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Print Clinical Governance

Clinical Governance
Date Added: 15/07/2009
Updated: 20090715231844
Posted by:

Shaun Howe

Viewed: 4932 times

What is Clinical Governance?

Clinical Governance (CG) is an NHS framework for quality assurance to improve the quality of health care and to make providers accountable for delivering a consistent standard on which patients can rely. All nGDS/PDS dentists have to comply with the requirements. But Clinical Governance should not be seen as a requirement only applicable to the NHS. All health-care should have quality assurance, just like any other area of work activity.

Scally and Donaldson NHS Executive 1998:

"It is still a widely held view, that clinical governance is a frequently changing imposition shrouded in mystery. Many dental teams are unsure about what it is, what it entails and what the benefits are for the practice and their patients."

A simpler description maybe:

"Clinical governance is about being able to demonstrate that you and your team have a safe, well-run practice with well informed patients who are fully involved in their treatment decisions, with whom you are striving to achieve a measurable health gain."

Standards for Better Health


Originally published by the Healthcare Commission, "Standards for Better Health" (2004) sets out 7 domains of clinical governance and 24 core standards within the 7 domains.

The Department of Health has published guidance on the Healthcare Commission’s core standards that can be translated into general dental practice (Primary Care Dental Services Clinical Governance Framework May 2006)

It is currently divided into 12 themes:

Infection Control

Child Protection

Dental Radiography

Staff, Patient, Public and Environmental Safety

Evidence-based Research and Practice

Prevention and Public Health

Clinical records, patient privacy and confidentiality

Staff involvement and development

Clinical staff requirements and development

Patient information and involvement

Fair and accessible care

Clinical audit and peer review

Further information on each of these areas can be found at in the following text.



Breaking down the Themes1

Each of the 12 themes identified by Standards for Better Health has its own sub-headings. This is not necessarily a definitive list but does give some insight:

Infection controlinfection control

  • Infection control policy (now in line with HTM 01-05)
  • Inoculation injuries policy
  • Staff induction programme to include infection control policy and staff training
  • Audit of policy compliance



Child protectionchild protection


  • Identification and CRB checks for all staff
  • Child protection policy


Dental radiography See full size image

  • Quality assurance system
  • X-ray malfunction plan
  • Records of staff training and updates
  • X-ray equipment maintenance records


Staff, patient, public and environmental safetyenvironmental safety

  • Significant events analysis procedures and resulting changes to procedures
  • Dissemination of safety alert bulletins to staff
  • Medical devices: CE compliant, staff training in their use and incident reporting
  • Medicines: appropriately sourced, purchased and stored. Medical emergency kit
  • Compliance with:
    • Carriage of Dangerous Goods and use of Transferable Pressure Equipment (Amendment) Regulations 2005
    • Hazardous Waste Regulations 2005 (including management of waste amalgam/mercury)
    • Health and safety at Work Act 1974
    • Management of Health and Safety at Work Regulations 1999
    • Workplace (Health, Safety and Welfare) Regulations 1992
    • Control of Substances Hazardous to Health Regulations 2002
    • RIDDOR (Reporting of Injuries, Disease or Dangerous Occurrences Regulations 1995)
  • see also Infection Control, Child Protection and Dental Radiography)

Evidence-based practice and researchEvidence based practice

  • Relevant NICE guidelines are followed
  • Clinical care is informed by other evidence-based guidelines
  • Existing care pathways and referral protocols are followed
  • Where appropriate, principles of research governance are applied


Prevention and public healthprevention

  • An evidence based prevention policy for all oral disease and conditions appropriate to the needs of the local population and consistent with local and national priorities, including:
    • Links to existing community based strategies
    • Tobacco use cessation
    • Alcohol consumption advice


Clinical records, patient privacy and confidentialityconfidentiality

  • Compliance with:
    • Data Protection Act 1998 (including a data protection policy)
    • Caldicott Guidelines 1997
    • Access to Health Records 1998
    • Confidentiality Code of Practice 1998 (including a confidentiality policy with satisfactory arrangements for confidential discussions with patients)


Staff involvement and development

morph climbing steps

  • Employment policies, including job descriptions for all posts
  • Appraisal, personal development plans and links to mentoring schemes
  • Appropriate staff training undertaken and records of staff training maintained
  • Records of practice meetings and evidence of staff involvement
  • Protected time for staff meetings and clinical governance
  • Confidential process for staff to raise concerns about performance
  • Links to local Practitioner Advice and Support Scheme (PASS) or similar
  • Evidence of regular basic life support training
  • Evidence that staff opinion is sought about practice matters (eg staff surveys, practice meetings)




Clinical staff requirements and development


  • All GDC requirements are met including:
    • GDC registration where appropriate
    • Supervision of clinical staff
    • CPD requirements
    • Handling complaints
    • Dealing with poor performance (including practice policy)


Patient information and involvement


  • Patients’ and carers’ views on services are sought and acted upon
  • Patients have opportunities to ask questions and are given sufficient information to make informed decisions about their care
  • Patient information leaflets are available in languages appropriate to the local population
  • Well-publicised complaints system that is supportive of patients
  • Other patient feedback methods are available (eg suggestion boxes)
  • Evidence that practice has acted on findings of patient feedback
  • Information for patients on how to access NHS care out of hours


Fair and accessible care


  • Compliance with:
      • Race Relations (Amendment) Act 2000
      • Human Rights Act 1998
      • Disability Discrimination Act 1995
  • Emergency/urgent appointments available during the day


Clinical audit and peer reviewFile:Clinical audit cycle.jpg

  • All staff involved in identifying priorities for and involved in clinical audit or peer review
  • Evidence of compliance with any locally agreed requirements for clinical audit or peer review
  • Evidence that changes have been made where necessary, as a result of clinical audit or peer review


What is Quality Assurance?2

Quality Assurance in dentistry refers to a planned and systematic process that provides confidence by regularly auditing protocols and practice procedures to ensure a continuous improvement programme. It ties in with clinical governance in many ways. It will also allow external auditors to see that improvement (where necessary) is in place or is planned.

Defining Quality:

Some definitions currently in use are:
  • Quality is a degree of excellence
  • Quality is exceeding the customer's product or service expectations by delighting them
  • Quality is consistent conformance to consensus standards/guidelines for any process
  • Quality is doing right things right. It is customer orientation, innovation, team work, everyone's responsibility and never an accident
Modern dental care comprises a complex raft of services. These are as diverse as:
  1. Infection control
  2. Compliance with salutatory requirements
  3. The attitude and behaviour of the team
  4. Customer service
  5. Any treatment delivered
Avedis Donabedian is recognised as a "doyenne" of quality assessment in healthcare. Using a concept of "goodness" he identified three inter-related components:

"Goodness" of technical care. This broadly relates to clinical effectiveness, a component part of clinical governance. This defined as "The ability to achieve the greatest improvement in oral health that science, technology and clinical skill can offer, at any moment in time."

"Goodness" of the team. How they interact with each other and their patients. Equates to customer service.

"Goodness" of the practice environment. The facilities available to facilitate the delivery of care in practice.

Donabedian also provides a framework for measuring and assessing quality in the form of structure, process and outcome.

  • The physical features of healthcare delivery:
  • The premises
  • The number of clinicians and team members
  • The range and type of equipment
This alone does not mean clinical quality can be delivered. All of theses things can be measured easily but in the absence of certain things means that clinical quality certainly cannot be delivered. An example would be the presence of an X-Ray machine and films, but no means of developing the radiograph.
Process:Donabedian describes the complex number of interactions between the team and patients as the "process" of care. This includes all things that happen in a practices to facilitate care. Process includes patient records that can provide a more or less accurate reconstruction of what happened in the surgery.

Outcome:Outcome is defined as "the changes in a patient's current and future health status that can be attributed to past health care or interventions". If outcomes then become the final indicator of health they then become the final arbiter of quality.
I hope this will have given you an oversight into CG and QA. Both are complex and interesting subjects that are inextricably tied with each other. You should feel free to research this further as many, many authors have written on this. It is a constantly evolving subject that will impact on our professional lives more and more. Even if you were never involved (other than in any auditing process) in a CG/QA project, it is wise to at least understand why audits are carried out.

Many may suggest that Dental Hygienists can only play a supporting role in any CG/QA project. My personal experience shows that on the contrary, the Dental Hygienist is possibly well placed within the team to oversee such a scheme, but remember, the net benefit is a better experience for the patient combined with contented staff who work within clearly defined protocols and policies. Practices that have such schemes in place have lower staff turnover due to an education processes that are included within any staff induction training. Gone are the days of someone off the street being dropped into a surgery on day one without any experience!

"The greatest obstacle to discovery is not ignorance - it is the illusion of knowledge"
Daniel Boorstin

I have used Donabedian Principles here but many other authors have written widely on this subject and its relevance to healthcare. Further reading can be found at:

DONABEDIAN, A. 2003. An Introduction to Quality Assurance in Healthcare New York: Oxford University Press.

RATTAN,R. CHAMBERS,R. and WAKELEY,G. 2002. Clinical Governance in General Dental Practice. Radcliffe Medical Press.

Follow these links for further downloads: for Standards for Better Health and other Clinical Governance documents for Quality Assurance in Healthcare


The following have been essential (and are integral) in helping me to build this outline:
  1. BDA Clinical Governance toolkit (2nd edition)
  2. FGDP (UK) Certificate in Appraisal of Dental Practice
  3. BDA advice sheet E10

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