Quality Governance Manager

Job summary

The post holder will support the Quality Governance Lead to oversee all aspects of quality governance, within the Surgical Division. They will directly support the Quality Governance Lead, Divisional Leadership team and Directorate Governance Leads. The post holder will be a fundamental part of the Quality Governance Team for the Division, ensuring that services meet the required level of quality assurance standards within the Trust.

The post holder will be responsible for monitoring, implementing and enhancing quality governance policies and procedures ensuring adherence to national and internal legislation and guidance, which will include reporting and effective management of clinical and non-clinical incidents. The post holder will be expected to be appraised of best practice in quality assurance and governance nationally and locally including external bodies.

Main duties of the job

To support the Quality Governance Lead in promoting clinical incident reporting and ensuring that all Patient Safety Incident reports are accurately recorded, investigated and actioned in line with WAHT Policy.

To provide managerial support to the Quality Governance Lead and in their absence to Directorate Lead/Senior Nurse in managing and developing Directorate arrangements for clinical governance and specifically clinical risk management and patient safety.

To provide support, advice and guidance to all levels of staff across the Surgical Directorates to ensure that there are processes in place to systematically assess and prioritise clinical risks with corrective action programmes in place.

To provide general awareness training on Clinical Governance, patient safety and quality to various staff groups at all levels across the Surgical Directorate in response to identified need following patient safety incident investigations, external assurance monitoring mechanisms and training needs analysis

About us

Our purpose is simple - Putting Patients First. We are looking for exceptional colleagues who can help us achieve this.

Worcestershire Acute Hospitals NHS Trust is a large acute and specialised hospital trust that provides a range of local acute services to the residents of Worcestershire and more specialised services to a larger population in Herefordshire and beyond.

The Trust operates hospital-based services from three sites in Kidderminster, Redditch and Worcester

Our workforce is over 7,000 strong, and our caring staff are recognised as providing good and outstanding patient-centred care. You could be one of them.

We are committed to recruiting the best people to work with us to achieve our Vision - working in partnership to provide the best healthcare for our communities, leading and supporting our teams to move 4ward. Our 4ward behaviours, which we ask all staff to demonstrate, underpin our everyday work and remain firmly at the heart of all we do.

Our objectives are simple:

Best services for local people Best experience of care and best outcomes for our patients Best use of resources Best people

Better never stops, and our Clinical Services Strategy provides a clear future vision for our Trust, our hospitals, our services and our role in the wider health and care system.

We are proud to have achieved Timewise accreditation - this means we are committed to embedding flexible working within our organisation as a flex positive employer.

Job description

Job responsibilities

Job Purpose:

Towork closely with the Surgery Divisional Management Team to design, implement, deliver,and evaluate the Clinical Governance and assurance framework for the Division.

Toensure all Divisional Quality Governance Activities are in line with the corporate governance agenda of Worcestershire Acute Hospitals NHSTrust.

To ensure staff and clinician engagement in the SurgeryDivisional Clinical Governance agenda. To ensureeducation and training programmes are devised and delivered in relation to qualitygovernance, risk, patient

safety, clinical audit, and continuous quality improvement.

To play a keyrole on assisting the Surgery Division to identifyand define the informationrequired to monitor clinicaleffectiveness, patient safety, compliance and quality outputs of the servicesprovided.

Todevelop and maintain relationships inter-divisionallyand with the corporate clinical governance team to ensure that allclinical governance activity is in accordance with both Trust policy and the corporate strategic intent.

Toco-ordinate and ensure incidents and complaint investigations and responseshappen within agreed time frames. Ensuring that reports are of high quality and any associated action plans are SMART, monitoredand evidenced.

To monitor actions arising from incidents investigation, complaints, audit, and other sources are completed within the division and that learning is sharedacross the Division and organisation where appropriate.

Toprovide reports to Surgery Divisional Board and present executive brief onreports at Divisional Governance Meetings.

To supportand report in to the Surgery Divisional Governance Board, Directorate Governance meetings and help to drive the Quality Governanceagenda with the Surgery Division.

Provide leadership where necessary in accordance with governance organisational team structure.

General Duties:

Quality Governance and Risk Management:

Co-ordinate the implementation of the SurgeryDivisional quality governance programme ensuring that thisreflects the trust overall governance strategic intent

Facilitate and supportthe Surgery Divisionto plan, prepareand gather evidencefor external assessments (CQC,peer visits)

Support the Surgery Division to achieve National Initiatives

Assemble and analyse qualitative and quantitative information (with Divisional & Directorate leads) in ways that

assist staff in reflecting and improving on service deliveryand practice.

In liaison with Surgery Divisional Management Team ensure that any necessaryGovernance reports arecompiled within agreed time frames. Ensure that such reports are evidenced withthe necessary data and narratives

to provide appropriate assurance to the Trustin relation to clinical quality,outcomes, and processes.

Facilitate the downward dissemination of decisions and discussions at Governance and Quality committees and provide clarity regarding how they may relate to theindividual division, and develop associated programs to address and monitor theimpact of change.

In liaisonwith Divisional and Corporate teams,assist in the building and development of information resources pertinent to quality governanceand act as a resource for the division to develop improvement programs toenhance patient experience and outcome.

Facilitateand support the Surgery Divisional Management Team and resources to co-ordinateand report the activities ofdivisional quality and clinical governance groups against objectives, standards,and targets.

Assist the Divisional Management Team to exerciseresponsibility for risk management acrossthe division.

Supportthe implementation of the trust incident reporting system within the division,providing support in the investigation of incidents where appropriate.

Co-ordinate and support the management of mortality review tracking.

Co-ordinateand support the management of external serious incidents (including HealthcareSafety Investigation Branch - HSIB) and comprehensive investigations within thedivision in association with the divisional resources and the corporateclinical governance team.

Co-ordinateand support the investigation, response and reporting of complaints and patientfeedback within the division, working in association with teams at directorateand clinical department levels.

Participatein management of an effective and appropriate Divisional Risk Register inliaison with Divisional management team. Ensuring that the DATIX system remainsaccurate and current staff are adhering to the policy. To ensure that allrisk-related information is stored and filed systematically and securely.

Providesupport to the division to ensure that external and internal inspections, haveappropriate action plans and that have corrective actions have been completedwith an associated follow up audit planned, as required.

Workalongside clinical audit and quality governance leads within directorates andservices to develop, implement, and monitor audit and improvement programmesthat support the needs of the organisation.

Monitorthe implementation and on-going compliance with NICE and national guidanceincluding effective responses to national reports.

To supportthe governance team in production of reports focussingon themes generated from patients, service users an their that learning from patient experience,complaints,feedback and friends andfamily test is shared.

Co-ordinateand participate in Divisional Quality Review visits and programmes, includingthe follow-up of resulting actions.

Work in consultation with divisional clinicalleads to developappropriate outcome measuresthat are monitored and reported, as necessary.Ensure there are systems in place for capturing and sharing of data.

Identify clinical governance training needs within the division to ensure these needsare met.

UnderstandCQC regulation and the impact of any adverse findings of quality measurement,internal/external reviews and changesin service deliveryand advise the divisional management of such. Assist inpreparing the division for unannounced and announcedinspections.

Collaborate effectively with the corporate teams covering the elements of Trust quality governance initiatives.

Person Specification

Qualifications

Essential

Graduate level of education and/or relevant professional qualification, or significant governance experience within the NHS. Evidence of continued learning or professional development. Teaching qualification or appropriate level of teaching/presentation experience. Active registration as a healthcare professional.

Desirable

Masters level qualification (or working towards same) Certificate in leadership and Team skills (or working towards)

Experience

Essential

Previous experience within an associated specialty within clinical governance. Relevant experience in clinical governance within a medium to large NHS organisation. Supervisory Management Role. Experience of the clinical governance function within healthcare. Experience of involvement in clinical audit. Experience of working closely with clinicians of varying seniority. Experience of analysing problems and identifying solutions. Experience of using Windows based software. Proven track record of delivering clinical governance objectives in line with organisational strategy. Understanding of and working experience of process mapping. A track record in delivering presentations and developing and delivering training. Development and use of information systems to support change.

Desirable

Experience of using clinical outcomes systems. Ability to concentrate for long periods of time while analysing data and producing reports /trackers

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