Structure | Responsibility for clinical governance | DPH or other named person |
| | Different people responsible for clinical governance in different settings |
| | A team approach. |
| The resources and training to support clinical governance | Business manager appointed to work on clinical governance systems |
| | Quality Manager |
| | Clinical Governance Support Officer |
| Meetings | Staff meetings, team briefings and structured departmental meetings |
| | Business planning meetings with objective setting |
| | Debriefs after incidents |
| Other | Use of the European Business Excellence Model |
| | The support infrastructure (including secretarial, information technology and library support) |
| | Departmental training and skills audit |
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Process | External peer review | National: Faculty Training Visit; Revalidation Pilot; Kings Fund Organisational audit; NHS Benchmarking club |
| | Local: Three Counties Meeting; RDPH visit |
| Plans and Meetings | Business, training and action plans. |
| | Special topic meetings; Difficult decisions groups |
| | Communicable disease meetings; Risk management analysis |
| Audit | Systems for scoping, standards, measurements and logging of review dates |
| | Emphasis on good written records of the audit process and making audit a continuous process |
| | Subjects chosen: high risk areas; policies like the National Service Frameworks; the previous year's Annual Report |
| Controls assurance | Standards and quality assurance for routine activities (for example, taking telephone messages; on-call rota, etc) |
| | Linking control assurance to business planning process; |
| | Updating of objectives and appraisals |
| Risk management | Applying a clinical governance checklist to: chemical incidents; communicable disease episodes and the handling of complaints. |
| | Written protocols, procedures and terms of reference for risk management programs. |
| | Identifying areas of highest risk; “postmortems” and incident debriefs after events. |
| Other | Procedure manuals; measures of library usage and paper output. |
| | Time management; stress management; assertiveness training |
| | Reporting back of major training undertaken; including more people in processes of reflection |
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Outcome | Peer review and benchmarking | (Peer review—see process section above) |
| | Links with educational consortiums |
| | Dental public health benchmarking |
| Plans and paperwork | Business and clinical governance action plans |
| | Production of and updating protocols |
| | Publications; Written debriefs after incidents; Annual quality control reports |
| Other | Sharing good practice |
| | Meeting objectives, reaching key milestones, |
| | External feedback. |
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Culture | Policies | Mission statements and Clear set of shared values |
| | Induction programmes |
| | Policy documents drawn up with assistance from Human Resources officials. |
| Team building and organisational development | Away days |
| | Lunchtime seminars and journal clubs |
| | Psychometric tests and group analysis techniques. |
| Ethos | Developing “blame free” or “learning and reflective” culture & non-hierarchical structures |
| | Becoming more multidisciplinary in approach (for example, Health visitor secondments to department) |
| | Broadening the Public Health network. |
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Knowledge | Information management | Use of CD ROM to transfer large amounts of information |
| | Databases such as Medline, Cochrane Library, Effective Health Care Bulletin and Bandolier |
| | Access to library facilities |
| Information technology | Many different electronic information systems including: email; internet; intranet; public drive for the department; Web pages; Chatweb; Microsoft Minder and Netit |
| | Annual Report and Health Improvement Programme (HImP) directory on website |