"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 can flourish" (1)
The term Clinical Governance (CG) was first introduced by the Labour government and underpinned by a statutory duty of quality set out in the Health Act 1999.The new government established for the first time a national framework, within which the NHS at a local level, can work towards realising consistent and systematic improvements in the quality of patient of care. Clinical Governance places a clear responsibility upon NHS organisations for the delivery and continuous improvement of patient care. In practice this means implementing principles that will result in a high quality of care for patients by a highly motivated and qualified workforce. The introduction of the contractual framework of community pharmacy in April 2005 laid out specific requirements for CG consisting of principles which were to be integrated into each pharmacy by a nominated clinical governance lead.(2) The contractual framework makes clear the role of community pharmacy and its contribution to the achievement of the targets for the health sector. Primary Care Trusts will support pharmacy contractors in implementing the new framework and monitoring compliance was only to begin in October 2005. For the introduction of CG to be successful it is essential that there is of mutual benefit to community pharmacy and the rest of the local NHS, while improving quality service to patients.
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Clinical Governance is composed of seven principle elements, "Education," "Clinical audit," "Clinical Effectiveness," "Risk Management," "Research and Development," and "Openness." The principles above are all extremely important in their contribution to clinical governance and I will discuss in detail some of the above in this essay.
As part of the CG requirements, pharmacies have to participate in a clinical audit of their services and have the necessary arrangements in place to verify the quality of advice given to patients. Clinical audit involves the pharmacist and their staff participating in one practice based audit and one PCO determined multidisciplinary audit each year. Patient involvement entails the public to complete "Community Pharmacy Patient Questionnaire" to express their level of satisfaction at the services provided by their local community pharmacy. The pharmacies should review the surveys and consider changes to improve their services. Risk management ensures pharmacists provide sufficient evidence of recording, reporting, monitoring, analysing and learning from patient safety incidents. Clinical effectiveness programmes ensure the correct operating procedures are in place for the management of repeat NHS prescriptions, medicines use reviews and standard operating procedures. Staffing and staff management ensure that the people operating within the pharmacy have all the necessary training skills related to their role in the pharmacy and up to date with the legality issues surrounding confidentiality procedures, health and safety issues etc. Pharmacy operators must also ensure that there is an induction and written operating procedures for locums, who will be undertake the role of responsible pharmacist at different pharmacy premises. Pharmacists must also demonstrate their commitment to continuing professional development (CPD) through a CPD record, acquire information via up to date reference sources and comply with regulations. (3)
Pharmacists have been implementing many of the aspects of CG in their roles as front line carers for patients on a day to day basis for many years. The structures put in place for the development of a CG framework; build upon the existing strengths possessed by pharmacy's and highlights areas where improvements can be made. For CG to be successful and for processes to become embedded in pharmacies, pharmacists must be able to recognise the compelling nature of it outcomes. They should be clear on the intended benefits and understand that CG is an opportunity for them as individuals to adapt to change, generate new knowledge and continue to improve in their professional performance. (4) Clinical Governance activities can raise awareness of learning needs for example through audit and also for the continuing development of the services they provide within their organisation to provide the best form of patient care possible. Adverse incident reporting is an important element of CG but in general incident reporting to external bodies is at an early stage in community pharmacy and will require considerable culture change. The development of the "No blame" culture is essential and is important for pharmacists to realise that incidents and mistakes do occur but as long as the necessary procedures are taken to prevent dispensing errors and near misses through examination of these errors in an objective way to prevent the same problems happening over and over again. (5)
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Clinical effectiveness is made up of a range of quality improvement activities and initiatives including evidence, guidelines and standards to identify and implement best practice. Clinical Governance invites pharmacists and their working team to perform at very high professional level, which improves the quality of patient care and helps improve patient trust. This generates a feel good factor for the pharmacist and his team, in the services they are providing to the public and gives them the confidence and makes them better equipped for issues which present themselves in their pharmacies. Risk management is key part in CG, as the safety of patients is the main priority for all the healthcare team. The reporting of dispensing errors to an external board could minimize the risks of potential hazardous situations caused by dispensing errors, by effectively setting motions in place to reduce or remove risks. The principles of CG applies to all practitioners, including community pharmacists, who have an important contribution to make to the development of a coherent strategy for assuring and improving the service provision across the local health community. (6) This involves working and communicating as a multi-disciplined team across primary care but also between primary and secondary care, to improve the overall quality of patient care. Clinical Governance also has systems in place to identify poorly performing pharmacists and provides retraining and other support at an early stage for pharmacists but the onus is on them to acquire the necessary skills to act as professional pharmacists and build on their existing knowledge.
There is no doubt that Clinical Governance is a positive driving force behind improving patient care but there are questions of how practical it can be in the day to day running of busy pharmacies. Many pharmacists especially the older generation have found it particularly difficult to come to terms with the massive impact of paperwork associated with clinical governance and finding time to implement everything is a problem and many feel that time filling out forms would be better fulfilled advising patients. Cost is another problem, training staff to be effective in CG and employing locums, buying CG packs and having to close the pharmacy to attend PCT meetings are certainly not cheap. There are numerous other problems which could be mentioned which pharmacists find challenging and wrong with CG.
In conclusion, the concept behind Clinical Governance has been put forward to undoubtedly benefit the entire health system. It is therefore important that systems are in place to maintain a high standard of clinical care. Pharmacists have been at the forefront of patient care and have been providing dependable services to the community for many years. The system of CG brings together all the elements which seek to promote quality care and the challenge of it shouldn't be underestimated. The cultures involved will need to be understood and greater sensitivity shown to pharmacists to help them review and justify their performance. Many pharmacists are apprehensive about CG and feel the changes involved could be an unnecessary intrusion and many will only be won over when they can see that it's in their interest and that of their patients.
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Clinical Governance; Quality in the new NHS (HSC 1999/065) Department of Health, London, 1999
Department of health, 28/4/05 Implementing the new Community Pharmacy Contractual Framework
PSNC, Essential service 8- Clinical Governance Requirements in the New Community Pharmacy Contractual Framework
Continuing Professional Development: Quality in the new NHS. (HSC 1999/154) Department of Health, London, 1999.
Doing Less Harm. Department of Health 7 national Patient Safety Agency, London, 2001.
Pharmacy in the Future-Implementing the NHS plan. Department of Health, London,2005