PEPs - Clinical Quality and Evidence

Module 5 - Clinical Governance

Clinical governance

The concept of clinical governance was introduced formally by a White Paper ¹ in 1997, following the Bristol Heart Surgery scandal in 1995 ² .

“[Clinical governance] is a framework through which organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.” ³

Clinical governance has the following themes:

1.Public and Patient Involvement (PPI) enables patients to provide feedback regarding their treatment as well as giving patients and patient organisations a voice in determining how services are provided. PPI is facilitated through:

  • Local patient feedback questionnaires;
  • Involving the Patient Advice and Liaison Service (PALS) in handling issues with patients;
  • National patient surveys organised by the Care Quality Commission, which feed into Trusts’ rankings;
  • Healthwatch England, a network of 152 organisations that enable communities to influence healthcare services at a local level (formerly known as Patient Forums);
  • Foundation Trust Board of Governors. These are elected by members of the local community and contribute to decisions regarding who runs the hospital, how it is run and what services it should provide;
  • Involvement of patients and users in clinical networks (to be termed clinical councils) and in commissioning services.

Image Above: Schematic diagram of different methods of involving patients and the public and how and where this information can be used.

Understanding clinical audit online learning for patients (Oct 2012) (20 Minutes)

This online learning package has been written and developed by HQIP specifically for patients and volunteers who are interested in learning more about clinical audit.  

The package will take around 20 minutes to complete. A certificate of completion is available at the end which you could add to your portfolio.

2. Risk management: creating systems to understand, monitor and minimise risks to patients and to learn from mistakes. In recent years risk management has grown and now includes the following:

  • Complying with protocols (hand washing, discarding sharps, identifying patients correctly, etc.);
  • Learning from mistakes and near-misses: informally for small issues, formally for the bigger events;
  • Reporting significant adverse events via critical incidents forms;
  • Analysing and  responding to complaints;
  • Assessing identified risks in terms of the probability of occurrence and their potential impact;
  • Implementing processes to reduce risk and its impact: the scope of implementation will often depend on the budget available and the seriousness of the risk;
  • Never events ⁴ - these are outcomes that should never happen, such as amputating the wrong leg;
  • Promoting a blame-free culture to encourage everyone to report problems and mistakes.

Malcolm Gladwell on Culture and Airplane Crashes

3. Clinical audit: the continual evaluation and measurement by health professionals of their work and the standards they are achieving.

NICE: evidence into practice - how to use audit to improve patient care (1 hour)

Please visit The University of Manchester Library for instructions on how to access BMJ modules both on-campus and off-campus.

On completion of this module you will:

  • Have a working knowledge of evaluating existing practice against agreed national standards
  • Have a working knowledge of using healthcare audit to change and improve practice
  • Be able also to use patient encounters to promote smoking cessation
  • Be able to discuss social and/or preventive aspects of care including health education and promotion.

4. Staffing and staff management: the recruitment, management and development of staff as well as the promotion of good working conditions and effective methods of working. Effective staffing and staff management includes:

  • Appropriate recruitment of staff;
  • Ensuring that underperformance is identified and addressed;
  • Encouraging staff retention by motivating and developing staff;
  • Providing good working conditions.

5. Education and training: the support available to enable staff to be competent in their roles, developing skills and ensuring that staff are up to date with developments in their field. It includes:

  • Identifying, running and attending courses and conferences (commonly referred to as CPD – Continuous Professional Development) relevant to the individual’s specialty and development needs;
  • Identifying competencies needed for jobs and acquiring those skills, as well as developing relevant competencies in others;
  • Regular assessment, designed to ensure that training is appropriate and effective;
  • Appraisals: a means of identifying and discussing weaknesses, and opportunities for personal development.

6. Clinical effectiveness and research: the degree to which the organisation is developing and ensuring best practice. Best practice is based on evidence of effectiveness (where such evidence exists) in order to provide the best outcomes for patients, i.e. “that you do the right thing to the right patient at the right time and in the right place”. It includes:

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

Quality: using measurement to effect change (30 Minutes) - NOTE: You may have already viewed this material as a part of Module 4

Please visit The University of Manchester Library for instructions on how to access BMJ modules both on-campus and off-campus.

After completing this module you should know:

  • How transparency and indicators can drive quality improvement on a national level
  • On an institutional level, how measurement is used to produce better outcomes
  • How the right targets can motivate managers and frontline staff.

7. Clinical information: the systems in place to collect and interpret clinical information and use it to monitor, plan and improve the quality of patient care. These systems should ensure that:

  • Patient data is accurate and up-to-date;
  • Confidentiality of patient data is respected and all such data, be it paper based or electronic, is protected in line with current legislation ⁵ ;
  • The data is used fully and appropriately to measure quality of outcomes (e.g. through audits) and to develop services tailored to local needs.
  1. The new NHS: modern, dependable (1997)
  2. The report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984-1995: learning from Bristol (2001)
  3. G Scally and L J Donaldson, 'Clinical governance and the drive for quality improvement in the new NHS in England' BMJ (4 July 1998): 317,61-65
  4. Patient Safety Incident Data - National Patient Safety Agency
  5. Safeguarding the confidentiality of patient information - Public Health England