Clinical Governance and Risk Practitioner, SUWON

This is a post within a small team, working within the Surgery, Women's & Oncology divisional management structure, focusing on delivering all aspects of quality assurance and clinical governance, through the maintenance of robust systems and processes within the directorates, to underpin safe clinical practice. This role encompasses patient safety, risk management, clinical audit and clinical effectiveness., The post holder will: 1. Work with Lead CGRP and team to develop and deliver the full governance agenda. 2. Assist named Directorate Management Teams in developing and delivering the full governance agenda, required to monitor the quality of clinical services delivered in the Division. 3. Contribute to the development of information resources pertinent to specific elements of clinical governance as a resource for the Division, which underpin robust assurance and service development. 4. Assist the Lead CGRP in preparing reports to monitor and enhance the Division's approach to the management of clinical quality, and to enable the Division to provide robust assurance to the Trust (for example, through monthly reports to the Clinical Governance Committee and other ad hoc work). 5. Ensure that decisions taken by the Clinical Governance Committee, Clinical Improvement Committee, and Patient Safety and Effectiveness Committee are communicated and implemented within the Division. Monitor and review any changes implemented as part of the divisional clinical governance action plan., 1. Support the management of incident reporting systems within the services - proactively managing the contribution of this system to the Division. 2. Lead the coordination of responses to Serious Incidents Requiring Investigation (SIRIs), divisional level and local investigations within the Division, in association with the Divisional Nurse and the Trust Clinical Governance Teams. 3. Maintain an appropriate and effective risk register, based on robust assessment, to ensure that risks are controlled and managed. 4. Assist the Divisional Nurse, matrons and sisters in defining local practice, which is compliant with the CQC outcome measures, by supporting the assurance database and collating credible evidence which demonstrates compliance. 5. Assist the Divisional Management Team in following up external inspections, developing action plans and verifying the completion of corrective actions as required, with associated evidence. 6. Assist in reporting and monitoring outcome measures/quality priorities to assess and develop the quality of services provided. 7. Assist in the effective dissemination and implementation of OUH policies. 8. Contribute to maintaining the divisional system for developing and maintaining policies, protocols and LocSSIPs. 9. Assist in supporting responses to patient experience feedback and ensure effective action planning to enhance the delivery of the service. 10. Support the divisional clinical audit strategy, underpinned by Trust and national priorities, horizon scanning for prospective reports, guidance or service developments to ensure compliance with relevant national standards in relation to clinical audit and effectiveness. 11. Work alongside the clinical audit leads within Directorates to develop and implement local audit programmes that include all mandatory audits identified by the Clinical Audit Manager and service developments and priorities. 12. Support the systems for registration and monitoring of audits, to accurately report on audit activity and progress against audit plans. 13. Work alongside the clinical governance leads within Directorates to develop and implement robust mortality review processes. 14. Support the investigation and responses to NICE guidance, Mortality and Morbidity data, Legal/Inquest reports and Dr Foster Intelligence. 15. Contribute to a programme of generic clinical governance training sessions in services on to multidisciplinary teams. 16. Develop and contribute to an induction programme for all new staff regarding clinical governance and relevant policies/practices.

• Educated to degree level, clinical professional qualification, or equivalent experience., Experience of delivering clinical governance, demonstrating evidence of achieving the integration and delivery of governance within a clinical service/ directorate and Division
• Experience of responsibility for managing e.g. CQC, Patient safety response framework, NICE, and national benchmarks.
• Experience of analysing problems and identifying solutions; and liaising with service leads to implement measurable improvements in patient care.
• Experience of managing incidents and clinical audits.
• Experience of writing and presenting formal reports at Trust-level committees. Including the ability to write reports for different audiences, clearly and succinctly communicating the most important issues.
• Experience of using Ulysses or comparable risk management software in a Governance role, or ability to learn new systems quickly.
Desirable criteria
• Experience of supervising or managing others.
• Experience of project design and management., Working knowledge of all of the principles of Clinical Governance in the NHS
• Working knowledge of current thinking on patient safety and the Patient Safety Incident Response approach to investigating incidents, human factors and the 'Just Culture' approach to learning.
• Knowledge of Data Protection, Freedom of Information and Caldicott principles
• Understanding of principles of assurance. For example, the importance of providing robust assurance in reports and presentations. Particularly, providing evidence of quality and identifying causes of issues and appropriate actions. Demonstration of the ability to learn this skill will be considered.
• Understanding of NHS structures and processes including commissioning and regulation bodies.
Desirable criteria
• Working knowledge of Care Quality Commission (CQC) standards and application to the service, directorate and division., Ability to adapt communication style to communicate with internal and external professionals and patients/their families.
• Ability to build good working relationships with staff of all levels and disciplines.
• Ability to challenge in a tactful and constructive manner, to hold individuals to account in difficult circumstances.
• Ability to adapt to the changing needs and priorities of the service, Directorate, Division, and Trust.
• Ability to assimilate guidance from various sources to advise services on ad-hoc enquiries, using judgement in applying the guidance in specific circumstances.
• Ability to interpret complex information to identify and inform effective action; communicating important messages in a persuasive and motivational way; relating the importance of action to the impact on patient care.
• Methodical and enquiring approach, with excellent attention to detail.
• Organised and systematic with the ability to manage a demanding work schedule, prioritising and completing tasks to deadlines.
Desirable criteria
• Strong quantitative data analysis skills, including presentation of data in appropriate formats, cleaning and validating data, and an understanding of the limitations of data sources., Diligent and takes responsibility for own work area.
• Willingness to work flexibly as part of a team, supporting others to deliver our shared aim of providing high quality patient care.
• Computer literate, with good working knowledge of databases and Microsoft Office applications.
• Compassion for patients and staff, and enthusiasm for supporting services to deliver excellent patient care.
• Full understanding of processes of quality improvement methodology standard setting, assessment and assurance within the NHS
• Ability to reflect on situations, take constructive feedback on board, and motivation to continuously learn and improve.
• Polite, positive, and professional attitude
• Calm under pressure
  
  Oxford University Hospitals NHS Foundation Trust is one of the largest NHS teaching trusts in the country. It provides a wide range of general and specialist clinical services and is a base for medical education, training and research.
The Trust comprises of four hospitals - the John Radcliffe Hospital, Churchill Hospital and Nuffield Orthopaedic Centre in Headington and the Horton General Hospital in Banbury. Our values, standards and behaviours define the quality of clinical care we offer and the professional relationships we make with our patients, colleagues and the wider community. We call this Delivering Compassionate Excellence and its focus is on our values of compassion, respect, learning, delivery, improvement and excellence. These values put patients at the heart of what we do and underpin the quality healthcare we would like for ourselves or a member of our family. Watch how we set out to deliver compassionate excellence via the OUH YouTube channel., Oxford University Hospitals NHS Foundation Trust is one of the largest NHS teaching trusts in the country. It provides a wide range of general and specialist clinical services and is a base for medical education, training and research. The Trust comprises four hospitals - the John Radcliffe Hospital, Churchill Hospital and Nuffield Orthopaedic Centre in Headington and the Horton General Hospital in Banbury. Our values, standards and behaviours define the quality of clinical care we offer and the professional relationships we make with our patients, colleagues and the wider community. We call this Delivering Compassionate Excellence and its focus is on our values of compassion, respect, learning, delivery, improvement and excellence. These values put patients at the heart of what we do and underpin the quality healthcare we would like for ourselves or a member of our family. Watch how we set out to deliver compassionate excellence via the OUH YouTube channel.