This paper describes the early development of clinical governance in an acute NHS Trust. Three Trust-wide workshops and 17 individual departmental workshops were held between 1998-1999. The discussions in these workshops were used to define the key founding principles of clinical governance and the operational structure. The philosophy behind clinical governance, to improve quality of services, was recognised as being part of mainstream trust business, not an optional add-on. The authors found that teamwork and multidisciplinary collaboration are essential components of future quality improvement. Effective leadership skills need to be supported and developed, with responsibilities shared between a core group within each department rather than one individual. Contributions should be recognised and rewarded. Collaboration with primary care and involvement of patients are prerequisites. Specific objectives should be agreed by each department and used to monitor progress. More effective use of existing resources (staff, time, IT and training) can be made.