Clinical Governance and Patient Safety
On this page
Overview of Clinical Governance and Patient Safety
A simple definition of Clinical Governance is the recognition and maintenance of good practice, learning from situations and improving the quality of services delivered to patients. Clinical Governance is also a framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.
It is the responsibility of every member of staff within the organ donation and transplantation pathway not just the remit of a few. Everyone needs to work together to ensure that patients and donor families receive the best possible care. There is no single thing which is clinical governance but there are a series of key elements that aim to:
- Identify and pursue opportunities to improve practice
- Address areas of clinical concern, identify lessons learned and, where appropriate, implement changes
- Share lessons learned amongst the donation, retrieval and transplant community as appropriate
- Put systems in place to reduce risks
- Ensure continuous improvement
- Establishing a supportive, inclusive learning culture
All incidents reported to the Organ and Tissue Donation and Transplantation (OTDT) Directorate that may affect any part of the pathway (which includes not only organ donation but also retrieval, transplantation and activities within transplant support services) are managed by the Patient Safety Team within OTDT.
The team includes:
- Chief Nurse - OTDT
- Deputy Chief Nurse - OTDT
- Patient Safety Lead - OTDT
- Patient Safety Managers - OTDT
All of the above members have clinical backgrounds and work closely with the clinical teams, the Associate Medical Director - Patient Safety and other relevant experts such as Advisory Group Chairs. The team are supported by the Patient Safety Coordinator - OTDT.
The team review all incidents that are reported and investigate where appropriate. For oversight, the Quality Assurance team review the risk rating and review all cases within the Directorate prior to their completion. This provides independent oversight of all incidents reported.
The Patient Safety Team aim to complete investigations within 90 days, and often sooner. In some cases, this may not be possible however, as a full investigation is required from colleagues in other organisations. Once an incident has been fully reviewed and investigated the individual who reported the incident will always be sent a summary of the outcome and any key actions or learning.
Patient Safety Improvement Group (PSIG)
Alongside designative representatives for retrieval, donation, transplant support services and other expert links, the Patient Safety Team form the Patient Safety Improvement Group (PSIG). This group are responsible for reviewing and monitoring in detail all incidents reported to OTDT including serious adverse events and reactions (SAEARs) reported to the Human Tissue Authority as part of NHS Blood and Transplant (NHSBT)'s assisted function.
PSIG's remit is to:
- Have oversight of all incidents and review in detail individual incidents, ensure areas of concern are addressed, learning is shared, and, where appropriate, practice is changed
- Identify and review key themes and trends of incidents, and, where appropriate, develop key actions following these reviews
- But most importantly to ensure that key learning points are disseminated in a timely way to all stakeholders
Whilst PSIG ensures a detailed review of incidents are completed the OTDT Clinical Audit, Risk and Effectiveness Group (CARE) has a wider oversight.
OTDT Clinical Audit Risk and Effectiveness Group
The OTDT Clinical Audit Risk and Effectiveness (CARE) group is chaired by the Chief Nurse - OTDT. Membership includes the Medical Director - OTDT, senior operational, nursing and medical representation, patient safety and quality assurance team members, scientists, legal and data privacy representatives.
It monitors and provides oversight of clinical complaints and legal claims, Clinical Audit, Clinical Risk Register and reviews and, where appropriate approves, clinical policies proposed by the Advisory Groups. It also provides a wider oversight of incidents.
Within NHSBT the OTDT CARE group reports to the OTDT Senior Management Team and the Clinical Quality and Safety Governance Group (CQSGG). CQSGG then reports to the NHSBT Clinical Governance Committee (CGC) which has oversight of governance across NHSBT. The NHSBT CARE Committee meets every 3 months, is a sub-group of the NHSBT board and is chaired by a NHSBT Non-Executive Directorate.
Appendix
Governance Improvement Group: Terms of Reference