Home Essential Service: Clinical Governance
Clinical Governance is a key part of the Essential Services that ensures that service quality is monitored and improved wherever possible.
As part of the Clinical Governance requirements, pharmacies have to participate in clinical audit of their services and have arrangements in place to verify the quality of advice provided to patients. They must have procedures for providing information to patients, obtaining views and dealing with complaints from patients. They must also implement relevant risk management measures.
Pharmacies must have staff management, training and development procedures in place for their staff, and ensure handling of all data, meets legal and ethical requirements including confidentiality and data protection.
Patients will have the opportunity to feed back on their level of satisfaction with their local pharmacy service by completing a patient survey. A pharmacy will review the survey results and consider changes to improve service provision for the benefit of patients.
Contractors are required to co-operate with local Patient and Public Involvement Forum visits and consider the action recommended by any report produced.
Contractors are required to ensure that there are confidentiality policies in place for all staff and that they are appropriately trained.
Service Specification
Click on the link below to download the Service Specification for Essential Service 8 - Clinical Governance:
Clinical Governance Service Specification (PDF Format)
The original service specification has not been fully implemented in relation to the Community Pharmacy Patient Questionniare (CPPQ), further information is available on the CPPQ page of the website.
Related Resources: Patient and Public Involvement
Complaints Briefing Paper and Recording Templates
Community Pharmacy Patient Questionnaire (formerly Patient Satisfaction Survey)
Practice leaflet requirements
Related Resources: Clinical Audit
RPSGB Guide to Audit (PJ 13th August 2005) (PDF Format)
The National Electronic Library for Health (NeLH) can be used to access up to date information to support clinical pracice and can be found by clicking here
Related Resources: Risk Management
Chaperone Policy
The briefing document below prepared by PSNC summarises the Chaperone Guidance issued by the National Clinical Governance Support Team. It is not mandatory to have in place a chaperone policy, but pharmacy contractors may wish to consider the adoption of a policy in order to protect patients and staff.
PSNC briefing on Chaperone Policy (PDF Format)
Patient Safety Incident Reporting
Overview of Community Pharmacy Reporting to the NPSA
Report an Incident (NPSA NRLS Online Form)
PSNC Incident Reporting Form
NPSA Root Cause Analysis e-learning Package
Seven steps to patient safety for primary care
Information on the NPSA reporting system and significant event auditing is available on the National Patient Safety Agency website http://www.npsa.nhs.uk/
Guide to significant event audit (Pharmaceutical Journal, 5th August 2006)
SOPs
SOPs Top Tips (PDF Format)
Child Protection
RPSGB Guidance on Child Protection (PDF Format)
RPSGB guidance on reporting sexual activity in children under 13 years
Related Resources: Education, training & CPD
CPD: RPSGB Online Recording website
Related Resources: Use of Information
RPSGB guidance on the recording of interventions (PDF Format)
NHS Code of Practice on Confidentiality (PDF Format)
RPSGB Guidance on NHS Code of Practice on Confidentiality (PDF Format)
Additional Resources
RPSGB and NHS Clinical Governance Support Team - Clinical Governance for Community Pharmacists website
RPSGB guidance on protection of vulnerable adults (PDF Format)
RPSGB guidance on raising concerns (PDF Format)
RPSGB interim guidance on identifying and remedying poor performance (PDF Format)
CPPE offer a variety of workshops and e-learning tools around Clinical Governance issues and can be found by clicking here.
Frequently asked questions
My PCT have asked for information on complaints made to the pharmacy, do I have to tell them?
Complaints records contain sensitive personal data and their disclosure should be avoided. When monitoring of the new pharmacy contract begins in October 2005, PCTs will want to be satisfied that the pharmacy has an adequate complaints system, and that there is learning from incidents; they are not required to have sight of the complaint records themselves nor to aggregate data from complaints made to community pharmacies. The exception is if the PCT is investigating a specific complaint, because then the pharmacy has a duty to co-operate fully with the investigation.
Who decides the topic of the practice based clinical audit?
The Practice based audit is chosen by the pharmacy contractor; however, it should have a clear outcome, which will assist with developing patient care. The PCT determines the topic of the annual multi-disciplinary clinical audit.
Where can I access information on suitable practice based clinical audits?
The RPSGB have produced a number of audit templates which could be used by contractors. They are available on the Audit section of the RPSGB website.
The new contract book says the two audits should be capable of being completed within 5 days of pharmacist time - is that 5 days for both audits or for each one?
Funding was negotiated for a total of 5 days of pharmacist time, during which both audits should be completed.
Where can I access training and information on root cause analysis (RCA)?
CPPE provide an open learning programme to provide support on implementing the clinical governance arrangements under the New Contract. They also provide workshop sessions on risk management issues within their portfolio of learning. The National Patient Safety Agency (NPSA) also provide a number of resources on their website, including a RCA toolkit.
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