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?
If you would like to apply for one of these posts please contact
Angela Slaven for an application pack on 01555 842084 or email tsh.jobs@nhs.net. For an informal discussion please
contact Sheila Smith on 01555 842193
Closing Date:
The closing date for applications is 20 November 2013
This post will be also be advertised in SHOW/JOB
CENTRE
The State Hospital
Carstairs
Lanark ML11 8RP
Telephone 01555 840293
Fax 01555 840024
E-mail info@tsh.nhs.uk
http://www.tsh.scot.nhs.uk
Private & Confidential
Date
13 February 2016
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 Resources
The State Hospital
Carstairs
Lanark
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 Slaven
Human Resources
The State Hospitals Board for Scotland
Carstairs, Lanark ML11 8RP
Chairperson Terry Currie
Chief 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
Head of Clinical and
Risk Governance
Clinical Effectiveness
Team Leader
Clinical Effectiveness
Co-ordinator
Clinical Effectiveness
Co-ordinator
Clinical Effectiveness/
Risk Administrator
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
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 selfassessment 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 responsibilities
Working 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 exercises
o Action plan development
o 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 responsibilities
Contribute 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 keyholder 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
Internal
The 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 building
The 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
External
NHS 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 communications
Communication is verbal (face-face and over the telephone), written (via letters, fax, email) and through a variety of other interaction such as meetings, group/committee work,
presentations, training.
Type of communications
Using 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
Physical
Frequent 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.
Mental
On 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.
Emotional
Accommodating 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
Environmental
The 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 AGREEMENT
A separate job description will need to be signed off by each jobholder to whom
the job description applies.
Job Holder’s Signature:
Head of Department Signature:
Date:
Date:
STATE HOSPITAL’S BOARD FOR SCOTLAND
PERSON SPECIFICATION: Clinical Effectiveness Co-ordinator
Qualifications
Experience
Essential
Desirable
Degree level qualification or
Degree in science, social science, IT or
equivalent experience
clinical area.
3 years experience in an analytical
Previous experience of clinical audit or
environment.
clinical care pathways.
Experience of maintaining data
Previous experience in healthcare.
systems.
Experience of working with complex
Experience of manipulating,
databases.
analysing and reporting on data.
Experience of delivering training.
Skills
Experience working with large
Project management skills.
amounts of complex data,
including numerical analysis,
Change management skills.
quality assurance, and
presentation.
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
Knowledge of wider clinical
Access and Microsoft Excel.
effectiveness processes and quality
improvement methodology.
Special Aptitudes /
Ability to contribute to a range of
Communication skills to encourage
Personal Qualities
hospital groups and committees.
engagements and enhance
understanding of the subject.
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
contacts at all levels.