Introduction to Clinical Governance Dr Lee Gruner BSc, MBBS, BHA, FRACMA, MBA (Executive) GAICD Dr...

Introduction to Clinical Governance

Dr Lee GrunerBSc, MBBS, BHA, FRACMA, MBA (Executive)

GAICD

Dr Lee Gruner Management for Clinicians 2008 1

CLINICAL GOVERNANCE

Origins•What was the catalyst?•Why this terminology?


What is corporate governance?

• Corporate governance is the system by which companies are directed and managed. It influences how the objectives of the company are set and achieved, how risk is monitored and assessed, and how performance is optimised. Good corporate governance structures encourage companies to create value and provide accountability and control systems commensurate with the risks involved.


THE KING EDWARD MEMORIAL HOSPITAL STORY


Lessons from King Edward Memorial Hospital

• Issues relating to poor child and maternal outcomes dating back over 10 years

• Three reviews in 3 years culminating in the Douglas Enquiry in 1999

• Douglas Enquiry focused on areas for improvement and high risk cases

• Findings related to management / medical staff and clinical practice issues


Findings

Lack of safety and quality systems at state, board and hospital level :

• Ineffective accreditation and credentialing systems, inadequate incident reporting systems,

• Poorly performing statutory mortality reporting and investigation systems

• Non-existent inter-hospital comparative data analysis.


Findings Significant leadership, management and clinical

performance problems • A culture of blame, unsupportive of open disclosure of errors

and adverse events;• Lack of clarification of senior staff responsibilities and

accountability;• Non-existent “safety nets” or systems to effectively monitor

performance and respond to performance issues;• Ineffective or non-existent systems to ensure staff had the

right credentials, training, support and performance management to meet the demands and skill requirements of their roles and responsibilities;


Findings

• Failure to meet the emotional needs of many women and their families, excluding them from decisions about care or failing to give them honest, complete and timely information when things went wrong; and

• Failure to address serious and ongoing management and clinical problems that resulted in serious adverse events and poor outcomes for women and their families


Findings - Management

• Management failed to:– Make important decisions– Create an open and transparent culture– Monitor safety and quality – Ensure proper supervision/ training of staff– Define accountability and reporting responsibility– Address serious issues relating to adverse pt outcomes– Respond adequately to complaints


Findings- Clinical Practice

• Senior doctor procedures deficient:– Insufficient involvement in complex cases– Inadequate decisions– Inadequate credentialing and appointment procedures– Inadequate performance management – Inadequate supervision of junior staff– Failed to provide timely analysis of staffing needs



• Junior doctor work practices:– Did much of the complex work– Poorly supervised– Requests for help ignored– Blamed for errors– Sink or swim culture– Inadequate orientation and training– Ad hoc performance management



• Clinical practice issues:– Little best practice– Poor outcomes– No benchmarking


Lessons • To assure safe, quality care, governments, boards, health care

leaders and managers must create an open and transparent culture, where people willingly discuss and address errors and systems problems.

• Effective organisations have people at all levels doing the right thing.

• Organisational structures are only effective if people know and aim to meet their responsibilities and are held accountable for their actions.

• Effective management ensures that their organisation has systems that effectively monitor the key aspects of its performance and ensure timely and appropriate responses to performance issues.


Lessons learned• To do a good job, people need the right credentials,

training, support, performance management and development consistent, with the demands and skills requirements of their roles and responsibilities.

• A caring, concerned health care service recognises the importance of involving patients and their families in care, provides information about care options, involves them indecisions about care and advises them openly and honestly when things go wrong.


Implementing change

• In the 9 years since the Douglas Enquiry:–How far have we come?–What have we really learnt?


WHAT IS CLINICAL GOVERNANCE?


Clinical governance

• A governance system for health care organisations that promotes an integrated approach towards management of inputs, structures and processes to improve outcomes in health care service delivery where staff work in an environment of greater accountability for clinical quality


Clinical Governance – what does the definition mean?

• A governance system for health care organisations that promotes an integrated approach towards management of inputs, structures and processes to improve outcomes in health care service delivery where staff work in an environment of greater accountability for clinical quality


An integrated approach

• Considers the whole patient experience• Considers all quality variables not just the

medical care– Reliability- doing what is promised– Empathy- respect/ concern– Tangibles- environment/ food– Responsiveness- response to needs– Assurance- credible service/ seamless

organisation / good equipment


inputs

• Financial resources• Buildings and equipment• Staff• Policies


Structures

• Clinical Governance Committee• Procedures/ guidelines• Education and training of staff• Reporting system for adverse events• System for patient feedback


Process

• Implementation of risk management• Job descriptions• Multidisciplinary management of clinical care• Communication• Management of patient information • Collection of data on clinical care• Acting on patient feedback


Clinical governance

Aims to ensure that:• systems to monitor the quality of clinical

practice are in place and functioning properly• clinical practices are reviewed and improved• clinical practitioners meet standards set by

regulatory bodies


Elements of clinical governance

• Human resource systems• Review of clinical practice• External assessment of practice• Commitment to ongoing education


Human resource systems

• Medical appointments and credentialing systems

• Management and support of the clinical performance of colleagues , developing guidelines and protocols

• Effective management of poorly performing colleagues


Review of clinical practice

• Clinical audit• Evidence based clinical practice• Implementation of clinical effectiveness

evidence• Risk management


Commitment to ongoing education

• Continuing education for all clinical staff• Development of clinical leadership skills• Continuing professional development for

all staff


External assessment of practice

• External accreditations• Consumer feedback audits• Internal audit


ENGAGING MEDICAL STAFF

What motivates medical staff?What methods can we use to get medical staff involved?


KEY ELEMENTS OF A CLINICAL GOVERNANCE CULTURE

•Identify 4 barriers to developing a robust clinical governance culture•Which of these are most important?


Barriers to a good Clinical Governance system

• Lack of leadership• Inadequate Time and resources• Inadequate training and education• Lack of accountability of staff• Negative organisation culture• Resistance to change• Poor systems and processes• Fear of repercussions


IDENTIFYING KNOWLEDGE AND SKILLS OF MEDICAL LEADERS

•What knowledge and skills do medical leaders require to support a robust clinical governance system?•What behaviour should they display?•How can they acquire the skills and knowledge?•What strategies do we put in place to support this and to overcome the barriers?


Overcoming the barriers

• Building systems and processes:– Reporting– Implementation of change following analysis of

incidents– Appropriate committee structure– Appropriate policies– Feedback systems


Success of Clinical Governance depends on:

• Educated and committed leadership• A vision of what Clinical Governance will deliver in

the context of organisational strategy• Education of key staff • Provision of appropriate resources – people/

time / funding• A working coordination mechanism with

appropriate systems- data/ reporting/ feedback/ policies

• A change management environment



• Education and training– Structured education program– Adequate resources for education– Management led education of all staff

• Leadership– Education of Board and executive– Involvement of executive to drive the process– Appropriate resources



• Resistance to change:– Develop staff champions– Adopt a change management approach– Openly address the culture of blame– Positive reinforcement of change– Reward and recognition systems


Major implications in introducing clinical governance

• Development of leadership skills and knowledge amongst clinicians.

• Development of mechanisms to ensure the 'audit loop' is closed - to ensure that change in clinical practice takes place in the light of audit, research, evidence, risk management and complaints findings

• Development of appropriate accountability structures



• Implementation of evidence-based practice across organisations.

• Development of effective multidisciplinary and inter-agency working.

• Integration of continuing education and continuing professional development into quality improvement programs.



• Development of leadership skills and knowledge amongst clinicians.

• Development of mechanisms to ensure the 'audit loop' is closed - that is, to ensure that change in clinical practice takes place in the light of audit, research, evidence, risk management and complaints findings.

• Development of appropriate accountability structures



• Implementation of evidence-based practice across organisations.

• Development of effective multidisciplinary and inter-agency working.

• Integration of continuing education and continuing professional development into quality improvement programs.


CLINICAL GOVERNANCE PRINCIPLES


Clinical Governance PrinciplesIntegrated approach• Integral part of everyone’s job• Obligation to seek to improve what we do by

continuously examining our work• Obligation to advise on improvements• Management has an obligation to ensure staff

have skills and tools to do their work


Clinical Governance PrinciplesConsistent approach • Standardised structures and processes• Support of active collaboration in all activities• Integration of clinical and non clinical

functions that contribute to standards of clinical care

• Respect individuals and teams contributing to care, education and research


Clinical Governance Principles

Strategic focus• Led by CEO of the health service• Top down approach• Integral part of strategic planning


Clinical Governance Principles

Provides assurance on standards of care• Quality Control measures• Appropriate Quality Assurance activities• Evidence of improvement in care• Evidence of regular policy review and

improvement • Evidence of service improvement • Evidence that risks are identified and managed


DEFINING THE GAPS IN HEALTH SERVICES IN 2008

•What needs to be done better?•What still needs to be put in place- structure and process?•Are there still gaps in the inputs?


Introduction to Clinical Governance Dr Lee Gruner BSc, MBBS, BHA, FRACMA, MBA (Executive) GAICD Dr...

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