Clinical Compliance Officer

Job description

Job responsibilities

JOB SUMMARY

To manage the annual programme of clinical audits and together with the Matron for bedded care drive forward quality improvement work. The post holder will support individual staff members in carrying out audits, carry out their own audits, and work to drive forward the Hospices quality improvement agenda.

Will provide administrative support for clinical governance activities, coordinate the review of care-related policies and procedures, and support the production of the annual Quality Account.

KEY ACCOUNTABILITIES

Provide administrative support to the clinical governance function, including agenda preparation, accurate minute taking, action and decision log maintenance, and meeting follow up.

Responsible for the coordination of the review and approval of care related policies and procedures, supporting policy owners with the production of revised policies, using the agreed template, and coordinating approval of policies in a timely manner.

Coordinate the production of the annual quality account, working with identified leads to produce their content for the report including quality account priority leads.

Develop a thorough understanding of the Vantage system and, in particular, the modules which support incidents, risks and complaints.

Ensure patient safety information is displayed on the patient safety boards in a timely manner.

To work with the Matron for bedded care, Director of Care and the Care team leads and other individual staff members to ensure that the annual clinical audit programme is, in a timely manner, formulated, carried out, and accurately reported.

To work with the leadership of the Care Directorate to use clinical incident and clinical outcomes data to inform the creation and design of clinical audit and quality improvement work.

To support clinical audit at the design, data collection, analysis, reporting, and recommendation stages.

To support and advise individual staff members carrying out particular audits and other quality improvement work, including with reporting and data visualisation.

To be able to present data and findings, both verbally and in writing, to diverse audiences in a manner that is intelligible, concise, accurate, and accessible.

To monitor and promote compliance with actions, escalating concerns where necessary.

To ensure clinical audit reports are of an acceptable standard.

To present completed clinical audits to the Quality Assurance and Improvement Group

Support production of quarterly care and clinical governance reports and annual quality accounts

To support the patient experience agenda, including gathering, analysing, and reporting as required and the Hospice Engagement Group.

To support participation in national and regional audits, as required.

To manage and coordinate the updating of all care related policies and procedures.

To assist in administering the Vantage incident, complaints, policies and risk management system.

To develop and manage the Vantage Clinical Audit module.

To liaise with the SystmOne support Officer and business intelligence team to extract clinical data for audit purposes.

To have a working understanding of Care Quality Commission regulations.

To stay current with clinical audit best practice and quality improvement in general.

To participate, where appropriate, in the formulation and revision of policies and procedures relating to quality and audit.

To support the Hospice with CQC Provider Information Requests and any other work relating to inspection.

To manage the CQC Compliance Vantage module.

To support care directorate staff with clinical governance processes, as required.

Promote a safeguarding is everyones business culture.

Ensure adherence with relevant Infection Prevention and Control policies and procedures.

GENERAL

Where you are a member of a professional body you are required to conform to the professional standards set by that body. You are required to ensure your registration is current and practice continuous professional development.

Because of the special nature of the hospice and its work the post holder may on occasion be asked to undertake other duties to help maintain our high standard of care; to uphold the hospice values at all times.

THIS JOB DESCRIPTION IS NOT NECESSARILY EXHAUSTIVE AND MAY BE SUBJECT TO REVIEW BY THE DIRECTOR OF CARE IN CONJUNCTION WITH THE POST HOLDER

Person Specification

Experience

Essential

• Experience of designing, conducting, and reporting on clinical audit and quality improvement projects.
• Report writing.

Desirable

• Operational clinical background.

Qualifications

Essential

• Relevant degree or equivalent experience.
• Able to demonstrate excellent written English skills.
• Strong numeracy.
• Able to demonstrate strong skills in Microsoft Excel and general proficiency in Microsoft Word, PowerPoint, and Publisher.
• Good understanding of the clinical audit process.

Desirable

• Clinical audit qualification.

Personal Qualities

Essential

• Passion for improving the lives of patients and their families.
• Commitment to quality, safety, and patient-centred care.
• Adaptability and resilience.
• A collaborative and team-oriented approach.
• Able to manage a variety of competing deadlines and demands.
• Ability to prioritise workload and use initiative.
• Ability to work with different teams and to promote the value of audit and pursue effective change.

Desirable

• Ability to persuade others of the value of a given change, improvement or innovation.

Specific Skills

Essential

• Excellent communication, and interpersonal skills.
• Excellent written and verbal skills.
• Able to manage and prioritise own workload.
• Ability to work accurately with excellent attention to detail.
• Excellent written English skills.
• Strong numeracy.
• Strong skills in Microsoft Excel and general proficiency in Microsoft Word, PowerPoint, and Publisher.
• Good understanding of clinical audit cycle and quantitative methodology.
• Ability to convey complex information to a variety of audiences, both verbally and in writing.

Desirable

• Good presentation skills.
• Good understanding of clinical governance.

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 Elizabeth Hospice

Address

565 Foxhall Road

Ipswich

Suffolk

IP3 8LX

Employer's website

https://www.stelizabethhospice.org.uk/ (Opens in a new tab)