It is a one to one discussion between the trainer and the trainee about goals to be set or those that have been achieved. It is a two-way informal and confidential communication about feedback on past performance and to identify educational and professional development needs.




It is an objective standard setting exercise, with an integral element of performance review in the process.




It is a process whereby doctors will have to demonstrate regularly to the GMC that they are fit to practise medicine. It would be done by repeated assessments.



Clinical governance 


Formal definition by department of health (1988)-‘Framework through which NHS organizations 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 can flourish.’


Informal definition-‘Systems to ensure lessons learnt are implemented and mechanism to ensure systems are in place and functioning effectively.’



Three basic things



-aiming for excellence in clinical care


Building blocks are

-clinical audit,

-clinical effectiveness,

-clinical risk management,

-quality assurance,

-staff development,

-evidence based practice,




Clinical effectiveness  


It can be defined as the extent to which specific clinical interventions, when deployed in the field for a patient or population,do what they are intended to do. It can be achieved by informing, changing and monitoring these changes resulted in improvements.


Clinical negligence


It is said to be occurred when the doctor did something wrong (act of commission eg. wrong side or patient) or failed to do something which they should have done (act of omission eg. minor sepsis leading to multiorgan failure).


Clinical risk management


Steps taken to identify the risks of adverse events, assessing their frequency and severity, and reducing or eliminating them in order to improve the quality of patient care.


Clinical audit


It is a systematic, critical analysis of the quality of clinical care, including the procedure used for diagnosis and treatment, the use of resources and the resulting outcome and treatment.




It is a process of going from known to unknown. It is a process of gathering data and information with an aim to prove or disprove existing facts and genesis of neoconcepts.


Audit loop or cycle


It starts from observing the current practice, finding out the set standards of care, comparing the practice with standards and implement the changes. It is an ongoing process and should be repeated to keep changes long-lasting.


Audit versus research 


Both involve gathering data and information. Local versus wider applicability. Known to unknown and vice-versa. Audit is reviewing current medical practice to identify deficiencies which can be remedied, while purpose of research is to enrich the medical knowledge.


Steps of Randomised controlled trial



-Literature review

-Statistical analysis

-Working protocol, patient advice sheet, consent form

-Ethical committee approval


-Data collection, analysis and interpretation

-Writing up, submitting and milking




National Institute for Clinical Excellence (NICE) (Web:

·         Established in 1999

·         NICE works on behalf of the NHS and the people who use it

·         NICE makes recommendations on treatments and care using the best available evidence

·         NICE produces three kinds of guidance:

o        Technology appraisals - guidance on the use of new and existing medicines and treatments within the NHS in England and Wales.

o        Clinical guidelines - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS in England and Wales.

o        Interventional procedures - guidance on whether interventional procedures used for diagnosis or treatment are safe enough and work well enough for routine use in England, Wales and Scotland.



National Patients Safety Agency (NPSA)


·         NPSA seeks to improve the safety and quality of care through reporting, analysing and learning from adverse incidents and 'near misses' involving NHS patients.

·         Its main role is to prevent accidents/incidents by

o        collecting and analysing information on adverse incidents from local NHS organisations, NHS staff, patients and carers

o        by taking into account other safety-related information from a variety of existing reporting systems

o        by learning lessons and ensuring that they are fed back into health care and treatment is organised and delivered

o        by ensuring that where risks are identified, work is undertaken on producing solutions to prevent harm, specify national goals and establish mechanisms to track progress



Commission for Health Improvement(CHI)


·         Ceased to exist on 31 March 2004. All functions have now been taken over by the Healthcare Commission

·         The CHI had four functions:

o        Clinical Governance Review

o        Monitoring and reviewing how the NHS meets the recommendation of National Service Frameworks (NSF) and NICE

o        Investigating serious service failures in the NHS

o        Leading and reviewing NHS healthcare improvements



Healthcare Commission


·         Its legal name is the "Commission for Healthcare Audit and Inspection. It became operational on 1 April 2004.

·         It replaced CHI but also took over some responsibilities from other commissions. In particular:

o        it takes over the private and voluntary healthcare function of the National Care Standards Commission

o        it covers the elements of the Audit Commission's work which relate to efficiency, effectiveness and economy of healthcare

·         One of its main functions is to promote the quality of both the NHS and the private and voluntary healthcare across England and Wales. In particular it takes over the handling of complaints if they have not been successfully resolved at a local level



National Service Frameworks (NSF)

o        put in place strategies to support implementation

o        establish ways to ensure progress within an agreed time scale

o        form one of a range of measures to raise quality and decrease variations in service, introduced in The New NHS and A First Class Service. The NHS Plan re-emphasised the role of NSFs as drivers in delivering the Modernisation Agenda.

·         There will usually be only one new framework a year.

·         Each NSF is developed with the assistance of an external reference group (ERG) which brings together health professionals, service users and carers, health service managers, partner agencies, and other advocates. ERGs adopt an inclusive process to engage the full range of views. The Department of Health supports the ERGs and manages the overall process.

·         NSFs implemented so far include

o        Long-term conditions (due end 2004)

o        Older people (March 2001)

o        Coronary Heart Disease (March 2000)

o        Mental Health (1999)

o        Diabetes (1999)



Evidence-Based Medicine (EBM)

·         The most common definition of EBM is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research." (Sackett, D.)

·         The steps involved in EBM are:

o        A clinical problem arises out of the care of a patient

o        Construct a well defined clinical question from the case

o        Conduct a search using the most appropriate resources

o        Appraise that evidence for  its validity (i.e. closeness to the truth) and applicability (i.e. usefulness in clinical practice

o        Integrate that evidence with clinical practice & patient preferences and apply it to practice

o        Evaluate your performance with the patient



Opponents of EBM


EBM is "old hat". Clinicians have been using the literature to guide their decisions for a long time. The label is new.


EBM is "cook book medicine". It suggests that decisions are based solely on the evidence, down playing sound clinical judgement.


EBM is the mindless application of population studies to the treatment of the individual. It takes the results of studies of large groups of people and tries to apply them to individuals who may have unique circumstances or characteristics, not found in the study groups.


Often there is no randomised controlled trial or "gold standard" in the literature to address the clinical question.


There is often great difficulty in getting access to the evidence and in conducting effective searches to identify the best evidence.


Proponents of EBM


The new focus on EBM "formalises" that "old hat" process and filters the literature so that decisions are made based on "strong" evidence.


EBM should be one part of the process. Decisions must be blended with individual clinical expertise, patient preferences and when available good evidence.


The last step in the EBM process is to decide whether or not the information and results are applicable to your patient and to discuss the results with the patient.


Clinicians might consider the "evidence pyramid" and look for the next best level of evidence. Clinicians need to understand that there may be no good evidence to support clinical judgement.


Librarians can help identify the best resources and teach clinicians effective searching skills.