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The Portland hospital

Clinical Governance - measuring and ensuring the quality of care

16 March 2011

By Mr Patrick Walker, Consultant Gynaecologist, Chairman of Clinical Governance at the Portland Hospital and HCA International's newly appointed Responsible Officer.


1st January saw the biggest single change in the regulation of the medical profession for 150 years - the introduction of Responsible Officers (ROs) to begin the process to establish medical revalidation.

For the private sector as well as the NHS, the RO is now responsible to the board of a hospital for ensuring that:

  • there is timely collection of appropriate data
  • that mechanisms are established to identify early signs of poor performance
  • that mechanisms are in place to support remedial procedures when required
  • that mechanisms are in place to oversee recommendations on practice from the GMC and to refer doctors to the GMC when necessary. 

Absolutely central to this regulatory role, the Responsible Officer will, importantly, rely upon a rigorous and effective clinical governance system.

The standard definition that clinical governance (CG) is a mechanism for ensuring that organisations continually improve the standards of their procedures and performance, is one that most of us agree with.  It is, in many ways, another way of saying ‘measuring and ensuring the quality of care'.

The pillars that support CG are traditionally: clinical audit, clinical effectiveness, risk management, continuing education, utilisation of optimal IT, patient satisfaction and quality assurance. Indeed, the Clinical Governance Committee was established to co-ordinate these functions at the Portland Hospital for Women and Children in central London.

The committee drafted, refined and introduced a clinical governance pack for all consultants, which was later expanded for all members of staff.  This pack outlines and explains clinical governance functions including details of risk management and performance assessment mechanisms. Early pieces of work included defining precise criteria for those women who could be safely booked for delivery at the Portland - the majority - and identifying those few with medical co-morbidities where optimum delivery might be achieved elsewhere.

The policy that all women booked for delivery must attend a midwifery booking clinic was implemented and that in any cases where there were pre-existing or developing medical conditions, these would be looked at by a multidisciplinary team of obstetricians, paediatricians and anaesthetists.

For surgeons, the importance of scope of practice was endorsed and a system established to ensure that doctors regularly review their case load and skill mix to ensure that they only perform procedures specifically within their individual competence. Renewal of practicing privileges now takes place every two years. In future rounds of renewals there will be, in addition to the current checks on confirmation of essentials such as registration, indemnity insurance, CRB and Hepatitis immunisation status and analysis of incident reports, further evidence sought to demonstrate active CME and annual appraisal

Last year The Portland Hospital's Chief Executive Janene Madden commissioned an independent expert report from Professor James Walker, Senior Vice President of the RCOG, to look at Portland procedures and protocols.  The intention was to ensure that the very best practice was being employed and to seek any further advice about emerging protocols or technologies that would ensure that the hospital remained at the forefront of modern obstetric care.

Among the recommendations from Professor Walker that have been introduced, are the rationalisation of the risk management committee into the clinical governance committee and implementation of a new TRIPs policy (Traffic Lights Response Instructional Pathway) for the labour ward where each clinical situation is graded and the precise response and action times and desired personnel present, is clearly defined and colour coded for simplicity, consistency and maximum safe care.

The integration of risk management procedures to the formal governance structure has established a new protocol. The chair of clinical governance, the chief nursing officer, the integrated governance manager and an administrative assistant now meet every Monday morning to examine all reported clinical incidents. These are graded and investigative procedures commenced, statements sought where required and the group make a decision as to whether all appropriate protocols have been followed, if there are any learning points, if any action is required or if there is a pattern of events suggesting a generic issue which would benefit from review.

Every second month the full clinical governance committee meets and discusses all CG issues with specific attention to reviewing the work of the clinical incident review panel. Any individual incident can be reviewed. In very rare cases where a potentially serious incident may have occurred, the group has a mechanism for seeking an internal independent expert review of the case, or very exceptionally an independent expert external review.With respect to consultant performance, any individual incident or possible pattern of performance is judged by the criteria described in Duties of a Doctor, Good Medical Practice, as defined by the GMC.

It needs effective team work, commitment and a great deal of resource but rigorous and effective clinical governance benefits everyone involved in healthcare, especially our patients. 

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