Clinical Governance Lead

Job responsibilities

PURPOSE

The Governance Lead will provide the leadership and co-ordination of organisational and clinical quality governance across the business, to support the delivery of a high-quality safe service in compliance with regulations.

The role will promote an open culture and a positive learning environment encouraging the reporting of mistakes and service failures so that lessons can be learnt, and the appropriate improvement actions can be embedded, as well as learning from excellent practice and contributing to the dissemination of this ultimately to improve patient safety, patient experience, and patient outcomes.

KEY ACCOUNTABILITIES

• Responsible for ensuring that structures and systems are in place that enable improvements in the delivery of safe effective patient care.
• Responsible for the management of the service documentation, including the ratification and release of new policies and procedures.
• Responsible for providing the quality framework to underpin the governance of service delivery and ensuring that the working within the quality framework is embedded into everyday practice.
• Responsible for leading and providing oversight on governance, quality, and safety matters across the business.
• Responsible for providing expert governance advice, information, and guidance across the areas of responsibility.
• Responsible for developing effective relationships across the business and its services users.
• Responsible for evaluating the quality of clinical and non-clinical services, against agreed standards e.g., Care Quality Commission (CQC) in particular IRMER, Fundamental Standards, identifying areas of concern and in need of further improvement.
• Responsible for ensuring a robust non clinical and clinical audit programme in place, across all modalities and staff groups.
• Responsible for the implementation of systems which promote organisational learning within all staff groups along with identification or emerging themes and priorities through analysis of quality data to ensure continuous quality improvement.
• Responsible for for overseeing the implementation of a robust incident management system ensuring that it is straightforward for front line staff to report an incident. Has the appropriate functionality grade the incident and to record the investigation details, the appropriate monitoring tools to measure outcomes.
• Assist the Support Manager in the timely investigation of complaints. Ensuring all communication with patients, relatives and carers are open, honest and that investigations are transparent and independent. Ensure compliance with the requirement to inform patients/relatives (being Open/Duty of Candour) has been met.

KEY PERFORMANCE INDICATORS

• Monitor compliance with regulatory standards and produce reports on the Services compliance and information for key internal stakeholders at the Governance meeting. The reports are to provide performance metrics identifying themes, trends and points of concern.
• Evidence that all reported incidents are appropriately managed, concerns raised and actions for improvement addressed and learning shared.
• Coordinate and oversee being open and Duty of Candour within the Service is achieved as per policy when incidents occur.
• Evidence that the Service Policy and Procedure library is being proactively managed in line with current legislation and guidance.
• Ensure that the Service wide Risk Register is being maintained and managed.
• To act as a single point of contact for all matters relating to governance within the Service
• Maintain clinical credibility by being visible and accessible to the wider Service and allocation of time to work alongside modality service leads to maintain an understanding of clinical workstreams.

RELATIONSHIPS:

Internal

• To support the integrated governance agenda ensuring that the service meets the requirements of the legislative framework and to work closely and report as required and to be accountable to the Chief Operating Officer and Clinical Director and regarding governance, quality, and safety.
• Key to the success of the role will be good communication skills and the development of effective relationships and synergies across clinical and organisational services. The post holder will have the expert knowledge to provide direction and advice by ensuring close working with:
• Support Manager
• Nursing Lead
• Modality Leads
• Consultants
• Nurses
• ODPs
• Radiographers
• Administrators
• Domestics

External

• Supporting on-site inspections and /or assessments by regulatory bodies such as the HSE and CQC.
• Supporting external agencies that provide the business with specialist advice, Health & Safety, IPC and water management consultants.

DECISION MAKING

• Will make significant decisions using a variety of information sources and applying their own judgement that may have a significant impact on the business.

Qualifications

Essential

• HCPC or NMC registered
• Bachelors degree (or equivalent) in Nursing or Radiography
• Postgraduate qualification
• IOSH certificate (Preferred)
• Professional clinical knowledge and experience of clinical governance, risk management and quality improvement acquired through training to postgraduate level or equivalent applied learning.

Experience

Essential

• Experience of engaging and influencing clinicians / practitioners.
• Experience of operating successfully at a senior level in a complex organisation.
• Experience in managing an aspect of governance on a service basis.
• Experience of working across multi-professional boundaries to enhance knowledge of governance processes and cross - professional learning for improved patient experience.
• KNOWLEDGE:
• Knowledge of health and safety regulations.
• Experience of undertaking risk assessments.
• Experience of a CQC inspection and knowledge of their standards pertaining to diagnostic services.
• Knowledge of QSI.
• Previous supervisory/management.
• Experience of being to analyse, interpret, and make recommendations on highly complex and sometimes conflicting data, and formal reports relating to risk, patient safety, complaints, claims, inquests, infection control, clinical and quality indicators, and corporate performance to identify service improvement.
• SKILLS AND COMPETENCIES:
• Excellent interpersonal skills.
• Attention to detail.
• Self-starter.
• Calm under pressure.
• Conflict Resolution skills.
• Strong Customer Service skills.
• Clinically Competent.
• Effective Leadership skills.
• Flexible.
• The ability to prioritise against service deadlines. Discuss sensitive and contentious information with staff of all grades and disciplines always maintaining confidentiality and integrity.
• Credibility with Managers and Clinicians.
• Microsoft office competencies Keyboard skills.

INTEGRITY

Essential

• Continuously uphold and promote the clinics business ethics & demonstrate our 7 core values:
• Open & honest
• Respectful & relaxed
• Communicate effectively
• Have the highest safety levels
• Infection Control Champions
• Drive forward standards & service
• Staff support & development
• Always working lawfully and in accordance with all regulatory, compliance and financial requirements e.g., General Data Protection Regulations, Health and Safety, the Ionising Radiations Regulations including IR(ME)R.
• Always working in accordance with company policy, procedures, processes, standards, and controls.

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).