Clinical Governance

What about Alder Hey

The Board of Clinical Governance
The Board of Clinical Governance is responsible for:-
Ensuring that the Trust has suitable frameworks for clinical
governance, directing action and evaluating progress. It provides a
strategic framework to the development of clinical governance in the Trust
and assures the Trust Board that elements of Clinical Governance are
regularly reviewed and monitored.

Objectives:-

To evaluate progress and variations in practice on clinical governance
issues. This includes reviewing and evaluating the following
pillars of the clinical governance agenda:-

1. Continuing professional development
2. Clinical risk management
3. Mechanisms of ensuring clinical effectiveness including audit, evidence-based medicine and use of pathways, guidelines and research and development
4. Users experience and views including complaints
5. Continuous quality improvement and clinical outcome indicators

To provide a forum for discussion and action on national clinical
governance initiatives e.g. from NICE & CHI, to review/provide
information on national service frameworks including clinical indicators
and to liaise with the Clinical Policy Evaluation Group to effect action.

To agree key priorities for the clinical effectiveness agenda (as
proposed by the Board of Clinical Directors) & ensure that actions are
taken and followed up through agreed channels.

To review the minutes of identified committees on an agreed basis.

To receive and appraise reports from each Core Group every six
months to include: action on risk management, complaints, critical
incidents, patient feedback, professional development and PDP's
action on clinical effectiveness to include action to date on key clinical
priorities, progress on audit, input from the evidence based medicine
unit, R & D activities, and the development of guidelines/pathways.

To provide summary reports to the Trust Board.

To provide an annual report on implementation of clinical governance and
agree development plans.

Members of The Board of Clinical Governance are:
Mr C Vellenoweth – Chairman
Mr T Bell – Chief Executive
Mrs R Burke – Director of Service Development
Mr S Ryan – Medical Director
Mr A Sharples – Director of Finance & Information
Dr M Peak – Clinical Governance Coordinator
Mr R Franks – Cardiac Surgeon
Mrs J Kelly – Lay Member
Ms E Rathbone – Lay Member
Mrs M Fitzhugh – Manager, Risk Management
Miss N Elliott – Director of Human Resources
Dr D Casson – CG Lead – Medicine
Dr J Woollard – CG Lead – Community & Mental Health
Dr I Billingham – CG Lead – Surgical, Theatre & Anaesthetics
Mr P Newland – CG Lead – Support Services
Dr B Phillips – CG Lead – AED
Mr A Darbyshire – Nurse Consultant, ICU
Mrs M Mitchell – Therapies
Mr R Cooke – Chief Nurse
Prof R Smyth – Evidence Based Child Health Unit

Contacts

Rebecca Burke - Clinical Governance Executive Lead
Dr Steve Ryan - Clinical Governance Executive Lead
Dr Matthew Peak - Clinical Governance Co-ordinator
Dr David Casson - C G Lead - Medicine
Dr Jane Woollard - C G Lead - Community & Mental Health
Dr Imogen Billingham - C G Lead - Surgery, Theatre and Anaesthetics
Mr Paul Newland - C G Lead - Support Services
Karen Wratten - Clinical Governance Administrator - 0151 252 5562

How does Alder Hey ensure clinical effectiveness?

• Using best available evidence to inform practice
• Developing structured guidelines & pathways
• Auditing practice
• Supporting systems for clinical review and implementing ( CPEG & Horizon scanning )
• Developing Care Group priorities and action plans
• Implementing national advice from NICE, Royal Colleges etc
• Ensuring staff are up-to-date with relevant information

How does Alder Hey work with patients and families to strive to ensure a quality patient experience?

• Patient surveys, evaluations and action plans
• Opportunities to voice concerns ( PALS )
• Arrangements to manage complaints & learn lessons
• Appropriate consent arrangements
• Systems developed include Patient Access Strategy Group, Informed Consent Project Group, Complaints Review Panel

How does Alder Hey promote continued learning in order to improve clinical effectiveness?

• All staff training is monitored by the Training and Education Policy Group
• Effective PDP process with follow up
• Consultant Appraisal System
• Development of clinical leadership skills
• Excellence through learning programme

How does Alder Hey handle risk management?

• Clinical Risk Management procedures
• Operational Risk Management/Controls Assurance
• Clinical Negligence Scheme for Trusts (CNST)
• Clinical Incident Review
• Clinical Negligence Advisory Group (CNAG)
• Medication error review
• Mortality review
• Encouraging an open/learning culture of reporting near misses

How does Alder Hey ensure continuous improvement in quality?

• Developing Care Group Quality Plans
• Developing and monitoring outcome measures
• Sharing outcome measures with the national benchmark groups
• Regularly reviewing audit results
• Managing poor performance in a positive way
• Learning lessons from complaints & incidents
• Effective record management
• Excellence through learning programme