Governance, patient safety and quality

Governance in healthcare is referred to as clinical governance, “a system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish”. It involves monitoring systems and processes to provide assurance of patient safety and quality of care across the organisation.

Audit and monitoring

Matrons provide assurance that wards, departments and services are delivering safe, high quality care. They do this through audits and by monitoring patient and staff experience and satisfaction. These audits include the ward environment, patient experience, quality improvement, assurance, infection prevention and control and other metrics. Matrons provide real-time feedback, share learning from incidents and develop, maintain and monitor action plans following investigations. Themes and findings from audits can be used for trust-wide improvement. NHS Improvement recently published a guide to ward and unit accreditation tools that can be adopted and used locally.

Other audits that matrons may participate in include the Patient-Led Assessment of the Care Environment (PLACE) and the 15 Steps Challenge, as well as local safety and quality audits that feed into the patient safety forum or clinical audit committee. Data from the Model Hospital can be used to benchmark findings from nursing metrics to improve productivity in clinical care delivery.

Quality and safety performance

Quality includes patient experience, safety and clinical effectiveness and is a key marker of operational performance. The matron should monitor quality using a quality scorecard and develop plans to address any area needing improvement. Outcomes of interventions should be monitored and reported – based on the CQC domains – to the quality committee or groups.

Matrons can use performance improvement measures such as a clear process for assessing risk, daily reviews of learning from risk, incidents and complaints and a process for escalating care. Here the matron should use local quality improvement (QI) strategies – refer to the QI section – to drive local improvements.

Patient safety

Safety in healthcare is everyone’s business. Even with the very best intentions, people make mistakes. Improving safety is about reducing risk and minimising mistakes to reduce avoidable harm. The NHS’s ambition is to become the safest healthcare system in the world.

The national priorities for patient safety that matrons should contribute to include:

  • ensuring good understanding of patient safety and the incident management system
  • implementing the NHS patient safety strategy and supporting World Patient Safety Day
  • attending the patient safety collaborative programme, responding to the patient safety agenda, the Francis Inquiry, developing new patient safety measurements, using the serious incidents policy, NHS Safety Thermometers, using clinical commissioning group (CCG) and regulatory levers to support patient safety improvement
  • working with the risk management team, collaborating with other national NHS and provider organisations such as NHS Resolution (formerly the NHS Litigation Authority), Medicines and Healthcare products Regulatory Agency, NHS Digital, Health Education England (HEE), independent sector, royal colleges and CQC.

Further information

Debriefing and learning from practice

Matrons should lead staff in using debriefing to stop and reflect after challenging situations. Debriefing can be undertaken in organised sessions in wards, departments or services – for example, after dealing with patients at the front line of care who have challenging mental health issues, more of whom are now admitted to settings for patients with physical conditions.

Safeguarding all people

NHS England has developed 12 safeguarding programmes based on national legislation covering adults and children, which every NHS organisation, system leader and practitioner must implement. The matron has an essential role here, so must fully understand their duty to report safeguarding incidents to protect their patients, colleagues and community.

Matrons should also hold safeguarding advice and supervisory sessions in wards, departments and services, in accordance with NMC professional practice guidance, to help staff through challenging situations.

Safeguarding incidents that must be reported include:

  • domestic abuse and violence against pregnant women
  • serious violence and sexual exploitation of schoolchildren
  • illegal drug dealing through ‘county lines’
  • human trafficking and other incidents, according to the NHS safeguarding policy and procedures.

Environmental cleanliness and IPC

Matrons have a pivotal role in applying the hygiene code and the Health and Social Care Act to ensure a clean and safe environment, liaising with the estates team in reviewing and improving the environmental infrastructure. Infection prevention and control (IPC) and improving cleanliness in the healthcare setting are part of the patient safety portfolio and reduce healthcare-associated infections. Matrons should lead their staff in improving the clinical environment to meet the requirements of the hygiene code and the Health and Social Care Act to ensure safety of patients, families and carers through:

  • overseeing the domestic, clinical and non-clinical cleaning responsibilities in the area covered
  • leading monthly hand hygiene audits, as well as formative rounds and peer review audits, checking and challenging practice
  • leading monitoring of local compliance, with the estates, facilities and IPC teams, through clinical environmental spot checks and audit, followed by updating the risk register with mitigatory actions
  • using quality dashboards and league tables for benchmarking and monitoring cleaning practices
  • participating in the 15 Steps process ensuring corridors, walkways and visual display areas are clear, clean and tidy, so that the organisation’s infrastructure is safe
  • contributing to the environmental cleaning service-level agreement and cleaning schedules
  • leading the implementation of standards in the area they cover to meet Clostridioides (formerly known as Clostridium) difficile objectives,16 as well as maintaining zero tolerance of methicillin resistant Staphylococcus aureus (MRSA) bloodstream infection
  • supporting ward, department and service leaders and IPC in local outbreak management and action planning
  • contributing to embedding antibiotic prescribing review and stewardship, according to the Escherichia coli bloodstream infection and antimicrobial resistance strategy
  • contributing to embedding local compliance with IPC-related policy, such as the hand hygiene and uniform policies, which includes ensuring staff are bare below the elbow and hair is tied back when in the clinical area
  • ensuring early identification and appropriate isolation of patients with infection risks
  • embedding compliance with the aseptic non-touch technique for surgical and invasive procedures
  • promoting education and development on all elements of IPC for staff and patients locally, including dedicated campaigns where there is an increased incidence of infections
  • leading staff in monitoring compliance with sharps and waste management, ensuring safe practices across the organisation.

Matron’s Handbook – next sections