Clinical Governance and Risk Management

Introduction

The Chief Executive at St. Andrew’s Hospice is responsible for quality of services provided. The Chief Executive has delegated the responsibility for delivering the Clinical Governance agenda to the Clinical Governance Committee chaired by the Medical Director. The Clinical Governance Committee meets quarterly. The Clinical Governance Committee members comprise:

Medical Director (Chair)
The Chief Executive.
The Director of Nursing Services.
The Ward Manager.
The Director of Support Services.
Infection Control Lead
Clinical Audit Chair
Macmillan Pharmacist
Director of Patient & Public Liaison

External Membership
The Minutes of the committee meetings, together with policy documents, are received and approved by the Board of Management.

Definition of Clinical Governance

An internal framework through which voluntary sector providers of Hospice and Specialist Palliative Care demonstrate accountability for and ensure continuous improvement in the quality of their services for patients and those who care for them. Clinical Governance aims to safeguard high standards of care, creating an environment in which excellence of care will flourish.

Remit of St. Andrew’s Hospice Clinical Governance Committee

To co-ordinate quality improvement within St. Andrew’s Hospice in all its departments, concentrating on the core values of Human Dignity, Compassion, Justice, Quality and Advocacy.
To promote equity of service provision and palliative care education for patients and staff in Lanarkshire
To provide support and direction to staff with key responsibility for Clinical Governance, including Risk Management, in the following areas: Health, Safety and Environment ; Infection Control; Medicines Management; Care of Children and Vulnerable Adults; Audit
To produce a Quality Development Plan at three year intervals, to be agreed in consultation with the Hospice Board of Management, which supports the concurrent Hospice Operating Plan
To promote clinical audit and critical incident reporting as valuable tools to monitor and improve existing practice. To oversee and monitor progress in order to ensure that lessons are learned from complaints, adverse incidents and enquiries for the benefit of clinical services.
To review outcomes of care against local and national standards and guidelines with particular reference to Health Improvement Scotland.
To ensure patients’ and carers’ views are incorporated into service provision.

The Clinical Governance Committee receives and discusses the following:

Reports from staff with key responsibilities: -

Health, Safety and Environment: Susan Dillet
Infection Control: Susan Jackson
Medicines Management: Linda Johnstone
Child/Vulnerable Adult Protection: George Beukan
Audit: Catriona Ross
The drafts of all policies.
Accidents and Incident Reports.
Reports of Complaints.
Inspection Reports.