JOB TITLE: Quality & Patient Safety Manager 1. PURPOSE OF POSITION Quality is an integral component of health in New Zealand. The Health Quality & Safety Commission (a standalone Crown agency) in its Statement of Intent 2014-2018 aims to achieve improved quality, safety and experience of care, improved health and equity for all populations and achieve the best value from public health system resources. This means doing the right thing, and doing it right, first time. The Taranaki DHB has a culture of high expectation in regard to standards, quality processes and systems and strives to ensure that risk is identified and mitigated and that the best patient care services are funded within available resources. This senior operational leadership role is responsible for assisting the General Manager Quality & Risk accomplish the Taranaki DHB s objectives of providing leadership, direction and accountability for effective integrated quality and risk management systems and processes that result in continuous improvement, increased patient safety and managed risk. At this stage, accountability and responsibility for integrated systems, processes and outcomes for the Manager Quality and Patient Safety primarily relate to: Patient Safety Clinical Risk Management Quality Improvement and Assurance Infection Prevention and Control Customer Services Privacy Consumer Participation Certification This position description is indicative and may change dependent on the needs of the organisation and the skills of the successful person. 2. ORGANISATIONAL VALUES The Taranaki DHB is committed to the strategic actions and behaviours of Work Together : Treating people with trust, respect and compassion Communicating openly, honestly and acting with integrity Enabling professional and organisational standards to be met Support achievement and acknowledging successes Creating healthy and safe environments Welcoming new ideas 3. DIMENSIONS Reports to: General Manager Quality & Risk Number of people reporting to you 7 Financial limits authority $10,000 Operating Budget Approximately $390,000 per annum Page 1 of 7
4. WORKING RELATIONSHIPS External Ministry of Health Health Quality & Safety Commission HealthCert Office of the Health & Disability Commissioner Office of the Privacy Commissioner Department of Internal Affairs HealthShare Canterbury DHB (Infection, Prevention & Control) Midland Quality & Risk teams Internal Clinical and Non-Clinical Team Leaders and Managers Clinical Board Committees of the Clinical Board Chief Medical Advisor Director of Nursing and Midwifery Nursing Directorate Team Quality & Risk Team 5. ACCOUNTABILITIES Key area of responsibility 1. Team Leadership and Management Provide operational leadership direction and ensure high performance of the Quality and Patient Safety team. 2. Individual Development and Performance Recruit or insource required resources and provide development opportunities for individual team members, both professionally and personally. Expected outcomes Provide clarity around purpose and goals for the team and constantly communicate this direction. Demonstrate absolute commitment to consistency in the leadership and management of the team. Ensure the Quality and Patient Safety team s operational, financial, FTE/staffing goals and targets are met. Measure and communicate team performance and achievements. Build and develop a strong operational team culture within the team as well across teams resulting in the highest quality. Promote innovation, information and idea sharing within and across team. Provide a safe and healthy workplace. Assume the Acting General Manager Quality & Risk role, including delegated authority, as required. Recruit and select new staff in accordance with Taranaki DHB guidelines. Negotiate individual contracts and manage contractual obligations of employment contracts for team members. Identify and provide appropriate training/development opportunities for team members. Manage individual performance effectively, including managing out poor performance. Recognise and respond to motivational and empowerment issues. Set and evaluate key individual performance measures. Last Updated: May 2017 Page 2 of 7
Key area of responsibility 3. Quality Culture and Improvement Establish a high level of commitment to quality within the Quality and Patient Safety team. Develop a service culture which is consumer focused and performance driven. 4. Patient Safety, Quality Improvement and Assurance, Risk Management and Legal Compliance Operations Accountable for developing and implementing effective DHB wide operational policies, procedures and systems that increase patient safety, enable quality improvement and assurance, reduce risk and ensure legal compliance. Expected outcomes Ensure continuous improvement that focuses on increasing patient safety and decreasing clinical risk. Champion a proactive patient safety, quality improvement and risk management culture that reflects best practice, is consumer centred and incorporates consumer participation. Ensure obligations under the HDC Health and Disability Consumers Code of Rights are met and the DHB s consumer complaints system is consumer centred and responsive to consumer issues. Ensure that quality improvement science methodology, including robust evaluation and ongoing monitoring, is effectively utilised. Take responsibility for ensuring the DHB s hospitals comply with Ministry of Health certification requirements. Provide appropriate information and facilitate education to support patient safety, quality improvement and assurance and clinical risk management. Support the management of clinical governance matters. Ensure direct reports effectively and efficiently manage, evolve and are accountable for their areas of operational responsibility including but not limited to: Patient Safety Quality Improvement and Assurance Clinical Risk Management Legal compliance, including but limited to: o Certification o Infection Prevention and Control o Health and Disability Consumers Code of Rights o Privacy Act and Health Information Privacy Code o Public Records Act Organisational Accountabilities Expected Outcome for all Managers and Team Leaders Health Equity The TDHB strives to eliminate health inequalities and achieve health equity for the Taranaki population. In practical terms this means all Managers, Team Leaders and roles with responsibility for managing staff, are required to implement relevant health equity policies, procedures, approaches and guidelines issued from time to time including: Implementing the Pae Ora Framework which requires: o Demonstrating the principles of Partnership, Participation and Protection under the Treaty of Waitangi; o improving understanding of the determinants of ethnic inequalities in health, in particular the Drivers of ethnic inequalities in health and the Pathways to Inequalities Last Updated: May 2017 Page 3 of 7
Organisational Accountabilities Expected Outcome for all Managers and Team Leaders Health and Safety both of which are referenced in the TDHB Pae Ora Framework, Appendix 1; o Enabling Māori participation in design and delivery of services; o Ensuring Health Equity assessment is undertaken with appropriate input where services, policies or programmes are expected to improve outcomes for Māori; o Ensuring appropriate health literacy responses are developed and implemented to support effective engagement with and delivery for Māori and high needs communities; Taking affirmative action to increase the Māori workforce within your team according to the Māori workforce targets set for the TDHB; Providing leadership for self and team to: o Review clinical practice and those of your peers, through a health equity and quality lens; o ensure collection of high-quality ethnicity data according to the TDHB Ethnicity Data Collection Policy and procedures; o audit, monitor and evaluate health impact and outcome data to improve the delivery of high-quality health care for Māori; Provide critical analysis of those organisational practices that maintain disparities in health care. The Taranaki DHB is committed to ensuring that a safe and healthy work environment is achieved and maintained. All Team Leaders and Managers will support the DHB s health and safety culture by: Planning, organising and managing health and safety activities directed at preventing harm and promoting health and wellbeing in the workplace. Following, implementing and ensuring compliance of all Health and Safety policies, procedures and processes. Working closely with and supporting the Health and Safety Representative(s) role. Ensuring a safe working environment and work practices through risk and hazard identification and management. Ensuring health and safety is a standard agenda item in all meetings. Ensuring health and safety reported events are followed up and closed off within required timeframes. Ensuring health and safety audit activity occur; results reviewed and improvement actions implemented. Ensuring health and safety management accountability for all direct reports is monitored and reviewed as part of the performance review process. Last Updated: May 2017 Page 4 of 7
Organisational Accountabilities Expected Outcome for all Managers and Team Leaders Actively supports staff rehabilitation and provides return to work options. Ensuring health and safety related Key Performance Indicators are measured, reported and performance monitored. Personal Development Fully contributes to the individual s team performance and is committed to identify and pursue opportunities for developing new knowledge and skills. Participates in the performance appraisal process where personal performance and development is reviewed. Willing to accept new responsibilities, acquire and demonstrate relevant new knowledge. 6. VARIATION TO DUTIES Duties and responsibilities described above should not be construed as a complete and exhaustive list as it is not the intention to limit in any way the scope or functions of the position. Duties and responsibilities can be amended from time to time either by additional, deletion or straight amendment to meet any changing conditions, however this will only be done in consultation with the employee. 7. CAPABILITY REQUIREMENTS Capabilities are the behaviours demonstrated by a person performing the job. Capabilities identify what makes a person most effective in a role. Those listed below are expected for the Manager and Team Leader roles in the organisation. The required capabilities can change as the organisation develops and the roles change. Capability Be a Values Leader Understand own leadership style; develop self; display trust and integrity; be resilient and adaptable. Engage Others Develops others; motivate and empower; demonstrate care and respect; communicate effectively; foster a positive culture. Develop Coalitions Build constructive relationships; create opportunities for thinking and working across boundaries; promote and demonstrate diversity of thinking, ideas and approaches; display team work and lead collaboratively. Leading Care Demonstrate an understanding of the purpose of care and the needs of those providing and receiving care; connect DHBs purpose and value to the unit s work; model responsibility and Last Updated: May 2017 Page 5 of 7
Capability accountability; identify and implement strategy and tactics for achieving the purpose; demonstrate a commitment to the principles of Te Tiriti o Waitangi; maximise the contribution of all staff to identify and remove barriers to addressing inequaliies; achieve results related to the provision of great care. Mobile System Improvement Estagblish evidence based decisions; enable a culture of continuous improvements; establish the change imperative; demostrate organisational and political agility; idnetify innovations and support their adoption; nurture organisaional learning. Managing Vision and Purpose Communicates a compelling and inspired vision or sense of core purpose; talks beyond today and about possibilities; makes the vision sharable by everyone; can inspire and motivate entire units. Managerial Courage Doesn t hold back anything that needs to be said; provides current, direct, complete, and actionable positive and corrective feedback to others; lets people know where they stand; faces up to people problems on any person or situation quickly and directly; is not afraid to take negative action when necessary. Business Acumen Knows how businesses work; knowledgeable in current and possible future policies, practices, trends, technology and information affecting their business and organisation. Drive for Results Can be counted on to exceed goals successfully; is constantly and consistently one of the top performers; very bottom-line orientated; steadfastly pushes self and others for results. Intellectual Horsepower Is bright and intelligent; deals with concepts and complexity comfortably; described as intellectually sharp, capable and agile. Standing Alone Will stand up and be counted; doesn t shirk personal responsibility; can be counted on when times are tough; willing to be the only champion for an idea or position. Political Savvy Can manoeuvre through complex political situations effectively and quietly; anticipates issues and plans their approach accordingly; views politics as part of organisational life and adjusts to that reality. Strategic Agility Sees ahead clearly; can anticipate future consequences and trends accurately; has broad knowledge and perspective; is future orientated; can crate breakthrough strategies and plans. Organisational Agility Knowledgeable about how the organisation works; knows how to get things done through formal Last Updated: May 2017 Page 6 of 7
Capability channels and the informal networks; understands the origin and reasoning behind key policies, practices, and procedures and understands the culture of the organisation. 8. EDUCATION A tertiary health related qualification. 9. SKILLS A proven leadership / management record. Ideally this will include experience in patient safety, quality improvement and assurance, risk management and legal compliance. 10. EXPERIENCE A clinical / health professional background Senior health management experience. An understanding of the District Health Board environment. Last Updated: May 2017 Page 7 of 7