Quality Patient Safety & Risk Manager

Purpose of the Post

The purpose of the post is to oversee the work of the Quality, Patient Safety & Risk Department in advancing patient safety and continuous quality of patient care improvement across the hospital, in line with national policy and standards within IEHG governance structures.

The post holder will support the General Manager and Clinical Director in achieving excellent standards in clinical governance. They will be responsible to develop, deliver, implement and evaluate a comprehensive quality and safety programme with associated structures, policies and processes. This will involve supporting the implementation of the HSE Risk and Incident Management Policy and guidance including oversight on the management of the Hospital’s risk evaluations and processes and ensuring effective clinical incident management structures monitoring systems, policies and processes are developed and maintained. The post holder will oversee and manage St Columcille’s Hospital service user experience under the ‘Your Service, Your Say’ policy.

Principal Duties and Responsibilities

Leadership and Accountability (Clinical Governance)

· Responsibility for the management and development of the Quality, Patient Safety and Risk Department

· Ensure the on-going implementation of Risk and Incident Management programme at the hospital in line with relevant national policies, procedures, protocols and guidelines within IEHG governance structures

· Provide support to the Hospital Management Team in the implementation and management of the hospital’s quality, patient safety and risk functions

· Provide analysis reports on adverse patient safety incidents, to identify trends and opportunities for further learning, quality and safety improvements and risk reduction strategies

· Provide Clinical Risk reports for Hospital Management, Quality and Safety Executive, and Safety Programme (Clinical Governance)

· Support the Quality Agenda for the hospital, engendering patient safety focus.

· Assist in the provision of education and guidance for relevant staff on risk and incident management in line with best practice

· Assist in the development of a framework for Open Disclosure Training in SCH in conjunction with the national team and hospitals leads.

· Support the monitoring the effectiveness of Open Disclosure Training across SCH on an ongoing basis and in line with relevant & new legislation.

· Support the collation and interrogation of quantitative and qualitative data on patient needs, experience and outcomes of care to highlight areas for improvement across SCH.

Clinical Risk and Incident Management

· Work in collaboration with clinical services, senior and frontline managers to develop and implement effective organisational wide clinical risk and incident management structures, systems and processes in line with best practice.

· Develop and implement processes whereby learning from incidents and near misses is gleaned and used as an education and development tool for the organisation

· Collate and monitor key performance indicators related to incident and risk management in line with SCH, IEHG and national requirements

· Co-ordinate the development, implementation and monitoring of clinical risk management policies

· Manage and oversee clinical incident reporting for SCH onto the National Incident Management System (NIMS)

· Oversee, encourage and develop practice relating to the reporting, rating and review of clinical incidents (to determine contributory factors, root causes and actions required) in all clinical areas

· Keep abreast of clinical risk management issues and co-ordinate implementation of actions arising from developments in national and international practice in the area of risk and incident management

· Investigate serious clinical incidents/serious reportable events in agreement with hospital management in line with HSE Incident Management Framework 2020

Quality Improvement (QI)

· Assist in the development of the hospital’s quality improvement programme

· Develop and oversee the Clinical audit function at the hospital as part of the Quality, Patient Safety and Risk Department

· Co-Ordinate and support agreed quality improvement projects within teams and across the organisation with the application of quality improvement methodologies

· Manage day to day communications with QI teams to ensure appropriate progress is achieved, tracked and implemented

· Ensure that the element of improvement measurement and data analysis are incorporated into all quality improvement projects and provide assistance in this regards within available resources

· Co-ordinate and assist with Clinical Audit (Internal and External), Self-Assessments and National Reports

· Maintain and manage the Quality System around PPPG development and approval at the hospital

· Support the implementation of Quality and Patient Safety initiatives and policy within IEHG governance structures

· Have a working knowledge and oversee the implementation of Health Information and Quality Authority (HIQA) Standards; HSE policies, procedures, protocols and guidelines as they apply to the role

· Oversee and manage St Columcille’s Hospital service user experience under the ‘Your Service, Your Say’ policy.

Human Resources / Supervision of Staff

· Lead, manage and support the department staff and enable other team members to carry out their responsibilities, ensuring appropriate delegation of responsibility and authority

· Review the conduct and completion of assignments of staff in accordance with the operational plan and expected quality standards

· Keep in touch with workloads of staff members to gauge levels of wellbeing and morale in the team

· Management the performance of staff, dealing with underperformance in a timely and constructive manner

· Conduct regular team meetings to keep staff informed and to hear views

· Create and promote a positive working environment among staff members, which contributes to maintaining and enhancing effective working relationships with other teams and disciplines

· Solve problems and ensure decisions are in line with local and national agreements

· Identify and agree training and development needs of team and design plan to meet needs

· Pursue and promote continued professional development in order to develop leadership and management expertise and professional knowledge

Standards, Regulations, Policies, Procedures & Legislation

· Contribute to the development of policies and procedures and ensure consistent adherence to procedures and current standards within area of responsibility

· Effective discharge the day to day operations, including compliance with HSE Financial regulations and all HSE policies and procedures

· Maintain own knowledge of relevant policies, procedures, guidelines an practices to perform the role effectively and to ensure standards are met by own team

· Maintain own knowledge of relevant regularisation and legislation internal and external to HSE

· Have a working knowledge of the Health Information and Quality Authority (HIQA) Standards and other standards as they apply to the role e.g. Standards for Healthcare, National Standards for the Prevention and Control of Healthcare Associated Infections, Hygiene Standards etc. and comply with associated HSE protocols for implementing and maintaining these standards

· Support, promote and actively participate in sustainable energy, water and waste initiatives to create a more sustainable, low carbon and efficient health service

Education and Training

· Provide advice on a day to day basis for staff with regard to the management of clinical incidents and risks

· Provide information/education, updates and training as appropriate to the role

Eligibility Criteria

Qualifications and/ or experience

Eligible applicants will be those who on the closing date for the competition:

(a) Have satisfactory experience in an office under the HSE, TUSLA, other statutory health agencies, or a body which provides services on behalf of the HSE under Section 38 of the Health Act 2004 at a level not lower than that of Grade IV (or equivalent)

And

(b) Significant experience of working in the health services in a post that has involved risk management, incident management and investigations as relevant to this role

And

(c) Candidates must have at the latest date of application:-

An academic award in Quality, Risk or Audit in Healthcare at Level 6 (or higher) on the Quality and Qualifications Ireland (QQI) framework or equivalent

Or

A professional qualification in a health related area

And

(d) Have the requisite knowledge and ability (including a high standard of suitability and management ability) for the proper discharge of the duties of the office

Health

Candidates for and any person holding the office must be fully competent and capable of undertaking the duties attached to the office and be in a state of health such as would indicate a reasonable prospect of ability to render regular and efficient service.

Character

Candidates for and any person holding the office must be of good character.

Post Specific Requirements

· Experience of working at a senior level in a healthcare environment in a post that has involved quality and patient safety relevant to this role.

· Experience of leading change in a complex organisation.

· Experience of managing and working collaboratively

Other requirements specific to the post

The successful post holder will participate in the Senior Management Weekend On-Call rota.

Skills, competencies and/or knowledge

Professional Knowledge & Experience

· Demonstrates knowledge and experience relevant to the role as per the duties & responsibilities, eligibility criteria and post specific requirements of the role

· Maximises the use of ICT, demonstrating excellent computer skills particularly Microsoft Office, Outlook etc.

· Demonstrate the ability to work in line with relevant policies and procedures

· Demonstrate commitment to developing own professional knowledge and expertise

Planning and Managing Resources

· Demonstrate the ability to effectively plan and manage resources, effectively handle multiple projects concurrently, structuring and organising own workload and that of others effectively

· Demonstrate responsibility and accountability for the timely delivery of agreed objectives

· Challenges processes to improve efficiencies where appropriate, is committed to attaining value for money

Commitment to a Quality Service

· Demonstrates evidence of practicing and promoting a strong focus on delivering high quality customer service for internal and external customers and an awareness and appreciation of the service user

· Ensure attention to detail and a consistent adherence to procedures and standards within area of responsibility

· Embraces and promotes the change agenda, supporting others through change

· Demonstrate flexibility and initiative during challenging times and an ability to persevere despite setbacks

Evaluating Information, Problem Solving & Decision Making

· Demonstrate numeracy skills, an ability to analyse and evaluate information, considering a range of critical and complex factors in making effective decisions. Recognises when it is appropriate to refer decisions to a higher level of management

· Demonstrate initiative in the resolution of complex issues / problem solving and proactively develop new proposals and recommend solutions

· Ability to confidently explain the rationale behind decisions when faced with opposition

Team Working

· The ability to work both independently and collaboratively within a dynamic team and multi stakeholder environment

· Demonstrate an ability to work as part of the team in establishing a shared sense of purpose and unity across a number of teams delivering on different projects

· Demonstrate leadership; creating team spirit; leading by example, coaching and supporting individuals to facilitate high performance and staff development

· Demonstrate a commitment to promoting a culture of involvement and consultation within the team, welcoming contributions from others

Communications & Interpersonal Skills

· Demonstrates excellent communication and interpersonal skills including the ability to present complex information in a clear, concise and confident manner (written & verbal). Strong presentation skills

· Demonstrate the ability to influence people and events and the ability to build and maintain relationships with a variety of stakeholders, working collaboratively within a multi stakeholder environment

· Demonstrate commitment to regular two-way communication across functions and levels, ensuring that messages are clearly understood

Campaign Specific Selection Process

Ranking/Shortlisting / Interview

A ranking and or shortlisting exercise may be carried out on the basis of information supplied in your application form. The criteria for ranking and or shortlisting are based on the requirements of the post as outlined in the eligibility criteria and skills, competencies and/or knowledge section of this job specification. Therefore it is very important that you think about your experience in light of those requirements.

Failure to include information regarding these requirements may result in you not being called forward to the next stage of the selection process.

Those successful at the ranking stage of this process (where applied) will be placed on an order of merit and will be called to interview in ‘bands’ depending on the service needs of the organisation.

Code of Practice

The Health Service Executive will run this campaign in compliance with the Code of Practice prepared by the Commission for Public Service Appointments (CPSA). The Code of Practice sets out how the core principles of probity, merit, equity and fairness might be applied on a principle basis. The Code also specifies the responsibilities placed on candidates, facilities for feedback to applicants on matters relating to their application when requested, and outlines procedures in relation to requests for a review of the recruitment and selection process and review in relation to allegations of a breach of the Code of Practice. Additional information on the HSE’s review process is available in the document posted with each vacancy entitled “Code of Practice, Information for Candidates”.

Codes of practice are published by the CPSA and are available on www.hse.ie/eng/staff/jobs in the document posted with each vacancy entitled “Code of Practice, Information for Candidates” or on www.cpsa.ie.

The reform programme outlined for the Health Services may impact on this role and as structures change the job description may be reviewed.

This job description is a guide to the general range of duties assigned to the post holder. It is intended to be neither definitive nor restrictive and is subject to periodic review with the employee concerned.

Please complete and upload the application form attached to the job advert as CVs will not be accepted for this position