Clinical Governance

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. The CHI review of the Trust was carried out in 2001, as a result of this the Trust has an action plan for which progress is monitored six monthly.


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

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

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

Quality systems for clinical record keeping that:

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

Clear policies aimed at managing risk:

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

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 through TEREMA and LEO


How does it work?
What are we doing towards achieving the clinical governance agenda?
Further Details

For further information, please contact the Deputy Director of Nursing and Quality.