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What is Clinical Governance?

  • June 04, 2021

Clinical Governance is a framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. Clinical governance encompasses quality assurance, quality improvement and risk and incident management.

You will very often get asked about Clinical Governance in your NHS Interview! This Blog aims to outline how to address each pillar in your interview.

The aim is to ensure that the whole screening pathway, including associated follow-up services, is functional and safe.

Programme standards
The national programme defines standards against which data is collected and reported annually. The programme standards provide a defined set of measures that providers have to meet to ensure local programmes are safe and effective

Quality improvement
Quality improvement makes local programmes safe, effective, patient-centred, timely, efficient and equitable.

Self-assessment systems should be embedded alongside external review so that continuous improvement becomes an integral part of service delivery.

What are the main components of Clinical Governance?

1) Risk management. Risk management is about minimising risks to patients by:

  • identifying what can and does go wrong during care
  • understanding the factors that influence this
  • learning lessons from any adverse events
  • ensuring action is taken to prevent recurrence
  • putting systems in place to reduce risks

2) Clinical audit. Clinical audit is a way that doctors, nurses and other healthcare professionals measure the quality of the care they offer. It allows them to compare their performance against a standard to see how they are doing and identify opportunities for improvement. Changes can then be made, followed by further audits to see if these changes have been successful.

3) Education, training and continuing professional development. It is vital that staff caring for patients have the knowledge and skills they need to do a good job. It is for that reason that they are given opportunities to update their skills to keep up with the latest developments as well as learn new skills.

4) Evidence-based care and effectiveness. Care for patients should be based on good quality evidence from research.
The National Institute for Health and Clinical Excellence (NICE) is responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health

5) Patient and carer experience and involvement. If a Trust is to offer the highest quality care it is important that they work in partnership with patients and carers. This includes gaining a better understanding of the priorities and concerns of those who use our services by involving them in our work, including our policy and planning.

6) Staffing and staff management - Staffing and staff management is vital to a Trusts ability to provide high-quality care. A Trust needs to have highly skilled staff, working in an efficient team and in a well supported environment.

The 7 Pillars of Clinical Governance

Traditionally, clinical governance has been described using 7 key pillars. Although it has been refined over the past few years, this approach remains the easiest to remember and to describe at a trainee interview level. It is also the approach that your interviewers are most likely to expect from you since this is what they would have learnt too. The 7 pillars are as follows:

1) Clinical Effectiveness & Research
Clinical effectiveness means ensuring that everything you do is designed to provide the best outcomes for patients i.e. that you do "the right thing to the right person at the right time in the right place”.
In practice, it means:

  • Adopting an evidence-based approach in the management of patients
  • Changing your practice, developing new protocols or guidelines based on experience and evidence if current practice is shown inadequate
  • Implementing NICE guidelines, National Service Frameworks and other national standards to ensure optimal care (when they are not superseded by more recent and more effective treatments)
  • Conducting research to develop the body of evidence available and therefore enhancing the level of care provided to patients in future.

2) Audit

The aim of the audit process is to ensure that clinical practice is continuously monitored and that deficiencies in relation to set standards of care are remedied. 

3) Risk Management

Risk Management involves having robust systems in place to understand, monitor and minimise the risks to patients and staff and to learn from mistakes. When things go wrong in the delivery of care, doctors and other clinical staff should feel safe admitting it and be able to learn and share what they have learnt. This includes:

  • Complying with protocols (hand washing, discarding sharps, identifying patients correctly etc)
  • Learning from mistakes and near-misses (informally for small issues, formally for the bigger events – see next point)
  • Reporting any significant adverse events via critical incidents forms, looking closely at complaints etc.
  • Assessing the risks identified for their probability of occurrence and the impact they could have if an incident did occur. Implementing processes to reduce the risk and its impact (the level of implementation will often depend on the budget available and the seriousness of the risk)
  • Promoting a blame-free culture to encourage everyone to report problems and mistakes.

4) Education and Training
This entails providing appropriate support available to enable staff to be competent in doing their jobs and to develop their skills so that they are up to date. Professional development needs to continue through lifelong learning.
In practice, for doctors, this involves:

  • Attending courses and conferences (commonly referred to as CPD – Continuous Professional Development)
  • Taking relevant exams
  • Regular assessment, designed to ensure that training is appropriate
  • Appraisals (which are a means of identifying and discussing weaknesses, and opportunities for personal development)

5) Patient and Public Involvement (PPI)

PPI is about ensuring that the services provided suit patients, that patient and public feedback is used to improve services into day-to-day practice to ensure an increased level of quality and suitability, and that patients and the public are involved in the development of services and the monitoring of treatment outcomes.
This is being implemented through a number of initiatives and organisations, including:

  • Local patient feedback questionnaires
  • The involvement of the Patient Advice and Liaison Service (PALS) in handling issues with patients.
  • National patient surveys organised by the Healthcare commission, which then feed into trusts’ rankings
  • Local Involvement Networks (LINks), which have been introduced to enable communities to influence healthcare services at a local level (these used to be called “Patient forums”)
  • Foundation Trust Board of Governors who are elected by members of the local community and have a say on who runs a hospital and how it should be run, including the services it can provide.

6) Using Information and IT
This aspect of clinical governance is about ensuring that:

  • Patient data is accurate and up-to-date
  • Confidentiality of patient data is respected
  • Full and appropriate use of the date is made to measure quality of outcomes (e.g. through audits) and to develop services tailored to local needs.

7) Staffing and Staff Management
This relates to need for:

  • appropriate recruitment and management of staff,
  • ensuring that underperformance is identified and addressed
  • encouraging staff retention by motivating and developing staff
  • providing good working conditions
  • From the above explanations, you may have noted that some of the pillars are more directly related to the day to day responsibilities of a junior doctor:
  • Clinical Effectiveness
  • Audit
  • Risk Management
  • Education & Training

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