Occupations and Terms of Reference › Quality manager
Universal terms of reference · POS-024 · version 1.0 · status: draft · next review 2027-10-27
Quality manager
To run the quality management system day to day, so that services meet the agreed standards, quality indicators are on track, and improvement is measured.
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 run the quality management system. You coordinate audits, quality indicators, accreditation readiness, complaints learning and improvement projects across services.
Reports to: Chief quality and safety officer.
Leads or supervises: Quality assurance, patient safety, accreditation, clinical audit, infection prevention and complaints teams.
What you do on a typical day
- Review quality indicators with service leads each month.
- Plan and track the audit and improvement programme.
- Prepare for accreditation and external surveys.
- Review complaints themes and improvement actions.
- Report quality performance to the quality committee.
Working conditions and demands
- Works across all services.
- Needs to hold teams to standards without losing their engagement.
- Deadlines set by accreditation and regulators.
What good looks like
- Indicators are reported on time and acted on.
- Audits are completed and actions closed.
- Surveys are passed with few findings.
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.
- Quality means the patient's experience as well as the clinical result; both are measured.
- Problems are reported early and without blame, and learned from.
- Standards are followed the same way on every shift and at every site.
- Every staff member can raise a concern without fear of reprisal.
- Improvement work is planned, measured and kept going until it is embedded.
- Data is used to improve care, and is protected while it is used.
- Where a standard cannot be met, the gap is recorded and escalated the same day.
2. Identification
| Item | Detail |
|---|---|
| Position code | POS-024 |
| ISCO-08 | 1342 (skill level 4) |
| ESCO | to map |
| Department | Quality and safety |
| Facility types | Hospital, Ambulatory, Transport, Medevac, Fitness, Aesthetic |
3. Reporting line and working relationships
Reports to: POS-008. Supervises: POS-025, POS-026, POS-028, POS-029, POS-030, POS-035.
| Works with | Nature of the relationship |
|---|---|
| Chief quality and safety officer | Sets quality strategy; quality manager delivers it. |
| Chief medical officer | Clinical audit and standards. |
| Chief nursing officer | Nursing quality and audit. |
4. Key accountabilities
| Domain | Accountability | Evidence of delivery | Checked | Linked competencies | Linked trainings | Linked policies | Standards |
|---|---|---|---|---|---|---|---|
| Quality system | Runs the quality management system and its improvement programme. | Programme delivered; actions closed | Monthly | C-01 | T-05 | POL-INC | 1, 2 |
| Indicators | Reports quality indicators and acts on trends. | Indicator report issued monthly | Monthly | C-02 | T-05 | – | 2 |
| Accreditation | Keeps the organisation ready for accreditation and surveys. | Readiness plan current; findings closed | Quarterly | C-03 | T-07 | – | 1, 2 |
| Complaints learning | Reviews complaints themes and turns them into improvement actions. | Complaints themes reported quarterly | Quarterly | C-01 | T-08 | POL-WHISTLE | 2 |
5. Decision rights
| The post holder decides | Consults or escalates |
|---|---|
| Quality improvement priorities within the approved plan | Indicator failures that put patients at risk (CQO) |
| Audit schedule within the programme | Survey findings that threaten accreditation (CQO and CEO) |
6. Qualifications and experience
| ID | Qualification | Mandatory | Validity |
|---|---|---|---|
| Q-01 | Degree in a health, nursing or quality-related field | Yes | Lifetime |
| Q-02 | Quality management qualification (for example, lead auditor) | Yes | Lifetime |
| ID | Experience | Minimum years | Mandatory |
|---|---|---|---|
| E-01 | Quality or clinical audit management in a health service | 5 | 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 |
| 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-03 |
| T-08 | Speaking up, inclusion and equality leadership | essential | periodic | Every 2 year(s) | POL-WHISTLE · POL-EQUAL | – |
8. Health, fitness and language
| ID | Requirement | Frequency | Tier | Minimum in low-resource settings |
|---|---|---|---|---|
| H-01 | Immunity to vaccine-preventable diseases relevant to the setting, documented at entry | At entry or as set | essential | Documented hepatitis B status at entry |
| H-02 | Tuberculosis screening at entry, then as the national rule requires | At entry or as set | essential | Symptom screening at entry and after exposure |
| 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 | Follows quality procedures | Runs the quality system in a service | Designs quality management across services | Quality audit | Every 12 months | T-05 |
| C-02 | Audit and indicator analysis | Collects audit data | Analyses audit results | Designs the indicator framework | Audit review | Every 12 months | T-05 |
| C-03 | Accreditation readiness | Knows standards | Prepares a service for survey | Leads survey readiness across services | Survey outcome | Every 24 months | T-07 |
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 | Quality indicators reported on time | 100% | indicator report | Monthly |
| PI-02 | Audit actions closed on time | 100% | action tracker | Monthly |
| PI-03 | Survey findings closed within plan | 100% | survey tracker | Quarterly |
| PI-04 | Complaints themes actioned | 100% | complaints log | Quarterly |
11. Career ladder and promotion
| Level | Role | Minimum experience to move on | Qualifications | Competency minimums | Trainings required | Assessment |
|---|---|---|---|---|---|---|
| Executive | Quality manager | 5 years (recommended) | Q-01, Q-02 | C-01 expert, C-02 practitioner | T-05 | 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 |