Clinical governance

Clinical governance is a way that organisations and individuals make sure they deliver the highest quality healthcare. It is designed to help us to continuously monitor and improve standards of care. The clinical governance strategy and accompanying structures, policies and processes provide a framework to ensure patients receive the best quality of care and service possible.

Clinical governance covers the following areas:

  • Activities for improving quality

  • Improving patient and staff safety

  • Identifying and managing risks

  • Improving patient experience

  • Effective claims management

Clinical governance focuses on experiences and learning to improve clinical outcomes, anticipate possible risks to patient safety and eliminating or reducing the risk of harm. Established clinical governance processes enable the Trust to provide evidence to patients, the public, commissioners and to statutory bodies that the Trust provides services that are safe, effective, patient centred, timely, efficient and equitable.

As an organisation, we are responsible for monitoring compliance with the Care Quality Commission (CQC) Essential Standards of Quality and Safety for services we provide, by asking ourselves five key questions:

  • Are we safe?

  • Are we effective?

  • Are we caring?

  • Are we responsive to people’s needs?

  • Are we well-led?

The Clinical Governance department consists of:

Clinical audit and effectiveness

Clinical audit is the systematic and critical analysis of the quality of care provided from service provision to clinical interventions. The aim is to evaluate how well we provide healthcare and what is established as good practice is applied on a day-to-day basis with patients. All health care professionals are required to continuously evaluate their work and the standards they are achieving. The clinical audit department has a team of specialists who, as well as facilitating priority clinical audit projects, provide training and advice on audits.

Clinical effectiveness measures the extent to which a particular intervention works and guides health professionals to follow evidence-based practice, and implement national guidelines and recommendations. Click here for more information about evidence-based practice.

Risk management, including health and safety

Risk management is a term used for a logical and systematic method of establishing, identifying, analysing, evaluating, treating, monitoring and communicating risks associated with any activity, function or process in a way that will enable the Trust to minimise losses and maximise opportunity. Risk management is the responsibility of everyone in the organisation and requires commitment and co-operation from all employees. A specialist team is available to provide advice, support and training to staff on clinical and non-clinical risk management.

Medical-legal / claims

This department deals with clinical negligence claims against the Trust, inquests and requests for medico-legal advice.

For more information about clinical governance, please visit the sites below: