Clinical Effectiveness and Quality Assurance Manager

Job description

Job responsibilities

Management/Supervision of Staff

Being available and accessible to all individual members of staff to discuss and address any needs, concerns, issues and initiatives in a supportive, constructive and effective manner, including the escalation of matters to the Head of the department.

Provide advice and support to team members in relation to any elements of their work (technical or the other nature) to ensure their full potential is achieved.

Provide effective and regular appraisals to team members.

Monitoring team performance, recognising achievements, challenging constructively poor performance and providing opportunities for reflecting and improving on the management and results of the teams activities.

Identify, manage and if necessary escalate complex and sensitive human resources issues.

Provide local induction to new starters and monitor their competencies and progress.

Systems

Managing the team roster on a frequent basis ensuring is up to date.

Manage and review annual leave requests to ensure all potential conflicts or risks are solved prior approval.

Report timely and accurately any information in relation to staff sickness and other absence.

Monitoring episodes of absence and apply the Trusts policies and procedures in relation to to return to work forms, monitoring Bradford Score target, etc..

Managing all the processes associated to return to work for members of the team after an episode of absence, including referrals to support services (e.g. Occupational Health) when appropriate.

Recording all relevant information in relation to staff appraisals and reviews.

Monitoring staff training compliance.

Monitoring pay review dates, discuss and complete necessary form with appropriate staff.

Recruitment

Using TRAC system for department vacancies and following processes in a timely manner to avoid any delays in employing staff and for staff leavers.

Clinical Audit and Clinical Guidelines

Provide advice to clinicians/users on clinical audit and the Trust processes for registration.

Provide advice/support to clinicians/users on projects re audit criteria design/data collection forms using MS forms.

Compile the Annual Forward Plan (in conjunction with CEQA Facilitators) with audits from the HQIP list, confirming with clinicians it is their intention to participate.

Check for monthly updates from HQIP National Clinical Audit Directory for any new additions or changes to the Directory entries and update.

Check HQIP/National Audit websites for national audit publications.

Scanning published national audit reports for outlier status and contact Audit Project Lead/Senior Manager to inform for response/assurance. Outlier reports can also be notified by the Chief Executive to CEQA department to action.

Monitoring HQIP National Audit Benchmarking Reports to disseminate to relevant leads clinicians for information.

Liaise with the Integrated Governance Manager for discussions with regard to Integrated Care Services clinical audits.

Contact Deputy Medical Directors with regard to any issues concerning clinical audit which cannot be rectified within the Specialty.

Provide advice to clinicians/users on clinical guidelines and processes for their management.

Oversight of CEQA Intranet page.

Ensure the Clinical Audit and Clinical Guidelines inbox is managed timely and effectively.

Analysis, interpretation and representation of data.

Development, review and implementation of policies, procedures and guidelines.

Lead and oversee the production of relevant reports and presentations (internal and external): monthly Divisional reports (clinical audits and clinical guidelines), monthly reports for Trusts committees and groups, Clinical Audit Annual Report, etc.

Monitoring audits at pre-check registration stage to ensure compliance with all requirements before submission for Divisional Audit Lead sign-off. Advise on other QI methods / Research, if clinical audit does not seem the correct approach.

Monitoring audits at pre-check completion sign-off stage to ensure all fields are completed and actions are SMART, submit for Divisional Audit Lead sign-off.

Manage the access of members of the team to the relevant systems and the addition of information not accessible from the front end.

Review National Audit reports and NCEPOD reports, enter recommendations and send self-assessments to clinicians for completion following set timeframe. Provide advise and support to clinicians.

Training

Produce and deliver face-to-face and online clinical audit training session for annual Foundation Doctor Training Sessions, James Paget Management Programme/Future Leaders Development Programme (with CEQA Facilitators).

Provide clinical audit training from ad-hoc requests for staff or departments.

Meetings

Attend monthly Clinical Effective Group (CEG) meeting.

Support the team to attend all required meetings.

Attend the Joint Procedural Document Approval Group (JPDAG).

Deputise for the Head of Clinical Effectiveness and Quality Assurance as required.

Person Specification

Education and Qualifications

Essential

• Degree or diploma level qualification in a relevant subject (data management, audit) or relevant demonstrable experience
• Leadership/Managerial Qualification or relevant experience
• Project or Change Management Qualification or relevant experience
• Evidence of ongoing professional development

Knowledge and Experience

Essential

• Specialist knowledge on clinical audit and best practice guidelines
• Experience of developing and implementing policies, standard operating procedures and guidelines
• Knowledge of NICE guidance
• Significant experience of clinical governance in an acute care NHS setting
• Extensive experience of working with Microsoft programmes including Excel, Word, PowerPoint and videoconferencing systems such as Microsoft Teams
• Experience in managing a team including processes such as managing absence, booking annual leave and staff roster management
• Experience of managing projects
• Experience in facilitating meetings at senior level and confidential matters
• Experience in developing and monitoring action plans

Desirable

• Knowledge of CQC compliance framework
• Knowledge of non-NICE guidance
• Significant experience of delivering clinical audit and effectiveness objectives

Skills and Knowledge

Essential

• Ability to challenge existing practice and escalate any risks or concerns
• Ability to train and advise on appropriate techniques
• Excellent written and verbal communication with staff at all levels
• Ability to develop positive relationships with internal and external stakeholders
• Ability to motivate teams, enhance morale and maintain a positive working environment, including team building sessions
• Strong leadership skills
• Ability to prioritise, plan and manage time well including dealing with tasks at short notice
• Excellent analytical skills, problem solving, reasoning and decision making
• Ability to design and implement changes to make improvements
• Excellent IT skills including using systems to record, report and analyse data such as workforce performance and management data
• Coaching skills including appreciative enquiry, listening and constructive challenging
• Ability to make and implement decisions
• Ability to work across a multi-disciplinary team
• Excellent negotiation and influencing skills to drive change and performance

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Certificate of Sponsorship

Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).

From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).

Employer details

Employer name

James Paget University Hospitals NHS Foundation Trust

Address

James Paget University Hospitals NHS Foundation Trust

Lowestoft Road, Gorleston-on-Sea

Great Yarmouth

NR31 6LA

Employer's website

https://www.jpaget.nhs.uk/work-for-us/ (Opens in a new tab)