Clinical Governance Framework

Clinical Governance can be defined as a framework through which Hospitals and their staff are accountable for continuously improving the quality of patient care. It is central to the Hospital’s agenda for management to verify that appropriate systems and processes are in place to monitor clinical practice and safeguard high quality care.

Ensuring‘Quality Care and Patient Safety’ is the key driver in Pun Hlaing Siloam Hospital’s delivery of health services to the people of Myanmar. The commitment to quality care is shared by our Health Professionals, Managers and staff through a comprehensive Clinical Governance framework for monitoring, assessing and continuously improving the quality of care to our patients, and to confirm our quality standards are in accordance with accepted International benchmarks (American, United Kingdom, New Zealand and Australian).

Clinical Governance is defined using the Australian Council on Healthcare Standards International (ACHSI) definition:

the system by which the governing body, managers and clinicians share responsibility and are held accountable for patient care, minimising risks to consumers, and for continuously monitoring and improving the quality of clinical care

Safety is defined as:

a state in which risk (measured in terms of consequences and likelihood) has been reduced to an acceptable level

Why Clinical Governance?

Clinical Governance is a framework in which the quality of patient care in a health care system is continuously being improved, safeguarding high standards of care.

Clinical governance aims to shift the performance of all hospitals closer to the standards of the best. It hopes to reduce unjustifiable variations in the quality of care provided, in terms of outcomes, access and appropriateness. It is needed, to reassure the community that the care received in this hospital is of the highest standard. It requires the development of a culture where healthcare professionals are motivated to routinely think ‘Am I doing it right? How can I do better?’

Five themes characterise Clinical Governance

  1. Patient centered –Putting patients at the centre of care and strengthening the public and patient voice.
  2. Information focus – –Access to good quality information helps people to understand their health situation, make informed decisions about their care and treatment, and manage their own health.
  3. Quality improvement – Meet International standards as developed by recognised Health Care Clinical Excellence, such as Australia, New Zealand, United Kingdom and USA.
  4. Staff focus –Important to support a skilled workforce who is able to adapt and respond to changes and the challenges required in sustaining the delivery of safe and effective care.
  5. Leadership –Senior healthcare staff should accept full managerial and professional accountability for high quality health care.


The over-arching Clinical Governance structure at Pun Hlaing Siloam Hospital has been developed and is monitored and evaluated by the Clinical Governance Committee (CGC).The Clinical Governance Committee is comprised of a membership of 5 exclusive core craft group specialist doctor representatives, and will be chaired by a senior exclusive physician elected by the specialists.

  • The members and chairman will rotate every 2 years
  • The CGC will meet every month and report to the shareholder Board every quarter
  • The CGC can co-opt members as required

Clinical Governance Committees

Key sub committees under the jurisdiction of the CGC will include, but not limited to:

  1. Morbidity and Mortality
  2. Infection Prevention and Control
  3. Credentialing and Re-credentialing
  4. Medications Management
  5. Products and Innovation Evaluation
  6. Clinical Quality, Safety and Risk Management

To monitor the quality and safety progress, achievements and opportunities for improvement, medical and non-medical indicators have been formulated to establish the Clinical Governance Dashboard (CGD).

The CGD will be monitored and evaluated by the Clinical Governance Committee (CGC) at its monthly meeting. The CGD findings and recommendations will be presented to the Hospital Board on a quarterly basis.

Operationally the Clinical Governance Framework requires:

  • Organisation and clinical leadership, including oversight by a designated senior clinician
  • Staff performance review including quality issues
  • Clinical audit
  • Clinical risk management
  • Research and dissemination of information about effectiveness of clinical practice
  • Staff education, training and continuing professional development
  • Managing and learning from complaints
  • Seeking and responding to user and patient views
  • Use of clinical information about patient experiences
  • Appropriate management and feedback mechanisms must exist to ensure all systems are in place and functioning effectively.

Best practice

International Nursing Associations strongly believe that improving the patient’s experience of health care is also the central purpose of clinical governance.

Good care means:

  • Getting good treatment – high quality, safe and effective treatment delivered by capable health care teams.
  • Being treated as a person – with respect, honesty and dignity.
  • Being safe and comfortable – feeling confidence in the care environment.
  • Being informed and having a say in the care they receive.

These elements should be present at every point of contact with the hospital. The healthcare journey includes health awareness, access to care, continuity of care and support for patients, families and carers.

All healthcare providers strive to provide safe and good quality health care; improve patient experience, tackle effectiveness and update practice in the light of evidence from research.

Understanding what influences attitude and behaviour has been given much greater attention in looking at what makes for higher quality and compassionate care.

Participating in Clinical Governance

Clinical Governance is intended to improve standards of care and also to protect the public from unacceptable care. An underlying challenge for clinical governance in primary care is to move away from professional development based on individual disciplinary education, towards multidisciplinary team based learning. The emphasis on continuing professional development for all clinicians, be they doctors, dentists, nurses, or other healthcare professionals will encourage clinicians to reflect on their educational needs and meet those requirements. Achieving this is an active process and can be met in a variety of ways, including through traditional lectures, but may be best met through peer discussion, discussing published literature, or consulting guidelines.

Clinical Governance in the future

In order for Clinical Governance to succeed, hospitals need to move away from a ‘blame culture’ to a ‘culture of learning’. It is important that quality in PHSH is maintained and that necessary changes are made to ensure that patients become central to the hospital care agenda and that their voice is heard.

Tips for Clinical Governance


  • Have clinical and organisational leadership
  • Conduct performance reviews including quality issues
  • Undertake clinical audits
  • Work together to improve performance
  • Manage and learn from complaints
  • Seek and respond to patients views


  • Ignoring quality issues as part of core business
  • Undervaluing staff education, training and continuing professional development
  • Ignoring problems – it’s important to be proactive and transparent

Key benefits of effective Clinical Governance

  • Individuals and team reflection on their practice and implementation of lessons learnt
  • Open and participative climate in which education, research and the sharing of good practice is valued
  • Commitment to quality that is shared by professionals and managers and supported by clearly identified resources, both human and financial
  • Routine engagement with the public and users through an organisation-wide strategy, and user representation
  • Working as a multi-disciplinary team
  • Board level discussion on quality issues
  • Strong leadership from the top
  • Good use of information for planning and monitoring clinical governance

Setting Standards of Care

Quality care is defined as:

  • The extent to which a health care service or product produces a desired outcome
  • The continuous improvement of all processes and the products and services that are the outcomes of those processes

Standards of care are usually set nationally in developed countries, such as in the UK by the National Institute of Clinical Excellence (NICE) and in NSW Australia by the Clinical Excellence Commission (CEC).

The benchmarks and targets are agreed through wide consultation and use of research into the effectiveness and cost effectiveness of clinical practices.

For Pun Hlaing Siloam Hospital, current recognised International Standards are suitable to adopt and adapt to Myanmar practice.

Organisational Culture

Organisational culture is a major factor in understanding the performance of clinical teams, and how to support changes in work practices. Each organisational team and has its own culture, ways of working and values that will influence the way clinical governance is implemented.

Change is unlikely to be achieved without the enthusiasm and support of motivated clinical champions and leaders.

In essence, Clinical Governance requires a culture in which the organisation and their clinical team members:

  • Consider quality issues as part of core business
  • Work together to improve performance
  • Are willing and able to acknowledge their problems
  • Value personal development and education
  • Feel valued in their work
  • Recognise the importance of the patient’s experience of care and seek to obtain patients’ feedback
  • Seek ways of improving care as a matter of routine
  • Proactively implement standards of care developed internationally

What about poor performance?

  • A system of Continuing Professional Development (CPD) is needed in order to maintain clinical standards. International Standards requires all clinical practitioners be required to participate in continuous education in order to remain on the accredited list.
  • In the case of doctors, this process will dovetail with the re-credentialing process, to be conducted every 3 years, following initial credentialing.
  • In hospitals, health directors and managers need to have put into place processes to identify performance issues, and procedures to deal with poor performance. These procedures aim to identify practice as it begins to slip, and to proactively support and develop clinical staff, enabling improvements without risk to the quality of patient care. In some cases, this may result in an investigation, leading to suspension or dismissal of professionals.
  • Systems need to be developed to monitor the performance of Specialist doctors and investigate poor practice. Cases of suspected poor performance or misconduct should be referred to the appropriate professional regulatory body.

Committee for Medication Management

Reporting to the Director Clinical Excellence, the Medication Management Committee is responsible for the strategic co-ordination of activities being undertaken to deliver safe, effective and cost efficient use of medications to patients of Pun Hlaing Siloam Hospital. The Committee provides expert advice on medication safety issues in PHSH and supports actions to improve medication safety.

Infection Prevention and Control Committee

The new Infection Prevention and Control Committee commenced in March 2015 and is responsible for setting the strategic direction for the prevention and control of Health Acquired Infections (HAI) in PHSH and PHC. Key responsibilities include ensuring action on the five priority areas of:

  • hand hygiene
  • adherence to precautions to prevent the spread of infections in hospitals
  • effective use of cleaning programs
  • correct use of antibiotics and;
  • adherence to evidence based guidelines in intensive care units

What are the plans for the future?

For successful clinical governance, hospitals need to make a major change, by moving away from a ‘blame culture’ to one of learning. Pun Hlaing Siloam Hospital needs to reinforce the importance of quality and highlight that many more changes are required to ensure that the patients become central to the care agenda and that their voice is heard.

Will clinical governance make any difference for patients?

As the systems are put in place, there needs to be genuine interest in making it work. The main challenge for the leaders of clinical governance in Pun Hlaing Siloam Hospital is to change the culture and attitude of staff. This coupled with a more proactive role adopted by the designated committees and Managers should assist with the development and progress of clinical governance and hence to more coordinated and better clinical care outcomes for patients.

Clinical Quality, Safety and Risk Management Committee

The Framework for Managing Quality, Safety and Risk in Pun Hlaing Hospital will:

  • focus on the safety and quality of clinical care
  • promote leadership and accountability for the safety and quality of health care with a systemic orientation
  • focus on the principles for managing the safety and quality of health services
  • provide an organisational focus for quality activities and reporting, recognising the essential role played by leaders, consumers and all health service staff in quality improvement
  • recognise the essential cultural requirements of quality and safety improvement.
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