Integrated Clinical Governance Manager

Clinical Governance 1. Assess, monitor and review performance to ensure full compliance with the CQC/HIS/HIW National Minimum Standards. Together with the DOCS, lead the preparation for inspection or assessment visits from the CQC/HIS/HIW and other relevant regulatory bodies and work closely with the DOCS in leading the accurate and timely reporting process to the CQC/HIS/HIW. 2. Attendance at the suite of Governance meetings providing associated Clinical Governance update report (as required) including Medical Advisory Committee; Clinical Governance Committee; Clinical Audit and Effectiveness Committee; Health & Safety/Risk Committee; local associated committees (infection, prevention and control; blood transfusion; pain management; decontamination), chairing as appropriate or delegated. 3. Support the efficient co-ordination of the Clinical Governance Committee to ensure it functions effectively, according to an annual plan and in line with Spire Healthcare policy. 4. In collaboration with the DOCS, review and update relevant strategies, policies and procedures including the Clinical Governance Strategy. 5. Proactively manage the Datix incident reporting system, ensuring all incidents are investigated in a timely manner and the lessons learnt are shared with all relevant teams and team members. 6. Act as an exemplary role model in quality improvement offering advice and support to others, whilst ensuring continuous governance compliance throughout the hospital. 7. Responsible for effective dissemination and central reporting of all issued alerts and collation of actions required. 8. Review current national regulation and guidance (as issued) to ensure all hospital activity and policies are compliant. 9. Share examples of best practice with colleagues across the Spire Group. Medical Governance 1. Escalation of concerns related to specify Consultant document provision, if delays occur, to the Hospital Director. 2. Collate documentation consultant biennial review programme; including complaints and incident reporting. 3. Support DOCS in ensuring all mandatory requirements relating to introduction of new procedures are met in readiness for MAC approval 4. To review hospital PROMs results and escalate outliers for review to the Clinical Governance committee. 5. To review Consultant Intervention Ratio results and escalate outliers for review to the Clniical Governance committee. 6. Meet with MAC chair, Hospital Director and DOCS to discuss any concerns relating to medical governance/Consultant practice including incidents, complaints, mandatory documentation, behaviour concerns, soft intelligence from within the hospital and wider healthcare community. Clinical Leadership 1. To work closely with all clinical departments promoting patient focused quality care. 2. Be a point of contact for the SMT, clinical and non-clinical staff. 3. To act as an exemplary role model, and ensure evidence based practice is undertaken within all clinical teams taking every opportunity to promote innovative practice. 4. Lead, support and empower staff to realise their full potential. Risk Management 1. Manage and co-ordinate clinical and non-clinical risk activities ensuring compliance with relevant regulatory bodies. 2. Ensure appropriate reporting, investigation and management of incidents is undertaken in accordance with requirements of CQC/HIS/HIW and HSE. Develop and devise procedures as necessary. 3. Co-ordinate the dissemination, integration and implementation of corporate and local policies and procedures. Work with colleagues to develop appropriate policies where appropriate, and ensure they are reviewed within the required time frames. 4. Adopting a multi-disciplinary approach, in conjunction with colleagues, work to develop an organisational culture which encourages professionals to review practice, report untoward incidents and share lessons learnt without fear of recrimination or censure. Patients and Customers 1. Ensure that the views of patients and customers are used to guide and inform the provision of services through patient forums, engagement with patient representative groups, dissemination of feedback form questionnaires, complaints etc. 2. To ensure that results from patient satisfaction surveys are analysed and acted upon through the Clinical Governance committee. 3. To ensure lessons and trends from patient complaints are reviewed, discussed, analysed and acted upon via the Clinical Governance Committee. 4. Ensure that relevant and appropriate information, advice and support is available to all service users and stakeholders. Health & Safety 1. Be an active member and contribute to the smooth running of the Health & Safety Committee ensuring appropriate information and reports are available as required. Audit 1. Work closely with the DOCS to ensure that clinical audit activity is in line with both the annual corporate and local plan, prioritising audits against key performance indicators. 2. Ensure that the local annual audit plan is devised and delivered and actions and outcomes are delivered and where appropriate monitored through a robust action plan. 3. Oversee audit activity to ensure compliance within the clinical departments throughout the Hospital. 4. Engage with National Audit Programmes and ensure timely submission of data as relevant to hospital practices.