Senior Governance Facilitator

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Job overview

We are seeking a highly motivated and dedicated individual to join our Divisional Governance Team for Medicine at Royal Albert Edward Infirmary. The Governance Team provides leadership, support and guidance across the whole governance agenda within the division and this senior post holder will work with and support the Deputy Head and Head of Governance to deliver the quality governance agenda.

Applicants would be expected to show significant demonstrable experience of successfully delivering governance with sound knowledge of the Patient Safety Incident Response Framework and investigation tools, compassionate engagement, duty of candour, complaints, risk, clinical audit, embedded learning, compliance and assurance. The ability to manage a significant workload effectively within a large Division and exceptional communication skills, both written and verbally are required. Strong administrative skills with a proven ability of using Trust Systems and Microsoft Office packages are also required.

Main duties of the job

To support the Head/Deputy Head of Governance in ensuring that systems and processes are implemented and monitored in order to achieve governance, assurance and quality objectives within the Division of Medicine, dealing with highly complex incidents and complaints and data of a sensitive nature.

Acting on own experience and knowledge the post holder will achieve best practice and results being guided by Trust policies and principles.

To support the Head/Deputy Head of Governance and to comply with CQC and other regulatory and quality requirements in order to deliver the governance objectives for the division, displaying expertise within won specialism, including:

1. Clinical quality and the delivery of safe/compassionate care
2. CQC registration, outcomes and action plans
3. Patient safety
4. Risk and incident assessment and management
5. Complaints management
6. CQUIN and quality metrics
7. Health and safety
8. Information governance

Key results from the job holder

1. To oversee systems and processes in place to promote patient safety and learning from incidents.
2. To oversee the Datix incident reporting system to ensure that incidents are reported and managed in line with the Trust Incident and Investigation policy.
3. To monitor and investigate incidents and ensure that Datix is completed correctly and in a timely manner by divisional leads and managers.
4. To be responsible for analysing complex clinical and non-clinical incident data and provide reports, identifying trends for specialties.
5. To ensure that any incidents requiring rapid review and escalation are identified and undertaken.
6. To lead on/participate in investigations, e.g. complaints, incidents, root cause analysis as required.
7. To ensure that action plans as a result of an incident, complaint, investigation or risk assessment are monitored and delivered with non-compliance escalated to the relevant specialty governance meetings and/or relevant divisional governance meetings.
8. To oversee the Divisional Risk Assessment register and ensure that it is effectively populated, to analyse and identify trends and actions arising and to monitor on a regular basis to ensure risks are controlled.
9. To lead on Health and Safety activities and adherence to health and safety guidance for the Division.
10. To lead on the collation, accurate analysis and presentation of data to support and maintain patient safety.
11. To monitor compliance in relation to the implementation of NICE Guidance, Technology Appraisals and clinical guidelines within designated clinical teams.
12. To oversee the review of support individual authors in ensuring new or reviewed polices taken through the appropriate approval process in accordance with Trust policy.
13. To produce the divisional Safe, Effective, Care (SEC) report for review by Head of Governance.
14. To lead on the collation and presentation of data for Specialty Meetings and attend the meetings as the governance representative.
15. To oversee systems and processes are in place to promote and embed learning as a result of complaints, concerns and results of patient engagement projects.
16. To support on the formulation of responses to complaints.
17. To lead on the provision reports on trends analysis as a result of concerns and complaints received.
18. To oversee the collation of improvement plans as a result of concerns or complaints are monitored and delivered with non-compliance escalated to the relevant specialty governance meetings and/or relevant divisional governance meetings.
19. To represent the Head of Governance at Corporate Meetings as and when required.
20. In agreement with Head of Governance commence Rapid Review investigations and undertake concise investigations.
21. Undertake Root Cause Analysis.

Person specification

Qualifications
Essential criteria

1. Degree/Diploma studies or relevant experience
2. Evidence of continuing professional development

Desirable criteria

1. Specialist skills course or relevant governance qualification
2. ECDL/IT Qualification

Experience
Essential criteria

1. Experience of working on own and as a member of a team
2. Previous experience in a health care setting
3. Ability to prioritise workload effectively
4. Can meet deadlines within the allotted time frames
5. Working with sensitive/confidential information
6. Competent in computer literacy

Desirable criteria

1. NHS Experience
2. Experience within a governance related area (e.g risk management, incidents, complaints etc)
3. Medical terminology
4. Sensible initiative taker

Skills
Essential criteria

1. Excellent verbal, written and interpersonal communication skills
2. Ability to maintain and improve standards of care
3. Ability to interpret highly complex and sensitive data and present to all levels of staff
4. Excellent organisation skills
5. Able to work under pressure, manage constantly conflicting priorities and meet deadlines

Desirable criteria

1. Proficient computer skills
2. Knowledge of clinical audit/research methodology
3. Knowledge of statistical techniques

Knowledge
Essential criteria

1. Up to date governance theory and methodology
2. Up to date knowledge of the Datix risk management system
3. Up to date knowledge of root cause analysis /other investigation methodology

Desirable criteria

1. Experience of audit
2. Research
3. Understanding of resource management
4. Understanding of NHS policy and other key documents
5. Knowledge/experience of Quality Improvements techniques

Additional
Essential criteria

1. Flexible and positive approach to work
2. Personal and Professional integrity
3. Digression within the role and team
4. Works well within a team

Desirable criteria

1. Attention to detail
2. Requirement to work to policy and procedure