Principle 3 – Safeguards are in place which provide confidence that clinical governance processes are fair and free from discrimination and bias

Outcome 3a. Your board oversees and scrutinises the development and implementation of equality, diversity and inclusivity strategies in support of clinical governance processes.


Your board members act as role models and ambassadors for improving equality, diversity and inclusivity (EDI).

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

  • remove or minimise disadvantages experienced by individuals who share protected characteristics
  • identify barriers different groups may face in engaging with the processes supporting clinical governance, and put steps in place to remove these barriers
  • proactively look for barriers that may prevent individuals in speaking up, and address any potential barriers
  • think broadly about groups who might face barriers, by considering factors such as protected characteristics, and different types and patterns of work.

When developing clinical governance processes, your organisation involves groups who may face barriers based on a protected characteristic, whenever it is appropriate and relevant to do so.

Your organisation ensures emerging EDI challenges and risks associated with the policies and practices of clinical governance for doctors, AAs and PAs are actively monitored and regularly reviewed.

Outcome 3b. Decision-making processes in support of clinical governance processes are fair and free from bias and discrimination.


Your organisation has in place and consistently applies principles and criteria to ensure decisions made in support of clinical governance are fair, impartial and evidenced based. 

Training and guidance is provided to doctors, AAs and PAs to ensure decisions are fair, free from bias and meet the requirements of equality legislation.

Your organisation actively considers conflicts of interest in relation to decision making.

Decisions are internally monitored and audited to ensure quality, fairness and consistency. Procedures put in place to support decision making are reviewed and amended to reflect learning.

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