Active Hospital Toolkit

Active Hospital Toolkit

Introduction to Governance

All NHS services are supported by a governance process which will be led by the directorate involved. This section is an introduction to how we have set out our Governance framework.

Following a governance process will ensure that interventions remain consistent, safe and high quality. It will enable organisations to share learning and quality improvement.

How to use the Governance framework

Each section of the toolkit has a governance section – this is because  it is important to think about governance throughout the design, delivery and maintenance of your Active Hospital. Each section will suggest key elements of the seven pillars of Governance that may be most relevant to focus on at that stage of the project.

Or if you prefer all 7 pillars can be found and explored within the governance section.

Below you can find out more information about the Governance framework and Governance matrix  that we have created to assist you with embedding good governance within your practice

Governance Structure

Clinical governance was first established in the UK in 1997 (1).  The most widely accepted definition is “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” (2).  Since then, clinical governance principles have been incorporated into service development across the NHS, particularly in the secondary care. There are generally held to be seven pillars of clinical governance, namely, patient and public involvement, staffing and staff management, clinical effectiveness and research, using information and IT, education and training, risk management and audit.

Pearson et al (2017)  suggested a clinical governance matrix framework that can be used to provide assurance of quality from an individual and team level up to multiple services and across organisations(3). It is based on the pillars of clinical governance and current CQC domains of quality. The matrix framework is designed to be flexible for bespoke use with agreed measures as well as being a comparable methodology to use across different pathways/teams (3).

Clinical governance dashboard tools can be transferable across disciplines, departments, trusts and organisations to assist with quality improvement (4). The principles and language are now very familiar and recognised by all professionals and departments working across the NHS.  The NHS has been called upon to adopt a systematic approach to quality improvement (5).

Applying the NHS clinical governance framework to an Active Hospital project will ensure patient safety and quality of care is consistent. As the activities of the project effect patients across the trust, it is also important that there is a systematic approach to the overall team governance and also that there is a mechanism for feeding back governance issues into each pathway effected. This allows for a credible integration of a governance structure. All departments within NHS trusts will have existing governance processes with regular meetings and quality improvement activities.

Clinical champions from each of the Oxford Pilot pathways were invited to attend quarterly Active hospital Governance meetings and will then feedback to specific pathways when applicable.

  1. Jay M. The new NHS sets out the government’s commitment to giving the people of this country a modern and dependable health service. Nurs Times. 1997;93(51):3.
  2. Scally G, Donaldson LJ. The NHS’s 50 anniversary. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ. 1998;317(7150):61-5.
  3. Pearson B. The clinical governance of multidisciplinary care. International Journal of Health Governance. 2017;22(4):246-50.
  4. Guha S, Hoo WP, Bottomley C. Introducing an acute gynaecology dashboard as a new clinical governance tool. Clinical Governance: An International Journal. 2013;18(3):228-37.
  5. Ham Ca, Berwick DMa, Dixon Ja. Improving quality in the English NHS: a strategy for actio

Governance Matrix

The Active Hospital toolkit Governance Matrix is based on the pillars of clinical governance and current Care Quality Commission (CQC) domains of quality. It is designed to be flexible for bespoke use with agreed measures as well as being a comparable method to use across different pathways/teams.

It has the breadth and flexibility to be an effective tool, both to identify and resolve governance gaps and by providing assuring evidence of continuously improving quality of care.

The Care Quality Commission (CQC) is the independent regulator of quality standards for health and social care in England. The CQC recognises and assesses services and organisations across five domains of quality. Specifically they assess whether services are safe, effective, caring, responsive and well led (1). Understanding and acceptance of these five domains of quality is now well established. These headings have been adapted one axis of the matrix. The other axis is made up of the seven pillars (2).

Using Pearson’s matrix structure ensures balance across clinical governance with clear assurance as a new service is developed and implemented (2). The matrix offers a consistent approach and message but also allows for comparison across pathways and trusts. The matrix will act a dashboard to feedback to the central team on current governance status. Creating and engaging with a robust clinical governance structure within the Moving Medicine Active Hospital Project provides the safety net for clinical staff to push the boundaries of service development.

The Active Hospital Project should nominate a governance lead who will be responsible for ensuring the governance framework is implemented (2). This would normally be the lead consultant for the service.


  1. CQC. Five key question we ask 2009 [Available from:
  2. Pearson B. The clinical governance of multidisciplinary care. International Journal of Health Governance. 2017;22(4):246-50.


Active Hospital toolkit Governance Matrix