Directs, coordinates and implements Quality and Patient Safety initiatives to ensure operational alignment with assigned Hospital/Institute and organisational objectives. Provides leadership and raises awareness of Quality and Governance, working collaboratively to ensure the quality of Clinical Care is delivered in accordance with CQC standards along with recommending and overseeing implementation of changes in practice. Leads the Quality Governance agenda by monitoring achievements against required standards, identifying risks to quality of care and services along with planning and recommending changes for continuous improvement.
- Collaborates with leadership and support teams to develop, maintain and execute an integrated Quality Plan to achieve quality, safety and patient experience goals.
- Incorporates enterprise priorities and regulatory requirements and benchmarks.
- Clearly communicates priorities to stakeholders at all levels.
- Drives continuous improvement activity around quality, safety and patient experience priorities and coordinates improvement projects.
- Collaborates with Continuous Improvement and Project Management.
- Measures and analyse data reflecting processes and outcomes prioritized by Hospital/Institute.
- Identify opportunities for quality improvement and assist in establishing quality assurance systems which provide reliable and meaningful data and inform continuous improvement initiatives
- Facilitates dashboard reviews, data analysis and decision-making from data, monitoring, and reporting compliance which supports the requirements of regulators, and provides user friendly metrics which inform and help to engage staff.
- Identifies changes required because of significant incidents and complaints related to clinical practice, ensuring remedial actions are proportionate, supported by training where necessary and deliver sustainable improvements.
- Actively participates in the development and implementation of training and education programmes, with external partners where necessary, to enable clinical teams to deliver on leading change and service improvements to move to positions of higher levels of quality and safety and beyond compliance.
- Promotes a culture of excellence through local quality initiatives, utilising the evidence base and accepted best practice to integrate theory with practice.
- Collaborates with Quality Patient Safety Institute, Regional Quality, Office of Patient Experience and Nursing Quality Leadership, direct site accreditation, infection prevention, patient safety, clinical quality, peer review and associated performance improvement activities, ensuring the hospital meets the statutory requirements of the CQC.
- Implements systems and process to continually assess the quality and effectiveness of care and service through audit and feedback from patients.
- Manages CQC accreditation process during pre-activation and once operational, ensures compliance with all regulated activity standards and regulations.
- Ensuring effective risk management processes are in place to proactively minimize risks to patients, visitors and staff.
- Responsible for managing infection prevention across the hospital and outpatient facility.
- Responsible for oversight of safety and fire protection team.
- Provides authoritative, expert advice, providing support to executive leadership on matters relating to governance, quality and compliance.
- Assists with the development, review and maintenance of policies, procedures and guidelines, which ensure sound corporate governance and contribute to a culture of safety and continuous improvement, while also distilling national guidelines and accepted best practice to inform local response.
- Advises and monitors the corporate governance implications of business strategies.
- Acts as the budget holder for department budget, leading on budgeting setting activity.
- Responsible for developing team Key Performance Indicator’s (KPI) and supporting objective setting and assessment for direct reports.
- Supports the Leadership team with the introduction of new clinical initiatives with the minimum disruption to the pursuit of business goals.
- Responsible for implementing and ensuring compliance with national guidance guidelines and policies.
- Other duties as assigned.
- Bachelor's Degree in Nursing, Healthcare Administration, Business, Engineering or related field required.
- Master's Degreepreferred.
Competencies (Complexity of Work):
- Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.
- Must be able to work in a stressful environment and take appropriate action.
- Requires strong communication, organizational and time management skills.
- In-depth knowledge of hospital accreditation and current trends in Quality Management preferred.
- Continuous professional development in the respective field preferred.
- Minimum five years’ management experience in process quality improvement, accreditation, quality management or related field.
- Experience of working in a highly-regulated environment with a solid understanding of the Care Quality Commission (CQC) requirements.
- Experience leading or managing a hospital through the care quality commission (CQC) accreditation.
- Manual dexterity to operate office equipment.
- Requires frequent data entry, standing, walking and sitting.
- Normal or corrected vision, hearing and speech.
Personal Protective Equipment:
- Follows standard precautions using personal protective equipment as required.