Our governance structure

The principle of our governance structure is one of local accountability, supported by specialist expertise and with clear leadership which ensures that trends and outcomes are identified and that national guidance and regulation is observed.

The Executive team are responsible for ensuring agreed governance processes are followed and maintained. Each unit has a Clinical Director with dedicated sessional time to review quality and effectiveness, investigate incidents, and chair quality meetings. The clinical director is assisted in this task by Dr Lisa Das, Consultant Community Gastroenterologist at Barts Health NHS Trust. Lisa provides Clinical supervision to Dr Stevan Fox, Clinical Director Endoscopy who in turn supports the other Endoscopists.

We are also fortunate that we have access to the wider clinical governance team within InHealth Group. This brings additional expertise in specialist areas such as Health and Safety, complaints management, breakdown and analysis of Incident reporting, as well as root cause analysis.

Staff working in our units also hold regular education sessions and meet with Consultant Medical staff colleagues from other units. Some of our sites are registered with JETS and are therefore a training site for Endoscopists. Nursing staff also attend courses run by Gastro-Intestinal Nursing (GIN).

The governance framework benefits from a 4 strand approach:

  1. pro-active management of performance and compliance against an agreed set of professional and other regulatory standards
  2. An operational policy and standard operating procedures which we review annually to ensure policy and practice are aligned
  3. implementation of national regulatory requirements, and
  4. Real time feedback from patients, referrers and clinical incident review

Meeting structures

Each unit holds a monthly user group meeting which is chaired by the clinical lead. This meeting reviews audit and performance information. Actions are monitored and progress assessed.

Every six months, a Quality Circle meeting is held which is attended by all the staff working in the unit as well as the Head of Nursing (Endoscopy) and a senior member of the management team. Minutes are recorded and then collated by the Head of Nursing who incorporates them into a report for the Executive meetings and then subsequently into an annual governance report. Example Quality Circle minutes can be downloaded here.

In addition to the quarterly Quality Circle meetings there are quarterly InHealth Group Clinical Governance meetings which bring together all of the services within the InHealth group and ensure learning and policy development is consistent across the wider organisation.

Finally, there are bi-annual clinical governance meetings which are chaired by our independent governance assessor, Dr Lisa Das during which BSG guidance, new medical approaches and national policy directives are discussed and the IEL approach agreed. Additionally, any trends and important issues arising from audit and performance information is also put on the agenda to ensure the organisation is maintaining the highest standards of clinical care possible.

If you would like to find out more about our quality, governance processes, or would like to receive more information about our service, please contact us.

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