A short guide to a CHI clinical governance review in our organisation

What is the Commission for Health Improvement (CHI)?

CHI is a statutory independent body established to review and improve the quality of patient care across the NHS.  One of CHI’s key tasks is to carry out clinical governance reviews in every NHS organisation.

What is a clinical governance review?

Clinical governance reviews look at the quality of care provided by an NHS organisation and the arrangements that it has made to assure and improve care.  A review looks at the effectiveness of the clinical governance arrangements and identifies best practice and areas for improvement.  A review has three broad stages: preparation, visit and report.  Each review leads to an action plan.  The review is based on evidence and is carried out by trained staff.  They are consistent across different parts of England and Wales and are challenging but fair.

Each review will look at the effectiveness of clinical governance arrangements from three angles:

The patients experience

·         the history and organisation of their journey through our nhs organisation

·         the outcome of their treatment

·         their views and opinions

·         the environment in which they were treated, including protection of privacy and dignity

The clinical team

·         how (a sample of) clinical teams work together to control, influence and improve the quality of patient care

·         what systems and processes clinical teams use for clinical audit, risk management, staffing and staff management

·         how our teams use information in making management decisions

·         how our teams act on research findings and ensure that services are effective

·         how our teams record, assesses and responds to patients’ experiences

The corporate strategy

·         an assessment of how our organisation manages relevant systems, including risk management, complaints handling, patient involvement, research and clinical effectiveness, clinical audit, information management, general management and human resources management including the education and training of staff

What preparation is needed as part of a review?

Our organisation will be asked to provide a range of data including PAS and complaints, stakeholder information, undertake a staff and organisational questionnaire and a self-assessment prior to the start of the review.  Wherever possible CHI will obtain information already in the public domain from sources such as the NHS Executive and the Department of Health.  We will be informed of the details for preparation for the review, including information requirements, during the pre review stage.

The information collected in the preparatory phase will be analysed to produce an evidence summary, which will determine the areas to be reviewed.

What takes place during a visit?

The CHI review team will talk to individuals, teams, and local stakeholders to collect additional information.  They will also observe clinics and other services during their five-day visit.

Who is on the review team?

Reviews are conducted by a fully trained multidisciplinary team consisting of clinicians (doctor, nurse, AHP) a manager and lay people.  A review manager co-ordinates the work of the team.

What happens after the visit?

The review team will draft a report of their findings and recommendations.  This report will be discussed within our organisation to allow us to comment on its factual accuracy.  The report will be published and made publicly available.  It will contain key findings and recommendations, and identify best practice as well as areas for improvement.  CHI will not publish and confidential information.

Our organisation will be required to produce an action plan to address CHI’s findings and recommendations.  CHI will work closely with the local Regional Office/National Assembly for Wales so that they can assist with the follow up to the review, help with any problems, and assist in monitoring progress.

What does the review mean for you, as members of staff?

It’s work as usual.  Apart from the data collection, the main involvement of staff is to talk to the review team.  Information given to the review team will be treated in confidence.  You will have the chance to talk to the CHI team in a number of ways.

·         On an informal one to one basis prior to the review, away from the organisation

·         As part of their clinical team during a review

·         During the review week if your work area has been selected

Will CHI name individual members of staff in the report?

CHI looks at the quality of patient care as a whole, not the particular performance of individual members of staff.  Reports will contain key findings and recommendations.  CHI will ensure that all staff comments are anonymous.

Who do I contact with any queries?

Jacqui Grimwood, Clinical Governance Review Co-ordinator, on Ext 2740 who will help with any general or specific queries.

Information about CHI can also be found on their website: www.chi.nhs.uk

This guide is also available as a MSWord document.