New Good Governance Handbook and
QI/Clinical Audit Guide for Provider Boards
Kate Godfrey, Director of Operations for Quality Improvement and
Development, HQIP
Dr John Bullivant, GGI Chairman
www.hqip.org.uk
www.good-governance.org.uk
The original Good Governance Handbook (2012)
and Clinical Audit Board Guide (2010)
Rationale for the new guides
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changes in the architecture of the NHS in England,
Health and Social Care Bill
lessons from Mid Staffordshire and Keogh Reviews
enhanced focus on well-led organisations
Emphasis on board’s role in quality improvement, cost
effective outcomes, transparency
• The target audience for these guides are aspiring lead
clinicians and NEDs
• Also useful to Commissioners
Clinical Audit Guide: key themes
1. Suitability of clinical audit: right tool?
2. CA strategy aligned to broader strategic interests
3. Balancing local and national priorities
4. Timescales, prioritisation
5. Professionalism
6. Patient and stakeholder involvement
7. Internal/external relationships
8. Digitalisation & info sharing
9. Education & training
Clinical Audit Q&A for Boards
Question
Answer 1
Answer 2
Is our Clinical Audit
Strategy aligned to the
organisation’s strategic
objectives and board
assurance framework
Clinical Audit is planned
and monitored by the
clinical audit department
and activity is reported
on at the relevant board
sub- committee Clinical
Audits that coincide with
strategic priorities are
used for assurance
We ensure that the
clinical audit programme
is aligned to our strategic
objectives and we have
identified where clinical
audit can provide
assurance and where
there are gaps. These
gaps will be addressed in
forthcoming plans and
budgets
Clinical Audit Q&A for Boards
Question
Answer 1
Answer 2
Are patients and
stakeholders engaged in
the clinical audit
process?
The results of our clinical
audits are publicly
available and we
disseminate a summary
of them to
commissioners and
stakeholders.
To ensure PPE, we invite
patient and stakeholder
representatives and
Healthwatch to our
quality improvement
team meetings. Our
clinical audit reports
have become more
patient-friendly and a
summary of the result is
disseminated to
stakeholders and patients
in our newsletter.
Group Work
Good Governance Institute (GGI) and Healthcare Quality Improvement Partnership (HQIP)
Conference copy
November 2014
Clinical Audit Maturity Matrix
Progress level
1 Basic Level
Principle accepted and
commitment to action
2 Early Progress in
development
3 Results being achieved
4 Maturity Comprehensive assurance in
place
Timescales
Our annual audit cycle
develops direct year-byyear clinical audit data.
We analyse clinical audit data
systematically and conduct reaudits in areas where standards
have not been met to ensure
improvements to the quality of
our services.
We operate a rolling audit
programme, which covers all
stages on an on-going basis, and
ensures prioritisation beyond the
annual cycle.
Education and
training
We run regular sessions
to train new Clinical Audit
staff and junior doctors
in clinical audit
methodology.
We have reviewed how we can
use audit data more
intelligently to design
measures to improve
outcomes, especially in areas
where standards have not
been met.
We recognise the importance
of training opportunities for all
members of staff involved in
the clinical audit cycle to
understand statutory guidance
and how to use clinical audit
most effectively. Clinical audit
is covered in our inductions
and further learning material is
provided by the organisation.
Junior doctor clinical audit
projects are supported by the
clinical audit team.
Broadening our education and
training approach to quality
improvement and clinical audit
in particular is already showing
greater staff engagement in
planning, conducting and
evaluating national and local
clinical audit. Junior doctor
clinical audit and other quality
improvement projects are
supported by the clinical audit
team and their suggestions for
improvements are welcomed.
Clinical audit is an important
feature of our induction and
further training programmes on
clinical governance. In addition,
we have regular clinical audit
workshops and invite our staff to
participate in further speciality
specific external training and
networking. Junior doctor clinical
audit quality improvement
projects are a valuable quality
improvement resource, and focus
on priority issues.
→
Key Elements ↓
The Good Governance Handbook: key themes
1. Clarity of purpose, roles and behaviours
2. Application of Principles
3. Leadership & strategic direction
4. Effective relationships – external stakeholders,
patients and community
5. Effective relationships - Internal incl. members
The Good Governance Handbook: key themes
6. Transparency & public reporting
7. Systems and structures: Quality and safety,
boundary issues
8. Challenge on delivery of agreed outcomes
9. Risk & Compliance
10.Organisational effectiveness: adding value
Good Governance Q&A for Boards
Example
assurance
question
Answer 1
Answer 2
Do we ensure
clarity about
the purpose,
roles and
desired
behaviours of
our board?
The purpose and role of our
board is adequately described
by the regulator, and in our
contracts. We have used the
various templates available to
organise how our board
operates at this level.
Our governance procedures and
activities are focused on
outcomes and the quality of care
we provide. Good governance is
of concern to everyone in our
team, with the board providing
strong support at all levels and
assurance as well as ensuring
constant improvement.
Good Governance Q&A for Divisions/Directorates
Example
assurance
question
Answer 1
Answer 2
Does our
division/
directorate
apply each of
the principles
of good
governance in
its day-to-day
workings?
Our division/directorate
management focuses on
supporting the board and
implementing its decisions.
Our division/directorate
management applies the
principles of good governance. It
ensures the implementation of
the board’s decisions but also
scrutinises and challenges the
latter. Adhering to the
subsidiarity principle, we
delegate decisions to the wards
in our directorate/division
where appropriate.
Good Governance Q&A for Departments
Example
assurance
question
Answer 1
Answer 2
Does our
department
have effective
external
relationships
with
stakeholders,
patients and
the
community?
The organisation has a PALS and Our well-established procedures
PPIteam who undertake this.
ensure close collaboration with
commissioners, patients, carers
and third party organisations
when a patient is discharged into
the community. The department
engages regularly with patients,
formal and informal carers and
other community organisations
to ensure continuity in our
patients’ care.
Barriers to change: lessons learnt
• Current practice in escalating Clinical Audit into decision-making and
actions
• Board assurance – strategic use and relationship with internal audit
• The role of key stakeholders in Clinical Audit and quality improvement
and what guidance is needed
• What is needed to guide assurance for commissioners?
• The current challenges and opportunities around information
governance and partnership working in Clinical Audit (including crossboundary use in health and social care)
• Who uses this guide? How might the guide be useful in induction and
training?
Next steps – project timeline
• Publication December 2014 / January 2015
• 2015 workshops:
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Wednesday 14 January – LONDON
Wednesday 21 January – MANCHESTER
Thursday 22 January – LEEDS
Wednesday 28 January- BIRMINGHAM
Thursday 29 January- BRISTOL
Wednesday 11 February – LONDON
• More info at www.hqip.org.uk or www.good-governance.org.uk