Governance Framework

All NHS services are supported by a governance process which will be led by the directorate involved. The toolkit provides you with resources to support specific governance priorities for an Active Hospital intervention. Following this governance process will ensure that interventions remain consistent, safe and high quality. It will enable organisations to share learning and quality improvement.

As Active Hospital interventions affect the whole Trust rather than a single directorate, there needs to be a systematic approach to overall team governance and a mechanism for feeding back governance issues into governance meetings for each pathway. This allows for credible integration of a governance structure.


This image shows specific activities against each governance domain as examples. More can be found about activities in each domain by exploring the 7 pillars within this toolkit.

Active Hospital toolkit Governance Framework

Using a clinical governance matrix framework can be helpful in providing assurance of quality across individuals, teams, multiple services and across organisations

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 this 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