OPCG schedule itemDomain*Area†
NSF, national service framework; HImP, Health Improvement Programme.
*Domain: 1 = improving quality; 2 = managing risks; 3 = improving performance; 4 = corporate accountability; 5 = leadership and collaboration.
†Area: 1 = structure; 2 = process; 3 = outcome.
(1) Teams work across boundaries to address quality issues52
(2) Staff identify best practice through benchmarking against other providers12
(3) Where appropriate, staff modify their care processes to reflect the best practice of others13
(4) Research evidence is regularly reviewed and discussed12
(5) Training in evidence-based practice and critical appraisal is available to staff11
(6) Research information is used consistently to inform our approach to quality improvement13
(7) Clinical issues are raised for discussion22
(8) Discussions on clinical issues are not dominated by any single profession12
(9) Staff participate in clinical audit activity11
(10) Training in clinical audit is available to staff11
(11) Topics for audit are selected according to their potential impact on care quality12
(12) Risk management data is regularly reviewed and discussed22
(13) Following identification of a problem from risk data, clinical quality is improved23
(14) Clear action plans are developed in response to identified clinical risks22
(15) Staff are trained to use the risk management system22
(16) Adverse incident data is regularly reviewed and discussed22
(17) Clear action plans are developed in response to adverse incidents22
(18) Following identification of a problem from adverse events data, clinical quality is improved23
(19) Staff are trained to use adverse event systems22
(20) Complaints are collated21
(21) Following identification of a problem from complaints data, clinical quality is improved23
(22) There is a “no blame” culture around reporting adverse events and near misses22
(23) Staff can raise clinical concerns about their colleagues in confidence22
(24) There is good access to agreed clinical performance indicators11
(25) Clinical indicators are used to reflect on, review and integrate services13
(26) Staff have development plans which identify training and development opportunities32
(27) Training identified in staff development plans matches individual needs to organisational needs32
(28) New skills gained through development activity are used in clinical settings33
(29) There is an annual staff appraisal process for most staff31
(30) An agreed work and development programme is used as the basis of staff appraisal32
(31) Staff appraisal is used as an opportunity to reflect on progress and plan future development32
(32) There is an executive director with responsibility for developing the clinical governance agenda41
(33) Service delivery plans include quality improvement activity52
(34) Clinical areas have a nominated clinical governance lead41
(35) There is a formal clinical governance committee, reporting to the board41
(36) There are local arrangements to collate information for the clinical governance committee41
(37) Organisation-wide clinical governance systems are underpinned by systems in clinical areas41
(38) Decisions about service developments or cutbacks are made on clear criteria53
(39) Local and national priorities from NSFs and HImPs are used to prioritise service development52
(40) NSF implementation is integrated with business planning and quality improvement programmes52
(41) External guidelines are critically appraised before local adoption or development52
(42) Clinical protocols are shared with staff who work outside this organisation53
(43) The organisation shares a common vision for clinical governance52
(44) Leadership skills are identified and developed through leadership training programmes52
(45) Clinical teams receive performance feedback52
(46) Clinical teams respond to changes in their environment by reorganising their work processes53
(47) Staff have clear and shared objectives52
(48) There are clear processes for involving service users in service development52
(49) There are clear criteria for establishing user involvement groups52
(50) Service improvement activity focuses on the patient experience of care52
(51) Local health and social care agencies work jointly on clinical governance issues52
(52) Local partnerships with health and social care agencies have clear, shared purposes52
(53) Staff question what they are doing and are able to develop new and innovative models of service53
(54) Staff evaluate the best ways of training and learning from experience52