Job responsibilities
JOB
PURPOSE
Responsible
for the implementation and coordination of the Quality Management System within
the department.
Ensure
that enabling quality systems and processes are established, implemented and
maintained.
Coordinate
compliance with Trust and CSU Governance policies and procedures.
Work
collaboratively with the CSU leadership team to design, implement and review
quality management system policies and procedures.
To
communicate complex information to colleagues and other healthcare staff.
To
contribute towards the training of support, technical, scientific and medical
staff in relation to delivery of the quality management system.
Provide
day to day management to departmental quality administrators and/or quality
supervisors and ensure that these individuals complete appropriate,
role-specific training in the quality management system.
3. JOB
DIMENSIONS
As Quality Manager the jobholder
will provide management support to the Service Lead/Manager, with cross-site
input, where applicable to the service. The jobholder may be required to
Support the departments senior team and deputise in the absence of key staff
to deliver service.
The
principal responsibility will be to lead on the implementation and continual
development of the quality management system within the department.
Linked
to the above, the jobholder will lead on the coordination of external
assessment visits from regulatory and accreditation bodies at department level
(e.g. UKAS, MHRA, EFI, HTA) and coordinate the completion of any resulting
improvement actions.
The
jobholder will contribute towards overall service improvement by developing
systems and processes that empower departmental teams to contribute to
improvement and by actively participating in CSU policy development.
The
jobholder will be expected to analyse, interpret and compare a range of complex
facts and situations. For example, in performing/supporting incident
investigations and formulating improvement actions in response to external
audit findings. . There will be a requirement to communicate complex or
sensitive information relating to the provision of the clinical service to
other healthcare practitioners and organisations.6. CORE BEHAVIOURS AND SKILLS
In
order to work effectively in the role, the jobholder, must be able to
demonstrate a number of attributes and abilities. These will include:
Strong management and leadership
skills.
Ability to effectively motivate and
influence others.
Ability to work collaboratively
across organisational boundaries.
Ability to work flexibly in line with
service needs.
Provide expertise in terms of risk
management to support the department in mitigating risks to staff and
delivering safe and effective laboratory services.
Maintain expertise in quality
management and clinical governance functions whilst continuously developing new
skills subject to the changing requirements of the service.
Able to work independently as an
autonomous practitioner and effectively within a team, as required.
Able to communicate clearly and
effectively, both verbally and in written/electronic format.
Able to write clear and coherent
policies and procedures.
Able to present complex and
wide-ranging information in suitable formats to key stakeholder groups which
include leadership teams as well as large groups of staff.
Able to deliver effective training in
delivery of the quality management system to support, technical, scientific and
medical staff.
7. CORE KNOWLEDGE AND UNDERSTANDING
Quality management and clinical
governance theory and practice
Regulatory and accreditation body
requirements applicable to the clinical laboratory setting.
Conventional IT software and its use
to both evaluate and present complex information.
People governance policies.
Risk management including how to
describe, assess, control and escalate risks.
Relevant national legislation and
guidelines relating to NHS Pathology laboratories, including health and safety
requirements.
Information Governance policy.
8. PRINCIPAL DUTIES & AREAS OF
RESPONSIBILITY
To be responsible for the
implementation and coordination of the Quality Management System within the
department.
To coordinate risk management
activities within the department.
Where designated by the department,
coordinate matters relating to staff Health and Safety.
Plan and implement, in consultation
with other managers, changes to CSU and department level policies.
Ensure that processes needed for
delivery of the quality management system are established, implemented and
maintained.
Lead on the coordination of external
assessment visits from regulatory and accreditation bodies (e.g. UKAS, MHRA,
EFI, HTA) at departmental level and coordinate the completion of any resulting
improvement actions.
Lead on ensuring that the quality
management system is functioning effectively within the department, such that
risks to patient care and staff safety are well mitigated. Escalate using the
appropriate line management structures where necessary.
Support laboratory management teams
in maintaining robust quality systems and processes in relation to regional
collaborations and actively engage in related quality groups/forums, as
appropriate.
Ensure that nonconformities of all
types are managed effectively within the department, in line with relevant CSU
policies. E.g. PALS, complaints, DATIX incidents/trends, audit findings).
Ensure that suitable mechanisms are
in place to: collate user needs and requirements from all sources; review the
feedback; formulate documented actions plans and share learning.
Ensure that mechanisms are in place
to ensure that critical information pertaining to management review inputs are
effectively captured and appraised at department level with escalation to the
CSU quality assurance group meeting where appropriate.
Produce Quality reports on the
departments performance in relation to the Quality Management system (including
quality indicators) and ensure that effective management review takes place.
Work collaboratively with the CSU
leadership team to design, implement and review quality management system
policies.
Where applicable, plan and coordinate
the tasks and activities undertaken by quality administrators assigned to
support effective delivery of the quality management system.
Coordinate, in line with CSU policy,
the departmental approach to Governance on behalf of and in collaboration with,
operational managers, such that all applicable internal and external quality
standards are met.
Feedback on compliance with LTHT
Pathology governance policies and procedures via reports to be reviewed in the
CSU Quality Assurance forum.
Maintain joint responsibility with
other Quality Managers for maintaining the content and structure of the
electronic quality management system.
Plan, develop and coordinate training
relating to the quality management system in a manner that is consistent with
the Pathology training policy, including audit training.
Deliver regular internal audit
training to departmental audit teams
Deliver quality management system
training to quality administrators/supervisors
(initial and follow up every 2 years).
Deliver quality management system
training to departmental staff of all grades on an ad-hoc basis in relation to
new and updated quality systems and processes
Plan and coordinate the department
internal audit programme, including audit training, ensuring that all key
quality management activities and technical processes are covered and
prioritised on the basis of risk.
Ensure that learning arising from
audit findings is adequately embedded within the quality management system.
Coordinate incident reporting and
investigation at department level, including reporting incidents to relevant
external bodies (e.g. MHRA, HTA, NHS Screening Programmes, HSE via the Trust
H&S team).
Adhere to and promote the use of, the
Pathology Quality Policy and Quality Manual.
Ensure that effective document
control is maintained within the department in conformity with CSU and local
policy.
Ensure that risk management systems
and process are in place and followed with regular managerial review of
on-going compliance.
Communicate accurately complex
information to users of the service in a manner that is in accordance with
departmental procedures.
Supports the design of policies and
procedures which act to ensure that: expensive and complex analytical
equipment, reagents and laboratory consumables are used safely and
effectively. Orders supplies that
support the delivery of quality and risk management activities.
To maintain registered status as a
Biomedical Scientist with the HCPC, where applicable to speciality.
Maintain a good working knowledge of
the relevant statutory, regulatory and accreditation body-based requirements
relating to the quality management system and be able to advise other members
of the department on how to achieve compliance with these requirements.
