VOL: 97, ISSUE: 01, PAGE NO: 36
Jane Ridgway, RGN, is personnel manager and formerly clinical governance manager, Dorset County Hospital, Dorchester
Elaine Maxwell is director of nursing, Dorset County Hospital, Dorchester
For the first time in the history of the NHS a statutory obligation - the Health Act 1999 - requires NHS organisations to account for the quality of their services. But clinical governance is more than this: it means each individual within that organisation accepting responsibility for the quality of service that they provide and constantly striving to improve it.
Clinical governance needs to become a state of mind. We need to ask ourselves three questions:
- How good is my (or my team’s) clinical practice?
- How do I know?
- What can I do to make it (even) better?
Reflection on practice
To answer these questions we need to reflect on our practice, measure practice and use quality management techniques in a cycle of continuous improvement. As we are expected to ask ourselves these questions, so employers should have systems in place to enable us to answer them. Clinical governance therefore requires structures for questioning, reviewing and changing practice.
Three main components contribute to clinical governance:
- Quality processes;
- Performance management.
Governance requires teams to recognise their roles and be accountable for what they do and how they do it. As individuals we are accountable for our practice, but so are our colleagues and managers. Concerns about the performance of colleagues should be raised with the appropriate managers. There is then a corporate responsibility to address these concerns.
All health care staff must ensure that systems run smoothly, for patients’ benefit. However, there are barriers to overcome, including the historical divisions of power and the hierarchical nature of many professions. We must act responsibly and sensitively when questioning the practice of colleagues and ensure that there is an explicit framework for questioning practice, and a culture in which counselling and support are alternatives to disciplinary action.
Management responsibilities need to be clear and policies must identify any arrangements for delegating, deputising and cover for absence. We should all be aware of mechanisms for reporting untoward incidents, using them to manage a situation. This includes procedures for staff to alert more senior clinical or managerial staff if the team cannot agree on a patient’s management plan.
As professionals, we have responsibilities to our employers while retaining our personal accountability to the public and our professional body. This means abiding by trust policies and highlighting concerns about them to those with designated responsibility for each policy. Accountability also includes responsibility for forward planning. Risks need to be assessed to prevent untoward incidents and work should be prioritised at times of pressure.
Clinical governance requires us to ensure that existing quality processes work properly or to report their shortcomings. We also need to identify where there are no processes agreed and ensure that gaps are filled. The types of processes required include assessment of staff competency, evaluation of activities and review of clinical knowledge.
Staff need to be confident of their clinical care. This involves identifying what we are required to do (scope of practice) and how we should do it (competency). All too often, neither scope nor competencies are clear and agreed by both employer and employee. Role-specific job descriptions provide clarity about the exact scope and competencies required for a particular job.
In order to maintain competence in a changing service we need to continuously develop. Professional development should include reflective practice, in-house training, reading journals and formal higher education. Responsibility for it should be shared with the employer.
Clinical governance requires us to have up-to-date systematic evidence of what is being done. While clinical audit is effective, not all practice can be subject to constant audit. We therefore need to build a portfolio of measures to help us. Complaints, incidents, accidents, performance indicators, individual projects and peer review should be used together to provide a complete picture. Any missing pieces need to be investigated and the gaps filled.
Much of our ‘knowledge’ is based on custom and practice, or on evidence produced in settings other than our own. Clinical governance requires us to review that knowledge with an ever-questioning approach.
Health care, however, is a team effort and judgements about best practice need to be made by teams, not individuals, to avoid fragmented approaches to care.
Think for a moment about how changes to practice are brought about in your clinical area. When you discover new evidence relating to your practice area what do you do? Why not set up a forum for the multidisciplinary team in your area to question practice systematically, review the evidence and implement change as appropriate - part of a learning zone with designated time, committed to knowledge acquisition? This could include learning from colleagues (both inside and outside the team) and reviewing incidents and complaints to learn from past mistakes.
Of course, the ability to critically appraise research is an acquired skill, and employers should provide training. We are responsible for ensuring that there are enough skilled people in our team. We need to be able to question the validity of evidence presented to us, know how to access new information and, in the absence of research, join debates on best practice.
Performance management benefits and protects health care workers. Once the scope and competence have been agreed, performance should be reviewed against them. This is achieved through systems of appraisal and individual performance review, and clinical supervision.
Through regular review, satisfactory, good and exemplary practice can be recognised and rewarded accordingly. Support and training can be provided for those finding achieving their objectives, and the requirements of their job descriptions, more difficult.
Responsibility for governance
The overall aim of clinical governance is to improve the quality of care for patients. This can only be achieved if we are clear about what we currently do and how. Individuals and organisations must share responsibility for producing comprehensive systems to determine what should be done, how it should be done, developing staff to do it, measuring what is done and acting where problems with process/outcome are identified.