Hospital level

Reports are generated as part of monitoring activity, which are analysed and reviewed by a multi-disciplinary Clinical Governance Committee. This committee assesses whether the remedial actions taken are appropriate and sufficient. These reports are then provided to the Medical Advisory Committee for final review and action, where this requires the involvement of the consultants.

Corporate level

Corporate level reports are generated to enable benchmarking adverse hospital incident rates, for example, in relation to other GHG hospitals. A Clinical Governance Management Report is produced monthly and contains data such as:

• The number of CQC requirements not met by due date;
• Serious untoward incidents;
• Stage two and three complaints;
• Trends for patient satisfaction;
• Infection rates;
• Incident rates;
• Health and safety issues; and
• Clinical speciality issues.

These are reviewed monthly by the Group Governance Board, chaired by the Group Medical Director. Other members include the Group Clinical Governance Director, Chief Nursing Director, and the Group Clinical Leads for Pathology, Pharmacy, Imaging, Physiotherapy, and Health and Safety.

A review of all data is undertaken and appropriate action is taken at corporate level to address any issues of concern. Feedback is provided to all hospitals through our Clinical Governance Bulletin.

The trend of decreasing reported adverse and non-adverse incidents demonstrates some degree of success in our clinical governance initiatives. However, we recognise the need to continually improve on the quality and safety of care delivered.

GHG has been a leading participant in developing a sector-wide project for submitting clinical indicators that will enable benchmarking against the rest of the independent sector and, in the longer term, the NHS. Testing of the system is under way and the first reports should be accessible in the first quarter of 2010.