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Position Name : Quality Assurance Coordinator
Location: Oxford OX3
Job ID : b8be4fb4a3ea2b31
Description : Two opportunities are available within the Surgery, Women’s and Oncology (SUWON) Division Clinical Governance Team.
Permanent position within Surgery Directorate (available immediately)
Maternity leave cover post in the Renal, Transplant and Urology (RTU) directorate, available from 18thApril 2022 to 25thFebruary 2023 (dates are flexible).
In your application, please specify which post you are applying for, or if you are interested in both positions.
Both of these posts would suit an enthusiastic person who is highly motivated to make a positive impact on the quality of patient care.
The Trust and SUWON Division has a positive culture of learning and improvement. The SUWON Divisional Governance Team strives to support our Directorate Leadership Teams to deliver excellent patient care.
These roles would suit a candidate who is able to adapt to the changing needs of the service to support clinical leaders to provide high quality care for patients.
The aim of the role is to support the delivery of the Division’s and Trust’s clinical governance agenda, relating to patient safety, clinical risk, and clinical outcomes.
The post holder will maintain and implement effective governance processes within the directorate, to provide assurance on the quality of patient care, and facilitate the directorate’s plans for improvement.
Interviews will be conducted via MS Teams.
Work with the CGRP for their clinical area to prioritise their work based on the needs of the service and the clinical governance agenda.
Appropriately escalate risks and facilitate actions to maintain high quality patient care.
Support the Directorate Matrons in providing a monthly Directorate Quality Report,
reported to the Divisional Governance Committee.
Support the Medical Governance Lead in preparing a Quarterly Mortality Report and
any other reports requested of the Directorate.
Support processes relating to incidents: encouraging appropriate incident reporting;
carrying out data quality checks; providing information for incident investigations;
facilitating timely closure of incidents; daily monitoring of incidents; providing informal
training for staff on incident reporting and management systems (such as Ulysses).
Support processes relating to audit: ensuring regular completion of necessary audits;
following up on results which do not meet agreed standards; supporting action plans;
writing commentary for reports to provide assurance; providing informal training of staff
on systems (such as the “My Assurance” app).
Attend Directorate and Divisional Governance Meetings.
Ensure there is a robust and accessible system for organising evidence underpinning
assurance, to enable efficient responses to regulatory bodies (such as the CQC), Trust
and Divisional requirements.
Oxford University Hospitals NHS Foundation Trustis one of the largest NHS teaching trusts in the country. It provides a wide range of general and specialist clinical services and is a base for medical education, training and research. Find out more here www.ouh.nhs.uk
The Trust comprises of four hospitals – theJohn Radcliffe Hospital,Churchill HospitalandNuffield Orthopaedic Centrein Headington and theHorton General Hospitalin Banbury.
COVID-19 Vaccination Update: There has been a national announcement that COVID-19 vaccinations will be mandatory for all patient-facing staff from 1 April 2022. This role could be affected by this, we therefore urge all applicants to consider this before applying. Patient-facing staff who have not had both vaccinations by 1 April 2022 will not be able to continue in their role.
Please See attached Job Description and Person Specification
Incidents and Investigations
Monitor incident reports on a daily basis.
Escalate concerns to matron/clinical lead/medical governance lead/identified
Review incident reports to ensure they contain an appropriate level of detail. Verify
data quality (such as category of incident, department, and other required data fields).
Confirm the level of impact for incidents are appropriately recorded, by liaising with
clinical staff and applying current Trust guidance.
Where the level of impact of an incident is confirmed as moderate or above,
commence an Initial Summary Report (ISR) within agreed timeframes. The ISR should
be submitted to the Matron/Medical Governance Lead and Divisional CGRP team, who
will review the report and submit it to the Trust Patient Safety Team.
Share learning from investigations at Service and Directorate Governance meetings.
Monitor all action plans to facilitate timely closure and escalate issues appropriately.
Identify themes and trends in incidents and support the Matrons with action plans.
Ensure that safety alerts are disseminated throughout the Directorate and required
responses are coordinated and returned.
Maintain and develop systems for analysing data relevant to the quality of patient care.
Directorate Quality Assurance Coordinator JD Jan 2022 4 of 9
This includes cleaning data and presenting findings in clear charts, to inform the
Directorate and Divisional Management Team of the current position on indicators of
Assurance and risk
Regularly review and update the Directorate Risk Register.
Support preparation of risk assessments.
Identify appropriate risks which should be considered for escalation to the Divisional
risk register, with advice from the CGRP and Directorate Management Team.
Provide regular updates on risk ratings and actions to control risks.
Assurance and Regulatory Bodies
Support the Directorate in preparation for regulatory visits. This may include supportive
visits to departments to assist with preparation for official visits.
Review findings of visits (both internal and external), in consultation with the Matron
and CGRP, to coordinate and facilitate Directorate action plans.
Coordinate and support the process for providing progress updates to the Division, in
consultation with relevant managers (e.g. Matron/Sister/Charge Nurse/Clinical
Lead/Medical Governance Lead/Operational Service Manager (OSM)/Clinical
Identify evidence for CQC standards and ensure there is a robust system for
organising and updating evidence.
Identify gaps in assurance and develop relevant sources of evidence, in consultation
with Matrons, Medical Governance Leads, and CGRPs.
Prepare responses to CQC requests, for approval by the Directorate and Divisional
Key performance indicators (KPIs)
Support the directorate to meet KPIs. The post holder’s responsibility is to monitor
these KPIs and support the Directorate Management Team to meet these targets.
Example KPIs include: patients with sepsis receiving IV antibiotics within 60 minutes,
VTE risk assessments being completed within 6 hours of admission.
The post holder will communicate with directorate leads, analysing data and facilitating
Quality Priorities, Specialised Dashboard and CQUINs
Support the Matrons with plans to deliver work relating to Quality Priorities, Specialised
Dashboards and Commissioning for Quality and Innovation targets (CQUINs). Provide
assurance on progress to meet the priorities.
Ensure all relevant NICE guidance is considered by the relevant Directorate lead, and
the level of compliance is agreed.
Coordinate annual review of compliance with relevant NICE guidance.
Where partial compliance is agreed, support the management team to complete a risk
assessment/service development plan.
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Where the service considers that there are justified reasons to not implement NICE
guidance, support the development of a paper for the Trust Clinical Governance
Support the Clinical Lead to develop and coordinate the audit plan.
Ensure the reporting system is regularly updated, to reflect the progress and learning.
Facilitate provision of certificates to audit leads on completion of audits.
Support audit leads with preparing audit summary reports for submission to Trust
committees, and coordinate Directorate approval of reports.
Monitor issues regarding the submission and validation of audit data
Liaise with the Divisional Team to ensure that high priority audits are completed.
Communicate with departments which do not meet required standards, to find out the
reasons, and their plan for improvement.
Support/facilitate action plans to improve standards.
Write commentary for reports to provide assurance.
Provide informal training of staff on systems (such as the “My Assurance” app).
Dr Foster and NHS choices alerts
Coordinate responses to Dr Foster and NHS choices alerts, as required by the
Divisional Governance Team, ensuring approval of responses from the relevant
Facilitate learning from relevant Dr Foster Intelligence and NHS choices alerts to
support service developments.
Ensure there are robust processes for completing and recording mortality reviews
within the directorate.
Respond to requests for updates on mortality from the Divisional CGRP team.
Monitor and update Learning from Death action plans.
Coordinate the Directorate’s submission for the Division’s Quarterly Mortality Report.
Review and Work with agreed methodologies for capturing patient experience,
including ambulatory and outpatient services.
Support patient experience initiatives.
Set up bespoke feedback for specific areas of service.
Ensure wards have robust system for Friends and Family Test Survey (FFT).
Ensure monthly reporting of patients’ experiences to contribute to the Directorate
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