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Detailed job description and main responsibilities

The Perinatal Governance and Quality Improvement Lead will:

• Support the perinatal services in meeting its statutory requirements  and clinical governance objectives by overseeing, monitoring and reporting on the  progress of national drivers such as risk management, infection prevention and control, Care Quality Commission standards and regulations, regulatory initiatives and in particular lead on: Saving Babies Lives Care Bundle V3 (SBLCBv3), NHS Resolution Maternity and Perinatal Incentive Scheme (MPIS), Maternity 3 year single delivery plan, Maternity Core Competency Framework, National Maternity Preceptorship Framework, Clinical audit agenda, MBRRACE and the Perinatal Mortality Review Tool, MatNeoSip, and the national maternity reports relating to Ockenden, Kirkup and Nottingham service review.
• Act as representative for the specialities at governance and assurance framework groups within the Trust.
• Oversee the implementation of clinical audit and other clinical effectiveness processes as a mechanism for improving quality, risk and safety. This will include development of a clearly defined annual audit programme along with the obstetric and midwifery leads for Quality Improvement.
• Ensure systems are in place to monitor the quality of care, KPI’s and outcomes to give assurance that all clinical teams are delivering ongoing quality improvements in the standards of care based on best evidenced based practice.
• Support clinical teams with external reviews, Quality Assurance visits and ensure processes and support in place for on-going monitoring and quality improvement methodology applies to action plans.
• Implement agreed systems and processes to provide assurance of the delivery of patient safety and prevention of harm in line with national and local standard of care.
• Support and work alongside the Trust claims team to ensure eligible Early Notification cases are reported to NHS Resolutions
  Identify required development and service changes within the maternity and neonatal services, and actively participate in seeking consensus in development and implementation of change.
• Responsible for the management and maintenance of the risk registers in collaboration with the individual department risk leads for maternity and neonatal services.
•  Identify risks associated with the provision of the speciality services and the delivery of high-quality patient care, escalating risks to the senior management teams as appropriate and implementing quality improvement plans to mitigate the risks.
• Co-ordinate the reporting of the divisional risks, and potential risks, identifying trends and contributing to proposals for the management of such risks.
• Ensure there is a robust performance management framework within the service to deliver on all aspects of the risk management and clinical governance agenda.
• Actively engage and liaise with the LMNS to support quality, risk and governance processes across the system.
• Encourage and engage with the Maternity Voices Partnership chairs to support with co-production of services and governance oversight.
• Enable the implementation of processes to ensure that all staff receive feedback following submission of incident forms, involvement in Patient Safety Investigation Response Framework and complaints.
• Support the Head of Midwifery and the Head of Perinatal Governance and Quality Improvement in the overall management of the complaints process.
• Monitor the Datix incident reporting system for Maternity and Neonatal services and support staff to investigate thoroughly and in a timely way.
• Work closely with the Trust safety and quality team and service leads, to ensure learning from Safety Incidents, internal reviews, complaints and claims are translated into learning and sustained improvement across all clinical areas in the service and Trust.
• Lead on and work closely with the Trust Patient Safety, Quality team and LMNS on Patient Safety Incident response framework.
• Undertake, and support others to undertake, detailed incident investigations using a robust and clear process, in line with the patient safety framework/patient safety incident response framework which focuses on Human Factors Ergonomics (HFE), system and process service improvements.
• Ensure early communications with staff and families when safety incidents are identified, define involvement and engagement needs and provide ongoing support during and after investigations.
• Lead for liaison and meetings with families who have experienced distressing, emotional impacts to their maternity journey.
• Responsibility for the overview and management of cases which are emotive and distressing for both the service user and staff.
• Responsibility for oversight of the completion of the PMRT reviews and family liaison in sensitive and emotive situations with bereaved parents.
• Work collaboratively with the Professional Midwifery Advocates (PMAs) to ensure that staff feel supported when involved in incidents/adverse outcomes, providing pastoral support where required.
• Review and ensure the development of SMART action plans in response to investigations which are evidence based and aim to address the identified contributory factors in order to enable sustained quality improvement.
• Develop and maintain Quality Improvement Trackers in line with PSIRF.
• Develop and maintain relationships with the Maternity and Newborn Safety Investigations (MNSI) ensuring all incidents that meet the MNSI and Early Notifications eligibility criteria as referred in timeframes expected.
• To ensure governance and quality is embedded within the wards including the dissemination of risk, audit, learning from excellence complaints and trends are shared.
• Review and maintain the accuracy of the maternity dashboard to enable the comparison, monitoring and delivery of divisional KPI’s, CQUIMS (MSDS), NMPA, NNPA, NMI and CIPS.
• Actively participate in Divisional and Trust meetings, representing all elements of the service provision.
• Represent the service and the organisation at system wide meetings, working collaboratively with partners within the Local Maternity and Neonatal System (LMNS).
• Experienced and strong analytical skills with the ability to interpret data, and to use measures to influence key decisions on priorities and drive a systematic, accurate approach for reporting and improvements.
• Liaise with service users regarding the development of the service whenever feasible.
• Be experienced and trained in quality improvement methodologies.

•    Collaborate with the senior leadership team to enable a positive safety culture within the division and demonstrate an inclusive and mentoring approach to leadership, working with clinical teams to agree and ensure the maintenance of high standards of practice and behaviours.

•    Promote a Just, learning, and restorative culture.

•    Support the Head of Perinatal Governance and Quality Improvement to monitor, investigate and report on the Division’s performance, spanning a broad range of issues, including incident trends, complaints, mortality and morbidity and legal claims. 

•    Empower the staff in the Division to positively embrace formal and informal complaints, comments and praise as a learning tool to influence behaviour and alter practice and culture.

•    Ensure a strong patient safety focus and an open culture to incident reporting and that practice is challenged positively and best practice is shared and championed.

•    Provide all line management support and function to the staff working directly within the Maternity Quality, Safety and Risk team.

•    Lead the annual appraisal process for members within your direct line management ensuring personal development plans and career conversations are in place with objectives to meet personal and service requirements.

•    Provide expert, visible leadership and expert advice on clinical effectiveness, patient safety and quality and co-ordinate all aspects of clinical governance. 

•    Undertake individual staff appraisals annually and support others to undertake this role for their staff line reports.

•    Be able to think critically and be visionary in approaches to midwifery care.

•    Be analytical in thought with attention to detail and able to communicate to help solve problems in everyday maternity challenges.

•    Act as a champion for maternity and midwifery building strong teams within the unit.

•    Foster a learning culture, be recognised as a role model and demonstrate support for the ongoing professional development of staff.

•    Actively participate in the Maternity Lead on-call rota.