Clinical governance is:

 “A framework through which NHS Organisations are accountable for continuously improving the quality of their services and safe guarding high standards of care by creating an environment in which excellence in clinical care will flourish.” 

     - A First Class Service, June 1998

There are close links between clinical risk management, clinical effectiveness and audit and quality, which are all components of clinical governance.  The CHI review of the Trust was carried out in 2001, as a result of this the Trust has an action plan for which progress is monitored six monthly. 

What are the main components of Clinical Governance for the Trust?

1)       Clear lines of responsibility for the quality of clinical care:

·          The Chief Executive is ultimately responsible for the quality of clinical care

·          A senior clinician is responsible for ensuring systems for Clinical Governance are in place and are monitored

·          Committees reporting to the Clinical Governance Committee who report quality and risk issues regularly to the Risk & Incident advisory and Trust Boards

2)       A comprehensive programme of quality improvement activities:

·          All clinical staff to be involved in clinical audit programmes including participation in the  National Confidential enquiries

·          Evidence based practice applied routinely and well designed Research and Development activity is encouraged

·          Continuing professional development (CPD) programmes for all health professional staff

3)       Quality systems for clinical record keeping that:

·          Safeguard confidentiality of patient information, and can be effectively monitored

4)       Clear policies aimed at managing risk:

·          Systems in place to identify and manage risks

·          Clinical risk systematically assessed to reduce risks

5)       Procedures for all professional groups to identify and remedy poor performance:

·         Incident (including accidents/ concerns/ near misses) reporting identifies adverse events, openly investigates, learns and improves

·         Effective complaints procedures in place

·         Professional performance monitored and reviewed before patients suffer any harm or potential harm

·         Staff supported in reporting concerns about colleagues professional conduct, with clear procedures to ensure early action is taken

·         Patient safety and team working developed and supported through TEREMA and LEO

How does it work?  

·          National quality standards are set through National Service Frameworks and the National Institute of Clinical Excellence (NICE)

·          Mechanisms to ensure delivery of high quality clinical services Trust-wide are continually being developed, implemented and monitored

·          Effective systems to monitor the delivery of quality standards through the Healthcare Commission (CHI Trust Review undertaken in July 2001; CHI Investigation of Maternity Services in November 2002; CHI/Audit Commission NSF CHD review in October 2003)

·          Patients, carers and their relatives will be regularly consulted on the views abort the services provided (PALS service introduced from September 2002 and Patient and Public Partnership Strategy in place from February 2003

·          The Trusts Clinical Governance agenda is designed to be long term, building on current good practice, and recognising areas of excellence in order to influence our philosophy of continual clinical quality improvements

What are we doing towards achieving the clinical governance agenda?

·          The Trust Clinical Governance Committee meets quarterly

·          Quarterly Clinical Governance reports to the Trust Board which include changes in practice following incidents or complaints and through Clinical Audit

·          Individual Directorate/Departmental priorities identified and Clinical Governance Development Plans in place and being implemented

·          Clinical Audit programme

·          Continuing improvements of Clinical Risk Management, supported by developments through the National Patient Safety Agency (NPSA)

·          Working towards meeting the objectives in the CHI Action plan

·          Risk assessments and trigger lists within all Directorates

·          Links with all other Trust wide quality improvement initiatives

Ø                  Essence of Care Clinical Benchmarks

Ø                  Standards for Practice and Care

Ø                  CNST - Clinical Negligence Scheme for Trusts

Ø                  Education and Training

Ø                  Appraisal and Personal Development Plans

·            Effective Complaints and Claims System

·            Well-developed Education Centre and Health-Science Library Services

Further Details

For further information, please contact:

Ruth Lallmahomed, Deputy Director of Nursing & Quality, telephone:  01932 722711