Job overview

The Governance Lead Nurse will work alongside and support the Critical Care Matron in providing a high quality service to all key stakeholders and users across the organisation. Deputising at meetings where appropriate and working alongside other governance leads within the acute pathway.

To provide specialist advice to the Critical Care Department regarding legislation, guidance and the regulatory framework relevant to the management of clinical risk and to improving clinical standards and patient safety.

Main duties of the job

To lead on the identification of risks associated within the speciality; develop and implement action plans, attend local and speciality and pathway meetings, reporting progress on an ongoing basis.

To provide guidance and support in the implementation of clinical standards (quality) initiatives in line with the Trust’s clinical risk management and Health and safety framework.

To lead on the investigation and analysis of incidents associated or related to the speciality or its work streams, developing and implementing actions plans, providing feedback, quarterly reviews/reports as appropriate.

To support the implementation of clinical audit and other clinical effectiveness processes such tenderable audits as a mechanism for improving quality, risk and safety.

To lead the analysis and reporting of the findings of the above mentioned audits, collating results, formulating action plans and leading the implementation and ongoing review of them.

To support delivery of an integrated Clinical Effectiveness and Audit Plan and ensure this is consistent with the Trust’s Clinical Effectiveness and Audit Policy.

For other duties please refer to the job description.

Working for our organisation

Every day, our teams at Nottingham University Hospitals NHS Trust (NUH) make a difference. We save lives, we improve lives and we usher in new life. We are proud to play a central role in supporting the health and wellbeing of people in Nottingham, Nottinghamshire and our surrounding communities.

With more than 18,000 colleagues, we are the largest employer in Nottinghamshire and one of the biggest and busiest NHS Trusts in the country, serving more than 2.5m residents of Nottingham and Nottinghamshire and a further four million people across the East Midlands and beyond.

We provide a range of national and internationally renowned specialist services and we are at the forefront of new surgical procedures and research programmes. We are home to the East Midlands Major Trauma Centre, the Nottingham Children's Hospital and in partnership with the University of Nottingham we host a Biomedical Research Centre carrying out vital research into hearing, digestive diseases, respiratory, musculoskeletal disease, mental health and imaging.

As a teaching hospital, we are instrumental in the education and training of doctors, nurses and other healthcare professionals. We are proud of our strong relationships with universities across the East Midlands, including the University of Nottingham, Nottingham Trent University and Loughborough University.

This is an exciting time to join NUH and help support our future ambitions.

Detailed job description and main responsibilities

• Provide clinical expertise, specialist advice and support across the whole spectrum of the theatre services related to the quality and safety agenda.
• Be an expert clinical practitioner, prioritising and planning workload to include the ability to work in clinical practice. Support the specialty in providing a clinical response in line with its key objectives.
• To work in a clinical capacity as appropriate to maintain competence and to support the Critical Care team delivery of key services.
• To collaborate and shadow the other clinical teams on a regular basis, to ensure a good understanding of the whole speciality.

• Actively seek ways to involve and promote patient and public involvement in service design and delivery. Ensure that feedback and comments are included in service and department reviews and that these are used to improve services for Critical Care.
• Contribute to the Divisional and Service strategies for raising the profile of patient and public involvement.

• Maintain the principles of governance by encouraging achievement of standards of excellence, which are underpinned by open communication and team working across all disciplines and to support the Pathway and Division and any future developments to the Trust Governance/ Assurance structure.
• Ensure effective communication between all service providers within the speciality in relation to the quality, risk and safety agenda by attending specialty meetings and representing the specialties at trust meetings as required.
• Represent the specialties at local and national networking to maintain and develop knowledge in governance and patient safety. Present outcomes of local research and developments, both internally and external to the trust.
• Support the development of and implement a system of feedback to all staff that incorporates the outcomes of incident investigation such as Serious Incidents (SI’s) including creating clear actions to support learning.
• Ensure that the importance and implications of education, research, and ideas are raised in appropriate forums.
• To support the development of the ‘Shared Governance’ Structure in Critical Care.

• Support the implementation of education and training relating to quality, risk and safety to all members of staff and students in collaboration with the Education Team and Quality Improvement Leads (QILS) in Critical Care.
• Work with multi-professional staff across the services to ensure that staff understand the national standards of care, the role of the Care Quality Commission and NHS Resolution and provide support to deliver these standards consistently.
• Use Safety forums and Networks proactively sharing good practice and innovation with others. Attend and participate in the relevant groups within the Acute Directorate and disseminate information to the clinical teams.
• Ensure that the training needs of all disciplines of staff in relation to the quality risk and safety agenda are included in the annual Training Needs Analysis and action plans to address gaps are in place.
• Contribute and participate in the continuing development of all staff working with alongside the Critical Care Clinical Educators and other Governance leads across the specialty and the Directorate.
• Undertake personal professional development, seeking opportunities to enhance skills as identified via a personal development plan. Work alongside peers within the Directorate and wider Division, sharing best practice and collaborating.

• Support the Clinical Effectiveness Leads in the co-ordination of the clinical effectiveness agenda ensuring a robust framework is embedded across the speciality and pathway ensuring they remain responsive to the changing needs of the service and health policy.
• Contribute to the production and prioritisation of systems, plans and work programmes to ensure improved clinical quality and incorporate the Trust’s priorities outlined in its objectives for clinical effectiveness.
• To assist, collate and analyse data in preparation and for the presentation of reports on clinical governance topics to the relevant forum when required. For example:

• Audit and Research projects, programmes and initiatives
• Risk Registers
• Patient involvement/experience feedback
• Incident investigation reports/analysis of incident trend data
• Evaluation of training within the department
  • Monitor the delivery of the key components of clinical effectiveness, report any variance from the plan, and recommend corrective action to the Critical Care Matron/ Speciality Lead/ Pathway Medical Lead/ Pathway General Manager and Pathway Lead Nurse.
  • Influence and develop policy and clinical guidelines internally.
  • Work with others to undertake Incident Review Meetings detailed reports (IRM) on Moderate Harm and Serious Incidents and reporting outcomes to Acute Directorate Governance group. Support others to develop the skills associated with IRM’s..

• Contribute to the development of and co-ordinate the delivery and implementation of the clinical governance and risk management strategies, policies and work programme, for the Specialty within the Acute Directorate.
• Support multi-professional staff in the identification and assessment of risk
• Ensure the local risk register is maintained and report into the Quality, Risk and Safety meetings at Specialty, Directorate and Divisional level.
• Work with Medical Leads, Matrons, Governance Leads, PDM’s, Ward managers and deputies to facilitate the implementation of new ways of working that benefit patient safety and the patient user experience.
• Co-ordinate patient safety initiatives across the Specialty and lead on specific patient safety initiatives as required.
• Establish and maintain a system for the distribution and record actions following safety notices alerts etc.

• Provide leadership and expert advice on clinical effectiveness, patient safety and quality, and co-ordinate all aspects of clinical governance ensuring integration of corporate clinical effectiveness objectives.
• Contribute to a culture of positive performance management through leadership, working with clinical teams, to agree monitoring arrangements for the setting and maintenance of high standards of practice.
• Provide clear information, and support staff wishing to raise concerns about standards of care delivery or service provision and advice for staff regarding Duty of Candour requirements.
• Ensure the involvement of all staff through open and direct communication to sustain a high level of commitment and flexibility from the workforce, supporting Trust initiatives.
• Actively contribute to strategic and operational developments relating to the Speciality and Pathways nursing services, so that high quality patient focused services are promoted.
• Provide line management responsibilities if appropriate, in line with the ward Manager Band 7 job description for the trust.