Band 7 Assistant Clinical Governance Manager

Detailed job description and main responsibilities

Governance and Performance

1. In conjunction with Heads of Service and identified Leads and Champions, support the implementation of the division’s governance work programme in line with the integrated business plan and Clinical Strategy.
2. Embed and monitor outcomes and standards relating to CSE, CQC and NHSLA in clinical services ensuring that Leads, where identified, are involved on an ongoing basis.
3. Support the clinical services to identify and collect information on aspects of practice to evidence compliance, for example, areas of good practice, audit and innovation.
4. Liaise with appropriate clinicians, and support them where necessary, to ensure that requests for information regarding clinical governance are returned within agreed timeframes for assurance purposes.
5. Undertake impact assessments for new business and clinical processes to ensure that clinical governance gaps have been identified, assessed and escalated if appropriate.
6. Support services in the Division to develop local clinical governance reporting structures at team level.
7. Participate in CRES projects to ensure clinical risks associated with plans are identified and discussed feeding back to the divisional Clinical Forum for discussion and clinical assurance.
8. Work with Operational Managers, Clinical/Professional Leads and the Patient Experience Lead to develop information on clinical services which is current and ensures Children and Families are able to access information as and when required.

Risk Management

9. Take lead responsibility for monitoring processes relating to incidents and complaints to ensure that agreed timescales are adhered to, action plans developed and followed up.
10. Collate and analyse data from the Risk Management System (Datix) as required for performance monitoring, audit and to support service reviews.
11. Co-ordinate a programme of audit related to the risk agenda, ensuring compliance with statutory duties, quality and principles of Governance and patient safety.
12. Develop an audit methodology to provide assurance that actions from closed serious incidents have been implemented.
13. Ensure that information from Datix is used to inform clinical audits and notify possible risks to the Clinical Governance Manager to ensure appropriate escalation.
14. Take the lead role, as required, on disciplinary investigations and RCA’s.
15. Support staff with investigations arising from incidents including information gathering, ensuring actions from recommendations are monitored where appropriate and lessons learnt cascaded to services.
16. Ensure there is a system in place to ensure risk assessments are undertaken and any action arising is implemented and monitored.
17. Co-ordinate an ongoing risk assessment work plan to ensure risk assessments are within timescales for updates.
18. Co-ordinate and prepare reports for divisional and corporate committees and inspections by external regulators and internal auditors as required.
19. Identify and analyse trends from incidents for discussion at Divisional, Service and Team meetings in order to agree actions and implementation plans.
20. Disseminate alerts and follow up responses as appropriate ensuring timescales are adhered to. Support clinical services with identification of equipment and processes which may pertain to alerts.
21. Maintain close links and foster good working relationships with services within the division and corporate departments as appropriate.

Clinical Audit and Effectiveness

22. Work with clinicians to ensure a programme of clinical audit activity is undertaken across the Division through the annual planning process. Maintain an overview of the Trust forward audit plan.
23. Take lead responsibility for the development, review and monitoring of the Division’s Forward Audit Plan.
24. Support the Divisional Clinical Effectiveness and NICE Leads in monitoring the implementation of actions arising from Audits and NICE Guidelines.
25. Support the Clinical Effectiveness Lead with co-ordinating the Clinical Effectiveness meetings, plan and ensure distribution of agenda and meeting papers and taking of minutes.
26. Support the development of annual clinical audit and effectiveness report.
27. Attend meetings and represent the Division as directed by the Clinical Governance Manager which will include: Risk Management, Operational Development meeting, Corporate Clinical Effectiveness Committee, Infection Control Committee and Essence of Care.

Management and Leadership Responsibilities .

1. Have an understanding of the national perspective and future strategy for the NHS and related areas of health to ensure that staff in your team/s are fully aware of the implications and can contribute effectively to service improvement.
2. Develop and empower all members of your team to perform to high standards and innovate.
3. Ensure supportive staff management arrangements are in place and carry out appraisals/personal development reviews (PDR’s) for direct reports. Ensure all staff in your team/s have annual PDR’s resulting in specific objectives and effective personal development plans
4. Develop staff knowledge and skills to promote equality and diversity and address inequalities both in employment and service delivery. Ensure specific equality objective are included in PDR’s.
5. Develop a working culture that ensures Health and Wellbeing and promotes a ‘Great Place to Work’ and Learning for staff.