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Clinical Governance Annual Report 2022-2023

Clinical Governance Annual Report 2022-2023

Contents Page:

1. Introduction
2. Clinical Governance Arrangements
   1. NHS Greater Glasgow and Clyde purpose
   2. Clinical Governance in NHS Greater Glasgow and Clyde
      1. The NHSGGC Clinical and Care Governance Committee
      2. The NHSGGC Board Clinical Governance Forum
      3. Divisional Clinical Governance Forums/Groups
   3. Clinical Governance Arrangements - Key activities during 2022-2023
   4. Clinical Governance Policies and Frameworks
      1. NHSGGC Clinical Governance Policy
      2. NHSGGC Policy and Procedure Duty of Candour Compliance
      3. NHSGGC Policy on the Management of Significant Adverse Events
      4. NHSGGC Healthcare Quality Strategy
      5. NHSGGC Clinical Guidelines Framework
      6. NHSGGC Framework for Addressing Clinical Quality Publications
      7. NHSGGC New Interventional Procedure Policy
3. Key Messages
   1. Safe Care
   2. Effective Care
4. Safe Care
   1. Clinical Risk Management
      1. Significant Adverse Event Reviews (SAERs)
      2. Significant Adverse Event Review Outcomes
      3. Contributory factors and thematic analysis from Significant Adverse Event Reviews
      4. Recommendations from SAERs
   2. Duty of Candour
      1. Duty of Candour Update from 2021/22
   3. Training
      1. Significant Adverse Events Reviewer Training
      2. Duty of Candour Training
      3. Commissioner Training
   4. Morbidity and Mortality
   5. Datix
      1. Procurement for a new NHSGGC Risk Management System
      2. Risk Registers
      3. Datix Data Quality Improvement
      4. Support to End Users
      5. Communication
5. Effective Care
   1. Quality Improvement Programmes
      1. Scottish Patient Safety Programme (SPSP) Acute Adult Collaborative
      2. Maternity and Children Quality Improvement Collaborative
      3. SPSP Mental Health
      4. SPSP Primary Care Programme
   2. Quality Improvement Capability
      1. Engagement and coordination
      2. National QI Training Programmes
      3. NHSGGC Quality Improvement Training
      4. Return of Investment
   3. Evaluation
   4. Clinical Guidelines
   5. Clinical Quality Publications
   6. Scottish National Audit Programme (SNAP)
   7. New Interventional Procedures Policy
   8. Hospitalised Standardised Mortality Ratio
   9. Spotlight on Innovation and Improvement
6. Plan for 2023-2024
   1. Safe Care
   2. Effective Care
7. Conclusion

 

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