PHECC Governance Validation Framework at the National Patient Safety Office Conference

Healthcare organisations aim to deliver reliable, safe and efficient patient care to the public. Because of this the general healthcare landscape is constantly changing and, at any given time, there are many new initiatives either ongoing or in development which seek to improve the quality of care. Safety in healthcare is of paramount importance and drives many of the new initiatives.

The Department of Health recognises patient safety as the corner stone to quality healthcare and their National Patient Safety Office (NPSO) focuses on leading key patient safety policy initiatives. The NPSO focus on safe care using evidence in practice to improve quality through clinical guidelines, audit and focused patient safety initiatives.
The NPSO hosted a conference in Dublin Castle on the 25th & 26th of October. The conference theme was “Teamworking for Patient Safety”. Many of the excellent initiatives that are taking place at all levels across the healthcare system and learning from the international context on teamworking and clinical governance were showcased during the event.

PHECC produced a poster and an abstract for the conference, under the Clinical Effectiveness stream, that introduces the Governance Validation Framework (GVF) to the wider healthcare community.

Our submission outlines how PHECC is the regulator for pre-hospital emergency care in Ireland and, within its statutory remit, prepares Clinical Practice Guidelines (CPGs) for pre-hospital emergency care and makes them available to pre-hospital emergency care service providers and other persons considered appropriate. PHECC also recognises, in accordance with rules made by the Council, those pre-hospital emergency care service providers which undertake to implement the clinical practice guidelines. These are known as ‘Licensed CPG Providers’, there are 27 of them at present and they are currently subject to an annual licence renewal cycle.
Click here to view the full document

Drivers for the Project:

Setting and implementing standards and monitoring of compliance are important levers in driving improvements in quality and safety in healthcare. In accordance with its strategic plan PHECC has developed a Governance Validation Framework (GVF) to further enhance patient safety, improve the quality of service provision and provide PHECC Council with the assurance that its licensed CPG providers are operating in-line with PHECC rules and requirements for their recognition. The GVF is designed to be compatible with existing national healthcare improvement standards.

Patient Safety Initiative Development:

The development of the GVF utilised a collaborative approach with all PHECC licensed CPG providers. An initial trial model was developed which included template based self-assessment, onsite review, staff and management engagement and culminated in a final report to the organisation. This model was field tested with self-selected providers. Following the trial feedback was sought from a number of sources e.g. the development team, the external assessors, lead assessor, PHECC senior management team and the CPG providers who participated in the trial. The framework was further refined and a final GVF model was approved by PHECC in July 2017. The project has now transitioned into its implementation phase.

Click here to view the full document

Benefits for Patient, Providers and PHECC:

The GVF is a quality assurance initiative which includes a patient focussed risk-based approach that has been developed to support quality improvement within PHECC licensed CPG providers. The framework utilises self-assessment by the provider, followed by review and external assessment. Providers prepare, submit and maintain an annual quality improvement plan. GVF is designed to: 
  • ensure and continuously improve patient safety
  • promote quality improvement within licensed CPG providers
  • support pre-hospital practitioners in their activities
  • assure PHECC of the quality of licensed CPG providers activities/operations. 


The GVF will support a three-year license renewal cycle which is focussed on protection of the patient and quality improvement. Alongside existing renewal requirements providers will be required to submit annually:
  • a structured medical directors report
  • a structured risk based self-assessment and
  • a quality improvement plan.
When linked with the provider renewal system PHECC are confident that GVF will positively impact and improve patient safety, the pre-hospital practitioners’ environment and the quality of service provision of PHECC licensed CPG providers.