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Clinical Governance Facilitator

County Durham and Darlington NHS Foundation Trust
£28,407 to £34,581 per annum pro rata
Closing date
29 May 2024

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Other Health Profession
Band 5
Contract Type
Full Time
The Urgent and Emergency Care Group have an exciting opportunity in their high-performing Clinical Governance Team for a strong team-player who is passionate about promoting a safe, effective experience for our patients and improving quality outcomes. The successful candidate will be process driven with excellent attention to detail. They will be proficient in the use of MS Office in particular Excel, with the ability to produce high quality reports, data analysis and possess effective communication skills.

The post-holder will work collaboratively with multidisciplinary teams to achieve effective risk management processes, supporting critical analysis to drive quality and safety improvement.

The role will provide challenge and reward as well as excellent career development opportunities. The successful candidate must have degree-level qualification or have relevant equivalent experience and ideally have experience of working within patient safety, experience or risk, assurance and compliance processes within an NHS Trust.

Please contact Rachel Oliver on for an informal discussion prior to applying

Main duties of the job

To facilitate a systematic approach that uses techniques to deliver and measure sustained improvements in quality and governance.

To use own initiative to provide support to the Care Group Triumvirate and Senior Leads providing assurance of clinical quality standards within the Care Group.

To facilitate and monitor clinical governance process within the care group

To facilitate the process for clinical quality monitoring within the care group and support clinical teams in service improvement p

To support the Care Group Triumvirate and Senior Leads in their diverse portfolio of work including patient safety incidents, risk management, patient experience, clinical audit/ effectiveness, assurance and compliance and service improvement projects.

To maintain the systems and processes vital to effective clinical quality within the care group.

To facilitate all staff within the care group to deliver high quality care within the parameters of a comprehensive clinical governance framework.

To act as a key link within the care group to support teams in the delivery of service improvement activity.

About us

If you are being interviewed you must accept an interview slot in the system to continue, even if you have arranged with the manager

You must be able to produce ALL certificates stated essential in the person specification or you will not be able to complete pre-employment checks

We provide hospital services from two acute sites - Darlington Memorial Hospital and University Hospital of North Durham. We have a centre for planned care in Bishop Auckland and provide care from community hospitals in Chester-le-Street, Shotley Bridge, Barnard Castle, Sedgefield and Weardale as well as over 80 other community based settings and providing care in patients' homes.

We particularly welcome applications from disabled and Black, Asian and Minority Ethnic (BAME) candidates as BAME and disabled people are currently under-represented

From April 1 2024 we are unable to offer sponsorship for healthcare roles that do not meet the minimum salary �23,200, to apply you must have Right to Work in the United Kingdom. If you are in the UK on a VISA please ensure you have no restrictions that would prevent you from taking this post

Full Job Descriptions can be found in the adverts supporting documents

Job description

Job responsibilities


To support project objectives and undertake data collection utilising a broad range of approaches & methodologies that effectively underpin clinical audit, patient safety, patient experience & clinical effectiveness projects.

To oversee data streams for all aspects of clinical quality, including patient safety, audit, patient experience and clinical effectiveness.

To provide advice and support to a range of clinical services in relation to safety, effectiveness and experience including incident management, audit, patient safety and patient experience projects

Provide support to teams to monitor the progress with and the effectiveness of recommendations made as a result of learning from patient safety incidents and complaints.

Responsible for the day to day supervision of staff, allocation and re-allocation of work, training of new staff, undertake return to work interviews to ensure delivery of agreed objectives.

To oversee the distribution of NICE guidance and to monitor compliance with NICE recommendations.

To provide support to enable the timely management of the Risk Register.

Facilitate the development and implementation of governance communications on behalf of the care group.

To provide support to the Triumvirate and Senior Leads in the collation and presentation of data for onward presentation to care group and organisational forums / committees.

To assist in the facilitation of the care groups quality committee meetings, collating feedback and preparing comprehensive reports/ key messages.

To provide support to clinical services with the process for the clinical quality improvement frameworks, supporting services with data collection and interpretation of results.

To collate action feedback from services following service improvement identification and provide monthly updates on the status of action implementation.

To facilitate and empower clinical teams to complete service improvement initiatives.

To analyse data streams and identify trends and themes, areas of good practice and ensure these are shared throughout the care group.

To facilitate clinical quality & service improvement projects to successful completion

To analyse data streams in relation to staff experience / safety culture work streams, identifying key recommendations for improvement.

To facilitate the implementation of clinical governance projects.

To provide appropriate support and advice on quality & service improvement methodology, data analysis and report writing to healthcare professionals.

To facilitate the development of communication processes for the Care Group e.g. bulletins, newsletters

To write project plans and undertake data collection utilising a broad range of approaches & methodologies that effectively underpin clinical audit, patient experience & clinical effectiveness projects.

To regularly and effectively use IT systems to produce meaningful statistical information. To be able to manipulate and display this information in graph and chart format.

To analyse data and produce reports, making recommendations for service improvement where appropriate

To identify service improvement methodologies and tools that can be ultlised by services

To assist in the development of training materials in relation to clinical quality projects

To facilitate workshops/ focus groups/ training sessions in relation to a range of clinical quality indicators.

To attend, takes notes/minutes, organise meetings as required for the Associate Director of Nursing/Associate Director of Governance.

To propose changes to and implement policies and procedures with regard to clinical governance.

Plan and prioritise work to prescribed deadlines.

Undertake project work and produce reports/review papers on relevant topics for consideration by management.

Person Specification



  • Educated to foundation degree level or equivalent demonstrable experience in healthcare / governance related discipline.
  • Demonstrated evidence of continued professional development both academic and relevant engagement within appropriate field such as NHS Workshops, Conferences, Improvement Programmes
  • Working knowledge of clinical governance, patient safety & quality issues in healthcare
  • Knowledge of patient safety, clinical audit, patient experience, risk register processes.
  • Evidence of effective report writing and presentation skills
  • Management experience (programme, project or line management


  • Degree level qualification

Special Requirements


  • Highest level of professionalism at all times
  • Excellent time management skills to meet the requirements of the role which is CDDFT site based, office hours.
  • Ability to work to deadlines
  • Self motivated
  • Ability to challenge and enquire whilst maintaining effective relationships and ability to cope in stressful situations
  • Able to travel, sometimes at short notice including cross site cover to other CDDFT Sites.



  • Relevant experience of the health service within a clinical governance/ risk/ audit/ safety/ experience/ quality related discipline
  • A proven track record of successfully implementing change
  • Ability to work effectively under pressure, prioritise workload and meeting deadlines.
  • Experience of working autonomously.
  • Experience of dealing with highly charged and emotional situations
  • Relevant experience in communicating and facilitating work streams with corporate colleagues and management
  • Working with risk management processes including, patient safety, risk registers, CAS / NICE guidance.
  • Management of complex data streams and ability to analyse data
  • Experienced in the ability to think critically in order to ensure the main points of concern are captured and responded to appropriately
  • Experience of working with computerised patient administration and other databases

Special Skills & Knowledge


  • Proficient in the use of IT packages. E.g. Excel, Word, Powerpoint and Outlook Email
  • Ability to set and manage targets and meet deadlines of self and others
  • Ability to present facts in a non-discriminatory and non-judgemental way
  • Ability to confidently present to groups of people
  • Thorough understanding of the principles and practice of clinical governance systems, required outputs and their use to improve clinical practice
  • Proven ability to analyse complex problems and to develop and successfully implement practical and workable solutions to address them
  • Understanding of the changing NHS environment and its implications for service delivery
  • Understanding of NHS improvement methodologies including: Well Led, LEAN methodology.


  • Knowledge of the NHS complaints procedure and responding complaints
  • Track record of project management
  • Experience of working across primary and acute care
  • Experience of working successfully with clinicians from a variety of backgrounds and seniority
  • Experience of training, facilitating group discussions and supporting education and development
  • Track record of project management

Employer details

Employer name

County Durham & Darlington NHS Foundation Trust


University Hospital Of North Durham

North Road



Any attachments will be accessible after you click to apply.


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