1

Clinical and Care Governance Strategy

2019 – 2021

Making Quality Real

“Our ambition is that every day every one of us delivers, sees and experiences standards of

healthcare that we would want for our own loved ones. This can only happen by putting the

person receiving care, and their carer, at the centre of everything we do, working as a team

and making sure we have the information and data we need to deliver excellent care and

treatment”

Professor Peter Stonebridge Mrs Sarah Dickie

Medical Director Interim Nurse Director

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Version Control

Version Number

Purpose Change Author Date

1.0 Document presented to Tayside NHS Board

Medical Director and Nurse Director

05 December 2013

2.0

Document reviewed and presented to Clinical and Care Governance Committee 17th August 2017 Updates

Realistic Medicine (SG 2016)

HIS Review of Quality of Care

Integration Joint Boards and new arrangements of Clinical Governance across HSCP

i-matter and culture and collective leadership framework

Development of staff and curricula for Quality Improvement

Volunteering

Patient Information

Medical Director and Nurse Director

17 August 2017

3.0

Document reviewed and presented to Clinical Quality Forum for approval on 11 November 2019 and endorsed by Care Governance Committee 5 December 2019 Updates:

Information condensed and made easier to read and understand.

Addition of reading list.

Addition of Duty of Candour legislation.

Inclusion of the Health and Social Care Standards: My support, my life. Scottish Government (2017).

Medical Director and Nurse Director

11 November 2019

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Contents

1. INTRODUCTION TO THE CLINICAL AND CARE GOVERNANCE STRATEGY .................... 4

2. DOMAINS OF CLINICAL AND CARE GOVERNANCE........................................................... 6

2.1. ADVERSE EVENT AND CLINICAL RISK MANAGEMENT ..................................................... 6

2.2. CONTINUOUS IMPROVEMENT ................................................................................................. 7

2.3. PERSON-CENTREDNESS ........................................................................................................... 8

2.4. CLINICAL EFFECTIVENESS ....................................................................................................... 9

APPENDIX 1 – STAFF CONTRIBUTIONS TO CLINICAL AND CARE GOVERNANCE .............. 11

APPENDIX 2 - RECOMMENDED READING LIST ....................................................................... 12

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1. INTRODUCTION TO THE CLINICAL AND CARE GOVERNANCE STRATEGY

“Clinical governance is a system 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.” (Scally and Donaldson,

1998).

This strategy details the responsibilities that all staff have in contributing to the quality of care for

people who use NHS Tayside and Tayside Health and Social Care Partnership services and the

importance of culture and organisational arrangements in achieving safe, effective and person-

centred care.

In 2000, the Scottish Executive described four levels of clinical governance responsibilities. NHS

Tayside defines these levels below and each will be referred to throughout this document and

within additional supporting documents.

Overseeing – members of Clinical Quality Forum and Care Governance Committee, non-

executives.

Delivering – management structure, including clinicians involved in management –

Triumvirate and management leads, clinical governance leads

Practising – clinical, administrative and support staff

Supporting – staff employed in activities underpinning clinical governance, e.g. those

involved in clinical effectiveness, audit, complaints handling and risk management.

Each of these roles are important if quality of care is to be given the highest priority across NHS

Tayside and partner organisations. Every member of staff has a role in quality and this strategy

helps staff understand their role across the entire scope of clinical and care governance.

A one page document (Appendix 1) has been developed

in collaboration with staff to lift the veil on what clinical

and care governance is and how they contribute to this

on a daily basis, regardless of what their role may be.

This is also available on the Clinical Governance and

Risk Management Staffnet page HERE.

A recommended reading list (Appendix 2) has also been developed to support the one page

document and this strategy. The reading list details documents and websites that staff need to be

aware of or have read according to their role.

The 3 documents below provide the historical context for clinical governance:

Clinical Governance NHS MEL (1998) 75

Clinical Governance NHS MEL (2000) 29

Clinical Governance Arrangements NHS HDL (2001) 74

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The strategy describes the four key domains of clinical and care governance as:

1. Adverse event and clinical risk management

2. Continuous improvement

3. Person centredness

4. Clinical effectiveness

These domains are detailed fully within this document and include the expectation of staff dependent on their role.

“Clinical governance is about … accountability, structures and processes. However, it will only achieve

the desired outcomes of improved quality of care and public reassurance about standards of care, if it

is underpinned by a wide range of activities most of which require to be owned and led by clinicians

individually and collectively. Clinical governance is not the sum of all these activities; rather it is the

means by which these activities are brought together into a structured framework and linked to the

corporate agenda of NHS bodies” (Clinical Governance NHS MEL (1998) 75).

The current whole system arrangements for clinical governance in health and social care in Tayside

are illustrated in Figure 1. These arrangements will adapt given the maturing landscape and

anticipated changes and developments across the organisation.

Figure 1: Clinical and Care Governance Arrangements across the whole system from people

receiving care to the Board

NHS Tayside Board

Care Governance Committee Standing Committee for Clinical Governance

Clinical Quality Forum Assurance and learning across NHS Tayside and the

three Health and Social Care Partnerships

Local Clinical Governance Groups and Forums within Divisions and Health and Social Care Partnerships Clinical Care and Professional

Governance Forums

Clinical Risk

Management

Local Teams / Wards / Departments / Communities who

support people receiving care, their carers and families

Organisational Support for Clinical Governance and Risk Management Clinical Governance Chairs

Patient Safety, Clinical Governance and Risk Management Team Professional and Clinical Leadership/Hospital Huddles

Nursing and Midwifery Directorate Improvement and Organisational Development

Business Unit

Quality and Performance Reviews/Assurance Frameworks

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2. DOMAINS OF CLINICAL AND CARE GOVERNANCE

2.1. ADVERSE EVENT AND CLINICAL RISK MANAGEMENT

The aim of this domain is to ensure there are adequate

and effective adverse event and risk management

processes in place throughout the organisation to enable

learning from adverse events which will reduce the risk of

future harm. It focuses on the reporting and reviewing of

adverse events and near misses, in an open, honest and

safe environment; continually highlighting good practice;

identifying improvements, ensuring business continuity

plans are in place and the implementation of patient

safety programmes.

Included within this domain are:

Adverse Event Review – Reviewing adverse events and near misses at an appropriate level to

ensure continual learning and improvement to services for people who access our services and

staff.

Duty of Candour – Ensuring that people receiving care, and their families, are informed when they

have been harmed, either physically or psychologically as a result of the care provided. This

ensures that services are compliant with the Duty of Candour Procedure (Scotland) Regulations

2018.

Risk Management – Continual development, monitoring and review of service and strategic level

risks to ensure these are proactively managed and progressed across the organisation with clear

timescales and actions plans associated to these.

Business Continuity Plan – Developing and maintaining effective and up to date business

continuity plans to increase the resilience of the organisation so that it is able to continue to deliver

the critical services that our users rely upon. Ensuring our services are compliant with the business

continuity plans element of the Civil Contingencies Act 2004.

Patient Safety - Working collaboratively and in conjunction with services/partners, to develop

approaches that systematically improve the safety for patients through generating new ideas, sharing

knowledge and spreading safe practice.

Staff responsibilities at each of the four levels for this domain:

Overseeing

Seek assurance through Care Governance Committee, Clinical Quality Forum and

Quality and Performance Review processes on all aspects of adverse event and

clinical risk management and ensure actions and learning have been identified and

shared throughout the organisation.

Delivering

Provide assurance to the members of the Quality and Performance Review panel

in relation to their adverse event and risk management processes. Ensure there

are appropriate structures and mechanisms in place to consider and act on

information, highlight good practice and identify and share learning to ensure there

is continual improvement in systems, practice and care for people accessing

services.

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Practising

Ensure all staff are able to report adverse events, are aware of Duty of Candour

legislation and patient safety initiatives and can access information regarding any

aspect of adverse event and clinical risk management as required. Have open and

honest discussions with patients and their families when there has been harm.

Supporting

Provide training, information, tools and methods to enable teams to report, monitor

and learn from their adverse events and near misses and ensure they are

proactively monitoring and mitigating risks across their services. Support teams to

ensure they are meeting legal and national requirements in relation to duty of

candour, continuity planning and patient safety. Produce an annual duty of candour

report that is available in the public domain.

2.2. CONTINUOUS IMPROVEMENT

The aim of this domain is to ensure that all services learn

about what works and what doesn’t and supports teams

to make improvements. The key policy drivers include the

Chief Medical Officer’s Annual Report 2014-15, Realistic

Medicine and Excellence in Care approach. These

reports emphasise the need to put the person receiving

health and care at the centre of decision-making and

create a personalised approach to their care. They also

recognise the importance of valuing and supporting all

health and care professionals as vital to improving outcomes for the people in their care.

Included within this domain are:

Applied Quality Improvement – Application of improvement models, tools and techniques within

clinical areas, such as the ‘Model for Improvement’.

Capacity and Capability – Building capacity and capability in quality improvement and design

skills through a variety of courses and programmes, such as Scottish Improvement Leadership

(ScIL).

Innovation - Forging and maintenance of links with Academic Health Science Partnership; links to

industry, support for funding application, academic evaluation, business development, publishing

and income generation.

Quality Improvement Infrastructure - Management and coordination of a physical and virtual

infrastructure to support innovation and collaboration. Physical elements – Improvement academy

facility and funding for backfill to support innovation. Virtual elements – Website and local, national,

UK and international networks.

Staff responsibilities at each of the four levels for this domain:

Overseeing

Tayside NHS Board is committed to quality improvement demonstrated by the

commitment to NHS Tayside Vision and Values, the Transforming Tayside

programme and work on culture. The Clinical Quality Forum supports quality

improvement at all levels providing the platform for assurance and the identification

and support to key areas of work requiring improvement specifically closing the

loop for quality of care.

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Delivering

Continuous improvement is supported at executive level by ensuring the resources

to drive improvement are effectively used. Clinical leads and managers have a

responsibility for developing programmes of quality improvement adopting

improvement science as an approach to improving clinical care. This ensures

quality improvement is at the heart of everything the Boards do and strategies are

collaborative with the people of Tayside at the heart of our work.

Practising

Local teams identify quality improvement work supported by measurement and

evaluation. These quality improvement ideas can be supported by improvement

practitioners and other support functions, or by accessing an appropriate

educational offer. This approach allows for the flexible use of a range of quality

improvement methods across a range of settings, as it is our experience that

successful quality improvement work can be achieved using a plurality of methods

across a range of settings.

Supporting Provide training, information, tools and methods to enable teams to undertake

quality improvement.

2.3. PERSON-CENTREDNESS

The aim of this domain is to enable all practitioners and

leaders to develop cultures of person-centredness that

positively contribute to patient and staff well being. It

focuses on:

enhancing care experiences

sharing decision making

enhancing how we engage the public in

reviewing and improving our services

implementing best person-centred practices as

advocated by Scottish Government through

‘Excellence in Care’ and Healthcare Improvement Scotland; practical examples include

person-centred visiting and advocacy

developing capability within the system to create environments where staff and therefore

evidence based care flourishes.

Included within this domain are:

Shared decision making – Enabling practitioners and the public to engage in decision making

that meets the needs of people, their preferences and values.

Enhancing care experience – Ensuring our services are compliant with the patient feedback

element of the Patient Rights (Scotland) Act 2011. Enabling services to create cultures and

processes that support learning, act on care experience information, including complaints, survey

feedback, patient stories; Care Opinion contributions and informal verbal comments.

Public Involvement, Communication and Engagement

Public Involvement – The process of public involvement is giving ordinary people the chance to

work in public partnership within NHS Tayside and to become involved in the decision-making

process.

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Communication and Engagement – A planned and sustained approach to communications and

engagement that will enable effective stakeholder involvement, support the delivery of our priorities

for 2019-2022, underpin our decision-making processes and protect and enhance the reputation of

health and care services in Tayside.

Person-centred cultures – Develop facilitators of person-centred cultures and care through the

practice development programme and the collective and compassionate leadership programme.

Patient Information – All patient information leaflets are to be developed, monitored and reviewed

in line with NHS Tayside ‘Good Practice Guidelines for Writing and Reviewing Patient Information’.

By doing this, we will ensure that everyone accessing our services receives information in a format

that meets their requirements and is suitable for their needs.

Equality and Diversity – Ensuring that all staff and people accessing our services are provided

with services that meet the diverse needs of its users and are given equal access to these services

regardless of protected characteristics.

Volunteering – Volunteers provide services alongside staff and make valuable contributions to

enhance the quality of the services we provide to the people we care for. NHS Tayside actively

recruits and allocates volunteers throughout the organisation ensuring necessary support

structures are in place for their volunteers and staff.

Staff responsibilities at each of the four levels for this domain:

Overseeing Clinical Quality Forum through the Quality and Performance Review process seek

assurance on progress against the Person-Centred Board work plan.

Delivering

Enable implementation of Person-Centred Board priorities into all services. Ensure

all staff are supported to understand and practice in accordance with best person-

centred principles and practice.

Practising

Be able to understand the principles of person-centred practice and contribute to

the development of more person-centred cultures and therefore better care and

care experiences and better team relationships.

Supporting

Provide support systems and processes (e.g. learning collaborative; learning

programmes; clinical supervision; guidance, training and research) that enable the

adoption of person-centred practices. Produce regular reports on progress with all

aspects of this domain.

2.4. CLINICAL EFFECTIVENESS

The aim of this domain is to ensure that people who

receive care get the right care, at the right time, in the

right way. It focuses on ensuring our staff and services

are informed and up to date with evidence based

practice; research and development and guidelines as

well as highlighting the importance of having agreed

outcome measures and established clinical audits.

Evidence Based Practice - The foundation for staff to

base their clinical practice on, it ensures that up to date

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information is used to inform clinical practice. An ‘evidence base’ can also be used for other

activities such as improvement. Evidence may be presented as advice, guidelines or standards.

The Health and Social Care Standards, My support, my life, produced by Scottish Government in

2017 set out standards on what should be expected when people use health, social care or social

work services in Scotland. There are five standards:

1: I experience high quality care and support that is right for me.

2: I am fully involved in all decisions about my care and support.

3: I have confidence in the people who support and care for me.

4: I have confidence in the organisation providing my care and support.

5: I experience a high quality environment if the organisation provides the premises.

Research and Development – Enables clinical practice to be progressed and developed, it finds

new ways of doing things.

Outcome Measures – Indicators that enable a judgement to be made on whether or not

interventions have resulted in a change in someone’s health status.

Clinical Audit – Enables aspects of clinical practice to be measured against standards to drive

improvement and provide assurance regarding practice.

Staff responsibilities at each of the four levels for this domain:

Overseeing Seek assurance through Care Governance Committee, Clinical Quality Forum and

Quality and Performance Review processes on all aspects of clinical effectiveness.

Delivering

Ensure there are appropriate structures and mechanisms in place to learn from

research and evidence. Ensure continual improvement to practice for patients and

people accessing our services by identifying and sharing learning in relation to

clinical effectiveness. Provide timely collated quality of care self assessments as

requested by Healthcare Improvement Scotland.

Practising

Ensure they are up to date with evidence based practice and change practice

according to relevant standards, guidelines and research. Contribute to audits and

research.

Contribute to quality of care self assessments and reviews as requested by

Healthcare Improvement Scotland.

Supporting

Provide training, information, tools and methods to enable teams to undertake

audit, learn from adverse events and feedback. Support improvement. Collate a

register of improvement projects for dissemination. Share relevant links and

information about guidelines.

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APPENDIX 1 – STAFF CONTRIBUTIONS TO CLINICAL AND CARE GOVERNANCE

12

APPENDIX 2 - RECOMMENDED READING LIST

RECOMMENDED READING LIST FOR ALL STAFF IN RELATION TO

CLINICAL AND CARE GOVERNANCE

Every member of staff working in NHS Tayside and the Health and Social Care Partnerships has a responsibility for Clinical and Care Governance and each

of us contribute everyday regardless of our role and level of leadership.

The aim of this document is to inform staff of key documents that are available about all aspects of Clinical and Care Governance to ensure that staff are

clear and well informed about how the activities that we are involved in on a daily basis contribute to the delivery of the Clinical and Care Governance

Strategy 2019 – 2021. This in turn ensures that we are supporting safe, effective and person centred care.

Within the Clinical and Care Governance Strategy 2019-2021, we refer to responsibilities falling into 4 levels (2000, Scottish Executive):

Overseeing –members of Clinical Quality Forum and Care Governance Committee, non-executives.

Delivering – management structure, including clinicians involved in management – Triumvirate and management leads, clinical governance leads

Practising – clinical, administrative and support staff

Supporting – staff employed in activities underpinning clinical governance, e.g. those involved in clinical effectiveness, audit, complaints handling and

risk management.

This reading list follows the same structure to ensure staff are clear regarding what are the key documents they need to be aware of and where to access

them for further information. The following symbols depicts the level at which you need to be aware/have read the documents dependent on your role.

*** - This is a key document/resource for your role and the expectation would be that you would be well versed in the content of it.

* - You need to have an awareness of this and where you can access it.

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Link Overseeing Delivering Practising Supporting

NHS Tayside Vision, Aim and Values https://www.nhstayside.scot.nhs.uk/YourHealthBoard/index.htm *** *** *** ***

NHS Tayside Transforming Tayside web pages

https://www.nhstayside.scot.nhs.uk/OurServicesA-Z/TransformingTayside/index.htm *** *** *** ***

Transforming Tayside Staffnet page http://staffnet.tayside.scot.nhs.uk/OurWebsites/TransformingTayside/index.htm *** * * *

Clinical and Care Governance Strategy 2019-21

http://staffnet.tayside.scot.nhs.uk/NHSTaysideDocs/groups/working_safely/documents/documents/prod_231679.pdf

*** * ***

How do I contribute to Clinical and Care Governance?

http://staffnet.tayside.scot.nhs.uk/NHSTaysideDocs/groups/working_safely/documents/documents/prod_317495.pdf *** * *** ***

Clinical Governance and Risk Management Staffnet Page

http://staffnet.tayside.scot.nhs.uk/safeeffectiveworking/ClinicalGovernanceandRiskManagement/index.htm *** * ***

ADVERSE EVENT AND CLINICAL RISK MANAGEMENT

Adverse Event Management Policy http://staffnet.tayside.scot.nhs.uk/NHSTaysideDocs/groups/working_safely/documents/documents/docs_016314.pdf

*** * ***

Adverse Event Management Resource Pack http://staffnet.tayside.scot.nhs.uk/NHSTaysideDocs/groups/working_safely/documents/documents/prod_325457.pdf

*** * ***

Learning from Adverse Events through Reporting & Review – A National Framework for Scotland: July 2018

http://www.healthcareimprovementscotland.org/our_work/governance_and_assurance/learning_from_adverse_events/national_framework.aspx

*** *** * ***

Duty of Candour Legislation http://www.legislation.gov.uk/ssi/2018/57/made *** *** * ***

Duty of Candour Flowchart http://staffnet.tayside.scot.nhs.uk/NHSTaysideDocs/groups/working_safely/documents/documents/prod_297911.pdf

*** * ***

Quick Guide to Duty of Candour http://staffnet.tayside.scot.nhs.uk/NHSTaysideDocs/groups/working_safely/documents/documents/prod_302734.pdf *** * *** ***

Risk Management Strategy 2015 – 20 http://staffnet.tayside.scot.nhs.uk/NHSTaysideDocs/groups/working_safely/documents/documents/prod_150658.pdf

*** * ***

Risk Management Guidance Note http://staffnet.tayside.scot.nhs.uk/NHSTaysideDocs/groups/working_safely/documents/documents/prod_187777.pdf

*** * ***

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Link Overseeing Delivering Practising Supporting

Integrated Joint Board Risk Management Policy and Strategy

http://staffnet.tayside.scot.nhs.uk/NHSTaysideDocs/groups/working_safely/documents/documents/prod_249967.pdf *** *** * *

Patient Safety Staffnet Page http://staffnet.tayside.scot.nhs.uk/safeeffectiveworking/ScottishPatientSafetyProgramme/index.htm * *** * ***

Resilience planning policy

http://staffnet.tayside.scot.nhs.uk/NHSTaysideDocs/idcplg?IdcService=GET_FILE&dDocName=DOCS_025250&Rendition=web&RevisionSelectionMethod=LatestReleased&noSaveAs=1

*** * *

CONTINUOUS IMPROVEMENT

Realistic Medicines https://www.gov.scot/publications/chief-medical-officer-scotland-annual-report-2015-16-realising-realistic-9781786526731/

*** * *

Improvement Academy website http://www.ahspartnership.org.uk/ahsp/improvement-team-nhs-tayside/improvement-academy

* * ***

Service Improvement website http://www.ahspartnership.org.uk/ahsp/improvement-team-nhs-tayside

* * ***

PERSON CENTREDNESS

Informed Consent Policy (If working within a Clinical Service)

http://staffnet.tayside.scot.nhs.uk/NHSTaysideDocs/idcplg?IdcService=GET_FILE&dDocName=DOCS_016304&Rendition=web&RevisionSelectionMethod=LatestReleased&noSaveAs=1

*** *** *

Volunteering Policy

http://staffnet.tayside.scot.nhs.uk/NHSTaysideDocs/idcplg?IdcService=GET_FILE&dDocName=DOCS_059981&Rendition=web&RevisionSelectionMethod=LatestReleased&noSaveAs=1

*** * ***

Volunteer Services Website http://eds.tayside.scot.nhs.uk/Internet01/GettingInvolved/VolunteerServices/index.htm

*** * *

Carer Staffnet Page http://staffnet.tayside.scot.nhs.uk/OurWebsites/CarersInformation/index.htm?SSContributor=true

*** * *

Patient Information Guidelines http://staffnet.tayside.scot.nhs.uk/NHSTaysideDocs/groups/pil/documents/documents/prod_216545.pdf

*** * *

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Link Overseeing Delivering Practising Supporting

Embracing Equality, Diversity and Human Rights Policy

http://staffnet.tayside.scot.nhs.uk/NHSTaysideDocs/idcplg?IdcService=GET_FILE&dDocName=DOCS_016482&Rendition=web&RevisionSelectionMethod=LatestReleased&noSaveAs=1

* *** * *

Equality, Diversity and Human Rights Staffnet Page

http://staffnet.tayside.scot.nhs.uk/OurWebsites/EqualityDiversityandHumanRights/index.htm

*** * * NHS Tayside Complaints and Feedback Staffnet Page

http://staffnet.tayside.scot.nhs.uk/safeeffectiveworking/ComplaintsandFeedback/index.htm * *** * *

Excellence in Care website https://www.nhstayside.scot.nhs.uk/OurServicesA-Z/ExcellenceInCare/index.htm

*** * *

Customer Care LearnPro https://nhs.learnprouk.com/lms/user_level/NavigatorHome.aspx

*** * *

Care Opinion https://www.careopinion.org.uk/ *** * *

SPSO – Valuing Complaints dedicated website

https://www.valuingcomplaints.org.uk/ * *** * *

HIS Patient Feedback Models https://ihub.scot/improvement-programmes/people-led-care/person-centred-health-and-care/real-time-and-right-time-evaluation-report/

*** * *

Patient Rights (Scotland) Act 2011 http://www.legislation.gov.uk/asp/2011/5/contents *** * *

Person-centredness – the ‘state’ of the art – IPDJ editorial

https://www.fons.org/library/journal/volume5-person-centredness-suppl/article1

*** * *

The Community Empowerment (Scotland) Act 2015

http://www.legislation.gov.uk/asp/2015/6/contents/enacted *** * *

NHS Tayside Participation Staffnet page http://staffnet.tayside.scot.nhs.uk/OurWebsites/Participation/index.htm

*** * *

Participation Standard http://staffnet.tayside.scot.nhs.uk/OurWebsites/Participation/ParticipationStandards/index.htm

*** * *

Transforming Tayside 2019-2022 and Communications and Engagement Strategy and Action Plan

https://www.nhstaysidecdn.scot.nhs.uk/NHSTaysideWeb/idcplg?IdcService=GET_SECURE_FILE&dDocName=PROD_320663&Rendition=web&RevisionSelectionMethod=LatestReleased&noSaveAs=1

* *** * ***

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Link Overseeing Delivering Practising Supporting

CLINICAL EFFECTIVENESS

Healthcare Quality Strategy https://www.gov.scot/publications/healthcare-quality-strategy-nhsscotland/ * *** * *

Health and Social Care Standards http://www.newcarestandards.scot/ *** * *

Quality of Care Approach http://www.healthcareimprovementscotland.org/our_work/governance_and_assurance/quality_of_care_approach.aspx

*** * *

Getting it Right for Everyone – A Clinical, Care and Professional Governance Framework

Currently unavailable on Staffnet – hard copies available from CGRM team

*** * *