Band 7 Quality Governance Manager

at  Royal Free London NHS Foundation Trust

Incident, Risk, Investigations

• Maintain professional behaviour at all times and promote a positive image of Royal Free London NHS Foundation Trust at all times, in line with World Class Care values.
• Access, monitor and review clinical incidents reported via the Trusts incident reporting system (DCIQ). Liaising with senior nursing teams and clinical governance lead to ensure investigations are completed and presented in line with Trust timescales.
• In collaboration with the Head of Quality Governance have oversight and responsibility for all aspects of the quality governance agenda, developing an effective patient safety framework that is quality centric.
• Ensure delivery of the rolling programme of governance activities in line with trust, hospital, division and service requirements
• Develop and coordinate good integrated governance practice within the business unit.
• Supporting the development and maintenance of effective working relationships, communication, co-operation and engagement with internal stakeholders.
• Support the Head of Quality Governance in interpreting and assessing the relevance of national policy and guidance, providing support to governance teams regarding implementation and evaluation.
• Liaise with the Head of Quality Governance to agree and achieve deliverables, as appropriate.
• Provide specialist advice on quality assurance around patient safety and clinical governance.
• Provide scrutiny and challenge of highly complex, technical, and sensitive clinical and non-clinical information.
• Analyse complex information from incident investigations (including patient safety incident investigations) and audits and working with performance and contracting colleagues to support the establishment of appropriate action plans to bring about positive change.
• Leading and ensuring division’s compliance on the Duty of Candour .
• Work with the complaints and legal team to triangulate information from thematic reviews arising out of complaints, legal claims and incident data.
• Provide monthly, quarterly and yearly reports triangulating the information and data from clinical governance activity.
• Leading the management of patient safety events and the sharing of learning from these events. This includes reviewing and ensuring that investigations have been appropriately carried out in accordance with agreed guidelines and timeframes and to determine if the investigation is fair and/or in need of further information or interviews and providing feedback on key areas for improvement, challenge or further actions. This will include

THE POST HOLDER IS RESPONSIBLE FOR:

Supporting the Head of Quality Governance in developing, implementing and monitoring
an effective and reliable system of working to ensure robust divisional governance which
is in line with national best practice.
Managing the divisional governance staff in dealing with all activities relating to patient
safety, risk, compliance and audit and act as the lead and central point of contact for
divisional governance activities
Acting as a leader who horizon scans to ensure the divisional governance activities
remain in line with Trust standards and expectations.
Support and develop a culture of informed questioning, challenge, trend analysis and
information triangulation to ensure lessons are learned and the division changes
practice in a way which has a positive effect on patients, outcomes, patient experiences
and supports the trust ambition to reach zero avoidable harm incidents.
Ensure compliance with Duty of Candour, including responsibility for communicating
with patients requiring notification.
The post holder is responsible for developing systems and managing processes for
sharing and implementing processes to ensure organisational learning.
The post holder will work closely with the quality governance, operational and corporate
management teams and staff at all levels of the organisation.

THE POST HOLDER IS RESPONSIBLE FOR:

• Supporting the Head of Quality Governance in developing, implementing and monitoring an effective and reliable system of working to ensure robust divisional governance which is in line with national best practice.
• Managing the divisional governance staff in dealing with all activities relating to patient safety, risk, compliance and audit and act as the lead and central point of contact for divisional governance activities
• Acting as a leader who horizon scans to ensure the divisional governance activities remain in line with Trust standards and expectations.
• Support and develop a culture of informed questioning, challenge, trend analysis and information triangulation to ensure lessons are learned and the division changes practice in a way which has a positive effect on patients, outcomes, patient experiences and supports the trust ambition to reach zero avoidable harm incidents.
• Ensure compliance with Duty of Candour, including responsibility for communicating with patients requiring notification.
• The post holder is responsible for developing systems and managing processes for sharing and implementing processes to ensure organisational learning.
  The post holder will work closely with the quality governance, operational and corporate management teams and staff at all levels of the organisation.
  Our trust has around 10,000 staff serving 1.6 million patients. It comprises Barnet Hospital, Chase Farm Hospital, the Royal Free Hospital and more than 30 services in the community. This larger scale organisation provides an unprecedented opportunity for us to continue our pioneering work, particularly in finding ways to deliver even better care to our patients.
  Our mission is to deliver world class care and expertise in our clinical services, underpinned by world class teaching and research and we will continue to measure our progress against our five governing objectives: excellent outcomes, excellent patient and staff experience, excellent value for taxpayers’ money, being safe and meeting our external duties, and building a strong organisation.
  Everyone is welcome at Royal Free London NHS Foundation Trust. We’re proud of our diversity and we continue to undertake new initiatives to advance equality for LGBT+, BME, gender equality, staff carers and people with disabilities and lived experiences to promote good relations and understanding between our staff.
  Click here to view our video Welcome to the Royal Free

1. RESPONSIBILITIES

Incident, Risk, Investigations

• Maintain professional behaviour at all times and promote a positive image of Royal Free London NHS Foundation Trust at all times, in line with World Class Care values.
• Access, monitor and review clinical incidents reported via the Trusts incident reporting system (DCIQ). Liaising with senior nursing teams and clinical governance lead to ensure investigations are completed and presented in line with Trust timescales.
• In collaboration with the Head of Quality Governance have oversight and responsibility for all aspects of the quality governance agenda, developing an effective patient safety framework that is quality centric.
• Ensure delivery of the rolling programme of governance activities in line with trust, hospital, division and service requirements
• Develop and coordinate good integrated governance practice within the business unit.
• Supporting the development and maintenance of effective working relationships, communication, co-operation and engagement with internal stakeholders.
• Support the Head of Quality Governance in interpreting and assessing the relevance of national policy and guidance, providing support to governance teams regarding implementation and evaluation.
• Liaise with the Head of Quality Governance to agree and achieve deliverables, as appropriate.
• Provide specialist advice on quality assurance around patient safety and clinical governance.
• Provide scrutiny and challenge of highly complex, technical, and sensitive clinical and non-clinical information.
• Analyse complex information from incident investigations (including patient safety incident investigations) and audits and working with performance and contracting colleagues to support the establishment of appropriate action plans to bring about positive change.
• Leading and ensuring division’s compliance on the Duty of Candour .
• Work with the complaints and legal team to triangulate information from thematic reviews arising out of complaints, legal claims and incident data.
• Provide monthly, quarterly and yearly reports triangulating the information and data from clinical governance activity.
• Leading the management of patient safety events and the sharing of learning from these events. This includes reviewing and ensuring that investigations have been appropriately carried out in accordance with agreed guidelines and timeframes and to determine if the investigation is fair and/or in need of further information or interviews and providing feedback on key areas for improvement, challenge or further actions. This will include:

i. Validating SEIPS investigation methodology, AAR, MDT, and resultant action plans.
ii. Producing thematic reviews of patient safety events to identify trends and patterns for a defined population.
iii. Facilitating the dissemination of wider learning and sharing good practice and supporting quality improvement.

iv. Ensuring that recommendations from patient safety events are integrated into quality improvement strategies and plans.

• Support the Head of Quality Governance in ensuring that the Learning from Deaths policy is embedded in the hospital site, with a process for regular robust reviews.
• Encouraging a culture of openness and transparency that responds rapidly to potential or actual failures.
• Support the oversight and co-ordination of the hospital participation and implementation of recommendations from NCEPOD and NatSSIPs 2
• To conduct appraisals and ensure staff are compliant in mandatory and statutory training and records are kept up to date.
• Act as an effective role model and mentor promoting excellence through practice.