POSITION DESCRIPTION Clinical Audit Facilitator Mental Health Services Date Produced/Reviewed: September 2014 Position Holder's Name... Position Holder's Signature... Manager / Supervisor's Name... Manager / Supervisor's Signature... Date... Document ID: Obtain from Objective Version: 1.0 Department: Name of Department Last Updated: September 2014 Document Owner: Person s Title Next Review Date: September 2016 Approved by: Name of Approval Group/Committee Date First Issued: dd/mm/yyyy Counties Manukau District Health Board
Purpose of the Position Working within Mental Health service, the Clinical Audit Facilitator is responsible for designing, project managing and undertaking clinical audits aimed at producing changes to practice and improving the care delivered to our patients. Under the direction of the Research Committee, the Clinical Audit Facilitator assists with setting the services audit programme and co-ordinates and monitors clinical audit activities across Mental Health services. The Clinical Audit Facilitator also supports and facilitates building capability in other staff, by sharing knowledge, assisting in audit design and developing an organisational culture of audit, continuous improvement and evidence-based practice. Vision & Values Organisational Shared Vision Our DHB shared Vision is to work in partnership with our communities to improve the health status of all, with particular emphasis on Māori and Pacific peoples and other communities with health disparities. We will do this by leading the development of an improved system of healthcare that is more accessible and better integrated. We will dedicate ourselves to serving our patients and communities by ensuring the delivery of both quality-focussed and cost effective healthcare, at the right place, right time and right setting. Organisational Values Partnership Care and Respect Professionalism Teamwork Innovation Responsibility Working alongside and encouraging others in health and related sectors to ensure a common focus on, and strategies for achieving health gain and independence for our population Treating people with respect and dignity, valuing individual and cultural differences and diversity We will act with integrity and embrace the highest ethical standards Achieving success by working together and valuing each other s skills and contributions Constantly seeking and striving for new ideas and solutions Using and developing our capabilities to achieve outstanding results and taking accountability for our individual and collective actions Page 2 of 11
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Mental Health DAMHS Clinical Director General Manager MH Act Coordinator Executive Assistant Office Admin Clinical Nurse Director Clinical Quality & Risk Manager Professional Leaders Professional Leader Consumer, Family/ Whanau Centred Care Service Development & Improvement Leader Business Manager Human Resources Registrar Training Facilitator (0.4) Workforce Development Co-ordinator Clinical Audit Facilitator Quality Coordinators Consumer Advisors Family Advisor PER Team Finance And Information Clinical Head Youth Service Manager Child & Youth Clinical Head Infant, Child & Family Clinical Head Integrated Care Adult Service Manager Integrated Care Adult Clinical Head Acute &Hospital Service Manager Acute & Hospital Clinical Head MHSOP Personal Assistant Assessment & Liaison He Kaakano EPIT Maternal Infant & Child Youth Vaka Toa Tamaki Oranga Te Rawhiti Manukau Awhinitia The Cottage Personal Assistant Taumata ICT Te Puna Waiora Faleola Personal Assistant Psych Liaison Adult Acute Pathway Watchhouse MHSOP Community Tiaho Mai Koropiko Dual Disability Page 4 of 11 W:\Mental Health\Admin Office\Organisational Structure\ Current Structure
Nature and Scope of Responsibilities Key Accountability Standards / Achievements Assist the Clinical Director in developing a Design and implement clinical audit programme clinical audit programme Implement the programme and other audit activities by undertaking audits, assisting others to undertake audits and suggesting developments. Ensure all audits comply with organisational requirements for audits and are approved as audit projects by the Research Office Maintain accurate, up-to-date records of ongoing clinical audit projects Co-ordinate the involvement of relevant multidisciplinary partners (including specialist clinicians, operational staff, academic partners, patients and service users, etc) in audit projects Report progress and the impacts of projects Advise on ethical issues related to audit design and findings Support development and implementation of clinical audit policies Undertake clinical audit Design audit approaches and tools as necessary Set up a project timetable that is achievable and plan data collection, analysis and report writing so that reports are delivered according to the proposed timescales and format Set up audit project working groups, incorporating multidisciplinary partners and user representatives. Maintain communication with group members keeping them informed about project progress. Conduct literature searches and obtain relevant references. Prepare and submit applications for ethical approval, as appropriate Collect and analyse data, and interpret results, making decisions about whether clinical guidelines are being followed Page 5 of 11
Key Accountability Standards / Achievements Present clinical audit findings to the Research Committee for approval and advice on the development of recommendations. Propose changes to practices and procedures aimed at enhancing patient care. Co-ordinate the Implementation of Liaise with relevant committees and departments to facilitate and ensure the recommendations implementation of audit recommendations and changes to practice. Track the implementation of recommendations and record progress Monitor and assess the impact of changes to practice by undertaking re-audit. Communication of Clinical Audit Findings: Co-ordinate the dissemination of clinical audit reports. Write reports and prepare presentations suitable for a varied audience including lay persons, key stakeholders and clinicians Contribute to writing papers for publication in peer reviewed scientific and academic journals. Write articles for publication in popular media, such as magazines and newsletters where relevant Present findings at conferences, seminars and meetings where relevant. Assist the Clinical Director and MH Research Committee in collating information and preparing clinical audit briefings for relevant committees. Clinical Audit Facilitation and Training: Facilitate the involvement of staff in clinical audit projects by providing general supervision, advice and guidance. Design and deliver training on clinical audit methodologies and processes to staff Assist in the development of good working relationships with internal and external partners to facilitate the development of clinical audit. Undertake reviews of clinical audit proposals and draft clinical audit reports, as necessary. Contribute to promotion of an evidence-based Page 6 of 11
Key Accountability Professional Development Health & Safety To recognise individual responsibility for workplace health and safety under the Health & Safety Act 1992 CULTURAL SAFETY Commitment to the principles of Treaty of Waitangi Honouring cultural diversity Standards / Achievements culture within the service. Maintain and update their own knowledge base as appropriate. Attend educational opportunities and conference relevant to the role. For all Staff: CMH Health and Safety policies are read and understood and relevant procedures applied to own work activities Workplace hazards are identified and reported including self-management of hazards where appropriate Can identify Health & Safety representative for area Respect, sensitivity and cultural awareness are evident in interpersonal relationships. Our cultural differences are acknowledged by respecting spiritual beliefs, cultural practices and lifestyle choices of women and their families. Communication and interpersonal skills The post holder will be required to interact on a daily basis with a range of mental health and other staff across CMH. The post holder will be expected to have excellent communication and negotiation skills as many situations will call for tact, diplomacy and negotiation and will require information to be handled in a discreet and sensitive manner. Using a range of well-developed interpersonal skills, the post holder will motivate, influence, and lead others to improve services. They will be able to present highly complex information and ideas verbally and in writing to ensure messages are conveyed accurately to multi-disciplinary audiences. This will include the use of highly developed presentation skills which will include the Page 7 of 11
post holder using a variety of software applications to aid in the presentation of complex and potentially contentious information. Problem Complexity On a daily basis the post holder will be challenged by a wide range of complex issues and situations. There will be a requirement to be able to prioritise issues and negotiate timeframes, while still providing a quality customer service. The range of problems will be diverse and require solutions customised to meet the circumstances of the service. There is an expectation to provide innovative options and strategies to the service which is either evidence based or developed through use of research processes. The post holder will use analytical skills to develop and interpret complex data and clinical information to inform and develop new solutions based on extending existing systems and processes. It will be critical to monitor and meet deadlines, maintain accuracy and quality of information. The post holder will have the ability to provide judgments derived from the analysis of complex information gathered from a wide variety of sources, and use quality improvement methodologies to demonstrate opportunities for quality improvement gains. The post holder will refer to the Clinical Quality and Risk Manager of Mental Health Services for validation of direction. Scope for Action The post holder is encouraged to use initiative and problem solving skills to develop innovative approaches to issues. The post holder is responsible to initiate, undertake and complete clinical audit activities across the service. Discretion is required to be exercised in releasing confidential information to the appropriate parties. Relationships Internal: Clinical Director, Mental Health Services Clinical Nurse Director, Mental Health Services Professional Leaders, Mental Health Services External: Patients, family/whaanau and carers Private service providers/non-government CMH Quality and Risk Teams NGO s Page 8 of 11
Clinical Quality and Risk Manager, Mental Health Services PER and REAMHS Team Clinical Information Analyst Mental Health Clinical staff management Quality and Risk Managers KO Awatea Dimension of the Position The post holder will be responsible to the Clinical Quality and Risk Manager of Mental Health Services for the achievement of agreed objectives and will operate within the confines of Counties Manukau District Health Board. Positions reporting to this position Directly Nil Indirectly Nil Person Specification Qualification/Training Experience Minimum Tertiary qualification relevant to the role, with demonstrable ability to independently carry out audit research 3 years experience in a health audit and/or research environment in a researcher Preferred Post-graduate research diploma Experience of managing and undertaking clinical audit and health research projects Experience of working in Page 9 of 11
Skills/Knowledge/ Behaviour or support role Understanding of medical and research terminology Knowledge of a range of clinical audit methodologies and procedures Able to design and manage audit projects that vary in complexity and duration Knowledge of relevant legislation and guidelines Able to undertake literature reviews and draw out relevant findings from literature Able to write in a range of styles, from academic papers for publication to popular reports and magazine articles Knowledge and experience of using a range of statistical methods mental health and/or addictions audit and/or research Advanced Microsoft Office skills Knowledge of project management techniques and methods Practical experience of using a range of descriptive and comparative statistical analyses and interpreting the results to produce meaningful outcomes and recommendations Personal and Professional Qualities Self-motivated, flexible and enthusiastic team player, willing to pick up routine and emerging tasks as they arrive Diplomacy, tact, sensitivity, confidentiality Excellent verbal and written English communication skills Customer-focussed High level of personal integrity and selfresponsibility Resilient Sense of humour Ability to work independently Page 10 of 11
and use own initiative Clean driver s licence Excellent organisational skills Ability to reason through practical problems and present possible solutions High level of computer literacy, including Microsoft Office Suite Understanding of the Treaty of Waitangi Able to persuade and influence others to participate in audits and adopt changes to practice Page 11 of 11