Clinical Governance & Quality Improvement
Advancing healthcare excellence through systematic oversight and continuous quality improvement at Jimma University Specialized Hospital.
About Our Unit
Our Mission
To promote continuous quality improvement and patient safety initiatives that enhance clinical outcomes and institutional accountability.
Our Vision
To become a national benchmark for excellence, safety, and value-based care through evidence-based practices and to be the leading center of clinical excellence and quality healthcare in Ethiopia by 2030.
Our Goals
Establishing a high-standard healthcare environment rooted in equity, safety, and continuous learning. We optimize clinical processes, improve patient outcomes, and enhance patient experience to build long-term community trust. Our focus includes maximizing resource utilization, driving digital transformation, ensuring institutional accountability, and fostering a sustainable culture of excellence.
Our Role at JUSH
The Engine Room for Hospital Standards
Standard Setting
Developing clinical guidelines and protocols that ensure consistent, high-quality care across all departments.
Risk Management
Identifying and mitigating clinical risks to prevent medical errors and enhance patient safety.
Clinical Auditing
Regular review of clinical performance against set standards to ensure compliance and excellence.
Patient Feedback
Managing complaints and satisfaction surveys to drive meaningful improvements in service delivery.
Staff Training
Continuous professional development regarding quality standards and best practices.
Accreditation Prep
Ensuring JUSH meets national and international hospital standards and accreditation requirements.
Quality Officers' Key Tasks
The boots-on-the-ground for JUSH excellence
Monitoring KPIs
Tracking hospital performance indicators including mortality rates, infection rates, and patient satisfaction metrics.
Conducting Rounds
Regular "Quality Walks" through wards to ensure service quality, protocol compliance, and SOP adherence.
Data Analysis
Collecting and interpreting clinical data to present to the board and cascade improvement projects.
Incident Reporting
Investigating adverse events and suggesting systemic fixes to prevent future occurrences.
Accreditation Prep
Ensuring JUSH meets national and international hospital standards and accreditation requirements.
Leadership & Team
Dedicated professionals committed to healthcare excellence
Dr. Yonas Shwangzaw
Director, CG&QIU
Specialist in Nuclear Medicine with extensive experience in clinical governance and quality improvement initiatives.
Leading the unit's strategic vision to establish JUSH as a national benchmark for healthcare excellence and continuous quality improvement.
Quality Officers
Mr. Zekarias
Laboratory, Pathology & Radiology
Mr. Kedr
OR & Pharmacy
Mr. Khalid
IPD Services, CBHI & Audit
Mr. Temsgen
ER, IPC, Nursing & NICU
Mr. Gali
Liaison, Referral & OPD
Mrs. Ehtalem
Leadership, Management & HR
Mrs. Jalane
Physiotherapy & Palliative Care
Mr. Feyissa
Patient Safety & Risk Management
Mr. Sisay
MCH, Biomedical & Facilities
Department Quality Initiatives
Explore quality improvement programs and achievements across our key departments
Quality Metrics Dashboard
Key Performance Indicators demonstrating JUSH's commitment to excellence, safety, and continuous improvement
Patient Satisfaction
Overall patient satisfaction with healthcare services
Staff Satisfaction
Employee engagement and satisfaction levels
Clinical Effectiveness
Adherence to clinical protocols and best practices
Safety Compliance
Patient safety and risk management compliance
Accreditation & Compliance Scores
Institutional achievements across multiple accreditation and compliance frameworks
EHAQ Networking
Total EHAQ Score
EHSIG Score
CASH & IPC Score
Good Governance
Self-Regulation
PSFH - Critical
PSFH - Core
PSFH - Developmental
Clinical Performance Indicators
Key clinical outcomes and safety metrics tracked across departments
Inpatient Mortality Rate
Maternal Mortality Rate
ICU Mortality Rate
Emergency Mortality Rate
Neonatal Death Rate
Surgical Site Infection
Patient Admission Rate
Key Achievements
Quality Officers
Dedicated professionals across all service areas
Service Coverage
Quality oversight across all hospital departments
Vision Target
National benchmark for healthcare excellence
News & Updates
Stay informed about JUSH's latest quality improvement initiatives, accreditation achievements, and institutional milestones
EHAQ Accreditation Score Reaches 75%
JUSH successfully achieved a comprehensive EHAQ score of 75%, demonstrating significant progress in quality standards and patient safety protocols across all departments.
Patient Safety Initiative Reduces Incident Rate by 23%
Through systematic implementation of new incident reporting protocols and staff training, JUSH reduced adverse events by 23% in the first quarter of 2026.
EHAQ Accreditation Score Reaches 75%
JUSH successfully achieved a comprehensive EHAQ score of 75%, demonstrating significant progress in quality standards and patient safety protocols across all departments.
Patient Safety Initiative Reduces Incident Rate by 23%
Through systematic implementation of new incident reporting protocols and staff training, JUSH reduced adverse events by 23% in the first quarter of 2026.
Clinical Effectiveness Audit Completed Successfully
Comprehensive audit of clinical protocols revealed 96.3% adherence rate, with identified improvement areas now under active remediation by respective departments.
Maternal Mortality Rate Reaches New Low of 0.42%
Continuous quality improvement efforts in obstetrics have resulted in exceptional maternal health outcomes, significantly below national benchmarks.
PSFH Critical Standards Certification Achieved
JUSH received certification for Patient Safety and First Harm (PSFH) Critical standards, recognizing excellence in patient safety management systems.
Staff Training Program Reaches 100% Participation
All clinical staff completed mandatory quality improvement and patient safety training, ensuring consistent understanding of protocols across the institution.
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Stay informed about JUSH's continuous quality improvement journey and institutional achievements
Get in Touch
Contact the Clinical Governance & Quality Improvement Unit
Location
CG&QIU, Ground Floor
Administration Building
Jimma University Specialized Hospital
Jimma, Ethiopia