JOB DESCRIPTION. Clinical Governance and Quality, Borders General Hospital. Clinical Governance Facilitator for Patient Safety.

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Juniper McLaughlin
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1 JOB DESCRIPTION 1. Job Identification Job Title: Clinical Risk Facilitator Job Reference: Department & Base: Responsible To: Hours of Work: Date JD Written / Updated: SS911 Clinical Governance and Quality, Borders General Hospital Clinical Governance Facilitator for Patient Safety Full time 37.5 hours per week January Job Purpose To facilitate the co-ordination of clinical adverse event management systems and processes across NHS Borders and have the operational lead role for Clinical Adverse Event Management within the Clinical Governance and Quality Team. Supporting the development of a just culture in NHS Borders using a human factors approach. To manage the screening, interpretation, and analysis of coding of Adverse Clinical Event reports on Datix, and the collation of correspondence and communications related to Clinical Risks. To provide specialist advice and guidance in the management of adverse event reviews. To facilitate and support clinical staff and managers to develop proactive approaches to managing clinical risk and creating a positive patient safety culture. To provide specialised on the job training, advice and guidance on the completion of clinical adverse event reporting templates on Datix. To ensure that clinical adverse event recording, monitoring and review systems are in place and that lessons learned from the analysis of adverse events inform service review and development. To ensure the information in the clinical adverse event database is accurate and complete and is used to inform quarterly and annual reporting. Job Description 1

2 3. Organisational Position Medical Director Head of Quality and Clinical Governance Clinical Governance Facilitator - Safety Clinical Governance Facilitator - Effectiveness Clinical Governance Facilitator Person Centredness This Post Clinical Risk Facilitator 4. Scope and Range This is an NHS Borders wide post. NHS Borders provides the full range of hospital based services such as acute, community and day hospitals, and covers a population of 109,700. In addition, NHS Borders is responsible for the delivery of the full range of Primary Care and Mental Health Services and is jointly responsible with Scottish Borders Council for Learning Disability Services. Clinical services within NHS Borders are organised under four Clinical Boards, Borders General Hospital, Borders Primary and Community Services, Mental Health and Learning Disabilities. The post holder is a member of the Clinical Governance and Quality Team, which functions across NHS Borders. There is no budgetary responsibility. OUR VALUES IN ACTION Care and Compassion Quality and Teamwork Dignity and Respect Openness, honesty and responsibility Job Description 2

3 5. Main Duties/Responsibilities Management of Clinical Adverse Event Reports Detailed inspection, interpretation and analysis of all the information reported on the Clinical Adverse event System, Datix, informing judgement about the appropriate action and level of follow-up required for each individual adverse event. Responsible for the production of quarterly and annual reports, and ad-hoc statistical data as required for meetings and departments, as well as response to freedom of information requests. Contribute to the development, implementation and review of the clinical adverse event strategy and policy, addressing national drivers and local needs. Undertake, with the Clinical Governance and Quality Facilitator Patient Safety, thematic review of adverse event data to inform the focus of improvement activities and the patient safety programme. Promote the principles of a Just culture in the management of adverse events ensuring appropriate support is deployed for patients, families and staff during the adverse event review process. Liaison with patients, families, staff and external governing bodies to provide support and guidance throughout adverse event review. Reviews and reports Alert line manager and Head of Quality and Clinical Governance as appropriate about any high profile adverse events and communicate with the Director of Nursing and Midwifery, Medical Director, Associate Medical Director for Clinical Governance and Quality and senior managers as appropriate regarding major and extreme adverse events. Oversee the arrangement of and facilitate adverse event review processes making sure these are carried out within appropriate timescales. Compile, and produce documents and reports from complex information using Root Cause Analysis methodology and tools, collating information gathered from written communication with staff and from health records - >40% of this post entails interpretation of frequently complex information. Support internal processes where there are adverse event management implications e.g. Fatal Accident Inquiries, complaints and claims. Oversee appropriate responses to outcomes and learning from adverse event reviews and investigations. Present regular updates on Clinical Risk activity and investigations to the Clinical Governance Groups and Clinical Board Level Groups, as required. Training Facilitate the development and maintenance of staff s ability and clear understanding of grading of incidents through provision of specific training in the use of the Risk Matrix. Coach other staff in the use of a human factors approach and root cause analysis techniques in the review of adverse events. Responsible for ensuring that the Clinical Risk internet microsite is maintained. Other Influences departmental policies within own and other work areas and advises on any changes necessary as a result of new guidelines or legislation. Contribute to the self-assessment processes leading to external peer review by bodies such as Healthcare Improvement Scotland. Ensure Data Protection legislation is adhered to. Respond to Freedom of Information requests as required. Job Description 3

4 6. Systems and Equipment Competent use of networked computer including Microsoft Office applications and in particular Word and Excel. Use of specialised computer programmes Datix. Use of telephone and other general office equipment including photocopier, printers, shredder. Knowledge of Patient Information Systems i.e. TRAK, SciStore and E-Pex. Responsible for manual and electronic filing systems / orders and maintains stationary stocks as required. Willing to undertake training in the use of other appropriate software 7. Decisions and Judgements The post holder will have a high level of autonomy in the management of their workload and be expected to anticipate problems taking preventative/corrective action as appropriate. The post holder will be required to assess and prioritise the workload as appropriate, according to the quantity and severity of adverse events arriving on a day-to-day basis, planning own workload around unpredictable and conflicting demands e.g. dealing with queries from staff at all levels and from different areas, managing ongoing reviews and new adverse events arriving. There is a requirement to process complex information, in relation to clinical incident reporting and review. Making decisions as to the severity of adverse events based on the information given. The post holder is responsible for deciding the level of follow up required for each adverse event and to take actions accordingly and work within appropriate timescales. The post holder advises managers and clinicians on decision making regarding communications of adverse events with other areas/managers re collaborative actions and feedback. The post holder will be required to recognise/decide when Senior Managers, Line Managers and the Head of Quality and Clinical Governance should be alerted about significant adverse events and when to escalate to significant adverse event review. Identifies where trends in statistical data require escalation to the next level of review or to Senior Management level. Will be required to assess and guide staff undertaking reviews in the use of the NPSA decision tree to ensure appropriate pathways are following in the management of adverse events. Job Description 4

5 8. Communications and Relationships Adhere to Data Protection, Caldicott Guidelines and NHS Borders policies relating to information and confidentiality. The post holder is required to provide specialist advice to and have key relationships with frontline healthcare professionals and work with a wide variety of disciplines, agencies and organisations, having an understanding of their roles and terminology. The post holder requires highly developed communication and interpersonal skills. They will be required to advise/persuade individuals and groups to gain co-operation where there may be resistance/barriers to change or to acceptance the information. The post holder will require positive negotiation and motivation skills to influence change within and out with area of direct responsibility. They will be required to be supportive to staff during highly stressful situations. The post holder will be required to be effective at networking with healthcare professionals, multi-disciplinary teams and departments and various services within NHS Borders. Liaises and maintains regular communication with other services out with NHS Borders as shown in table: Internal to the organisation Board and Joint Executive Team members Clinical Governance and Quality teams Training and Development Department Clinical teams, staff and managers across NHS Borders Clinical support services Medical Records Risk, Health and Safety Specialist Advisors PMAV, Moving and Handling, Information Governance etc External to the organisation Healthcare Improvement Scotland Scottish Ambulance Service Scottish Borders Council Social Work Procurator Fiscal Central Legal Office Police Scottish Ambulance Service Local Groups Directorate Governance Groups Topic Improvement Groups such as Falls, Frailty, Pressure Damage, Medicines, Infection Control BGH Integrated Clinical Governance Group PCS Integrated Clinical Governance Group MH Integrated Clinical Governance Group LD Integrated Clinical Governance Group Board Clinical Governance Committee Attend local and managerial meetings and report on Clinical Risk activity and update on investigations. Meet 4-6 weekly with line manager to update, discuss progress, identify problem areas and plan actions to address issues. Job Description 5

6 9. Physical Demands of the Job The post requires prolonged periods of intense concentration, a high degree of accuracy and the ability to retain and communicate complex and sensitive information. Frequent/daily computer use for prolonged periods of time. Frequent interruptions by staff, telephone and other colleagues often whilst trying to complete complex pieces of work within set timescales and deadlines. Ability to drive and travel widely within NHS Borders. Dealing with all levels of staff in tense and on occasion distressing circumstances and barriers to change and/or questioning. 10. Most Challenging/Difficult Parts of the Job Unpredictability of workload entailing a need to frequently reprioritise and alter plans, balance competing demands and accommodate the needs of clinical areas/staff, whilst ensuring timely and appropriate investigation is initiated. Requirement to manage several reviews at one time. Working across the Organisation with a wide variety of staff from different disciplines, all with differing levels of understanding of Clinical Risk Management. Supporting staff in highly emotional situations when dealing with adverse event follow-up and reviews. Frequent exposure to difficult and distressing issues. Managing to create a positive clinical risk and patient safety culture and having a positive impact on the way in which Clinical Risk Management is perceived throughout the organisation. Job Description 6

7 11. Person Specification Knowledge Training and Experience Required 1. Qualifications Clinical qualification Essential The post holder must be educated to degree level or equivalent Evidence of study at post graduate diploma level or the equivalent training and experience 2. Experience Relevant experience post registration, working in a clinical setting with a wide range of knowledge of clinical areas, and NHS working Specialist experience and knowledge of Clinical Risk Management, adverse event reporting system systems and processes, human factors and investigation methodologies Experience and knowledge of coding information and data analysis Experience and knowledge of risk assessment, root cause analysis Experience and knowledge of audit and surveys Experience of presenting information at meetings Experience in delivering training Experience of supporting, motivating and negotiating with staff groups Experience of managing situations where difficult and contentious issues have been addressed Line management experience Job Description 7

8 3. Skills Excellent communication and interpersonal skills Ability to build effective working relationships and work in partnership Excellent IT skills including competent use of Microsoft Office Ability to process complex information and produce reports Report writing skills Pays attention to detail Has a systematic approach Presentation skills Ability to work flexibly Excellent time management skills Ability to anticipate problems and take preventative/corrective action Ability to work under pressure and to strict deadlines Able to work on a variety of projects simultaneously and prioritise workload 4. Personal Qualities Must be willing, and have the ability to travel widely within NHS Borders Ability to work autonomously and as part of a team Ability to remain calm in circumstances that may be distressing and hostile 5. Other Willingness to undertake further training if required Job Description 8

9 TERMS AND CONDITIONS Grade and salary: Hours of work: Annual leave: Public Holidays: Superannuation: scheme. Band 6: 26,302-35,225 per annum pro rata Permanent 37.5 hours per week 27 days per annum pro rata Details of other types of leave entitlement (such as sick leave) are set out in the Agenda for Change handbooks. 8 days per annum pro rata on dates designated by NHS Borders Details of other types of leave entitlement (such as sick leave) are set out in the Agenda for Change handbook. The post-holder is entitled to join the NHS superannuation pension If Unsuccessful: If you have NOT heard from us within 4 WEEKS of the closing date, then we regret that your application has not been successful on this occasion. However, we appreciate your interest in working with NHS Borders and your time and effort in completing the application form. We would welcome your application for future posts. Equal Opportunities: In NHS Borders, we believe that all staff should be treated equally in employment. We will not discriminate against any member of staff, or job applicant, on grounds of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex and sexual orientation. Trade Union membership. Disclosure checks: We carry out criminal record checks on new staff who fall within certain staff groups within NHS Borders, through Disclosure Scotland. We send out Disclosure Forms to all shortlisted candidates for these staff groups, and ask for these to be completed and returned at interview. If a successful-at-interview candidate forgets to bring their completed form to interview, then they will be required to return the form (and proofs of identity) within 7 days, otherwise the provisional job offer will be withdrawn. Unsuccessful candidates forms will be shredded. The Rehabilitation of Offenders Act does not apply to this post. Tobacco policy: We have a Tobacco policy in place. When selecting staff, we do not discriminate against applicants who smoke, but staff must observe our policy on smoking. Job Description 9

10 Hepatitis B: We offer Hepatitis B immunisation through our Occupational Health Service (OHS). If you think you may be at risk of contracting Hepatitis B through your job, you should ask for this immunisation at OHS. If your work involves exposure-prone procedures, you must keep to the document Protecting Health Care Workers and Patients from Hepatitis B, and the NHSiS Management Executive Directive on this issue. You must be immune to Hepatitis B, and if you cannot prove that you are immune, OHS will investigate to find out whether you are Hepatitis B positive or not. Health and Safety at Work: You must look after the health and safety of yourself and anyone else who may be affected by what you do at work. You must also co-operate with us to make sure that we keep to legal and organisational safety regulations. You can get more information from the NHS Borders Health & Safety Adviser. The closing date for completed application forms is: 5pm on Thursday 25 February 2016 Job Description 10

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