Job summary
The post holder will support the divisional triumvirate to deliver effective and responsive quality governance systems, providing senior specialist support and advice, and participate in the management of the compliance for quality governance across the Trust. The postholder will enable the divisions to continuously improve patient safety, experience, outcomes, and effectiveness. The postholder will support the divisional management and reporting of the RLDatix IQ risk, complaints/feedback, mortality and incident reporting system in relation to the risk register, complaints, learning from deaths and patient safety incidents. The postholder will work in partnership with lead clinicians, senior managers, nurses, specialists, and service providers in order to maintain support, mentorship and advice. The post holder is required to manage a portfolio of evidence for external inspections and internal assurance to ensure the Trust meets its regulatory requirements. The post holder will be required to provide regular assurance and gap analysis reports to various committees of the board and the executive team for assurance purposes.
Main duties of the job
- Establish a high quality profile and agenda within the Division regarding clinical governance.
- Establish and maintain effective methods to assure triangulation of governance within the Division.
- Develop pathways and feedback loops to ensure learning from incidents, risks, complaints and deaths.
- Provide an overview of reporting and auditing, ensuring support is given to those undertaking these, to ensure these are high quality and timely.
About us
Join us atUHSussex, every day is different, you can be the change, better neverstops
AtUHSussexwe're proud to be at the heart of the NHS. As one of theUK's largest acute Trusts, we're a leading example of the excellence, the ambition and the values that have embodied the NHS for over 70 years.
Improving lives:We are a vibrant and inclusive organisation, with hardworking, talented and dedicated individuals, who work together towards a common goal, to always put ourPatient First.Our mission is summed up by our 'where better never stops' motto and no matter the role atUHSussex, you will play a part in driving us forwards and in improving the lives of patients across Sussex.We treat our patients and staff with the same compassion and empathy we expect for ourselves. We're here for them when they need us, and we go above and beyond to meet their needs. This can be seen in ourwellbeing programmefor staff which is extensive and designed to support you when you need itbecausewe know that to look after others we must first look after ourselves.
Build a career with us:As a university trust and a leader in healthcare research, we value learning, teaching and training so that we can be the best that we can be. From the moment you start with us and throughout your career we will help you to grow and develop. We hope that in choosingUHSussexyou are choosing a long and happy career where you will be able to see the difference you make and feel valued for all that youdo.
Job description
Job responsibilities
Main Duties and Responsibilities
Leading by personal example, to establish a high profile for quality governance within the Trust and collaborate within the clinical operating model to share good practice. Actively contribute to help communicate Trust-wide lessons learnt and celebrate success.
- Working independently; acting as lead advisor to clinicians regarding clinical governance methods, tools, data collection, data analysis and interpretation, report writing, presentations and the facilitation of action planning and policy implementation.
- Ensure that the Trust Board and relevant committees are provided with up to date, accurate information.
- Develop quality governance, quality improvement and risk reports in line with Trust requirements. Identifying local and divisional trends by analysing aggregated data and triangulating information to give a holistic picture of quality within the division and to support the identification of risks and quality improvement opportunities.
- Analyse evidence from a variety of sources to ensure it supports regulatory and statutory requirements, escalating risk and non-compliance where necessary.
- Enable the division to fully participate in relevant national programmes including audits CQUINS GIRFT Patient Reported Outcome Measures (PROMs) programmes and National Confidential Enquiries into Patient Outcome and Death (NCEPOD).
- Ensure a Divisional Audit Plan is in place to deliver national and local clinical audits in line with the Clinical Audit Plan and monitor the completion of action plans associated with patient safety incidents, complaints, claims, inquests or other investigation and that these remain embedded within the division.
- Lead on the identification of opportunities for quality improvement and developing and implementing plans to deliver quality improvement priorities including through monitoring and identifying areas of improvement in relation to NICE, CQC and other quality standards and guidance.
- Ensure the analysis and learning has been completed as part of the implementation of the Trusts Learning from Deaths policy. Support the preparation for inquests, claims responses and mortality and morbidity meetings.
- Provide the quality assurance methodology for the review of all PSII reports ensuring alignment and compliance to the NHSE Patient Safety Incident Response Framework (PSIRF).
- Provide specialist support and advice with regard to investigation methodology and investigation report writing.
- Facilitate patient safety incident investigations, after action reviews, hot debriefs and thematic reviews.
- Working in collaboration with the divisional director of nursing, and chief of service produce high quality (based on national HSIB system based best practice) incident investigation reports.
- Demonstrate good understanding and background knowledge of national systems-based models such a SEIPS and Safety I & Safety II methodology.
- Work alongside the divisions as part of the Trust Clinical Operating Model (COM) as an initial point of contact to advise and assist with incident management, and Duty of Candour.
- Support the divisional directors of nursing with the quality governance from the beginning of the investigation process, (i.e. setting the terms of reference) throughout (i.e. PSII report writing, through to closure).
- Support the complaints managers (divisional business partner model) as required with the process of complaints investigation.
- Attend divisional quality governance meetings/SDR and clinical safety huddles.
- Assist the Head of Patient Safety and Risk in ensuring and assuring compliance of the risk management system with relevant standards for CQC.
- Assist the Head of Patient Safety and Risk in preparing the Trust to meet the requirements of national bodies, including NHS Resolution, the National Reporting Learning System (NRLS), and CQC.
- Attend inquest as required.
Communication
- Promote an open culture in dealing with patients, families, staff and external stakeholders to ensure that patient safety incidents are fully reported, documented and the necessary action taken.
- Nurture positive relationships with clinical staff to ensure effective communication of all issues relating to patient safety, experience, outcomes, effectiveness, and risk.
- Assist divisions with risk assessment and ensure appropriate action is implemented.
- In line with patient safety investigation and working collaboratively with patients, families carers and staff; the post holder will present complex, sensitive or contentious information to a large group of staff or members of the public, or
- Working with patients and families in line with the Duty of Candour Regulation 20, the post holder will both provide and receive complex, sensitive or contentious information; where there are significant barriers to acceptance which need to be overcome using developed interpersonal and communication skills such as would be required when communicating in a hostile, antagonistic or highly emotive atmosphere.
Service Delivery and Improvement
- Oversee the development and implementation of the divisional quality improvement plan to deliver Trust and divisional quality objectives, identifying quality gaps, improvement priorities and monitoring and reporting on progress and impact
- Support the improvements in patient experience and engagement through implementation of the Trusts strategy.
- Ensure national and local compliance for clinical audit, NICE guideline, CQUIN, and report on progress.
- Ensure effective divisional systems are in place for identifying and disseminating learning and monitoring the impact on patient safety.
- Ensure the division implements the Trusts Risk Management Strategy and Policy including reporting and providing assurance that risks are effectively managed ad mitigated.
- Inform the development of divisional and Trust wide policy and strategy; ensuring corporately agreed policies, strategies and priorities are reflected in divisional policy, procedure, and planning.
- Co-ordinate the implementation of the Trust Risk Strategy and Policies within the division including responsibility for ensuring the integrity of the DCIQ risk registers and H&S risk assessments.
- Support business planning and overall performance management as appropriate by ensuring quality impact and risk assessments are an integral part of the process.
- Participate in the development and implementation of the Trust clinical & quality governance systems and processes contributing to the achievement of organisational objectives.
- Critically analyse PSI, identify trends, prepare written reports and make recommendations for action as appropriate.
- Keep updated on all relevant national guidance including the NHSE Patient Safety Incident Response Framework and Never Events.
- Ensure divisional quality governance mechanisms are in place and operating effectively and in line with Trust policy including mortality and morbidity meetings, divisional and speciality level governance meetings and representation at Trust level quality meetings.
- Be familiar with the Trusts Duty of Candour policy and advise on its use in supporting PSII.
- Be responsible for safe use of organisation resources and equipment/orders supplies for area of work.
- Use computer software to create reports, documents and drawings, and adapt design information systems to meet the specifications of others.
- Develop spread sheets and other tools for audit approaches, creation of audit data collection tools, clinical audit governance database/responsible for development and maintenance of audit database for organisation.
- Ensure compliance with the information governance requirements including consent, confidentiality, and information storage in line with Trust and national policy and legislation.
- Interpret and analyse themes and trends in line with the Trust quality objectives for True North, supporting the development of corporate reporting dashboards and frameworks in line with the Trust strategic direction on harm reduction.
- In collaboration with the Patient First safety programme, support divisional patient safety initiatives (breakthrough objectives), Strategic Deployment Reviews (SDR) Catch-balls and safety huddles and peer reviews.
People Management and Development
- Promote and participate in multidisciplinary training aimed at ensuring that new and existing staff fully understand the Trusts approach to quality governance management.
Patient Care Delivery
- Support the implementation and evaluate a systematic approach to the national requirement for DoC in response to all incidents (resulting in moderate/significant harm or death) in collaboration with the divisions and senior managers within the Trust.
- Support and promote the open disclosure (DoC) of patient safety Incidents to patients and relatives.
- Work in a clinical environment as required, with both the Peer Review process and Business Continuity (within the post holders professional scope of practice).
Learning and Development
- To be responsible for proactively developing own practice and knowledge.
- Maintain professional clinical registration.
- Hold an accredited investigation training qualification.
- Analyse evidence from a variety of sources to ensure it supports regulatory and statutory requirements, escalating risk and non-compliance where necessary.
Job description
Job responsibilities
Main Duties and Responsibilities
Leading by personal example, to establish a high profile for quality governance within the Trust and collaborate within the clinical operating model to share good practice. Actively contribute to help communicate Trust-wide lessons learnt and celebrate success.
- Working independently; acting as lead advisor to clinicians regarding clinical governance methods, tools, data collection, data analysis and interpretation, report writing, presentations and the facilitation of action planning and policy implementation.
- Ensure that the Trust Board and relevant committees are provided with up to date, accurate information.
- Develop quality governance, quality improvement and risk reports in line with Trust requirements. Identifying local and divisional trends by analysing aggregated data and triangulating information to give a holistic picture of quality within the division and to support the identification of risks and quality improvement opportunities.
- Analyse evidence from a variety of sources to ensure it supports regulatory and statutory requirements, escalating risk and non-compliance where necessary.
- Enable the division to fully participate in relevant national programmes including audits CQUINS GIRFT Patient Reported Outcome Measures (PROMs) programmes and National Confidential Enquiries into Patient Outcome and Death (NCEPOD).
- Ensure a Divisional Audit Plan is in place to deliver national and local clinical audits in line with the Clinical Audit Plan and monitor the completion of action plans associated with patient safety incidents, complaints, claims, inquests or other investigation and that these remain embedded within the division.
- Lead on the identification of opportunities for quality improvement and developing and implementing plans to deliver quality improvement priorities including through monitoring and identifying areas of improvement in relation to NICE, CQC and other quality standards and guidance.
- Ensure the analysis and learning has been completed as part of the implementation of the Trusts Learning from Deaths policy. Support the preparation for inquests, claims responses and mortality and morbidity meetings.
- Provide the quality assurance methodology for the review of all PSII reports ensuring alignment and compliance to the NHSE Patient Safety Incident Response Framework (PSIRF).
- Provide specialist support and advice with regard to investigation methodology and investigation report writing.
- Facilitate patient safety incident investigations, after action reviews, hot debriefs and thematic reviews.
- Working in collaboration with the divisional director of nursing, and chief of service produce high quality (based on national HSIB system based best practice) incident investigation reports.
- Demonstrate good understanding and background knowledge of national systems-based models such a SEIPS and Safety I & Safety II methodology.
- Work alongside the divisions as part of the Trust Clinical Operating Model (COM) as an initial point of contact to advise and assist with incident management, and Duty of Candour.
- Support the divisional directors of nursing with the quality governance from the beginning of the investigation process, (i.e. setting the terms of reference) throughout (i.e. PSII report writing, through to closure).
- Support the complaints managers (divisional business partner model) as required with the process of complaints investigation.
- Attend divisional quality governance meetings/SDR and clinical safety huddles.
- Assist the Head of Patient Safety and Risk in ensuring and assuring compliance of the risk management system with relevant standards for CQC.
- Assist the Head of Patient Safety and Risk in preparing the Trust to meet the requirements of national bodies, including NHS Resolution, the National Reporting Learning System (NRLS), and CQC.
- Attend inquest as required.
Communication
- Promote an open culture in dealing with patients, families, staff and external stakeholders to ensure that patient safety incidents are fully reported, documented and the necessary action taken.
- Nurture positive relationships with clinical staff to ensure effective communication of all issues relating to patient safety, experience, outcomes, effectiveness, and risk.
- Assist divisions with risk assessment and ensure appropriate action is implemented.
- In line with patient safety investigation and working collaboratively with patients, families carers and staff; the post holder will present complex, sensitive or contentious information to a large group of staff or members of the public, or
- Working with patients and families in line with the Duty of Candour Regulation 20, the post holder will both provide and receive complex, sensitive or contentious information; where there are significant barriers to acceptance which need to be overcome using developed interpersonal and communication skills such as would be required when communicating in a hostile, antagonistic or highly emotive atmosphere.
Service Delivery and Improvement
- Oversee the development and implementation of the divisional quality improvement plan to deliver Trust and divisional quality objectives, identifying quality gaps, improvement priorities and monitoring and reporting on progress and impact
- Support the improvements in patient experience and engagement through implementation of the Trusts strategy.
- Ensure national and local compliance for clinical audit, NICE guideline, CQUIN, and report on progress.
- Ensure effective divisional systems are in place for identifying and disseminating learning and monitoring the impact on patient safety.
- Ensure the division implements the Trusts Risk Management Strategy and Policy including reporting and providing assurance that risks are effectively managed ad mitigated.
- Inform the development of divisional and Trust wide policy and strategy; ensuring corporately agreed policies, strategies and priorities are reflected in divisional policy, procedure, and planning.
- Co-ordinate the implementation of the Trust Risk Strategy and Policies within the division including responsibility for ensuring the integrity of the DCIQ risk registers and H&S risk assessments.
- Support business planning and overall performance management as appropriate by ensuring quality impact and risk assessments are an integral part of the process.
- Participate in the development and implementation of the Trust clinical & quality governance systems and processes contributing to the achievement of organisational objectives.
- Critically analyse PSI, identify trends, prepare written reports and make recommendations for action as appropriate.
- Keep updated on all relevant national guidance including the NHSE Patient Safety Incident Response Framework and Never Events.
- Ensure divisional quality governance mechanisms are in place and operating effectively and in line with Trust policy including mortality and morbidity meetings, divisional and speciality level governance meetings and representation at Trust level quality meetings.
- Be familiar with the Trusts Duty of Candour policy and advise on its use in supporting PSII.
- Be responsible for safe use of organisation resources and equipment/orders supplies for area of work.
- Use computer software to create reports, documents and drawings, and adapt design information systems to meet the specifications of others.
- Develop spread sheets and other tools for audit approaches, creation of audit data collection tools, clinical audit governance database/responsible for development and maintenance of audit database for organisation.
- Ensure compliance with the information governance requirements including consent, confidentiality, and information storage in line with Trust and national policy and legislation.
- Interpret and analyse themes and trends in line with the Trust quality objectives for True North, supporting the development of corporate reporting dashboards and frameworks in line with the Trust strategic direction on harm reduction.
- In collaboration with the Patient First safety programme, support divisional patient safety initiatives (breakthrough objectives), Strategic Deployment Reviews (SDR) Catch-balls and safety huddles and peer reviews.
People Management and Development
- Promote and participate in multidisciplinary training aimed at ensuring that new and existing staff fully understand the Trusts approach to quality governance management.
Patient Care Delivery
- Support the implementation and evaluate a systematic approach to the national requirement for DoC in response to all incidents (resulting in moderate/significant harm or death) in collaboration with the divisions and senior managers within the Trust.
- Support and promote the open disclosure (DoC) of patient safety Incidents to patients and relatives.
- Work in a clinical environment as required, with both the Peer Review process and Business Continuity (within the post holders professional scope of practice).
Learning and Development
- To be responsible for proactively developing own practice and knowledge.
- Maintain professional clinical registration.
- Hold an accredited investigation training qualification.
- Analyse evidence from a variety of sources to ensure it supports regulatory and statutory requirements, escalating risk and non-compliance where necessary.
Person Specification
Experience and qualifications
Essential
- Educated to Masters level in a relevent healthcare, risk or quality improvement associated subject or equivalent experience
- Investigation training (HSIB Silver) or equivalent accredited course within last 2 years
- A good knowledge of the principles of risk and patient safety management and how to apply them in practice
Skills and knowledge
Essential
- Excellent communication, negotiation and liaison skills
- Ability to work autonomously and mange highly complex information with attention to details and accuracy
Person Specification
Experience and qualifications
Essential
- Educated to Masters level in a relevent healthcare, risk or quality improvement associated subject or equivalent experience
- Investigation training (HSIB Silver) or equivalent accredited course within last 2 years
- A good knowledge of the principles of risk and patient safety management and how to apply them in practice
Skills and knowledge
Essential
- Excellent communication, negotiation and liaison skills
- Ability to work autonomously and mange highly complex information with attention to details and accuracy
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.
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).
Additional information
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).
