Framework for Clinical Governance

July 2002

Working in Partnership to improve the health and social well-being of local people and to deliver fair, effective, high quality healthcare by a skilled, valued workforce

Introduction
This framework sets out the Clinical Governance arrangements in place for Mansfield District PCT, including individual and corporate responsibilities, accountability arrangements, systems in place and guidance regarding further help and support.

What is Clinical Governance?

Clinical Governance has been defined by the government as: a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care, by creating an environment in which excellence in clinical care will flourish (A First Class Service Quality in the new NHS, 1998) What does this mean for Mansfield District PCT? In simple terms, it is making sure that systems are in place across the PCT for maintaining and improving the quality of care we provide and that this is encouraged and supported. The principles of Clinical Governance are fundamental to the work of the PCT. This is reflected in Our Mission: Working in partnership to improve the health and social wellbeing of local people and to deliver fair, effective, high quality healthcare by a skilled, valued workforce and in the values we hold: Valuing our staff our greatest resource High Quality Care Evidence Based Effective Care Building Partnerships Involving and engaging patients and the public Fair Access Value for Money

(Organisational Arrangements Document, April 2002)

Clinical Governance - why?

Working to the principles of the Clinical Governance framework will:  Ensure that quality is placed at the heart of the health care we provide  Ensure that we achieve the highest standards of care possible  Help prevent mistakes  Help secure public confidence  Meet our responsibilities as laid down by the Government

Clinical Governance How do we do it?

Each component process of Clinical Governance will not suffice on its own the idea is that each is linked to provide a systematic system, with the right balance of accountability and continuous quality improvement (Baker et al, 1999)

HIGH QUALITY CARE

Continuing Professional Development

Professional Self Regulation

Leadership

Clinical Risk Management

Clinical Effectiveness

Communication

Patient Involvement

High Quality Data

Ownership

Figure 1: Building Blocks of Clinical Governance (adapted from Clinical Governance Model, National Clinical Governance Support Team)

Clinical Governance who is involved? The principles apply to everyone engaged in the delivery of healthcare. For Mansfield District PCT this means all our employed staff in all the services we provide. It also applies to staff employed within General Practice and other independent contractors (Dentists, Pharmacists, Optometrists). Involving patients is also a key component of clinical governance. Patients can provide their own expert views on a range of issues, including: Living/coping with their condition Access to services Patient preferences for treatment options How well or badly treatment and care are delivered Outcomes important to patients Patient information and support needs Patient involvement does not mean that patients must be involved in every task or at every stage of clinical governance activities but appropriate involvement from the earliest stages will ensure that patient views inform activities from the outset. (Lugon & SeckerWalker, 2001)

Research & Development

Responsibilities - where do I fit in?

Clinical Governance

Individuals are responsible for:

Ensuring the provision of high quality care Professional accountability and self-regulation Commitment to CPD and creating a learning environment Input to appraisal process, clinical audit and risk management Sharing good practice

Managers are responsible for: Supporting individuals (e.g. using appraisal, service development, supervision/direction, leadership) Ensuring accountability arrangements and systems are in place within their services Promoting a culture that supports learning and encourages reporting

The Patient Experience

The Clinical Quality Directorate are responsible for: Providing strategic leadership Co-ordinating accountability, monitoring and reporting arrangements Supporting the dissemination of good practice Providing advice and

The PCT Board and Executive Committee are responsible for: Promoting the principles of Clinical Governance as core PCT values Promoting a supportive, learning culture Ensuring adequate resources are available to deliver Clinical Governance Maintaining overall accountability for Clinical Governance

guidance

Figure 2: Responsibilities for Clinical Governance Mansfield District PCT

Clinical Governance - Leadership and Accountability Arrangements PCT BOARD

Chief Executive Eleri de Gilbert Executive Chair Dr Ted Steiner Director of Clinical Quality Dr Dean Temple
Corporate Responsibility

Overall Accountability
Overall responsibility for ensuring effective processes are in place to deliver & monitor Clinical Governance Acting as professional advisor to the Board in relation to Clinical Governance issues

Risk Management Committee

Non-Clinical Risk SubCommittee

-

Clinical Governance Sub-committee

Membership comprises Senior Clinicians and Managers Role- advisory, monitoring and developmental

Individual Practice Clinical Governance Leads

Clinical Governance agenda at Practice level Supported by Clinical Governance Leads Forum

Everyone engaged in the provision of healthcare for and on behalf of Mansfield District PCT
Supported by: PCT Prescribing sub-committee, Education and Development sub-committee, NSF Task Groups, Practice Managers Forum, Nurse and AHP Modernisation Forums, Primary Care Quality Forum (North Notts), LMC, LPC, LOC, LDC

To ensure the Clinical Governance Agenda is being taken forward an Annual Development plan will be produced, performance against which will be regularly reviewed by the Clinical Governance Sub-Committee and reported to the PCT Board.

Quality in the NHS other parts of the jigsaw

National Institute for Clinical Excellence National Service Frameworks

Clear standards of service

Patient & public involvemen t

Professional self-regulation

Clinical Governance

Lifelong Learning

Dependable local delivery

Commission for Health Improvement National Patient Safety Agency National Clinical Assessment Authority etc

Monitored Standards

(Adapted from A First Class Service, Quality in the New NHS, 1998)
Figure 3: Quality links in the NHS

Key points about Clinical Governance in Mansfield District PCT  Every member of staff recognising their role in providing high quality care and sharing good practice  Themes of quality, accountability, transparency and continuous improvement which need co-operation, teamwork and support to flourish  Individual health professionals remaining responsible for the quality of their own clinical practice. Professional self-regulation remains an essential element in the delivery of quality patient services  Ensuring that all staff are appropriately qualified and receive training and development in line with their personal development plans  Promoting a culture of learning - having systems in place to deal with and learn from incidents and complaints, and to identify and manage risks  Improving care using quality improvement methods (e.g. Clinical Audit), identifying aspects of care that need improvement, making plans for improvement and monitoring the outcome  Encouraging a culture of excellence, partnership and accountability  Ensuring there are clear management arrangements for health care provided  Linking with National standards, internal and external systems of accountability  Celebrating success as well as looking to improve  Centred around the patient experience

Communication Process for Clinical Governance

A clearly defined communication process is essential to ensure that: The PCT Board and other relevant committees can monitor the implementation of clinical governance and performance Patients, the public and other stakeholders are informed of the PCT performance and progress against plans PCT Staff are kept up to date with Clinical Governance issues and progress, reliable mechanisms are in place to keep staff aware of policies, guidelines, training initiatives etc and that feedback mechanisms are in place to ensure appropriate sharing of good practice and appropriate learning.

In order to ensure that information reaches the appropriate people in a timely manner, different approaches are required: Printed Strategies, PCT reports and minutes, Annual Report, PCT Newsletter, Policies, Guidelines, ad-hoc information etc E-mail, Intranet, Internet Committees, Team Brief, Team meetings etc

Electronic Verbal

The Clinical Quality Directorate will work with the Communications Manager to ensure a robust communications process is in place across the PCT, in-line with the Communications Strategy.

Information relating to Clinical Governance - cascade and feedback

Clinical Quality Directorate

* *

D. Clinical Governance Sub-Committee

*
A For Information: Chief Executive PCT Directors Board Chair Executive Chair Communications Manager
Secretary LMC/ LDC/ LOC/ LPC where appropriate

*
B PCT Assistant Directors of: Rehabilitation Services Community Nursing Services Childrens Services Public Health

C Clinical Governance Leads General Practice & other local Contractors

Cascade to all relevant staff

using existing Directorate and Practice mechanisms

Information will be targeted according to relevancy

Clinical Governance Where to go for help and support

Topic Appraisal & Revalidation PCT Contact Medical Staff Dr Dean Temple, Director of Clinical Quality Nurses, AHPs and Other staff Debbie Lee, Head of Clinical Practice and Professional Development Dean Temple, Caldicott Guardian Colin Draycott, Risk/Complaints Manager Suzanne Meredith, Clinical Quality Manager Dr Dean Temple, Director of Clinical Quality PCT Committee / Policies/ Procedures/ Documents Regional/National Contacts DOH website

Caldicott Clinical Audit and Effectiveness Clinical Governance Lead

Clinical Negligence Scheme for Trusts Clinical Risk Management Clinical Supervision Complaints/Litigation

Colin Draycott, Risk/Complaints Manager Colin Draycott Risk/Complaints Manager Debbie Lee, Head of Clinical Practice and Professional Development Colin Draycott, Risk/Complaints Manager

Caldicott Development Plan Clinical Governance Sub-Committee Application process for Audit Projects Clinical Governance Sub-Committee Clinical Governance Sub-Committee Clinical Governance Annual Report Clinical Governance Development Plan Risk Management Committee Clinical Governance Sub-Committee Risk Management Strategy Risk Management Committee

NHSIA website NHSLA website

Continuing Professional Development

Debbie Lee, Head of Clinical Practice & Professional Development Colin Draycott, Risk/Complaints Manager Heather Lindsay, Data Quality Officer Dr Peter Bakaj, CME Tutor, Chair of SubCommittee Debbie Lee, Head of Clinical Practice and Professional Development Suzanne Meredith, Clinical Quality Manager Suzanne Meredith, Clinical Quality Manager Colin Draycott, Risk/Complaints Manager Alison Sherratt, Knowledge and Information Manager, Resource Centre, Ransom Hall Jo Green, Project Manager CHD Dr Dean Temple, Director of Clinical Quality Mental Health Dr Chris Kenny, Locality Director of Public Health Older People James Rooney, Director of Operational Services Diabetes- Dr Chris Kenny, Locality Director of Public Health

Controls Assurance Data Quality Education & Development

Complaints Procedure Risk Management Committee Clinical Governance Sub-Committee Non-Clinical Risk Sub-Committee Education, Training and Development Strategy AHP & Nursing Strategy Risk Management Committee Controls Assurance Action Plan Education and Development Committee Education, Training and Development Strategy Expert Patient Programme Steering Group Clinical Governance Sub-Committee Committee to be determined

DOH website

CASU website

Expert Patient Programme Guideline Development Information Governance Information/Library Services National Medicines Management Collaborative Programme National Service Frameworks

NHSIA website

PCT NSF Groups North Notts NSF Groups

Topic NICE Guidance Nurse Prescribing

PCT Contact Christine Lawson, Prescribing Advisor Christine Lawson, Prescribing Advisor Debbie Lee, Head of Clinical Practice and Professional Development Colin Draycott, Risk/Complaints Manager Christine Lawson, Prescribing Advisor Christine Lawson, Prescribing Advisor Debbie Lee, Head of Clinical Practice and Professional Development Dr Dean Temple, Director of Clinical Quality Debbie Lee, Head of Clinical Practice and Professional Development Debbie Lee, Head of Clinical Practice and Professional Development Suzanne Meredith, Clinical Quality Manager Colin Draycott, Risk/Complaints Manager

PCT Committee / Policies/ Procedures/ Documents NICE Guidance Implementation Process Prescribing Sub-Committee North Notts Prescribing Group Extension to Nurse Prescribing Implementation document

Regional/National Contacts National Institute for Clinical Excellence

Patient Advice and Liaison Service Patient Group Directions Prescribing Policies and Procedures (Clinical) Poor Performance

Prescribing sub-group AHP/Nurse Modernisation Forum Clinical Governance sub-committee Performance Panel

Professional Leadership Research & development Research Governance Significant Event/ Incident Reporting

AHP/Nurse Modernisation Forum Application process for Research Projects Significant Incident reporting arrangements Incident reporting procedure Clinical Governance, Non-clinical risk and Risk Management Committees North Notts Health Community Workforce Development Group

DOH website Trent Focus Trent Institute National Patient Safety Agency

Workforce Planning & Development

Debbie Lee, Head of Clinical Practice and Professional Development

Trent Workforce Confederation

References & Bibliography Baker R, Lakhani M, Fraser R & Cheater F, A model for clinical governance in primary care groups, BMJ, 318, 779-83, 1999 Department of Health, A First Class Service: quality in the new NHS, HSC (98) 113, 1998 Department of Health, The New NHS: Modern Dependable, The Stationery Office, 1997 Hallet L, Thompson M, Clinical Governance a practical guide for managers, emap psm, 2001 Lugon M, Secker-Walker J, Advancing Clinical Governance, The Royal Society of Medicine Press Ltd, 2001 Mansfield District PCT, Organisational Arrangements, April 2002 Zwanenberg, van T & Harrison J, Clinical Governance in Primary Care, Radcliffe Medical Press, 2000

Useful On-line resources for Clinical Governance

Organisation Bandolier Cancer Services Collaborative CASU Centre for Reviews and Dissemination (CRD) Clinical Evidence Clinical Governance Research and Development Unit (CGRDU) CLIP database Cochrane Library Commission for Health Improvement (CHI) Department of Health Health Evidence Bulletins Wales ImpAct National centre for Health Outcomes Development (NCHOD) National Co-ordinating Centre for NHS Delivery and Organisation (NCCSDO) National electronic Library for Health (NeLH) National Guideline Clearing House (NGC) National Institute for Clinical Excellence National Institute for Clinical Excellence (NICE) National Patient Safety Agency National Primary Care Development Team National Service Frameworks web page NHS Beacons programme NHS Clinical Governance Support Team NHS Information Authority (NHSIA) NHS Learning Zone NHS Litigation Authority (NHSLA) NMAP OMNI Our Healthier Nation in Practice (OHNiP) database Scottish Intercollegiate Guideline Network (SIGN) Trent Focus WISDOM

Website www.jr2.ox.ac.uk/bandolier www.nhs.uk/nationalplan/npch14.htm ns.casu.org.uk www.york.ac.uk/inst/crd www.clinicalevidence.com www.le.ac.uk/cgrdu/index.html www.eguidelines.co.uk/clip/clip_main.htm www.update-software.com/clibhome/clib.htm www.doh.gov.uk/chi/index.htm www.doh.gov.uk www.uwcm.ac.uk/uwcm/ib/pep www.jr2.ox.ac.uk/bandolier/ImpAct/index.html www.his.ox.ac.uk/nchod www.sdo.lshtm.ac.uk www.nelh.nhs.uk www.guideline.gov/index.asp www.nice.org.uk www.nice.org.uk www.npsa.org.uk www.npdt.org www.doh.gov.uk/nsf/nsfhome.htm www.nhsbeacons.org.uk www.cgsupport.org www.nhsia.nhs.uk www.doh.gov.uk/learningzone/index.htm www.nhsla.com nmap.ac.uk www.omni.ac.uk www.ohn.gov.uk/database/database.htm www.sign.ac.uk www.trentfocus.org.uk www.wisdomnet.co.uk

Mansfield District Primary Care Trust Ransom Hall Ransom Wood Business Park Southwell Road West Rainworth Mansfield Nottinghamshire NG21 0ER Telephone: 01623 414114 Fax: 01623 414117