Site Governance Lead Job Profile and Person Specification 1
Context Barts Health NHS Trust is one of Britain s leading healthcare providers and the largest trust in the NHS. It was created on 1 April 2012 by bringing together three trusts: Barts and The London NHS Trust, Newham University Hospital NHS Trust and Whipps Cross University Hospital NHS Trust. The new trust has a turnover of approximately 1.1 billion and approximately 15,000 employees. Together our hospitals - Newham University Hospital in Plaistow, St Bartholomew s (Barts) in the City, The Royal London in Whitechapel and Whipps Cross in Leytonstone - deliver high quality clinical care to the people of east London and further afield. The hospitals offer a full portfolio of services that serve the needs of the local community, and are home to some of Britain s leading specialist centres including cancer, cardiac, trauma and emergency care. Barts Health also has one of the UK s busiest children s hospitals and internationally renowned surgical facilities. Our vision is to create a world-class health organisation that builds on strong relations with our partners and the communities we serve one dedicated to ending the historic health inequalities in east London. We will build an international reputation for excellence in patient care, research and education. And as members of UCLPartners, the largest academic health sciences system in the world, we will ensure that our patients are some of the first in the country to benefit from the latest drugs and treatments. We are looking for the best talent to lead our ambitious new healthcare organisation. In return, the Barts Health will provide unsurpassed professional development opportunities, enabling investment in a range of new initiatives that would mean: Doctors and nurses in training will be able to gain experience in different hospitals along the whole patient pathway; there would be greater opportunity for career progression we could retain good staff who might otherwise leave to gain promotion; becoming world-class will enable us to recruit some of the best doctors and researchers in the world who can share their knowledge and experience; joining forces with other partners in an Academic Health Science System will mean that staff would be better able to secure funds and pool their talents to develop new technology, techniques and treatments. 2
1. ROL DTAILS Role Title: Site Governance Lead Grade: Band 7 Location: Accountable to: The post holder will have a primary base but will be expected to work between all sites as necessary Head of Governance 2. ROL PURPOS The post holder will work as a senior member of the site Governance team to lead and deliver a range of quality governance activities at site level and within individual service groups, to ensure compliance with the site s governance and risk framework. This includes effective complaint handling, gathering patient feedback, patient safety, incident reporting and meeting the regulatory requirements of external standards and inspection such as those undertaken by the Care Quality Commission. As Governance Lead the post holder will have a key part to play in the implementation of the site s Safe and Compassionate Quality Improvement plan and activities and in developing a proactive, open learning and improvement culture, in order to reflect Bart s Health ambition to be a leader in safety and health care excellence. 3. KY WORKING RLATIONSHIPS Site xecutive Team (Managing Director, Nurse Director, Medical Director etc.), Head of Governance, Governance Coordinator, Governance Admin staff, General Managers, Service Managers, Clinical Directors, Clinical Service Leads, clinicians, Consultants, Associate Directors of Nursing, Senior Nurses, Matrons, Ward Sisters and Charge Nurses. The post holder will also liaise and work collaboratively with corporate patient safety, health and safety, compliance, central complaints and patient experience teams to achieve the Bart s Health quality and safety strategy improvement objectives through site-based leadership teams and at clinical service level. 4. DIMNSIONS The turnover of the Trust is 1.3 Billion and operates with an establishment of around 16,000. Budgetary: Manages or supervises: Located: None Governance Coordinator and Admin Support Staff St Bartholomew s Hospital Hours: 37.5 Band 7 5. KY RSULT ARAS Contributing significantly to the development and maintenance of a robust site and clinical service line governance and risk framework, leading specific projects and developments as directed by the Site Director of Nursing (DoN) and the Head of Governance 3
Supporting Site xecutive Team (Tier 1) & Tier 2 Site management and the Head of Governance in implementation of the site Safe and Compassionate quality improvement plan Lead role in the on-going development and delivery of the site s patient experience and engagement plans and activities Support the Head of Governance in effective and the timely management of complaints on site, so that trajectories and targets are met on an on-going basis Contributes to meeting CQC regulation standards and supports staff in the preparation for site inspections Works with Service Leads to ensure that robust action plans are developed and implemented following the outcome of a CQC inspection (or mock inspection) or in the event of CQC enforcement action or non-compliance reports Work with the Head of Governance and SI investigators to facilitate the delivery of an effective serious incident (SI) pathway for the site Promote and implement a patient safety culture in all service lines, delivering education and training in all aspects of governance as necessary Provide expert governance advice and support to specified service group(s), including monthly reports and analysis of key issues as necessary Monitor and report site performance against Trust and local key performance indicators and standards, providing support to service lines as appropriate to achieve against those indicators Work with the Tier 2 management team to maintain an effective site risk register in designated service group(s) Plan and monitor implementation of the site and service line clinical audit programme to support quality and patient safety improvement and robust governance, ensuring the results are discussed at the relevant service line/site quality and safety committees, with appropriate action taken as necessary. Demonstrate competent Datix user skills and the ability to train and instruct others in the team and service line staff It is anticipated that safety, quality and clinical outcomes including reported patient experience in service lines will improve on a continuous and sustainable basis through the activities of the post holder in supporting the service lines to achieve. Deputise for the Head of Governance as required 6. MAIN DUTIS AND RSPONSIBILITIS The post holder is expected to: Leadership 4
Have a significant leadership role in the sites delivery and implementation of the Trust s Safe and Compassionate Quality Improvement Plan, leading projects and developments (TtFG) with minimal supervision Act as a catalyst for change and lead quality improvement initiatives, using excellent leadership, communication and negotiation skills Provide supervision and support to the Governance Coordinator(s) and Admin staff by directing / prioritising the work of the whole team Deputise in the absence of the Head of Governance, supporting the Site Director of Nursing by attending meetings, leading and maintaining the governance framework and work of the team In conjunction with the Head of Governance actively seek out best practice and innovation from within the NHS and elsewhere, participating in benchmarking and or research around the topic of governance and risk reduction as appropriate stablish and maintain collaborative relationships and effective team working with clinical leads and managers to ensure increased understanding/compliance with all governance standards and the management of risk Operational Assist the Head of Governance Manager to maintain the site Governance and Risk framework and Risk Register, continuously monitoring the service lines and site position, updating monthly in readiness for presentation at relevant site and Trust wide committees. Demonstrate effective communication with services, and frontline staff on site and Trust wide to provide help and support to a range of governance activities including local resolution, formal complaint handling, incident management and risk assessment and mitigation of risk, monitoring its impact. stablish and maintain good relationships with external key stakeholders e.g. Health watch, patient and service user groups and the local community. To assist in the coordination of and preparation for CQC and other external inspections, including any mock reviews liaising with key personnel, at all levels of the site. nsure the relevant regulations and standards are embedded in practice and evidenced in the delivery of care and services. Responsible for supporting the services in collating that evidence to demonstrate compliance. Work with services to develop action plans to develop areas identified within mock /real CQC as requiring improvement. Work with the Head of Governance to identify services and areas of good practice as well as concern and liaise with the lead professionals to agree a programme of dissemination of good practice, or remedial action, to assist in the setting and maintaining of standards and the reduction of risk Research and keep abreast of national and local Trust and sector developments which impact on the governance service and ensure that these are communicated across the site at the appropriate level. This includes benchmarking the Trust against other providers to identify areas of good practice. 5
nsure that the services maintain accurate and timely Governance records, ensuring the maintenance of quality systems and processes in your own work and that of the governance team valuate the quality of your own work and others within the team, in order to identify risks and improve performance. Support the Head of Governance and through the Trust s Talent and Performance /appraisal process, identify own educational and professional development needs. Contribute to the effective use of the site governance budget and resources. Governance responsibilities Work with the Head of Governance to monitor and support progress against agreed site action plans relating to quality & safety improvement, CQC, risk and governance. Undertake qualitative and quantitative analysis from governance activities as required and directed by the Head of Governance or Site Tier 1 identifying trends and highlighting areas of good practice as well as concern Work collaboratively with site colleagues to agree actions that maintain standards and mitigate identified risk. Arrange and attend meetings relating to site governance and safety, participating in the meetings and taking minutes if required. a) Complaints handling Identify and implement processes to ensure patient/carer concerns are resolved quickly through local resolution (wherever possible) and in line with the Trust Complaints policy, in collaboration with front line teams and the PALs/AIRs service. Be a senior accessible point of contact for service users and their families/carers regarding complaints about services they have received. Provide effective day-to-day management of a complaints case load and when required oversee the overall site complaints service without supervision, ensuring responses are sent within agreed timescales. Develop and communicate the Trust Complaints Policy and processes to all service lines across the site. 6
Provide senior advice and support on both local resolution and effective formal complaints handling and investigation to services, teams, and individuals thereby supporting learning and development. Quality check and where necessary edit draft complaint responses (using track changes and comments so that the lead investigator can learn from your experience) received from lead investigators. Develop tools and training and/or provide access to suitable training, to enable site lead investigators to produce high quality complaint responses. Organize and facilitate complaint and local resolution meetings (LRM) with complainants in order to clarify or resolve concerns. Support the Governance Coordinator in the effective management of LRM s. nsure the sites processes for responding to requests for PHSO second stage complaint reviews are effective and understood across all service lines to ensure that all information is made available and the deadlines for responding are adhered to. nsure statutory duty of candor, transparency and openness in dealing with complainants and complaints across all service lines is adhered to at all times. b) Patient Safety and Risk Management Work with the site Head of Governance on effective risk register management, to ensure it accurately reflects the site risks and is reviewed and updated on a regular basis. Interrogate the risk management database (DATIX), to identify recurrent or adverse trends and work with others to plan remedial action under the leadership of the Tier 1 (site executive) & 2 management teams. Liaise with the corporate safety and compliance teams and clinical staff to ensure action plans to comply with national safety alerts (CAS) are developed, implemented and closed within expected deadlines, ensuring there is evidence available to demonstrate actions taken. Work with the site Head of Governance to ensure an effective SI pathway, ensuring investigators are supported in the SI investigation and a timely / high quality report is produced which is then shared with the family under the Duty of Candor. Attend serious incident meetings and collaborate and assist other sites in SI RCA where required. 7
Attend RCA and investigation training to gain and ensure skills and competencies are maintained. Participate in SI and incident investigation to main RCA investigatory skills and competency To coordinate the processes for the investigation of all reported site and service incidents (including SIs). To ensure that any actions or all recommendations from SI investigations are implemented, in a timely way and that lessons are learned and sustained changes to care and practice made. nsure evidence of actions taken is attached to Datix. nsure statutory duty of candour, transparency and openness in incident and SI management across all service lines. c) Patient experience and feedback To support and co-ordinate the site (service groups) patient experience activities and work streams, working in collaboration with the Patient xperience Leads, including learning from patient complaints, PALs & AIRs issues, triangulating with Friends and Family Test data. Input into the implementation of the Barts Health Patient xperience Strategy at site level, attending the site Patient xperience Board as necessary. Work with the patient xperience leads to co-ordinate mechanisms to obtain patient comments and suggestions, e.g. surveys/observations/interviews, on how to improve the service and environment. This includes promoting the Friends and Family Test (FFT) in all relevant areas to achieve high participation rates for the site. Support the Patient xperience leads in working with service users and the service lines or localities to support a culture which achieves best practice and consistent high performance to improve patient engagement and overall the experience of the service user. Work with the site Head of Governance to ensure a robust site governance system is in place for the development, approval (site Quality Board or equivalent) and implementation of high quality patient information leaflets and site clinical policies and procedures. d) Quality assurance, audit, data collection and analysis Work with the site Head of Governance to undertake qualitative and quantitative analysis from governance activities, identify trends and highlight areas of good practice as well as concern, working with colleagues to agree actions that maintain standards and mitigate risk. Act as an expert Datix User able to create records, design and run reports and support and train others in these skills and competencies Take a lead role to ensure that services identify action plans in response to recommendations made from complaint and SI incident investigations. nsure 8
robust mechanisms are in place for regularly reviewing action plans, ensuring that evidence of completion is submitted to Datix once actions have been closed. Monitor site and service line performance against complaints, incident and SI management targets, escalating poor performance to the site Head of Governance and Site xecutive (Tier 1) where necessary. Work with the site Head of Governance to support implementation of compliance with NIC guidance across all site service lines. ncourage and ensure consultants and clinical teams register all (national and local) audit projects with the CU system. Collate and report the site position in relation to NIC guidance as required liaising with service line Clinical Directors, Senior Nurses and Service Managers to reflect evidence of appraisal, implementation and audit of guidance. Provide reports to groups and committees as required in respect of trends and learning from complaints, incidents, audit, FFT and patient surveys. With the site Head of Governance, undertake regular (quarterly for Quality Assurance Committee) site and service line patient experience (complaint, PALs, AIRs & FFT) thematic analysis to enable shared learning and implementation of actions by services to rectify issues identified. Maintain the integrity of all governance information using agreed methods and procedures. Report site and service data and information clearly, in the required format and at the agreed time. Staff development and training Act as a specialist resource within the site using knowledge and experience of quality governance and risk management to support compliance with regulation & governance standards and in the management of risk. Motivate and support all, to recognise their role in complying with all external standards, regulations and inspections Work with the site Head of Governance to ensure that site-based staff receive the necessary governance training/instruction to manage clinical and non-clinical risk through delivery of or access to appropriate training. Develop and provide teaching and training sessions on effective complaints management and good customer care skills to staff as required. Support new staff induction and encourage good practice in incident reporting and complaints handling by role modeling and leading by example. Use awareness of individuals learning needs and styles to develop education and training to meet those needs and for a range of target audiences. 9
Work with the site Head of Governance to ensure the on-going training and development needs of the Governance Coordinator and Admin Support staff are identified and met through annual appraisal and regular team review and one to ones. The job description is not intended to be exhaustive and it is likely that duties may be altered from time to time in the light of changing circumstances and after consultation with the post holder. ADDITIONAL INFORMATION ffort, skills and working conditions Physical Standard keyboard skills required. High levels of accuracy required skills in handling large volume of data. Facilitation and training Physical effort Mental effort motional effort Working conditions Professional Standards delivery/presentation skills. The role will not normally involve the post holder in a high level of physical activity. The post holder maybe sat at a computer station for prolonged lengths of time or attending meetings. Will be required to travel between multi-trust sites and to relevant local/regional meetings. The post holder will regularly be required to sit and to walk within and between locations The post holder requires high levels of concentration as they deal with heavy demands for a variety of sources Likely to experience frequent and unpredictable interruption due to the operational nature of the post The work is often unpredictable and the post holder may have to adapt to change in a short time frames and be able to deliver revised outcomes or deadlines Frequent requirement for concentration when analysing and interpreting data/information from internal and external sources Frequent concentration when preparing for meetings and report writing The post holder will experience workload pressure and must on occasions be able to work successfully under time or resource constraints Some exposure due to management of staff. Some exposure associated with learning from adverse events and dealing with emotive or distressing events/patient outcome Frequent VDU use involving exposure to VDU screens whilst inputting data. The post holder works across sites in acceptable working conditions. Office based but may need to visit a range of sites and clinical settings. As an NHS Manager, you are expected to follow the Code of Conduct for NHS Managers (October 2002) www.nhsemployers.org/~/media/mployers/documents/recruit/codeofconductfornhs mana gers 2002.pdf. All staff employed in recognised professions are required to ensure they work to the professional standards and/or Codes of Practice set out for their professional group. 10
qual Opportunities and Dignity at Work It is the aim of Barts Health NHS Trust to ensure that no job applicant or employee receives less favourable treatment on the grounds of race, colour, creed, nationality, ethnic or national origin, sex, marital status or on the grounds of disability or sexual preference, or is placed at a disadvantage by conditions or requirements which cannot be shown to be justifiable. Selection for training and development and promotion will be on the basis of an individual's ability to meet the requirements of the job. To this end Barts Health NHS Trust has an qual Opportunities Policy and it is for each employee to contribute to its success. All staff should treat other staff, patients and the public with dignity and respect. Appraisal All staff will actively participate in an annual Appraisal process. All staff should have a personal/professional development plan and in conjunction with their manager, should actively determine and pursue agreed training and development needs and opportunities. Statutory and Mandatory Training All staff need to ensure that their statutory and mandatory training is up to date so that they can work safely and efficiently to provide the very best care to our patients. It is essential that all staff are fully compliant with the Statutory and Mandatory training as outlined in the Trusts Statutory and Mandatory Policy Safeguarding Barts Health NHS Trust is committed to safeguarding and protecting children and vulnerable adults. All health employees have responsibility for safeguarding and promoting the welfare of children and young people in accordance with "Working Together to Safeguard Children" HM Gov 2006. This applies to employees with both direct and indirect contact with children and families. mployees who do not provide specific services for children and families or vulnerable adults require basic knowledge of their responsibilities to identify and refer concerns appropriately. All employees must undertake training in safeguarding children and vulnerable adults but will have different training needs to fulfil their responsibilities depending on their degree of contact with vulnerable groups and their level of responsibility. Confidentiality and Data Protection mployees will have access to confidential information and will be required to ensure that the highest level of confidentiality is maintained at all times, adhering to all policies relating to confidentiality. mployees are required to obtain process and/or use person identifiable information in a fair and lawful way. The use of such information is governed by the Data Protection Act 1998 (DPA) and includes both manual and electronic records. Staff are expected to hold data only 11
for the specific registered purpose and not to use or disclose it in any way incompatible with such purpose, and to disclose data only to authorised persons or organisations as instructed, in accordance with the Data Protection Act 1998. Access to Health Records All staff who contribute to patients health records are expected to be familiar with, and adhere to Barts Health NHS Trust s Records Management Policy. Staff should be aware that patients records throughout Barts Health NHS Trust will be the subject of regular audit. In addition, all health professionals are advised to compile records on the assumption that they are accessible to patients in line with the Data Protection Act 1998. All staff that has access to patients records has a responsibility to ensure that these are maintained and that confidentiality is protected in line with Barts Health NHS Trust Policy. Health and Safety All staff are required to comply with the requirements of the Health and Safety at Work Act and other relevant health and safety legislation and Barts Health NHS Trust Policies and Procedures. All staff are required to make positive efforts to promote their own personal safety and that of others by taking reasonable care at work, by carrying out requirements of the law or following recognised codes of practice and co-operating with safety measures provided or advised by Barts Health NHS Trust to ensure safe working. Managers are responsible for implementing and monitoring any identified risk management control measures within their designated area/s and scope of responsibility. In situations where significant risks have been identified and where local control measures are considered to be potentially inadequate, managers are responsible for bringing these risks to the attention of the appropriate Committee if resolution has not been satisfactorily achieved. All staff must ensure that waste produced within Barts Health NHS Trust is disposed of in such ways that control risk to health, or safety of staff and the public alike in accordance with relevant legislation and procedures contained within the policy. Infection Control Barts Health NHS Trust has made a public commitment to make healthcare associated infection a visible and unambiguous indicator of the quality and safety of patient care and work towards reducing it. All Directors and staff will demonstrate their ownership of, and their support, to this goal through management and corporate action. No Smoking Policy There is a no smoking policy in operation in Barts Health NHS Trust. In accordance with this policy smoking is positively discouraged and is not permitted in any areas. 12
Person specification Post Site Governance Lead Band 7 Site St Bartholomew s Hospital ssential = Desirable = D or D Application form Interview Qualifications and knowledge xperience 1 st level degree or equivalent experience or study Intermediate qualification or demonstrable experience in the use of Microsoft Office Applications Completion of a management qualification or equivalent Comprehensive knowledge of Microsoft Office Applications and use of databases and commercial IT systems Good level of clinical governance knowledge and demonstrable experience of working within a clinical governance arena Comprehensive understanding and knowledge of external assessment or regulation. In the NHS or other public service xperience of working in the NHS D xperience of Governance, Risk Management and/or Health and Safety, which includes the ability to evaluate current local position against national and local standards within the NHS. Complaints handling and investigation experience. xperience of evaluating evidence against prescribed standards for a range of assessments Clinical experience or professional registration or qualification D 13
ssential = Desirable = D or D Application form Interview Skills The ability to work on personal initiative and as part of a team, working across professional boundaries at all levels of the site and organisation Demonstrates the skill required to present complex issues clearly and concisely at all levels including site Quality Governance Board level Good organisational skills; able to work effectively under pressure and to identified and work successfully towards deadlines vidence of good presentation skills in a range of media and training materials Demonstrates skills in analysis and interpretation of risk, performance, clinical and other data and reports Personal and people development Able to write concise and grammatically correct reports and summaries, presenting information clearly Competent Datix (or equivalent risk management data base ) user and demonstrable evidence that they can teach others to use the system Demonstrable experience of effectively managing staff and the professional development of self and team D Can develop and deliver training and facilitate Task and Finish Groups / work streams Communicati on Able to maintain effective relationships and develop networks both internally and with external organisations to ensure effective governance Can handle sensitive situations and communicate appropriately with patients, complainants and relatives when things have gone wrong, as a result of the SI or complaints process Ability to present complex issues clearly and concisely at all levels of the organisation, including to executive colleagues 14
ssential = Desirable = D or D Application form Interview Specific requirements Able to pay attention to detail where necessary Assertive but polite and professional Able to maintain discretion regarding sensitive issues Self motivated, proactive and resourceful 15