Clinical Governance Quality and Assurance Facilitator

1 week ago


Rotherham, United Kingdom The Rotherham Hospice Full time

Supports the delivery of clinical governance/regulatory monitoring and compliance. Participates in the preparation, co-ordination and delivery of mock CQC inspections within the Hospice. Liaise and communicate with all staff to provide governance/assurance advice and support in line with the Hospice frameworks, policies and procedures. Provides expert administrative support to clinical forums, working closely with the forum Chairs.
Attends and actively participates in clinical governance, quality and assurance meetings, providing relevant updates and information. This includes supporting the Clinical Services Directors to prepare required reports and documents for the Clinical Quality Sub-committee. Attends and participates in the sub-committee meetings as required, provides administrative support in the absence of the Hospice PA. Develops and delivers education and training sessions related to clinical governance, quality/continuous improvement and assurance supporting staff understanding and compliance with required standards and delivery.
Operationally administers and monitors governance systems for the evaluation and assurance of quality standards, safety, outcomes and the management of risk. This includes the tracking of progression of incident reports, delivery of associated action plans, regular review of risks by risk holders co-ordination of the Hospice response to MHRA/other alerts received. Operationally manages the Hospice complaint/concern tracking system ensuring that responses to complaints are completed within the required timescales. Operationally supports Hospice staff to complete incident reporting recording of complaints and to undertake risk assessments ensuring high quality data content.
Supports investigating officers to complete PSIRF investigations. Undertakes complaint/incident investigation as delegated within role scope. Co-ordinates the completion and sending of templates to escalate concerns regarding other providers raised through the incident reporting system. Works with the Clinical Heads of Service to develop and produce a monthly governance infographic, attending clinical governance meetings as required to provide feedback on learning, themes and trends.
Has oversight and administers the repository of clinical policies monitoring that thoseidentified lead the development, review or implementation of clinical policies within required timescales and escalating breaches to the appropriate Director. Provides agreed regular governance reporting to individual Directors/Senior Leadership Team on a bi-monthly basis. Provides regular reporting on the Hospice levels of compliance on regulatory assurance. Escalates any potential serious incidents/governance issues to the relevant Head of Service, Director or CEO.
Undertakes research, collates and prepares information as requested by the Director of Quality & Assurance (routine and ad-hoc requests) Participates in external clinical governance forums, engages with external partners in sharing learning and best practice in clinical governance. Participates in stakeholder engagement working closely with patients and families to gather feedback and insights to shape and improve the quality of care. Provides regular reporting of the feedback received.



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