National Office of Clinical Audit
Job Description
Job Title:
Audit Coordinator – Irish Audit of Surgical Mortality
Reporting To:
Manager – NOCA or nominee
Tenure:
1 Year Fixed Term Contract
Location:
RCSI St. Stephens Green
The National Office of Clinical Audit (NOCA) has been established to design, develop and implement
frameworks to facilitate sustainable national clinical audit programmes in agreed specialties through the
convening of a robust Governance Board. RCSI will oversee the operational and administrative management
and convene the Governance Board of NOCA.
The first audit stream identified for delivery under the National Office of Clinical Audit and now ready for user
testing is that of the Irish Audit of Surgical Mortality (IASM).
Audit of Surgical Mortality is an internationally recognised audit process that provides confidential,
independent, peer review, which is systematic and objective. RCSI have and will continue to consult with the
Royal Colleges responsible for the Scottish Audit of Surgical Mortality (SASM) and the Australian and New
Zealand Audit of Surgical Mortality (ANZASM).
The objectives of an audit of surgical mortality in Ireland will be to review all deaths that occur following of an
episode of surgical care and to provide opportunities for improvements in patient outcomes by:
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Reducing mortality associated with surgery
Increasing patient safety, confidence and overall experience
Promoting and encouraging reflective practice
Provide Surgeons and Anaesthetists the opportunity to participate and contribute to
measurable clinical audit
The longer term objectives of IASM are to provide regular, documented, critical analysis of the outcomes of
surgical care. The gathering of information from multiple sources over time, will allow detection of system
issues and emerging trends. In addition, in consultation with SASM and ANZASM, Irish clinicians will be ideally
positioned to benchmark clinical outcomes against international standards.
Methodology
In brief, individual surgeons and anaesthetists will log on to IASM portal following a death associated with any
surgical care. All cases in which a surgeon was responsible for, or had significant involvement in, the care of a
patient will be included in the audit, whether or not the patient underwent a surgical procedure.
National Office of Clinical Audit
The clinical details pertaining to the management of each case will be recorded within the IASM portal. This
will be completed by the consultant / treating surgeon and anaesthetist associated with the case. The
completed template will be received by IASM Audit Office, where it is totally de-identified.
The IASM Audit Office will invite first-line assessment by a surgeon / anaesthetist from the same surgical
specialty but from a different hospital. The first-line assessor will be unaware of the name of the deceased,
the treating surgeon or the hospital where the death occurred. From international experience, we envisage
two possible outcomes of first line assessment:
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The information provided by the treating surgeon is adequate to reach a conclusion about the case
and to identify any issues of management, if present.
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A further in-depth second-line assessment or case note review is necessary either:
for clarification of issues of patient management identified or suspected by the first-line assessor,
or because the information provided by the treating surgeon was inadequate to reach a conclusion.
The participant will be notified of the status and in particular will be aware if second line assessment has been
requested. In addition if second line assessment is requested the Clinical Director of the hospital will also be
notified.
RCSI now wish to recruit IASM Audit Co ordinator to oversee the implementation and administrative and
operational delivery of IASM.
Responsibilities:
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Oversee a sustainable programmatic approach to surgically related clinical audit involving
consultation with all relevant stakeholders
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Provide regular progress reports while supporting the IASM Governance Board in the convening of
surgical expertise in the preparation, analysis and interpretation of regular reports derived from deidentified audit data and make recommendations for appropriate action
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Regularly review the IASM functions and activities including maintaining security and confidentiality
of case data to ensure robust processes are in place and maintained
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Develop and maintain linkages with public and private hospitals nationally in the promotion and
fulfilment of clinical audit
The objectives of this post include
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Establishment of a satisfactory IASM structure across surgery and anaesthesia
Creation of appropriate systems for local feedback of Audit results
Support national IASM governance structures, including working with the National Office of Clinical
Audit, including supporting and working with the NOCA Manager and the National Governance
Committee for IASM
Preparation of an Annual Reports of National IASM results
Oversee collation and confidential retention of all audit data
Development of a National IASM database
Identification and promotion of ongoing development of IASM
National Office of Clinical Audit
Key Responsibilities
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Identify best practice and document valid process mapping of the procedures involved in the
collection, interpretation and inputting of data for IASM
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Support Clinical Leads in ensuring successful Implementation / introduction of IASM and act as a
support for clinicians accessing IASM Portal
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Develop guidelines and support documents for Units about to participate in IASM, this includes
development and implementation of a robust communication strategy and education plans required
in relation to achieving aim and objectives of IASM.
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Provide adequate support to clinicians to ensure timely, comprehensive and accurate collection of
data and transmission to IASM
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Monitor the quality of data being provided to IASM and proactively seek improvement when
deficiencies are identified
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Encourage voluntary participation through positive and proactive promotion of IASM
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Support procedures to feedback the results of the Audit in an appropriate manner, including the
production of an Annual Report, in collaboration with Clinical Lead
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Represent the IASM at relevant committees, conferences etc
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Liaison with other stakeholders i.e. NOCA, Surgery Programme, Programme, HSE QPSD, HCAI,
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Formulate, manage and implement best practice policies and procedures and ensure adherence to
same.
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Participate in ongoing developments in IASM and clinical audit nationally
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Support for activities of Lead Clinician and for IASM Governance Committee.
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Maintain professional standards in relation to confidentiality, ethics and legislation.
Required Skills and Behaviour
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Strong leadership and communication skills to engage with all stakeholders, both clinical and non
clinical
A higher degree in Quality Management, Project Management, Healthcare or Medical Education
Management or related field would be advantageous
Experience of clinical audit data collation and interpretation of output
Proven track record of managing others to deliver projects and or services
Proven track record of identifying improvement measures and delivering measurable and sustainable
benefits
Excellent coaching skills, with ability to transfer knowledge and skills effectively
National Office of Clinical Audit
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Excellent facilitator, experienced in workshop design and management of collaborative problem
solving workshops
Attention to detail and exceptional documentation skills
Self-starter, high personal energy, positive approach to dealing with challenges and ambiguity
Excellent project management skills and able to move a team forward, maintain momentum and
project planning and management discipline.
Ability to deal with conflict positively and effectively
Track record of building positive working relationships with people who work in a challenging and at
times stressful work environment.
Completer finisher and flexible working arrangements
Can co-ordinate and motivate a multi-disciplinary team