Main Duties and Responsibilities
Supports and develops a culture of informed questioning, trend analysis, and assurance to ensure lessons are learned and the hospital changes practice in a way which has a positive effect on patient outcomes and patient experience.
Demonstrates a high level of professional leadership and within clinical areas develops a culture to ensure that all staff actively contributes to the development of a Quality Strategy.
Actively promotes modernisation and new ways of working activity across the hospital while ensuring professionals contribute to and influence business and service planning developments.
Represents a key function of the Hospital Management Team by leading and co-ordinating quality and risk management throughout the hospital, ensuring delivery of best practice and quality of care at all times.
Collaborates with the Group Director of Quality and Patient Safety informing of any significant development within the area of responsibility in a timely manner.
Works closely with the Clinical Director, Director of Nursing, and Clinical Leads to ensure that lessons learned from incidents, risk assessments, risk investigations and complaints are disseminated to the wider team, and where appropriate share across the whole hospital.
Deliver strong professional leadership with the highest level of interpersonal and communication skills to enable and empower the Quality and Risk team.
Work in collaboration with the Hospital Manager and Management Team to develop best practice in the delivery of the strategic plans ensuring patient safety, quality of care and patient experience are of the highest possible standard hospital wide.
Provide progressive solutions to operational issues, which take into account models of best practice and are incorporated into business and clinical plans.
Actively contributes to the performance management and monitoring of quality standards across services, taking corrective action where necessary to ensure that objectives and targets are achieved and that all performance monitoring requirements are achieved.
Oversees the further development and sustainability of a system of key performance indicators/measures for monitoring against standards for quality governance and patient safety.
Contribute to the strategic planning, operational management and commercial viability of the Hospital.
In collaboration with all staff, develop and sustain a culture of patient safety and quality, where all staff is aware of their responsibilities and accountabilities.
Establishes good working relationships and networks effectively with external organisations and individuals to keep up to date with best practice standards.
Participates in internal initiatives with a view to ensuring that the Hospital Safety Plans and Safety Statements are regularly reviewed and evaluated to ensure compliance with and aligned to new legislation, new standards, new equipment etc.
Effectively lead the Quality and Risk team towards achieving service goals and objectives.
Assume responsibility for one’s own learning and development needs with evidence of commitment to on-going professional development.
Quality Improvement & Quality Assurance
Provide an overarching view of all clinical governance and quality indicators including complaints, incidents, nursing quality indicators, audit results and patient feedback. Uses this information to identify any emergent themes and lead on action to remedy as required.
Identify areas for continuous improvement related to patient care, based on an aggregate of data from audits, incidents, complaints, monitors and feedback.
Ensure that there is a system for learning from incidents and near misses so that these can be shared across the organisation, with relevant analysis and innovative improvement plans.
Facilitate and support clinical audit, collection of quality related data from a range of sources (incidents, indicators, patient trackers, complaints, outcomes, surveys) and evaluation of clinical outcomes within departments.
Develop and co-ordinate systems and processes which proactively collect quality/patient safety performance, patient feedback and patient views.
Support the effective functioning of the established clinical governance model, with leadership and direction to committees, teams and groups.
Collect and analyse the information in response to performance indicators and ensure processes are in place to evaluate performance against relevant indicators. The information may then be used at different levels of the organisation – senior management, quality committee and staff.
Participate in a BSHS quality indicator programme, which is aligned to JCI accreditation standards.
Support the development of KPI’s based on the Annual Quality Improvement Plan.
Foster and develop a culture within the organisation that strives for excellence in the delivery of patient care.
Lead the hospital accreditation survey process, lead on maintaining JCI accreditation, and supporting achievement of other relevant quality standards as appropriate e.g. INAB, JAG. Assures hospital compliance with regulations and standards using regular audits, surveys, and centralised tracking.
Act as a source of knowledge and advice for senior staff on current developments in accreditation and quality both nationally and internationally.
Aim to ensure that the Hospital consistently strives to maintain and improve on Joint Commission International (JCI) standards.
Develop a rolling action plan and aim to ensure actions are achieved to specified deadlines.
Assist in the development and implementation of policies, procedures and guidelines to support best practices and JCI accreditation.
Support the development of an effective, compliant and integrated system that covers all aspects of clinical risk and is integral to all the business processes of the organisation,
Lead and co-ordinate the development and management of the hospital’s risk management and quality management programme and for ensuring that there is a robust risk management system in place which appropriately assesses and mitigates organisational risks.
Work with the clinical areas/departments and clinical governance staff to escalate clinical risks through the management structure for consideration of entry onto the corporate risk register.
Maintain responsibility for implementing, coordinating and monitoring risk management programs including risk detection, assessment and prevention.
Champion a culture of safety through the development of a high reliability organisation and continuous improvement.
Provide regular reports on adverse events, monitoring trends and working with others to identify and implement targeted improvements.
Provide expertise on the investigation of serious reportable or sentinel events, using multiple methodologies including root-cause analysis, systems analysis and clinical peer review.
Actively manage and investigate patient complaints within the Hospital.
Work with our Group Insurance Advisor to reduce risks and aim to ensure compliance with insurance coverage.
Actively engage with our Legal Advisors in the timely management of medico-legal claims.
In the course of your employment, you may have access to or hear information concerning the medical or personal affairs of patients and/or staff, or other health services business. Such records and information are strictly confidential and unless acting on the instructions of an authorised officer, on no account must information concerning staff, patient or other health service business be divulged or discussed except in the performance of normal duty. In addition, records must never be left in such a manner that unauthorised persons can obtain access to them and must be kept in safe custody when no longer required.
This job description is subject to periodic revision following discussion with the post holder. This job description is subject to change in order to meet future developments at Bon Secours Hospital Dublin and may include any other duties and responsibilities as determined by the Line Manager.
Policies and Procedures
The duties and responsibilities of this post will be undertaken in accordance with the policies, procedures and practices of the Bon Secours Hospital Dublin, which may be amended from time to time.
Hours of Work
The person appointed will work 37 hours per week. You will be required to work the agreed roster as advised to you by your Line Manager. Your contracted hours of work are liable to change between the hours of 8.00am to 8.00pm and flexibility in hours of attendance in response to service needs will be a requirement, including occasional weekends.
You will also be required to share the “Out of Hours” on-call rota with the Hospital Management Team.
|Qualifications||A Higher degree in a healthcare discipline||MSc Degree|
A minimum of 5 years management experience in healthcare
Have an effective track record of achievement in a large complex organisation in either the private or public sector
Previous experience / knowledge if JCI Quality Accreditation system or similar
Have experience if working and delivering results through cross divisional working at managerial level
|Skills, Competencies and / or knowledge||
Leadership & Direction
Managing and Delivering Results:
Influencing to achieve:
Personal Commitment and Motivation
All posts in the Bon Secours Hospital require a high level of flexibility to ensure the delivery of an effective and efficient service. Therefore, the post holder will be required to demonstrate flexibility as and when required by their manager or hospital management.