DOCUMENTATION

Clinical Governance ... Risk Management ... Incident Reporting ... Clinical Audit ... Clinical Guidelines

Clinical Governance

The Trust's objectives and strategy for implementing clinical governance can be found in Trust Strategy for Clinical Governance PP(02)106.

Further information can be found in a Guidance for Clinical Teams Governance Programmes document (appendix 4 in the strategy document listed above).

Where directorates or clinical teams are setting up committes/groups to progress clinical governance there should be a document setting out terms of reference and an operational policy for the group. A blank proforma for doing this is provided.

Risk Management

The Trust's policy and levels of accountability can be found in Policy and Strategy for Risk Management PP(04)093 (revised Jan. 2004)

Incident Reporting

Full instructions for all aspects of incident reporting and investigation can be found in Policy and Procedure for Incident Reporting and Management PP(04)105 (revised Jan 2004).

Managers are strongly advised to read the relevant pages and appendices before embarking on investigation of ‘red’ category incidents.

Clinical Audit

The Trust has issued guidance to directorates and specialities on content on clinical audit programmes - Trust Guidance to Directorates and Clinical Teams. Further help can be found in Guidance for using audit forms.

Audit design forms should be used to register each clinical audit with the Governance Support Department:

Audit design form stage 1 (may be omitted if clear standards have been agreed).

Audit design form stage 2 (use this form to register your audit).

Format for reports and audit findings

Governance Coordinators will be pleased to advise on design of clinical audit and help you with completing the forms on request.

Clinical Guidelines

The Drug and Therapeutic and Pink Book Committees have produced document which explains the process to be followed when drafting a clinical guideline. This can be found in: Introducing Guidelines to the West Suffolk Hospitals NHS Trust.

The above document contains a Guidelines Appraisal Check List; the aim of this list is to ensure that all guidelines contain relevant and essential information (e.g. reference to clinical evidence) before they are approved for distribution and use in the Trust.

To help ensure that Clinical Guidelines contain all the information required by the check list, a Trust Guidelines Template has been made available.

Note: Before installing this template on your computer you should read Using the Trust Guidelines Template: Quick Start; this explains how to install and use this template.