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P-220 Is there a need for a governance lead in a hospice setting?
  1. Rachel McCarty
  1. Nottinghamshire Hospice, Nottingham, UK


Background Nottinghamshire Hospice is a small hospice providing community and bereavement support, wellbeing and therapy services. In 2022 a newly appointed Senior Leadership Team and its trustees appointed a Governance Lead to co-ordinate key aspects of its Quality Assurance programme.

Definition Governance is seen as ensuring the hospice’s integrity, rigorous policies and procedures and overseeing regulatory and legal compliance. It includes promoting good relations with stakeholders, staff and volunteers.

Aims To provide a focussed approach on key areas of quality assurance and improvement and recognisable outcomes. Key areas of focus are:

  • Structured approach to policies and procedures.

  • Implementation of a new patient and carer feedback system.

  • Implementation of a data software platform.

  • Quality Improvement coordination.

  • Implementing the Patient Safety Incident Response Framework.

Results Policies, procedures and Standard Operating Procedures (SOPs):

  • 14 policies and SOPs were developed during 2022 -2023 and 15 policies reviewed.

  • A total of 29 policies were produced during 2021–22.

  • 16 policies and SOPs are under development during 2023 – 2024.

Implementation of patient and carer feedback (I Want Great Care). Online and paper system established, first reviews received.

Implementation of data Software platform (Vantage)

  • Incident Module go live date – May. Plans in place for: CQC evidence; Complaints; Risk.

Patient Safety Incident Response Framework (PSIRF)

  • PSIRF plan in development, agreed with Integrated Care Board (ICB).

Quality Improvement coordination

  • Staff updated on new regulatory approach.

  • Quality Improvement Group action plan in place.

  • Implementing information sharing systems.

Conclusion The role of a Governance Lead enables:

  • A focussed approach to Quality Improvement initiatives.

  • Clinical staff to input expertise into policies and procedures.

  • Fast-tracking of developments ensuring the ongoing quality assurance of services.

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