Divisional Quality & Safety Manager

at  University Hospitals Sussex NHS Foundation Trust 279

Main Duties and Responsibilities Leading by personal example, to establish a high profile for quality governance within the Trust and collaborate within the clinical operating model to share good practice. Actively contribute to help communicate Trust-wide lessons learnt and celebrate success. Working independently; acting as lead advisor to clinicians regarding clinical governance methods, tools, data collection, data analysis and interpretation, report writing, presentations and the facilitation of action planning and policy implementation. Ensure that the Trust Board and relevant committees are provided with up to date, accurate information.
Develop quality governance, quality improvement and risk reports in line with Trust requirements. Identifying local and divisional trends by analysing aggregated data and triangulating information to give a holistic picture of quality within the division and to support the identification of risks and quality improvement opportunities. Analyse evidence from a variety of sources to ensure it supports regulatory and statutory requirements, escalating risk and non-compliance where necessary. Enable the division to fully participate in relevant national programmes including audits CQUINS GIRFT Patient Reported Outcome Measures (PROMs) programmes and National Confidential Enquiries into Patient Outcome and Death (NCEPOD).
Ensure a Divisional Audit Plan is in place to deliver national and local clinical audits in line with the Clinical Audit Plan and monitor the completion of action plans associated with patient safety incidents, complaints, claims, inquests or other investigation and that these remain embedded within the division. Lead on the identification of opportunities for quality improvement and developing and implementing plans to deliver quality improvement priorities including through monitoring and identifying areas of improvement in relation to NICE, CQC and other quality standards and guidance. Ensure the analysis and learning has been completed as part of the implementation of the Trusts Learning from Deaths policy. Support the preparation for inquests, claims responses and mortality and morbidity meetings.
Provide the quality assurance methodology for the review of all PSII reports ensuring alignment and compliance to the NHSE Patient Safety Incident Response Framework (PSIRF). Provide specialist support and advice with regard to investigation methodology and investigation report writing. Facilitate patient safety incident investigations, after action reviews, hot debriefs and thematic reviews. Working in collaboration with the divisional director of nursing, and chief of service produce high quality (based on national HSIB system based best practice) incident investigation reports.
Demonstrate good understanding and background knowledge of national systems-based models such a SEIPS and Safety I & Safety II methodology. Work alongside the divisions as part of the Trust Clinical Operating Model (COM) as an initial point of contact to advise and assist with incident management, and Duty of Candour. Support the divisional directors of nursing with the quality governance from the beginning of the investigation process, (i.e. setting the terms of reference) throughout (i.e.
PSII report writing, through to closure). Support the complaints managers (divisional business partner model) as required with the process of complaints investigation. Attend divisional quality governance meetings/SDR and clinical safety huddles. Assist the Head of Patient Safety and Risk in ensuring and assuring compliance of the risk management system with relevant standards for CQC.
Assist the Head of Patient Safety and Risk in preparing the Trust to meet the requirements of national bodies, including NHS Resolution, the National Reporting Learning System (NRLS), and CQC. Attend inquest as required. Communication Promote an open culture in dealing with patients, families, staff and external stakeholders to ensure that patient safety incidents are fully reported, documented and the necessary action taken. Nurture positive relationships with clinical staff to ensure effective communication of all issues relating to patient safety, experience, outcomes, effectiveness, and risk.
Assist divisions with risk assessment and ensure appropriate action is implemented. In line with patient safety investigation and working collaboratively with patients, families carers and staff; the post holder will present complex, sensitive or contentious information to a large group of staff or members of the public, or Working with patients and families in line with the Duty of Candour Regulation 20, the post holder will both provide and receive complex, sensitive or contentious information; where there are significant barriers to acceptance which need to be overcome using developed interpersonal and communication skills such as would be required when communicating in a hostile, antagonistic or highly emotive atmosphere. Service Delivery and Improvement Oversee the development and implementation of the divisional quality improvement plan to deliver Trust and divisional quality objectives, identifying quality gaps, improvement priorities and monitoring and reporting on progress and impact Support the improvements in patient experience and engagement through implementation of the Trusts strategy. Ensure national and local compliance for clinical audit, NICE guideline, CQUIN, and report on progress.
Ensure effective divisional systems are in place for identifying and disseminating learning and monitoring the impact on patient safety. Ensure the division implements the Trusts Risk Management Strategy and Policy including reporting and providing assurance that risks are effectively managed ad mitigated. Inform the development of divisional and Trust wide policy and strategy; ensuring corporately agreed policies, strategies and priorities are reflected in divisional policy, procedure, and planning. Co-ordinate the implementation of the Trust Risk Strategy and Policies within the division including responsibility for ensuring the integrity of the DCIQ risk registers and H&S risk assessments.
Support business planning and overall performance management as appropriate by ensuring quality impact and risk assessments are an integral part of the process. Participate in the development and implementation of the Trust clinical & quality governance systems and processes contributing to the achievement of organisational objectives. Critically analyse PSI, identify trends, prepare written reports and make recommendations for action as appropriate. Keep updated on all relevant national guidance including the NHSE Patient Safety Incident Response Framework and Never Events.
Ensure divisional quality governance mechanisms are in place and operating effectively and in line with Trust policy including mortality and morbidity meetings, divisional and speciality level governance meetings and representation at Trust level quality meetings. Be familiar with the Trusts Duty of Candour policy and advise on its use in supporting PSII. Be responsible for safe use of organisation resources and equipment/orders supplies for area of work. Use computer software to create reports, documents and drawings, and adapt design information systems to meet the specifications of others.
Develop spread sheets and other tools for audit approaches, creation of audit data collection tools, clinical audit governance database/responsible for development and maintenance of audit database for organisation. Ensure compliance with the information governance requirements including consent, confidentiality, and information storage in line with Trust and national policy and legislation. Interpret and analyse themes and trends in line with the Trust quality objectives for True North, supporting the development of corporate reporting dashboards and frameworks in line with the Trust strategic direction on harm reduction. In collaboration with the Patient First safety programme, support divisional patient safety initiatives (breakthrough objectives), Strategic Deployment Reviews (SDR) Catch-balls and safety huddles and peer reviews.
People Management and Development Promote and participate in multidisciplinary training aimed at ensuring that new and existing staff fully understand the Trusts approach to quality governance management. Patient Care Delivery Support the implementation and evaluate a systematic approach to the national requirement for DoC in response to all incidents (resulting in moderate/significant harm or death) in collaboration with the divisions and senior managers within the Trust. Support and promote the open disclosure (DoC) of patient safety Incidents to patients and relatives. Work in a clinical environment as required, with both the Peer Review process and Business Continuity (within the post holders professional scope of practice).
Learning and Development To be responsible for proactively developing own practice and knowledge. Maintain professional clinical registration. Hold an accredited investigation training qualification. Analyse evidence from a variety of sources to ensure it supports regulatory and statutory requirements, escalating risk and non-compliance where necessary

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