Associate Director of Clinical Governance
2 weeks ago
Incident Management / Patient Safety Support the continual development of an open and honest safety culture; encourage staff to actively report incidents, recognise and acknowledge process and systems failures, recognise human factors and review, reflect and engage in multidisciplinary learning. Implement robust systems and processes that will reduce clinical risk, reduce levels of harm and reduce hospital mortality Ensure that all incidents are reported, investigated appropriately and reviewed in accordance with regulatory requirements and that resultant actions and lessons learned are acted upon. Develop divisional and departmental key performance indicators (KPIs) and associated dashboards, to ensure the timely delivery of duty of candour, the timely investigation of incidents and the continuous improvement of quality of investigations and investigation reports. Provide support to the relevant Executive Directors and Divisions who have a designated lead responsibility for ensuring the trust meets required standards Monitor and review progress against the agreed action plans in support of the CQC Fundamental standards.
Provide regular patient safety reports to the appropriate assurance committees and sub committees of the Board of Directors. Monitor and review all safety / risk policies, procedures and guidelines on a regular basis ensuring that the trust complies with statutory and local obligations Develop appropriate education and training opportunities for Trust staff in conjunction with Executive Directors and Senior Managers Ensure the continual integration between the components of safety including complaints, litigation, clinical incidents/adverse events, health and safety and clinical effectiveness. Monitor compliance with the Trusts Incident Reporting Procedures and Patient safety incident response plan Assist in the investigation and reporting of Incidents and other high risk / significant events Ensure best practice with regards to adverse event reporting, monitoring, trend analysis, action plans and changes in practice Risk Management Support the continual development of a culture where Risk Management is integral to all of the Trusts processes. Author and implement the risk management policy and strategy ensuring annual milestones are achieved.
Co-ordinate the continued development of the trusts risk register ensuring relevant governance committees and Directors are informed of, and where necessary consulted on, all significant risks and associated risk action plans. Assist Divisional senior management teams and Clinical Governance Managers and heads of departments to identify and implement risk registers and risk control action plans within their areas. Coordinate all risk management external reviews. Ensure that there are structured and systematic processes for the assessment, analysis, control, prioritisation of organisational risks.
Develop appropriate policies and procedures where any deficit may exist. Quality Support the Chief Nurse & Director Quality in coordinating and authorship of the Trusts annual Quality Account and contribute to the Trusts Annual Report. Implement the Trusts Health and Safety Strategy and associated policies and procedures related to health and safety matters in consultation with the health and safety committee. Prepare for regulatory enquiries and visits, for example: CQC enquiries / inspections, NHSE/I enquiries and implementation of guidance.
Provide support to the Associate Director of Corporate Governance in relation to responding to Coroners enquiries and any actions required and following receipt of any Regulation 28 Reports Emergency Preparedness, Resilience and Response Reporting to the Chief Operating Officer (COO) and in conjunction with the EPRR manager ensure rapid and rigorous implementation of all emergency preparedness aspects of the Civil Contingencies Act. Ensure that the Trust Major Incident Plan is regularly updated in line with local, regional and national guidance and information. Ensure that timely, appropriate and rigorous testing of the major incident plan is undertaken. Ensure that debriefs and action plans are generated following testing of the major incident plan and that the action plans identify recommendations to address gaps and weaknesses in the Trust system Support rigorous follow up of action plans ensuring that significant risks to the organisation are entered onto the Trust risk register Monitor and provide support for a comprehensive programme of risk assessment that is informed by regional and national guidance in emergency preparedness.
Ensure that training and on-going planning to support the emergency planning agenda takes place and is monitored and evaluated Health and Safety Support the development of a culture where Health & Safety is integral to all of the Trust processes. Provide support through the Occupation Safety Manager to the relevant executive directors and senior managers who have designated lead respo
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