The RNOH will remain the UK’s leading specialist orthopaedic hospital, further enhancing its international profile for outstanding patient care, research and education

Clinical Governance

What is Clinical Governance?

The most frequently referred to definition of Clinical Governance appears to be that outlined in the Department of Health's 'A First Class Service. Quality in the new NHS', that sets out the framework outlined in the White Paper for improving the quality of the patient experience as well as the clinical outcome. This consultation document describes Clinical Governance 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'.

Clinical Governance is therefore not a new concept, rather it builds on existing systems for ensuring quality.

What does clinical governance mean at the RNOH?

The Trust regards clinical governance as a key priority for all staff that participate in the delivery of our services. Clinical governance reinforces the importance of quality and assures that all members of staff, from Board to the most junior member, look at the quality of their service. It isn't about 'policing' or inspecting individuals, but rather assessing and evaluating the effectiveness of the service provided, therefore learning from successes as well as recognising areas where improvements are required. Clinical governance reinforces the Trust's commitment to the provision of patient focused high quality clinical care.

How is clinical governance achieved at the RNOH?

The Trust's approach to clinical governance is led by the clinical governance committee, which has representation from the Trust executive and clinical groups as well as external organisations. Patient representatives have also been appointed to several groups that report to the clinical governance committee to ensure a broader patient perspective. The facilitation and implementation of clinical governance is the primary function of the Clinical Governance Department, which was established in July 1999. The department works closely with the clinical units to ensure ownership by all members of staff and that clinical governance underpins the working practice of all staff in the delivery of a quality service to our patients. All team members promote the identity and role of the department whilst undertaking their individual specific roles. The Clinical Governance Department consists of the director of nursing, clinical risk manager, customer care co-ordinator, clinical audit lead and the clinical audit facilitator.

In addition to this local framework several statutory bodies monitor the development of clinical governance. The National Institute for Clinical Excellence (NICE) provides guidance to the NHS on best practice and the Care Quality Commission (CQC) has been established to provide assessment and effective monitoring of local arrangements and to reduce variations in the quality of care. Our CQC review was in November 2001 and a final report was published in February 2002. If you wish to see the full report and the RNOH action plans please use the link below.

The Clinical Governance Department works closely with London South Bank University to set up training courses relating to clinical governance. The priority aim of this programme is to ensure that all staff have a basic understanding of clinical governance and its significance in their working lives. The department runs a series of successful multi-disciplinary clinical governance seminars for staff to develop an understanding of clinical governance and how it may apply to their own particular area of work. All staff are also introduced to clinical governance on their initial induction programme when they commence employment.

Many of the functions for delivering effective clinical governance in the Trust are supported by the Quality Team. The key contacts for the team are:

Roisin Mulvaney, Deputy Director of Quality, 020 8909 5734
Ashantel Lakhani, Information Governance Manager and FOI Lead,  020 8909 5824
Diane Young, Involvement Lead, 0208 909 5394
Lucy Quinn, Patient Safety Lead, 020 8909 5592
Muhammad Kashif, Clinical Audit Lead, 020 8909 5375
Parvin Ahmed–Hasib , Quality Manager, 0208 909 5883
Juliette Harris, Patient Experience Lead, 020 8909 5439

For general enquiries about the Quality Team, please contact Dorcas Thairu, Quality Team Administrator, 020 8909 5628

CQC website: www.cqc.org.uk
NICE website: www.nice.org.uk

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