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Detailed job description and main responsibilities

Role Requirements

Undertake Learning Responses following patient safety incidents in line with the Trust’s Patient Safety Incident Response Policy and Plan. Considered the expert in providing robust system-based reviews utilising agreed frameworks (SEIPS) to support achievable improvement.

Act with a high level of integrity and professionalism whilst carrying Patient Safety Incident Investigations (PSIIs) and After-Action Reviews (AARS) to be conducted within the expectations of a just and restorative culture. 

Professionally responsible and accountable for a caseload of concurrent investigations, working autonomously in leading the delivery of timely and effective Learning Responses.  

For all Learning Responses (PSII’s and AARs) ensure the production of comprehensive, logical, well-written reports. To provide and receive highly complex, sensitive and contentious information relating to patient safety incidents and present information to teams and groups. 

Use highly developed facilitation and interpersonal skills to conduct AARs, PSII investigatory interviews and other exploratory processes.

Escalate any emerging and urgent clinical risk.

Support the development of SMART quality and safety improvement action plans. Work with Service Lines, Care Groups and Corporate representatives to identify learning from incidents and investigations. To inform changes in processes and practice with the aim of preventing or reducing the likelihood of recurrence of similar incidents, or to improve the overall safety and quality of care provided.

Contribute to thematic reviews aligned to current Trust priorities as part of a wider multidisciplinary team to identify improvements to current systems and processes.

Contribute to the development and improvement of systems learning approach and cultural changes associated with the introduction of the PSIRF and lead on allocated improvement and innovation projects.

Find innovative ways to share lessons learnt and key insights for patient safety improvement.

Contribute to the planning, managing and overseeing the delivery of a number of multidisciplinary quality improvement projects and initiatives to achieve a beneficial change to Patient Safety in line with the quality objectives of the organisation and national safety priorities.

Be responsible for interrogating and analysing data held on the Trust’s risk management information system (Datix); using the findings to inform investigations and reports produced for various governance meetings.

Support organisational learning from Safety & Quality domains and contribute directly to building incident investigation capacity and capability by designing and delivering systems-based training programmes, teaching and supporting individual’s development of investigation skills and knowledge either as a whole or an ad-hoc basis. 

Maintain specialist knowledge of investigative techniques, analysis and synthesis of information by undertaking professional development relevant to role eg HSSIB higher level courses.

Monitor and interpret national guidance and policy to ensure Trust procedures and practice comply with/exceed best practice.

As the subject mater expert, responsible for making judgements in relation to incident investigations, reviewing data, records and complex facts some of which may differ or conflict, providing advice on plans to address such matters. This will require the review of highly complex acts or situations requiring analysis, interpretation and comparison of a range of options. Due to the nature of the role, some situations may have unique characteristics and complicated aspects which do not have obvious solutions.

Involved in continuously reviewing and improving various elements of the Trust’s incident investigation process in line with current guidance under the PSIRF. 

Contribute to writing, developing, implementing and monitoring Trust strategies, strategy delivery plans, policies and frameworks relating to Patient Safety in line with local and national objectives. 

Attend and be available, as is reasonable to present the findings of reviews both locally and at forums such as Coroners court.

Line management of staff within the teams, either directly or through delegated responsibility to support the Quality Governance team to develop robust systems and mechanisms to ensure that it is learning from patient safety investigations.

Budget holder for the Quality Governance team and responsible for all planning, HR and financial dimensions.

Managerial and Leadership

Provide expert advice, guidance and support to all staff on matters related to Learning Responses, ensuring compliance at all times with local and national guidance.

Ensure learning identified through an investigation is optimised and fedback to the relevant governance groups, to progress changes in training, development, systems, policy, procurement processes to improve the quality of the care provided by the Trust. 

Support the production of business cases for future service developments, working with internal and external stakeholders; ensuring resource requirements for service developments are identified and agreed. 

Create psychologically safe environments when interacting with individuals or groups of people to maximise effective learning and improvement. Support the wider creation of a psychologically safe learning organisation using Just Culture principles. 

Responsible for leading the Trust’s SuStaIn/ TRiM programmes to support staff affected by incidents. 

Undertake Duty of Candour and compassionate engagement with patients, families, carers and significant others in a timely and sensitive manner to ensure the patient’s voice is heard and findings are agreed prior to completion. 

Ensure staff involved are given the opportunity to participate, review draft responses and agree final responses prior to sign off. 

Exhibit highly developed and effective persuasion skills to influence others and take a lead role with all managers, clinicians, and support staff to create an organisational climate that encourages professions to review practice, report problems and draw conclusions without fear or recrimination or censure.

Work collaboratively with subject experts to ensure efficacy of reviews. This includes whilst leading a number of concurrent investigations and supporting multiple transient investigation teams.

Work with partners and other agencies to support cross-system learning responses and ensure system wide learning is attained. 

Undertake peer reviews and quality assurance audits of patient safety investigations. Represent the Trust at both local and national networks and conferences regarding Trust developments and play an active role in sharing progress and learning with others.

Managerial/Organisational Relationships

Professionally accountable to the the Head of Quality, Governance and Safety and expected to build strong relationships with key department staff including Risk & Incident team, the Deputy Medical Director for Quality and Safety, and Deputy Chief Nurses.

Build, manage and maintain highly complex and effective relationships and alliances across internal and external departments, services and organisations at a local and national level and ensure highly effective relationships are maintained. 

Explain strategy and organisational decisions in relation to Patient Safety to everyone in the organisation.

Provide professional advice and leadership to support change management programmes related to Patient Safety initiatives and to draw on the specialist skills of others in doing so.

Advise and influence clinical and managerial teams so that patients, carers and public are appropriately involved and consulted in service evaluation/redesign following investigations and those changes are made which lead to improved patient experience. 

Have the ability to constructively challenge and question clinical practice where necessary.

Pro-actively manage stakeholders, respond to, and resolve conflict between different stakeholders when this arises through facilitation or other appropriate mechanisms. 

Key Working Relationships

Key working relationships include:  

• Executive Directors (Chief Nurse/Medical Director and their deputies).
• Build strong relationships with key staff Care Group Management Teams (ACNO’s and Quality Managers) and Service Line Management Teams.
• Other Corporate teams to raise awareness and share information on a regular basis as necessary – Legal, PALS & Complaints, Mortality, Safeguarding, Freedom to Speak Up Guardians and Communications team. 
• Liaise with external stakeholders and agencies including the NHS Devon ICB, NHS England, CQC, Coroner and HSIB.
• Engage compassionately with those affected by patient safety incidents (Patients, families, carers, and staff).
• Communicate comfortably with any member of staff throughout the organisation as relevant to incident investigations conducted.
• Patient safety professionals in other healthcare or social care providers.

Working conditions 

Work in a complex and multi-disciplinary environment, able to act with minimal guidelines and be able to set standards for others. There will be a frequent requirement for concentration where the work pattern is unpredictable due to the nature of meetings, events and the schedules of staff required for investigations and learning responses.

They will be required to travel to other locations within the Trust footprint as necessary and may be required to attend internal and external meetings in various locations, such as on clinical wards, in theatre and laboratory environments or the Mortuary. 

Mental and emotional effort 

There will likely be times when there is exposure to distressing or emotional circumstances due to contact with staff and service users who may be experiencing significant distress as well as regular reviewing and investigating of incidents.