Head of Governance and Improvement

Job responsibilities

MAIN DUTIES

• Ensure the Hospice meets CQC compliance with the Assessment Framework (and relevant future assessment frameworks) and CQC inspection regimes across all services, departments, and processes, aiming to raise the Hospices inspection rate back to outstanding.
• Develop and implement as Hospice Quality Improvement strategy with input from relevant members of SMT. This will be aligned to internal and external reporting and assurance requirements and follow the principles of PSIRF to enable the organisation to measure and continuously improve the quality of the service it provides.
• Organise and chair the quarterly Clinical Operations meeting. Liaise with the Director of Nursing & Quality before sending meeting invitations, agenda and supporting information to meeting attendees.
• Monitor and report on clinical risk and incidents, including risk assessments, incidents and the directorate risk register.
• Ensure responses are proportional and in keeping with the work of the Hospice, balancing Safety 1 and Safety 2.
• Analyse qualitative and quantitative data from several sources in governance and clinical areas to ensure relevant actions and recommendations reach beyond just the results of the quality and improvement work.
• Contribute to strategy and work on ad hoc projects as appropriate.
• Submit data and evidence to relevant external agencies, e.g. Hospice UK, CQC
• Ensure all that staff are engaged effectively and efficiently in governance processes by building relationships with clinical staff and departments.
• Monitor complaints and compliments across all services, identifying themes and trends which, by addressing, may change practice and improve our care.
• Develop a robust clinical governance Quality Improvement Plan providing updates to the Director of Nursing and Quality on a quarterly basis ensuring the Hospice meets all quality assurance standards.
• Share lessons learned in adaptable ways to all departments, ensuring changes to practice are mirrored in policies, training and competences as required
• Work with the Head of Facilities and Health & Safety Officer to ensure the maintenance of the building and equipment meets all regulatory requirements. Ensure these are recorded for CQC and HSE compliance purposes.
• Support St Johns as a learning organisation, sharing lessons learned in adaptable ways to all departments.
• Work in partnership with The VOICE Co-ordinator to implement the patient feedback protocol i.e. the patient and family survey process
• Consistently review how data is presented at meetings, revising reports as necessary, to ensure recognition of trends and themes.
• Support department managers in their responsibilities for compliance and Board assurance.
• Manage what is stored in the CQC evidence database, ensuring evidence accurately showcases the work of the Hospice.

Infection Prevention and Control

• Lead the infection prevention and control work across the Hospice to meet CQC requirements, meeting with the IP&C link nurses and Head of Facilities quarterly ensuring all relevant audits give full assurance to the Board.
• Submit all patient safety incidents to the HUK patient safety project to allow incident comparison with other Hospices

Audit and Data

• Working with the relevant members of SMT, design and agree the quality and clinical audit schedule, monitoring delivery against agreed schedule.
• Compile audit reports to meet CQC requirements and to assure the Board, ensuring recommendations and actions are completed in a timely manner.
• Monitor and CAS alerts and field notices, track response and required actions ensuring these are completed in a timely manner.
• Apply PSIRF to all elements of risk management in patient care, updating the PSIRP annually
• Submit all patient safety incidents to the HUK patient safety project to allow incident comparison with other Hospices
• Support clinical data requests and reports, working with the IT department, to ensure data is consistent and accurate for the Board and for ongoing commissioning.
• Complete gap analyses from high profile reports on clinical care, devising action plans.
• Ensure all clinical managers provide assurance about the quality of clinical data inputted and produced by their department.
• Educate staff in audit, ensuring accurate completion and reporting.
• Analyse clinical data from electronic patient records (EMIS) across all services, highlighting areas of unmet or increasing need such as specific disease groups, faith groups and hard to reach patient groups, producing reports on how the Hospice can support these going forward.

Information governance

• Understand how information governance applies in patient and staff records, ensuring policies and procedures are adhered to at all times.
• Advise on organisational compliance with confidentiality, clinical information governance and data protection in patient care.

Risk and incident management

• Review trends in clinical incidents and complaints, ensuring that After Action Reviews are completed (PSI if needed) and change implemented when required to improve quality, safety and patient experience.
• Monitor complaints regarding the clinical service and ensure a response to patient and care satisfaction surveys address any negative feedback when necessary.

Policies and procedures

• Ensure all policies and procedures are updated in a timely manner, with the admin assistant.
• Ensure all policies and procedures are updated with relevant national, regional and local guidelines, regulations and evidence based research.
• Ensure the Hospice is compliant with all relevant aspects of the Data Protection Act 2018.
• Ensure Data Impact Assessments are completed when appropriate.

Equality and Inclusion

• Ensure the Hospice is compliant in Equality and Inclusion training in order to meet CQC requirements
• Ensure the Hospice completes and meets all Equality Impact Assessments across all departments.

Personal development and People Management

• Manage the work of the governance team, leading, advising and guiding on workload, working with HR if there are any performance or conduct issues.
• Advise the Medical Director and Director of Nursing & Quality on any educational opportunities internally and externally, coming from incidents and risks, sharing lessons learned and any practice changes quarterly with relevant staff groups across the Hospice
• Educate hospice staff on relevant governance and compliance issues to ensure compliance is met.

Professional development

• Maintain your own required organisational standards for all mandatory training, acting as a role model in your team and the organisation
• Maintain and improve own professional competence in governance issues by attending training courses, study days and conferences as appropriate.
• Attend your annual appraisal, identifying areas of development for the future year.

DUTIES AND RESPONSIBILITIES TO ST. JOHNS HOSPICE

1. Confidentiality
2. Health and Safety
3. External Interests
4. Statutory Training
5. Flexibility
6. Safeguarding
7. Disclosure and Barring
8. Equality and Inclusion
9. Volunteers

Please see the uploaded Recruitment Pack for full details.

Experience

Essential

• Experience of CQC inspections and regulatory compliance in health and social care.
• Providing evidence to demonstrate meeting CQC Assessment Framework.
• Robust recent post-registration experience in clinical governance and risk management.
• Safeguarding legislation and compliance.
• Developing policies and procedures.
• Clinical and general audit.
• Supporting change in clinical and practice.
• Team management.
• Electronic patient records.
• Clinical record keeping.
• Data Impact Assessments.
• PSIRF and PSIRP.

Desirable

• Experience in a palliative care or hospice setting.
• Experience of teaching and development of training packages.
• Experience of implementing assessment framework in Hospice setting.
• Understanding of EMIS.
• Teaching / education- groups and 1-1.

Qualifications

Essential

• First Level Degree (Healthcare).
• Registered with relevant governing body, i.e. NMC.
• Leadership qualification.

Desirable

• Masters Degree.
• Qualification in Education /Training or equivalent experience.

Values and personal attributes

Essential

• Organised and able to prioritise workload in a fast-changing environment.
• Able to work effectively on own initiative, and in a team.
• Motivating, committed to the Hospice values.
• Resilient, can manage stressful situations.
• Able to troubleshoot within sphere of responsibility.
• Approachable, trouble shooting skills.
• Honest.
• Supportive to colleagues.
• Able to influence and provide leadership support to senior clinicians and managers.
• Innovative in approach.

Knowledge and Skills

Essential

• Understanding of the IG toolkit, GDPR and data management.
• Excellent analytical skills including statistical variation.
• Robust report writing skills.
• Robust IT skills including databases.
• Proven ability to work with multi-disciplinary teams, clinical and non-clinical.
• Able to influence, motivate and coach others around compliance issues and change.
• Excellent interpersonal skills.
• Change management.
• Ability to promote and implement equal opportunities.
• Proportionate response to risk and governance.
• Safety I and Safety II.
• Completer Finisher.

Desirable

• Supervision and/or coaching experience / qualification.

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.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).