| (1) Teams work across boundaries to address quality issues | 5 | 2 |
| (2) Staff identify best practice through benchmarking against other providers | 1 | 2 |
| (3) Where appropriate, staff modify their care processes to reflect the best practice of others | 1 | 3 |
| (4) Research evidence is regularly reviewed and discussed | 1 | 2 |
| (5) Training in evidence-based practice and critical appraisal is available to staff | 1 | 1 |
| (6) Research information is used consistently to inform our approach to quality improvement | 1 | 3 |
| (7) Clinical issues are raised for discussion | 2 | 2 |
| (8) Discussions on clinical issues are not dominated by any single profession | 1 | 2 |
| (9) Staff participate in clinical audit activity | 1 | 1 |
| (10) Training in clinical audit is available to staff | 1 | 1 |
| (11) Topics for audit are selected according to their potential impact on care quality | 1 | 2 |
| (12) Risk management data is regularly reviewed and discussed | 2 | 2 |
| (13) Following identification of a problem from risk data, clinical quality is improved | 2 | 3 |
| (14) Clear action plans are developed in response to identified clinical risks | 2 | 2 |
| (15) Staff are trained to use the risk management system | 2 | 2 |
| (16) Adverse incident data is regularly reviewed and discussed | 2 | 2 |
| (17) Clear action plans are developed in response to adverse incidents | 2 | 2 |
| (18) Following identification of a problem from adverse events data, clinical quality is improved | 2 | 3 |
| (19) Staff are trained to use adverse event systems | 2 | 2 |
| (20) Complaints are collated | 2 | 1 |
| (21) Following identification of a problem from complaints data, clinical quality is improved | 2 | 3 |
| (22) There is a “no blame” culture around reporting adverse events and near misses | 2 | 2 |
| (23) Staff can raise clinical concerns about their colleagues in confidence | 2 | 2 |
| (24) There is good access to agreed clinical performance indicators | 1 | 1 |
| (25) Clinical indicators are used to reflect on, review and integrate services | 1 | 3 |
| (26) Staff have development plans which identify training and development opportunities | 3 | 2 |
| (27) Training identified in staff development plans matches individual needs to organisational needs | 3 | 2 |
| (28) New skills gained through development activity are used in clinical settings | 3 | 3 |
| (29) There is an annual staff appraisal process for most staff | 3 | 1 |
| (30) An agreed work and development programme is used as the basis of staff appraisal | 3 | 2 |
| (31) Staff appraisal is used as an opportunity to reflect on progress and plan future development | 3 | 2 |
| (32) There is an executive director with responsibility for developing the clinical governance agenda | 4 | 1 |
| (33) Service delivery plans include quality improvement activity | 5 | 2 |
| (34) Clinical areas have a nominated clinical governance lead | 4 | 1 |
| (35) There is a formal clinical governance committee, reporting to the board | 4 | 1 |
| (36) There are local arrangements to collate information for the clinical governance committee | 4 | 1 |
| (37) Organisation-wide clinical governance systems are underpinned by systems in clinical areas | 4 | 1 |
| (38) Decisions about service developments or cutbacks are made on clear criteria | 5 | 3 |
| (39) Local and national priorities from NSFs and HImPs are used to prioritise service development | 5 | 2 |
| (40) NSF implementation is integrated with business planning and quality improvement programmes | 5 | 2 |
| (41) External guidelines are critically appraised before local adoption or development | 5 | 2 |
| (42) Clinical protocols are shared with staff who work outside this organisation | 5 | 3 |
| (43) The organisation shares a common vision for clinical governance | 5 | 2 |
| (44) Leadership skills are identified and developed through leadership training programmes | 5 | 2 |
| (45) Clinical teams receive performance feedback | 5 | 2 |
| (46) Clinical teams respond to changes in their environment by reorganising their work processes | 5 | 3 |
| (47) Staff have clear and shared objectives | 5 | 2 |
| (48) There are clear processes for involving service users in service development | 5 | 2 |
| (49) There are clear criteria for establishing user involvement groups | 5 | 2 |
| (50) Service improvement activity focuses on the patient experience of care | 5 | 2 |
| (51) Local health and social care agencies work jointly on clinical governance issues | 5 | 2 |
| (52) Local partnerships with health and social care agencies have clear, shared purposes | 5 | 2 |
| (53) Staff question what they are doing and are able to develop new and innovative models of service | 5 | 3 |
| (54) Staff evaluate the best ways of training and learning from experience | 5 | 2 |