Job responsibilities
Job title:Integrated Governance Lead
Responsible to:CEO
Accountable to:CEO
Key working relationships:
Director of Patient Services, Finance Manager, Therapy Team, Ward
teams Director of Operations; Chief
Executive
1. JOB SUMMARY
It is the hospitals objective to be known as a high reliability
organisation. As such, the values and behaviours of the organisation should
reflect this objective building on a platform of continuous improvement.
The Integrated Governance Lead will support the management team embed a
culture of High Reliability and be key in the development and leadership of a
Quality Improvement for Holy Cross Hospital. The Integrated Governance Lead
will work with the hospital teams to:
Recognise potential points of failure and
identify opportunities for improvement.
Actively participate in a culture of openness and
responsiveness. Where escalated, the key management teams will provide feedback
in response to information that is shared.
Consistently concentrate and observe processes to
inform decision making and identification of new operational initiatives.
Concentrate on any deviation or process failure
regardless of how small to an agreed standard thus preventing the potential for
major accident or incident
Provide a framework to ensure our teams become
experts within their field, update and continue to develop the skills within
the team increasing scope where appropriate.
Develop leaders who know who in the organisation has specialised knowledge and utilise this
to the benefit of the patient.
Escalate any patient or staff safety
concerns immediately.
Ensure Holy
Cross Hospital remains compliant with regulation.
2. MAIN DUTIES AND
RESPONSIBILITIES
2.1.1. To review best practice and evidence globally and adapt for local
implementation
2.1.2. To Chair the Integrated Governance Committee,
preparing with the support of the CEO the necessary papers and recommendations
for change Monthly.
2.1.3. Review Holy Cross Hospitals patient and
family engagement program, including the development of a patient and family
participation group and patient participation survey. Ensure the patient
engagement survey, meets the requirements of the Family and Friends Test. To
present the results of both the participation group and surveys, developing an
appropriate action plan to ensure Holy Cross Hospital is patient centered in
its delivery of care.
2.1.4. Challenge
long-held beliefs through the identification and presentation of results,
focusing on variations in best practice.
Introduce evidence-based benchmarks and other performance metrics. Design
and co-ordinate quality/safety improvement projects and tools to ensure
successful completion. Where required review or establish the necessary
steering group/s, support the clinical teams to embed evidence-based standards/guidelines.
With clinical leads, develop robust data collection tools and management
systems, evaluating and presenting of results and recommendations.
2.1.5. To work with the Director of Patient Services
and clinical teams in reviewing Clinical Risks and implementing the necessary
mitigations
2.1.6 To develop and implement a Patient Safety
Incident Response Framework (PSIRF) Work with the lead for training and
development to devise a series of workshops providing assurance of hospital
wide understanding of PSIRF
2.1.7. Work with and support the Lead for Infection,
Prevention and Control (IPC) in the implementation of the annual IPC program,
audit and quality improvement plan. With the Director of Patient Services and
therapy leads ensure teams use the results of audit and quality initiatives to
change and improve clinical practice.
2.2. Operational Focus
2.2.1. Work with the Operations
Director to ensure there is a coordinated approach to Health and Safety and
Emergency Preparedness as part of hospital wide Integrated Governance,
including but not exhaustive:
Risk Management Strategy
Fire Safety
Manual Handling
COSHH
Display Screen Equipment
Hospital Security and Remote Worker
Accidents and Incident Reporting
Safety: Estates: Environment and Equipment
Management of Medical Gasses
Management of Contractors
2.2.2 Work with the Information
Services Manager to ensure adherence to Information Governance including:
Data Security and Accountability
Data Quality and Integrity
Data Ownership and Stewardship
Accessibility and Usability
Compliance with General Data Protection Regulation (GDPR)
2.3. People management and
development
2.3.1 Work
with the learning and development lead and ward and department managers in
reporting mandatory and statutory
training compliance and focused remedial action plans.
2.3.2. Work with
Human Resources (HR) team to report workforce metrics such as:
Recruitment
and retention
Succession
plans
Diversity
Equity and Inclusion
Employee
engagement and Belonging
3. Legislative requirements
To highlight
and advise on regulatory body changes and requirements to ensure Holy Cross
Hospital remains regulatory compliant.
4. PERSONAL DEVELOPMENT
4.1 Participate in the annual hospital
appraisal scheme
4.2. Take responsibility for own personal
development actively seeking learning opportunities as appropriate
4.3. Be committed to further development of own
skills and knowledge
5. HEALTH AND SAFETY
5.1. Work at all times within the scope of the
Health and Safety at Work Act of 1974 and the hospital policy for reporting of
accidents, incidents, hazards and risk management.
5.2. Maintain and protect the safety,
confidentiality and dignity of patients and families.
5.3. Manage and maintain a clean, safe and tidy
environment.
Take an active role in the prevention and control of
infection.
6. GENERAL
6.1. Attention to detail, including in
terms of presentation, punctuality and supporting the maintenance of a safe and
welcoming environment for all
6.2 Maintain
the principles of the Data Protection Act of 1998 both within and outside of
the hospital environment
6.3. Act in accordance with the hospitals Data
Protection Policy
6.4. Be aware of personal compliance with work
practice legislation.
This
post is exempted under the Rehabilitation of Offenders Act 1974 and as such
appointment to this post will be conditional upon the receipt of a satisfactory
response to a check of police records via Disclosure and Barring Service (DBS)
This job description represents an outline of the main components
of the job and is not intended to be exhaustive.
It may, with consultation be subject to additions and amendment as
the need arises. It has been checked for
overt or implied discrimination within the scope of the Hospitals policies on
equality and diversity and none was found.
In
addition to the duties and responsibilities listed the post holder is required
to perform other duties as might reasonably be required.
