About this role
Job summary
We are recruiting a Clinical Governance Lead to provide visible leadership across our clinical teams, supporting the continuous improvement of patient and family services and helping us to deliver high-quality, effective and responsive care.
Main duties of the job
Working collaboratively with our Corporate Governance Lead, you will help ensure a joined-up and proportionate approach to governance, assurance and risk management across the Hospice. Together, you will ensure that clinical and corporate governance arrangements are aligned, clearly reported and used to drive learning and continuous improvement across the organisation.
You will support the implementation of our clinical governance framework, lead audit and quality improvement activity, oversee clinical risk and patient safety processes, and help ensure our continued readiness for Care Quality Commission inspections. You will also oversee clinical complaints oversight, incident reporting, PSIRF learning responses, clinical policy development and the effective use of clinical governance data and systems.
You will act as the Hospices Medical Devices Safety Officer, Medicines Safety Officer and Patient Safety Incident Response Framework (PSIRF) Learning and Response Lead, and participate in the clinical on-call rota.
About us
St Nicholas Hospice Care is a local charity supporting nearly 2,000 people every year across West Suffolk and Thetford. We provide care in multiple settings, offering specialist clinical support, practical help, and services for families, carers, and those experiencing bereavement
Our Benefits
- 25 days annual leave increasing to 29 with service
- Enhanced Occupational sick pay scheme
- Access to a group pension plan
- A Health Cash Plan & Wellbeing programme
- Free onsite parking
- Access to Blue Light Card scheme with a range of discounts
Job description
Job responsibilities
General
To ensure that continuous quality improvement supports the operational and strategic direction of SNHC clinical services
To produce the annual Quality Account, providing direction and support in the achievement of the identified priorities for improvement
To develop and lead on the delivery of the organisations Quality Improvement (QI) Plan and the clinical elements of the User Engagement Plan
To manage data requirements in relation to service activity and the organisations clinical database
Producing reports as required for internal and external audiences including the Clinical Committee, Integrated Care Board, Executive Team and internal governance groups
To provide oversight of clinical risk management arrangements within Service Delivery, ensuring teams have identified and completed relevant risk assessments, monitoring completion of updates and reviews of the Service Delivery Risk Register. Maintaining the Service Delivery Risk Register monitored by the Clinical Quality Governance Group and Clinical Committee and escalating significant risks through the organisation's wider governance framework where appropriate. Responsibility for ownership and management of individual clinical risks remains with the relevant operational and clinical risk owners
Work collaboratively with the Corporate Governance Lead to ensure appropriate alignment between clinical governance, corporate governance, organisational assurance and the wider risk management framework
Audit and Quality Improvement
To chair the Audit and Quality Improvement group
Demonstrate expertise in improvement methodology, tools and measurement
Support staff development in undertaking audit and QI projects. To include audit identification, tool development, auditing, analysis and outcome monitoring
To produce the annual clinical audit plan and monitor outcomes and compliance
Escalating non-compliance of the plan to the Clinical Committee to ensure Senior Clinical accountability
Provide leadership and improvement expertise for an annual allocated set of quality improvement projects to maximise engagement, impact and learning
With the Senior Educator support the development of a research active hospice through identifying, proposing and supporting the implementation of the key infrastructure requirements
Promote the use of co-design and co-production of QI projects with patients and service users
With the Senior Educator (and where necessary the Marketing and Communications Team) support staff in the publication of projects for local and national presentation.
Patient Safety
To monitor the organisations key performance requirements in relation to patient safety events - Medicines Management, Pressure Ulcer Prevention, Care and Falls
To support the Director of Care and Transformation, Head of Nursing and Quality and Facilities Team Manager in relation to Infection Prevention and Control compliance across clinical services
To have oversight and coordination of incident reporting processes (including clinical incidents, accidents and near misses). Monitoring reporting on RADAR (incident database) and providing monthly reporting on data including themes and actions plans
Completing root cause analysis (RCA) incident investigations as required. Supporting the completion of investigations and thematic reviews under the PSIRF framework
To have oversight of any Duty of Candour incidents to support the Director of Care and Transformation and the Head of Nursing and Quality as required to ensure compliance with statutory reporting
To act as the organisations Medical Devices Safety Officer and Medicines Safety Officer
Provide clinical governance oversight in relation to health and safety matters affecting patient care and clinical service delivery, working collaboratively with operational managers and the Corporate Governance Lead to ensure appropriate escalation, reporting and organisational learning
User Engagement and Experience
To maintain oversight and management of the organisations response to clinical complaints to ensure the organisation complies with response times and policy
To support complaint investigations as required by the Director of Care and Transformation
Be responsible for completing thematic reviews of complaints, concerns and compliments
To lead on the development and delivery of the clinical elements of the organisations User Engagement Plan
Supporting the co-ordination of user surveying, action plans and with the Director of Supportive Care have oversight of the Have Your Say Group
Clinical Effectiveness
Responsible for the oversight, maintenance and development of the organisations clinical database, SystmOne
Ensuring accurate and timely data provision from the database to meet the requirements and deadlines of both internal and external stakeholders
To produce and complete returns for the Hospice UK benchmarking data and Hospice UK patient safety community of practice
Work collaboratively with the Corporate Governance Lead in the development and effectiveness of RADAR, the organisations governance database
Promote compliance with information governance, confidentiality, clinical records management and appropriate use of patient information within clinical services, working collaboratively with the organisation's Data Protection Officer on matters relating to UK GDPR and Data Protection legislation
To oversee the programme of clinical policy and procedure review and development to ensure that the delivery of safe and effective care is supported by up-to-date policy and guidance with delegated responsibility for the review of specific policies
Leadership and Management
To provide line management of the organisations SystmOne administrator, including annual appraisals, one to one meetings and, as required, recruitment and induction of a postholder
Be responsible for the delivery of a Quality Improvement (QI) education programme, provision of support and guidance to staff members conducting QI projects, promoting engagement in QI, monitoring QI activities and outputs and promoting the spread of learning from QI activities to other departments
Be responsible for the organisational preparedness for CQC inspections through the provision of training and education, development of a guide to inspection and promoting the CQC key lines of enquiry and assessment framework
To maintain the organisations evidence in relation to CQC compliance. Working with the Chief Executive to support the programme of Trustee Mock Inspections and production of inspection action plans. Undertaking deep dive inspections into specific areas as required
Work with the Director of Care and Transformation on the production of the organisations annual Quality Account
To promote a culture of innovation and quality improvement
Work in partnership with the Corporate Governance Lead to support integrated and effective governance across the Hospice. Both posts are expected to work collaboratively to ensure that governance activity is aligned, proportionate and clearly reported, with clear boundaries of accountability and no unnecessary duplication
Staff Support & Training
Provide advice on governance processes
Support training in: Incident reporting, Audit, and Governance systems
Person Specification
Experience
Essential
- Experience of leading and delivering clinical governance, audit and quality improvement within a regulated healthcare environment
- Has an extensive knowledge of health and social care regulation and
- legislation, especially with regard to regulated activity, and has contributed to a CQC inspection
- Has knowledge and experience of policy development in relation to clinical practice
- Has knowledge and experience of working within the Patient Safety Incident Response Framework (PSIRF) to ensure the delivery of safe, effective and high-quality care
- Has delivered both audit and quality improvement projects
- Understands the key risks in relation to clinical care
- Has knowledge and expertise in quality improvement tools and methodology
- Experience in delivering education programmes for staff in relation to quality improvement and safety
Desirable
- Experience of delivery of clinical governance agendas within palliative or end of life care
- Experience of working with service users and volunteers
- Has participated in research projects
- Has experience of oversight of databases clinical / incident reporting
- Experience of chairing meetings of staff and organising and leading cross team group working on specific projects
- Teaching or facilitation experience
Skills and Abilities
Essential
- Empathy with the work and values of St Nicholas Hospice Care
- Sensitive to the issues and concerns facing those living with dying, death and bereavement
- Experience of managing staff
- Ability to promote innovation and continuous improvement
- An effective communicator with the ability to motivate and influence
- A pragmatic and detailed thinker who can translate information into action
- Flexible, adaptable and able to respond to changing needs and demanding situations
- Able to manage conflict and achieve solutions
- Good numeracy, analytical skills and IT skills
- Ability to translate complex information into meaningful reports for a variety of stakeholders
- Well-organised and able to manage a diverse portfolio
Qualifications
Essential
- Has a degree or equivalent healthcare professional experience/qualification with professional registration with the
- appropriate professional body (e.g. NMC/HCPC/GMC)
Desirable
- Has training/qualification in Quality Improvement methodologies
- Has training/qualification in project management methodologies
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.
Employer details
Employer name
St Nicholas Hospice Care
Address
Hardwick Lane
Bury St Edmunds
Suffolk
IP33 2QY
United Kingdom
Employer's website
https://stnicholashospice.org.uk/ (Opens in a new tab)