title: Clinical governance: learning and changing practice.
abstract: BACKGROUND
  This paper describes a very simple, non-threatening method for improving communication and sharing learning points.
  
  
  OBJECTIVE
  To test whether sharing anonymised reporting of problems and helpful hints is acceptable and useful to staff.
  
  
  METHODS
  A pink slip (pinkie) was designed and made available in every clinic venue. All staff were asked to write about any episodes where practice was less than optimum or to share good clinical experiences. The forms could be completed anonymously if preferred. A senior nurse collated the reports monthly and fed them back to all staff as a report. In May 2000 all staff were surveyed for their opinion of the scheme.
  
  
  RESULTS
  Over 22 months, 139 'pinkies' were returned. Fifty-six of the 100 'less than optimum' events were classified as 'system failures'. The response to the staff survey was very positive, with 62% of staff replying. Fifty-four of the 55 staff found the scheme helpful. A third of those who responded had contributed and all but two individuals felt able to contribute if the situation arose again.
  
  
  CONCLUSIONS
  This simple system of self completed pink slips has allowed examples of less than optimum practice and helpful suggestions to be shared across a large service that has a predominantly part time work force providing services from over 15 venues. The system is seen as non-threatening and was acceptable to over 95% of the staff who responded to the survey. Fifty percent of doctors and nurses had made a submission. Changes in practice have resulted since its introduction.
authors.affiliation: Ella Gordon Unit, St Mary's Hospital, Portsmouth, Hampshire, PO3 6AD, UK.
authors.forename: S
authors.initials: S
authors.lastname: Ingram
authors.forename: S
authors.initials: S
authors.lastname: Randall
mesh_terms: D000554:Ambulatory Care Facilities / Q000592:standards*; D003142:Communication; D005193:Family Planning Services / Q000592:standards*; D006801:Humans; D008485:Medical Audit / Q000379:methods*; D019300:Medical Errors / Q000517:prevention & control; D011361:Professional Competence; D012308:Risk Management / Q000379:methods