Band 8b Head of Quality Governance

Quality & Governance is a key quality function which is led by the Medical Director. The department is led by the Associate Director of Quality & Governance with support from the Head of Quality and Governance.

Patient experience, PALS and complaints are led by the Director of Nursing & Midwifery and the Associate Director of Nursing, and the post holder will closely cooperate with them.

The post holder will be responsible for managing the corporate Quality and Governance team. The post holder will provide professional leadership to Divisional Governance Managers who are line managed by the Divisional Director of Operations.

The post holder is responsible for
- Developing, implementing and monitoring an effective and compliant system of working to ensure robust quality governance which is in line with national best practice and aligns across the clinical divisions
- Managing the governance staff, including the professional leadership of the divisional governance teams
- Dealing with all activities related to patient safety, risk, legal claims, compliance and audit and act as the lead and central point of contact for all governance related activities
- Supporting the Associate Director of Quality & Governance in their strategic and assurance roles
- Acting as a pre-emptive, self-relating practitioner who horizon scans to ensure the divisional governance activities remain in line with current best practice

The post holder will work closely with the executive team, the divisional leadership, patient safety specialist and staff at all levels in the organisation.

North Mid is part of North Central London integrated care system - consisting of the NHS and Local authority organisations in Camden, Islington, Barnet, Enfield and Haringey. As with other ICS’s, we are working increasingly closely with partners and indeed many of our financial and performance objectives are measured at this system level. Whilst all organisations remain as standalone, statutory bodies we have an ICS infrastructure for making shared decisions and agreeing shared approaches.

We are proud of our staff and want to ensure their training allows them to provide excellent clinical care. We are also a training unit for medical students from UCL and St George’s University Grenada, and for nursing and midwifery students from Middlesex and City Universities.

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Responsible for all aspects of the quality and governance agenda
- Have oversight of the quality and governance agenda
- Ensure that processes and delivery are effective in promoting excellent quality, learning and continued improvement
- Lead professionally the three divisional Quality and Governance teams who are line managed by the Divisional Director of Operations

Clinical Audit and Effectiveness
- To have oversight of the hospital’s participation oversight and implementation of recommendations from NCEPOD
- To have oversight of the hospital’s participation in the National Clinical Audit programme
- To have oversight of the hospital compliance and responsiveness to NICE recommendations

Policies and Guidelines
- To ensure that the Trust maintains an up to date register of policies and guidelines, including owners, authors and expiry dates
- To oversee the process of maintenance and assurance in regards to policies and guidelines

Incidents
- Leading the management of serious incidents and the sharing of learning from these incidents. This includes reviewing and ensuring that investigations are appropriately carried out in accordance with agreed guidelines and timeframes
- are fair and comprehensive in their scope and delivery o are addressing the right information
- provide feedback on key areas for improvement, challenge or further actions.
- Provide appropriate root cause analysis and resultant action plans
- Ensuring that SIs are declared and de-escalated according to agreed standard criteria and the NHS Serious Incident Framework
- Producing thematic reviews of serious incidents to identify trends and patterns for a defined population

Mortality
- Ensuring that Learning from Death policy is embedded in the hospital
- Ensuring that the Morbidity & Mortality review groups at Trustwide, divisional and departmental level are adequately supported and their reporting is following agreed standards

Claims and Litigation
- To have oversight of the Trust handling of claims and litigation
- Line management of the Trust legal & claims team

RESPONSIBILITY FOR PATIENTS
- Identify and escalate any anomalies to appropriate leads for action
- Ensure patients who suffer harm whilst under our care, are managed in line with Being Open or Duty of Candour as indicated by level of harm
- Together with the Associate Director of Nursing, ensure that patient feedback and experience is taken into account when delivering the quality and governance agenda.

RESPONSIBILITY FOR POLICY AND SERVICE DEVELOPMENT

a) Training
- Ensure all training in Quality and Governanc