Leeds Teaching Hospitals

Patient Safety & Quality Manager (XN08)

This job is now closed

Job summary

We are seeking to appoint an experienced individual to join a team of four Patient Safety and Quality Managers at Leeds Teaching Hospitals NHS Trust. These posts play a key role in the delivery of the Trusts quality and safety programme, effective governance, regulation and sharing learning. We are looking for individuals who are able to communicate and work effectively within operational and corporate teams. Candidates must be motivated and passionate about the provision of high quality, safe and effective care to patients with a desire to influence and work in close partnership with clinical and managerial staff.

Main duties of the job

The post holder will work across the organisation and with Clinical Service Units (CSUs). Support will also be provided to the corporate nursing and medical directorate teams in the delivery of quality governance and ensuring the fundamental standards of quality and safety are met.

Key responsibilities will be to support CSU teams to ensure robust systems for quality, safety and governance are in place. The post holder will be linked to specific designated CSUs to provide the required level of support in the delivery of quality in relation to safety, effectiveness and patient experience. The post holder will also provide support to CSUs through project leadership regarding specific quality improvement programmes and to key areas of governance, as agreed. The post holder will be responsible for undertaking investigations under the Patient Safety Incident Review Framework (PSIRF).

About us

The Patient Safety Team is part of the Trust Quality Governance Team based at St James University Hospital. The Team assist the organisation with Patient Safety related activities linking with CSU governance teams, risk management, corporate nursing, national patient safety manager and patient safety specialist networks.

Leeds Teaching Hospitals is committed to our process of redeploying 'at risk' members of our existing workforce to new roles. As such, all our job adverts are subject to this policy and we reserve the right to close, delay or remove adverts while this process is completed. If you do experience a delay in the shortlisting stage of the recruitment cycle, please bear with us while this process is completed, and contact the named contact if you have any questions.

Date posted

20 September 2023

Pay scheme

Agenda for change

Band

Band 8a

Salary

£50,952 to £57,349 a year

Contract

Permanent

Working pattern

Full-time, Flexible working

Reference number

C9298-MDI-0084

Job locations

Leeds General Infirmary

Great George Street

Leeds

LS1 3EX

Job description

Job responsibilities

Principal Duties and Areas of Responsibility

The post holder is responsible for:

Quality and Safety

Work with the corporate nursing and medical directorate teams in the delivery of quality governance and ensuring the fundamental standards of quality and safety are met

Work with CSUs to support them in the delivery of quality and safety improvements

Support designated CSUs to establish effective governance arrangements at specialty and CSU level, including the regular review of key quality indicators, including:

o Complaints

o Incidents, including Duty of Candour

o Infection rates: Root Cause Analysis (RCA) reports and actions

o Serious Incidents and Never Events

o Safeguarding and Serious Case Reviews

o Pressure Ulcers: Root Cause Analysis (RCA) reports and actions

o Falls: Root Cause Analysis (RCA) reports and actions

o Friends and Family Test

o Medicines Management

o Claims

o Coroners Inquests

o Mortality and Morbidity Reviews

o Clinical Audit

o NICE and Best Practice Guidance

Support the establishment of processes within designated CSUs to share learning from incidents, complaints, claims, coroners inquests, clinical audit and other sources; arrange for Quality and Safety briefings, Learning Points Bulletin and Patient Safety Alerts published by NHS England to be reviewed and ensure action is taken within designated time scales where appropriate.

Support the establishment of processes within designated CSUs to review incident investigation reports and track implementation of actions and provide assurance that these have been completed.

Review actions with designated CSUs in response to inspections by the Care Quality Commission (CQC) under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and ensure processes are in place to monitor and track implementation.

Support designated CSUs in the collection of evidence to post in the shared (G) drive and to prepare for inspection where this is known in advance.

Review progress against CQUIN goals with designated CSUs, working in conjunction with Assistant Director of Operations (ADOPs).

Review progress against ward healthcheck with designated CSUs, working in conjunction with ADOPs.

Liaise with Quality Information Manager on the development and provision of information for CSUs and specialties.

Review literature, policy documents and guidance relating to quality and safety and share key messages with designated CSUs.

Contribute to a culture that promotes a positive learning environment and staff engagement.

Provides training and updates for CSU staff on specific topics relating to quality and safety as required.

Contribute to CSU business and financial plans and ensure that quality and safety priorities are included in this.

Governance and Risk

Work with the Quality Governance team to implement agreed standards and processes for effective governance.

Contribute to the development and review of policies and procedures relating to governance and risk and lead on specific policy development, as agreed.

Lead on the delivery of CSU and trust wide specific projects and programmes of work relating to quality and safety, as agreed.

Support CSUs to ensure the CSU risk register is subject to regular review and updated to reflect the key risks. Review risk scores (likelihood and severity) and provide challenge to the CSU to support them to ensure risk scores are appropriate and escalated in line with the Trust Risk Policy.

Review local risk assessments undertaken by designated CSUs and support the actions to be taken to mitigate risks.

Review Quality Impact Assessments (QIAs) relating to Waste Reduction Programmes (WRPs) for CSUs, ensuring these are fully completed, working in conjunction with the Quality Governance team.

Support CSUs to ensure processes are in place within designated CSUs to respond to Regulation 28 from the Coroner (Coroners (inquests) Regulations 2013) that are issued when concerns are raised during a Coroners investigation that requires action to reduce the risk of harm to other people.

Review designated CSUs annual Risk and Safety Audit submission and associated action plans, providing independent scrutiny and challenge.

Review Trust wide reports on incidents, complaints, claims, coroners inquests and other reports relating to quality, safety and governance; share key messages with designated CSUs to facilitate learning.

Lead on specific Trust wide quality governance portfolios, as agreed.

Support CSU staff in the investigation of incidents.

Lead on investigations, including Serious Incidents.

Represent the corporate team and Trust at local, regional and national workshops and events, where agreed.

Provides updates and reports for committees and corporate/CSU teams, as agreed.

Utilise available resources within the quality governance team effectively.

Quality Improvement

Support designated CSUs in the implementation of quality improvement goals and reviewing progress against the measures identified.

Provide support to CSUs through project leadership to specific quality improvement programmes.

Provide leadership and support to Trust Wide Quality Improvement programme, focussing on a specific programme, as agreed.