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Clinical Governance Competencies

Clinical Governance Competencies

Competencies are the abilities that individuals acquire in order to translate taught knowledge into doable practices. To ensure effective and efficient implementation of clinical governance healthcare teams should acquire the following competencies:   

Clinical Effectiveness

Definition: Care for patients based on good quality evidence from research.


  1. Understand evidence based medicine
  2. Integrate best evidence into practice
  3. Define practice measurements
  4. Track and analyze practice variances
  5. Identify waste in practice

Clinical Audit

Definition: A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change.


  1. Choosing suitable topics for clinical audit using priority setting
  2. Defining practice standards required for clinical audit
  3. Assessment of structure, process, outcome of clinical practice
  4. Calculating the sample size required for clinical audit 
  5. Designing appropriate tools for collecting required data
  6. Data analysis and comparison with practice standards
  7. Ability to conduct practice improvement projects

Clinical Risk Management

Definition: An approach to improving the quality and safety of healthcare by identifying what places patients at risk of harm and taking action to prevent or control the risks.


  1. Identifying  sources of harm to patients in clinical practice
  2. Establishing systems for adverse event reporting
  3. Ability to analyze and evaluate adverse event risk
  4. Methods of analysis of adverse event contributing factors
  5. Measures used to control risk of adverse events

Education and Training

Definition: Education: The process of obtaining knowledge or skills. Training: The process of bringing a person to an agreed standard of proficiency (ability).


  1. Alignment of training objectives with strategic plans
  2. Defining competencies related to clinical best practice
  3. Conducting training needs assessment
  4. Developing  training programs
  5. Assessment of trainees and training programs

Information Management and IT

Definition: The creation, use, sharing, and disposal of data and information across an organization over time.


  1. Capacity to develop an information plan for clinical care
  2. Knowledge of data needed to calculate performance indicators
  3. Documenting patient data necessary for continuity of care
  4. Understanding classification of disease and interventions
  5. Compliance with data protection acts and confidentiality
  6. Collection, analysis, presentation of performance data over time

Patient and Public Involvement

Definition: The active participation of patients, users, carers, community representatives and the public in the development of health services and as partners in their  own health care.


  1. Producing patient education and information material
  2. Talking with patients, truth telling, disclosure
  3. Consenting patients to their care plans
  4. Sharing patients in decisions related to their clinical care
  5. Using patient’s experience in developing clinical services
  6. Handling complaints and patients in distress

Research and Development

Definition: Work directed toward the innovation, introduction, improvement of processes and products.


  1. Identifying problems solvable through research
  2. Development of appropriate and valid research design
  3. Applying intervention, data collection, data analysis
  4. Research results presentation, dissemination and publication

Staffing and Staff Management

Definition: The process of acquiring, deploying, and retaining a workforce of sufficient quantity and quality to create positive impacts on the organization’s effectiveness.


  1. Capacity to develop a staffing plan
  2. Defining job specifications, descriptions, required competencies
  3. Clarifying staff responsibilities, accountability, reporting arrangements
  4. Support of staff through training, appraisal, supervision
  5. Protection of staff against work hazards and violence