What is clinical governance? (2024)

Incident reporting

An incident is any event or circ*mstance that led to unintended or unexpected harm, loss, or damage. A near miss is an event or occurrence which, but for skilful management or a fortunate turn of events, would have led to harm, loss, or damage. Most incidents can be investigated locally: the seniority of the investigating team depends on the severity of the incident. A significant incident is an event sufficiently serious to warrant a formal root cause analysis investigation and usually involves death or serious injury/ill health, major damage to property, loss of a service, a major health risk, or a threat to the strategic objective(s) of the organisation. In England,these must be reported via the Strategic Executive Information System but also via the National Reporting andLearning system (NRLS) if patient safety is involved. Therecent UK Duty of Candour legislation requires that every healthcare professional must be open, honest, and supportive when a patient suffers as a result of treatment received.6 An apology and support should be offered, and an explanation that there will be an investigation (by definition usually a significant incident investigation) after which the results will be shared. A never event is a serious incident that in theory is wholly preventable, because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented.7 In England, these must be reported via the NRLS. Sharing of lessons learned from other incidents through the RCoA Safe Anaesthesia Liaison Group (SALG) is voluntary. Meaningful safety recommendations relevant to anaesthesia and critical care have also emerged from the recently formed Healthcare Safety Investigation Branch. Finally, certain work-related injuries must be reported under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013, including those where the result is that the employee is unable to work for more than 7 days subsequently.8

Morbidity and mortality

An effective morbidity and mortality (M&M) meeting should identify events that have resulted in adverse outcomes, foster discussion, and lead to the dissemination of learning. Ideally this should be multidisciplinary and within a ‘safe’, non-critical environment where staff are encouraged to share and ‘speak up’, and focus on systems and process variations rather than individuals and blame. Cases that may be discussed include any deaths arising from elective surgery; deaths involving an unscheduled period in intensive care; deaths where it was necessary for the patient to return to the operating theatre within 14 days of initial surgery; deaths where a significant incident has been identified; or patients who suffered major complications but did not die. The Scottish Audit of Surgical Mortality was a nationwide process involving an external review of all perioperative deaths in Scotland. This no longer exists, but the structured judgement review is a national process introduced by the Royal College of Physicians using validated methodology to learn from mortality.9 SALG summaries of anaesthesia-related incidents should also be reviewed at M&M meetings.

Risk register

This is a systematic record of risks to the organisation, with a description and severity rating of the risk, along with the impact and consequences. Many risks cannot be eliminated and therefore it must be decided whether to accept, manage, or possibly avoid (i.e. cease a certain procedure) the risk. Therisk register should be reviewed regularly.

Guidelines

Where there is variation in practice that affects patient outcomes, and research demonstrates evidence of effective practice, guidelines such as those published by the RCoA, the Association of Anaesthetists, the National Institute for Healthand Care Excellence, or the Scottish Intercollegiate Guidelines Network may assist practitioners in making decisions. Appropriately implemented, guidelines may potentially improve the quality of care for patients and increase theefficiency of healthcare organisations through standardisation.10, 11 However, although guidelines are usually developed systematically and with rigour, they can be open to interpretation. Hence they should still be scrutinised, and decisions made on how best to adopt them locally.

Standards

A standard is a statement, reached through consensus, which clearly identifies the desired outcome. Standards should be measurable, often through the use of audit, and also achievable. By meeting standards such as the voluntary ACSA standards, the quality of service provision should improve.

Quality improvement

The purpose of QI is to bring about measurable improvements by applying systematic change methods and strategies within a healthcare setting. QI has recently been described in more detail in this journal.12

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Alan Macfarlane BSc (Hons) MRCP FRCA EDRA is a consultant anaesthetist at Glasgow Royal Infirmary where he is clinical governance lead for anaesthetics and theatres. He is also an Honorary Clinical Associate Professor at the University of Glasgow. His major clinical and research interests are regional anaesthesia; he is treasurer of Regional Anaesthesia-UK, a member of the ESA scientific subcommittee for regional anaesthesia and an editor of BJA Education.

4. Luoma A., Wilson S. Clinical risk management for anaesthetists. BJA Educ. 2015;15:14–19. [Google Scholar]

11. Royal College of Anaesthetists Guidelines for the Provision of Anaesthetic Services 2018. Available from https://www.rcoa.ac.uk/gpas2018 (accessed 22 October 2018).