Grade VII Q&S Manager (Risk & Incident)

Quality \& Safety Manager (Risk \& Incident Management) Job Specification

Reference Number:

Job Title: Grade VII

Reference No: 06\.036(2026\)

Department / Directorate: QRSM Directorate

Reports to: Manager or Deputy

Tallaght University Hospital (TUH) is a model 4, voluntary, academic teaching hospital partnered with Trinity College and situated in south west Dublin. With a staff of over 4,000 people from 63 different countries, it provides both acute and tertiary care to an increasing population of circa 800,000 people and is a provider of local, regional and national specialties. It is also a National Urology Centre, the second largest provider of dialysis services in the country, Pelvic and Acetabulum National Centre and a designated Trauma Unit.

The Hospital is part of the newly established HSE Dublin \& Midlands Region, which serves a population of over 1\.2 million across seven counties, and operates under the governance of an independent Board of Directors who give their time on a voluntary basis. TUH is also supported by the Adelaide Health Foundation, the Meath Foundation and Tallaght University Hospital Foundation.

TUH recognises the role it plays in our community both as an employer and provider of healthcare and is committed to building a sustainable future for our region both now and into the future with a focus on patient outcomes.

The Hospital is ambitious, recognising that healthcare delivery is undergoing seismic change and will be different now and into the future, largely due to digital and technological advances along with research continuing to discover and test new treatment options. TUH wants to be a leader in determining that future. It is a *“Hospital without Walls”* always looking to optimise care both within and beyond in line with the Sláintecare vision of providing the right care, in the right place, at the right time whilst empowering our patients and staff.

TUH Vision and Values

The vision of the Hospital is “*People Caring for People to Live Better Lives”* through excellent health outcomes supported by evidenced based practice, positive patient and staff experience in an empowering and caring environment. A culture of innovation and quality improvement in everything we do.

Our TUH CARE values – for patients, their families, our community and staff are:* Collaborate – together and with our academic and care partners

• Achieve – our goals, positive outcomes and wellbeing


• Respect – for patients, each other and our environment


• Equity – for patients and staff

At TUH we view our staff as our most valuable asset and every member of the Team is valued equally. We recognise that a skilled, satisfied and motivated workforce is a prerequisite to high quality care.

A full overview of TUH is available on https://tuh.ie/About\-us/

Details of the Service:

The Hospital is part of the Dublin Midlands Region and serves the catchment population of 650,000 across Tallaght, Clondalkin, Firhouse, Rathfarnham, Terenure, Templeogue, West Wicklow and parts of Kildare. The most recent census revealed that 28% of the population of the state reside within this network area.

There is currently capacity for 472 inpatient and day care beds at Tallaght University Hospital. These figures do not include South Dublin Mental Health services at Tallaght University Hospital which has an additional capacity of 52 public beds. Tallaght University Hospital provides a wide range of secondary and tertiary services across the Medical, Surgical, Paediatric and Diagnostic spectrum. It is also the regional centre for Orthopaedics, Urology and Renal Medicine/Dialysis.

Purpose of the Post:

The Quality and Safety Department provides support to all hospital staff to enable them to incorporate safe management practice and quality in all activities in the hospital. Activities include analysing incidents and identifying trends, co\-ordination of incident reviews, promotion of clinical audit throughout the organisation and promoting the health and safety of staff and patients.

The Quality and Safety Manager plays a pivotal role in assuring the full participation of the Hospital in the delivery of high quality care that is evidence based including the advancement of Quality Improvement programmes by departments and individuals.

The Quality and Safety Manager will act as deputy to the Q\&S Risk \& Incident Lead.

Principal Duties and Responsibilities

Risk and Incident Management:* Adequately identify, assess, manage and monitor risk within their area of responsibility.

• Participate and advise in System Reviews as per the HSE Incident Management Framework, 2020\.


• Support and advise staff in conducting Risk Assessments.


• Have a working knowledge of the Health Information and Quality Authority (HIQA) Standards as they apply to the role for example, Standards for Healthcare, National Standards for the Prevention and Control of Healthcare Associated Infections, Hygiene Standards etc. and comply with associated HSE protocols for implementing and maintaining these standards as appropriate to the role.

Quality Improvement* To oversee the implementation of recommendations from both national and local Systems Analysis Reviews and report on progress to the Hospital Executive.

• Support hospital management and multi\-disciplinary teams in the assessment and corresponding quality improvements against hospital priorities and the National Standards for Safer Better Healthcare.


• Promote feedback and shared learning throughout the hospital from local and national incidents, reviews and patient feedback.


• Proactively identify inequities / inefficiencies in service administration and implement solutions to improve service delivery, in line with legislation and benchmarking against best practice structures and ensure that the Quality and Safety Executive is kept informed of trends and gaps in service provision.


• Participate in Quality \& Safety walkarounds to promote effective leadership and compliance with standards.

Clinical Audit* Provide specialist advice on all aspects of the audit cycle to clinical teams in order to support them to audit clinical practice against national, regional and local standards, policies and guidelines.

• To oversee the implementation of recommendations from both national and local Clinical Audits and report on progress to the QSRM


• Facilitate and support the development of Quality Improvement programmes by departments and individuals. Ensure hospital staff are familiar with overall Quality Improvement methodologies through regular education / training sessions.

Data Analysis: Strategic Input* To use data and evidence to monitor service quality and assess against key performance indicators.

• The Quality and Safety Manager will assist in analysing and interpreting healthcare quality data, identify good practices for sharing, implement benchmarking, address issues and identify opportunities for improvement across the organisation.


• Develop and maintain a network of co\-operative relationships at Hospital, Region and National level to keep up to date on initiatives and developments in the area of Quality and Safety.


• To attend and participate in committee meetings, work groups, and/or process improvement teams as required.

Managerial Responsibilities:* To deputise for the Q\&S Risk \&Incident lead or Quality Improvement Lead in their absence.

• To mentor and supervise other members of the Quality and Safety team to include clerical /administrative staff to carry out their responsibilities, ensuring appropriate delegation of responsibility and authority.


• Keep in touch with workloads of staff members to gauge levels of wellbeing and morale in the team.


• Create and maintain a positive working environment among staff members, which contributes to maintaining and enhancing effective working relationships.


• Act as a resource to hospital staff on issues related to Quality and Safety.


• Contribute to Hospital\-wide induction and teaching sessions, workshops and conferences.


• Liaise with the Hospital Executive Management Team, Directorate Management teams, Hospital Departments and other members of the Quality and Patient Safety Directorate to support self\-assessment and accreditation processes.


• Engage in the HSE performance achievement process in conjunction with your Line Manager and/or staff as appropriate.


• Promote and maintain a Patient focused environment by ensuring service users are treated with dignity and respect.


• Promote an ethos and culture of Open Disclosure and act as an Open Disclosure Champion within the organisation.


• Seek feedback from service users / families / relevant person(s) to evaluate services and implement change.


• Carry out any other duties as appropriate to the post and delegated by the Q\&S Risk \&Incident Lead, GM for QSRM or Dir QSRM.

*The above Job Description is not intended to be a complete list of all duties involved and consequently, the post holder may be required to perform other duties as appropriate to the post which may be assigned to him/her from time to time and to contribute to the development of the post while in office*

Qualifications \& Experience required

Must have:* Degree in relevant field

• 5 years’ relevant administration experience


• Minimum of 2 years Supervisory / Management experience


• Practical experience of use of IT systems / packages


• Fluent command and understanding of the English language to include spoken and written word.

Desirable:* Masters in a relevant field

• Experience in the Health Sector environment

Candidates must possess sufficient administrative capacity to discharge the functions of the office and have management ability and experience including:* An academic award in

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