Document Title and Code: Clinical Governance Policy NMA-CGP1.
Version 2
Author: Andrea O’ Reilly and Eithne Ni Dhomhnaill, Nursing Matters and Associates.
Authorised by:
Issue Date: April 2013; reviewed and updated 01/2017. Reviewed February 2020: No changes.
Review dates: February 2023

1.0 Policy Statement:
It is the policy of The Centre that clinical governance will be used to promote a culture of learning and continuous quality improvement in the Centre.
2.0 Purpose:
The purpose of this policy is to outline the process and procedures for clinical governance in The Centre.
3.0 Objectives:
3.1.1 To outline the roles and responsibilities for clinical governance in The Centre.
3.1.2 To outline the process of clinical governance in the Centre.
3.1.3 To promote a culture of continuous learning in The Centre.
4.0 Scope:
This policy applies to all management and staff directly employed by or providing services to residents of The Centre.
The following policies must be read in conjunction with this document.
■ The Centre Risk Management Policy and Procedures.
■ The Centre Safety Statement.

5.0 Definitions:
5.1 Clinical Governance: is a system through which service providers are accountable for continuously improving the quality of their clinical practice and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish (Scally and Donaldson, 1998; HIQA, 2010).
5.2 Quality Improvement: ‘a planned, systematic approach to monitoring, analysis and improvement of performance to achieve optimal patient outcomes and patient experience’
(Kirkpatrick, C., 2007).
6.0 Responsibilities.
6.1 The Registered Provider.
The Registered Provider of The Centre is legally obliged to establish and maintain a system for:

  1. Reviewing the quality and safety of care provided to, and the quality of life of, residents in the designated centre at appropriate intervals; and
  2. Improving the quality of care provided at, and the quality of life of residents in, the designated centre.
    (Care and Welfare Regulations, 2013).
    In The Centre, the above requirements are addressed through the implementation of a clinical governance framework for continuous quality improvement in the home.
    The registered provider sits on the clinical governance committee of the centre. He/She has overall responsibility for ensuring that structures and processes are in place for continuous quality improvement. This includes ensuring clear roles, responsibilities and reporting relationships are identified and supported with policies and procedures for clinical governance and quality management.
    6.2 The Person in Charge.
    The person in charge of the Centre reports to the registered provider and is the clinical governance lead for the home. She has responsibility for ensuring that all nursing and clinical staff are aware of the structures and processes for clinical governance and the implementation of policies, procedures and action plans for clinical governance in the Centre. She arranges the schedule of meetings for the clinical governance committee and ensures that minutes of meetings are recorded and disseminated to staff in accordance with their roles. She is also accountable for ensuring that the direct care and services to residents comply with the National Standards and regulations. Her primary role is to ensure that care and services provided to residents in the home is evidenced based and complies with relevant standards and legislation. This includes leading the development of evidence based policies and procedures for the delivery of care and services to residents and ensuring that all nursing and care staff are familiar with policies and procedures pertinent to their roles. She also is responsible for implementing systems for monitoring quality and safety of care through the clinical governance framework outlined in this policy.
    6.3 The Assistant Director of Nursing.
    The Assistant Director of Nursing is a member of the clinical governance committee and is responsible for infection prevention and control in the home. She reports directly to the Person in Charge. The Assistant Director of Nursing deputises for the Person in Charge and provides feedback to the person in charge and the clinical governance committee on matters related to quality and safety at floor level. The Assistant Director of Nursing completes the monthly quality indicator form for clinical governance meetings. She is also the secretary of the clinical governance committee.
    6.4 Clinical Nurse Managers.
    Clinical Nurse Managers report to the Assistant Director of Nursing and are responsible for supervising the care of residents in their designated area. Each clinical nurse manager (CNM) is responsible for supervising the nursing and care team at floor level. He/she assigns tasks to the team on a day to day basis and delegates responsibility to nurses and care staff in accordance with the assessed needs of residents and the competencies and skills of the team. The CNM is the clinical leader of the team on a day to day basis. He/she ensures that each resident has an individual assessment and care plan in place, which is updated in accordance with each resident’s changing needs. He/she ensures that nursing and care staff carry out their work activities in a safe manner and in accordance with standards and policies of the home. CNMs report directly to the Assistant Director of Nursing on all matters related to the quality and safety of care and service delivery in their area and are accountable to the Person in Charge for the performance of their role.
    6.5 Registered Nurses.
    Registered nurses have responsibility for implementing policies and procedures for clinical governance, risk management and health and safety in the course of their work. This includes completing assessments and care plans for residents in their care and keeping care plans updated in accordance with each resident’s changing needs. Registered nurses are responsible for ensuring that the care needs of residents are communicated to the rest of the care team both by reporting changes to the CNM on duty, ensuring that oncoming staff are updated on residents’ changing needs at handovers and providing direction to the health care assistants on the care needs of individual residents.
    6.6 Healthcare Assistants.
    Health care assistants (HCA) are responsible for providing care and services to each resident under the direction of the registered nurses and as delegated by the CNM. Each HCA is responsible for carrying out all work activities in a safe manner and in accordance with the policies and safety statement of the home. The HCA reports directly to the registered nurse in his/her area regarding the care of individual residents, and is accountable to the CNM for the overall performance of his/her duties. HCAs report to the CNM for issues related to their assigned duties; concerns about the quality and safety of the environment and individual residents.
    6.7 All Staff.
    All staff employed in The Centre have a responsibility for complying with the policies and procedures and safety statement of the home. Staff must familiarise themselves with all policies relevant to their work and all risks relevant to their area of work. Staff must report to their line manager any difficulty they may have regarding the policies of the home, including:
    ■ The need for explanation of any policy or safety requirements related to their work.
    ■ Any difficulty with understanding any aspect of a policy or safety statement relevant to their work.
    ■ Any concerns about their ability to carry out their work in accordance with any policy or safety requirements.
    All staff are responsible for complying with safe working practices in accordance with policies, training and instructions for use of equipment. Additionally, staff must report without delay any hazards or risks noted in the course of their work, including any defects in equipment.
    6.8 Clinical Governance Committee.
    The Clinical Governance Committee oversees continuous quality improvement and clinical risk management. The Committee is comprised of the Registered Provider, Person in Charge; the Assistant Director of Nursing, a registered nurse and a healthcare assistant. Registered nurses and healthcare assistants rotate their membership every six months. Other staff and disciplines attend the meetings as required. The group meets every month to review the quality and safety of care and services and to develop action plans for continuous improvement.
    6.8.1 Terms of Reference for Clinical Governance Committee.
    Terms of reference for the clinical governance committee are:
  3. Analysis of clinical risk and quality data to identify areas for improvement.
  4. Development of action plans for improvement activities in the nursing home.
  5. Development of an audit programme for the nursing home.
  6. Investigation of incidents including root cause analysis.
  7. Communication with all stakeholders regarding improvement initiatives.
  8. Analysis of complaints data and implementation of improvement activities related to complaints.
  9. Analysis of feedback from residents’ council and implementation of improvement initiatives based on residents’ feedback.
  10. Maintenance of the risk register.
    6.8.2 Activities of the Clinical Governance Committee.
    Members of the Clinical Governance Committee have shared responsibility for trending and analysis of quality data; developing improvement action plans and evaluation of improvement initiatives related to clinical governance and risk management. The committee meets every month to review the quality and safety of care and services and to develop action plans for continuous improvement. Activities of the Clinical Governance Committee include:
    ■ Identifying and agreeing key quality indicators and key performance indicators for the home.
    ■ Arranging the schedule of meetings for the Committee.
    ■ Developing procedures for agreeing the agenda for each meeting – The Agenda for coming meetings will be agreed at the end of each meeting. A member of the committee can add items to the agenda by contacting the DON at least two days before the meeting.
    ■ Developing a procedure for informing committee members about each meeting, including other disciplines– this is agreed at each meeting depending on who needs to be communicated with regarding the items discussed at the meeting.
    ■ Trending and analysing quality and risk data collated such as key quality indicators; incident/accident reports and so on.
    ■ Reviewing evidence based information, such as clinical guidelines; changes to national standards and regulations; safety alerts and making changes to practices based on these.
    ■ Identifying areas for improvement.
    ■ (If separate, liaising with the Health and Safety Committee through the Health and Safety Coordinator in order to develop and implement improvement plans for health and safety in the home).
    ■ Developing, implementing and monitoring improvement plans for quality and clinical risk management in The Centre.
    ■ Conducting risk assessments and maintenance of the risk register for clinical, occupational and resident specific risks.
    ■ Collaboration with the Health and Safety Coordinator to update the risk register in accordance with identified environmental risks.
    ■ Development of an annual audit programme for the Centre.
    6.9 The Health and Safety Coordinator/ Officer
    The Health and Safety Coordinator sits on both the Health and Safety Committee and the Clinical Governance Committee for the home. He is responsible for co ordinating all health and safety activities in the home as outlined in both the Safety Statement and Risk Management policy for The Centre. He reports to the Registered Provider and collaborates with the clinical governance committee in the development and monitoring of safety improvement plans; risk assessments and the maintenance of the risk register for the home.
    Fig 1: Governance and Management Structure.
    Insert management structure here.

7.0 Clinical Governance Framework.
The framework for clinical governance in The Centre is based on the model of clinical governance developed by the Healthcare Commission, UK and consists of the following elements:

  1. The Centre’s Organisational Structure.
  2. Choose as required The ‘Seven Pillars’ of Clinical Governance or 8 themes of the National Standards, 2016
  3. The Centre Quality Improvement Process.
    7.1 Clinical Governance Organisational Structure.
    The clinical governance organizational structure (Fig. 1) outlines the reporting relationships and accountability for clinical governance at The Centre.
    7.2 Pillars of Clinical Governance.
    Clinical governance is supported by seven key elements referred to as the ‘pillars’ of clinical governance. These are:
  4. Patient and public involvement.
  5. Risk Management.
  6. Clinical audit.
  7. Staffing and staff management.
  8. Education, training, continuing personal and professional development.
  9. Clinical effectiveness programmes.
  10. Use of clinical information to support clinical governance and healthcare delivery.
    These pillars provide the key elements of the clinical governance framework at The Centre.
    The Eight Themes of the National Standards, 2016
    These are:
    Theme 1: Person-centred Care and Support
    Theme 2: Effective Services
    Theme 3: Safe Services
    Theme 4: Health and Wellbeing
    Theme 5: Leadership, Governance and Management
    Theme 6: Use of Resources
    Theme 7: Responsive Workforce
    Theme 8: Use of Information
    7.3 The Centre Quality Improvement Process.
    The Centre uses a seven step process for continuous quality improvement. These steps occur in a cyclical process and are:
  11. Identifying areas for improvement or ‘problem’ areas based on continuous review and trending quality data (detailed below) at clinical governance meetings.
  12. Prioritising areas for improvement based on the following criteria:
    ■ Areas of High Risk.
    ■ Areas of High Volume.
    ■ Areas of high cost.
    ■ Required by regulations and standards.
  13. Analysing problem areas to identify the exact nature of the problem and factors contributing to it.
  14. Developing an action plan for improvement.
  15. Making improvements.
  16. Evaluating changes for improvement using appropriate measures and methods such as key performance measures or indicators; satisfaction surveys and / or audit.
  17. Continuous monitoring of performance through monitoring quality and safety data in order to ensure improvements are being sustained and / or identify any further areas for improvement.
    8.0 Use of Quality Data to Support Clinical Governance and Quality Improvement.
    The Centre, through its clinical governance framework will collect, trend and analyse data on a continuous basis to inform and support the clinical governance and quality improvement cycles. This data includes:
    ■ Evidence based data such as national standards, legislation; safety alerts and recognised clinical guidelines.
    ■ Use of audit; monthly data on key quality indicators; resident council feedback; resident / visitor satisfaction surveys; staff feedback and inspection reports to monitor progress and identify areas for improvement.
    ■ Use of risk and safety data including safety audits; risk assessments; adverse events; incidents / accidents; and complaints to manage risk and protect the safety of residents.
    ■ Use of any identified performance measures to measure improvement.
    ■ Use of all of the above to monitor sustainability for improvement and continue to identify further improvement needs.

9.0 The PDCA Cycle: A key element of the continuous quality improvement process at The Centre is the Plan, Do, Check, Act (PDCA) cycle for problem solving and improvement. The four steps of the cycle will be used as follows:

  1. Plan: Where the need for improvement is identified, a systematic approach to planning for the improvement will be undertaken. This will involve answering the following questions:
  2. What are we trying to accomplish?
  3. How will we know that a change is an improvement?
  4. What change can we make that will result in an improvement?
  5. Do: Once the actions and measures of improvement are set, change on a small scale will take place.
  6. Check: The change will be monitored / measured using the specific measures identified in the planning phase.
  7. Act: Where improvement has been established larger scale change will be implemented.
    10.0 Format of Meetings.
    10.1.1 Meetings will be held once a month.
    10.1.2 Items for the agenda for meetings will be suggested at the previous meeting and circulated by the (Specify) to all relevant staff and committee members at least two days prior to the meeting.
    10.1.3 The (Specify) will ensure that the monthly quality indicator form is completed and submitted to the Person in Charge before each meeting.
    10.1.4 Minutes of meetings will be taken by a person designated by the Person in Charge and circulated to all relevant staff and committee members as determined and agreed by the committee at the end of each meeting.
    10.1.5 Each meeting will be comprised of:
  8. Reading and agreement of minutes from previous meeting.
  9. Review of key quality indicators since previous meeting.
  10. Review of any complaints; incidents/accidents; inspections; audits; surveys; feedback from resident council meetings; education/training days held; new standards/guidelines since last meeting.
  11. Identification of actions required and development of action plans.
  12. Review of risk assessments and update of the risk register as required.
  13. Review /update of existing action plans.
  14. Any other business.
  15. Confirm next meeting.
  16. Close.
    11.0 Review and Analysis of Quality and Safety Data.
    11.1.1 When reviewing the quality indicator form, the committee will look at trends and in particular identify any trends of concern in the data. This, for example, may include an increasing trend in the number of falls that are occurring in the home. Where there are evolving trends that are of concern, the committee will discuss the causes and implications of these trends. For example, if there is an increase in falls, the committee will establish the reason for this.
    11.1.2 If there are no known or obvious explanations for evolving trends, the committee will decide on the need for more detailed investigation of the area. This may include for example, conducting a clinical audit of the area of practice or a more detailed review of the area of practice to establish patterns and causes as per standard templates.
    11.1.3 Once, the reason for a trend has been established, the committee will decide on the most appropriate measures that will be taken to improve practice.
    11.1.4 Risk assessments will be reviewed so as to establish the progress of any actions planned to either eliminate or implement control measures for the risk identified. If a risk has been eliminated, the risk assessment will be archived. For other risks that cannot be eliminated, once the control measures have been implemented, the risk will be entered onto the risk register.
    11.1.5 Complaints will be reviewed to identify the status of each complaint and identify any further actions that need to be taken. Additionally, the committee will identify the seriousness and trends of complaints with a view to identifying any changes to practice that need to be made for continuous improvement.
    11.1.6 Where new evidence, such as amendments to standards or regulations; safety alerts; clinical updates and so on are being reviewed, the committee will discuss the implications of the evidence for The Centre and make changes as required to ensure compliance with these updates.
    11.1.7 Incidents and accidents will be reviewed and categorised according to the seriousness and risk rating for future occurrence. Additionally, if any incident has led to harm or had the potential to harm a person, the person in charge will arrange for a root cause analysis of the incident, if not already completed. The committee will discuss ways to prevent recurrence of incidents and develop action plans to support this.
    11.1.8 If the committee is concerned about trends in the amount or type of incidents occurring, root cause analysis will also be conducted to address these.
    11.1.9 Findings of internal and external audits and inspections undertaken by statutory bodies will be reviewed and improvement plans developed to address these.
    12.0 References.
  17. Sale, D. (2005) Understanding Clinical Governance: Making it Happen. Palgrave MacMillan, London.
  18. NHS Quality Improvement Scotland (2005) National Standards: Clinical Governance and Risk Management: Achieving safe, effective, patient focused care and services.
  19. Royal College of Nursing (2003) Clinical Governance: An RCN Resource Guide.
  20. The Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People, 2013).
  21. National Standards for Residential Care Settings for Older People in Ireland, HIQA (2016).

Appendix 1: Clinical Governance Meeting Form.
DATE OF MEETING: …../…../……… TIME:


Minutes of Previous Meetings Read •
Comments / Changes to Minutes:

Review of Quality Indicators •

Outcome of Discussions/Agreed Actions:

Any issues about Communication /Involvement with Residents, Family, Visitors discussed? (Eg. meetings/written communication, satisfaction surveys etc.) Yes: • No: •

Outcome of Discussions/Actions Planned:

Any issues about Risk Management /Health and Safety discussed? Yes: • No: •
Comments/Discussions (if not addressed in previous sections):

Outcome of Discussions/Agreed Actions:

Any issues about Audits discussed? Yes: • No: •

Outcome of Discussions/Agreed Actions:

Any issues about Staffing / Staff Management discussed? Yes: • No: •

Outcome of Discussions/Agreed Actions:

Any issues about Training/Education discussed? Yes: • No: •

Outcome of Discussions/Agreed Actions:

Any issues about clinical effectiveness discussed? (Eg. planned changes to clinical practice; results of evaluations/audits done etc.) Yes: • No: •

Outcome of Discussions/Agreed Actions:

Any issues about use of quality information discussed? (eg. Changes to information to be collected; additional sources of best practice information etc.) Yes: • No: •

Outcome of Discussions/Agreed Actions:

Summary of Actions Planned.
Action Timeframe Responsible Person(s).

Items for next meeting:

Next Meeting.
Date: …./…/…..Time: Venue:
Signed: ……………………… Date: …………