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Clinical Governance

What is Clinical Governance?

Clinical governance is the system through which healthcare providers are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical excellence will flourish.

In BPAS our clinical governance is underpinned by incident, complaint and complication investigations, clinical audit, clinical policy development, change management processes and risk management methodologies. These happen across all levels of the organisation to form the full clinical governance framework.

The CGC is accountable to the BPAS Board of Trustees (henceforth the Board) and provides assurance to Board that appropriate clinical governance mechanisms are in place and effective throughout the organisation. As a Board sub-committee it will be responsible for ensuring that clinical aspects of the BPAS balanced scorecard are reported.

It seeks to ensure that the principles and standards of clinical governance are applied and that appropriate mechanisms are in place for the effective engagement of representatives of patients and clinical staff.

The purpose of the REC is to examine proposals for research, audits or service evaluations involving clients, or materials derived from clients, or which are to be carried out within BPAS units or by BPAS staff as appropriate and to ensure that such activities conform to generally accepted ethical principles and standards.

The REC will also from time to time provide advice on ethical issues that affect BPAS and which the REC elects to consider or which are referred for its consideration by the Clinical Governance Committee, the Clinical Advisory Group, the Finance and General Purposes Committee or the BPAS Board.

The purpose of the QRC is to critically review regional service provision, discuss decisions taken by or outputs of the Clinical Governance Committee or Clinical Advisory Group, and to identify regional areas of risk, need, and gaps in service provision.

The QRC is chaired by the Director of Risk and Governance.

The ICC is directly accountable to the Clinical Governance Committee but if necessary has direct access to the Chief Executive and BPAS board via the Director of Infection Prevention and Control.

The ICC is responsible for overseeing and directing infection control throughout the organisation and advising the Clinical Governance Committee of its progress. It will also advise the organisation on compliance with national recommendations and legislation such as Care Quality Commission Standards and the Health Act.

The ICC is chaired by the Director of Client Experience and Infection Prevention Control.

This group reports to the Clinical Governance Committee and ensure that BPAS:

  • Review identified fitness to practice concerns of doctors, nurses/midwives and operating department practitioners, agree an appropriate course of action, and record and update information on plan progress.
  • Oversee the granting and renewal of practising privileges.
  • Ensure compliance with GMC new starter processes and the BPAS leavers process for doctors.
  • Ensure induction/probation criteria are met to ensure competent medical staff.
  • Ensure an annual appraisal process meets revalidation requirements and receive regular reports on appraisal and revalidation including any concerns.
  • Discuss and agree policies related to appraisal and revalidation and managing concerns about doctors.
  • Highlight and share new information from NHS England or other bodies with the aim of ensuring a consistent approach to the management of concerns and revalidation.
  • Agree an annual audit programme for doctors.

The Responsible Officers Advisory group is chaired by the Medical Director who is the Responsible Officer for BPAS.

The Clinical Advisory Group (CAG) provides guidance to the Medical Director, her associated functions, and the Clinical Governance Committee on matters relating to the clinical operation of BPAS.

Items considered by CAG including clinical policies and procedures, clinical training, audit and service evaluation, Internal and external quality assurance schemes, clinical incidents arising from complaint and incidents, the selection of drugs, therapeutics and devices, research proposals requiring additional clinical advice and the eligibility criteria for practicing privileges

The CAG is chaired by the Head of Clinical Policy and Evaluation.

The duties of this committee are:

  • To review and approve annually the BPAS drug formulary
  • To make recommendations on the selection of new drugs and therapeutics, considering current evidence and national recommendations (e.g., NICE),
  • To review and approve policies and procedures relating to the use of drugs and therapeutics
  • To ensure there are robust and coordinated processes in place for the introduction of new drugs/devices
  • To review cost effectiveness and availability of drugs and monitor supply risk.
  • To define the scope of Point of Care Testing (POCT) considering the clinical need, financial implications, technical feasibility, and the resources available
  • To ensure there are procedures in place to monitor the quality and safety of Point of Care Testing
  • To monitor medication and device errors and actions to prevent their recurrence
  • To receive and review assurances that medicines management audits are undertaken, and action plans completed as required
  • To advise on drug/device alternatives in case of shortages and ensure clear guidance to unit staff on application, including via email between formal meetings
  • To ensure dissemination and responses to relevant alerts from the National Patient Safety Agency
  • To review and approve Patient Group Directions, standing order prescriptions, and drug treatment algorithms
  • To review and make recommendations on any proposal submitted to Research & Ethics Committee that would involve research into drugs and therapeutics

The drugs and therapeutics committee is chaired by the Medical Director

The governance structure at BPAS is under review as of September 2023. This page will be updated shortly.