Principle 1 – Organisations create an environment which delivers effective clinical governance for doctors

This checklist is a tool to support the creation of effective clinical governance environments.

1a. Board knowledge, skills and competences

Your organisation’s board has the knowledge, skills, competences and access to relevant information to enable it to exercise its responsibilities effectively with respect to clinical governance for doctors.

Description

Your organisation’s board receives training and development opportunities necessary to effectively discharge their responsibilities around clinical governance for doctors, and to understand their accountability for the quality of care provided by doctors.

Your organisation’s board has access to summary information and data from clinical governance processes for doctors (including complaints, incident reporting, medical appraisal, management of concerns about doctors and clinical indicators) and the ability to interpret and scrutinise the information appropriately.

Clinical/medical leaders including responsible officers are given access to your organisation’s board and provide input on matters relating to clinical governance for doctors.

A suitably qualified and trained non-executive director has a specific role in providing support and challenge to the board on clinical governance systems for doctors including revalidation and management of concerns.

Prompts

  • How does your organisation ensure that the board (including non-executive directors) has the right training and development opportunities to support the effective oversight of clinical governance arrangements for doctors?
  • How does your organisation identify the clinical governance information about doctors it needs to undertake its role effectively?
  • How does your organisation ensure the board is kept up dated on changes to clinical governance processes for doctors and the impact of those changes?
  • How does your organisation’s board engage with clinical/medical leaders?

1b. Promoting clinical governance for doctors

Your organisation’s board provides leadership on promoting the importance of clinical governance for doctors.

Description

Your organisation actively promotes the benefits of effective clinical governance processes for doctors (including those that support access to supporting information for appraisal and medical revalidation). This includes the positive contribution those processes make to the professional development of individuals and ultimately safe and effective patient care.

Your organisation works with local patient groups to publicise and promote awareness of  the revalidation processes it has in place to make sure doctors are up to date and fit to practise, including an understanding of how concerns about doctors are dealt with.

Your organisation ensures all doctors working within the organisation including locum doctors, doctors in training and clinical academics, for example, have access to clinical governance information about their practice.

Prompts

  • How does your organisation demonstrate its commitment to the delivery of effective governance processes for doctors?
  • How does your organisation ensure doctors (including locum doctors, doctors in training and clinical academics, for example) have access to information about their practice and are encouraged to use it as part of their professional development?
  • How does your organisation work with local patient groups to promote awareness of revalidation processes and how they are applied locally?

1c. Culture of honesty, learning and improvement

Your organisation’s board actively encourages a culture of honesty, learning and improvement.

Description

Your organisation makes sure systems are in place to give early warning of any failure, or potential failure, in the clinical performance of individuals or teams.

These may include systems for conducting audits and considering patient feedback and making sure any concerns about the performance of an individual or team are investigated and, if appropriate, addressed quickly and effectively.

Your organisation ensures there are readily available and accessible policies and processes in place which encourage doctors to speak up and which ensure doctors are not at risk of detrimental treatment as a result of doing so.  This includes ensuring your organisation can demonstrate how decisions made about the issues raised doctors speaking up are fair.

Doctors have a professional duty of candour. Your organisation puts in place processes to support them in reporting adverse incidents, and near misses, and in being open and honest with patients if something goes wrong with their care.

Your organisation puts systems in place to monitor, review, and improve patient care by:

  • Collecting and sharing information on patient experience and outcome
  • Training staff in patient safety and supporting them to report adverse incidents

And makes sure systems or processes are in place so that: 

  • lessons are learnt from analysing adverse incidents and near misses
  • lessons are shared with the healthcare team 
  • concrete action follows on from learning
  • practice is changed where needed.

Doctors are supported in giving honest and open feedback on their colleagues, and there are systems and processes in place to make sure that any workplace issues raised are addressed fairly.

Prompts

  • How does your organisation make sure it responds quickly when things go wrong?
  • How does your organisation evaluate whether its policies for speaking up are effective? For example, do they result in creating unintended barriers to those who wish to speak up?
  • Does your organisation  offer sufficient assurance to those raising concerns that they will not suffer as a result of speaking up and that there is a zero tolerance approach to victimising staff who speak up?
  • What steps does your organisation have in place to support doctors who have spoken up?
  • How does your organisation make sure that decisions made about doctors who speak up are fair and transparent, and this can be demonstrated if necessary?
  • How does your organisation make sure challenges made about clinical governance processes are recorded, acted on, and the outcomes fed back to those who raised concerns?
  • How does your organisation identify opportunities for learning and improvement from matters raised by workers speaking up?
  • How does your organisation support and encourage staff in being open and honest with patients when things go wrong?
  • How does your organisation support doctors to provide honest and open feedback about their colleagues?

1d. Monitoring risks

Your organisation’s board monitors risks associated with clinical governance systems for doctors.

Description

Your organisation’s board plays a proactive role in identifying, monitoring and managing risks to clinical governance systems for doctors.

Your organisation makes use of available information to inform their clinical governance arrangements for doctors, such as the GMC’s organisational dashboard for revalidation and fitness to practise.

Prompts

  • How does your organisation ensure it has a clear view of risks associated with clinical governance systems for doctors?
  • How does your organisation assure itself that the risks are being reviewed and managed appropriately?
  • How could the reporting systems for your organisation’s board on risks associated with clinical governance systems for doctors be improved?