Governance for Quality and Safety

AMENDED

Quality Improvement Facilitator

Governance for Quality and Safety

Job Specification & Terms and Conditions

Job Title, Grade, Grade Code / Quality Improvement Facilitator: Governance for Quality and Safety
Grade GVIII – Grade Code 0655
Campaign Reference / NRS02489
Closing Date / Friday 14th August 2015 at 12 noon
Proposed Interview Dates / September 2015
Informal Enquiries / Maureen Flynn, Quality Improvement Division Lead, Governance for Quality and Safety- email
Location of Post / The team lead is open to engagement in respect of flexibility around location subject to reaching agreement on a minimum level of availability at Dr Steevens’ Hospital and/or for relevant Dublin based meetings
Organisational Area / Corporate: Quality Improvement Division
Details of Service / The Quality Improvement Division (QID) established in January 2015 is a Corporate function that delivers on the identified priorities for quality improvement in the HSE
QID Vision: working in partnership to create safe quality care.
QID Mission:to provide leadership by working with patients, families and all who work in the health system to innovate and improve quality and safety of care by championing, educating, partnering and demonstrating quality improvement.
QID Priorities:

Building capacity and capability for improvement
Building clinical and collective leadership
Leading a National Person CentredProgramme
Integrating and supporting national safety programmes
Partnering on key quality programmes. One of the partnering on key quality programmes is The improving programme: governance for quality and safety currently being established
Information and analysis to support improvement

The primary objective of the work of the Division is to improve the quality and safety of services for all groups (patients, clients and service users) and to enable a culture where improving quality of care is the priority shared purpose across the HSE. The QID agenda will be delivered by working in collaboration with the services and other agencies.
Division Structure:
A team lead is appointed to each QID priority area, as outlined above, to direct and plan the programme of work to deliver on the priority. Each Lead will have a team of people with experience in different areas of healthcare improvement including working with patients, healthcare staff, managers and policy makers. Team leads will work together to ensure collaboration and sharing of expertise across the teams. All team members may not report to the team lead.
The National Director’s office will support this work with business management support, programme management, communication and support for stakeholder management, and strategic development.
Reporting Arrangements / Initially reporting to the QID team lead Governance for Quality and Safety who reports to the National Director Quality Improvement Division
Key Working Relationships / Key working relationships will be within the QID Division, Quality and Patient Safety leads for the service divisions, Systems Reform Group, HSE service divisions, Hospital Group Boards/Executive Management teams and Chief Officers of Community Health Organisations; Department of Health; Regulators; professional Colleges.
Purpose of the Post / The purpose of the post isto support the delivery of QID strategic programmes.
The initial improving quality programme is Governance for Quality and Safety informed by the clinical governance development initiative. Working in partnership with HSE Divisions, Hospital Groups (HGs) and Community Healthcare Organisations (CHOs) to identify their needs in relation to governance for quality and safety, the programme will facilitate agreed approaches and Quality Improvement projects with Divisions, Hospital Groups and Community Healthcare Organisations.
A focused initiative for clinical governance development commenced in 2011. In collaboration with health service providers a number of resources were developed including a framework for the implementation of clinical governance set out in the‘Report of the Quality and Safety Clinical Governance Development Initiative – Sharing our Learning’ was published in May 2014 and ‘Report of the Quality and Safety Clinical Governance Development Initiative Primary Care – Sharing our Learning’published in April 2015. The main purpose of the reportsis to consolidate the learning and make core recommendations for health service providers, policy makers and commissioners to inform their own specific action plans.
A demonstration Quality Improvement project was completed in collaboration with the MaterHospital to enhance the Board of Directors role in overseeing and contributing to the improvement of the quality of care provided at the clinical frontline. The learning from this project is directly applicable to the establishment of Hospital Groups and Community Healthcare Organisations and any staff with an interest in governance and patient safety.Other boards and staff involved in governance for quality and patient safety can also learn from this work. The improving programme - governance for quality and safety will facilitate Boards interested in adapting the tools to support their Board to assume greater responsibility for, and strengthen its impact on, the hospital’s quality of clinical care.
This post will add to a small team who together are responsible for a portfolio of improvement activities for governance for quality and safety.
Principal Duties and Responsibilities / The facilitator provides guidance and supports to a nominated group of boards, executive management teams and HSE divisions in undertaking governance for quality and safety Quality Improvement projects.
Governance for Quality and Safety Programme
Input to the design of strategic programme to support Governance for Quality and Safety development
Coordinate the provision of targeted governance for quality and safety support projects including ‘Boards on Board’ Quality Improvement projects focusing on the quality of care
Assess the situation with regards to its readiness for improvement
Work with local project team to develop Plan Do Study Act (PDSA) cycles that will test change packages for governance for quality and safety
Provide support to the HSE Directorate, National Divisions, Hospital Groups and Community Health Organisations in the development of structures and processes for governance for quality and safety within relevant services
Provide support and advice to national leads preparing models of care for the national clinical programmes and strategy division on governance arrangements for quality and safety.
Engage with the Clinical Director programme in supporting Clinical Directors in the establishment of structures and processes for effective governance for quality and safety
Seek opportunities to share learning from Quality Improvement action projects through presentations and the publication of reports, case studies and journal articles.
Provide advice to services on queries related to governance for quality and safety as required.
Patient and Staff engagement
Incorporate partnership with patients and staff in the support programme for governance of quality and safety
Increase staff understanding of the effective arrangements for governance for quality and safety – by providing guest presentations/lectures
Share information with staff on governance for quality and safety resources, through guidance toolkits, journal publications, newsletters and website
Information and analysis
Take ownership of data within work streams
Consider the mechanism to measure staff perceptions of governance for quality and safety development within their service
Work with other Quality Improvement teams in the use of guidance for health service providers on the preparation and use of a ‘Quality Profile’ for their service.
Prepare and report monthly on work programme
Prepare an annual report on the programme for inclusion in the QID annual report
Quality Improvement Division
Represent QID at meetings and other events relevant to the area of responsibility
Other duties as specified by the lead for Governance for Quality and Safety
To act as spokesperson for the Organisation as required
Demonstrate pro-active commitment to all communications with internal and external stakeholders
Have a working knowledge of the Health Information and Quality Authority (HIQA) Standards as they apply to the role for example, Standards for Healthcare, National Standards for the Prevention and Control of Healthcare Associated Infections, Hygiene Standards etc and comply with associated HSE protocols for implementing and maintaining these standards.
To support, promote and actively participate in sustainable energy, water and waste initiatives to create a more sustainable, low carbon and efficient health service.
The above responsibilities and duties reflect those contained within the initial assignment. Assignment to other work programmes would carry similar duties and responsibilities
The above Job Description is not intended to be a comprehensive list of all duties involved and consequently, the post holder may be required to perform other duties as appropriate to the post which may be assigned to him/her from time to time and to contribute to the development of the post while in office.
Eligibility Criteria
Qualifications and/ or experience / All staff of the HSE, Child and Family Agency (Tusla), other statutory health agencies, the Department of Health and bodies which provide services on behalf of the HSE under Section 38 of the Health Act 2004 are only eligible to apply at this time.
Candidates must by the closing date for receipt of applications:
Possess the following, as relevant to the role:

Significant experience of leading change in complex health sector systems.
Significant experience of leading quality improvement in a healthcare setting.
Experience of managing and working collaboratively with multiple stakeholders.
Experience of using improvement methods such as LEAN, clinical microsystems, collaborative models, Plan Do Study Act (PDSA) cycles and process mapping.
Evidence of leading on the writing of business cases, project initiation documents, project reports and journal articles.
Have the requisite knowledge and ability (including a high standard of suitability and management ability) for the proper discharge of the duties of the office.

Health
A candidate for and any person holding the office must be fully competent and capable of undertaking the duties attached to the office and be in a state of health such as would indicate a reasonable prospect of ability to render regular and efficient service.
Character
Each candidate for and any person holding the office must be of good character.
Age
Age restrictions shall only apply to a candidate where he/she is not classified as a new entrant (within the meaning of the Public Service Superannuation Act, 2004). A candidate who is not classified as a new entrant must be under 65 years of age on the first day of the month in which the latest date for receiving completed application forms for the office occurs.
Other requirements specific to the post /

Flexibility around working hours will be required in response to the varying demands of the role.
The position is office based; however, the successful candidate will be required to visit relevant clinical settings and attend off site meetings throughout Ireland as required.
Access to transport as post will involve travel

Skills, competencies and/or knowledge / Professional Knowledge & Experience
Demonstrate:

A proven track record of achievement in managing health sector projects to successful outcomes
Understanding of and experience in the use of improvement science, change management, and project management methodologies
Knowledge of relevant IT systems e.g. MS Word, Excel, Project Manager
Knowledge of a person centered approach to quality improvement
Experience and knowledge of the issues and developments and current thinking in relation to best practice in quality improvement
Experience of coaching with the ability to transfer quality improvement knowledge and skills effectively
Experience in the facilitation, design and management of collaborative problem solving workshops.

Managing & Delivering Results (Operational Excellence)
Demonstrate:

Excellent organisational and time management skills to meet objectives within agreed timeframes and achieve quality results.
Evidence of effective quality improvement project planning and organisational skills including an awareness of resource management and the importance of value for money
The ability to improve efficiency within the working environment and the ability to evolve and adapt to a rapid changing environment
The ability to work to tight deadlines and operate effectively with multiple competing priorities
A capacity to operate successfully in a challenging operational environment while adhering to quality standards
The ability to take personal responsibility to initiate activities and drive objectives through to a conclusion
The ability to seek and seize opportunities that are beneficial to achieving organisation goals and strives to improve service delivery

Teamwork, Leadership & Building and Maintaining Relationships
Demonstrate:

Ability to lead, direct and influence others, in partnership, with a wide variety of stakeholders in a complex and changing environment
Motivation and an innovative approach to the job within a changing working environment
The capacity to inspire teams to the confident delivery of excellent services
A vision in relation to what changes are required to achieve immediate and long term organisational objectives
Strong team work skills including the ability to build and maintain relationships in a multidisciplinary team/ multi-stakeholder environment
Evidence of being a positive agent of change and performance improvement
Effective conflict management skills

Critical Analysis & Decision Making
Demonstrate:

Excellent analytical skills to enable analysis, interpretation of data and data extraction from multiple data sources
The ability to evaluate complex information from a variety of sources and make effective decisions
Considers the impact of decisions before taking action
Anticipates problems. Recognises when to involve other parties (at the appropriate time and level)
Makes timely decisions and stands by those decisions as required

Communication & Interpersonal Skills
Demonstrate:

Excellent interpersonal and communications skills to facilitate work with a wide range of individuals and groups
Excellent oral and written communication skills, including facilitation skills
A capacity to negotiate and then ensure delivery on stretched objectives

Commitment to a Quality Service
Demonstrate:

Evidence of interest and passion in engaging with and delivering on better outcomes for service users
A core belief in and passion for the sustainable delivery of high quality user focused services

Campaign Specific Selection Process
Ranking/ Shortlisting/Interview / A ranking and or short listing exercise may be carried out on the basis of information supplied in your application form. The criteria for short listing are based on the requirements of the post as outlined in the eligibility criteria and skills, competencies and/or knowledge section of this job specification. Therefore it is very important that you think about your experience in light of those requirements.
Failure to include information regarding these requirements may result in you not being called forward to the next stage of the selection process.
Those successful at the short listing stage of this process (where applied) will be placed on an order of merit and will called forward to interview ‘bands’ depending on the service needs of the organisation.
Code of Practice / The Health Service Executivewill run this campaign in compliance with the Code of Practice prepared by the Commission for Public Service Appointments (CPSA). The Code of Practice sets out how the core principles of probity, merit, equity and fairness might be applied on a principle basis. The Code also specifies the responsibilities placed on candidates, facilities for feedback to applicantson matters relating to their application when requested, and outlines procedures in relation to requests for a review of the recruitment and selection process and review in relation to allegations of a breach of the Code of Practice. Additional information on the HSE’s review process is available in the document posted with each vacancy entitled “Code of Practice, Information for Candidates”.
Codes of practice are published by the CPSA and are available on the document posted with each vacancy entitled “Code of
The reform programme outlined for the Health Services may impact on this role and as structures change the job description may be reviewed.
This job description is a guide to the general range of duties assigned to the post holder. It is intended to be neither definitive nor restrictive and is subject to periodic review with the employee concerned.

HEALTH SERVICES EXECUTIVE

Quality Improvement Facilitator - Governance for Quality & Safety

Grade VIII

Terms and Conditions of Employment

Tenure / The current vacancy is whole time and permanent.
A panel will be created from this campaign from which current and future permanent, specified purpose, whole-time and part time posts will be filled. The tenure of these posts will be indicated at “expression of interest” stage. The posts are pensionable.
Appointment as an employee of the Health Service Executive is governed by the Health Act 2004 and the Public Service Management (Recruitment and Appointment) Act 2004.
Remuneration / The Salary scale for the post is: €64,812 - €74,551 (7 point scale as at 01/11/2013)
Working Week / The standard working week applying to the post is:37 hours
HSE Circular 003-2009 “Matching Working Patterns to Service Needs (Extended Working Day / Week Arrangements); Framework for Implementation of Clause 30.4 of Towards 2016” applies. Under the terms of this circular, all new entrants and staff appointed to promotional posts from Dec 16th 2008 will be required to work agreed roster / on call arrangements as advised by their line manager. Contracted hours of work are liable to change between the hours of 8am-8pm over seven days to meet the requirements for extended day services in accordance with the terms of the Framework Agreement (Implementation of Clause 30.4 of Towards 2016).
Annual Leave / The annual leave associated with the post will be in line with HSE annual leave entitlements and will be outlined at job offer stage.
Superannuation / All pensionable staff become members of the pension scheme.
Applicants for posts in the Mental Health service are advised that Section 65 of the Mental Treatment Act, 1945, does not apply to new entrants to the Mental Health Services as defined by the Public Service Superannuation(Miscellaneous Provisions) Act, 2004 (Section 12 of that Act) New entrants
Probation / Every appointment of a person who is not already a permanent officer of the Health Service Executive or of a Local Authority shall be subject to a probationary period of 12 months as stipulated in the Department of Health Circular No.10/71.
Ethics in Public Office 1995 and 2001
Positions remunerated at or above the minimum point of the Grade VIII salary / Positions remunerated at or above the minimum point of the Grade VIII salary scale are designated positions under Section 18 of the Ethics in Public Office Act 1995. Any person appointed to a designated position must comply with the requirements of the Ethics in Public Office Acts 1995 and 2001 as outlined below;
A) In accordance with Section 18 of the Ethics in Public Office Act 1995, a person holding such a post is required to prepare and furnish an annual statement of any interests which could materially influence the performance of the official functions of the post. This annual statement of interest should be submitted to the Chief Executive Officer not later than 31st January in the following year.
B) In addition to the annual statement, a person holding such a post is required, whenever they are performing a function as an employee of the HSE and have actual knowledge, or a connected person, has a material interest in a matter to which the function relates, provide at the time a statement of the facts of that interest. A person holding such a post should provide such statement to the Chief Executive Officer. The function in question cannot be performed unless there are compelling reasons to do so and, if this is the case, those compelling reasons must be stated in writing and must be provided to the Chief Executive Officer.
C) A person holding such a post is required under the Ethics in Public Office Acts 1995 and 2001 to act in accordance with any guidelines or advice published or given by the Standards in Public Office Commission. Guidelines for public servants on compliance with the provisions of the Ethics in Public Office Acts 1995 and 2001 are available on the Standards Commission’s website