintain appropriate records of audits, inspections, incidents, complaints, corrective actions, and quality-improvement activities.

Leadership and Administrative Duties:

• Coordinate and support departmental quality focal persons and quality-improvement teams.
• Provide technical guidance and coaching to staff on quality and compliance matters.
• Participate in management and quality committee meetings.
• Coordinate cross-functional quality initiatives and ensure accountability for agreed actions.
• Maintain confidentiality and professional integrity when handling sensitive quality, compliance, incident, and patient-related information.

Other Duties as Required:

• Participate in organizational development, accreditation, licensing, and quality-improvement initiatives.
• Support emergency preparedness and organizational risk-management activities.
• Provide quality and compliance support during major operational changes, projects, and new service implementation.
• Perform other duties assigned by senior management.

• Bachelor’s Degree in Health Services Management, Healthcare Administration, Public Health, Nursing, Medicine, Pharmacy, Laboratory Science, Quality Management, Business Administration, Management, or a related field.
• Minimum of five (5) years of progressive experience in healthcare quality, compliance, clinical governance, healthcare administration, audit, risk management, or a related field, with at least two (2) years in a supervisory or managerial role.
• Experience in hospital quality management, healthcare accreditation, regulatory compliance, clinical governance, or healthcare audit is highly preferred.

KNOWLEDGE, SKILLS AND ABILITIES:

• Strong knowledge of healthcare quality management, compliance, patient safety, risk management, and continuous improvement principles.
• Good understanding of Ethiopian healthcare regulatory and licensing requirements.
• Knowledge of healthcare accreditation standards and quality-assurance frameworks.
• Strong auditing, root-cause analysis, risk-assessment, and corrective-action skills.
• Excellent analytical and problem-solving abilities.
• Strong knowledge of quality indicators, KPI development, data analysis, and performance monitoring.
• Excellent policy, SOP, report-writing, and documentation skills.
• Strong communication, facilitation, negotiation, and interpersonal skills.
• Proficiency in Microsoft Office applications, particularly Excel and PowerPoint.
• Ability to work collaboratively with both clinical and non-clinical teams.
• Strong leadership, coordination, and project-management abilities.
• High level of integrity, confidentiality, accountability, and attention to detail.
• Ability to work under pressure, manage competing priorities, and operate effectively in a fast-paced healthcare environment.