CLINICAL EFFECTIVENESS CO-ORDINATOR (2 posts)

This post is recognised as a healthcare support worker post.

Salary: Band 5 - £21,388 - £27,901 plus £1,166 High Secure Environment Allowance per annum. 

Hours: Full Time – 37.5 Hours per week    Post details: The post-holder will contribute to continuous improvement

across the organisation and will play a key role in embedding clinical governance to ensure that patients receive the highest quality of care. The postholder will work as part of the Clinical Effectiveness team developing, implementing and supporting clinical effectiveness activity relating to:

Reviews and Inspections/Standards and Guidelines Structured documentation e.g. ICPs and CPA Clinical Audit/Quality Improvement Projects

 Qualifications/Experience: 

Essential: Degree or equivalent clinical qualification Experience in an analytical environment

Desirable: Degree in science, social science, IT or clinical area

Experience: 3 years experience in an analytical environment.

   Interested?

Closing Date:

If you would like to apply for one of these posts please contact Angela Slaven for an application pack on 01555 842084 or e-mail tsh.jobs@nhs.net. For an informal discussion please contact Sheila Smith on 01555 842193

The closing date for applications is 20 November 2013

This post will be also be advertised in SHOW/JOB CENTRE

The State Hospital CarstairsLanark ML11 8RPTelephone 01555 840293Fax 01555 840024E-mail info@tsh.nhs.ukhttp://www.tsh.scot.nhs.uk

Private & Confidential Date 19 May 2023 Your Ref Our Ref Enquiries to Angela Slaven Direct Line 01555 842084 E-mail tsh.jobs@nhs.net

To Whom It May Concern:

VACANCY AT STATE HOSPITAL, CARSTAIRS

Further to your recent enquiry regarding a vacancy, I have pleasure enclosing a recruitment pack for your information.

If after reading this material you are interested in the position, please complete the application form and return it to myself at the address below not later than the date shown on the advert, or alternatively e-mail your completed application form to tsh.jobs@nhs.net

Human ResourcesThe State Hospital

CarstairsLanark

ML11 8RP

Please note it is not our policy to acknowledge receipt of returned applications.

I look forward to hearing from you.

Yours sincerely

Angela Slaven

Angela SlavenHuman Resources

The State Hospitals Board for ScotlandCarstairs, Lanark ML11 8RP

Chairperson Terry CurrieChief Executive Andreana Adamson

JOB DESCRIPTION

1. JOB IDENTIFICATION

Job Title: Clinical Effectiveness Co-ordinator

Responsible to (insert job title): Clinical Effectiveness Team Leader

Department(s): Clinical Effectiveness

Directorate: Finance and Performance Management

Job Reference:

No of Job Holders: 2

Last Update (insert date): 01/03/2013

2. JOB PURPOSE

The post holder plays a key role in embedding clinical governance to ensure that patients receive the highest quality of care. The post holder works collaboratively with staff across the organisation to continuously improve the systems, structures and processes of care delivery in accordance with national and local priorities.

3. DIMENSIONS

The post holder is managerially accountable to the Clinical Effectiveness Team Leader. They will

provide specialist clinical governance and effectiveness advice to clinical and non-clinical staff

either directly to clinical teams or departments or through their membership of key hospital

committees and working groups.

The postholder works as part of the Clinical Effectiveness team developing, implementing and

supporting clinical effectiveness activity relating to:

Reviews and Inspections/Standards and Guidelines

Structured documentation e.g. ICPs and CPA

Clinical Audit/Quality Improvement Projects

The post holder contributes to the development and implementation of the Clinical Governance Strategy and programme of work, and must simultaneously manage a number of different clinical effectiveness activities as well as the delivery of various key corporate objectives that have been allocated to the department.

4. ORGANISATIONAL POSITION

5. ROLE OF DEPARTMENT

The State Hospital’s strategic aims are:

1. Expert, high quality treatment and care delivered by multi-professional teams in safe and secure settings.

2. Patient treatment and care pathways that are focussed on achieving timeous and appropriate admission, treatment and transfer of patients.

3. Maintenance of public, staff and patient safety

The Clinical Effectiveness Department contributes to the achievement of these aims by providing a service which:

Develops and manages the implementation of the Clinical Governance Strategy and Framework and monitors progress through the coordination of reports to the Clinical Governance Committee and through the production of the Annual Clinical Governance Report;

Manages a programme of clinical effectiveness and audit activity to evaluate the quality of care against the evidence base to determine whether it meets best

Head of Clinical and Risk Governance

Clinical Effectiveness Team Leader

Clinical Effectiveness Co-ordinator

Clinical Effectiveness Co-ordinator

Clinical Effectiveness/Risk Administrator

practice; Works collaboratively to continuously improve the systems, structures and

processes of care delivery and improve clinical outcomes; Develops performance management systems including clinical key performance

indicators to monitor the quality of care delivery; Manages a programme of Integrated Care Pathways, based on the key stages of

the patient’s journey admission, treatment and transfer, which embed and report on standards of multidisciplinary care delivery;

Ensures that effective arrangements are in place with national healthcare quality improvement agencies and departments;

Coordinates NHS Healthcare Improvement Scotland reviews including self-assessment exercises, submissions, and review visits. In addition, the department leads the development of appropriate structures and systems so that the organisation is assured that care is being improved in line with national clinical standards;

And is a major contributor to key corporate activities including health planning, IM&T developments including the EPR, performance management, lifelong learning, patient involvement, human rights and the Forensic Mental Health Services Managed Care Network.

6. KEY RESULT AREAS

Education & training Coordinate the planning, design, implementation, delivery and evaluation of clinical effectiveness training to include:

Induction programmes for clinical professions (medical, nursing, occupational therapy, student nurses, social work, dietetic and pharmacy)

Deliver 2 day Clinical Audit workshops to all professions within the hospital Ensure that clinical effectiveness and clinical governance activities are

appropriately reflected in corporate Learning and Development Strategies and Training Plans

Develop, review and co-ordinate the production and dissemination of educational material on the concept, design and implementation of ICPs e.g. leaflets, information folders for wards, and bulletins about ICPs for hospital staff.

Coordinate the production and dissemination of regular communications for staff and patients about clinical effectiveness activities including summaries of findings, new activities, training opportunities etc.

Provide day-to-day support for colleagues by sharing knowledge and experience and actively providing encouragement and feedback.

Support staff throughout the hospital to find, critically appraise and apply evidence of good clinical practice including national clinical standards, guidelines, good practice statements and relevant research articles or reports.

Promote the reputation of the State Hospital and the quality of work undertaken by delivering papers and presentations on clinical effectiveness activities at both internal and external events (conferences and workshops), and by writing for publication (internal bulletin, external journals etc).

Corporate responsibilitiesWorking with departmental colleagues and clinical staff to contribute to the development, implementation and evaluation of the hospital’s Clinical Effectiveness Strategy and development plans and the clinical effectiveness programme of work.

Review and develop appropriate organisational mechanisms to ensure that national clinical standards, guidelines, NICE appraisals, good practice statements, investigations of serious service failures, health technology assessments, performance assessments and national patient safety information notices are disseminated and implemented as appropriate.

Ensure that the Clinical Effectiveness and other Quality of Care issues are addressed through involvement in committees and groups, at both national and local levels.

Prepare and present papers to State Hospital committees and groups. In particular the post holder will frequently prepare reports on a range of issues for the Senior Management Team, the Clinical Governance Committee and, occasionally, the Board. Ensure that the State Hospital’s perspective is reflected in the development of the national agenda through active representation at national fora and influencing activities including information provision, presentations, contribution to discussions and consultation exercises.

Fully contribute to the work of a number of national committees and fora including the Forensic Mental Health Services Managed Care Network.

Support the development of the forensic services nationally through the Forensic Mental Health

Services Managed Care Network by facilitating the work of short-term working groups as

assigned by the Network Board. This involves bringing together short-term working groups, the

formulation of ideas and construction of a plan of work, collation of supporting materials, and

project management of the work of the group including the production of the final report. The post

holder will also be involved in the development of national standards for forensic services.

Actively facilitate, contribute to and project manage the work of a number of State Hospital committees and groups as determined by the national and local priorities by providing specialist advice on clinical governance and effectiveness, and associated quality improvement methods such as service evaluations and reviews, audits, ICPs, surveys, questionnaire design, focus groups, action planning, change management etc.

Reviews and Inspections/Standards and Guidelines

The post holder will facilitate reviews and inspections through: Ensuring standardised approaches to NHS HIS standards activities are promoted Liaising with the lead operational people and assisting in their activities e.g.

o Self-assessment exerciseso Action plan developmento Report writing & reporting to the various groups

Liasing with outside organisations e.g. NHS HIS and other services Preparing reports to the various groups as necessary (i.e. collation of individual

reports) Collating and presenting information on the service contribution to the national

picture Attending IT/Audit network events Ensuring that the necessary Clinical Effectiveness projects relating to the

standards are undertaken

Structured documentation e.g. ICPs and CPA

Co-ordinate the planning, design, implementation, delivery and evaluation of ICPs for the organisation. This responsibility is across all levels within the organisation, from agreeing the strategy/ developments with the senior management team and providing high level information, to working with individual clinicians in the ward. The postholder is responsible for gaining commitment at all levels to ensure the continuing success of ICPs.

Create, update, implement and evaluate the structures, roles and systems required to support ICPs in consultation with appropriate staff and management. For example ICP link nurse system, ICP intranet system, systems to maintain ICPs throughout the hospital. Ensure that adequate systems are in place to support succession planning.

Organise, co-ordinate, motivate, and negotiate with clinical staff and management to facilitate the development of multidisciplinary ICPs, which focus on the needs of the patient and support the delivery of packages of care across disciplines and with other agencies. Use facilitation skills / change management skills with clinicians to ensure clinical practice is driven forward and appropriate national standards of care are incorporated into ICPs.

Design ICP variance reports to meet the needs of the clinical teams to ensure maximum impact and provide feedback/information on a regular basis for clinical teams. The postholder should also use change management skills to engage staff in discussions about practice, gain consensus for improvements and also how to resolve identified problems.

Clinical Effectiveness/Quality Improvement Project Work Work with Clinical Teams to develop and implement core programmes of ward-based projects, which each team will participate in facilitating benchmarking and peer review.

Ensure that clinical effectiveness training is in place to support the development of the competencies necessary to ensure the delivery of ward-based programmes. Work with teams to explore variations in practice, establish appropriate peer review mechanisms and use consensus methods to identify areas for improvement.

Co-ordinate, conduct and deliver on a portfolio of clinical audit projects at any one time, each at different stages of development. Within this portfolio ensure that individual clinical audit projects are managed and supported in accordance with the Clinical Effectiveness Department Best Practice Statements including: Planning and designing the project from inception in collaboration and consultation

with relevant staff and patients leading to the production of an agreed project plan. Extraction of clinical data from a variety of sources e.g. clinical electronic systems,

paper records. Determining and carrying out complex analysis and interpretation of data Presentation of results at local and national level and report writing Development and provision of clear structured reports that allow clinicians to base

decisions relating to patient care on accurate, easily interpreted and meaningful information.

Development of databases to allow storage and retrieval of data. Performing quality assurance of data collected to ensure a high level of accuracy (e.g.

checking for data collection and entry errors) Ensuring that project teams receive appropriate information in a timely manner Action planning Change Management Re-audit

Maintain and promote a responsible approach to confidentiality, adhering to the Caldicott Principles and the Data Protection Act, with particular regard for patient or staff specific information and other sensitive documents and reports.

Departmental responsibilitiesContribute to the development and implementation of the Clinical Effectiveness Strategy by working closely with the Clinical Effectiveness Team Leader.

Assist in the selection process of new staff through contributing to recruitment and selection including; the development of job specifications, job descriptions, adverts, interview schedules and interviews.

Assist in the PDP process of the Clinical Effectiveness and Risk Admin Assistant.

Discuss issues of departmental staff performance with peer colleagues and line manager and, where appropriate, develop and implement approaches to manage performance

Assist in the development of and implementation of departmental procedures and Clinical Effectiveness Department policies and procedures e.g. Best Practice Statements for Clinical Effectiveness Projects and working documents for Clinical Effectiveness projects.

Ensure that Hospital policies and procedures are understood and adhered to at all time.

7a. EQUIPMENT AND MACHINERY

The post holder should demonstrate a good working knowledge of office equipment including a desktop computer system, laser jet printer, ink jet printer, safe haven fax, photocopier, shredder, and document binder.

Windows applications: Word, Excel, PowerPoint, Access, Outlook Express and Internet Explorer.

Other applications include the State Hospital Intranet, DATIX and RiO.

Presentation equipment including; overhead projector, laptop for presentations, microphone, screen and flip chart.

Be familiar with and understand how to use the hospital radio system in order to escort visitors and the personal alarm system.

Be familiar with and understand how to use the electronic key dispersal systems, lanyards and belts to ensure a safe and secure environment when acting as the key-holder for a building.

7b. SYSTEMS

Establish, develop and maintain a range of IT solutions to manage data obtained from audit projects and other clinical effectiveness activities e.g. excel spreadsheets, access databases, word documents

Creating, maintaining and modifying the general and project specific systems (both manual and electronic) within the department, e.g. appropriate filing of electronic and paper records.

8. ASSIGNMENT AND REVIEW OF WORK

The post-holder is responsible for identifying and managing a programme of clinical effectiveness activities, which meets both national and local priorities. Thereafter, the workload of the post holder is generated primarily from these clinical effectiveness projects and committees and working groups. The nature of the work varies according to both the task and what experience and skills other staff members are able to offer. As a Clinical Effectiveness Co-ordinator, the post holder has flexibility in how this work is undertaken through collaboration with all those involved. As there is a departmental emphasis on team working, the overall approach taken and the outcome of the work is always discussed and the outcome reviewed by the Clinical Effectiveness Team Leader This also maximises the sharing of skills and experiences and ensures that the Clinical Effectiveness staff are kept up to date on each other’s activities.

9. DECISIONS AND JUDGEMENTS

The workload of the post holder is under the direction of the Clinical Effectiveness Team Leader. The post holder has flexibility in how the pre-determined aims and objectives are met. To this end, the post holder is responsible for managing their own workload under the broad direction of the Clinical Effectiveness Team Leader. The post holder will have an Annual Personal Development plan with objective setting, an interim review at 6 months and monthly meetings with the Clinical Effectiveness Team Leader.

On a daily basis the post holder is responsible for assessing, deciding (through drawing on experience) and managing the programme of work in relation to competing priorities.

They must be able to anticipate problems and develop solutions without being asked on a regular basis

10. MOST CHALLENGING/DIFFICULT PARTS OF THE JOB

Ensuring clinicians use the results of clinical effectiveness projects to change and improve clinical practice.

Ensuring clinical teams use ICPs and variance reports to change and improve clinical practice.

Articulating the importance of, and establishing credibility and active participation with all staff involved in responding to the clinical effectiveness programme of work.

Keeping on top of an ever-changing workload which consists of competing and altering priorities – all of which in themselves, present complex project management challenges.

Working with different disciplines to achieve consensus on standards of clinical practice.

The job is varied , requiring innovative and flexible thinking

Complex data analysis and development of comprehensive clinical audit databases

Presenting and discussing controversial information (e.g. findings and recommendations from audit projects) to staff groups, some of whom may be resistant.

Making sure that, at all times, the postholder articulates information with tact and diplomacy.

Explaining complex analytical techniques used in the clinical effectiveness field in terms that are always easily understood.

11. COMMUNICATIONS AND RELATIONSHIPS

InternalThe post holder communicates directly with the Clinical Effectiveness Team Leader and Clinical Effectiveness Department colleagues (refer to organisational chart). In addition to communicating directly with a wide range of clinical staff, at various grades, in different specialties (e.g. doctors, nurses, OTs), the post holder also communicates with non clinical such as staff in other departments such as; IT, Human Resources, Learning Centre, Estates, and Hotel Services.

The post holder will have occasional face-to-face communication with patients through their involvement in projects, through presentations at events with patients in attendance and informal contact when visiting patient areas.

The postholder may present controversial findings and recommendations at (e.g.multidisciplinary) meetings that highlight apparent deficiencies in practice/services. Information is imparted on a range of topics from the national agendas e.g. NHS and non specific NHS (i.e. NHS HIS, European Convention of Human Rights, Forensic Mental Health Network) to our local agenda (i.e. systems, structures and processes involved in delivering forensic mental health services)

Examples of frequent communication and relationship buildingThe post holder requires an ability to build relationships with all staff across the hospital. At professional group meetings and clinical team meetings the post holder has to communicate in order to motivate, negotiate, and persuade clinical staff to agree standards of practice and also agree improvements to practice. This will be supported by presenting and communicating complex information.

The post holder has to develop a strategies to encourage clinicians to agree to change, for example by adapting the style of reports to meet their needs and also by gaining support of staff prior to the meeting

ExternalNHS Scotland, the wider NHS in the UK and international health services, including clinicians and other health professionals within and out with forensic services and mental health e.g. in primary and secondary care and NHSiS organisations such as NES and NHS HIS.

Mode of communicationsCommunication is verbal (face-face and over the telephone), written (via letters, fax, e-mail) and through a variety of other interaction such as meetings, group/committee work, presentations, training.Type of communicationsUsing the interactions listed and with the groups identified above, the post holder provides advice, guidance, training and presentation material.

12. PHYSICAL, MENTAL, EMOTIONAL AND ENVIRONMENTAL DEMANDS OF THE JOB

PhysicalFrequent use of a VDU on a daily basis for long periods of time when analysing data or writing papers or reports.

There is an occasional requirement to stand for varying lengths of time when photocopying (e.g. twice per week for 10 minutes) and when presenting. Positioning equipment e.g. overhead projector, laptop and screen.

MentalOn a daily basis the post holder analyses data (including working with figures), prepare reports, responds to consultations and compiles presentations and papers. This requires that the post holder frequently undertakes periods of intense concentration which may last for several hours and which is often interrupted (by telephone or visits into the office) to help others.

An understanding of complex analytical techniques is used to ensure accurate and meaningful data anlysis.

The postholder is frequently required to respond to requests for ad-hoc assistance/information e.g. advice on audit projects/best practice/NHS HIS standards/ICPs.

Acknowledging that participating in the area of clinical effectiveness is seen by many as a task rather than an essential component of care and as such having to constantly motivate, enthuse and persuade staff to contribute to promoting the ownership of the clinical governance agenda.

EmotionalAccommodating and responding to personal dynamics and the politics of working within a complex organisation.

Ensuring that interactions and the sensitivities associated with our patient population are managed appropriately

As a result of working within a high secure psychiatric environment with a high percentage of patients who are mentally disordered offenders, when undertaking audits the post holder is exposed to confidential, sensitive and distressing information which is contained within the legal documents and patient medical records

EnvironmentalThe service is a high secure mental health working environment that cares for individuals detained under mental health and related legislation. Patients detained are considered to pose a grave and immediate danger to themselves and the public. Working in this service involves being subjected to searching and security procedures,

responsibility for keys, and working in a restrictive, locked environment.

To ensure compliance with hospital policies, procedures and health and safety requirements within a high secure psychiatric environment, administrative staff are required to undertake relevant mandatory breakaway training used in the management of violence and aggression and also in hostage taking training.  There is a need for constant awareness of security procedures carried out including, baggage scanning, walk through metal detectors, physical body searches, CCTV coverage within hospital grounds, dress code and a personal alarm system and of adherence to policy prohibiting items including glassware, umbrellas and mobile phones.

13. KNOWLEDGE, TRAINING AND EXPERIENCE REQUIRED TO DO THE JOB

Degree level qualification in a relevant discipline and/or equivalent experience (at least 3 years in a Clinical Governance / Effectiveness / Trials or Research post)

Experience of working in support of clinicians involved in Clinical Governance / Effectiveness / Trials or Research projects, or a background in a data management related role.

In addition to the above, demonstrable skills obtained in a previous role(s) which demonstrate:

Experience of project management High level of communication skills, both oral and written and interpersonal skills

gained through experience in the areas identified as above Experience of working in and with multidisciplinary teams Facilitation, influencing and negotiating skills Experience of planning and development High level of I.T. skills and a highly competent user of all Microsoft Office

applications e.g. Word, PowerPoint, Excel, Access, Internet Explorer and Outlook

Experience of designing and maintaining databases to support clinical governance / effectiveness / quality etc.

Time management skills Evidence of Continuing Professional Development Experience of presenting management and board level reports and papers Change management skills Experience of developing and delivering training programmes An understanding of clinical governance Data analysis and report writing Extensive knowledge of medical terminology is necessary to inform data

analysis

14. JOB DESCRIPTION AGREEMENTA separate job description will need to be signed off by each jobholder to whom the job description applies.

Job Holder’s Signature:Date:

Head of Department Signature:Date:

STATE HOSPITAL’S BOARD FOR SCOTLAND

PERSON SPECIFICATION: Clinical Effectiveness Co-ordinator

Essential Desirable

Qualifications Degree level qualification or

equivalent experience

Degree in science, social science, IT or

clinical area.

Experience 3 years experience in an analytical

environment.

Experience of maintaining data

systems.

Experience of manipulating,

analysing and reporting on data.

Previous experience of clinical audit or

clinical care pathways.

Previous experience in healthcare.

Experience of working with complex

databases.

Experience of delivering training.

Skills Experience working with large

amounts of complex data,

including numerical analysis,

quality assurance, and

presentation.

Project management skills.

Change management skills.

Critical appraisal skills.

Analysis and investigations skills;

seeking, analysing, interpreting

and using information to identify

problems and generate solutions.

Ability to communicate complex

information in understandable

terms both orally and in writing.

Facilitation, influencing and

negotiation skills.

Knowledge Detailed knowledge of Microsoft

Access and Microsoft Excel.

Knowledge of wider clinical

effectiveness processes and quality

improvement methodology.

Special Aptitudes /

Personal Qualities

Ability to contribute to a range of

hospital groups and committees.

Ability to self-manage time and

workload.

Ability to concentrate on detailed

work where accuracy is required.

Work with others, building and

maintaining good working

relationships with colleagues and

Communication skills to encourage

engagements and enhance

understanding of the subject.

contacts at all levels.