Introduction Clinical governance is essential to the delivery of high quality safe and effective patient care. It provides a framework to continuously improve the quality of hospice services.

Aims To critically appraise the current clinical governance systems within our hospice and to re-design these to be efficient, transparent and encourage staff engagement.

Methods Workshops were held to examine existing governance structures and highlight areas of need and develop a solution which was both readily implementable and effective. The workshops reviewed current literature and examples of good practice surrounding clinical governance in hospices.

Results A consensus decision was reached to construct clinical governance under the ‘three pillars’ of patient safety, clinical effectiveness and patient experience as described by the Clinical Governance Toolbox (1). In order to enhance engagement with clinical governance three new groups were created for each ‘pillar’. Each group consists of a multi-professional membership of clinical and non-clinical staff and is Chaired by a member of the senior management team. The group members will be responsible for disseminating information and educating staff and volunteers in their day-to-day work as well as in a monthly newsletter. The Clinical Governance board, drawing together the work of the three pillars, will provide organisational oversight. The Clinical Governance Board is comprised of staff members, Trustees and an external scrutinizer.

Conclusions In adopting this clinical governance structure we believe we have developed a streamlined system that will promote best practice in all members of staff through clarity, communication, accessibility and inclusiveness. Importantly this process has also improved awareness of clinical governance throughout our team through the dynamic workshops responsible for re-designing our systems.