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Introduce clinical governance HSC 1999/065 - Clinical governance in the NHS
"A framework through which NHS organizations 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" (Department of Health, 1998).
"Clinical governance is the system through which NHS organisations are accountable for continuously monitoring and improving the quality of their care and services and safeguarding high standards of care and services" (NHS Quality Improvement Scotland, 2005)
In other words it is a system in which healthcare provider organisations themselves are responsible and accountable, not only for implementing standards of healthcare excellence, but also subjecting them to continuous review and improvement. The standards were to be set by the National Services Frameworks and evidence provided by NICE on clinical and cost effectiveness. In essence, it is having mechanisms to ensure that health service providers create the best possible outcomes - as viewed by the organisation and patients - and make best use of the available resources. And the most important resource is people...
Watson (2004, p39) describes clinical governance as "a manifestation of public and Government frustration with the health services," and it is hard to argue to the contrary. But despite continued questions as to its capacity to make real improvements to service and care quality, clinical governance is here to stay. And to be effective, a clinical governance programme must include the following five dimensions (though other sources refer to six or seven - see diagram below). Whichever way you name them, they all add up to the same thing.
Processes for recording and deriving lessons from untoward incidents, complaints and claims
A risk management programme - assessment, systems and standards
Effective clinical audit - evaluation of care programmes and practice
Quality improvement programme - seeking out and listening to users of services. Fostering evidence-based practice to develop guidelines and protocols and define best practice
A supportive, non-blaming culture with strong leadership, support frameworks to identify and improve poor performance and committed to the concept of life-long learning.
Introduced in isolation, none of these dimensions will provide effective clinical governance. The key is to ensure they are connected and that the loop is closed, thereby providing a coherent and comprehensive programme. Success in achieving this will depend on strong and effective management and leadership whose primary aim is to foster an open and participative 'blame free' culture that emphasises both avoiding and learning from mistakes in equal measure. But there is still no guarantee that together they will enhance the quality of patient care and as Watson (2004) points out, criticism of the concept is considered almost heretical.
Currie et al (2004, p7) describe clinical governance as "an umbrella term for everything that helps to maintain and improve high standards of patient care. It covers a whole range of quality improvement activities that many nurses are already doing - for example, clinical audit and practice development. It also provides a framework to draw these activities together in a more coordinated way." Their point about "activities that many nurses are already doing" is precisely the key question that hangs over the concept. Many of the activities included under the governance umbrella are things that have been pursued for many years - and yet Bristol and Alder Hey still happened. And more recently, reports of substandard care at Mid Staffordshire NHS Foundation Trust (you can download the initial report here: http://www.cqc.org.uk/_db/_documents/Investigation_into_Mid_Staffordshire_NHS_Foundation_Trust.pdf and the update reports can also be found on the CQC website) and Birmingham Children's Hospital.
Learning from experience
Healthcare organisations, but especially NHS trusts, have available to them a rich source of material generated by untoward incident reporting, complaints and claims, but is this information being put to good use? Often the completion of an untoward incident report or the final letter to a complainant is seen as an end in itself, especially where staff are hard pressed. Taking the process a stage further, however, by using the material to identify required changes may require minimal effort. What is needed is a multi-disciplinary mechanism for reporting and systematically reviewing untoward incidents, complaints and claims to distil the lessons that can be learned from them.
Risk management programme
Healthcare organisations need to ensure that they have in place effective risk management programmes based on a proper assessment of clinical risk and with appropriate systems and controls to counteract the risk. Risk management is concerned with identifying and measuring risks with the ultimate purpose of reducing the frequency of adverse events and harm to patients to the benefit of patient care. It should not be exercised as a reactive 'witch hunt', solely organised to root out unsafe practitioners. More on error and risk management in a later session.
Clinical audit programme
An effective clinical audit programme that evaluates care programmes and practice is also an essential component of clinical governance. It should also be able to demonstrate that practice has changed because of the programme. It is likely that where clinical audit is being most effectively used, the subjects for audits have originated from issues arising in the risk management programme or are being used to test evidence-based practice. To be most effective the clinical audit programme should reflect key organisational issues and concerns. More on quality and audit in a later session.
Recent incidents have demonstrated that clinicians can differ widely in their perceptions of current and best practice. A key issue for health organisations is to know what current best practice is and that this is being practised within the organisation. The test of successful clinical governance will come when a Chief Executive can ask about the evidence-based practice in any given specialty and be given a response that conforms to best practice guidelines and protocols  .
The critical and cohesive element of a successful clinical governance programme is effective management and leadership that foster a real cultural change. This will only be achieved through an open and participative 'blame free' culture. An essential ingredient is a commitment to the concepts of life-long learning and professional development. Many performance difficulties can initially be tackled within the context of life-long learning.
National faces of governance
Care Quality Commission has sole responsibility for monitoring and review.
CQC standards are within 7 domains
Clinical & cost effectiveness
Accessible and responsive care
Care environment and amenities
NICE - now National Institute for Health and Clinical Excellence. National Service Frameworks (NSFs) and NICE guidance are integral to the standards based system. They have a key role in supporting local improvements in service quality. Organisations' performance will be assessed not just on how they do on national targets but increasingly on whether they are delivering high quality standards across a range of areas, including NSFs and NICE guidance.
(from the Ombudsman website)
"From 1 April 2009 a single, simpler complaints process will be introduced for the NHS and social care in England. From that date if people are not satisfied with the way a local NHS body or practice has dealt with their complaint they can ask the Health Service Ombudsman to look into it. This will reduce complexity by taking away one stage of the current three-stage process - the review by the Healthcare Commission.
The Health Service Ombudsman, Department of Health, Healthcare Commission and others have been working closely together for some time now through an NHS Complaints Transition Board to ensure a smooth transition to the new complaints process.
Transition to the new two-stage complaints process is well underway. The complaints work of the Healthcare Commission has nearly come to an end and the Health Service Ombudsman is taking on an increasing proportion of those cases where local resolution has not been possible.... In addition, social care and health complaints will be dealt with as part of the same complaints system from 1 April 2009. Social care complaints that are not resolved locally will need to be brought to the Local Government Ombudsman."
In the recently published Principles of Good complaint handling, (see reading) the Ombudsman has identified 6 core principles for all public bodies to guide and improve practice. They are
Getting it right - which includes acting in accordance with the law and relevant guidance, and with regard for the rights of those concerned, having clear governance arrangements, which set out roles and responsibilities, and ensure lessons are learnt from complaints, ensuring that staff are equipped and empowered to act decisively to resolve complaints and focusing on the outcomes for the complainant and the public body
Being customer focused - includes having clear and simple procedures, ensuring that complainants can easily access the service dealing with complaints, and informing them about advice and advocacy services where appropriate, listening to complainants to understand the complaint and the outcome they are seeking and responding flexibly, including coordinating responses with any other bodies involved in the same complaint, where appropriate.
Being open and accountable - publishing clear, accurate and complete information about how to complain, and how and when to take complaints further, publishing service standards for handling complaints, providing honest, evidence-based explanations and giving reasons for decisions and keeping full and accurate records.
Acting fairly and proportionately - treating the complainant impartially, and without unlawful discrimination or prejudice, ensuring that complaints are investigated thoroughly and fairly to establish the facts of the case, that decisions are proportionate, appropriate and fair and that complaints are reviewed by someone not involved in the events leading to the complaint. It is also about acting fairly towards staff complained about as well as towards complainants.
Putting things right -acknowledging mistakes and apologising where appropriate, providing prompt, appropriate and proportionate remedies, considering all the relevant factors of the case when offering remedies and taking account of any injustice or hardship that results from pursuing the complaint as well as from the original dispute.
Seeking continuous improvement -using all feedback and the lessons learnt from complaints to improve service design and delivery, having systems in place to record, analyse and report on the learning from complaints, regularly reviewing the lessons to be learnt from complaints and where appropriate, telling the complainant about the lessons learnt and changes made to services, guidance or policy.
Currie, L Morrell, C & Scrivener, R (2003) Clinical Governance: an RCN resource guide. London, RCN - available here: http://www.rcn.org.uk/__data/assets/pdf_file/0011/78581/002036.pdf
Department of Health (1998) A First Class Service: Quality in the new NHS London, HMSO
McSherry, R & Pearce, P (2006) Clinical Governance - a guide to implementation for healthcare professionals Oxford, Blackwell
Sale, DNT (2006) Understanding Clinical Governance and Quality Assurance: Making it Happen Basingstoke, Palgrave MacMillan
Swage, T (2004) Clinical governance in healthcare practice (2nd ed) Edinburgh, Butterworth Heinemann
Tilley, S & Watson, R (Eds) (2004) Accountability in nursing and midwifery (2nd ed) Oxford, Blackwell
Watson, R (2004) 'Accountability & Clinical Governance' in Tilley, S & Watson, R (Eds) (2004) Accountability in nursing and midwifery (2nd ed) Oxford, Blackwell
DoH Clinical Governance guidance: http://www.dh.gov.uk/en/Publichealth/Patientsafety/Clinicalgovernance/DH_114 (last accessed 20/9)
Parliamentary & Health Service Ombudsman (2009) Principles of good complaint handling: http://www.ombudsman.org.uk/pdfs/Principles_of_Good_Complaint_Handling.pdf (last accessed 20/9)
Care Quality Commission: http://www.cqc.org.uk/ (last accessed 20/9)
NHS Institute for Innovation and Improvement: http://www.institute.nhs.uk/ (last accessed 20/9)
Parliamentary and Health Service Ombudsman: http://www.ombudsman.org.uk/index.html (last accessed 20/9)
The Wisdom Centre - clinical governance: http://www.wisdomnet.co.uk/clingov.asp (last accessed 20/9)