Contents

1 ContentsSECTION1:IntroductionIssues for your considerationThinking through the idea of clinical governanceSECTION2:Components of clinical governance :User and Carer InvolvementClinical Risk ManagementEvidence Based PracticeInformation ManagementClinical AuditComplaints and complimentsBenchmarking/Peer ReviewLeadership/People ManagementContinual Personal and Professional DevelopmentCulture SECTION3:Getting Started:What are we already doing in our team/ clinical area?Putting ideas into practiceProving the clinical governance systemKeeping up to dateManaging changeBibliographyWebsites1 IntroductionClinical governance is a framework to ensure continuous qualityimprovement in health care. This document is written to support and direct clinical staff in the NHS inWales in implementing the framework.

2 It gives a short introduction tothe elements of clinical governance with a question at the end of eachsection to direct you in obtaining information prior to additionaldocuments being published. The document also provides some initialguidance on "putting the ideas into practice".There are three additional documents based on the elements of clinicalgovernance to follow this document. They will be:CLINICALGOVERNANCE- A FOUNDATION TOCLINICALPRACTICE User and carer involvement Risk Management Evidence Based Practice Information managementCLINICALGOVERNANCE-MONITORINGP RACTICE FORIMPROVEMENTThis document will aid clinicians in deciding how best to monitor theirpractice. It addresses: Audit Complaints and compliments Benchmarking/Peer ReviewCLINICALGOVERNANCE- STAFF FOCUS Managing change Leadership Continual professional development People Management CultureThe supporting documents will all have the same format:First the big picture the policy in Wales in relation to the topic covered,including the strategic approach required by the National Assembly , how this relates to finally- what does this mean for the individual clinician and the teamin which they work.

3 There will be examples of work that has already toolkit and all future release documents are designed to be living documents that can be used to support work within clinical teams. Theexercises in it can be used as a basis for team discussion and is intended that this resource will be of value to all staff throughout theNHS, including contractor professions working mainly in primary care. There will be information that will be new to some readers and a greatdeal that will be familiar to others. The framework of clinical governance does not introduce new individualconcepts but brings together existing and well-known quality initiatives,and provides a framework to ensure continuous quality improvement inclinical many clinicians providing care in challenging circumstances, clinicalgovernance may feel an additional burden, but it should be an integralpart of everything you do and most importantly, it will aid you inensuring quality in your clinical area.

4 Although clinical governance is presented as a series of separatecomponent parts, they link FOR YOUR CONSIDERATIONYour comments on this document will be welcomed. The informationcontained in it is not share with us information you have on relevant useful web sites,organisations and contacts that we could include in future 2002 a series of supporting documents will be published that give youfurther information on the component parts of clinical will comprise:CLINICALGOVERNANCE- A FOUNDATION TOCLINICALPRACTICE User and carer involvement Risk Management Evidence Based Practice Information managementCLINICALGOVERNANCE-MONITORINGP RACTICE FORIMPROVEMENTThis document will aid clinicians in deciding how best to monitor theirpractice. It addresses: Audit Complaints and compliments Benchmarking/Peer ReviewCLINICALGOVERNANCE- STAFF FOCUS Managing change Leadership Continual professional development People Management Culture3If you feel there are issues in relation to implementing clinical governancethat are not covered by the above please inform address correspondence toFreda LewisClinical Quality Improvement BranchNHS Quality DivisionNational Assembly for WalesCathays ParkCardiffCF10 1 THINKING THROUGH THE IDEA OFCLINICALGOVERNANCEINTRODUCTIONC linical governance in the health service in Wales was first announced in1998 in Putting Patients First.

5 However, it is not a radically new conceptso much as a new way of looking at existing activities in order to improvethe quality and safety of clinical governance is defined in Quality Care and clinical Excellence (Welsh Office, 1999) as:" a framework through which NHS organisations are accountable forcontinuously improving the quality of their services and safeguardinghigh standards of care, by creating an environment in whichexcellence in clinical care will flourish".This means clinical governance is a way of improving and maintainingthe quality of the care you provide and being governance is at the centre in the following diagram:5 NationalInstitute for clinical Excellence Professional self-regulationClinicalgovernanceLifelon g learningPatient &publicinvolvementDependablelocal deliveryCommissionfor Health Improvement Performance Framework Patient and user surveysMonitoredstandardsClear standardsof service atnational levelYou can see from this diagram that policy in relation to qualityimprovement falls into three strands:High Quality Standards Quality of Delivery Monitoring and Evaluation of Standards and Delivery You may well feel you are providing a good quality service and arealways trying to improve it.

6 BUT, how can you prove it? How do youshow patients, their relatives, or the health service, that you are providinga high quality service ?What documented evidence do you have? How complete and reliable isit?Looking at your mechanisms for clinical governance and working as ateam will help address any identified governance is a framework, which brings together components are: Patient/ client/ carer experience and involvement clinical Risk management including adverse events, complaints Research and effectiveness / evidence based practice Information management Education, training, continual personal and professionaldevelopment and professional self regulation clinical audit Staff and Staff management6 There should be a clear strategy for clinicians, underpinned by leadership,providing direction and integration of the component are additional issues clinicians need to have an awareness of suchas how to manage change effectively.

7 Learning from others and howculture parts do not exist in isolation but link and build one on the otherto support clinicians in improving the quality of the care they offer and todemonstrate that quality to will already be involved in, or have an awareness of, many ofthe component GOVERNANCEis about: Every member of the clinical team and the team as a whole. Being able to demonstrate the quality of the care you provide,therefore being externally accountable. Improving care by providing evidence based care. Monitoring the quality of care provided. Ensuring your team / clinical area is well managed; that best useis made of resources and staff training needs met. Making links across the patient experience / , their teams and organisations must do three things:1.

8 Be aware of the quality, efficiency and safety of the care they Be accountable, individually and collectively, for Continually try to improve key feature of clinical governance is about creating a supportiveculture. 7 Don t re-invent the wheel, make use of existing systems, structures IS THE CULTURE OF YOUR ORGANISATION AND YOURTEAM?Culture involves the way you think and act, and the values you are different cultures in organisations. Some are supportive,learning cultures that ensure that lessons are learnt from mistakes. Whilstothers have a closed culture that does not make sure that things changewhen a mistake clinical governance requires a culture in which team members: Are encouraged to discuss their practice and experiences Are encouraged to reflect on their practice Learn from their mistakes in a safe environment Work together to improve services for patients Work in partnership with patients and their families Value personal development and education Feel valued in their work Expect to provide evidence based, high quality care Expect to record what they doA team that is attempting to develop a culture where clinical governancecan be effective might look like this:8So what is the bottom line on clinical governance ?

9 WELL, IT WON T GO AWAY!9 Individual: Examines own performance and shows an interest in theperformance of othersUndertakes professional development with some regardto needs of the teamCommitted to quality improvementOrganisation: Good communication within the team and withpartnersShared objectivesShared decision makingEffective systems to address potential and actualmanagerial problemsValues:Committed to quality improvementAcceptance of responsibility for patient careAcceptance of responsibility for staff welfareCommitment to professional developmentCommitment to research and development(Adapted from Roland and Baker)DUTY OFQUALITYT here are clear lines of responsibility and accountability laid down in theHealth Act (1999) which means the Chief Executives of Trusts, HealthAuthorities and Local Health Groups (LHGs) have ultimate responsibilityfor assuring the quality of services provided by their do this by.

10 Ensuring that systems for clinical governance are in place andmonitored for their effectiveness ensuring formal arrangements exist for Boards to discharge theirresponsibilities for clinical quality ensuring regular reports on the quality of clinical care are giventhe same importance as monthly financial reports ensuring an annual report on clinical governance is submitted tothe BoardThis does not mean clinical governance is only the Chief Executivesconcern. It is ultimately their concern but clinical governance iseverybody s HAS THIS DEVELOPED?The National Health Service has been concerned about quality for manyyears. Medical audit evolved into clinical audit and clinical effectivenessled to evidence based practice. These are all initiatives that haveaddressed the quality of care provided.