CLINICAL GOVERNANCE

CLINICAL GOVERNANCE M S Arul Inban Carmarthenshire VTS HDR 3 May 2005

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.

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.

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.

What are the elements of clinical governance?

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to abstain from continuing education after qualification because too much of what is learnt during training becomes outdated too quickly.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)

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.

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.

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

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.

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 > at the Right Time > to the Right People

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.

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

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.

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.

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

CHIEF EXECUTIVE (Accountable Officer) TRUST BOARD CLINICAL GOVERNANCE COMMITTEE CLINICAL GOVERNANCE FORUM DIRECTORATE MULTIDISCLINARY CLINICAL GOVERNANCE TEAMS

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

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.

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

THANK YOU (means ‘THANK YOU’ in ‘Wingdings’ font language)

CLINICAL GOVERNANCE