About this role
Job summary
The Endoscopy Clinical Quality & Governance Manager is responsible for the leadership, development and oversight of the Endoscopy clinical governance, quality assurance and patient safety framework. The post holder will provide expert professional leadership in governance, risk management, audit, quality improvement, JAG compliance, workforce competency and professional standards, ensuring the delivery of safe, effective and high-quality patient care.
Working collaboratively with the Clinical Operations Manager, Deputy Matron and Matron, the post holder will influence service development, lead governance and quality improvement initiatives, and provide assurance that Endoscopy services meet Trust, regulatory and national standards.
Main duties of the job
Lead the Endoscopy clinical governance, patient safety and quality assurance agenda, ensuring effective systems are in place to monitor and improve clinical standards. Act as the lead for JAG accreditation, clinical audit, quality improvement programmes and regulatory compliance. Lead the investigation and review of incidents, risks, complaints and patient feedback, ensuring learning is embedded into sustainable improvements in practice. Provide expert professional leadership and assurance on clinical standards, governance, risk management and patient safety. Lead the development, implementation and review of policies, guidelines and standard operating procedures in line with Trust and national standards. Provide strategic oversight of workforce competency, education and professional development programmes, working closely with Band 6 Clinical Educators. Analyse governance, quality and performance data to identify trends, risks and opportunities for service improvement. Work collaboratively with the Clinical Operations Manager, Deputy Matron, Matron and multidisciplinary teams to support service development and continuous improvement.
About us
Oxford University Hospitals NHS Foundation Trust is one of the largest NHS teaching trusts in the country. It provides a wide range of general and specialist clinical services and is a base for medical education, training and research. The Trust comprises four hospitals - the John Radcliffe Hospital, Churchill Hospital and Nuffield Orthopaedic Centre in Headington and the Horton General Hospital in Banbury.
Our values, standards and behaviours define the quality of clinical care we offer and the professional relationships we make with our patients, colleagues and the wider community.
We call this Delivering Compassionate Excellence, and its focus is on our values of compassion, respect, learning, delivery, improvement and excellence.
These values put patients at the heart of what we do and underpin the quality healthcare we would like for ourselves or a member of our family. Watch how we set out to deliver compassionate excellence via the OUH YouTube channel.
In 2023NHS England launched its first sexual safety charter, and our Trust proudly signed it. We pledge zero tolerance for inappropriate sexual behaviour and commit to the ten core principles
Oxford University Hospitals promotes a safe, respectful hiring environment.
If you want to make a difference with us, come and join our team. Together, we will uphold the highest standards of care and professionalism.
Job description Job responsibilities
The Endoscopy Clinical Quality & Governance Manager is responsible for providing leadership and oversight of the Endoscopy clinical governance, quality assurance and patient safety framework, ensuring the delivery of safe, effective and high-quality care in accordance with Trust, national and JAG standards.
The post holder will:
Lead the development, implementation and evaluation of governance systems, policies, guidelines and standard operating procedures to ensure compliance with regulatory requirements and best practice. Lead the Endoscopy quality assurance programme, including JAG accreditation, clinical audit, service evaluation, quality improvement initiatives and monitoring of clinical standards. Lead the investigation and review of incidents, complaints, risks and patient safety concerns, ensuring learning is embedded into sustainable improvements in practice and service delivery. Analyse complex governance, quality and performance data to identify themes, emerging risks and opportunities for improvement, providing assurance and recommendations to the Endoscopy leadership team. Provide expert professional leadership and advice to nursing, medical and multidisciplinary teams regarding clinical governance, patient safety, quality standards and evidence-based practice. Provide strategic oversight of workforce competency, education and professional development programmes, working in partnership with Band 6 Clinical Educators, Divisional Education Leads and Practice Development teams. Lead and influence quality improvement, service development and transformation initiatives, ensuring governance, patient safety and regulatory standards are embedded throughout service changes. Work collaboratively with the Clinical Operations Manager, Deputy Matron and Matron to provide effective leadership, maintain high clinical standards and support the ongoing development of the Endoscopy service.
Person Specification
Essential Essential
Registered Nurse with current NMC registration relevant to the clinical specialty Significant post-registration experience within Endoscopy or a relevant clinical specialty, including experience of clinical governance, quality improvement and patient safety Demonstrable experience of leading governance systems, clinical audit, risk management, incident review and implementing improvements in clinical practice. Experience of leading quality improvement programmes, service development and implementation of evidence-based standards. Knowledge and experience of JAG standards, regulatory requirements and clinical governance frameworks relevant to Endoscopy Experience of developing, implementing and reviewing policies, guidelines and standard operating procedures. Ability to analyse complex quality, governance and performance information and translate findings into service improvements Experience of workforce development, competency frameworks, education oversight and maintaining professional standards. Excellent communication, leadership and organisational skills with the ability to exercise professional judgement and work autonomously.
Desirable
Master's degree in Nursing, Healthcare Leadership, Quality Improvement or a relevant subject, or working towards Leadership qualification or formal training in quality improvement, clinical audit or patient safety Experience of supporting external accreditation or regulatory inspections (e.g. JAG) Existing technical clinical skills relevant to Endoscopy.
Disclosure and Barring Service Check This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Certificate of Sponsorship Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
UK Registration
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).
Employer details Employer name Oxford University Hospitals NHS Foundation Trust
Address John Racliffe
Oxford
OX3 9DU
United Kingdom
Employer's website https://www.ouh.nhs.uk/ (Opens in a new tab)