RQ514 – Quality & Continuous Improvement Manager

Job Title & Grade: Quality and Continuous Improvement Manager

Campaign Reference: RQ514

Closing Date: Thursday Feb 15 th 2024

Proposed Interview Date: Week Commencing Monday Feb 19 th 2024

Taking Up Appointment: As soon as possible

Informal enquires: Informal queries can be directed to Elizabeth McGrattan – emcgrattan@peamount.ie

Location of Post: Peamount Healthcare, Newcastle, Co. Dublin
Details of Service :

Peamount Healthcare is an independent voluntary organisation that provides a range of high-quality health and social care services. We help people return home after a serious illness, we provide safe and homely residential care for those who need it, and we support people to live as independently as possible in the community. Peamount Healthcare is committed to the following values:

Person-centred – seeing each person as unique, giving them a voice and focusing on ability. Respect – creating a supportive environment where everyone is given courteous and respectful care and support.

Excellence – enabling interdisciplinary teams to deliver high-quality integrated care, and meaningful outcomes with a focus on continuous improvement.

Team working – fostering an inclusive, healthy working environment where people are valued and recognised for their individual and shared achievements.

Quality improvement – supporting teams to embed continuous improvement methodology as part of everything we do.

Education & Research – partnering with academia to support education, learning, research and evidence-based care.

Reporting Relationship: The Quality and Continuous Improvement Manager will report directly to the CEO.

Purpose of the Post : To lead, advise and manage the development and implementation of Quality, Service Improvement, Risk and Patient Safety structures and processes in Peamount Healthcare. The post will involve a systematic and coordinated approach to problem-solving and
improvement using specific methods and tools to deliver high-quality care for Patients and Residents.
The post holder will co-ordinate the Quality, Risk and Patient Safety agenda and is accountable for the organisational achievement of
conformance and performance with internal and external compliance requirements. To lead and manage the Quality, Risk and Safety team in supporting Heads of Departments/ PIC’s and Staff in the task of delivering quality and continuously improving safe services. To identify areas of improvement across the organisation

Areas of work:

  • Rotations may include any of the following areas (All Adult services): Respiratory Rehabilitation, Age Related Rehabilitation, Neuro Rehabilitation, Age related residential care, Adult Intellectual Disability services, Neuro-disability residential services.
  • Involvement in nutrition related committees, audits, projects, food service improvements, providing staff education on nutrition related topics, staff health promotion and providing student training where required.  

The specific duties in above areas will be discussed and agreed with the Dietitian manager upon commencement in post and with regular review. Flexibility is essential and will be required at times to cover the range of different areas and tasks as listed above. Other areas not listed above may be discussed and agreed with the Dietitian manager.

Eligibility Criteria Qualifications & Experience :
  •  Registered General Nurse or Health and Social Care Professional
    with at least 5 years’ experience.
     Experience in working in health services in a post that has involved quality, patient safety and service improvement.
  • Experience of leading change in a complex organisation.
  • Have the knowledge and ability to be able to operate successfully in a challenging operational environment while adhering to the highest quality standards.
  • Experience of supporting, developing and empowering staff in improving services.
  • Have a working knowledge of the National Standards Safer Better Healthcare, Disability, Older Persons and Infection Control HIQA, The National Patient Safety Strategy HSE, Framework for Improving Quality HSE, and HSE National Service Plan.
  • Understand the function of the Health and Safety Authority (HSA). 
  • Knowledge of Quality Management Systems.
  • Have a knowledge of implementing quality systems and improvement methodologies across healthcare settings.
  • A Qualification in Quality in Healthcare or Risk Management is desirable.

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


Each candidate for and any person holding the office must be of good character

Skills, Competencies and Knowledge

Professional Knowledge and Experience

  • Demonstrate a high degree of commitment, professionalism and
    dedication to the philosophy of quality health care provision.
  • In-depth knowledge of applying standards to practice, quality
    improvement process, clinical governance and quality improvement frameworks.
  • Understanding of evidence-based practice and consequence of
    variation from practice.
  • Knowledge and experience of implementing standards, policies, procedures and guidelines in the area of quality.
  • Understanding of and experience in a team in the use of quality
  • Understanding of and experience in a team in the use of improvement science, change management and project
    management methodologies.
    Managing and Delivering Results in a complex environment.
  • Excellent organisational and time management skills to meet objectives within agreed timeframes to achieve quality and service improvements.
  • Ability to work to tight deadlines and operate effectively with
    multiple competing priorities.
  • Experience and knowledge of the issues and developments and
    current thinking about best practices in healthcare quality improvement.
  • Flexibility and adaptability in a changing complex work environment.

Critical Analysis & Decision Making

  • Excellent analytical skills to enable analysis, interpretation of data
    and data extraction from multiple data sources.
  • Understanding and knowledge of both quantitative and qualitative
  • Ability to evaluate complex information from a variety of sources and make effective decisions.
  • Ability to think and act strategically and develop practical, innovative and creative solutions to improve Quality and Patient Safety.
    Leadership, Teamwork, Building and Maintaining Relations.
  • Experience in successfully leading and managing a diverse team.
  • Experience of coaching, with the ability to transfer knowledge and
    skills effectively.
  • Ability to lead and manage change to improve service delivery.
  • Ability to build and maintain positive working relationships in a
    multidisciplinary team to achieve organisational goals.
  • Has the ability to effectively motivate others.
  • Demonstrate evidence of influencing skills in a complex work

Communication skills

  • Establish, implement, maintain, support and continuously review
    efficient and effective working relationships and communications
    both within and between clinical and clinical support service
  • Develop positive and responsive relationships with all internal and
    external stakeholders.
    Commitment to Quality
    Evidence of interest and passion in engaging with and delivering on
    better outcomes for services/patients and residents.

Other requirements specific to the post

  • Access to own transport as the post will involve some travel.
Principal Duties & Responsibilities

The role will involve working with the CEO, Director of Nursing & Social Care, Director of Rehabilitation, Consultants, Department Managers, Nurse Managers and staff in the delivery of programmes to implement a culture of Staff Engagement, Continuous Quality Improvement & Patient Safety across the organisation.

Leadership and Accountability

  • Work collaboratively with managers and staff to develop &
    implement continuous quality improvement initiatives.
  • Lead & develop opportunities for learning and development in
    Quality and Service Improvement Methodologies for Managers
    and Staff.
  • Provide Leadership to staff within his/her area of responsibility.
  • Review and analyse resources within the Department making suggestions and proposals to the CEO on how to best enhance Quality Improvement, Staff Engagement & Patient Safety.
  • Support the persons in charge (PICs) and persons
  • participating in the management of designated centres with
  • notifications to regulatory bodies and in preparing HIQA Action Plans.
  • Prepare monthly updates and annual reports of the service.
  • As the designated COVID-19 response manager, process map and implement policy and national procedures in response to Covid-19.
  • Chair the Quality Steering group.
  • Provide quarterly reports for the Board Quality sub-committee
  • Provide quality updates to the CEO for IMR meetings

Quality Improvement & Project Management

  • Lead in the development of Peamount Healthcare’s quality
    improvement programme.
  • Lead the implementation of Peamount Healthcare’s Quality Strategy
  • Ensure that improvement projects identified and developed are relevant to clinical teams, and management and meet the
    requirements of external bodies.
  • Ensure that the measurement and analysis of data is incorporated into all quality improvement projects.
  • Co-ordinate and support quality improvement projects within teams and across the organisation with the application of
    quality improvement methodologies.
  • Manage day-to-day communications with the team(s) to ensure staff receive the necessary support to work effectively to deliver on quality improvement projects.
  • To work with key stakeholders, and the identified ‘Improvement champions’, to build a continuous improvement
    environment to support an ongoing programme of service improvement.
  • To support the delivery of better value and greater efficiency through the identification and elimination of unnecessary complexity within processes and the identification of better ways of working.
  • To conduct implementation reviews to ensure successful
    delivery has been achieved and to ensure that improvements can be made for future projects with continued consideration of the budget requirements.
  • Ensure accurate attention to detail and consistent adherence of procedures and current standards within the area of
  •  Ensure consistent and high-quality approach to all projects and programmes, by building organisational competency and understanding through the provision of guidance and support

Quality and Patient Safety

  • Develop, implement and promote programmes to improve quality & patient safety across Peamount Healthcare.
  • Support the work of the committees within the organisation.
  • Deliver excellence in patient safety and clinical risk management across the organisation.
  • Work with Clinical Departments and services in the implementation of the National Standards for Safer, Better Healthcare, National Standards for Residential Services for Children and Adults with Disabilities and National Standards for Residential Care Settings for Older People.
  • Ensure the CEO and Management Team are briefed on progress to address patient safety issues both informally and formally.
  • 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 and comply with associated protocols for implementing and maintaining these standards.

Safety and Risk Management

  • Responsible for managing Peamount Healthcare’s Safety and Risk functions ensuring the reporting system, tracking and
    investigation reports are managed within an appropriate timeframe.
  • Manage the effective use of the organisation’s risk register and liaise with the Risk, Health and Safety Coordinator.
  • Work collaboratively with the Risk Manager in developing improvement systems for proactive management of risk and
  • Generate reports as required for the Board, CEO & Executive
    Management Team.
  • Participate in incident reviews, trending analysis and investigations as appropriate to this role.
  • Ensure the collection and safe storage of all relevant
    documentation about risk and adverse incidents and
    ensure document control systems are maintained.
  • As the Open Disclosure Lead for the organisation, adhere to national guidance and ensure oversight of procedures and processes.

Patient Advocacy

  • Oversee feedback from patients, residents and services on
    their care.
  • Assist teams to ensure that whenever possible evaluation
    provides an opportunity for patients/resident and the public perspectives to be heard and taken into account.
  • Ensure ongoing evaluation of patient/resident satisfaction using feedback from observations and surveys to develop

Education & Training

  • Identify and escalate training gaps in front-line teams in their delivery of safe patient care and provide training as
  • Contribute to the development of a best-in-class Quality and Safety Improvement agenda, through the provision of excellent work, and through timely and accurate communication means.
  • Contribute to research about QI project.
  • Enhance learning from risk reporting activity across Peamount Healthcare. Liaise proactively with all staff and design and implement appropriate systems to optimise risk reporting.
  • Liaise with other internal/external bodies as appropriate, such as would be required for the optimisation of patient safety in the organisation.

The above Job Specification is not intended to be a comprehensive 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.

Campaign Specific Selection Post

A ranking and or short-listing exercise may be carried out based on information supplied in your CV. The criteria for ranking
and or shortlisting are based on the requirements of the post as outlined in the eligibility criteria and skills, competencies and/or knowledge section of this job specification. Therefore, you must think about your experience in light of those requirements. Failure to include information regarding these requirements may result in you not being called forward to the next stage of the selection process. Those successful at the ranking stage of this process (where applied) will be placed on an order of merit and will be called to interview depending on the service needs of the organisation.

Code of Practice

Peamount will run this campaign in compliance with the Code of Practice prepared by the Commission for Public Service Appointments (CPSA).
The Code of Practice sets out how the core principles of probity, merit, equity and fairness might be applied on a principle basis. The Code also specifies the responsibilities placed on candidates, facilities for feedback to applicants on matters relating to their application when
requested and outlined procedures about requests for a review of the recruitment and selection process and review in relation to allegations of a breach of the Code of Practice. Codes of practice are published by the CPSA and are available on
www.hse/ie/eng/staff/jobs The reform programme outlined for the Health Service may impact on this role and as structures change the job description may be reviewed.  The job description is a guide to the general range of duties assigned to the post holder. It is intended to be neither definitive nor restrictive and is subject to periodic review with the employee concerned.

Annual registration:

The reform programme outlined for the Health Service may impact on this role and as structures change the job description may be reviewed. The job description is a guide to the general range of duties assigned to the post holder.  It is intended to be neither definitive or restrictive and is subject to periodic review with the employee concerned.


The current vacancy available is a Permanent post on a full-time basis. The post is pensionable. Appointment as an employee of Peamount Healthcare is governed by the Health Act 2004 and the Public Service Management (Recruitment and
Appointment) Act 2004.


Remuneration is by the salary scale approved by the Department of Health: Assistant Director of Nursing
Current salary scale with effect from 1st October 2023: €63,110 (point 1) to €75,570 (point 8).

Working Week:

The hours allocated to this post are 37.5 hours per week. The allocation of these hours will be at the discretion of the Department Head and by the needs of the service. HSE Circular 003-2009 “Matching Working Patterns to Service Needs (Extended Working Day/Week Arrangements); Framework for Implementation of Clause 30.4 of Towards 2016” applies. Under the terms of this circular, all new entrants and staff appointed to promotional posts from Dec 16 th , 2008, will be required to work the agreed roster / on-call arrangements as advised by their line manager. Contracted hours of work are liable to change between the hours of 8 am-8 pm over seven days to meet the requirements for extended day services by the terms of the Framework Agreement (Implementation of Clause 30.4 of Towards 2016

Annual Leave:
As per Health Service Executive (HSE)

All employees will be subject to a probationary period as per the probation policy. This policy applies to all employees irrespective of the type of contract under which they have been employed. A period of 6 months’ probation will be served:
• On commencement of employment.
• Fixed term to permanent contract.
• Permanent employees commencing in promotional posts will also undertake a probationary period relating to their new post.


Employees of Peamount Healthcare are required to be members of the
Hospitals Superannuation Scheme. Deductions at the appropriate rate will
be made from your salary payment.
If you are being rehired after drawing down a public service pension your
attention is drawn to Section 52 of the Public Services Pension (Single and
Other Provisions) Act 2012. The 2012 Act extends the principle of
abatement to retired public servants in receipt of a public service pension

who secure another public service appointment in any public service body.


Maternity leave is granted by the terms of the Maternity Protection Acts 1994 and 2001.

Sick Leave:

Peamount Healthcare operates a Sickness Absence Management policy in line with the new Public Service Sick Leave Scheme as introduced in 31 st March 2014.

Pre-Employment Health Assessment:

Before commencing in this role a person will be required to complete a form declaring their health status which is reviewed by the hospital’s Occupational Health Service and if required undergo a medical assessment with this department. Any person employed by Peamount Healthcare must be competent of undertaking the duties attached to the office and be in a state of health such as would indicate a reasonable prospect of ability to render regular and efficient service.

Validation of Qualifications & Experience:

Any credit given to a candidate at an interview, in respect of claims to qualifications, training and experience is provisional and is subject to verification. The recommendation of the interview board is liable to revision if the claimed qualification, training or experience is not proven.


Peamount Healthcare will seek up to two written references from current and previous employers, educational institutions or any other organisations with which the candidate has been associated. The hospital also reserves the right to determine the merit, appropriateness and relevance of such references and referees.

Garda Vetting:
Peamount Healthcare will carry out Garda vetting on all new employees. An employee will not take up employment with the hospital until the Garda Vetting process has been completed and the hospital is satisfied that such an appointment does not pose a risk to clients, service users and employees.
Candidates for and any person holding the office must be of good character.
Health & Safety:

These duties must be performed by the hospital health and safety policy. In carrying out these duties the employee must ensure that effective safety procedures are in place to comply with the Health, Safety and Welfare at Work Act. Staff must carry out their duties safely and responsibly in line with the Hospital Policy as set out in the appropriate department’s safety statement, which must be read and understood. Comply with and contribute to the development of policies, procedures, guidelines, and safe professional practice and adhere to relevant legislation, regulations and standards. Have a working knowledge of the Health Information and Quality Authority (HIQA) Standards as they apply to Peamount. Protection and Care and comply with associated Peamount protocols for implementing and maintaining these standards as appropriate to the role. To support, promote and actively participate in sustainable energy, water and waste initiatives to create a more sustainable, low carbon and efficient health service.

Quality, Risk & Safety Responsibilities :

It is the responsibility of all staff to:

  • Participate and cooperate with legislative and regulatory requirements with regards to Quality, Risk and Safety.
  • Participate and cooperate with external agencies on safety initiatives as required.
  • Participate and cooperate with internal and external evaluations of hospital structures, services and processes as required, including but not limited to:
  • National Standards for Safer Better Healthcare.
  • National Standards for the Prevention and Control of Healthcare Associated Infections.
  • HSE Standards and Recommended Practices for Healthcare Records Management
  • Safety audits and other audits specified by the HSE or other regulatory authorities.
  • To initiate, support and implement quality improvement initiatives in their area which are in keeping with the hospitals continuous quality improvement programme.

It is the responsibility of all managers to ensure compliance with regulatory requirements for Quality, Safety and Risk within their area/department

Training and Education:

Participate in mandatory training programmes. Pursue continuous professional development to develop
professional knowledge and keep updated with current legislation.

Specific Responsibility for Best Practice in Hygiene :

Hygiene in healthcare is defined as “the practice that serves to keep people and the environment clean and prevent infection. It involves preserving one’s health, preventing the spread of disease and recognising, evaluating
and controlling health hazards.”

  • It is the responsibility of all staff to ensure compliance with hospital
    hygiene standards, guidelines and practices.
  • Department heads/ managers have overall responsibility for best practices in hygiene in their area.
  • It is mandatory to complete hand hygiene training every 2 years and sharps awareness workshops yearly.