JOB DESCRIPTION. Head of Quality and Compliance. Director of Quality and Safety ORGANISATIONAL CONTEXT

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1 JOB DESCRIPTION JOB TITLE: DEPARTMENT: GRADE: REPORTS TO: Head of Quality and Compliance Quality and Safety 8b Director of Quality and Safety ORGANISATIONAL CONTEXT The Medical Director and Director of Nursing & Allied Health Professions (AHPs) are the Executive Directors jointly accountable to the Trust Board for delivery of the quality agenda. Moorfields Eye Hospital NHS Foundation Trust City Road, London EC1V 2PD Phone:

2 The Director of Quality and Safety is the lead for Moorfields central quality & safety support and delivery services, driving the quality strategy and supporting the work of the divisional teams to deliver local high quality services. JOB SUMMARY: As a senior member of the quality and safety team, the post holder is responsible for leading and driving quality improvement and regulatory compliance to achieve the best service standards and outcomes for patients and the Trust. Key responsibilities include: Work with Directors to lead and develop the quality strategy. Lead/support implementation of the quality strategy, plans for quality improvement, quality assurance and related organisational learning. Lead/support delivery of the Trust s quality account. Lead the smooth and timely management of the Quality and Safety Committee. Leading and developing processes and systems to ensure compliance with regulatory and NHS requirements and best practice including, but not limited to, the Care Quality Commission (CQC), NHS Improvement, NHS England, NHS Litigation Authority, and relevant Clinical Commissioning Groups. Promoting collaboration and transfer of best practice within and between Clinical Divisions. Lead quality programmes and projects. Oversee the management and review of Trust policies and procedures ensuring appropriate arrangements and infrastructure is in place. Ensure appropriate policies and procedures are in place to support quality improvement. Provide line management to the Head of Quality and Compliance and other staff who join the team. Be the trust s central point of contact for CQRG. WORKING RELATIONSHIPS: Internal Director of Nursing and Allied Health Professions and the Medical Director Clinical leads for quality and safety Service directors Quality Partners Divisional teams: - Divisional directors - Divisional managers - Divisional heads of nursing Matrons Quality and Safety related Heads of Department e.g. Head of Risk and Safety External Commissioner quality leads Care Quality Commission NHS Improvement 2

3 and Head of Clinical Governance, Patient Experience Manager Heads of Department KEY RESULTS AREAS To lead and promote quality in the trust through effective leadership of the quality functions of the central department and the provision of support to Clinical Divisions Evidence of measurable improvements in organisational quality standards, both outcomes and outputs, year on year. Delivery of regulatory requirements and actions, for example CQC action plans. Evidence of quality developments in divisions. Successful delivery across all key responsibilities. MAIN RESPONSIBILITIES Quality improvement Lead the implementation, monitoring and review of the Quality Strategy, Quality & Governance Framework and Quality plans in line with trust objectives and priorities ensuring that they reflect changing legislation and regulations. Ensure the Quality Strategy, Quality & Governance Framework and Quality plans support continuous improvement and the delivery of high standards of care. In collaboration with the service improvement team, the Clinical Divisions and corporate services, lead/support the development of a trust wide work programme for quality improvement, including quality priorities and metrics and ensure timely delivery and monitoring for effectiveness and impact on standards of patient and service user care and treatment. Ensure quality improvement and clinical governance techniques and tools are embedded in trust decision making, planning and performance management processes. Actively engage with internal and external stakeholders to ensure the trust is leading edge in delivering all aspects of Quality Improvement. Co-ordinate the development of quality information published on the Trust s website to promote the implementation and delivery of quality improvement plans at local service level. Provide leadership, specialist advice and support to the Trust Board, Senior Managers and Trust staff in relation to developing quality 3

4 improvement initiatives to deliver leading edge practice that improves people s experiences of the Trust s services and leads to better evidence-based outcomes. Lead the development and delivery of quality scorecards/dashboards by working with frontline clinical staff to develop appropriate quality metrics and indicators to promote continuous improvement in the quality of patient care. Compliance and assurance In conjunction with the Head of Contracting negotiate with commissioners to agree an appropriate set of quality targets and indicators as part of the annual Contract Quality Schedule. Lead the co-ordination of an annual plan for CQUINs agreed with commissioners and where required lead on specific CQUINs. Ensure regulatory requirements in relation to corporate and clinical quality management are met. Review and interpret new national guidance and/or legislation relating to Quality Improvement and identify local implementation for the Trust. Lead/support the development and publication of the annual Quality Account/Quality Report, ensuring appropriate consultations and involvement with internal and external stakeholders throughout the process. Ensure processes and systems are in place across the organisation to maintain the Trust s CQC registration, including variations to registration which reflect the changing regulated activities and locations of the Trust. Ensure appropriate CQC compliance monitoring programmes and processes are in place across Clinical Divisions, corporate services and across the rest of the trust (for example Moorfields Private) to be able to evidence registration and ensure awareness of and readiness for external inspection and registration validation. Oversee all external assessments of the Trust s NHS services (e.g. CQC visits, NHSLA assessments etc) and ensure recommendations from these are acted upon by the Trust. Oversee the Trust s compliance framework relating to the Care Quality Commission, NHSI, Commissioning and other external reviews and accreditation processes including the submission of periodic returns and reports as required. 4

5 Ensure there are systems in place to co-ordinate monitoring and follow-up of recommendations from internal and external audits Continue to develop the quality assurance model (supported by the quality dashboard) to triangulate data and information to produce a worry list (quality concern areas) which is prioritised and addressed by agreed committee action. Work with key internal stakeholders (e.g. performance and information) to improve ward to Board (and vice versa) information and communication, to facilitate Board assurance on key quality and safety areas. Quality and safety committee Manage the Trust s Quality & Safety Committee (Board sub-committee), ensuring there is an annual cycle of business in place to address internal and external reporting requirements, also that there is a high quality agenda, minutes and papers, and regular reports from this group are available to the Board. Policy management Lead the Trust s policy management processes, including compliance and governance. Ensure the Trust has arrangements in place for the effective initiation, consultation, approval and continuous review of corporate policies and procedures. People management Responsible for the management of the Quality and Compliance Manager and any other team members that join. Role model the Moorfield s Way values and behaviours both individually and through the team. Financial responsibility Responsibility for managing any departmental budget / approved project implementation costs and benefits delivery, including realising agreed financial savings. Planning and reporting Produce and/or co-ordinate the production of cyclical, routine, periodic and ad hoc analysis, information, data and high quality reports for Trust Board, Quality & Safety Committee, Trust Management Board, Executive Directors, managers, frontline staff and other committees as 5

6 required. Provide expert advice, information and support to senior managers, clinicians and committees on matters relating to quality and compliance and ensure the Trust is kept informed of related national strategic issues. Central/Strategic Contribute to the delivery of the trust s objectives on quality, safety and governance and ensure delivery of the trust s strategy, our Vision of Excellence. Contribute to the delivery of national standards and external requirements for all aspects of quality. Support Clinical Governance half days (both organisational and within divisions) as manged by the Head of Clinical Governance From Moorfields perspective, manage the agenda and administrative arrangements for the Commissioners Clinical Quality Review Group (CQRG). Be responsible for managing an annual quality away day. General Contribute to the development and delivery of the Trust s annual business planning cycle and the Annual Quality & Governance Delivery Plan with priorities and deliverables which support the achievement of the Trusts objectives Staff management, training, development, appraisal and performance and capability management in accordance with Trust policies and procedures Contribute to the design and delivery of quality, risk, governance and compliance training programmes delivered by the Quality & Governance Team. Contribute to the design, implementation and monitoring of internal indicators and metrics which enable the Trust to understand and improve its performance in relation to quality, risk, business continuity, safety and compliance. Work with the team to actively learn from other organisations and adopt good practice to improve performance at Moorfields. 6

7 GENERAL DUTIES 1. To comply at all times with the requirements of the Health & Safety regulations under the Health & Safety at Work Act (1974) and to take responsibility for the health and safety and welfare of others in the working environment ensuring that agreed safety procedures are carried out to maintain a safe environment. 2. To comply at all times with the trust s data security policy. Also to respect confidentiality of information about staff, patients and health service business and in particular the confidentiality of electronically stored personal data in line with the Data Protection Act. 3. Disclosure Barring (DBS) (formerly CRB) checks are now a mandatory part of the NHS recruitment process for staff who, in the course of their normal duties, have access to patients. Moorfields Eye Hospital NHS Foundation Trust aims to promote equality of opportunity for all with the right mix of talent, skills and potential. Criminal records will be taken into account for recruitment purposes only when the conviction is relevant. Having an unspent conviction will not necessarily bar you from employment. This will depend on the circumstances and background to the offence and the position you have applied for. Moorfields Eye Hospital is exempt under the Rehabilitation of Offenders Act. This means the convictions never become spent for work which involves access to patients. Failure to disclose any unspent convictions may result in the offer of employment being withdrawn or if appointed could lead to dismissal. The Disclosure Barring Service (DBS) has published a code of practice for organisations undertaking DBS checks and a copy is available on request. 4. The trust has adopted a security policy in order to help protect patients, visitors and staff and to safeguard their property. All employees have a responsibility to ensure that those persons using the trust and its service are as secure as possible. 5. It is the responsibility of all trust employees to fully comply with the safeguarding policies and procedures of the trust. As a Moorfields employee you must ensure that you understand your role in protecting adults and children that may be at risk of abuse. Individuals must ensure compliance with their safeguarding training. 6. The trust is committed to a policy of equal opportunities. A copy of our policy is available from the human resources department. 7. The trust operates a no-smoking policy. 8. You should familiarise yourself with the requirements of the trust s policies in respect of the Freedom of Information Act and comply with those requirements accordingly. 9. The role description gives a general outline of the duties of the post and is not intended to be an inflexible or finite list of tasks. It may be varied, from time to time, after consultation with the post holder. 10. All appointments within the National Health Service are subject to pre-employment health screening. 11. It is the responsibility of all employees to ensure that they comply with the trust infection control practises, as outlined in the health Act 2008 and staff must be familiar with the policies in the trusts infection control manual, this includes the bare 7

8 below the elbow policy. Employees must ensure compliance with their annual infection control training. 12. You are responsible for ensuring that all equipment used by patients is clean / decontaminated as instructed by manufacturers and in line with the infection control / guidelines protocol and policy. 13. It is the responsibility of all employees to ensure compliance with the Health and Social Care Act, 2008, in preventing risk of infections to patients, visitors and other staff within the trust. 14. All staff are required to implement infection control policies and practices, including hand hygiene, waste disposal, staff uniform and occupational health responsibilities, as detailed in the trust intranet. 15. It is the responsibility of all staff to ensure that they have evidence of annual/or otherwise infection control training. 16. All staff are responsible for ensuring that equipment used in the patient environment is cleaned, decontaminated and maintained in line with trust policy. 17. Any other duties as designated by your manager and which are commensurate with the grade. NB. The role description is a reflection of the current position and may change emphasis or detail in light of subsequent developments, in consultation with the post holder. August

9 PERSON SPECIFICATION POST: Head of Quality and Compliance Requirements Education / Qualifications / How Tested Educated to degree level (or equivalent) AF Postgraduate qualification or equivalent level of knowledge AF Relevant professional qualification AF Experience Experience and working knowledge of risk management Experience of working as a senior manager (Band 8+) in the NHS for at least 3 years Experience of investigations and analysis Evidence of participation in quality improvement projects Experience of leading and motivating staff at times of change Experience of health care inspections, particularly CQC Experience of managing teams and budgets Experience of business process mapping to identify and deliver change Effective analytical and problem solving skills. Ability to analyse complex facts and situations and develop a range of options Experience of report development and writing; ensuring the accuracy of information and effective translation for different audience Knowledge Working knowledge of the application of risk management systems and techniques Demonstrable understanding of NHS quality improvement frameworks and requirements Moorfields Eye Hospital NHS Foundation Trust City Road, London EC1V 2PD Phone:

10 Requirements Demonstrable understanding of the NHS regulatory and compliance frameworks under which NHS Foundation Trusts operate Working knowledge of national guidelines and ability to research good practice solutions Knowledge of quality systems and development of quality KPIs Experience of developing and implementing strategies, policies, guidelines and projects. Knowledge of current healthcare policy in the NHS and how this applies to the local health economy. Skills/abilities Excellent written and verbal communication (including presentation) skills, is able to communicate highly complex information that may be difficult to understand to internal and external stakeholders and make presentations to internal and external groups on a regular basis Excellent interpersonal skills and have the ability to communicate concerns, complex / contentious issues in a diplomatic manner that does not offend or escalate Proven ability to analyse complex problems and to develop and successfully implement practical and workable solutions to address them Negotiation and influencing skills, with the ability to make informed decisions Ability to implement change projects / programmes Ability to deal with changing priorities, work under pressure, work to tight deadlines and be flexible Ability to develop and lead teams, and to coach and train staff Ability to motivate, empower and facilitate teams from different professional disciplines to be proactive in risk management and quality improvement / How Tested I AF / I AF / I AF / I 10

11 Requirements Ability to work collaboratively with staff at all levels across the Trust and with external stakeholders and committed to teamwork / How Tested Good standard of numeracy Experience of working with Microsoft Word, PowerPoint, Excel and Outlook Personal qualities Self-motivated and keen to learn Ability to adapt and work flexibly when required High level of attention to detail and accuracy Determination and has the ability to achieve deadlines Ability to work as a team member as well as using own initiative Be able to work effectively within a multidisciplinary team and establish relationships across the Trust and with outside organisations Excellent communication skills and the ability to manage difficult situations Problem solving and decision making skills Punctual, with a good attendance record Smart appearance and professional attitude Ability to work closely with medical consultants and senior managers and staff at all levels Able to demonstrate systematic approaches to work Means of Assessment include application form (AF), Interview (I), Test (T), Presentation (P) 11