As outlined above, hospitals should establish a CG&QIU to oversee all clinical governance and quality improvement functions of the hospital. The CG&QIU should be comprised of a director and officers. The CG&QIU should be multidisciplinary, with members from different clinical, administrative and support backgrounds. The director of the CG&QIU should be a member of the hospital senior management team. The CG&QIU director and officers should be full time in their role for CG&QI activities.

Roles of the CG&QI Unit include:

a) To develop the CG&QI strategy and present to the Senior Management Team for approval,

b) To develop an implementation plan for the CG&QI strategy and monitor its execution,

c) To ensure that CG&QI activities relate to the vision and mission of the hospital, and are aligned with the hospital strategic and annual plans,

d) To co-ordinate all CG&QI activities,

e) To promote and support the participation of all staff in CG&QI activities,

f) To receive and analyse feedback information from patients, staff and visitors,

g) To receive clinical audit reports and maintain a record of all clinical audit activities,

h) To review selected hospital deaths

i) To work very closely with the HMIS Focal Officer/Unit in monitoring HMIS performance

j) To conduct peer review in response to specific quality and safety concerns and to take appropriate action and follow-up when deficiencies are identified, and

k) To build the capacity of and update hospital staff on quality improvement activities and findings including:

a) Comparisons across time

b) Comparisons between Case Teams/Departments

c) Comparisons with other health facilities.

This unit should work closely with the Medical Director of the hospital as most of the activities are closely related.