Clinical Governance Committee

The Clinical Governance Committee establishes, maintains and monitors the clinical governance strategy, structure and activity within the hospital, focusing on patient experience and clinical excellence at all times.

Purpose of the Committee

  • Guide and promote clinical governance within the hospital
  • Provide, monitor and evaluate the implementation of the clinical governance and quality strategy
  • Identify and define performance indicators
  • Review results of clinical audit against defined indicators
  • Review adverse clinical incidents
  • Review patient complaints
  • Review nursing and consultant medical record audits
  • Make themselves available to staff in advisory capacity, encouraging a positive culture of peer review and, where appropriate, whistle-blowing
  • Promote and maintain a professional code of conduct


  • The Managing Director is Chair of the Clinical Governance Committee.
  • Chair - Physician/Surgeon
  • Chief Executive Officer
  • Consultant user
  • Consultant anaesthetist
  • Infection control nurse
  • Pharmacy manager
  • Quality and Clinical Governance Manager
  • Resident medical officer
  • Nursing Services Manager


  • Reports to the Directors
  • Meets monthly – minutes and annual report


The Britannia Hospital believes that clinical and non-clinical improvements come from strong teamwork that has the right information to drive results forward. We are constantly striving to foster a supportive environment for our staff and consultant users in which we can generate a culture of safe and evidence based practice that meets and exceeds the standards of our patients and those who regulate and accredit us. It is through the experience of our patients and personnel coupled with our ability to meet both mandatory and voluntary external standards that we measure our quality of care.

Our clinical governance and quality strategy is based around the measurement of performance outlined within the National Minimum Care Standards and the new standards for better health. Our key quality objectives outlined in our clinical governance and quality strategy are:

  • Promoting systems for increased staff and patient satisfaction
  • Revalidation and consultant appraisal – using quality data to determine clinical privileges
  • Implement basic multidisciplinary consensus on treatment, audit and outcome measurement for all key clinical areas/departments in accordance with evidence based guidelines
  • Foster a culture of safe and evidence based practice in order to:
    • Support regulatory and accreditation compliance
    • Make our services publicly accountable

Patient Satisfaction Survey

The experience of our patients means everything to us as an organisation and being able to carefully gauge what our patients think about our services is the best way to approach service development.

We encourage patients to complete a questionnaire asking them about every aspect of their experience of the Britannia Hospital, we take these results very seriously and answer questionnaires individually where requested, acting on all comments where necessary. When indicated as appropriate we will contact you for help with action points.


All patients have access to the hospital Complaints Policy. We will endeavour to deal effectively with each complaint at the time the issue arises. Patients can expect to receive written acknowledgment, a full investigation and resolution of their complaint within the defined timescales as indicated within the policy.