Detailed job description and main responsibilities

To assist in interpretation of standards and how quality can be measured within the Trust; and act as the point of contact for provision of expert advice in relation to national standards issues in particular with: Policy leads, CQC leads, corporate directorates, Operational governance.

To provide support to corporate directorates in relation to operational governance and implementation of OP10/Risk Management Assurance strategy, i.e. risk management, incident reporting, attend corporate directorate governance meetings as and when required. 

To work effectively with Policy/Trust clinical leads to provide expert guidance, support to ensure implementation and monitoring of regulatory standards are included in Trust policy/processes.

To implement data quality validation checks against data used for assurance purposes in relation to compliance with regulatory standards (in particular CQC, NICE, National Guidance, Strategies and Key Policies)

To assist development and use of key systems and processes in place within the Trust used to provide assurance of compliance with regulatory standards (in particular; Health Assure) for CQC, etc.

To assist in development, implementation and monitoring of process to ensure regular and timely information is available for reports to Trust Governance Committees, particularly in relation to NICE, Confidential Enquiries, Care Quality Commission Registration.

To support the identification, development and implementation of key information flows and ensure they are integrated into the Trust reporting system and mapped against National compliance standards. (e.g. Clinical Audit, Creating Best Practice, Nursing Metrics etc.)

To assist in co-ordination of the review and implementation of new national guidance such as NICE, PMRT, NSFs or Confidential Enquiries. This will include ad hoc guidance issued by Department of Health Committees.

To assist in development and delivery of education of trust staff at all levels around all areas of responsibility (in particular; Quality Assurance and Compliance, Datix, PMRT Trust Induction, compliance system)

To develop and implement effective use of key Trust systems to provide assurance against regulatory standards (Compliance System, Datix etc.)

To use the data identified to produce effective intelligence to support the assurance process and be able to highlight areas of concern using agreed triggers.

To produce a newsletter for the Trust to focus on sharing lessons across the Trust.

To actively share knowledge/lessons learnt across the trust for purposes of assurance.

To produce reports to working groups/committees on a regular/ad hoc  basis.

ORGANISATIONAL AND WORKING RELATIONSHIPS

The post holder’s working relationships will include senior staff in all clinical settings in the Trust

·         External and Trust Level

·         Trust Policy/Clinical Leads

·         Corporate directorates

·         Executive Directors in relation to the implementation of quality assurance programmes covering organisational standards.

·         Compliance Manager.

·         Specialist Leads

·         Divisional Level

·         Divisional Healthcare Governance Managers and other members of the operational governance team in relation to interpreting national standards and applying them to local conditions.

·         Operational Divisional/Directorate governance

·         Governance Support Team Leaders

SPECIFIC DUTIES AND RESPONSIBILITIES

Leadership

Acting as role model by demonstrating leadership and expert knowledge by maintaining credibility within the Trust and wider healthcare community, ensuring a positive image of the Trust is maintained at all times.

Providing specific advice relating to national standards (as detailed above) to all levels of staff (in particular; policy leads, clinical leads, specialists groups, divisional governance (inc. operational governance)

Provide specialist advice and guidance to Clinicians regarding ‘best practice guidelines’ in relation to clinical care and the reviewing, implementing and auditing of national guidance for example NICE

Undertaking specific project / audit work relating to compliance with national standards regulation and governance activity as required.

To act across for the Quality Assurance Unit members.

Service delivery

Work with the Compliance Manager and Quality Assurance Lead to develop the Trusts robust quality assurance systems and processes.

Ensure that reports are produced

The development, maintenance and review of Trust wide policies and Strategies pertinent to specific projects and workloads within the role including all policies relating to national guidance, best practice and NICE.

In conjunction with the other Healthcare Governance Managers and Trust Governance Leads to be jointly accountable for the delivery of an efficient and effective quality control service that reflects the needs of patients, their families and which meets the contracted quality indicators for the Trust.

Work in collaboration with the Trusts CQC leads to assist in ensuring compliance is monitored and gaps highlighted

To support the Compliance Manager and Quality Assurance lead in their roles of ensuring the Trust management systems for monitoring of the Trust activity listed below are fit for purpose and able to deliver Assurance reports to trust level committees:

·         NICE

·         Care Quality Commission Registration Regulations

·         National Audits including Care Quality Commission Themed reviews

·         National Guidance

Clinical Audit / Research

To co-ordinate all cross unit, district wide or Trust wide clinical audit projects particularly in relation to NICE or Care Quality Commission Registration standards.

Work with Clinical Audit Lead to assist in development, maintenance and review health economy wide policies pertinent to NICE Implementation.

Ensure that all national guidance is appropriately distributed to lead clinicians for review and implementation, where relevant, in a timely manner.

Attend relevant groups/committees

To act as co-ordinator for the NICE process within the organisation.

Act as Trust co-ordinator for confidential enquiries and other external reports and guidance issued nationally and ensure that these are considered at all relevant levels within the organisation

To assist the Compliance Manager and Quality Assurance Lead on the implementation of a robust quality assurance process.

Monitor and collate data for key performance indicators relating to Registration standards, National 

Guidance and Audit and Effectiveness

Education and Training

Implement, promote and deliver the quality assurance programme, including identifying the training needs of all the different staff groups within the Trust.

Implement, promote and deliver training programmes for CQC, NICE and Confidential enquiries.

To act as a senior mentor and facilitator for staff within the Trust, thereby ensuring practice meets the professional and managerial standards required by the Trust.

Information Management

Plan, implement and maintain a trust wide system for storing data in order to:

Produce and present summaries of compliance activity on a regular basis.

Produce Corporate Directorate / Division / Trust reports.

Maintain RWT Information databases relating to:

·         CQC

·         NICE, NCEPODs

·         National Confidential Enquiries.

·         Trusts document management system

·         Perinatal Mortality Review Tool (PMRT)

Produce timely and accurate reports based on the information stored in these systems.

Personal development

All RWHT staff have a responsibility to:

·         Always act in accordance with the Code of Conduct for NHS Managers.

·         Maintain up to date skills and knowledge and maintain awareness of patient led service issues

·         Adhere to Trust policy procedures and guidelines with particular reference to Infection Prevention

·         Adhere to Trust standards of behaviour, expected performance and code of dress outlined in HR policies available on the Trust Intranet

·         Take responsibility for own learning and development by recognising and taking advantage of all opportunities in full participation in KSF / appraisal, supervision, action learning and by maintaining a professional / portfolio of learning.

·         Work across organisational / divisional boundaries to ensure a seamless service is delivered at all times to patients, staff and organisation.

·         Undertake specifically allocated project work which expands your knowledge and experience base and support team work across the Trust.

·         Where appropriate to maintain accreditation within the appropriate Professional Body by ensuring compliance with their standards as appropriate.

·         To actively be involved with the appraisal system in the Trust and maintain the required PDP.

To autonomously manage and organise the work portfolio of the post providing progress reports and feedback reports to relevant managers