Clinical Governance

Do you know what clinical governance is about? Can you explain how it affects your daily practice?

Topics related to clinical governance feature in all ST interviews & consultant interviews.

On this page we explain what clinical governance is about and how you can discuss it knowledgeably at an interview.

A well known-definition which you should avoid

The most widely used definition of clinical governance is as follows:

"A framework through which NHS 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."
— G Scally and L J Donaldson 'Clinical governance and the drive for quality improvement in the new NHS in England' BMJ (4 July 1998): 61-65

Although you should of course familiarise yourself with this definition, there is no need to memorise it. Under pressure, most candidates remember the beginning and the end, and mess us the middle part. Even if you remembered it perfectly, you would only demonstrate that you have a good memory and not that you understand the concept.

Instead, you should derive you own practical and down-to-earth definition.

How can you define clinical governance?

Anything which avoids the word “flourish” and can be delivered in your own natural words will do, provided it addresses the concepts of quality and accountability. Here are a few examples:

Clinical Governance is a quality assurance process designed to ensure that standards of care are maintained and improved and that the NHS is accountable to the public.

Clinical Governance is an umbrella term which encompasses a range of activities in which clinicians should become involved in order to maintain and improve the quality of the care they provide to patients and to ensure full accountability of the system to patients.

The 7 Pillars of Clinical Governance

Traditionally, clinical governance has been described using 7 key pillars. Although it has been refined over the past few years, this approach remains the easiest to remember and to describe at a trainee interview level. It is also the approach that your interviewers are most likely to expect from you since this is what they would have learnt too. The 7 pillars are as follows:

Clinical Effectiveness & Research

Clinical effectiveness means ensuring that everything you do is designed to provide the best outcomes for patients i.e. that you do "the right thing to the right person at the right time in the right place”.

In practice, it means:

Adopting an evidence-based approach in the management of patients
Changing your practice, developing new protocols or guidelines based on experience and evidence if current practice is shown inadequate.
Implementing NICE guidelines, National Service Frameworks and other national standards to ensure optimal care (when they are not superseded by more recent and more effective treatments)
Conducting research to develop the body of evidence available and therefore enhancing the level of care provided to patients in future.

Audit

The aim of the audit process is to ensure that clinical practice is continuously monitored and that deficiencies in relation to set standards of care are remedied.

Risk Management

Risk Management involves having robust systems in place to understand, monitor and minimise the risks to patients and staff and to learn from mistakes. When things go wrong in the delivery of care, doctors and other clinical staff should feel safe admitting it and be able to learn and share what they have learnt.

This includes:

Complying with protocols (hand washing, discarding sharps, identifying patients correctly etc)
Learning from mistakes and near-misses (informally for small issues, formally for the bigger events – see next point)
Reporting any significant adverse events via critical incidents forms, looking closely at complaints etc.
Assessing the risks identified for their probability of occurrence and the impact they could have if an incident did occur. Implementing processes to reduce the risk and its impact (the level of implementation will often depend on the budget available and the seriousness of the risk)
Promoting a blame-free culture to encourage everyone to report problems and mistakes.

Education and Training

This entails providing appropriate support available to enable staff to be competent in doing their jobs and to develop their skills so that they are up to date. Professional development needs to continue through lifelong learning.

In practice, for doctors, this involves:

Attending courses and conferences (commonly referred to as CPD – Continuous Professional Development)
Taking relevant exams
Regular assessment, designed to ensure that training is appropriate
Appraisals (which are a means of identifying and discussing weaknesses, and opportunities for personal development)

Patient and Public Involvement (PPI)

PPI is about ensuring that the services provided suit patients, that patient and public feedback is used to improve services into day-to-day practice to ensure an increased level of quality and suitability, and that patients and the public are involved in the development of services and the monitoring of treatment outcomes.

This is being implemented through a number of initiatives and organisations, including:

Local patient feedback questionnaires
The involvement of the Patient Advice and Liaison Service (PALS) in handling issues with patients.
National patient surveys organised by the Healthcare commission, which then feed into trusts’ rankings
Local Involvement Networks (LINks), which have been introduced to enable communities to influence healthcare services at a local level (these used to be called “Patient forums”)
Foundation Trust Board of Governors who are elected by members of the local community and have a say on who runs a hospital and how it should be run, including the services it can provide.

Using Information & IT

This aspect of clinical governance is about ensuring that:

Patient data is accurate and up-to-date
Confidentiality of patient data is respected
Full and appropriate use of the date is made to measure quality of outcomes (e.g. through audits) and to develop services tailored to local needs.

Staffing & Staff Management

This relates to need for

appropriate recruitment and management of staff,
ensuring that underperformance is identified and addressed
encouraging staff retention by motivating and developing staff
providing good working conditions

From the above explanations, you may have noted that some of the pillars are more directly related to the day to day responsibilities of a junior doctor:

Clinical Effectiveness
Audit
Risk Management
Education & Training

Whenever you discuss Clinical Governance in an answer, you may prefer to discuss these in more depth and simply mention the other three. You can remember these 4 key pillars with the mnemonics CARE

Other (less useful) mnemonics

If you are the type of person who likes to remember information through the use of mnemonics, here are a couple which will enable you to remember the all the components of clinical governance (though not necessarily in the most useful order):