Clinical governance is defined as:

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.

There are three key attributes to clinical governance:

• Recognisably high standards of care

• Transparent responsibility and accountability for those standards

• An ethos of continuous improvement

Clinical governance refers to the structures, processes and systems in place in an organisation to manage the quality of service provision. This framework needs to be appropriate to each organisation, and this policy sets out the approach.

There are eight key elements to clinical governance. These are outlined below, along with the mechanisms in use in the Practice to deliver each of the elements, and the expectations that are placed on partners and staff at the Practice.

 

1.Education and training

It is the professional duty of all staff to keep their knowledge and skills up to date, and they must therefore engage in regular continuing professional development (CPD) within accordance to their specific qualifications. All Medics are expected to document their learning for their individual learning portfolios.

Titanium Safety supports the ongoing development of our staff, both financially and by allowing time for CPD. 

Our approach to training for all staff is set out in the Training Policy. It is recognised that non-clinical staff also need to update their skills regularly in order to support the delivery of high quality medical services.

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2.Clinical audit

Clinical audit is the review of clinical performance and the refinement of clinical practice as a result. Within the company, this may refer to: 

• the use of case studies to highlight specific issues that are then generalised within our patient population

The range of topics covered in local audits should meet one of the following key criteria:

• Respond to newly published local pathways

• Respond to newly published national evidence

• Respond to a clinical significant event or substantiated complaint

• Provide a general update in an area of the staff’s own expertise

 

One partner is designated to manage the agenda for clinical meetings, to ensure that the topics selected meet the criteria and provide a balance over a year. It is his/her responsibility to arrange for a clinical evaluation to be presented on any topic that is causing particular concern either locally or more widely.

 

3.Clinical effectiveness

Clinical effectiveness is about providing the best evidence-based care for the patient while making good use of available clinical resources. Clinicians in the Practice are expected to work within formularies, protocols and pathways where these have been developed for specific conditions. This will ensure that patient care is guided by the best available evidence of the effectiveness.

4.Openness

Processes which are open to public scrutiny, while respecting individual patient and practitioner confidentiality, are an essential part of quality assurance. 

Titanium Safety uses a number of mechanisms to enable patients and other interested parties to be involved in identifying needs and making improvements. These include:  

• Complaints – all patient complaints are managed through the Company Director and are scanned regularly for learning points and for patterns. Complaints about clinical care are shared immediately with the Medics concerned and those that give rise to clinical learning points are shared more widely with our medics.

Titanium safety aims to co-operate at all times in a spirit of openness with other healthcare providers, NHS and local authority organisations, and any organisation with regulatory or watchdog powers such as the Care Quality Commission and HealthWatch.

 

5.Risk management

Risks - to patient, medics, other staff and the organisation as a whole - are managed through a range of policies and protocols through risk assessment. 

The key policies relating to minimising risk for patients are: 

• Patient Dignity & Equalities Policy 

• Confidentiality Policy 

• Consent Policy 

• Chaperone Policy 

• Infection Control Policy 

• Safeguarding Policies (adult and children)

All of these are available on the company website.

Risks are minimised through other aspects of clinical governance, especially through attention to education and training, clinical audit and clinical effectiveness.

The Practice approach to learning from critical events, near misses and risk is set out in the Significant Events Policy. The Practice takes a “no blame” approach and encourages all staff to discuss any incident that has or could have posed a risk or actual harm. The learning from incidents is shared across the whole copmany, and any actions are reviewed until fully implemented. Clinical incidents are referred from the general Significant Events meeting to a clinical meeting, to enable a detailed discussion in a confidential environment.

 

6.Information management

High quality clinical care depends on high quality information management. This starts with the generation of good patient records, and it is the responsibility of every medic to ensure that the details are recorded in a way that:

• is easily understood by colleagues, and by the patient if requested

• reflects exactly what takes place, including any discussion relating to risk, eg consent, offer of a chaperone

• provides clear information about the agreed care plan

• identifies any differences of opinion between the clinician and the patients

The company will use patient data for purposes consistent with our Data Protection registration (see Data Protection Policy) and will maintain patient confidentiality at all times when using data for clinical governance purposes. Patient records will be searched to provide evidence for internal audits and case studies, and to ensure clinical effectiveness.

The company will meet its statutory duty to provide anonymised patient data to

Department of Health sources, and will also provide patient-identifiable data in accordance with the Health & Social Care Act 2012 for those patients who have not explicitly withheld their consent.

 

7.Human Resources

The company is committed to delivering medical care through a team of fully qualified and suitably experienced medics, supported by an administrative resource. In order to achieve this, the company regularly reviews the skillset of its team, offering development opportunities where appropriate, and ensuring that the full range of care skills is available at an appropriate level. This means that all clinical staff are encouraged to work within the higher range of their skillset rather than carrying out tasks that could be fulfilled by a less qualified clinician.

When recruiting potential new medics, the interview will always include questions designed to demonstrate an awareness of clinical governance principles. 

Implementation

The Clinical Governance lead for the company is the company director. It is his/her responsibility to ensure that the principles in this Policy are implemented effectively. Specifically, s/he will:

• provide clinical governance leadership and advice

• promote high quality care within the company

• keep an overview of the level of current awareness maintained by individual clinicians

• act as the expert in dealing with clinical complaints and significant events initiate and review local audits as appropriate

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