Qualifications: Degree or equivalent experience in relevant subject

Transcription

1 Job Description Job Title: Quality and Audit Lead Location: Responsible to: Director of Hours: Organisational Development Accountable to: Chief Executive Responsible for: St Clare Hospice Full time Qualifications: Degree or equivalent experience in relevant subject Key Working relationships: Directors and department managers CEO CQC Registered Manager Head of Education and Training IT Manager Facilities Manager Patients and families All staff groups CCG Quality Manager Job summary The post will support the whole organisation taking responsibility for the quality, audit and improvement requirements for the Hospice ensuring compliance with national and local legislation and initiatives. To support Hospice teams in providing best practice and learning through the promotion of quality improvement, learning and audit. To act as the specialist advisor in relation to quality improvement across the organisation. To lead on specific quality improvement programmes and to be the internal expert advisor on quality matters. To coordinate and contribute to the governance work across the organisation including the preparation of the annual quality account, data collection and reports to support contractual requirements, annual report preparation, annual review preparation and CQC compliance. To assist the Registered Manager and Hospice teams in meeting CQC responsibilities. Take the lead in creatively communicating with services users and stakeholders to gain information with which to support the evaluation and development of services.

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3 Key responsibilities Develop and lead a framework of quality improvement and audit across the organisation. Manage and support the implementation of a full audit programme across the organisation to ensure compliance with statutory requirements and the promotion of best practice. Contribute to the completion and analysis of monthly contractual data collection work and the quarterly balanced scorecard. Take the lead on ensuring all information is updated and ready to support all the outcomes that are required within our CQC assessment. Ensure the organisational risk register is up to date. Under the guidance of the Director Organisational Development manage the complaints database and provide regular trend analysis reports ensuring compliance with statutory requirements. To offer specialist skill and support during the planning, piloting and early stages of all service developments ensuring quality runs throughout. Support clinical and non clinical managers in analysing incidents, accidents and feedback to ensure the organisation has a robust action and training plan to support learning and our strive for excellence. Work with and coach staff in all departments and localities to set and monitor standards identifying any training needs. Take an active role in Information Governance under the support and direction of the IT Manager, developing and implementing operational requirements to ensure full compliance with the Information Governance toolkit and GDPR. To support the clinical team in the use of the data collection software programme to ensure consistency, efficiency and accurate implementation of activity data. Support with clinical and non clinical policy review and development. To analyse incident reporting, using root cause analysis, identifying any trends and making recommendations for improving practice. To produce routine and ad-hoc reports for internal and external stakeholders including commissioners which relate to quality, activity levels and service utilisation. Complete and submit the annual Quality Account according to Department of Health directives and timescales. Take an active role in the completion of the organisations Annual Report under the direction and guidance of the Director of Finance and Resources. In collaboration with the CEO, Director of Patient Care, and Communications Manager develop initiatives for user involvement. Take the lead in the implementation of tools and methods to gain feedback and produce and annual review. Support the Fundraising Team by providing clinical activity data where needed for cases for support In collaboration with the Communications Manager, take an active role in the completion of the Impact Report In conjunction with the relevant managers, review relevant national reports and identify relevant recommendations to implement within the hospice.

4 Support the hospice management team to develop and analyse surveys for fundraising, clinical, retail and HR functions. Support the review of internal policies within the hospice. Provide an expert resource for organisational governance and risk management including presenting information at monthly and quarterly directors meetings and at the Information Governance Steering Group and the Clinical Governance Working Group. To take the lead in ensuring the Hospice work, research and audit findings are published and presented locally and nationally as appropriate to demonstrate the excellent work of the Hospice. Ensure that results from audit and quality improvements are implemented, in conjunction with the department Managers. Keep updated regarding the quality agenda in health care, making recommendations for the Hospice to adopt. Provide adhoc Training on governance areas to relevant staff. With the Head of Education & Training work closely with the Hospice managers to deliver education and training initiatives as required internally and externally Support and coach staff across the organisation to ensure they confident and competent in quality and audit work. This post requires lengthy periods of VDU use for data analysis. General The above is not an exhaustive list of duties and the postholder will be expected to perform different tasks as necessitated by the changing role within the organisation and the overall business objectives of the organisation, as deemed reasonable and requested by the postholder s line manager, departmental Director or CEO. Provide cover for colleagues as directed by the line manager. The post-holder will have access to confidential data on patients and services within St Clare Hospice. Failure to maintain confidentiality will lead to disciplinary action, which could ultimately lead to dismissal. The post holder may be required to participate in the assessment of risk and thereby contribute towards clinical and corporate governance agenda as appropriate. The post will be subject to regular annual appraisal and review of the Personal Development Plan. The post holder will be expected to produce work of a high standard and to promote quality at all times. St Clare Hospice is committed to Equal Opportunities for all present and potential members of staff and patients, irrespective of gender (including gender reassignment), marital status, sexual orientation, race, colour, creed, religion, belief, nationality, ethnic origin, age, and disability, a positive diagnosis of HIV/AIDS or Trade Union membership. Therefore St Clare Hospice expects its entire staff to understand, support, and apply this policy through their working practices which requires all individuals to be treated with respect, dignity, courtesy, fairness and consideration.

5 The post holder will be expected to keep themselves updated on all matters relating to Hospice policy. The post holder must familiarise themselves with matters relating to health and safety management as they affect them personally and/or the Hospice, reporting any potential risks to life or property immediately in accordance with the Hospice s Health and Safety Policy and procedures. They must use all equipment provided to undertake their role safely. Refrain from smoking in any area of the Hospice building. This is an outline Job description and may be subject to change, according to the needs of the service, in consultation with the post holder. Signed (employer) Date Signed (employee) Date