Clinical Governance Unit

The National Institute of Mental Health, Sri Lanka after it was upgraded to a national institute in 2008 developed internal policies and guidelines to ensure quality of services to clients. A policy folder was introduced in 2009 which also established a system of clinical governance. This document tries to streamline the establishment of a Clinical Governance Unit at NIMH.

To set up a sustainable, effective Clinical Governance Unit at NIMH under the Quality Management Section of the Planning and Development Unit that reaches all of its targeted objectives. The NIMH Clinical Governance Unit will function as a role model for other health institutions across Sri Lanka.

Systematic approach where managerial and clinical accountability, organizational culture and systems which enable probity, are implemented with a focus on assurance/improvement of patient and staff safety.

1. Managing patient safety and quality improvement ensuring best uses of services, clinical resources as well as ensuring the professional/institutional reputation 2. Outcomes are tracked within various established frameworks and committee structures to ensure that patients, who come to NIMH, experience care that is safe, timely, effective, efficient, patientcentered, value-based and equitable 3. To continuously transform the culture, ways of working and systems of healthcare delivery so as to ensure that quality assurance, patient safety and quality improvement become an integral and natural part of everyday work

1. Quality assurance and improvement

a. Integrated approach by the institution b. Infrastructures foster development of evidence-based practices (systematically find and use contemporaneous research findings as the basis for clinical decision-making) c. Innovations are valued and shared with all d. Clinical data are sound and used to monitor patient care and clinical outcomes

2. Professional accountability

a. Leadership skills are developed in line with professional and clinical requirements b. Poor clinical performance is identified to prevent further harm c. Professional and practice development are aligned to governance frameworks

3. Creating a safe environment for staff and patients

a. Clinical risk management systems are in place b. Complaints are taken seriously and action taken to prevent recurrence of the root causes

4. Nurturing an honest and open culture

a. Proactive approach to reporting, dealing with and learning from adverse events

1. The Lead Consultant who is appointed by the Director – NIMH with the concurrence of the Board of

Consultants of NIMH from among the Senior Consultant Psychiatrists of NIMH shall head the

Clinical Governance Unit. 2. A Clinical Governance Review Committee shall be established consisting of the Lead Consultant –

Clinical Governance as the Chair, One Consultant Psychiatrist, One Non – Psychiatry Consultant,

Medical Officer – Quality Management as the Secretary, Medical Officer – Health Informatics, One

Special Grade Nursing Officer, Nursing Officer – Quality Management, One Occupational

Therapist, One Pharmacist and One Psychiatric Social Worker appointed by the Director – NIMH. 3. The total number of the committee is 10 and the quorum shall be 5.

The Committee shall be appointed for period of one year and renewed annually under the guidance of the Director - NIMH

1. The Director and Deputy Director of NIMH may participate in the Review Committee as ex officio member in an advisory role regarding administrative action.

2. The Committee members shall function in this committee as part of administering their fiduciary duties.

3. All decisions of the committee shall be by consensus. Vote based decisions are highly discouraged however in extraordinary situations decisions may be taken by 2/3 majority vote.

4. If a complaint with regard to Clinical Governance error is made against a member of the committee that committee member must withdraw from all committee activities until such time he/she is cleared of such a charge.

5. Complaint and inquiry Procedure of the Clinical Governance Unit

a. All complaints must be received by the Director – NIMH b. Complaints can be made by a NIMH staff member, Quality Management Section, a patient, a guardian or any state officer. c. A written complaint can be made to the committee preferably attested by the Justice of Peace. d. The Director – NIMH at his/her discretion reviews the complaint and decides whether it is to be processed through administrative inquiry or through the clinical governance unit. e. Complaints are required to be made within 1 month of the alleged event. f. The names of the Committee members must be displayed on the notice board of NIMH so that all staff/ patients/guardians are aware of them. g. Anonymous complaints will be rejected in total. h. The inquiry process with regard to a complaint must be completed within 3 months of receiving a complaint. i. The Committee shall meet at least once a month to review complaints and as and when necessary.

j. The Director of NIMH shall ensure a safe and secure place for the meeting to be held without outside interference. k. Evidence from the clinical records and evidence given by staff and patients involved in an incident shall be reviewed with due diligence and in detail. l. After giving due consideration to evidence the committee shall deliberate on the said incident. m. After which the decision shall be forwarded to the Director, NIMH for disciplinary action or with other recommendations. n. A suitable penalty may be recommended to the Director by the Committee for consideration to a person found guilty of an offense. o. Penalties may vary from verbal warning, written warning, internal transfer, transferring to another institution or interdiction depending on the severity of the offense.

1. All committee members must behave with the utmost confidentiality when dealing with a complaint made.

2. Matters pertaining to on-going investigations should not be discussed anywhere else except during committee meetings.

3. An Impartial and unemotional approach must be taken with regard to all complaints and personal bias must be avoided at all times.

4. When in doubt expert opinion can be taken with regard to any matter.

1. The Clinical Governance Unit shall conduct clinical audits from time to time in collaboration with other units of NIMH 2. The Clinical Governance Unit shall conduct a Clinical Governance Meeting monthly at NIMH where relevant topics with regards to quality improvement will be taken into discussion 3. Statistics with regards to clinical events, clinical indicators and other special monitoring data will be reviewed monthly by the clinical governance unit.