Clinical governance

Question 1

What is clinical goverance?

Answer 1

A systematic approach to maintaining and improving quality of patient care within the NHS

Question 2

What are the 7 areas of clinical governance?

Answer 2

1. Risk management
2. Clinical audit
3. Education, training and CPD
4. Evidence based care and clinical effectiveness (i.e. NICE)
5. Patient involvement
6. Staffing and management
7. Information management

Question 3

What it clinical audit?

Answer 3

To review processes, procedures and or outcomes to see how accurate and effective they are at conforming to a set of standards, followed by implementing changes and re-auditing

Question 4

What are the main aims of audit? (max 7)

Answer 4

1. Demonstrate quality of service
2. Identify areas of change
3. Improve quality
4. Assist with the implementation of policies and guidelines
5. Monitor consistency of performance
6. Measure actual performance against a benchmark
7. Compliance with ISO standards (e.g. ISO15189)

Question 5

What is internal external audit?

Answer 5

Internal audit- Carried out by a laboratory to assess its own processes and conformance with ISO standards and clinical governance framework

External audit- Carried out by external bodies i.e. UKAS, EQA…

Question 6

What are prospective and retrospective audits?

Answer 6

Prospective audit- Collection of data used for an audit in real time

Retrospective audit- Historical review of data

Question 7

What are the 3 areas that can be audited?

Answer 7

1. Structure- Is there infrastructure to deliver a service?
2. Process- Measure adherence to SOPs described in the QMS
3. Outcome- Used to evaluate a clinical outcome?

Question 8

What are two types of process audits?

Answer 8

Horizontal- evaluate one process over many departments e.g. training across departments

Vertical- Evaluate all process used by a department e.g. evaluating all the processed imposed on one sample from booking in to reporting (inc SOPs and competence)

Question 9

What factors impact the selection of an issue to audit?

Answer 9

Have the standards or guidelines changed?
Is there new evidence about effective practice?
Has there been an incident? (adverse occurrence audit)

Question 10

What are the 6 steps to complete a clinical audit?

Answer 10

1. Define criteria and standards
2. Data collection/observation
3. Comparison of data against standard criteria
4. Evaluation/analysis
5. Implement improvements
6. Review