Clinical Governance and Quality Improvement
- To oversee the eight Pillars of Clinical Governance including the new pillar of Sustainability;
- the delivery of the SWLEOC quality and improvement is the responsibility of the Lead for Quality Improvement, supported by the leads of each department in the Centre;
- the role is one of assurance and risk and incident monitoring in the Centre;
- incidents are reviewed and monitored and where required, rapid reviews are arranged on those incidents where harm has occurred as a result of the incident. Learning is then shared amongst teams and presented at Clinical Governance each month;
- risks are also monitored and reviewed monthly, and it is the Quality Lead’s responsibility to ensure that the risk register is updated with the current risks;
- the Quality Lead is also the link between patient and the Centre thus coordinating complaints and Patient Advice Liaison Service queries;
- monitoring Health and Safety at SWLEOC and reporting to the hosting Trust;
- the Quality Lead also links SWLEOC with the main hosting Trust reporting to their committees and attending meeting and feeding back to SWLEOC;
- the Quality lead is responsible for running a regular patient forum to gain feedback, from patients with lived experience, about the service and new service initiatives or changes.
- Raising awareness of SWLEOC governance issues throughout the Centre;
- producing reports for the hosting trust and the partner trusts for the Clinical Quality and Assurance Committee;
- ensuring all incidents reported in Datix (recently changed to Patient Safety Incident Response Framework (PSIRF)) are investigated and the correct level of harm is reported to the independent bodies;
- ensuring complaints are investigated on time.
The service was implemented from the start. It has evolved in a way that the Quality Lead is more in touch with the bedded areas and works very closely with the clinical staff.
Reports are created monthly for each area which highlight the issues and the learning from incidents and complaints as well as sharing compliments.
- Directly line managed by the Associate Director of Nursing Services at SWLEOC;
- daily interaction with Matrons of bedded areas, PACU, Theatres, POA, scheduling and outpatient teams and research;
- working closely with the medical director, and assistant medical director and Surgical directors and intensivist and Anaesthetic Leads;
- the interactions are varied looking at incidents around the Centre and promoting rapid reviews ensuring representation from all teams;
- for example, when a cancellation occurs, the Quality Lead organises a weekly cancellations meeting looking at why this has happened and then feedback at other meetings like the anaesthetic meeting and Governance meetings.
On site in the post-operative area
All the IT systems used by the Centre as required to investigate complaints and incidents. This includes Lifebox, Bluespier, Datix (for incidents and risks), Clinical Manager for patient letters and patient investigations, PACS for imaging.
In the role of Quality Lead, it is important to have a clinical background. For example, having a background in nursing and as the Matron for PACU has provided insight into clinical matters and the background knowledge required to report on incidents.
One of the biggest challenges was to ensure that Governance was highlighted as a priority to all teams and individuals as it is imperative that everyone engages and participates in Governance.
The Quality Lead requires a lot of support from the management team and for everyone to work collaboratively to resolve issues.
- Governance is everyone’s’ business and must be a priority;
- it is imperative to have a positive culture with an ethos of constant improvement, and a willingness to learn from mistakes;
- strong communication channels and robust dissemination must be in place to learn from incidents, complaints and rapid reviews and to understand all the risks on the risk register. This applies to every employee in the Centre no matter their grade or role.
- Governance board papers: these are produced monthly and include incident themes, complaints, PALS, CAS alerts, improvement work;
- quality report: quarterly for the Assurance Group, a resume of SWLEOC performance linking incidents and complaints, triangulating the report with the improvements and evidence of learning and change;
- quarterly inpatient experience report;
- six-monthly Health and Safety report;
- Quality Governance meeting agenda and preparation of the data/ information to inform meetings.
Staff
Staff Member: Head of Quality and Improvement (Band 8A x 1 WTE)
Role:
- fully responsible for Governance and quality at SWLEOC;
- also manage the Practice Educator and X-ray team;
- responsible for deputising for the Associate Director of Nursing in their absence and attending internal and external meetings.