MERCY PUBLIC HOSPITALS INC POSITION DESCRIPTION
Core Mercy Values: Compassion, Hospitality, Respect, Innovation, Stewardship, Teamwork
Position title: Quality and Safety Director, Health Employee name: Services
Entity/Group: Quality, Risk and Service Improvement Date: 17 June 2015
Business Unit/Department: Health Services
Position reports to: Group Executive Director, Quality, Risk and Positions reporting to this Quality Managers (3 EFT) Service Improvement one: Quality Coordinators (3 EFT) Administrative Assistant (0.5 EFT) Quality portfolio holders (varies)
Mercy Public Hospitals Inc. Senior Manager / Clinician Quality and Safety Director, Health Services Page 1 of 7 Position Purpose: The position of Quality and Safety Director, Health Services reports to the Group Executive Director Quality, Risk & Service Improvement and is responsible for managing and overseeing the Quality and Safety Program in the Health Services division of Mercy Health. The Health Services division includes: Mercy Hospital for Women, Werribee Mercy Hospital, Mercy Mental Health, Mercy Palliative Care, O’Connell Family Centre, Mercy Care Centre Young and Mercy Health Service Albury.
The Quality and Safety Director, Health Services is a member of the Health Services Leadership Team and will work closely with the Clinical Director Quality and Risk to formulate and implement a strategic and systems driven approach to the management of quality and safety in Health Services. The position is also responsible for the implementation of clinical governance principles and activities to reduce patient harm and improve the effectiveness of care. This is done in consultation with the Group Executive Director Quality, Risk & Service Improvement, Chief Executive Health Services, Health Services Leadership Team, key committees and other individual stakeholders.
Responsibilities of the position include: clinical safety and risk, clinical effectiveness, accreditation, quality improvement, quality assurance and compliance.
The position requires high level communication and negotiation skills, particularly in dealing with sensitive clinical information and adverse clinical events.
The position is predominately based at Mercy Hospital for Women and Werribee Mercy Hospital with some travel to other sites required.
Qualifications: Relevant tertiary qualifications Postgraduate qualification in Management/Business/Administration preferred At least five years experience leading quality management systems in complex and multifaceted healthcare settings. At least two years experience leading, managing and developing staff.
Resource management: Annual Operating Expenditure:
Annual Capital Expenditure:
Mercy Public Hospitals Inc. Senior Manager / Clinician Quality and Safety Director, Health Services Page 2 of 7 Mandatory Organisational Competencies Personal Competencies Job Competencies Orientation (on commencement) Commitment to the Mercy Values of: Comply with the requirements of the Compassion, Hospitality, Respect, Innovation mandatory training/specific job related and Stewardship competencies policy and procedure. Diversity & Equity (Annual) Demonstrated ability to build relationships Sound knowledge of the concepts and with people at all levels. principles of quality management and evidence based practice in a hospital with particular emphasis on systems improvement from a strategic perspective. Emergency Procedures (Annual) Ability to manage and work as part of a team. Significant experience in preparing a health service to undertake accreditation: knowledge of the ACHS framework and standards to be achieved. Work Health & Safety (Annual) Capacity for constructive self-reflection and Knowledge of relevant Legislation, e.g. learning from actions and feedback. Privacy and Australian Standards. Infection Control (Annual) Highly developed leadership skills. Demonstrated project management skills including the ability to negotiate appropriate outcomes and motivate staff to achieve organisational objectives. Excellent interpersonal and written skills, with Proven experience in data extraction analysis the capacity to work closely with members of and the production of statistical reports. the leadership team, executives and senior clinical personnel. Proven capacity to define and reconcile Knowledge of current trends in health service complex and competing priorities, together provision (policies, health care delivery with the ability to identify and engage key systems, relevant standards and health care stakeholders in addressing the same. funding arrangements). Demonstrated capacity to facilitate change and support and involve staff and consumers in planning and service development initiatives.
Mercy Public Hospitals Inc. Senior Manager / Clinician Quality and Safety Director, Health Services Page 3 of 7 Generic Requirements
Act professionally and in accordance with the Mercy Health Code of Conduct Participate in annual Performance Development Review (PDR) process
Key Result Areas Key Activities Standard Measures (Applies to all Senior Managers / Clinicians). Demonstrates and upholds the Values and Ensure the values of Mercy Health are Shows compassion and provides support to Mission of Mercy Health (applies to all Senior incorporated into daily work practices. colleagues and patients. Managers / Clinicians). Consistently shows respect and values each person’s dignity. Seeks opportunities to be innovative for improvement. Communicates openly and honestly as an effective team member. Demonstrates an understanding of individual Maintain a safe environment for Risk assessments completed and controls responsibility for safety, quality & risk and patients/self/colleagues and members of the implemented. participates in organisational quality and public. Incident/s reported as soon as practicable. safety initiatives Escalate concerns regarding safety, quality Undertake incident investigations. and risk if/when unable to rectify yourself. Injured employees are managed within Lead, develop, implement and participate in Guidelines. evaluation and continuous improvement and Orientation records. clinical indicator processes. Training records. Demonstrate and champion the principles of Accreditation outcomes. Person Centred Care: Patient satisfaction and experience survey – Respect and Dignity results. – Information Sharing Develop and action annual Quality Plan and – Participation business plan. – Collaboration.
Mercy Public Hospitals Inc. Senior Manager / Clinician Quality and Safety Director, Health Services Page 4 of 7 Key Result Areas Key Activities Standard Measures (Role Specific) Quality and Safety Planning and Management Direct and manage the Quality and Safety Accreditation requirements are met. Program in Health Services at Mercy Health, Health Services annual Quality Plan to meet organisational objectives in relation developed, including summary of to patient safety and clinical governance, achievements and identified priorities for ensuring coordination and cooperation with action. services provided by other personnel and Indicator data is used to improve quality and departments. safety for consumers. Ensure quality, safety and clinical risk Compliance with Department of Health and management principles are integrated into Human Services Policy and Funding the day-to-day operations of all facets of Guidelines related to patient safety and Health Service and that accreditation clinical risk, namely, Sentinel Event requirements are met. Reporting and Root Cause Analysis. Engage in the development of clinical practice improvement activities that use evidence based practice and quality improvement principles and techniques to improve patient safety and standards of clinical care. Provide advice to the Executive on matters pertaining to the operation of quality, safety and clinical risk in Health Services. Facilitate Quality, Safety and Risk leadership in programs and services within Health Services.
Mercy Public Hospitals Inc. Senior Manager / Clinician Quality and Safety Director, Health Services Page 5 of 7 Ensure quality and safety data is reported throughout the organisation, including to the Board and consumers. Collaborate with quality, risk and consumer participation and experience programs in Aged Care, Home Care and Support Services.
Key Result Areas Key Activities Standard Measures (Role Specific) Human Resources Management Ensure appropriate identification and Health Services staff receive education in management of all resources (human, quality and safety. physical, financial and information) relating to Quality and Safety Team are trained and quality and safety functions. knowledgeable in quality and safety Develop workforce capacity in quality and methodologies. safety within Health Services. Promote and ensure professional competence of Quality and Safety Team through the establishment and maintenance of continuing education, professional development and staff appraisal. Teaching, Education and Research Take a role in the development of quality, Attendance at appropriate fora and meetings. safety and clinical risk at local, state, national Conference presentations. and international level through participation in Staff education programs. relevant meetings, interest groups and Active involvement in managers’ meetings through active research collaboration and and staff orientation. participation in the area of Quality and Safety. Contribute to the ongoing education of staff and development of in-service training programs in the areas of quality and patient safety. Consultation and Communication Establish and maintain effective lines of Ensure appropriate quality and safety communication within the Department of reporting and communication relationships
Mercy Public Hospitals Inc. Senior Manager / Clinician Quality and Safety Director, Health Services Page 6 of 7 Health and Human Services, Mercy Health are in place. and the community. Travel across all campuses and sites as Liaise with other Program Directors, Clinical required within management responsibilities. Directors and Managers, as required. Establish and keep up to date all Attend and actively participate in Health departmental policies and procedures and Services Leadership Team. ensure accessibility to all staff members. Provide Mercy Health committee representation as necessary.
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Mercy Public Hospitals Inc. Senior Manager / Clinician Quality and Safety Director, Health Services Page 7 of 7