Job Summary:

An opportunity for has arisen for the post of the Assurance Manager to work as part of the Assurance Team, working to deliver against key objectives. As an Assurance Manager you will be responsible for providing the practical day-to-day specialist implementation and monitoring support to the development of effective assurance, accreditation, regulation and/or risk management systems and processes across the Trust.

Key relationships include Chief Executive Executive Directors Divisional Directors Divisional and Director Management Teams staff with lead responsibility for clinical and non-clinical standards, contractors and purchasers, external assurance, and audit staff.

Main duties of the job

Main Responsibilities

The following describes the range of duties within the role. The balance of duties will vary depending on agreed annual work programme the deliverables agreed at a strategic level, and the most effective use of assurance resources and skills.

Supporting Delivery of Accreditation, Regulation and Assurance Outcomes

Supporting Structures to Deliver Outcomes

Training and Evaluation of Impact

Advising on Local Practice/Policy Developments

Project Management, Audit and Analysis

About us

Oxford University Hospitals NHS Foundation Trustis one of the largest NHS teaching trusts in the country. It provides a wide range of general and specialist clinical services and is a base for medical education, training and research. Find out more herewww.ouh.nhs.uk

The Trust comprises four hospitals - the John Radcliffe Hospital, Churchill Hospital and Nuffield Orthopaedic Centre in Headington and the Horton General Hospital in Banbury.

Our values, standards and behaviours define the quality of clinical care we offer and the professional relationships we make with our patients, colleagues and the wider community. We call thisDelivering Compassionate Excellenceand its focus is on our values of compassion, respect, learning, delivery, improvement and excellence. These values put patients at the heart of what we do and underpin the quality healthcare we would like for ourselves or a member of our family. Watch how we set out to deliver compassionate excellence via theOUH YouTube channel.

Job description

Job responsibilities

Supporting Delivery of Accreditation, Regulation and Assurance Outcomes

• To work with Executive Directors and the Assurance Team to develop and deliver programmes of Assurance, Accreditation and to ensure the delivery of each
• To work with the Head of Accreditation and Regulation to support the peer review, clinical accreditation and Ulysses programmes, undertaking relevant work as directed.
• To prepare and present regular progress reports on accreditation and assurance project activities.
• To support managers in applying the principles of assurance and the requirements of externally derived Healthcare standards such as the Care Quality Commission or the Health and Safety Executive.
• To support the development and annual review of the Assurance Directorates strategies and policies.
• To identify any areas of duplicate accreditation and assurance activity to support streamlined activities and efficiency.

Supporting Structures to Deliver Outcomes

• To carry out quality and assurance audits to ensure that the trust strategies and policies are working and to identify gaps and changes to training needs analysis, where appropriate
• To support the development and implementation of trust wide assurance and/or risk management systems and processes.
• To work with Executive Directors and the Assurance Team to develop and deliver programmes of assurance and risk management to ensure the delivery of key objectives.
• To prepare and present regular progress reports on assurance, governance, and risk project activities.
• To support the Senior Risk Manager with maintenance of the Corporate Risk Register and Board Assurance Framework as directed.
• To support managers in applying the principles of assurance and the requirements of externally derived healthcare standards such as NHS England, CQC and service specific network review requirements.
• To contribute to annual reports as required, such as the Annual Governance Statement, Annual Report, Risk Appetite Statement and Governance Frameworks.
• To support the development and annual review of the Assurance Directorates strategies and policies
• To support an annual review of Committee Effectiveness of the Board sub-committees and the Trust Management Executive.

Training and Evaluation of Impact

• Support the development and implementation of training tools to support the assessment of measures to deliver assurance outcomes and meet Board requirements in clinical and non-clinical areas.
• Provide Directorates with information which is organised and presented in such a way that it facilitates and encourages reflection, celebrates success, and drives quality improvements in assessing impact measures appropriately.
• Take the lead on designing and delivering training to meet the needs of clinical and non-clinical staff in developing assurance systems and structures to assess the delivery of national standards and targets.
• Support the delivery of quality and assurance audits to ensure that the trust strategies and policies are working and to identify gaps and training needs
• To review the effectiveness of training and develop training programmes and materials to support strategy and policy.

Knowledge Management

• Ensure that lessons are learnt from assurance, regulation, accreditation and/or risk activity, standards assessment, and statutory inspections.
• Ensure that learning is fed through to staff responsible for governance within the Trust to enable learning.
• Develop and make long-term plans for systems and related mechanisms for assurance, accreditations, and regulation.
• Ensure that data, processes, and assessment outcomes are maintained such that their retrieval and availability can inform future practice and act as an audit trail for quality improvement.
• Ensure that assurance activity complies with current guidance on Data Protection and confidentiality.

Advising on Local Practice/Policy Developments

• Guide and support those engaged in assurance activity within the Trust in the effective design and management of audit processes to meet required standards.
• Assessment of the suitability and adequacy of supporting systems, processes and documentation for accreditations, compliance, and inspections
• Promote the active involvement of specialists and where appropriate carers and patients in assurance activity.
• Ensure that findings and action plans from compliance activity are reported and published appropriately on the intranet and at internal and external events.
• Work with governance colleagues to develop and use data indicators, including conducting data analysis to signal the need for reviews/audits of practice.
• Maintain and produce specific reports to support the corporate systems of assurance, accreditation, regulation and/or risk.

Project Management, Audit and Analysis

• Support the implementation of quality improvement projects in both the Assurance Directorate and across the organisation as appropriate.
• Take part in engagement activities to support change management activities.
• Carry out audits on risk, assurance and/or accreditation activities.
• Design and implement audit tools to support the Assurance Directorates strategic aims.

Wider Responsibilities:

• Contribute to the corporate development of the Trust through the management of key areas of work defined by the Director of Regulatory Compliance and Assurance.
• Contribute as requested to the day-to-day management of the Trust, and its relationships with external bodies.
• Identify areas where action is necessary to ensure that the Trust is compliant with the requirements of legislation (mainly Health & Social Care Act).
• Maintain on behalf of the Trust effective relationships with external professional advisers.

Communication and Key Relationships

• Build and maintain professional working relationships with staff at all levels across the Trust and to positively represent the Assurance Directorate and the Trust Values.
• Communicate with staff at all levels across all mediums as appropriate.
• Liaise with the Communications staff to ensure that the compliance issues affecting assurance projects are effectively briefed in discussion with the Senior Accreditation and Regulation Manager and the Director of Regulatory Compliance and Assurance.

General Conditions Risk Management
The management of risk is the responsibility of everyone and will be achieved within a progressive, honest, and open environment.

Staff will be provided with the necessary education, training, and support to enable them to meet this responsibility.

Staff should be familiar with the

• Major Incident Policy
• Fire Policy
• Information governance

and should make themselves familiar with the local response plan and their role within that response.
Responsibilities for Health and Safety
The post holder is responsible for ensuring that all duties and responsibilities of this post are carried out in compliance with the Health & Safety at Work Act 1974, Statutory Regulations and Trust Policies and Procedures. This will be supported by the provision of training and specialist advice where required.
Infection Control
Infection Control is everyones responsibility. All staff, both clinical and non-clinical, are required to adhere to the Trusts Infection Prevention and Control Policies and make every effort to maintain high standards of infection control at all times thereby reducing the burden of Healthcare Associated Infections including MRSA.

All staff employed by OUH have the following key responsibilities:

• Staff must wash their hands or use alcohol gel on entry and exit from all clinical areas and/or between each patient contact.
• Staff members have a duty to attend mandatory infection control training provided for them by the Trust.
• Staff members who develop an infection (other than common colds and illness) that may be transmittable to patients have a duty to contact Occupational Health.

Child Protection
The post holder will always endeavour to uphold the rights of children and young people in accordance with the UN Convention Rights of the Child.
Safeguarding Children and Vulnerable Adults
The Trust is committed to safeguarding children and vulnerable adults throughout the organisation. As a member of the trust there is a duty to assist in protecting patients and their families from any form of harm when they are vulnerable.
Information Governance
All staff must complete annual information governance training. If you have a Trust email account this can be completed on-line, otherwise you must attend a classroom session. For further details, go to the Information Governance intranet site.
Data Quality
Data quality is a vital element of every member of staffs job role. Oxford University Hospitals recognises the importance of information in the provision of patient care and in reporting on its performance. Data quality is therefore crucial in ensuring complete, timely and accurate information is available in support of patient care, clinical governance, performance management, service planning, and financial and resource planning and performance.

All staff should ensure that they have read and understood the Trusts Data Quality Policy.

Person Specification

Knwowledge, experience and skills

Essential

• Masters level of education (or working towards) and/or relevant professional qualification.
• Knowledge of Data Protection Act and freedom of information Act.
• Knowledge of audit and audit methodologies
• Development and use of information/software systems to support change.
• Experience of devising, introducing, implementing, developing, and reviewing compliance practice across a complex service.
• Proven track record of delivering compliance objectives in line with organisational strategy
• Experience of training a range of people, both clinical and non-clinical on digital systems
• Experience of compiling reports with the results of audit data for Board and Committees
• A track record in delivering presentations and developing and delivering training
• Experience of leading projects and implementing these across the organisation to tight deadlines.
• Decision making skills with the ability to resolve issues effectively
• Demonstrable evidence of project management and delivery of objectives using technology support

Desirable

• Training
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