Introduction to Clinical Governance
Northern Doctors Services is committed to increasing junior doctor involvement in Clinical Governance activities.
The Introduction to Clinical Governance Program offers junior doctors the opportunity to develop valuable skills in leadership, quality improvement, patient safety, and healthcare systems. Participation can strengthen your CV and help distinguish you when applying for future jobs, specialty training, and career opportunities.
The program aligns with the PMCV JMO Curriculum and supports competencies recognised across many specialty training pathways.
By joining the program, junior doctors can contribute meaningful input and feedback to important organisational projects and clinical governance initiatives, while gaining experience beyond day-to-day clinical work.
Northern Health also benefits by creating a broader and more engaging training environment for junior doctors by encouraging greater junior doctor participation in service improvement.
Program Outline
Domain 1
Committee Participation
Activities / commitment:
- Participate in a National Standards or Clinical Improvement Committee
- Link up with a medical representative on the Committee for orientation/debrief
- Attend at least 3 meetings within a 6-month period
- Become familiar with relevant terminology (National Standards resources, Terms of Reference, Agenda, Action lists and Minutes)
- Examples of committees — see Appendix A below
Outcomes:
- Write a brief reflection on your participation — e.g., what did you learn? How could the committee be improved? How could we involve more JMS in Quality activities?
- Receive a Statement of Participation
Domain 2
Clinical Audit
Activities / commitment:
- Undertake a clinical audit
- Link up with a mentor familiar with the audit topic and process
- Review previous audit findings
- Identify dataset and audit questions
- Complete audit
- Write up findings and recommendations
- Examples of audits — see Appendix B below
Outcomes:
- Work with mentor to write up audit findings in standardised format to be presented to relevant committee
- Receive a Statement of Participation
Domain 3
Safety Review
Activities / commitment:
- Participate in a Patient Safety activity
- Complete 5 Mortality/Morbidity Reviews
- Participate in an adverse event review (e.g., SCIRT)
- Attend 3 QRM meetings
Outcomes:
- Work with a mentor to complete and present at the Unit’s regular Mortality and Morbidity Review Process
- Write a reflection of your participation in a SCIRT or QRM meeting — e.g., what did you learn? How could the committee be improved?
- Receive a Statement of Participation
Domain 4
Quality Improvement
Activities / commitment:
- Undertake a quality improvement cycle (Plan, Do, Study, Act)
- Identify a gap or improvement opportunity
- Identify a mentor, stakeholders and audit measures
- Develop and undertake baseline audit
- Develop and implement improvement activity
- Undertake repeat audit
- Write up findings
Outcomes:
- Work with mentor to write up quality improvement findings in standardised format to be presented to relevant committee
- Receive a Statement of Participation
Appendix A — Northern Health Quality Improvement Committees
2
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2
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3
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6
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5
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1
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1
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2
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Appendix B — Examples of Potential Clinical Audits
| Audit | Committee / Audit Owner |
|---|---|
| Review of Suicide & Self Harm (SASH) incidents / identifying gaps in care | Predicting, Preventing & Managing Self Harm & Suicide committee |
| Emergency surgery consent documentation | Consent & Shared Decision-Making committee |
| VTE | VTE & Anticoagulation committee |
| Medication | Standard 4 Medication Safety |
| Psychotropic medication consent | Predicting, Preventing and Managing Cognitive Impairment committee |
| Delirium Management | Predicting, Preventing and Managing Cognitive Impairment committee |
| Goals of Patient Care / Medical Treatment Decision Maker / ACP | End of Life Committee |
| Deaths documentation | Healthcare Record Advisory Committee |
| Medical handover | Medical Handover Working Group |