Governance and Quality

Overview of Clinical Governance

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 Donation and Transplantation (ODT) 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 Clinical Governance Team within ODT.

The team includes:

  • Assistant Director – Education and Governance
  • Head of Clinical Governance
  • Clinical Governance Support Managers

All of the above members have clinical backgrounds and work closely with, and are supported by the Clinical Governance Support Assistant. 

The team investigate all incidents that are reported and for oversight the Quality Assurance team review the risk rating and close down all submissions within the Directorate. This provides independent oversight of all incidents reported.

The Clinical Governance Team aim to complete investigations within 90 days, and in many cases 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.

Clinical Governance Improvement Group (GIG)

Alongside designative representatives for retrieval, donation, transplant support services and other expert links, the Clinical Governance Team form the Clinical Governance Improvement Group (GIG). This group are responsible for reviewing and monitoring in detail all incidents reported to ODT including serious adverse events and reactions (SAEARs) reported to the Human Tissue Authority as part of NHS Blood and Transplant (NHSBT)’s assisted function. 

GIG’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 GIG ensures a detailed review of incidents are completed the ODT Clinical Audit, Risk and Effectiveness Group (CARE) has a wider oversight. This group is chaired by the ODT Associate Medical Director and membership includes senior operational, nursing and medical representation, clinical governance, quality assurance and scientists.

ODT Clinical Audit Risk and Effectiveness Group

The ODT CARE group is chaired by the ODT Associate Medical Director and membership includes senior operational, nursing and medical representation, clinical governance, quality assurance and scientists.

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 ODT CARE Group reports to ODT Senior Management Team (SMT) and the NHSBT CARE Committee which has oversight of Governance across NHSBT. The NHSBT CARE Committee meets every two months and is chaired by the NHSBT Medical Director, this Committee is accountable to the NHSBT Governance and Audit Committee which is chaired by a NHSBT Non-Executive Director and is a sub-group of the NHSBT Board.

Terms of reference

Updated September 2023



Governance Improvement Group: Terms of Reference