SECTION THREE: CLINICAL QUALITY AND SAFETY
3.1 CLINICAL GOVERNANCE STRATEGY
We have a well-established Quality & Safety Committee reporting system to the Board which provides assurance on the provision of safe and high-quality care to the population of patient who we serve. The Committee is established in accordance with the Articles of Association and Board Terms of Reference. The implementation of our clinical governance strategy, which is incorporated into the Quality & Safety Committee, includes:
1. Clinical Effectiveness ▪
Clinical audit
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Prescribing compliance Policies and protocols
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▪ Project/service delivery review and evaluation
2. Service user safety ▪
Incident reporting and management
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Safety alert management
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Risk management
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Fit and proper persons/safe staffing
3. Service user experience ▪
Patient feedback
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Service user experience surveys Quality of care surveys/audits
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4. Staff experience ▪
Mandatory training
Revalidation & appraisal Education and training
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▪
The Committee has the duty and responsibility to review and have oversight of quality, safety and information governance in relation to the following areas, which are standing items on the monthly agenda: Pan Domain: Project/service overview for existing & developing services, which incorporates all aspects of risk management, governance (clinical and IG), quality and safety in the delivery of healthcare Safety & Caring Domain: Review, approve and monitor those risks on the Corporate Risk Register which relate to Patient Safety & Quality and high-risk operational risks which could impact on patient care. Ensuring that an appropriate comprehensive quality & information governance framework and system is in place throughout the NNPC organisation which is in line with national standards. New projects are designed and implemented using Project Initiation documents which include Quality, Equality and Data Protection Impact Assessments with risks being identified and managed throughout. All new projects are taken through the Quality Committee for quality assurances and reported through to the Board.
Effectiveness & Responsive Domain: Demonstrating service improvement and safety through audit which, for example, demonstrates compliance with safeguarding adults & children, infection
NNPC Quality Account 2021/22
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