Job summary
The Clinical Governance Co-ordinator (CGC) will provide expert advice and leadership on governance and assurance for the Care Group and/or Division they support. The postholder will primarily support community/place-based services.
The postholder will at all times work to further the Trust's overall approach to Patient Safety and Quality.
This role is key to the development, implementation and sustainability of: the Trust's Integrated Governance, Assurance and Safety agenda; the Patient Safety Incident Response Framework; a Just and Learning Culture.
The CGC is a core member of the Divisional Governance team structure, supporting compliance with CQC, NHSLA and NHSE requirements, and delivering the Trust's Governance objectives.
The postholder will coordinate the overall day-to-day delivery of the Governance agenda (including national guidance relating to Governance and Risk Management requirements), through the development and implementation of procedures, policies and processes across their Division's Governance programme/s.
Main duties of the job
Leading by personal example, to establish a high profile for effective Governance (patient safety and quality) within the Division/s, working with others to ensure good practice, communicate lessons learnt and celebrate success.
Be the key point of contact, and expert within the Division/s, for any Governance queries or enquiries e.g. incidents, complaints, claims, risk management, audit, providing advice, guidance and direction as required.
Support the Divisional management team regarding Governance issues, agreeing priority areas for focus, risk management, evaluation, audit and improvement.
To investigate and analyse issues arising from all types of Governance data to develop actions to address issues and trends, to support planning and in order to share learning.
Assist in the development of corporate and/or clinical policies and lead on Divisional policies/ procedures related to Governance.
Participate in, and support, external reviews as required, such as CQC visits/inspections.
To assist with the development of Governance and Risk Management information materials and participate in education and training programmes as required.
Maintain their own competence and remain up to date with knowledge of Governance developments, and both local and national drivers, within this their area of specialty.
About us
The postholder will join the Trust's central Patient Safety and Quality team but willwork closely with the Associate Director of Nursing and Professional Practice for the Divisions they support and other Clinical Governance Coordinators, within the different Care Groups and/or Divisions.
The Patient Safety and Quality team are committed to achieving high quality work through their engagement with individuals and teams, patients and families, across the Trust, for the benefit of maintaining and improving safety for patients and staff.
Job description
Job responsibilities
Coordination and strategic management
- Coordinate the overall day to day delivery and strategic development of the Governance agenda (including CQC and NHSE requirements, NHSLA Risk Management Standards and other national guidance relating to Governance) and advise and develop plans for change in practice, policies and procedures as necessary, this work includes the following duties to:
- work as a key member of the Divisions management team to ensure that robust Governance arrangements are in place and Governance is embedded
- be responsible for providing specialist advice to the Division on the implementation of Governance policies and procedures that enable the Division to strategically develop its Governance management
- promote patient and public involvement and engagement initiatives to assure patients and the public of safe systems of care within the Division/s
- collaborate in partnership with the central Patient Safety and Quality team and the Trusts Patient Safety Specialist and Divisional leads, to ensure the delivery of Patient Safety and Quality, advising on actions required, developing plans, and monitoring performance
- work with the Divisions management teams to ensure the delivery of integrated Governance
- ensure outcomes and learning from incidents, complaints, feedback and investigations are shared, identifying lessons learnt and practice/process changes required are monitored to closure
- With the Associate Director of Nursing and Professional Practice (ADNPP), Clinical Leads and (Medical) Governance Leads, develop plans for Governance assurance, within each clinical area within the Division/s and agree monitoring arrangements that will ensure delivery, producing reports on progress and plans to address any shortfalls
- Support and guide other members of staff within the Division/s who undertake incidents and complaints reviews and investigations. Gain the cooperation of senior clinicians involved in patient safety incidents or complaints.
- Analyse highly complex information and interpret findings to produce recommendations and actions which identify learning and support changes in practice
- Contribute to the network of Governance expert leads (patient safety professionals) within the Trust, to enable a learning environment and to assist the spread of good practice across the Trust
- Maintain expert specialist knowledge of the healthcare Governance, patient safety and quality assurance agenda and requirements, communicating these effectively to a range of audiences within the Division
- Advise and support the development, implementation and audit of evidence-based guidelines such as National Institute for Clinical Excellence (NICE) in collaboration with the Trusts Clinical Audit and Clinical Effectiveness teams
Responsibility and accountability
- Actively support the Trusts patient safety review processes, for example by regular attendance at, and participation in, the Incident Review Group
- Constructively challenge processes and behaviours in relation to Governance, risk and quality of care, escalating to direct line managers any performance issues as required
- Participate in a process of Peer Governance Review across the Trust
- Be an active and participative member of the Trusts Governance related meetings
- Continuously model and positively promote a Just and Learning Culture as part of the Trusts openness and proactive incident reporting and reviewing culture
- Be responsible for ensuring daily review of incidents reported within previous 24-hour period (or preceding weekend) and ensuring that incident details are accurately maintained, that correct escalations and notifications take place, ensuring that final approval for closure of reported incidents is undertaken and they are closed within the trust policy timeframes
- Ensure that any incident that meets the threshold, as described in the Patient Safety Incident Response Framework (PSIRF) and the Trusts Patient Safety Incident Response Plan (PSIRP), is escalated to the Trusts central Patient Safety and Quality Team, and to their ADNPP, for prompt review
- Be responsible for the preparation, delivery and performance monitoring of action plans, relating to Divisional Governance information and documentation, ensuring it is kept up to date and available for review and assurance as required
- Expertly lead on the monitoring and documentation of compliance with CQC requirements and other regulatory requirements
- Lead on the delivery of Governance education by designing and providing training on key Governance topics for delivery within the Division and across the organisation, as required
- Be responsible for the design and implementation of improvements to Governance processes and policies to ensure the roll out of key lessons from Governance activities across the Division
- Provide advice to staff on all Governance issues, leading the dissemination of information and learning
- Analyse the results of Governance reviews/audits and develop actions plans that advise the Division of any remedial actions required
- Undertake other duties that are commensurate with the grade of the post
Planning and organisation
- Analyse Governance information that comes from the central functions and advise the Division on implications and actions required
- Lead on the identification of Governance projects required within the Division and the successful implementation and evaluation of the projects undertaken
- Provide regular updates on Divisional Governance performance, as required and agreed with the Divisions ADNPP and/or the Patient Safety Specialist
- Assist in monitoring implemented changes designed to improve an area of service
Decisions, judgement and freedom to act
- Accountable for decisions affecting their sphere of responsibility
- Guided by broad polices and protocols, uses discretion and initiative for implementation of such polices
- Seeks further advice and support for actions that effect areas outside their area of responsibility
Communication and working relationships
- Work closely with the Patient Safety Specialist and the central Patient Safety and Quality Team to understand and promote the Trusts integrated Governance strategy and PSIRF
- Liaise closely with the Divisional management team, in particular the ADNPP, regarding the implementation of actions required from patient safety reviews, including monitoring all actions to completion
- Jointly, with other Clinical Governance Coordinators and the central Patient Safety and Quality Team, maintain pleasant working relationships and present a professional and helpful manner when dealing with colleagues and visitors
- Work with colleagues to continually strive to improve the visibility of Patient Safety and Quality initiatives
Job description
Job responsibilities
Coordination and strategic management
- Coordinate the overall day to day delivery and strategic development of the Governance agenda (including CQC and NHSE requirements, NHSLA Risk Management Standards and other national guidance relating to Governance) and advise and develop plans for change in practice, policies and procedures as necessary, this work includes the following duties to:
- work as a key member of the Divisions management team to ensure that robust Governance arrangements are in place and Governance is embedded
- be responsible for providing specialist advice to the Division on the implementation of Governance policies and procedures that enable the Division to strategically develop its Governance management
- promote patient and public involvement and engagement initiatives to assure patients and the public of safe systems of care within the Division/s
- collaborate in partnership with the central Patient Safety and Quality team and the Trusts Patient Safety Specialist and Divisional leads, to ensure the delivery of Patient Safety and Quality, advising on actions required, developing plans, and monitoring performance
- work with the Divisions management teams to ensure the delivery of integrated Governance
- ensure outcomes and learning from incidents, complaints, feedback and investigations are shared, identifying lessons learnt and practice/process changes required are monitored to closure
- With the Associate Director of Nursing and Professional Practice (ADNPP), Clinical Leads and (Medical) Governance Leads, develop plans for Governance assurance, within each clinical area within the Division/s and agree monitoring arrangements that will ensure delivery, producing reports on progress and plans to address any shortfalls
- Support and guide other members of staff within the Division/s who undertake incidents and complaints reviews and investigations. Gain the cooperation of senior clinicians involved in patient safety incidents or complaints.
- Analyse highly complex information and interpret findings to produce recommendations and actions which identify learning and support changes in practice
- Contribute to the network of Governance expert leads (patient safety professionals) within the Trust, to enable a learning environment and to assist the spread of good practice across the Trust
- Maintain expert specialist knowledge of the healthcare Governance, patient safety and quality assurance agenda and requirements, communicating these effectively to a range of audiences within the Division
- Advise and support the development, implementation and audit of evidence-based guidelines such as National Institute for Clinical Excellence (NICE) in collaboration with the Trusts Clinical Audit and Clinical Effectiveness teams
Responsibility and accountability
- Actively support the Trusts patient safety review processes, for example by regular attendance at, and participation in, the Incident Review Group
- Constructively challenge processes and behaviours in relation to Governance, risk and quality of care, escalating to direct line managers any performance issues as required
- Participate in a process of Peer Governance Review across the Trust
- Be an active and participative member of the Trusts Governance related meetings
- Continuously model and positively promote a Just and Learning Culture as part of the Trusts openness and proactive incident reporting and reviewing culture
- Be responsible for ensuring daily review of incidents reported within previous 24-hour period (or preceding weekend) and ensuring that incident details are accurately maintained, that correct escalations and notifications take place, ensuring that final approval for closure of reported incidents is undertaken and they are closed within the trust policy timeframes
- Ensure that any incident that meets the threshold, as described in the Patient Safety Incident Response Framework (PSIRF) and the Trusts Patient Safety Incident Response Plan (PSIRP), is escalated to the Trusts central Patient Safety and Quality Team, and to their ADNPP, for prompt review
- Be responsible for the preparation, delivery and performance monitoring of action plans, relating to Divisional Governance information and documentation, ensuring it is kept up to date and available for review and assurance as required
- Expertly lead on the monitoring and documentation of compliance with CQC requirements and other regulatory requirements
- Lead on the delivery of Governance education by designing and providing training on key Governance topics for delivery within the Division and across the organisation, as required
- Be responsible for the design and implementation of improvements to Governance processes and policies to ensure the roll out of key lessons from Governance activities across the Division
- Provide advice to staff on all Governance issues, leading the dissemination of information and learning
- Analyse the results of Governance reviews/audits and develop actions plans that advise the Division of any remedial actions required
- Undertake other duties that are commensurate with the grade of the post
Planning and organisation
- Analyse Governance information that comes from the central functions and advise the Division on implications and actions required
- Lead on the identification of Governance projects required within the Division and the successful implementation and evaluation of the projects undertaken
- Provide regular updates on Divisional Governance performance, as required and agreed with the Divisions ADNPP and/or the Patient Safety Specialist
- Assist in monitoring implemented changes designed to improve an area of service
Decisions, judgement and freedom to act
- Accountable for decisions affecting their sphere of responsibility
- Guided by broad polices and protocols, uses discretion and initiative for implementation of such polices
- Seeks further advice and support for actions that effect areas outside their area of responsibility
Communication and working relationships
- Work closely with the Patient Safety Specialist and the central Patient Safety and Quality Team to understand and promote the Trusts integrated Governance strategy and PSIRF
- Liaise closely with the Divisional management team, in particular the ADNPP, regarding the implementation of actions required from patient safety reviews, including monitoring all actions to completion
- Jointly, with other Clinical Governance Coordinators and the central Patient Safety and Quality Team, maintain pleasant working relationships and present a professional and helpful manner when dealing with colleagues and visitors
- Work with colleagues to continually strive to improve the visibility of Patient Safety and Quality initiatives
Person Specification
Qualifications, training and experience
Essential
- oEducated to first level degree or equivalent level of experience
- oExperience demonstrating ability to interpret highly complex, sensitive data/information
- oPrevious experience of working autonomously
Desirable
- oPost graduate study at MSc level or equivalent experience
- oClinical qualification or equivalent healthcare experience
- oPrevious experience and success in supporting and delivering the risk and clinical governance/patient safety agenda including experience in risk management and audit techniques (preferably in a health setting)
- oPSIRF PSII training
- oPSIRF Engagement training
Knowledge, experience and skills
Essential
- oHighly effective verbal communication
- oLeadership and influencing skills with the ability to enthuse motivate and involve individuals and teams: the ability to present and facilitate engaging education sessions to promote and develop patient safety
Desirable
- oAwareness and understanding of the National Patient Safety Strategy and its components
- oEvidence of leadership/QI and/or change management
- oExperience of incident investigation and report writing
Person Specification
Qualifications, training and experience
Essential
- oEducated to first level degree or equivalent level of experience
- oExperience demonstrating ability to interpret highly complex, sensitive data/information
- oPrevious experience of working autonomously
Desirable
- oPost graduate study at MSc level or equivalent experience
- oClinical qualification or equivalent healthcare experience
- oPrevious experience and success in supporting and delivering the risk and clinical governance/patient safety agenda including experience in risk management and audit techniques (preferably in a health setting)
- oPSIRF PSII training
- oPSIRF Engagement training
Knowledge, experience and skills
Essential
- oHighly effective verbal communication
- oLeadership and influencing skills with the ability to enthuse motivate and involve individuals and teams: the ability to present and facilitate engaging education sessions to promote and develop patient safety
Desirable
- oAwareness and understanding of the National Patient Safety Strategy and its components
- oEvidence of leadership/QI and/or change management
- oExperience of incident investigation and report writing
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.
