Governance of healthcare organisations and health systems requires many different competencies, with a great emphasis on evidence and information governance, which are traditional fields of librarians’ expertise. However, stakeholders are unaware of how health and hospital libraries are contributing with specific activities and what are the trends in library support for health/clinical governance in Europe, mainly because traditional methods of measuring impact are restricted to specific library activities or are not showing direct impact long term. The paper aims to discuss these issues.
A model combining components of clinical and health governance (C/HG), related library activity types, and the possible impact was developed based on a literature review and tested by a European expert panel. A web-based survey was offered to the members of the European Association for Health Information and Libraries (EAHIL) to offer further insight into activities and examples of contribution to C/HG.
Librarians from 25 European countries participated in the survey. The model proves that librarians in Europe are involved in supporting most identified components of C/HG, with examples of clinical effectiveness and research, education and training, patient and public involvement, partnership engagement, formulating strategic direction, etc.
The authors were unable to cover the roles of libraries in all European countries in this paper, but dialogue and research will continue within the EAHIL group.
No such comparative research has been undertaken before, looking at what activities and tasks libraries undertake to support C/HG. This research has highlighted valuable services and tools that can be replicated in libraries across health care organisations and at the same time promote libraries and librarians as significant actors in organisational governance.
Ibragimova, I. and Korjonen, M.H. (2019), "The value of librarians for clinical and health governance (a view from Europe)", International Journal of Health Governance, Vol. 24 No. 1, pp. 66-88. https://doi.org/10.1108/IJHG-11-2018-0062
Emerald Publishing Limited
Copyright © 2019, Emerald Publishing Limited
Governance of healthcare organisations requires many different competencies, including methods of locating evidence of best practice, integrating best evidence into care pathways, auditing of clinical practice, handling of complaints, adverse event analysis and proactive risk management. Few healthcare practitioners have the complete set of those competencies; therefore, they often need support and training from other professional staff. Librarians traditionally play important roles both in locating best evidence and in training others, and although new roles of libraries are emerging, it has been difficult to identify what activities they undertake to support clinical and health governance (C/HG) and how to evaluate their impact.
The aim of this paper is to research how librarians in different types of organisations are contributing to all components of C/HG with specific types of activities, where are the gaps that they can fill with new products and services, and also to identify common trends in library support for C/HG in Europe.
Our literature review retrieved no recent publications providing a broad picture of librarians’ value for all aspects of clinical and specifically health governance, though many professional papers are devoted to their involvement in such components as evidence-based practice (EBP), lifelong learning, risk management and other emerging roles (e.g. “Librarians Embedded in Ethics”, “Mining Data in Electronic Health Record Systems: Opportunities for Librarians”, “Research Information Management: Defining RIM and the Library’s Role” and “Isn’t it the right time for librarians to officially join clinical trial teams?”).
It is not always known or clear to stakeholders (including decision makers) what libraries and librarians can provide and where their services fit. Authors from the USA showed that though medical librarians “possess expertise to navigate various search resources and can investigate inquiries during health information system project lifecycles” they were not included in implementation and research teams (Saimbert et al., 2010). Research from Italy about hospital-based HTA stated that “the librarian is almost never represented within the HTA evaluation group” (Balduini et al., 2013). “Information professionals carry out many activities involved in mobilising research into practice but this is often not recognised” concluded recent research on public health decision making in the UK and Scotland (van der Graaf et al., 2018).
Libraries in healthcare organisations research and measure their impact on health services and patient outcomes to demonstrate how exactly they contribute to organisational objectives. The Rochester study (Marshall, 1992) was among the first to relate information services provided by librarians to patient care outcomes. Since then there was a large number of papers published on clinical librarian services within primary and secondary care, including systematic reviews and other evaluations (Klein et al., 1994; Weightman et al., 2005; Bryant and Gray, 2006; Sutton and Grant, 2010; Brettle et al., 2011; Marshall et al., 2014; Perrier et al., 2014).
The early systematic reviews found limited evidence of effectiveness and impact of clinical librarians, because of poor quality of reporting, scale and design of many studies though they showed that clinical librarian services were well used and liked by clinicians. The study (Brettle et al., 2011) concentrated on methods of clinical librarian service evaluations, and stated that the quality of studies was improving, but “more work is needed on reducing bias and providing evidence of specific impacts on patient care”. It concluded that “the Critical Incident Technique as part of a mixed method approach appears to offer a useful approach to demonstrating impact”.
A special attention was payed to developing tools to measure impact and value of library services (Urquhart and Turner, 2016; Urquhart and Tbaishat, 2016). Measures to show financial impact were: value of time saved, value of resource collection against cost of alternative sources, cost avoidance and revenue generated through assistance on grant submissions. “Few papers provided an insight into the longer term impact on the library service resulting from submitting return on investment (ROI) or other financial impact statements” (Madden et al., 2016). Recently, a generic tool to routinely measure the impact of health library services was developed and tested (Ayre et al., 2018).
Services provided by librarians in healthcare setting are complex interventions “made up of a number of elements and wide ranging potential outcomes which are affected by other factors within the organisation. An experimental design to ascertain their effectiveness and impact is inappropriate and would be compromised by a wide range of confounding variables”, that is why “demonstrating the direct impact of clinical librarian services on patient care is extremely difficult to prove, studies should determine if clinical librarians make a contribution to patient care rather than a direct impact” (Brettle et al., 2015).
The Critical Incident Technique (which asks for responses regarding a particular use of the library services), together with interviews and questionnaires showed “that clinical librarians contribute to a wide range of outcomes in the short and longer term and really do make a difference, in particular around direct contributions to choice of intervention (36%); diagnosis (26%); quality of life (25%), increased patient involvement in decision making (26%) and cost savings and risk management including avoiding tests, referrals, readmissions and reducing length of stay (28%)” (Brettle et al., 2015, 2016). They were able to prove that clinical librarians improve quality and help save money as well as affecting patient care directly.
Libraries are developing other ways of reporting impact, e.g., through case studies (prepared and published both by librarians and health services staff): knowledge management stories (https://tinyurl.com/y9lqu4xy); impact case studies (https://tinyurl.com/ydgbgydl); library impact – case studies (https://tinyurl.com/yd4r9e4k).
Librarians working in the variety of healthcare organisations increasingly need to justify their work and the very existence of their libraries, and research findings such as these are important, as are tools to evaluate impact. Still there are limitations to their practical implications. Types of interventions considered in library impact research are usually either very broad (literature search; literature search and critical appraisal; literature search and critical appraisal/synthesis of evidence; training; journal club) (Brettle et al., 2016), or are using more traditional categorisation based on library services (collections, research and publishing support services, personal services, teaching services and guidelines) (Halkoaho et al., 2018).
A more detailed list of library activity types related to specific components of C/HG could help all stakeholders to better understand how libraries can achieve impact shown in the previous studies, and encourage librarians from other countries to develop new products and services. Then evaluation tools can be developed to show short- and long-term impact of such activities. The survey research method was chosen to show how librarians are contributing to components of C/HG with specific types of activities and also to identify common trends in library support for C/HG in Europe. These findings will help decision makers on different levels of the health system to improve their practices by incorporating library functions and services in different components of C/HG.
In its broadest sense, clinical governance is an organisation-wide approach to continuous improvement of healthcare quality by all the individuals who are involved in a patient’s care. Usually, it is presented to comprise the following seven components: patient and public involvement, staffing and staff management, clinical effectiveness and research (EBP), using information and IT, education and training, risk management and audit. Based on literature search (PubMed, Google Scholar, EmeraldInsight, European Association of Health Information and libraries (EAHIL) conference abstracts and EAHIL journal) and job descriptions (available on the internet), a list of library activities types related to each component of clinical governance was constructed.
Governance in the health sector refers to a wide range of steering and rule-making-related functions carried out by governments and decision makers as they seek to achieve national health policy objectives. Health governance can be presented by its eight sub-functions (components): accountability, partnerships, formulating policy/strategic direction, generating information/intelligence, organisational adequacy/system design, participation and consensus, regulation, transparency. Each of these eight components has a related set of tools that are used to enable them. Certain library activity types that can be incorporated in support of those tools – this list was also constructed based on literature search and authors’ professional experience.
The initial list (74 types) was refined and extended by a focus group of experts (librarians and information specialists) in two rounds (first round – 26 types changed and 30 added, second round – 10 changed or added). The suggested model is presented as a four-column table (Table I). First column – clinical governance and health governance components. Second – examples of related clinical governance measures (Pearson, 2017) and examples of related health governance tools (Barbazza and Tello, 2014). Those were used to better understand the view of stakeholders on each component and to assign related types of library activities. Third column – related library activities types (111 types). Fourth column – established impact of library services (Brettle et al., 2016).
Based on this model, a web-based survey (SurveyPlanet) was offered through the mailing list to the European members of the EAHIL. Ethical research committee review was not required. The survey was anonymous, the two mandatory fields being the type of organisation and the target audiences (the country information was collected automatically). Participants (one for each organisation) were asked to mark all types of activities in which they (their library) are involved, and to provide examples of those. The survey was opened for four weeks (September 2018).
In total, 83 participants from 25 European countries completed the survey. About one-third of them provided examples of their activities in support of specific components.
The largest groups were from hospitals (31.1 per cent) and from medical libraries (14.3 per cent), others represented research institutes (10.7 per cent), university public health or medical library (10.7 per cent), university teaching hospitals (9.5 per cent), national ministry or health agency (8.3 per cent), freelance librarians (3.6 per cent), 10.7 per cent were from other types of organisations (mostly a combination of a research institute and a hospital).
By target audiences: the most frequently named groups were researchers (89 per cent) and physicians (83 per cent), then nurses (77 per cent), other hospital healthcare practitioners (77 per cent), and public health professionals (54 per cent), less participants stated providing services to non-hospital healthcare practitioners (40 per cent), patients and public (38 per cent), other health and non-health professional staff locally or internationally (36 per cent) and decision makers on all levels (30 per cent).
When asked about clinical governance (Figure 1), practically all the participants stated that they supported clinical effectiveness and research (98 per cent) and education and training (96 per cent); the majority supported patient and public involvement (84 per cent), staffing and staff management (72 per cent), using IT and information (77 per cent); less than a half were involved in risk management (38 per cent), and audit (32 per cent). Nearly half supported other aspects of clinical governance (48 per cent).
When asked about health governance (Figure 1): the majority stated support for partnerships (71 per cent) and for participation and consensus (60 per cent); half – for formulating policy/strategic direction (50 per cent) and for generating information/intelligence (52 per cent). Less than half provide support for transparency (47 per cent), organisational adequacy/system design (44 per cent), accountability (38 per cent) and regulation (21 per cent).
The highest number and the largest variety of library activities were reported for the libraries of National Health Agency/Health Ministry, medical libraries and the libraries of other type of organisations (mostly a combination of a research institute and a hospital) (Figure 2).
In this section, the survey results are analysed by library activity types related to each component of C/HG, the activity types with highest percentage for each component are highlighted, and some examples provided by respondents are included. The charts present percentage for each type of activity (using the numbering from Table I). (For full results, please contact authors).
Patient and public involvement
Those activities are targeted both at patients/public and healthcare practitioners: (1.9.) providing information literacy training to the community (49 per cent); (1.7.) providing training to practitioners on consumer information and health literacy (37.3 per cent); (1.2.) creating resource guides for/with patients/carers and practitioners (34.9 per cent). Very specific role is (1.8.) involvement/leading systematic assessment of organisation’s health literacy attributes (print and oral communication, navigation) (21.6 per cent).
Examples: “Development of a national health information portal with training courses for patient and families about reliable information sources”; “Delivering information to health professionals to help them answer queries on health products from the general public”; “Assist Health Professionals to find information in other languages suitable for non-English speaking immigrants/asylum seekers”; “Update the library website with links to online patient care association portals”; “Informational literacy courses ‘Reliable information – an important factor in patient empowerment’ are conducted for different patient groups or patient organizations”; “We help the patients who go to the library preparing posters to be taken to the ward, in the various fields of medicine, in Italian and downloaded from reliable medical sites”; “Involved in a multi-professional Team for planning patient education & empowerment activities – enhancing patients in proposing health topics to discuss in group with experts” (Figure 3).
Staffing and staff management
Though the majority stated involvement in staff development (63.8 per cent), the provided examples reveal that there are three different understandings of this component: mentoring, coaching and training of library staff; information literacy and similar types of training activities for health professionals; involvement in leadership and similar development programmes for health professionals (24 per cent) and providing information on those topics.
Examples: “Signposting to staff & leadership development opportunities for ENT specialists via regularly updated library-maintained notice board with conferences & courses as well as promotion via library blog/Twitter”; “Assisting staff on management courses with their research. Alerts bulletin for leadership and management staff”; “Supporting knowledge management techniques to improve conversations (randomised coffee trials, Lego Serious Play, knowledge cafes, fish bowl conversations), run training in techniques use of and facilitation; ‘Working with Practice Nurses to create training tables for key competencies’”.
Clinical effectiveness and research (EBP)
The survey results support what is known from literature: practically all libraries are involved in a great variety of activities in support of this component of CG.
They organise EBP resources:
(3.2.) decisions about subscriptions, negotiating license agreements (75.9 per cent); and
(3.3.) participating in library purchasing consortium (55.4 per cent).
They provide training:
(3.4.) in quality filtering, critical analysis of literature, searching techniques (75.9 per cent);
(3.15) on scholarly communication topics (54.2 per cent); and
(3.5.) develop database guides and instructions (65 per cent).
They support practice:
(3.7.) by search for evidence and clinical guidelines on which to base local protocols, guidelines and service recommendations (54.2 per cent); and
(3.8.) by involvement in hospital-based health technology assessments (15.6 per cent).
They organise preservation of locally produced knowledge and open access to locally produced content (45.7 per cent), and support clinicians and researchers in refining their CVs and public expertise profiles (54.2 per cent).
Examples: “Searching for evidence for NHS queries (for projects, publications, audits) and for clinicians updating guidelines”; “Producing library-branded evidence packages with citations and some select full text articles (as ILLs) for specific queries”; “Assisting NHS authors with evidence synthesis & summary by providing basic templates for preparing literature reviews based on refining their results against inclusion/exclusion criteria”; “Systematic searching for HTA, systematic reviews, education on how to search in databases”; “Provided the search and summary for both the national clinical strategy and the local clinical strategy”; “Training courses on how to search information for systematic reviews and guidelines”; “Help staff select where to publish and proof read articles for publication. Support ORCID registration” (Figure 4).
Using information and IT
Though the majority (77 per cent) support this component of CG, there are only 3 (of 14) types of activities that at least one-third of libraries are involved in:
(4.9.) building websites and other information and knowledge tools (48 per cent);
(4.8.) building repositories for data and information (36 per cent); and
(4.7.) coordinating/organising discovery systems with a single central index and search interface that allows searching across local library services, subscriptions collections and open access resources (27.7 per cent).
Other important role is involvement in data protection:
(4.1.) data protection/GDPR responsible for organisations (21.6 per cent); and
(4.6.) identifying, acquiring and promoting materials on data protection, copyright law, research ethics (26.5 per cent).
Much less are involved in planning and policy around information governance:
(4.2.) writing data management plans and being responsible for data repositories (16.8 per cent);
(4.3.) embedded in multidisciplinary teams in developing organisational policies around IT, information and data management (18 per cent);
(4.5.) implementation of national strategies around patient data, knowledge management, IT management (13.2 per cent); and
(4.4.) board and committee accountability around areas of information governance and ethics (4.4 per cent).
New activity for librarians is (4.14.) involvement/leadership in current research information systems (CRISs) adoption and management (13.2 per cent).
Examples: “Teaching doctors and health professionals to use new information technologies, collaborating with the IT department to find new ways for clinical information management”; “Library participates in all IT security programs in the country”; “Assisting and designing a data management plan using thesauri”; “Support the redesign of local intranet and roll out of Office 365, including support of skype training and provision of loanable equipment”; “Support for document best practice and metadata entry in cataloguing organisational documents”; “Some new apps [e.g. Browzine] would not be there if I did not inquire, install, promote and let everyone us it” (Figure 5).
Education and training (lifelong learning)
Libraries provide (5.9.) information literacy training (71 per cent); (5.8.) information skills teaching integrated in certain in-house training (51.8 per cent); they also develop and provide access to training resources: (5.1.) undertake staff information needs and behaviour assessments to develop appropriate and responsive services (51.8 per cent); access to onsite and internet-based health learning resources and creating systems for managing learning objects (38 per cent); develop e-learning modules (40.9 per cent); and support professional training and development: current awareness services for clinical staff and managers to keep up to date with developments in their fields (40.9 per cent); identifying, acquiring and promoting materials to support licensing, certification and recertification examinations (19.2 per cent); involvement in planning, development, design, evaluation of their institutions’ inter-professional education programmes (19.2 per cent); helping to establish and lead a journal club (12 per cent).
Examples: “Embedded in education team and deliver training to junior doctors as part of the curriculum”; “Researching the information behaviour of food scientists so we understand their needs supporting researchers in their bibliographic searches”; “E-learning allows us to teach bigger groups. The e-course lasts for 8 weeks. In the end of the course the doctors and nurses know how to use professional databases and how to search for the necessary information”; “Providing tools for clinicians to track activity in their own field” (Figure 6).
The highest number of respondents for this component stated literature search activity for patient safety initiatives, practice guidelines review and root cause analysis (25.3 per cent). Other types are less represented: participating in clinical activities (executive walk rounds, grand rounds, morning reports, institutional review boards and mortality and morbidity conferences) (8.4 per cent); involvement in co-producing patient education materials about safety (10.8 per cent); role in the research needed to ensure safe development of clinical trial protocols (8.4 per cent).
Examples: “I follow the publications in the databases dedicated to Risk Management and disseminate them to those responsible”; “Provide a range of literature search and summary services, and work closely with Clinical Governance colleagues to raise awareness of the support available for the creation and renewal of clinical guidelines, as well as providing support of the visualising of the same through our pathway publisher tools”; “Conducting health evidence searches to assist clinicians updating local guidelines and checking available literature for most recent guidelines for specific topics or lack of guidelines if appropriate” (Figure 7).
One-third of respondents (32 per cent) support this component: by assisting staff undertaking clinical audits to differentiate and refine types of research methodology and develop their critical appraisal skills (14.4 per cent); checking of claims made in literature or of material (patient, or promotional) (9.6 per cent); writing and undertaking evaluation of research projects (9.6 per cent).
Examples: “I participate in the creation of questionnaires for clinicians or nurses concerning the construction of measurement scales”; “Clinical audit formulation and retrieval of relevant guidelines/evidence”; “Support evidence search and appraisal skills for clinical audit team and people they refer for support. Support with audit dissemination through the Trust Expo event”; “Leading a chapter of external accreditation related to Patient centeredness” (Figure 8).
Other aspects of healthcare organisation governance
Librarians act as advisors on all aspects of information and knowledge matters (26.5 per cent) and provide background information for planning teams (10.4 per cent).
Examples: “Provides useful information on economic, financial and health management issues”; “I take pride in being able to provide the non-medical employees with information if needed. Our technical or building department might want to know de norm for the thickness of roof slabs or whatever. I will try my best to find it [and usually do]”; “Worked with planning and strategy teams at national, regional and local level to provide evidence for decision making”; “I am available for the participation and creation of limited projects to be submitted to the various company departments”; “The Library member of Emergency Committee”; “We provide a diagnostic tools and outcome measures catalogue, which lists any in use and their copyright status/or costs, we do add some other value e.g. links to articles about the tools and any educational material on their use” (Figure 9).
Library services connected to performance management tools and activities in healthcare: providing information on outcome measures and outcome harmonisation initiatives to decision makers (16.8 per cent); management of key performance measurement tools (26.5 per cent).
Most examples are about measuring and making visible research output of their organisations: “Manage Key Performance Indicator for peer-reviewed articles authored in-house”; “Managing the scholarly output of my organization, the impact measures and benchmarking indicators”; “Evaluation of the research quality of the Institute also with bibliometric indicators”.
Librarians are members of committees and other groups to enable partnerships and delivery of services (53 per cent); libraries are delivering new, innovative systems and tools to enhance library and information services (43.3 per cent) and act as a first point of call for advice (27.7 per cent).
Examples show partnerships with different types of libraries (“I am part of the Bibliosan system, the network of libraries of Italian biomedical research institutions”; “Taking part in Lithuanian Research Library Consortium. Close cooperation with the Association of Lithuanian Colleges’ Libraries”; “Participating in a community of medical libraries and a community with academic libraries. Being able to make use of the library systems of the university library in the same place”; “Practically act in collaboration with high schools and public libraries and universities for common projects evaluating the costs and benefits of the collaboration”; “Transforming local library services to work in a federated way, manage a partnership library with a university and staff from another Trust”) and with other types of organisations (“Collaborating with local Biobank on research project – systematic review”; “Member of multidisciplinary team on Learning Disability and provision of health information resources for this client group”; “Provide a copyright first responders service to advice librarians on copyright & licensing issues – work with the Copyright Licensing Agency & Library And Archive Copyright Alliance”; “Member of Cancer, member of Alzheimer group”) (Figure 10).
Formulating policy/strategic direction
Librarians support this component by responding to consultations and acting in advocacy capacity in library and information matters (36 per cent) and by working in partnership in developing strategies, national policies, guidelines, standards, manuals and protocols in library and information areas (30 per cent).
Examples: “Attending regional Clinical Librarian meetings for London/KSS as well as NHS/HE CPD networking events to develop standardised local and regional practices for LKS”; “Providing literature searches for national clinical guideline development; advice and assistance in developing guidelines for literature searching for guidelines” (Figure 11).
Libraries participate in this by developing tools for information and library services and other healthcare services (36 per cent) and by undertaking audits and reviews of library and information services and staff (21.6 per cent). On a smaller scale they are involved in the development of health technology assessments, clinical guidelines, health impact assessments, research reports and other projects’ reports on the regional and national levels (13.2 per cent), in assessments and audits of healthcare organisations (7.2 per cent).
Examples: “User surveys and impact forms as well as impact case studies from selection of users of the service to improve LKS offering for NHS staff”; “Creation of Health Education England Value & Impact Toolkit”; “Work on Terminology (in a committee related to the Minister of Health)” (Figure 12).
Organisational adequacy/system design
Libraries are involved in forward thinking of new developments and requirements (30 per cent); in developing organisations with continuous evaluation of existing services and future proofing services (12 per cent); provide support for peer-to-peer learning programmes for healthcare professionals (14.4 per cent). Examples: “Specifically in e-health we look at horizon scanning of the use of technology in health care”; “Participate in Trust’s forward thinking event”; “Involvement of Patient Library in developing a cancer patient rehabilitation program”.
Participation and consensus
The majority (56.6 per cent) stated active participation in library and information, as well as healthcare, meetings and approaches on a national level. Less are participating in development of consensus statements, standards, processes and strategies to improve healthcare (14.4 per cent) and collaborate with patients’ associations for developing indicators of surveys aiming to assess patients and citizens’ opinion about organisation of healthcare services (7.2 per cent). Examples: “Participation in an international working group for promoting information and initiatives in palliative care”, “Membership of national and regional groups at which new systems and services are presented and document delivery policy discussed”; “Attending NHS/HE collaborative events and discussion with external colleagues about up-to-date LKS service provision via surveys, working groups”.
This component of HG (includes development and implementation of rules, procedures, decrees, codes of conduct, performance standards, accreditation, licensing/certification) is supported by a 21 per cent of respondents by: providing information on available health literacy measures to decision makers (18 per cent) and publishing the Code of Ethics of Health Information Services open to patients and laypeople (6 per cent). Nobody stated involvement in statutory and regulatory activities. Examples: “Support MDT on learning disability with requirements re health literacy for this group of clients and also contribute to review of lay summaries of patient information for cancer clinical trials as PPI member and library/information professional”.
About half of respondents (47 per cent) support this: by publicising information on library and information services to different healthcare organisations, target audiences, other libraries (38.5 per cent), by acting as an independent service for patients and healthcare organisations without bias (20.4 per cent), by actively contributing to organisations’ internal procedures around transparency, making recommendations where improvements can be made (10.8 per cent), and by promoting the culture of communicating to patients results of their contribution (clinical trials, etc.) (7.2 per cent). As an additional type of activity one respondent suggested “Developing a system to aid transparency in research to avoid research waste”.
Examples: “Our mantra is ‘putting the patient first’. Through personal PPI activity promotes in partnership with researchers the feedback of lay summary results of clinical trials to research participants, their families and the wider interested public through open access publication”; “We use a variety of tools such as social media and communities of practice to engage with other organisations and services” (Figure 13).
No previous comparative research has been undertaken before examining the activities and tasks libraries undertake to support C/HG. Libraries in healthcare organisations provide services to a number of stakeholders, e.g., healthcare practitioners/specialists, patients and members of the public, researchers and decision makers. With responses from 25 European countries, we have identified C/HG components in which librarians are involved, with examples that the majority of libraries support clinical effectiveness and research, education and training, patient and public involvement, partnership engagement, participation and consensus, using IT and information, formulating strategic direction, generating information and intelligence, etc. Half or nearly half support other aspects of clinical governance, formulating policy/strategic direction. Many also support risk management, audit, transparency, organisational adequacy/system design, accountability and regulation. What is clear is that librarians in health and hospital libraries do not only provide services and products within the library environment, but have greater engagement and participation in wider activities of their organisations.
The variety of library activities can be grouped in three main groups:
infrastructure: development of library staff and resources as a basis for support of C/HG (e.g. negotiating license agreements for evidence-based information resources, developing standards in library services);
programme management: development of library products and delivering services in support of C/HG (e.g. online guides, horizon scanning bulletins; training on scholarly communication topics); and
direct participating in C/HG (e.g. involvement in community health needs assessment, in ethical committees, in design and facilitation of leadership development programmes, in clinical audits and HTA).
Importantly, our model and responses from European health and hospital librarians suggests that:
library and information staff are embedded in C/HG and should be recognised as experts in this role;
we can further develop and enhance the traditional library role to a significant knowledge governance core role of every health and hospital organisation;
therefore, formally recognise the librarian role as critical to C/HG; and
develop evaluation tools to measure such impact of the tasks that libraries undertake for C/HG.
We should then replicate these roles, tools and measurements across other libraries in healthcare organisations. By doing so, we can promote libraries and librarians as significant actors in organisational governance and enable libraries to develop these emerging roles more formally and reduce risks of closure or funding cuts. These findings will also help decision makers on different levels of the health system to improve their practices by incorporating library functions and services in different components of C/HG.
We recommend that further research and ongoing dialogue continues to cover the roles of libraries in all European countries via EAHIL, and the rest of the world in collaboration with other library and information associations and membership bodies.
Components of clinical and health governance and related types of library activities
|Clinical governance components||Related clinical governance measures||Related library activity types||Related library services impact measures|
|1. Patient and public involvement||Safeguarding vulnerable patients
Continuous improvement in friends and family test scores
Continuous improvement of patient reported experience measures
Continuous improvement in complaint response times
Education and learning from complaints and compliments
|1.1. Undertaking patient information needs assessments to understand further information needs in specific health areas
1.2. Creating resource guides for/with patients/carers and practitioners
1.3. Finding and providing patient education materials to reinforce the verbal explanations and instructions
1.4. Involvement in adapting and designing patient education materials
1.5. Sometimes be first contact for a patient seeking information (“making every contact count” – MECC)
1.6. Redirecting certain groups of patients/public to better sources of information, providing contact to get information from other sources and organisations
1.7. Training practitioners on consumer information and health literacy (understanding the needs of health literacy-challenged patients, screening for health literacy, awareness of consumer health resources and demonstrating communication strategies to use in practice including plain language and active listening)
1.8. Involvement/leading systematic assessment of organisation’s health literacy attributes (print and oral communication, navigation, etc.)
1.9. Information literacy training to the community (including how to find the most credible and reliable health and scientific information)
1.10. Involving patients and carers in practical peer training on how to find the most credible and reliable health information (peer-to-peer training)
1.11. Coordinating institutional multi-professional group (healthcare workers, patients and patients’ representatives) for planning patient education activities in a participative way
1.12. Organising narrative opportunities to enhance patients and carers telling their experience (e.g. literary competitions)
1.13. Enhancing patients’ feedback in implementing patient centred projects
1.14. Development, validation and promotion of tools for evaluating health information for consumers (transparency, understandability, clarity, etc.)
|Increased patient involvement/shared decision making
Improved patient care experience
Improved patient access to information
Advice to patient or carer
|2. Staffing and staff management||Achieving mandatory training targets
Reducing lost time and staff sickness due to stress
Recruitment, induction and retention KPIs
Talent mapping, coaching, mentorship and leadership development
|2.1. Involvement in staff development
2.2. Involvement in leadership development programmes (design and facilitation)
|Supervision and leadership of staff|
|3. Clinical effectiveness and research (evidence-based practice)||Improving mortality data and reducing HCAI
Improving clinical outcomes and PROMs
Improving published research
Teams using patient feedback to improve services
Continuous improvement in timed treatment pathway targets
Clinical benchmarking and peer-review of service performance
|3.1. Developing systems to acquire, organise and disseminate essential clinical information resources
3.2. Making decisions/suggestions about subscriptions, negotiating license agreements for evidence-based information resources for the organisation
3.3. Participating in library purchasing consortium
3.4. Training in quality filtering, critical analysis of literature and targeted searching techniques
3.5. Developing database guides and instructions (written, video)
3.6. Embedding knowledge of clinical evidence by attending clinical forums/consultations or supervisions/continuing professional development sessions to produce evidence summaries specific to individual patients, wider clinical problems or managerial work streams
3.7. Search for evidence and clinical guidelines on which to base local protocols, guidelines and service recommendations
3.8. Involvement in hospital-based health technology assessments
3.9. Pre-packaging information
3.10. Undertaking research around evidence-based working methods (e.g. evidence hierarchies, critical appraisal tools, literature search protocols)
3.11. Supporting the research chain within organisations
3.12. Developing search strategies for organisations
3.13. Contributing to preparing grant applications
3.14. Supporting individuals undertaking research by assisting them to differentiate and refine types of research methodology and development, to be aware of research reporting guidelines, to use and refine their critical appraisal skills to locate appropriate clinical literature
3.15. Training, online guides, individual support on scholarly communications topics (reference management tools, linking profiles with unique identifiers like ORCID, to use and understand impact indicators, comply with institutional/national open access policies, understand publishers’ licenses and creative commons)
3.16. Assisting individuals with registering and publishing their research (publishing of research protocols in various new kinds of journals and registers, publishing preprints, selecting journal for publishing)
3.17. Discovery and preservation of locally produced knowledge (e.g. collecting and distributing staff publications), organising open access to locally produced content
3.18. Supporting clinicians and researchers in refining their CVs and public expertise profiles (biblio and altmetrics, ORCID identifies, etc.)
|Interventions based on best practice or current evidence
Implementing clinical guidelines
Improved quality of care
Meet quality standards
Choice of assessment or test
Choice of intervention
Service development or delivery underpinned by evidence base
Revision of care pathway, guidelines, protocol
Avoidance of referral, readmission, clinical tests or hospitalisation
Reduce length of stay
Improved healthcare outcomes
Improved quality of life for patient or carers
Address inequalities in access to care or unmet service need
Support QIPP plans (quality, innovation, productivity and prevention)
Commissioning/decommissioning of services
|4. Using information and IT||Adhering to information governance requirements
Continuously reducing episodes of harm using electronic records and prescribing
Personalisation of recorded care plans
Shared electronic record reducing duplication
Clinically determined meaningful data used in dashboard KPIs
|4.1. Data protection/GDPR responsible for organisations
4.2. Writing data management plans and being responsible for data repositories
4.3. Embedded in multidisciplinary teams in developing organisational policies around IT, information and data management
4.4. Board and committee accountability around areas of information governance and ethics
4.5. Involvement in implementation of national strategies around patient data, knowledge management, IT management, etc.
4.6. Identifying, acquiring and promoting materials on data protection, copyright law, research ethics
4.7. Coordinating/organising discovery systems with a single central index and search interface that allows searching across local library services, subscriptions collections and open access resources
4.8. Building repositories for data and information
4.9. Building websites and other information and knowledge tools
4.10. Data analysts and data wranglers
4.11. Involvement in data modelling and statistical work
4.12. Embedded in project management and health information system lifecycle teams
4.13. Assisting with integration of evidence-based resources into electronic patient record and hospital information systems
4.14. Involvement/leadership in research information management (RIM)/current research information systems (CRISs) adoption and management
|Reduction of complaints
Improved patient safety
|5. Education and training (lifelong learning)||Education and learning from clinical incidents
All staff completing personal and development plans
Health Education England local quality visit reports
Appraisal objectives meet competency framework or curriculum needs
Completed regular appraisal/performance review for all staff
|5.1. Undertaking staff information needs and behaviour assessments to develop appropriate and responsive services
5.2. Working closely with clinical teams in developing information collections and training modules
5.3. Current awareness services for clinical staff and managers to keep up to date with developments in their fields (contents page service; alerts of updates on key government websites, limited selective dissemination of information service)
5.4. Horizon scanning bulletins
5.5. Providing access to onsite and internet-based health learning resources and creating systems for managing learning objects (including institutional OA repositories)
5.6. Identifying, acquiring and promoting materials to support licensing, certification and recertification examinations
5.7. Developing e-learning modules
5.8. Information skills teaching integrated in certain in-house training
5.9. Information literacy training
5.10. Supporting an evidence-based culture with focus on staff professional development
5.11. Helping to establish and lead a journal club
5.12. Managing educational centres
5.13. Involvement in planning, development, design, evaluation of their institutions’ inter-professional education programmes
|Updated knowledge and skills relevant to professional tasks
Compliance with requirements of regulatory and professional bodies
Gain of qualifications
Delivering/supporting education/training of staff
|6. Risk management||Transparent reporting culture and regularly updated risk register
Risks are anticipated and mitigated across the patient pathway
Completed and actioned quality impact assessments
Continuous reduction in risk register scores
Service development, innovation and transformation at pace and scale
|6.1. Involvement in writing organisational risk management plans and anticipating risks and mitigation
6.2. Participating in clinical activities (executive walk rounds, grand rounds, morning reports, institutional review boards and mortality and morbidity conferences)
6.3. Literature search activity for patient safety initiatives, practice guidelines review and root cause analysis
6.4. Involvement in co-producing patient education materials about safety, hands hygiene, infections prevention
6.5. Role in the research needed to ensure safe development of clinical trial protocols
|Safer care environments
Reduction of complaints
Improved patient and staff safety
Improved accountability/transparency of services
|7. Audit||Closed audit cycles improving patient safety, patient outcomes, patient experience measures
Evidence of closed audit cycles
Re-audit of adopted changes in practice
|7.1. Assisting staff undertaking clinical audits to differentiate and refine types of research methodology and development, use and refine their critical appraisal skills to locate appropriate clinical literature
7.2. Involvement in data and information audits of organisations (e.g. clinical trials)
7.3. Checking of claims made in literature or of material (patient, or promotional)
7.4. Writing and undertaking evaluation of research projects
7.5. Being involved as leader of a specific chapter/section of external accreditation
7.6. Managing patients and public involvement in self-assessment phase of external accreditation
|Evaluation or audit|
|8. Other aspects of healthcare organisation governance||8.1. Providing background information for planning teams
8.2. Supporting disaster preparedness and emergency response programmes within the organisation
8.3. Act as an advisor on all aspects of information and knowledge matters
8.4. Member of internal ethical committee
|Support organisational financial strategies (e.g. cost improvement programme)
Demonstrate value for money/providing cost-effective service
Business development (e.g., income generation, tenders)
|Health governance components||Related tools||Related library activity types|
|9. Accountability||Performance-based contracts
Fair competitive elections, systems of judicial redress, procedures to combat corruption
Performance measurement tools and activities
|9.1. Providing information on outcome measures, outcome harmonisation initiatives to decision makers
9.2. Management of key performance measurement tools (e.g. for measuring the research output of an organisation)
|10. Partnerships||Inter-ministerial and interdepartmental committees
Public-private task force
Integrated budgets and accounting, co-funding arrangements or earmarked grants
Cross-cutting information education systems
Common workforce training, qualifications, support and advice
Ad hoc, initiative-specific committees
|10.1. Member of committees and other groups to enable partnerships and delivery of services
10.2. Writing funding bids and managing grants
10.3. Delivering new, innovative systems and tools to enhance library and information services
10.4. Acting as first point of call for advice
10.5. Establishing and promoting high-impact, multi-sectoral partnerships and collaboration
10.6. Support for cross-cutting information education systems
|11. Formulating policy/strategic direction||National health plan
National targets, goals and performance measures
Multi-year strategic plan
Policies, operational guidelines, training manuals, protocols
Medium-term expenditure frameworks and national health accounts
Targets-and priority-setting techniques (e.g. WHO-CHOICE)
|11.1 Responding to consultations and act in advocacy capacity in library and information matters
11.2. Working in partnership in developing strategies, national policies, guidelines, standards, manuals and protocols in library and information areas
11.3. Involvement in developing national strategies around patient data, knowledge management, IT management
11.4. Involvement in localising and tailoring research evidence to make it useful and usable for local decision makers (e.g. local commissioning and planning processes for public health interventions)
11.5. Involvement in developing national strategies behind staff development and recruitment
11.6. Support for developing national healthcare policies, operational guidelines, training manuals and protocols
|12. Generating information/intelligence||Commission reports by independent researchers
Inter-ministerial fact-finding commissions or task force, parliamentary investigations
Periodic audits, public expenditure and performance reviews
Health technology assessments
Internationally recognised tools for conducting a situation analysis (e.g. HMNb Health Information Systems Situation Assessment Tool)
Health impact assessment
Environmental impact assessment; geographic information systems, or health needs assessment
Patient reported outcome measures (PROMs)
|12.1. Undertaking audits and reviews of library and information services and staff (are they fit for purpose, impact on population health, impact on staff development, and impact on organisations)
12.2. Involvement in assessments and audits of healthcare organisations
12.3. Developing tools for information and library services and other healthcare services
12.4. Involvement in the development of health technology assessments, clinical guidelines, health impact assessments, research reports and other projects’ reports on the regional and national levels
12.5. Co-leading projects where PROMs are implemented
12.6. Development, validation and promotion of tools for evaluating health information for consumers (e.g. ETHIC – Evaluation Tool of Health Information for Consumers)
12.7. Validating tools in different languages to assess heath literacy level of patients (the use of the same cross-cultural tools, validated in different languages, is essential for implementing multicenter studies to measure and compare the functional HL levels across countries)
12.8. Involvement in community health needs assessment
|13. Organisational adequacy/system design||Implementation or annual operational plan
Monitoring and evaluation plan
Mission/vision statement, organisational chart
On-the-spot training measures
Peer-to-peer learning programmes
|13.1. Fundamental involvement in developing organisations with continuous evaluation of existing services and future proofing services
13.2. Forward thinking of new developments and requirements
13.3. Support for peer-to-peer learning programmes for healthcare professionals
|14. Participation and consensus||Open meetings, public workshops, national forums, citizen advisory committees, citizen juries
National health forums
Formal consultations in drafting legislation
|14.1. Active participation in library and information, as well as healthcare, meetings and approaches on a national level
14.2. Participating in development of consensus statements, standards, processes and strategies to improve healthcare
14.3. Active collaboration with patients’ associations for developing indicators of surveys aiming to assess patients and citizens’ opinion about organisation of healthcare services
|15. Regulation||Rules, procedures, decrees
Codes of conduct
Performance standards, accreditation, licensing/certification
Statutory bodies (e.g. national regulatory agency)
“Hard laws” (binding legislation); “soft laws” (non-binding recommendations)
|15.1. Involvement in statutory and regulatory activities, e.g., checking of medical claims
15.2. Publishing the Code of Ethics of Health Information Services open to patients and laypeople
15.3. Providing information on available health literacy measures to decision makers
|16. Transparency||Watch dog committees (facility boards, health authority, ombudsman, parliamentary committees)
Releasing performance information to providers and the public
Inspectorates, fact finding commissions
Publically available budgetary and financial information
Citizen report cards
|16.1. Acting as an independent service for patients and healthcare organisations without bias
16.2. Publicising information on library and information services to different healthcare organisations, target audiences, other libraries
16.3. Actively contributing to organisations’ internal procedures around transparency, making recommendations where improvements can be made, e.g., publishing results of research, making data open access, informing senior management where procedures are inadequate or services not comprehensive
16.4. Promoting the culture of communicating to patients results of their contribution (clinical trials, etc.)
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The authors are grateful to the focus group members who gave so generously their time: Luc Hourlay, Ivana Truccolo, Maria Garcia-Puente, Štefica Dodig, Lovela Machala Poplašen, Frank Norman.