Principle 1 – Your organisation creates an environment which delivers effective clinical governance doctors, AAs and PAs

Outcome 1a. Boards have appropriate knowledge, skills, competences and access to the right information


Your board:

  • understands its accountability for the quality of care provided by all doctors, AAs and PAs
  • ensures consistent standards of governance are maintained for all doctors, AAs and PAs 
  • receives the training and development necessary to enable it to effectively fulfil its responsibilities around clinical governance for doctors, AAs and PAs
  • identifies, accesses, and appropriately interprets and scrutinises, the clinical governance data and information it requires for doctors, AAs and PAs, to effectively undertake its role. This might include data on: complaints, incident reporting, appraisals, management of concerns and clinical indicators.
  • is updated on changes to clinical governance processes for doctors, AAs and PAs, and the impact of those changes.

Clinical/medical leaders including responsible officers have access to your board and provide input on matters relating to clinical governance for doctors, AAs and PAs.

A suitably qualified and trained non-executive director has a specific role in providing support and challenge to your board on clinical governance arrangements for doctors, AAs and PAs.

Outcome 1b. The benefits of effective clinical governance processes are promoted and widely understood


Your organisation promotes the benefits of effective clinical governance processes to doctors, AAs and PAs, as well as to patients and the public. This includes explaining how:

  • revalidation provides assurance that doctors, AAs and PAs are up to date and fit to practise 
  • you manage concerns about doctors, AAs and PAs
  • processes contribute to individual’s professional development, and to safe and effective patient care.

Your organisation ensures all doctors, AAs and PAs working within the organisation, including those on a short-term or temporary contract, have access to clinical governance information about their practice, and are encouraged to use it as part of their professional development. Your organisation provides adequate feedback to all of these doctors, AAs and PAs when concerns arise.

Outcome 1c. There is a culture of honesty, openness, learning and improvement


Clinical excellence and the well-being of doctors, AAs and PAs are at the centre of your organisation’s approach to delivering quality patient care. 

Your organisation has arrangements in place to monitor, review, and improve patient care by:

  • collecting and sharing information on patient experience and outcomes
  • ensuring arrangements identify good practice and give early warning of any failure, or potential failure, in the clinical performance of individuals or teams
  • ensuring any concerns about an individual or team are investigated and, addressed promptly and effectively (see our 'Principles of a good investigation').

Your organisation takes active steps to create an environment in which doctors, AAs and PAs are encouraged to talk about errors and concerns safely1.

Your policies and processes ensure all doctors, AAs and PAs know that there are a variety of routes to speaking up and that when they do speak up that they will feel safe and encouraged to do so. Your policies and processes are communicated effectively, and as a result of doing so demonstrate a zero-tolerance approach to victimisation of any staff who speak up.

You have clear processes in place that demonstrate a zero tolerance approach to detriment of any staff member who speaks up.

You support doctors, AAs and PAs’ duty of candour by encouraging them to: report adverse incidents, and near misses, give honest and open feedback on their colleagues, and be open and honest with patients if something goes wrong with their care.

You check that procedures and policies for the managing, categorising and escalating of concerns are applied correctly.

Your organisation demonstrates openness and a desire to learn, by sharing outcomes and learning arising from individuals speaking-up, adverse incidents and near misses widely, including with healthcare professionals and patients. Your Board considers and discusses discrepancies between local and other independent investigations.

Your organisation ensures challenges made about clinical governance processes are recorded, acted on, and the outcomes fed back to those who raised concerns.

1 See GMP, paragraph 76.