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.
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.
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.
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.
This
list is not exhaustive, and the changing needs of the service may, from time
to time, require the development of other appropriate duties, tasks and
skills. These will be fully discussed with the post holder in advance of
their implementation.
The
Pathology Department of Leeds Teaching Hospitals NHS Trust is located on
several sites. Subject to appropriate consultation, the post holder may be
required to work in a laboratory based at an alternative site as required by
the Service Manager.
In
addition, the Trust requires compliance with a number of corporate policies
and procedures. These policies will be discussed with your line manager
during your period of induction and further information is available from the
Trusts intranet site.
