Implications For Clinical Governance Research Articles

Clinical governance implications of a Victorian coronial finding regarding contrast-related anaphylaxis for health services and private providers of radiology services.

What is known about the topic? Anaphylaxis is a rare but inherent risk of treatments and investigational agents. What does this paper add? Using a recent coronial finding in Victoria, this letter explores clinical governance responsibilities of health services and private providers of radiology services with respect to anaphylaxis recognition and management. What are the implications for practitioners? There is a strong case for health service and corporate governance teams (for stand-alone clinics) to ensure that all staff have recent, adequate training to recognise and initiate treatment of anaphylaxis. Reliance on an ambulance response is not enough.

Attention Deficit Hyperactivity Disorder - A Pre Audit Study of the Pattern of Drug Treatment in a Specialist Community Child and Adolescent Mental Health Service in the UK

Attention deficit hyperactivity disorder (ADHD) is a neuro developmental disorder and a common disorder of childhood with functional impairments and a significant personal, family and psychosocial burden. This is a pre audit study of children and young people with ADHD who were referred to the Specialist Community Child and Adolescent Mental Health service in Calderdale, Halifax in East Yorkshire. The main aim of the pre audit study was to determine and study the pattern of drug treatment with psycho stimulant medication in the service as well to study the socio-demographic characteristics of the children and young people referred. This was a cross - sectional study. Twenty cases were randomly selected from the available records and data was extracted directly from the medical records using data sheets designed for the pre-audit study. Males constituted 85% of the study sample and Females 15%. Age group 9-12 constituted 65% of the sample. The modified release preparation of Ritalin was more commonly prescribed than the immediate release preparation. Some practical advantages and limitations of brands are highlighted. The initial findings are useful and would help to modify the data sheet for improved quality and help to set the ‘audit standards’ for the main audit study. This has clinical governance implications in terms of delivering the most expedient quality care in a Child and Adolescent Mental Health Service.

An audit of consenting practices in a district general hospital. Can we improve?

Informed consent, as the declaration of patients' will, forms the basis of legality of medical procedures. A standard form based on the Department of Health model is widely used in the National Health Service (NHS). The aim of this audit process was to assess the current consent practice in comparison to the UK's General Medical Council guidance and local policy and make any appropriate improvements. 254 adult consent forms were reviewed during the patients' admission. Data collected included legible documentation, grade of health professional completing the consent form, providing additional written information, use of abbreviations, securing the consent form in the medical records and, providing a copy to the patient. After initial assessment, interventions in an attempt to improve adherence to guidelines were introduced. A repeat audit of a further set of 110 notes was completed to assess the effectiveness of our interventions. Our baseline assessment of 254 consent forms comprised of 198 (78%) elective and 56 (22%) emergency procedures. 87 (34%) consent forms were secure in the medical records. Grade of health professional was recorded in 211 (83%). 191 (75%) forms were legible. 48 (19%) patients were given copy of the consent. Only 24 (9%) patients were given additional written information. Abbreviations were used in 68 (27%) forms. Only 12 (5%) of consent forms met all criteria simultaneously. Re-audit after intervention assessed 110 consent forms; 30 (27%) for elective and 80 (72%) for emergency procedures. 52 (47%) of consent forms were secure in medical records, grade of health professional was recorded in 94 (85%), 101 (75%) forms were legible, 42 (38%) patients received copy of consent and 41 (37%) of patients received additional written information. Initially only 5% of consent forms completely met GMC guidelines. This demonstrates an alarmingly poor adherence to such guidance that plays a vital role in patient safety, patient ethics autonomy, not to mention potential medico-legal and clinical governance implications for surgical practice. Our intervention has improved the quality of consenting within our hospital according to these guidelines. With these interventions set to continue and further develop, we expect that the quality of the consenting process will continue to provide patients with all that it is designed to.

Standard of medical tribunal reports in a high secure setting

Aims and methodTo investigate whether medical tribunal reports were meeting acceptable standards as set out in the practice direction issued by the Tribunal Service in 2010. We looked at 50 medical reports and compared the content of the reports with a 13-item checklist that was derived from the recommendations set out in the practice direction.ResultsThe results show a number of areas where the reports are not meeting acceptable standards. For 5 of 13 items in our checklist, less than 80% of reports evaluated included the required information.Clinical implicationsThe results have important clinical governance implications. As clinicians we need to improve our report writing, not least because it is our professional and statutory duty but also to avoid potential repercussions from the tribunal in terms of their legal power to order remedies, sanctions and costs. Improvements might be achieved through robust performance management of individual clinicians and consideration being given to including this in revalidation procedures.

Financial and clinical governance implications of clinical coding accuracy in neurosurgery: A multidisciplinary audit

Clinical coding is the translation of documented clinical activities during an admission to a codified language. Healthcare Resource Groupings (HRGs) are derived from coding data and are used to calculate payment to hospitals in England, Wales and Scotland and to conduct national audit and benchmarking exercises. Coding is an error-prone process and an understanding of its accuracy within neurosurgery is critical for financial, organizational and clinical governance purposes. We undertook a multidisciplinary audit of neurosurgical clinical coding accuracy. Neurosurgeons trained in coding assessed the accuracy of 386 patient episodes. Where clinicians felt a coding error was present, the case was discussed with an experienced clinical coder. Concordance between the initial coder-only clinical coding and the final clinician-coder multidisciplinary coding was assessed. At least one coding error occurred in 71/386 patients (18.4%). There were 36 diagnosis and 93 procedure errors and in 40 cases, the initial HRG changed (10.4%). Financially, this translated to £111 revenue-loss per patient episode and projected to £171,452 of annual loss to the department. 85% of all coding errors were due to accumulation of coding changes that occurred only once in the whole data set. Neurosurgical clinical coding is error-prone. This is financially disadvantageous and with the coding data being the source of comparisons within and between departments, coding inaccuracies paint a distorted picture of departmental activity and subspecialism in audit and benchmarking. Clinical engagement improves accuracy and is encouraged within a clinical governance framework.

IV steroids for MS relapse: clinical governance implications

The face of the NHS is set to change enormously during the next decade providing more choice, more personalized care and real empowerment of people to improve their health (Department of Health, 2005b). Fundamental to this approach will be the management of patients' health needs in the community setting. Using a robust clinical governance framework, the MS team at the National Hospital for Neurology and Neurosurgery worked with the voluntary and commercial sector to design a trial to gather evidence for a new approach to the management of acute MS relapse using intravenous steroids within a home environment. The study was completed in advance of recent governmental initiatives/reforms. This paper focuses on the clinical governance implications of cross-boundary working. It is hoped that by sharing the processes put in place, others contemplating the delivery of acute care outside of hospitals or design of collaborative research trials will find the frameworks useful.

Delivery of psychological therapies: clinical governance implications for trusts

PurposeThe purpose of this paper is to provide an overview of the clinical governance issues involved in the provision of psychological therapies within a context of massive demand and expansion underpinned by recent policy developments at the Department of Health. Raises awareness of the potential risks to Trusts involved in inadequate governance of therapy provision.Design/methodology/approachThe paper shows an informed review of the recent policies and influences affecting the development of psychological therapies and the clinical governance issues arising from them.FindingsThe paper compares the realities of service provision with the ideal model of service delivery recommended by the Department of Health. Raises concerns for all those Trusts providing psychological therapies about their governance and risk management arrangements.Originality/valueThe paper shows the key summary and opinion for all Trusts responsible for provision of psychological therapies.

Do patients with frank haematuria referred under the two-week rule have a higher incidence of bladder cancer?

The new NHS guaranteed that everyone with suspected cancer would be able to see a specialist within 2 weeks of their GP deciding that they need to be seen urgently. We investigated whether referrals under the two-week rule for frank haematuria results in a clinically significant advantage over normal referral pathways in patients with suspected bladder cancer. Patients referred for frank haematuria specifically under the two-week cancer rule were prospectively recorded over a 2-year period. Results of haematuria investigations were compared to a control group of routine frank haematuria referrals. Of the 32 patients in each group, four bladder cancers were found in the 2-week rule group and five bladder cancers were found in the control group (P > 0.05). The number of other demonstrable urological causes of frank haematuria was also the same in the two groups. The incidence of bladder cancer and other urological pathologies is the same irrespective of referral pattern. It is not clear whether seeing such patients within 2 weeks confers any clinically significant advantage over conventional referral pathways. Not all patients with macroscopic haematuria are referred or seen under the two-week rule, this has considerable clinical governance implications for all departments of urology.

Support workers in intermediate care

Despite the proliferation of support worker roles in the UK, little is known about their actual numbers, employment conditions or levels of training. Intermediate care services appear to be an important employer of support workers, but the diversity of intermediate care services makes the task of understanding support worker roles even more complex. This paper presents data from 33 services which were involved in an NHS Modernisation Agency's Changing Workforce Programme project, the Accelerated Development Programme for Support Workers in Intermediate Care in England. Within this project, the main employers of support workers were primary care trusts and/or social services. Participating intermediate care teams were involved in admission avoidance, assisted discharge and reablement, or combinations of these services, and the majority of care was provided in the patient's own home. The 33 services employed 794 support workers and 368 professionally qualified staff. The mean ratio of professionally qualified staff to support workers was 0.95 (range = 0-4.9, SD = 1.05). Support worker roles included multidisciplinary working, meeting rehabilitation needs, providing personal care and enablement. Team leaders included nurses, social workers, physiotherapists, professional managers, home carers and support workers. The most commonly reported sources of support worker training were National Vocational Qualifications and in-house training. In 80% of the services, at least half of the support workers had a qualification. Three models of supervision emerged across the services: the allocation of a mentor; team supervision; and formal and informal line management. These findings illustrate the diversity of employment of support workers in intermediate care. The variations in training, supervision and skill mix have implications for clinical governance and support worker regulation. The employment of support worker staff jointly across health and social care raises cross-boundary issues around employment contracts and pay.

Informed consent for radiological procedures: a Scottish survey

PurposeThe main purpose of the study was to investigate practices relating to informed consent for radiological procedures.Design/methodology/approachAll Health Boards in Scotland (15) were included in the survey and 62 hospitals were contacted. A questionnaire was developed and sent to superintendent radiographers and radiology managers. Quantitative data were entered in to SPSS‐PC for analysis.FindingsA response rate of 95.2 per cent (59/62) was achieved. A total of 15 hospitals described having a trust policy document on consent and six hospitals reported departmental policies. The majority of hospitals used consent forms for interventional procedures, but not for conventional procedures, although two hospitals obtained informed consent for intravenous urography, and one for barium enemas. All departments (n=25/25) using consent forms required the patient to sign the consent form and 20 departments retained the form. Nine departments placed these in the patient's medical records.Research implications/limitationsThe survey demonstrated considerable diversity in hospital practices regarding informed consent for radiological procedures. The findings have significant implications for clinical governance, especially regarding risk management. Some staff may be putting themselves at risk in an increasingly litigious society. The transferability of this Scottish study needs to be established through surveys in other parts of the UK.Practical implicationsThe study reports diversity in practice when gaining informed consent for radiological procedures and the lack of standardisation for this process.Originality/valueNo previous UK empirical studies on informed consent for radiological procedures has been published.

NICE guidelines and law: clinical governance implications for trusts

Clinical guidelines from National Institute of Clinical Excellence (NICE) have been developed by a rigorous process using the highest‐level evidence base. Their objectives are to reduce the variations in clinical care and end the postcode lottery of healthcare delivery. They are backed strongly by the government's agenda, are expected to be implemented and to be monitored, and this is to be monitored by CHAI. Up until now, clinical guidelines have had a secondary status to expert witness testimony in determining the standard of care in law in medical litigation. However, guidelines from NICE may have a more influential role in determining the standard of care in law by setting the standard of expected clinical practice. Trusts need to be sensitive to this as part of their risk management strategy. Trusts should facilitate the implementation of guidelines from NICE and audit their use through the framework of clinical governance. In the rare event that a trust should decide to positively diverge from such guidelines, it should do so only through a mechanism of due process that is required in public law for the accountability of the reasonableness of such a decision.

Are evidence-based guidelines being followed for the monitoring of ocular toxicity of hydroxychloroquine? A nationwide survey of practice amongst consultant rheumatologists and implications for clinical governance.

To determine whether consultant rheumatologists monitor the ocular toxicity of hydroxychloroquine according to standards set by national guidelines. An observational cross-sectional questionnaire study of all consultant rheumatologists in the UK was undertaken. The main outcome measure was the proportion of rheumatologists who practise in compliance with nationally set standards. A wide variation in practice was found. Nearly half the respondents did not assess either baseline visual symptoms or visual acuity, and 3% undertook infrequent visual monitoring at intervals of longer than 1 yr. At least a quarter of rheumatologists within the survey routinely referred patients to ophthalmology, either for baseline visual screening or for regular visual monitoring. Such use of ophthalmology services was outside the recommendations of the guidelines and would suggest that these referrals were unnecessary. No differences in monitoring practices were ascertained between respondents from district general and teaching hospitals. The present study shows that nationally set guidelines for the monitoring of ocular toxicity of hydroxychloroquine are not consistently followed by rheumatologists with regard to baseline assessment, referral to ophthalmology and frequency of monitoring. Clinical guidelines aim to reduce variations in practice and to promote uniform and consistent best practice. The present study demonstrates a lack of conformity to national guidelines in respect of the monitoring of ocular toxicity of hydroxychloroquine. Clinical governance provides a framework for assuring quality in health care. The implications of this study for clinical governance would include understanding why barriers to the use of guidelines might occur and how they might be overcome, risk management, accounting for the reasonableness of a decision for positive divergence and audit.

Management of childhood gastroenteritis in the community.

Good evidence-based research exists for the management of gastroenteritis. However, we encountered local anecdotal evidence of wide variations in the management of gastroenteritis. In order to assess the prevailing practice in gastroenteritis management in primary care, in the Tees Health region, an anonymous questionnaire study involving general practitioners (GPs) and health visitors (HVs) was performed. Three case scenarios were presented in the questionnaire, involving a breast-fed infant, a formula-fed infant and a four-y-old child all with diarrhoea and vomiting, but able to tolerate oral fluids and not ill enough to need hospital admission. Most GPs (78.6%) and HVs (80.5%) advised continuation of breast-feeding, though the practice of giving advice to stop breast-feeding, starve the child and substitute inappropriate fluids such as flat coke, was still common. For infants who were bottle-fed, this inappropriate advice was given much more commonly (only 25.6% and 52.8% of GPs and HVs, respectively gave advice to continue bottle-feeding). This was even more true for the four-y-old, for whom advice to continue with a normal diet was very much the exception (7.7% of GPs and 19.5% of HVs). Advice given to parents of children with gastroenteritis was inconsistent and, in many cases, inappropriate. This has implications for clinical governance. There is an urgent need for the development and implementation of local guidelines.

Management of childhood gastroenteritis in the community

Good evidence-based research exists for the management of gastroenteritis. However, we encountered local anecdotal evidence of wide variations in the management of gastroenteritis. In order to assess the prevailing practice in gastroenteritis management in primary care, in the Tees Health region, an anonymous questionnaire study involving general practitioners (GPs) and health visitors (HVs) was performed. Three case scenarios were presented in the questionnaire, involving a breast-fed infant, a formula-fed infant and a four-y-old child all with diarrhoea and vomiting, but able to tolerate oral fluids and not ill enough to need hospital admission. Most GPs (78.6%) and HVs (80.5%) advised continuation of breast-feeding, though the practice of giving advice to stop breast-feeding, starve the child and substitute inappropriate fluids such as flat coke, was still common. For infants who were bottle-fed, this inappropriate advice was given much more commonly (only 25.6% and 52.8% of GPs and HVs, respectively gave advice to continue bottle-feeding). This was even more true for the four-y-old, for whom advice to continue with a normal diet was very much the exception (7.7% of GPs and 19.5% of HVs). Advice given to parents of children with gastroenteritis was inconsistent and, in many cases, inappropriate. This has implications for clinical governance. There is an urgent need for the development and implementation of local guidelines. Public Health (2001) 115, 292–294