(Caring for Scotland, 2001 p.32)
This essay will aim to critically analyse clinical governance from a number of key perspectives including delivery of care, evidence based practice, professional development, communication and support systems within the organisation, where concerns regarding practice can be raised safely.
The patients journey through the health care system has not always been an easy one. The Scottish Executive Health Department has taken steps in an attempt to improve this through the action plan “Our National Health: A Plan For Action, A Plan for Change”(2001)
The plan is to an extent based on Maxwell’s 6 dimensions of quality (Maxwell 1984) and addresses equity of access to effective and appropriate care by: extending timing of availability of care: greater access through: NHS24: increasing staffing levels and lowering the historical boundaries between hospitals, the community and adjunctive providers such as local authorities and voluntary organisations. Waiting times, clearly identified along with hospital cleanliness by patients as areas of deficiency are also addressed as priorities. Perceived drawbacks in terms of increasing staffing, caused by difficulties in recruitment and retention, is the greater use of agency staff, potentially reducing continuity of care, and the influx of foreign nurses which has the potential to create problems through both language difficulties and different standards of training. This has been addressed to an extent by the current drive to encourage trained nurses to return to work by offering flexible contracts and re-learning programs. In terms of equity of access recent reports suggest a “postcode lottery” where different levels of care and treatments are available dependent on where the patient lives, recently highlighted in the media with regard to individuals suffering from Alzheimer’s disease.
Clinical governance involves effort, co-ordination and communication from all involved in giving care to the patient, including contribution from the patient. The NHS Modernisation Agency (2002), among others, stresses that public and patient involvement is a prerequisite for effective clinical governance. An example of teamwork and evidence based practice is the integrated care pathway, seen as a multidisciplinary pre-determined plan designed for a specific condition or set of symptoms. Successful integrated care pathways focus on multi-disciplinary communication, a continuing audit in order to decrease variations in approach, and identify and prioritise specific areas for research and development. Concerns and barriers, however, raised by Campbell, Hotchkiss et al (1998) include lack of flexibility, increased litigation, obstructive interpersonal politics, lack of management commitment, and conversely, management support coming from a cost driven rather than quality driven perspective.
The Scottish Intercollegiate Guidelines Network (SIGN) was founded in 1993 by the Academy of Royal Colleges and Faculties in Scotland. Its remit was to sponsor and support the development of evidence based clinical guidelines for the NHS in Scotland. The guidelines consist of a series of statements, gathered from assimilated evidence of best practice focused on individual diagnoses and are designed to assist both clinician and patient in deciding on most appropriate pathway of care for patients. An additional advantage is that statements are reviewed at a maximum of two years after publication to reflect new evidence, reflecting a process of continuous improvement.
Education, training and continuing professional development are also integral to improving quality of service and safeguarding high standards of clinical care. Kennedy (2001 p. 322) stated that “ a patient is entitled to be cared for by health care professionals with relevant and up to date skills and experience.” Education and training needs can be identified in various ways however clinical supervision with a good management support, can be a safe and effective means of reflecting on and developing individual practice. On a wider scale organisations such as the RCN support practice development by supporting individuals and teams to continually develop and maintain effectiveness in being both patient-centred and evidence based.
Staff also need to work in an environment where they feel confident and safe in reporting incidents of unprofessional practice. The Whistleblowers Protection Act 1999 has been effective since July 1999 and encourages people to raise concerns about malpractice in the workplace and will help ensure that organisations respond by addressing the message rather than the messenger; and resisting the temptation to cover up serious malpractice
The Kennedy report (2001) discussed a “culture of safety” where errors should be analysed as a learning experience and that there should be a blame free culture where staff are encouraged to report errors and near misses (sentinel events).
Locally, Renver-PCT has a clear clinical governance strategy entitled “Working Together To Do Our Best For Patients” which was formulated by the Clinical Governance Manager following lengthy consultation with staff at all levels and members of the public. There is also a dedicated complaints officer who works within timescales and a defined reporting system for dealing with complaints. An extensive trust wide quality initiative entitled Quality Improvement (previously titled “quality through leadership”) aims to ensure establishment of effective communication and information systems.
The trust also has dedicated practice development nurses for each speciality, responsible for continuing professional development, organising training and ensuring that UKCC Post Registration Education and Practice (PREP) requirements are met. The Clinical Development Centre focuses on audit, research and evidence based practice aligned with the Clinical Standards Board for Scotland (CSBS). There is an ongoing risk management strategy. Networking with other areas is encouraged where information on best practice is discussed and shared.
In conclusion Clinical Governance is essentially about the development of a culture that supports and promotes improvements both in practice and in patient care. It requires organisation wide commitment. Key strategies for effective clinical governance involves effective teamwork, leadership, ownership, openness and, most importantly, communication. The additional recurring theme is that the public and patients need to be involved in all aspects of the planning, organisation and environment of care.
Campbell, Hotchkiss et al (1998) Education and Debate: Integrated Care Pathways BMJ (10TH January 1998 pp 133-137
Currie L., Morrell C. & Scrivener R. (2003) Clinical Governance: an RCN Resource Guide London: Royal College of Nursing
Kennedy I. (2001) The Bristol Royal Infirmary Enquiry London: Her Majesty’s Press p.322
NHS Modernisation Agency (2002) Improvement Leaders Guide: Involving Patients and Carers Ipswich: Ancient House Printing Group
NHS Scotland (2001) Caring for Scotland: The Strategy for Nursing and Midwifery in Scotland Scottish Executive Edinburgh
NHS Scotland (2001) Our National Health: A Plan for Action, a Plan for Change Scottish Executive, Edinburgh
Scally G. & Donaldson L. (1998) Clinical Governance and the Drive for Quality Improvement in the new NHS in England BMJ (4th July 1998 pp 61-65)
Quality Centred Health Care Management: Unit Four: The Concept and use of Quality Standards
Quality Scotland (2003): URL http://www.qualityscotland.co.uk/