Resources

The Clinical Governance Training Package (October 2024) offers a structured, modular curriculum designed to embed clinical governance principles across NHS organisations. It covers foundational concepts while also providing practical guidance on governance roles, performance measurement, and staff engagement.

1. Clinical Governance Overview 

Clinical governance is a system used to improve the quality and safety of healthcare. It involves monitoring how care is delivered, learning from mistakes, and making sure patients are safe. A strong culture of teamwork, openness, and continuous improvement is key. 

2. Adverse Incidents 

An adverse incident is something unexpected that causes or could cause harm to a patient, visitor, or staff member. Reporting these incidents helps identify risks and prevent them from happening again. The Trust uses the Datix system to report and manage incidents within 24 hours. The focus is on learning and support—not blame. 

3. Patient Safety Incident Response Framework (PSIRF) 

PSIRF is the NHS’s way of responding to safety incidents. It replaces older systems and focuses on: 

• Supporting patients, families, and staff. 

• Using different tools to learn from incidents. 

• Investigating only when needed, to avoid repeating the same reviews. 

• Improving care through learning, not punishment. 

4. Response Methods 

The Trust uses several ways to learn from incidents: 

• After Action Review (AAR): A group discussion to understand what happened and why. 

• Multidisciplinary Team (MDT) Review: A broader look at past incidents using staff insights. 

• Patient Safety Incident Investigation (PSII): A deep dive into serious incidents. 

• SWARM (Huddle): A quick team response right after an incident. 

• Thematic Review: A look at patterns across multiple incidents. 

5. Being Open 

When something goes wrong, staff are encouraged to be honest, compassionate, and clear with patients and families. This helps everyone understand what happened and how things will be improved. Key principles include: 

• Acknowledgement: Take concerns seriously. 

• Truthfulness and Timeliness: Share information clearly and quickly. 

• Support: Help patients and staff cope and learn from the experience. 

6. Staff Involvement 

Staff play a vital role in clinical governance. They’re encouraged to: 

• Attend incident review meetings. 

• Share their insights and experiences. 

• Keep reporting incidents. 

• Help create and follow action plans for improvement.