JOB DESCRIPTION Patient Safety, Quality and Clinical Governance Manager

JOB DESCRIPTION Patient Safety, Quality and Clinical Governance Manager

Job Title: Patient Safety, Quality and Clinical Governance Manager Reports to: Associate Director of Quality and Clinical Governance Location: Salary: Key Working Relationships: Main base will be in Hounslow with cross site travel to all Greenbrook Healthcare Services Equivalent to Band 8b c. 50,000 to 60,000 (dependent on experience) Senior Clinical Team: Associate Director of Quality and Governance, Medical Director, Deputy Medical Director, Director of Nursing, Regional Clinical Directors and Senior Administration Assistant to the Clinical Team Local Management teams: Service Managers, lead GP s and lead nurses Job Summary: This is a senior, influential and pivotal role across the whole organisation. The post holder will promote and oversee the high quality clinical governance systems used within all services across Greenbrook Healthcare; he/she will be instrumental in ensuring the consistency of high standards in relation to patient safety, quality and governance processes. The post holder will provide guidance and support to the local management teams for all services and the senior management team to ensure the organisation has robust, effective clinical governance processes. Although the post holder will be primarily based in the Central Support Office in Hounslow they will offer various levels of direct support working at each site based on their fluctuating requirements. 2

Our Vision and Values: Greenbrook is passionate about providing high quality NHS care and putting patients first. To underpin this, we have established a set of Core Values: Patients First Quality Integrity Safe and Efficient Communicating and Listening Teamwork Our first priority is to our patients, providing them with excellent, safe and timely care We work hard to improve the quality of our services, learning from our successes and mistakes, and avoiding blame We are open, honest, empathetic and respectful, avoiding discrimination at all times We provide safe clinical care to every patient, in a timely fashion. We keep our administrative actions and processes simple We communicate clearly and listen well, whilst employing the highest standards of confidentiality We recognise the importance of good teamwork, within our own teams and across organisational boundaries Our training, policies, procedures and practices are all intended to support behaviours in line with our values we expect all staff to uphold these. Key Responsibilities: Ensure the organisation has a robust clinical governance structure that supports the provision of high quality care with effective monitoring and reporting systems to evidence delivery, ensuring polices are adhered to. Provide high quality leadership and role modeling to the clinical teams in relation to clinical governance. Ensure provision of effective and timely expert, high quality support and guidance to each service in relation to the reporting, investigation and management of incidents and identified risks. Provide support, coaching and teaching on all aspects of effective governance. To oversee processes which ensure service level risk registers are managed effectively and ensure the organisational risk register is reflective of identified risks across all the services. 3

Prepare Board and organisational reports on incident, risk and complaint trend analysis Benchmark performance against national and local standards and highlight areas for improvement Lead the teams to provide advanced analytical skills to understand complex, sensitive and contentious data from varied data sources and provide clear analysis in board level reports. Support and guide each Service through their CQC preparations and inspections to ensure continual compliance with CQC standards. Monitor each site to ensure they have robust processes for evidence collection, storing and audit trails. Provide support and management of higher level, complex and Serious Incidents (SI s) and complaints. Support Services to develop their own SI Action plans Have organisational overview of the Datix system and ensure services are progressing complaints and incidents in line with policy and agreed timescales Promote the reporting of all incidents and near misses through nurturing a culture of continued learning and improvement Oversee the management of the annual audit planner across the organisation, to include service specific and organisation analysis of themes and trends Have overview of quality governance reports to ensure quality, consistency and accuracy Participate and facilitate training for all staff groups Work with the Business Development team to develop and mobilise clinical governance structures for new services. Provide regular briefings to the Associate Director of Quality and Clinical Governance and the Senior Clinical Team as required. Deputise for the Associate Director of Quality and Clinical Governance as required Attend and chair as required each Service s monthly clinical governance meetings Support the Associate Director of Quality and Clinical Governance with patient safety, quality and governance related projects. 4

Undertake other such duties commensurate with the seniority and experience of the post. Maintain own continuing professional development and knowledge of relative legislation, standards and guidance. Health & Safety To act responsibly in respect of own and colleagues health, safety, welfare and security, following safe work practices and complying with Health and Safety Policies. Equality and Diversity To support the equality, diversity and rights of patients, carers and colleagues, to include: Acting in a way that recognises the importance of people s rights, and interpreting them in a way that is consistent with practice procedures and policies, and current legislation Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues Behaving in a manner which is welcoming, non-judgmental and respects the circumstances, feelings, priorities and rights of every individual. Communication To demonstrate politeness, courtesy, respect and sensitivity in dealing with patients/ clients, visitors/relatives and colleagues, maintaining good customer relations. To adapt communication skills to meet the needs of patients who may have barriers to understanding e.g. language To work cohesively with all members of the team in ensuring that the very best services to patients are provided at all times. Education and Training/Self-Development To identify own training and development needs and undertake appropriate training/ education as required To demonstrate skills and activities to others who are undertaking similar work To participate in an annual performance review process, including taking responsibility for maintaining a record of own personal and/or professional development To attend all statutory and mandatory training as and when required to do so 5

General This job description is intended as a guide to the main elements of the role and should not be considered as a complete listing of all duties and tasks that may be undertaken. The post holder will be expected to undertake any other duties that may be requested by the line manager in order to facilitate the smooth running of the service. Greenbrook Healthcare is constantly evolving and subject to change, therefore this job description is subject to review dependent on the needs of the service and the company. Any amendments will be discussed with the post-holder. The post is subject to the Terms and Conditions of Employment of Greenbrook Healthcare. SUPPLEMENTARY INFORMATION Health Clearance Health clearance is required for this appointment. Disclosure and Barring Service (DBS) Check A DBS check (previously Criminal Records Bureau check) will be required before appointment for all posts with access to children or vulnerable adults. Confidentiality Patients have the right to expect that staff will respect their privacy and act appropriately. In the performance of the duties outlined in this Job Description, the post-holder may have access to confidential information relating to patients and their carers, staff and other healthcare workers. They may also have access to information relating to the company as a business organisation. All such information from any source is to be regarded as strictly confidential. Information relating to patients, carers, colleagues, other healthcare workers or the business of the service may only be divulged to authorised persons in accordance with the Data Protection Act, and policies and procedures relating to confidentiality and the protection of personal and sensitive data. The post holder must always keep all patient-related information confidential; this includes if the patient is deceased and if the post-holder is no longer employed by Greenbrook Healthcare. Data Quality/Security The post holder is responsible for ensuring that he/she maintains the integrity and quality of both computerised and manual data. 6

Safeguarding Greenbrook Healthcare is committed to safeguarding and promoting the welfare of children, young people and vulnerable adults, and expects all staff to undertake this commitment. Clinical Governance / Raising Concerns Greenbrook Healthcare aims to provide the highest standards of care. To further this aim the post holder is expected to adhere to acceptable working practices as defined in policies and guidelines. The post holder has a personal responsibility to keep up to date and, if s/he encounters unacceptable practice, to raise this in a responsible and appropriate manner, if necessary through the whistleblowing procedure. Codes of conduct and professional standards All staff should adhere to any codes of conduct or professional standards set by the regulatory bodies with whom they are registered or by professional bodies of which they are a member. Uniform and Dress Code All nursing and Emergency Care Practitioners should adhere to infection control principles and must wear a uniform when on duty. Smoking Smoking is not allowed on any part of Greenbrook Healthcare premises. Policies & Procedures The post holder is expected to comply with Greenbrook Healthcare s policies and procedures. Personal Property Greenbrook Healthcare is unable to accept responsibility for articles of personal property lost or damaged on its premises whether by burglary, fire, theft or otherwise and staff are advised to insure against all risks. 7

Person Specification Job Title: Patient Safety, Quality and Clinical Governance Manager Criteria for Selection Essential Requirements Desirable Requirements Assessment Method: e.g. A = App. form I = Interview T = Test Education/ Qualifications Clinical background Evidence of continued learning and professional development Hold Professional registration A Experience and Knowledge Experience of working in Clinical governance Experience in patient safety and quality improvement Experience of developing and implementing improvement methodologies RCA training A, I & T Previous experience of working closely with clinicians of varying seniority Sound understanding of the Serious Incident (SI) framework and duty of candour RCA investigation experience (analysing problems & identifying solutions) and SI report writing Claim management Knowledge and understanding of the Care Quality Commission regulatory and inspection framework and assurance processes. Experience at a senior level within healthcare organisations Experience of policy and report development and writing Experience of developing and presenting training packages Knowledge of risk registers, audit, patient experience, involvement and feedback Experience of analysing and benchmarking data Proven ability to develop and manage clinical governance systems in complex environments Previous Datix experience 8

Criteria for Selection Essential Requirements Desirable Requirements Assessment Method: e.g. A = App. form I = Interview T = Test Experience of dealing with highly sensitive and confidential issues and supporting staff Skills and Abilities Ability to analyse and prioritise complex clinical risks. Able to work under pressure to short deadlines High level of verbal and nonverbal communications skills Attention to detail and meticulous standards Computer literate -Microsoft Office (Word, excel, PowerPoint etc) Demonstrable political judgement and an astute approach to handling diverse interests and complex relationships Ability to collaborate constructively with internal and external partners to create the conditions for successful partnership working A & I Ability to work in busy environments across multiple sites within the organisation Ability to present information clearly and concisely Demonstrable credibility in working with and influencing senior staff Self-motivated and able to motivate and influence others Ability to work independently and as part of a team Able to adapt and work flexibly 9

Criteria for Selection Essential Requirements Desirable Requirements Assessment Method: e.g. A = App. form I = Interview T = Test Able to support others and recogonise own support needs Willingness to undertake additional responsibilities to support the organisation as required Other The post holder will need a flexible approach and be willing to travel to our sites across the London area. A & I Clean driving licence 10