Occupations and Terms of Reference › Chief quality and safety officer (CQO)
Universal terms of reference · POS-008 · version 1.0 · status: draft · next review 2027-10-27
Chief quality and safety officer (CQO)
To make sure care and services are safe, effective and of good quality across the organisation, and that the organisation meets its accreditation and legal standards.
Each part of this page links to the related trainings, competencies and policies. The links are the same for every facility, so an organisation can see at a glance what a role requires and what it is trained in.
Job description
Job summary. You make sure that care and services are safe and of good quality. You lead the quality management system, patient safety, risk management, complaints and accreditation, and you make sure learning from events leads to real improvement.
Reports to: Chief executive officer.
Leads or supervises: Quality, patient safety, risk, complaints, clinical audit and accreditation teams.
What you do on a typical day
- Review serious incidents, complaints and risk registers.
- Chair the quality and safety committee; track improvement actions.
- Plan and run clinical and operational audits with service leads.
- Prepare for accreditation surveys and inspections.
- Support staff who report safety concerns.
- Report quality and safety performance to the board each quarter.
Working conditions and demands
- Accountable for the quality and safety management system.
- Works with clinical and non-clinical teams at every site.
- Needs to hold uncomfortable findings to account while keeping staff engaged.
What good looks like
- Serious incidents are investigated and learning is shared.
- Quality indicators are on track and reported to the board.
- Accreditation surveys are passed with few findings.
- Patients and staff feel safe to raise concerns.
Place in the organogram
Reporting line, from the top: see the organogram on the Occupations page. The lines above and below this role are listed in section 3.
1. Golden rules
These rules apply in every setting.
- Every decision that affects patient safety is made on evidence and recorded.
- Patient safety and quality come before financial targets; no trade-off that puts patients at risk is accepted.
- Every staff member can raise a concern without fear of reprisal, and every concern is answered.
- Legal, licensing and accreditation duties are known, owned and reviewed.
- Finances, people and information are managed openly and within the law.
- Mandatory training and policies apply to the executive as much as to frontline staff.
2. Identification
| Item | Detail |
|---|---|
| Position code | POS-008 |
| ISCO-08 | 1219 (skill level 4) |
| ESCO | to map |
| Department | Governance |
| Facility types | Hospital, Ambulatory, Transport, Medevac, Fitness, Aesthetic |
3. Reporting line and working relationships
Reports to: POS-003. Supervises: POS-024, POS-025, POS-026, POS-027, POS-035, POS-028, POS-029.
| Works with | Nature of the relationship |
|---|---|
| Chief medical officer | Clinical audit and governance. |
| Chief nursing officer | Nursing quality and safety. |
| Chief operating officer | Operational risk and facilities safety. |
| Accreditation body | Assessment, surveys and improvement plans. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Quality management system | Runs the quality management system and makes sure it meets accreditation and legal standards. | Quality plan delivered; internal audit findings closed | Quarterly | C-01 · C-04 | T-05 · T-07 | – | 1, 2 |
| Patient safety | Leads patient safety, incident learning and safety improvement. | Serious incidents reviewed within policy timeframe; actions tracked | Monthly | C-02 | T-05 · T-07 | POL-INC · POL-SAFEG | 2 |
| Risk management | Maintains the organisational risk register and makes sure risks have owners and controls. | Risk register reviewed quarterly; high risks reported to the board | Quarterly | C-02 | T-07 | POL-INC | 2 |
| Complaints and speaking up | Makes sure complaints and concerns are investigated fairly and learning is shared. | Complaints answered within policy timeframe; themes reported | Monthly | C-05 | T-08 | POL-WHISTLE · POL-EQUAL | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Quality improvement priorities within the approved plan | Serious incidents with legal, regulatory or public impact (CEO and board) |
| Audit programme and inspection schedule | Accreditation findings that put accreditation at risk |
| Required corrective actions following incidents | Risks that exceed the board's risk appetite |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Degree in health, nursing, engineering or a related field | Yes | Lifetime |
| Q-02 | Quality management or patient safety qualification (for example, lead auditor) | Yes | Lifetime |
| Q-03 | Master's in quality, safety or health management | No | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Senior quality or patient safety management in a health service | 8 | Yes |
7. Training requirements
Recommended common practice. Each facility adapts the list to its national law. Essential items apply in every setting; recommended items apply where resources allow.
| ID | Training | Tier | When | Validity | Linked policies | Linked competencies |
|---|---|---|---|---|---|---|
| T-01 | Facility induction | essential | at_entry | Once | POL-WHISTLE · POL-EQUAL · POL-DATA | – |
| T-02 | Safeguarding adults | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-03 | Safeguarding children | essential | periodic | Every 3 year(s) | POL-SAFEG | – |
| T-04 | Data protection and confidentiality | essential | annual | Every 1 year(s) | POL-DATA | – |
| T-05 | Incident reporting and open disclosure | essential | periodic | Every 2 year(s) | POL-INC | C-01 · C-02 · C-03 |
| T-06 | Governance, accountability and assurance | recommended | periodic | Every 3 year(s) | – | – |
| T-07 | Emergency and major incident command | essential | annual | Every 1 year(s) | POL-INC | C-02 · C-04 |
| T-08 | Speaking up, inclusion and equality leadership | essential | periodic | Every 2 year(s) | POL-WHISTLE · POL-EQUAL | C-05 |
8. Health, fitness and language
| ID | Requirement | Frequency | Tier | Minimum in low-resource settings |
|---|---|---|---|---|
| H-03 | Fitness-to-work assessment at entry and after serious illness or injury | Every 12 months | recommended | Fitness check at entry |
| Language | Level | Mandatory |
|---|---|---|
| Official language of the country of practice | professional | Yes |
| English | working | Yes |
9. Competencies by level
| ID | Competency | Foundation | Practitioner | Expert | Assessed by | Revalidate | Linked trainings |
|---|---|---|---|---|---|---|---|
| C-01 | Quality management systems and improvement | Follows quality procedures | Leads quality improvement in a service | Designs the quality management system for the organisation | Quality system audit | Every 12 months | T-05 |
| C-02 | Patient safety and risk management | Reports risks and incidents | Leads incident and risk reviews | Designs risk and safety controls across the organisation | Risk review | Every 12 months | T-05 · T-07 |
| C-03 | Clinical and operational audit | Takes part in audit | Leads audits in a service | Designs the audit programme | Audit review | Every 12 months | T-05 |
| C-04 | Accreditation and external standards | Knows relevant standards | Prepares a service for survey | Leads accreditation across the organisation | Survey outcome | Every 24 months | T-07 |
| C-05 | Leading change and engaging staff | Works in a team | Leads an improvement team | Leads a culture of safety and learning | 360 feedback | Every 24 months | T-08 |
10. Performance evaluation
- Probation: 6 months, with a sign-off review (recommended value).
- Appraisal: every 12 months against the competencies and indicators below.
| ID | Indicator | Target | Data source | Frequency |
|---|---|---|---|---|
| PI-01 | Serious incidents investigated within policy timeframe | 100% | incident register | Monthly |
| PI-02 | Internal audit actions closed on time | 100% | audit tracker | Quarterly |
| PI-03 | Complaints answered within timeframe | 100% | complaints register | Monthly |
| PI-04 | Accreditation standards met at survey | set by accreditation body | survey report | Annually |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Chief quality and safety officer (CQO) | 8 years (recommended) | Q-01, Q-02 | C-01 expert, C-02 expert | T-05 · T-07 | Executive appointment and performance review |
12. Policies the post holder follows
Each policy is a standard template that the facility adopts and adapts. Templates are maintained centrally, so every facility works from the same version.
POL-SAFEG · Safeguarding adults and children
Purpose: Protect patients from abuse, neglect and harm, and make sure every concern is recognised and acted on.
Scope: All staff, volunteers and contractors.
Key rules:
Scope: All staff, volunteers and contractors.
Key rules:
- Recognise signs of abuse and neglect and record them factually.
- Report every concern to the designated safeguarding lead the same shift.
- Do not investigate alone.
- Share information only as the safeguarding procedure allows.
POL-DATA · Data protection and confidentiality
Purpose: Keep patient and staff information private, secure and used only for care and legal purposes.
Scope: All staff who access records or systems.
Key rules:
Scope: All staff who access records or systems.
Key rules:
- Access only the records needed for your work.
- Keep records secure; do not leave screens or paper unattended.
- Do not share information without a lawful basis.
- Report any breach to the data protection officer within 24 hours.
Linked trainings: T-10 · Review every 12 months · Template 0.1 (draft)
POL-WHISTLE · Speaking up (whistleblowing)
Purpose: Let staff raise patient safety or conduct concerns without fear of reprisal.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Raise a concern with your line manager or the named speaking-up officer.
- If that route fails, escalate to the board or the national regulator.
- Retaliation against anyone who speaks up is a disciplinary offence.
- Concerns are recorded, investigated and the outcome given to the person raising them.
Linked trainings: T-01 · Review every 12 months · Template 0.1 (draft)
POL-EQUAL · Equality, diversity and inclusion
Purpose: Give every patient and colleague fair access, respectful treatment and reasonable adjustments.
Scope: All staff and patients.
Key rules:
Scope: All staff and patients.
Key rules:
- Treat every person with dignity regardless of background.
- Make reasonable adjustments, including interpreters, for language and disability.
- Report discrimination through the speaking-up route.
- Monitor access and outcomes by group.
Linked trainings: T-01 · Review every 24 months · Template 0.1 (draft)
POL-INC · Incident reporting and open disclosure
Purpose: Report and learn from incidents and near misses, and tell patients honestly when things go wrong.
Scope: All staff.
Key rules:
Scope: All staff.
Key rules:
- Report every incident and near miss the same shift.
- Give the patient and family an honest account and an apology where appropriate (open disclosure).
- Take immediate action to protect others.
- Learn: contribute to the review and follow the agreed actions.
13. Standards that name this role
14. Record history
| Date | Change | Approved by |
|---|---|---|
| 2026-10-27 | Draft record, batch 1 of the position build | Awaiting approval |