Evans, S. (2004), "An inspector calls ... the practical reality of clinical governance", International Journal of Health Care Quality Assurance, Vol. 17 No. 5. https://doi.org/10.1108/ijhcqa.2004.06217eaa.001
Emerald Group Publishing Limited
Copyright © 2004, Emerald Group Publishing Limited
An inspector calls ... the practical reality of clinical governance
An inspector calls . . . the practical reality of clinical governance
Formed by legislation in the UK that became the Health and Social Care Act 2003, the Health Care Commission came into being on 1 April 2004 to promote improvement in the quality of National Health Service (NHS), private and voluntary healthcare across England and Wales. It aims to do this by becoming an authoritative and trusted source of information and by ensuring this information is used to drive improvement. It seems it will be the inspector of clinical governance.
Clinical governance has been a political reality since 1997. But what does clinical governance mean to the public, to patients or to clinical staff? Asked to define clinical governance or to give practical examples of its application, these groups are unlikely to respond authoritatively. At the very least there has been a communications failure. Both public and health professionals are vague in their understanding of the concept. More seriously, seven years after its formal introduction, aspects of clinical governance still cannot be measurably demonstrated at the vital interface between patient and practitioner. If the new Health Commission is true to its stated intent, it will be inspecting and subsequently driving improvement at this interface as a matter of priority. This is not to say there is poor delivery of clinical governance on the “frontline”, rather, there is no nationally agreed way of determining and objectively measuring the delivery of the clinical governance principles at patient/practitioner level.
Implementation of clinical governance has remained somewhat ethereal, a management, rather than clinical objective, oddly uninspiring to clinical staff and a mystery to the patients who are the direct beneficiaries. As an early priority, the new Health Commission should be driving to make the principles, practice and benefits of good clinical governance a tangible, physical reality of the patient and practitioner relationship.
Clinical governance is defined by the Department of Health (1998) as:
A framework through which NHS organisations 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.
The Health Service Circular, Clinical Governance: Quality in the New NHS (Department of Health, 1999) describes four main elements to clinical governance:
Clear lines of responsibility and accountability for the overall quality of clinical care.
Clear policies aimed at managing risks.
Procedures for all professional groups to identify and remedy poor performance.
A comprehensive programme of quality improvement activities.
These principles apply to everyone engaged in the delivery of healthcare.
It is probably fair to say that most healthcare providers are tackling the first two in a structured way. The third and fourth elements however, demand attention.
Ultimately, staff deliver the quality of care. However, to deliver care in a structured, resource-bounded and consistent way they must understand the “quality” required and be able to define it in unambiguous terms. They must also have the means to show objective evidence of effective delivery to the required parameters. More to the point, they should have personally-felt reasons to do this. Altruism is an ever more dilute ingredient of the quality mix and is not supplied in common concentration throughout healthcare. Staff should want to show they have delivered. This desire to show good work seems to be slipping away in today’s healthcare environment and is noticeably missing from the current approach to clinical governance – too often management-led clinical governance has the sense of being a policing process, checking-up on the professionals, rather than drawing out their innate professionalism and encouraging them to prove their value, effectiveness and skill.
Thus staff need straightforward but powerful tools first, to define the clinical delivery requirement in clear and precise language. Once the requirement is understood (universally, across all healthcare providers using the same tools), staff need the means to document their activity in pursuit of these requirements, including their direct contribution to the continuous improvement of clinical services. They need to be able to do this is an efficient and non-bureaucratic manner and they need to feel that the evidence documented majors on the quality of their care and not on the quantity of work they have delivered. It is currently very difficult for clinical staff to do this and still more difficult for patients and the public to access such evidence as does exist.
With the arrival of an inspector of clinical governance and with all that implies, it is now essential that dedicated technical systems be developed for use by clinical staff to define and thereafter assure the quality of care, to test the delivery of healthcare objectively, to record what occurs and to provide evidence that clinical activity is justified, effective and worthwhile – from the patient’s perspective. It is argued here that such systems should be primarily operated by the staff at the patient interface (ranging through the most junior to the most senior clinical tiers) and only secondarily by their managers. Dedicated systems for doing this are just beginning to appear. These should not be confused with long-standing tools designed to show performance against targets – not the same thing at all!
It is suggested that the focus of clinical governance needs to shift. Presently it centres on the clinically safe and cost-effective delivery of targets. Clinical staff would be pleased to see it focus on documenting their ability to deliver good care, safely, efficiently and effectively in the best interests of their patients and of the healthcare service as a whole. This need not clash with the business objectives of healthcare providers or the political prerogatives of government. These over-arching parameters provide the structure and resource-boundaries mentioned above. They give the delivery of good clinical governance its context.
Professor Aidan Halligan as director of clinical governance for the NHS and head of the Clinical Governance Support Team (CGST) described clinical governance thus:
… patient-centred care that is accountable in giving safe, high quality service in an open and questioning environment. Fundamentally, clinical governance is a cultural shift, and the challenge is to do something right and to do it right now (Halligan, 2001).
In Halligan’s (2001) view, clinical governance is intended to (“… empower highly motivated, highly skilled frontline staff to deliver a high quality service”.
The question remains: “What is in it for them?”. Unless clinical governance serves the professional and patient agenda first it will remain a management tool and not achieve its great potential. Fortunately staff will soon have the means to show they can deliver according to the best principles of clinical governance. New tools are appearing designed exclusively for this purpose and entirely consistent with the remit of the Health Commission. They are for the use of staff and will help to demonstrate to all interested parties (not least the patient) that good care is being delivered in a regulated and resource-constrained environment. It falls to healthcare providers to provide clinical staff with these tools and the freedom and flexibility to do the job.
Stephen EvansChief Executive, CIRIS Healthcare, Woodbridge, UK
About the Guest Editor
Stephen Evans is the Chief Executive of a Cambridge-based company which develops systems for regulation and continuous improvement in healthcare. A radiographer by profession, Stephen worked in many and varied clinical roles both in the UK and abroad, commencing 1973 and continuing in clinical practice until taking a director’s role at Ipswich Hospital in the early 1990s. From 1995 to 2000 he was General Secretary and Chief Executive of the Society and the College of Radiographers.
Department of Health (1998), A First-Class Service Quality in the New NHS Services, Circular 1998/113, Department of Health, London
Department of Health (1999), Clinical Governance: Quality in the New NHS, HSC 1999/065, Department of Health, London
Halligan, A. (2001), “Right here, right now”, NHS Magazine, 6 July