Clinical governance is defined by the Australian Council on Health Care Standards as the system by which the management and clinicians share responsibility and accountability for provision and quality of patient care, creation of a patient-safe environment and for continuous monitoring and improvement of patient care (ACHS 2004). Clinical governance is a framework within which all role-players and stakeholders involved in patient care engage in activities whose aim is to improve quality and safeguard standards of care on a continuous basis (Royal College of Nursing 1998).
The concept of Clinical Governance was launched in 1998 (Royal College of Nursing 2003) as part of the strategy to “Creating a First Class Service” in the British National Health Service (NHS) and the aim was to provide a health service that continually improves the overall standard of patient care, that ensures that clinical decision-making is based on the most up-to-date evidence of what is known to be effective and reduces variations in outcomes. In the British NHS, clinical governance is defined as a “framework through which health service organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish (NHS 1998).
From the abovementioned definition, it is clear that clinical governance places quality at the centre of health service organisations, devises and implements accountability and responsibility mechanisms for quality, promotes creation of the environment for successful and sustainable realisation of improvements, excellence and innovation in clinical care delivery and entrenches duty to serve with high standards of care. It is emphasised that successful implementation of clinical governance requires the institutionalisation of the culture of quality improvement which is a process implemented over time (NHS, ND).
Vanu Som (2004) defined the clinical governance concept as “a governance system for healthcare organisations that promotes an integrated approach towards management of inputs, structures and processes to improve clinical quality.” According to Laubscher (2008), clinical governance is neither a form of policing, a new form of hospital management that is going to take over the role of the hospital manager or his/her management team, a magical system that will solve all the problems associated with inferior or inadequate patient care, going to draw up a list of rules and regulations for everybody to follow nor the introduction of new concepts of governing clinical practice.
Laubscher (2008) argues that clinical governance is a system that ensures and improves quality and safety of clinical patient care; a culture of support and problem solving where respect for autonomy will remain a cornerstone of clinical practice; a culture of trust in which people are prepared to report their errors, near-misses; and free lessons in contrast to a blaming and shaming culture. The goal of clinical governance is to move to open discussion and mutual respect rather than conflict, personal abuse and blame. The concept is one which includes an understanding that doctors, nurses, pharmacists and other clinicians are human and therefore they make mistakes. The primary goal is to create a culture that ensures and improves the quality of patient care and where staff and associated healthcare professionals are accountable for continually improving the quality of their services towards patient safety. On the whole, clinical governance can be viewed as a mechanism to facilitate multidisciplinary teams and ensure that they all work towards the same goal namely the continuous improvement of the quality of patient care. It is hoped that the cooperative and collaborative working practices engendered will have a positive influence on both the behaviour of medical professionals and the delivery of care (Vanu Som 2004).
Hospitals are big entities or service points that consume significant amounts of financial and non-financial resources. This in conjunction with increasing concerns over value for money and the way that money is spent has resulted in the area of hospital governance receiving considerable attention and debate (Murphy and O’Donohoe 2006). Defining governance in a hospital setting may not be as straightforward as it would appear. Some may consider governance in purely financial terms while others believe that clinical governance should be the primary governance concern (Murphy and O’Donohoe 2006). According to the Concise Oxford Dictionary 10th Edition, governance is the action or manner of conducting the policy and affairs of a state, organisation or people. Governance is a shared process of top level organisational leadership, policy making and decision-making of the Board, the Chief Executive Officer, senior management and clinical leaders as well as an interdependent partnership of leaders (Bader 1993).
One of the challenges confronting public hospitals is balancing the ability to function as a hospital in the hospital industry with the need to be accountable for the use of public funds. Public hospitals tend to operate under strict procurement procedures and public service rules with consequent delays in decision-making. Governance in a hospital setting does not only concern economic and financial dimensions but the societal aspect associated with the provision of healthcare as well. It could be argued that hospital governance takes a more overarching institutional approach to governance in the hospital setting. As the concept of hospital governance has been broadened to include both financial and non-financial elements, Eeckloo et al (2002) argue that its purpose is to enable a more integrated approach of supporting and supervising all hospital activities including clinical performance. Eeckloo et al (2002) when considering the concept in Belgian context defined hospital governance in terms of its processes whereby it referred to it as “the process of steering the overall functioning and effective performance of a hospital by defining its mission, setting objectives and having them realised at operational level.”
Taylor (2000) produced a theoretical paper from literature and identified nine principles and 5 benchmarks of “good” governance in hospital settings. He argued that it is advisable to adhere to the key principles of governance in the development and implementation of governance models in hospitals namely knowledge of what governance is, achievement of goals, Executive Management Team (EMT) relationships, unity in direction, unity of command, accountability, ownership needs, self-improvement and understanding governance costs. When examining governance in a hospital setting, there are more elements to consider than merely the financial. Due to the nature of the setting and the service provided within it, the concept of clinical governance which is inward focused has emerged. Ezzamel and Willmot (1993) produced a paper in the United Kingdom on the public sector reform with respect to governance and accountability where they advanced that the key to improving governance practices lies in the development of communication and accountability between those who fund, obtain and supply public services. Clinical governance tries to improve the quality of healthcare provided through integrating the financial, service performance and clinical quality aspects of a hospital. It recognises the essential role of clinicians in delivering quality in this setting (Vanu Som 2004).
The key to the implementation of clinical governance rests on maximising and developing a culture based not only on collaboration, teamwork and the sharing of expertise but one in which innovation and learning are nurtured against a backdrop of openness, trust and public discussions (Milton Keynes General 2006). Clinical governance is an integral part of integrated hospital governance which is defined as systems, processes and behaviours by which health service organisations lead, direct and control their functions in order to achieve organisational objectives, safety and quality of service and in which they relate to patients and carers, the wider community and partner organisations (DH 2006). However, within the NHS organisations, the various functional governance processes (financial, information, clinical and corporate) are often unlinked and as a result issues are often managed in isolation (Milton Keynes General 2006). With respect to the healthcare dimension of the public service, the capacity of a government to provide a good standard of healthcare is deemed one of the most important elements contributing to a country’s standard of living (Murphy and O’Donohoe 2006). Freedman (2002) highlighted that the introduction of clinical governance means that hospitals now have to report on issues of quality whereas previously there had only been financial accountability. Clinical governance demands a major shift in values, culture and leadership to place greater focus on the quality of clinical care and to make it easier to bring about improvement and change in clinical practice (Laubscher 2008).
3.2. Rationale for Clinical Governance
Clinical governance has been put in place to tackle the wide differences in quality of care as a response to major failures in health services, to improve the performance of health services and bring health services closer to the standards of the best (DFID 1999). Clinical governance seeks to provide an opportunity for all role-players and stakeholders to engage in a multidisciplinary collaborative manner, to understand, learn and develop the fundamental components required to facilitate the delivery of quality patient care- a no-blame questioning learning culture, excellent leadership and an ethos where staff are valued and supported as they form partnerships with patients. The following are expected to be in place when clinical governance has been implemented:
Individual and team reflection on their practice and implementation of lessons learnt;
An open and participative climate in which education, research and the sharing of good practice are valued;
A commitment to quality that is shared by professionals and managers and supported by clearly identified resources both human and financial;
Routine engagement with the public and users through an organisation-wide strategy and user representation;
Working as a multidisciplinary team;
Regular Board level discussion on quality issues;
Strong leadership from the top;
Good use of information for planning and monitoring clinical governance.
3.3. Principles of Clinical Governance
The Royal College of Nursing outlines a number of key principles guiding the implementation of clinical governance (see Table 2):
Table 2 – Principles that Guide the Implementation of Clinical Governance
The focus of clinical governance is to improve the quality of patient care;
Clinical governance is applicable to any area where health care is being delivered;
True partnerships between all professional groups, between clinical staff and managers and between patients and clinical staff are prerequisite for the implementation of clinical governance;
Public and patient involvement is an essential requirement for effective clinical governance;
The application of the Total Quality Improvement philosophy in health care guides clinical governance and creates an enabling environment which celebrates success and converts mistakes to learning opportunities;
Clinical governance is an overarching framework which applies to all health care staff involved in clinical care delivery as individuals, teams and service areas;
Clinical governance does not replace individual clinical judgement or professional self-regulation, but augments their implementation in clinical practice;
Clinical governance is all about a cultural change towards collective knowledge as well as interdependence in management, systems and processes in order to improve and maintain high standards of quality care and patient safety (Laubscher 2008). The change in organisational culture from a culture of “blame” to one of learning and harnessing the knowledge and expertise of all clinicians is one of the cornerstones of quality improvement through clinical governance (Laubscher 2008).
According to DFID (1999), organisational culture is a major factor in understanding the performance of clinical teams and how to support changes in working practices. In addition, each clinical team and organisation has its own culture, ways of working and values that will influence the way clinical governance is implemented. However, change is unlikely to be achieved without the enthusiasm and support of motivated clinical champions and leaders. In essence, clinical governance requires a culture in which organisations and their clinical teams consider quality issues as part of their core business, work together to improve performance, are willing and able to acknowledge their problems, value personal development and education, feel valued in their work, recognise the importance of the patients’ experiences of care and seek to obtain patients’ feedback, seek ways of improving care as a matter of routine and proactively implement standards of care (DFID 1999).
3.4. Components of Clinical Governance
According to NHS (1998), the National Health Service envisaged components of clinical governance as shown in Table3.
Table 3- Components of Clinical Governance in the NHS
Clear lines of responsibility and accountability for quality of clinical care
Comprehensive programme of quality improvement activities (audit, confidential enquiries, evidence-based practice and clinical quality/quality improvement programme)
Clear policies aimed at managing risks (controls assurance, clinical assessment)
Procedures to remedy poor performance of professionals (incident reporting, learning from complaints, procedures and staff duty to report)
Clinical governance consists of an integrated system of different types of patient care related activity all aimed at improving quality of care (NHS 2006). Implementing quality through clinical governance can be summarised as representing a systematic joining up of initiatives to improve quality, instituting mechanisms for establishing standards and ensuring that these standards are met and fostering new approaches to leadership, strategic planning, patient involvement and the management of staff and processes (Milton Keynes General 2006). According to Milton Keynes General (2006), the following constitute focus areas for clinical governance (see Table 4).
Table 4 – Focus Areas for Clinical Governance
Patient & Public Focus: Patient information; Complaints; Consent; Delivery of services; Patient involvement in developing services
Clinical and cost-effectiveness: Clinical audit and reviews of clinical services; Research and Development; Guidelines and policies; Education and Training; Multidisciplinary working;
Safety- risk management: Incidents and incident processes; Infection; medicines; waste management; Occupational health & safety;
Risk assessments and risk registers.
Use of information to support healthcare delivery
When the World Health Organisation (WHO), first considered clinical governance, it highlighted four (4) dimensions including professional performance, resource allocation, risk management and patient satisfaction. According to Laubscher (2008), clinical governance is composed of education and training, clinical audit, clinical effectiveness, research and development, openness and risk management.
3.5. Challenges confronting the implementation of clinical governance
The implementation of clinical governance has not been without challenges. There is often no common understanding of what clinical governance is and how it fits into and becomes part of the overall organisational culture (Holt, ND). Holt (ND) reflects on the common problems experienced with the implementation of clinical governance in the NHS (see Table 5).
Table 5 – Challenges in the Implementation of Clinical Governance in the NHS
Clinical governance not prioritised in the agenda of the governing authorities;
Clinical governance structures are overcomplicated and bureaucratic;
Hospitals are in effect running two systems- the normal line management system and another parallel system linked to various clinical governance committees and groups;
Leadership for clinical governance is unclear;
Lack of management capacity and capability at middle management level to implement;
Clinical governance activities are regarded by many as an additional chore and an unreasonable call on their precious time;
There is no real understanding of continuous quality improvement as a philosophy;
Organisations are totally focussed on centrally handed down targets which are included in clinical governance programmes and reports;
There is little strategic input into clinical governance, which means the programmes tend to drift along;
People involved in clinical governance activities have not been trained in appropriate methodologies;
Clinical governance is not undertaken as a team activity;
Health service organisations need a plan to develop the quality of their clinical services. The plan should be based on an objective assessment of the needs and views of patients, assessed exposure to clinical risk, regulatory requirements, staff capabilities, unmet training needs and a realistic appreciation of how present performance compares with that of similar services and best practice standards (DFID 1999). Ownership of the plans needs to be generated not just at Board level but right down the organisation to individuals and teams. Health service organisations must be clear how information from patients is used to assess and improve the quality of services. Empowering patients with information and increasing their contribution to planning services can greatly influence the development of clinical governance (DFID 1999). A health organisation establishing a culture of clinical governance must develop excellence in the selection, management and effective use of information and data to support policy decisions and processes.
People who work in health service organisations must be able to make the best possible contribution, individually and collectively, to improving the quality of health care. The ideal of a service that enables all staff to develop and use their full potential which is aligned with the organisational objectives is rarely met. One step towards this goal is for education and training to support the organisational implementation of clinical governance so that knowledge and skills are reinforced in the workforce (DFID 1999). However, developing a workforce that is fit for purpose goes much wider than this. An effective workforce also needs appropriate technical support such as access to valid best evidence to support clinical decisions (DFID 1999). One of the problems in implementing clinical governance is that there is no universal understanding or model of how clinical governance might operate successfully in a healthcare organisation (Palmer, ND). However, experience has shown that it is the direct improvement in clinical quality that interests clinical professionals and engages their attention (Palmer, ND).