CLINICAL GOVERNANCE

Dr. ADIB A. YAHYA,MARS

Clinical Governance is :
"A framework through which health care 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." (NHS)

Effective Clinical Governance ensures:

continuous improvement of patient services and care
a patient centred approach that includes treating
patients courteously, involving them in decisions
about their care and keeping them informed
a commitment to quality, which ensures that health
professionals are up to date in their practices and
properly supervised where necessary
a reduction of the risk from clinical errors and
adverse events as well as a commitment to learn
from mistakes and share that learning with others
The goal of clinical governance is for all staff to be
striving to continuously improve care.

The term clinical governance may seem to

imply that it is the exclusive responsibility and
domain of clinical staff but this is not the case.
It is everyones concern the nurse, the GP,
the dentist, the pharmacist, the receptionist, the
cleaner everyone in fact whose work impacts
on the patients experience of healthcare
So what does clinical governance really mean?
Quite simply it is about:
HIGH QUALITY, ACCOUNTABLE CARE

Clinical Governance requires changes at three levels:

Individual health care professionals need to embrace
change, adopting reflective practice which places
patients at the centre of their thinking.
Teams need to become true multi-disciplinary groups,
where understanding about roles, about sharing
information and knowledge and about support for each
other becomes part of their everyday practice.
The Healthcare organisation is also committed to
embracing the changes required by putting systems and
local arrangements in place to support you as an
individual and the teams within which you work.

There are seven key components of Clinical

Governance, known affectionately as
'The 7 Pillars' :
Risk Management
Clinical Audit
Education, training and continuing personal
and professional development
Research and Development
Information
Patient and Carer experience and involvement
Staffing and staff management

SYSTEMS
AWARENESS
TEAMWORK
COMMUNICATION
OWNERSHIP

EDUCATION,TRAINING
PROFESSIONAL DEVELOPMENT

STAFF AND
STAFF MANAGEMENT

CLINICAL AUDIT

RESEARCH AND
EFFECTIVENESS

RISK MANGEMENT

USE OF
INFORMATION

PATIENT AND PUBLIC

INVOLVEMENT

PATIENT PROFESSIONAL PARTNERSHIP

STRATEGIC CAPACITY

LEADERSHIP

Patient and Public Involvement

Involving patient groups and local communities in all
aspects of planning, provision, monitoring and evaluation
of care is one of the key underpinning principles of
clinical governance and one that represents a
fundamental culture shift for the HOSPITAL
Patient and Public Involvement includes:
Appointing a Patient Advice & Liaison Manager
Providing patients with information about the services we
provide
Actively seeking patients views on those services, and making
changes as a result
Involving patients in the planning and delivery of services.
Working with GP practices to establish Patient Participation
Groups

Use of Intelligent Information

Accurate and appropriate information is vital. It can help identify the
priority health needs of the local population, and assure the safety
and quality of current clinical provision of care.
Information we need includes:

Robust and reliable public health information

Robust and reliable comparative national data
Robust and reliable clinical information

Some of the work includes:

Ensuring we have a Data Protection Officer to oversee the

confidentiality and security of information
Monitoring the accuracy of performance and activity information
received from secondary care providers
Starting to collect community data with scanned forms
Routinely making information on activity available to clinicians and
staff

Risk Management
Ensuring the safety of everyone who comes into contact with the
health services is one of the most important challenges facing
healthcare today.
There are three important things we can do which will help promote
patient safety:

Put systems and processes in place to proactively identify clinical and nonclinical risk
Implement a systematic strategy to minimise them, monitor them and learn
from them
Promote a fair blame culture, so that staff are willing to report their
mistakes and near misses.

Some of the steps to take include:

Introducing an electronic Incident Reporting System in order that we
can record, analyse and monitor incidents and complaints.
Introducing staff training on incident reporting and Root Cause
Analysis
Disseminating learning from incidents across staff groups will be a
key priority.
Ensuring the Complaints Procedure is in place within the hospital.

Research and Clinical Effectiveness

All clinical decisions and actions initiated by or on behalf
of the HOSPITAL should be based upon a reliable,
robust and ever developing evidence base. In order to
promote this the HOSPITAL needs to develop systems
to:
Promote and monitor clinical effectiveness
Encourage and monitor the use of evidence based practice

Some of the steps include:

Developing and agreeing evidence based protocols of care

Ensuring that the standards and guidelines are implemented
throughout the HOSPITAL
Providing training on searching for evidence is available to all
staff.
Developing systems to determine whether clinically effective
practice is being implemented at grass roots level.
Ensuring that research governance arrangements are in place
Ensuring that evidence based prescribing is implemented

Clinical Audit
Clinical Audit is a structured process, which ensures we are carrying
out best practice by reviewing what we are doing, compared with
that which we should be doing.
It is seen as an essential component of professional practice and
can demonstrate efforts being made to deliver high quality care to all
patients.
Some of the steps include:
The development of a Clinical Audit Strategy
The establishment of a Register to monitor Clinical Audit activity,
progress and evaluation across all areas of the Services.
Support, advice, guidance and training to all individuals or groups
undertaking audits.
The production of a Clinical Audit Guide for distribution to all
interested parities.
Providing a quarterly review of clinical audit activity to the Clinical
Governance Committee.

Staffing and staff management

The quality of clinical care is intimately related to the quality and
morale of the staff and the way they are managed and supported.
The ultimate aim is to have a staff group that is:

Highly motivated
Fully cohesive and effective in relation to current needs and
demands
Flexible enough to respond positively to changing need and patterns
of care

Some of the work includes:

Introducing a corporate induction programme for all new employees

Achieving Improving Working Lives Practice status
Developing a range of Human Resources (HR) policies.
Undertaking an Annual Staff Survey
Developing the Hospital Newsletter, website and intranet site to help
keep staff informed of key issues and associated information
Holding a regular programme of open meetings so that staff can
raise issues with the Chief Executive, directors and non-executive
directors

Workforce Planning, Education and Training

Staff are the most important resource in all HEALTHCARE
organisations.
Thoughtful and imaginative investment in staff development shows a
real commitment to clinical governance.
The importance of life long learning and leadership development is
important not only for individuals and the teams in which they work,
but also for the ongoing development of the HOSPITAL
Some of the steps include:
Developing a system to ensure equity of access to training and
development opportunities via the Education Links system and by email.
Ensuring processes are in place to support a range of internal and external
learning opportunities, higher and further education.
Developing new roles and changes to work patterns to ensure we have the
right workforce for future requirements.

PENGORGANISASIAN
PENANGGUNG JAWAB :
PIMPINAN RS / CEO

KOORDINATOR:
DIREKTUR MEDIK / KOMITE KLINIK

PENGENDALI :
SUBKOMITE CLINICAL GOVERNANCE

PELAKSANA :
DEPARTEMEN / PERORANGAN

PERAN
Pimpinan RS :
Penanggung Jawab
Prioritas Patient Care
Menentukan Koordinator
Membentuk Subkomite Clinical Governance

Koordinator :
Koordinasi dan monitor
Dukungan terhadap Tim Departemen
Review Kemajuan

Pengendali :
Bertanggung Jawab kegiatan day-to-day
Mendukung Tim Clinical Gov Departemen
Anggota terdiri dari :
Perwakilan Tim Departemen
Organisasi Pendidikan
Manajemen Resiko
Informasi

Pelaksana :

Tiap Departemen membentuk tim Clin Gov

Melaksanakan arahan dari Pengendali
Asessment kemampuan Departement
Identifikasi kelemahan dan kekurangan pelayanan
Perencanaan tahunan Departemen
Komunikasi dan Disseminasi informasi intra maupun
inter departemen
Kebutuhan pendidikan

Penanggung Jawab
(CEO)

Koordinator
(DirMed / KomKlin)

7 PILLARS

internal
Pengendali
drivers (SubKom.Clin Gov)

Pelaksana
(Dept / Perorangan)

external
drivers

Standards
Regulations
Authority

Langkah-Langkah Pengembangan
Clinical Governance
Tiap departemen harus menyediakan waktu
untuk mendiskusikan implikasi dari clinical
governance.

1.

Bagaimana situasi di Departemen? Contoh

pelayanan yang baik dan yang buruk?
Di bagian mana perlu perbaikan dengan sumber
daya yang tersedia? Bagaimana perbaikan dapat
dicapai?
Bagaimana dukungan nyata
(staf,IT,perpustakaan,dsb) yang dibutuhkan?
Bagaimana keterlibatan multidisipliner secara efektif
dapat dicapai

2.
3.
4.
5.
6.
7.

Tiap departemen harus memiliki penanggung jawab

untuk Nursing Clin Gov dan Medical Clin Gov
Tiap departemen mengembangkan programnya sendiri
meliputi tujuan dan sasaran dengan azas prioritas
Program departemen harus diketahui Pengendali,
Koordinator dan Pimpinan
Kebutuhan pelatihan untuk pengembangan
kepemimpinan dan keterampilan khusus
Pertemuan rutin antar Departemen
Kembangkan jejaring dengan institusi kesehatan lain.

Unwritten Rules yang Menghambat Status Quo

We know best
My own work has no effect on others areas
Clinician dont need managers
The more senior you are the more you know !
Dont admit to mistakes
Even though we talk about quality we only
assess on the quantity
But Ive always done it this way

There are no rewards for doing well

Everyone understands the jargon
It is wrong to seek answers / consult others
Dont fix it if its not bust
Doctors time is more valuable than nurses
Nothing ever changes
Everything is changing all the time
The pass was much better
( Adapted from : Cullen et al. British Journal of Clinical Governance
2000; 5(4):233-239)

HARUS DI INGAT
Clinical Governance suatu perkembangan
yang evolusioner, bukan revolusioner.
Cinical Governance sudah dijalankan
bertahun-tahun tetapi dalam bentuk
fragmented,haphazard & instropective
Clinical Governance is NOT just about
systems, it is also about the CULTURE
of an organization.