The clinical governance workload for all but the smallest department is such that the governance leadership should be divided into subsets, for example leads for guidelines, incidents, quality improvement, ACSA.
There should be effective processes for communication within the anaesthetic department and between other departments in the organisation to ensure that any learning to improve safety or quality is embedded in practice, excellent practice is recognised and poor behaviour is addressed. Systems should be established that minimise the opportunities for human error.
All members of the anaesthetic department should promote a safety culture, engaging in collaborative team working with a flattened hierarchy. All team members should be positively encouraged to: reflect and debrief, challenge negative behaviours, acknowledge positive behaviours, reflect on decision making and performance, report, document and review actual incidents and near misses and excellence.
There should be a clear process for the identification, development and regular review of guidelines, SOPs and clinical pathways. This review should take into consideration their use and effectiveness.
There should be a reliable mechanism for sharing guidelines and SOPs and providing ready access to guidelines at the point of use.
Departments should have a clear process to consider national guidance from recognised bodies. This should include a review of the guidance and a decision on whether these require local implementation and endorsement.
All guidelines should have a clearly documented author and review date and should be published in line with local clinical governance policies with appropriate oversight.
Relevant patient information should be recorded and kept up to date.
All anaesthetic records should contain the relevant portion of the recommended anaesthetic data set for every anaesthetic and should be kept as a permanent document in the patient’s medical record.
