Clinical Governance, Audit and Quality Improvement Lead
| Posting date: | 16 May 2024 |
|---|---|
| Salary: | £35,000.00 to £37,000.00 per year |
| Additional salary information: | £35000.00 - £37000.00 a year |
| Hours: | Full time |
| Closing date: | 16 June 2024 |
| Location: | Elland, HX5 0QY |
| Company: | NHS Jobs |
| Job type: | Permanent |
| Job reference: | B0115-24-0005 |
Summary
Clinical Governance, Audit and Quality Improvement Lead Salary £35,000 - £37,000 Full Time Equivalent Grade CL3 Hours 37.5 hours per week (would consider 30 hours per week) Responsible to Director of Clinical Services Accountable to Director of Clinical Services (DCS) Overgate Hospice is an independent charity with a mission to ensure that patients and those close to them live with the best possible quality of life. This is enabled by provision of the highest standard of compassionate and evidence-based specialist palliative and end of life care for adults in Calderdale who have active, progressive life limiting illness. Job Summary As a senior member of the Nursing Team the role is integral in working with the Clinical and non-clinical teams to collate, analyse and utilise data collated from a variety of sources to help to identify areas for improvement. This will involve assisting in the development of a robust Audit system, process and programme that will underpin the delivery of exceptional care and service. The primary function of the Clinical Governance, Quality and Audit lead is to co-ordinate and manage the clinical Audit and Quality initiatives undertaken by the Hospice and to assure that meaningful data is captured from these activities and is used to foster a learning culture and drive quality improvement within the hospice This will involve close working relationships with all Hospice departments. To proactively lead and engage with patients and other service users to monitor outcomes and service satisfaction and to work with others in developing meaningful action to drive service improvement and /or development in line with the hospice strategy. The role will require on site working as the primary place of work. Minimum Qualifications Required RN Level 1 (Adult) with current NMC registration and educated to degree level or equivalent. Demonstrable experience of working at a senior level within a clinical care setting is essential, palliative care experience is desirable. Experience at leading quality improvement initiatives. Recognised teaching skills/qualification. Demonstrable personal profile of continuous professional development and using data to improve clinical services/outcomes. Demonstrable IT skills including Microsoft Word, Excel and System One. Evidence of Quality Improvement training in healthcare is highly desirable. Duties and Responsibilities To co-ordinate an Annual Audit Programme as agreed with Chief Executive, Director of Clinical Services and Medical Director. To ensure that the Care Quality Commission (CQC) statutory audit requirements are met. To coordinate, undertake, manage, and promote clinical and workforce audit activity within the operational teams. To undertake specific audits as identified in the annual plan and update the annual plan and relevant trackers as audits are completed. To monitor the effectiveness of actions taken as a result of audit findings. To monitor the effectiveness of actions taken as a result of incidents. To work with Clinical Leads and Operational Managers on operational and other matters relating to the audit process, including the analysis of themes, and identifying potential sources of learning from audit and incidents. To lead on quality improvement projects in conjunction with the DCS and medical director. To attend departmental meetings in order to promote and maintain good multi-professional communication about current audit projects and shared learning opportunities. To collate and analyse data to produce and share high quality clinical reports to underpin patient safety, quality and experience and be able to verbally present this information within meeting settings. To attend, provide required reports and actively contribute to the Clinical Governance, Audit and Quality improvement meetings and Clinical Subcommittee. To participate in the reporting and investigation of complaints, accidents and adverse incidents /near misses informing the Director and Deputy Director of Clinical Services (DCS) or Chief Executive of any occurrences as soon as possible in line with Hospice policy. To act as a source of guidance on audit process and methods of data collection and documentation for colleagues wishing to undertake audits of services. To work with the senior clinical team to explore potential IT options for data analysis. To participate in benchmarking processes at local and national level to drive improvements in care. Maintain the strictest level of confidentiality relating to Hospice information. To act as a designated witness for the destruction of controlled drugs. To maintain the clinical activity and quality dashboard. To interpret and analyse clinical activity data, and prepare reports s, including clinical Key Performance Indicators for clinical meetings, Senior Leadership Team, Clinical Subcommittee, and the Board of Trustees. To support the Information Governance audit framework. Professional The post holder will maintain continued personal professional development and knowledge of current nursing and palliative care issues to meet both own revalidation requirements and organisational objectives. To work within the NMC Code of Professional Practice and within the policies, procedures, and guidelines of Overgate Hospice. The post holder will organise and manage own time and workload effectively. Promote a culture of openness, honesty, respect and integrity and learning/improvement using the organisational behaviour framework to underpin this. Education The post holder will be actively involved in the ongoing education and development of staff (including volunteers) through involvement in developing and delivering education about audit (process and results) both in-house and externally with the support of the DCS and Deputy DCS and the Education Team and will contribute to a system of training evaluation (including production of reports). The post holder will support volunteers and assist in their development. Overgate General Duties and Responsibilities Overgate Hospice is a no smoking organisation. The employee must maintain a safe working environment in accordance with Overgate Hospices Health and Safety policies and abide by the Health and Safety at Work Act (1974). The employee must attend and undertake mandatory training. The employee must ensure that they comply with all Hospice policies and procedures at all times and participate in the development and implementation of Hospice policies. The employee must maintain strict confidentiality at all times, applying to all aspects of Hospice business and work within the guidelines of the Data Protection Act. Employees must demonstrate commitment to their own personal development and are required to make a positive contribution to fundraising and raising the profile of the Hospice locally and nationally. Use all Hospice resources economically and cost effectively. Employees must adhere to the Hospices Standards of Behaviour Framework in all aspects of their work. To work closely with the Volunteer Services Co-ordinator as appropriate to ensure that any volunteers are supported in their roles addressing any issues as they arise. This job description is not exhaustive and will be subject to periodic review. The employer and the employee share responsibility to review and amend it as appropriate. Maintains own registration with the Nursing Midwifery Council (NMC). Safeguarding Children and Vulnerable Adults All Hospice staff are required to act in such a way that at all times safeguards the health and wellbeing of children and vulnerable adults. Familiarisation with and adherence to the Hospice safeguarding policies is an essential requirement of all employees as is participation in related mandatory/statutory training. Valuing Diversity and Equality All employees should carry out their duties in accordance with the values and principles of valuing diversity and equity of provision. It is the responsibility of all employees to support the Hospice vision of promoting a positive attitude to diversity and equality of opportunity, to eliminate discrimination and disadvantage in service delivery and employment, and to manage, support or comply through the implementation of the Hospices Equal Opportunities Policy. Healthcare Associated Infection Healthcare workers have an overriding duty of care to patients and are expected to comply fully with best practice standards. You have a responsibility to comply with Overgate policies for personal and patient safety and for prevention of health care associated infection.