Develop, deliver, and maintain a robust and integrated clinical governance, framework that embeds quality, safety, and risk into all aspects of current and future care services. Chair or support relevant governance meetings, to include attendance and input into the Clinical Governance Committee, Quality Improvement meeting, Clinical Risk Management Group, and Executive Governance and Risk Meetings. Ensuring timely comprehensive reporting on all Clinical Governance Activity. Facilitate investigation of all reported incidents and complaints, including the gathering of complex and sensitive information from those involved; writing reports and tracking associated actions; ensuring the appropriate learning and disciplinary actions are actioned.
Escalate serious, or potentially serious incidents or complaints in a timely and transparent manner, advising on investigative procedures and HIW reporting responsibilities. Ensure robust monitoring and trend reporting of all incidents, accidents and near misses, ensuring learning is taken forward and embedded. Lead the development of an overall strategic framework for service user safety, to include the management of medical facilities and equipment, the prompt review and actioning of medical and catering alerts, and the timely review of allocated policies and procedures. Ensure robust mechanisms are in place to obtain and review service user feedback to inform outcome measures and improve service user experience, with clear priorities for action; liaising with colleagues to ensure these are embedded in the practice.
Ensure a robust equipment maintenance Ensure robust mechanisms are in place to support accurate collation of data to inform KPIs. Striving to meet and report on critical KPI targets. Design and coordinate clinical audits, ensuring timely dissemination and implementation of findings. Ensure effective risk management processes are in place and monitored to ensure risks are properly identified, reported and effectively mitigated.
Work closely with the Director for Nursing and Clinical Services in their capacity as Registered Manager with Healthcare Inspectorate Wales (HIW) to ensure compliance requirements are well understood and appropriately actioned. Agree and implement a programme of compliance monitoring to provide assurance and a position of preparedness for regulatory inspection. Collaborate with the Governance and Risk Manager, Designated Safeguarding Leads and Registered Manager to ensure clarity and compliance with regulatory reporting, and compliance with national safeguarding requirements. Build and maintain appropriate relationships with third party regulators and statutory partners, driving improvements arising from regulatory meetings or inspections.
Quality Improvement: Develop and implement the hospices Quality Strategy in alignment with national standards and best practice. Chair the quality improvement meeting, promoting engagement from key stakeholders. Lead on the monitoring of clinical quality indicators and KPIs, ensuring negotiation with external stakeholders e.g hospice UK and Welsh Government in relation to data submission that supports funding. Adopt an agile, end-to-end approach to delivering service improvements and change projects across care; deliver regular service reviews and devise effective project management plans for any necessary evolution to ensure delivery of the best possible outcomes.