Job overview
The Clinical Audit and Effectiveness Team plays a key role in supporting the organisations statutory requirements for participation in national clinical audit activity as identified with the NHS England Quality Accounts list, including statutory and mandatory audits, non-mandatory audits (advised to participate), confidential enquiries, and registries. Alongside the provision of a local forward measurement plan and registration of ad-hoc activities to support governance requirements to support learning, inform on assurance and compliance with best practice standards and to support continuous improvement in patient care, where indicated. The Clinical Effectiveness Analyst role will undertake with the support of clinical leads various designated measurement projects required to demonstrate compliance with best practice standards and ensure SMART action plans are aligned to support and evidence improvement. A key requirement of this role will be to work to reduce the manual data collection burden of the team by supporting the development and implementation of automation of data capture and reporting where possible.
Main duties of the job
1. To project manage, to develop and undertake local measurement activities to support organisational requirements
2. To work directly with clinical leads and multidisciplinary teams to plan, review, implement and streamline new and existing measurement processes and where possible work with both clinical teams and Data & Digital services to establish IT solutions for automated of data extraction and reporting directly from the EPR to reduce the manual data collection burden
3. To report audit outcomes & findings into appropriate clinical forums to ensure learning is captured, assurance gained and/or recommendations for improvement agreed with leads and timescales, and SMART actions monitored through to implementation
4. To develop and maintain standard operating procedures (SOPs) linked to designated activities, to ensure alignment best practice, updating systems and process where changes occur
5. To provide advice, guidance, training and support to team colleagues and clinical services on own role and responsibilities, enabling healthcare professionals and others with the aim of promoting evidence-based practice and ultimately improving the quality & outcomes of clinical care for patients
6. Support the delivery of a prioritised Trust Clinical Audit Measurement Programme in relation to Trust wide activities
7. Support line management with team responsibilities including training, appraisals, recruitment as required.
Working for our organisation
As part of the Clinical Audit & Effectiveness Team you will be collaborating with colleagues who are responsible for supporting clinical teams with all their clinical audit and effectiveness requirements. This includes project management and oversight of key workstreams, establishing and supporting data collection required to inform on compliance with standards, data analysis and report production and presentation. Activity is established annually to form the Trust Forward Measurement Plan, broken down into divisional and Trust wide audits requiring facilitation and completion. Roles within the team include Data Coordinators for specific workstreams, primarily national activity, Clinical Audit Facilitators to support national and local divisional requirements, ensuring learning and assurance is captured, plus recommendations and actions agreed and monitored. The team are continuously reviewing systems and processes and developing the Clinical Effectiveness Framework to focus team resource on delivery of the organisational requirements and the Trust Quality Strategy. Clinical Audit & Effectiveness activity is undertaken to meet specific deadlines, either for data submission externally for national reporting or internally for local reporting on compliance with established standards.
Detailed job description and main responsibilities
1. To project manage and plan the development of systems and processes to support ongoing measurement requirements, to allow for reporting on compliance with agreed standards
2. To work closely with clinical leads and teams as well as Data and Digital services to establish systems to capture, extract and report on clinical data for audit purposes
3. To supervise and undertake the collection of clinical data to support both local and national measurement requirements to include the quality schedule, CQUIN, Trust policy requirements, ensuring timely collection, submission and reporting in line with established deadlines.
4. To establish monthly meetings with designated clinical leads and teams for to establish data collection and measurement processes, systems, and procedures for data capture to allow for ongoing monitoring against established standards, to review outcomes, capture learning and assurance or recommendations for improvement.
5. To present relevant audit findings at appropriate specialty, divisional and Trust clinical effectiveness forums and work with clinical leads and teams on quality improvement initiatives where they are indicated
6. To ensure regular reporting systems are in place to feed into specialty and divisional clinical effectiveness forums, ensuring data is available for the Head of Clinical Audit & Effectiveness to report at Trust Clinical Effectiveness Group, to include any recommendations, lessons learnt and actions are agreed with clinical leads following review of results etc.
7. To support the Clinical Audit and Effectiveness Team, sharing audit and measurement knowledge and providing advice in relation to various work streams including national and local measurement activity
8. To consult closely with multi-disciplinary personnel throughout the Trust to meet the needs of the forward measurement plan, escalating any risks through to relevant leads and line management
9. To be innovative, using knowledge gained from various systems and processes to enhance the quality of designated activities
10. To provide in-house training for multi-disciplinary personnel throughout the Trust on the clinical audit & effectiveness process in particular activity around designated work streams. This will involve feeding back results to clinical teams, support with induction and provision of training to various clinical teams
11. To tabulate information using Microsoft packages, applying statistical analysis, to produce presentations and reports with a high level of accuracy fulfilling the requirements of the measurement plan
12. To ensure that the clinical audit and effectiveness documentation, databases and SharePoint pages are kept up-to-date, and all information is accurate and completed appropriately
13. Adhere to departmental standard operating procedures, using up to date templates and tools to ensure all relevant data for audit is captured and recorded. Including storage of on-going and completed audit activity
14. To be accountable for the quality, accuracy and validity of all information collated and distributed by the Clinical Audit and Effectiveness Team including all aspects of the measurement process, representing the department at various forums as required
15. To undertake other general duties to contribute to the completion of departmental objectives in line with the role
16. To be motivated to work as part of a team, supporting colleagues, sharing ideas / good practice with others, in a variety of settings.
Person specification
Essential
Essential criteria
* Maintaining and Evidencing High Level Continued Professional Development
* Educated to Degree level in relevant subject (i.e. maths, IT, English) or relevant NHS experience
* European Computer Driving Licence (ECDL)
* Experience working within a healthcare setting with exposure to clinical processes and terminology
* Project management experience
* Computer literate with an Excellent working knowledge of Microsoft Word, Excel, PowerPoint and Access
* Using simple statistics, data analysis and interpretation and manipulation of data
* Creating statistical reports, documents, charts and presentations
* Arranging, facilitating, participating and presenting reports to multi-disciplinary meetings
* Experience of NHS and clinical terminology / navigation of Clinical Documentation
* Previous Clinical Audit / Measurement experience
* Excellent Communication Skills
* Ability to understand, absorb and comply with detailed procedures
* Ability to multitask; to plan, organise and prioritise own workload, adhering to tight deadlines
* An understanding of clinical audit theory and practice, along with other Quality Improvement Initiatives
* Developing and delivering education and training to groups
* Clear and accurate written and verbal communication. Effective listening skills
* Flexible attitude to workload, willing to adapt to the changing needs of the service
* Friendly and caring manner - demonstrate ability in dealing sympathetically and sensitively with people
* Proven ability to work in a team, be supportive of team members
* Able to take on board new ideas, skills and knowledge
* Able to manage priorities under pressures
* Able to use own initiative and work without close supervision within agreed protocols
* Ability to adhere to the Trust policy on confidentiality, Caldicott, Data Protection Act, Protection of Patient Information etc.
* Actively seeks to develop own knowledge, skills and ability
Desirable criteria
* Demonstrable evidence of participation in Quality Improvement initiatives
* Experience in supervising a team
* Current driving licence and access to vehicle to work Cross site or throughout the health economy