Clinical audit and improvement manager

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Detailed job description and main responsibilities

Human resources:

1. Provide active first line management of departmental staff including recruitment, induction, sickness/absence monitoring, appraisal and personal development plans in line with processes.

2. Lead the departmental team to implement, deliver and adhere to national, regional and Trust initiatives, guidelines, policies and procedures such as confidentiality, health & safety.

3. Develop and implement training and development opportunities for departmental staff.

Physical and financial resources

1. To be aware of budgetary controls and monitoring and support the budget holder in this.

2. Contribute towards the procurement and maintenance of all physical assets, including IT equipment and software.

3. To be responsible for the safe and proper use by users of IT equipment and software such as Snap, Tableau.

Service

1. To contribute to and implement the clinical audit and improvement strategy and produce policies for the department in line with national and local clinical governance priorities.

2. To co-ordinate the development of the Trust clinical audit and improvement programme, reflecting national, regional and local priorities including the requirements of NICE, national audit programme, PSIRF, quality improvement priorities and CQC outcomes. To maintain a database of all types of projects to ensure there are accurate records, communication and planning.

3. To coordinate the process for reviewing, monitoring and reporting progress with national guidance in the Trust. To maintain a database of responses ensuring that relevant guidance is included in the Clinical audit and improvement programme to confirm compliance. To support individual guidance leads and managers to assess and implement guidance, including carrying out risk assessments.

4. To oversee the project management of the clinical audit and improvement programme, delegating and prioritising work as appropriate within departmental resources.

5. To act as the QICA lead within the Clinical Outcomes & Data Unit, contributing to the implementation of the Clinical Outcomes Data Strategy, the functioning of the unit via the CODU Steering Group and the triage of projects.

6. To develop and oversee the Trust clinical audit database to support regular reports, archive, classification and management of projects.

7. To provide regular reports of audit and improvement activity and findings to divisions, governance committees and the Trust Board, including the trust's annual Quality Accounts and annual clinical audit and improvement reports.

8. To provide evidence and act as lead for relevant CQC outcomes (clinical audit & national guidance).

9. To work closely with a wide range of healthcare professionals to ensure that appropriate clinical audit and improvement tools are designed to measure standards of care and deliver improvements where indicated.

10. To communicate efficiently with staff at all levels, including the presentation of the results of complex projects to small and large groups.

11. To promote good practice at all stages of projects, requiring advice and technical support:

• project planning:

1. To ensure appropriate use of the local project proposal process
2. To organise meetings with relevant participants to establish clear aims and objectives of the project and responsibilities of staff taking part

• design and methodology:

1. Undertaking fieldwork as necessary including population and sample definition
2. Design and co-ordinate questionnaires and other data collection tools as required, including encouraging and supporting data requests from the Trust's EPR

• data collection:

1. Use tools provided to retrieve information from the EPR when is cannot be extracted
2. Occasional review of patients' records to support audit processes
3. To support data quality and use of electronic information sources

• Analysis/Interpretation:

1. Design databases/spreadsheets to prepare statistical analysis using relevant software including Snap, Access and Excel
2. Undertake analysis of data and produce preliminary reports for interpretation with participants

• Reports and action plans:

1. Produce detailed reports integrating all information extracted from data analysis
2. To advise on recommendations and improvement planning
3. To facilitate the change process to ensure maximum benefit to patient care

• Presentation and dissemination:

1. Organise presentation seminars to disseminate results of audits (Trust wide)
2. Produce comprehensive presentation slides (Powerpoint)
3. Present reports to participants, interested groups and committees.
4. To support clinicians to submit projects for publication through appropriate media (journals, posters and conference presentations)

12. To resolve conflicting situations about complex queries arising from projects and raise issues with data quality appropriately.

13. To act as a core member of the Clinical and Research Governance Committee, to attend and facilitate pre-meetings and committee meetings to ensure NICE guidance implementation is supported and monitored, opportunities for clinical audit and improvement are identified and concerns from QICA are escalated

14. To attend committees as required to provide clinical audit and improvement advice and promote a quality improvement culture as appropriate.

15. To contribute to supporting arrangements for managing clinical audit and improvement within Divisions.

16. To undertake the provision of training to Health Care Professionals and other staff as required in clinical audit and improvement, including on Trust induction.

17. To oversee the maintenance of the Clinical Audit and improvement intranet pages as an information and training resource for the trust.

Professional Requirements

1. To develop professional and personal skills through continual professional development and training in clinical audit and improvement, clinical governance and quality improvement activities.

2. Participate in meetings and activities at local, regional and national level; specifically, the National Quality Improvement and Clinical Audit Network (NQICAN) and NICE managers forum.

Freedom to act

1. The postholder has significant discretion to work within a set of defined parameters.

2. Work autonomously, prioritising own workload.

Person specification

Qualifications

Essential criteria

• Degree or equivalent level of experience
• Evidence of continuing professional development

Desirable criteria

• Recognised qualification in clinical audit or quality improvement

Experience

Essential criteria

• Experience of managing clinical audit and quality improvement projects
• Line management experience
• Evidence of effective people management and leadership skills
• Extensive IT knowledge across a range of areas including Microsoft Office, and clinical systems
• Experience of data management (design, data abstraction, analysis, and presentation)
• Exposure to national frameworks, including NICE guidance and the modernisation agenda
• Developing and delivering training programmes

Desirable criteria

• Use of relevant software (eg Snap)

Skills

Essential criteria

• Excellent communication skills
• Effective project management skills to meet deadlines
• Ability to present written and verbal information effectively
• Strong analytical skills and ability to interpret and manage large volumes of complex, sensitive or contentious information
• Well-developed time management skills with an ability to deliver to multiple and conflicting deadlines
• Ability to work flexibly as part of a multi-disciplinary team

Desirable criteria

• Ability to critically appraise relevant literature

Knowledge

Essential criteria

• Detailed knowledge of clinical audit and improvement tools and methodologies
• Extensive knowledge of the NHS including current initiatives relating to quality and improvement
• Clear understanding of the principles of Clinical governance
• Understanding of General Data Protection Regulation and confidentiality

Desirable criteria

• An understanding of clinical terminology

Values

Essential criteria

• Ability to demonstrate the organisational values and behaviours

Other

Essential criteria

• Ability to think creatively with excellent problem-solving skills
• A self-starter with the strength of character to influence others
• Organised and logical approach to work and high-level attention to detail

The closing date for this post may be extended if there are insufficient applicants or brought forward if there is a high volume of applicants.

We want to ensure that everyone who works at the Christie or uses our services is welcomed, valued and treated with dignity and respect. The Christie values diversity and is committed to ensuring equal opportunities for all and fair representation across the organisation at all levels. In support of these commitments, we particularly welcome applications from Black, Asian and other ethnic minority people and people with disabilities for this post. Appointment will be only on merit.

We are committed to creating a balanced and diverse workforce. As such we welcome and encourage applications from people of all backgrounds. Together we will foster inclusion and tackle inequity and health inequalities in cancer care.

As users of the disability confident scheme, we guarantee to interview all disabled applicants who meet the minimum criteria for the vacancy

All positions within the Christie are subject to the receipt of satisfactory written references, medical clearance and evidence of your Right to Work in the UK. Some roles will require a Disclosure & Barring Service (DBS) check. Please note if you are successfully appointed to a post with this Trust, you will be required to pay for your own DBS Disclosure.

By applying for this post you are agreeing to The Christie NHS Foundation Trust transferring the information contained in this application to its preferred applicant management system. If you are offered a job information will also be transferred into the national NHS Electronic Staff Records system. Please note, all communication regarding your application will be made via email, please ensure you check your junk/spam folders as emails are sometimes filtered there.

If you have not heard from us within four weeks of the closing date, I regret that on this occasion your application will have been unsuccessful.

The Inter-Authority Transfer (IAT) process is a critical and beneficial component of ESR and will form part of the recruitment process. In the event that you are successful following interview your previous NHS employment data, if applicable will be transferred from your current / most recent employer.

Overseas candidates wishing to apply for this position and who would require immigration sponsorship, may wish to self-assess the likelihood of obtaining a Certificate of Sponsorship for the post on the UKVI website.

You should be aware the Trust operates a No Smoking Policy and therefore employees are not permitted to smoke at work.

Employer certification / accreditation badges

Applicant requirements

The postholder will have access to vulnerable people in the course of their normal duties and as such this post is subject to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service to check for any previous criminal convictions.

Documents to download

• Job Description and Person Specification (PDF, 261.2KB)
• The Christie Values and Behaviours (PDF, 919.5KB)
• Strategy Brochure (PDF, 1.0MB)
• Travel to The Christie (PDF, 3.8MB)