Head of Clinical Governance, Quality and Mortality

Job overview

The Head of Clinical Governance, Quality and Mortality will provide strategic leadership and expert oversight for a comprehensive programme of work aimed at maintaining and enhancing patient safety, clinical quality, risk management, audit, and mortality governance across the Trust and its wider healthcare community. The post-holder will lead and shape a progressive quality agenda aligned with regulatory requirements, national priorities, commissioners’ expectations, independent audit standards, and the Trust’s overarching mission and values. This will include ensuring compliance with statutory and regulatory frameworks, including those set by the Care Quality Commission and relevant national bodies. Working as part of a dynamic senior leadership team, the post-holder will deliver an effective and responsive governance service, supporting managers and clinical teams across the Trust. They will take a proactive approach to identifying, analysing, and managing key patient safety risks, ensuring robust systems are in place and that timely, proportionate actions are implemented to mitigate or respond to identified concerns.

The role requires visible and credible leadership to promote a culture of openness, learning and continuous improvement, ensuring that governance processes translate into meaningful improvements in patient outcomes and experience.

Main duties of the job

Expert for the Trust in all aspects of patient safety and risk management, accountable to the Associate Director of Clinical Governance, Quality and Safety and reporting internally on patient safety & risk management issues to the Trust Board of Directors and externally to:

• Integrated Care Board (ICB) NHS England Care Quality Commission (CQC) Medicines & Healthcare products Regulatory Agency (MHRA) Other external agencies
• Integrated Care Board (ICB)
• NHS England
• Care Quality Commission (CQC)
• Medicines & Healthcare products Regulatory Agency (MHRA)
• Other external agencies
• Provide expert advice on the CQC Fundamental Standards as they relate to patient safety and advising Executive Leads as appropriate
• Responsible for advising the Chief Nurse and Medical Director on quality and safety concerns of the highest sensitivity which (may) have political/ reputational/ financial ramifications for the organisation both locally and nationally
• Responsible for overseeing and leading the risk, governance, national guidance and audit teams
• Responsible for ensuring completion of national and external audits including Specialised Service Quality Dashboards
• Provide expert advice, guidance and training to support the development of clinical practice and healthcare systems
• Accountable for the development and delivery of a range of training programmes to staff from Board to ward level in relation to clinical governance. This will include (but is not limited to) the following: incident and risk management and Duty of Candour.
• To deputise for the Associate Director of Clinical Governance, Quality and Safety in their absence

Detailed job description and main responsibilities

• Provide expert advice on the CQC Fundamental Standards as they relate to patient safety, risk and mortality and advising Executive Leads as appropriate
• As local expert for the Trust in patient safety and risk management, maintain constructive relationships with national and regional bodies (NHSE, ICS, MHRA, HSE, CQC etc), influencing key national policy developments and frameworks
• Responsible for reporting governance and risk management issues internally to the Board of Directors and externally to various agencies (ICB, NHSE etc). This includes providing expert advice and input with respect to identification and monitoring of the Trust’s Safety Quality Priorities, Local Quality Requirements which inform the Trust’s Quality Account.
• Be responsible for analysing and triangulating complex data from different sources and providing written reports to different committees, and supporting the completion of the Quality Account
• Lead on governance within the Trust, working with the divisions, and contribute to national, regional and Trust-wide clinical governance improvement programmes.
• Lead on and contribute to national, regional and Trust-wide clinical and patient safety improvement programmes.
• Ensuring national and local evidence best practice is high quality, distributed, implemented and regularly reviewed.
• Manage and actively promote the relationships with key stakeholders. In particular, the post-holder will work with the regional quality and safety team, ICB quality teams and regulators.
• Deputising for the Associate Director of Clinical Governance, Quality and Safety including managing the budget in the absence of the Associate Director
• Managing across the Quality Team including the Medical Examiners Office team
• Communicating with patients and/or their relatives when things have gone wrong in line with the Duty of Candour. This can involve communicating complex and sensitive information that may not be received positively and which requires a high-level of interpersonal skills in order to achieve the right outcome
• Maintain an up-to-date and comprehensive knowledge of local and national governance, patient safety and risk management issues, including the interpretation of national health policies to ensure that goals and standards are reflected in the Governance Team’s strategies and programme of work.
• Providing expert advice to the divisional teams on risk, audit, quality improvement and quality governance, providing assurance to the Board and the subcommittees of the board as requested by the Executive teams.
• Be accountable for the operational management of the Medical Safety Device Officer, Central Alerting System Liaison Officer and medical device safety within the Trust
• Liaise with representatives from the external organisations, including Healthcare Partners Limited (HPL)

Working with Others:

• Advising discussion on the organisation of Trust governance structures relating to clinical safety, including the establishment of Committees, improvement groups and reporting and monitoring structures and processes. This includes ensuring that Trust-wide safety Committees operate within the Trust’s governance framework and deliver against key standards.

• As the accountable Trust officer for safety alerts responsible for ensuring that safety alerts are acted upon across the organisation and that equipment safety issues identified at RSCH are escalated to the appropriate national body.  Ensuring that the compliance with safety alerts is audited every 3 months.
• Responsible for compliance with the Trust’s internal audit programme as it pertains to governance and patient safety. This will include reporting to the Trust’s Clinical Audit and Effectiveness Committee as required.
• Ensure that the Divisional and Trust Risk Registers drive the development of Trust and Divisional strategic plans to improve clinical effectiveness and that emerging patient safety issues are identified and acted upon both Divisionally and across the Trust.

• Attendance and/or present oral/written reports and perform actions agreed at meetings with a key responsibility for Quality Governance. These include: Medicines Safety Group, Quality and Performance Executive Committee, Quality and People Committee, Mortality Meetings, Board and sub-Board committees as required including CASSCO and the Council of Governors.
• Principal expert for the trust on maintaining positive, reciprocal relationships and communications with key external partners with responsibilities or requirements for patient safety and clinical quality.  These include Care Quality Commission and NHS Resolution.
• Model a collaborative and influencing style of working, negotiating with others to achieve the best outcomes.
• Attend and provide governance input to the quality priority groups as required.

Data and systems management:

• Analyse complex compliance data and identify, develop and implement remedial actions to address emerging safety concerns and potential regulatory breaches, reporting progress through to the Quality Committee & Board of Directors
• Responsible for managing the eQuip medical device competency module
• Accountable for monitoring data to ensure robustness of reporting systems and the management of those system.
• Accountable for the quality and timeliness of quality risk information which supports risk management locally, feeds the Trust performance scorecard and is reported externally to the CQC.

Project and change management:

• Plan, manage and quality check data for submission against external risk management/ governance standards/ accreditations/ inspections (e.g. CQC Fundamental Standards, HSE inspections, National Audit Office submissions etc).
• Be responsible for providing governance expertise in the preparation for external inspections, including CQC inspections
• Develop, implement and be accountable for a human factors infrastructure within the Trust, incorporating quality improvement into patient safety and implementing learning following the investigation of patient safety events.

• Work at Executive, Divisional and Specialty levels to promote and embed a safety-oriented culture and to provide project-management, staff development and other practical support for projects aimed at improving patient and staff safety.