Quality Governance Analyst - Mortality (XN06)
The post holder will manage the Learning from Deaths process and oversee the implementation of the Mortality Review Policy. They will support the work of the Mortality Improvement Group. The post holder will have a high level of expertise in utilising dating from a variety of sources including Hospital Episode Statistics (HES) and Dr Foster Mortality Tools, in order to provide reports to the Mortality Improvement Group, and senior service managers.
The post holder will work as part of the Quality Governance Team within the Clinical Effectiveness portfolio, co- ordinating the learning from deaths process supported by the Quality Governance Facilitators.
The post holder will provide information and analysis support to Clinical Service Units in relation to their Mortality data and support them to understand their data.
The post holder will support the Clinical Effectiveness and Compliance Manager in the management of the Mortality Improvement Group, and deputise as required in relation to the Mortality portfolio.The post holder will work with the Coding team, Informatics, the Medical Examiner Office, Bereavement, and the Associate Medical Director to implement the Mortality Review Policy PRINCIPAL DUTIES & AREAS OF RESPONSIBILITY Extracting and analysing data from different systems Analysing Hospital Episode Statistics and of Mortality data sources such as Dr Foster.
Extracting and analysing data from different systems Manipulation of spreadsheets and databases to an advanced technical level Producing complex written, verbal, tabular and graphical information.Understanding of Medical terminology, anatomy and epidemiology to a basic level.
Understanding key mortality indicators such as SHMI and HSMR and associated monitoring processes Understanding Mortality datasets and National Study/ Audit submission on mortality Identify and resolve complex data problems.
Project Management Using advanced analytical and/or statistical techniques to support performance management and service improvement.
Training and mentoring junior staff.
Ability to co-ordinate junior staff to support the Mortality Review Process Summarise and present complex information Liaise with senior managers and consultants offering guidance and interpretation on complex information.
Prioritise, schedule and monitor to completion, all workload, meeting deadlines and maintaining a consistent high quality output.
Understand and Monitor CQC Outlier Alert process and requirements for external Mortality Reporting To liaise with Clinical Coding and have an understanding of coding To support the Mortality Improvement Group and Project Group and set the agenda for discussion, supported by the Clinical Effectiveness and Compliance Manager To attend the Regional Mortality Group To oversee the Learning from Deaths process and to support CSUs to capture and share Learning from Deaths and Structured Judgement Review.
Provide timely and accurate information to managers in a format that is readily understood and relevant to the decision making process.Provide proactive analyses of performance through the use of measures of activity, efficiency and data accuracy.
Provide proactive analyses of issues raised by the Trust Integrated Performance Report and performance meetings.
Provide technical support and advice to clinical & corporate teams on the advanced use of Excel and the application of modelling and statistical tools.
Monitor and forecast progress against internal Trust, local and national targets.
Ensure a timely and accurate response to any queries, both internal and external.
Propose new developments in reporting Interpret complex data issues for non-information staff Assist in developing activity capacity plans, providing guidance to directorates on methodology, monitoring actual progress over time and investigating discrepancies.
Represent information reporting aspects on formal project management boards as required.Data Quality Identify, monitor and report on data quality issues.
Support the ongoing development of Trust information systems.
Audit of systems The post will develop and will need to incorporate other duties to meet the changing needs of the organisation and these changes will be agreed between the post holder and their line manager The NHS Appreciation of and compliance with the Data Protection Act, Freedom of Information Act and Caldicott guidance.
Specialist knowledge of NHS national targets, performance/clinical indicators, CQC standards A good knowledge of the Patient Administration Systems and associated processes.Broad knowledge of Trust services, structure, objectives and policies e.g.
clinical coding & patient administration.
An understanding of Hospital Mortality Statistics Technical Knowledge Advanced skills in the use of Excel Understanding of Dr Foster systems and data flow Skilled in bringing together data from a range of disparate sources and an awareness of the associated pitfalls Clear understanding of the importance of data quality issues and the impact of this on any analyses.
Specialist understanding of the complexity associated with using performance and clinical indicators.Advanced knowledge of trust information systems Understanding of the Trusts financial and commissioning systems and processes.
THE LEEDS WAY VALUES Our values are part of what make us different from other trusts, so we see this as a strength, as well as a responsibility.
They have been developed by our staff and set out what they see as important to how we work.
Our five values are: Patient-centred Collaborative Fair Accountable Empowered All our actions and endeavours will be guided and evaluated through these values Additionally, the following are core values which relate specifically to this post: Professionalism
- acquiring, applying and sharing knowledge, skills and best practice to meet objectives and promote high standards Excellence
- consistently providing high quality work and seeking to improve their own performance Flexibility
- responding positively to change and seeking innovation in working practices Commitment
- a firm commitment to achieving departmental objectives Partnership
- working with others both internally and externally with mutual respect, understanding and trust; building good relationships with all contacts Integrity
- to act with integrity in all dealings with Trust data Data Quality
- a firm commitment to improving data quality Customer Focus
- a strong customer focus Abide by the Trust policy on standards of business conduct.
Logical approach to problem solving and ability to be objective Able to identify and appraise options, accounting for risks and longer-term strategic ramifications Honest, open and tactful Strong organisational skills Ability to work to a high degree of accuracy within tight deadlines.
An effective oral and written communicator able to summarise and convey complex information, often to non-technical staff.Ability to keep team members informed of progress, changes and deadlines.
Adaptable approach to changing priorities, such as maintenance of on-going projects while dealing with urgent ad-hoc requests.
Ability to develop good relationships with all professional contacts, internal and external to the organisation.
Strong and motivational leadership and ability to work as part of a team.
Work independently, looking for innovative opportunities for the future and acting upon them.
Accountable for own work and work of the team.
Application of Human Resources policies and procedures.
COMMUNICATION & WORKING RELATIONSHIPS Internal Quality Governance colleagues Informatics colleagues Assistant Directors of Operations (ADOPs) Clinical Directors and Lead Clinicians CSU General Managers & Business Managers Patient Services & Administration Staff Clinicians & senior nursing staff.
Finance and Income Managers Planning Managers Bereavement Clinical Coding Medical Examiner Office External Clinical Commissioning Groups Department of Health NHS England NHS Digital NHS Improvement Dr Fosters Care Quality Commission Other as required SPECIAL WORKING CONDITIONS PHYSICAL EFFORT: Extensive use of computer keyboard and mouse for input and manipulation of data.
Very occasional moving of equipment e.g.projector, laptops.
MENTAL EFFORT: Daily prolonged periods of a working day carrying out complex calculations and analyses.EMOTIONAL EFFORT: Occasional case note audits where you may come across some distressing information.
WORKING CONDITIONS: Extended and frequent use of VDU equipment for most of a working day.
As the post has a citywide remit, there is a requirement to be able to attend meetings and events both on and off site.