Clinical Governance Policy

Date:  15/11/2021

Purpose:

• To clarify the governance structures and responsibilities within Hei Hei Health Centre; and
• To ensure that we are well positioned to provide excellent clinical care; and
• To ensure that equity is at the core of our activity.

Responsible Staff:

Clinical matters and equity:  Clinical Director

Nursing matters:  Senior Practice Nurse, reporting to Clinical Director.

Staffing matters:  Staff Admnistrator

Complaints:  Complaints Administrator

Quality:  Quality Administrator

Audit:

No audit has been assigned to this policy to date

Training Resources:

RNZCGP talk about clinical governance

Linked Policies:

Complaints Policy

Quality Improvement Strategy

Maori Health Plan

Policy:

General management structure:

We operate a collegial approach to clinical governance.

All decisions shall have equity at their fore - no practice activity shall increase inequity of health unless balanced by greater activity that shall redue inequity.

Clinical matters shall be discussed at weekly clinical meetings involving the clinical team, and general matters at monthly meetings, involving the whole team.

Nursing matters should be discussed within the nursing team and then presented to the clinical team meeting by the senior practice nurse, or appointed deputy.

Medical matters should be discussed within the medical team and then presented to the clinical team meeting by the clinical director or nominated deputy.

The clinical director shall take into account all perspectives before making a decision on any matter so presented.

Inclusion of Patient Feedback

Complaints are to be notified as per the Complaints Policy.  As a rule anonymised feedback from complaints should be presented to the monthly meetings by the complaints administrator.

Patient feedback is also sought through the Patient Experience Survey and when this data is available, it should be summarised by the complaints administrator and presented to the team for consideration.

A Maori participation meeting should be held as required to encourage the participation of our Maori patients and to seek their specific advice.  This should take place where needed, but generally every 2-4 years as appropriate.

Clinical Effectiveness

Clinical effectiveness can be measured but doing so is complex and time consuming.  Over time, our intent is to generate appropriate measures by which clinical effectiveness can be measured.

Where reports are available in CBIT and GPVu, these can be used to assess and support clinical processes.

The Nursing team is responsible for ensuring that GPVu and CBIT are being used to ensure effective, efficient, safe care is being provided to patients.

Quality Improvement and Patient Safety

Patient safety is not the same as nothing bad happening.

Our Quality Improvement Policy should be followed to ensure that safety is enhanced and incidents are used as a springboard for learning.