The Purple Book

Clinical Governance

A framework through which we are accountable for continually improving the quality of services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.

• CLINICAL EFFECTIVENESS & RESEARCH
• QUALITY AND SAFETY
• EDUCATION AND TRAINING
• STAKEHOLDER ENGAGEMENT
• INFORMATION GOVERNANCE
• WORKFORCE

CLINICAL EFFECTIVENESS & RESEARCH

Our over-arching philosophy is to:

• Adopt an evidence-based approach to the management of patients
• Modify and adapt our practice with the development of new protocols or guidelines based on experience and evidence from our or national current practice demonstrating need for improvement or change.
• When available and appropriate, to implement NICE guidelines, National Service Frameworks and other national standards to ensure optimal care.
• Provide the highest level of care in the most efficient and effective manner within resources available
• Conduct research to develop the body of evidence available, therefore enhancing the level of care provided to patients in future as well as contribute to the body of knowledge around emerging models of care.

QUALITY AND SAFETY

This includes:

• Compliance with policy and procedure (hand washing, discarding sharps, identifying patients correctly etc)
• Regular audits will be undertaken to ensure that clinical practice and systems are reviewed in order to inform need to change or adapt practices.
• Identifying and recording risk and mitigations on a risk register
• Learning from mistakes and near-misses applying the Patient Safety Incident Response Framework
• Reporting any significant adverse events via critical incidents forms and reviewing complaints and other feedback.
• Assessing the risks and implementing processes to reduce the risk and its impact.
• Promoting a blame-free culture to encourage everyone to report problems and mistakes.
• Providing a regular forum for debriefing following significant events to enhance learning from events of all types including deaths and near misses.
• Introduce Schwartz Rounds

EDUCATION AND TRAINING

• Providing equal access to continuing development opportunities such as relevant courses and conferences
• Developing training sessions appropriate to new pathways, procedures or guidelines
• Engaging in appraisals in line with professional lines of accountability

STAKEHOLDER ENGAGEMENT

A system for regular patient and public feedback will be used to improve services to ensure an increased level of quality and suitability. We will ensure that the services we provide suits both the individual patient and their significant others but also complements or improves other integrated services. This will be delivered through a number of initiatives, including:

• Compassionate involvement and engagement of those affected by patient safety incidents following the Patient Safety Incident Response Framework
• Local patient feedback questionnaires
• The involvement of the Patient Advice and Liaison Service (PALS) in handling issues with patients.
• GP feedback questionnaires.
• Acute Trust clinician feedback questionnaires and clinical forums.

These will also be informed by external mechanisms:

• National patient survey
• Friends and Family Test
• Local Involvement Networks (LINks)

INFORMATION GOVERNANCE

We will regularly review and ensure that:

• Patient data is accurate and up-to-date
• Confidentiality of patient data is respected
• Full and appropriate use of data is made to measure quality of outcomes and reduce opportunity for error
• IT systems will be reviewed to ensure ease of use and flexibility
• IT systems will be assessed to ensure capability to ensure dynamic learning to maximise opportunities to identify suitability of patients for the Service as well as identify patients who are not suitable or more at risk.

WORKFORCE

• Developing opportunities for developing the Service exploring new models to attract imaginative and dynamic staff
• Providing identifiable strong leadership to motivate staff and attract new staff
• Developing a Team structure with identifiable and accountable roles to ensure clarity of responsibility and accountability with opportunities to explore expansion and efficiency reviews.
• Provide robust, supportive and motivational working conditions to support retention and attraction of staff
• Providing a forum and processes to monitor and support performance.

Lone Working

Current Policy: lone-worker-policy.pdf
Request for Information from Police: PoliceRequest then email request to: SNMailbox.SafeguardingMH@met.police.uk