Clinical Governance

This process has been re-organised to a ‘per trust’ approach in 2018/2019 and Governance lead is Dr Lamprini Vrana. There is a monthly joint (adult congenital and paediatric) governance meeting where both adult and paediatric activity are discussed. The rolling agenda follows a formatted trust approach.

Service requirements for mortality discussion are met via completion of documentation for child death review process which are then fed back into local and national reporting structures.   Unit activity data including PRAIS scoring is reviewed at each meeting. Morbidity events as defined by NICOR are discussed using nationally published data to assess unit performance and review areas for quality improvement.  NHSE quality dashboard indicators are used to stimulate discussion of areas for improvement and to identify areas of best practice such that this can be appropriately discussed with local and national commissioners.  

Clinical incidents and patient complaints are shared through this meeting in order to share learning. Following the ongoing development of our regional network and videoconferencing solutions, local and network partners are now invited to take part in the learning from this meeting in order to cascade this as widely as possible.  Quality improvement and audit activity within the department are reviewed for dissemination.

The annual unit NICOR report is discussed in the context of national performance at the trust Clinical Effectiveness Audit and Guidelines Committee on an annual basis.          

Dr Jansen and Dr Coats organise the monthly morbidity and mortality meeting for the adult congenital service.

The centre regularly submits data to NICOR (National Institute for Cardiovascular Outcomes Research) on surgical outcomes for CHD patients.

CHD is present in about 0.8% of live births, and with approximately 30,000 births each year in this region, there are approximately 300 new cases of congenital heart defects per year. Our unit has been collecting data since 1986 and our team pride ourselves in our data quality that is amongst the highest in the country.  

Our overall data quality index score (DQI) has been steadily increasing over the last few years, maintaining above 97%.  Our most recent DQI score for 2018/19 is recorded at 99.00%.  

In light of the current pandemic, NHSX and NHS Digital have delayed the publication of the 2018/19 report to September 2020.

The centre took part in a number of the audits, quality improvement projects and service development projects in 2019/20. 

Details of these can be found in the document section below.