Royal College of Nursing - Clinical Governance

ROYAL COLLEGE OF N URSI NG
Clinical
governance:
an RCN resource guide
Clinical governance:
Acknowledgements
About this guide
Our sincere thanks go to the many contributors
who gave up their time to share their
This guide is primarily aimed at nurse leaders
experiences to encourage others to get involved
working at directorate, unit and ward level, who
in clinical governance. We are grateful to
have a responsibility for co-ordinating and
colleagues across the RCN and beyond who
implementing clinical governance.
helped improve the quality of this guide by
commenting on successive drafts. We would It should also prove useful to RCN members
also like to acknowledge the expertise and who would like to know more about clinical
leadership provided by Gill Harvey, Director of governance.
the RCN Quality Improvement Programme
The guide summarises the key themes of
1995-2003. We would also like to take this
clinical governance and also provides, where
opportunity to wish Gill well in her new job at
available, real life case studies that show clinical
the University of Manchester.
governance in action.
The guide provides readers with information on
a wide range of RCN services and products that
The authors: support members in implementing clinical
governance. In addition, it offers across-the-
Lynne Currie board information on a range of external
R&D Fellow resources available throughout the UK.
Quality Improvement Programme
RCN Institute
Oxford
Clare Morrell
Senior R&D Fellow
RCN Institute
Oxford
Ross Scrivener
Information Manager
RCN Institute
London
Clinical governance:
Contents
Forewords 4 Supporting nurses in the workplace 21
From the RCN General Secretary 2 Staffing and staff management 21
From England 3 Education, training and continuing
From Scotland 4 professional development 21
From Northern Ireland 5 Team working 22
From Wales 6 Support from the RCN 22
Support from other agencies 22
An introduction to clinical governance 7
5 The building blocks of clinical governance 24
1 Placing patients’ experience at the
heart of health care 9 Consultation and patient involvement 26
Planning and organisation of care 9 Organisational and clinical leadership 26
Environment of care 9 Planning of services 27
Support from the RCN 10 Performance review 27
Support from other agencies 11 Health community partnerships 27
Support from the RCN 28
2 Making information work for you 12
Patients’ experience 12
Resources, processes and outcomes 13 6 Summary and conclusion 29
Support from the RCN 13
7 References and further reading 31
Appendices
3 Quality improvement in action 15
1 RCN Services 33
Risk management 15
Incident reporting 16 2 Clinical governance resources 37
Complaints 16 3 Patient and public involvement at
Research and effectiveness 17 two mental health trusts 47
Clinical audit 17 4 Information literacy skills 49
Support from the RCN 18 5 Implementing clinical governance
Support from other agencies 19 at organisational level 54
1
CLINICAL GOVERNANCE: AN RCN RESOURCE GUIDE
Forewords
Foreword from the Royal The single most important way to show staff that they
are valued is through appropriate pay and career
College of Nursing General development. But it’s also about providing a safe, healthy
Secretary and supportive working environment. Supporting staff
with the time and resources for continuing professional
Nurses deliver the majority of direct care and are development. By making use of the information in this
essential to shaping and providing quality care. publication, you can help clinical governance grow and
Improving care and making that care more patient- flourish, bringing benefits to staff as well as patients.
centred is at the heart of health service modernisation.
Beverly Malone
The advent of clinical governance is an excellent
opportunity to make sure that nursing staff at all levels RCN General Secretary
are able to influence improvements in practice, leading
to an improved experience for patients.
It is a pleasure to contribute this foreword to the Royal
College of Nursing’s latest publication on clinical
governance. The Royal College of Nursing (RCN) has a
strong track record in supporting nursing staff to
improve patient care. The popularity of our publications
on clinical governance demonstrates the eagerness of
nurses to get involved with understanding the concept
and translating it into practice.
This latest publication demonstrates the variety and
quality of RCN resources to support nurses in
developing clinical governance. The RCN leadership
programmes – clinical, primary care and political –
have helped thousands of nurses develop their potential
and use their enhanced confidence to make a real
difference to the patients they care for. Members’ help in
identifying topics has supported the development and
implementation of RCN clinical guidance.
All four UK countries have taken clinical governance on
board.As, increasingly, they shape their health services
to meet the specific needs of the communities they
serve, they are also developing their own systems for
improving care. Understanding these policies, locating
resources, and identifying ways to influence are key to
nurses wherever they practice.
Clinical governance is about improving patient care. But
it requires patient involvement and valuing staff. By
listening to patients’ stories, nurses on the RCN clinical
leadership programme have been able to make simple
but effective changes which improve patients experience
of care.
2
Foreword from England unprecedented scale.At last, we have the opportunity –

we must make sure we take it.
In the past, the assumption by staff and patients alike Members of the RCN are at the frontline in dealing with
has been made that health care is effective, safe, that patients and have an invaluable contribution to make in
nurses and doctors know everything and that patients promoting clinical governance and team working
do as they are told.A series of high profile health service systems in the areas that they work. This publication is a
failures played out in a very public way over the past relevant, timely and welcome initiative in developing
decade have woken us up to the fact that a lot of health clinical governance awareness throughout the RCN
care is not effective, is frequently unsafe and that our membership.
learning as health care professionals does not stop when
we qualify but continues all our professional lives. Professor Aidan Halligan
Twenty-first century patients are demanding care from Deputy Chief Medical Officer
a twenty-first century health care sector and twenty-
first century health care professionals. Director of Clinical Governance for the NHS (England)
Developing robust and sustainable clinical governance

frameworks ensures systems through which NHS
organisations are accountable for continuously
improving the quality of their services and for
safeguarding high standards of care by creating an
environment in which excellence in clinical care will
flourish. This is reinforced and enshrined by the
statutory duty for quality that was placed on all NHS
organisations in the Health Act 1999.
Clinical governance is a unifying concept that embraces
the hitherto micro-managed components of quality. It
recognises that in organisations, what you permit is
what you promote and that staff will work to what is
valued and ultimately, what is measured. Clinical
governance is the engine that drives movement from
protection of the professions to protection of the public.
It recognises the importance of teams, organisations
and systems in health care rather than individuals
working on their own. It upholds the concept that
everyone has something to contribute and no one has a
monopoly of knowledge or experience.
Each and every one of us, whether we use health
services or work in them as clinicians or managers,
must surely recognise that the quality of care we provide
or receive has the highest priority of all. Clinical
governance provides the opportunity to generate
productive alliances and a unity of purpose as never
before, and will lead to sustainable changes on an
3
Foreword from Scotland

Clinical governance is five years old in 2003.While there
can be few health care professionals working in NHS
Scotland who have not heard this phrase, its meaning
and significance are still widely misunderstood and
there is considerable variation in the progress made in
putting it into practice.
Clinical governance is the mechanism by which the
public can be assured that NHS organisations have
comprehensive and robust systems in place for
continuously improving the quality of their services and
safeguarding high standards of clinical care. It is the
framework through which all the components of
quality, including patient and public involvement, are
brought together and placed high on the agenda of each
organisation.
Although clinical governance, underpinned by the
statutory duty of quality in the Health Act 1999, is a
corporate responsibility, its delivery depends on the
staff who deliver care and treatment to patients. The
lead responsibility for taking it forward lies at local
level. Nationally, NHS Quality Improvement Scotland’s
role is to assist by setting standards for clinical
governance and monitoring performance. Two rounds
of visits to each part of NHS Scotland have been
undertaken leading to the publication of national and
local reports in 2002 and 2003. NHS Quality
Improvement Scotland has also recently been given
responsibility for supporting and encouraging the
implementation of clinical governance locally.
For this reason, the publication of this resource guide is
welcome and timely. Members of the RCN are at the
frontline in delivering care to patients and have a vital
contribution to make in promoting clinical governance
in the areas that they work. This guide will promote
greater awareness and understanding of clinical
governance and provides useful practical advice about
making it a reality.
David R Steel
Chief Executive, NHS Quality Improvement Scotland
4
Foreword from Northern Ireland clinical risk management, complaints monitoring and
research and development in order to drive up quality.
In Northern Ireland we are moving towards the Nurses recognising the challenges and opportunities
implementation of clinical and social care governance, that clinical and social care governance provides for
reflecting our integrated health and social care services. improving the quality of services and safeguarding high
Nurses, midwives and health visitors are well placed to standards of care for patients will welcome the guidance
contribute to the implementation of the framework for offered in this RCN publication.
clinical and social care governance. Through this
framework, organisations are accountable for Judith Hill
continuously improving the quality of their services, Chief Nursing Officer
safeguarding high standards of care and tackling poor
performance. Department of Health, Social Services & Public Safety
Northern Ireland
Nurses must build on their ability to function as part of
a multidisciplinary team. Effective team-based working
is central to providing safe, high quality patient care. In
the future, multidisciplinary teams will be charged with
collaboratively providing the highest quality of service
in a safe environment.
Nurses must continuously strive to ensure the
meaningful engagement of service users in the design,
delivery and evaluation of services. Service users are
integral to determining if the services we provide are fit
for purpose in terms of accessibility, acceptability,
effectiveness and equity.
There is a requirement for organisations, professionals,
and therefore we as nurses, to embrace and implement
the concepts of clinical and social care governance,
professional regulation, continuous professional
development and effective user involvement.
Clinical and social care governance, underpinned by the
statutory duty of quality, provides an opportunity to
ensure that appropriate systems and processes are in
place. Furthermore, it facilitates the creation of a culture
of openness and honesty where we can learn from our
successes and our mistakes, and sustain and share good
practice.
In Northern Ireland we will continue to develop the
leadership skills of nurses and provide opportunities for
nurses to develop the skills, knowledge, competence and
confidence required to contribute to this quality agenda.
We must build on and strengthen the nursing
contribution to clinical audit, critical incident reporting,
5
Foreword from Wales

As nurses, we constantly strive to maintain and improve
high standards of patient care, patient safety and patient
experience. The focus on clinical governance provides a
framework which draws together initiatives, processes
and systems and ways of working which ensures that
patients are at the centre of all that we do.
Clinical governance activity is not an option but a core
function of every nurse’s daily practice. It is important
to recognise that time and attention must be given to
strong leadership development, communication, team
working, values and culture change in addition to
quality improvement activities such as clinical audit,
critical incident reporting, risk management and
complaints monitoring. Success and excellence should
be acknowledged and celebrated but equally lessons
learnt must be shared and addressed to benefit all.
Nurses in Wales have the skills and must develop the
confidence to drive the clinical governance agenda
forward in their wards, their teams and their trusts and
to make a difference. Professional accountability
involves being pro-active in ensuring professional
knowledge and skills are up to date. This equally applies
to clinical governance. This clinical governance resource
guide provides an important reference source for all
nurses who have the ambition and drive to lead the
clinical governance agenda and make a difference to
patients.
Sue Gregory
Executive Director of Nursing
Bro Morgannwg NHS Trust
6
An introduction to clinical governance

“Clinical governance is a framework ✦ an improvement-based approach to quality in health
which helps all clinicians – including care needs to create an enabling culture which
celebrates success and learns from mistakes
nurses – to continuously improve quality
and safeguard standards of care” ✦ clinical governance applies to all health care staff. It
needs to be defined and communicated clearly so
(Royal College of Nursing, 1998) that all staff understand its relevance to their work
✦ clinical governance does not replace individual
The launch of clinical governance in 1998 placed quality
clinical judgement or professional self-regulation; it
at the centre of the NHS reforms.Although it was
complements these and provides a framework in
introduced across the NHS, its principles apply equally
which they can operate.
across the independent sector, as shown by the creation
of the Care Standards Act (2000). Clinical governance Clinical governance requires changes in culture, team
aims to integrate all the activities that impact on patient working, ways of thinking and behaviour.Wherever
care into one strategy. This involves improving the nurses work, they are members of multi-professional
quality of information, promoting collaboration, team teams and have a responsibility for quality. Effective
working, and partnerships, as well as reducing clinical governance will strengthen accountability for
variations in practice, and implementing evidence individuals, teams and organisations.
based practice. Please note that the term used in
Box 1 (page 8, top) outlines the policy and support
Northern Ireland is health and social care governance,
available for clinical governance across the four
which denotes the integration of health and social care.
countries of the UK.
Clinical governance is an umbrella term for everything
that helps to maintain and improve high standards of The inquiry into events at the Paediatric Cardiac Unit in
patient care. It covers a whole range of quality the Bristol Royal Infirmary proved very influential in
improvement activities that many nurses are already the Government’s plans to modernise the NHS. The
doing – for example, clinical audit and practice inquiry’s final report, the Kennedy Report, suggested
development. It also provides a framework to draw these that change “can only be brought about with the willing
activities together in a more co-ordinated way. and active participation of those involved in health care:
the public, patients, health care professions, trusts and
The RCN has developed a number of key principles
health authorities, and government” (Kennedy, 2001
which underpin the implementation of clinical
p.434).
governance. These are based on the work of the Quality
Improvement Programme, and have been refined in the The sections of this guide are set out under the
light of recent policy initiatives: following key headings, which have been adapted from
✦ clinical governance must be focused on improving the English Department of Health’s (DH) reporting
the quality of patient care framework for clinical governance (DH, 2003):
✦ placing patients’ experience at the heart of health
✦ clinical governance should apply to all health care,
care
wherever it is being delivered
✦ making information work for you
✦ clinical governance demands true partnerships
between all professional groups, between clinical ✦ quality improvement in action
staff and managers, and between patients and ✦ supporting nurses in the work place
clinical staff ✦ the building blocks of clinical governance.
✦ public and patient involvement is an essential Figure 1 (page 8, bottom) highlights the relationships
requirement for effective clinical governance between and across the key themes of clinical
✦ nurses have a key role to play in the implementation governance, and outlines the importance of the flow of
of clinical governance information.
7
Box 1: Clinical governance policy and support across the UK
Country Policy/legislation Support
England The new NHS: modern, dependable Clinical Governance Support Team
Northern Ireland Best practice – Clinical and Social Care

best care** Governance Support Team**
Scotland Designed to care NHS Quality Improvement Scotland

Partnership for care NHS Centre for Change and Innovation
Wales Putting patients first Clinical Governance Support &

Development Unit
** Following a comprehensive consultation with stakeholders on Best practice – best care, clinical governance is now a statutory requirement in
Northern Ireland. The Health and Personal Social Services (Quality, Improvement and Regulation) Order (2003) has now received Royal Assent.
This order outlines the intention to create a Regulation and Improvement Authority, and a Clinical and Social Care Governance Support Team
for Northern Ireland. Details on developments in clinical governance in Northern Ireland can be found at www.dhsspsni.gov.uk.
Figure 1: Key themes of clinical governance
Building blocks Supporting nurses in Quality improvement Placing the patient at

✦ Consultation and the workplace in action the heart of health
patient ✦ Staffing and staff ✦ Risk management care
involvement management ✦ Incident reporting ✦ Planning and
✦ Leadership ✦ Education, training organisation of
✦ Complaints
and continuing care
✦ Planning of ✦ Research and
services professional ✦ Environment
effectiveness
development of care
✦ Performance ✦ Clinical audit
review ✦ Team working
✦ Health community
partnerships
Making information work for you

✦ Information on the patients' experience
✦ Information on resources, processes and outcomes
8
1
has been achieved in mental health (CHI, 2002; 2003).
Placing patients’ In their review of St George’s Healthcare NHS Trust in
London, the Commission for Health Improvement
experience at the (CHI) stated:“The trust board understands the
principles of involving patients and the public. There is
strategic direction supported by core policies. There is
heart of health care innovative work being undertaken by some service
centres….” (CHI, 2003; p. 7) Full examples of patient
and user involvement at two mental health trusts are
given in Appendix 3.
“Patients in their journey through the
health care system are entitled to be Case study: seeking patients’ views
treated with respect and honesty and to A maternity department wanted to seek the views of
be involved, wherever possible in their patients: the general questionnaire used by
decisions about their treatment” their trust was of little help to them. They chose a
method used successfully by another hospital team
(Kennedy Report, 2001; p. 280) on the Clinical Governance Development
Improving the patients’ experience of health care is seen Programme. Patients are now given a pre-paid
as the central purpose of clinical governance.While postcard when they are ready to leave hospital: it
people will encounter health care in many ways, there is invites comments on the care they received. They
a push from Government to make sure that the focus of are asked to return the card to a post-box on the
health care remains fixed on the patient’s journey. ward – or send it back by post. Community
midwives remind patients to return the cards. Staff
Patient and public involvement is vital to improving the are pleased by patients response to the cards.
quality of health services, and opportunities can be Positive comments have helped improve staff
provided to make sure that patients are able to morale, while criticisms are followed up promptly.
contribute to a range of activities – including planning Links between the hospital and the community have
new services, staff training and education, and the improved.
development of information. Patients should be given Taken from Clinical Governance Support Team
opportunities to be involved in decision-making Lesson Card 12 CGST. Source: www.cgsupport.org
because they are the experts on receiving health care.As
such, they have an influential role to play in the
development of health services. Environment of care
The environment of care is the subject of many
Planning and organisation complaints from patients. Cleanliness and décor in
public areas, wards and bathrooms are as much a
of care quality issue for patients as staff communication skills.
Making sure that patients and staff are safe means
Strategies for patient and public involvement in the
thinking about the environment in which care is
planning and organisation of care should be developed delivered. Issues like hand washing, moving and
at both clinical and organisation level. Such strategies handling, and clear labelling of drugs are all related to
are based on a commitment to equality and to the environment of care, and all have potential safety
partnerships between patients and professionals. implications for patients and staff.
Strategies to involve patients and public should be The environment of care is considered as part of reviews
tailored to meet the needs of local populations. In areas by CHI. To help build a safer environment of care, there
where there is a diverse population, for example, is also a new mandatory reporting system for patient
communication strategies should include the safety initiatives and prevented patient safety initiatives
translation and interpretation of information and offer in the NHS. This is operated and managed by the
clear channels for feedback. Some innovative work National Patient Safety Agency (NPSA) (see Appendix
around patient involvement and joint decision-making 2).
9
Case study: Patient stories: maintaining Support from the RCN

the patient’s privacy and dignity
As nurses on the Medical Assessment Unit, we have The RCN offers many services to help nurses implement
thrown ourselves into the routine of each day, clinical governance, using patients’ experience.
always responding to what we considered to be the
needs of our patients. Our participation in the RCN RCN Clinical Leadership Programme
Clinical Leadership Programme provided us with an The RCN Clinical Leadership Programme is patient-
opportunity to step back and take time to consider centred, practical, and needs-led. It aims to assist
the reality of life for patients. The insights gained practitioners in developing patient-centred leadership
from patients’ stories and our observation of care strategies to deal with the realities of day-to-day
studies led us to re-evaluate both the delivery and practice. The programme runs over 18 months and
the environment of care. One issue that emerged involves the release of clinical leaders for 25% of their
was how the layout of the trolleys compromised the time.A local facilitator is required to devote 100% of
privacy and dignity of patients. On arrival for their time for the duration of the programme. The
assessment, patients were asked to undress and sit programme uses a mix of workshops, action learning,
in a hospital gown on one of our trolleys while observation of care and patient stories. Participants use
waiting to see the doctor. One of the trolleys was techniques such as shadowing, personal development
situated in a corner of the unit, and partially planning, team role audit, and team action planning.
blocked access to the patients’ toilets. This meant Trusts work in pairs, which provides support for the
that anyone wishing to use the toilet had to walk senior nurses and opportunities for networking.
through the trolley bay, past the half-undressed
patient. This was embarrassing both for the patient The RCN Clinical Leadership Programme develops
on the trolley and the person trying to squeeze clinical leaders’ skills in the following areas:
past. ✦ patient stories, pre and post-programme. Patients
After we identified this problem, we held agree the themes, and actions plans are devised and
discussions with ward staff and we agreed to monitored for those areas that are identified as
remove the trolley from the corner of the unit. This needing improvement
space was then used to create a seated area for up
✦ observation of care. Patients agree the themes, and
to six ambulant, fully dressed patients. This change
action plans are devised and monitored. There is also
led to an increase in capacity, from 12 trolley
a steering group in each organisation to ensure that
patients to 11 trolley patients and six seated
any problems that emerge from the patients stories
patients. The increased capacity in our unit freed up
and the observations of care are solved.
additional space in A&E, and meant patients could
benefit from being cared for in an appropriate There are patient representatives on the steering groups
environment for their condition. and the advisory group for the leadership programme.
Our observations of care highlighted the odd For more information call 0207 7647 3836 (England),
assortment of old, torn chairs, and using the 0131 662 6162 (Scotland), 029 2075 1373 (Wales) or
networking skills gained from participating in the email: [email protected]
leadership programme, we approached the charities
office and were successful in obtaining funding to
Researching patient evaluation and public
buy six new chairs and a coffee table. The benefits
involvement
we achieved from listening to our patients’ stories
and from observing what happens on the unit led us Patient evaluation and public involvement is one of the
to realise the advantages to be gained from actively research and development priorities for the RCN. This
involving our patients in planning future initiatives. commitment was clearly stated at RCN Congress in
2000, when a resolution urging RCN Council to take a
Case study provided by Jo Myers, Mid Essex
lead in developing effective partnerships with patients
Hospitals NHS Trust, Old Matron’s House,
and the public was passed.
Broomfield Hospital, Chelmsford, Essex, CH1 7ET.
This work plan for researching patient evaluation and
involvement has been developed as a result of a UK-
10
wide listening exercise with patients, nurses,

researchers, and policy makers.
For more information please call the Administrator on
01865 224107.
You will find the full range of relevant RCN services in
Appendix 1.
Support from other agencies
College of Health
The College of Health is a national charity. It represents
the interests of patients and promotes greater user
involvement in health and social care. The college also
hosts the Patient Involvement Unit for the National
Institute for Clinical Excellence (NICE).
www.collegeofhealth.org.uk
Commission for Patient and Public

Involvement in Health (CPPIH)
Because of the NHS Reform and Health Care Professions
Act (2002), the Commission for Patient and Public
Involvement in Health was established in England in
January 2003. The CPPIH will oversee the new patient
and public involvement system, ensuring patients have a
strong voice in their local NHS. The CPPIH will:
✦ carry out national reviews of services from the
patient’s perspective, based on Patients’ Forums
✦ alert appropriate bodies when it has concerns about
the safety and welfare of patients
✦ set standards, providing training and performance
managing Patients’ Forums and providers of
independent complaints advocacy services
✦ advise the Secretary of State for Health about the
effectiveness of the new patient-centred system.
www.doh.gov.uk/involvingpatients/statusreptdec.htm
Patients’ Forum
The Patients’ Forum is a network of national and
regional organisations concerned with the health care
interests of patients, carers, and their families. It
provides a forum for sharing experiences, information
and ideas. Its aim is to support patients in informing
and influencing the decision-making process.
www.thepatientsforum.org.uk
11
2
Case Study: Introducing Essence of Care
Making information in an acute trust
Essence of care (EOC) suggests that comparing and
work for you sharing best practice should occur at three different
levels: ward, between wards, and between
directorates. This means involving and motivating
staff who may already be under pressure to meet
“Information is the basic building block service delivery and performance targets. To give
of any system of standards and quality” people the time they needed to learn about the
system, the introduction of EOC in our trust was
(Kennedy Report, 2001, p. 394) staged over a period of several months. We agreed
To demonstrate improvements in quality, organisations that topics for benchmarking would be introduced
need good information. Good data is essential in order one at a time, on a rolling programme, at
three-monthly intervals.
to plan, commission, implement, manage and evaluate
services. The health service would benefit from the It was encouraging that most of the initial
delivery of an integrated information system across benchmarking events were well attended. This
health and social care. Such a system needs to meet the suggested that the initiative had struck a chord with
information needs of patients, clinical staff, and the staff. The buzz of conversation that became a
departments of health and social care. hallmark of the benchmarking group work was an
indication that benchmarking can offer a stimulus for
exploring quality improvement. In particular, staff felt
it was useful to have time to share ideas and help
Information about the patient with problem solving.
experience We found that establishing relationships between
providers and patients took much longer than
Collecting and using information from patients helps anticipated. Patients need time to learn about the
staff to deliver the kind of services that patients want. systems and processes that professionals take for
All acute trusts, primary care organisations and local granted. Sensitivity, patience and a sense of humour
health boards in England and Wales now undertake an are all needed in equal measure. Using a skilled
annual patient survey. The information collected will be facilitator during benchmarking group work can help
used to track changes in patient experience, support oil the wheels, establish trust and make sure
local quality improvement initiatives, and inform the everyone’s contribution is valued.
national performance ratings and performance At the outset, we asked the trust’s Patient Panel to
indicators (DH, 2001). decide on the priority of EOC topics for
implementation. Two Patient Panel representatives
Essence of care (DH, 2001) is a resource pack designed
were then recruited onto the EOC implementation
to support measures to improve quality. It focuses on strategy committee. As well as contributing to
areas of care that are known to be important to patients, decisions about implementation, these
and its clinical practice benchmarks were developed by representatives are also responsible for feeding back
multi-professional teams and patient representatives. progress to the Patient Panel. As each benchmark
The benchmarking tools relate directly to the topics has been implemented, volunteers from either the
patient representatives identified as being important, Patient Panel, or drawn from patients who responded
including food and nutrition, hygiene, continence, to information provided in the wards and clinics, have
privacy and dignity. contributed to the benchmarking sessions. They have
readily given their opinions and exercised judgement
Essence of care has been adapted for use in Wales
from the patients’ perspective, providing valuable
through a publication called Fundamentals of care
insight into aspects of care that may otherwise have
(Welsh Assembly, 2003).
been overlooked.
This case study was provided by Chrissie Dunn,
Senior Nurse Practice Development, Post Graduate
Centre, Royal Berkshire and Battle Hospitals NHS
Trust, London Road, Reading, RG1 5AG.
12
Information about resources, access, and interactive quizzes. Nurse can (and do)
use the CE-net any time, day or night, to support
processes and outcomes evidence-based practice, or for their own continuing
professional development (CPD).
Good information systems provide a way of helping
This example was provided by Sue Jones, Assistant
staff identify what resources are needed, what processes
Director of Nursing, United Bristol Healthcare NHS
are effective, and what outcomes are achieved.
Trust, Marlborough Street, Bristol, BS1 3NU.
Improvements in the way information is captured,
managed and used can support the delivery of quality Appendix 4 provides detailed examples on locating
patient care. It may also support the continuous information on two particular clinical topics.
monitoring and evaluation of services.
Information systems have been developed to support a Support from the RCN
range of frameworks for care (for example, National Here is information on some of the RCN services
Service Frameworks). These systems are used as the basis aimed at helping nurses implement this aspect of
for collecting data on clinical indicators and performance clinical governance (see Appendix 1 for the full range
management. Consistent information collected at of RCN services).
regional and national level can be used to target resources
and to address inequalities in service provision. Information in Nursing Group
The NHS Information Agency (NHSIA) provides a This group promotes informatics as a core element of
clinical governance information checklist. This website nursing care and considers a wide range of information-
is intended for NHS trust boards, clinical governance focused issues, including patient records, knowledge
leads, and clinical governance professionals, and management, information literacy and clinical systems,
provides easy access to a wide source of relevant nursing common language (terminology) and
information.You will find it online at tele-health or e-health.As well as providing expert
www.nhsia.nhs.uk/phsmi/clinicalgovernance/cg_reques advice to help develop RCN policy, in line with
t.asp. anticipated advances in information and
communication technologies (ICT), members are also
Good information systems are also important to help active in informing and advising other stakeholders
health professionals in locating information on research including policy makers and professional bodies across
and effectiveness, clinical audit and clinical guidelines. the UK.
These are discussed in more detail in section 3
(Research and effectiveness, and Clinical audit). The focus of current work is on developing a collaborative
strategy among the research, informatics and quality field
of support, and facilitating a strong nursing presence at
Case study: Nurses take the lead
NHS modernisation projects across the UK.
Nurses have not always had easy access to their
evidence base. To improve this situation, a small
The National Audit of the Management of
group of staff at United Bristol Healthcare NHS Trust,
Venous Leg Ulcers
with the active support and encouragement of local
nursing leadership, has developed a friendly web-
This project is run by the RCN and funded by the
based resource called CE-net. CE-net allows any
Commission for Health Improvement (CHI). Its focus is
nurse from any web terminal within the trust to
the use of good quality data to develop a national audit
programme. Its aim is to support long-term
access local and national guidelines, key evidence-
improvement in the management of venous leg ulcers
based health care resources, and all the major
across England and Wales. The project will be developed
bibliographic databases. CE-net uses a jigsaw
during 2003, tested during 2004, and rolled out in 2005.
metaphor to take staff through all elements of clinical
effectiveness such as research and development, The project is clearly linked to the clinical guideline on
clinical audit, and patient involvement. It also the management of venous leg ulcers. It will lead to the
provides a portal to established national websites collection of clear, consistent data, which will be entered
like the RCN and the Nursing and Midwifery Council. into a web-based data management system.As a result,
Other sections include full text book and journals practitioners will be able to benchmark their practice,
13
exchange information and share their experiences on

improvements in patient care.We also hope to link the
initiative to online learning opportunities.
For further information, telephone 0207 647 3831 or
email: [email protected]

Modernisation Agency
The Modernisation Agency was established in England
to help staff implement the changes outlined in the NHS
plan. It is currently working on a range of projects
including:
✦ improving access to primary health and social
services
✦ promoting safe, effective and high quality care
through clinical governance
✦ redesigning patient journeys for cancer, coronary
heart disease and critical care services.
www.modern.nhs.uk
NHS Patient Survey Programme

This programme covers acute, primary, mental health
and ambulance trusts. Information from the survey
informs the ‘star rating’ system of performance
indicators published annually. Trusts can use this
information to identify priorities for quality
improvement.
NHS Information Authority

The role of the NHS Information Authority is to support
the development of national electronic care records and
provide information services and knowledge for
decision-making. It also supports the establishment of
health informatics as a registered national profession,
and it provides reliable and secure information
infrastructure services.
www.nhsia.nhs.uk/def/home/asp
Information Statistics Division (Scotland)

In Scotland, the Information Statistics Division (ISD) is
part of the Common Services Agency (CSA). Health
service activity, staffing and finance data is collected,
validated, interpreted and disseminated by the ISD. The
data is collected from NHS boards, trusts and general
practices.
14
3
are as important to the safe care of patients as the
Quality technical skills of staff
✦ the absence of systems for monitoring the safety of
improvement clinical care at national or local level put the care of
patients at risk
✦ the absence of a systematic approach to learning
in action from things that went wrong prevented effective
remedial action from being taken (Kennedy, 2001; p.
352).
“Patients are entitled to expect that their Organisation with a memory (DH, 2000) described the
care will be of such quality as is Government’s commitment to patient safety. Key
among its raft of recommendations was the
consonant with good practice, based on
introduction of a mandatory reporting scheme for
sound evidence” patient safety incidents and prevented patient safety
(Kennedy Report, 2001; p. 380) incidents (DH, 2000; p. 80). As a result, a special health
authority, the National Patient Safety Agency (NPSA),
Quality improvement involves a range of activities was established in July 2001. The NPSA’s remit is to
including risk management, incident reporting, co-ordinate the efforts of UK NHS to report and learn
handling complaints, research and effectiveness, and from adverse events. More information online at
clinical audit. These activities are sustained through www.npsa.org.uk
good leadership, continuing professional development,
team working and effective information systems.
Case study: The Handy Hygiene Campaign
at the Oxford Radcliffe
Research evidence suggests that hospital acquired
Risk management infection (HAI) affects 8% of hospital patients, and
Risk management is a process to raise the quality and each HAI delays discharge by 11 days and costs
safety of services. It is identified as “a particular £3,154. For the NHS in England, this represents 3.6
approach to improving the quality of care, which places million bed days lost, costing £1 billion a year.
special emphasis on occasions in which patients are Cross contamination of microbes by the hands is a
harmed or disturbed by their treatment” (Hands, 1999). major route of spread of HAI. Hand hygiene can
It is supported through identifying, evaluating and prevent cross infection, but compliance with
reporting risks. recommendations is generally poor. In high
demand situations, including critical care units,
A risk management strategy should contain systems for overcrowding and under-staffing, hand
incident reporting and investigation, and learning from decontamination with an alcohol-based hand rub
complaints. It should also include plans for minimising solution appears to be the most effective way of
the cost of negligence claims. Risk management is also improving compliance. Research carried out in
concerned with all aspects of patient safety, and Switzerland has shown that increasing hand
includes infection control. decontamination by staff using alcohol hand rubs
The importance of patient safety was a key feature of leads to reductions in HAI, as well as decreasing
the report into events at the Bristol Royal Infirmary MRSA colonisation by 50%. Furthermore, the
(Kennedy, 2001). The inquiry’s key messages about Patient Empowerment Project showed that the
patient safety were: number of hand decontamination episodes
increased significantly with the implementation of
✦ the absence of a culture of safety and a culture of patient education.
openness resulted in concerns and incidents not
In response to this evidence, the Handy Hygiene
being routinely or systematically discussed or Campaign was launched in the Oxford Radcliffe
addressed, leading to a continuation of unsafe Hospitals NHS Trust (ORH). Managers committed to
practices four measures that will greatly assist in reducing
✦ the physical environment and working arrangements the number of infections by improving hand
15
decontamination. These four measures are the Case Study: Effective incident reporting at
provision of: Queens Medical Centre, Nottingham
● alcohol hand rub by every bedside In 2000, Queens Medical Centre, Nottingham,
● good quality paper towels across all four sites developed and launched a new incident reporting
system. The key to its success was in acting on the
● a programme of training and education for all
feedback received from staff using the system.
staff about the importance of this campaign
Some staff had felt reluctant to report incidents for
● information for patients on the importance of fear of being blamed and/or disciplined for making
hand decontamination and the crucial role they a mistake, others were unclear about what
play in ensuring this simple yet effective act is represented an incident, and some reported feeling
encouraged. comfortable with the process.
The patient information leaflet sets out the who, An incident reporting manual was prepared and a
why, how, when and the where of hand hygiene. It copy was disseminated to all wards and
asks all patients to ask health care workers: “Have departments. The new system was launched
you cleaned your hands?” The ORH believes that through a series of workshops, and each workshop
the Handy Hygiene Campaign will make a difference was introduced by one of the trust’s executives to
to patient outcomes, through using the best reinforce the importance of effective incident
elements of research to drive forward improvements reporting. The trust board also released a statement
in managing and controlling infection risks. to promote the low-blame, non-punitive approach
to incident reporting.
This case study was provided by Luisa Goddard,
Infection Control Services, Radcliffe Infirmary, Since the introduction of the new system, there has
Woodstock Road, Oxford, OX2 6HE. been a 200% increase in the number of clinical
incident reports, especially those reported by
medical staff. The quality of the reports has also
Incident reporting improved and they now provide relevant
A clinical incident, also known as an patient safety information leading to effective investigations and
changes in practice. The trust continues to learn
incident or a prevented patient safety incident, might
from past mistakes.
include drug errors, unexpected deaths or patient falls.
Usually, these incidents occur because of problems in a This case study was provided by Chris Cooper,
system of working. For example, this could be because Quality & Clinical Governance Manager and Phil
of poor communication within and across clinical Fox, Clinical Risk Lead, Queens Medical Centre
University Hospital, Floor C, South Block,
teams, a lack of clarity about protocols and procedures,
Nottingham, NG7 2UH.
or as a result of equipment failure. Other sources could
include inadequate training in equipment use, failure to
follow good practice, and poor record keeping. Complaints
Effective incident reporting allows organisations to:
Complaints are a feature of the NHS. No organisation or
✦ investigate a problem
profession can ignore, or avoid them. Local resolution is
✦ put it right the key and, ideally, nurses should be involved in all
✦ learn from what went wrong (sometimes called root stages of investigation. It is important to recognise that
cause analysis). people who make a complaint often want a full and
frank response to their concerns, as well as answers to
Where there is an effective system of incident reporting, specific questions.Any complaint that cannot be
staff can report incidents and be confident that the right resolved through local resolution may be referred to
culture is in place for dealing with them. independent review. If there is still dissatisfaction the
As a nurse, when you believe there is a potential danger Health Service Commissioner (Ombudsman) may be
to patients, you have a statutory duty to report your asked to investigate. There is a Health Ombudsman in
concerns.You can do this by talking to a senior staff each of the four countries of the UK (information at
www.ombudsman.org.uk).
member, a risk manager, or the Commission for Health
Improvement. Effective record keeping is crucial in the investigation of
16
complaints. If care and treatment interventions are not management of pressure ulcers in primary and
recorded properly, it will be difficult to establish what secondary care.
happened to the person making the complaint. Good
Further details on guideline development can be found
record keeping is a safeguard for staff too, as well as
below in Support from the RCN, and in Appendix 2.
being a duty of professional practice.
Case Study: Developing evidence-based

nursing practice
Research and effectiveness
A pilot scheme undertaken in Dudley Priority Health
To make sure that care is both safe and effective, clinical NHS Trust aimed to change the culture in an
decisions should be made on the basis of the best organisation that had little history of nursing
available evidence. Evidence can come from a variety of research or development. The scheme enabled
sources, including well designed research studies, three designated staff to develop the skills they’d
professional consensus and patient experiences. need for evidence-based practice and to guide the
production of evidence-based information that
Practising from an evidence base usually involves five could be disseminated to nurses throughout the
stages: trust. The three nurses represented mental health,
1 identifying areas of practice that are viewed as community nursing and learning disabilities, and
problematic they were released from their clinical caseload for
2.5 days each week for six months. The Director of
2 identifying best available evidence (remembering Nursing, Clinical Governance Manager and Nurse
that there are different sources of evidence, Researcher provided leadership and direction for
including research findings, patient experience, and the scheme.
clinical experience)
The team met each fortnight to plan activities and
3 using the identified evidence to define best practice review progress. Nurses throughout the trust were
surveyed and asked to identify practice issues that
4 putting this evidence into practice
required some supportive evidence. Staff meetings
5 measuring performance against expected outcomes, and contacts in the course of clinical work extended
through peer review or clinical audit. the consultation. A number of clinical topics were
identified that nurses felt required some action in
In undertaking evidence-based practice, staff need to be
order to change and improve practice.
able to assess the quality of evidence. However, this does
Consequently, protocols for eight practice-based
not mean that they have to be researchers – rather that
topics were devised.
they must be able to evaluate and review a range of
evidence. In other words, they need critical appraisal The outcomes of the pilot scheme were numerous:
skills. Getting different kinds of evidence into practice care and treatment was more evidence-based, staff
were given training on the newly developed
may also be facilitated by staff who have both
protocols, staff computer skills improved, they
implementation and change management skills (RCN,
became more creative at information giving, their
2000).
critical appraisal skills improved, and awareness
You’ll find details about how to access different sources was generally raised about the importance of
of evidence in Appendix 4. evidence-based practice.
Evidence-based clinical guidelines are a key feature of This case study was provided by Alison Hodgson,
the research and effectiveness agenda. The agencies Clinical Governance Manager, Clinical Governance
responsible for developing guidelines include the Department, Shousters House, Ridge Hill, Brierley
National Institute for Clinical Excellence (NICE) and the Hill Road, Stourbridge, West Midlands, DY8 5ST.
Scottish Intercollegiate Guidelines Network (SIGN), as
well as the national professional organisations.
Clinical audit
The RCN has been developing clinical guidelines for
nursing for a number of years. Guidelines under Clinical audit is a process to improve patient care
development include peri-operative fasting, and the through the regular review of care against clear
17
standards, and the implementation of change.Aspects on: pressure relieving devices, disturbed (violent)
of the structure, processes and outcomes of care are behaviour, falls, and osteoporosis. For more information
selected and thoroughly evaluated against standards. call the Administrator on 01865 224718 or email:
Necessary changes are then implemented at an [email protected]
individual, team or service level. Further monitoring is
used to confirm any improvement in care delivery Quality Improvement Programme
(NICE, 2002). Information Service
Clinical audit is a way of implementing guidelines or This service provides information support across a wide
other kinds of evidence. By reviewing care in this way range of issues. Staff are available to help RCN members
practitioners can identify priorities for action look for research articles, clinical guidelines and care
planning and improvement. For example, a group of pathways. The service can also help staff who want to
nurses on a surgical unit were concerned about the know more about clinical governance, or who need
length of time patients had to fast before an operation. advice on how to conduct a clinical audit. For more
The nurses collected data on actual fasting times that information call 0207 647 3831, or email:
they presented to medical colleagues. A group was set [email protected]
up to review the available literature and set standards
for optimum fasting times for the unit. A new protocol Recognition and assessment of acute pain in
was agreed and six months later the same nurses children audit tool
collected data and found that fasting times had been
reduced by 40%. To be able to manage pain well, there must be systems in
place that help children to communicate their
Within most NHS trusts, support exists to help nurses experience of pain. This audit tool was developed to ask
carry out clinical audit projects. There is usually a children to describe who listened to them when they
clinical audit/effectiveness/governance team that has were in pain – and the audit protocol helps nurses
expertise in measurement, action planning and change. monitor how well they assess children’s pain.
Activity sheets enable children to draw pictures or write
their stories about their pain. Information received from
Support from the RCN parents, carers, staff, and records is also used to monitor
the effectiveness of pain assessment.
Here is information on some of the RCN services aimed
at helping nurses implement a range of quality This publication is part of a series on the recognition
improvement initiatives. (Appendix 1 has the full range and assessment of pain in children. Other publications
of RCN services.) include the clinical guideline, an implementation guide,
Ouch! Sort it out: children’s experiences of pain, and All
Clinical guidelines about pain, a booklet designed for children. These are
available from RCN Publishing, PO Box 3030, Swindon
Work on developing clinical guidelines for peri-
SN3 4TQ, or via www.rcn.org.uk
operative fasting and for managing pressure ulcers in
primary and secondary care is ongoing. Published A website (www.rcn.audit.org.uk) lets nurses download
guidelines include The management of venous leg ulcers, a data entry template that helps them analyse and
The recognition and assessment of pain in children, and present their findings. There are also translated versions
Risk assessment and prevention of pressure ulcers. For of the audit tools available on the website in Punjabi,
further information please call 01865 224140, or email: Urdu and Bengali.
[email protected]
The National Collaborating Centre for Nursing and Research & Development Co-ordinating
Supportive Care is one of seven centres funded by NICE Centre
to develop national clinical guidelines for the NHS in The centre provides and co-ordinates access to
England and Wales. The centre is located at the RCN information on nursing research and practice
Institute in Oxford. It is a professionally led group with development. Information is available through the
expertise, experience and resources to develop clinical website given below. This includes information on
guidelines. Guidelines are currently under development research networks, policy, funding, ethics, training and
18
support units, research in progress, dissemination and Clinical Resource Efficiency Support Team
use, and practice development. (CREST)
Through its networks, the centre is developing CREST is part of the Department of Health, Social
bibliographies and databases on its website, where links Services, and Personal Services (DHSSPS) in Northern
are made to other useful sites on the Internet. The Ireland. One of its key initiatives is the Northern Ireland
centre is fully interactive via the Internet or by letter. For Task Force on Diabetes, which was established in March
more information call 0161 236 2049, or email: 2002.
[email protected]
www.diabetes.org.uk/n.ireland/nireland.htm
Support from other agencies National Institute for Clinical Excellence

(NICE)
Clinical Governance Support Team
The NHS Clinical Governance Support Team website is NICE is a special health authority with a remit to
part of the NHS Modernisation Agency. It is a valuable appraise systematically health interventions before they
resource providing a clear insight into clinical are introduced in the NHS in England and Wales. It
governance and its application in a clinical setting. The offers clinicians guidance on which treatments work
website includes useful resources, educational tools, best for patients and which do not. Its work supports
case studies and links. One example is the “lesson doctors, nurses, midwives and other health
cards” that draw on the work of the teams who are professionals – those who make the complex decisions
involved in the Support Team Development about the treatment of individual patients. The website
Programmes. The focus is on the process of achieving includes technical and summary reports of guidelines
change. Careful analysis of the teams’ work allows the commissioned by NICE, health technology appraisals
CGST to identify those aspects of their experience that and referral practice guidelines.
might be useful to others. The cards describe the
www.nice.org.uk
context and identify the lessons that can be drawn. The
first collection was published in September 2002, and
more will be added. Links are given to the eurekas NHS Quality Improvement Scotland (NHS QIS)
and/or case studies on which the lessons are based. NHS QIS is made up of the Clinical Standards Board for
Scotland (CSBS), the Health Technology Board for
www.cgsupport.org
Scotland, the Nursing and Midwifery Practice
Commission for Health Improvement (CHI) Development Unit, the Clinical Resource and Audit
Group (CRAG) and the Scottish Health Advisory Service
The Commission for Health Improvement was
(SHAS)
established to improve the quality of patient care. One of
its main roles is to review the care provided by the NHS www.nhshealthquality.org
in England and Wales (Scotland has its own regulatory
body, the Clinical Standards Board Scotland). CHI aims Scottish Intercollegiate Guideline Network
to address unacceptable variations in practice by (SIGN)
identifying notable practice, and areas where
The Scottish Intercollegiate Guideline Network (SIGN)
improvements are required. Recently, the Government
has proposed changes to CHI which will establish an was established in 1993, and sponsors and supports the
independent Commission for Healthcare Audit and development of clinical guidelines for NHS Scotland.
Inspection (CHAI). CHAI will bring together some of Where a SIGN guideline exists for which the Clinical
the work of the Audit Commission, the Commission for Standards Board in Scotland is setting standards, it will
Health Improvement and the National Care Standards be referenced.
Commission. It will also be responsible for inspecting www.sign.ac.uk
both the public and private health care sectors. CHAI
will work at a local and national level to monitor and National Patient Safety Agency (NPSA)
improve clinical care throughout England and Wales.
The NPSA is responsible for designing and
The new commission is expected to be up and running
implementing a system for reporting patient safety
sometime in 2004.
incidents involving NHS patients. The site offers a range
www.chi.nhs.uk of resources including alerts, a library of briefings and
19
presentations, research, news, events and message

boards. The NPSA’s Corporate plan 2003-2006, states:
The Minister for Health and Community Care in
Scotland has given a commitment to adopting the
principles set out in ‘An Organisation with a Memory’…
We will be working closely with NHS QIS over the next
three years to ensure this commitment is met (page 7).
The NPSA is also working in partnership with the Welsh
Assembly, and is in discussion with colleagues in
Northern Ireland to extend the national system of
reporting across the UK.
www.npsa.org.nhs.uk
Patient Advice and Liaison Service (PALS)

The Patient Advice and Liaison Service supports the
effective handling of complaints.All NHS trusts have
established a local PALS.
Serious Hazards of Transfusion (SHOT)

SHOT was launched in 1996 and collects data on serious
sequelae of blood components. The data contributes to
improving the safety of the transfusion process, informs
policy within the Transfusion Service, improves
standards of hospital transfusion practice, and aids the
production of clinical guidelines for the use of blood
components. SHOT is based at the Manchester Blood
Transfusion Centre and is affiliated to the Royal College
of Pathologists. It has representatives from a wide range
of Royal Medical Colleges and professional bodies,
including the RCN.
www.shot.demon.co.uk
20
4
questionnaire/interview process, the trust is
Supporting staff in piloting an ‘organisational barometer’ programme
which follows groups of new staff and seeks their
the workplace views and experiences of employment in the Trust

over a period of time. Groups will be interviewed at
three-monthly intervals from three to 18 months
IWL champions – communication within a trust as
“A patient is entitled to be cared for by large as Oxford Radcliffe Hospitals is always
health care professionals with relevant challenging. Champions have been established to
and up-to-date skills and expertise” act as a conduit for information – 40 people have
become champions and more are required
(Kennedy Report, 2001; p. 322) IWL intranet site – this site shows details of the
The need to improve the quality of care requires a Trust’s progress, giving the IWL Standard and
commitment to good employment practice and details on a wide range of issues, including staff
professional development. This encompasses a focus on attitude survey results, diversity, childcare, IWL
staffing and staff management, education, training and group members (champions), and benefits.
continuous professional development, and on team For more information go to
working. www.oxfordradcliffe.nhs.uk/staffbenefits.asp
Staffing and staff management Education, training and

continuing professional
The Improving working lives initiative was developed to
make the NHS a better place to work. It aims to development
transform practices to enable staff to manage a healthy
balance between life and work. This is vital if the NHS is Educating, training and developing staff are an integral
to have enough staff to deliver services, be able attract part of clinical governance. It’s not just about helping
the next generation of health care professionals, and staff to develop their clinical skills though – it’s also
modernise. about helping and supporting staff to work in different
ways. These different ways of working include
partnerships and collaborations with patients and
Case study: putting Improving Working
managers, across disciplines and professions. Good staff
Lives into practice
development needs the provision of adequate resources,
The Oxford Radcliffe Hospitals Trust achieved including both money and protected time.
practice status under the NHS Improving Working
Lives (IWL) Standard in July 2002. This standard is
Case study: education, training and
aimed at improving the working lives of all NHS
continuing professional development
staff, enabling them to achieve a work-life balance.
In an acute trust, a team of practice educators and
Some of the initiatives at the trust include:
clinical facilitators provides support to nurses to
Work free zone – a relaxing work-free area where facilitate the concept of life long learning. This
staff can go to relax or take part in a number of includes preceptorship for newly qualified nurses. A
activities such as yoga, massage, reflexology clinical facilitator meets with nurses during their
Flexible working options – a comprehensive range first week and at regular intervals during their
of flexible working options which are open to all preceptorship period. They monitor and evaluate
staff, including job share, annualised hours and the quality of the preceptorship experience, and
home working provide additional support if needed. All newly
Benefits – a benefits booklet details the benefits qualified nurses have preceptors in their own
available to all staff. The trust is also continuing to clinical areas.
negotiate staff discounts with local businesses The practice educators support staff, through
Organisational barometer – to complement the exit education and training, to develop their skills and
21
competencies, through sharing best practice and RCN practice development

networking. Nurses are supported in transferring Practice development focuses on supporting individuals
their knowledge into practice, reflecting on practice, and teams to continually develop and maintain their
clinical supervision, mentoring, personal effectiveness in being both patient-centred and
development and career advice. evidence-based. The aim is for a culture of effectiveness
Clinical nurse specialists and specialist advisors that is sustainable and not dependent on individuals.
also provide study sessions to update staff on The focus in practice development is the patient and
current practices. As nurses progress through their their experience rather than the staff member –
careers, they are offered specific programmes to although the two are closely related.
support their development (for example, the RCN
Through using clinical supervision, action learning
Clinical Leadership Development Programme).
processes and critical companionship, practitioners are
When a nurse returns to nursing following a career
helped to use, and make transparent, their widespread
break, a clinical facilitator is available to provide
knowledge, information and evidence in their practice
support during clinical placements, along similar
to help achieve greater effectiveness.
lines of preceptorship.
This example was provided by Gillian Arblaster, More information on:
Head of Clinical Practice, Nursing and Quality www.rcn.org.uk/practice_development/ or contact the
Department, University Hospitals Coventry and Head of Practice Development on 0207 647 3673.
Warwickshire NHS Trust, Clifford Bridge Road,
Walsgrave, Coventry, CV2 2DX.
Team working
Changing Workforce Programme (CWP)
Good team working requires trust, commitment, and The Changing Workforce Programme is part of the NHS
respect. It also requires that the contribution of all Modernisation Agency, linked to the Human Resource
members of the team, and the patients they serve, is Directorate and supported by the Workforce Taskforce.
valued. Teams need strong leadership and good channels Working with teams across England, CWP supports the
of communication. They also need to be able to identify implementation of new ways of working.
and solve problems in order to deliver patient-centred
www.modern.nhs.uk
care. It is worth noting that many of the complaints
made by patients can be traced to poor channels of
communication across and within clinical teams. Nursing and Midwifery Council
The NMC was established “to ensure nurses, midwives
and health visitors provide high standards of care to
Support from the RCN their patients and clients”. It also sets standards for
education.You can access a wide range of publications
Information on some of the RCN services aimed at from the website.
helping nurses implement clinical governance in www.nmc-uk.org
relation to supporting nurses in the workplace (see also
Appendix 1).
Workforce Confederation
The Workforce Confederation covers integrated
RCN Learning Zone
workforce planning, commissioning education and
The RCN Learning Zone is an Internet-based training, developing human resource practices, and
application that uses new technology to provide a anticipating what a future NHS workforce might look
unique, flexible resource for busy nurses. It helps them like.
to find and apply the information they need to improve
patient care. For more information go to: www.doh.gov.uk/workdevcon
www.rcn.org.uk or contact the RCN Learning Zone team
via email at: [email protected]
22
National Workforce Unit Scotland

The National Workforce Unit is part of the Human
Resources Directorate of the Scottish Executive Health
Department. The unit co-ordinates work at a national
level, as part of the drive to develop a more strategic and
systematic approach to workforce issues.Workforce
development takes account of changing roles and skill
mixes, new ways of working and job redesign, education
and training of staff, recruitment and retention, and
career packages and pathways.
23
5
Box 2 shows the statements on which the senior
The building blocks management team can base self-assessment: have they
achieved these statements in their service delivery area?
of clinical
Box 2: Self-Assessment Statements (example for Acute
governance Care Organisations)
Senior management team:

1. The trust board has shown effective leadership and
“The public are entitled to expect that support to our senior management team to enable
means exist for them to become involved us to implement culture change within our service
in the planning, organisation and delivery area (SDA).
delivery of health care” 2. Managers and clinical practitioners across this SDA
are working well together to lead all aspects of
(Kennedy Report, 2001; p. 400) clinical governance.
The building blocks for clinical governance are effective 3. We have integrated all aspects of clinical
leadership, strategy and planning of services – governance across this SDA.
requirements clearly articulated in the Kennedy Report. 4. From our clinical governance priorities, we are
Effective leadership, strategy and planning require the implementing actionable plans.
establishment of partnerships between and across
5. We use our clinical performance monitoring
health and social care agencies, and between patients
mechanism to bring about improvements to the
and the public. They also require the creation of
patient experience.
leadership development programmes, and a robust
system for reviewing performance. 6. We know the extent to which all the services for
which we are responsible comply with mandatory
All NHS organisations should now have systems and clinical standards and requirements.
processes in place for clinical governance. This means
7. Within this SDA, we have a culture of open and
✦ recognising the chief executive’s statutory duty of honest reporting and management of any situation
quality that may threaten the quality of the patient
✦ identifying a clinical governance lead experience.
✦ creating a clinical governance sub-committee. 8. We know the extent to which all our staff
Figure 2 outlines the infrastructure for accountability, demonstrate competence and appropriate
and the systems and processes required for effective standards of performance.
clinical governance. 9. Where our staff are working in extended roles, we
have robust mechanisms to manage any
There is also a range of tools available so that acute,
additional risks to patients, staff and the
combined, mental health and ambulance trusts can
organisation.
undertake a self-assessment exercise to review their
own clinical governance arrangements. These tools can 10. The working relationship between staff from this
be downloaded from SDA and staff from relevant external organisations
www.chi.nhs/uk/eng/assessment/index.shtml support the delivery of high quality, ongoing
patient care.
The tools for senior managers have been designed to
(Source: www.chi.nhs/uk/eng/assessment/index.shtml)
encourage participants to meet together and discuss
issues relating to:
✦ strategic capacity (leadership, policy and strategy)
✦ organisational integration
✦ performance review systems that support learning
and improvement
✦ partnership working.
24
Figure 2: Infrastructure, systems and processes for clinical governance at organisational level
External drivers for clinical

governance at
organisational level: Departments of Health Inspection and review
✦ Clinical guidelines (NICE, mechanisms:
SIGN) Trust/health boards & primary care ✦ Commission for Health
✦ National Service organisations Improvement (CHI)
Frameworks (England & Wales)
✦ Performance Assessment Chief executive ✦ Clinical Standards Board

Frameworks (Scotland)
✦ Patient surveys Clinical governance lead ✦ Regulation &

Improvement Authority
✦ National Patient Safety
(Northern Ireland)
Agency Clinical governance sub-committee
✦ Patient organisations
Placing
Planning & organisation of care
the patients' experience at the
Environment of care
heart of health care
Information
on the patients' experience/information
Making information work for you
resources, processes and outcomes
Risk
management/ incident reporting/
Quality improvement in action complaints/ research and effectiveness/
clinical audit
Staffing
and staff management
Supporting staff in the workplace Education, training and
professional development
Team working
Consultation
and patient involvement/leadership/
Building blocks of clinical governance
planning/performance review/partnership
25
Consultation and patient Organisational and clinical

involvement leadership
The Health and Social Care Act (2001) describes the Leaders in the modern NHS are expected to be able to
statutory duty placed on NHS organisations in England lead on a number of key areas. Their role is to:
and Wales to secure patient involvement and
✦ improve the quality of patient care
consultation. Patients are to be involved and consulted
on a range of activities including the planning, ✦ influence improvements in the health of the
development, and operation of services. population
The NHS plan for Scotland sets out a commitment to ✦ promote the NHS as being well-led, well-managed
involve people through giving them a stronger voice in and accountable
the design and delivery of health services. The Scottish ✦ lead on strategies to motivate and develop NHS staff.
plan outlines patient and public involvement at four
levels: clinical, service, organisation and strategic. The Leadership Centre (England), which is part of the
Modernisation Agency, the Centre for Change and
Case study: consultation with patients in Innovation (Scotland), and the Centre for Health
planning services to meet patients’ needs Leadership (Wales), were created to co-ordinate
management and leadership development across the
A project to establish an integrated evening care NHS. They recognise that good leaders are needed
service in rural Clydesdale, Scotland, followed throughout the organisation – not just at board level.
consultations with users through the Elderly Forum
and the Clydesdale Citizen’s Jury. Through joint
Case study: leadership and change
working, the project would inform and influence
management initiatives for senior staff
both the development of integrated investment
nurses
tools and care pathways, and joint policies covering
roles and responsibilities. The Senior Staff Nurse Professional Development
Initiative at the United Lincolnshire Hospitals Trust
The service became operational in November 1999
used the clinical governance framework as a
with three teams consisting of a nurse and a carer.
strategy for looking at leadership and change. The
Since then, four teams have been developed, plus a
initiative was launched within the surgical and
satellite base to provide a more appropriate and
medical directorates, and had three aims: to help
flexible response to the needs of the community.
senior staff nurses understand their role in relation
The new service has brought benefits including a
to leadership, clinical expertise and change
single point of referral, an integrated team who
management; to help them apply the function and
meet both health and social needs of clients, the
meaning of clinical governance to the their role; and
avoidance of inappropriate admissions to hospital,
to enable them to fulfill their role in practice. These
improved quality of life for patients, improved
aims were achieved through using knowledge
support and education for carers, and the
management approaches, clinical effectiveness,
development of joint training packages and
patient process redesign tools, and reflective
assessment tools.
practice.
This case study was provided by Amelia Caullay,
Following an initial study day, senior staff nurses
(former) Project Manager, Integrated Evening Care
were given a project proposal to complete and
Service, Lockhart Hospital, Lanark, Scotland.
return to the Professional Development Nursing
ML11 7RX.
Team (PDNT). The PDNT then met with the senior
staff nurses to discuss and approve the proposals,
leading to the formulation of project plans. These
plans aimed to integrate organisational needs with
the senior staff nurses’ proposals for advancing
practice, and to enable senior staff nurses to
network and exchange information
26
Some of the benefits of this initiative to patients, England and Scotland have a Performance Assessment
staff and the organisation include: placing the Framework in place (NHS Executive, 1999; Scottish
patient at the centre of all decisions about care, Executive, 2002). These were developed following a
improving the quality of care delivered to patients, widespread consultation with key stakeholders. The
meeting both the personal and the professional areas covered by the frameworks are outlined in Box 3.
development needs of senior staff nurses,
improving clinical leadership skills, and embracing Box 3:
the concepts of audit and benchmarking. The
programme also produced a falls assessment, a The Performance Assessment
theatre recovery nurse skills achievement pack, and Framework
an ophthalmic cataract pathway.
England Scotland
This example was provided by Alison George-Jones,
1. Health improvement 1. Health improvement and
Matron Trauma and Elective Orthopaedics Surgical reducing inequalities
Division, Pilgrim Hospital, Sibsey Road, Boston,
2. Fair access to 2. Fair access to health
Lincs, PE21 9QS.
care services
3. Effective delivery of 3. Clinical governance,

Planning of services appropriate health care quality and effectiveness
of health care
Clinical governance needs to be taken into account in 4. Efficiency 4. Patients’ experience,

the planning of services. The overall objectives of the including service quality
NHS plans for England, Northern Ireland, Scotland and 5. Patient/carer experience 5. Involving public and
Wales are to promote collaboration and encourage joint communities
decision making. For example, the NHS plan for 6. Health outcomes 6. Staff governance*
Scotland describes how existing Health Improvement
7. Organisational and financial
Programmes and Implementation Plans will be replaced performance and efficiency
by a Local Health Plan. These local plans will set out the
*While a seventh area focusing on human resources was
objectives, strategies and actions that organisations will
initially considered for inclusion in the English Framework, it
use to improve the health of the local population.
was omitted because the new Strategic Framework for Human
Improvement, expansion and reform: the next 3 years Resources will address this important area.
(DH, 2002) outlines the transformation of NHS services
in England. This will be achieved by raising standards, Health community partnerships
tackling inequality, being more accessible and flexible,
and designing services around the needs and choices of Partnership working across the NHS is also important
patients and the public. Planning services for the future in terms of clinical governance. The four countries have
means focusing on priorities, achieving value for each approached this slightly differently. In Northern
money, and being prepared to change old practices. Ireland, the Department of Health and Social Services
combines both health and social care, which facilitates
partnerships locally. In Wales, there are 22 local health
Performance review boards, which share boundaries with 22 local
authorities. The health action zones in England and
Performance review is concerned with how Northern Ireland provide good examples of health
organisations achieve high levels of patient and staff community partnerships.
satisfaction, and how well they meet a range of national
targets set for improving health. Research in the USA In Scotland, NHS boards are expected to continue to
has highlighted a number of characteristics held by make full use of existing mechanisms for securing
organisations that perform well: strong leadership, the public involvement in local decision making. They do
ability to manage change, multi-disciplinary teams, and this by drawing on the expertise and experience of local
good use of information technology (NHS health councils, and by ensuring that the councils are
Confederation, 2002a-b). fully involved in assessing the design and quality of
local services. NHS boards in Scotland are also
27
responsible for showing how resources and priorities Support from other agencies
are drawn together to care effectively for a range of
patient groups.
Leading Empowered Organisations (LEO)
Appendix 5 provides two examples of the way clinical
governance has been introduced across two Leading Empowered Organisations is a three-day
organisations. These highlight how the strategic programme designed for a wide range of health care
development and implementation of clinical governance professionals, and offered by the Centre for the
is part of a much wider, holistic approach to Development of Nursing Policy and Practice at the
organisational governance. University of Leeds.
www.nursingleadership.co.uk/rcn_leo/leo_info.htm
Support from the RCN NHS Centre for Change and Innovation (CCI),
Scotland
Here is information on some of the RCN services The CCI incorporates existing strategic change and
aimed at helping nurses develop their skills in service redesign units in Scotland, and builds on their
strategy, leadership and planning of services (see also achievements. It supports front line staff in leading
Appendix 1). change, and encourages innovation and the spread of
good practice.
RCN Political Leadership Programme
www.scotland/gov.uk/pages/news/2002/11SEHD224.aspx
The programme helps develop RCN members’ skills in
influencing policy at local and national level. It makes
clear the processes of policy development and enables NHS National Nursing Leadership Project
nurses to communicate effectively with policy makers The NHS National Nursing Leadership Project ensures
and politicians. The programme focuses on four main the targets set out in the NHS Plan are met, and that all
areas: RCN forums and fields of practice, country and clinical leaders experience leadership training. The
regional boards, activist training, and bespoke project is part of the Leadership Centre, and is located at
programmes aimed at consultant nurses and strategic the Modernisation Agency.
leaders. For more information call 01204 552440, or www.nursingleadership.co.uk/home.htm
Primary Care Leadership Programme

This programme aims to develop nurses’ ability to
influence health improvement and service
developments in primary and community care. It
supports multi-agency groups who work together in an
environment of change to develop their leadership
skills. For further information call 020 7647 3835, or
email: [email protected].
In Wales, the programme is funded by the Welsh
National Assembly to meet the needs of non-executive
members of local health boards – more information via
email: [email protected].
28
6
Case study: a journey from public inquiry
Summary and to CHI review
United Bristol Health care NHS Trust (UBHT) has
conclusion gone through major change following the Bristol
Royal Infirmary Public Inquiry, the publication of the
Kennedy Report and the evolution of clinical
governance. From the outset, the events
In his foreword, Professor Halligan suggests that clinical
governance came about because of a series of high surrounding paediatric cardiac surgery were
profile service failures that were played out in a very catastrophic and affected everyone in a large
public way. Clinical governance is about ensuring that teaching trust with lots of specialties. In the mid-to-
all health care organisations, and the people that work late 1990s, there was a period of ‘exposure of
in those organisations, are accountable for quality. events’, and a new chief executive and new director
of nursing were appointed. In 1998 the public
We began this publication with an assertion that clinical inquiry began its work and around this time clinical
governance places quality at the centre of all attempts to governance was being implemented across the
modernise the NHS. It aims for the integration of all NHS. Sir Ian Kennedy presented the final report with
activities that impact on patient care, and its its 198 recommendations in 2001.
implementation is underpinned by a range of
principles. These principles are worth reiterating here. A core lesson for UBHT was the need for openness
Clinical governance: and honesty, both as an organisation and across
departments, teams and individuals. This led to the
✦ requires us to be patient-focused at all times development of a blame-free culture, and the
✦ must be focused on improving the quality of patient organisation developed a strong patient focus.
care Multi-professional working was the key to all of
this, as well as the systems and processes required
✦ should apply to all health care, wherever it is being to support sound clinical governance. A
delivered
fundamental cultural shift at this time was the chief
✦ demands true partnerships between all professional executive’s accountability for clinical care.
groups, between clinical staff and managers, and The learning for UBHT began with immediate issues
between patients and clinical staff arising from the exposure brought by the inquiry.
✦ regards public and patient involvement as essential This included the need to be open with the parents
who had lost children and to support them through
✦ requires that nurses have a key role to play in its
the legal processes. We also needed to care for staff
implementation
and ensure the board focused on clinical
✦ requires a safe, open, enabling culture which leadership. We also focused very much on putting
celebrates success and learns from mistakes things right in children’s cardiac services – audit
✦ is for all health care staff. It needs to be defined and results for children’s heart surgery here are now
communicated clearly so that all staff understand its among the best in the country, and are published on
relevance to their work the Internet for parents to access.
✦ requires that each individual practitioner is Learning then progressed through clinical
responsible and accountable for the quality of the governance, ensuring the infrastructure at
care they provide corporate level, focusing on systems and processes
and on requirements for education and training. Our
✦ does not replace individual clinical judgement or recent Commission for Health Improvement (CHI)
professional self-regulation; it complements these review demonstrated our commitment to putting
and provides a framework in which they can operate. patients first. Patient Advice and Liaison Services
Each section of this guide is prefixed with a quote from (PALS) are well resourced and staff have clear
the Kennedy Report. The following case study describes responsibilities for public involvement. Indeed, the
how the Bristol Royal Infirmary at United Bristol NHS parents stakeholder group from the inquiry still
Trust has taken forward the recommendations from the meet, and their agenda remains focused on
Kennedy Report in implementing clinical governance. children’s cardiac surgery. This group also provides
29
an opportunity for the board to develop the more

general clinical governance agenda with parents.
CHI described the culture across the trust as ‘fair
and just’, and our approach to risk management
and investigations as open: we act in good faith and
we avoid apportioning blame.
Clinical governance at UBHT remains evolutionary,
and our objective is to make it much more a part of
everyone’s business. A major challenge will be the
need to ensure no slippage in a particularly
challenging financial year ahead. Clinical
governance at UBHT will continue to ensure that
every patient benefits from the lessons of the past.
This example was provided by Lindsey Scott,
Director of Nursing, United Bristol Healthcare Trust,
Marlborough Street, Bristol, BS1 3NU.
There are two key questions staff often ask about

clinical governance: what is it, and what is my part in it?
We hope that this publication has helped answer the
first question. For the second question, it depends on
the individual’s role. Those responsible for leading
clinical governance must ensure that the processes of
clinical governance cascade through the organisation, or
through their particular directorates, units, or wards.
However, those leading clinical governance, at whatever
level of the organisation, can’t do it all on their own.
Each individual practitioner – nurse, doctor or therapist
– must be able to demonstrate a commitment to
continuing professional development, to reporting risk
and poor practice, and to teamworking, and show a
willingness to get involved in local improvement
projects.
According to Professor Liam Donaldson, the Chief
Medical Officer for England:“The prize to be gained is
enormous as the benefit of improved quality flows to
patients up and down the country. Important tests of the
success of the new arrangements will be their ability to
prevent the kinds of serious service failures which hit the
headlines during the early 1990s, and to recognise early
and resolve cases of poor clinical performance before
they result in disaster.” (Donaldson, 2000; p. 11-12)
30
7
Department of Health (2003) clinical governance
References and reporting processes.
www.doh.gov.uk/clinicalgovernance/reportingprocesses
further reading .htm.
Department of Health Social Services and Public Safety
(1998) Fit for the future. Belfast: DHSSPS.
Clinical Standards Board for Scotland (2002) Improving Donaldson, L (2000) Clinical governance: a quality
clinical care in Scotland: generic clinical governance concept, in Clinical governance in primary care (Eds.
standards. Edinburgh: CSBS.
Zwanenberg and Harrison).Abingdon: Radcliffe
Commission for Health Improvement (October 2002) Medical Press.
Clinical governance review: South Birmingham Mental
Hallett, L, Thompson, M (2001) Clinical governance: a
Health NHS Trust. London: CHI.
practical guide for managers. London: Emap Public
Commission for Health Improvement (February 2003) Sector Management.
Clinical governance review: St George’s Healthcare NHS
Trust. London: CHI. Hands, D (1999) Integrated care, in Clinical governance:
making it happen (Eds. Lugon and Secker-Walker).
Department of Health (1997) The new NHS: modern, London: Royal Society of Medicine Press.
dependable. London: The Stationery Office.
Kelson, M (2001) Patient involvement in clinical
Department of Health (1998) A first class service. governance, in Advancing clinical governance (Eds.
Quality in the new NHS. London: The Stationery Office.
Lugon and Secker-Walker). London: Royal Society of
Department of Health (2000) An organisation with a Medicine Press.
memory. London: The Stationery Office.
Kennedy, I (2001) The report of the public inquiry into
Department of Health (2000) Improving working lives. children’s heart surgery at the Bristol Royal Infirmary
London: The Stationery Office. 1984 - 1995: Learning from Bristol. London: The
Department of Health (2000) The NHS plan: a plan for Stationery Office.
investment, a plan for reform. London: The Stationery Minster for Health and Social Services (2001) Improving
Office. health in Wales. Cardiff: National Assembly for Wales.
Department of Health (2001) Essence of care: patient- National Assembly for Wales (2001) Clinical governance
focused benchmarking for health care practitioners. – a toolkit for clinical teams. Cardiff: National Assembly
London: The Stationery Office. for Wales.
Department of Health (2001) Building the information
National Institute for Clinical Excellence (2002)
core - implementing the NHS Plan. London: The
Principles for best practice in clinical audit. London:
Stationery Office.
NICE.
Department of Health (2001) Reforming the NHS
National Patient Safety Agency (2003) Corporate plan
complaints procedure. London: The Stationery Office.
2003-2006. London: NPSA.
Department of Health (2001) Health and Social Care
Act. www.HMSO.gov.uk/acts2001/10015—b.htm. NHS Confederation (2002a) Creating high performance
– why is it so hard? Leading edge 4, May 2002.
Department of Health (2002) Improvement, expansion
and reform: the next 3 years. London: The Stationery NHS Confederation (2002b) Creating high performance
Office. – what can we do? Leading edge 5, May 2002.
Department of Health (2002) NHS trust-based patient NHS Executive (1999) Clinical governance: quality in the
surveys: inpatients - acute hospitals. London: The NHS. Leeds: NHSE.
Stationery Office. NHS Executive (1999) Health service circular 1999/154
Department of Health (2002) Partnership working. Continuing professional development: quality in the new
www.doh.gov.uk/pricare/pdfs/nsf_partnershipworking. NHS. Leeds: NHSE.
31
NHS Executive (1999) The NHS performance assessment

framework. Leeds: NHSE.
Royal College of Nursing (2000) Clinical guidelines for
the management of venous leg ulcers: implementation
guide. London: RCN.
Scally, G, Donaldson, L (1998) Clinical governance and
the drive for quality improvement in the new NHS in
England, British Medical Journal 317 (7150): 61-65.
Scottish Executive (1997) Designed to care. Edinburgh:
Scottish Executive Health Department.
Scottish Executive (2000) Our national health. A plan for
action, a plan for change. Edinburgh: Scottish Executive
Health Department.
Scottish Executive (2002) Choices and challenges: the
strategy for research and development in nursing and
midwifery in Scotland. Edinburgh: Scottish Executive
Health Department.
Scottish Executive (2002) Performance assessment
framework. Edinburgh: Scottish Executive Health
Department.
Scottish Executive (2003) Partnership for care.
Edinburgh: Scottish Executive Health Department.
Welsh Office (1996) Framework for the development of
multi-professional clinical audit. Cardiff: National
Assembly for Wales.
Welsh Office (1998) NHS Wales, putting patients first.
Cardiff: National Assembly for Wales.
Welsh Office (1998). Better health, better Wales. Cardiff:
National Assembly for Wales.
Welsh Office (2003) Fundamentals of care. Cardiff:
National Assembly for Wales.
32
Appendix 1:
information call 0131 662 1010, or email:
RCN services [email protected]
Clinical Leadership Programme

The RCN offers a wide range of services to help and The RCN Clinical Leadership Programme is patient-
support members – many of them relevant in centred, practical, needs-led, and consistent with the
developing an understanding of clinical governance, NHS Plan. The programme uses a mix of workshops,
and the skills to support it. There are also a range of action learning, observation of care and patient stories.
research and development projects which are relevant to Participants also use techniques such as shadowing,
the development of clinical governance. Many of these personal development planning, team role audit, and
services and projects are detailed here. team action planning. Trusts work in pairs, which
For a complete guide to the RCN, the organisation provides support for the senior nurses and
publishes RCN members’ guide to services and benefits – opportunities for networking.
an updated copy is sent to members when they renew For more information call:
their membership. 020 7647 3836 (England)
You can access initial information about any of the 0131 662 6162 (Scotland)
RCN’s services by contacting RCN Direct, the 24-hour 029 2075 1372 (Wales)
advice and information service for RCN members – or visit: www.rcn.org.uk
telephone 0845 772 6100. RCN Direct acts as a gateway
www.nursingleadership.co.uk/rcn_leo/rcn_info.htm
to the many services offered by the RCN, from
employment rights to highly specialised best practice http://www.nursingleadership.co.uk/about_us/scotland
advice. .htm
RCN Direct is also available online via the RCN website. Distance learning
RCN members can log into the members’ area to access
The RCN offers a range of distance learning
downloadable briefing sheets on selected topics. RCN
programmes for various nursing specialties. Distance
Direct Online: www.rcn.org/direct
learning provides teaching support from a distance,
For each of the services listed here, contact RCN wherever students choose to study. Face-to-face
Direct unless another contact point is specified. teaching is replaced by specially commissioned learning
materials, books, joint articles, learning tapes and other
Activists in the workplace resource materials. Students also have the opportunity
RCN stewards represent and support members who face to attend group tutorials held at a regional study centre
difficulties at work. They also offer advice on – the RCN has regional study centres at Belfast,
employment rights, act as mediators between employer Birmingham, Cardiff,Winchester, Leeds, London and
and employee, and help identify poor working practices. Edinburgh. Further centres are due to open in Bolton
Activists are also in a strong position to influence and and Exeter. For more information, call 020 7647 3700 or
support the development of local policy on issues such email [email protected].
as clinical governance. Nurses who are worried about
poor practice in their workplace can also contact their Specialist nursing forums
RCN steward for help and advice. RCN forums are groups of nurses from across the UK
who are interested in the same area of practice,
Clinical Effectiveness Adviser, Scotland research, management or education – there are nearly
The Clinical Effectiveness Adviser in Scotland is a joint 100 forums and sub groups representing every area of
appointment between RCN Scotland and the RCN nursing practice. The forums allow members to share
Quality Improvement Programme. The adviser provides knowledge and ideas, and give them a chance to take
advice on policy and professional issues, as well as being part in local and national activities. For more
involved in the national clinical effectiveness agendas. information visit the members’ section of the RCN
The adviser also supports the adaptation, spread and website, at www.rcn.org.uk/RCN, or contact RCN Direct.
implementation of guidelines in Scotland. For more
33
Health and safety apply the information they need to improve patient care.
RCN safety representatives play a key role in protecting The website is divided into six areas to keep members in
RCN members at work. One of their main roles is to touch with each other and to develop their skills. The six
ensure a safe working environment, and they also areas are:
campaign to raise awareness of health and safety issues ✦ portfolio development
nationally. Some of them are involved in the National
Patient Safety Agency’s reporting system. ✦ career zone
✦ learning areas
Information Nursing (IN) Group ✦ clinical guidelines
The aims of this RCN forum are to promote the
✦ meeting places
importance of health informatics to the future of health
care, including all aspects of information for health ✦ information services.
from electronic patient records to tele- and e-health. For more information go to: www.rcn.org.uk or contact
the RCN Learning Zone team via email at:
Improving Working Lives programme [email protected]
All RCN regional offices are engaged in conducting and
leading IWL assessment teams across the English Library and Information Services
regions. The RCN Library and Information Service is one of
Europe’s largest nursing libraries. It is constantly
Learning Representative Support Network developing new ideas to make resources more accessible
RCN learning representatives help nurses become more to nurses. The library combines traditional library-
pro-active about their learning needs at work. The based resources with the latest online information
representatives also liaise with management about services. Members have access to e-journals, which can
nurses’ learning needs. Supported by RCN staff they be downloaded free of charge. Other library services
form a national network and work in collaboration with include a photocopying service and free literature
other RCN branch members to help with the integration searching, Internet use, and information skills sessions.
of the RCN forums and fields of practice. They also For information call 0207 647 3610, or email:
promote the range of the RCN’s continuing professional [email protected]
development initiatives and contribute to the
organisation of study days, seminars and workshops National Collaborating Centre for Nursing
and Supportive Care
Learning resource centres The National Collaborating Centre for Nursing and
RCN learning resource centres provide local access, local Supportive Care is one of seven centres funded by the
information and quiet study for RCN members. There National Institute for Clinical Excellence (NICE), and is
are three types: based in the RCN Institute in Oxford. It is a
professionally led group with expertise, experience and
✦ RCN Learning Resource Centres, located within an resources to develop clinical guidelines – these are
NHS trust or a college of further education currently under development on: pressure relieving
✦ RCN Information Point, located within a nursing devices, disturbed (violent) behaviour, falls, and
agency, nursing home or independent hospital osteoporosis. For more information call 01865 224718,
or email: [email protected]
✦ RCN Kiosk, a quick reference centre that can be
established almost anywhere.
Patient evaluation and public participation
For more information call 0207 647 3610, or email: Patient evaluation and public involvement is a key
[email protected] research and development priority for the RCN. The
RCN’s strategy has evolved on the basis of a four-
Learning Zone country listening exercise where nurses, researchers,
The RCN Learning Zone provides Internet access to a policy makers and patients came together to discuss the
unique and flexible resource for nurses to find and best way forward. This strategy underpins current and
34
future work. For more information please call 01865 In Wales, the programme is funded by the National
224695 or email: [email protected] Assembly Government to meet the needs of non-
executive members of local health boards. For more
Political Leadership Programme information email: [email protected]
The RCN Political Leadership Programme supports
members in developing the skills to influence policy. It Quality Improvement Network
makes clear the processes of policy development and The RCN Quality Improvement Network is open to all
enables nurses to communicate effectively with policy members who are interested in promoting quality. It
makers and politicians. The programme focuses on four aims to promote networking and information sharing,
main areas: to provide support and education, and to link practice
and policy development. The network has a national
✦ forums and fields of practice
steering group and eleven regional committees across
✦ country and regional boards the UK. Network members receive a newsletter twice a
✦ activist training year, and the regional committees co-ordinate a wide
range of meetings and seminars at local level. For more
✦ bespoke programmes, aimed at consultant nurses information call 01865 228443, or email:
and strategic leaders. [email protected]
For further information call 01204 552440, or email:
[email protected] Quality Improvement Programme
The programme, part of the RCN Institute, covers
Practice development clinical governance, guidelines and audit. Its research is
Practice development is a continuous process of exploring and increasing understanding of the
improvement leading to effective patient-centred care. processes of implementation, and the programme is
The RCN Practice Development Team helps to support also developing learning resources to help implement
its members through a number of initiatives, such as clinical effectiveness and clinical governance. The
facilitation, clinical supervision and action learning. For programme also runs education events and produces
more information contact: 0207 647 3673, or visit the guidance for nurses on quality improvement and
website at: clinical governance.
www.rcn.org.uk/practice_development/pdteam.html As part of its work, the programme offers an
information service offering support across a wide
Professional advocates range of issues. Staff can help RCN members look for
The RCN is running a professional advocate pilot research articles, clinical guidelines and care pathways,
scheme in South Essex to help members become and provide information on clinical governance and
professional advocates. This pilot started in spring 2002, conducting a clinical audit.
and is broadening the scope of RCN activists’ work and For information call 0207 647 3831, or email:
the perception of activists by members, managers and [email protected]
the public. The project is making members more aware
of the potential nursing leadership opportunities open
Research & Development Co-ordinating
to them. For further information please email:
Centre
[email protected]
The RCN R&D Co-ordinating Centre co-ordinates and
Primary Care Leadership Programme shares knowledge and information about nursing
research and practice development. It also supports the
This programme aims to develop nurses’ ability to work of the RCN Research Society throughout the UK.
influence health improvement and service For more information call 0161 236 2049, or email:
developments across primary and community care. It [email protected]
supports multi-agency groups who work together in an
environment of change to develop their leadership
skills. For further information call 020 7647 3835, or
email [email protected]
35
Research Society
The RCN Research Society promotes research in
nursing. Research is every nurse’s business, and the
Society provides support for nurses who are actively
involved in all aspects of research, wherever they work.
For more information call 0161 236 2049, or email:
[email protected]
Working Well Initiative

The RCN Working Well Initiative is an ongoing
campaign focusing on the health, safety and wellbeing
of nurses.As well as lobbying policymakers and
employers to improve working conditions, the RCN
undertakes regular surveys of RCN members to identify
important issues in this area and to monitor change.A
range of helpful publications are produced under the
Working Well banner, including information on:
✦ bullying and harassment at work
✦ internationally recruited nurses
✦ workability
✦ latex allergy
✦ manual handling assessments in hospitals and the
community
✦ shifting patterns and employee friendly working
✦ sharps injury awareness.
Information on these and other publications is available
from RCN Direct or from the RCN website at
www.rcn.org.uk
36
Appendix 2:
Professions Act (2002), the Commission for Patient and
Clinical governance Public Involvement in Health was established in January
2003. The CPPIH will oversee the new patient and
resources public involvement system ensuring people and patients
have a strong voice in their local NHS. More information
is available at
www.doh.gov.uk/cppihconsultation/consult.pdf
This appendix offers a selection of resources relating to
clinical governance. It also provides details of some of Common Services Agency (Scotland)
the key agencies working in this field, plus key
www.show.scot.nhs.uk/csa
publications and useful websites (all web addresses
were accessed and checked prior to publication). The aim of the agency is to deliver services that are
responsive to need, that represent value for money, and
are delivered to a high standard. Services include: blood
Agencies transfusion services, quality screening programmes,
national specialist health services, and health statistics,
analysis and information to inform decision-making.
College of Health
www.collegeofhealth.org.uk Information Statistics Division (ISD)
The College of Health is a national charity that (Scotland)
represents the interests of patients and promotes greater www.show.scot.nhs.uk/isd
user involvement in health and social care. In Scotland, the ISD is part of the Common Services
Agency (CSA) which acts as an umbrella for a range of
Commission for Health Improvement (CHI) services across Scotland. Health service activity,
www.chi.nhs.uk manpower and finance data are collected, validated,
interpreted and disseminated by the ISD. This data is
The Commission for Health Improvement was
received from NHS boards, trusts and general practices.
established to improve the quality of patient care in the
NHS. It does this by reviewing the care provided by the
Health Ombudsman
NHS in England and Wales. Scotland has its own
regulatory body, the Clinical Standards Board Scotland. www.ombudsman.org.uk/hse
CHI aims to address unacceptable variations in practice The Ombudsman is an independent adviser to whom
by identifying notable practice, and areas where patients can turn to investigate their complaints against
improvements are required. The Government’s proposed hospitals or community health services on the grounds
changes to CHI will mean the establishment of an of poor service, failure to purchase or provide a service,
independent, single new Commission for Healthcare or poor administration.
Audit and Inspection (CHAI) which will bring together
the work of the Audit Commission, the Commission for Modernisation Agency
Health Improvement and the National Care Standards
www.modern.nhs.uk
Commission. CHAI will have responsibility for
inspecting both the public and private health care The Modernisation Agency was established by
sectors, and will work at local and national level to Department of Health to help staff make the changes set
monitor and improve clinical care in England and out in the NHS plan. The agency is working on a range
Wales. The new commission is expected to be up and of projects which include: improving access to primary
running sometime in 2004. health care and social services, promoting safe,
effective, high quality care, and redesigning patient
Commission for Patient and Public journeys for a range of patient groups. It has produced a
Involvement in Health (CPPIH) series of Improvement Leaders’ Guides, with titles
including process mapping, analysis and redesign,
www.doh.gov.uk/involvingpatients
involving patients and carers, matching capacity and
As a result of the NHS Reform and Health Care demand, and sustainability and spread.
37
Clinical Governance Support Team (CGST) timely, reliable clinical audit data to help measure the
www.cgsupport.org quality of care in the NHS. It also provides the
infrastructure to collate local clinical data for analysis
The NHS Clinical Governance Support Team is part of and feedback.
the NHS Modernisation Agency. It is a useful resource
providing a clear insight into clinical governance and its National Institute for Clinical Excellence
application in a clinical setting. The website includes (NICE)
lesson cards that draw on the work of teams that have
www.nice.org.uk
gone through Support Team Development Programmes.
The focus is on the process of achieving change. Careful The role of NICE is to appraise health interventions
analysis of the teams’ work allows the CGST to identify before they are introduced in the NHS in England and
aspects of their experience that might be useful to Wales. It offers guidelines on which treatments work
others. The cards describe the context and identify the best for patients and which do not. Its work supports a
lessons that can be drawn from learning situations. The wide range of health care professionals, who often have
first collection was published in September 2002 with to make complex decisions about the treatment of
more to be added. Links are given to the eurekas and/or individual patients. The NICE website provides
case studies on which the lessons are based. technical and summary reports of the guidelines
commissioned by NICE, health technology appraisals
Changing Workforce Programme and referral practice guidelines.
www.modern.nhs.uk
NHS Quality Improvement Scotland
The Changing Workforce Programme (CWP) is part of (NHS QIS)
the NHS Modernisation Agency. It is a NHS-based team
The goal of NHS QIS is to support staff in their efforts to
linked to the Human Resource Directorate and is
improve the quality of care and treatment which they
supported by the Workforce Taskforce.Working with provide, and to assure the public that the services
teams across England, the programme supports the provided by NHS Scotland are safe and meet nationally
implementation of new ways of working. agreed standards.
NHS National Nursing Leadership Project The purpose of the new board is to set standards,
support clinical governance, review, monitor and
www.nursingleadership.co.uk
investigate, share good and bad experiences, develop a
The NHS National Nursing Leadership Project ensures new relationship with NPSA and provide the health
that the targets set out in the NHS plan are met, and that service in Scotland with the necessary tools to find out
all clinical leaders experience leadership training. The what is clinically effective in practice. Organisations that
project is part of the Leadership Centre, located within are now part of the NHS QIS include: the Clinical
the Modernisation Agency. Standards Board Scotland (CSBS), the Health
Technology Board for Scotland (HTBS), the Nursing and
NHSIA Clinical Governance Programme Midwifery Practice Development Unit (NMPDU), the
www.nhsia.nhs.uk/phsmi/clinicalgovernance Scottish Health Advisory Service (SHAS), and the
Clinical Resource and Audit Group (CRAG).
The NHS Information Authority (NHSIA) is developing
a range of tools to help staff monitor and improve the Clinical Resource and Audit Group (CRAG)
quality of care by highlighting areas for improvement. (Scotland)
Included in the toolbox are a checklist and information www.show.scot.nhs.uk/crag
guide, a training package and a clinical governance
analytical toolkit. CRAG, which is part of NHS QIS, is the lead body within
the Scottish Executive Health Department promoting
National Clinical Audit Support Programme clinical effectiveness in Scotland. It provides advice to
(NCASP) the Health Department, acts as a national forum to
support and facilitate the implementation of the clinical
www.nhsia.nhs.uk/phsmi/pages/ncasp.asp
effectiveness agenda, and funds a number of clinical
NCASP (England) is responsible for the provision of effectiveness programmes and projects.
38
Clinical Standards Board for Scotland NHS Information Authority

(CSBS) www.nhsia.nhs.uk/def
www.clinicalstandards.org The NHS IA is a Special Health Authority with a remit to
support the effective use of national electronic health
The Clinical Standards Board for Scotland (CSBS),
records to improve patient care, provide national
which is now part of the NHS Quality Improvement
services that give staff, patients and the public access to
Scotland, is a regulatory body, established as a Special relevant information and knowledge for decision
Health Board in 1999. Its role, in line with the Scottish making, establish and maintain Health Informatics as a
Executive’s commitment to quality, openness and public recognised and respected national profession, and
accountability, is to promote public confidence that the provide reliable and secure information infrastructure
services provided by the NHS are safe and that they services, which provide the NHS value for money.
meet nationally agreed standards. It also demonstrates
that, within the resources available, the NHS is NHS Patient Survey Programme
delivering the highest possible standards of care.
www.nhssurveys.org
Scottish Intercollegiate Guidelines Network The NHS plan requires each NHS trust in England to
(SIGN) obtain feedback from patients about their experiences
of care. The NHS Patient Survey Programme will cover
www.sign.ac.uk acute, primary care, mental health and ambulance
trusts and others. There are also plans for surveys
SIGN is a network of clinicians and health care focusing on the National Service Frameworks for mental
professionals, including representatives of all the UK health, older people, diabetes, etc. The Advice Centre
Royal Medical Colleges as well as nursing, pharmacy, identifies and develops questionnaires, provides
dentistry and professions allied to medicine. Its documentation and advice on how to conduct the
objective is to improve the effectiveness and efficiency surveys, acting as a data centre to collate, check quality
of clinical care for patients in Scotland by developing, and analyse the survey data and provide feedback to
publishing and disseminating guidelines, which identify health service providers on how to use the survey
and promote good clinical practice. results to improve patient care.
National Patient Safety Agency Nursing and Midwifery Council

www.nmc-uk.org
www.npsa.org.uk
This organisation, established by Parliament “to ensure
The NPSA in England is responsible for designing and nurses, midwives and health visitors provide high
implementing a system for reporting patient safety standards of care to their patients and clients”, also sets
incidents involving NHS patients. The website offers a standards for education. From the NMC website, you
range of resources including alerts (e.g. administering can access a number of publications covering PREP and
vincristine), a library of briefings and presentations, life long learning.
research, news, events and message boards for
professional groups. The NPSA is also working with the Patient Advice and Liaison Service (PALS)
Welsh Assembly to extend the national reporting and
Patient Advice and Liaison Services supports the
learning system to Wales.At the time of writing, the effective handling of complaints.All NHS trusts have
NPSA is in discussions with the NHS QIS and has also established a local PALS. The National Patient Safety
met with colleagues from Northern Ireland to Agency (NPSA) has also established an in-house PALS.
determine how they can work together in the future This allows the agency to provide a single, central point
(NPSA Newsletter, 20 December 2002). From May 2003 of contact for any member of the public who wishes to
the NPSA has identified new terms for adverse events report their experience of an adverse event or a near
and near misses.Adverse event has become patient miss directly to the NPSA. The PALS team at the NPSA
safety initiative, and near miss has become prevented can be contacted at [email protected] or by calling
patient safety initiative. 0800 015 2536.
39
Patients’ Forum Publications

www.thepatientsforum.org.uk
The Patients’ Forum is a network of national and An organisation with a memory (2000)
regional organisations concerned with the health care www.doh.gov.uk/orgmemreport
interests of patients and their families and carers. The
aim of the Patients’ Forum is to “provide a forum for This report examines the key factors at work in
national and regional organisations representing the organisational failure and learning, covering a range of
interests of people who use health services to share practical experience from other sectors and the present
experiences, information and ideas, to strengthen their state of learning mechanisms in the NHS, and giving
work and to participate in informing and influencing conclusions. Its recommendations include the creation
decision-makers”. of a new national system for reporting and analysing
patient safety incidents, to make sure that key lessons
Workforce Confederations are identified and learned, along with other measures to
support work at local level to analyse events and learn
www.doh.gov.uk/workdevcon
the lessons when things go wrong.
Workforce Confederations replace the Education and
Training Consortia. Since April 2002, all national Building a safer NHS for patients (2001)
training charges for undergraduate and continuing www.doh.gov.uk/buildsafenhs
professional development have been merged into a
single funding stream, which has been allocated to 24 The report focuses on action, nationally and locally,
workforce confederations across the country. The necessary to establish a system that ensures that lessons
confederations have four main functions: integrated from patient safety incidents in one locality are learnt
workforce planning, the commissioning of education across the NHS as a whole. The system will enable
and training, the development of human resource reporting from local to national level. It will introduce a
practices and the ability to anticipate what a future NHS new integrated approach to learning from medical error,
workforce might look like. patient safety incidents and prevented patient safety
incidents, and it will capture adverse event information
from a variety of sources. Local reporting of adverse
events and action to reduce risk within the organisation
concerned is essential. On a selected basis, reports to
national level will enable service-wide action where
patterns, clusters or trends reveal the scope to reduce
risk or prevent recurrence for future patients in other
parts of the country.
Changing relationships: findings of the patient

involvement project
(ISBN 1-85717-468-2)
This research paper shows how the policy framework
has shifted in response to wider cultural changes and
high profile investigations such as the Bristol Inquiry. It
presents the results of the King’s Fund Patient
Involvement Project. This examined what patient-
centred care means on the ground through 45
interviews with a wide range of stakeholders, including
representatives of regulatory, teaching and professional
bodies, medical practitioners, and patient and
consumer groups. The research found widespread
disparities in the understanding of what patient-centred
care is and how to achieve it, alongside a tendency to re-
40
define existing activities to fit the concept. It suggests clinicians to compare different key elements of
that patients, users and carers must play a central role in performance and understand how changes in one area
shaping and evaluating what it means in the future, if may have implications for others. The PAF for strategic
clinical encounters are to be transformed, and more health authorities comprises areas of performance
power and control devolved to them. which, taken together, give a balanced view of the
performance of the NHS, and include: health
Clinical audit handbook (1999) improvement, fair access, effective delivery of
(ISBN: 0-70202418X) appropriate health care, efficiency, patient/carer
experience, and health outcomes.
The Clinical audit handbook provides a clear and
practical guide to implementing clinical audit in The PAF for NHS hospital trusts is similar and is
practice. The book provides examples of practical designed to complement the information contained in
applications of clinical audit with a strong nursing focus. the health authority PAF. It will enable hospital trusts to
assess and compare their performance against a full
range of measures. It has four areas, including clinical
Dearing report (1997)
effectiveness and outcomes, efficiency, patient/carer,
The Dearing report (Higher education in the learning and capacity and capability.
society – report of the National Committee of Inquiry into
higher education) expressed the view that everyone National Service Frameworks
should embrace lifelong learning to keep up with the
current and future pace of change in the world. This is www.doh.gov.uk/nsf
reflected in the nursing sector in the form of continual National Service Frameworks (NSFs) set national
personal and professional development supported by standards and define service models for a specific care
the Royal College of Nursing and the Nursing Midwifery group. They put in place programmes to support
Council. implementation and establish performance measures
against which progress within an agreed timescale will
Improvement leaders’ guide to involving patients be measured. There is a rolling programme of NSFs
and carers (2002) covering: care of older people, child health, coronary
www.modern.nhs.uk/improvementguides/patients heart disease, diabetes, long term care, mental health,
renal services, and children’s services (with maternity).
This booklet from the Modernisation Agency includes
an introduction to patient and public involvement and Practicalities of producing patient information
covers methods such as critical incident technique, (POPPI)
focus groups, patient shadowing and patient diaries,
discovery interviews and questionnaires and critical (ISBN: 1857174704)
friends groups. www.kingsfundbookshop.org.uk
This publication is designed to support a wide range of
NHS performance indicators
health professionals in the pubic, commercial and
www.doh.gov.uk/nhsperformanceindicators voluntary sectors, to develop the quality and impact of
These indicators cover vital services such as treatment the information they produce. Fully updated and in line
for heart disease, cancer and mental health. They also with the latest developments in new media, such as CD
cover other issues that really matter to patients, ROMs and the Internet, the guide also shows how to use
including length of wait for admission, cleanliness of traditional media, such as print, to the best advantage.
hospitals, and how easily they can get to see their GP. POPPI provides a step-by-step guide to each stage of the
The indicators also tell us about the overall health of the information process, from developing and information
population, how efficiently the health service is being policy, to writing and disseminating print and electronic
managed and how well staffed it is. materials.
The indicators are grouped into different categories or

areas according to the NHS Performance Assessment
Framework (PAF). The PAF enables NHS managers and
41
Principles for best practice in clinical audit (2002) related sectors, develops and equips staff with the skills
(ISBN: 1857759761) they need to:
www.nelh.nhs.uk/nice_bpca.asp. ✦ support changes and improvements in patient care
Clinical audit is at the heart of clinical governance.All ✦ take advantage of wider career opportunities
NHS organisations must have a comprehensive quality ✦ realise their potential.
improvement programme with clinicians fully
participating in clinical audit. Principles for best There is increasing evidence that lifelong learning, as
practice in clinical audit sets out the principles that part of good employment practice, lies at the heart of
should guide the changes needed for this process. The effective organisational performance. The framework is
book looks at using audit and creating the environment, directed at those responsible for making lifelong
preparing for audit, selecting criteria, measuring levels learning happen – NHS organisations, managers and
of performance and making improvements. supervisors, education providers, the professions,
Workforce Development Confederations and staff
themselves. It is wide in scope, touching on many
Realising clinical effectiveness and clinical
aspects of learning and development – ranging from
governance through clinical supervision (2001)
induction through to continuing personal and
www.radcliffe-oxford.com/education/ professional development and leadership and
E02_Clinical_Supervision/default.asp management. It sets out the characteristics of an
This comprehensive package of learning materials has effective learning organisation. It also emphasises that
been designed for use in a wide range of situations and staff need to take responsibility to develop and to
to meet the development needs of nurses at every level participate in lifelong learning.
in the profession. Its flexibility enables participants to
work independently and adapt their learning to the level
of support available from their colleagues and
educational facilities. The programme, based on the
broad experience of innovators who have been in the
forefront of clinical supervision research and
development throughout the UK, follows the models of
open learning, action learning, critical companionship
and reflective practice. If participants so choose, they
can seek academic accreditation.
Royal Society of Medicine’s

Clinical Governance Bulletin
www.rsm.ac.uk/pub/cgb
The Clinical Governance Bulletin is a bi-monthly
publication for health professionals and managers,
which highlights and disseminates best practice.
Articles focus on a broad range of issues in health
management such as risk management, clinical
effectiveness managing resources, and improving
communication.
Working together, learning together (2001)

www.doh.gov.uk/lifelonglearning
This document details the Department of Health’s
approach to lifelong learning and development. The aim
is to ensure that the NHS, working with its partners and
42
Useful web resources Cochrane Library

www.update-software.com/clibhome/clib.htm
Centre for Reviews and Dissemination The Cochrane Library is published quarterly on CD-
ROM and the Internet, and is distributed on a
www.york.ac.uk/inst/crd subscription basis.Abstracts of Cochrane Reviews are
NHS Centre for Reviews and Dissemination (CRD) is a available without charge and can be browsed or
facility commissioned by the NHS Research and searched. The library consists of:
Development Division. It identifies results of good ✦ Cochrane Database of Systematic Reviews – regularly
quality health research and disseminates actively the updated reviews of the effects of health care
findings to key decision-makers and consumers. It
publishes the findings of systematic reviews into ✦ Database of Abstracts of Reviews of Effectiveness –
specific topics in the Effective Healthcare Bulletins critical assessments and structured abstracts of good
series. The site includes full online access to all CRD systematic reviews published elsewhere
publications including the Effective Healthcare Bulletin ✦ Cochrane Controlled Trials Register – bibliographic
series in PDF format. information on controlled trials
✦ other sources of information on the science of
Clinical Evidence reviewing research and evidence-based health care.
www.clinicalevidence.org The Cochrane Library is one of several databases
available to staff working in the NHS via the National
This is a compendium of evidence on the effects of
electronic Library for Health. Registering via a NHSnet
common clinical interventions. The evidence is drawn
connection is the quickest method.All you need to do is
from systematic reviews and randomised controlled
apply online or by mail in order to receive a password.
trials. Each section presents a concise account of what is
Once the NeLH has verified your status as a NHS
known about prevention and treatment of a wide range
employee, they will send a password.
of clinical conditions. Clinical Evidence is published by
the BMJ Publishing Group. If you are an NHS employee,
you can register with the National Electronic Library for Delivering 21st century IT support for the
Health (NeLH) to gain access to the full text online NHS – national strategic programme (2002)
version. www.doh.gov.uk/ipu/whatnew/deliveringit/nhsitimppla
n.pdf
Clinical Governance Research and The national strategic programme is concerned with
Development Unit major developments in the deployment and use of
www.le.ac.uk/cgrdu information technology (IT) in the NHS. It aims to
connect delivery of the NHS Plan with the capabilities of
The Clinical Governance Research and Development modern information technologies to support patients,
Unit (CGRDU) is a resource for primary care deliver services designed around the patients, support
organisations and strategic health authorities, staff through effective electronic communications
established in 1999 and based at the University of which will lead to better learning and knowledge
Leicester. Its remit includes: research into effective management thereby cutting the time it takes to find
methods of implementing change in behaviour and essential information. In addition, the programme aims
performance, the determination of methods for the to improve management and delivery of services by
professional development of individuals, teams, and providing good quality data to support NSFs, clinical
primary care groups, the creation of a library of audit, and governance and management information.
evidence-based protocols for systematic audits, the
development and evaluation of ways of involving DIPEX
patients in clinical governance, and the dissemination of
www.dipex.org/
information and advice to primary care organisations
on the most feasible and effective approaches to clinical The Database of Individual Patient Experience (DIPEX)
governance. is a site consisting of patient testimonies organised by
43
condition. The conditions covered include hypertension them to move up the escalator. Meanwhile, efficiencies
and cancers. and skill mix benefits are generated by delegating roles,
work and responsibilities down the escalator where
Health of Wales (HOWIS) appropriate.
www.wales.nhs.uk
National electronic Library for Health
HOWIS is the official website of NHS Wales.
www.nelh.nhs.uk/
Leadership development over the Internet The NeLH provides health care professionals and the
(NHS National Nursing Leadership Project) public (through NHS Direct Online and the New Library
www.nursingleadership.co.uk/elearning Network) with knowledge and know-how to support
health care-related decisions. The NeLH will also
The NHS Nursing Leadership Project has developed a
include virtual branch libraries containing collections of
range of free, online programmes that can be
information about a specific aspect of health, or a
undertaken at work or at home, at a pace dictated by
particular disease or condition. Each collection is put
you. These programmes are accredited towards PREP
together by a specialist in that particular field and
and Continuing Professional Development. They cover
scrutinised by his or her peers.
skill development in ways to make meetings more
effective, strategies that help professionals make the
right choices about life and career, techniques for National electronic Library for Health
mastering paper, and the importance of recognising the Guidelines Finder
balance between work and life. www.nelh.nhs.uk/guidelinesfinder
Leading an Empowered Organisation (LEO) The Guidelines Finder is being developed in

collaboration with Sheffield Evidence for Effectiveness
www.nursingleadership.co.uk/rcn_leo/leo_info.htm and Knowledge. The database currently holds details of
Leading an Empowered Organisation is a three-day over 600 UK national guidelines with links to Internet
programme designed for health care professionals from downloadable versions of the guidelines and where
all disciplines with all levels of experience and available, to the NeLH full text-guidelines collection.
expertise. It is offered by the Centre for the Development
of Nursing and Policy and Practice (CDNPP) at the National electronic Library for Health NSF
University of Leeds. Zones
www.nelh.nhs.uk/nsf
Learning from Bristol: the report of the
public inquiry into children’s heart surgery The NeLH National Service Frameworks Zones provide
at the Bristol Royal Infirmary 1984 – 1995 a gateway to the key sites and resources related to
www.bristol-inquiry.org.uk implementation of the NSFs for all health care
practitioners and managers. It includes supporting
The Bristol Inquiry website has been reorganised to health care guidelines and care pathways and
allow easy access to the final report (Kennedy).Visitors information resources for patients. The NeLH will be
to the site can view all the material published commissioning supporting resources where
throughout the course of the Inquiry.A Welsh language appropriate. The first of these is the What Works, the
version of the summary and recommendations is guide to the evidence base for Standard 1 of the Mental
available. Health NSF – promoting mental health. The NeLH has
also provided online access to the Cancer Service
Lifelong Learning and Skills Escalator (DoH) Collaborative Change Case Studies from the Service
www.doh.gov.uk/hrinthenhs/learning/section4b/skillses Improvement Guides.
calatorhomepage.htm
The essence of this approach is that staff are encouraged National electronic Library for Health
through a strategy of lifelong learning to constantly Pathways and Protocols
renew and extend their skills and knowledge, enabling www.nelh.nhs.uk/carepathways
44
This library within the NeLH provides a national point NHS plan technical supplement on target
of access for sharing and disseminating clinical setting for health improvement (2001)
protocols and integrated care pathways. Launched in www.doh.gov.uk/nhsplantechnicalsupplement
2001, the Care Pathways Database provides information
with contact details for over 2,000 care pathways This provides background to the setting of health
currently in use or in preparation in over 200 NHS outcome targets including many of those published in
organisations. Full-text care pathway definitions can be the NHS plan, to assist the process of setting health
included in the database and nearly 200 of these are targets and assessing progress across the whole range of
currently available for browsing and downloading. The influences on health.
NeLPP will also provide access to e-booking referral
protocols and Patient Group Directions that specify Northern Ireland’s Health and Care Portal
rules for the permitted supply and administration of www.n-i.nhs.uk/
medicines in local NHS organisations other than by
means of a prescription. This website is the gateway to Health and Social Care
Services in Northern Ireland.
National standards of cleanliness for the
NMAP Nursing, Midwifery and Allied Health
NHS (2001)
Professionals Gateway
www.nhsestates.gov.uk/download/cleaning_standards/ http://nmap.ac.uk/
cleaning_standards_toolkit.pdf
NMAP offers free access to a searchable catalogue of
These standards are available from the NHS Estates Internet sites covering health and medicine. Each record
website, together with other supporting documentation appearing on the NMAP site has been evaluated and
such as score sheets for auditing purposes. checked against explicit criteria. The site is hosted and
managed by the University of Nottingham. NMAP
NHS Complaints Procedure – Managing focuses on material about nursing, midwifery and allied
Complaints for Service Improvement health professions. Users can search NMAP or select one
of the other BIOME gateways to find Internet resources
www.doh.gov.uk/complaints in other areas of the life sciences. Other facilities include
These pages contain the legislation that sets out the an online tutorial about searching and using medical
legal framework for the operation of the NHS sites on the Internet called Internet for Nursing,
complaints procedure, all the guidance issued since Midwifery and Health Visiting
April 1996 as well as information for patients on how to (www.vts.rdn.ac.uk/tutorial/nurse).
complain about the NHS. There is also information on
the process of reform. Patient and public involvement strategy –
example
NHS Estates – The Patient Experience www.addenbrookes.org.uk/resources/pdf/ppi/ppi_strat
egy_170702.pdf
www.nhsestates.gov.uk/patient_environment
This example of a patient and public involvement
NHS Estates has established a number of projects that strategy is one of many published by trusts and
focus on the patient environment. These areas include: available online. This published strategy is from
the patient’s journey, listening to patients, patient power, Addenbrooke’s NHS Trust, which has a home page
enhancing privacy and dignity, developing design dedicated to patient and public involvement.
excellence, personal places (premises for mental health
care), clinical planners network. Two examples of the QualityHealthcare.org
resources you will find here are guides to ward
www.qualityhealth care.org/qhc
housekeeping services (Housekeeping – a first guide to
new, modern and dependable ward housekeeping services This is a global knowledge environment created to help
in the NHS and Process mapping the housekeeping health care professionals around the world accelerate
service – a toolkit for change) and details of the NHS their progress toward unprecedented levels of
Customer Care training programme. performance and improvement. Key topics include:
45
improvement methods and patient safety. Registration Journals

is free for health care professionals, and the site allows
you to download tools, participate in discussion groups, A highly selective list of some of the more useful
and find colleagues around the world who are working journals that focus on key themes of clinical
on issues like yours. governance:
Scottish Health on the Web (SHOW) Clinical Governance

www.show.scot.nhs.uk/ Clinical Governance – an International Journal (formerly
British Journal of Clinical Governance)
A range of information related to the NHS in Scotland is
available on this website. Journal of Clinical Risk
Quality and Safety in Health Care
Toolkit for producing patient information
(2000)
www.doh.gov.uk/nhsidentity/toolkit-patientinfo.htm
A Department of Health publication designed to
support the efforts of organisations towards improving
communications.
Wisdom Centre pack on Clinical Governance

www.disdomnet.co.uk/clingov.asp
This guide collates resources that address issues in
clinical governance.
46
Appendix 3:
some progress: the trust has become a PALS pathfinder
Patient and public site, a well-publicised service that is led with
enthusiasm. Other aspects of the action plan are being
involvement at two piloted in selected clinical teams.
The trust has a customer care training programme, but
mental health not all relevant staff have attended the training and
some do not have the adequate skills and knowledge to
deliver a consistently high quality of consumer care.
trusts Ways of involving patients
Some trust service centres have used innovative
The two examples provided below describe the approaches to involve patients and the public in service
achievements of two trusts in meeting the clinical development, projects that are generally initiated by
governance agenda around patient and user enthusiastic clinical teams. These have led to service
involvement. These examples describe the sort of improvements, but there is no systematic way to spread
challenges organisations face when implementing these good practices to other teams.
clinical governance.
Approaches include:
✦ talk back sessions established by the care of the
Example 1: St George’s elderly team, where patients give feedback about
Healthcare NHS Trust their experiences of care
✦ public meetings, newsletters, local adverts and public
(Source: Commission for Health Improvement (2003) consultation events to inform the public about the
Clinical governance review: St George’s Healthcare NHS trust’s work
Trust. London: CHI.)
✦ information booklets about trust services and advice
The set up at St George’s about various health conditions are displayed and
available to patients, although a majority of them are
St George’s Healthcare NHS Trust has a patient
in English only
information system and partnership steering group
which reports to the trust’s board. This is supported by a ✦ a language line, run through contractors, provides
patient information and partnership operational group, interpreting services, although staff and patients’
chaired by a non-executive director. The patient advice relatives are often used to communicate with patients
and liaison service (PALS) manager is the key who don’t speak English
operational lead for patient and public involvement,
✦ trust policies guide staff in helping patients make
supported and led by the director of nursing and
informed choices about their care and provide proper
operations.
consent for treatment. Staff are aware of these
The trust board receives regular reports on complaints policies and are confident to use them. For example,
and considers actions from independent reviews. Teams there is a ‘do not attempt resuscitation’ policy, which
receive complaints reports and use information from is understood by staff
patient surveys to discuss complaints regularly. The
✦ suggestion boxes are available for patients to submit
trust board receives updates on progress against its plan
comments about their experiences
to improve patient and public involvement, although
progress is at an early stage. ✦ patient surveys are regularly undertaken
St George’s has a strategy for patient and public ✦ a complaints handling procedure is in place, although
involvement that was ratified by the trust board and is a patients do not feel fully supported by the complaints
key strategic commitment in the trust’s clinical process, nor do they believe that the root causes of
governance strategy. This strategy includes a detailed their complaints are always understood or taken
action plan, against which the organisation has made seriously.
47
Listening to patients The trust uses various methods of informing and

There are examples of sustained changes in practice involving its patients, although information provided is
resulting from listening to patients and from not always consistent across the trust. These include:
complaints. Such changes include improved liaison with ✦ information leaflets for users and carers,
patient transport providers and improved information co-ordinated by the patient information office. Most
for patients and GPs about which drugs to stop and start leaflets are in English and a few have been translated
before admission for a cardiology procedure. into other languages
✦ a range of advocacy services, including those
provided by Birmingham Citizen Advocacy and
Example 2: South Birmingham MIND (awareness of the Birmingham Citizen
Mental Health NHS Trust Advocacy service is not yet widespread)
(Source: Commission for Health Improvement (2002) ✦ good systems of capturing and responding to
Clinical governance review: South Birmingham Mental complaints – complaints are taken seriously and
Health NHS Trust. London: CHI. responded to quickly. Formal systems for learning
from complaints mean complaints in one area are
shared with other departments.
User involvement
The trust has a user involvement strategy, developed Involvement in decisions about care
with the help of service users. Target dates need now to
Involvement of users in care planning is not yet as
be established to meet this plan.
developed within the organisation as the trust hoped it
User Voice is an independent user-led organisation, would be. Service users do not always get a copy of their
supported by the trust, which co-ordinates user care plan, and there is little carer input into these plans.
involvement and provides group advocacy for patients.
The trust is notable in the way it has made sure User
Voice is represented on a range of trust committees and
on some managerial and clinical groups. The trust has
recognised that User Voice is not representative of the
diverse local communities served by the trust, so it is
helping the group to become more representative. For
example, carers were not fully involved, and so the trust
appointed a carers support worker in conjunction with
Rethink (previously the National Schizophrenia
Fellowship). The trust has also developed good
partnership working with social care services.
Improving action following feedback

Mechanisms for getting feedback from users and carers
is not uniform across trust departments, and frontline
staff can’t always see how consultation with service
users and the public can result in improvements in
practice. This lack of formal structure for monitoring
feedback, which leads to improvement in practice, is a
challenge that staff are aware of. Staff and the trust are
aware that formal feedback structures don’t yet cover all
service groups, and that there is scope to improve action
taken as a result of feedback from service users. To
create more opportunities to improve the service, the
trust is therefore considering making the User Voice
group a sub-committee of the main board.
48
Appendix 4:
for adolescents diagnosed with ADHD. Clinical Evidence6
Information is a compendium of critically appraised topics. Sue has a
quick look there and finds a section on the effects of
literacy skills treatment for children with ADHD.
Government policy
The next port of call is the Department of Health
Online7 for updates on relevant Government policies.
Example 1: Locating Sue is aware of National Service Frameworks8 (NSFs),
part of the Government’s agenda to improve quality and
information about Attention reduce variations in health care. She looks at the NSFs
Deficit Hyperactivity Disorder for Mental Health and Children’s Services.
Sue Edwards, a school nurse, was asked to produce She searches the Department of Health publications
information leaflets about Attention Deficit database, POINT9, and finds School nurse practice
Hyperactivity Disorder (ADHD), which would include development resource pack10. This includes a section on
helpful resources and contact details, to inform staff, child and adolescent mental health, which suggests
parents and pupils. practice examples for school nurses to follow to help
improve education, encourage evidence-based
Sue identified her three information needs: interventions and develop mental health promotion
1 to get up to speed with current best practice in this strategies for children, parents and teachers. This
area document is free to download.
2 to find out more about ADHD patient information Sue finds two other publications through this route:
and patient advocacy groups Promoting children’s mental health within early years and
school settings (guidance from the Department for
3 to investigate whether there are any networks where Education and Skills, 2001).A DH newsletter Mental
she can discuss and disseminate information on Health Promotion Update (2002) has a section on
ADHD with other like-minded health professionals. promoting mental health and wellbeing for children and
young people. The newsletter illustrates models of good
Sue’s search practice, including four examples of UK initiatives
working with young people and schools to promote the
Evidence-based guidelines mental health of young people.
Firstly, Sue looks for evidence-based guidelines and
high quality systematic reviews to answer her questions. Professional organisations
Through a resource of the National electronic Library Sue discovers the Royal College of Psychiatrists11
for Health, (NeLH) called Guidelines Finder1, she locates research unit includes FOCUS12, an initiative that
a guideline for evidence-based assessment and promotes effective practice in child and adolescent
management of ADHD from SIGN2 (Scottish mental health. Sue finds FOCUS features latest news,
Intercollegiate Guidelines Network). current initiatives, available resources, events, useful
The National Institute for Clinical Excellence (NICE)3 is links and a downloadable guide to finding the evidence.
another source of guidelines and it also appraises new
therapies. NICE4 has appraised the drug Health gateways
Methylphenidate and its efficacy for children affected by Sue investigates a further selection of health gateways
ADHD. that provide access to quality assured information. She
searches NHS Direct online13 and finds the Contact a
Systematic reviews Family (CaF) directory14. CaF is a leading UK charity
Sue explores other resources available via the NeLH, providing support, advice and information to
including the Cochrane Library5 that contains individuals and parents of children with medical
systematic reviews, summaries of the best available conditions. Sue is reassured that all CaF material is
evidence. Sue finds a systematic review of interventions written and checked by leading medical specialists.
49
The link takes her to a section on ADHD with examples convenes practical workshops and training events on
of patient advocacy groups that she can include in her ADHD. Sue investigates other resources listed in the CaF
leaflets. Two organisations catch her attention. The first directory including Young Minds17, and Hyperactive
is adders.org15 that includes an ADD Simulation, a visual Children’s Support Group18. Sue does a quick search on
programme that can be run on a computer. She feels NMAP19, a second gateway to quality health information
this may be useful for presentations to the teachers and on the Internet, and locates the School Nurses web page,
pupils. The second site,ADDISS Information Services16, a section in Nurses Network. There is a document, How
is another source of valuable patient information. The schools can help children with ADD/ADHD, which lists
site includes a newsletter containing support group ten basis points for schools to implement to help
details. It also gives details of a new publication she feels children with ADHD.
might be worth purchasing for the school, Managing
The final part of Sue’s search involves locating forums
ADHD in the inclusive classroom, which provides
and discussion lists. In the forums and branches section
practical strategies for teachers.
of the Royal College of Nursing Extranet, there are two
forums with websites, Children and Young People
Networking and CPD Mental Health Forum and the RCN School Nurses
Sue is keen to continue her professional development Forum. She finds two further discussion lists at
and notices that ADDISS holds an annual three-day JISCmail20, a national academic mailing list service
conference, which brings together professionals and School-health-edu, CAHMS-research and Paediatric-
non-professionals to discuss ADHD.ADDISS also nursing forum archives.
Summary
Type of evidence Resource Example
National clinical SIGN Attention deficit and hyperkinetic disorders in children
guidelines NICE and young people (2001)
Systematic reviews The Cochrane Library The efficacy, safety and practicality of treatments for
(now free via the NeLH) adolescents with ADHD (2000), NHS Centre for Research
& Dissemination
Critically appraised Clinical evidence (free via the Effects of treatments for attention deficit hyperactivity
topics NeLH) disorder in children (2001)
Standards and service National Service Frameworks NSF for Mental Health
models (DH Online) NSF for Children’s Services
Professional bodies Royal College of Psychiatrists FOCUS

RCN Paediatric health adviser Finding the evidence: a gateway to the literature in child
and adolescent mental health, (2001)
Primary literature Bibliographic databases Medline and Embase
Research papers Online journals BMJ – Evidence based management of attention deficit
(quantitative/ hyperactivity disorder
qualitative) (2001, vol. 323, pp. 1232-1235 24th November.)
Nursing Standard/BNIPlus
Health gateways NHS Direct Online Contact a Family Directory (CaF)

OMNI / NMAP School Nurses section of Internet site Nurses Network
RCN Mental Health Zone
Tacit knowledge Discussion lists JISCmail
Forums RCN specialist forums, including RCN School Nurses
Patient advocacy groups Forum
adders.org and ADDISS Information Services
If you want further information on searching for information, please contact the RCN Information Service
on 0207 647 3831, or email: [email protected]
50
Links: Example 2: Locating

1 www.nelh.nhs.uk/guidelinesfinder/
information on falls prevention
2 www.sign.ac.uk/index.html and awareness
3 http://sign.ac.uk/guideliknes/fulltext/52/index.html
Mary Davies, a senior community care nurse based at a
4 http://nice.org.uk/article.asp?a=11667 GP practice in north east London, is undertaking a
5 www.nelh.nhs.uk/cochrane.asp patient awareness programme about falls prevention for
older people living in her area. Her aim is to visit a
6 www.nelh.nhs.uk/clinical_evidence.asp numbered of sheltered accommodation establishments
7 www.doh.gov.uk to give a short presentation to residents and staff on
how to avoid slips, trips and broken hips. This is based on
8 http://doh.gov.uk/nsf/nsfhome.htm a recent campaign by the Department of Trade and
9 http://tap.ukwebhost.eds.com/doh/point.nsf/ Industry that Mary has read about (now part of the
Publications?ReadForm Help the Aged commitment to the health and wellbeing
of older people).
10 www.doh.gov.uk/cno/resourcepack.htm
Before Mary embarks on her assignment she wants to
11 http://rcpsych.ac.uk/ find out:
12 http://rcpsych.ac.uk/cru/focus/index.htm 1 what guidance already exists
13 http://nhsdirect.nhs.uk/innerpage2.asp? 2 availability of patient information
Code=RS&Topic=31
3 whether there are any training courses or practical
14 www.cafamilt.org.uk/ support for health care staff1.
15 http://adders.org
Mary’s search
16 http://asddiss.co.uk
17 http://youngminds.org.uk Clinical guidelines
Mary is aware of the Department of Health’s National
18 http://hacsg.org.uk
electronic Library for Health (NeLH) website, which
19 http://nmap.ac.uk provides access to best current practice2. From this
website, via the Guidelines Finder3, she discovers a
20 www.jiscmail.ac.uk
recent guideline Prevention and management of hip
fractures in older people in the section on the risk of
falls4, produced by the Scottish Intercollegiate Guideline
Network (SIGN) in 2002. She also finds, under
International Guidelines listed on the National
Guideline Clearing House (NGC) website5, an American
guideline for the Prevention of falls in older persons,
produced collaboratively by the American Academy of
Orthopaedic Surgeons,American Geriatrics Society and
the British Geriatrics Society (2001).
Reviews
Searching the NeLH further, Mary accesses the
Cochrane Library6, and Clinical Evidence7 sections. Here
she locates a systematic review of Interventions for
preventing falls in older people (2001), and a randomised
controlled trial of a General practice programme of home
based exercise to prevent falls in elderly women (1997).
51
Standards and models Courses

Mary now broadens her search. She knows about the Are there any training courses about falls and older
Department of Health’s National Service Framework for people she could take advantage of? From the ROSPA
older people (2001)8, which includes a detailed section website13, Mary learns that this organisation runs
on preventing and managing falls. However, Mary courses aimed at nurses on preventing accidents in the
decides she would also like to find out about what the home, and that the Health Development Agency20 runs a
other professional organisations have published on this training course for health professionals to help older
subject matter. From the Royal College of Physicians’9 people avoid falls. She has also heard, via the Royal
website, Mary locates a guideline Enhancing the health College of Nursing’s Forum for Nurses Working with
of older people with a section that refers to the Older People, of an RCN distance learning, continuing
prevention and management of falls (1998). professional development course for gerontological
nursing21.
Primary literature, research papers and
journals
Mary knows that online databases, also accessed via
NeLH, such as Pub Med (one of MEDLINE’s most
comprehensive medical bibliographical databases)10,
and the National Research Register11, can provide her
with further information. She undertakes a general
search and discovers a number of references to articles,
plus ongoing research at St George’s Hospital Medical
School in London on exploring the risk of falls from the
perspective of older people, carers and health
professionals.
She also discovers that she can search a number of
journals herself, directly online. She finds, via the British
Medical Journal (BMJ)12, Guidelines for the prevention of
falls in people over 65, developed by the Department of
General Practice and Primary Care at Bart’s, the Royal
London and Queen Mary’s School of Medicine (2000).
Information for patients

Mary has collected quite a lot of material which will give
her professional guidance, but she also needs sources of
patient information that she can pass on to the residents
when she gives her presentation. To do this, she returns
to her original source of information on prevention
home falls1, as it has links to material aimed at older
people, produced by the Royal Society of Prevention of
Accidents (ROSPA)13,Age Concern14, and Help the
Aged15, that can be easily viewed and downloaded.Via
NMAP16, the specialised internet gateway for nursing,
she comes across Patient UK17,Active for Life18, and
the Health Education Board for Scotland19 which all
have patient-aimed information available on falls
prevention.
52
Summary
Type of evidence Resource Example
National clinical SIGN Prevention and management of hip fractures (2002)
guideline
Systematic reviews The Cochrane Library Preventing falls in older people (2001)
Critically appraised Clinical Evidence General practice programme of home based exercise to
topics prevent falls in elderly women (1997)
Standards and service National Service Frameworks NSF for older people (2001)
models
Professional bodies Royal College of Physicians Enhancing the health of older people (1998)
Primary literature Bibliographic databases Medline (Pub Med)
Research papers Online journals BMJ – Guidelines for the prevention of falls in
(quantitative/ people over 65
qualitative)
Health gateways NMAP Patient UK – falls
Tacit knowledge Patient information forums Help the Aged

RCN Forum for Nurses Working with Older People
Links: 11 www.update-software.com/National
1 www.preventinghomefalls.gov.uk 12 http://bmj.com/cgi/content/full/321/7267/1007
2 www.nelh.nhs.uk 13 www.rospa.co.uk/CMS/
3 www.nelh.nhs.uk/guidelinesfinder/ 14 www.ace.org.uk
4 www.sign.ac.uk 15 www.helptheaged.org.uk
5 www.guidelines.gov/ 16 http://nmap.ac.uk
6 www.nelh.nhs.uk/cochrane.asp 17 http://patient.co.uk/illness/f/falls.html
7 www.nelh.nhs.uk/clinical_evidence.asp 18 http://active-for-life
8 www.doh.gov.uk/nsf/olderpeople.htm 19 www.hebs.scot.nhs.uk/
9 www.rcplondon.ac.uk 20 www.had-online.org.uk
10 www.ncbi.nlm.nih.gov/entrez/query 21 www.rcn.org.uk
53
Appendix 5:
The new CSCG structure

Implementing
In autumn 1998, a senior clinician was given lead
clinical governance responsibility for ensuring the development and
implementation of CSCG arrangements, building on the
considerable number of quality initiatives already in
at organisational place.A working group was established to take forward
this agenda and their remit included creating general
level awareness of CSCG in the organisation, educating staff
and beginning a baseline assessment based on the
EFQM Excellence Model. This assessment led to a draft
framework that set in place a basic structure to address
implementation.
Example 1: The integration of To support the first CSCG post, in October 1999 the trust
clinical and social care appointed a clinical and social care governance co-
ordinator was appointed, a role that continues to evolve.
governance in Down & Lisburn In January 2000, a new trust board sub-committee for
Health and Social Services CSCG superseded the initial working group – see figure
1. Members of this group have designated lead
Trust responsibility for the key components of CSCG.
Clinical governance became a statutory requirement for These key components form the building blocks of the
Northern Ireland from April 2003, but Down Lisburn structure:
Health and Social Services Trust made a corporate
decision to embrace this approach as early as 1998.With ✦ organisational audit
an absence of local guidelines and a requirement to ✦ user consultation
incorporate the social care component of integrated
health and social care (Northern Ireland) into this ✦ complaints
structure, the trust in these early stages made reference ✦ staff consultation
to the arrangements laid out in the document A first
✦ clinical audit
class service, quality in the new NHS (DH 1998).
✦ health & safety
This document has now been superseded by the
Northern Ireland document Best practice – best care ✦ research
(DHSSPS, 2001) and now its successor, Governance in ✦ evidence-based practice
the HPSS – clinical and social care governance: guidelines
for implementation (2002). These laid out broad ✦ risk management
guidance for health and social services trusts to follow ✦ performance management
on clinical and social care governance (CSCG).
✦ continuing professional development
The trust had already embarked on the journey to
✦ continuous quality improvement plans.
quality. It had an established and recognised
commitment to continuous improvement evidenced in The CSCG structure is further underpinned by the
the many awards received for Charter Mark, ISO arrangements for professional governance, developed by
9000:2000, Investors for People (trust-wide) and the the trust in 1994 and reviewed in 2000. This is a
Health Quality Service Accreditation (Mental Health structure through which professionals can provide input
Services).Also, since 1998 the trust has used the on issues relating to CSCG, and a means of ensuring that
European Foundation for Quality Management professionals develop and provide a high quality service
Excellence Model 1999 (EFQM) to underpin and bring which achieves good outcomes based on patients’ and
cohesion to the continuous improvement agenda. clients’ needs – see figure 1 overpage.
54
Figure 1: Clinical and social care governance structure, Down Lisburn Trust
HSS Executive
Trust Board
Chief executive: accountable officer
Trust board sub-committee for CSCG
Professional groupings: Programmes of care:

Nursing, medical, social work Mental health, disability, primary care,
allied health professionals acute services
Individual staff Individual staff
Process service users, staff and management representatives,

and co-ordinated by a patient advocate (a joint
The trust’s service directorates (acute, mental health appointment with the National Schizophrenia
and disability and primary care) have adopted this Fellowship). In its first three years, this alliance has
structure according to their local governance driven a number of initiatives to empower users, for
arrangements and requirements. For each, individuals example user involvement in service planning and in
(multi-disciplinary) have been assigned lead selection and recruitment, and focus groups to inform
responsibility and accountability for the key the continuous improvement agenda. Queen’s
components of CSCG. Reporting arrangements are in University, Belfast, is formally evaluating these latter
place for these local CSCG committees through to the initiatives.
trust board sub-committee.At first, not every key Trust-wide, a user consultation policy is being
component was fully grounded throughout the trust, so developed, and, within directorates, new Charter Mark
a corporate agenda was set, mirrored within the principles and standards.
directorates, for the development of action plans to
address the key components – for example, a structured
Improving staff appraisal, development and
approach to the management of risk, clinical audit, user
consultation and continuing professional development. consultation
The trust has notably improved staff development and
consultation. The structure for staff appraisal and
Benefits development has been formally aligned with the trust’s
strategic and operational objectives, and the trust’s
objectives permeate to directorate, team and individual
User consultation level. Staff consultation has been used to evaluate this
In the Mental Health Directorate, for example, the process, and the organisation has received Investors in
Mental Health Alliance group was established to include People status.
55
Greater emphasis is now placed on developing staff. Example 2: The integration of

Staff have also been consulted and engaged about
workplace issues through a staff survey. The climate clinical governance at Queens
now encourages innovation and creativity, evidenced in Medical Centre, Nottingham
the development of care pathways, practitioner
development initiatives and an increased involvement
The Queen’s Medical Centre (QMC) in Nottingham aims
in research and audit.
for an environment where clinical governance is part of
an integrated governance framework developed to
Ongoing improvement assure continuous quality improvement.
CSCG continues to be a developing agenda that grows
with the increasing understanding of its requirements. There are many aspects of an organisation’s governance
The challenge for the trust is to embed a culture of designed to identify, assess and manage the many risks
continuous improvement throughout all its activities, inherent in providing health services. These include:
reinforced with robust systems to ensure the safety and ✦ clinical governance – continuous improvement of the
wellbeing of all patients and staff. quality, safety and effectiveness of health care
✦ corporate governance – how the organisation
conducts corporate business to meet statutory
obligations
✦ research governance – making sure that research is
carried out in an ethical, equitable and safe manner
✦ information governance – how we collect, store and
use information, some elements of which impact on
other areas of governance
✦ human resource governance – including recruitment,
retention, training and development
✦ other aspects of governance, including health and
safety and environmental management.
It is against this increasingly complex framework of
controls and safeguarding mechanisms that QMC has
been working towards integration. Integration should
allow the trust to take a holistic approach, with clinical
care at the core, underpinned by clinical governance.
The integration of governance

In February 2003, the trust board at QMC approved a
paper that set out the way forward for the integration of
governance. This paper described the desired outcomes
of integration as:
✦ improved systems for setting the strategy and
priorities for governance
✦ better links between the governance functions,
particularly between clinical audit, risk management,
clinical practice and patient partnership
✦ clear understanding of the accountability for
governance at all levels of the trust
56
✦ proactive management of governance at divisional, ✦ to provide a resource to divisions, directorates and

directorate and departmental levels departments and their staff for governance activities,
✦ a central support and skills function to act as a such as communication, training, support and
resource to divisions, directorates and departments co-ordination.
✦ further development of clinical effectiveness

✦ better systems and processes to integrate all aspects
2. Accountability
of governance, particularly at a local level. The corporate responsibilities for governance are
Several important changes were identified which would discharged through the trust board. The executive
impact on clinical governance, bringing it into the directors have specific responsibilities, with the Medical
mainstream of clinical services and making it more Director and Director of Nursing and Patient Services
accessible and meaningful to staff, patients and carers. sharing the lead for clinical governance. Their remit
includes:
Governance Forum Medical Director:
This forum, chaired by a senior clinician, brings ✦ clinical standards and outcomes
together the many individuals with central governance
roles: ✦ clinical audit
✦ quality and clinical governance manager ✦ management of serious untoward incidents
✦ clinical risk lead ✦ results of patient feedback
✦ claims & litigation manager ✦ the management of clinical risk
✦ deputy director of nursing ✦ CHI reviews.
✦ health audit manager Director of Nursing and Patient Services:
✦ non-clinical risk lead ✦ patient partnership, including PALS, patient

involvement and patient feedback
✦ patient partnership manager
✦ development of clinical practice, including clinical
✦ central intelligence manager protocols, clinical pathways and patient information
✦ research governance manager ✦ management of serious untoward incidents.
✦ senior finance representative Each of QMC’s four divisions (surgery, diagnostics and
✦ senior it representative facilities; medicine, women, children and clinical
support) is responsible for managing governance
✦ service improvement manager activity in its directorates and departments, which are
✦ trust secretary. required to develop local governance plans that reflect
national and local priorities for action. The divisions,
The forum’s remit includes:
directorates and departments are supported in
✦ responding to public scrutiny of governance, that managing governance by members of the central
could arise from national public inquiries such as the governance functions such as the Clinical Risk Lead and
Bristol Royal Infirmary and other serious incidents Patient Partnership Lead.
✦ sharing information across the governance functions It is important to note that in order to achieve clear
✦ developing and advising on co-ordinated governance accountability at an organisational level, divisions are
strategy represented on key committees, and include the clinical
governance committee, the risk performance
✦ ensuring consistency in the development of policies management committee, and the hospital management
and procedures team. This assures staff at all levels that there are routes
✦ advising on systems and processes to support staff in for raising concerns, learning and sharing lessons and
divisions, directorates and departments delivering the governance agenda.
57
Figure 2: Governance jigsaw
Systems and processes Incident reporting system

The incident reporting system enables staff to report,
manage and, together with the DATIX risk management
Governance Jigsaw
database, review incidents and identify trends, learn
The trust has developed a Governance Jigsaw (figure 2)
lessons and share experiences across the organisation.
which has been designed as a resource to help
individuals and groups to fit together, and to
understand governance and how it impacts on their Clinical audit and effectiveness
work. Clinical audit and effectiveness measures are used to
identify, implement and assess clinical care against
Risk assessment tool good practice. Through the Governance Forum,
A single risk assessment tool enables staff to identify, activities are now closely aligned and integrated as a key
assess and mange any risk, clinical or non-clinical, quality assurance tool of clinical governance,
which impacts on the environment or care. particularly as part of the risk management process.
58
June 2003
Published by the
Royal College of Nursing
20 Cavendish Square
London
W1G 0RN
020 7409 3333
The RCN represents nurses and
nursing, promotes excellence in
practice and shapes health policies.
Publication code 002 036

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ROYAL COLLEGE OF N URSI NG

Foreword from England unprecedented scale.At last, we have the opportunity –

Developing robust and sustainable clinical governance

Foreword from Scotland

Foreword from Wales

An introduction to clinical governance

Box 1: Clinical governance policy and support across the UK

Country Policy/legislation Support

Northern Ireland Best practice – Clinical and Social Care

Scotland Designed to care NHS Quality Improvement Scotland

Wales Putting patients first Clinical Governance Support &

Figure 1: Key themes of clinical governance

Building blocks Supporting nurses in Quality improvement Placing the patient at

Making information work for you

Case study: Patient stories: maintaining Support from the RCN

wide listening exercise with patients, nurses,

Support from other agencies

Commission for Patient and Public

exchange information and share their experiences on

Support from other agencies

NHS Patient Survey Programme

NHS Information Authority

Information Statistics Division (Scotland)

Case Study: Developing evidence-based

Support from other agencies National Institute for Clinical Excellence

presentations, research, news, events and message

Patient Advice and Liaison Service (PALS)

Serious Hazards of Transfusion (SHOT)

the workplace views and experiences of employment in the Trust

Staffing and staff management Education, training and

competencies, through sharing best practice and RCN practice development

National Workforce Unit Scotland

governance Care Organisations)

Senior management team:

External drivers for clinical

✦ Performance Assessment Chief executive ✦ Clinical Standards Board

✦ Patient surveys Clinical governance lead ✦ Regulation &

Consultation and patient Organisational and clinical

3. Effective delivery of 3. Clinical governance,

Clinical governance needs to be taken into account in 4. Efficiency 4. Patients’ experience,

Primary Care Leadership Programme

an opportunity for the board to develop the more

There are two key questions staff often ask about

NHS Executive (1999) The NHS performance assessment

Clinical Leadership Programme

Working Well Initiative

Clinical Standards Board for Scotland NHS Information Authority

National Patient Safety Agency Nursing and Midwifery Council

Patients’ Forum Publications

Changing relationships: findings of the patient

The indicators are grouped into different categories or

www.nelh.nhs.uk/nice_bpca.asp. ✦ support changes and improvements in patient care

Royal Society of Medicine’s

Working together, learning together (2001)

Useful web resources Cochrane Library

Leading an Empowered Organisation (LEO) The Guidelines Finder is being developed in

improvement methods and patient safety. Registration Journals

Scottish Health on the Web (SHOW) Clinical Governance

Wisdom Centre pack on Clinical Governance