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Clinical Governance – Knowledge, Attitude And Practice Study

Deepa Iyer

*Honorary SHO, Department Of Orthopaedics, Royal Free Hospital, Pond Street, London NW3 2QG

Address for Correspondence

Dr. Deepa Iyer,
Honorary SHO, Department Of Orthopaedics, Royal Free Hospital, Pond Street, London NW3 2QG


Clinical Governance is a system for improving the standard of clinical practice.It was first described in a government White Paper as ‘ a new system in NHS Trusts and primary care to ensure that clinical standards are met, and that processes are in place to ensure continuous improvement, backed by a new statutory duty for quality in NHS Trusts.
METHOD: Questionnaires with all the components of Clinical Governance  were distributed amongst 10 doctors, who included Pre registration House Officers, Senior House Officers and Registrars, and were requested to complete it by just ticking the appropriate boxes of Knowledge, Attitude and Practice regarding a  component. These questionnaires were later collected, analysed and the following results were obtained.
RESULTS: It was indeed a very positive result obtained. Out of the 10 doctors, all of them were well aware of Clinical Governance, though not all of them having participated in all its components. 8 out of 10 doctors, were aware of all the components of Clinical Governance, and 8 out them had been a part of majority of the components.
It does emphasise the fact that the NHS is moving towards improvement and that with growing emphasis on the components of Clinical Governance, Junior doctors are encouraged to know about it, and to be a part of it, for the betterment of patient service.

J.Orthopaedics 2006;3(1)e1


Clinical Governance is a powerful, new and comprehensive mechanism for ensuring that high standards of clinical care are maintained throughout the NHS and the quality of service is continuosly improved.

Clinical Governance is a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. Clinical Governance provides the opportunity to understand and learn to develop the fundamental components required to facilitate the delivery of quality care – a no blame, questioning, learning culture, excellent leadership, and an ethos where staff are valued and supported as they form partnerships with patients. These elements have perhaps previously been regarded as too intangible to take seriously or attempt to improve. Clinical Governance demands the re – examination of traditional roles and boundaries – between health professionals, between doctor and patient, and between managers and clinicians – and provides the means to show the public that the NHS will not tolerate less than best practice.

Literature Review

Ayers noted there was uncertainty about clinical governance and how to implement it.Quality is a major issue in the NHS, but previous initiatives introduced over the past 20 years, such as resource management, clinical guidelines and clinical effectiveness, were not particularly successful in improving the quality of the service provided.Clinical quality has always engendered a multiplicity of approaches. Universally accepted definitions have been difficult to achieve, and some have even considered the term too subjective to be useful.

The new frame work is rapidly evolving, with the expectation that quality will improve incrementally in the future. This framework challenges clinicians’ traditional autonomy and will only succeed to the extent that they find it supportive and helpful.

There are 7 components to clinical governance, these are:

1. Patient and public involvement
How we involve patients and carers in their care and clinical governance activities e.g. research and development. This includes the patient experience and access to services and quality of clinical care. An example of measuring this would be through a patient survey.

2. Clinical risk management
The system for risk management including the way in which the different elements, e.g. incidents and complaints are brought together and how they link with other governance activity.

3. Clinical Audit
This will include how topics are selected and how we report, implement and follow up recommendations.

4. Clinical effectiveness
How we implement and apply effective clinical practice e.g. evidence based guidelines and hence improve the patient experience and outcomes.

5. Staffing and staff management
The Trust's approach to human resource management, staff development and performance, such as appraisals.

6. Education, training and continuing personal and professional development
The Trust's strategy and plans for education, training and continuing development, with descriptions of education and training activities e.g. number of staff who have had mandatory training.

7.  Use of information to support clinical governance and health care delivery
This involves our strategy and plans for IM&T and how we utilise information and involve patients to help identify needs.   


Integrating approaches of Clinical Governance.


      Pie Diagram Showing the Results obtained.


The questionnaire used and the results were as follows: 





Clinical Audit




Continual Professional Development/ Lifelong Learning




Evidence Based Practice




Clinical Risk Management and Critical Incidence Reporting




Multidisciplinary Team working




Research and Development




Guidelines and Protocols




Clinical Effectiveness




Discussion :

Since a variety of variables were used in this short study, I will refrain myself only to some of them, which deserve special mention. Herewith I have dealt only with Clinical Audit, Clinical Effectiveness, and Continuing Professional Development.

Clinical Audit: 

Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structure, processes, and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated, changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery. This definition is endorsed by the National Institute for Clinical Excellence. 

For clinical audit to become an important component of how we manage our health services a very real change needs to take place in the standing of audit programmes within the NHS. Audit can no longer be seen as a fringe activity for enthusiasts –within clinical governance, the NHS needs to make a commitment to support audit as a mainstream activity.

  • Clinical audit is used to improve aspects of care in a wide variety of topics. It is also used in association with changes in systems of care, or to confirm that    current practice meets the expected level of performance.

  • Clinical audit projects are best conducted within a structured programme, with effective leadership, participation by all staff, and an emphasis on team working and support.

  • Organizations must recognize that clinical audit requires appropriate funding. Organizations need to recognize that improvements in care resulting from Clinical audit can increase costs.

  • The participation of staff in selecting topics enables concerns about care to be Reported and addressed. Participation in choice of topic is not always Necessary, but may have a role in reducing resistance to change.

  • The priorities of those receiving care can differ quite markedly from those of Clinicians. Service users should therefore be involved in the clinical audit Process.

  • There are practical approaches for user involvement in all stages of audit,  Including the design, the collection of data about performance, and in Implementing change.

  • Organizations should ensure that their healthcare staff learn the skills of Clinical audit.

  • The most frequently cited barrier to successful clinical audit is the failure of  Organizations to provide sufficient protected time for healthcare teams.

  • Those involved in organizing audit programmes must consider various Methods of engaging the full participation of all health service staff.

Clinical Effectiveness: 

Clinical effectiveness can be ensured with interventions, which have been shown to be effective to appropriate patients. It manifests itself in improved patient outcomes.
The use of clinically effective interventions in practice is based on:

  • Appraisal of relevant information or data

  • Dissemination to relevant staff

  • Adaptation of procedures to meet local needs

  • Implementation of the evidence through developing guidelines

  • Evaluation of the change in practice through clinical audit and analysis of outputs and outcomes to demonstrate clinical effectiveness in practice.

Although current health care practice has evolved over the years through personal experience, expert views and trial and error, there is a great deal of evidence about clinical effectiveness of services and treatments. Evidence of cost effectiveness of treatments is harder to find.  

Continuing Professional Development (CPD): 

CPD is the means by which members of professional associations maintain, improve and broaden their knowledge and skills and develop the personal qualities required in their professional lives.

Continuing Professional Development is a continuous process of personal growth, to improve the capability and realise the full potential of professional people at work.

This can be achieved by obtaining and developing a wide range of knowledge, skills and experience, which are not normally acquired during initial training or routine work, and which together develop and maintain competence to practise.

There are a number of reasons why one may wish to undertake CPD, including:


The desire to develop professional knowledge and skills.


A condition placed on continuing membership of a professional body.


To demonstrate professional standing to clients and employers.


To assist with career development or a possible career change.


In the NHS, CPD is determined through appraisal with a personal development plan agreed between the individual professional and their manager with the commitment of the necessary time and resources. A key development in ensuring that health professionals maintain their competence is the move among the regulatory bodies to develop CPD strategies for the revalidation/re-certification of their members.

There are, however, certain principles that those involved in CPD may want to bear in mind.

  • CPD contributes to improved patient healthcare and to a healthier society.

  • Each individual is responsible for taking part in and recording their own relevant CPD activities.

  • CPD also helps doctors to improve their professional effectiveness, career opportunities and work satisfaction.

  • CPD should cover all areas of Good Medical Practice. Doctors should keep up to date in all areas of their practice.

  • Doctors should also recognise when unexpected opportunities for CPD arise and should allow time to consider and discuss these opportunities informally. A range of different activities will normally be suitable.

  • CPD should also include public and patient involvement. For example, patients and the public should be involved in developing CPD schemes, setting standards and monitoring quality. Doctors must be up to date with what patients and the public expect.

  • Doctors should discuss and review their CPD with others. Yearly appraisal gives a formal, structured opportunity for doctors to discuss their CPD needs. Appraisal provides a way of making sure that any CPD identified is relevant to a doctor's practice and learning needs. Doctors should use personal development plans to make sure that they, their organisations and patients benefit as much as possible from their CPD.

  • Assessment measures, where available, should be used for part of doctors' CPD. These measures should allow doctors to be clear about how they are developing. They will help doctors to judge their progress. Valid and reliable assessment tools and systems are still developing. (Indeed, developing these tools would be a valuable CPD activity for doctors.)

Individual doctors need to keep themselves up to date in all areas.

These are:

ุ      good professional practice;

ุ      maintaining good medical practice;

ุ      relationships with patients;

ุ      working with colleagues;

ุ      teaching and training;

ุ      probity; and

ุ      health.

I wish to thank Mr. Nicholas Garlick, Consultant Orthopaedic Surgeon, for his invaluable help and suggestions,
without which this venture would have been impossible. My sincere thanks to the Department of Orthopaedics at the Royal Free Hospital, London,
who very actively participated and offered immense guidance,which made this endeavour a success.

Reference : 

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  2. Journal of diagnostic Radiography and Imaging, Vol 4, Issue 3, 113 – 162.

  3. ( Accessed on 23/11/05)

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  6.  (Accessed on 13/01/06)

  7.  (Accessed on 13/01/06)

  8. (Accessed on 13/01/06)

    (Accessed on 13/01/06)


This is a peer reviewed paper 

Please cite as : Deepa Iyer: Clinical Governance – Knowledge, Attitude And Practice Study

J.Orthopaedics 2006;3(1)e1





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