Clinical Governance: A Systems Approach

Background

The delivery of high quality care should be the core concern of all healthcare organisations and practitioners (Scally & Donaldson, 1998). In the past, the attention of healthcare organisations was predominantly occupied by financial and other resource management matters as well as activity targets (Heyrani et al., 2012). This trend prompted a decline in the standards and quality of healthcare services causing the public to become sceptical about the quality of the care offered by healthcare organisations.

Moreover, the ambiguity surrounding the concept of quality in healthcare made it difficult to measure the quality of healthcare with precision. According to Heyrani et al. (2012), the concept of quality in healthcare is a product of a complicated web of contingent and interacting factors. Consequently, the definition of the concept varies depending on the perception from which it is approached. Further, a typical healthcare organisation features a broad spectrum of staff and departments, which are expected to function harmoniously to achieve a unified cause (Heyrani et al., 2012).

Presented with these challenges and motivated by the desire to provide quality healthcare, the British government, through the National Health Service (NHS), developed a comprehensive framework that would ensure the provision of quality healthcare (Heyrani et al., 2012). The framework was named clinical governance.

What is Clinical Governance

Clinical governance was developed to address the challenges that faced healthcare organisations in their quality improvement endeavours. Therefore, since the concept of quality in healthcare is difficult to define with precision, clinical governance has different definitions that reflect the variations in the understanding of what quality in healthcare means.

England’s Department of Health defined clinical governance as, “a framework through which NHS organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish” (Heyrani et al., 2012, p. 84). The Australian Council on Healthcare Standards later defined it as “The system by which the governing body, managers and clinicians share responsibility and are held accountable for patient or client care, minimising risks to consumers and for continuously monitoring and improving the quality of clinical care” (Department of Health, 2009, p. 1). According to Starey (2001, p. 1), clinical governance “is a system for improving the standard of clinical practice.”

The three definitions differ only in their wording, but their core concepts are similar. All of them underscore the importance of quality and accountability in a healthcare system. It suffices to say that by developing the concept of clinical governance, the Labour government had crafted a vehicle by which it could hold healthcare organisations accountable for fostering quality healthcare as well as the creation and maintenance of an ambient environment that could support clinical excellence at all levels (Government of Western Australia, Department of Health, 2001).

The Rationale behind Clinical Governance

As noted in the introduction, the notion of quality in the healthcare system was bogged in a morass of ambiguity, misplaced priorities, and complexity (Heyrani et al., 2012). Consequently, despite there being a need for quality care and a commitment among healthcare practitioners to offer the requisite quality, the outcomes of their attempts were always unsatisfactory (Heyrani et al., 2012). It became apparent that there were lapses in the policy framework governing the healthcare system.

The relationships among the numerous departments that constitute a healthcare organisation were in dire need of being streamlined. Similarly, the manner in which healthcare practitioners interacted with one another and the conditions of their working environments were in need of an overhaul. The Government of Western Australia, Department of Health (2001) notes that healthcare practitioners always bore the brunt of poor healthcare outcomes when the actual problem was an imperfect practice environment characterised by inadequate resources, outdated equipment, and lack of access to updated evidence-based information to support professional practice.

For example, in the U.S., a reputable reporter died as a result of a chemotherapy overdose while undergoing treatment for breast cancer. This occurrence prompted the disciplining of the 16 nurses who were involved in the treatment, yet the failure resulted from lapses in the design of the medication system (Government of Western Australia, Department of Health, 2001).

In response to this nature of challenges, the concept of clinical governance was developed. The idea was borrowed from the concept of corporate governance, which had been introduced into the corporate world in the early 1990s and had started showing positive outcomes for business operators (Heyrani et al., 2012). The philosophy behind the development of clinical governance was to improve the quality of healthcare delivery at all levels of the healthcare system by consolidating, codifying, and standardising healthcare policies and approaches (Government of Western Australia, Department of Health, 2001).

The concept sought to bring all quality activities in the healthcare system under one umbrella to eliminate the possibility of ignoring some areas and over focusing on others. Coupled with commitment from healthcare practitioners, clinical governance has the potential to revolutionise the healthcare system.

Elements of Clinical Governance

The concept of clinical governance was initially underpinned by seven pillars. Nevertheless, like any other human developed concept, it has been subject to improvement. Consequently, the concept has undergone a continuum of alterations aimed at improving it or adapting it to the needs of different countries and regions across the world.

The initial seven pillars include Risk management, Clinical audit, Education, training and continuous professional development, Evidence-based care and effectiveness, Patient and carer experience and involvement, Staffing and staff management, and the Use of information to improve patient care (Chandraharan & Arulkumaran, 2007). These pillars were condensed by Starey (2001) into what he called the six elements of clinical governance. They include Education, Clinical audit, Clinical effectiveness, Risk management, Research and development, and Openness. To show how these elements relate to one another, Starey (2001) developed the model below.

Clinical Governance

According to the Government of Western Australia, Department of Health (2001), the initial seven pillars can be condensed into four key pillars. They include Clinical audit, Clinical risk management, Clinical effectiveness and knowledge management, and Professional education and development. These four pillars have been formulated into a clinical governance system, which is used in all healthcare facilities in Western Australia. The clinical governance system is as shown in the figure below.

WA Clinical Governance framework

Despite the variations in the number of pillars that underpin the concept of clinical governance, the core ideas remain the same. The model used notwithstanding, it is essential for healthcare organisations to pay attention to all the elements of clinical governance to maximise its benefits. The main ideas underlying each of the pillars of clinical governance are explored below.

Risk management

Under the umbrella of clinical governance, risk management is concerned with minimizing any possible risks to the least possible level. It goes beyond anticipating what might go wrong during care to include what actually goes wrong (McSherry & Pearce, 2011). The need to identify possible and actual risks stems from the desire to understand the factors that influence these risks. A clear understanding of the factors is essential for the development of remedial measures that can curb identified risks. Additionally, it helps in the development of evidence-based knowledge that helps improve the clinical experience for both practitioners and patients (McSherry & Pearce, 2011).

Further, it provides an avenue through which healthcare practitioners can learn lessons from adverse occurrences that transpire during care provision. Such lessons add to the skills and experience of those involved. It encourages the documentation and analysis of adverse occurrences to understand their underlying causes so that measures can be taken to curb their recurrence (State Government of Victoria, Department of Health, 2009). Finally, it encourages the consideration of every factor when a negative clinical outcome occurs instead of simply victimising healthcare practitioners as has always been the case.

Clinical audit

Clinical audit refers to the cyclical process by which healthcare practitioners evaluate their service delivery (Government of Western Australia, Department of Health, 2001). Prior to the inception of the concept of clinical governance, well-meaning healthcare practitioners had their individual methods of measuring the quality of their services (Heyrani et al., 2012). However, when clinical governance was incorporated into the healthcare system, the evaluation of the quality of care ceased to be a personal affair. Today, all practitioners are part of the program.

It allows practitioners to evaluate their performance and compare it to the standard measure. The main idea behind this practice is to help to identify areas of weakness so that appropriate remedial measures can be taken to improve service quality (Chandraharan & Arulkumaran, 2007). It ensures continuous quality improvement because after every improvement, a further audit is conducted to measure the new performance against established standards.

Education, training, and continuous professional development

It is essential for healthcare practitioners to have the latest knowledge and skills that they require to provide quality care. Consequently, under the clinical governance framework, healthcare practitioners are provided with the opportunities and, sometimes, the resources they need to update their knowledge and skills to match contemporary requirements (Chandraharan & Arulkumaran, 2007).

This pillar is strengthened by the fact that medical knowledge keeps getting better as new ways of care provision and new drugs are discovered (Scally & Donaldson, 1998). Additionally, the Government of Western Australia, Department of Health (2001) notes that the public is constantly bombarded with news concerning new discoveries in the medical field. These developments raise the expectations of the public. Consequently, healthcare practitioners should keep up with the latest developments or risk becoming irrelevant and incompetent.

Evidence-based care and effectiveness

The concept of evidence-based care emerged in the 1970s and has since then grown to worldwide popularity (Dizon & Lizarondo, 2010). Evidence-based care requires healthcare practitioners to rely on research-generated evidence to guide their practice. This trend leads to the accumulation of evidence-backed knowledge, which facilitates the effectiveness of practice in patient care. If healthcare provision is guided by robust evidence from clinical research, the chances of adverse outcomes are greatly minimised (Chandraharan & Arulkumaran, 2007). Therefore, the incorporation of evidence-based care and effectiveness into the clinical governance framework was an attempt to improve healthcare outcomes and restore public confidence in the NHS (Heyrani et al., 2012).

Patient and carer experience and involvement

The main concern of clinical governance is to bring healthcare to the highest possible level of quality. This feat can only be achieved if both practitioners and patients engage in objective quality improvement programmes (Hockins & Critchlow, 2002). Patient and carer experience and involvement as an element of clinical governance provides room for the development of such programmes. Under these programs, practitioners are involved in forums where they share their experiences and suggest ways of improving areas of weakness. Similar forums can also be organised for patients to allow them to raise pertinent issues that can help improve healthcare provision.

The idea behind this pillar is that treating practitioners and patients as partners in the quest for quality healthcare brings on-board the perspectives of all stakeholders leading to the development of comprehensive remedial measures whenever an adverse outcome occurs (McSherry & Pearce, 2011).

Staffing and staff management

As an element of clinical governance, staffing and staff management ensures that healthcare practitioners are adequately qualified. The need for high quality care calls for highly skilled and knowledgeable staff members. This requirement cannot allow any healthcare organisation to recruit under qualified staff members because they are likely to compromise the quality of healthcare services provided by that organisation.

In conjunction with the education, training, and continuous professional development pillar, this element ensures that once the right people are recruited, their knowledge and skills are updated regularly to keep up with the pace of new developments. Additionally, it ensures that every healthcare facility is adequately staffed with qualified staff because understaffing has been found to be a major contributor to poor healthcare delivery (McSherry & Pearce, 2011).

Use of information to improve patient care

Patient care is the main concern of healthcare systems. It needs to be provided at the highest possible level of quality. Normally, healthcare practitioners use the information generated by patients to guide most of their decisions (Wattis & McGinnis, 1999). As such, patients need to give the required information and any additional information that can improve the quality of healthcare they are accorded. Similarly, practitioners need to furnish patients and their family members with the necessary information to ensure that they understand the condition of the patient. If either side withholds vital information, the quality of healthcare provided is bound to be adversely affected (McSherry & Pearce, 2011).

Consequently, information is supposed to be shared freely between healthcare practitioners and patients to improve the quality of patient care. Moreover, when the operations of a healthcare system are open to public scrutiny, poor quality is likely to be greatly minimised unlike in behind the scenes operations, which no one has the chance to criticise and help to improve.

Clinical Governance Model for the Podiatry Project

The podiatry project in question can be examined under the auspices of two of the elements of clinical governance that have been discussed. They include evidence-based care and effectiveness and the use of information to improve patient care. Evidence-based practice is essential for the improvement of the quality of healthcare. In the practice of evidence-based care, only practices that are backed by robust evidence can be used in the provision of healthcare. In the long run the effectiveness of healthcare services is achieved because best practices are adopted in clinical practice (Hockins & Critchlow, 2002).

This approach goes hand-in-hand with the use of information to improve patient care. Best practices in evidence-based care can only be developed when both practitioners and patients are actively involved in the development of frameworks that govern the provision of healthcare. In other words, when patients, practitioners, and managers of healthcare organisations share information freely, the clinical outcomes are bound to be positive and can facilitate the development of evidence-based care models. For example, since podiatry is concerned with the treatment of feet, the two elements of clinical governance mentioned above can be incorporated into the model below to create an evidence-based podiatry model.

Clinical Governance Model for the Podiatry Project

The ethical leadership element ensures that only the best and appropriate evidence-backed clinical practices are used in the provision of care for, say, an ankle dislocation. A patient-oriented culture ensures that the clinical practices chosen to treat the dislocation are the most suitable for the particular category of patient. The knowledge sharing element provides an avenue through which the patient and care provider can exchange all the necessary information to make the clinical experience pleasant for both.

Finally, the element of knowledge-based trust provides a framework within which patients and care providers learn to develop trust in each other based on the knowledge shared between them during the treatment process. This model can go a long way in improving the quality of podiatry care for ankle dislocation or any other case that requires the same kind of care.

References

Chandraharan, E., & Arulkumaran, S. (2007). Clinical governance. Obstetrics, Gynaecology and Reproductive Medicine, 17(7), 222-224.

Dizon, J. M., & Lizarondo, L. (2010). A systematic review of the effectiveness of Evidence Based Practice (EBP) programs for allied health professionals. The JBI Database of Systematic Reviews and Implementation Reports, 8(8), 252-264.

Government of Western Australia, Department of Health. (2001). Introduction to Clinical Governance – A Background Paper (Information Series No. 1.1). Perth, Australia: Office of Safety and Quality in Health Care, Health Care Division, Western Australian Department of Health.

Heyrani, A., Maleki, M., Marnani, A. B., Ravaghi, H., Sedaghat, M., Jabbari, M., & Abdi, Z. (2012). Clinical governance implementation in a selected teaching emergency department: A systems approach. Implementation Science, 7(1), 84.

Hockins, N., & Critchlow, B. (2002). Noble’s hospital clinical governance strategy: A framework for continuous quality improvement. Web.

McSherry, R. & Pearce, P. (2011). Clinical governance- a guide to implementation for healthcare professionals (3rd ed.). England: Wiley-Blackwell.

Scally, G., & Donaldson, L. (1998). Clinical governance and the drive for quality improvement in the new NHS in England. Bmj, 317(7150), 61-65.

Starey, N. (2001). What is clinical governance? Hayward Medical Communications, 1(12), 1-8.

State Government of Victoria, Department of Health, (2009). Victorian clinical governance policy framework –A guidebook. Melbourne, Australia: Statewide Quality Branch, Rural and Regional Health and Aged Care Services, Victorian Government, Department of Human Services.

Wattis, J., & McGinnis, P. (1999). Clinical governance and continuing professional development. Advances in Psychiatric Treatment, 5(3), 233-239.

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