Quality and Patient Safety Team Leader

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1 Date : February 2018 Job Title : Quality and Patient Safety Team leader Department : Quality and Risk Location : All Waitemata DHB Sites Reporting To : Quality and Risk Manager Direct Reports : Quality and Patient Safety Leads Functional Relationships with : Internal Quality and Risk Manager All clinical and non-clinical staff Chief Medical Officer Clinical lead Patient Safety and Patient Experience Community Engagement Manager Complaints and Adverse Events Manager Corporate Compliance Manager Director i3 / Clinical Lead Quality Director of Patient Experience General Managers and Heads of Divisions Heads of Department and Charge Nurse Managers Information Management Group/Decision Support Institute for Innovation and Improvement Legal Team Maori Health/Pacific Support Services/Asian Health Services Mental Health Quality Team Patient Experience Team Planning, Funding and Heath Outcomes Professional Leaders Nursing/Medical/Allied Health Service/Operations Managers and Clinical Directors Volunteers External Service Users and their Whānau and families Quality and Patient Safety Teams in other DHBs Statutory Bodies Health Quality and Safety Commission Health and Disability Commissioner Health Advocacy Service Ministry of Health NGOs Our Purpose, Values and Standards At the heart of Waitemata DHB is our promise of best care for everyone. This promise statement is the articulation of our three-fold purpose to: 1. promote wellness, 2. prevent, cure and ameliorate ill health and 3. relieve the suffering of those entrusted to our care. Waitemata District Health Board -Quality and Patient Safety Team Leader February 2018 FINAL.doc- Page 1

2 At the heart of our values is the need for all of us to reflect on the intrinsic dignity of every single person that enters our care. It is a privilege to be able to care for patients, whānau and our community, a privilege that is sometimes overlooked in our day to day work. Our standards and behaviours serve as a reminder to us all about how we are with our patients and with each other. Purpose of the role : Role Purpose Provide line management and leadership to the Quality and Patient Safety Leads Promote the delivery of safe, effective and patient-centred care and the board priorities of better outcomes and enhanced patient experience Champion a culture in which reporting of incidents, investigation and proactive risk management is routine practice and is recognised by staff as a means of improving the quality of clinical care and reducing risks to patients. Work collaboratively with colleagues across all Divisions, Services and Department to provide expert advice and support on all aspects of quality and patient safety with particular reference to adverse event and complaint investigation, report writing and facilitating lessons learned. Support the identification and monitor the completion of recommendations and actions required to improve Quality and Patient Safety within the DHB Be the named Quality and Patient Safety Lead for an identified Division and Services Waitemata District Health Board -Quality and Patient Safety Team Leader February 2018 FINAL.doc- Page 2

3 KEY TASKS Staff Management and Leadership Adverse Event Management EXPECTED OUTCOMES Meet regularly with Quality and Patient Safety Leads as a team and individuals to keep them informed and updated, to address system issues and plan together. Establish clear objectives and personal development plans through annual appraisals with individual team members that contribute to overall team and individual targets and provide regular constructive feedback on progress. Manage the Quality and Patient Safety Leads annual leave, sick leave and any performance issues. Ensure cover arrangements are in place in the event of any absences (annual leave, sick leave and vacancies). With support from the Quality and Risk Manager lead the recruitment, selection and orientation of new team members. Role model expectations and reinforce systems and processes to ensure service standards and the DHB values are evident in service delivery. In conjunction with Quality and Risk Manager, build a team culture of excellence and innovation that empowers team members to be active participants in planning and implementation of improvements to service delivery. Ensure that the DHB process for reporting and managing adverse events and near misses is followed and provide advice and support where required, responding to day to day queries and advising staff of actions required to help reduce and manage any issues that may impact on Patient Safety, promoting open learning, a just culture and open disclosure throughout the DHB. Validate and data quality check all patient related incidents, reported on the Incident reporting system, ensuring that incidents are correctly classified and SAC rated. Ensuring that all o SAC 3 & 4 rated events are followed up by the local manager and learning o takes place as per the Adverse Events Management policy and procedure. SAC 1 & 2 and Always Review and Report events are appropriately escalated and are managed and investigated in line with the Adverse Events Management policy and procedure. Support the General Managers and Heads of Division in identifying potential Lead Investigators and Investigation Team members. Lead and facilitate the adverse events management process within the Divisions ensuring the independence and robustness of adverse event investigations. Work alongside the lead investigator and investigation team as Investigation Facilitator, providing advice on the process, expert questioning to ensure clarity of information, findings, recommendations and actions. Support the lead investigator with key tasks by working alongside the clinical experts / lead investigators to draft timelines, identify information sources (individuals and/or documentation), coordinate investigation meetings and, if required, draft the investigation reports. Quality assure/check all the Adverse Event reports and ensure appropriate sign off of the final report, before submitting approved reports to the Adverse Events Committee (AEC). Coordinated the AEC presentation details with the Complaints and Adverse Events Manager. Waitemata District Health Board -Quality and Patient Safety Team Leader February 2018 FINAL.doc- Page 3

4 KEY TASKS EXPECTED OUTCOMES Support the identification and facilitate the delivery of achievable and effective actions that translate into improvements in organisational learning and patient safety. Monitoring the completion of agreed recommendations / action plans. Escalate any areas of concern with regard to non-delivery of agreed recommendations / action plans to the General Manager and Head of Division. Complaint Management Ensure that the DHB process for managing complaints is followed and provide advice and support where required, responding to day to day queries. Assist and guide staff including clinical staff and managers on how to investigate and respond to complaints, within the DHB response timeframes. Acting as facilitator working alongside the General Managers and Head of Divisions to manage complex complaints, where necessary collate the information required in a complaint response. Review, quality assure and where necessary revise complaint responses, to ensure all issues raised in the original complaint are responded to in a clear and concise manner. Working with the Patient Experience Team, advocate for family meetings to support the complaint response. When required support the Complaints and Adverse Events Manager with responding to complaints received from the Health and Disability Commissioner. Monitor response timeframes to help ensure required timeframes are achieved. Work with Divisions and Services to identify and facilitate the delivery of achievable and effective actions to improve services and mitigate any identified issues that impact on patient safety and experience. Monitoring the completion of agreed recommendations / action plans. Escalate any areas of concern with regard to delays in responding to complaints as well as non-delivery of agreed recommendations / action plans to the General Manager and Head of Division. Communication Work with the Divisions and Services to help ensure timely and effective feedback to staff, patients and whanau about complaints and adverse events both verbally and written and ensure that any lessons learned are disseminated to all appropriate personnel on a one to one basis or to larger groups via team, service or department meetings or study days. Data and reporting Use a variety of data such as adverse events, complaints and other suitable data scores to identify any themes and trends that requires further investigation and action. Collate, prepare and provide regular Quality reports for Divisional meetings and other appropriate committees/groups (as requested by the Divisions or Services) highlighting trends, themes and learning, including any areas of concern and actions taken, as well as agreed opportunities or recommendations for improvement. Maintain an up-to-date Adverse Event and recommendations/action plan tracker. Advise and support staff within the Divisions and Services to enable them to identify, effectively manage and escalate potential risks to patient safety. Waitemata District Health Board -Quality and Patient Safety Team Leader February 2018 FINAL.doc- Page 4

5 KEY TASKS Compliance and Audit Processes EXPECTED OUTCOMES Support and actively engage with the preparation for any Health Disability Service Standards Audits. Work with the Corporate Compliance Manager in undertaking interim audits as required by the HDSS work plan. Staff Training Develop staff knowledge of the adverse event/incident reporting system to enable greater use and improved reporting with regard to quantity and quality. Work with the Quality and Risk Manager and the Complaints and Adverse Events Manager to deliver education and training material to promote effective adverse event and complaint management. Patient Safety Improvement Activities Professional Development Statutory & Treaty of Waitangi obligations Using the learning from adverse events and complaints, assist in the identification of patient safety improvement activities. Lead or support any appropriate patient safety improvement activities generated internally or by external bodies such as the Ministry of Health, Health and Disability Commissioner and Health Quality and Safety Commission. Remain up to date with national and international best practice in relation to patient safety, adverse event investigation tools and techniques, quality improvement and risk management. Collaborate with other quality and patient safety champions and experts within New Zealand and internationally to promote and sustain best practice and a quality and patient safety culture throughout the DHB. Ensures the professional and political integrity of WDHB by carrying out all functions in compliance of the Treaty of Waitangi and by demonstrating a serious commitment to keeping the Treaty alive. Shows sensitivity to cultural complexity in the workforce and patient population. To recognise individual responsibility for workplace Health & Safety under the Health and Safety at Work Act 2015 Contribute to a safe and healthy workplace at WDHB by: Following & complying with H&S policies & processes & applying them to their own work activities, including using/wearing Personal Protective Equipment as required. Participating in activities directed at preventing harm & promoting well-being in the workplace Identifying, reporting & self-managing hazards where appropriate Early and accurate reporting of incidents at work and raising issues of concern when identified. Waitemata District Health Board -Quality and Patient Safety Team Leader February 2018 FINAL.doc- Page 5

6 PERSON SPECIFICATION POSITION TITLE: Quality and Patient Safety Team Leader Minimum Preferred Qualification Relevant tertiary qualification in a healthrelated subject or equivalent work experience Qualification, or equivalent work experience, in adverse event investigation tools Post graduate qualification in the primary profession or Masters level qualifications in health administration or management Clinical qualification Project or process management qualification or equivalent work experience Experience 5 years senior health care advisory / management experience Skills Knowledge Behaviour Experience in managing, leading and developing a team Appraisal and objective setting experience Experience in complaint management and investigation Experience in adverse event /incident management and investigation Experience in working with senior management and Clinicians Experience in applying evidence based practice Experience of successful project management Experience in audit processes Well-developed analytical skills with experience in presenting complex data appropriately to different audiences Experience of working in Quality Structures within a healthcare provider Excellent report writing skills. Excellent facilitation, communication and interpersonal skills with the ability to manage conflict Excellent IT skills and database management with the ability to learn and effectively utilise data systems/bases e.g. Excel, Risk Monitor PRO, PiMs, Concerto, workforce/timecard databases Skilled presentation of data Effective organisational and time management Experience in process management and process capability dashboards Previous experienced in leading, driving and motivating multi-discipline, culturally diverse and cross departmental project teams Experience with Strategic planning Auditing experience Experience in the application of the principles of continuous quality improvement Experience in working with project and continuous improvement methodologies Recruitment experience Change management experience Experience in delivering training Effective programme management skills with the ability to influence and negotiate at all levels of the organisation Knowledge of human resource processes with particular reference to staff management Knowledge of risk management tools and processes Knowledge of the quality of service frameworks for policy, procedure and Waitemata District Health Board -Quality and Patient Safety Team Leader February 2018 FINAL.doc- Page 6

7 skills. Knowledge of the Health and Disability Sector Service Standards Knowledge of working with Maori, the principles of the Treaty of Waitangi (Te Tiriti O Waitangi) and education/management of cross cultural communication protocol development and documentation Knowledge of organisational systems and client process in health and disability Detailed knowledge of relevant health legislation and compliance framework Strong critical thinking skills High level of attention to detail Ability to work across professional and organisational boundaries. Ability to prioritise workloads and work under pressure meeting tight deadlines Ability to be flexible and thrives on challenges Ability to cope with challenging and changing situations Demonstrates a continuous passion for excellence and innovation Demonstrates a confident, collaborative approach and can do attitude A systems thinker Upholds confidentiality with a reputation for high integrity and discretion Waitemata District Health Board -Quality and Patient Safety Team Leader February 2018 FINAL.doc- Page 7

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