Clinical

Governance

What do you know about Clinical Governance (CG)?

Clinical Governance is the framework that helps organisations provides safe and high quality care. It
is fundamentally about the ability to produce effective change so that high-quality care is achieved.

This definition is intended to embody three key attributes: recognizably high standards of care,
transparent responsibility and accountability for those standards, and a constant dynamic of
improvement.

Clinical Governance relates to only those aspects of such organizations that relate to the delivery of
care to patients and their carers; it is not concerned with the other business processes of the
organization except in so far as they affect the delivery of care.

The chief executive is responsible for its implementation. He delegates most of the tasks to other
colleagues like director of nursing, medical director etc. Ultimately, each healthcare professional has
a role to play in its implementation.

There are 7 pillars of clinical governance:

Education and training- it covers the support available to enable staff to be competent and up to
date. Professional development need to continue through lifelong learning. In NHS trusts, the
continuing professional development of clinicians has been the responsibility of the trust. It has also
been the professional duty of clinicians to remain up-to-date.

Clinical audit- is the review of clinical performance, the refining of clinical practice as a result and the
measurement against agreed standards- a cyclical process of improving the quality of clinical care.

Clinical effectiveness - by use of evidence based medicine. Clinical effectiveness has been promoted
through the development of guidelines and protocols for particular diseases. The development of
NSFs and NICE are further attempts to improve the responsiveness of the service to evidence of
effectiveness.

Risk management - it involves having robust systems in place to understand, monitor and minimise
the risks to patients, staff and the organisation and to learn from mistakes and past experience.

Research and development - Good professional practice has always sought to change in the light of
evidence from research. The time lag for introducing such change can be very long. Techniques such
as development of guidelines, protocols and implementation strategies are all tools for promoting
implementation of research evidence. NSF and NICE are supporting this further.

Openness - Poor performance and poor practice can too often thrive behind closed doors. Processes
which are open to public scrutiny are an essential part of quality assurance. Open proceedings and
discussion about clinical governance issues should be a feature of the framework. As part of
openness, the NHS publicises complaints procedures to patients, deals with problemdoctors openly,
encourages doctors to admit their own mistakes as part of a blame free culture etc.

Patient and public involvement- This means listening to what the public thinks of the services
provided, and learning from their experiences.

Isn't clinical governance only for doctors, nurses and allied health professionals?

Definitely not! Clinical governance is for everyone. It relates to all people who are involved in the
treatment and care of patients. Clinical governance is the appropriate governance (or control) of
clinical (patient health) care, and therefore encompasses everything that has any impact on the
quality and patient experience of that care. This means that it ranges from issues of cleanliness,
comfortable environments, good food and excellent communication through to the skills required to
produce first-class results in complex operations.

Similarly the domestic worker on a hospital ward has a key role to play in ensuring a clean and
pleasant environment for patients, as well as helping to control infection. Other NHS staff, such as
office based managers and secretaries also contribute to high standards of care. They may never see
a patient during their working day, but they have a responsibility for making certain that all aspects
of their work take account of the quality and safety of care to patients.

So all NHS staff, whatever their role, are responsible for making sure that their own contribution to
the massive jigsaw that makes up health care provision is delivered to the highest possible standard
for patients - and that's what clinical governance is all about.

What does Clinical Governance mean to you?

Clinical Governance to me means providing the best care possible to the patient sitting in front of
me. Apply seven pillars of clinical governance to your particular situation.

Have you seen Clinical Governance in action?

Yes- Quote any implementation of change you have noticed for e.g. after an audit.
How does Clinical Governance affect patient safety?

Discuss the seven pillars above

Do you think the current system of clinical governance is effective?

Although the current system has made effective improvements, there is still room for further
improvements for e.g. in promoting a blame free culture.

How does Clinical Governance impact on your daily work?

Clinical Governance:

 Provide a better experience for staff

 Provide a better experience for patients and carers

 Improve the quality of care for patients

 Make the changes you want to make happen

Does Clinical Governance work?

Clinical Governance works as long as it is:

 an active pursuit driven by, and focused on, quality

 recognises the complex nature of health care systems

 is not strangled by paper and procedure

Do you think Clinical Governance is useful or is it just another layer of bureaucracy?

It is essential for improvements in patient care Clinical Governance brings together all the activity
that contributes to the clinical service provided to patients.

Who, in your Hospital, is responsible for Clinical Governance?

Most trusts have a clinical governance committee headed by usually the Chief executive or the
Medical director.

What is Clinical Risk Management?

Clinical risk management means identifying the risks to patients and what needs to change to
improve safety. It builds on the basic concept of duty of care to provide high quality healthcare
protecting patients and staff. Clinical care pathways or protocols have been widely developed in
some disciplines and may minimise the chances of adverse incidents occurring.

What is a Near-Miss situation?

A near miss is an unplanned event that did not result in injury, illness, or damage - but had the
potential to do so.A critical incident is defined as one which led or could have led to harm if it was
allowed to progress. It should be preventable by a change of practice.

Avoid the trap of minimising the problem: we can often learn from near-misses (where less distress
occurs) better than instances where patient care is affected.

e.g. - A nurse programmes a computerised syringe pump incorrectly and it gives a patient too much
drug too quickly. What factors do you think may have resulted in this error?

Having reviewed the incident it is vital to learn from what happened and implement preventative
measures or a safety net. In the syringe pump example, it may become obvious that it is not the
most suitable apparatus: the pump design makes it complicated to use; the operating instructions
are poor; and extensive training is required to achieve the required competency for use. An outcome
may be to notify all potential users of the hazard and to recommend a change in the type of pump
used.

What happens to Critical Incidents Forms once they have been submitted?

It is essential to recognise that clinical incident reporting is not part of a disciplinary mechanism, but
is part of a reflective system that supports an improvement in the quality of service that the
directorate provides. A robust clinical incident reporting procedure in line with education and
training acts as a foundation to the directorates' clinical governance framework.

By reporting and subsequently assessing any clinical incidents, clinical risks can be reduced or
managed, and the overall quality of patient care improved.

A clinical incident is defined as anything associated with the patient and his or her clinical treatment
or care, and is an event that led to harm, or could have led to harm if it had been allowed to
progress. It should be preventable by a change of practice. It does not relate to any incidents
involving staff, relatives or visitors to the Trust.

Further, these critical incident forms feed into NRLS (read the section on NRLS).

How would you introduce change?

RAID is a 4 step process to introduce any change:

R- review- where are we now? Gathering information, listening to pts and staff, looking at audit,
documentation and process

A- Agree- gain consensus, build teams, formulate recommendations, shape the future

I- intervene- project management, priorities, dealing with transition, motivate and support staff,
expect and deal with resistance
D- Demonstrate- project analysis, show the differences, identify lessons, plan next objectives

What are the GMC good medical practice guidelines? What do you think the most important
aspects of the GMC's 'Good medical practice' guidelines are?

Good Medical Practice sets out the principles and values on which good practice is founded; these
principles together describe medical professionalism in action.

GMC good medical practice (2006) guidelines

 Make the care of your patient your first concern

 Protect and promote the health of patients and the public

 Provide a good standard of practice and care

 Keep your professional knowledge and skills up to date

 Recognise and work within the limits of your competence

 Work with colleagues in the ways that best serve patients' interests

 Treat patients as individuals and respect their dignity (Treat patients politely and
considerately. Respect patients' right to confidentiality)

 Work in partnership with patients

 Listen to patients and respond to their concerns and preferences

 Give patients the information they want or need in a way they can understand

 Respect patients' right to reach decisions with you about their treatment & care

 Support patients in caring for themselves to improve and maintain their health

 Be honest and open and act with integrity

 Act without delay if you have good reason to believe that you or a colleague may be putting
patients at risk

 Never discriminate unfairly against patients or colleagues

 Never abuse your patients' trust in you or the public's trust in the profession.

You are personally accountable for your professional practice and must always be prepared to justify
your decisions and actions.

What is the difference between a protocol and a guideline?

A protocol is a step-by-step outline for undertaking a specific task. They normally have to be
followed exactly, whereas with a guideline the recommendations need to be considered in the light
of the particular patient and settings as well as the strength of the evidence base.

A guideline is 'a systematically developed statement to assist decisions about appropriate healthcare
for specific circumstances.' Clinical guidelines are based on the best available evidence and provide
recommendations for practice about specific clinical interventions for specific patient populations.

Who is a good doctor?

GMC- Good doctors make the care of their patients their first concern: they are competent, keep
their knowledge and skills up to date, establish and maintain good relationships with patients and
colleagues, are honest and trustworthy, and act with integrity.

How do you seek informed consent for the procedures that you do?

I work in close partnership with my patients. I consider consent as an important part of the process
of discussion and decision making, rather than an isolated process. I explain to them their condition
and treatment options in a way they can understand. The amount of information I share with them
depend on their wishes. The information I share is in proportion to the nature of their condition, the
complexity of the proposed investigation or treatment, and the seriousness of any potential side
effects, complications or other risks. I respect their right to make decisions about their care. (GMC
guidance)

What do you consider to be sufficient level of information for the patient?

In practice the law has tended to regard the level of information required to be that acceptable to 'a
responsible body of medical opinion' (the Bolam test). More recently the courts have said they will
depart from this approach if they see fit. The ultimate legal test being what the court itself thinks is a
reasonable amount of information. The difficulty for the clinician, of course, lies in foreseeing what
the court would regard as a reasonable amount of information in any given case.

What is the legal age for consent?

The legal age of consent for medical or surgical treatment is 16 years or over. In such cases, there is
no legal requirement to obtain consent from a parent/guardian.

What is the legal position for consenting children less than 16 years of age?

A child under 16 may consent, if the health professional feel that they are capable of understanding
the nature and possible consequences of the medical/surgical procedure (Fraser ruling). The same
holds true for contraceptive advice. However, the value of parenteral support should be discussed.
The health professional should also consider the best interests of the child. There is no lower age
limit below which a health professional cannot give medical/surgical treatment.

Where a child is too young or is not considered to be Fraser ruling competent, then the parents must
be involved in the consent process. One parent is usually sufficient. However for sensitive issues
where opinions may vary, such as circumcision, consent should be sought from both parents.

What is the legal position to child or parenteral refusal to treatment?

A Fraser competent child cannot refuse a treatment thought to be in his best interests in England
and Wales. Parenteral consent will be needed.

It may be unlawful to proceed with treatment of a child considered not to be Fraser ruling
competent in the face of parenteral refusal. Remember the recent MMR controversy.

How would you ensure quality in your unit?

How would you ensure that your team is up to scratch?

Use the seven pillars of clinical governance to answer the question. So I would ensure quality in my
unit by:

 Education and Training –Supporting continuing professional development of all staff to

ensure that they are competent and up to date.

 Clinical audit- Regularaudits to review and improve clinical performance.

 Clinical effectiveness – by use of evidence based medicine.

 Risk management – by ensuring robust systems are in place to understand, monitor and
minimise the risks to patients, staff and the organisation and to learn from mistakes and past
experience.

 Research and development -by supporting research as well as ensuring that the research is
implemented in patient care with a minimal time lag.

 Openness - promoting a blame free culture to ensure mistakes are reported/discussed and
lessons learnt.

 Patient and public involvement- to ensure services are responsive to the needs and
aspirations of the patient and the public.

I also encourage reflective practice, provide regular feedback and ensure participation of all team
members in decision making.

How do you think a blame-free culture can be brought about in the NHS?

In aviation, airline staff is rewarded for reporting mistakes and failures. More importantly, they can
be disciplined, if not sacked, for not reporting. That says something about the culture and the pride
which airline workers have in their safety record.

What will it take to instill that sense of pride about safety in NHS staff? We recognise that there may
be many barriers to creating a ‘blame free’ culture. But we feel that many of those barriers are
psychological, the fear of what someone else could do to you. Part of that process is helping NHS
staff realise they don’t need to feel threatened or feel guilty about reporting after they’ve done so.
We’ve got to look after the staff and recognise the traumas that many staff experience from being
involved in adverse events.
What is the trust risk register?

A trust risk register is a management tool that enables an organisation to understand its
comprehensive risk profile. It is simply a log of risks of all kinds that threaten an organisation’s
success in achieving its declared aims and objectives. It is a dynamic living document, which is
populated through the organisation’s risk assessment and evaluation process.

Example risk register

Ref Source Date in Description Lead officer Rating Action Completion rate
register summary

Failure to meet Monitor

Trust Chief
1 2/10/2009 waiting list Extreme performance Ongoing
board executive
targets against targets

Increase
theatre Jan 2008
capacity

All Obsolete bed Director of Capital bid for 5 year

2 11/06/2010 High
wards stock nursing replacement programme

Give me an example of an adverse clinical incident you were directly involved in and how you
handled this?

Quote a clinical incident which you were involved in or are aware of:

Steps in dealing with an adverse clinical incident- Ensure the safety of the patient first, involve your
seniors, thorough documentation of the incident, debrief or actions taken to prevent its recurrence
in future.

The general principles of dealing with an adverse clinical incident:

 What went wrong and why?

 What are the systems failures?

 What is the individual contribution in that failure?

 What lessons can be learnt?

You think a surgical emergency in the theatres has been mismanaged. What do you do?

 Number 1 priority – patient safety.

 Discuss with surgeon and call for help

  Inform theatre sister and consultant in charge

 Careful documentation – critical incident – afterwards debrief

A nurse gives a substantially large dose of opioid to a patient? What do you do?

 Number 1 priority- check patient safety

 Careful documentation of the incident in the notes. Fill in an Incident report form.

 Explain the incident to the patient

 Inform the charge nurse. Discuss the likely reasons- mistake, training deficits etc.

 Possible action - retraining, extra supervision

How would you ensure local delivery of national standards?

On an individual or team level, I will ensure delivery of national standards by

 Regular audits to review and improve my practice

 Evidence based medicine by appropriately using NICE and other national guidelines

 Ensuring optimum resource allocation to ensure delivery of national standards

 Regular liaison with departmental heads and PCT

 Having procedures in place to remedy situations where practice is not in line with national
standards

 Ensuring the team is aware of the goals and their roles in achieving it

What monitoring of standards would you undertake in your service?

 Audit compliance with clinical national standards for e.g. compliance with NICE guidance or
guidance from relevant medical society

 Compliance with NSF

 Robust clinical governance mechanisms are in place

 Robust Risk management strategy

 Patient and public involvement in clinical services.