Job responsibilities
JOB
PURPOSE
The
post holder is responsible for supporting the Head of Nursing and CSU
Clinical Quality Matron to facilitate the ongoing accreditation and
development of the quality systems within Trauma and Related Services,
working with Medical, Nursing, Management and Heads of support services. The
post holder will assist the Head of Nursing and the Clinical Quality Matron
in the development and maintenance of a quality programme across all
specialities within the CSU.
The
post holder will co-ordinate multi-speciality meetings, activities with other
professions and agencies. The post holder will be able to initiate the
planning and coordination of these activities. The post holder will be able
to manage a number of these complex activities at any time on a daily basis.
The
post holder will attend meetings and provide administrative support to
clinical colleagues as required, for example during Peer Review.
The
post holder will also be involved in the development and maintenance of audit
schedules, service improvements and root cause analysis where needed within
the CSU.
Quality
system(s) and/or projects will be allocated to the post holder who will be
responsible for ensuring day to day management and updating of the quality
systems. The post holder will be
expected to attain basic knowledge of all areas and discuss and highlight
incidents as they occur.
The
post holder will collate information for the Head of Nursing and Clinical
Quality Matron. The post holder will
set agendas, attend meetings, take minutes and liaise with staff to ensure
that actions are completed
The
Post holder will create and maintain action trackers for all patient safety
incidents including outcomes of meetings and following up actions.
The
post holder will collate the formal complaints for the CSU and ensure
accurate and up to date records and tracking logs are maintained as well as
assisting the managers with completing responses.
The
post holder will support the CSU education program, booking rooms, updating
calendars and spread sheets and preparing materials for study days and
quality.
The
post holder will collate the PALs complaints for the CSU and ensure accurate
and up to date records and tracking logs are maintained as well as assisting
the managers with completing responses.
The
post holder will track all investigations via a dashboard and upload action
logs to datix.
The
post holder will support the administrative team within the CSU with
additional duties as required and following discussion with their line
manager, such as triumvirate PA holiday cover, to ensure service delivery.
The
post holder will be based at the Leeds General Infirmary (LGI) but may be
required to travel and work across other hospital sites within the Trust.
JOB
DIMENSIONS
The
post holder will work with Medical, Nursing, Management and other colleagues
within and outside the CSU, to support the senior team in the development,
implementation and maintenance of the current quality systems and in moving
towards quality systems for all services within Neurosciences and will be
required to liaise with other internal Trust departments and external
Healthcare providers.
The post holder will be jointly responsible for the issue and document
control of all policies/procedures within their area and also ensuring review
dates are notified to the Head of Nursing and CSU Clinical Quality Matron and
added to the agenda of the appropriate review meeting.
The post holder will support the Head of Nursing and CSU Clinical Quality
Matron in ensuring continuous improvement across all aspects of the
Directorate through audit, patient questionnaires and service improvement
initiatives.
The post holder will support CSU and speciality Triumvirate teams with
collating and gathering information on a regular basis as well as preparing
presentations for specialty and CSU governance meetings and other meetings,
such as HCAI.
PRINCIPAL
DUTIES & AREAS OF RESPONSIBILITY
KEY
RESPONSIBILITIES
Assists in the delivery of the service by providing relevant data for
presentation at local meetings as required.
Assists the Senior Triumvirate team in providing relevant information to
support to all staff as required. .
Assist the Head of Nursing and Clinical Quality Matron in the day to day
delivery of the quality service within the CSU.
Keep accurate records for data, analytical and auditing purposes as required
and requested by Nursing, Medical and Management teams and in line with local
and Trust policies and procedures.
Ensures accurate record keeping and tracking of complaints as well as
maintaining a spreadsheet for themes and outcomes and the recording of action
plans.
Ensures accurate record keeping and tracking of patient safety incidents
including HCAI, pressure ulcers and falls with harm within the CSU as well as
the upkeep of action plans and maintaining spreadsheets and trackers,
providing information to support the Matrons and Head of Nursing as required.
Ensures accurate records for incidents and investigations for data and
presentation purposes.
Works with the relevant specialty Governance leads to monitor the progress of
the Annual Clinical Audit programme and any agreed action plans and ensure
the target level of performance is achieved for audits.
Works with the relevant matrons and clinical leads to ensure progress of the
annual Nursing and medical audit programmes and any agreed action plans and
to ensure the target level of performance is achieved for audits.
To work with relevant specialty Governance leads and clinical leads to
coordinate CSU and specialty governance including agenda setting, minute
taking and tracking actions.
Ensures the collection of up to date evidence for assurance of the annual
self-assessment audit.
Ensures that the root cause analysis meetings are arranged and reporting
requirements are completed on time.
Analysis
and Data Management
To produce routine performance reports to measure key indicators of service
delivery.
Personal
Development
To keep up to date on legislation relevant to Clinical Governance.
To participate in the Trusts appraisal processes and have in place a
Personal Development plan.
The post holder must take responsibility in agreement with his/her line
manager for his/her own personal development by ensuring that continuous
professional development remains a priority.
The post holder will undertake all mandatory training required for the
role.
