Deputy Quality & Accreditation Manager - UPMC Sports Surgery Clinic, DublinLocation: Sports Surgery ClinicJob type: Fixed TermOverview of role: The Deputy Quality & Accreditation Manager will be responsible for supporting the quality function within the hospital and will work closely with the wider UPMC Quality function and Senior Leadership Team. This role will support management with JCI accreditation within the hospital and will be responsible for ensuring and co-ordinating all aspects of evidential compliance in the form of policies & procedures, KPI's, QIP's, audits, tracers and data collection. This position is responsible for contributing to hospital-wide and departmental quality initiatives. This involves performing the assessment and analysis of operations and processes.Primary Duties and Responsibilities: Work in collaboration with the General Manager, Quality, Risk & Patient Safety Manager in the development of the hospital quality improvement/quality assurance programme.Coordinating the Joint Commission International (JCI) accreditation and national accreditation and licensing process (HIQA).Assist with conducting or supporting clinical and non-clinical audit activities.Ensure application of a tracking method to monitor progress towards goals by collecting accurate and timely data to produce quality and service outcomes.Liaise with Administrators, Department Heads, Managers and committees to identify Quality Improvement Projects required; and lead or co-facilitate as appropriate to finalise and advance project goals. Effectively communicate improvements to management and staff throughout the organisation.Be accountable for the quality of the service provided, including customer service and technical aspects.Manage audits and reports on patient and customer complaints, compliments, and patient satisfaction feedback.Support the Management team in the implementation of initiatives aimed at on-going service development and improvement by fostering a high level of morale among staff while ensuring effective communication.Co-ordinate and support quality improvement projects within teams with the application of quality improvement science and methodologies.Manage day to day communications with the team(s) to ensure groups receive the necessary support to work effectively to deliver on the improvement projects.Ensure that the measurement and analysis of data is incorporated into all quality improvement projects.Schedule meetings, follow up on agreed actions and maintain minutes.Provide updates to demonstrate working to agreed programme plans.Produce individual workplans to ensure activities are on track with agreed programmes.Assist with policy development and review including document control management.Assist with staff education and training on quality improvement and risk management projects and tools and other projects as required.Committee participation as required to promote Quality, Patient Safety, Innovation and Risk Management activities.Maintain accountability for ongoing self-development activities, especially related to presentation facilitation, change management and the application of quality improvement activities.Performing internal audits, compliance assessments, data analysis and developing corrective and preventative action (CAPA) plans.Conducting root cause analysis (RCA) and risk assessments to identify systematic issues and improve safety outcomes.Promoting a culture of operational excellence, patient safety and continuous improvements across all departments.Any other duties that may be assigned from time to time by Hospital Management. General Through the course of the working day or week there may be a requirement to work in other areas of the hospital in line with patient requirements as requested by your Line Manager. Staff must produce satisfactory documentary evidence of all training and experience claimed by them, if required to do so by the organisation. To respect the organisational values of the Hospital.Quality & Safety – Safe Culture Quality and Safety are rooted in the daily work of all individuals at UPMC. As an employee you are required to actively participate throughout your working day in pursuit of excellence.You are required to work in conjunction with your line manager in the planning, monitoring, analysing and improvement of all quality programmes.Participate in the development of performance indicators in conjunction with your department manager and the business objectives. Initiates, participates in and evaluates audit according to JCI, Hospital policy and Lean requirements under the guidance and supported by an audit lead.Qualifications & Experience:Clinical/Healthcare background is essential.Received or currently undergoing a qualification in Quality in Healthcare (Degree or equivalent) desirable.Experience: 3 years experience in a similar role or healthcare setting.Previous experience working with JCI or similar accreditation system.Knowledge of and understanding of Q Pulse and or similar reporting platforms is essential.Excellent IT skills: MS Office skills to include, MS Teams, Word, Excel and PowerPoint, knowledge and experience of using an email system effectively.Demonstrate a knowledge of applying standards to practice, quality improvement process and quality and safety frameworks.Experience in the application of knowledge on standardisation to practice / process.Prior management or project management skills are desirable that demonstrate the incumbent's ability to plan, implement and manage complex projects. Demonstrate a high level of knowledge of developments within the healthcare quality.Knowledge of information systems and process improvement techniques.Experience in data management processes for healthcare or quality data systems.Hands on experience with electronic health record (EHR) systems for data integrity and compliance verification.Competence in creating and interpreting Business Intelligence (BI) reports and dashboards using Power BI. Excellent technical writing skills for preparing SOP's, CAPA reports and audit findings, validation documentation and regulatory submissions.Knowledge of IT security and GDPR principles relevant to healthcare data protection and compliance.Familiarity with Hospital Information Systems (HIS) software.Strong auditing and risk management capability, including conduting internal audit and leading Root Cause Analysis (RCA) and Corrective Action and Preventative Action (CAPA) initiatives.Demonstrated ability to interpret and apply national and international regulatory standards within a hospital setting.Data management and analysis expertise is essential, specifically Excel.EqualOpportunity Statement and Benefits UPMC is an equal opportunity employer.We celebrate diversity and are committed to creating an inclusive environmentfor all employees.At UPMC we provide a total rewards programthat is not only market competitive, but fair and provides growth opportunitiesfor all our colleagues.Compensation – Competitive pay for the work employees do – base pay, performance related payand premium pay where applicable.Benefits –Fully paid maternity and paternity leave for new parents. Competitive PensionPlan.Performance and Recognition – Rewards for performance that supports the goals and mission ofUPMC through our annual ACES programme.Work-Life Balance – Flexibleworking opportunities to support you to work around external familycommitments.Developmentand Career Opportunities – Opportunities for each employee to reachtheir career goals through continued learning and/or advancement.AboutUPMC UPMC is a renowned multinational academic medicalcentre committed to delivering people-focused care that's close to home.Headquartered in Pittsburgh and affiliated with the University of PittsburghSchools of the Health Sciences, UPMC shapes the future of health throughclinical and technological innovation, research and education.UPMC expands its expertise globally, bringing world-class care acrosscontinents through its UPMC International division — an owned and operatednetwork of hospitals and ambulatory care centres in Italy, Ireland andCroatia. UPMC International brings new access to the signature specialtyservices of UPMC Hillman Cancer Centre, UPMC Sports Medicine and others tomore people in more places around the world. In Ireland UPMC has provided high-quality healthcare in the South East since2006. UPMC's operations in Ireland now include UPMC Whitfield Hospital inWaterford, UPMC Sports Surgery Clinic in Dublin, UPMC Kildare Hospital inClane, and UPMC Aut Even Hospital in Kilkenny. Outpatient care is available atthe UPMC Carlow Outreach Centre, UPMC Hillman Cancer Centre radiotherapylocations in Waterford and Cork, UPMC The 4th Practice in Mallow, and acrossUPMC Sports Medicine Clinics in Dublin, Waterford, Limerick, Tipperary, Cork, andMayo. UPMC has also established a nationwide Concussion Network. UPMC'sGlobal Technology Operation Centre is based in Kilkenny.