Head of Clinical Governance, Quality and Mortality

Job description

Job responsibilities

Provide expert advice on the CQC Fundamental Standards as they relate to patient safety, risk and mortality and advising Executive Leads as appropriate

As local expert for the Trust in patient safety and risk management, maintain constructive relationships with national and regional bodies (NHSE, ICS, MHRA, HSE, CQC etc), influencing key national policy developments and frameworks

Responsible for reporting governance and risk management issues internally to the Board of Directors and externally to various agencies (ICB, NHSE etc). This includes providing expert advice and input with respect to identification and monitoring of the Trusts Safety Quality Priorities, Local Quality Requirements which inform the Trusts Quality Account.

Be responsible for analysing and triangulating complex data from different sources and providing written reports to different committees, and supporting the completion of the Quality Account

Lead on governance within the Trust, working with the divisions, and contribute to national, regional and Trust-wide clinical governance improvement programmes.

Lead on and contribute to national, regional and Trust-wide clinical and patient safety improvement programmes.

Ensuring national and local evidence best practice is high quality, distributed, implemented and regularly reviewed.

Manage and actively promote the relationships with key stakeholders. In particular, the post-holder will work with the regional quality and safety team, ICB quality teams and regulators.

Deputising for the Associate Director of Clinical Governance, Quality and Safety including managing the budget in the absence of the Associate Director

Managing across the Quality Team including the Medical Examiners Office team

Communicating with patients and/or their relatives when things have gone wrong in line with the Duty of Candour. This can involve communicating complex and sensitive information that may not be received positively and which requires a high-level of interpersonal skills in order to achieve the right outcome

Maintain an up-to-date and comprehensive knowledge of local and national governance, patient safety and risk management issues, including the interpretation of national health policies to ensure that goals and standards are reflected in the Governance Teams strategies and programme of work.

Providing expert advice to the divisional teams on risk, audit, quality improvement and quality governance, providing assurance to the Board and the subcommittees of the board as requested by the Executive teams.

Be accountable for the operational management of the Medical Safety Device Officer, Central Alerting System Liaison Officer and medical device safety within the Trust

Liaise with representatives from the external organisations, including Healthcare Partners Limited (HPL)

Working with Others:

• Advising discussion on the organisation of Trust governance structures relating to clinical safety, including the establishment of Committees, improvement groups and reporting and monitoring structures and processes. This includes ensuring that Trust-wide safety Committees operate within the Trusts governance framework and deliver against key standards.

Attendance and/or present oral/written reports and perform actions agreed at meetings with a key responsibility for Quality Governance. These include: Medicines Safety Group, Quality and Performance Executive Committee, Quality and People Committee, Mortality Meetings, Board and sub-Board committees as required including CASSCO and the Council of Governors.

Principal expert for the trust on maintaining positive, reciprocal relationships and communications with key external partners with responsibilities or requirements for patient safety and clinical quality. These include Care Quality Commission and NHS Resolution.

• As the accountable Trust officer for safety alerts responsible for ensuring that safety alerts are acted upon across the organisation and that equipment safety issues identified at RSCH are escalated to the appropriate national body. Ensuring that the compliance with safety alerts is audited every 3 months.
• Responsible for compliance with the Trusts internal audit programme as it pertains to governance and patient safety. This will include reporting to the Trusts Clinical Audit and Effectiveness Committee as required.
• Ensure that the Divisional and Trust Risk Registers drive the development of Trust and Divisional strategic plans to improve clinical effectiveness and that emerging patient safety issues are identified and acted upon both Divisionally and across the Trust.

Model a collaborative and influencing style of working, negotiating with others to achieve the best outcomes.

Attend and provide governance input to the quality priority groups as required.

Data and systems management:

• Analyse complex compliance data and identify, develop and implement remedial actions to address emerging safety concerns and potential regulatory breaches, reporting progress through to the Quality Committee & Board of Directors
• Responsible for managing the eQuip medical device competency module
• Accountable for monitoring data to ensure robustness of reporting systems and the management of those system.
• Accountable for the quality and timeliness of quality risk information which supports risk management locally, feeds the Trust performance scorecard and is reported externally to the CQC.

Project and change management:

Work at Executive, Divisional and Specialty levels to promote and embed a safety-oriented culture and to provide project-management, staff development and other practical support for projects aimed at improving patient and staff safety.

• Plan, manage and quality check data for submission against external risk management/ governance standards/ accreditations/ inspections (e.g. CQC Fundamental Standards, HSE inspections, National Audit Office submissions etc).
• Be responsible for providing governance expertise in the preparation for external inspections, including CQC inspections
• Develop, implement and be accountable for a human factors infrastructure within the Trust, incorporating quality improvement into patient safety and implementing learning following the investigation of patient safety events.

Person Specification

Qualifications

Essential

• A masters or equivalent/ degree in a management, health, audit, research, patient safety, improvement, or change related discipline.
• Management qualification or extensive experience
• Quality improvement qualification or previous experience
• Patient Safety Level 1-4 Training, or work towards the qualification
• Patient Safety Science or good experience

Desirable

• Human Factors qualification
• Professional registration
• Teaching qualification or extensive experience

Skills, Knowledge & Experience

Essential

• Extensive experience in Quality Governance, Risk Management, Patient safety, incident management and mortality & ME service.
• Demonstratable experience in analytical review, interpretation and judgement
• Knowledge in undertaking and supporting external inspections, including CQC inspections
• Have significant knowledge of national patient safety policy and strategy, and levers for change in the NHS system; and ability to interpret national advice, guidance and requirements and advise their organisation on how these should be implemented.
• Knowledge of the NHS patient safety strategy and how it can be implemented

Desirable

• Extensive knowledge and experience in the application of human factors

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.

Employer details

Employer name

Royal Surrey NHS Foundation Trust

Address

Royal Surrey NHS Foundation Trust

Guildford

GU2 7XX

Employer's website

https://www.royalsurrey.nhs.uk/ (Opens in a new tab)