CLINICAL GOVERNANCE

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CLINICAL GOVERNANCE

• M S Arul Inban
• Carmarthenshire VTS HDR
• 3 May 2005

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What is clinical governance?

• Clinical governance is a system for improving the
  standard of clinical practice.
• Clinical governance was first described in a
  government White Paper on health in 1997 as a
  new system in NHS Trusts and primary care to
  ensure that clinical standards are met, and that
  processes are in place to ensure continuous
  improvement, backed by a new statutory duty for
  quality in NHS Trusts.
• Clinical governance is a powerful, new and
  comprehensive mechanism for ensuring that high
  standards of clinical care are maintained
  throughout the NHS and the quality of service is
  continuously improved.

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DEFINITION of clinical governance?

• Clinical governance is the system 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 clinical
  excellence will flourish.
• It is a framework to describe activities in NHS
  which aim to improve or maintain the quality of
  patient care.
• It is also a vehicle for delivery of uniform and
  quality clinical care throughout the country.

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Why, clinical governance?

• Alleged decline and disparity in standards and
  quality of health care provision.
• Series of publicised lapses in quality of health
  care prompted doubts in the minds of patients and
  public about the overall standards of care they
  may receive.
• Increase in number of complaints.
• Increased public awareness of health care
  provision.
• Increased patients and carers expectations and
  demands from the health care system.
• Patients have the right to quality health care.
• Public / Govt. have responsibility to ensure
  quality health care.
• It is an agenda of modernising NHS.
• Financial issues might have priority over Quality
  in health care system.

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What are the elements of

• clinical governance?

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Education and Training

• In the modern health service, it is no longer
  acceptable for any clinician to abstain from
  continuing education after qualification because
  too much of what is learnt during training
  becomes outdated too quickly.
• Continuing Professional Development has become a
  professional requirement for all health care
  professionals.
• It is the responsibility of the employer and the
  relevant professional body to ensure that the
  health care professionals are up-to-date.
• Different systems have emerged to support CPD.
• Postgraduate Education Allowance (PGEA) for
  GPs
• CPD programmes for hospital doctors
• Post Registration Education and Practice
  (PREP) for nurses
• Trained educators to support such
  approaches (e.g. GP tutors)

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Clinical Audit

• Clinical audit is the the refining of clinical
  practice by review of clinical performance.
• It involves the measurement of performance
  against agreed standards.
• A cyclical process of improving the quality of
  clinical care.
• Audit has been part of good clinical practice for
  generations.
• Participation in audit has been a requirement of
  NHS trust employees,
• including doctors, and protected time has
  been provided.
• It is facilitated by trained staff and committees
  in NHS trusts, and through Medical Audit Advisory
  Groups (MAAGs) in primary care.
• Medical audit has moved to become Clinical Audit,
  as it involves all members of the clinical team,
  at all levels.
• With all its previous experience and history of
  audit activity, it becomes an effective
  contributor to quality improvement in the
  clinical governance framework
• Management cost pressures have made it difficult
  to sustain a comprehensive programme of clinical
  audit activity, particularly in primary care
  where audit has not been underpinned by
  contractual arrangements.

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Research and development

• Good professional practice can be possible only
  in the light of evidence from research.
• The development of research practices and
  research networks in primary care, along with the
  national research and development programmes is
  essential.
• Guidelines, Protocols and Implementation
  Strategies and all other similar tools for
  promoting quality of health care can be possible
  only through research evidence.
• Quality of care can only be assured through
  Evidence Based Medicine.
• R D is the backbone of Evidence Based Medicine.
• Promoting research in the operational practice of
  Clinical Governance should be an agreed national
  priority.
• However, Funding is always an issue.

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• Research
• Attempts to define best practice
• Usually involves testing hypothesis or
  experimenting new methods
• May involve intrusion beyond normal clinical
  activity
• Ethical Committee approval Patients Consent is
  a must
• Involves allocating patients randomly ( treatment
  / placebo)
• May involve collaboration with manufacturers

• Audit
• Attempts to find whether best practice exists
  locally
• Usually involves setting standards (never
  involves hypothesis or experimenting)
• Does not involve intrusion beyond
  normalclinicalactivity
• EC approval Patients Consent is needed when
  the public involved directly
• Involves selecting a rep. Sample (but not
  allocating patients randomly in groups)
• May involve collaboration with patients

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clinical effectiveness

• In patients who have had a total hip replacement,
  the use of low molecular weight heparins as
  thromboprophylaxis, in comparison with standard
  heparins,
• resulted in a reduction of total deep vein
  thrombosis (DVT) from 149 of 685 patients (22)
  to 117 of 735 patients (16) and of proximal DVT
  from 86 of 685 patients (13) to 40 of 735 (5)
  patients.
• Therefore,in order to prevent one episode of
  proximal DVT, 14 patients would need to be
  treated with low molecular weight heparin instead
  of standard heparin.

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clinical effectiveness

• Research Development to ensure improvements to
  patient care
• Guidelines to reduce unwanted variations in
  practice
• Education to ensure practitioners know what best
  practice is
• Clinical Audit to ensure best practice is taking
  place locally
• Outcome measurement to ensure we are achieving
  best practice
• Cost Effectiveness to ensure value for money
• To put it simply, it is about, Doing
• the Right Thing gt at the Right Time gt to the
  Right People

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Risk management

• Providing health care is a risky business
• Risks are associated with everything we do
• Risks may arise from environment, procedures,
  interventions, treatment and so on
• Risks can be to
• the patient
• the health care
  staff
• the health care
  provider organisation
• Risk management is about delivering care safely
• It aims to develop good practice and reduce the
  likelihood of harmful incidents occurring
• all risks need to be minimised as part of any
  quality assurance programme.

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• Reporting incidents, accidents and near misses
• When an incident or accident is reported, it
  should be investigated so that the situation can
  be put right and lessons can be learned to
  prevent recurrence.
• Risk Assessment
• As part of a continuous process all staff
  should be involved in identifying potential
  hazards to patients and themselves.
• Risk prevention strategies can then be
  employed to reduce the chance of any kind of
  harm.
• Complaints
• Each complaint must be investigated using a
  standard policy for managing complaints and
  action taken.
• A number of complaints about the same issue
  may point to the need for change in practice to
  avoid further recurrence.
• Other issues
• immunisation of staff
• cleaner environment
• hand washing
• and so
  on

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Openness

• Poor performance and poor practice can too often
  thrive behind closed doors.
• All processes which are open to public scrutiny,
  while respecting individual patient and
  practitioner confidentiality, and which can be
  justified openly, are an essential part of
  quality assurance.
• Open proceedings and discussions about clinical
  governance issues can be effective only in a
  blame free culture and environment
• The aim should be improving quality, not finding
  a victim to take the blame.

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Patient Experience

• The customer (patients and users of health care)
  can provide valuable feedback on the quality of
  service they receive.
• It is important to take their views into account
  when monitoring existing services and when
  developing new ones.
• As a result National Patient and User Surveys are
  being developed.

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Workforce Issues

• Staff should be appropriately qualified to do
  their job.
• Professional Registration should be up-to-date.
• All staff should have Personal Development Plan
  and be supported in their learning needs.
• Appraisal systems should be in place to enable
  feedback of performance and areas for
  improvement.
• Good quality and up-to-date documentation and
  information are essential for providing good
  quality service.
• Record keeping is important for continuity of
  patient care and communication.
• Good Communication Skills vital to all staff at
  all levels

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CHIEF EXECUTIVE (Accountable Officer)
 
TRUST BOARD
CLINICAL GOVERNANCE COMMITTEE
CLINICAL GOVERNANCE FORUM
DIRECTORATE MULTIDISCLINARY CLINICAL GOVERNANCE
TEAMS
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• CHI Commission for Health Improvement
• inspects NHS hospitals to ensure Clinical
  Governance activities are in place and are
  effective
• NICE National Institute for Clinical Excellence
• provide national standards of clinical care
  against which clinical practice can be measured
• NSF National Service Frame Work
• guidance document that outlines how health
  care for a specific disease or condition can best
  be provided

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• The system of clinical governance brings together
  all the elements which seek to promote quality of
  health care.
• The challenge to those (we) responsible should
  not be underestimated.
• We need to understand the cultures and
  sensitivities involved to help health care
  professionals to review and justify their
  performance.
• Many clinicians are still apprehensive about
  clinical governance and feel the changes involved
  could be an unnecessary intrusion.

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All the activities of CLININICAL GOVERNANCE
areonly in the BEST INTERESTS of HEALTH CARE
PROFESSIONALS and their PATIENTS
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THANK YOU

• (means THANK YOU in Wingdings font language)