Job Description

Job Title: Audit Coordinator – Irish Audit of Surgical Mortality

Reporting To: Manager – NOCA or nominee

Tenure: 1 YearFixed Term Contract

Location:RCSI St. Stephens Green

The National Office of Clinical Audit (NOCA) has been established to design, develop and implement frameworks to facilitate sustainable national clinical audit programmes in agreed specialties through the convening of a robust Governance Board. RCSI will oversee the operational and administrative management and convene the Governance Board of NOCA.

The first audit stream identified for delivery under the National Office of Clinical Audit and now ready for user testing is that of the Irish Audit of Surgical Mortality (IASM).

Audit of Surgical Mortality is an internationally recognised audit process that provides confidential, independent, peer review, which is systematic and objective. RCSI have and will continue to consult with the Royal Colleges responsible for the Scottish Audit of Surgical Mortality (SASM) and the Australian and New Zealand Audit of Surgical Mortality (ANZASM).

The objectives of an audit of surgical mortality in Ireland will be to review all deaths that occur following of an episode of surgical care and to provide opportunities for improvements in patient outcomes by:

  • Reducing mortality associated with surgery
  • Increasing patient safety, confidence and overall experience
  • Promoting and encouraging reflective practice
  • Provide Surgeons and Anaesthetists the opportunity to participate and contribute to
  • measurable clinical audit

The longer term objectives of IASM are to provide regular, documented, critical analysis of the outcomes of surgical care. The gathering of information from multiple sources over time, will allow detection of system issues and emerging trends. In addition, in consultation with SASM and ANZASM, Irish clinicians will be ideally positioned to benchmark clinical outcomes against international standards.

Methodology

In brief, individual surgeons and anaesthetists will log on to IASM portal following a death associated with any surgical care. All cases in which a surgeon was responsible for, or had significant involvement in, the care of a patient will be included in the audit, whether or not the patient underwent a surgical procedure.

The clinical details pertaining to the management of each case will be recorded within the IASM portal. This will be completed by the consultant / treating surgeon and anaesthetist associated with the case. The completed template will be received by IASM Audit Office, where it is totally de-identified.

The IASM Audit Office will invite first-line assessment by a surgeon / anaesthetist from the same surgical specialty but from a different hospital. The first-line assessor will be unaware of the name of the deceased, the treating surgeon or the hospital where the death occurred. From international experience, we envisage two possible outcomes of first line assessment:

  1. The information provided by the treating surgeon is adequate to reach a conclusion about the case and to identify any issues of management, if present.
  1. A further in-depth second-line assessment or case note review is necessary either:

for clarification of issues of patient management identified or suspected by the first-line assessor,

orbecause the information provided by the treating surgeon was inadequate to reach a conclusion.

The participant will be notified of the status and in particular will be aware if second line assessment has been requested. In addition if second line assessment is requested the Clinical Director of the hospital will also be notified.

RCSI now wish to recruit IASM Audit Co ordinator to oversee the implementation and administrative and operational delivery of IASM.

Responsibilities:

  • Oversee a sustainable programmatic approach to surgically related clinical audit involving consultation with all relevant stakeholders
  • Provide regular progress reports while supporting the IASM Governance Board in the convening of surgical expertise in the preparation, analysis and interpretation of regular reports derived from de-identified audit data and make recommendations for appropriate action
  • Regularly review the IASM functions and activities including maintaining security and confidentiality of case data to ensure robust processes are in place and maintained
  • Develop and maintain linkages with public and private hospitals nationally in the promotion and fulfilment of clinical audit

The objectives of this post include

1. Establishment of a satisfactory IASM structure across surgery and anaesthesia

2. Creation of appropriate systems for local feedback of Audit results

3. Support national IASM governance structures, including working with the National Office of Clinical Audit, including supporting and working with the NOCA Manager and the National Governance Committee for IASM

4. Preparation of an Annual Reports of National IASM results

5. Oversee collation and confidential retention of all audit data

6. Development of a National IASM database

7. Identification and promotion of ongoing development of IASM

Key Responsibilities

  • Identify best practice and document valid process mapping of the procedures involved in the collection, interpretation and inputting of data for IASM
  • Support Clinical Leads in ensuring successful Implementation / introduction of IASM and act as a support for clinicians accessing IASM Portal
  • Develop guidelines and support documents for Units about to participate in IASM, this includes development and implementation of a robust communication strategy and education plans required in relation to achieving aim and objectives of IASM.
  • Provide adequate support to clinicians to ensure timely, comprehensive and accurate collection of data and transmission to IASM
  • Monitor the quality of data being provided to IASM and proactively seek improvement when deficiencies are identified
  • Encourage voluntary participation through positive and proactive promotion of IASM
  • Support procedures to feedback the results of the Audit in an appropriate manner, including the production of an Annual Report, in collaboration with Clinical Lead
  • Represent the IASM at relevant committees, conferences etc
  • Liaison with other stakeholders i.e. NOCA, Surgery Programme, Programme, HSE QPSD, HCAI,
  • Formulate, manage and implement best practice policies and procedures and ensure adherence to same.
  • Participate in ongoing developments in IASM and clinical audit nationally
  • Support for activities of Lead Clinician and for IASM Governance Committee.
  • Maintain professional standards in relation to confidentiality, ethics and legislation.

Required Skills and Behaviour

  • Strong leadership and communication skills to engage with all stakeholders, both clinical and non clinical
  • A higher degree in Quality Management, Project Management, Healthcare or Medical Education Management or related field would be advantageous
  • Experience of clinical audit data collation and interpretation of output
  • Proven track record of managing others to deliver projects and or services
  • Proven track record of identifying improvement measures and delivering measurable and sustainable benefits
  • Excellent coaching skills, with ability to transfer knowledge and skills effectively
  • Excellent facilitator, experienced in workshop design and management of collaborative problem solving workshops
  • Attention to detail and exceptional documentation skills
  • Self-starter, high personal energy, positive approach to dealing with challenges and ambiguity
  • Excellent project management skills and able to move a team forward, maintain momentum and project planning and management discipline.
  • Ability to deal with conflict positively and effectively
  • Track record of building positive working relationships with people who work in a challenging and at times stressful work environment.
  • Completer finisher and flexible working arrangements
  • Can co-ordinate and motivate a multi-disciplinary team