Job Title: Quality Improvement and Clinical Audit Coordinator
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 Coordinator is a specialist member of the Quality, Risk and Accreditation Team with responsibility for coordinating the 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 escalate 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
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Co-ordinate and maintain 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.
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Support departments to select relevant audit topics, define audit criteria and standards, identify appropriate samples and data sources, and complete the full audit cycle.
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Provide practical advice, templates and coaching on audit design, data collection, analysis, report writing, action planning and re-audit.
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Undertake and support clinical audits, tracer audits, practice-observation audits and focused reviews, including preparation for JCI, HIQA and other external assessments.
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Review submitted audit reports for methodological quality, accuracy, clear findings and appropriate recommendations before governance reporting.
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Monitor completion of the approved audit programme and escalate overdue, incomplete or low-quality audits to the relevant manager and governance forum.
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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
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Maintain the central organisational register of QIPs, recording the improvement aim, baseline position, actions, accountable owner, milestones, measures, status, risks and evidence of completion.
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Monitor QIPs across the organisation, follow up with responsible owners and provide regular exception reports on overdue actions, barriers, outcomes and areas requiring escalation.
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Support departments to develop SMART improvement aims, outcome/process/balancing measures, realistic implementation plans and defined sustainability arrangements.
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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.
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Confirm that QIPs are closed only when objective evidence demonstrates implementation and, where appropriate, sustained improvement or effective risk reduction.
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Promote the sharing and spread of successful improvement initiatives and learning across departments.
Departmental KPIs and Performance Measurement
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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.
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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.
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Ensure that KPI measures are relevant, evidence-based, measurable and capable of supporting decision-making and improvement rather than data collection alone.
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Establish and maintain a schedule for departmental KPI submission, validation, analysis and reporting.
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Analyse KPI performance and trends, identify variation or deterioration, and work with departmental managers to develop and monitor QIPs where targets are not achieved.
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Support data-quality checks and validation so that performance information reported to governance committees is accurate, complete, timely and reproducible.
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Develop clear dashboards and reports that highlight performance, trends, exceptions, improvement actions and evidence of sustained progress.
Education, Practice Development and Collaborative Working
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Develop an agreed annual programme of audit and quality-improvement education in partnership with the Nurse Education and Practice Development Team.
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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.
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Work collaboratively with Health and Social Care Managers and multidisciplinary clinical teams to strengthen audit capability, ownership of data and local improvement skills.
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Provide coaching and support to departmental audit leads, QIP owners and staff undertaking improvement projects.
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Contribute to staff induction, management development, quality forums and organisational learning events as required.
Governance, Reporting and Assurance
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Prepare 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.
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Present findings clearly, identify significant gaps or deteriorating performance, and recommend proportionate escalation or corrective action.
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Maintain complete, version-controlled records of audit tools, datasets, reports, QIPs, re-audits and evidence of closure in accordance with hospital requirements.
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Support the triangulation of audit and KPI findings with incidents, complaints, risks, patient feedback and accreditation findings to identify organisational priorities.
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Contribute specialist clinical-audit and improvement evidence for JCI, HIQA and other regulatory, accreditation or assurance activities.
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Assist in evaluating the effectiveness of organisational quality and patient-safety initiatives and report whether intended outcomes have been achieved.
Professional Responsibilities
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Act as a visible resource and advocate for evidence-based quality improvement, clinical effectiveness and patient-centred care.
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Maintain current knowledge of clinical audit, quality-improvement science, measurement, patient safety, JCI requirements, HIQA standards and relevant national guidance.
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Manage competing priorities, meet agreed deadlines and communicate promptly where delivery or data quality is at risk.
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Handle clinical and organisational information confidentially and in accordance with data-protection, records-management and hospital requirements.
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Participate in relevant committees, working groups and quality initiatives as requested by the Head of Quality, Risk & Accreditation.
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Undertake other duties consistent with the specialist nature and level of the post.
Essential Criteria
Knowledge / Experience
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Relevant third-level professional qualification in nursing, a Health and Social Care Profession, healthcare, quality or another related discipline.
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A minimum of three years' relevant clinical or healthcare experience.
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Demonstrable experience of clinical audit and/or structured quality-improvement work in a healthcare setting.
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Experience of analysing clinical or operational data and producing clear reports for clinical or management audiences.
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Understanding of the full clinical audit cycle, QIP development, performance measurement and re-audit.
Skills / Competencies
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Strong knowledge of clinical audit methodology, quality-improvement approaches and measurement for improvement.
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Ability to develop robust KPI descriptors, validate data, interpret trends and translate findings into practical action.
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Excellent written, verbal, facilitation and presentation skills.
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Ability to build effective working relationships with the Nurse Education and Practice Development Team, Health and Social Care Managers, nursing, medical, administrative and support-service colleagues.
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Ability to influence, coach and constructively challenge staff and managers while maintaining a collaborative approach.
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Excellent planning, project-management and organisational skills, with the ability to manage multiple audit and QIP workstreams.
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High level of accuracy, attention to detail and commitment to data integrity.
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Strong analytical and problem-solving skills, with the ability to identify risks, variation and priorities for improvement.
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Proficiency in Microsoft Office and experience using electronic audit, quality-management, reporting or dashboard systems.
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Patient-centred approach and commitment to quality, clinical effectiveness and continuous improvement.
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Ability to work independently, exercise sound judgement and escalate concerns appropriately.
Desirable Skills
Knowledge / Experience
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Postgraduate qualification or recognised training in healthcare quality, clinical audit, patient safety or quality-improvement methodology.
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Experience of developing healthcare KPIs, dashboards or quality reports.
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Experience of co-ordinating a clinical audit programme or organisation-wide QIP register.
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Experience of JCI accreditation, HIQA standards or healthcare regulatory inspection.
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Experience with quality and audit systems such as MEG Audits, QPulse, Datix, PolicyStat or equivalent platforms.
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Experience of delivering education, coaching or facilitation to multidisciplinary healthcare teams.
This Job Description is intended as a basic guide to the scope and responsibilities of the position and is subject to regular review and amendment. The role holder will be required to be flexible in this position and is expected to facilitate working additional hours on occasion, when requested.
Blackrock Health Hermitage Clinic is an Equal Opportunities Employer
