Introduction

Emergency Departments operate in complex, high-pressure environments where clinicians juggle uncertainty, volume, and acuity—often simultaneously. In this setting, clinical governance becomes more than a managerial tool. It’s the framework that enables safety, drives quality, and sustains public trust.

For Emergency Medicine consultants, clinical governance is an essential responsibility. You don’t just lead shifts—you lead a safety culture. This article outlines the seven pillars of clinical governance in the ED, illustrates each with ED-specific examples, and defines what excellent consultant leadership looks like in real-world practice.

What Is Clinical Governance?

The Department of Health defines clinical governance as:

“A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical excellence will flourish.”

In the Emergency Department, this encompasses:

• Early warning score escalations

• Learning from cardiac arrests or unexpected deaths

• Ensuring timely antibiotics for sepsis

• Keeping induction packs current

• Upholding dignity during overcrowding

It touches every aspect of ED life—from the most chaotic trauma call to the quiet dignity of an end-of-life conversation in Resus.

The Seven Pillars of Clinical Governance 

Seven pillars of clinical governance based on the NHS approach (Dehghanian & Heidarpoor, 2019)

1. Clinical Effectiveness

Definition: Using evidence-based, up-to-date clinical guidelines to provide the most effective patient care.

ED Application:

• Consultants ensure that junior doctors use the RCEM Best Practice Guidelines, NICE algorithms, and local SOPs for conditions like PE, chest pain, or paediatric fever.

• In trauma care, applying ATLS principles during primary surveys and ensuring timely pelvic binders, TXA, and damage control resuscitation reflect clinical effectiveness in action.

Example:
A new protocol on head injury management reduces unnecessary CTs without missing intracranial bleeds. The consultant leads a teaching session, updates the whiteboard algorithm, and follows up via audit.

2. Risk Management

Definition: Proactively identifying, managing, and reducing clinical risks and system failures.

ED Application:

• Consultants escalate ED safety risks, such as delayed triage during crowding or prolonged ambulance handover times.

• Every Datix report logged after a near-miss (e.g. insulin overdose not monitored, hypokalaemia left untreated) feeds into governance.

Example:
Following a missed hyperkalaemia case, the consultant pushes for mandatory blood gas checks on arrival for critically unwell patients, and creates a checklist for the resus bay.

3. Patient and Public Involvement (PPI)

Definition: Involving patients in the development, delivery, and evaluation of care.

ED Application:

• Consultants review complaints and FFT data and lead service improvements based on feedback, such as improving waiting room signage or updating the triage script.

• During departmental walkarounds, patients may raise concerns about privacy during mental health assessments—leading to environmental changes.

Example:
After a formal complaint about pain relief delays in elderly trauma patients, a consultant leads a quality improvement (QI) project to introduce a "Pain First" protocol at triage, with pain scores documented and reviewed hourly.

4. Clinical Audit

Definition: Comparing actual clinical practice against national or local standards to identify gaps and improve care.

ED Application:

• Consultants oversee audits on topics like sepsis bundle completion, antibiotic time-to-delivery, CT in suspected SAH, or compliance with head injury guidelines.

• Critical audits become embedded into M&M meetings, teaching sessions, and appraisal.

Example:
A consultant reviews audit results showing suboptimal time-to-CT in head injury. They engage radiology, rework the head injury pathway, and re-audit after education sessions.

5. Staffing and Training

Definition: Ensuring the ED is safely staffed and clinicians are appropriately trained, supervised, and supported.

ED Application:

• Consultants ensure middle grades have on-site support, induction is robust, and senior supervision is visible during nights.

• They proactively monitor junior wellbeing, burnout risks, and training needs.

Example:
Following a near-miss during paediatric resus, the consultant arranges a simulation-based teaching series on paediatric emergencies, open to all staff including HCSWs.

6. Clinical Information

Definition: Accurate, timely, and secure documentation and use of clinical data.

ED Application:

• Consultants must ensure that documentation meets medico-legal standards, supports coding, and is consistent with GMC guidance.

• Accurate triage notes, clear escalation plans, and complete discharge summaries are essential.

Example:
After feedback from the inpatient team about unclear referrals, the consultant introduces a structured SBAR note template and re-educates juniors during a governance hour.

7. Education and Continuing Professional Development (CPD)

Definition: Supporting lifelong learning, clinical development, and reflective practice.

ED Application:

• Consultants lead weekly teaching programmes, simulations, and case-based discussions.

• They mentor juniors on CPD, ARCP requirements, and reflective writing.

Example:
After a challenging intubation case, the consultant facilitates a multidisciplinary simulation session on failed airway management and invites the ODPs, anaesthetics team, and nursing staff.

Consultant-Specific Governance Roles

Consultants are not just involved—they are accountable. Their responsibilities include:

Sign-Off of Serious Incidents

• Lead RCAs following deaths, misdiagnoses, or critical delays.

• Conduct Duty of Candour meetings with patients and families.

• Draft SI reports and represent the department at governance boards.

Learning from Death Reviews

• Review notes, identify care gaps, and share learning at mortality meetings.

• Highlight missed sepsis, under-triage, or delayed escalation.

Complaint Handling

• Draft and sign complaint responses.

• Reflect openly and involve the whole team in feedback and change.

Mentoring and Leadership

• Provide supportive feedback, particularly after distressing cases or patient deaths.

• Identify struggling trainees early and offer tailored support.

Sponsoring Quality Improvement

• Oversee QI on flow, safety, patient experience, and staff wellbeing.

• Examples: introducing electronic whiteboards, frailty assessments at triage, or PPE safety spot checks.

Real-World Consultant Governance in Action

Case 1: Missed TIA at Night

• Consultant reviews the case and identifies gaps in triage documentation and senior sign-off.

• Audits follow, leading to a triage checklist and inclusion of TIA red flags on the whiteboard.

Case 2: Drug Error in Resus

• Consultant leads debrief, logs incident, and works with pharmacy to standardise packaging and create drug prep trays with checklists.

Top Tips for Consultant-Led Governance

• Make it routine, not reactive – Embed governance into huddles, handovers, and teaching.

• Model openness – When consultants report their own errors, juniors follow suit.

• Stay clinically visible – Governance is best led from the shop floor, not the office.

• Drive change gently but persistently – Use influence, evidence, and relationships to improve culture.

Takeaway Messages

• Clinical governance is central to the consultant role in Emergency Medicine.

• It’s the consultant’s responsibility to lead by example and embed safety in every shift.

• A strong governance culture protects patients, supports staff, and sustains services.

Conclusion

In Emergency Medicine, clinical governance is not a framework—it’s a culture. Consultants are not only clinical leaders but guardians of quality and safety. Whether responding to cardiac arrest or reviewing mortality data, your leadership shapes outcomes.
Embrace that role. Reflect often. And let the culture of safety start with you.

Further reading

Governance, patient safety and quality- NHS England

Dehghanian, Danoosh & Heidarpoor, Peigham & Attaran, Nona & Khoshnevisan, MohammadHossein. (2019). Clinical governance in general dental practice. Journal of International Oral Health. 11. 107. 10.4103/jioh.jioh_10_19.