Clinical Governance & Risk Management - Vocabulary Flashcards
INTRODUCTION
Clinical governance has evolved from simple rules and ethics into a detailed system focused on improving quality, ensuring patient safety, and holding professionals accountable.
Emphasizes delivering better, safer, and more compassionate care using the latest evidence and updated practices.
LEARNING OUTCOMES
Define and explain the concept of Clinical Governance.
Identify key components of Clinical Governance systems.
Discuss historical development and frameworks of Clinical Governance.
Analyze factors contributing to successful Clinical Governance implementation.
Assess the role of Quality Improvement in Clinical Governance.
Evaluate the impact of quality and accountability frameworks on patient outcomes, interpersonal collaboration, and health care.
WHAT IS CLINICAL GOVERNANCE?
A framework that helps managers and clinicians (e.g., nurses, doctors, physiotherapists) to:
improve the quality of services,
safeguard standards of care,
do so continuously, thoughtfully, and in a coordinated fashion,
by creating an environment in which excellence in clinical care will flourish.
SIMPLIFIED DEFINITION
Clinical Governance is an umbrella term for a systemic approach to maintain and improve the quality and standards of patient care.
Integrates clinical performance, accountability, and continuous improvement.
To make this work:
Every member of the health facility staff should recognize their role in providing high-quality care.
Patient care should be improved using the most suitable method by:
identifying aspects of care that need improvement,
making plans to improve them,
monitoring the success.
KEY PRACTICES
Learning From Experience:
Not only identifying what went wrong, but also identifying good practice and what works well.
Puts patient experience at the heart of clinical care.
Accountability
Developing true partnerships involving managers, clinical staff, and patients.
OUR ROLE IN CLINICAL GOVERNANCE
Systems in place to enable staff to work in the best possible way.
We as caregivers perform to the highest possible standards.
Shared common ground among: Nurses, Medical Doctors/Practitioners.
PURPOSE OF CLINICAL GOVERNANCE
Create a culture of continuous improvement where quality and safety are embedded in everyday practice.
Encourage feedback:
Regularly ask for input from everyone on how things can be improved.
Set clear goals:
Ensure everyone knows what quality and safety standards are and why they matter.
Provide training:
Ongoing education and practice to help everyone stay skilled and informed.
Recognize efforts:
Celebrate and reward people who contribute to improvements.
Be open to change:
Be willing to adjust processes based on new information and feedback.
By doing these things, you create an environment where everyone is involved in making things better and ensuring high standards are met consistently.
Source attribution: Murray, Elizabeth. [2017]
EVOLUTION (HISTORY) OF CLINICAL GOVERNANCE
1) Origins (the 1990s – UK NHS)
Catalyst: Bristol Heart Scandal—babies died at high rates after cardiac surgery at the Bristol Royal Infirmary. Overall 170 children died in the Bristol unit between 1986-1995.
Reasons identified: shortages of key surgeons and nurses, lack of leadership, accountability, and teamwork.
Response: The UK’s National Health Service (NHS) introduced clinical governance in 1998, as part of the white paper “A First Class Service: Quality in the New NHS.” It aimed to embed quality improvement and patient safety into clinical practice.
2) Early 2000s:Establishment of key pillars of clinical governance.
Healthcare organizations became accountable for quality, not just finances.
3) Integration and Expansion (2005-2015)Frameworks embedded in accreditation, professional standards, regulatory oversight.
Expansion beyond the UK to Australia, Canada, New Zealand, and others.
Shift toward multidisciplinary team-based governance, linking clinical effectiveness with leadership and culture.
4) Modern Era (2015 - Present)Digital health, patient-centered care, and real-time data analytics reshaped governance.
Focus on learning health systems, continuous improvement, and transparency.
Emphasis on just culture: supporting staff learning while maintaining accountability.
Response to challenges like the COVID-19 pandemic, testing governance structures globally.
ORGANIZATION & THEIR ROLES
World Health Organization (WHO) – Global Patient Safety Initiatives
Specialized agency of the United Nations responsible for international public health.
Leads global efforts to improve patient safety via policies, research, and advocacy.
Key initiative: Global Patient Safety Action Plan 2021-2030, providing a framework to eliminate avoidable harm in healthcare worldwide.
Joint Commission International (JCI) – Accreditation and Safety Standards
Division of The Joint Commission (USA) providing international accreditation.
Sets global standards for patient safety and quality.
Accreditation indicates an institution meets rigorous, evidence-based criteria.
Hospitals often pursue JCI to demonstrate high-quality, safe care.
Australasian Institute of Clinical Governance (AICG) – Not-for-profit (HEAL division)
Focuses on clinical governance education and training across Australia, New Zealand, and the Pacific.
In collaboration with The Pacific Community (SPC), adapted their Certificate in Clinical Governance for Pacific Island countries.
National and international frameworks work together to improve global health outcomes.
FIJI'S CLINICAL GOVERNANCE FRAMEWORK
Visual representation of Fiji's framework isn’t standardized; framework is a system of structures and processes to ensure quality and safety in healthcare.
MHMS (Ministry of Health and Medical Services) aims to strengthen this framework with a focus on patient safety and alignment with global standards.
Foundational principles: patient focus, information management, quality improvement, and staff focus.
BREAKDOWN OF KEY ASPECTS OF FIJI'S FRAMEWORK
Accountability and Oversight: responsibility for quality and safety within organizations.
Patient Safety: create a safe environment, minimize risks and harm.
Quality Improvement: continuous improvement mechanisms.
Risk Management: identify, assess, and mitigate risks.
Information Management: effective data use for monitoring and decision-making.
Staff Focus: ensure staff competency, support, and value.
Patient Involvement: engage patients/public in decisions.
Clinical Audits: regular audits to assess practice quality and identify improvements.
National Standards and Regulations: align with global best practices.
HOW IT'S IMPLEMENTED IN FIJI
Mandatory patient safety training and enhanced infection control protocols.
Incident reporting systems digitized to improve data collection and analysis.
National Clinical Governance Committee oversees framework implementation.
Partnerships with organizations like AICG to enhance capacity and expertise.
QUOTES & GROUP DISCUSSIONS
Florence Nightingale (1914): “The world, more specifically the Hospital world, is in such a hurry, is moving so fast, that it is too easy to slide into bad habits before we are aware.”
Activity prompts: discuss in groups and present on how speed in hospital settings can lead to bad habits and patient safety risks.
BRAINSTORMING & FRAMEWORK SUMMARY
The fast-paced hospital environment creates pressure to keep up with patient care and administrative tasks, risking the adoption of bad practices.
Framework pillars and governance aim to counteract this by embedding safety, learning, and accountability.
Source attribution: Murray, Elizabeth. [2017]
FRAMEWORK (PILLARS) OF CLINICAL GOVERNANCE
Clinical Effectiveness
Staffing & Staffing Management
Risk Management
Education & Training
Patient & Public Involvement
Information Use & IT
Audit & Evaluation
These form the SEVEN PILLARS (FRAMEWORK) OF CLINICAL GOVERNANCE.
DETAILED PILLARS
1) CLINICAL EFFECTIVENESS
Umbrella term for activities to improve quality of patient care.
Actions include reviewing current practices, developing new guidelines based on experience and evidence, and conducting research to build evidence for better outcomes.
2) STAFFING & STAFF MANAGEMENT
Appropriate recruitment and management of staff.
Address underperformance, promote retention, provide good working conditions.
3) RISK MANAGEMENT
Robust systems to understand, monitor, and reduce patient and staff risks.
Includes protocol compliance, learning from mistakes/near-misses, adverse event reporting, risk assessment, and a blame-free culture.
4) EDUCATION & TRAINING
Ongoing CPD, multidisciplinary training, and staff development.
Examples: medication safety audits, competency assessments, reflective practice, and documenting learning hours.
5) PATIENT & PUBLIC INVOLVEMENT
Involve patients in decision-making and service design.
Use feedback to improve services; be transparent about outcomes and patient rights.
6) INFORMATION USE & IT
Accurate, up-to-date patient data; protect confidentiality.
Use data for quality measurement (audits) and to tailor services locally.
7) AUDIT & EVALUATION
Regular audits against standards; feedback loops; staff engagement in audits; action based on results.
CLINICAL EFFECTIVENESS (DETAILS)
Definition: A broad set of activities to improve quality of patient care.
Activities include:
Reviewing current practices,
Developing new guidelines/protocols from experience and evidence,
Conducting research to strengthen the evidence base for future care.
Right care principle: ext{Right care} o ext{Right patient} o ext{Right time} o ext{Right clinician} o ext{Right way}
Expressed as a sequence of quality benchmarks, often summarized in frameworks and checklists.
STAFFING & STAFF MANAGEMENT
Focus on: recruitment, management, underperformance, retention, working conditions.
Quality of staffing directly impacts clinical effectiveness and patient outcomes.
RISK MANAGEMENT
Definition: Robust systems to understand, monitor, and reduce risks to patients and staff.
Key activities:
Complying with protocols,
Learning from mistakes and near-misses,
Reporting adverse events,
Assessing risk probability and impact,
Promoting a blame-free culture.
RISK MANAGEMENT PROCESS:
1) Risk Identification: systematic detection of potential risks (clinical and operational) including complaints, incident reports, near misses, audits.
2) Risk Assessment: evaluate likelihood and consequences; use risk matrices or scoring systems.
3) Risk Mitigation: action plans to reduce/eliminate risks; implement safety protocols, checklists, training.
4) Incident Reporting and Learning: promote no-blame culture; root cause analysis (RCA); share lessons.
5) Monitoring and Reporting: continuous evaluation of risk strategies; adjust based on data/outcomes.
6) Continuous Improvement: ongoing education and safety culture.Example: Hand hygiene to prevent hospital-acquired infections (HAIs) – infection risk, likelihood, severity, mitigation, monitoring, and improvement steps.
Near misses and sentinel events: monitor near misses, investigate to prevent recurrences; sentinel events indicate death, permanent harm, severe temporary harm, or life-sustaining interventions are required.
CLINICAL AUDIT & FEEDBACK
Regular and systematic audits to assess performance against standards.
Actionable feedback to clinicians; ownership of outcomes by staff.
Example: Antibiotic prescribing – NICE guidelines for community-acquired pneumonia; multidisciplinary teams; education; re-audit after 6 months; outcome: improved guideline adherence and reduced unnecessary antibiotic use; supports antimicrobial stewardship.
EDUCATION, TRAINING, AND CPD
Ongoing training and skills development for all staff.
Competency maintenance and updating; support for evidence-based practice and guidelines.
Examples: Medication safety audits with double-checks; CPD portfolios; mandatory safety training; multidisciplinary training.
PATIENT & PUBLIC INVOLVEMENT
Involves patients in decision-making and service design.
Collect and act on patient feedback; ensure transparency about outcomes and patient rights.
Example: Co-design of a diabetes education program with patients; steering groups; focus groups; translated materials to be clear and culturally sensitive; improved outcomes and satisfaction; alignment with NICE guidelines.
USE OF INFORMATION & EVIDENCE-BASED PRACTICE
Use of data to identify trends (e.g., rising HAPUs) and drive quality improvement.
Access to guidelines, research, and best practices; integration of evidence-based protocols into practice.
Example: Reducing hospital-acquired pressure ulcers via evidence-based practice – risk assessment (e.g., Braden Scale), regular skin checks, repositioning every 2 hours, pressure-relieving mattresses, nutritional support.
Monitoring and evaluation: real-time documentation; adherence to new protocol; outcome measurement (e.g., % reduction in HAPUs, here 40\% reduction after six months).
CLINICAL AUDIT (REPEAT) & FEEDBACK
Audit cycles include planning, data collection, comparison with standards, implementing change, and re-audit.
Tool: Plan-Do-Study-Act (PDSA) cycles to test improvements in small steps.
Benefit: iterative learning and continuous improvement throughout governance.
BENEFITS OF CLINICAL GOVERNANCE
Improves patient care and safety.
Promotes evidence-based practice.
Minimizes clinical risk and harm.
Builds trust and accountability.
Ensures consistency and transparency.
Encourages continuous professional development.
BENEFITS OF RISK MANAGEMENT
Identifies potential risks to patient safety.
Implements strategies to reduce harm.
Encourages incident reporting and a culture of learning from incidents/errors.
Protects healthcare staff from legal issues.
Enhances safety culture within organizations.
Effective risk management reduces fear around error reporting and promotes learning.
CHALLENGES IN CLINICAL GOVERNANCE
Resistance to change from staff.
Time and resource limitations.
Lack of awareness or training.
Poor communication between teams.
Challenges often stem from system or cultural barriers rather than individual failures.
CHALLENGES IN RISK MANAGEMENT
Under-reporting of incidents.
Blame culture vs Just culture.
Complex systems hard to navigate.
Emotional toll on staff involved in incidents.
SUMMARY
Clinical Governance vs Risk Management:
Clinical governance focuses on quality improvement, education, leadership, patient-centered care, and accountability.
Risk management focuses on risk identification, analysis, and mitigation to improve safety.
Both are interconnected and essential for safe, effective, high-quality healthcare.
Emphasizes patient-centered care, evidence-based practice, accountability, and systematic risk identification and mitigation.
DISCUSSION TOPICS: DISCHARGE TIMELINES & CONSEQUENCES
Scenario: Hospitals with strict discharge timelines to free bed space may hurry patients out even if still in need of care.
Consequences (group discussion prompts):
For Medical Staff: stress, burnout, compromised clinical judgment.
For Patients: premature discharge, higher readmission rates, worsened recovery.
System-level: increased burden due to readmissions, longer overall hospital utilization.
BLAME CULTURE VS JUST CULTURE
Blame Culture:
Individuals are singled out and blamed for mistakes.
Leads to reluctance to accept responsibility, fear of punishment, risk aversion, and reduced reporting.
Consequences: more errors, reduced patient safety, burnout, reduced trust, and hesitation to speak up.
Just Culture:
Errors are acknowledged as inevitable; focus on underlying causes and system improvements.
Promote open reporting without fear of blame, analyze system failures, support staff involved in errors (second victims), and foster learning.
FACTORS CONTRIBUTING TO SUCCESSFUL CG IMPLEMENTATION
Leadership and Management Commitment:
Strong, visible support from senior leadership; clear vision and strategic alignment; leaders champion quality improvement and patient safety.
Example: Executive Walk-Rounds where leaders visit frontline units to discuss patient safety concerns.
Organizational Culture:
Openness, learning, and continuous improvement; incident reporting without blame (just culture); teamwork and respect.
Example: Just Culture after a medication error; structured safety huddles (Pre-Op Briefs and Debriefs) in OR teams.
Effective Clinical Risk Management:
Systems to identify, assess, manage, and learn from clinical risks; audits, risk assessments, and safety protocols; timely response to adverse events.
Example: Falls prevention in elderly patients using multifactorial risk assessment and individualized care plans (bed alarms, non-slip socks, mobility aids).
Patient & Public Involvement:
Active involvement of patients in decision-making and service design; feedback mechanisms; transparency about outcomes.
Example: Diabetes education program co-designed with patients; inclusion in steering groups; improved satisfaction and adherence to NICE guidelines.
Use of Information & Evidence-Based Practice:
Data-driven improvement; access to guidelines and research; integration into daily practice.
Clear Accountability & Clinical Effectiveness:
Defined roles and responsibilities; systems for measuring outcomes; accountability for standards.
Examples: Stroke care pathway with defined roles; chronic disease management plans in primary care.
Effective Communication:
Open channels across disciplines; handover protocols (ISBAR: Identify, Situation, Background, Assessment, Recommendation); regular case conferences.
Performance Monitoring & Evaluation:
KPIs, benchmarking, regular review of quality metrics, incidents, and feedback.
Education, Training, and CPD:
Ongoing staff development; competency maintenance; continuing education.
CO-Design & Transparency:
Continuous sharing of results and learning to improve care.
Positive Example: NICE guidelines adherence, antimicrobial stewardship, and patient outcomes improvements.
MODEL FOR IMPROVEMENT
The Model for Improvement emphasizes three fundamental questions:
1) What are we trying to accomplish? ext{What are we trying to accomplish?}
2) How will we know that a change is an improvement? ext{How will we know that a change is an improvement?}
3) What change can we make that will result in improvement? ext{What change can we make that will result in an improvement?}PDSA cycle (Plan-Do-Study-Act) is used to test changes in small steps.
MEDICATION SAFETY & PATIENT SAFETY CASE STUDY
Objective: Help student nurses recognize how and why medication errors occur and how to prevent them in daily practice.
Case scenario: A patient admitted for pneumonia receives 100\,\text{mg} of metoprolol instead of the prescribed 25\,\text{mg}}. The nursing student is preoccupied; label is smudged; chart not updated after rounds.
Discussion prompts (group):
What went wrong? What should the student have checked/done differently? Which mistakes can you prevent as a nurse? What one commitment will you make to stay safe?
Common errors categories:
Prescribing, Transcribing, Dispensing, Administering, Monitoring.
IOM definition of medical error (Kohn, Corrigan & Donaldson, 2000):
A medical error is a mistake where the planned action wasn’t done correctly or the wrong plan was used. ext{IOM 2000}$$
Adverse events vs errors:
Adverse event: harm due to medical management, not the underlying condition.
Types of errors:
Omission: actions not taken (e.g., no post-op assessment or missed medication).
Commission: wrong action (e.g., giving medication to the wrong patient).
Monitoring near misses: if a medication error is avoided, investigate to prevent recurrence.
Sentinel events: death, permanent harm, severe temporary harm, or life-sustaining intervention required.
Slips and lapses: execution errors where actions occur but are misaligned with plan (e.g., wrong charted dose).
Mistakes: plan itself is wrong; harder to detect; high risk for patients.
Common causes of adverse events:
Human factors (staffing, education, competency),
Communication failures,
Leadership (policies, procedures, practice guidelines).
Human error theories:
Person approach: blame individuals and retrain; discouraged reporting.
Systems approach: errors arise from system flaws; aim to strengthen barriers and safeguards.
References: Reason (2000) on system design and error management.
CLINICAL GOVERNANCE FRAMEWORK (SYSTEM VIEW)
Stakeholder Involvement; System and Process; CPD; Accountability; Risk Management; Compliance and Standards; Clinical Audit; Service User and Staff Experience; Clinical Effectiveness; Complaint & Complement; Transparency; Learning & Sharing; Improving Quality of Care; Excellent Outcome.
ADDITIONAL CONSIDERATIONS & SUPPORTING POLICIES
National and local policies reinforce governance principles.
Alignment with accreditation, regulatory, and legal requirements.
Institutional structures: Clinical Governance Committees or Quality Boards.
Resource considerations: staffing, time, technology, finances.
Multidisciplinary collaboration and Change Management with stakeholder buy-in.
ROLE OF QUALITY IMPROVEMENT IN CLINICAL GOVERNANCE
Quality improvement is integral to clinical governance and forms a continuous cycle of enhancing patient care and safety.
It uses data and evidence to identify improvement areas, implement changes, and evaluate effectiveness.
Outcome: continuously high-quality, safe, and effective services.
ROLE OF QUALITY IMPROVEMENT: KEY OUTCOMES
Component of CG: accountability and quality improvement; improves population health; enhances patient experiences and outcomes; reduces costs; improves provider experience.
Benefits include enhancement of patient safety, care effectiveness, patient-centeredness, efficiency, timeliness, and staff engagement.
THE MODEL FOR IMPROVEMENT (REVIEW)
Plan-Do-Study-Act (PDSA) cycles are central to testing changes in practice incrementally.
REFERENCES (NOTES)
Core sources include NHS England patient safety guidance, WHO Global Patient Safety Action Plan, NICE guidelines, JCI standards, and foundational texts on blame vs just culture and clinical governance frameworks.