Quality Manager (Cellular Pathology)

Quality Manager (Cellular Pathology)

Job description

Job summary

Pathologyat Leeds Teaching Hospitals has an exciting opportunity for a Quality Managerto join the team within its Cellular Pathology department.

Yourprimary responsibility will be to coordinate the Governance process (Health andSafety, Risk Management and Quality Management) in collaboration with themanagement team.

You will work closely with the Service Manager, Clinical Leadand Operational Leads to ensure the effective development and implementation ofthe quality management system.

Yourgeneral duties will include

Ensuring the effective management ofchange, compliance to the departmental audit schedule

Overseeing incident reports andinvestigation,





risk management and corrective and preventative actions (CAPA)

Assist in establishing and monitoringKey Performance Indicators (KPIs)

Co-ordinating test validation andverification

Ensuring compliance with accreditation / regulatorybody requirements.

Co-ordinate matters relating to staffHealth and Safety.

Youwill be registered with the HCPC and have extensive post registrationexperience as a Biomedical Scientist within a relevant speciality.

You will holdan MSc or equivalent, in Biomedical Science or related field and will ideallyhave experience of quality management and / or governance activities.

AQuality Management and / or Service Improvement qualification would be desirable.

Expected Shortlisting date : 30 / 09 / 2024

Planned Interview date : 07 / 10 / 2024

Main duties of the job

Youwill have Primarily responsibility for the implementation and coordination ofthe Quality Management System within the department.







The jobholder willcontribute towards overall service improvement by participation in and theimplementation of departmental policy development and by active participationin a range of people governance procedures consistent with Trust policies.

Ensurethat enabling quality systems and processes are established, implemented andmaintained.

Coordinatecompliance with Trust and CSU Governance policies and procedures.

Workcollaboratively with the CSU leadership team to design, implement and reviewquality management system policies and procedures.

Tocommunicate complex information to colleagues and other healthcare staff.

Tocontribute towards the training of support, technical, scientific and medicalstaff in relation to delivery of the quality management system.







Provideday to day management to departmental quality administrators and / or qualitysupervisors and ensure that these individuals complete appropriate,role-specific training in the quality management system.

Thejobholder will lead on the coordination of external assessment visits fromregulatory and accreditation bodies at department level ( UKAS, HTA) andcoordinate the completion of any resulting improvement actions.

About us

Thedepartment provides Histopathology, Non Gynae Cytology, Andrology, Muscle,Nerve, Immunohistochemistry, Molecular, and Mortuary services for LeedsTeaching Hospitals Trust and surrounding primary care centres.

Weare a well equipped and innovative department being the first laboratory in theUK digitally scanning 100% of surgical slides, also introducing the UKs firstautomated tissue sectioners.

We process circa 58,000 surgical cases,





3000andrology cases, 2,000 autopsy cases and 6000 non-gynaecological cytology casesper annum.

We are a continuallyimproving department, striving for high quality staff and processes. As atraining hospital we serve to expand the knowledge and skills of all staff.

There are plenty of opportunities to become involved, and further developmentis encouraged. We endeavour to follow The Leeds Way at all times putting the patient first at all times.

Leeds Teaching Hospitals is committed to our processof redeploying at risk members of our existing workforce to new roles.

Assuch, all our job adverts are subject to this policy and we reserve the rightto close, delay or remove adverts while this process is completed.







If you doexperience a delay in the shortlisting stage of the recruitment cycle, pleasebear with us while this process is completed, and contact the named contact ifyou have any questions.

Job description

Job responsibilities

In order to work effectively in the role, the jobholder, must be able to demonstrate a number of attributes and abilities. These will include :

Responsibility for the management and coordination of the Health and Safety, Risk Management and Quality Management activities of the department

To contribute to the training of support, technical,





scientific and medical staff to be familiar with and to adhere to the Pathology Quality Policy and Quality Manual and to contribute actively towards the improvement of service quality by participation in relevant discussions with other team members

To contribute actively towards the improvement of general service quality by participation in relevant discussions with other managers and team leaders

To participate actively in other people governance procedures that are consistent with Trust HR policies

To take account of changes in service delivery by demonstrating a flexible approach to work

To actively participate in the laboratory quality assurance and risk management programmes

To plan and manage the laboratory audit processes which includes Devise audit calendar,





manage the audit programme adjusting the calendar to reflect actual activity and the need for re-audits Train staff in audit techniques Prepare the audit checklists and documentation with on going evaluation of suitability based on feedback from auditors and auditees Participate as an auditor

Manage the resolution of non-compliances (corrective action, root cause analysis and preventive action); coordinating other senior staff where the action required is within their remit and taking direct responsibility for non compliances with QMS.

Report on the effectiveness of the audit process

PRINCIPAL DUTIES & AREAS OF RESPONSIBILITY

To be responsible for the implementation and coordination of the Quality Management System within the department.

To coordinate risk management activities within the department.

Coordinate matters relating to staff Health and Safety.

Plan and implement, in consultation with other managers,





changes to CSU and department level policies.

Ensure that processes needed for delivery of the quality management system are established, implemented and maintained.

Lead on the coordination of external assessment visits from regulatory and accreditation bodies ( UKAS, HTA) at departmental level and coordinate the completion of any resulting improvement actions.

Lead on ensuring that the quality management system is functioning effectively within the department, such that risks to patient care and staff safety are well mitigated.

Escalate using the appropriate line management structures where necessary.

Support laboratory management teams in maintaining robust quality systems and processes in relation to regional collaborations and actively engage in related quality groups / forums, as appropriate.

Ensure that nonconformities of all types are managed effectively within the department, in line with relevant CSU policies.

PALS, complaints, DATIX incidents / trends, audit findings).

Ensure that suitable mechanisms are in place to : collate user needs and requirements from all sources; review the feedback;

formulate documented actions plans and share learning.

Ensure that mechanisms are in place to ensure that critical information pertaining to management review inputs are effectively captured and appraised at department level with escalation to the CSU quality assurance group meeting where appropriate.

Produce Quality reports on the departments performance in relation to the Quality Management system (including quality indicators) and ensure that effective management review takes place.

Work collaboratively with the CSU leadership team to design, implement and review quality management system policies.

Where applicable, plan and coordinate the tasks and activities undertaken by quality administrators assigned to support effective delivery of the quality management system.

Coordinate, in line with CSU policy, the departmental approach to Governance on behalf of and in collaboration with, operational managers, such that all applicable internal and external quality standards are met.

Feedback on compliance with LTHT Pathology governance policies and procedures via reports to be reviewed in the CSU Quality Assurance forum.

Maintain joint responsibility with other Quality Managers for maintaining the content and structure of the electronic quality management system.

Plan, develop and coordinate training relating to the quality management system in a manner that is consistent with the Pathology training policy, including audit training.

Deliver regular internal audit training to departmental audit teams

Deliver quality management system training to quality administrators / supervisors (initial and follow up every 2 years).

Deliver quality management system training to departmental staff of all grades on an ad-hoc basis in relation to new and updated quality systems and processes

Plan and coordinate the department internal audit programme, including audit training, ensuring that all key quality management activities and technical processes are covered and prioritised on the basis of risk.

Ensure that learning arising from audit findings is adequately embedded within the quality management system.

Coordinate incident reporting and investigation at department level, including reporting incidents to relevant external bodies ( HTA, HSE via the Trust H&S; team).

Adhere to and promote the use of, the Pathology Quality Policy and Quality Manual.

Ensure that effective document control is maintained within the department in conformity with CSU and local policy.

Ensure that risk management systems and process are in place and followed with regular managerial review of on-going compliance.

Communicate accurately complex information to users of the service in a manner that is in accordance with departmental procedures.

Supports the design of policies and procedures which act to ensure that : expensive and complex analytical equipment, reagents and laboratory consumables are used safely and effectively.

Orders supplies that support the delivery of quality and risk management activities.

To maintain registered status as a Biomedical Scientist with the HCPC, where applicable to speciality.

Maintain a good working knowledge of the relevant statutory, regulatory and accreditation body-based requirements relating to the quality management system and be able to advise other members of the department on how to achieve compliance with these requirements.

This list is not exhaustive, and the changing needs of the service may, from time to time, require the development of other appropriate duties, tasks and skills.

These will be fully discussed with the post holder in advance of their implementation.

The Pathology Department of Leeds Teaching Hospitals NHS Trust is located on several sites. Subject to appropriate consultation, the post holder may be required to work in a laboratory based at an alternative site as required by the Service Manager.

Person Specification

Qualifications

Essential

- Biomedical Sciences (or equivalent) Masters degree (MSc)
- HCPC Registered healthcare scientist

Desirable

- Management qualification
- Quality Management and / or Service Improvement qualification

Skills & Behaviours

Essential

- Specialist knowledge of Quality Management and Clinical Governance
- Specialist knowledge of regulatory and accreditation body requirements relating to clinical laboratory services
- Advanced keyboard skills and attention to detail ( evaluating and interpreting complex datasets; generating data reports;

investigating and reporting incidents).

Able to effectively motivate and influence - Excellent written and oral communication skills.

Desirable

Evidence of delivering training in quality management systems and processes

Experience

Essential

- Extensive experience within the clinical laboratory setting
- Successful working as a member of a team.
- Supervisory or management experience.

Desirable

- Experience of leading Quality Management and / or governance activities
- Experience of risk management activities, including Health and Safety aspects
- Experience of working within a formal managerial / leadership role

▶️ Quality Manager (Cellular Pathology)
🖊️ Leeds Teaching Hospitals
📍 Leeds