Band 7 - Divisional Governance Manager - North Middlesex in London

North Middlesex University Hospital

, one of London’s busiest acute hospitals, is seeking an experienced Divisional Governance Manager to join their committed and fast-paced team.

North Middlesex University Hospital is a major district general hospital in Edmonton, London.

Established from origins dating back to an 1842 workhouse, the site evolved through military hospital service in World War I to become a cornerstone of community healthcare, recently merging into the Royal Free London NHS Foundation Trust.

Job Summary

The post holder will be responsible for the co-ordination of a robust clinical quality, risk and governance framework within the Division, in order to support the divisional management and corporate risk team in the delivery of high quality and safe services.

The post holder will be responsible for liaising with clinical leads, matrons, clinical directors, service managers, clinical support services staff and corporate staff in order to deliver the Division’s governance agenda on behalf of the divisional leadership triumvirate.

The post holder will support the Divisional Directors and Divisional Head of Nursing in the quality and safety aspects of operational management within the Division.

The Department

Clinical Governance & Risk management is a key quality function which is led by the Medical Director.

The department is led by the Associate Director of Risk & Governance with support from the Head of Risk and Governance and the Legal Claims Officer.

These are new posts which will support the clinical divisions to embed sound clinical governance systems and processes to improve safety and learning across the organisation.

The post holder will be supported by a Governance Administrator (Band 5) and will be responsible for line management of the Governance Administrator.

Main Duties and Responsibilities

• The post holder will have the responsibility for critically analysing all incidents and communicating the outcomes/recommendations to the multidisciplinary team and facilitate and enable staff to be actively involved in the incident reporting and reviewing process and promoting an open and just culture
• Ensure the approach to Divisional risk management is in line with the organisation’s Risk Management Strategy in collaboration with the Clinicians, Service Managers and Head of Nursing to ensure that Clinical Governance requirements are met at all times.
• Triangulate risk identification, mitigation and closure with other available data
• To assist in the coordination of and preparation for CQC and other external inspections, including any ‘mock’ reviews liaising with key personnel.

Ensure the relevant regulations and standards are embedded in practice and evidenced in the delivery of care and services

• Be responsible for supporting the Divisions leads in collating that evidence to demonstrate compliance.

Work with relevant leads to develop action plans to develop areas identified within ‘mock’/real CQC as requiring improvement

• Ensure that the Division maintains accurate and timely Governance records, ensuring the maintenance of quality systems and processes in your own work and that of the governance team
• Work with the Head of Risk and Governance to ensure an effective SI pathway, ensuring investigators are supported in the SI investigation and a timely / high quality report is produced which is then shared with the family under the Duty of Candour
• To coordinate the processes for the investigation of all reported incidents (including SIs).

To ensure that any actions or all recommendations from SI investigations are implemented, in a timely way and that lessons are learned and sustained changes to care and practice made.

• Ensure evidence of actions taken is attached to Datix
• Ensure robust mechanisms are in place for regularly reviewing action plans, ensuring that evidence of completion is submitted to Datix once actions have been closed
• Ensure statutory Duty of Candour, transparency and openness in incident and SI management across the Division
• Work with the Head of Risk and Governance to undertake qualitative and quantitative analysis from governance activities, identify trends and highlight areas of good practice as well as concern, working with colleagues to agree actions that maintain standards and mitigate risk
• Act as an expert Datix User able to create records, design and run reports and support and train others in these skills and competencies
• Monitor Divisional performance against complaints, incident and SI management targets, escalating poor performance to the Divisional triumvirate team and Head of Risk & Governance where necessary
• Work with the Head of Risk & Governance to support implementation of compliance with NICE guidance across all Programmes
• Collate and report the Divisional position in relation to NICE guidance as required liaising with Clinical Directors, Senior Nurses and Service Managers to reflect evidence of appraisal, implementation and audit of guidance
• Provide reports to groups and committees as required in respect of trends and learning from complaints, incidents, audit, FFT and patient surveys
• Report Divisional data and information clearly, in the required format and at the agreed time
• To regularly report to and liaise with all staff to inform and educate on changes in practice to reflect current best practice developments within quality and patient safety, using persuasive skills to influence change in practice as required or necessary
• Provide support to the Morbidity and Mortality (M& M) processes within the division working with the departmental mortality leads.

Ensure the learning from the mortality reviews are disseminated widely across the Division and the trust

• Ensure divisional and specialty level governance is optimal and robust two way reporting appropriately to divisional management level, facilitating ward to board and back communications
• Support the development of a robust audit programme informed by quality and patient safety priorities and areas for improvement
• Support the delivery of audit programme in the division, prioritised as per the trust audit strategy
• Drive aggregate learning across the division, triangulating incidents, complaints, claims, audit, etc. to ensure quality and safety themes are being identified and communicated
• Ensure action plans from SIs, incidents, complaints and claims are implemented and learning is maximized
• Amend/update relevant policies and guidelines with support from central team
• Provide regular governance reports to Divisional Governance meetings and Trust committees
• This post is subject to the terms and conditions of employment of The North Middlesex University Hospital NHS Trust.
• To undertake any other duties commensurate with the grade and in line with the requirements of this post in negotiation with the Medical Director.
• All employees are expected to uphold and adhere to the Trust’s Corporate Values at all times

Requirements

• Degree in relevant subject or relevant experience
• Relevant postgraduate development Exceptional organisational & interpersonal skills
• Demonstrable ability to communicate at all levels and across organisational boundaries
• Excellent IT skills, including Excel
• Ability to work under pressure and within set timescales
• Adaptable to meet changing environments and goals
• Ability to write and present clear, concise and relevant reports to various audiences
• Ability to absorb and interpret new information quickly
• Understanding of Risk Management Processes
• Experience of assessing quality and risk
• Robust understanding of clinical governance processes
• Knowledge and experience of quality assurance
• Significant NHS experience
• Knowledge of CQC requirements
• Flexible & adaptable to change
• Able to motivate self and engage others
• To work autonomously
• Able to demonstrate a commitment to self- development
• Able to work professionally with wide range of people

As a thank you to all our invaluable Bank Staff members, we are happy to offer the following advantages:

• Flexible working hours
• Access to free Bank Partners Core Skills training
• Weekly salary
• Priority of shifts over all agency workers
• Competitive pay
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