Donna Wilkes

· Resource and support the implementation of Centacare’s Practice Governance Framework as required by the General Manager Practice Governance and in close collaboration with the PGU and other key stakeholders.

· Contribute to and support the Head of Client Risk & Safeguarding in making recommendations relevant to the role, including practical resourcing for non-clinical staff to ensure optimal, sustained outcomes for clients.

· Identify, review and report reportable incidents as determined by NDIS, SIRS, QCSS and VHC. Ensure reportable incidents are reported within mandated timeframes.

· Apply a quality framework to improve service delivery and provide recommendations for continuous improvement.

· Actively promote and support a robust and open practice governance culture.

· Manage the responsibilities of the role within all current Legislation, Standards and Policy.

· Undertake all formal reporting requirements relevant to the responsibilities of the role, as required by the Head of Client Risk & Safeguarding and General Manager Practice Governance.

· Manage the procedures and processes outlined in Centacare’s Open Disclosure Framework.

· Undertake open discussions (or resource and support identified operational staff) with clients, carers, family members and statutory bodies in line with the Framework and relevant Standards and Guidelines as required.

· Monitor, assess and report information about the quality and safety of supports and services to clients.

· Undertake a review of the evidence-base and efficacy of current policies, procedures, tools and the best application for non-clinical staff (at all levels) as required within the PGU.

· Undertake research and provide subject matter expertise input into all relevant areas of organisational policy and procedure, and practices.

· Support in the implementation of all relevant organisational policy, procedure and practice.

· Identify, prevent and escalate risks and reportable incidents as required.

· Provide advice and support senior management, clinical divisions, external health agencies and other stakeholders on developing, implementing and maintaining effective HHS wide patient safety systems and continuous improvement activities.

· Facilitate the development, coordination, delivery and evaluation of patient safety an d quality improvement management activities relating to safety and quality improvement portfolios, clinical reviews and data review processes and reporting.

· Support and undertake critical analysis of clinical care standards, delivery and outcomes compared with contemporary clinical practice both nationally and internally to achieve best practice supporting clinical incident reviews by leading review teams or participating in review teams for more complex matters.

· Provide education, training and assistance to clinical areas on quality improvement activities, clinical incident management, patient safety and evaluation processes, maintaining relevant online registers as required by GCHHS policy and procedures.

· High level knowledge of and expertise in systems and legislation as it relates to health service governance, patient safety, complaints management, accreditation and quality systems.

· Experience in clinical governance functions relevant to my role.

· Comply with policies, procedures and instructions relating to work health and safety that are relevant to my role.

· Ensure safer work practices, procedures and controls are in place that are specific to the hazards within the area as set out in the work health and safety legislation and relevant codes of practices.

· Coordinate accreditation requirements for residential aged care and community services.

· Act as an key internal contact for all quality reviews and accreditation

· Support the CEO and Executive in managing the Board Clinical Governance committee

· Support development and implementation of the quality work plan

· Monitor incidents for trends and assist Residential Managers to identify trends and actions for improvement

· Facilitate audit processes from design, implementation, collation, reporting and manage actions

· Attend Facility Team Leader meetings to provide advice and assistance with continuous improvement of quality systems, processes and outcomes

· Lead quality improvement across the organisation including refinements to models of care and streamline our response to compliance

· Advise on best practice quality systems and approaches

· Develop, monitor and report on Quality Indicators

· Act as resource to staff on continuous quality improvement implementation, monitoring and evaluation

· Develop, review and quality check all policies and procedures prior to publishing

· Ensure mandatory reporting requirements are lodged within allocated timelines

· Support the development of Quality Audit reports

· Understand the monitoring in place for programs, including performance and compliance against contracts in conjunction with the Customer Experience Manager

· Manage and oversight the program of scheduled reviews, evaluations and research

· Develop evaluation plan template for relevant programs and projects

· Connect with other quality managers across the sector to share best and emerging practice

· Connect across the organisation to understand how to improve quality outcomes and processes

· Attend program area meetings where feasible e.g. Community Quality Meeting, Team Leader Meetings, Medication Advisory Committee, Work Health & Safety Committee

· Assist with the management of clinical information management system (iCare), e-learning system (Altura), governance, risk compliance system (ionMy), My Aged Care Portal, Sharepoint, OneDrive and other software systems as required

· Provide leadership and expert quality management that is informed by the Chair/Board, executive teams and service line managers to assist in meeting identified healthcare outcomes and improve efficiency and client safety through implementation of best practice, system manager key performances indicators and the Aged Care Standards, Aged Care Act 1997, National Safety & Quality health Service (NSQHS) Standards.

· Establish and maintain frameworks, processes and system to continually monitor, review and support evaluation of quality activities and standards of care that align with district priorities and strategic direction.

· Provide strategic direction and priorities for quality improvement in clinical services aligning activities with Aged Care Standards, Aged Act 1997 and ACHS EQuiP National Standards.

· Provide leadership, support and training that assist staff in achieving accreditation.

· Provide direction, support and training in implementation continuous quality improvement concepts, tools and processes that aligns with local, state, national or international quality initiatives.

· Undertake a mentorship role in the professional development of staff and for quality coordinators new to the role, to support a high standard of quality improvement practices.

· Promote a culture of evidence based practice, identify and initiate quality improvements projects and contribute to research in the area of quality improvement.

· Coordination and evaluation of clinical indicator submissions, patient satisfaction surveys and standards of care self-assessments. Ensure data is submitted in a timely manner, and data analysis reports are provided for key forums and staff (eg. clinical governance committee, team and management meetings)

· Provide support, advice, coordination and assistance in the management of directorate clinical review activities, eg. clinical reviews, HEAPS, RCA, mortality and morbidity reviews).

· Liaise and work collaboratively with key national and state-wide quality and safety groups, including data submissions. For example:

- Quality Coordinator Network

- QPS Benchmarking

- Queensland Statewide Bedside Audit

- Consumer Engagement

· Follow defined quality standards, occupational health and safety policies and procedures relating to the work being undertaken in order to ensure high quality, safe services and workplaces.

· Take reasonable care to ensure my own health and safety and take reasonable care to ensure my acts or omissions do not adversely affect the health and safety of others.

· Maintain data quality and manage all information in accordance with legislation, standards, policies and procedures.

· Team Leader for National Standard No. 9 – Recognising and Responding to Clinical Deterioration.

· Develop and review NSQHS accreditation compliance workbook

· Project Manager of quality improvement initiatives

· Review and analysis of clinical incidents and provide support to Nurse Unit Managers in the management of these incidents

· Undertake research on patient safety initiatives

· Conduct regular audits to identify patient safety issues

· Develop policies, procedure and work instructions that are evidence based and align with organisational requirements and national standards

· Deliver and provide education on patient safety issues by attending Ward meetings

· Conduct HEAPS, PRIME CI and other patient safety related training on request

· Coordinate the RCA, HEAPS and clinical review processes

· Manage RCA’s in alliance with Health and Other Legislation Amendment Act (2007)

· Manage all clinical incidents in alliance with the Queensland Health Clinical Incident Management Implementation Standard Version

· Communicate and network with patient safety and quality organisations/groups.

· Attend workshops/conferences that involve new developments, legislation and industry standards with regard to patient safety

· Disseminate information with regard to patient safety to all areas of the hospital.

· Liaise with Directors and Executive members