Head of Quality, Risk & Accreditation

As a member of the executive team, this role is responsible for the successful delivery of a quality improvement and risk culture throughout the Blackrock Health Hermitage Clinic (BHHC). The Head of Quality, Risk & Accreditation is responsible for the awareness, facilitation of reporting and collation of data and information in relation to organisational risk management. As a key member of the senior management team, the Head of Quality, Risk & Accreditation will demonstrate strong influencing and relationship development skills and facilitate effective communication with colleagues in the hospital. The purpose of this role is to provide assurance that controls and procedures are operated in accordance with best practice and with the appropriate regulations, and to make recommendations for the improvement of such controls and procedures. The position requires a strategic approach to the implementation of quality and risk initiatives, embracing continuous quality improvement and the management of changes necessary to achieve organisational objectives.Job Background/ContextThe Head of Quality, Risk & Accreditation, is responsible for leading and managing the quality, safety & risk management programme within the BHHC. While the primary functions of this role are in relation to promoting patient safety and achieving and maintaining compliance with accreditation standards, the post holder is also responsible for actively promoting a culture of continuous quality improvement. This role provides leadership for JCI and HIQA Accreditation and inspections, safety assessments, educates other practitioners on the system-based causes for adverse incidents and medication errors, consults with management and staff and communicates literature-based ideas regarding effective patient safety strategies to others within the organization. Key Responsibilities Managing & Delivering Results (Operational Excellence)Identifies, assesses, manages and monitors risks within the organisationAchieves objectives in a timely, efficient and professional manner.Sets relevant performance achievement measures Implement and manage change and business processes redesignImprove efficiency within the working environment to evolve and adapt to a rapid changing environmentOperate successfully in a challenging operational environment while adhering to quality standardsTake personal responsibility to initiate activities and drive objectives through to a conclusionPrepare, provide and present a regular report on operational performance in respect of quality, risk and accreditation to Hospital Executive Continuous Quality ImprovementEnsure audits and data collection processes are established and implementedAnalyse and summarise performance improvement data and report on findings and outcomes to Hospital Executive team on a regular basisIdentify, promote, and co-ordinate agreed quality improvement initiativesDevelop, implement and monitor the project plan / quality improvement work-planDevelop and maintain a tracking system to ensure project milestones are metActively participate in the facilitation of Quality Improvement projects and act as a resource to Quality improvement developmentIdentify the costs benefits/implications for new initiatives/projectsCollaborate with areas of pre-existing quality improvement in the Hospital, such as nurse education, internal or clinical audit, existing medical teaching processes or continuing self -driven educational activities.Develop a network of contacts and links with all departments in the hospital, external Accreditation experts, Joint Commission International and other accreditation/quality bodies as requiredMaintain an awareness of current developments in Accreditation/Quality Improvement both nationally and internationally and advise the Executive Management team of opportunities for development and improvement.Facilitate the development of an awareness, within the Hospital, in which the continuous improvement of service excellence becomes a conscious priority for all staffStimulate and elicit information, feedback and ideas from staff and act as a conduit in the optimisation of quality awareness process.Develop strong team working within the service that enables staff to perform to their full potentialGuide the continued development and implementation of the Quality Report to the hospital Executive, Clinical Governance and Board by collaborating with senior management and frontline clinical staff to develop appropriate quality metrics and indicators to promote continuous improvement in the quality of patient care. Person Centred CareDevelop and promote a culture of person centred care throughout the hospitalMonitor compliance with Planetree certification programmeSupport managers in the development of patient centred initiatives within their department Data ValidationEnsure data is validated in compliance with JCI QPS standardsEnsure relevant departmental and service staff are appropriately trained for data collection and validation Clinical Governance and Risk ManagementContribute to the development and maintenance of a sound clinical governance and risk management framework that fosters a culture and system of ownership and accountability, whilst encouraging innovation and problem solving.Maintain a repository of organisational learning from safety incidents and risk management and disseminate learning to enable mitigation of future risk. Establish robust mechanisms for ensuring that, where learning is identified, the necessary changes are put in place and all corrective actions are closed out so to prevent recurrence.Develop a wider appreciation of the value of the systems approach in preventing, analysing and learning from errors.Develop and support delivery of uniform training for incident and risk management, to ensure consistent investigative processesEnsure this promotes the integration of clinical risk management, clinical audit, the management of under-performance and education and training.Promote patient involvement in clinical governance to bring a patient focused approach to clinical qualityMaintain and update the corporate risk Register and provide support guidance and leadership for departmental risk registersAttend and chair meetings throughout the organisation as appropriateAddress all complaints received.Manage Medico legal cases that arise. Including conducting any internal investigations that may be required and actively engaging with third parties acting on behalf of BHHC. Reporting and Management of IncidentsEnsure systems and records are in place to enable assessments and inspections to be successfully completed.Support the management of reporting of incidents, ensuring corrective & preventative actions are put in place and learning is shared throughout the organisation.Lead and input into the design of the structure and framework to support the quality improvement programme in order to maintain JCI accreditation, achieve additional quality certifications and ensure compliance with regulatory requirements. Data ProtectionDevelop a sound data protection framework that fosters a culture and system of ownership and accountability in compliance with GDPRPromote the integration of information governance throughout The Hospital to improve information handling activities, raise patient and service user confidence in the organisation as a provider of care.Increase employee awareness through training and development.Regularly review data protection compliance complianceImplement adequate arrangements for the management of informationSupport and guide operational managers regarding requirements.Update own training needs in relation to data protection Training and CommunicationDevelop, organise and facilitate training sessions on quality improvement, clinical governance and risk management, eg root cause analysisWork with clinical and operational leads to devise policies and procedures tosupport service delivery and staff development.Ensure that new initiatives and governance performance trends are communicated fully throughout the organisation.Communicate knowledge and expertise to other staff through the delivery of training and writing of articles for newslettersMake recommendations on training needs as appropriate People ManagementProvide management and leadership for Quality team and ensure an effective learning environment taking an active part in the delivery of services as appropriate.Promote an environment that is conducive to the development of best practice, enhances staff retention and promotes good industrial relations.Maintain a high level of staff morale, promoting good communication, team spirit and job satisfaction among members of the multidisciplinary team. Strive to ensure that staff are accountable, responsible and have authority to practice and manage within their roles.Play a role in the recruitment and selection of staff for the service.Ensure that all new staff in the Department receive an adequate orientation and induction programme, have a clear understanding of their duties, responsibilities and standards of performance at all times.Ensure that the team are effectively supported with annual reviews and the development of personal development plans.Comply with all HR system and policy requirements including recording of relevant data Learning and EducationTake personal responsibility for own professional development and keep up to date with evidence based practice and research.Provide professional and personal development opportunities for all staff working with the relevant Learning and Education specialists to develop an appropriate programme of learning and education based on a planned (individual, department and organisation) training needs assessment.Maintain accurate records of all study leave and education resources used. Develop and implement an enhanced staff competence assessment relevant to the Department. Facilitate study days and leave, in accordance with the BHHC Study Leave Policy and within budgeted allowances. Essential CriteriaKnowledge/ExperienceGraduate or registered healthcare professional qualificationExperience in quality / risk related roleKnowledge of national and international regulations and recognised best practice and how they impact on organisational performance.Understanding of policy framework within which our services are delivered.Demonstrable understanding of quality improvement benchmarking and implementing improvements in practice.Skills/ Competencies (as per BHHC Competency Framework)Leadership & ManagementCommitment to Quality & Risk ManagementResource ManagementTechnical & Professional ExpertiseCommunication & Interpersonal SkillsProblem Solving & Decision makingResults Driven & AccountableDriving InnovationDesirable SkillsKnowledge/ ExperienceExperience of JCI or other accreditation processExperience of HIQA regulations and standardsLean Methodology qualificationMaster’s DegreeSkills/ CompetenciesSenior Management expertise, particularly as it relates to quality and safety Blackrock Health Hermitage Clinic is an Equal Opportunities Employer