Name

Date
Venue

FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA

MINISTRY OF HEALTH
 At the end of this session, participants will be able to
◦ Understand the concept of Clinical Governance
◦ List the major components of Governance
◦ Explain the importance of each component of Clinical Governance and
associate it with quality improvement
◦ Understand the relevance of collecting and utilizing high quality
clinical data
◦ Understand quality as it is defined from the perspective of
patient’s/clients.
 Section 1. Introduction
 Section 2. Operational standards for CG&QI
 Section 3. Implementation Guidance
 Section 4. Assessment checklist
 Section 5. Indicators
 Section 6. Appendices
 Clinical Governance is a concept which brings together all the activities that
demonstrate to patients and the community that care providers hold themselves
responsible for providing safe, high quality health care.

 It is about continuous improvement of the quality of services and creating

accountability and transparency. It encompasses safety, effectiveness and positive
patient experience.

 Ensures safe, high quality care from all involved in the patient's journey and
patients are the main focus and priority.

 Quality is a moving target and continuous improvement in quality means that what
is considered of an acceptable quality today may not be acceptable this time next
year
1. The hospital has an established Clinical Governance and Quality
Improvement Unit that is led by an assigned Senior Physician or GP.

2. The hospital develops and implements a CG&QI strategy and an

operational plan that addresses the key components of quality.

3. Procedures are established to monitor clinical practices and

standards through services specific process and outcome measures
to ensure problems identified are addressed.
4. The hospital implements a regular clinical audit program in each service area.

5. Procedures are established to assess and minimize risk arising from the provision
and delivery of health care. A system is also in place for reporting and analyzing
incidents, errors and near misses.

6. The hospital adopts a statement of patient rights and responsibilities, which is

posted in public places in the hospital.

7. The hospital continuously and systematically reviews and improves all aspects of
its activities that directly affect patient safety and apply best practice in assessing and
managing risks to patients, staff and others.
8. The hospital monitors patients’ experiences with care through patient satisfaction
surveys conducted on a quarterly basis.

9. The hospital implements a strategy for the involvement of patients and the public
in service design and delivery including procedures to be followed when engaging
with patients and the public.

10. The hospital develops and implements a strategy to provide patient focused care
which incorporates compassion, respect and dignity for patients, effective
communication, and better hotel services in the care delivery.

11. The hospital participates in benchmarking activities to learn from and share good
practices with other hospitals.
 Organizational structure for CG&QI

 CG&QI activities in hospitals should be supported by appropriate

structures and responsibilities that serve to
◦ Encourage involvement of all staff
◦ Assign responsibility for CG&QI at SMT

 CG&QI unit should be established, reports to the CEO. It should be led

by senior physician or a GP and should be a member of the SMT.

 The Head should be selected based on a defined set of criteria

(leadership, clinical, analytic and research skill and commitment)
◦ To develop the CG&QI strategy and present to the Senior
Management Team and Governing Board for approval,
◦ To develop an implementation plan for the CG&QI strategy and
monitor its execution.
◦ To ensure that CG&QI activities relate to the vision and mission of
the hospital, and are aligned with the hospital strategic and annual
plans,
◦ To co-ordinate all CG&QI activities,
◦ To promote and support the participation of all staff in CG&QI
activities,
◦ To receive and analyse feedback information from patients, staff and visitors,

◦ To receive clinical audit reports and maintain a record of all clinical audit
activities,

◦ To work very closely with the HMIS Focal Officer/Unit in monitoring HMIS
performance and

◦ To conduct peer review in response to specific quality and safety concerns and to
take appropriate action and follow-up when deficiencies are identified etc..
 The CG Unit should develop and oversee the implementation
of the hospital’s CG&QI Strategy. Strategies need to address
the following:
◦ Risk management (risk assessment and Incident reporting)
◦ Clinical effectiveness (clinical audit, Process and outcome
measurement, Professional competence)
◦ Patient and public involvement in healthcare planning and service
delivery
◦ Complaint Handling and Management Procedure
◦ Patient focused care
◦ Benchmarking
◦ Openness
 Health care managers should ensure the services that they provide for
users meet their needs and being delivered in the most effective and
appropriate manner.

 Examples of uses of process and outcome measures,

◦ To compare outcomes between individual clinicians working in the same service, in order
to see if they are achieving comparable results.

◦ To provide feedback to a service about the course of response (recovery or deterioration)

of those receiving help.

◦ As a pointer to the need for further investigation or action as part of a quality improvement
process.
 Measures should be,
◦ Valid (does it measure what it is supposed to)
◦ Reliable (is it reproducible when taken at different times or in different
circumstances?)
◦ Sensitive to change (does it discriminate between good and poor quality of care,
and can it detect small but worthwhile improvements?)
 HMIS (defined set of indicators)
 The SMT must ensure that clinical outcomes are monitored within the
hospital, and that timely action is taken to address any problems
identified.
 In addition to the HMIS/KPI indicators, hospitals may select additional
clinical indicators for monitoring on a quarterly or annual basis.
 Clinical audit can be defined as “a quality assurance process
that seeks to improve patient care and outcomes through
systematic review of care against explicit criteria and the
implementation of change”.

 Clinical audit aims to ensure that all patients receive the most
effective, up to date and appropriate treatments.

 Clinical audit against good practice criteria or standards

answers the question – “are patients given the best care?”
 Clinical audit involves 5 main steps
1. Plan for audit

2. Identify/develop standards or criteria for clinical care in selected area

3. Assess current practice against standards

4. Implement QI on identified gaps

5. Re-assess practices against standards (Sustain improvements)

 Risk can be defined as ‘the likelihood, high or low, that
somebody or something will be harmed by an unwanted event
or incident, multiplied by the severity of the potential harm’.

 Clinical risk management (CRM) is an approach to improving

the quality and safe delivery of health care.

 It places special emphasis on identifying circumstances that

put staff/patients at risk of harm and acting to prevent or
control those risks.
 Risk management involves assessing the environment for potential
risks to patients and staff then taking action to minimize any risks
identified.

How bad?

Is there a need
What can go
for action?
wrong?

How
often?
 Risk management proactively reduces identified risks to an acceptable
level.

 Focuses on assessment and prevention, rather than reaction and

remedy.

 Risk assessment looks at:

◦ Hazards – which are situations with the potential to cause harm; and
◦ Risks - which are defined as the probability that a specific adverse event will
occur in a specific time period or as a result of a specific situation.
 Risk assessment involves 5 steps
1. Identify the hazards (what can go wrong?)

2. Decide who might be harmed and how (what can go wrong, who is exposed to the
hazard)?
3. Evaluate the risks (how bad? how often?) and decide on the precautions (is it
necessary to take further action?) A risk matrix can be used to evaluate the risks

4. Record the findings, propose action and identify who will lead on each action

5. Review the risk assessment and update if needed

 Low risk (green) – quick, easy measures should be implemented
immediately and further action planned when resources permit.

 Moderate risk (yellow) – actions should be implemented as soon as

possible, but no later than one year.

 High risk (orange) – actions should be implemented as soon as

possible, but no later than six months.

 Extreme risk (red) – action should be taken immediately.

 Areas that could be considered for assessment include, but are not
limited to:
◦ The physical environment – is it clean, safe, free from hazards such
as broken furniture or equipment?

◦ Are emergency exits clearly labelled and free from obstruction?

◦ Are infection prevention policies and procedures implemented

adequately?

◦ Hazardous materials – are these stored safely and securely?

◦ Is all equipment in good working order, is maintenance required to
minimize errors and breakdowns?

◦ Are policies for medication administration implemented to minimize drug

error?

◦ Are policies for laboratory sample collection, analysis and reporting

implemented to ensure that the correct specimen is taken from the correct
patient and that accurate results are obtained and reported in a timely
manner?

◦ Are clinical guidelines adhered to in order to ensure evidence based clinical

practice?
 Hospitals should establish systems to report, analyse and learn
from adverse events and service failures that involve risk to
patients, visitors and/or staff.

 Each event is unique. However, there are often similarities and

patterns in the sources of risk, which may go unnoticed if they
are not reported and analysed.

 Reporting of incidents, errors and near-misses helps us to

understand why things have gone wrong and to take action to
minimize the risk.
 A systems approach to looking at incidents recognises that human
beings make mistakes and accepts that some errors will happen in
the best run health systems in the best organisations.

 This approach moves away from blaming individuals and instead

focuses on incidents as a source of learning for change.

 Taking a systems approach to looking at patient safety involves

looking at what factors contribute to incidents and asking:
◦ What went wrong?
◦ Where did it happen?
◦ Why did it happen?
 Once the causes are identified action can then be taken.
 This may involve
 staff training,
 development of protocols,
 implementation of defence mechanisms
 safeguards such as double checking with colleagues,
 effective labelling of medications etc.
 A successful reporting and learning system to enhance patient safety should ensure
that:
 Reporting is safe for the individuals who report,
 Reporting leads to a constructive response,
 There is expertise to analyse reports, and
 Information and recommendations arising from incident reports are
disseminated.
 An Incident Officer should be assigned to receive and
investigate all Incident Reports.

 The Incident Officer should investigate all reports received,

ideally in collaboration with the relevant Case
Team/Department Head.

 The Clinical Governance and Quality Improvement Unit should

receive regular summary reports of all incidents reported.
 Clinical effectiveness is the extent to which specific clinical
interventions do what they are intended to do. It can be described as
the right person doing:
 the right thing (evidence based practice)
 in the right way (skills and competence)
 at the right time (providing treatment/services when the patient needs them)
 in the right place (location of treatment/services)
 with the right result (clinical effectiveness/maximizing health gain).
 Clinical effectiveness depends on adequate manpower and resources,
including equipment and drugs. It also requires that health professionals
have up-to-date knowledge of the most effective diagnostic tests,
treatments and procedures.
 Patient focused care includes the quality of caring, compassion, dignity
and respect with which patients are treated.

 Every patient wants to be treated as an individual, and has the right to

courtesy, respect, privacy and confidentiality and to receive full
information about their condition, investigations provided and
treatments offered.

 The effective management of every patient is made up of a mix of

professional skill and compassion. It requires a careful balance of:
◦ Consideration,
◦ Talking and Listening.
 Patient focused care includes the quality of caring,
compassion, dignity and respect with which patients
are treated.

 Every patient wants to be treated as an individual, and has the right to

courtesy, respect, privacy and confidentiality and to receive full information
about their condition, investigations provided and treatments offered.

 The effective management of every patient is made up of a mix of

professional skill and compassion. It requires a careful balance of:
◦ Consideration,
◦ Talking and Listening.
 Hospitals should adopt a statement of patient rights and responsibilities.

 Patient focused care also includes the quality of “hotel” services provided to
patients such as housekeeping, nursing, laundry, food services etc.

 The hospital should ensure that these services are provided to a high standard
within the available budget.

 Patient focused care can only be improved by analysing and understanding patients’
satisfaction with their own experiences.
 Health services should be tailored to the needs and expectations of
the population served.

 The perspective of patients and the public can help identify what does
and doesn’t work in the delivery of treatments and services.

 Before involving patients and the public it is important to identify:

◦ What you want to know,
◦ Why you want their views,
◦ How you will use their views, and
◦ What the patient and service will gain from this involvement.
 Involvement of patients and the public can take place in three ways:
Approach Activity

Informing  Patient information leaflets

 Poster displays in hospital or community
 Publications in local press
 Presentations at public meetings

Consulting  Patient satisfaction surveys

 ‘Suggestion boxes’
 Complaints procedures
 Participatory public meetings
 Patient interviews
 Focus groups
Partnership  Community representation on hospital Governing Board
 Stakeholder membership of service or hospital planning committees
 Complaints provide unique information about the quality of health care
from the perspective of patients/clients.

 It ensures that any identified risks are managed appropriately and that
action is taken to minimise or eliminate those risks.

 A key component of complaint management is the systematic recording

of issues, risks, complaints, and their resolution.

 A focal person or committee could be established for the receipt and

management of serious complaints from members of the public users
and staff.
 Benchmarking is a tool to facilitate shared learning among
hospitals in a non-critical environment.
 Benchmarking should be a supportive and learning process

led by hospitals themselves.

 Hospitals should participate in benchmarking activities and

develop networks to learn from and share good practice with

each other.
 There are a variety of ways in which this can be done such as

hospital twinning, mentoring of management or professional

staff, benchmarking clubs, exchange visits, master classes etc
 Standards Yes No

1.
The hospital has a Clinical Governance and Quality Improvement Unit (CG&QIU) that is led
by an assigned Senior Physician or General Practitioner?

2
The CG&QIU establishes and leads a multidisciplinary Quality Committee?
3
The hospital is implementing a clinical governance and quality improvement strategy and

an operation plan that addresses the key components of quality?

4
Are procedures established to monitor clinical practices and standards through services’
specific process and outcome measures to enable the hospital to address any problems
identified?
5
Is the hospital implementing a regular clinical audit programme in each service area?
 yes No
Standards

6
Are procedures established to assess and minimize risk arising from the provision and delivery of health
care?

7.
A system in place for reporting and analyzing incidents, errors and near misses?
8
Is the hospital’s statement of patient rights and responsibilities posted in public places in the
hospital?
9
Is the hospital monitoring patients’ experiences with care through patient and satisfaction
surveys conducted on a quarterly basis?
10
Has the hospital developed and implementing a strategy to provide patient focused care
which incorporates compassion, respect and dignity for patients, effective communication,
better hotel services and involvement of patients in the care delivery?

11
Is the hospital participating in benchmarking activities to learn from and share good practice
with other hospitals?