Quality Improvement and Clinical Audit Administrator

Quality Improvement and Clinical Audit Administrator Blackrock Health Hermitage Clinic Location: On site / Lucan, Co. Dublin, Ireland
job type: Permanent / Full time
Sector and subsector: Audit Audit
Salary: Negotiable salary

Job Title: Quality Improvement and Clinical Audit Administrator

Department: Quality

Job Function: Quality Improvement, Clinical Audit and Organisational Performance

Reporting to: Head of Quality, Risk & Accreditation

Location: BlackRock Health Hermitage Clinic

Job Purpose

The Quality Improvement and Clinical Audit Administrator is a member of the Quality, Risk and Accreditation Team with responsibility for supporting the coordination of hospital wide clinical audit programme and supporting the systematic delivery, monitoring and evaluation of quality improvement initiatives.

The post holder will work closely with clinical and operational leaders to translate audit findings, patient safety information, patient feedback, accreditation requirements and performance data into measurable Quality Improvement Plans (QIPs). The role will maintain central oversight of QIPs across the organisation, monitor progress against agreed milestones and outcomes, and elevate delays or barriers through the appropriate governance structures.

A key requirement of the role is to work in close partnership with the Nurse Education and Practice Development Team and with Health and Social Care Managers to develop meaningful departmental Key Performance Indicators (KPIs), agree definitions and data sources, establish reporting arrangements, analyse trends and support improvement where performance falls below the agreed standard.

The post holder will provide expert advice on clinical audit methodology, measurement for improvement, data quality and QIP design, helping departments to demonstrate sustained improvements in the quality, safety and reliability of patient care and compliance with JCI Accreditation, HIQA standards and other applicable requirements.

Job Background/Context

Blackrock Health Hermitage Clinic is a private acute hospital providing medical, surgical and diagnostic services across a broad range of specialties. The hospital is committed to evidence based practice, measurable improvement and robust assurance of clinical outcomes.

The role works across all clinical and clinical support departments and is not limited to nursing services. It supports nursing, medical and Health and Social Care Professional teams to use clinical audit, KPIs and structured QIPs to identify variation, improve care and provide assurance to hospital governance committees and the Executive Management Team.

Key Responsibilities

Clinical Audit Programme

• Assist with the co ordination and maintenance of the hospital wide clinical audit strategy, annual clinical audit programme and central clinical audit register, aligned with organisational risks, incidents, complaints, patient feedback, regulatory requirements and strategic priorities.
• Support departments to select relevant audit topics, define audit criteria and standards, identify appropriate samples and data sources, and complete the full audit cycle.
• Provide practical advice, templates and coaching on audit design, data collection, analysis, report writing, action planning and re audit.
• Support the undertaking of clinical audits, tracer audits, practice observation audits and focused reviews, including preparation for JCI, HIQA and other external assessments.
• Review submitted audit reports for methodological quality, accuracy, clear findings and appropriate recommendations before governance reporting.
• Monitor completion of the approved audit programme and elevate overdue, incomplete or low quality audits to the relevant manager and governance forum.
• Ensure that audits identifying non compliance or variation generate proportionate QIPs and that re audit is completed to verify improvement.

Quality Improvement Plans and Improvement Support

• Maintain the central organisational register of QIPs, recording the improvement aim, baseline position, actions, accountable owner, milestones, measures, status, risks and evidence of completion.
• Monitor QIPs across the organisation, follow up with responsible owners and provide regular exception reports on overdue actions, barriers, outcomes and areas requiring escalation.
• Support departments to develop SMART improvement aims, outcome/process/balancing measures, realistic implementation plans and defined sustainability arrangements.
• Facilitate multidisciplinary improvement projects using recognised quality improvement approaches, including Plan Do Study Act cycles, process mapping, driver diagrams and measurement over time, as appropriate.
• Confirm that QIPs are closed only when objective evidence demonstrates implementation and, where appropriate, sustained improvement or effective risk reduction.
• Promote the sharing and spread of successful improvement initiatives and learning across departments.

Departmental KPIs and Performance Measurement

• Work closely with the Nurse Education and Practice Development Team and Health and Social Care Managers to develop a balanced suite of meaningful departmental KPIs linked to patient outcomes, clinical effectiveness, safety, patient experience, workforce competence and service performance.
• Support each department to prepare clear KPI descriptors specifying the purpose, definition, inclusion and exclusion criteria, numerator, denominator, target, data source, collection method, frequency, accountable owner and reporting route.
• Ensure that KPI measures are relevant, evidence based, measurable and capable of supporting decision making and improvement rather than data collection alone.
• Assist with establishing and maintaining a schedule for departmental KPI submission, validation, analysis and reporting.
• Analyse KPI performance and trends, identify variation or deterioration, and work with departmental managers to develop and monitor QIPs where targets are not achieved.
• Support data quality checks and validation so that performance information reported to governance committees is accurate, complete, timely and reproducible.
• Develop clear dashboards and reports that highlight performance, trends, exceptions, improvement actions and evidence of sustained progress.

Education, Practice Development and Collaborative Working

• Develop an agreed annual programme of audit and quality improvement education in partnership with the Nurse Education and Practice Development Team.
• Identify learning needs arising from audit results, KPI trends, QIPs, incidents, complaints and external findings, and work with the Nurse Education and Practice Development Team to develop targeted education and practice development interventions.
• Work collaboratively with Health and Social Care Managers and multidisciplinary clinical teams to strengthen audit capability, ownership of data and local improvement skills.
• Provide coaching and support to departmental audit leads, QIP owners and staff undertaking improvement projects.
• Contribute to staff induction, management development, quality forums and organisational learning events as required.

Governance, Reporting and Assurance

• Support the preparation of regular clinical audit, KPI and QIP reports for the Head of Quality, Risk & Accreditation, the Quality Improvement & Risk Management Committee and other relevant governance committees.
• Present findings clearly, identify significant gaps or deteriorating performance, and recommend proportionate escalation or corrective action.
• Maintain complete, version controlled records of audit tools, datasets, reports, QIPs, re audits and evidence of closure in accordance with hospital requirements.
• Support the triangulation of audit and KPI findings with incidents, complaints, risks, patient feedback and accreditation findings to identify organisational priorities.
• Contribute specialist clinical audit and improvement evidence for JCI, HIQA and other regulatory, accreditation or assurance activities.
• Assist in evaluating the effectiveness of organisational quality and patient safety initiatives and report whether intended outcomes have been achieved.

Professional Responsibilities

• Act as a visible resource and advocate for evidence based quality improvement, clinical effectiveness and patient centred care.
• Maintain current knowledge of clinical audit, quality improvement science, measurement, patient safety, JCI requirements, HIQA standards and relevant national guidance.
• Manage competing priorities, meet agreed deadlines and communicate promptly where delivery or data quality is at risk.
• Handle clinical and organisational information confidentially and in accordance with data protection, records management and hospital requirements.
• Participate in relevant committees, working groups and quality initiatives as requested by the Head of Quality, Risk & Accreditation.
• Undertake other duties consistent with the specialist nature and level of the post.

Knowledge / Experience

• A minimum of three years' relevant clinical or healthcare experience.
• Demonstrable knowledge of clinical audit and/or structured quality improvement work in a healthcare setting.
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