CLINICAL GOVERNANCE POLICY
[Name of Practice]
The [partners / directors] of [Name of Practice]  have an ongoing commitment to
clinical governance within the practice to improve the clinical effectiveness of
treatments and procedures used within the practice.
All staff members are encouraged to input ideas to the clinical team to improve
standards of care & systems of delivery of care within the practice.
The methods used to achieve this aim are –
1
CLINICAL MEETINGS
The veterinary surgeons, nurses and clinical support staff will hold a clinical meeting
to discuss clinical cases every [x]  weeks. These meetings will be at [lunctime / 8.30
am / evening]  and all clinical staff, whether full or part time should make every
effort to attend.
Items for discussion should be noted as they arise [on the computer under agenda
items / on the list in the vets’ office]  and these will be used as the basis for the next
clinical meeting.
Minutes of the meeting will be kept & circulated as soon as possible after the
meeting, including to any staff unable to attend.
Action points will be drawn up from the minutes & progress with these will be
discussed at the next meeting.
Records:
 minutes or notes of clinical meetings
 notes detailing actions as result of meetings
2
COMMUNICATION OF INFORMATION OBTAINED AT CPD MEETINGS
Any vets or nurses who attend CPD meetings must bring back to the practice a
summary of what they have learned – this can be a short presentation at the clinical
meeting / a memo to other staff / an internal e mail to other staff. The summary
should be presented or circulated within 4 weeks of the CPD meeting.
Records:
 meeting minutes , memos , emails, etc
3 SIGNIFICANT EVENT
In the case of an unexpected event such as a surgical or medical complication,
serious complaint, accident or anaesthetic death, the details must be recorded as
soon as possible by all staff involved. Following this a “no blame” meeting will be
held within 14 days to discuss anything that could have been done to avoid this and
to consider any changes in procedure that might be implemented as a result of
lessons learned.
Records:
 notes of event
 minutes of “no blame” meeting
 notes detailing changes in procedure
4 PRACTICE POLICIES OR PROTOCOLS
Following discussions with the practice team, and looking at the evidence base,
protocols will be drawn up for some of the common procedures in practice such as:

Adult and foal elective anaesthesia protocols

Emergency surgery protocols e.g. caesarean, fracture repair etc

Treatment monitoring protocol for EMS

Procedure followed in event of post operative wound infection, e.g.

Culture and sensitivity of swab etc
Records:


protocols
review notes
5 CLINICAL AUDIT
Example of clinical audits are available at www.vetaudit.co.uk
E.g. Audit of post–operative complications in castration
Records:
 audit reports
 follow up reports
NOTES
It is not necessary to adopt all 5 elements of this policy template.
Records listed in shaded boxes will have to be produced for RCVS PSS inspectors in
addition to the policy document
Practices should decide which parts of policy are relevant to them and choose
subjects according to practice team interests.

Amend as appropriate