Job responsibilities

As a Governance Manager you will be working as part of the Clinical & Quality team and your role is very important in providing assurance that our services are compliant, safe and delivering high quality care to our patients. You will lead and be responsible for clinical governance processes within PHL and as an experienced clinical leader ensuring your leadership style is always delivered in line with our values truly caring and team first approach.

You will work closely with the services leadership teams to ensure compliance with robust governance processes such as incident reporting, risk and complaints management that assures us of the responsiveness of our services. You will promote shared learning and quality initiatives, facilitate that these are embedded and sustained demonstrating a well led organisation. You will foster close working relationships to enable supporting a positive safety culture within the organisation, working collaboratively with our healthcare professionals and relevant external organisations to proactively manage governance, quality and safety. You will provide assistance, support and advice to our people, patients, and their families within our Governance framework in partnership with relevant operational and clinical managers.

Leadership and Management

To be a visible, accessible and approachable leader within the Clinical & Quality Team in order to support, motivate and inspire. Work collaboratively with operational and clinical teams and other directorates.

Provide support to clinical staff in tackling and resolving complex problems.

Ensure effective communication with all staff within PHL ensuring governance and patient safety culture is embedded within the organisation.

Line manage the Quality & Governance Facilitators

Clinical Governance, Compliance and Assurance

Ensure up to date knowledge is maintained for all areas of the clinical governance framework, including key legislative, regulatory and professional frameworks.

Assist the Director of Nursing and Quality in reviewing and monitoring the key strategic objectives and risk profile related to quality and safety, which are aligned to PHL priorities for quality improvement.

Ensure any safety alerts and national guidance is implemented in a timely and appropriate way, ie CQC standards, NHS England policies, CAS alerts and NICE guidelines.

Provide patient safety and governance reports for each service, relevant committees and forums, collating key quality indicators to support assurance mechanisms to demonstrate compliance with key standards and to escalate and action where improvements need to be made.

Working with the Patient Safety Specialist, service managers, clinical managers & leads, support with investigations into patient safety incidents and potential litigation claims, ensuring they are appropriately investigated and responded to in accordance with PHL policy, learning is cascaded and embedded.

Support delivery of local and national patient safety frameworks by ensuring that staff involved in incidents are supported, debriefed and offered individual feedback.

Support service managers, clinical managers and clinical leads when meeting with patients and their families and any external agencies affected by adverse incidents.

Actively support and promote a transparent learning culture just culture.

Provide feedback to staff, through various methods; newsletters, presentations and one to ones.

Working with the Service Managers and Senior Management Team ensure that the Risk Management Strategy is effectively conveyed to all staff and is translated into operational practice.

Support Senior Leadership Team and Services leaders to ensure the maintaining of the risk register accurately reflects risks and is up to date.

Provide leadership and expert advice regarding clinical risk management within PHL.

Develop appropriate action plans to minimise risks, including identifying resource implications, changes in clinical practice and administrative procedures required.

Support the Audit and Compliance team in ensuring that the programme of clinical audit reflects key areas of safety and quality identified from patient safety investigations, incident trends, NICE guidance and recommendations from compliance inspections.

Support the Patient Safety Specialist in the implementation and monitoring of key safety and quality initiatives such as Safety Thermometer, safety huddles etc.

Coordinate within PHL systems for receiving, monitoring and preparing responses for compliance with national guidance and policy received from for example: NHS England, the National Institute for Clinical Excellence, HSSIB and the CQC (not an exhaustive list).

Provide advice to clinicians and managers within PHL to ensure that compliance with key legislation and other regulations affecting healthcare are understood and embedded.

Support the complaints team and services leadership team to ensure that complaints are appropriately investigated, responded to and that learning is embedded using datix for recording and monitoring

Ensure that there is aggregate analysis undertaken of patient safety, effectiveness and patient experience data e.g. incidents, complaints, clinical audit, to ensure sharing of best practice and that issues are escalated for improvement appropriately.

Work closely with the Patient Experience team to ensure continuous improvement and learning from all forms of patient feedback including direct feedback, survey feedback and friends and family offering clinical oversight

• Research, write and embed all Clinical and Governance policies and procedures across the organisation
• Chair a delegated sub committee group
• Support the delivery of all governance meetings for each service

Ensure that the quality management system conforms to the requirements of ISO 9001

Ensure that the quality processes are delivering their intended outputs

Ensure reporting on the performance of the quality management system and on opportunities for improvement, in particular to the board

Ensure that the integrity of the quality management system is maintained when changes to the quality management system are planned and implemented.

Corporate Governance

To be fully aware of and committed to all policies, procedures and initiatives relating to Information Governance this will include, but is not limited to: data quality improvements, confidentiality and information security.

Experience

Essential

• Experience of working within clinical
• governance and compliance role in
• healthcare (ideally 3 years experience)
• An experienced (minimum 5 years)
• Nurse, Paramedic, Pharmacist or Allied
• Health Professional with current
• professional registration
• Experience of developing and
• implementing effective governance
• procedures and policies.
• Experience of coordinating risk
• management processes and risks
• reporting
• Experience and understanding of
• Information Governance (Data
• Protection)
• Demonstrated experience of
• developing and maintaining strong
• working relationships with senior
• managers.
• Proven track record of
• developing/implementing policies,
• procedures, and processes.
• Experience of successfully operating in
• a sensitive and confidential
• environment with diverse stakeholder
• input.
• Experience of drafting and presenting
• briefing papers for meetings,
• Significant experience of taking
• information from several sources in
• analysing and providing evidence to
• support governance, assurance and
• compliance and detailing robust recommendations to support
• improvement and development.
• Proven change management skills
• Knowledge and experience of serious
• incident investigations report writing
• and PSIRF
• Knowledge of dealing and responding
• to patient complaints

Desirable

• Educated to degree level or equivalent
• experience.
• Membership of Chartered Governance
• Institute (desirable)
• Evidence of leading and managing
• teams training to deliver work
• programmes and high performing
• teams
• Evidence of continuing professional
• development, with a particular focus on
• Clinical Governance, Compliance and
• Risk Management

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).