Clinical Governance – good practice

Peter Allanson concludes his two-part introduction to clinical governance by looking at how to set up and measure an effective system

Our earlier blog, Clinical governance – an introduction, set out the case for establishing a formal clinical governance system and suggested what a good system should aim to cover. This article goes a step further and looks at what might make up a system of clinical governance and how to measure progress in its creation and effective use.

It goes without saying that clinical governance is something a trust wants to do well. It will not happen on a shoestring but in setting up a web of committees and working groups it is essential to keep their purpose sharply in focus, with clearly outlined responsibilities that clearly articulate their contribution to quality and safety in service to patients and service users.

Assigning responsibility and accountability both to individuals and groups alongside a commitment to learning from successes as well as incidents, events and challenges are hallmarks of an organisation that is using its infrastructure positively and not as a process to tick regulatory boxes.

An effective clinical governance system is powerful and enabling and good for patients and clinicians.

Who is responsible and who is accountable?

Ward to board – that is the cliché (and in this case the reality) of what clinical governance has to cover. Ultimately it is the board that bears final responsibility but on the way to the board, it needs to be able to rely on a large number of colleagues.

Annex 1 is a matrix showing who is responsible, accountable, consulted or informed in any clinical governance system.

Executive accountability – trust board level

• Ultimately accountable: chief executive
• Operationally accountable: medical director and chief nurse

They ensure:

• Governance structures are in place and effective
• Strategic alignment with CQC, NHSE, and regulatory requirements
• Resources and culture support continuous quality improvement

Strategic leadership – clinical leadership

• Led by: medical director or chief nurse
• Supported by: director of governance / associate director of quality
• Role: oversee and coordinate trust-wide clinical governance functions, set priorities, review risks and performance

System management – clinical governance team

Led by a head of clinical governance or associate director of quality governance, responsible for:

• Coordinating committee schedules, agendas, papers, and minutes
• Supporting policy development and compliance monitoring
• Managing the trust-wide risk register and incident learning systems
• Ensuring integration between committees

Divisional / directorate accountability

Each division / directorate should appoint a:

• Clinical governance lead (could be a matron, senior clinician, or quality manager)
• Divisional director / clinical director accountable for quality and safety
• Governance facilitator or coordinator to manage processes

They:

• Chair or coordinate divisional governance meetings
• Ensure timely incident reviews, action plans, audits, and quality improvement (QI) reporting
• Cascade trust-wide learning and policies

Frontline responsibility

• All clinical staff are individually responsible for upholding safety, participating in audit/QI, and speaking up
• Ward / team managers ensure engagement with governance activities (e.g., learning huddles, complaint responses)

In addition, there will be a group of executives whose advice influence may be needed from time to time:

• Freedom to speak up guardian
• Clinical audit and QI leads
• Learning from deaths lead

This is quite a cast list but is key to a successful system.

System structure

To translate responsibility and accountability into delivery is the job of the structure. It should be designed to ensure that all aspects of work are covered and that escalation through the hierarchy is natural and welcomed. We will talk about culture later but the manner in which the organisation deals with the response to issues – positive or not – will be one of the hallmarks of success of the system.

System structure (bottom-up)

This section outlines the type of committee/group that is likely to be needed within a clinical governance system and, more particularly, shows where in the organisation they sit. It is important to recognise that the first inkling of an issue may arise informally during a huddle, handover or discussion between colleagues. Passing a hunch into the system is what should then happen and is the most difficult to legislate for and is largely dependent on attitude and expectation.

Frontline clinical services

Wards, clinics, theatres, and community teams identify risks, report incidents, gather patient feedback, and conduct audits and QI.

Clinical governance begins where care is delivered — in wards, clinics, theatres, and community settings. Every clinician, nurse, allied health professional, and support staff member plays a role in ensuring safe, effective, and compassionate care.

• incident reporting (Datix or similar)
• audits and QI projects
• complaints/compliments
• risk identification
• feedback from patients and carers

Each clinical team is expected to reflect, learn, and act on issues related to safety, outcomes, and patient experience.

Divisional / directorate governance committees

Divisional teams review safety data, escalate risks, track local improvements, and share learning.

Each clinical division or directorate (e.g., medicine, surgery, community health) should be expected to hold a regular (monthly?) meeting attended by clinical directors, governance leads, matrons, pharmacists, AHP reps to:

• review incidents, complaints, and risks
• monitor audit and QI activity
• ensure learning is shared and acted on
• escalate significant risks or recurring themes
• ensure compliance with policies, training, IPC, safeguarding

Output: reports, learning summaries, action plans that are fed upward to corporate-level committees.

Trust-wide subcommittees

Thematic groups focus on key domains:

• patient safety committee
• clinical effectiveness committee
• patient experience and involvement committee
• quality improvement and innovation committee
• Medicines, IPC, safeguarding, education and training

These subcommittees will normally involve subject experts either as core members or as occasional attendees.

Other key subcommittees (medicines governance, IPC, safeguarding, education and training) ensure detailed focus on statutory and specialist areas, and are often chaired by designated leads (e.g., DIPC, chief pharmacist, safeguarding lead).

Reports from these groups would go to the clinical governance committee (CGC) and may escalate issues via the risk register or ad hoc urgent reports.

Clinical governance committee (CGC)

Chaired by the medical director or chief nurse, this group oversees trust-wide quality performance, triangulates data from safety, effectiveness and experience. It reviews trust-wide performance and themes, agrees priority areas for improvement, reviews high risks and learning from serious incidents and ensures learning is embedded trust-wide. It also ensures external compliance (CQC, NHS Resolution, national audits, safeguarding boards) is being met.

This committee is where responsibility and accountability meet, as the involvement of the board, either in committee or at the board, is the next step. It is also the point where considering whether to involve regulators formally will take place.

Quality assurance committee (QAC) / trust board

Provides final assurance, reviews strategic risks, and approves trust-wide quality goals and reports. The CGC normally reports into this committee through its chair. This provides independent assurance that clinical governance systems are functioning and risks are understood and mitigated.

As a formal committee of the board, its membership is made up of non-executive directors, one of whom would chair it, and executive directors, including the chief medical officer and chief nurse. Other executive leads would attend by invitation.

Its role is to provide assurance to the board via highlight reports, undertake an annual quality governance review, take oversight of the quality account and strategy and escalate serious issues.

The next stop would be the board where the most serious issues – matters of safety, quality and reputation – are assessed and addressed.

Between them, these groups should aim to establish a governance cycle covering learning and assurance.

• Upwards: report risks, incidents, audits, patient feedback
• Downwards: National policy, CQC standards, Trust strategic goals
• Mechanisms: Safety bulletins, QI forums, training, reports

The key benefits are to provide

• trust-wide visibility of safety and quality
• timely escalation and assurance to the board
• shared learning from incidents and audits

and most importantly a culture of openness, accountability, and improvement.

Culture

The best clinical governance system in the world will be ineffective if the culture of the trust is unable to embrace the messages it is sending. So what needs to be true culturally to underpin clinical governance – and beyond?

Psychological safety

• Do staff feel safe to speak up about mistakes, concerns, or poor practice?
• Whistleblowing and freedom-to-speak-up routes are accessible and trusted.
• There is no fear of blame—the focus is on learning, not punishment.

If people don’t feel safe to report or challenge, governance fails at the first step.

Shared ownership of quality

• Quality and safety are everyone’s responsibility, not just the clinical governance team’s.
• Frontline staff are empowered and expected to participate in QI, audit, incident review, and feedback.
• Leaders are seen to engage with clinical governance activities.

Continuous learning mindset

• Mistakes are seen as learning opportunities.
• Collective reflection is normalised—e.g., safety huddles, Schwartz rounds, morbidity and mortality reviews.
• Improvement is part of daily work, not just projects or inspections.

Transparency and data openness

• Data are shared and discussed widely: incident themes, complaints, audit findings, etc.
• Dashboards and quality reports are available, accessible and understandable to all.
• Problems are not hidden but brought into the open early.

Collaboration over hierarchy

• Governance processes are collaborative across professions (nurses, AHPs, medics, managers) and ignore seniority.
• Divisional silos are broken down in favour of trust-wide learning.
• Patients, carers and service users are partners, not bystanders, in governance and QI.

Visible, value-driven leadership

• Executive and clinical leaders take part in governance forums, walkabouts, and learning events.
• Quality is clearly a priority— ie above financial or performance targets.
• Leaders model the behaviours they expect: openness, humility, curiosity.

Different types of trust

Before looking at how to monitor progress and measure effectiveness, here are a few thoughts about any shades of difference between the different types of NHS trust. While there are features common to all there are some differences that it is sensible to factor into the system.

What stays the same across all trusts

• Clear governance hierarchy from ward to board.
• Structured committee network: risk, audit, safety, effectiveness, experience, QI.
• Executive accountability: medical director / chief nurse / CEO.
• Frontline ownership of safety, learning and improvement.
• Triangulation of data: incidents, complaints, audits, patient feedback.
• Learning loops: upward escalation and downward dissemination.

Acute trusts

Focus:

• immediate safety (e.g., surgery, meds, deteriorating patient)
• high throughput and procedural risk

Tailoring needed:

• strong governance for theatres, ED, ITU
• mortality and morbidity reviews as central processes
• committees for: sepsis, deteriorating patient, perioperative safety
• more focus on clinical coding accuracy, HSMR/SHMI

Mental health trusts

Focus:

• relational care, risk management, safeguarding
• longitudinal experience and co-production

Tailoring needed:

• robust safeguarding, Mental Health Act compliance governance
• dedicated oversight of restraint, seclusion, rapid tranquilisation
• learning from suicides/serious self-harm
• strong focus on patient experience, involvement in care planning

Cultural emphasis:

• recovery-focused language
• trauma-informed care as a governance thread

Community trusts

Focus:

• distributed workforce and settings
• care in homes, schools, prisons, GP surgeries

Tailoring needed:

• emphasis on lone working, caseload risk management, delayed response risks
• governance adapted to services like health visiting, podiatry, or prison healthcare
• committees may combine domains (e.g., safety and effectiveness) for pragmatism
• digital governance for remote monitoring, virtual wards

Hybrid trusts (e.g. integrated acute + community, or community + MH)

• need mechanisms to balance central governance consistency with local service nuance
• may benefit from care group-level CGCs feeding a central committee
• consider cross-sector risks: discharge delays, interface incidents, record sharing.

Monitoring progress – how are we doing

Keeping systems dynamic is important while not continually digging up the roots to see how well the plant is growing. An effective clinical governance system based on the seven pillars (the PIRATES) is not created fully developed but understanding where you are and what you need to do to progress will help target resources where they can be most helpful.

Annex 2 offers a methodology in the form of a maturity matrix based on the pillars and adumbrating different levels of maturity. An honest appraisal of how your system is doing and where it sits on the matrix is step one. Step two is to determine where you think you can develop your system over the next year – what is your target for the next 12 months? And step three is what needs to be true to meet that target and what do you have to do/change to achieve the next level?

Focusing on what will make a material difference while being achievable makes this an exercise that everyone involved in clinical governance can embrace. To paraphrase Einstein, make everything as ambitious as possible – but not too ambitious.

This matrix shows in graphic form the different levels of responsibility within a clinical governance system.

RACI Matrix – Clinical Governance System

Key:
R = Responsible
A = Accountable
C = Consulted
I = Informed

Maturity Matrix to support the Development and Improvement of Quality and Clinical Governance at site level of a group model