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Applying clinical governance in hospice care

VOL: 97, ISSUE: 50, PAGE NO: 38

Penny James, BSc, MSc, RGN, is clinical care manager, Sue Ryder Care, Wheatfields Hospice, Leeds

Policy documents relating to clinical governance have focused on the NHS, yet the concept has been widely embraced by the hospice movement. The National Council for Hospices and Specialist Palliative Care (NCHSPC) has defined clinical governance in voluntary hospices as 'an internal framework through which voluntary sector providers of hospice and specialist palliative care demonstrate accountability for and ensure continuous improvement in the quality of their services for patients and those who care for them and the safeguarding of high standards of care by creating an environment in which excellence in clinical care will flourish' (NCHSPC, 2000).

Policy documents relating to clinical governance have focused on the NHS, yet the concept has been widely embraced by the hospice movement. The National Council for Hospices and Specialist Palliative Care (NCHSPC) has defined clinical governance in voluntary hospices as 'an internal framework through which voluntary sector providers of hospice and specialist palliative care demonstrate accountability for and ensure continuous improvement in the quality of their services for patients and those who care for them and the safeguarding of high standards of care by creating an environment in which excellence in clinical care will flourish' (NCHSPC, 2000).

The paper recommended that the principles underpinning clinical governance should be taken on board and that practices and activities should be undertaken as outlined within the Department of Health policy documents (DoH, 1997; 1998).

Sue Ryder Care's Wheatfields Hospice has provided specialist palliative care to the community of west Leeds for 21 years through inpatient, day hospice and community services. The hospice prides itself on providing timely and sensitive patient care. However, with the introduction and implementation of clinical governance the team recognised that the evidence to support its claim of providing a quality service was weak. Over a period of several years the hospice team has endeavoured to address this issue, and we are now in a position to say 'these are our areas of strength and this is our proof'.

What have we done so far?
Before a clinical governance framework can be implemented within an organisation, clear lines of responsibility and accountability need to be established. At Wheatfields, as clinical care manager, I am the recognised clinical governance lead. We decided that the initiative should be led by a non-medical professional to ensure that all clinical disciplines saw clinical governance as their responsibility, rather than just as a 'doctor thing'. I was seen as an appropriate person to take on clinical governance, since I am responsible for all non-medical patient services and this has proven to be effective.

Although I have the key responsibility to lead, drive and coordinate the clinical governance agenda, I do not have to do it all. All individual practitioners from any discipline have a role to play in ensuring clinical governance makes a difference. To this end all clinical job descriptions now make explicit reference to the individual's clinical governance responsibilities.

A significant amount of work has been undertaken at Wheatfields since clinical governance was embraced by the organisation. Table 1 gives examples of some of the initiatives.

Audit is a good measure of the quality of service or outcome, provided its results are published, action plans implemented and the information is used to inform practice. Thirty-one audits were undertaken in 2000 alone, each making recommendations with clearly defined timescales and lead individuals to ensure changes in practice occurred. All polices and procedures have nominated leads with regular review dates. As clinical governance lead I manage clinical incident reporting and clinical risk-management within the organisation.

Other work undertaken that falls under the umbrella of clinical governance has included:

- Work on eliciting user/carer views;

- Regular planned reflective practice/critical incident analysis;

- Comprehensive induction/preceptorship;

- Annual analysis of training needs, which drives the annual education programme;

- Agreed core educational competencies for nursing staff;

- Education boards in clinical areas.

Work in progress
The Yorkshire Hospice Peer Review (YHPR) is a collaborative project across 11 hospices that aims to develop and implement a multidisciplinary specialist palliative care audit tool. The NCHSPC recently recognised this project as one of the leading schemes for the provision of external review of specialist palliative care services.

Wheatfields was subject to the YHPR process in 2000 and much of the quality work to date has focused on the components of the peer review tool. It has formed the basis for planning and developing future work. Peer review has been a useful baseline and we now find ourselves moving from generic issues to more specific clinical care issues.

Benefits to the organisation
A successful care organisation must have patients and users at the core of its philosophy. Clinical governance examines the entire patient and carer experience and if it is to succeed the organisation must be striving towards effective teamwork. Staff should work as partners, with each other and with users and carers. Everything that occurs, including communication, should be open and transparent.

Benefits to patients
Patients have a right to be assured that the care they receive is of the highest possible quality. Their involvement in the decision-making process is crucial to ensure that their needs are met and that where individuals have concerns or complaints they are acted upon immediately.

Conclusion
Lilley (1999) sums up the way clinical governance has been interpreted within the hospice: 'It's everyone's business. It involves patients and users. It ignores departmental and service boundaries. Everyone is involved in developing his or her own professional capabilities. It is a continuous quest for improvements. It is about having an enquiring mind, finding out what works best, based on evidence and doing it every time. And finally it is about being open and transparent.'

The success of clinical governance locally will be a reflection on the culture of individual organisations. It will depend on how all professional groups work together in teams, the strength of the management structure and the effectiveness of communication within teams and the organisation as a whole (Wright and Poad, 1998). To date, Wheatfields has come a long way towards meeting the goals in its clinical governance agenda. However, more work is necessary because, like all quality initiatives, clinical governance is a continuous process.

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