Quality Improvement and Clinical Audit Facilitator

Job summary

An opportunity has arisen for an enthusiastic Quality Improvement and Clinical Audit Facilitator. There are opportunities to work across all of our mental health inpatient sites which cover BNSSG and BSW.

The post holder will be employed within the Trust's Quality Improvement & Clinical Audit Faculty, part of the wider Transformation Directorate which sits under the broader Medical Directorate. The clinical services of the Trust are organised into locality-based and specialist Delivery Units and the post holder will work closely with members of these units.

The post holder will be expected to support the continued development, delivery and promotion of the quality improvement implementation plan within the Delivery Units and lead the delivery of the Trust and National Clinical Audit programme.

Main duties of the job

To act as a member of the Trust's internal Quality Improvement consultancy, offering subject matter expertise, advice, coaching and signposting services to the wider organisation. Assist in the development of improvement plans and associated documentation as appropriate and facilitate the implementation of specific improvement initiatives within the scope of the Quality Improvement implementation plan. To develop Audits and associated documentation as part of the trust and national clinical audit programme as delegated by the Deputy Head of Quality Improvement and Trust Clinical Audit Lead. Support the rollout and delivery of the Quality Service Improvement Redesign programme across the organisation, including participating in the delivery of teaching sessions, both face to face and virtually.

About us

We are AWP (Avon and Wiltshire Mental Health Partnership NHS Trust) a diverse organisation with over 5,000 dedicated staff providing inpatient and community-based mental health care. We provide services from a range of locations to approximately million people living in Bath and North East Somerset (B&NES), Bristol, North Somerset, South Gloucestershire, Swindon, across the county of Wiltshire and in parts of Dorset. Our outstanding people promote mental health and wellbeing. The expertise and resources within AWP are dedicated to a person-centred approach for those who use our services and for all employees. We recognise that happy and fulfilled employees give better care.

At AWP we actively encourage applicants from all backgrounds; we are particularly keen to encourage applications from people from Black, Asian and minority ethnic backgrounds, those with disabilities and from the LGBTQ+ community. We want people to bring their unique blend of experiences, backgrounds, perspectives and knowledge to AWP, as diversity makes us stronger.

Job description

Job responsibilities

Quality Improvement Support the development of detailed improvement plans for the delivery of specific projects within the broader Quality Improvement Implementation Plan, its associated initiatives and workstreams within locality-based and specialist Delivery Units. Support the Head of Quality Improvement and the Deputy Head of Quality Improvement and Trust Clinical Audit Lead in the delivery of the Quality Improvement Implementation Plan. Work with locality-based and specialist Delivery Unit Quality Improvement Leads to ensure specific initiatives are aligned with the governance and methodology set out in the Quality Improvement Implementation Plan. To provide advice on all matters relating to clinical audit and quality improvement within both Delivery Units and on behalf of corporate leads. Ensure that baselines are captured to illustrate and monitor specific change, including trajectories and benefits. Support improvement project groups as requested to ensure regular meetings are held and participants are held to account. This includes the maintenance of good governance, appropriate reports and escalation as required. Support the production of reports on Quality Improvement progress, issues and items for escalation. Represent the Trust and QI Faculty professionally both internally and externally as a champion of Quality Improvement. Change Methodology Ensure that Quality Improvement initiatives and Clinical Audits are focused on Service Users and follow the principals of co-designed and production. Facilitate frontline staff to deliver continues improvement, enabling creativity, innovation and change in support of a culture focused on improvement. Support the broader change team to utilise quality improvement tools and techniques, providing coaching, mentoring and training. Assist in the Identification of appropriate benchmarks, develop surveys and collate both qualitative and quantitative data to support service delivery improvements, performance and quality. Work within the National and Local regulatory frameworks Use appropriate tools, software and techniques to manage, analyse and present data in a variety of formats. Advising staff of appropriate data extraction from existing systems to support measurement for improvement and Audit methodologies. To manage personal workload and determine priorities in the context of the Quality Improvement Implementation Plan, Delivery Unit clinical audit programme and Clinical Audit policy and strategy. The post holder will however be guided and advised by the Deputy Head of Quality Improvement and Trust Clinical Audit Lead and Faculty Leads. To ensure that all clinical audit activity and quality improvement activities are formally registered and meet the correct governance criteria prior to commencement. To provide appropriate support and advice on project design and methodology, data analysis, presentation and report writing to staff undertaking projects, liaising with the information department as appropriate. Clinical Audit To maintain accurate and comprehensive records of local clinical audit activity on the Trusts Clinical Audit Database. To liaise with the Quality Improvement and Clinical Audit Manager, maintaining awareness of any clinical audit requirements contained in national audit/benchmarking which relate to the Delivery Units, and to ensure that these are brought to the attention of the Delivery Units. To organise and attend Delivery Unit and Trust meetings as required, and to make presentations at meetings, forward plans and annual reports, as and when required. To liaise with the Deputy Head of Quality Improvement and Trust Clinical Audit Lead, maintaining awareness of any clinical audit requirements contained in national audit/governance initiatives which relate to the Delivery Units, and to ensure that these are brought to the attention of the Delivery Unit Clinical Audit /Quality Group. To work collaboratively with staff in the audit department and the Delivery Unit Clinical Leads & Directors to maintain a structure for managing and facilitating clinical audit at Delivery Unit level. For example, this includes facilitating the production of an annual clinical audit work plan which reflects a range of competing demands, such as: NICE guidance Quality Schedule and Quality Accounts requirements MH Act legislation Care planning & clinical risk issues To assist project leads in producing final reports at the end of clinical audit and quality improvement projects; and on the occasions where this duty falls to the post holder, to produce such reports to a high standard, with the support of the project lead To support the Delivery Units to follow the Trust policy in relation to tracking and follow-up of any audit action plans. Training and Development Support the rollout and delivery of the Quality Service Improvement Redesign programme across the organisation, including participating in the delivery of teaching sessions, both face to face and virtually. Support staff with training in clinical Audit skills as necessary. Support staff with training in Clinical Audit skills as necessary. To promote and encourage participation in clinical audit and other forms of quality improvement by all staff, and support and encourage clinically effective, evidence-based practice. To provide staff with guidance, as required, about principles of implementing change, ethical considerations when undertaking clinical audit, and the relationship between clinical audit and other strands of quality improvement, wider governance and assurance. Maintain personal skills portfolio and ensure personal training needs are appropriate to meet the demands of the job are brought to the attention of the Clinical Audit & Improvement Manager. To participate in an annual appraisal with line manager and agree goals & objectives for the year Maintain currency and cutting edge understanding of new developments, tools and techniques through the attendance of regional/ national events as agreed with line manager. Develop networking opportunities and professional affiliations in order to maintain currency and optimise adoption of best practice. Organising, Co-ordinating and Reporting To participate in Delivery Unit Quality and Standards group meetings/Q Hubs which will oversee progress with the Delivery Unit audit work plan (providing regular updates), as well as reviewing draft audit reports, and agreeing & reviewing action plans. To support the development of appropriate forums and networks for the presentation and discussion of clinical audit and quality improvement report findings, and to ensure reports are placed on the intranet to share findings. To manage personal workload and determine priorities in the context of the Clinical Audit programme/Clinical Audit policy and the QI strategy/programme. The post holder will however be guided and advised by the Deputy Head of Quality Improvement and Trust Clinical Audit Lead and the Head of Quality Improvement Ensuring oversight of project deadlines, milestones and where these are at risk, ensure timely escalation. To provide appropriate summary information for a range of corporate reporting requirements, quarterly and half-yearly progress updates for Quality and Standards Committee, Audit and NICE sub group, the Annual Quality Accounts, and Medicines Safety audit reporting schedule. To facilitate project/audit leads in producing final reports/posters/presentations at the end of clinical audit and quality improvement project cycles; and on the occasions where this duty falls to the post holder, to produce such reports to a high standard, with the support of the project lead. Produce a range of clear and concise formal and informal communication styles with and for a variety of individuals, teams and organisations. This may be technical/non-technical, highly complex, sensitive and potentially contentious at times. Data Management and Analytical Skills To use appropriate software for data handling for projects auditing software, excel spread sheets, Reportzone and only other procured departmental systems Understanding, analysing and interrogating data, presenting it in a variety of formats such as bar charts, pie charts, and statistical process control charts (SPC) To advise staff on data extraction from manual or computerised records. Liaise with the information department (BI) in relation to options for data extraction for both audit sampling and reporting purposes as well as opportunities to feed data directly into SPC charts to support measurement for improvement. Person Specification

Education and Qualification

Essential

Educated to degree level - preferably in a health related field or equivalent relevant training in clinical audit and quality improvement High degree of accuracy and ability to use MS packages. ECDL or equivalent a good working knowledge and experience in using of Excel, Word & PowerPoint

Desirable

Knowledge of health standards & current best practice CQC, NICE, NCAPOP Quality Improvement Qualification Knowledge or Qualification in Change Management/Project Management

Experience and Knowledge

Essential

Experience in Health /Social care related fields (preferably in mental health) Interest and some degree of experience in Clinical Audit, Quality Improvement or Clinical Quality Assurance Evidence of effective report writing skills audit reports, quality improvement reports, thesis

Desirable

Experience of using auditing /survey software Experience with Users/Carers organisations Experience of working with Survey/Consumer satisfaction work

Skills and Abilities

Essential

Excellent standard of numeracy, literacy and attention to detail Excellent communication skills Project planning and Organisational skills - ability to use initiative to plan and manage projects with minimal supervision Good Team working and persuasion / negotiation across all staff levels Ability to travel Trust wide/

Desirable

Coaching/Facilitation skills Training/Teaching skills

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