Job responsibilities
- Lead on collaboration with the MNSI (Maternity and Newborn Safety Investigations) programme ensuring the maternity service works in partnership with the maternity investigators and seeks to provide safety assurance.
- Ensure that the Quality, Safety and Risk Management framework is embedded within the division.
- Ensure that assurance processes are in place to comply with key components of MNSI, NHSR EN scheme and PMRT standards.
- Monitor the learning from incidents and complaints and ensure that trends are identified and actions addressed with support from the Maternity Investigation & Learning Coordinator. Ensure that there are appropriately robust measures to ensure that risks at all levels across the service are appropriately managed and that the HOM, DOM and Maternity & Neonatal Quality & Safety Lead are provided with appropriate assurance.
- Report on progress against locally and nationally agreed quality indicators to internal and external stakeholders
- Prepare reports for discussion at all relevant corporate risk, patient experience and quality meetings relating to Women's Health and Maternity Services.
- In conjunction with the Obstetric and Neonatal Consultant quality and safety leads and Compliance Lead, oversee the local Perinatal audit programme, to foster an active multi-professional approach to audit and disseminate the learning from completed audit projects in the wider arena.
- To proactively support and influence the matrons and band 7 leaders to support the quality improvements and safety agenda for maternity.
- Oversight of the local maternity quality improvement programme
- To review and oversee MBRRACE reports and other national guidance and ensure recommendations are integrated into unit policies and guidelines.
- To develop partnerships and represent the Trust at a local and regional level in order to share lessons learned and best practice.
- To keep abreast of the National Agenda in regard to Patient Safety.
- Ensure dissemination of the Patient Safety Alerts and national reports and co-ordinate the responses to ensure that appropriate action plans are in place and actioned.
- Deputise for the Mat/Neo Quality and Safety Lead as required
Quality and Safety:
Work in conjunction with the Mat/Neo Quality and Safety Lead to make recommendations for quality improvement projects based on learning from incidents.
Take the lead on supporting staff to undertake investigations, considering the complexity and sensitivity of communication required to meet the next level.
Support the team to review and produce high quality investigation reports and outcome letters to families.
Where required, take the patient safety incident response lead role.
Ensure recommended action is taken as a result of incident investigations, and that processes are in place to provide assurance of test of effectiveness.
Undertakes thematic reviews and safety analysis that require comparison, interpretation and synthesis of a wide range of clinical, human factors and organisational data.
Named oversight for all Quality improvement initiatives resulting from incidents, providing guidance and support to the improvement groups, reporting on the impact of the improvement.
Foster and encourage a culture of continual improvement, acting as a facilitator for quality improvement and audit in conjunction with the clinical leads across the department.
Work with the Mat/Neo Quality and Safety Lead, consultant Obstetrics and Gynaecology clinical governance leads and divisional data analyst to formulate maternity and gynaecology governance KPIs/metrics and report progress to various internal and external stakeholders.
Work with the Mat/Neo Quality and Safety Lead, consultant clinical governance leads and divisional data analyst to refine clinical quality dashboards so that they increasingly enable early intervention before significant risks or harm occur.
Lead on reporting to the perinatal and maternity governance meetings
Take the lead in producing written reports to support the Quality & Safety Committee and any other Trust forum as required, liaising with the gynae clinical governance leads and paediatric and neonatal quality and safety lead.
Represent the Trust at various internal and external quality and safety forums as required.
In conjunction with the senior leadership team, review compliance with the CQC domains
Support and advise the clinical area lead with their investigation and PSIRF response method as a result of incidents and near misses. Take the lead in maintaining the incident tracker and ensure that actions are completed and lessons are embedded.
Develop and implement systems to identify opportunities for learning and sharing good practice.
Lead on the timely response to relevant patient safety alerts and national reports and ensure recommendations are integrated into unit policies and guidelines.
Work with senior clinicians to monitor the implementation of NICE guidelines, National Service Frameworks and other relevant national recommendations.
In conjunction with the senior leadership team and divisional quality and safety team, be responsible for delivering relevant aspects of the Quality, Safety and Risk Management Strategy
Facilitate a proactive approach to risk management through support of the risk assessment process, supporting clinical leads to populate the Trust risk register and ensuring regular reviews and updates are maintained. Lead and collate relevant local risk assessments, ensuring identified actions are followed through.
Collate the evidence/information from maternity for the divisional reports required for assurance or inspections
Present an overview of the maternity and womens health quality and safety progress and challenges to the Divisional Governance meeting, contributing to any action planning as a result, supporting staff to implement the identified actions and overseeing completion of these.
Requires analysis of highly complex, multifactorial clinical incidents where information may be conflicting, incomplete or emotionally charged, forming expert judgements and recommendations.
Leads the development, review and implementation of maternity safety policies, guidance and governance systems, ensuring alignment with national standards including CNST, NHSR, PMRT and MNSI.
Training and Development:
Contribute to the multi-disciplinary training programme within the division
To contribute to the induction courses for new medical, midwifery and nursing staff
To ensure a training needs analysis is undertaken for the Quality & Safety team
Clinical and Professional Leadership
- To provide professional leadership and be an excellent role model and manager to the safety and quality team.
- Work with all staff to provide a culture that is developmental, flexible and supportive
- Influence and empower through motivating and supporting staff
- Follow all HR policies and be responsible for own staffs appraisals and development
Monitor and oversee duty rotas to ensure effective use of resources and adherence to the principles of Improving Working Lives
Responsible for undertaking training needs analysis for the quality & safety team, identifying cost-effective safety improvements and ensuring efficient management of resources within the Quality & Safety team.
Communication & Engagement
a. To be able to share learning from incidents with clinical multi-disciplinary teams in a way that promotes psychological safety and just culture, as well as engaging and motivating teams with the resulting improvement work.
b. To be able to support and debrief staff in a 1:1 or group forum following a clinical incident.
c. To provide education to multi-disciplinary teams, motivating staff to adopt a culture of continuous learning and improvement.
d. To support staff to collate written statements for MNSI and Coroners' investigations
e. To present highly complex, sensitive or contentious information to multi-disciplinary forums within service level, divisional, Trust and LMNS quality forums. This includes thematic learning from incidents or sharing details of complex cases and poor clinical outcomes for families
f. To discuss and share highly complex, sensitive or contentious information with families where there may be barriers to understanding or accepting the information. This includes sharing the findings of post-mortem results and investigation findings with families.
g. To support Tripartite meetings between families and MNSI to share and discuss the findings from MNSI investigations and to discuss the learning that will be shared with clinical teams to prevent recurrence
h. To liaise closely with and share information with external agencies such as LMNS/ICB, MNSI, CQC, NHSR, and MBRRACE.
i. To provide assurance to external agencies such as CQC and the LMNS/ICB.
j. Accountable for the accuracy, integrity and reporting of maternity governance data, including incident, audit and PMRT datasets, used for internal and external assurance.
To support the department and organisation by carrying out any other duties that reasonably fit within the broad scope of a job of this grade and type of work.
