Safe Practice

Clinical Governance

"Clinical governance is about ensuring that patients are safe and risks are managed."
Janet Seaton, Clinical governance facilitator, NHS24

The way that NHSScotland puts clinical governance into practice has many strands that run through a wide range of work, for example, implementing the NHSScotland Healthcare Quality Strategy, risk management, patient safety initiatives and supporting best practice.

The NHSScotland Healthcare Quality Strategy (2010)

The NHSScotland Healthcare Quality Strategy (2010) has three quality targets stating that all patients/clients have the right to receive healthcare that is safe, effective and person-centred. In achieving these quality ambitions the health care professional will

  • take patient's/client's needs into account
  • account for patients circumstances and preferences and work to maximise patient's health and wellbeing
  • encourage patients to take part in decisions about their health and wellbeing and provides them with information and support to do so.

The NHSScotland Healthcare Quality Strategy (2010) states:

''There will be no avoidable injury or harm to people from healthcare, advice or support they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times' (p7).

Read the Executive summary (p5) and the section on safety (p27).

What is your role in making the strategy successful from a safety perspective in your work setting?

Record your reflections on these issues in your portfolio and use this as evidence for your KSF development review.


Quality Councils and Shared Governance


Using the RCN Clinical Governance website can you identify initiatives being carried out in other units or departments in your health board that aim to meet some of the ambitions you have read about?

Record your reflections on this work and discuss them with your mentor. Include:

  • the drivers for this change or development
  • what is working well
  • what may not be and why you think this is
  • how you think this initiative could be implemented where you work

Chain of Responsibility

Whilst it is each individual clinician's and employee's responsibility to ensure their practice is safe, it is the Chief Executive who carries ultimate accountability for the quality of care provided within each NHS Health Board.

Draw a diagram which shows the chain of responsibility for safe practice from you as a newly qualified practitioner via your manager and the other members of the management team to the Chief Executive (CEO) of your organisation.

Clinical Governance in NHSScotland

As you found out in the introduction…

'Clinical governance is the system through which NHS organisations are accountable for continuously monitoring and improving the quality of their care and services, and safeguarding high standards of care and services.' (NHS Quality Improvement Scotland, 2005)

Further, NHSScotland (link TBC) state that:

'Clinical governance applies to all treatments and services. The three most recognisable components of clinical governance and those which involve you in quality improvement are:

  • clinical effectiveness activities including audit and redesign
  • risk management including patient safety
  • patient focus and public involvement'

Find out and record:

  • what clinical governance activities and initiatives are happening in your in your local area
  • what your role or the role of your team in this work is

A local clinical governance team or link person who is involved in clinical governance activities in your area, or information on the intranet might be a place to start.

Your role in Clinical Governance

As you'll have seen in the previous activity, clinical governance is about the culture and attitude of all those who work in NHSScotland as well as specific activities. NHSScotland has outlined three principles (link TBC) that need to be in place to achieve effective clinical governance.

These are:

  • having clear, robust national and local systems and structures in place that help identify and report on quality improvement
  • involving healthcare staff, patients and public
  • establishing a supportive, inclusive learning culture

Reflect on the part you can play in supporting clinical governance and putting these principles into place in your work setting. Record your reflections for your portfolio and identify actions you can take forward.

Reviewing your knowledge

With your mentor/KSF reviewer, discuss your learning needs in relation to quality and clinical governance.

Identify and agree the priorities for you to work towards while you are working in this clinical area. These should be reflected in your Personal Development Plan.

You might find the RCN Clinical Governance webpages useful. It has a range of learning activities that may help you meet your learning needs.

Ensuring your practice is safe

How does your line manager know that your clinical practice is safe?

There are a number of ways they can do this including working alongside you with a patient/client, critically reading your written account of a treatment session, or talking to you during clinical supervision sessions. Depending on the aspect of your practice, different methods will be appropriate.

  • record how this happens in your local department.
  • ask your mentor or a more experienced practitioner to observe you working with a patient/client and to give you feedback on the quality of your intervention.
  • record how you felt about your performance in this intervention and compare this with what the observer said
  • are their changes you could make to your practice as a result of this activity?

 You may wish to have a look at this link to the Quality Improvement Hub on Patient Safety

Record this experience for your portfolio.

Sharing evidence of best practice

NHS Healthcare Improvement Scotland is the lead organisation in improving the quality of healthcare delivered by NHSScotland. Use the resources section of their website to search for a resource that relates to your own clinical area.

You could focus on, for example:

  • a best practice statement
  • a standard for care
  • a clinical topic
  • a Managed Knowledge Network or community of practice relevant to your practice (you will find these via The Knowledge Network)

If you can't find what you are looking for, some resources that you may find useful are given below.

An excellent example is the Standards of Care for Dementia in Scotland.

The Evidence into Practice website can help you locate any additional information about best practice you may need.

If you work in the social care sector, the Care Inspectorate has produced a range of standards for this setting.

Based on the information you have accessed :

  • reflect on how the local care provided to patients/clients compares with what you have read about
  • do you have any suggestions for improving care based on this information?
  • who could you make these suggestions to?

Sharing best practice in teams

In the previous activity, you identified information about best practice and where there could be improvements. Now identify areas where there is best practice or progress towards this within the team that you work in.

Depending on the information you have:

  • explore and identify the most useful opportunities that exist for sharing information on best practice within the team you work in. This might be a weekly ward meeting, a journal club, a staff meeting or using other communication networks and opportunities


  • using the information you have obtained in the activity in Sharing Evidence of Best Practice, reflect on and plan how you might share this with colleagues

Think about the most appropriate setting and time to do this, and agree a plan with your mentor.

Make a summary on your sharing experience in your portfolio.

The Evidence into Practice website can help you locate any additional information about best practice you may need.

Portfolio activity

Make a portfolio entry which summarises what you have learned about Clinical Governance. Include what you have already recorded in this section, sharing best practice, your learning needs and what you have learned so far has changed aspects of your practice. Make sure you discuss this with your mentor/supervisor and/or NHS KSF reviewer, and that your future learning needs are reflected in your Personal Development Plan.

Add an alert to your Flying Start NHS® portfolio and /or make a date in your diary to revisit Clinical Governance.