Quality Governance Manager

Worcestershire Acute Hospitals NHS Trust

This job is now closed

Job summary

The post holder will support the Quality Governance Lead to oversee all aspects of quality governance, within the Surgical Division. They will directly support the Quality Governance Lead, Divisional Leadership team and Directorate Governance Leads. The post holder will be a fundamental part of the Quality Governance Team for the Division, ensuring that services meet the required level of quality assurance standards within the Trust.

The post holder will be responsible for monitoring, implementing and enhancing quality governance policies and procedures ensuring adherence to national and internal legislation and guidance, which will include reporting and effective management of clinical and non-clinical incidents. The post holder will be expected to be appraised of best practice in quality assurance and governance nationally and locally including external bodies.

Main duties of the job

To support the Quality Governance Lead in promoting clinical incident reporting and ensuring that all Patient Safety Incident reports are accurately recorded, investigated and actioned in line with WAHT Policy.

To provide managerial support to the Quality Governance Lead and in their absence to Directorate Lead/Senior Nurse in managing and developing Directorate arrangements for clinical governance and specifically clinical risk management and patient safety.

To provide support, advice and guidance to all levels of staff across the Surgical Directorates to ensure that there are processes in place to systematically assess and prioritise clinical risks with corrective action programmes in place.

To provide general awareness training on Clinical Governance, patient safety and quality to various staff groups at all levels across the Surgical Directorate in response to identified need following patient safety incident investigations, external assurance monitoring mechanisms and training needs analysis

About us

Our purpose is simple - Putting Patients First. We are looking for exceptional colleagues who can help us achieve this.

Worcestershire Acute Hospitals NHS Trust is a large acute and specialised hospital trust that provides a range of local acute services to the residents of Worcestershire and more specialised services to a larger population in Herefordshire and beyond.

The Trust operates hospital-based services from three sites in Kidderminster, Redditch and Worcester

Our workforce is over 7,000 strong, and our caring staff are recognised as providing good and outstanding patient-centred care. You could be one of them.

We are committed to recruiting the best people to work with us to achieve our Vision - working in partnership to provide the best healthcare for our communities, leading and supporting our teams to move 4ward. Our 4ward behaviours, which we ask all staff to demonstrate, underpin our everyday work and remain firmly at the heart of all we do.

Our objectives are simple:

Best services for local people
Best experience of care and best outcomes for our patients
Best use of resources
Best people

Better never stops, and our Clinical Services Strategy provides a clear future vision for our Trust, our hospitals, our services and our role in the wider health and care system.

We are proud to have achieved Timewise accreditation - this means we are committed to embedding flexible working within our organisation as a flex positive employer.

Date posted

01 May 2024

Pay scheme

Agenda for change

Band

Band 7

Salary

£43,742 to £50,056 a year

Contract

Permanent

Working pattern

Part-time

Reference number

C9365-24-0542

Job locations

Charles Hastings Way

Worcester

Worcestershire

WR5 1DD

Worcestershire Royal Hospital

Charles Hastings Way

Worcester

WR5 1DD

Job description

Job responsibilities

Job Purpose:

To work closely with the Surgery Divisional Management Team to design, implement, deliver, and evaluate the Clinical Governance and assurance framework for the Division.

To ensure all Divisional Quality Governance Activities are in line with the corporate governance agenda of Worcestershire Acute Hospitals NHS Trust.

To ensure staff and clinician engagement in the Surgery Divisional Clinical Governance agenda. To ensure education and training programmes are devised and delivered in relation to quality governance, risk, patient

safety, clinical audit, and continuous quality improvement.

To play a key role on assisting the Surgery Division to identify and define the information required to monitor clinical effectiveness, patient safety, compliance and quality outputs of the services provided.

To develop and maintain relationships inter-divisionally and with the corporate clinical governance team to ensure that all clinical governance activity is in accordance with both Trust policy and the corporate strategic intent.

To co-ordinate and ensure incidents and complaint investigations and responses happen within agreed time frames. Ensuring that reports are of high quality and any associated action plans are SMART, monitored and evidenced.

To monitor actions arising from incidents investigation, complaints, audit, and other sources are completed within the division and that learning is shared across the Division and organisation where appropriate.

To provide reports to Surgery Divisional Board and present executive brief on reports at Divisional Governance Meetings.

To support and report in to the Surgery Divisional Governance Board, Directorate Governance meetings and help to drive the Quality Governance agenda with the Surgery Division.

Provide leadership where necessary in accordance with governance organisational team structure.

General Duties:

Quality Governance and Risk Management:

Co-ordinate the implementation of the Surgery Divisional quality governance programme ensuring that this reflects the trust overall governance strategic intent

Facilitate and support the Surgery Division to plan, prepare and gather evidence for external assessments (CQC, peer visits)

Support the Surgery Division to achieve National Initiatives

Assemble and analyse qualitative and quantitative information (with Divisional & Directorate leads) in ways that

assist staff in reflecting and improving on service delivery and practice.

In liaison with Surgery Divisional Management Team ensure that any necessary Governance reports are compiled within agreed time frames. Ensure that such reports are evidenced with the necessary data and narratives

to provide appropriate assurance to the Trust in relation to clinical quality, outcomes, and processes.

Facilitate the downward dissemination of decisions and discussions at Governance and Quality committees and provide clarity regarding how they may relate to the individual division, and develop associated programs to address and monitor the impact of change.

In liaison with Divisional and Corporate teams, assist in the building and development of information resources pertinent to quality governance and act as a resource for the division to develop improvement programs to enhance patient experience and outcome.

Facilitate and support the Surgery Divisional Management Team and resources to co-ordinate and report the activities of divisional quality and clinical governance groups against objectives, standards, and targets.

Assist the Divisional Management Team to exercise responsibility for risk management across the division.

Support the implementation of the trust incident reporting system within the division, providing support in the investigation of incidents where appropriate.

Co-ordinate and support the management of mortality review tracking.

Co-ordinate and support the management of external serious incidents (including Healthcare Safety Investigation Branch - HSIB) and comprehensive investigations within the division in association with the divisional resources and the corporate clinical governance team.

Co-ordinate and support the investigation, response and reporting of complaints and patient feedback within the division, working in association with teams at directorate and clinical department levels.

Participate in management of an effective and appropriate Divisional Risk Register in liaison with Divisional management team. Ensuring that the DATIX system remains accurate and current staff are adhering to the policy. To ensure that all risk-related information is stored and filed systematically and securely.

Provide support to the division to ensure that external and internal inspections, have appropriate action plans and that have corrective actions have been completed with an associated follow up audit planned, as required.

Work alongside clinical audit and quality governance leads within directorates and services to develop, implement, and monitor audit and improvement programmes that support the needs of the organisation.

Monitor the implementation and on-going compliance with NICE and national guidance including effective responses to national reports.

To support the governance team in production of reports focussing on themes generated from patients, service users an their carers.Ensure that learning from patient experience,complaints,feedback and friends and family test is shared.

Co-ordinate and participate in Divisional Quality Review visits and programmes, including the follow-up of resulting actions.

Work in consultation with divisional clinical leads to develop appropriate outcome measures that are monitored and reported, as necessary. Ensure there are systems in place for capturing and sharing of data.

Identify clinical governance training needs within the division to ensure these needs are met.

Understand CQC regulation and the impact of any adverse findings of quality measurement, internal/external reviews and changes in service delivery and advise the divisional management of such. Assist in preparing the division for unannounced and announced inspections.

Collaborate effectively with the corporate teams covering the elements of Trust quality governance initiatives.