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Clinical Governance Annual Report 2024-2025

NHS Greater Glasgow and Clyde (NHSGGC) aims to provide high quality care, which is person-centred, effective, and safe. This report outlines some of our key work and activity during the year in helping to meet this aim, as well as providing assurance that we are meeting our clinical governance obligations. Each year we highlight some of the improvement and good practice work that has taken place across the Board in the Spotlight and Innovation section and this year we feature eighteen projects that show learning, improvement or good practice. Within the report we also look ahead to 2025-2026 to outline some of our key objectives and areas of focus for the year ahead.

Contents:

1. Introduction
2. NHS Greater Glasgow and Clyde purpose
   1. Clinical Governance in NHS Greater Glasgow and Clyde
   2. Clinical Governance Polices and Frameworks
3. Key Messages
4. Programmes of work
   1. Clinical Governance Arrangements
   2. Clinical Risk Management
   3. Duty of Candour
   4. Morbidity and Mortality
   5. Datix
   6. Quality Improvement Programmes
   7. Clinical Guidelines
   8. Clinical Quality Publications
   9. Scottish National Audit Programme (SNAP)
   10. New Interventional Procedures Policy
   11. Quality of Care Review
5. Spotlight on Innovation and Improvement
   1. Mental Health
   2. Acute Services
   3. Primary Care and Community
   4. Physiotherapy Band 4 HCSW in Mental Health Test of Change
   5. Neuropsychological Assessment in East CAMHS
   6. Does annual antipsychotic medication monitoring in mental health services change
      patient management?
   7. Tackling Health Inequalities for People Accessing the Pain Management Service
   8. Careful and Kind Bereavement Care for Staff
   9. Sustainability in Orthotics: Digital Shape Capture for Ankle Foot Orthoses
   10. Macmillan Physical Activity Project Summary - August 2023-24
   11. Implementing Occupational Therapy in Cancer Older People’s Service
   12. How a Stroke Early Supported Discharge Could Improve Hospital Flow and Reduce Costs
   13. Supporting Vulnerable Families to Achieve Optimal Oral Care
   14. Integrating Patient Feedback into Redesign of MSK Classes
   15. Assertive Outreach Model within Specialist Learning Disability Services
   16. Advanced Nurse Practitioners: Initiation of First Dose Medicines During Home Visits
   17. Empowering Patients to Self-Administer Vitamin B12 Using a Values-Based Approach
   18. Improving Outcomes for Care Home Residents at End of Life
6. Capability Building
   1. Clinical Risk Training
   2. Quality Improvement Capability
7. Plan for 2025-2026
8. Conclusion
9. Glossary of Abbreviations

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