Clinical Governance Group - Terms of Reference

Read alongside

Quality Improvement Programme

1.0 Purpose

1.1 The Clinical Governance Group provide assurance to the Board and stakeholders that clinical quality, safety, and governance are being managed to high standards. This group has no executive powers other than those delegated in these terms of reference.

2.0 Responsibilities

2.1 To review, develop and implement a rolling programme of audits and reviews ensuring lessons are learned and cascaded to staff.

2.2 To investigate clinical incidents using a root cause analysis approach and initiate changes to policy, processes and training as a result of any findings.

2.3 To assess and review the clinical performance of Clinical Partners and ensure outcomes for people meet nationally accepted standards.

3.0 Composition

3.1

• Chief Medical Officer (Chair)

• CEO RM

• Scale up Director

• Director of NHS Operations

• Associate Medical Director

• Compliance Manager

• Complaints Lead

• Governance Manager

• HR Director

• PAMS Lead

• IT Director

• Marketing Director

3.2 The group may invite other staff to attend a meeting to assist it with its discussions on any particular matter.

4.0 Scope

4.1 The group's authority comes from the Board.

4.2 The group’s chair will report to the Senior Management Team and Board after every meeting.

4.3 The Management Team may ask the group to convene to discuss any clinical governance issues or incidents upon which they require further advice/information from the group.

5.0 Quorum

 5.1 The group will be quorate with at least five members of the group present.

6.0 Frequency of meetings 

6.1 The group will meet quarterly. The chair may convene additional meetings as necessary.

7.0 Evaluation

7.1 The group's effectiveness and terms of reference will be reviewed at least annually by the management team and the group.

7.2 The group will review its handling of any significant audits or clinical incidents it reviews within three months of the end of the review and will report back to the Senior Management Team/Board on any lessons learnt.

8.0 Adopted – Clinical Governance meeting Friday Feb 28, 2020