Clinical Nurse Manager 2 - ICU Audit

JOB DESCRIPTION

Clinical Nurse Manager 2 ICU – Audit

Full-Time Permanent 


Reference No: 06.022 (2024 )
  PURPOSE OF THE ROLE
The CNM2 ICU NOCA Audit, will be responsible for TUH contribution to the NOCA Audit. The objectives of the Irish National ICU Audit include the following, Measure the quality of care in ICU by benchmarking outcomes, Use the Audit to drive improvements in the quality of care. Measure activity to inform the configuration of critical care. Provide data to support the Hospital In-Patient Enquiry (HIPE) system and activity-based funding (ABF). Audit healthcare-associated infection (HCAI), and Audit potential organ donors and organ donation. The Irish National Intensive Care Unit (ICU) audit is a quality and patient safety initiative that measures the Quality of Care in Each ICU, benchmarking against best international standards. Activity with the participating ICU’s is carefully measured to help improve the standard of Critical Care within the Hospital Groups and across the country.

The ultimate benefit of the Irish National ICU Audit will be to improve the quality of care in each ICU and to analyse activity, therefore helping to enhance critical care services. It will also provide data on the complexity of care for HIPE and ABF, and support for Organ Donation Transplant Ireland (ODTI) and the Health Protection Surveillance Centre (HPSC). Locally and nationally, the data will help to build on a database for research and development.

QUALIFICATIONS
1. Each candidate must on the latest date for receiving completed application forms for the office -:

Be a Member of the General Division of the active register of the Nursing and Midwifery board of Ireland.

Have a post graduate qualification of not less than level 7 on the NFQ framework in the specialist area.

Have at least 5 years post registration experience (or an aggregate of 5 years fulltime post registration experience) of which 2 years must be in the speciality (ICU).

Have the clinical, managerial and administrative capacity to properly discharge the functions of the role.

Demonstrate evidence of continual professional development.

Have excellent communication and interpersonal skills.

Desirable:

A track record of working across disciplines and general competency in report writing and data literacy i.e. understands the clinical indicators that will be collected and has the ability to use PC for data entry and report writing.

A recognized qualification in intensive care nursing is desirable.

Understanding of the fundamentals of database management.

Working knowledge or willingness to learn generating database queries using SQL. Ms Access

Working knowledge or willingness to learn data processing using Ms Excel, Python

Track record of participating in quality improvement and Audit Projects.

Ability to present Audit reporting using Ms Power Point.

2. Age Restrictions In Relation To Applications
Age restriction shall only apply to a candidate where they are not classified as a new entrant (within the meaning of the Public Service Superannuation (Miscellaneous Provisions) Act, 2004). A candidate who is not classified as a new entrant must be under 65 years of age on the first day of the month in which the latest date for receiving completed applications for the office occurs.

3. Health
A candidate for and any person holding the office must be fully competent and capable of undertaking the duties attached to the office and be in a state of health as would indicate a reasonable prospect of ability to render regular and efficient service.

4. Be of good character.

5. Garda Vetting
Garda Vetting is sought for all employees and prospective employees of Tallaght University Hospital. Given the specialised nature of the services provided, your appointment will be subject to satisfactory Garda Vetting and re-vetting in circumstances where the Hospital deems it appropriate. The Hospital will then process the necessary documentation to endeavour to obtain satisfactory Garda clearance for you. You are obliged to disclose previous and any criminal convictions acquired during the course of your employment. Should the Hospital obtain information from the Garda Vetting Unit to indicate that your Garda clearance report is not satisfactory and / or if you have supplied the hospital with false or misleading information in relation to your Garda clearance status, the Hospital reserves the right to withdraw or terminate this contract in accordance with Tallaght University Hospital Garda Vetting policy.
  6. Mandated and Designated Persons under Children First Act 2015 Schedule 2 of the Children First Act 2015 specifies the classes of persons defined as Mandated Persons for the purposes of the Act. This includes a range of disciplines that are employed by the hospital including all medical practitioners, registered nurses, physiotherapists, psychologists, social workers and others. This includes staff working in adult services. All mandated persons have two main legal obligations under the Children First Act 2015. Mandated persons, under the legislation are required to report any knowledge, belief or reasonable suspicion that a child has been harmed, is being harmed, or is at risk of being harmed. The Act defines harm as assault, ill-treatment, neglect or sexual abuse, and covers single and multiple instances. Mandated persons are also required to assist Tusla, if requested, in assessing a concern which has been the subject of a mandated report. Designated Officer are required to receive reports of suspected child abuse or neglect from any person who is of the opinion that (a) a child has been or is being assaulted, ill-treated, neglected or sexually abused, or (b) a child’s health, development or welfare has been or is being avoidably impaired or neglected. Full detailed list of mandated and designated staff together with details of their roles and responsibilities can be found on ; It is the responsibility of all staff employed by TUH to be aware of their roles and responsibilities under the legislation and to complete mandatory Children First Training.


PARTICULARS OF OFFICE

1. The appointment is fulltime, permanent and pensionable.
 
2. Remuneration:
Remuneration is in accordance with the salary scale approved by the Department of Health & Children. Current remuneration with effect from 1st January 2024 is:

€58,485 by 11 increments to €73,904 incl. 1 LSI

Salary scales will be updated in line with nationally agreed pay agreements and will be updated accordingly and retrospective payments applied as applicable.

3. Pension Arrangements and Retirement Age
There are three superannuation schemes currently in operation for staff in Tallaght University Hospital:

(a) Voluntary Hospital Superannuation Scheme (Non-New Entrant) 
(b) Voluntary Hospital Superannuation Scheme (New Entrant)
(c) Single Public Service Pension Scheme

Please read carefully the summary of the criteria for the three superannuation schemes below. This will assist you in identifying which scheme membership is applicable to your employment circumstances.

(a) If you have been continually employed in the public service prior to the 1st April 2004 and you have not had a break in service of more than 26 weeks, you will be included in the Voluntary Hospital Superannuation Scheme (Non-New Entrant) with a Minimum Retirement Age of 60 and a Maximum Retirement Age of 65.

(b) If you have been continually employed in the public service post the 1st April 2004 and you have not had a break in service of more than 26 weeks, you will be included in the Voluntary Hospital Superannuation Scheme (New Entrant) with a Minimum Retirement Age of 65. There is no Maximum Retirement Age.

(c) If you have commenced employment in the public service as a new entrant or you are a former public servant, returning to the public service after a break of more than 26 weeks, you will be included in the Single Public Service Pension Scheme effective from the 1st January 2013 with a minimum retirement age of 66 (rising to 67 and 68 in line with state pension changes). The maximum retirement age under this scheme will be age 70.

4. Duties:
The CNM2 NOCA Audit will perform such duties as are outlined in this job description.

5. Hours of work:
Normal working hours are 37.5 worked over 5 days. Your contracted hours of work are liable to change between the hours of 8 am to 8 pm over 7 days to meet the requirements for extended day services in accordance with the terms of the Framework Agreement. 

6. Probation:
The successful candidate will be appointed initially for a probationary period of 6 months. During the probationary period progress or otherwise will be monitored and at the end of the probationary period the service will (a) be certified as satisfactory and confirmed in writing or if not satisfactory, the probationary period may be extended by 3 months.

7. Annual Leave:
Annual leave entitlement is 25-28 working days (pro rata), depending on length of service, plus 10 Bank Holidays per annum as they occur. The annual leave year runs from 1st of April to 31st March each year.

8. Sick Leave:
Payment of salary during illness will be in accordance with arrangements as approved from time to time by the Department of Health and Children.

9. Termination of Office:
The employment may be terminated at any time by 2 months’ notice on either side except where circumstances are dictated by the Minimum Notice and Terms of Employment Act 1973/91. The Management’s right under this paragraph shall not be exercised save in circumstances where the Management is of the opinion that the holder of the office has failed to perform satisfactorily the duties of the post or has misconducted himself/herself in relation to the post or is otherwise unfit to hold the appointment.

GENERAL ACCOUNTABILITY

Maintain throughout the Hospital awareness of the primacy of the patient in relation to all Hospital activities.

Encourage recognition of the patient as an individual, ensuring patients’ needs and comfort are given priority.

Work within the Scope of Practice

Comply with all existing Hospital policies

Demonstrate knowledge of the Hospital/Departmental emergency plans

Ensure the provision of a high standard of care to the patient and families is consistent with the mission, vision, values and strategic plan of the Hospital.

Demonstrate behaviour consistent with the Values of the Hospital.

Reporting relationship will be to the CNM3 ICU and Assistant Director of Nursing Peri Op

Be professionally accountable to the Director of Nursing.

SPECIFIC ACCOUNTABILITY

Clinical Role

Be responsible for co-ordinating and implementing a Programme of clinical audit within the ICU as agreed with the Medical Director of ICU the ICU Clinical Nurse Managers and the Directorate Nurse Manager.

Liaise with intensive care medical and nursing staff regarding the information collected and identify any gaps in information provided prior to inputting to the data base.

Assist in other specific audits related to the National ICU Audit Programme, Critical Care Census as directed by the Medical Director of ICU, and in agreement with the ICU Clinical Nurse Managers and directorate nurse manager.

Ensure all audits are conducted in accordance with standards.

Follow policies and procedures in accordance with hospital guidelines, the National ICU Audit Programme and the National Office of Clinical Audit (NOCA).

Assist with the training and supervision of other staff classified as users of the database to maintain continuity and accuracy of data inputting.

Maintain/Update ICU clinical skills. This should be agreed with the ICU Nurse Manager, ICU Medical Director and the nurse assigned to the National ICU Audit Programme, preferably using a personal development planning process, to agree required continuing professional development (CPD).

Keep up to date with developments in ICU audit by attending seminars, meetings, training and other CPD opportunities as agreed with line manager using a personal development plan.

Develop implement and evaluate, with support from the National ICU Audit Coordinator, a suitable process to ensure validation of collected data.

Collect and collate data as per ICU audit dataset approved by National ICU Audit. Sources include nursing and medical notes, input from CIS, input by medical and nursing staff, links with other IT systems in hospital e.g. IPIMS, Microbiology, PACS, laboratory etc.

Collect and collate data for local audit and research purposes, and assist the ICU team in data analysis projects, submitting and presenting audit reports to hospital management and critical care programmes as required.

Ensure safe transfer of data to appropriate body (ICNARC, HIPE office in each hospital, national/central ICU database, etc.) in compliance with Data Protection requirements.

Assist the ICU NOCA Nurse with data validation queries from ICNARC in compliance with data protection requirements.

Receive data analysis reports from ICNARC and convey results back to the Unit staff. Work on improvement plans with ICU staff.

Facilitate access to audit data for relevant hospital personnel, which must be authorised in writing by the ICU Audit Consultant,

Provide education to ICU nursing and medical staff regarding the Audit process and the National ICU Audit.

Adhere to statutory obligations under the Data Protection Act to include the safe storage and safe transfer of data. Understand encryption of data.

Take responsibility for the collection and collating of data in relation to ICU e.g. rates of Organ Donation in the ICU.

Produce, in collaboration with the medical, nursing, audit and management staff an Annual Report for the ICU incorporating audit data and other local data required by the ICU Medical Director. The ICU Medical Director is responsible for final content of this Report which is normally circulated only within the Hospital.

Provide data analysis reports to the ICU Medical Director, Clinical Nurse Manager and the Directorate Nurse Manger/ADON

Submit agreed reports to the National ICU Audit Coordinator.

Revision of local standards of practice (SOP) and current policies of clinical practice under the supervision of ICU clinical audit lead and in line with national and international guidelines.

Information Technology

Ensure that the team makes the most effective and efficient use of developments in information technology for both patient care and administrative support in a manner, which integrates well with systems throughout the organisation.

Ensure that all staff are trained in the use of computer systems, which are used in the management of patient episodes in the Hospital, e.g.: EPR, Pims, Order comms, Symphony, sap, core.

Health & Safety

Ensure the compliance of all your staff with the Safety, Health and Welfare at Work Act, 2005.

Comply and enact Health and Safety responsibilities as outlined in Hospital policies, protocols and procedures relevant to your area.

Prepare risk assessments and departmental safety statements as required.

Hygiene/Infection Control

Ensure you are aware of your responsibility for Hygiene awareness. Hygiene is defined as “The practice that serves to keep people and environments clean and prevent infection.”

Act as a role model and actively promote infection control and prevention and ensure that staff in your area familiarise themselves with the hospital infection control policies and guidelines as outlined in the Infection Control Manual.

Ensure that staff in your area are aware that they work in an area where there is potential for transmission of infection.

Ensure that all your staff are advised that they have a responsibility to prevent the transmission of infection particularly in relation to hand hygiene.

Quality, safety and risk management

Support the delivery of the Quality, Safety and Risk Management Programme, including the appropriate identification, reporting and management of risks and incidents throughout the hospital.

Confidentiality

You will be aware of the confidential nature of Hospital work and in particular, the right of patients to confidentiality. To this end, you will not discuss workings of the Hospital or its patients or disclose any information of a confidential nature except as required to do so in the course of your work. No records, documents or property of the Hospital may be removed from the premises of the Hospital without prior authorisation. You must return to the Hospital upon request and, in any event, upon the termination of your employment, all documents or other property of the Hospital which are in your possession or under your control.

Data Management

Ensure compliance with the obligations required by the Data Protection Act 2018.

Development of Hospital Groups

The Hospital Structure is currently under review and therefore, reporting relationships may change. The development of Hospital Groups may require the post-holder to adopt a different reporting relationship and additional accountabilities. Full consultation will take place in advance of any such change.