Job Opportunity Clinical

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1 Job Opportunity Clinical Head of Governance Permanent Opportunity 45,000 to 50,000 per annum Your innovative approach to risk matches our ground-breaking approach to care The role This unique clinical governance role offers scope for professionals from a variety of disciplines who want to be part of a world-class specialist hospital and work in compliance and risk. This is an exciting opportunity for anyone with experience in audit, governance, risk compliance and data control. At the Royal Hospital for Neuro-disability, we don t just treat people with profound disabilities, we care for them as individuals through highly personalised care plans. As our Head of Governance, you ll face the challenge of creating a positive yet flexible safety culture, along with the outstanding communication and training systems needed to support it. An expert advisor to the hospital, you ll integrate the reduction and management of risk into our everyday operation. This broad-ranging role includes responsibility for compliance with statutory health and safety and CQC requirements as well as MHRA and NPSA alerts. Reporting to the Director of Nursing & Governance, you ll assist in the management of serious incidents, complaints and claims and have line responsibility for nurses specialising in infection control, tissue viability and continence. Acting as data controller and managing our compliance to the Data Protection Act will also be a key challenge. The person A qualified healthcare professional, with a senior-level background, you ll have a substantial trackrecord in management. Your experience could be in audit, risk or practice development, but you will have a thorough knowledge of internal compliance, risk management and experience of data control. As you will work with managers and staff across the organisation, exceptional communication and relationship-building skills are essential. About us The Royal Hospital for Neuro-disability is respected worldwide as an authority on neuro-disability care, influencing policy makers, medical professionals and commissioners. Balancing traditional practice with specialist therapies and life-changing technologies, our work makes that vital difference to the lives of profoundly disabled adults with acquired brain injuries and degenerative neurological conditions such as Huntington s disease. Our ground-breaking approach was recently featured on BBC s Panorama which followed brain-injured patients with disorders of consciousness. To apply for the post, please your CV to Closing date: Friday 28 December 2012

2 ROYAL HOSPITAL FOR NEURO-DISABILITY JOB DESCRIPTION POST: GRADE: Head of Governance Annual Review RESPONSIBLE TO: Director of Nursing & Clinical Governance LINE MANAGEMENT RESPONSIBILITY FOR: Risk Manager and Specialist Nurses KEY RELATIONSHIPS: Requires a close working relationship with all managers and staff across the organisation. Role Summary The Head of Governance is the Hospital s expert advisor on risk management ensuring compliance with legislative requirements, national and local policy, responsible for ensuring that risk management is embedded throughout the organisation by providing support, advice and guidance on all aspects of risk management. The Head of Governance is the Hospitals lead for the development and implementation of the Hospitals Risk Management Strategy, and as such will advocate and sponsor risk control and prevention strategies that integrate risk management consideration into everyday management. Risk Management Overview 1. Be responsible for the development of the Hospital s strategic plans for the reduction and management of risk across all elements of its services. 2. Implement, continuously review and develop the Risk Management Strategy and supporting documents, ensuring its communication to staff, the public and stakeholders, organising awareness training as necessary. 3. Establish and maintain effective communications systems so that information can be shared and effective problem solving processes are implemented, ensuring there are good communication systems between the Risk Management team, the organisation and stakeholders. 4. Be responsible for the overall development of a positive safety culture across the RHN. 5. Design and implement local solutions relating to risk management recommendations from the NPSA, the Care Quality Commission, and other external sources.

3 6. Maintain the implementation of the patient safety and risk management related training programme for all levels of staff. Work with the Governance and Development Team in the delivery of the programme. 7. Lead on providing support to the Risk Management and audit Committees. 8. Act as the data controller for the hospital managing access to medical records requests ensuring compliance to DPA. 9. Review and develop policies and procedures in relation to appropriate legislation which includes but not limited to H&S, DPA, MCA, Fire, Risk, Safeguarding. 10. Review and maintain the hospital policy index. Compliance 1. Be responsible for ensuring that the RHN complies with its statutory health and safety requirements, advising on new legislation and directly managing the Health and Safety team. 2. Act as the NHS nominated lead for the Central Alert System (CAS), including MRHA and NPSA alerts acting as a central point for all incoming alerts, including non-clinical alerts, i.e. estates, and ensuring appropriate distribution and records are developed and maintained in line with national requirements 3. Ensure that there are adequate systems in place to monitor compliance with legislation and regulation relating to risk. 4. Effectively manage the use of the Datix from ensuring timely upload of incident data to the effective use of the output data. Incident Management and Reporting 1. Be the lead for the Incident Policy, setting up systems and liaising with the Head of Departments with regard to the identification of potential complaints and claims. 2. Lead on the internal management of Serious Incidents, supporting Investigating Officers and Serious Incidents Investigation teams and monitor implementing of recommendations. 3. Ensuring that Serious Incidents reports are submitted to funders on time. 4. Review, scrutinise and quality check all Serious Incident reports prior to final publication. 5. Oversee and develop the RHN s incident reporting system ensuring also that meaningful data is available to support the Executive team and the corporate reduction of risk.

4 6. Ensuring learning from incidents occurs and is shared across the organisation. 7. Analyse incident submissions and provide feedback and support to Heads of Department and Executive Team in order to improve the overall quality of and approach to incident reporting. 8. Provide monthly reports to the appropriate directors of all incident and near misses. 9. Provide a bimonthly report of the hospital governance statistics to the DON/CG. Risk Management Legal Services 1. Ensure that claims are managed effectively in a timely fashion. 2. Ensure the highest standard of communication and professional contact with the legal advisors, insurers and any other appropriate external agencies. Risk Registers 1. Ensure maintenance of the RHN s Risk Register. 2. Liaise with staff across the RHN to ensure the timely compilation, production and maintenance of risk assessments utilising an appropriate range of sources and identifying relevant controls and assurance, ensuring that all identified risks are supported by a risk assessment. 3. Analyse risk register submissions and provide feedback and support to Heads of Department and Executive Team in order to improve the overall quality of and approach to risk register maintenance 4. Review and analyse risk register submissions and to ensure the onward reporting of all appropriate and relevant risks to the Risk Management Committee, Quality Assurance Committee, Audit Committee and Trust Board. Complaints Management 1. Ensure that the Royal Hospital s Complaints Procedure is understood and implemented throughout the organisation and ensures that it fosters a culture where complaints are seen as positive opportunities to learn from lessons and improve services. 2. Ensure that all complaints are logged and sent to relevant managers for investigation and response received within policy timeframes. Ensure all learning outcomes are updated on Datix system.

5 3. Ensure that a monthly update of complaints is available for the Complaints Review by Directors. 4. Corporate responsibilities for the co-ordination of complex complaints ensuring appropriate managers are aware of their responsibilities in addressing the complaints. Specialist Nurses (Infection Control, Tissue Viability, Continence Advisor) 1. Line management responsibility for the specialist nurses. 2. In conjunction with the specialist nurses help coordinate practice development activity within the RHN promoting a multidisciplinary approach. 3. Assist in ensuring that agreed standards are implemented. 4. Ensuring monthly reporting of infection control and tissue viability to DON/CG and external agencies. 5. Lead as required with specific practice development working groups. Human Resources 1. Support the Heads of Departments on the management of risk. In particular be their source of expert advice in incident and complaint investigation. 2. Ensure that staff in the Governance and Development Team are managed effectively, that they receive regular supervision and training/development, and are compliant with statutory and mandatory training 3. Ensure all direct reports have current objectives and a IPR that link to corporate goals and values Financial 1. Responsible for the management of the budgets for the service Education and Training/Self-Development 1. Identify own training and development needs and undertake appropriate training/education as required. 2. Participate in an annual individual performance review process where objectives will be agreed, performance monitored and personal development needs discussed. 3. To attend all statutory and mandatory training as and when required to do so.

6 4. Act responsibly in respect of colleague s health, safety and welfare following safe work practices and complying with the RHN s Health and Safety Policies. 5. Adhere to all Hospital Policies as applicable. This summary represents an outline of the major components of the job and is not intended to be exhaustive. It may with consultation be subject to additions and amendments from time to time as the need arises and therefore, in addition to the duties and responsibilities listed, the job holder is required to perform such other duties as might be reasonably be required.

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