HCSA clinical governance review procedure template

1Purpose

1. 1.1This procedure sets out how the Clinical Governance Officer at [Clinic name] oversees the quality and safety of the clinic's services each month.

2Each month

1. 2.1The Clinical Governance Officer reads a sample of [number] patient health records for accuracy, completeness and signature.
2. 2.2They review incidents, complaints and feedback received in the month, with the actions taken.
3. 2.3They check every clinician's registration and any new service against the licence.

3Recording

1. 3.1The review is written down, with what was found, the actions, an owner and a date for each.
2. 3.2The Principal Officer reads and signs the review, and the record is kept as evidence of the Clinical Governance Officer's oversight.

4Review

1. 4.1The Principal Officer reviews this document every [12] months, and sooner after an incident, a complaint or a change in the regulator's requirements.
2. 4.2Each review is recorded with the date, the reviewer and what changed, and the previous version is kept.
3. 4.3Staff are told of each change, and their acknowledgement is recorded.

5Where this sits in the HCSA framework

• Key Office HoldersClinical Governance Officer
  Code of practice for Key Office Holders