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Detailed job description and main responsibilities

1. Quality Improvement

• Support the development of detailed improvement plans for the delivery of specific projects within the broader Quality Improvement Implementation Plan, its associated initiatives and workstreams within locality-based and specialist Delivery Units.

• Support the Head of Quality Improvement and the Deputy Head of Quality Improvement and Trust Clinical Audit Lead in the delivery of the Quality Improvement Implementation Plan.

• Work with locality-based and specialist Delivery Unit Quality Improvement Leads to ensure specific initiatives are aligned with the governance and methodology set out in the Quality Improvement Implementation Plan.

• To provide advice on all matters relating to clinical audit and quality improvement within both Delivery Units and on behalf of corporate leads. 

• Ensure that baselines are captured to illustrate and monitor specific change, including trajectories and benefits.

• Support improvement project groups as requested to ensure regular meetings are held and participants are held to account. This includes the maintenance of good governance, appropriate reports and escalation as required.

• Support the production of reports on Quality Improvement progress, issues and items for escalation.

• Represent the Trust and QI Faculty professionally both internally and externally as a champion of Quality Improvement. 

2. Change Methodology

• Ensure that Quality Improvement initiatives and Clinical Audits are focused on Service Users and follow the principals of co-designed and production.

• Facilitate frontline staff to deliver continues improvement, enabling creativity, innovation and change in support of a culture focused on improvement.

• Support the broader change team to utilise quality improvement tools and techniques, providing coaching, mentoring and training.

• Assist in the Identification of appropriate benchmarks, develop surveys and collate both qualitative and quantitative data to support service delivery improvements, performance and quality.

• Work within the National and Local regulatory frameworks

• Use appropriate tools, software and techniques to manage, analyse and present data in a variety of formats.

• Advising staff of appropriate data extraction from existing systems to support measurement for improvement and Audit methodologies.

• To manage personal workload and determine priorities in the context of the Quality Improvement Implementation Plan, Delivery Unit clinical audit programme and Clinical Audit policy and strategy. The post holder will however be guided and advised by the Deputy Head of Quality Improvement and Trust Clinical Audit Lead and Faculty Leads.

• To ensure that all clinical audit activity and quality improvement activities are formally registered and meet the correct governance criteria prior to commencement.

• To provide appropriate support and advice on project design and methodology, data analysis, presentation and report writing to staff undertaking projects, liaising with the information department as appropriate.

3. Clinical Audit

• To maintain accurate and comprehensive records of local clinical audit activity on the Trust’s Clinical Audit Database.
• To liaise with the Quality Improvement and Clinical Audit Manager, maintaining awareness of any clinical audit requirements contained in national audit/benchmarking which relate to the Delivery Units, and to ensure that these are brought to the attention of the Delivery Units.
• To organise and attend Delivery Unit and Trust meetings as required, and to make presentations at meetings, e.g. forward plans and annual reports, as and when required.
• To liaise with the Deputy Head of Quality Improvement and Trust Clinical Audit Lead, maintaining awareness of any clinical audit requirements contained in national audit/governance initiatives which relate to the Delivery Units, and to ensure that these are brought to the attention of the Delivery Unit Clinical Audit /Quality Group.
• To work collaboratively with staff in the audit department and the Delivery Unit Clinical Leads & Directors to maintain a structure for managing and facilitating clinical audit at Delivery Unit level. For example, this includes facilitating the production of an annual clinical audit work plan which reflects a range of competing demands, such as:

1. NICE guidance
2. Quality Schedule and Quality Accounts requirements
3. MH Act legislation
4. Care planning & clinical risk issues

• To assist project leads in producing final reports at the end of clinical audit and quality improvement projects; and on the occasions where this duty falls to the post holder, to produce such reports to a high standard, with the support of the project lead
• To support the Delivery Units to follow the Trust policy in relation to tracking and follow-up of any audit action plans.

4. Training and Development

• Support the rollout and delivery of the Quality Service Improvement Redesign programme across the organisation, including participating in the delivery of teaching sessions, both face to face and virtually. Support staff with training in clinical Audit skills as necessary.
• Support staff with training in Clinical Audit skills as necessary.
• To promote and encourage participation in clinical audit and other forms of quality improvement by all staff, and support and encourage clinically effective, evidence-based practice.
• To provide staff with guidance, as required, about principles of implementing change, ethical considerations when undertaking clinical audit, and the relationship between clinical audit and other strands of quality improvement, wider governance and assurance.
• Maintain personal skills’ portfolio and ensure personal training needs are appropriate to meet the demands of the job are brought to the attention of the Clinical Audit & Improvement Manager.
• To participate in an annual appraisal with line manager and agree goals & objectives for the year
• Maintain currency and cutting edge understanding of new developments, tools and techniques through the attendance of regional/ national events as agreed with line manager.
• Develop networking opportunities and professional affiliations in order to maintain currency and optimise adoption of best practice.

5. Organising, Co-ordinating and Reporting

• To participate in Delivery Unit Quality and Standards group meetings/Q Hubs which will oversee progress with the Delivery Unit audit work plan (providing regular updates), as well as reviewing draft audit reports, and agreeing & reviewing action plans.
• To support the development of appropriate forums and networks for the presentation and discussion of clinical audit and quality improvement report findings, and to ensure reports are placed on the intranet to share findings.
• To manage personal workload and determine priorities in the context of the Clinical Audit programme/Clinical Audit policy and the QI strategy/programme. The post holder will however be guided and advised by the Deputy Head of Quality Improvement and Trust Clinical Audit Lead and the Head of Quality Improvement
• Ensuring oversight of project deadlines, milestones and where these are at risk, ensure timely escalation.
• To provide appropriate summary information for a range of corporate reporting requirements, e.g. quarterly and half-yearly progress updates for Quality and Standards Committee, Audit and NICE sub group, the Annual Quality Accounts, and Medicines Safety audit reporting schedule.
• To facilitate project/audit leads in producing final reports/posters/presentations at the end of clinical audit and quality improvement project cycles; and on the occasions where this duty falls to the post holder, to produce such reports to a high standard, with the support of the project lead.

• Produce a range of clear and concise formal and informal communication styles with and for a variety of individuals, teams and organisations. This may be technical/non-technical, highly complex, sensitive and potentially contentious at times.

6. Data Management and Analytical Skills

• To use appropriate software for data handling for projects e.g. auditing software, excel spread sheets, Reportzone and only other procured departmental systems

• Understanding, analysing and interrogating data, presenting it in a variety of formats such as bar charts, pie charts, and statistical process control charts (SPC)

• To advise staff on data extraction from manual or computerised records. Liaise with the information department (BI) in relation to options for data extraction for both audit sampling and reporting purposes as well as opportunities to feed data directly into SPC charts to support measurement for improvement.