Principle 3 – Safeguards are in place to make sure clinical governance processes for doctors are fair and free from discrimination and bias

This checklist is a tool to support the development of clinical governance safeguards which are fair, and free from bias and discrimination.

3a. Equality, diversity and inclusivity

Your organisation’s board provides leadership on equality, diversity and inclusivity (EDI) by overseeing and scrutinising development and implementation of EDI strategies.


Your organisation’s board members act as role models and ambassadors for EDI issues.

Your organisation ensures clinical governance policies for doctors are fair and free from bias and discrimination by ensuring they:

  • Remove or minimise disadvantages experienced by doctors who share protected characteristics. For example by making reasonable adjustments to processes underpinning clinical governance for disabled doctors.
  • Identify barriers different groups of doctors and patients may face in engaging with the systems supporting clinical governance, and put steps in place to remove these barriers.

Your organisation encourages consultation with and involves people who share personal characteristics in developing clinical governance processes for doctors whenever it is appropriate and relevant to do so.

Your organisation ensures emerging EDI challenges and risks associated with clinical governance for doctors’ policies and practices are actively monitored and regularly reviewed.


  • How does your organisation make sure its policies and practices which support clinical governance for doctors are fair, non-discriminatory, and comply with legal requirements?
  • How does your organisation ensure barriers to accessing the systems supporting clinical governance for doctors are identified and addressed?
  • How does your organisation engage with EDI issues, and what benefits does this bring?

3b. Decision-making

Your organisation’s board ensures decision-making processes are fair and free from bias and discrimination.


Your organisation puts in place principles and criteria to ensure decisions made in support of clinical governance for doctors are fair, impartial and evidenced based, and these principles and criteria are applied consistently.

Decisions are internally monitored and audited to ensure the quality, fairness and consistency of decisions, and to review the procedures put in place to support decision making.

Mechanisms exist for doctors to appeal, or request a review of, decisions made in relation to them.


  • What are your organisation’s principles of fair decision making, and how do these ensure your decisions are free from bias and discrimination?
  • What changes has your organisation made to its procedures in relation to supporting fair decision making based on learning from the monitoring and audit of decisions?
  • What training does your organisation provide to its staff to ensure decisions are fair, free from bias, and meet the requirements of equality legislation?
  • How does your organisation make sure that doctors are aware of processes to appeal or review a decision? And what safeguards are put in place to ensure these appeals and reviews are handled consistently and fairly?