Common Services Agency s2

JOB DESCRIPTION

1. SERVICE NHS Orkney

2. SERVICE AREA/DIRECTORATE Health Intelligence and Clinical Governance

3. JOB TITLE Clinical Governance Facilitator

4. GRADE 6

5. LOCATION Garden House

6. REPORTING TO Health Intelligence and Clinical Governance Manager

7. Professionally accountable to Medical Director and Director AHP, Nursing and Midwifery

2. JOB PURPOSE To facilitate and support clinical effectiveness and quality improvement programmes and support the function of clinical governance throughout NHS Orkney.

Works within and links across the Health Intelligence and Clinical Governance Department linking closely with Scottish Patient Safety Programme, Risk and Incident Management and other improvement and safety work.

To act as the HIS Board liaison coordinator, which will include ensuring the dissemination and delegation of the information/products as well as co-ordinating the preparation and response for any self assessments and reviews.

To set up systems of clinical effectiveness, quality assurance and quality improvement and facilitate external and internal reviews.

Provide guidance, support and direction on quality and clinical governance for heads of department and all health professionals. Linking together central policy and guidance with local strategy and activity and to then implement this – overcoming barriers to change across the Health Board.

Network and liaise with other organisations including Health Boards, HIS, external Agencies, Disability and Voluntary organisations.

To be a resource for the Board’s Quality and Improvement and Involving People Committees.

To ensure focus on Healthcare Quality Strategy and Clinical Governance and Risk Management Frameworks bringing relevant aspects of patient and public experience into the overarching workplan

To have key role in Long Term Condition managed clinical network, particularly supporting teams through preparing their self assessment and inspection process as well as maintaining their quality assurance frameworks.

To develop effective Board-wide system for the dissemination of clinical guidelines – including the monitoring of implementation of potential impact. 3. DIMENSIONS

NHS Orkney has an annual budget of £45 million and employs 580 staff.

 Report directly to Health Intelligence and clinical governance manager  Professionally accountable to Medical Director and Director of AHP, Nursing and Midwifery  Provides support to all health professionals across NHS Orkney.  Provide support and clinical guidance to Health Intelligence and Clinical Governance teams.

4. ORGANISATION CHART

5. ROLE OF THE DEPARTMENT

The Health Intelligence and integrated Clinical Governance Service will:

 provide timely data to enable services to respond to patient needs and service improvement  Increase health intelligence capabilities  Develop and monitor local quality markers  Support high priority service redesign based on evidence-based care pathways  Share best practice to facilitate service improvement  Implement and manage a robust research governance process  Support the delivery of the Quality Strategy including clinical governance and ensuring co- ordination with risk management and patient safety agendas..

6. KEY RESULT AREAS

To produce and maintain a Board wide reporting system that demonstrates performance against the clinical governance agenda.

To identify own training and development needs and undertake appropriate training and development as required, supported by regular PDP. Keep abreast of relevant national information developments as part of continuous professional development.

Accountable for standards of governance with a key role in setting standards ensuring quality and consistency in ensuring people do what they are contracted to do, and holding others accountable for their performance as well as being personally accountable

Responsibility for ensuring that NHS Orkney collects, interprets, reports and acts on quality data that will drive health improvement and clinical governance

Link with the patient experience officer to ensure feedback and learning from all patient experience related work is incorporated into departmental work

Ensure the Board and Directors are kept updated on relevant national and local patient safety and risk management issues and ensure these inform Board goals and standards.

Will be required to present statistical and performance information to a variety of audiences which will include both those with and without an understanding of statistical techniques.

Further develop systems in close collaboration with Clinical Directors to ensure effective reporting of clinical outcomes and data which reflects the quality of clinical care provided across the organisation.

Work closely with the Infection Control Team to integrate the clinical governance and infection prevention and control agendas

Support local, regional and national service improvement programmes, supporting the development of the health intelligence function in the Board.

Requirement to write and contribute to reports. These reports will vary in length and complexity, and will range from informal summaries to detailed comprehensive reports. It will also be necessary for the post holder to be able to summarise these reports and disseminate their findings. It will be necessary to be able to present information to specialist and non-specialist audiences in a way that they can understand the implications of the report

Quality Improvement Provide support, guidance and direction for all professions in all areas to use and develop best clinical practice. Develop and co-ordinate a system for all professionals to recognise triggers for improvement and ensure that they can access support for improvement from this system.

Set up and manage a system of review and implementation of all relevant national and professional clinical guidance, standards and best practice across NHS Orkney.

Have responsibility for the Operational Clinical Governance Group agenda, workplan and quality of information presented.

Quality assurance

Develop systems across NHS Orkney to collect information and data on key clinical indicators in order to monitor and manage clinical quality and governance processes

Produce an annual report on Clinical Governance which includes reports from both internal and external clinical governance and clinical effectiveness reviews

Training and development – draw up and implement a programme of training and development for all health professional. Covering clinical effectiveness, clinical audit, and the use of dashboards

Establish a system of research governance with ARI and ensure that clinical governance informs appropriate research and development agendas. Carry out any research as necessitated by other parts of role.

Lead projects / initiatives as directed. E.g. Rehab and Older Person Redesign, MCN quality assurance, Quality standards of GMS contract, evaluative aspects of public health.

To ensure that Information Management and Technology and telemedicine are involved in the systems created to assure and improve clinical quality and safety.

Ensure that there is a coordinated and coherent approach to Clinical Governance throughout the organisation and that effective systems are in place to collate information regarding Clinical Effectiveness, Patient Safety and Patient Experience.

Identify gaps in health information working with multi agency teams to agree and develop appropriate new innovative ways of collecting data and raising awareness of the need and importance of information governance to organisational practice.

Have an understanding of data protection, Caldicott Guardian, freedom of information systems and confidentiality principles and ensure development, implementation and monitoring of policies and standards

Arrange meetings with colleagues to plan objectives and work commitments for multidisciplinary work including service improvement, audits and projects

7. ASSIGNMENT AND REVIEW OF WORK

The post directly reports to the Health Intelligence and Clinical Governance Manager but has discretion to act on his/her own initiative using own judgement to carry out all duties and responsibilities as and when needed at own discretion.

This post is a senior post within the Health Intelligence and Governance Department with the post holder working unsupervised. The post holder reports to the Health Intelligence and Clinical Governance Manager who is responsible for agreeing objectives, performance reviewing and annual appraisal of the post holder in consultation with the Medical Director and Director AHP, Nursing & Midwifery.

The post holder is expected to anticipate problems and resolve them using their own initiative, and in direct liaison with other managers and external bodies and therefore works with a considerable degree of autonomy.

Keeps Health Intelligence and Clinical Governance manager informed through regular updates and reports.

When unsure of his/her scope consults the Health Intelligence and Clinical Governance manager

Operates within the Data Protection Act and all NHS Policies, including Health & Safety, Fire Regulations, Appraisal

8. COMMUNICATIONS AND WORKING RELATIONSHIPS

Communication is on both an individual and group basis and involves verbal, written and presentations. The purpose is varied and includes negotiating, influencing and encouraging others, at times with no line management authority over colleagues.

Excellent communications skills, both oral and written, are required to analyse performance, improvement and intelligence information,

This can involve obtaining and assimilating highly complex and highly sensitive information and communicating with the following:

(a) Senior managers within NHS Orkney and the Board. (b) Line managers, staff and their representatives. (c) Local authority partners, voluntary organisations, external contracts. (d) Scottish Government Health Department. (e) Colleagues from other Boards. (f) Liaise with NHS HIS and other external agencies

9. MOST CHALLENGING PART OF THE JOB

Analysing and interpreting standards, guidelines and related central and professional policies and initiatives into the local context.

Manage what are at times conflicting work and time priorities.

Balance the needs of different projects, committees, groups and individuals.

Develop, maintain and use creatively a wide network of effective relationships across all local / national disciplines and levels such as HIS, ISD, and other professional bodies.

Informal counselling and guidance which may arise through the nature of the job.

Dealing with professionals at different stages of Clinical Effectiveness awareness and with those who may not be aware / agree with its importance.

Be prepared to use effective language and debating skills at any time in promoting organisational or attitudinal change in what can sometimes be a less than comfortable environment.

10. SYSTEMS  Daily use of Microsoft Office Suite: Word, Access, Excel, PowerPoint, Project 2000, Outlook  Adobe Acrobat Reader and Writer – use to create and view PDF documents  Local and national database systems,  Photocopiers  Telephones  Printers  E-library  Laptop and projector

12. PHYSICAL EFFORT

 Long periods of time sitting at a desk operating a PC

13. MENTAL EFFORT

Requires occasional high levels of prolonged concentration on tasks with tight deadlines, for example, production of reports.

There are frequent unpredictable requests by senior staff or stakeholders to respond to immediate requests for support or urgent requests for information. 14. EMOTIONAL EFFORT

Will be expected to review and present sensitive clinical information as part of the daily workload and in presenting data to executive directors, senior managers and clinicians to review and identify any potential change to practice that is required

May deal with distressing or emotional circumstances in relation to certain data sets or in relation to clinical governance issues.

May have to resolve and handle conflict within the team and with other colleagues (internal and external), particularly around deadlines and work specifications.

15. WORKING CONDITIONS

Working Conditions: Office environment Clinical areas Primary and Community Care bases

16. JOB DESCRIPTION AGREEMENT A separate job description will need to be signed off by each jobholder to whom the job description applies.

Job Holder’s Signature: Date:

Head of Department Signature: Date:

Updated 9th May 2012 PERSON SPECIFICATION

Job Title: Clinical Governance Facilitator

Department: Health intelligence and clinical governance

Location: Garden House

FACTOR ESSENTIAL DESIRABLE

QUALIFICATIONS Degree level qualifications in Clinical practical experience TRAINING appropriate Health related subject or in the NHS RESEARCH equivalent qualifications and PUBLICATIONS experience

Experience of carrying out quality improvement.

EXPERIENCE Experience of strategy and policy Awareness of Scottish development in relation to clinical Patient Safety Programme governance, service development and/or health intelligence Awareness of Risk Experience of working at a managerial Management level in relation to quality assurance or health intelligence agendas

Well grounded experience of communicating highly complex information to specialists and non- specialists

Experience in working across multi disciplinary teams in health sector environment

KNOWLEDGE AND Ability to empower others. SKILLS High level project management skills are an essential within this post.

Working knowledge of information and clinical governance

IT skills – Word , Excel , PowerPoint Have appropriate knowledge to be able to support the development and production of major reports. This requires highly developed interpretation and report writing skills and the ability to explain complex information in simple terms

Ability to be adaptable to gain support and influence improvements Ability to work collaboratively on delivering improvements.

Excellent communication, organisational and time-management skills Must be creative and original in generating innovative approaches to problem solving.

Ability to motivate others

Self Belief – demonstrable “can do” PERSONAL ethos with a sense of confidence to be a QUALITIES shaper rather than a follower.

High degree of self awareness – know own strengths and limitations.

Demonstrable ability to manage self.

Demonstrable evidence of drive for improvement

Demonstrable evidence of high sense of integrity.

Self –motivated and able to work within a multi-disciplinary team