DRAFT
ROYAL BERKSHIRE AMBULANCE NHS TRUST
A CLINICAL GOVERNANCE STRATEGY
2002 - 2007
TABLE OF CONTENTS
INTRODUCTION ……………………………………………………………………………………3
BACKGROUND ……………………………………………………………………………………..4
CLINICAL GOVERNANCE AND RISK MANAGEMENT STATEMENT ……………….………5
CG MANAGEMENT ORGANISATION AND RESPONSIBILITIES …….………….6
4.1 Executive Responsibility………..…………….. ……………………………………………….6
4.2 Board Committee Structure ……………………………………………………………………....9
4.2.1
Clinical Governance responsibilities under the Service Directors……..……….9
4.3............................................................................... Clinical Governance and Risk Committee 9
4.4.......................................................................................... Trust Clinical Effectiveness Group 11
4.5........................................................................................... Local Ambulance Advisory Panel 11
4.6.......................................... Patient Advice and Liaison Service (PALS) - under development 12
4.7........................................................................................................................ Caldicott Group 13
4.8........................................................................................... Health and Safety Working Group 13
4.9....................................................................Vehicle, Equipment and Uniform Working Party 14
4.10.................................................................................................................... Audit Committee 14
4.11..........................................................................................................................................BSI 14
4.12...................................................................................... People and Organisation Committee 15
4.13.............................................................................. Line Managers and Heads of Department 15
4.14.................................................................................................................................. All Staff 16
5. CLINICAL GOVERNANCE ACTIVITIES AND TARGETS ……………………………………..16
6. MONITORING CLINICAL GOVERNANCE ACTIVITIES ………………………………………16
7. ROYAL BERKSHIRE AMBULANCE TRUST REFERENCES …………………………………..16
7.1 Acknowledgements……………………………………………………………………………...17
1.
2
3.
4.
APPENDICES
Appendix 1
THE SEVEN PILLARS OF CLINICAL GOVERNANCE ..................................................... 18
1 Consultation and Patient Involvement .................................................................... 18
2 Clinical Audit Activity ............................................................................................ 18
3 Clinical and Non-Clinical Risk Management ......................................................... 19
4 Research and Effectiveness ..................................................................................... 22
5 Staffing and Staff Management ............................................................................... 22
6 Education and Training ........................................................................................... 25
7 Use of Information to Support Clinical Governance and Healthcare Delivery ...... 26
Appendix 2
THE TARGETS AGREED FOR 2002-2003 FOR THE NINE PILLARS OF CLINICAL
GOVERNANCE SET OUT FOR THE SOUTH EAST REGION OF THE NHS. ............. 28
a) Clinical Governance Strategies ............................................................................... 28
b) Consultation And Patient Involvement ................................................................... 29
c) Clinical Audit Activity ............................................................................................ 30
d) Clinical and Non-Clinical Risk Management ......................................................... 31
e) Research and Effectiveness ..................................................................................... 32
f) Staffing and Staff Management ............................................................................... 33
g) Education and Training ........................................................................................... 34
h) Use of Information to Support Clinical Governance and Healthcare Delivery ...... 34
Appendix 3
GLOSSARY OF TERMS ......................................................................................................... 35
2
ROYAL BERKSHIRE AMBULANCE NHS TRUST
A CLINICAL GOVERNANCE MANAGEMENT STRATEGY
1.
INTRODUCTION
1.1
This strategy outlines the plan for the continued implementation of Clinical
Governance at the Royal Berkshire Ambulance NHS Trust. We have drawn on
experiences of other Trusts, both locally and nationally, inside and outside the
ambulance services, who have participated in the first wave of reviews undertaken by
the Commission for Health Improvement.
1.2
While recognising that this strategy for quality is ambitious, it is built on a foundation
of continued achievement both in performance and financial control of which the
Trust, and those working within it are rightly proud. This document provides an
understanding both of how Clinical Governance is organised within the Trust and
what the Trust’s priorities are, during the forthcoming five years and outlines goals
for the next two years.
1.3.
The key objectives addressed by the Strategy to deliver quality in the organisation are
to:
 integrate Clinical Governance and risk management activity in both the clinical and
non-clinical areas;
 ensure there is an effective and comprehensive system for untoward incident and
near misses review and complaints management;
 ensure a process for appropriate learning which leads to quality improvements;
 ensure that patients and other service users contribute to the development of the
Trust’s clinical and non-clinical services
 assist with statutory compliance in all areas of the Trust’s activities;
 provide a mechanism to assure the Trust Board that appropriate and necessary
control systems are in place to reduce and control risks;
 encourage financial benefits from improving quality and minimising risk.
1.4
The Trust Board believes that by approaching the control of risks in a strategic and
organised manner, the risks can be reduced to an acceptable level. This will result in
better quality care for patients and service users, a safer environment and a reduction in
unnecessary expenditure.
1.5
The Trust promotes the right of the individual to be informed and consulted on
pertinent issues. It recognises that inadequate communication is a major risk factor,
with perceived withholding of information potentially resulting in lowered staff morale
and subsequent reduction in the quality of service provision.
1.6
The involvement of all staff in Clinical Governance will be encouraged by promoting
an open, ‘blame-free’ culture, in which individuals are empowered to voice their
concerns in the knowledge that due attention will be paid to these, as evidenced by
3
feedback on how these issues have been addressed. The Trust recognises that in the
majority of adverse incidents there is an organisational failure leading up to the event1.
2
BACKGROUND
2.1
Since the advent of clinical governance as set out in the Government’s white paper The
new NHS Modern. Dependable2 and in A First Class Service. Quality in the new NHS
Health Services Circular 19983, organisations have been struggling with the concept of
clinical governance and how to put it into practice. It is clear that Clinical Governance
is the cornerstone of the Government’s strategy for the NHS, which is to ensure that
quality care is the driving force for the development of health services. The overall aim
is to improve standards of care by reducing and understanding variations, improving
outcomes and access to services. The clinical decisions taken will be based on up-todate evidence to ensure its effectiveness.
2.2
The framework that emerges for the implementation of Clinical Governance requires
local interpretation. Central to this is the use of a multi-professional, multi-disciplinary
and multi-agency approach, in addition to building on current systems for ensuring
quality care already in use, eg, clinical audit, risk management, quality assurance,
clinical effectiveness and staff and organisational development. Local ownership and a
shared interpretation of Clinical Governance are viewed as essential for successful
implementation.
2.3
The key to the success of Clinical Governance within each health organisation rests on
maximising and developing a culture based not only on collaboration, teamwork and
the sharing of expertise, but one in which innovation and learning are nurtured against a
backdrop of openness, trust and public discussions.
2.4
In considering the challenges for providing quality-driven healthcare for the 21st
century such as that envisaged in A First Class Service. Quality in the new NHS4,
central to this thinking is the desire reflected in this strategy of involving patients as
active partners in their own health care, thereby underpinning the Trust’s vision of the
clinical governance strategy.
1
Organisation with a Memory, Department of Health 2000
The stationary office Ltd. 1997 The new NHS Modern. Dependable. London
3 Department of Health 1998 A First Class Service. Quality in the new NHS Health Services Circular
1998
4 Department of Health 1998 A First Class Service. p113
2
4
3.
CLINICAL GOVERNANCE AND RISK MANAGEMENT STATEMENT
3.1
The following Clinical Governance and Risk Management Statement has been
distributed to all staff throughout the Trust as part of the Trust's Strategic Plan.
CLINICAL GOVERNANCE AND RISK MANAGEMENT STATEMENT
The vision of the Royal Berkshire Ambulance NHS Trust is:
“To be a model ambulance service”
The Trust recognises that the management of Clinical Governance and risk is a
key factor in achieving this aim, as is controlling any potential risk to staff and
general public. It is also the duty of the Trust to safeguard the assets and
reputation of the Trust.
The trust will ensure that quality improvement processes are in place, leadership
skills are developed at clinical team level, evidence based practice is in day-to-day
use and good practice, ideas and innovations are systematically disseminated.
Problems of poor clinical performance will be recognised and dealt with at an
early stage.
All professional development programmes will reflect the principles of clinical
governance .
Quality data will be collected to monitor clinical care & will be of a high standard
A systematic approach will be taken to the on-going identification and assessment
of risk, with prompt action initiated to eliminate or control those risks identified.
The management of Clinical Governance and risk is the responsibility of all
managers and staff throughout the Trust. This will be achieved within a
progressive, honest and open environment, where mistakes and untoward incidents
are identified quickly and acted upon in a positive and constructive way. Staff will
be provided with the necessary education, training and support to enable them to
meet this responsibility.
5
4.
CLINICAL GOVERNANCE ORGANISATION AND RESPONSIBILITIES
4.1.
Executive Responsibility
4.1.1 Whilst ultimate responsibility for quality lies with the Chief Executive and the Trust
Board, the overall executive responsibility for Clinical Governance has been
delegated to the Medical Director. He is a member of the Clinical Governance and
Risk Committee.
4.1.2 While the Directors are assisted in this role by several managers within the Trust,
whose departments support the various aspects of Clinical Governance, the Trust
believes that clinical governance will only develop if there is full ownership and
collaboration from staff at all levels of the organisation and its structure reflects the
importance the Trust places on the involvement of staff included in direct patient care.
4.1.3 The Medical Director provides board level leadership. The Clinical Governance and
Risk Committee (CGRC) provide the strategic direction that feeds into the Trust
Board. This is then cascaded down through the Trust Clinical Effectiveness Group
and Operations Committee to Operational staff via their Clinical Supervisors and
Work-based Assessors. These groups act as the drivers for change and development.
They are multi-professional representing the services they provide. At present the
Clinical Effectiveness Group, Operations Committee and the Clinical Governance and
Risk Committee take responsibility for clinical governance elements such as: risk,
clinical audit, information, staffing, education & continuing professional
development, clinical governance strategy and the clinical governance organisation &
responsibilities.
4.1.4 A key principle in the Trusts’ policy is that the Clinical Governance and Risk
Committee and the Clinical Effectiveness Group reports using an agreed format on
specific clinical governance issues. Of the ‘pillars of clinical governance’ the groups
are responsible for patient experience & involvement, risk management, clinical audit,
research & effectiveness and also consider items of information management,
staffing, education and continuous professional development which may impact
directly on their projects. Otherwise, these topics are considered in the relevant
departments / meetings outlined later in this document. The Clinical Effectiveness
Group is responsible for developing an agreed forward plan including patient
experience, clinical audit and clinical guidelines focussing on high risk or high
volume procedures. The programme is informed by claims and complaints and by
national initiatives such as the NSF standards and NICE guidance.
4.1.5 To support the staff and ensure the co-ordination and development of Clinical
Governance activity the Trust has in place the Clinical Governance and Risk
Committee and Clinical Effectiveness Group who provide expertise, facilitation and
training in the following areas; complaints, litigation, clinical risk, clinical audit and
research and development. An important role for the Clinical Effectiveness team is
that a senior member attends all Clinical Governance and Risk Committee meetings to
ensure a common approach and provide feedback both to and from the Clinical
Effectiveness Group.
4.1.6 The organisation for clinical governance with respect to risk, audit and effectiveness
and complaints is well developed in terms of structure. However, clinical governance,
6
incorporating all elements, is currently in its infancy and supporting structures and
processes continue to be refined and developed .
7
4.2
BOARD
COMMITTEE
S T R U C T U R E
EXECUTIVE TEAM
MEETING
CAPITAL
MANAGEMENT
AUDIT
COMMITTEE
CHARITABLE
COMMITTEE
M E E T I N G S
DIRECTORS’
REMUNERATION
COMMITTEE
APPOINTMENTS
COMMITTEE
STAFF
COUNCIL
PEOPLE &
ORGANISTION
COMMITTEE
B O A
R D
JOINT
NEGOTIATING
GROUP
T R U S T
VEHICLE,
EQUIPMENT &
UNIFORM WORKING
PARTY
OPERATIONS
COMMITTEE
LOCAL AMBULANCE
ADVISORY PANEL
MEETING
CLINICAL
EFFECTIVENESS
GROUP
RISK
MANAGEMENT &
CLINICAL
GOVERNANCE
COMMITTEE
Meeting Structure 1 April 2002
HEALTH & SAFETY
WORKING GROUP
CALDICOTT
GUARDIANS
8
4.2.1
Clinical Governance responsibilities under the Emergency Services, Customer Services
and Medical Director
Medical Director

LAAPs
Emergency Services and
Customer Services Directors
Corporate Services Manager
 Claims
 Complaints
Critical incidents analysis & reporting
 CNST
 Controls Assurance
 Health & Safety
 CHI preparation and Project Plan
 Public Involvement
 Co-ordination (RCGC)
Clinical Effectiveness Manager
 Co-ordination (Clinical Effectiveness Group)
 Clinical Audit
Research and Development
Clinical Guidelines / Document Review
 Clinical Governance Management
 Project management
 Trust Lead for NHS Plan
 Trust Lead for NSFs (Coronary Heart Disease and
the Older Patient)
 Trust lead for Category "C" projects
 Trust lead for Electronic Patient Report Forms
Representation on:
 Audit Committee
VEHICLE,
EQUIPMENT &
 IM&T
UNIFORM WORKING
 Caldicott
PARTY
 Vehicle, Equipment and Uniform Working Party
 People and Organisation Committee
 Staff Council
 Negotiating Group
9
4.3
Clinical Governance and Risk Committee
Role
The Clinical Governance and Risk Committee (CGRC) is established under the Trust Board.
It has a strategic role in the co-ordination and monitoring of the Trust’s Clinical Governance
and Risk Management Strategies ensuring there are processes for risk assessment in place, so
that risk is managed pro-actively and that there is no unnecessary duplication of effort or
information gathering, but equally making it clear where final responsibility lies for dealing
with individual issues.
The operational functions will be devolved as appropriate to sub-committees.
Terms Of Reference
1.
To ensure in light of information available that there are adequate risk assessment
processes in place throughout the Trust. The committee will set targets for Clinical
Governance and risk management where appropriate.
2.
The CGRC will promote a culture of continuous quality improvement.
3.
The Committee will receive reports at each meeting from the following subcommittee.







The Trust Clinical Effectiveness Group
The Local Ambulance Advisory Panel
The Health and Safety Working Group
Caldicott Guardians
Management Review Groups (BSI Quality Systems)
Major Incident Planning Officer
The Trust Patient Advisory Liaison Panel (when formed)
- and review Claims against the Trust presented by Marsh UK Limited
The Committee will devolve responsibility for action to one of these groups as is felt
appropriate.
4.
The Committee will ensure that risk management objectives remain in line with the
objectives of the Controls Assurance initiative within the NHS and the Controls
Assurance Statements in the Annual Accounts. However, the Committee will also
remain aware of its relationship with The Audit Committee whose function is to
assure The Board that Financial Controls are sound.
5.
The group will report to the Board quarterly
10
4.4
Trust Clinical Effectiveness Group
Role
The Clinical Effectiveness Group is established as a working group of the Trust’s Clinical
Governance and Risk Committee with the responsibility to ensure all operational staff
maintain and improve clinical standards.
This aim is achieved by providing a
multidisciplinary structure to support clinical effectiveness and by promoting an evidencebased practice culture throughout the Trust.
Improving clinical effectiveness will have a major impact in improving standards of care,
better use of resources and reducing clinical risk in the organisation in accordance with the
principles of Clinical Governance being adopted within the Trust.
Key points from Terms of Reference
1.
Identify priority areas, taking into account both local and national priorities and
initiatives
2.
Develop knowledge of Evidence-Based Practice (EBP) and Critical Appraisal Skills
within the Trust
3.
Develop facilities to enable widespread and easy access to knowledge
4.
Identify and improve current facilities within the Trust for information and
knowledge-acquisition within the Trust relevant to clinical effectiveness (CEf)
including record keeping
5.
Encourage the development of a systematic approach to CEf e.g.
-
Identify priority area
Identify current practice
Critical appraisal of best practice
Develop evidence-based guidelines, protocols and procedures
Compare current with best practice
Change practice if necessary
Monitor
6.
Review and recommend remedial action for adverse clinical incidents to the CGRC
and the management team for implementation
4.5
Local Ambulance Advisory Panel
RBAT have observed the Rules and Regulations for Paramedic Training, by
establishing the mandatory Local Paramedic Steering Committee.
11
Principal Objective
Composed of specialist consultants in fields related to ambulance work, the Local Ambulance
Paramedic Steering Committee oversee the training of Paramedics and review the clinical
policies and protocols under which they work.
Functions:
1.
To advise on and approve Drug Protocols for use by RBAT staff
4.6
2.
To advise on and approve clinical procedures undertaken by RBAT staff
3.
To provide specialist Consultant advice in each member’s clinical area and keep
the Ambulance service appraised of developments in clinical practice
4.
To consider the application of National Ambulance Guidelines within the local
area taking into account the local Health Care structure
5.
To approve the arrangements for the Paramedic course and re-assessment process
6.
Chairman or Deputy to oversee Paramedic Training course and determine that the
training has been carried out in accordance with the Rules, Regulations and
Syllabus. To sign the certificate application form of successful candidates
Patient Advice and Liaison Service (PALS) - under development
Proposed Role
Within the structure of Quality and Clinical Effectiveness the group to take responsibility for
all aspects of quality relating to patient care including complaints management.
The PALS will be established as a subcommittee of the Trust’s Clinical Governance and Risk
Committee with the responsibility to report on all significant matters which come to their
attention during the execution of their duties.
The PALS will operate within the limits of authority delegated to it by the Risk and Clinical
Governance Committee.
Proposed Terms of Reference for Discussion
1. To establish and monitor the effectiveness of a problem resolution system linking this to
systems of incident reporting to ensure that action is taken to address any trends identified
2. To establish a system of co-ordinating and quality-assuring all standard information for
patient use
3. To develop systems in which a culture of continuous quality improvement can be
developed. In the first instance this structure and function of the proposed group will be
developed
4. To lead the development of systems of patient involvement in clinical decision making
12
4.7
Caldicott Group
Role
Chaired by the Director of Finance and Business Services, this group advises and supports
the Trust in all issues concerned with confidentiality
Functions
1. Members of the group ensure confidentiality standards are being met
2. Members of the group have powers to monitor how standards are being met, identify
reasons why if they are not being met and ensure implementation of changes in practice
to meet those standards
3. To regulate and monitor the use of patient identifiable information (on an individual and
broader basis, for example information held in large databases)
4. To ensure that training in the ethical and legal issues around confidentiality is provided
for both clinicians and non-clinicians in the Trust
5. To advise on security issues, including, for example, how information should be protected
from direct access or browsing by anyone who is not treating the patient to whom the
information relates
6. To oversee training in the use of IT within the service and the protection of the
confidentiality of information held by the Trust.
4.8
Health and Safety Working Group
Role
The Health and Safety Working Group is established as a subcommittee of the Trust’s
Clinical Governance and Risk Committee with the responsibility to report on all significant
matters which come to their attention during the execution of their duties as described in the
Terms of Reference. This will include ensuring that systems are in place for reporting
accidents/non – clinical incidents and monitoring identified trends (including patients and
visitors).
Terms of Reference
To provide a staff consultation and discussion forum on all matters relating to health, safety
and the relational issues of Risk Management. Such matters will include:
-
the study of accident and risk report statistics and trends
the examination of safety reports and workplace inspections
the consideration of reports from appointed Safety Representatives
to consider & monitor the adequacy of safety and health communication and
awareness in the workplace
the development, introduction and monitoring of work safety rules and safe
systems of work.
13
4.9
Vehicle, Equipment and Uniform Working Party
Principal Objective:
To develop, evaluate and recommend to the Clinical Effectiveness and Operations Committee
the most appropriate type of vehicles, equipment and uniform which are cost efficient,
effective and fit for the purpose. Appropriate items are also taken to the CGRC.
Areas of Activity:

To oversee trials of medical equipment

To monitor equipment and uniform effectiveness and suitability and recommend the most
cost effective solutions.

To examine different vehicle and stretcher opportunities and take account of user views
when recommending appropriate capital purchases.

Monitor performance of existing vehicles, equipment and uniforms and their ongoing
developments.
4.10
Audit Committee
The Audit Committee, chaired by a non-executive director, will continue to have
responsibility for the management of financial risk. It will also co-ordinate activity in
accordance with the guidance given in HSC 1998/070 with regard to controls assurance, set
out in the NHS Executive Directions EL97/55.
The Finance Director has the responsibility for maintaining a sound system of internal control
that supports the achievement of the organisation’s objectives and for reviewing its
effectiveness.
The system of internal control is based on an on-going risk assessment process designed to
identify the principal risks to the achievement of the organisation’s objectives; to evaluate the
nature and extent of those risks and to manage them effectively and economically. The
system of internal control is underpinned by compliance with the requirements of the core
Controls Assurance standards:
 Governance
 Financial Management
 Risk Management (Risk Management System standard for 2001/2002-10-15
This Committee reports through the Chair to the Trust Board.
4.11
BSI
On the recommendation of the Board the Trust agreed to attain the standards set out by the
BSI organisation. The BSI Manager sets the agenda and timetable for the audits. Progress
14
and performance are monitored against the targets set, through individual department
Management Review Groups.
Regular reviews and reports should be presented to CGRC and Operations Committee by the
BSI Manager
4.12
People and Organisation Committee
The People and Organisation Committee reports directly to the Board
Role
To develop and recommend to the Board for approval, Organisational and Human Resources
Strategies and Policies to support the Trust’s business objectives and plans.
Areas of Activity:








4.13
Organisational development
Human Resources Policies and Procedures
Remuneration and reward systems
Manpower and planning and development
Employee relations
Communications
Training and Personal Development
Recruitment and Retention
Line Managers and Heads of Department
In conjunction with the Trust-wide Clinical Governance initiatives and systems, it is essential
that all managers accept that Clinical Governance is a part of their line management
responsibility. This will be reflected in the job descriptions and appraisal objectives of all
managers. Their responsibilities include:








active participation in the implementation of the Clinical Governance Strategy and
making any necessary changes and improvements;
implementation of specific Trust-wide Clinical Governance policies and procedures;
ensuring attendance of staff at Clinical Governance training sessions;
raising Clinical Governance Awareness at operational level;
encouraging staff to identify and report hazards and risks and responding
positively when they do so;
ensuring that all adverse incidents are reported through the incident reporting
system;
seeking advice on Clinical Governance issues as required;
facilitation of the Clinical Governance Assessment process and reporting the risks
identified to the Clinical Effectiveness Group or the Health and Safety Manager, as
appropriate.
15
4.14
All Staff
All Trust staff have responsibility to:





maintain general risk awareness at all times;
participate in Clinical Governance education and training;
comply with policies, procedures and protocols;
notify line managers of any identified risks or Clinical Governance issues;
adhere to the adverse incident reporting procedures.
5.
CLINICAL GOVERNANCE ACTIVITIES AND TARGETS
5.1
Clinical Governance is managed according to the nine pillars of clinical governance
which have been set out by the NHS and are the basis for monitoring by the South East
Regional Office. These activities are: Clinical Governance Strategy, Organisation and
responsibilities for Clinical Governance, consultation and public involvement, clinical
audit, clinical risk management, research and effectiveness, staffing and staff
management, education and training, use of information.
5.2
The targets that have been agreed are set out in appendix 1 and an annual forward plan
is attached (appendix 2).
5.3
A glossary of terms has been added for clarity and this appears in appendix 3.
6.
MONITORING CLINICAL GOVERNANCE ACTIVITIES
6.1
Clinical Governance activities will be reported to the Board on a monthly basis by the
Emergency Services Director, Customer Services Director, Medical Director and the
Corporate Services Manager
6.2
The Clinical Governance Action Plan and Outcomes will form a part of the Annual
Report.
6.3
The Clinical Governance and Risk Committee will be the forum for discussion and
development of Clinical Governance projects.
7.
ROYAL BERKSHIRE AMBULANCE TRUST REFERENCES
J:\Clinical Effectiveness\Clinical Governance\Strategy\RBAT Clinical Governance Strategy.doc
Controlled document: CEf 45
August 2002
Review due: August 2003
16
7.1
Acknowledgements
Written by:
C Breen
Clinical Effectiveness Officer
Approved by:
S Brown
Medical Director
10/09/02
Accepted by:
Debbie Dunning
Emergency Services Director
7/10/02
Approved by:
Ken Sealy
Non-Executive and Chairperson
At Clinical Governance and Risk Meeting: TBA
Ratified by:
Ian Ferguson
Chief Executive
At Board Meeting: TBA
17
APPENDIX 1
THE NINE PILLARS OF CLINICAL GOVERNANCE
Overall seven pillars of clinical governance were set out these have now been supplemented
by two additional requirements based on Clinical Governance strategy and clear
organisational structures with lines of responsibility, these latter two have been dealt with in
the main strategy document. Below is a discussion in more detail on the remaining seven
pillars.
1
Consultation and Patient Involvement
1.1
The NHS Plan sets out the Government’s ambitions to create a patient-centred NHS.
The involvement of users and external agencies in the development, delivery and
evaluating of health care services is an important aspect of the Clinical Governance
Agenda. The Trust recognises the need to involve and integrate users, carers and the
public at all levels of service delivery. With the aim of ensuring that they can act as a
powerful lever for change and improvement.
1.2
The Trust recognises that a considerable amount of work needs to be done to achieve
the targets of developing and implementing a public involvement policy, establishing
a PALS service and ensuring that there is organisational learning from claims and
complaints.
1.3
At the centre of patient involvement is the issue of informed consent to procedures,
treatment and personal care. The Trust is committed to implementing Good practice
in consent5, 6.
2
Clinical Audit Activity
2.1
Clinical Audit is an essential part of improving health services, through the accurate
and relevant measurement of practice against agreed standards. It is most effective
when applied to priority areas, where improvements in practice can be made if
required. Increasingly this agenda is defined nationally with standards set, for
example, within the National Service Frameworks (NSF) and ASA/JRCALC
guidelines.
2.2
The Trust must strive to provide detailed and accurate information on which clinical
decisions can be made and practice compared.
5
HSC 2001/023, Good Practice in consent; Achieving the NHS Plan commitment to patient-centred
consent practice, NHS Executive 2001
6 Good Practice in consent implementation guide: consent to examination or treatment. DOH 2001
18
3
Clinical and Non-Clinical Risk Management
3.1
Managing risks in clinical settings is a challenge to all those who deliver healthcare.
Recent reports7, 8 demonstrate the complexity of this process and make
recommendations to improve the situation.
3.2
The integration of Clinical and Non-Clinical Risk Management with Clinical Audit,
Research and Development, Complaints and Claims has been an important step in
managing a cycle of identification, assessment, action and evaluation.
3.3
The baseline assessments for the CNST and Controls Assurance have provided
valuable information on both the understanding and present compliance of issues
relating to both clinical and non-clinical risk.
3.4
Many of the risk targets discussed build on transferring existing, exemplary good
practice that flourishes within the organisation. These all have their roots within the
audit cycle and are concerned with the prevention of service failure.
3.5
Risk identification is crucial to the success of the Trust’s risk management
programme. This will be addressed through an ongoing programme of risk reviews.
The assessments will be undertaken by managers and staff, who will be provided with
education and training in risk management techniques relevant to the area in which
they are working.
3.6
Clinical risks identified will be analysed by the Clinical Effectiveness Group to
determine the potential for frequency of occurrence and severity of outcome. A copy
of all assessments undertaken will be passed to the CGRC, which will prioritise them
for action. A quarterly summary of actions will be forwarded to the Clinical
Governance and Risk Committee.
3.7
It is recognised that it is not possible to completely eliminate all risks. It is necessary
therefore to have control measures in place to reduce the likelihood of an adverse
occurrence or outcome. This will be addressed through the adoption of some or all of
the following measures:








7
8
the development of a comprehensive risk assessment process;
the development of a risk management training and education programme;
the utilisation of policies, protocols, procedures and guidelines;
risk acceptance (i.e. assuming the potential loss and allocating resources to
cover the financial consequences);
risk avoidance (i.e. utilising alternatives);
risk transfer (e.g. use of insurance, membership of the CNST);
contingency and disaster planning to reduce the effects of major internal
incidents (e.g. loss of utilities).
contingency and disaster planning for external Major Incidents for which the
Trust may respond
Organisation with a Memory, Department of Health 2000
Building a Safer NHS for Patients, Department of Health 2001
19
3.7
The risk control processes will be monitored regularly by the Clinical Governance and
Risk Committee. The Chief Executive and the Trust Board will be informed regularly
of the effectiveness of the systems in place, and whether these comply with the
changing requirements of the Controls Assurance Project.
3.8
The reporting of untoward incidents and near misses is one of the most essential parts
of Clinical Governance and risks management. It is also, in relation to clinical
incidents, one of the risk management standards of the CNST9, and will be an
important issue with regard to clinical governance.
3.9
The Trust will establish a unified system throughout the Trust for reporting all types
of incidents, including accidents and near misses, as a matter of priority. The
Glossary section describes what constitutes an incident, and these will be
supplemented by a Trust-wide awareness-raising and education programme for all
staff. This subject will also be included in the Trust induction programme for new
staff.
3.10
Staff will be encouraged to report incidents by the Trust’s commitment to the
establishment of an open and ‘blame-free’ culture. They will also be given feedback
by their line managers on the action taken (or not) as a result of the incidents they
have reported. Such feedback makes staff feel valued and encourages them to report
incidents.
3.11
The data collected will be collated and used to track and trend incidents. As such it
becomes a useful predictive and analytical risk management tool.
3.12
The provision of computer terminals on Resource Centres provides an excellent
opportunity for the use of immediate e-mailed risk management information.
Information can be entered directly onto the risk assessment form, thus making it
instantly available for analysis.
3.13
In the longer term risk assessments can be linked to the management of complaints
and claims, thus facilitating the exchange of information between these areas.
3.14
The Trust has developed a procedure for following up major clinical incidents. The
Trust will continue to develop procedures for reporting all incidents and accidents
3.15
High priority will be given to reducing the risks to patient, staff and all organisations
involved in Major Incidents within the operating area of the Royal Berkshire
Ambulance NHS Trust. This will be achieved by



9
Continued risk assessment of the operational area to identify high profile sites and
the development and continuous review of specific plans for those areas identified
Ensuring all staff are trained in their potential roles in a Major Incident and that all
staff are exercised in those roles
Continued development of key relationships in other response organisations and
the wider health economy aimed at disseminating good practice.
Clinical Negligence Scheme for Trusts, (Standard Number 4)
20
3.16
Adequate control of the potential for, and actual, cross infection reduces risk to both
patients and staff. The Health and Safety Working Party will report to the Clinical
Governance and Risk Committee.
3.17
The over-riding principles throughout this strategy document are those of risk
assessment, adequate training, control and monitoring. The Trust has addressed these
by delegating responsibility for health and safety risk assessments to line managers,
with the assessments being audited by the Health and Safety Manager. Health and
Safety guidance notes are produced which include forms to be used for risk
assessments.
3.18
All managers will ensure that they understand their responsibility for undertaking
health and safety risk assessments and health and safety is included in the induction
programme for all new staff, with updates planned as part of the Trust mandatory
refresher programmes.
3.19
High priority will be given to reducing the risks to staff from manual handling of both
patients and loads. The following initiatives have been undertaken to ensure that all
appropriate staff receives the necessary training:




training in manual handling techniques, commensurate with their roles, is
provided to all new staff, including bank staff, as part of their induction before
they commence their duties;
follow up training will be provided for all staff in the future, including bank staff,
on a regular basis;
records will be kept by the training department on the Promis database of all
training given and the names of staff attending
Managers are responsible for the manual handling risk assessments in their work
areas.
3.20
Regular reviews will be undertaken of the compliance with the Control of Substances
Hazardous to Health Regulations 1994 (COSHH). The results of these audits,
together with any recommendations for further action, will be reported to the Clinical
Governance and Risk Committee via the Health and Safety Working Party.
3.21
The Trust is committed to fire safety and has a Fire Officer advising. The overall
objective is to achieve compliance with Firecode, and where there are deficiencies
these are known, and are being addressed. The Trust recognises the importance of
building upon the good work already undertaken to ensure that fire safety remains a
high priority agenda item.

The introduction of mandatory bi-annual fire lectures for staff is being
considered;

The Trust has addressed the risk of fire resulting from smoking by initiating a
no smoking policy within Trust buildings.
3.22
The security of staff, patients and visitors, is a high priority for the Trust. To this
must be added the need to address an on-going problem of break-in theft and theft of
computer equipment in particular.
3.23
In order to address the various issues in a systematic way, a security strategy is being
drafted by the Estates Manager and the Emergency Services Directorate to be
21
approved by the Clinical Governance and Risk Committee before being presented for
ratification by the Trust Board. The Strategy will include:
 an education programme to raise staff awareness of security measures and the need
for vigilance;
 security risk assessments;
 security marking and securing of equipment;
 access control;
 use of closed circuit television (CCTV) system or dummies in lower risk areas;
 continued training for staff in the management of aggression and breakaway
techniques;
 continuous review of the lone worker policy and procedures for staff working in
the community or otherwise alone in Trust buildings.
 prevention of theft of personal / trust / patients’ property
3.24
The Trust is dependent upon reliable equipment, safe and suitable buildings and
vehicles and continuous power and supply services to carry out its responsibilities of
caring for patients. Buildings and vehicles will be regularly maintained so as to
minimise any risks to health and safety. This will be achieved following safe systems
of work, with contingency plans in place to deal with any emergencies.
3.25
All equipment will be adequately maintained, with maintenance records kept and the
case for replacement equipment identified through the business planning process.
4
Research and Effectiveness
4.1
Increasing knowledge about health interventions and service delivery provides a basis
for increasing the effectiveness of services. Encouraging an inquiring, research base
culture provides focus for clinically important questions. The implementation of
research findings, including Health Technology Assessments, NICE guidance and
work carried out by groups such as the Centre for Reviews and Dissemination,
underpins Clinical Governance. In order to support staff involved in these activities
we need to continue to develop our research capacity.
4.2
Research in the Trust is in its infancy and while we remain a small organisation, will
struggle to be of significant value. Collaboration with other ambulance services and
inter-sectoral institutions has most potential to deliver on the recently announced
research governance agenda10. The minimum we must ensure is that all healthcare
professionals have the skills to access and use information to inform their practice.
5
Staffing and Staff Management
5.1
The Trust Board recognises that staff who feel valued, supported and informed in
their work practice will have an enhanced sense of pride and loyalty to the Trust.
Consequently the risk profile of the Trust will be reduced and the quality of clinical
services enhanced. The Trust is committed to the welfare and development of its staff
in Improving Working Lives, as evidenced by its Pledge to achieving a Top
10
Research Governance Framework for Health and Social Care, Department of Health 2001
22
Performing People Organisation. This commitment is demonstrated by the Chief
Executive and managers continuing to take action to ensure:








staff are provided with a safe and pleasant environment in which to work;
staff are consulted to identify what their needs are;
staff are asked to feed back on the extent to which they consider their needs
are being met;
staff development and education needs are met;
staff are offered help, support and counselling when required;
staff are provided with satisfactory occupational health services, which include
access to help in dealing with work-related stress;
staff are regularly trained in such techniques as manual handling, resuscitation
skills, infection control, fire training and recognising and dealing with
aggression;
staff are fully informed regarding Trust-wide developments and have the
opportunity to provide feedback.
5.2
The Trust will continue to develop the induction programme for all grades and
disciplines of staff. These will include training in health and safety issues, as well as
other aspects of risk management. The programme will be mandatory and line
managers will be responsible for ensuring that all staff complete the course provided
by the HR department, as soon as possible after appointment.
5.3
Individual departments are encouraged to develop their own orientation programmes
to follow on from the Trust induction. These will incorporate specific objectives to be
achieved within a specified timeframe. (See example Appendix 4)
5.4
The Trust supports the professional development of its staff, whose education and
training needs are identified through its individual performance appraisal and
professional development review. Systems of clinical supervision will continue to be
developed, which will provide support and guidance for all clinical staff. At Resource
Centres the Clinical Supervisors and members of the Training Department will play
key roles in the development of a culture of clinical effectiveness and the use of
evidence-based clinical care.
5.5
The Trust will address the risks associated with the use of bank, agency and locum
staff through the implementation of the following control measures:




5.6
the introduction of an appropriate appraisal system for bank staff who do not
also hold a substantive post.
a review of the robustness of Trust and supplying agencies’ systems with
regard to ensuring the quality, authenticity and experience of bank, agency, or
locum staff.
the orientation of all agency staff when first employed within the Trust, by the
line-manager;
the provision of on-going supervision for all agency staff.
The Trust will address the risks associated with the use of outside contractors by the
appointment of only appropriate suppliers of services registered with quality
accreditation systems or approved by the Finance Department of the Royal Berkshire
Ambulance NHS Trust
23
5.6
The Health and Safety at Work etc.: Act 1974 and subsequent legislation oblige all
members of staff to accept some responsibility for maintaining a safe workplace
environment. Staff have a right to highlight their concerns about any health and
safety issue, either directly to their manager, or through their appointed health and
safety representative, or other members of the Trust Health and Safety Working Party.
5.7
Staff involvement and development are the cornerstones on which the success of
Clinical Governance will depend. The Trust is committed to developing sound
partnership working across all staff groups, ensuring there is clear ownership,
responsibility and accountability through established management development
programmes, workforce planning and Improving Working Lives.
5.8
These and other management training programmes facilitate:
 Clear team goal and objectives
 Clear lines of accountability and authority
 Diversity of skills and personalities
 Clear individual roles for staff
 Shared tasks
 Regular internal formal and informal communication
 Staff participation
 The ability to change and develop
 The confronting of crisis and conflict
 Feedback to individuals
 Team and individual rewards and awards
 Monitoring of team/individual objectives
 Outside recognition of achievement
 Two way external communication
 Feedback on team performance
5.9
The Trust recognises the significance of the contribution made by individual staff
members (e.g. through the Trust newsletter – the RBAT Times, an at the annual
“Awards Night”.
5.10
The targets therefore, have been developed to reflect the growing need to ‘manage’
professional life in today’s NHS and attempt to reconcile infinite demand with finite
resources in a disciplined manner.
5.11
The Trust will continue to work towards an understanding of the work life balance in
line with the demands of personal and professional lives.
5.12
The management of Clinical Governance is the responsibility of every staff member.
This will be reflected in all job descriptions and job plans, which will emphasise the
importance of the individual’s contribution to ensuring that Clinical Governance
practices underlie their various duties and responsibilities on an on-going basis.
24
6
Education and Training
6.1
Central to achieving Clinical Governance is the creation of an environment, which
enables and encourages the best clinical practice and performance, ensuring that we
have staff with the right skills at the right time to perform to their best. The Trust
believes that this will be delivered ultimately through a multi-professional approach
and over the next 5 years, will work towards ensuring a fully integrated education
programme is in place. The appraisal process is seen as the focus to be built on to
provide this.
6.2
The Trust also values the importance of ensuring that staff are supported and provided
with clear direction and leadership. The fundamental part of Clinical Governance is
centred on changing behaviour towards safer patient care. This change can only be
maintained through promoting a culture of continued learning.
6.3
The targets discussed build on an analysis having completed the baseline assessments
for Controls Assurance and CNST. The Trust endorses the principles of ‘lifelong
learning’ for all individuals and teams to meet the needs of patients, deliver good
health outcomes and Trust priorities, while enabling professionals to expand and fulfil
their potential.
6.4
To be successful, education and training need to operate on two dimensions to support
the clinical governance strategy. First, the education and training needed to generate
the organisational awareness and commitment and support for systems and
procedures. Second, the education and training needed to develop continuously the
individual professionals’ level of knowledge and skill.
6.5
The Clinical Governance Strategy will only be successful if supported by education
and training, at varying levels, for all staff. Programmes will be designed to maintain
awareness of Clinical Governance and to continue to provide all employees with the
necessary level of knowledge of the procedures for clinical governance and for
identifying and reporting risk situations.
6.6
The programmes will include an element of education about the necessary culture
change for all staff, and, to varying degrees, specific technical and practical training
for those involved at the different levels of the clinical governance management
structure.
6.7
Clinical Governance is an essential part of the staff induction programme. Attendance
will be mandatory for all new staff, and the process will be monitored to ensure
effectiveness and attendance. The programme will include information on clinical
risk management where appropriate, as well as health and safety and organisational
risks.
6.8
The following subjects will be included in an on-going annual education programme.


an overview of the general principles and objectives of Clinical Governance
management;
a definition of the role of staff in the Clinical Governance management
process;
25



raising awareness of the reporting requirements and indicators for each work
area;
the Trust’s strategic Clinical Governance management objectives;
the Trust Clinical Governance management structure.
6.9
The ongoing education programme will be enhanced through the provision of
literature, posters, Trust newsletter and the Trust Intranet, which allows access to the
Internet, including both local and Trust-wide Clinical Governance management
standards.
6.10
The acquisition of a portable information system (a suitable E-PRF) will considerably
enhance our ability to deliver training and information on amended policies and
procedures, etc and the Trust is actively involved in investigation of procurement.
7
Use of Information to Support Clinical Governance and Healthcare Delivery
7.1
The Trust recognises the importance of timely and accurate information to inform
Clinical Governance. This information needs to be comprehensive, routinely
available, relevant, up to date and accurate and capable of comparison with national
data.
7.2
The use of external peer review and clinical benchmarking will enable comparisons to
be made to identify scope for improvements and the Trust demonstrates its acceptance
of this by involvement with Regional audits directed and designed by the South-east
Clinical Governance Ambulance Group (SECGAG) and the South-east Ambulance
Clinical Audit Group (SEACAG)
7.3
The Trust recognises that a considerable amount of work is required to develop this
area, ensuring that the Trust has robust, user-friendly information available, most
effective and efficient being an electronic mobile data system. Clinical governance
strategy must seek to create health systems that are able to routinely adopt good
practice and electronic systems enhance this capability, particularly in an ambulance
service where the staff are scattered in pairs or individually across the county
7.4
The challenge of good clinical governance, is also to ensure that heath organisations
develop the information systems, the infrastructure and the training to enable access
and use of clinical information and research evidence to become part of routine
clinical practice.
7.5
Not infrequently, a major cause of risk is that members of staff are individually
uncertain as to what is expected of them, particularly in emergency situations. This
uncertainty can be compounded when other members of the same team have different
understandings of the actions to be taken in such circumstances. Up-to-date, easily
understood policies, protocols, procedures and guidelines are an essential part of
Clinical Governance and risk reduction.
7.6
There is adherence to a clear Trust format for policies and procedures, which are
indexed and annotated with a review date and authorship. A central record will be
kept of all documents, and an index compiled, updated at regular intervals and
circulated throughout the Trust. This will also be available on the Intranet to ensure
26
that different areas do not each draft their own document on the same subject. An
archive of obsolete or superseded policies will also be maintained for possible use in
the future defence of cases of alleged negligence against the Trust.
7.7
The Clinical Effectiveness Group will agree standards and procedures for the
definition, format, drafting and review of all clinical policies, protocols, procedures
and guidelines across the Trust. This will ensure that such documents are researchbased and follow any existing, relevant national guidelines. They will also have a
section identifying risk issues and how to minimise exposure.
7.8
Systems are in place for formulating, ratifying and circulating the policies, protocols,
procedures and guidelines. These will ensure that the documents are distributed to the
relevant clinical area(s), read and understood by the staff to whom they apply and
acted upon appropriately. Regular audits will be undertaken to ensure staff awareness
of and compliance with the content.
7.9
The Trust will support the Caldicott Group and Business Services Department in their
systems for the tracking, storage and retrieval of patient report forms. These will be
audited on an on-going basis, with the results of the audits monitored by the Caldicott
Group and reported to the Clinical Effectiveness Group.
7.10
The content of patient report forms will be subject to on-going audit both by the
Clinical Supervisors and the Clinical Effectiveness Department. The results of such
monitoring will be correlated by the Clinical Effectiveness Groups, with key findings
disseminated to appropriate staff groups and reported to the Board on a monthly basis.
7.11
High priority is given by the Trust to information management and technology
(IM&T) with the Finance Director being responsible for Information Services. A
comprehensive strategy will be produced for the development of systems and
services. A review of the existing systems, services and processes has taken place.
The focuse will now be on the procurement and implementation of an electronic
information management system which includes an E-PRF with the potential of
interactive e-learning. The Strategy will include standards and policies which address
the majority of risk issues relating to its implementation. The risks intrinsic to the
Trust will also be assessed and any necessary action taken to control them. These
risks include:
 the recruitment and retention of specialist staff;
 the risks associated with out-sourcing;
 the location and security of the network equipment and other hardware.
7.13
The development of a Trust-wide Intranet has resulted in there being at least one
computer terminal in each Resource Centre. From the risk management perspective,
this will provide easy access to clinical guidelines, which will be accessible through
the network, as well as other Trust policies and protocols. These will include risk
management policies and procedures. The system also allows completion of
electronic versions of several Trust proformas. The eventual delivery of a portable
electronic information system (includes an E-PRF) will enable more timely access to
these documents.
27
APPENDIX 2
The Targets Agreed For 2002-2003 For The Nine Pillars Of Clinical Governance Set
Out For The South East Region Of The NHS.
a)
Clinical Governance Strategies
Targets

CNST level 1 and achieve level 2
o Level 1 – 2001
o Level 2 - 2003

Maintain Controls Assurance accreditation
o Level 2 milestones – March 2003
o Level 3 milestones – March 2005

CHI visit, mid 2002
o Project group, including stakeholders, to agree action plan and subsequent
delivery

Maintain progress against Trust strategy objectives
28
b)
Consultation And Patient Involvement
Targets

To implement a patient, carer and public involvement Strategy by February 2003

The Trust will move towards the establishment of a PALS service by April 2003

The Clinical Effectiveness Group will identify and implement ways to ensure patients,
carers and the public are involved in their development

To achieve a coordinated approach to the development of patient information
o To build on existing good practice (e.g.: the Ethnic and Cultural Awareness
Handbook and the Multilingual Phrase Book) and implement ways to ensure
that minority groups have fair access to services.
o Improving advice for patients/users to obtain additional information about
their condition when not transported

Good Practice will be shared across the Trust through Clinical Supervisors and
training programmes

Identify groups for patient / user involvement by March 2003

Ensure reports on complaints and claims demonstrate (document/evidence) changes
which have reduced risk as a consequence.

CEfD to report on and draw up action plans where appropriate on patient experience
evaluation

The continued development of links into primary and secondary healthcare and social
care systems within the local health economy.
29
c)
Clinical Audit Activity
Targets

Ensure regular meetings of multi-disciplinary Clinical Effectiveness Group

Clinical Effectiveness Group will monitor outcomes and improvements from its
clinical audit programme

Clinical Effectiveness Group will agree priorities and set standards which will
monitor clinical outcomes

The Trust Clinical Effectiveness Group will work to ensure that all audit activity
undertaken closes the loop and follows through with actions and implementation

Resources required to support clinical audit will be reviewed November 2002

Conduct CHD multi-agency audit July 2003

Support national / regional audits
o Continue National MI audit begun August 2002 (pilot completed)
o Conduct 6 agreed performance indicator audits per year for benchmarking
with the South-east ambulance trusts
o Support the development of a cardiac arrest database with the South-East
Ambulance Clinical Audit Group (SEACAG)

Ensure patient input into July 2003

Develop annual report to include improvements made, actions taken,
multidisciplinary working and patient involvement

Audit support to validate progress being made towards risk management objectives
o Standardised accident/near miss/adverse incident reporting - 2002
o Compliance with 19 Controls Assurance Standards for level 2/3 milestones 2002
30
d)
Clinical and Non-Clinical Risk Management
Targets

Ensure staff are trained in all aspects of clinical and non-clinical risk assessment –
March 2003

Continue the rolling clinical and non-clinical risk assessment process building on
existing best practice, linking in work commenced to meet the requirements identified
for Controls Assurance, CNST and CHI – December 2002

Build on existing good practice linking the function of health & safety into the agreed
programme of clinical & non-clinical risk assessment for controls assurance – March
2003

To ensure the management of clinical and non-clinical risk is integrated into the
Trust’s business planning process

Continue the investigation of clinical and non-clinical incidents

Continue the development, review, training and dissemination of good practice in
Major Incident Planning, including other response organisations and organisations in
the wider health economy of the Operating Area of Royal Berkshire Ambulance NHS
Trust, where appropriate

Develop and publish quarterly Clinical Governance Newsletter – From April 2003

Develop a security strategy by March 2003
31
e)
Research and Effectiveness
Targets

Implement Research Governance focusing on:
o improving patient involvement
o monitoring of R&D activity
o implementing intellectual property strategy
o improving liaison with LREC

Provide regular training in Critical Appraisal Skills – annual programme to be
produced by July 2003

Ensure dissemination of results of pre-hospital research both within and external to
the Trust

Promote Internet website on research information e.g. KA24

Ensure that all healthcare professionals have access to evidence through electronic
and hard copy media
32
f)
Staffing and Staff Management
Targets

Develop strategies for protected time for on-going professional development which
are in balance with operational staffing levels required to deliver a quality service –
2004.

Continue provision of access to training management development programmes for
staff in management positions

The provision of a portfolio of evidence over a wide range of policies and procedures
that improve the working lives of NHS staff – Accreditation required April 2003
o A policy on harassment and bullying was implemented in Nov 2000
o A strategy for zero tolerance to protect NHS staff from violence has been
produce – April 2002 - and will continue to be enforced
o Produce and implement strategy for improving diversity
o Ratify the draft procedure for monitoring equal opportunities by 2003
o Produce a policy on recruitment and selection of black and ethnic minorities
by 2004
o Produce and implement strategy for flexible retirement (e.g. HDU for A&E
staff) – April 2003

Improve the use of the established appraisal system with quantifiable aims and
objectives, which promote best practice while identifying accountability to deliver the
overall clinical governance strategy. Aims and objectives identified may include:
o How best practice is identified
o How practice can be monitored effectively
o What is meant by clinical risk management
o How complaints can be used to influence changes in clinical practice
o The individuals role within the clinical governance framework
33
g)
Education and Training
Targets
 Scope and develop training needed to generate cultural change, knowledge and
awareness of the concept of clinical governance and the supporting infrastructure of
systems needed to support it

Continue provision of the education and training needed to sustain and continuously
develop the individual professional’s knowledge and skill, which will ultimately
determine the quality of care provided.

Develop and facilitate ‘self-learning into practice’ through Continuing Professional
Development (CPD) schemes

Improve mandatory Trust induction programmes for non-clinical staff, which includes
an introduction to clinical governance and clinical/non-clinical risk management

All staff to attend a department specific induction programme appropriate to the
specialty in which they are working

Develop the training of non-clinical staff in the Trust in the use of AEDs

All clinical staff to have attended CPR/AED training in any 12 month period, 90% of
eligible non clinical to have attended CPR/AED training in any 6 month period –
November 2003
h)
Use of Information to Support Clinical Governance and Healthcare Delivery
Targets

Maintain improvements in PRF completion

Develop a comprehensive strategy for IM&T

Procure an electronic mobile data system (includes an E-PRF) - April 2004

Identify standards, calibration and audit for medical equipment

Implement drug audit system (Audit commission report ‘A Spoonful of sugar’ 2002)
34
APPENDIX 3
GLOSSARY OF TERMS
Accident
Any untoward or unexpected event which results in injury to
or adverse effect on the physical or mental health of an
individual.
Adverse Clinical
Incident
An incident causing injury where a clinician is directly
responsible for the management of the person injured.
Blame Free Culture
Where individuals may feel free to raise matters of concern
without fear of retaliation.
It does not allow for wilful
neglect.
Clinical Negligence
A breach of a duty of care by Health Care professionals or by
others consequent on the decisions or judgements made by
Health Care professionals.
Clinical Governance
A framework 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
Clinical Waste
Waste arising from investigation, treatment, care or research
which is toxic, infectious or otherwise potentially dangerous.
Clinician
Those directly involved in the care and treatment of patients
including Ambulance Care Assistants.
Continuing
Professional
Development
See Lifelong Learning.
Corporate
Governance
The framework through which the Trust is held accountable
for the way in which it conducts its corporate business
including meeting its statutory financial duties.
CNST
Clinical Negligence Scheme for Trust. A mutual of over 400
Trusts nationwide subscribing to a central pool to cover
Clinical Negligence costs. The CNST is part of the NHS Litigation Authority - a Special Health Authority.
35
Incident
Any untoward or unexpected event which interferes with the
orderly progress of activity and which resulted, or could have
resulted, in one or more of the following:
 injury to, or adverse effect on, the physical or mental
health of any person;
 damage to or loss of any property, including buildings,
equipment, vehicles or materials;
 a “near miss” which could have resulted in the above
Lifelong Learning
A process of continuing development for all individuals and
teams which meets the needs of patients and delivers the
healthcare outcomes and healthcare priorities of the NHS and
which enables professionals to expand and fulfil their
potential.
Medical Devices
Agency
Assesses the safety and performance of healthcare products.
National Institute
for Clinical
Excellence (NICE)
A Special Health Authority established to promote clinical
and cost-effectiveness by producing clinical guidelines and
audits for dissemination throughout the NHS.
NHS Executive
The NHS Executive is part of the Department of Health, with
offices in London and Leeds and eight Regional Offices
across the country. It supports Ministers and provides
leadership and a range of central management functions to
the NHS.
NHS Trusts
Public bodies providing NHS hospital and community health
care.
Personal
Development Plan
(PDP)
Developed by individual health professionals as part of
lifelong learning.
Special Health
Authority
Health Authorities with unique national or supra-regional
functions which cannot be effectively undertaken by other
kinds of NHS bodies (for example, the Prescription Pricing
Authority).
36