Quality Governance Lead Diagnostics and Specialties, Band 8b

Job overview

Gloucestershire Hospitals NHS Foundation Trust is seeking an experienced Divisional Quality Governance Lead to provide senior leadership across the Diagnostic and Specialties (D&S) Division.  This is an opportunity to shape and influence meaningful improvements in patient care and support the delivery of high-quality, safe and effective care across our varied group of services.

Main duties of the job

Reporting to the Divisional Director for Quality and Nursing - D&S,  you will lead the delivery of the quality governance, patient safety, clinical effectiveness and patient experience across our services.

This will include:

To promote a quality focused culture through the Division

Lead and oversee divisional quality governance systems and risk management

Support the ongoing embedding of the Patient Safety Incident Response Framework (PSIRF)

Chair Governance meetings and produce high quality reports for assurance

Lead Incident Learning, audit and quality Improvement activity

Support preparation for regulatory inspections – including UKAS, MHRA, IRMER, CQC and national safety requirements

Actively support the aggregation of the Speciality Governance Dashboards/ matrix and any other quality measures.

Lead on the clinical effectiveness requirements for the division: identifying issues requiring escalation that will impact service delivery alongside the specialty quality leads.

Provide divisional ownership and oversight of the Quality Management System (QMS), ensuring a single, coherent and consistent approach to quality governance across all Diagnostics & Specialties services

Work closely with the Director of Quality Governance, the corporate Patient Safety and Quality Manager, patient experience, clinical effectiveness and quality improvement teams to provide a consistent approach to quality governance.

Detailed job description and main responsibilities

Main Duties and Responsibilities

Quality Governance

- Have the necessary capabilities, knowledge and leadership skills to oversee the delivery of the quality agenda.

- Promote a quality focused culture through the Division.

- Manage the Division’s clinical risk register.

- Be the point of contact for issues related to quality, safety and clinical effectiveness standards

- Chair governance meetings.

- Provide expert advice in relation to developing and implementing the Division’s strategy and quality management/reporting system .

- Leads the Division with any improvement plans/actions and to support readiness for regulatory inspections

- Develop and implement processes and structures so that there are clear roles and accountabilities in relation to quality governance.

- Analyse and challenge appropriate quality information.

- Work closely with Business Information to further develop our measurement programmes and be assured of the robustness of the quality of information.

- Support the Division to review and escalate risks and operate the risk management processes.

- Work closely with the Director of Quality Governance, the corporate Patient Safety and Quality Manager, patient experience, clinical effectiveness and quality improvement teams to provide a consistent approach to quality governance across the Division.

- Leads the Division’s Quality Meetings and prepare any reports and actions post meeting.

- Prepare quality reports (Board, Committee and Unit) as required.

- Actively support the aggregation of the Speciality Governance Dashboards/ matrix and any other quality measures.

- Promote a culture of quality improvement to ensure best practice in the delivery of patient care.

Safety

- Leads for the Division, alongside the patient safety corporate team, the implementation of the Patient Safety Incident Framework (PSIRF)

- Leads patient safety incident learning responses and investigations for the Division

- Promote and implement the Trust’s PSIRF Policy and Plan as the basis for reporting and responding to safety incidents, within the D&S Division

- Keep the management of safety incident on the database up to date and promote the timely reporting supporting the processes of trend/thematic analysis.

- Produce quality reports and present these at different meeting forums.

- Deputise for / represent the Divisional Director of Quality and Nursing within D&S when appropriate at meetings and committees, where relevant in their scope of practice.

- Leads the audit programme within the D&S Divisions

- Disseminate all national safety alerts and provide feedback of action taken

Clinical Effectiveness

- Lead on the clinical effectiveness requirements for the division

- Support quality improvement projects and programmes of work with the Gloucestershire Safety and Quality Improvement Academy (GSQIA).

- Work alongside the corporate teams (patient experience, patient safety, and clinical effectiveness) to ensure that regulatory requirements, are disseminated and have clear measurable and robust action plans.

Quality Management System (QMS)

- Provide divisional ownership and oversight of the Quality Management System (QMS),

- Provide assurance that document control processes are robust and effective

- Assess and support the ongoing maturity and effectiveness of the divisional QMS, identifying opportunities for improvement over time.

Accreditation and Regulatory Oversight

- Maintain oversight of a single, live Divisional Accreditation and Regulatory Register including proactive planning and horizon scanning for upcoming accreditation renewals

- Ensure clear identification of accreditation owners, renewal and surveillance cycles, and associated risks where standards are not met or accreditation is at risk

- Provide divisional and Board‑level assurance that accreditation and regulatory risks are understood, controlled and effectively managed.

Patient Experience

- To co-ordinate the Divisional complaints processes

- To develop improvement plans in response to feedback (surveys, FFT, concerns and complaints).

- To review the PALS report and feedback around current trends and metrics and highlight teams that may need support for improvement.

Clinical

- This role is also expected to be clinical credible and be up to date on evidence – based changes to safety practice and maintain professional registration.

Management and professional responsibilities

- To lead on the reporting of key performance metrics of quality and safety within the division. Support the audit and assurance of these metrics.

- Support the effective implementation of a comprehensive and systematic approach to Clinical Governance in the Division.

- Develop and review clinical policies and guidelines as appropriate.

- To encourage and foster a just and restorative culture

- To utilise the PSIRF framework for learning and improvement and be the key to ensuring we are meeting the criteria within the division.

- Ensure personal and professional development is maintained

- Maintain a safe working environment.

- To lead on the management of policies within the division

Leadership

- Maintain the quality framework and risk management strategy

- To chair and lead meetings within the division as appropriate and work with/challenge changes in practice that are required for improvement.

- To contribute to range of divisional committees that address the Quality agenda

- To work closely with the Patient Quality and Safety Manager for the D&S Division.

Responsibilities for Patients

- Be able to evidence integrity in their ability to communicate with both patients, their families and staff involved in incidents.

- Have proven leadership skills and the confidence to engage with senior personnel to investigate care issues and devise appropriate learning plans.

- Identify and escalate any anomalies to DDQN team/ Divisional Quality Governance Lead including cascading and actioning of Safety Alerts

- Ensure patients who suffer harm whilst under our care, are managed in line with Being Open or Duty of Candour as indicated by level of harm

- To ensure maximum learning is gained from all quality and patient safety work, and measures are taken to share this learning

- Take an active part in investigating formal complaints under the NHS Complaints Procedure

Information Governance, research and professional responsibility

- To follow systems within the service to ensure that confidential information is obtained, held, recorded, used, and shared in accordance with Caldicott and data protection requirements.

- Systematically review information systems that support the clinical quality/ clinical governance agenda to ensure timely information is collated.

- To maintain confidential reports/records.

- To work with the Divisional Leadership Team to continuously improve the quality of service and safeguard high standards of care by creating an environment in which enables excellence in clinical practice.

- Take responsibility for the maintenance and improvement of professional knowledge and skills