JOB DESCRIPTION
JOB TITLE: Clinical Quality & Patient Safety Lead
BASE: LOROS, Groby Road
HOURS OF WORK: 37.5 hours per week
RESPONSIBLE TO: Director of Care Services (DoCS)
JOB PURPOSE:
The key elements of the role are:-
1. To lead the on-going development of a proactive and robust clinical quality, safety and governance framework that enables the Hospice to measure and continuously improve the quality of the clinical services it provides in line with national recommendations and guidance.
2. To lead on clinical audit, clinical quality and patient safety and working with all managers, clinical leads and services, embed the principles of robust clinical governance and quality throughout LOROS.
3. To coordinate the compilation and maintenance of the necessary evidence and documentation that demonstrates compliance with any Quality Indicators set by Clinical Commissioning Groups (CCGs), requirements of and standards set by the Care Quality Commission (CQC) and relevant NICE Guidance.
4. To act as co-lead with the Health and Safety Manager for the management of the Sentinel Risk Management System.
RESPONSIBILITES
1. CLINICAL QUALITY & PATIENT SAFETY
1.1 Oversee the self assessment process for CQC and with reference to the Key Lines Of Enquiry, ensure all supporting evidence under each of the five key questions is up to date and appropriately maintained and all supporting documentation is available as required
1.2 Manage the electronic CQC folder to ensure all relevant documentation is in place and updated as required
1.3 Ensure the relevant documents are available to the CQC in relation to inspection visits including the Provider Information Return (PIR) and any required notifications
1.4 Support the registered manager in their role including submitting applications for new locations and or changes in regulated activities
1.5 Coordinate the CQC inspection process ensuring resulting ratings are communicated to all staff and volunteers and are displayed publicly around the hospice
1.6 Provide updates and awareness sessions for staff to inform them of CQC requirements and to help prepare staff for inspection visits
1.7 Manage LOROS’ Clinical Governance programme in line with internal policies and procedures and that meet the requirements of the local Clinical Commissioning Groups and the Care Quality Commission (CQC)
1.8 Oversee the agenda planning for Clinical Governance meetings ensuring all relevant reports, topics and documents are included and all supporting papers are available
1.9 Collate and follow up on actions generated at Clinical Governance and other clinically related meetings to ensure these are addressed by appropriate persons in a timely manner.
1.10 Monitor clinical incidents using the Sentinel incident reporting module, identifying trends and helping to ensure areas for service improvement are identified and addressed
1.11 Develop action plans as appropriate to meet the requirements of relevant patient safety alerts
1.12 Support the DoCS PA in addressing clinical CAS (Central Alerting system) and MHRA (Medicines and Healthcare products Regulatory Agency) alerts
1.13 Support the Head of Inpatient & Day Care Services with Root Cause Analysis investigations following SI’s ensuring time lines are met re initial reporting and submitting outcomes of investigations to the CCG
1.14 Ensure the Duty of Candour principles are followed in relation to all SI’s including Category 3 Pressure Ulcers, completing the necessary correspondence to patient’s and/or their relatives
1.15 Support the Head of Inpatient & Day Care Services in analysing patient data – e.g. the Hospice UK clinical benchmarking data, identifying areas for service improvement and supporting subsequent service developments
1.16 With the Health Safety Manager agree a programme of risk assessments within the clinical areas, ensuring these are completed within agreed timelines and communicated to relevant departments
1.17 Oversee the development of the LOROS annual Quality Account
1.18 Oversee the process for ensuring LOROS is compliant with the CCG Quality Schedule, supporting the submission of evidence of compliance in the format agreed with the CCG.
1.19 Oversee the annual CCG quality visit.
1.20 Oversee any other compliance processes as required e.g. – Cancer Peer Review, providing guidance and support
1.21 Be responsible for updating and as necessary developing new LOROS clinical policies
1.22 Prepare appropriate reports as required for internal and/or external meetings/reviews
1.23 Support the DoCS in dealing with concerns and complaints, undertaking investigations and compiling response letters as required
2. CLINICAL AUDIT
2.1 Lead and co-ordinate the annual clinical audit programme liaising with relevant staff members to ensure audits are undertaken at the appropriate times and all relevant information is recorded on the database
2.2 Be responsible for undertaking and presenting a number of the audits to support this process
2.3 Periodically review the audit tools to ensure they are fit for purpose and amend or develop new tools as required in collaboration with colleagues
2.4 Undertake clinical audit training and awareness sessions and stimulate ideas in relation to clinical interest audits
2.5 Oversee the clinical interest audit process, helping facilitate discussions with relevant staff members and co-ordinate any support required in the clinical areas
2.6 Ensure all audits are recorded on the database
2.7 Develop and lead a programme of audit presentation meetings, encouraging attendance from all departments
2.8 Support in the development and implementation of action plans to address audit findings to enable continuous quality improvements across the Hospice
2.9 Produce audit reports for presentation at the Clinical Governance and Board of Trustees meetings
2.10 Produce an annual report incorporating all clinical audit activity to be presented to the Board of Trustees and included in the annual Quality Account
3. MANAGEMENT/LEADERSHIP
3.1 Provide support and guidance to colleagues in line with the responsibilities of the post – e.g. Clinical Governance, Audit and CQC outcomes
3.2 Actively participate in appropriate groups and forums within LOROS and externally as required including the Clinical Governance Committee, CQC Core Team meetings and the weekly Significant Events meetings
3.3 Promote the work of LOROS as appropriate in the wider community
3.4 Represent LOROS as required, including deputising for the DoCS at appropriate local/regional and national meetings, conferences and events
4. EDUCATION & DEVELOPMENT
4.1 Participate in LOROS’s education and training programmes as appropriate in line with the responsibilities of the post – e.g. management of concerns/complaints
4.2 Present the ‘delivering safe, quality services’ session on the LOROS induction programmes
4.3 Be responsible for own personal development and keep up to date with any relevant regulations, legislation or other developments pertinent to the role
5. GENERAL:
5.1 All staff are subject to Equal Opportunities Legislation, the Data Protection Act and LOROS Confidentiality Policy.
5.2 To carry out and comply with the prevention and control of infection as per LOROS policies and procedures.
5.3 All staff are subject to LOROS policies, procedures and conditions of service, with reference to the Health and Safety at Work Act 1974.
5.4 Take reasonable care for the health and safety of themselves and of other persons who may be affected by their acts or omissions at work.
5.5 Co-operate with their employer as far as is necessary to meet the requirements of the legislation.
5.6 All staff should be aware of and aim to contribute to LOROS’ Vision and Mission and also strive to exhibit the Values & Behaviours at all times (see attached document).
The contents of this job description are not exhaustive and may be amended in accordance with the needs of the service after discussion with the post holder whose agreement will not be unreasonably withheld.
Signed………………………………………………………Date………………………………………
Postholder
Signed…………………………………………………… Date ………………………………………..
Line Manager
VISION
(Our long term aspiration for our society)
Everyone with an incurable illness has the right to excellent care. This should value and respect their uniqueness and their own choices. People should be enabled to live and die with dignity and with appropriate and compassionate support for them and their loved ones.
MISSION
(Our goals and activities in working towards our Vision)
LOROS is a charity whose aim is to enhance the quality of life of adult patients with cancer, progressive neurological conditions and end-stage organ failure for whom curative treatment is no longer possible. Patients are treated at the hospice and in the community based upon clinical need, regardless of background and the ability to pay.
LOROS specialises in holistic, multidisciplinary care, focused on the whole person and including family and carers. The care given takes into account the patients’ physical, psychological, social and spiritual needs as well as their own choices. Family members are supported in adjusting to loss and bereavement.
LOROS contributes to the education and training of its own and other health and social care professionals and of volunteers. The charity is also committed to research in order to improve the understanding and practice of palliative care.
VALUES & BEHAVIOURS
(How we will strive to be)
KEY FACTS – AUGUST 2016
No. of individuals receiving patient care from LOROS pa >2,500
Of whom admitted to Inpatient Ward 590
(approx ½ subsequently discharged)
No. of beds in Inpatient Ward 31
Average length of stay (days) 12
No. of participants in LOROS educational activities pa 2,200
No. of employees 330
No. of regular volunteers 1,100
Expenditure on patient care pa £7.7 million
Minimum amount of income to be raised pa £5 million
Portion of expenditure covered by NHS 1/3rd
Proportion of charity costs directed to care services 91%
Cost per hour of running the charity £870
Cost per Bed/Day including “overheads” (80% occupancy) £520
Cost per attendance for Day Therapy £240
No. of LOROS shops 28
No. of LOROS lottery members 24,800
Year LOROS registered as a charity 1977
First patient at Groby Road Hospice Sept 1985
LOROS is a registered charity and also a company limited by guarantee which is governed by a Board of up to 15 unpaid voluntary Trustees. It is regulated by the Charity Commission, Companies House and the Care Quality Commission.
All money raised is spent locally in Leicester, Leicestershire & Rutland.
P:\PERSONNEL\Job Descriptions\Director of Care Services Structure\2017\Clinical Quality Patient Safety Lead November 2017.doc