Clinicians Impression of Clinical Governance

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Clinicians Impression of Clinical Governance

• Dr Emma Glanville
• Consultant Psychiatrist
• Mental Health ACT.

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Clinical governance background

• High profile problems in health.
• Increasing emphasis.
• Structures evolving.
• Evidence base evolving.
• Local context.

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Barriers 1. Health is different.

• Business as usual after a major incident.
• Person injured is patient rather than staff.
• Death and disease is normal.
• Negative consequences (eg coroners case,
  litigation) occur sporadically, inconsistently
  a long time after the event.
• Lack of perceived benefits.

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Barriers 2. Psychiatry is different?

• Not as different as we like to think.
• Clear differences between wrong site surgery.
• But many parallels with other problems eg type II
  diabetes.

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Barriers3. No blame culture?

• Our culture is a blame culture.
• In the aftermath of such a disaster there must
  be an assignment of blame.
• Runciman 2003
• Medicine is a blame culture.
• Finding a balance between fatalism persecuting
  scapegoats.

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Barriers 4. Issue of evidence

• No sound evidence currently exists to support
  the claim that clinical governance will improve
  service quality
• (Thomas M 2002)

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Barriers4. The issue of evidence

• audit and feedback can be effective in
  improving clinical practice. When it is
  effective the effects are generally small to
  moderate. The relative effectiveness is likely
  to be greater when baseline adherence to
  recommended practice is low and when feedback is
  delivered more intensively.
• Cochrane Collaboration 2008.

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Barriers4. The issue of evidence

• As the natural heterogeneity of an intervention
  increases, experimental methods become
  progressively less helpful in understanding its
  effectiveness.
• Walshe 2007.
• Heterogeneous evolving activities in
  heterogeneous organisations in heterogeneous
  populations there will never be the definitive
  study.

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Barriers5. Managers vs clinicians?

• clinical governance committees provide a
  theatrical function, reassuring the board that
  all is well while allowing business as usual at
  lower levels within the organisation.
• Freeman 2004

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My project - Aims

• Focuses on clinicians and their opinions of our
  clinical review process for serious adverse
  incidents eg suicides, serious self harm,
  serious assaults (incl sexual assaults).
• Clinical review process aims to identify systems
  issues (rather than performance management
  issues).

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Incident
CRC discussion
Rating
Report
Investigation
Findings Recommendations
Feedback
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My project aims

• My aim is to investigate what clinicians feel
  about this process
• -is it worth putting in an incident report?
• -how do they experience the investigation?
• -what do they think of our findings
  recommendations?
• -do they think we make a difference?
• -how could they be more involved?

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My project further aims

• Better understanding of evidence around
  governance.
• Better understanding of research process
  particularly qualitative research.
• Better understanding of staff responses when
  things go wrong.
• Learning to provide leadership in clinical
  governance.

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Methods

• Interview with CATT clinicians.
• Questions around
• -their knowledge of CRC.
• -their experience of CRC processes.
• -their thoughts on our recommendations.
• -suggestions re learning about adverse events.
• Taped.

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Data Analysis

• Themes analysis conducted independently by two
  researchers.
• Key words and concepts.

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Where am I up to?

• Support from clinical director of service.
• Support from team leader and psychiatrist on
  CATT.
• Literature review.
• Questions designed.
• Ethics approval.

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Questions?