POSITION DESCRIPTION

Transcription

1 POSITION DESCRIPTION Clinical Quality and Risk Manager ARHOP This role is considered a non-core children s worker and will be subject to safety checking as part of the Vulnerable Children Act 2014 Position Holder s Name Position Holder s Signature Manager/Supervisor s Name Dana Ralph-Smith Manager/Supervisor s Signature Document ID: Obtain from Objective Version: 1.0 Department: Name of Department Last Updated: dd/mm/yyyy Document Owner: Person s Title Next Review Date: dd/mm/yyyy Approved by: Name of Approval Group/Committee Date First Issued: dd/mm/yyyy Counties Manukau Health

2 Position Description: Clinical Q&R Mgr ARHOP, Counties Manukau Health 2

3 PURPOSE OF THE POSITION The Clinical Quality & Risk Manager has six primary accountabilities: 1 Provide Divisional quality assurance, advice and coordination for feedback (complaints, compliments and suggestions) and the adverse events (serious and sentinel events) throughout the lifecycle. 2 Coordinate Divisional governance arrangements, certification and related audit processes. 3 Coordinate the development and review of controlled documents 4 Support quality improvement projects within ARHOP. 5 Support the effective identification and management of risk. 6 Measure, report and improve performance against care standards, KPI s and clinical indicators. PLACE IN THE ORGANISATION Director Hospital Services Director Patient Care, Chief Nurse & Allied Health Professions Clinical Director Medicine & Integrated Care General Manager ARHOP Head of Feedback / Adverse Events Clinical Director & Clinical Heads Clinical Lead Quality & Innovation Clinical Quality & Risk Manager Clinical Nurse Director ARHOP Position Description: Clinical Q&R Mgr ARHOP, Counties Manukau Health 3

4 NATURE AND SCOPE OF RESPONSIBILITIES Key Accountabilities Feedback (complaints, compliments and suggestions) and incidents/adverse (serious & sentinel) events management, Ministry of Health correspondence, Official Information Act requests, ACC information requests, Coroners Requests Coordinate Divisional governance arrangements, certification and related audit processes Controlled Documents Measure, report and improve performance against care standards, KPI s and clinical/patient safety indicators Standards/Achievements Through quality assurance, advice and coordination ensure there is timely, coordinated and appropriate resolution of patient complaints, incidents / adverse events, information requests, including the development and implementation of corrective actions. Ensure (leading where appropriate) that investigations/root Cause Analysis (RCA s) are timely, unbiased and meet best practice standards and CM Health values. Build staff capability in complaint and incident/adverse event investigation and management, including RCA training. Ensure Divisional governance meetings are coordinated and delivered and incorporate sign off as required, reporting, incidents, quality KPI indicators, care standards and risks and learning from complaints in a systematic way. Co-ordinate certification processes, including corrective action development and monitoring, for the Division. Audit, monitor, and evaluate processes for compliance with standards and best practice, and initiate change where appropriate. Provide feedback to all staff within the services by documenting/disseminating results of audits and assisting with the development of action plans as appropriate. Manage the process by which all Policies, Procedures and Guidelines are current, necessary and adhered to. Contribute to the development of standards of practice, protocols/policies for the service and organisation as appropriate. Support (leading as required) quality improvement activities arising from the learnings and recommendations from Feedback and Adverse Events and analysis of trends. Position Description: Clinical Q&R Mgr ARHOP, Counties Manukau Health 4

5 Key Accountabilities (Continued) Support the effective identification and management of risk. Other duties Commitment to the principles of Treaty of Waitangi Honouring Diversity Utilise Information Technology Standards/Achievements Support the development (as appropriate) and implementation of a programme of audit to improve clinical effectiveness, performance against care standards, KPI s, and clinical/patient safety indicators. Build staff capability with audit and other quality improvement methodology. Ensure managers maintain and update the service risk register and actively seek solutions to the issues raised. Provide advice to staff and managers on risk management Attend relevant Divisional and Organisational and other quality related meetings. Other duties as required Respect, sensitivity and cultural awareness is evident in interpersonal relationships. Our differences are acknowledged by respecting spiritual beliefs, cultural practices and lifestyle choices. Demonstrate ability to access and use available clinical information systems. Be conversant with applications required for specific discipline/role. Maintain own professional development by attending relevant IT educational programmes. Position Description: Clinical Q&R Mgr ARHOP, Counties Manukau Health 5

6 COMMUNICATION AND INTERPERSONAL SKILLS Will be required to interact on a regular basis with a range of Counties Manukau Health staff members including: Head of Feedback/Adverse Events, Service Managers, Clinical Nurse Directors, Clinical Heads, Clinical Directors, Directors of Nursing and Allied Health, General Managers, Director of Hospital Services, Director of Patient Care, Chief Nurse and Allied Health Professions, Chief Medical Officer, Finance & Business Manager, ELT, Maori and Pacific Health Teams, Ko Awatea, Strategic Project Management Office, and other Clinical Quality and Risk Managers. Externally there will be contact with: General Managers Localities Patients and their Whaanau Other DHBs Ministry of Health Regional and National Steering Groups & Forums Health & Disability Commissioner s office Situations may often call for tact, diplomacy and will require information to be handled in a discreet and sensitive manner. In conflict situations will be required to exercise sound judgement, negotiation and persuasiveness skills, toward facilitating a workable outcome. PROBLEM COMPLEXITY You will be regularly challenged by a wide range of conflicting demands and priorities. There will be a requirement to be able to prioritise issues and negotiate time frames, while still providing a quality customer service. The range of problems will be diverse and require solutions customised to meet the circumstances of the client. Therefore opportunities will arise to provide innovative options to the client based on proven outcomes. There will be demands to meet deadlines, maintain accuracy and quality of information. Failure to do so could have a significant financial and/or reputational impact on the organisation. You will refer to General Manager, ARHOP and Clinical Heads/Directors for advice or second opinion. SCOPE FOR ACTION You are empowered to make decisions or recommendations relating to the ARHOP Division within delegated authority limits. You are encouraged to use initiative and problem solving skills to develop innovative approaches to issues. Discretion is required to be exercised in releasing confidential information to the appropriate parties. Position Description: Clinical Q&R Mgr ARHOP, Counties Manukau Health 6

7 Matters which must be referred to either the General Manager or Clinical Director: Significant quality or safety issues Significant legal issues Serious clinical standards failure Any emerging factors that could prevent achievement of agreed objectives Any emerging factors that could prevent delivery within agreed budget Any matter that may affect the reputation of the services or organisation Significant financial issues Significant human resources issues DIMENSION OF THE POSITION You will be responsible to the General Manager ARHOP for the achievement of agreed objectives and operates within the confines of Counties Manukau Health. POSITIONS REPORTING IN THIS ROLE (numbers) Directly (numbers) : 0 Indirectly (numbers) : 0 PERSON SPECIFICATIONS (requirements for the role) Minimum Qualifications Health Professional Experience (including years) Tertiary qualification relevant to health Post graduate qualification or equivalent in relevant clinical area. 5 years post qualification clinical experience Experience developing a culture of innovation, performance, transparency and customercentric service. Experience in delivering sustainable system and process performance improvement. Preferred Masters in relevant discipline Position Description: Clinical Q&R Mgr ARHOP, Counties Manukau Health 7

8 Minimum (Continued) Experience in delivering change and performance with and through teams, by engaging them in the directions and delivery of plans, establishing clear work priorities, delegating effectively, ensuring capability to deliver, monitoring performance, and providing timely, regular feedback. Skills/Knowledge/ Behaviour Strong track record of managing complexity and risk whilst maintaining high standards of service delivery. Experience managing wideranging stakeholders. Knowledge and understand of medical/legal and ethical responsibilities. Project management experience Experience in certification and accreditation processes. Experience managing adverse events and complaints, including Root Cause Analysis process Sound knowledge of the Treaty of Waitangi with a commitment to biculturalism. Excellent communication skills. Ability to manage conflict. Consultative leadership style. Strong business acumen, seeing both short and long-term impacts of decision making. Strong verbal and numerical reasoning capability. Ability to work effectively with others (internally and externally) to accomplish organisational goals and objectives. Preferred Understanding of the NZ health and political sectors. Accepting of new ideas, assimilates new information, and application of this knowledge. Position Description: Clinical Q&R Mgr ARHOP, Counties Manukau Health 8

9 Minimum (Continued) Knowledge of quality management principles and improvement practices. Personal Qualities Sets and operates within the highest ethical and professional standards. Shows sensitivity to cultural complexity in the workforce and patient population Ability to build strong effective teams and networks Preferred Understanding of Quality Improvement methodologies and tools. Position Description: Clinical Q&R Mgr ARHOP, Counties Manukau Health 9

10 HEALTH AND SAFETY ACCOUNTABILITIES (Management Roles) Health and Safety (H&S) is a key accountability of all Counties Manukau Health (CM Health) staff. All CM Health Managers are responsible to: Zero harm Engage in safe workplace practices and manage the health and safety of your employees and other people in the workplace Engage in safe work practices Ensure all Incidents involving staff are reported, investigated and any corrective actions are completed and closed off when completed in the Incident reporting system in line with CM Health Policies and Procedures Ensure all corrective activities are completed and controls are reviewed after incidents Ensure all staff are Inducted/Oriented to the division/service/work area and recorded in the OneStaff database and participate in Occupational Health and Safety matters Risk management Safety Management System Requirements Work safely Manage all hazards, risks and incidents in the workplace by identifying, evaluating, reporting and controlling them effectively by maintaining a Hazard and Risk Register that is reviewed and kept up to date on an ongoing basis Stop work where there is an immediate risk of serious harm and escalate to the appropriate manager Maintain Occupational Health of employees due to workplace hazardous exposures Ensure you and the employees understand and follow CM Health s Occupational Health and Safety policies and Health and Safety regulations, what your responsibilities are under the policies and implement these requirements effectively into your work area Manage the work area s risk profile and how these relate to the corporate risk profile and implement and resource mitigation controls Engage your employees to participate in Occupational Health and Safety matter. Report for duty in a fit state, free from the influence of alcohol or other drugs Provide and wear the necessary Personal Protective Equipment for yourself and your staff when undertaking specific activities, or when in nominated areas Ensure procedures are in place for clinical and plant equipment to be operated safely Participate in relevant safety training, manage and maintain safety related competencies for yourself and your employees Be in possession of required and current Certificates of Competency (If relevant to your position) Position Description: Clinical Q&R Mgr ARHOP, Counties Manukau Health 10