Applications are invited from persons who possess the requisite experience, qualification and suitably meet the corresponding requirements for the following vacant role:
QUALITY, RISK AND HEALTH & SAFETY MANAGER
This position reports to the Executive Nursing Manager and will be responsible for the following performance areas:
1.Risk Management
- Risk Identification:
- Conduct a thorough risk assessment throughout the hospital, that poses a threat to life and property with a specific focus on clinical areas. Identify potential risks that may impact patient safety, staff well-being, and overall healthcare delivery.
- Collaborate with clinical teams, department heads, and other stakeholders to gather insights into potential risks associated with urology care and hospital operations.
- Clinical Risk Management Programme is implemented, supported and co-ordinated:
- Create a detailed risk management program that outlines strategies for identifying, assessing, and mitigating risks.
- Define roles and responsibilities for staff involved in risk management and establish clear communication channels for reporting and addressing risks.
- Align the risk management program with the overall company policy on risk management, industry standards, legal requirements, and accreditation criteria.
- Make recommendations to management on fire regulations, occupational diseases and waste disposal.
- Collaborate with the facilities department to ensure correct installation of equipment and up to date equipment schedule for servicing and repairs.
- Analyse clinical incidents and adverse events:
- Incident reporting
- Root cause analyses
- Corrective and preventative actions
- Utilise IOD’s and medical surveillance conducted by the IPP to develop quality improvement action plans.
- Collaborate with legal and compliance teams
1.4.1 Regulatory adherence:
- Stay abreast of local and international healthcare regulations, accreditation standards, and legal requirements relevant to the hospital.
- Collaborate with legal and compliance teams and appointed service providers to interpret and apply regulations within the hospital setting.
1.4.2 Mitigate legal risks:
- Identify potential legal risks associated with clinical practices, patient care,
- Provide guidance to clinical teams on legal considerations in their practices.
1.4.3 Documentation and reporting:
- Ensure comprehensive documentation of risk management activities, including incident reports, RCA findings, and actions taken to address legal and compliance concerns.
- Collaborate with legal and compliance teams to prepare reports for regulatory bodies, as required.
- Develop and implement internal Health & Safety policies/ strategies necessary for optimization of work processes.
2.Quality Assurance
2.1Continuous improvement of systems and processes on hospital level are implemented, co-ordinated and supported.
- Collaborate with relevant stakeholders, including department heads, clinicians, and nursing staff, to identify key performance indicators (KPIs) that directly impact clinical quality and nursing services.
- Ensure that selected KPIs align with organizational goals, industry benchmarks, and regulatory requirements.
2.1.1 Data collection and analysis:
- Implement a robust data collection system to gather information related to the identified KPIs.
- Utilize data analytics tools to analyse performance data, identify trends, and establish baseline metrics for continuous evaluation.
2.1.2 Benchmarking:
- Research and establish benchmarking standards against industry peers and best practices to provide context for KPI performance.
- Regularly review and update benchmarks to ensure they remain relevant and reflective of evolving healthcare standards.
2.2 Lead quality improvement initiatives.
2.2.1 Collaborative approach:
- Foster a collaborative approach by working closely with department heads, clinical teams, and frontline staff to identify areas for improvement.
- Establish a quality improvement committee or task force with representation from various departments to facilitate cross-functional collaboration.
2.2.2 Root cause analysis:
- Utilize root cause analysis (RCA) methodologies to identify the underlying causes of quality-related issues or suboptimal patient outcomes.
- Involve relevant stakeholders in the RCA process to gather diverse perspectives and insights.
2.3.2 Action plans and implementation:
- Develop targeted action plans based on the findings of RCAs, outlining specific interventions and strategies for improvement.
- Collaborate with department heads to implement and monitor the effectiveness of quality improvement initiatives.
- Establish a continuous feedback loop with clinical teams to ensure ongoing communication, learning, and adaptation to changes.
- Encourage a culture of continuous improvement and innovation.
3.1 Conduct regular clinical audits.
3.1.1 Audit framework:
- Develop a comprehensive clinical audit framework that encompasses various aspects of nursing services, including patient care, documentation, adherence to protocols, and communication.
- Clearly define audit criteria, standards, and methodologies to maintain consistency and objectivity in the audit process.
3.1.2 Data collection and analysis:
- Implement systematic data collection methods during clinical audits, ensuring a representative sample and comprehensive coverage of relevant areas.
- Analyse audit findings to identify strengths, weaknesses, and areas for improvement within nursing services.
3.1.3 Feedback and action planning:
- Provide constructive feedback to nursing staff and department heads based on audit results, highlighting both commendable practices and areas requiring attention.
- Collaborate with stakeholders to develop action plans to address identified deficiencies and enhance overall nursing service quality.
3.1.4 Follow up audits:
- Hospital accreditation standards are monitored and related initiatives are co-ordinated
- Schedule regular follow-up audits to assess the effectiveness of implemented actions and monitor sustained improvements.
- Adjust audit methodologies and focus areas based on evolving priorities and emerging trends.
3.Reporting
- An overall quality report on all aspects to the CEO.
- Provide a detailed quarterly report to the Nursing Manager on issues within the quality, risk and health & safety.
- Reporting of operational risks to FEO.
- Reporting to be on time and according to the annual board meeting schedule.
REQUIREMENTS
- Diploma or B.Cur in General Nursing (NQF 7).
- Registered with SANC.
- Infection Control qualification.
- Relevant post-registration qualification will be beneficial.
- Previous experience as a Senior Registered Nurse.
- Previous experience working in the private healthcare sector.
- Previous experience of managing clinical audits.
Closing date: 25 September 2024
Contact: Sanmarie Marais
E-Mail: Sanmariem@urology.co.za
GENERAL NOTE:
Please note that the Urology Hospital is a smoking free facility and an equal opportunity employer. Should you not hear from us within fourteen working days after the closing date please consider your application as unsuccessful. POPIA sections provides that everyone has the right to privacy, and it includes a right to protection against the unlawful collection, retention, dissemination and use of personal information and any attached text or documentation that are retained by the Urolocare hospitals for a period in accordance with relevant data legislation
