Clinical Governance and Quality Improvement
Clinical Governance and Quality Improvement
Clinical Governance and Quality Improvement
Date
Venue
Ensures safe, high quality care from all involved in the patient's journey and
patients are the main focus and priority.
Quality is a moving target and continuous improvement in quality means that what
is considered of an acceptable quality today may not be acceptable this time next
year
1. The hospital has an established Clinical Governance and Quality
Improvement Unit that is led by an assigned Senior Physician or GP.
5. Procedures are established to assess and minimize risk arising from the provision
and delivery of health care. A system is also in place for reporting and analyzing
incidents, errors and near misses.
7. The hospital continuously and systematically reviews and improves all aspects of
its activities that directly affect patient safety and apply best practice in assessing and
managing risks to patients, staff and others.
8. The hospital monitors patients’ experiences with care through patient satisfaction
surveys conducted on a quarterly basis.
9. The hospital implements a strategy for the involvement of patients and the public
in service design and delivery including procedures to be followed when engaging
with patients and the public.
10. The hospital develops and implements a strategy to provide patient focused care
which incorporates compassion, respect and dignity for patients, effective
communication, and better hotel services in the care delivery.
11. The hospital participates in benchmarking activities to learn from and share good
practices with other hospitals.
Organizational structure for CG&QI
◦ To receive clinical audit reports and maintain a record of all clinical audit
activities,
◦ To work very closely with the HMIS Focal Officer/Unit in monitoring HMIS
performance and
◦ To conduct peer review in response to specific quality and safety concerns and to
take appropriate action and follow-up when deficiencies are identified etc..
The CG Unit should develop and oversee the implementation
of the hospital’s CG&QI Strategy. Strategies need to address
the following:
◦ Risk management (risk assessment and Incident reporting)
◦ Clinical effectiveness (clinical audit, Process and outcome
measurement, Professional competence)
◦ Patient and public involvement in healthcare planning and service
delivery
◦ Complaint Handling and Management Procedure
◦ Patient focused care
◦ Benchmarking
◦ Openness
Health care managers should ensure the services that they provide for
users meet their needs and being delivered in the most effective and
appropriate manner.
◦ As a pointer to the need for further investigation or action as part of a quality improvement
process.
Measures should be,
◦ Valid (does it measure what it is supposed to)
◦ Reliable (is it reproducible when taken at different times or in different
circumstances?)
◦ Sensitive to change (does it discriminate between good and poor quality of care,
and can it detect small but worthwhile improvements?)
HMIS (defined set of indicators)
The SMT must ensure that clinical outcomes are monitored within the
hospital, and that timely action is taken to address any problems
identified.
In addition to the HMIS/KPI indicators, hospitals may select additional
clinical indicators for monitoring on a quarterly or annual basis.
Clinical audit can be defined as “a quality assurance process
that seeks to improve patient care and outcomes through
systematic review of care against explicit criteria and the
implementation of change”.
Clinical audit aims to ensure that all patients receive the most
effective, up to date and appropriate treatments.
How bad?
Is there a need
What can go
for action?
wrong?
How
often?
Risk management proactively reduces identified risks to an acceptable
level.
2. Decide who might be harmed and how (what can go wrong, who is exposed to the
hazard)?
3. Evaluate the risks (how bad? how often?) and decide on the precautions (is it
necessary to take further action?) A risk matrix can be used to evaluate the risks
4. Record the findings, propose action and identify who will lead on each action
Patient focused care also includes the quality of “hotel” services provided to
patients such as housekeeping, nursing, laundry, food services etc.
The hospital should ensure that these services are provided to a high standard
within the available budget.
Patient focused care can only be improved by analysing and understanding patients’
satisfaction with their own experiences.
Health services should be tailored to the needs and expectations of
the population served.
The perspective of patients and the public can help identify what does
and doesn’t work in the delivery of treatments and services.
It ensures that any identified risks are managed appropriately and that
action is taken to minimise or eliminate those risks.
1.
The hospital has a Clinical Governance and Quality Improvement Unit (CG&QIU) that is led
by an assigned Senior Physician or General Practitioner?
2
The CG&QIU establishes and leads a multidisciplinary Quality Committee?
3
The hospital is implementing a clinical governance and quality improvement strategy and
4
Are procedures established to monitor clinical practices and standards through services’
specific process and outcome measures to enable the hospital to address any problems
identified?
5
Is the hospital implementing a regular clinical audit programme in each service area?
yes No
Standards
6
Are procedures established to assess and minimize risk arising from the provision and delivery of health
care?
7.
A system in place for reporting and analyzing incidents, errors and near misses?
8
Is the hospital’s statement of patient rights and responsibilities posted in public places in the
hospital?
9
Is the hospital monitoring patients’ experiences with care through patient and satisfaction
surveys conducted on a quarterly basis?
10
Has the hospital developed and implementing a strategy to provide patient focused care
which incorporates compassion, respect and dignity for patients, effective communication,
better hotel services and involvement of patients in the care delivery?
11
Is the hospital participating in benchmarking activities to learn from and share good practice
with other hospitals?