Quality Assurance Manager Middlemore Central

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1 POSITION DESCRIPTION Quality Assurance Manager Middlemore Central Date Produced/Reviewed: 25 th July 2014 Position Holder's Name: Position Holder's Signature:... Manager / Supervisor's Name: Manager / Supervisor's Signature: Date: XXXXX Approval Date: July 2014 Review Date:: July 2015 D R A F T / A P.P.R.O.V.E.D Position Title: Quality Assurance Manager MMC

2 PURPOSE OF THE POSITION This key organisational role is responsible for the ongoing management of the Certification process for Counties Manukau Health including the relationship management with Health Cert, Ministry of Health and the Dedicated Audit Agency. To lead and facilitate all certification and accreditation processes in the organisation. To develop and implement a self-assessment framework for ongoing assurance of compliance with the Health and Disability Standards / certification. To coordinate and undertake assurance audits at the direction of the Clinical Director, Patient Safety and Quality Assurance. To promote and support a culture of continuous quality improvement and innovation in line with Certification requirements. To provide a coordinated Whole of System approach to quality and Certification. Provide leadership to ensure robust processes for Certification. Take a lead role in ensuring that there is a system in place for updating policies, procedures, guidelines and protocols in line with Certification. To provide strategic leadership in the effective use and development of routine data, outcomes data, evaluation and audit results to achieve Certification. All hospitals, rest homes and those providers of Residential disability care that have 5 or more residents need to meet the Health and Disability Services Standards Service providers seeking Certification under the Health and Disability Services (Safety) Act 2001 will need to demonstrate that their service complies with all relevant approved standards. This is achieved, working with the Quality and Risk Managers through the monitoring and maintenance of an ongoing audit process that covers the standards that require to be met. This role is also responsible for the overall organisational coordination of the Health Round Table benchmarking data and has a supportive role in the coordination of the SMO credentialing process. Vision & Values Organisational Shared Vision Our DHB shared Vision is to work in partnership with our communities to improve the health status of all, with particular emphasis on Maaori and Pacific peoples and other communities with health disparities. We will do this by leading the development of an improved system of healthcare that is more accessible and better integrated. We will dedicate ourselves to serving our patients and communities by ensuring the delivery of both quality focussed and cost effective healthcare, at the right place, right time and right setting.

3 Organisational Values Partnership Care and Respect Professionalism Teamwork Innovation Responsibility Working alongside and encouraging others in health and related sectors to ensure a common focus on, and strategies for achieving health gain and independence for our population Treating people with respect and dignity, valuing individual and cultural differences and diversity We will act with integrity and embrace the highest ethical standards Achieving success by working together and valuing each other s skills and contributions Constantly seeking and striving for new ideas and solutions Using and developing our capabilities to achieve outstanding results and taking accountability for our individual and collective actions PLACE IN THE ORGANISATION Director of Hospital Services Manager, Middlemore Central Clinical Director Patient Safety and QA Middlemore Central Staff Quality Assurance Manager Middlemore Central Divisional Quality & Risk Managers NATURE AND SCOPE OF RESPONSIBILITIES Key Accountability Standards / Achievements Certification process Coordinate the Certification processes for the organisation. Development / review of audit tools as required. Audit, monitor and evaluate the process for Best Practice and instigate change where appropriate. Contribute to the development of Standards of practice, protocols and policies. Facilitates an organisational Certification process through audit and the implementation of Ensure that there is a framework through which CM Health services are accountable for

4 Key Accountability organisational quality initiatives. Standards / Achievements continuously improving the quality of their services and creating an environment in which excellence will flourish in order to meet Certification standards. Develop a calendar of ongoing audit activities that will meet the Health and Disability Services Standards 2008 and oversee the outcomes. Support the Quality and Risk Managers in the preparation and management of the Certification visits. Coordinate and manage the certification processes for CMH within expected and agreed timeframes using audits and auditing procedures and action plans to develop a culture of enquiry and continuous quality improvement aimed at improving quality of practice and service delivery to achieve Certification. Development/review of audit tools as required in collaboration with Division quality and risk personnel within agreed timeframes. Audit, monitor, report and evaluate the process for best practice, and instigate change where appropriate. Provide feedback to all staff through timely communication through the organisation and within the divisions by documenting /disseminating results of audits and assisting with the development of action plans as appropriate Contribute to the development and maintenance of standards of practice, protocols /policies for the wider organisation Work with Technical Experts / Assessors to obtain the necessary information that will determine the extent to which Standards and associated criteria have been filled. Participate in quality improvement methodologies and techniques and use them to improve the quality of care. Review and monitor the Final/Draft Certification reports for audit to Health and Disability Service Standards (NZS 8134:2008 and amendments) Work with the Division s Quality & Risk Managers to evaluate the Corrective Action report ( CAR) and to prepare the Corrective Action Plan ( CAP) within the designated time

5 Key Accountability Policies, Procedures and Guidelines Service planning and development Manage the Complaints & Incidents and Risk Management processes and reporting to ensure all time frames are met. Standards / Achievements frames. Ensure that the corrective action is instigated within set timeframes when the Corrective Audit Report and Corrective Action Plan are identified as not complying with the requirements of Health and Disability Service Standards (NZS 8134:2008 and amendments) Monitor the audit findings for the Certification/ Integrated Audits and ensure evidence of work completed meets the Health and Disability Service Standards (NZS 8134:2008 and amendments) Manage the monitoring of the Integrated Audit follow-up programme within the timeframes set out in the Certification Schedule and is ongoing. Verify compliance to the Health and Disability Service Standards (NZS 8134:2008 and amendments) within the timeframes set out in the Certification Schedule Maintain a register which ensures that all Policies, procedures and Guidelines are current, necessary and are adhered to. Manage Documentation Directory including all controlled documents, policy development and review and update policies, procedures, guidelines and protocols. Participate in service planning processes at both operational and strategic level from a quality perspective to achieve Certification. Promote an interdisciplinary approach to Certification. Work with the Quality and Risk Managers to ensure the implementation of consistent practice across the DHB. Report on evolving trends. Review organisational audit programme on an annual basis. Disseminate all learnings and findings organisationally. Ensure investigations and corrective action plans are undertaken appropriately and meet relevant

6 Key Accountability Standards / Achievements Standards and Agreements and best practice. Ensure that the monitoring and verification of work to address clinical complaint corrective actions meet the relevant Standards and Agreements and best practice. Provide expert clinical review, monitoring and verification for the complaint investigation process and Risk Management reporting process working with the divisional Quality and Risk Managers. Ensure that all risks are identified, named, managed and reported to senior forums as required. Health Round Table Benchmarking SMO Credentialling related to Certification Reporting and Presenting Coordinate the follow-up of Health Round Table benchmarking data and ensure organisational dissemination. Issues related to CMH performance are identified at HRT Webinar relative to measures ( incidents, complaints, certification findings, service dashboards etc) and are included in a plan of action to follow up Investigate, take issues / actions to relevant services, ensures follow-up and completion and then report back to CGG ( Clinical Governance Group) prior to the next 6 monthly report. Work with the services To develop and maintain an organisational calendar for SMO credentialing to ensure that timeframes meet requirements. To develop a 360 process that meets the Credentialling calendar To maintain a register of SMO credentialling SMO credentialing register is current and designated timeframes are met. Prepare a reporting schedule that meets organisation and service based requirements that are timely, accurate and relevant. Present and report at relevant meetings using professional presentations skills aimed at the audience.

7 Key Accountability Utilisation of Information Technology Personal/ Professional Development Standards / Achievements Remain conversant with applications for the role Ensure that Information Technology is used in a manner which supports continuous quality improvement principles. Maintain and update own knowledge related to continuous quality improvement and audit. Establish a personal development plan to ensure continuing professional development at the level commensurate with the role. HEALTH & SAFETY Recognises individual responsibility for workplace Health & Safety under the Health and Safety Act 1992 CULTURAL SAFETY Commitment to the principles of Treaty of Waitangi Honouring Cultural Diversity Management roles: Work with Occupational Health and safety to ensure that all audits are completed and meet Certification standard. Ensure a safe working environment and safe working practices Plan, lead, organise and control Health & Safety activities directed at preventing harm in the workplace, in consultation with employees and Health & Safety representatives for area Ensure that all accidents/incidents in the workplace are investigated, and that hazards are recognised and adequate controls put in place Non Management roles: Counties Manukau DHB Health and Safety policies are read and understood and relevant procedures applied to own work activities Workplace hazards are identified and reported including self-management of hazards where appropriate Can identify Health and Safety representative for area Respect, sensitivity, cultural awareness is evident in interpersonal relationships. Our cultural differences are acknowledged by respecting spiritual beliefs, cultural practices and lifestyle choices.

8 Key Accountability Standards / Achievements Utilise Information Technology Demonstrate ability to access and use available clinical information systems. Is conversant with applications required for specific discipline/role. For example, PIMS, Concerto, Outlook, etc. Maintains own professional development by attending relevant IT educational programmes. COMMUNICATION AND INTERPERSONAL SKILLS Will be required to interact on a regular basis with a range of CMDHB staff members including: Clinical Director, Patient Safety and Quality Assurance Quality and Risk Managers (Service Specific) Clinical Directors and Clinical Nurse Directors Clinical Director Clinical Nurse Director Clinical Heads General Managers Maori Cultural advisor Pacific Cultural Advisor Service Managers Team managers and Charge Nurses Professional Leaders Clinical Nurse Educators Other CMDHB employees as appropriate Externally there will be contact with: Health Quality and Safety Commission. Ministry of Health HealthCERT Situations may often call for tact, diplomacy and will require information to be handled in a discreet and sensitive manner. In conflict situations will be required to exercise sound judgement, negotiation and persuasiveness skills, toward facilitating a workable outcome.

9 PROBLEM COMPLEXITY Will be regularly challenged by a wide range of situations where clinical and auditing knowledge regarding compliance and verification to Health and Disability Sector Standards (NZS 8134:2008 and amendments) is required. There will be a requirement to be able to prioritise issues and negotiate time frames, while still providing a quality customer service. The range of problems will be diverse and require solutions customised to meet the circumstances of the client. Therefore opportunities will arise to provide innovative options to the client based on proven outcomes. There will be demands to meet deadlines, maintain accuracy and quality of information. Failure to do so could impact on the organisation in terms of provision of quality Age Related Residential Care for older people in compliance within the terms and conditions of Health and Disability Sector Standards (NZS 8134:2008 and amendments). Will refer to Manager, Middlemore Central for advice or second opinion. SCOPE FOR ACTION Is empowered to make decisions or recommendations relating to Related Audit process. Is encouraged to use initiative and problem solving skills to develop innovative approaches to issues. Discretion is required to be exercised in releasing confidential information to the appropriate parties. DIMENSION OF THE POSITION Will be responsible to the Manager, Middlemore Central for the achievement of agreed objectives and operates within the confines of Counties Manukau District Health Board. POSITIONS REPORTING Directly Manager, Middlemore Central Indirectly Clinical Director, Patient Safety and Quality Assurance.

10 PERSON SPECIFICATIONS Minimum Qualification Tertiary qualification relevant to Health Experience Five to seven years clinical experience in a health related field Can demonstrate the application of a number of standards and audit methods to achieve quality improvement and can demonstrate that changes have been made as a result of their use. Experience undertaking analysis of feedback, identification of themes and preparing improvement plans. Ability to work across a number of organisations and diverse consumer/ user groups A highly visible facilitator who can influence behaviour, motivate others and act as a role model for patients and whanau centred care across the organisation. Understanding of the implementation, establishment and management of change Preferred Post Graduate qualification or equivalent in relevant clinical area and/or Quality. Clinician with current Practicing Certificate NZ Standard 8084 Lead Health & Disability Auditor or equivalent Background in Quality improvement Experience in Certification process Credibility and strong relationships with senior clinical staff.

11 Skills/Knowledge/ Behaviour Experience in problem solving, priority setting and planning. Ability to manage own workload within timeframes Ability to write clear, comprehensive reports within the scope set by the DAA Handbook Ability to demonstrate sound evidence based practice when verifying work carried out to address remedial actions Customer / Quality focus Research skill Negotiation / conflict management skills Understanding of Quality Improvement methodologies Personal Qualities Committed to ongoing Quality Improvement in health. Well organised with a capacity to demonstrate strong clinical leadership Strong communication skills - written and verbal. Willingness to update skills and knowledge of the wider health Focus on fostering and maintaining positive relationships Communicates, disseminates and facilitates while keeping to set time frames. Evidenced interest and commitment to developing excellence in the health sector Evidenced commitment to updating skills and knowledge of the wider health sector

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