Detailed job description and main responsibilities

Duties and Responsibilities

• To  utilise   high   level   communication skills   to   be   able   to   work   effectively   and collaboratively with all staff groups, including medical staff, nursing staff, senior managers and other healthcare professionals to explore complex issues and to make complex decisions related to Governance and Quality
• To employ effective change management skills to empower staff to bring about service improvements.
• To attend and participate fully at meetings and to be able to present information, which is frequently highly contentious, complex and sensitive. This will be to a range of staff including Trust Board and audiences greater than 20 at times as required in order to fulfil the requirements of the role.
• To develop and maintain excellent working relationships with key Governance and Quality improvement staff i.e., work in partnership with other Divisional Governance Leads, the Corporate Governance team and Quality Improvement staff in order to assist the Division in achieving its Governance and Safety objectives. 
• To utilise well developed analytical & problem solving skills with the ability to make decisions by determining key points from highly complex data comprising multiple information strands
• Required to concentrate continuously for long periods, and articulate the learning/actions from high level meetings to divisional level
• Act as the link between division and corporate requiring a high skill set and extensive knowledge base across a range of governance areas
• Act as a resource of expert professional knowledge for the division through application of theory in practice
• To frequently use IT skills g. systems, spreadsheets, databases, statistical packages to analyse data and produce reports in a useable form for the management team and corporate departments as required.
• To maintain up to date knowledge and interest with developing Quality & Safety practice in the Division with specific attention to key recognised sources of evidence based practice, including: HSE, NPSA, CQC, Monitor, AQuA and Royal Colleges.
• To attend and represent the Division at the appropriate corporate forum as required. This may require presenting highly complex, sensitive information to large groups in highly charged situations.
• The role involves a high degree of mental effort: able to concentrate, analysis of performance I governance data working in busy environment with interruptions; working to deadlines / immediate response.
• Frequently directly exposed to distressing, sensitive and confidential information and required to provide support to staff and patients in undertaking difficult conversations
• To identify, manage and reduce hazards in the Division and ensure that staff under his/her direction adhere to all safe systems of work applicable to the area of work and support the wider Division in promoting and monitoring safe systems of work.
• To undertake appropriate risk assessments and implement risk reducing measures.
• To ensure there are appropriate arrangements for reviewing significant risks and highlight risks that cannot be addressed at a local level through appropriate structures
• Provide training and support to ensure that staff are competent to develop and manage risk assessments relevant to their role and be fully aware of the legal requirements for general and specific risk assessments.
• To establish and monitor systems to ensure staff in the Division are up to date with Trust policies, procedures and statutory training.
• To ensure appropriate actions are taken to minimise risks.
• Manage the Directorate risk register, leading the Divisional risk management agenda.
• To lead on Trust critical/ serious incident reporting processes, ensuring that robust mechanisms are in place within the Division for compliance.
• To ensure the delivery of the Trust's governance agenda, both clinical and non-clinical participating in assessment and action planning.
• To ensure Directorate /Specialty governance structures are in place in line with and in support of Divisional and Corporate Governance structures
• Promote a culture that continually reviews performance using critical incident and complaints as tools for continuous improvement
• To ensure data relating to quality is accurate, complete and informs service planning.

Risk Management

• To lead and co-ordinate Risk Management activities in the division and be responsible for the development and implementation of risk management strategy at a local level, taking the lead on developing appropriate policy documents.
• To lead on managing the Divisional risk register and represent the Division at the Risk and Environmental Management Group (REMG) escalating risks for consideration onto the Corporate Risk Registers.
• To lead in the analysis,, action and evaluation of the service leading to minimisation of risk throughout the Division, with particular emphasis on the CQC/NHSLA standards and population and management of the Division, Directorate and Departmental Risk Registers. 
• To ensure mechanisms are in place so that key lessons are learnt across the division from all internal and external governance projects and other organisational reviews. 

Research

• Participation and coordination of clinical audit activity across the Division on a variety of topics, undertaking audits on behalf of the division to gain information' on patient experience and improve quality and safety
• To prepare information to inform other research and audits throughout the Trust
• Application of evidence based practice within the care delivery

Key results from the job holder

• To be an integral professional manager and Governance, quality and risk expert, as part of the Divisional Senior Management Team
• In conjunction with the Divisional Triumvirate the post holder will be responsible for providing leadership to develop, drive and co-ordinate Governance, Quality and Risk Management Strategies across the Division which are cohesive with the Trust Vision.
• Responsible for implementing strategies by liaising with all members of the multidisciplinary team thereby-safeguarding the high standards of care and creating an safe environment in which excellence in clinical care and quality improvement will flourish across the Division.
• To lead the division in coordinating the management of complaints and be responsible for an effective and efficient complaints management process which meets all statutory requirements and ensures lessons learnt.
• To take the lead in incident reporting management within the Division, interpreting data to identify trends and themes and escalating incidents as per Trust policy
• In collaboration with the Divisional, Triumvirate co-ordinate a quality strategy within the Division, ensuring collaboration at all levels is achieved from staff in the achievement of Statutory requirements, Fundamental Standards and other standards and associated external inspections e.g. CQC, NHSLA, HSE, DOH, Peer Reviews including reports on NCEPOD and Mortality reviews.
• Co-ordinate and lead divisional compliance with regulatory requirements while ensuring clinical guidelines re best practice within Trust Policy Procedures and Guidelines are articulated and implemented.
• Have an application of sound management, leadership skills and principles, providing expert advice which reflects knowledge and understanding of local/national policies and strategies.
• Lead on divisional investigations into claims, concerns, incidents and inquests. Liaising with patients, families and staff
• Act as experts in relation to Investigation process and learning e.g. (understanding and applying human factors).
• Presentation skills to a highly developed level in order to present highly complex data, reports, findings and provide assurance to Trust Board (and its delegated bodies)

Planning and Organisational Duties

Patient Experience

• To ensure that the Divisions complaints management system complies with all relevant legislation and devise systems for ensuring that action plans in response to complaints are compiled, audited and monitored.
• As part of divisional complaints management will be responsible for acting as a case manager, to investigate complaints, gather information and write draft final response letters to complainants on behalf of the Chief Executive, ensuring that the response is thorough and fair to all concerned.
• To be responsible for divisional input and maintenance of the complaints database to ensure provision of accurate record of all complaints received and produce meaningful information to allow the provision of information and the monitoring of trends and performance against standards. 
• To lead and co-ordinate the Division's Patient and Public Involvement activities and work streams, and take responsibility for the implementation of the Trust's PPI Strategy at a local This will include response to National surveys, patient experience audits and comments cards etc.
• To ensure that robust systems are in place for monitoring adherence to key patient experience standards, e,g: Same Sex Accommodation, and all other relevant Privacy & Dignity Standards providing advice which has an impact on Patient care.
• Will undertake audits to sample practice in divisional areas, collate and analyse results, compile action plans and inform the divisional senior management team of patient experience.