Claremont Hospital

Integrated Clinical Governance Manager

Information:

This job is now closed

Job summary

1. To lead on hospital Clinical Governance and work closely with the Director of Clinical Services, Hospital Director, Lead Consultant for Clinical Governance and the MAC chair in leading clinical quality and the Clinical Governance strategy within the hospital.

2. To take an active role in ensuring compliance with all hospital regulatory requirements.

3. To display and promote excellent clinical leadership in all areas of the hospital. To promote excellent customer service throughout the hospital, facilitating and co-ordinating corporate and local customer service initiatives and providing appropriate support to colleagues.

4. To provide and develop strong leadership for all aspects of the role initiating optimal clinical standards, managing business objectives, and aspiring to being the leading private healthcare provision within the locality.

5. To promote and facilitate effective and timely lines of communication within the teams, building relationships with all customer groups, and effecting delivery of actions.

Main duties of the job

1. Support all departments in ensuring compliance with CQC/HIS/HIW/ICB Essential Standards and maintain Provider Compliance Assessment Tool.

2. Link in with wider healthcare community, including but not limited to the CQC/HIS/HIW, local ICB, local NHS trusts.

3. Co-ordinate the compilation of the quarterly Governance reports, and provide support in the compilation of other Governance related reports including for example: Infection Control report and SSD reports, and ensure timely submission.

4. Collate all required information and ensure timely submission of accurate data to inform the corporate Clinical Scorecard and CQC/HIS/HIW submissions.

5. Initiate the investigation of Incidents and Complaints in a timely manner and manage Incident Reporting system and appropriate escalation of incidents. To support staff in the collation and submitting of RCAs within timescales as per corporate policy.

6. Promote and encourage an open reporting and learning culture within the hospital.

7. Develop own knowledge and practice and actively assist others to continually professionally develop.

About us

Our mission is to provide first-class independent healthcare for the local community in a safe, comfortable and welcoming environment; one in which we would be happy to treat our own families.

Claremont Private Hospital has been at the heart of the South Yorkshire community providing first class healthcare for over 60 years. Our hospital is situated in acres of beautifully landscaped grounds in Crosspool, South West Sheffield. Patients can enjoy a peaceful stay, easy access to their consultant, nursing care which is second to none and panoramic views from our modern and comfortable patient bedrooms, most of which are en-suite. We have over 280 highly experienced consultants practising privately at Claremont Private Hospital supported by a team of more than 200 hospital staff.

Details

Date posted

04 January 2024

Pay scheme

Other

Salary

£47,000 to £58,000 a year Depending on Experience

Contract

Permanent

Working pattern

Full-time, Flexible working

Reference number

E0159-24-0000

Job locations

Claremont Hospital

401 Sandygate Road

Sheffield

S10 5UB


Job description

Job responsibilities

Clinical Governance

1. Assess, monitor and review performance to ensure full compliance with the CQC/HIS/HIW National Minimum Standards. Together with the DOCS, lead the preparation for inspection or assessment visits from the CQC/HIS/HIW and other relevant regulatory bodies and work closely with the DOCS in leading the accurate and timely reporting process to the CQC/HIS/HIW.

2. Attendance at the suite of Governance meetings providing associated clinical governance update report (as required) including Medical Advisory Committee; Clinical Governance Committee; Clinical Audit and Effectiveness Committee; Health & Safety/Risk Committee; local associated committees (infection, prevention and control; blood transfusion; pain management; decontamination), chairing as appropriate or delegated.

3. Support the efficient co-ordination of the Clinical Governance Committee to ensure it functions effectively, according to an annual plan and in line with Spire Healthcare policy.

4. In collaboration with the DOCS, review and update relevant strategies, policies and procedures including the Clinical Governance Strategy.

5. Proactively manage the Datix incident reporting system, ensuring all incidents are investigated in a timely manner and the lessons learnt are shared with all relevant teams and team members.

6. Act as an exemplary role model in quality improvement offering advice and support to others, whilst ensuring continuous governance compliance throughout the hospital.

7. Responsible for effective dissemination and central reporting of all issued alerts and collation of actions required.

8. Review current national regulation and guidance (as issued) to ensure all hospital activity and policies are compliant.

9. Share examples of best practice with colleagues across the Spire Group.

Medical Governance

1. Escalation of concerns related to specify Consultant document provision, if delays occur, to the Hospital Director.

2. Collate documentation consultant biennial review programme; including complaints and incident reporting.

3. Support DOCS in ensuring all mandatory requirements relating to introduction of new procedures are met in readiness for MAC approval

4. To review hospital PROMs results and escalate outliers for review to the Clinical Governance committee.

5. To review Consultant Intervention Ratio results and escalate outliers for review to the Clniical Governance committee.

6. Meet with MAC chair, Hospital Director and DOCS to discuss any concerns relating to medical governance/Consultant practice including incidents, complaints, mandatory documentation, behaviour concerns, soft intelligence from within the hospital and wider healthcare community.

Clinical Leadership

1. To work closely with all clinical departments promoting patient focused quality care.

2. Be a point of contact for the SMT, clinical and non-clinical staff.

3. To act as an exemplary role model, and ensure evidence based practice is undertaken within all clinical teams taking every opportunity to promote innovative practice.

4. Lead, support and empower staff to realise their full potential.

Risk Management

1. Manage and co-ordinate clinical and non-clinical risk activities ensuring compliance with relevant regulatory bodies.

2. Ensure appropriate reporting, investigation and management of incidents is undertaken in accordance with requirements of CQC/HIS/HIW and HSE. Develop and devise procedures as necessary.

3. Co-ordinate the dissemination, integration and implementation of corporate and local policies and procedures. Work with colleagues to develop appropriate policies where appropriate, and ensure they are reviewed within the required time frames.

4. Adopting a multi-disciplinary approach, in conjunction with colleagues, work to develop an organisational culture which encourages professionals to review practice, report untoward incidents and share lessons learnt without fear of recrimination or censure.

Patients and Customers

1. Ensure that the views of patients and customers are used to guide and inform the provision of services through patient forums, engagement with patient representative groups, dissemination of feedback form questionnaires, complaints etc.

2. To ensure that results from patient satisfaction surveys are analysed and acted upon through the Clinical Governance committee.

3. To ensure lessons and trends from patient complaints are reviewed, discussed, analysed and acted upon via the Clinical Governance Committee.

4. Ensure that relevant and appropriate information, advice and support is available to all service users and stakeholders.

Health & Safety

1. Be an active member and contribute to the smooth running of the Health & Safety Committee ensuring appropriate information and reports are available as required.

Audit

1. Work closely with the DOCS to ensure that clinical audit activity is in line with both the annual corporate and local plan, prioritising audits against key performance indicators.

2. Ensure that the local annual audit plan is devised and delivered and actions and outcomes are delivered and where appropriate monitored through a robust action plan.

3. Oversee audit activity to ensure compliance within the clinical departments throughout the Hospital.

4. Engage with National Audit Programmes and ensure timely submission of data as relevant to hospital practices.

Job description

Job responsibilities

Clinical Governance

1. Assess, monitor and review performance to ensure full compliance with the CQC/HIS/HIW National Minimum Standards. Together with the DOCS, lead the preparation for inspection or assessment visits from the CQC/HIS/HIW and other relevant regulatory bodies and work closely with the DOCS in leading the accurate and timely reporting process to the CQC/HIS/HIW.

2. Attendance at the suite of Governance meetings providing associated clinical governance update report (as required) including Medical Advisory Committee; Clinical Governance Committee; Clinical Audit and Effectiveness Committee; Health & Safety/Risk Committee; local associated committees (infection, prevention and control; blood transfusion; pain management; decontamination), chairing as appropriate or delegated.

3. Support the efficient co-ordination of the Clinical Governance Committee to ensure it functions effectively, according to an annual plan and in line with Spire Healthcare policy.

4. In collaboration with the DOCS, review and update relevant strategies, policies and procedures including the Clinical Governance Strategy.

5. Proactively manage the Datix incident reporting system, ensuring all incidents are investigated in a timely manner and the lessons learnt are shared with all relevant teams and team members.

6. Act as an exemplary role model in quality improvement offering advice and support to others, whilst ensuring continuous governance compliance throughout the hospital.

7. Responsible for effective dissemination and central reporting of all issued alerts and collation of actions required.

8. Review current national regulation and guidance (as issued) to ensure all hospital activity and policies are compliant.

9. Share examples of best practice with colleagues across the Spire Group.

Medical Governance

1. Escalation of concerns related to specify Consultant document provision, if delays occur, to the Hospital Director.

2. Collate documentation consultant biennial review programme; including complaints and incident reporting.

3. Support DOCS in ensuring all mandatory requirements relating to introduction of new procedures are met in readiness for MAC approval

4. To review hospital PROMs results and escalate outliers for review to the Clinical Governance committee.

5. To review Consultant Intervention Ratio results and escalate outliers for review to the Clniical Governance committee.

6. Meet with MAC chair, Hospital Director and DOCS to discuss any concerns relating to medical governance/Consultant practice including incidents, complaints, mandatory documentation, behaviour concerns, soft intelligence from within the hospital and wider healthcare community.

Clinical Leadership

1. To work closely with all clinical departments promoting patient focused quality care.

2. Be a point of contact for the SMT, clinical and non-clinical staff.

3. To act as an exemplary role model, and ensure evidence based practice is undertaken within all clinical teams taking every opportunity to promote innovative practice.

4. Lead, support and empower staff to realise their full potential.

Risk Management

1. Manage and co-ordinate clinical and non-clinical risk activities ensuring compliance with relevant regulatory bodies.

2. Ensure appropriate reporting, investigation and management of incidents is undertaken in accordance with requirements of CQC/HIS/HIW and HSE. Develop and devise procedures as necessary.

3. Co-ordinate the dissemination, integration and implementation of corporate and local policies and procedures. Work with colleagues to develop appropriate policies where appropriate, and ensure they are reviewed within the required time frames.

4. Adopting a multi-disciplinary approach, in conjunction with colleagues, work to develop an organisational culture which encourages professionals to review practice, report untoward incidents and share lessons learnt without fear of recrimination or censure.

Patients and Customers

1. Ensure that the views of patients and customers are used to guide and inform the provision of services through patient forums, engagement with patient representative groups, dissemination of feedback form questionnaires, complaints etc.

2. To ensure that results from patient satisfaction surveys are analysed and acted upon through the Clinical Governance committee.

3. To ensure lessons and trends from patient complaints are reviewed, discussed, analysed and acted upon via the Clinical Governance Committee.

4. Ensure that relevant and appropriate information, advice and support is available to all service users and stakeholders.

Health & Safety

1. Be an active member and contribute to the smooth running of the Health & Safety Committee ensuring appropriate information and reports are available as required.

Audit

1. Work closely with the DOCS to ensure that clinical audit activity is in line with both the annual corporate and local plan, prioritising audits against key performance indicators.

2. Ensure that the local annual audit plan is devised and delivered and actions and outcomes are delivered and where appropriate monitored through a robust action plan.

3. Oversee audit activity to ensure compliance within the clinical departments throughout the Hospital.

4. Engage with National Audit Programmes and ensure timely submission of data as relevant to hospital practices.

Person Specification

Qualifications

Essential

  • Clinically Registered Professional Qualification

Desirable

  • Experience working as Clinical Governance Manager
Person Specification

Qualifications

Essential

  • Clinically Registered Professional Qualification

Desirable

  • Experience working as Clinical Governance Manager

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).

Additional information

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).

Employer details

Employer name

Claremont Hospital

Address

Claremont Hospital

401 Sandygate Road

Sheffield

S10 5UB


Employer's website

https://www.claremont-hospital.co.uk/ (Opens in a new tab)

Employer details

Employer name

Claremont Hospital

Address

Claremont Hospital

401 Sandygate Road

Sheffield

S10 5UB


Employer's website

https://www.claremont-hospital.co.uk/ (Opens in a new tab)

Employer contact details

For questions about the job, contact:

Details

Date posted

04 January 2024

Pay scheme

Other

Salary

£47,000 to £58,000 a year Depending on Experience

Contract

Permanent

Working pattern

Full-time, Flexible working

Reference number

E0159-24-0000

Job locations

Claremont Hospital

401 Sandygate Road

Sheffield

S10 5UB


Privacy notice

Claremont Hospital's privacy notice (opens in a new tab)