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Clinical Governance

A framework for continuous quality improvements

The government's white paper, A First Class Service (DoH 1998) described clinical governance as:

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

(HSC 1999/065)

In practice this means that the Trust needs to develop a culture, systems and ways of working which make sure that, at every level, the quality of patient care is at the heart of the way we provide services for patients. Clinical Governance is everything we do as individuals and as an organisation to strive to achieve excellence in the clinical services we provide

Clinical Governance is an umbrella term for the following key components central to our existing arrangements, in summary:

Clinical Effectiveness
Clinical Audit
Consultation
Research & Development
Evidence Based Healthcare
Education and Training
Incidents, Complaints and Claims
User/Patient Involvement
Clinical Risk management
Performance Appraisal and Continuous Professional Development
Clinical Information

What are the exiting arrangements for Clinical Governance within the Trust?

1. Individual responsibilities for Clinical Governance:

The Trust’s Chief Executive has overall accountability for all governance, both clinical and corporate arrangements within the Trust.
The Director of Nursing & Midwifery is the Executive Director responsible for ensuring the implementation and monitoring of a clear and robust clinical governance framework. As Chair of the Clinical Effectiveness & Standards Committee the Director of Nursing & Midwifery receives regular clinical governance updates from the Head of Clinical Governance.
The Head of Clinical Governance is responsible for providing leadership and supporting clinicians, clinical teams and individuals with clinical governance. The Head of Clinical Governance is also responsible for the development of systems and processes to enable the dissemination and action of National Guidance (NICE, National Confidential Enquiries, National Service Frameworks) producing regular exception reports to relevant Committees.
The Clinical Governance Facilitator is responsible for facilitating clinical effectiveness activities across the Trust, and supporting the Head of Clinical Governance in the development and implementation of the Trust Clinical Governance Policy.

2. Committee responsibilities for Clinical Governance:

Trust Board: Has the overall responsibility for ensuring the Trust has robust clinical governance arrangements in place
Integrated Governance Committee: As a sub-committee of the Trust Board, the Integrated Governance Committee must provide assurance that there are robust clinical governance arrangements being implemented across the Trust
Clinical Quality & Risk Committee: As a sub-committee of the Integrated Governance Committee, this committee receives regular reports from the Clinical Effectiveness & Standards Committee on Standards for Better Health and other clinical governance activities
Clinical Effectiveness & Standards Committee: The Head of Clinical Governance will provide this committee with regular reports and updates on Standards for Better Health and clinical governance activity
Business Unit Quality & Risk Groups: Clinical governance is a standard agenda item at all Business Unit Quality & Risk meetings. National guidance exception reports and any relevant clinical governance activity will be presented, and new guidance disseminated

3. A comprehensive programme of quality improvement activities:

All members of staff are encouraged to participate in the Trust-wide, National, Regional or local clinical audit programmes
The Trust will provide information to the National Confidential Enquiries
Research and Development (R&D) is a core function of the Trust. The Head of Research & Development undertakes activities to support researchers to deliver the R&D strategy of the Trust. The vision for the Trust is to develop a (R&D) culture in which researchers feel supported within an organisation that has seamless links inter-professionally and academically across Departments, Ethics Committees, Universities and Industries
Continuing professional development (CPD) programmes are available for all health professional staff
Delivery of educational and training programmes (including Health and Safety) for all staff members

4. Quality systems for clinical record keeping that:

Safeguard confidentiality of patient information
Record keeping will be audited on an annual basis

5. Procedures in place to identify and remedy poor performance:

Systems in place to identify, manage and reduce where possible risks
Incident reporting (including accidents/ concerns/ near misses) to identify adverse events.
Effective complaints/claims procedures in place
Patient safety and team working developed
Productive wards and theatres initiative underway
Provision of education and training to all staff members to ensure continued personal development and a safe working environment. This will include topics as listed below:

Data Protection and Freedom of Information
Root Cause Analysis
Clinical Audit
Risk Management (including Health and Safety)

How will West Middlesex University Hospital achieve the clinical governance agenda?

A ‘Board to Ward’ approach for Clinical Governance with regular reporting and assurance mechanisms
Monitoring of compliance towards national quality standards including National Service Frameworks, Confidential Enquiries, Royal College regulatory reviews and the National Institute for Health and Clinical Excellence (NICE) guidance
Achievement of compliance with external accreditation bodies including the Care Quality Commission, the National Health Service Litigation Authority (NHSLA) Risk Management Standards and the National Patient Safety Agency (NPSA)
Development of Care Quality Commission Quality and Risk Profiles to enable registration and ongoing monitoring. Information requirements will relate to the following essential standards of quality and safety:

Involvement and Information
Personalised care, treatment and support
Safeguarding and safety
Suitability of staffing
Quality and management

There must be delivery on Essence of Care benchmark standards including:

Principles of self-care
Personal and oral hygiene
Food and nutrition
Continence and bladder and bowel care
Pressure ulcers
Record keeping
Safety of clients / patients with mental health needs in acute mental health and general hospital settings
Privacy and dignity

Well developed effective and lean systems/processes designed to monitor the delivery of quality standards
Patients, carers and their relatives must be regularly consulted. This will enable ascertainment of their experience/views and expectations about the services provided to them and the care they received
When required, review, investigation and analysis of clinical and other safety related incidents and trend occurrence as identified by:
Support innovation and a culture of research and development
Participation in the Clinical Audit programme and production of a Clinical Audit Annual Report
Effective Complaints and Claims System
Well-developed Education Centre and Health-Science Library Services

Contact details - Clinical Effectiveness and Evaluation Department

Paula Guerra - Head of Clinical Governance - 020 8321 6880

Joanne Colgan - Clinical Governance Facilitator - 020 8321 5571

Stacey Humphries - Governance Clark - 020 8321 5571