UHWM, Quality And Patient Safety Manager

*** PLEASE, COMPLETE THE APPLICATION FORM FULLY, CV'S NOT ACCEPTED ***

Strategic Direction for Quality & Safety

• Provide strategic and operational leadership and direction on all aspects of quality and patient safety for staff and management teams within the hospital
• Provide clear leadership and direction on the implementation of the hospital’s accountability and governance structure for quality and safety
• Assist in the development of focused management, operation planning and control systems for the effective measurement and monitoring arrangements for the quality and safety of services
• Ensure that a strong proactive approach to risk identification/mitigation is in place throughout the hospital. Ensure that Risk Assessments are continuously reviewed and submitted to the Corporate Risk Register as required
• Develop collaborative working in the area of quality and safety with the Dublin and South East Health Region, Waterford Wexford Integrated Healthcare Area, National QPS and other relevant corporate HSE functions
• Have a working knowledge of the current HSE’s Patient Safety Strategy, Health Information and Quality Authority (HIQA) Standards as they apply to the role, for example, the Standards of Safer Better 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 as appropriate to the role
• Ensure there are clear structures in place to identify, report and investigate serious incidents and serious reportable events in line with the HSE’s Incident Management Framework and the Patient Safety Act
• Ensure continuous self-assessment is in place to advise on current practices and to identify any gaps versus best practice
• Ensure all incidents are managed and monitored in line with HSE policies and frameworks
• Ensure the dissemination of learning from incident reviews at local and national level
• Work to reduce clinical incidents and make evidential improvements to the quality of care and the safety of care of patients
• Provide reports and presentations to the Executive Management Team on internal and external investigations on the safety of patient care and the progress of actions within the hospital to implement recommendations from investigations
• Ensure complaints are dealt with promptly in accordance with the HSE National Complaints policy.
• Lead on the implementation of nationally agreed Standards including HIQA Standards, National Clinical Guidelines and all relevant National Policies, Procedures and Guidelines
• Provide ongoing monitoring and coordinate action plans to address areas of non-compliance with standards and guidelines in partnership with key personnel in the hospitals and Dublin and South East Health Region.

Operational Management

In liaison with the relevant managers:

• Act as a focal point for all internal and external Quality & Patient Safety (QPS) Reporting
• Ensure that quality and risk management functionality is effective and timely for dissemination to various committees and within the hospital
• Lead in the development of the hospital’s Quality Improvement, Quality Assurance and Risk Management programmes
• Monitor, evaluate and report on the implementation of the plan across the hospital in accordance with defined and agreed reporting structures
• Review and make recommendations on all significant quality and safety concerns indicating whether they have been correctly identified and are being appropriately managed
• Work with the CEO, Operations Managers, Clinical Director, Directors of Nursing & Midwifery, Nurse Management and other professionals to reduce clinical incidents making evidential improvements to the quality of care and the safety of care of patients through hospital initiatives
• Establish appropriate communication and management structures and processes for safety incident management within the hospital
• Co-ordinate the collection, measurement and presentation of data required for monitoring quality and patient safety indicators
• Keep abreast of quality, safety and risk management issues and co-ordinate implementation of actions arising from developments in national and international practice.

Risk and Incident Management

• Ensure collaborative working with Clinicians and Senior Managers to develop and implement effective, organisational wide risk management and complaint management structures, systems and processes
• Develop and monitor key performance indicators for risk management, to measure the effectiveness of the risk management system and assure the quality, accountability and proper management of the system
• Ensure the provision of expertise and support in the management and maintenance of the hospital’s risk register in accordance with best practice guidance
• Liaise with external stakeholders to ensure the timely collation and submission of relevant information
• Co-ordinate the development, implementation and monitoring of all risk management policies for the hospital
• Keep abreast of risk management issues and co-ordinate implementation of actions arising from developments in national and international practice around risk management
• Provide analysis, including reports on adverse patient safety incidents and claims to identify trends and opportunities for further learning, quality and safety improvements and risk reduction strategies
• Provide hospital committees with relevant information on matters relating to risk management
• Review past patient incidents and analyse the data to inform the hospital’s risk management priorities
• Co-ordinate UHW/KROH following SIMT review, in collaboration with the Risk Manager managing outcomes and monitoring of the recommendations/ implementation of Action Plans and QIPs
• Provide reports/presentations to the Executive Management Team on internal and external investigations, on the safety of patient care and the progress of actions within the hospital to implement recommendations from investigations
• Ensure regular reports/presentations are provided regarding performance of risk management structures
• Work with the Executive Management Team in identifying priorities for quality improvements and monitoring compliance with all National Standards relating to Quality, Safety and Risk.

Quality Improvement

• Promote and support the engagement of patients and the measurement of patient experience across the hospital
• Promote and encourage patient involvement and engagement via the Patient Partnership Forum in improving patient experience across UHW/KROH.
• Participate in the development, implementation and monitoring of Quality Improvement plans/action plans to address recommendations from serious incident investigations, inspections, compliance audits, complaints in any area where service delivery does not meet the recognised standard.
• Support hospital management and multi-disciplinary teams in the assessment and corresponding quality improvements against hospital priorities and the National Standards for Safer Better Healthcare
• Develop the hospital quality programme in line with the HSE DSE Strategic Plan, Patient Safety Strategy.National Standards, HSE Service Plan, Clinical Care Programmes, HSE Quality and Patient Safety Programmes, National Cancer Care Programme and HIQA planned approach to regulatory activity, etc.
• Support all members of the multi-disciplinary team in delivering the HSE quality programme and provide formal opportunities for collaborative working across specialties
• Promote and support the use of an agreed set of quality improvement methodologies across the hospital
• Provide reports to the Executive Management Team on the monitoring of the achievement of the quality improvement programme
• Provide support to the Executive Management Team in their reporting responsibilities on quality and safety both internally and external to the organisation
• Maintaining a Register of all Quality Improvement Projects across the hospital and monitoring their progress.
• Quality data collection and reporting.

Governance for Quality & Safety

• Work with the Executive Management Team and QPS Committee to monitor the governance framework for quality and safety within the hospital.
• Ensure all committees are functioning effectively, adhering to authorised and in-date Terms of Reference, and providing regular reports on activities, issues arising and action plans to the Quality and Patient Safety Committee.
• Provide support and expertise for the effective management of the Quality and Patient Safety Committee.
• Provide various hospital groups and committees with timely relevant information relating to quality and safety
• Provide on-going monitoring and co-ordinate action plans to address areas of non-compliance in partnership with key personnel.

Quality Assurance Audit/ Service Evaluations and Research

• Continue to develop an annual plan for clinical audits / service evaluations for the hospital in liaison with the Clinical Directors
• Maintain a register of research projects, clinical audits and service evaluations in UHW/KROH and monitor progress.
• Collate statistics on quality and safety outcome measures and provide reports monthly
• Benchmarks trends against relevant and appropriate Key Performance Indicators (KPIs)
• Lead a hospital quality improvement strategy with initiatives that assist in the delivery of a safe, effective and sustainable service
• Lead and participate on the hospital’s agreed accreditation process and other quality management systems
• Lead on the Management of the Hospital Quality Document Management System (currently HCI Knowledge/Q-Pulse)
• Develop a Document Control policy for UHW/KROH.
• Provide on-going monitoring and co-ordinate action plans to address areas of non-compliance in partnership with key personnel.

Development & Training

• Promote a transformational and facilitative leadership style to encourage and empower individual staff and leaders within the hospital.
• Foster a culture of openness, constructive and positive learning from errors incurred
• Promote the use of management tools and initiatives such as team-based performance managemenT
• Responsible for delivering a training plan so that managers within the hospital understand what is expected of them regarding Quality & Patient Safety
• Promote the building of capacity and capability in Senior Managers across the hospital in quality improvement programmes and quality improvement science methodology
• Ensure training and advice on the Risk Management Programme, Incident Management Framework, Incident and Claims analysis Clinical Audit and Quality Improvement methodologies and Complaints Management are provided
• Participate in other training and induction programmes as needed to provide information on Quality and Patient Safety.
• Identify and facilitate educational development needs of staff working across the different functions of the Quality and Patient Safety Department and ensure they are up to date with Mandatory training.

General

• To support, promote and actively participate in sustainable energy, water and waste initiatives to create a more sustainable, low carbon and efficient health service
• To act as spokesperson for the Organisation as required.
• Demonstrate pro-active commitment to all communications with internal and external stakeholders.

The above Job Specification is not intended to be a comprehensive list of all duties involved and consequently, the post holder may be required to perform other duties as appropriate to the post which may be assigned to them from time to time and to contribute to the development of the post while in office