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Clinical Governance

Junior doctors on their rounds

Clinical Governance covers:

“everything that contributes to maintain and improve standards of patient care”. It is a framework for organisations and staff to support the delivery high quality care and enables “the right care, at the right time, in the right place, for the right patient”.

Clinical Governance also incorporates clinical audit:

“a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change” .

From 2005, the Royal Berkshire NHS Foundation Trust developed an integrated framework of Clinical Governance that incorporates and builds on the Healthcare Commission’s Standards for Better Health (2004) , the NHS Litigation Authority standards (2007)  and more recently the Department of Health’s Vital Signs (2008) .

Effective clinical governance remains central to our day-to-day operation as the first choice the first choice provider of specialist clinical services for patients in our community. Adherence to the revised framework, a multi-disciplinary team approach identifying major issues and active communication via departmental minutes continues to be a vital part of safe and successful patient outcomes.

Quality and patient safety continue to drive development within clinical standards.  The Trust’s Hospital Standardized Mortality Ratio (HSMR) continues to be below the England average (of 100). The HSMR is monitored on a monthly basis and the Trust’s mortality has decreased over the years, with scores below 100 since 2006.

During 2007, the Trust developed more quantifiable and accurate ways of determining clinical quality and thus strengthening our commitment to patient safety. Data have been enhanced to provide information on quality issues such as mortality for emergency and elective admissions and reflect events within the Trust as they happen.  These Clinical Performance Indicators (CPIs) enable us to show improvement and provide early warning of risk.  The initial CPIs have been targeted at easily measurable or reportable outcomes, such as mortality.  Future developments of this work will identify CPIs for length of stay and readmissions rates and will aim to benchmark these data with other Trusts. However, the data do not provide information in their own right, but simply identify areas for review. 

Clinicians across the Trust are using these indicators to review patient records and provide regular assurance on quality of care and patient safety:

  • Clinical Governance –
    Quality in the new NHS, Department of Health (1998)
  • A First Class Service, Department of Health (1999)
  • Principles of Best Practice in Audit, NICE, (2002)
  • Standards for Better Health, Department of Health (2004)
  • NHSLA Risk Management Standards for Acute Trusts. NHSLA (April 2007)
  • Operational plans 2008/09–2010/11, National Planning Guidance and “vital signs”
  • DH/NHS Finance Performance & Operations (Jan 2008)

Useful Contacts

Royal Berkshire Hospital Foundation Trust

Craven Road

0118 322 5111



    Royal Berkshire NHS Foundation Trust,
    London Road,
    RG1 5AN
    Email us
    Tel: 0118 322 5111
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