Quality & RISK MANAGER
JOB DESCRIPTION
Title: Quality & Risk Manager
Purpose of the Position:
This is a key senior management post with responsibility and accountability for the operational provision of an effective, quality & risk management programme to meet the needs of the person served, staff and stakeholders and the strategic development of this plan to meet changing organisational needs. To promote best evidence risk management practices that foster a fair, open and learning culture and to implement systems and processes to ensure that the organisation learns from incidents and claims analysis.
Support Executive Management Team, Board of Directors, Medical Directors, Programme Managers, and Department Heads in establishing a proactive risk management culture, focussing on quality and safety within the rehabilitation programmes and departments.
Accountable to:
Chief Executive Officer
Liaison / Communication:
The proper performance of these duties will require a high degree of liaison and communication internally with Managers and Staff throughout the hospital and with external stakeholders in the course of their normal duties and responsibilities.
Overview of the Role
The Quality & Risk Manager will be responsible for the implementation and oversight of the hospital risk management programme with consistent application of Enterprise Risk Management and Incident Management Policies and Guidance. Responsible for the development, implementation and evaluation of a comprehensive risk management programme with associated structures, policies, procedures which are a vehicle for improving quality and safety in the hospital and to ensure the hospital consistently strives to achieve and improve compliance with the HIQA National Standards of Safer Better Healthcare.
He/she will be expected to keep abreast of all imminent developments in the areas of Healthcare Risk Management/Quality Improvement/Incident Management and will have to undertake training and qualifications that are necessary for the successful performance in the role.
He/she will work with the senior management Team to enable a hospital wide quality and risk management culture and to establish a systematic and proactive approach to identification, analysis, evaluation, and minimisation of risk within the hospital.
ACCOUNTABILITY, DUTIES AND RESPONSIBILITIES
General Accountability
* Maintain throughout the hospital awareness of the mission and values in relation to all safety activities, with primary responsibility for patient safety.
* Plan and manage for the professional organisation and management of an integrated Quality & Risk Management Programme and Patient Safety Initiatives that ensure continuous quality improvement throughout the organisation.
* Identify and implement operational processes to the standards of best practice in order to optimise use of resources and to ensure compliance with statutory requirements, standards, best practice and procedural documents.
* Implement a programme of monitoring and review to ensure compliance with legislation, regulations, best practice, standards, and procedural documents.
* Ensure systems are in place for the monitoring and review of risk management for the purposes of learning and improvement.
* Participate in and lead project working groups within the area of Risk Management, Incident Management and/or as delegated by Chief Executive Officer.
* Collaborate with various stakeholders in the development of service and hospital wide quality initiatives.
* Undertake duties appropriate to the grade as assigned by the Chief Executive Officer/Deputy Chief Executive Officer.
Specific Accountability
* Report to, advise and be accountable to the Chief Executive Officer on all matters relating to the risk management/Quality Improvement/Health and Safety and Incident Management functions.
* Lead and manage a team of staff to support the hospitals quality & risk management programme, responsibilities and agenda to include line management of the Access to Records Officer/Quality Improvement and Accreditation Officer and the Environmental Health and Safety Officer.
* Develop, deliver, implement and evaluate a comprehensive quality and safety programme with associated structures, policies and processes which are the vehicle for improving quality and safety in the organisation.
* Oversee the Health and Safety Function with direct line responsibility for the Environmental/Health and Safety Officer. Review the hospital safety statement and related health and safety policies/procedures/guidelines in consultation with relevant personnel and make recommendations to the Chief Executive Officer as necessary.
* Oversee the Access to Records office function to ensure compliance with FOI and Data Protection Legislation.
* Communicate and consult on the risk management programme to hospital management, internal committees and to the Board of Directors.
* Establish integrated risk management reporting structures and processes. Ensure communication and escalation of all patient safety, health and safety and organisational risks to the Chief Executive Officer/Executive Management Committee.
* Manage the hospital Incident Management Framework in line with HSE and NRH policies.
* Monitor incident management activity, systems and processes. Ensure all reporting requirements are met for the HSE, State Claims Agency and External regulatory bodies, e.g. HSA, HPRA.
* Conduct thorough incident/accident investigations and assist in the implementation of new control measures to mitigate the risk of future incidents utilising system analysis review structures. Prepare written reports to summarise findings.
* Liaise with and support designated officers in the investigation of complaints/allegations, e.g. safeguarding, Trust in care.
* Support staff in the aftermath of incidents using tools such as After Action Review (AAR).
* Prepare reports for multiple organisation committees with information on health and safety, patient safety performance and recommendations for improvement.
* Carry out reviews in accordance with the Incident Management Framework for all category 2 and category 1 incidents. Complete review for category 3 incidents as necessary and complete annual aggregate reviews for top hazard categories, e.g. falls, medication errors.
* Prepare briefings for hospital Board of Directors following patient safety incidents.
* Management of claims and ensure analysis to identify opportunities for learning, risk reduction and quality improvement. Liaise and support the State Claims Agency and Hospital Insurers in these investigations as required.
* Share learning from incidents, investigations, through defined processes.
* Develop, implement and review risk management procedural documents e.g. Safety Statement, Risk Management Policy, Incident Management Framework.
* Oversee the annual insurance renewal programme for the hospital.
* Oversee the Quality Improvement programme for the hospital supporting the implementation of the HSE Patient Safety Strategy (2019-2024).
* Lead for Open Disclosure in the NRH responsible for compliance with Open Disclosure policy and implementation of the National Open Disclosure Act and Patient Safety Act (2023).
* Provide professional support and advice to all managers on risk management process, incident management and continuous quality improvement process.
* Preparation and sharing of risk, incident activity, and quality improvement with Chief Executive Officer, Hospital Board of Directors and the Dublin South East Hospital Network.
* Manage the NRH corporate risk register.
* Develop a process for tracking implementation of recommendations from major reports, internal and external inspections, investigations and safety audits to ensure that assurance on implementation within the organisation.
* Maintain a repository of organisational learning from safety incident and risk. Manage and disseminate learning to enable mitigation of future risk.
* Ensure all risk management documentation; policy and guidance are kept up to date, as appropriate.
* Contribute to the development of performance indicators for risk management system which can be monitored (quality and safety profile).
* Provide reports as required to the Chief Executive Officer on performance in relation to quality and patient safety.
* Attend and provide Risk management reports for various organisational committees, e.g. Operational Management Committee, Hygiene, Infection Prevention and Control Committee.
* Research and develop business plans, service plans, in line with national standards of practice.
* Contribute to the organisations’ strategic plan targets for patient safety, Quality Assurance and Quality.
* Ensure the Risk Management structures and processes meets the necessary CARF standards (ensuring compliance in the Aspire Standard sections of legal requirements, risk management and health and safety).
Outline of Duties and Responsibilities
· Communication& Consultation
* Demonstrate pro-active commitment to all communications with internal and external stakeholders.
* Provide Risk Management support and advice to the CEO and Department/Programme Managers as required.
* Communicate and consult on risk matters with the Chief Executive, hospital Committee’s/Steering Groups.
* Report risks in an appropriate way to Chief Executive, Board of Directors, Programmes, Department Heads and staff as appropriate to their role and level of accountability.
* Liaise with Hospital Legal Advisors, State Claims Agency, Health Service Executive, Professional Bodies and other regulatory authorities on risk matters where necessary.
* Represent the hospital at the Dublin Hospital Group Risk Management Forum and others as requested. Provide feedback to relevant hospital committee’s/steering groups.
* Act as Chairperson for various organisational committees and subgroups with internal and external stakeholders.
· Proactive Risk Management Process
* Manage an overall risk management programme for the hospital.
* Establish integrated risk management reporting structures and processes.
* Provide advice and support to service colleagues in improving incident and risk management processes to ensure continuous quality improvement and patient, staff and other stakeholder safety.
* Provide advice and support service colleagues regarding risk assessments, which involves analysing risks as well as identifying, describing, estimating and evaluating the risks including legal requirements affecting the hospital.
* Provide advice on plans to control risks.
* Manage corporate risk register and support individual programmes and departments in managing local risk registers.
* Ensure identified risks and controls are recorded in the Corporate Risk Register. Continuous assessment of the corporate risk register and sub registers to enable the identification of current and emerging risks that present a threat or opportunity to the achievement of business objectives.
* Escalate operational and strategic risks when required to the Executive Management Committee, Quality, Safety and Risk Committee.
* Administer, maintain and manage the National Incident Management Systems (NIMS), including training of the NIMS software.
* Escalate the reporting of serious incidents internally and to external agencies e.g. the Health Service Executive, State Claims Agency and others as required.
* Participate, assist and/or co-ordinate in a timely manner, the investigation of serious incidents and in the development and implementation and monitoring or quality improvement plans, as required.
* Provide reports as required for Programmes, Department Heads, and relevant committee/s on incidents, quality, safety and risk.
* Develop a process for tracking the implementation of recommendations from reports, investigations and safety audits to ensure that assurance on implementation within the NRH.
* Support the Hospital Major Emergency Plan Committee and support the implementation of the Major Emergency Plan.
* Contribute to the development of performance indicators for risk management system which can be monitored (quality and safety profile).
* Manage incidents that have potential for claims or escalate to claims.
* Represent the hospital in the management of claims for compensation made against the Hospital (alleged clinical negligence, employer’s and public liability).
* Obtain legal advice when required for patient or other hospital risk related matters.
* Prepare and support staff attending court i.e. Coroners, Civil or Criminal courts for hospital related matters.
* Ensure claims are analysed for potential learning and quality improvement.
* Management of insurance policies and compliance with notification requirements.
* Participate as required and in the annual review of the Insurance Portfolio.
* Promote a just and fair culture which supports patients/service users and staff and has an emphasis on learning to improve from incidents and near misses.
* Use a structured approach in the proactive identification and actioning of those aspects of a service that have a potential to cause harm. This should include evidence from sources within the healthcare setting locally, nationally and internationally.
* Advise the Chief Executive/ Board of Directors on potential risks, serious incidents, incidents reviews, claims data and ensure processes are in place for sharing information on good practice in risk management.
* Maintain links with the Clinical Director to ensure communication of quality and risk matters are managed appropriately.
* Set short and long term goals for the direction of the risk management process.
* Participate in Executive Management Team out of hours cover.
· Standardised Policies Procedures, Guidelines
* Ensure processes are in place for the development of Policies Procedures, Guidelines, based on best available evidence, using standard format.
* Support the development of a Policy, Procedure, Guidelines framework for the development and management of organisational policies.
* Ensure all risk management documentation; policy and guidance are kept up to date, as appropriate.
* Maintain and review at a minimum annually the hospital Safety Statement.
· Quality Improvement
* In conjunction with the Quality Improvement and Accreditation Officer, support staff with quality improvement projects in line with the HSE Framework for Improving quality.
* Participate in multidisciplinary quality improvement initiatives to improve patient safety.
* Use recognised quality improvement tools to accurately diagnose issues, identify remedial actions, implement these and then to assess and measure the change that has occurred.
* Promote patient-focused approaches to clinical quality by participating in multidisciplinary audits that compare current practice to best practice standards or procedures.
* Ensure clinical audit programme has linkages to risk management and quality improvement programme.
* Develop Quality Improvement plans and monitor actions from internal reviews and external inspections i.e. HIQA, HSA.
· Education and Training
* Develop and support delivery of uniform training for incident and risk management, to ensure consistent investigative processes in line with the HSE policy and guidance are applied across the service.
* Oversee and manage the programme of risk management/health and safety training, e.g. fire training plan, waste management training.
* Provide education, instruction and training on risk management, risk management reporting mechanisms and build risk awareness in the organisation.
* Provide health and safety/risk management-based training for managers and staff based on role and meeting the need within the organisation.
* Develop and support delivery of uniform training on incident and risk management, to ensure consistent investigative processes in line with the HSE Incident Management Framework, Risk Management Policies and guidance are applied across the programmes.
* Monitor attendance at health and safety/risk management-based training.
* Attend education and training as appropriate to the post.
* Maintain continuous professional development keeping abreast of new knowledge, techniques and developments related to the role.
* Promote and ensure compliance with Safety and Risk Training.
* Present during Corporate Induction programme for new staff.
· Management of resources
* Accomplish staff results by communicating job expectations; planning, monitoring, and appraising job results; coaching, counseling, and disciplining employees; developing, coordinating, and enforcing systems, policies, procedures, and productivity standards.
* Ensure the efficient and effective use of resources for risk related activities and aligned to the department.
* Utilise technology to facilitate improvements in efficiency of service and use of data to support service development.
· Monitoring and review
* Ensure programme in place for continuous monitoring and review of risk management activities and corrective actions are implemented in areas of non-conformance.
* Conduct audits of compliance to policy and standards.
· Participate in Standard Quality Based Assurance Programme
* Establish and manage programme of audits to monitor performance of organisation, e.g. health and safety audits, patient safety rounds.
* Participate in external audits, inspections and quality assurance-based audits e.g. CARF, Health Service Executive, Environmental Protection Agency, State Claims Agency, and ensure follow up with external agencies as required.
* Assist in the completion of annual reports for external agencies as required e.g. Dublin South East Regional Health Authority.
* Ensure a programme of monitoring and review of compliance with standards relating to quality, safety and risk are in place i.e. HIQA Infection prevention and Control Standards, HIQA Safer Better Healthcare Standards, CARF Health and Safety, Risk Management Standards and others as developed.
* Participate and advise in collaborative Risk Management Programmes as may be organised through the Quality, Safety & Risk Committee, Health Service Executive, or hospital Insurers.
· Freedom of Information (FOI)/Access to Records
* Oversee the FOI/access to records function in the NRH and support the Risk Management Freedom of Information (FOI)/Access to Records Officer as necessary.
* Ensure systems are in place for the processing of Freedom of Information & General Data Protection Regulation requests in a timely manner and as per request deadlines.
* Assist the Risk Management Officer (FOI), handling Freedom of Information requests, ensuring General Data Protection Regulation policies are adhered to in retrieving information relating to claims handling, and the investigation of cases.
· Clinical Governance
* Participate in Quality, Safety & Risk Committee-present patient safety updates and reports at meetings.
* Report to the Board of Directors/or subcommittees as required.
* Co-ordinate the Medical Peer Review steering group to oversee the peer review of moderate/serious patient safety incidents.
* Promote good clinical governance practices throughout the NRH.
· Quality, Patient Safety & Risk Management
* The NRH is committed to supporting a culture of continuous quality improvement through effective governance, clinical effectiveness and outcome measurement.
* Quality and Patient Safety supports the Health Service to deliver high quality and safe services to patients and service users. This involves developing appropriate standards of practice that can be measured from the clinician and service user perspective and requires that the Manager is:
* Responsible to ensure compliance with Health Information and Quality Authority (HIQA) Standards as they apply to quality, safety & risk, CARF Accreditation Standards, national and local policies, procedures, guidelines, best practice standards, relevant government legislation and regulations.
* Participate in various standards, NRH accreditation and quality control groups to support the overall achievement and maintenance of the designated NRH quality and accreditation standards.
* To promote and effect a continuous quality improvement (CQI) environment for services at NRH in line with existing and future regulatory requirements.
* Department will work closely with other areas and services within the NRH in order to organise and assure implementation of all hospital and external quality, safety and risk management policies, procedures and requirements pertinent to services at the Hospital.
The extent of speed and change in the delivery of health care is such that adaptability is essential at this level of management. The post-holder will be required to maintain, develop and enhance the necessary professional knowledge, skills and aptitudes required to respond to a changing situation.
This Job description does not contain an exhaustive list of duties, and the post holder may be required to undertake additional responsibilities. It will be reviewed from time to time in order to adapt and develop the role, according to service needs and Hospital policies.
I agree that this position description clearly outlines the specific responsibilities and duties that are to be carried out as part of this role. I also understand that these represent the minimum requirements to perform the duties at the current level.
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