Enable Recite me Accessibility Tools:
Accessibility Options
To find out more, please see here.

Clinical governance is:

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

A First Class Service, June 1998


There are close links between clinical risk management, clinical effectiveness and audit and quality, which are all components of clinical governance.


What are the main components of Clinical Governance for the Trust?

1) Clear lines of responsibility for the quality of clinical care:

  • The Chief Executive is ultimately responsible for the quality of clinical care
  • A senior clinician is responsible for ensuring systems for Clinical Governance are in place and are monitored
  • Committees reporting to the Clinical Governance Committee who report quality and risk issues regularly to the Risk & Incident advisory and Trust Boards


2) A comprehensive programme of quality improvement activities:

  • All clinical staff to be involved in clinical audit programmes including participation in the National Confidential enquiries
  • Evidence based practice applied routinely and well designed Research and Development activity is encouraged
  • Continuing professional development (CPD) programmes for all health professional staff


3) Quality systems for clinical record keeping that:

  • Safeguard confidentiality of patient information, and can be effectively monitored


4) Clear policies aimed at managing risk:

  • Systems in place to identify and manage risks
  • Clinical risk systematically assessed to reduce risks


5) Procedures for all professional groups to identify and remedy poor performance:

  • Incident (including accidents/ concerns/ near misses) reporting identifies adverse events, openly investigates, learns and improves
  • Effective complaints procedures in place
  • Professional performance monitored and reviewed before patients suffer any harm or potential harm
  • Staff supported in reporting concerns about colleagues professional conduct, with clear procedures to ensure early action is taken
  • Patient safety and team working developed and supported


How does it work?

  • National quality standards are set through National Service Frameworks and the National Institute of Clinical Excellence (NICE)
  • Mechanisms to ensure delivery of high quality clinical services Trust-wide are continually being developed, implemented and monitored
  • Effective systems to monitor the delivery of quality standards
  • Patients, carers and their relatives will be regularly consulted on the views about the services provided
  • The Trusts Clinical Governance agenda is designed to be long term, building on current good practice, and recognising areas of excellence in order to influence our philosophy of continual clinical quality improvements


What are we doing towards achieving the clinical governance agenda?

  • The Trust Clinical Governance Committee meets quarterly ·
  • Quarterly Clinical Governance reports to the Trust Board which include changes in practice following incidents or complaints and through Clinical Audit
  • Individual Directorate/Departmental priorities identified and Clinical Governance Development Plans in place and being implemented
  • Clinical Audit programme
  • Continuing improvements of Clinical Risk Management, supported by developments through the National Patient Safety Agency (NPSA)
  • Risk assessments and trigger lists within all Directorates
  • Links with all other Trust wide quality improvement initiatives
  • Effective Complaints and Claims System
  • Well-developed Education Centre and Health-Science Library Services