Guidance

4. Clinical governance

Updated 10 October 2024

Applies to England

Clinical governance is the system 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 clinical excellence will flourish (Department of Health).

Clinical governance encompasses quality assurance, quality improvement and risk and incident management.

Responsibilities

The aim is to ensure that the whole screening pathway, including associated follow-up services, is functional and safe.

The NHSP team leader is the person locally with responsibility for clinical governance of the screening programme, safety and overall performance. Accountability for these should be written into their job descriptions.

Commissioning arrangements are important to good governance. Team leaders need to engage with commissioners to ensure that the quality of services provided are specified and that service level agreements are in place, ensuring that funding is secured and takes into consideration future needs of the service specifically around screening, equipment and staffing resources.

Providers of screening programmes must nurture good strategic partnership and have robust reporting mechanisms in place to their screening and immunisation team and commissioners. NHS services need to be competitive and demonstrate their effectiveness to the organisations that commission them and ensure they have internal review and audit in place to demonstrate continuous improvement against programme standards.

Programme standards and performance monitoring

Programme standards

The national programme defines standards against which data is collected and reported annually. The programme standards provide a defined set of measures that providers have to meet to ensure local programmes are safe and effective.

There should be equal access to uniform and quality assured screening across England. Families should be provided with high quality information so they can make an informed choice about newborn hearing screening.

NHSP programme standards will be reported annually and providers should ensure adherence through regular and robust interrogation of their screening data and performance management of their service and screeners.

Performance monitoring

Provider performance data is available via NHSP monthly, quarterly and annual reports and also via the national IT system and NHSP trends. Trends is an online system that allows local programmes, commissioners and other stakeholders to benchmark their programme performance and monitor improvements over time. Access is password protected and restricted to specified groups of users, managed by the screening helpdesk. The reports generated enable providers to monitor screener activity, adherence to care pathways and test protocols, including appropriate screen outcome setting plus yield and referral of the screen.

Key performance indicators

Screening key performance indicators (KPIs) are contained within both the Section 7a agreements between the DH and NHS England and in the Public Health Outcomes Framework (PHOF).

KPIs are a subset of programme standards that are collated and reported quarterly. Currently, there are 2 KPIs for the NHSP programme. Once a KPI consistently reaches the achievable level, the KPI will be reviewed to determine if other areas should be included instead.

The national screening programme will produce regular KPI reports for the provider of the screening programme and NHS England to monitor and evidence adherence to the screening pathway.

Local programme management tasks guidance will support local programmes in quality assuring the service they provide.

Quality assurance

Quality assurance (QA) is the process of checking that programme standards are met and encouraging continuous improvement, to ensure that all women and their babies have access to high-quality screening wherever they live. QA is essential in order to minimise harm and maximise benefits of screening.

Providers should have an internal quality assurance and risk management process that assures the commissioners of its ability to manage the risks of running a screening programme.

Participation in antenatal and newborn screening programme meetings will enable NHSP providers to engage with the screening and immunisation team as well as Screening QA Services (SQAS).

Participation in a formal process of QA is the responsibility of each local screening programme.

There are screening and quality assurance resources available for all screening programmes and you can also contact regional SQAS teams.

There is also specific guidance on the external quality assurance process for antenatal and newborn screening programmes.

Quality improvement

Quality improvement makes local programmes safe, effective, patient-centred, timely, efficient and equitable.

A quality improvement culture is an integral component of the governance and performance management processes for the screening and hearing care pathway for children.

Competent and motivated screening staff, evidence-based protocols and accurate information all underpin a high-quality service. Monitoring these components helps NHSP providers develop a greater understanding of what, if any, improvements are necessary in order to provide the highest quality screening service. In addition, rigorous audits will help reduce the risk of errors and, where this occurs, it will help identify them quickly and manage them effectively and sensitively.

Self-assessment systems should be embedded alongside external review, so that continuous improvement becomes an integral part of service delivery.

Undertaking a patient satisfaction survey will reassure local programmes about their services, while also highlighting areas for improvement.

Risk and incident management

In all services and programmes errors can, and will happen. Some errors will be relatively minor but others may be serious. The purpose of the Managing safety incidents in national screening programmes guidance is to set out the requirements for managing safety concerns, safety incidents and serious incidents in NHS screening programmes. It provides clarity for staff providing and commissioning NHS-funded services that may be involved in identifying or managing a screening incident. This should complement local risk management strategies and processes.

Programmes should use the screening incident management resource and the NHSP failsafe processes guidance to assist risk management and avoid or manage incidents effectively.