Quality and Safety Coordinator Mental Health Services Group February 2013

Transcription

1 Job Title : Quality and Safety Coordinator 1 x Regional Forensic Service & Community Alcohol and Drug Service 0.5FTE 1 x Adult Mental Health Service & Cultural Services 0.5FTE Department : Location : sites Reporting To : Clinical Effectiveness Lead Direct Reports : Nil Functional Relationships with : Internal Clinical Director- Mental Health & CADs Clinical Director- Forensic Services General Manager MHSG Head of Division Nursing Consumer & Family Advisor Team Professional Advisors, Kaumatua & Whaea Service Development Manager Service/Operations Managers & Service Clinical Directors Service Governance Groups & Clinical Teams (all Staff) WDHB Quality Team DSG MHSG Finance & IS team Sen. AO s MHSG Occupational Health Services/Staff Union Delegates WDHB Legal Team WDHB Provider Arm Services Awhina (Health Campus) External Service users and their Families Health Advocates WSN (Waitemata Stakeholder Network) and NGO providers Primary Care providers/gps (Pro-Care, Waitemata PHO) & Whanau Ora providers Regional MH and addiction providers (ADHB, CMDHB, Northland) Union representatives Health, Safety and Quality Commission Health and Disability Commission Coronial Services Ministry of Health Waitemata District Health Board -JOB DESCRIPTION - Page 1

2 Purpose : Support teams within context of new model whilst maintaining strong relationships with local Governance groups and clinical teams. To provide advice, facilitation and support to Governance groups, clinicians, managers, professional leaders and consumer advisors for a range of quality assurance and improvement activities, including supporting strong service culture of clinical audit. This role will also provide coordination for Health & Safety assurance requirements (link with Occupational Health and to local service Health and Safety leads/reps). Track and report on complaint and incident reviews. Develop appropriate reports to ensure business has the right information. The Expected Outcomes are: Maintenance of the direct link between quality activities and the delivery of clinical care Strengthened collaboration between management, professional groups and consumers in quality assurance and improvement activities Core contribution to service improvement activities utilising continuous improvement tools, strategies and methodologies, e.g. Te Aranga Hou Engagement with service clinical governance to promote the systematic review of clinical practice activities and workforce needs Support teams to increase their capability, accountability and engagement in quality health care delivery Greater engagement with the wider DHB Quality structures and innovations. Service Scope: Quality Assurance Encompasses the generation and reporting on both qualitative and quantitative measures and metrics from internal and external sources to ensure a proactive programme that enables the [Division] to understand any issues that are present. Activities include: o Coordination of internal and external audits, including certification processes and tracking of corrective actions o Risk management activities such as the identifying, reporting and the management of reportable incidents, complaints and corrective actions. o Centralised activities will enable greater communication across the services, including sharing of recommendations, activities and processes. It is proposed that we develop roles specifically oriented to these tasks to ensure consistent and standardised approaches to their management. These roles will not have responsibility for the content of matters such as complaints and incident reviews, which will be led by senior clinical staff and managers, but will be primarily oriented toward support of these processes and the tracking of implementation of corrective actions. It is essential that effective relationships with service Clinical Governance groups and clinical teams are maintained where possible. There is the potential for these roles to have some embedded links with key service areas. Waitemata District Health Board -JOB DESCRIPTION - Page 2

3 KEY TASKS Quality Assurance Activity Advise and assist in the establishment of revised quality assurance processes (aligned with WDHB) for: o Complaints resolution and responses o SIRPs o Incident reporting and reviews Clinical audit Together with clinical directors, nurse advisors Consumer Advisors and allied health professional leaders, to help to develop a structure and programme of multidisciplinary and intra-professional clinical audit within each service. EXPECTED OUTCOMES To support Governance groups and teams in the analysis of reportable events, so that they can learn lessons and identify areas which require changes and improvements. To investigate specific incidents as requested, including participating in formal Root Cause Analyses. Support complaint, SIRP, Incident reviews processes as agreed with Clinical Directors, HOD Nursing and GM Provide coaching and support to Clinical leaders, Managers, Professional leaders and Consumer Advisors in the strengthening their mandate for involvement in quality assurance activities WHDB processes for document control, complaints, SIRPS, etc are followed and we meet legislative requirements To promote and encourage participation in clinical audit amongst all service staff. To promote, facilitate and manage (where appropriate) clinical audit projects which involve all appropriate stakeholders, including patients/consumers, different staff groups and other organisations. To ensure that high standards for clinical audit are achieved by encouraging clinicians to critically appraise evidence of good practice. To provide appropriate training, support and advice on audit design and methodology, data analysis, presentation and report writing to staff undertaking clinical audits. To assist in the logging, recording and Intranet publishing of all clinical audit projects To ensure that a system is in place to follow-up recommendations and action plans arising from audit projects Promote health, wellbeing and minimization of risk Leadership, coaching, facilitation and coordination role: Promote the development of strategies that foster a healthy, positive workplace & clinical environment. Support the consolidation of processes and systems at service level that appropriately manage & minimize risk, A culture of positive and proactive risk management is supported in clinical teams. Initiatives to promote the wellbeing of staff and reduce workplace injury are in place Co-ordination and support is provided to services in the identification, analysis and treatment of risks. Reporting of risks occurs to relevant groups Risk management processes in place and supported in local teams Emergency plans are in place. Individual and managerial responsibility is understood for Workplace Health & Safety Waitemata District Health Board -JOB DESCRIPTION - Page 3

4 KEY TASKS facilitate organizational learning & Respond appropriately & in a timely manner to consumer, Whanau/family and staff concerns. Knowledge and Information Provide leadership and oversight in the effective use of information in knowing how we are doing. EXPECTED OUTCOMES under the Health and Safety in Employment Act WDHB health and Safety policies are read and understood and relevant procedures applied to operational group and to your own work activities. Workplace hazards are identified and reported; corrective actions are taken when necessary including self management of hazards where appropriate. Health and safety plan is implemented and managed in all services and reported on quarterly to GM. Health and safety representatives are appointed and trained for each area as appropriate. To work with the Clinical Governance groups and clinical staff to help develop indicators of clinical quality within each service and that regular reporting occurs as negotiated. To make effective use of KPIs to inform service & process improvement. To work with the Consumer Advisors to ensure that the services receive feedback from consumers, through the complaints process, compliments and specific feedback mechanisms. To ensure that the services learn lessons from this feedback and identify areas which require changes and improvements. Complaints, SIRPS, Incidents are logged and tracked appropriately and in timely manner, linking in with weekly reporting process from WDHB Quality team. Participate and contribute to local KPI groups. Support, coaching and leadership is provided for MHSmart champions and links with Te Pou maintained. Data is captured related to key workforce KPIs i.e. PDR completion, training, etc. Quality Documentation A work plan is develop with allocated tasks and completion is tracked. All policies are reviewed regularly and updated as appropriate. Coordination of new policy development occurs. Ensure all documentation reflects the principles of recovery. Ensure all documentation is responsive to Maori and Pacific Nation service user needs. Waitemata District Health Board -JOB DESCRIPTION - Page 4

5 KEY TASKS EXPECTED OUTCOMES Implement a process to ensure that team brochures/booklets are developed, updated, and meet a minimum standard. Personal and Professional Development Seeks regular supervision to discuss how to address area s of difficulty and review of quarterly practice Attends and participates in regular Quality and Safety Meetings Seeks feedback on own personal development All documentation is clear and submitted within timeframes Timely follow through on tasks Demonstrates a commitment to personal and professional development. To recognise Individual Responsibility for Workplace Health and Safety under the Health and Safety in Employment Act 1992 Treaty of Waitangi Principles To recognise and work with the principles of partnership, participation and protection. Company health and safety policies are read and understood and relevant procedures applied to their own work activities Workplace hazards are identified and reported, including self management of hazards where appropriate Can identify health and safety representative for area. Waitemata DHB s commitment to biculturalism is honored. Cultural advice and supervision is sought. Work co-operatively with culturally appropriate staff. Attend cultural awareness workshops Waitemata District Health Board -JOB DESCRIPTION - Page 5

6 Behavioural Competencies Adheres to Waitemata District Health Boards 5 organisational Values of: Respect Integrity Compassion Openness Customer Focus Behavioural Competencies Behaviour Demonstrated Communicates and Works Co-operatively Actively looks for ways to collaborate with and assist others to improve the experience of the healthcare workforce, patients & their families and the community & Iwi. Is Committed to Learning Proactively follows up development needs and learning opportunities for oneself and direct reports. Is Transparent Communicates openly and engages widely across the organisation. Enacts agreed decisions with integrity. Is Customer Focused Responds to peoples needs appropriately and with effective results Identifies opportunities for innovation and improvement Works in Partnership to Reduce Inequality in Outcomes Works in a way that: Demonstrates awareness of partnership obligations under the Treaty of Waitangi. Shows sensitivity to cultural complexity in the workforce and patient population. Ensures service provision that does not vary because of peoples personal characteristics. Improves health Work practices show a concern for the promotion of health and well-being for self and others. Prevents Harm Follows policies and guidelines designed to prevent harm. Acts to ensure the safety of themselves and others. VERIFICATION: Employee: Manager: Date: Review Date: Note: This job description forms part of an individual s contract of employment with WDHB and must be attached to that contract. Waitemata District Health Board -JOB DESCRIPTION - Page 6

7 PERSON SPECIFICATION Qualification Minimum Preferred Relevant quality training Tertiary qualification in health/quality/management or similar Experience Skills/Knowledge/ Behavior Knowledge of Mental Health and/or Alcohol and Drug services Current knowledge of government processes in the health sector Recent experience in medium to large health organisation Knowledge of project management methodologies Experience in successfully managing complex projects across service teams Experience in strategic planning, operational planning, and accountability report writing in a government sector Knowledge of quality improvement strategies Experience in implementing change Knowledge of systems theory and its application to health settings and issues Knowledge of key national mental health policy documents (e.g. MHC Blueprint,Te Tahuhu, Te Kokiri ). Excellent written and verbal communication skills Excellent interpersonal skills Leadership skills and initiative Conceptual thinker Achievement oriented Meets tight deadlines with professional product Customer focused Innovative and Analytical Thinking Problem solving skills Flexible team player Motivated and enthusiastic 3-5 years working in Mental Health and/or Alcohol and Drug services Implementation of Health Systems changes Previous experience with report writing to Boards and Government agencies Demonstrated success in project planning, implementation and monitoring Strong working knowledge of Microsoft office tools Experience of working with quality systems tools. Knowledge and behaviour aligned to Seven Real Skills Waitemata District Health Board -JOB DESCRIPTION - Page 7