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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 Trust’s 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.