Governance Support and Improvement Manager

Job description

Job responsibilities

Governance Support: Patient Safety and Risk Management

Support the governance programme and framework across Dental Services Division to include:-

• promoting a strong governance culture within the Dental Division, recognised through the design and facilitation of the Divisional local induction and regular engagement with Divisional Governance meetings and representation;
• risk management and assessment: supporting the implementation and monitoring of a Dental Services risk assessment dashboard for Health and Safety with relevant controls where applicable;
• incident management and reporting: review and monitoring daily of incidents/near misses reported in line with the Trusts KPI metrics and support investigations where required including serious untoward incidents
• support the collation of evidence for the Care Quality Commission submission, review and inspection;
• liaison with and reporting to Birmingham Community Healthcare NHS Foundation Trust on governance issues including being the Dental Services representative on the Trust Committees and other related groups where required;

Quality Improvement

• Support and lead aligning the Division alongside the Trusts Quality Improvement Strategy
• Manage the establishment and delivery of an annual programme of audit work within Dental Services, providing support for clinical teams in undertaking audit and effectiveness projects, including service improvement.
• Support the delivery of the patient/Service user engagement and co-design programme within Dental Services, liaising with patients to ensure representative opinion, developing excellent relationships with patient representatives and expanding clinical and patient engagement and co-designin all quality improvement work.
• Manage and deliver, in conjunction with the Trusts Patient Experience Team, the on-going customer services and patient experience survey process within Dental Services, ensuring patient feedback informs service delivery.
• Support clinicians and managers in improving performance in key areas and achieving high quality clinical services in line with organisational strategies, clinical governance, risk management and patient experience aim.
• Support the Governance Manager and General Management team on a day to day basis including the role of Duty Manager.
• Liaise with Trust Clinical Governance and Risk Management teams to support national and local clinical audit priorities and requirements.
• Liaise with Trust Patient Experience Teams to support national and local patient experience/involvement priorities and requirements.
• Represent Dental Services at internal and external meetings, presenting information effectively in a range of ways, including written reports and presentations

Clinical Audit and Effectiveness

• Develop, implement and support an annual Divisional audit programme to provide assurance, patient involvement and service improvement.
• Promote the engagement of all clinical services and professional groups in the development and delivery of the Divisional annual audit programme; through network and the business/ service development planning process.
• Ensure all audits are registered on Divisional and Trust agreed audit programme and lead on following up the progress, reports, action plans and outcomes from audit activity undertaken within the Division.
• Ensure the delivery of training, support and development opportunities for staff to develop their knowledge and skills within clinical audit and service evaluation. Inclusive of developing standards, literature searches, methodology, data collection/ evaluation and publication.
• To ensure recommendations from projects are followed up and where relevant re-audits/evaluations are carried out within appropriate timescales
• To identify areas of good practice, problems/ areas of concern relating to clinical practice and quality, liaising with the Governance Manager to agree remedial action including escalation when required.
• To work with clinical staff and students of all levels to ensure action plans arising from audits/service evaluations are implemented and monitored.
• To oversee the planning, management and dissemination of Dental Services audit presentation events as required.
• Active member of the Divisional Audit Group, providing a facilitation role, working closely with the chair; providing reports/ updates including the progress of audits/ service evaluations and escalation where appropriate.

Planning and Organisational Development

• Provide practical support to multi-disciplinary clinical and operational teams in planning, developing and implementing improvement and patient centred high quality care through sustainable change.
• Actively ensures the needs of patients and carers are involved in service improvement by expanding opportunities for user and carer involvement through co-design work within the Division.
• Operational awareness and be visible by spending time with clinicians and support teams in order to promote best practice and service improvement
• Plan, chair and support relevant Divisional working group meetings.
• Ensure service improvements and changes are captured in guidance documents, and standard operating procedures.
• Constructively challenge behaviours that hinder change or do not support the strategy and values of the organisation.
• Integrate the work of service improvement into every day working practices and encourage a whole system approach.
• Ensure the service improvement programme is informed by up to date awareness and alignment of the Dental Services Divisional strategic objectives, patient care requirements and the wider health economy.
• Support the review, scrutiny and where required, development of any policies/procedures/standard operating procedures/guidelines within the Division.
• To lead on the planning and co-ordination of the annual Dental Division Celebrating Excellence event.

To manage the Dental Services patient experience and complaint systems in line with NHS and Trust legislation, policies and procedures to ensure:

• To support the Divisional patient experience activities and work streams, working in collaboration with the Trust Patient Experience lead, including learning from patient complaints, customer feedback, triangulating with Friends and Family Test data.
• Provide effective day-to-day monitoring of complaints, concerns and compliments, supporting and managing the Governance Co-ordinators, to deliver and lead on this function.
• Promotion and facilitation of the early resolution of complaints and concerns including personal contact and face to face meetings where required.
• Ensure that responses and outcomes to complaints are patient focused and link to service improvement.
• Ensure appropriate and timely co-ordination and completion of investigations into complaints and concerns to meet relevant performance targets. To escalate delays to the Governance Manager as necessary.
• Ensure critical appraisal of complaint cases is undertaken to assure that all quality issues are identified and managed.
• Ensure complaints information and resolution is communicated across the service as appropriate and utilised to improve patient experience and care.
• Ensure opportunities for patient engagement and involvement with the Divisional and Trust patient forum(s) is promoted within the Division.

Analytical & Judgment Responsibility

• Support incident management and undertake Root Cause Analysis and investigations.
• Clearly identify the elements of change that will be measured quantitatively and qualitatively, ensuring the appropriate measurement technique is part of the service improvement plan.
• Use audit and patient survey data to support service improvement, providing evidence based information.
• Identify, document and measure benefit realisations via the Divisional audit programme.
• Evaluate results and impact on patient care during and after change implementation.
• Collate and analyse information to deliver timely progress reports, summaries and presentations for consideration and presentation to individuals and groups

Service Development Responsibility

• Analyse data from a range of sources and make informed decisions and recommendations based on that analysis.
• Act as Divisional operational lead for patient feedback systems, and the routine collection of data for analysis and reporting, ensuring action plans are developed and implemented.
• Identify the deliverables of service improvement and ensure they are achieved.
• Prepare and co-ordinate bids for service developments, ensuring effective, comprehensive, service plans with costs.
• Use and promote improvement tools and techniques including process mapping, lean methodology, group facilitation, data analysis.
• Support and teach operational and clinical staff service improvement skills and techniques when required at Trust & Divisional level
• Proactively promote a positive image of service improvement and its benefits to patients to include regular review for continual improvement.

Person Specification

Qualifications / training

Essential

• Educated to Degree level or equivalent experience.
• Further training to post-graduate diploma level or equivalent significant experience.
• Evidence of personal and professional learning & development.
• Clinical Audit training

Desirable

• Root Cause Analysis training

Experience

Essential

• Significant operational management and/or clinical experience.
• Relevant experience of working to tight timescales and delivering to time.
• Significant experience of using audit and/or surveys to identify improvements.
• Experience of dealing with complaints and investigations
• Relevant experience of implementing and facilitating change using tools and techniques associated with modernisation.

Skills and Knowledge

Essential

• Excellent understanding of the elements of clinical governance and the compliance framework within the NHS
• Knowledge of risk management, clinical effectiveness and quality governance
• Strong leadership skills, confident and possess the ability to lead change and manage resistance that may arise in the process.
• Advanced interpersonal communication skills - negotiation, influencing and networking.
• Excellent written communication skills resulting in excellent report writing and presentations.
• Ability to effectively relate to people from a range of different professional and cultural backgrounds.
• Manages projects and work to deadlines in a busy environment.
• Problem solving skills.
• Knowledge and understanding of the Clinical Audit process.
• Understanding of NHS issues related to quality and service improvement.
• Extensive experience of using IT systems to include Microsoft Windows, Word Excel, PowerPoint, outlook and the Intranet

Personal qualities

Essential

• Ability to be self-motivated
• Positive, energetic, enthusiastic and able to set an excellent example in leading people/teams
• Strong participative and supportive management style
• Ability to manage under pressure, working to tight deadlines
• Evidence of strong leadership skills with a positive and proactive approach to problem solving
• Keen to implement continuous service improvement

Other job requirements

Essential

• Ability and willingness to travel to other sites across the Division and the Trust
• Ability to work flexible hours, as required

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.

Certificate of Sponsorship

Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).

From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).

Employer details

Employer name

Birmingham Community Healthcare NHS FT

Address

Birmingham Dental Hospital

5 Mill Pool Way

Birmingham

B5 7EG

Employer's website

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