26UHWM0605 Temporary Grade VIII - Quality and Patient Safety Manager

University Hospital Waterford•Waterford, MI

2d•Onsite

About The Position

This role provides strategic and operational leadership in quality and patient safety for hospital staff and management. It involves developing and implementing governance structures, risk management systems, and monitoring service quality. The manager will collaborate with regional and national health bodies, ensure compliance with standards (like HIQA), and manage incident reporting and investigation processes. Key responsibilities include driving quality improvement initiatives, managing complaints, and fostering a culture of safety and learning. The role also involves developing training plans for staff and management on quality and safety protocols, and overseeing the hospital's quality management systems.

Requirements

Working knowledge of the current HSE’s Patient Safety Strategy.
Working knowledge of Health Information and Quality Authority (HIQA) Standards.
Knowledge of Standards of Safer Better Healthcare.
Knowledge of National Standards for the Prevention and Control of Healthcare Associated Infections.
Knowledge of Hygiene Standards.
Compliance with associated HSE protocols for implementing and maintaining standards.
Understanding of the HSE’s Incident Management Framework.
Understanding of the Patient Safety Act.
Experience in managing and monitoring incidents in line with HSE policies and frameworks.
Experience in disseminating learning from incident reviews.
Experience in providing reports and presentations to Executive Management Teams.
Experience in managing complaints in accordance with HSE National Complaints policy.
Experience in leading the implementation of nationally agreed Standards.
Experience in providing ongoing monitoring and coordinating action plans.
Experience in acting as a focal point for QPS Reporting.
Experience in ensuring quality and risk management functionality is effective.
Experience in leading the development of Quality Improvement, Quality Assurance, and Risk Management programmes.
Experience in monitoring, evaluating, and reporting on plan implementation.
Experience in reviewing and making recommendations on quality and safety concerns.
Experience in establishing communication and management structures for safety incident management.
Experience in coordinating data collection, measurement, and presentation for quality and patient safety indicators.
Experience in keeping abreast of quality, safety, and risk management issues.
Experience in developing and implementing organizational-wide risk management and complaint management structures.
Experience in developing and monitoring key performance indicators for risk management.
Experience in providing expertise and support in risk register management.
Experience in liaising with external stakeholders.
Experience in coordinating the development, implementation, and monitoring of risk management policies.
Experience in providing analysis and reports on adverse patient safety incidents and claims.
Experience in reviewing past patient incidents and analyzing data.
Experience in managing outcomes and monitoring recommendations/implementation of Action Plans and QIPs.
Experience in working with Executive Management Teams to identify priorities for quality improvements.
Experience in promoting and supporting patient engagement.
Experience in participating in the development, implementation, and monitoring of Quality Improvement plans.
Experience in supporting management and multi-disciplinary teams in quality improvements.
Experience in developing hospital quality programmes.
Experience in supporting multi-disciplinary teams in delivering the HSE quality programme.
Experience in promoting and supporting the use of quality improvement methodologies.
Experience in providing reports on the monitoring of quality improvement programmes.
Experience in supporting reporting responsibilities on quality and safety.
Experience in maintaining a register of Quality Improvement Projects.
Experience in quality data collection and reporting.
Experience in monitoring governance frameworks for quality and safety.
Experience in ensuring committees function effectively.
Experience in providing support for committee management.
Experience in providing information to hospital groups and committees.
Experience in developing annual plans for clinical audits / service evaluations.
Experience in maintaining registers of research projects, clinical audits, and service evaluations.
Experience in collating statistics on quality and safety outcome measures.
Experience in benchmarking trends against KPIs.
Experience in leading hospital quality improvement strategies.
Experience in leading and participating in accreditation processes.
Experience in managing a Hospital Quality Document Management System.
Experience in developing Document Control policies.
Experience in promoting transformational and facilitative leadership.
Experience in fostering a culture of openness and learning.
Experience in promoting team-based performance management.
Experience in delivering training plans for managers on Quality & Patient Safety.
Experience in building capacity and capability in Senior Managers in quality improvement programmes.
Experience in providing training and advice on Risk Management, Incident Management, Clinical Audit, Quality Improvement, and Complaints Management.
Experience in participating in training and induction programmes.
Experience in identifying and facilitating educational development needs of staff.
Commitment to sustainable energy, water, and waste initiatives.
Ability to act as spokesperson for the Organisation.
Pro-active commitment to communications with internal and external stakeholders.

Nice To Haves

Experience in managing the Hospital Quality Document Management System (currently HCI Knowledge/Q-Pulse).

Responsibilities

Provide strategic and operational leadership and direction on all aspects of quality and patient safety.
Lead the implementation of the hospital’s accountability and governance structure for quality and safety.
Develop and implement focused management, operation planning, and control systems for monitoring quality and safety.
Ensure a strong proactive approach to risk identification and mitigation.
Develop collaborative working in quality and safety with regional and national health bodies.
Ensure clear structures are in place to identify, report, and investigate serious incidents and reportable events.
Ensure continuous self-assessment of current practices and identification of gaps versus best practice.
Manage and monitor all incidents in line with HSE policies and frameworks.
Disseminate learning from incident reviews at local and national levels.
Work to reduce clinical incidents and improve the quality and safety of patient care.
Provide reports and presentations to the Executive Management Team on investigations and action progress.
Ensure complaints are dealt with promptly in accordance with the HSE National Complaints policy.
Lead the implementation of nationally agreed Standards, including HIQA Standards and National Clinical Guidelines.
Provide ongoing monitoring and coordinate action plans to address areas of non-compliance.
Act as a focal point for all internal and external Quality & Patient Safety (QPS) Reporting.
Ensure quality and risk management functionality is effective and timely for dissemination.
Lead the development of the hospital’s Quality Improvement, Quality Assurance, and Risk Management programmes.
Monitor, evaluate, and report on the implementation of the plan across the hospital.
Review and make recommendations on all significant quality and safety concerns.
Work with hospital leadership to reduce clinical incidents and improve patient care quality and safety.
Establish appropriate communication and management structures for safety incident management.
Coordinate the collection, measurement, and presentation of data for quality and patient safety indicators.
Keep abreast of quality, safety, and risk management issues and coordinate implementation of actions.
Develop and implement effective, organizational-wide risk management and complaint management structures.
Develop and monitor key performance indicators for risk management.
Ensure the provision of expertise and support in the management and maintenance of the hospital’s risk register.
Liaise with external stakeholders for timely collation and submission of relevant information.
Coordinate the development, implementation, and monitoring of all risk management policies.
Provide analysis, including reports on adverse patient safety incidents and claims, to identify trends and opportunities for improvement.
Provide hospital committees with relevant information on risk management.
Review past patient incidents and analyze data to inform risk management priorities.
Coordinate outcomes and monitoring of recommendations/implementation of Action Plans and QIPs following SIMT review.
Ensure regular reports/presentations are provided regarding the performance of risk management structures.
Work with the Executive Management Team in identifying priorities for quality improvements and monitoring compliance with National Standards.
Promote and support the engagement of patients and the measurement of patient experience.
Promote and encourage patient involvement and engagement via the Patient Partnership Forum.
Participate in the development, implementation, and monitoring of Quality Improvement plans/action plans.
Support hospital management and multi-disciplinary teams in assessment and quality improvements.
Develop the hospital quality programme in line with strategic plans and national standards.
Support all members of the multi-disciplinary team in delivering the HSE quality programme.
Promote and support the use of agreed quality improvement methodologies.
Provide reports to the Executive Management Team on the monitoring of the quality improvement programme.
Support the Executive Management Team in their reporting responsibilities on quality and safety.
Maintain a register of all Quality Improvement Projects and monitor their progress.
Oversee quality data collection and reporting.
Monitor the governance framework for quality and safety within the hospital.
Ensure all committees are functioning effectively and providing regular reports.
Provide support and expertise for the effective management of the Quality and Patient Safety Committee.
Provide timely relevant information relating to quality and safety to various hospital groups and committees.
Continue to develop an annual plan for clinical audits / service evaluations.
Maintain a register of research projects, clinical audits, and service evaluations and monitor progress.
Collate statistics on quality and safety outcome measures and provide reports monthly.
Benchmark trends against relevant Key Performance Indicators (KPIs).
Lead a hospital quality improvement strategy with initiatives for a safe, effective, and sustainable service.
Lead and participate on the hospital’s agreed accreditation process and other quality management systems.
Lead on the Management of the Hospital Quality Document Management System.
Develop a Document Control policy.
Promote a transformational and facilitative leadership style.
Foster a culture of openness and learning from errors.
Promote the use of management tools and initiatives such as team-based performance management.
Deliver a training plan for managers regarding Quality & Patient Safety expectations.
Promote the building of capacity and capability in Senior Managers in quality improvement programmes.
Ensure training and advice on Risk Management, Incident Management, Clinical Audit, Quality Improvement, and Complaints Management are provided.
Participate in other training and induction programmes as needed.
Identify and facilitate educational development needs of staff within the Quality and Patient Safety Department.
Support, promote, and actively participate in sustainable energy, water, and waste initiatives.
Act as spokesperson for the Organisation as required.
Demonstrate pro-active commitment to all communications with internal and external stakeholders.