Clinical Governance Practice Research Articles

La « gouvernance clinique » : sur un mode de travail particulier chez les directeurs d’hôpital

ContextThe public healthcare system in France is in search of a new “spirit” to address the symptoms of disaffection it currently experiences. Management sciences are exploring how leadership can enhance workplace well-being, emphasizing “salutogenic” approaches and caring leadership. In contrast to previous interpretations of “clinical governance,” often focused on the use of evidence-based clinical data, we investigate the potential use of psychoanalytic theories to shed light on clinical governance practices attentive to the diverse elements contributing to organizational atmosphere. ObjectivesWe aim to return to the conceptions and practices of hospital administrators themselves. The demonstration will revolve around identifying the objects of the specific work done by clinical governance, and the actions taken by hospital administrators practicing this way. Our aim is to extend to the healthcare field the path laid out by institutional psychotherapy in psychiatry, ensuring healthcare institutions do not perpetuate, at their highest hierarchical level, the social symptoms of their time. MethodOur approach is rooted in empirical interpretation sciences and relies on a qualitative analysis methodology that emphasizes proximity to the lived experience of our interviewees. Our field investigation has been ongoing for several years, conducted in collaboration with management teams from institutions of various sizes and regions. The abductive hypothesis of a form of clinical governance gradually emerged while working closely with two well-known hospital administration teams. We engaged in co-thinking with the involved directors to validate our interpretations. ResultsWe revisit the concept of “clinical governance” to describe a way of managing hospitals which symbolically and attentively, though sometimes unconsciously, works with a number of identified objects. We define these objects as related to the organization: hierarchy, space, resources, information, the “scope” of action, and time. Others elements are related to the institutional network: speech, the Self, the perception of others, conviviality, and affects. Each of these elements is examined from the perspective of its symbolic significance, beyond its material or practical aspects, with the understanding that their circulation is of particular interest to clinical governance. InterpretationOur results call for a renewal of institutional psychotherapy in general hospitals, through the perspective of daily “asepsis” of the milieu as facilitated by clinical governance. This involves a recognition by hospital administrators of the symbolic value of the objects we have listed. Clinical governance enables administrators to interpret the symbols behind the apparent materiality of what healthcare professionals discuss. While our results are partial and exploratory, they pave the way for a psychoanalytic clinical perspective regarding hospital governance, alongside management sciences.

A Study on Clinical Governance and Awareness in Quality Standards in Health from the Perspective of Nursing Management

Nurses, who are seen as the focal point in the implementation of clinical governance, have great importance in terms of knowledge, awareness, issues that they consider as obstacles and difficulties, and their suggestions for solutions. With this study, the clinical governance knowledge and awareness levels of the working nurses were examined, and it was aimed to contribute to the literature on the best practice of clinical governance by taking their opinions and suggestions. The population of the research consists of 716 nurses working in Sivas Health Services Application and Research Hospital. Questionnaires were collected both online and face-to-face. The responses of 122 nurses who voluntarily participated in the study were included in the study. The study was carried out with a mixed method and both qualitative and quantitative research methods were used. The study included 4 demographic questions and 9 questions about education, work, and knowledge level. In the literature, McSherry et al. (2012), Wallace et al. (2001) 4 Likert-type items were conveyed about the obstacles to clinical governance in their studies, and 2 open-ended semi-structured interview forms were used to determine their opinions and suggestions. In the study, which was shown as an obstacle to clinical governance and was found to be significant as a result of the analysis, the mean score of information technologies, lack of finance, and time was 1.72±0.79, the mean score of negative attitude towards research related to evidence-based practice was 2.07±0.89 The mean score for education and organizational culture change requirement was 1.83±0.85, and the mean score for cultural resistance to change was 2.02±1.04. Considering these values, it was determined that all expressions had a high level of disability score average.

Medical cannabis and neurological disorders: a clinical overview

In the UK, in addition to licensed medical cannabis products, over 30 000 patients are prescribed unlicensed preparations. The conditions for which these unlicensed products are commonly prescribed and have been identified as having potential therapeutic value, include neurological conditions, as well as those conditions that require modulation of the central and/or peripheral nervous system via targeting the endocannabinoid system, such as during chronic pain. Considering the growing evidence base, this article examines some of the pre-clinical and clinical rationale underpinning the increase in the prescription of these products since their rescheduling in 2018. Beyond this, the article outlines the regulatory environment for prescribing, some of the barriers that patients face, and the work of Sapphire Medical Clinics to uphold stringent clinical governance practices, while providing a patient-centred service.

Barriers to the Implementation of the HIV Universal Test and Treat Strategy in Selected Primary Care Facilities in South Africa's Eastern Cape Province.

Background:The South African government implemented the Universal Test and Treat (UTT) approach to treating HIV in the second half of 2016. As part of a contribution to the successful implementation of UTT, this study looked at barriers to implementation of UTT emanating from weaknesses of the health system in 2 Community Health Centers in South Africa’s Eastern Cape Province.Methods:This was a quantitative cross-sectional design which had both descriptive and analytical components. Convenience sampling was used to select and recruit 2 primary care facilities and 30 nurses. Self-administered questionnaires were used to solicit data from facility managers and nurses. In addition, a record review was used to access 6 months’ data for the period 1 October 2017 to 31 March 2018. Data were analyzed using Stata 14.1. Categorical data were presented using frequency and contingency tables. The 95% confidence interval (95% CI) is used for the precision of estimates and the P-value of statistical significance is P < .05.Results:Facilities were found to have poor leadership and governance; human resource challenges that include shortages, lack of skills and lack of developmental support; poorly resourced service delivery platforms and poor information management. Of the three 90-90-90 targets, health facilities only satisfactorily achieved the second 90 of initiating all who test positive for HIV within a week (93.1% or n = 288/307).Conclusions:This study has been able to identify potential barriers to the implementation of the UTT strategy at the selected facilities including the lack of structured programs in place to monitor performance of healthcare staff, knowledge gaps, and a lack of good clinical governance practices as evidenced by the lack of customized protocols and Standard Operating Procedures.

Mapping clinical governance to practitioner roles and responsibilities.

While clinical governance is assumed to be part of organisational structures and policies, implementation of clinical governance in practice (the praxis) can be markedly different. This paper draws on insights from hospital clinicians, managers and governors on how they interpret the term "clinical governance". The influence of best-practice and roles and responsibilities on their interpretations is considered. The research is based on 40 in-depth, semi-structured interviews with hospital clinicians, managers and governors from two large academic hospitals in Ireland. The analytical lens for the research is practice theory. Interview transcripts are analysed for practitioners' spoken keywords/terms to explore how practitioners interpret the term "clinical governance". The practice of clinical governance is mapped to front line, management and governance roles and responsibilities. The research finds that interpretation of clinical governance in praxis is quite different from best-practice definitions. Practitioner roles and responsibilities held influence practitioners' interpretation. The research examines interpretations of clinical governance in praxis by clinicians, managers and governors and highlights the adverse consequence of the absence of clear mapping of roles and responsibilities to clinical, management and governance practice.

Is medical perspective on clinical governance practices associated with clinical units' performance and mortality? A cross-sectional study through a record-linkage procedure.

Objective:Assessment of the knowledge and application as well as perceived utility by doctors of clinical governance tools in order to explore their impact on clinical units’ performance measured through mortality rates and efficiency indicators.Methods:This research is a cross-sectional study with a deterministic record-linkage procedure. The sample includes n = 1250 doctors (n = 249 chiefs of clinical units; n = 1001 physicians) working in six public hospitals located in the Emilia-Romagna Region in Italy. Survey instruments include a checklist and a research-made questionnaire which were used for data collection about doctors’ knowledge and application as well as perceived utility of clinical governance tools. The analysis was based on clinical units’ performance indicators which include patients’ mortality, extra-region active mobility rate, average hospital stay, bed occupancy, rotation and turnover rates, and the comparative performance index as efficiency indicators.Results:The clinical governance tools are known and applied differently in all the considered clinical units. Significant differences emerged between roles and organizational levels at which the medical leadership is carried out. The levels of knowledge and application of clinical governance practices are correlated with the clinical units’ efficiency indicators (bed occupancy rate, bed turnover interval, and extra-region mobility). These multiple linear regression analyses highlighted that the clinical governance knowledge and application is correlated with clinical units’ mortality rates (odds ratio, −8.677; 95% confidence interval, −16.654, −0.700).Conclusion:The knowledge and application, as well as perceived utility by medical professionals of clinical governance tools, are associated with the mortality rates of their units and with some efficiency indicators. However, the medical frontline staff seems to not consider homogeneously useful the clinical governance tools application on its own clinical practice.

The relationship between senior management team culture and clinical governance: Empirical investigation and managerial implications.

Health care organizations are pressured to improve the cost-effectiveness of service delivery. Clinical governance is an important trigger to improve care quality and safety and rank high in the reform agenda of health systems. The senior management team culture plays a major role in establishing clinical governance practices, because it strongly influences the values, attitudes, and behaviors of the members of an organization. The aim of this study was to investigate the relationship between senior management team culture and clinical governance in the public health care organizations of three Italian regions. The assessment of senior management culture was conducted using the Competing Values Framework and a corresponding instrument adapted for the Italian context. Clinical governance was assessed using an ad hoc instrument focused on the senior management team's perception and attitude toward clinical governance. The survey achieved a 54% response rate. The results of four different models demonstrate that organizations characterized by different dominant cultures are associated with significant differences in attitudes toward clinical governance. In particular, on average, dominant cultures with a prevailing external focus are associated with a more positive attitude toward clinical governance. The selection and appointments of top managers should consider the style of leadership that is most apt to facilitate the growth of rational and developmental cultures. Furthermore, the training of top managers and leading doctors should reinforce leadership aptitude and approaches that are consistent with the desired organizational cultures.

A Canadian perspective on clinical governance

Purpose – The purpose of this paper is to provide an overview of the state of clinical governance practices globally as well as a more detailed examination of the clinical governance landscape in Canada. The paper explores the concept that established clinical governance practices are more important than ever as healthcare systems are increasingly under pressure to reduce costs while dealing with the challenges of ageing populations. Additionally, it suggests that healthcare could benefit by studying and adopting some of the successful governance policies that exist in other jurisdictions or sectors where quality and safety are an integral part of their governance mandate, such as the airline or nuclear energy sectors. Design/methodology/approach – This paper explores the status of clinical governance practices in Canada. This is achieved through a combination of author experience in addition to the review of existing literature and assessments on clinical governance practices and patient safety. Findings – While individual success stories can be found, standardized clinical governance practices across the range of healthcare providers remain largely absent. By focussing on standardized processes, and by placing an emphasis on improved clinical governance, healthcare providers can control and in some cases lower costs while improving efficiency and increasing patient safety. While progress has been slow for many years, the authors speculate that healthcare has reached a tipping point. As information systems develop and become more reliable and robust, and systems move to a patient-centric collaborative approach to care, there is a tremendous opportunity for healthcare and life sciences organizations to exploit and capitalize on both their growing information repositories, and the big data trends that have been embraced and leveraged by other sectors in recent years. Practical implications – Managing costs and delivering safe, efficient care to patients remain top considerations for healthcare boards and healthcare systems alike. As healthcare systems grapple with the increasing costs and risk associated with ageing populations and a more complex healthcare delivery model, effective clinical governance policies focussed on quality outcomes are essential. Originality/value – This paper highlights the responsibility of healthcare boards to learn lessons from other safety-critical industries and develop their own capacity to evaluate progress toward the goals identified above. It also provides insight into the role that leaders on both the corporate and clinical sides of the industry have to play, and the need for meaningful measures that will drive a quality agenda. The paper also emphases the link between established clinical governance practices and greater efficiency, reduced costs and improved patient safety.

Clinical governance in Dutch hospitals

Purpose – For accountability purposes, performance information sharing and clear divisions of responsibilities between medical specialists and executive boards are critical. The purpose of this paper is to explore whether these aspects of clinical governance have been taken up by executive boards and medical specialists in the Netherlands. Design/methodology/approach – This cross-sectional study aimed to explore the information-sharing between medical specialists and executive boards in Dutch hospitals as one key aspect of clinical governance. Between November 2010 and February 2011, 67 medical staff board chairs and 40 chief executive officers completed an online questionnaire concerning information-sharing and the clinical governance practices within their respective hospitals. Findings – Almost all respondents acknowledged the importance of information-sharing. However, the actual sharing differed per type of performance information. Policy/management information was shared more often than patient care information. Similarly, medical specialists differ in the degree of responsibility the take for specific clinical governance tasks. Almost all were involved in managing complication registries (99 per cent), while few managed hospital accreditation (55 per cent). Research limitations/implications – With executive boards and medical specialists being increasingly dependent of a shared budget, they have an extra incentive to share information and to take up clinical governance tasks. The study showed that Dutch medical specialists are sharing many types of performance information with the executive board, but that this should be increased to comply with the codes. Thus far, few hospital managers in the study have formalised this in an information protocol, which is potentially the next step for other hospital staff to incorporate as well. Those who have an information protocol seem to be aware of the business case for quality. Originality/value – This study is the first attempt to explore to what extent Dutch medical specialists share performance information with their respective executive boards and take up clinical governance tasks.

DEVELOPING AN EDUCATIONAL INTERVENTION TO ADDRESS THE DISCREPANCIES IN PRN ‘AS REQUIRED’ PRESCRIPTIONS WITHIN A HOSPICE SETTING

BackgroundWithin the current healthcare arena, the identification of risks within organisations and minimising their negative impact on patient care is fundamental. Reports from the national and international literature have identified...

Time, risk and midwife practice: the vaginal examination

In this article, we examine the impact on midwifery practice of clinical governance in the UK with its shift from individual autonomous practice based on personal experience and intuition (embodied knowledge) to the collective control of work based on guidelines and protocols (encoded knowledge) associated with the scientific–bureaucratic approach to care. We focus on the ways in which midwives use partograms and associated vaginal examinations to monitor and manage the progress of labour. The partogram represents (among other things) a timetable for dilation of the cervix during labour. Women who fail to keep up with this timetable are shifted from a low-to-high risk category and subjected to additional surveillance and intervention. In this article, we draw on empirical evidence taken from two independent ethnographic studies of midwifery talk and practice in England undertaken in 2005–2007 and 2008–2010, to describe the ways in which midwives practice of vaginal examinations during labour both complies with, while at the same time creatively subverts, the scientific–bureaucratic approach to maternity care. We argue that although divergent in nature, each way of practicing is mutually dependent upon the other: the space afforded by midwifery creativity not only co-exists with the scientific–bureaucratic approach to care, but also sustains it.

Tabriz Clinical Governance Research Project (TCGRP): Study Protocol

Ab s t r a c t The Tabriz Clinical Governance Research Project (TCGRP) was conducted in Tabriz, East Azerbaijan Province of Iran. The project was done based on the National Clinical Governance Movement of the Iranian health system since 2009. The TCGRP aimed to monitor the progress of clinical governance in Tabriz hospitals. The TCGRP had three components: 1- A comprehensive literature review was conducted to identify draft indicators. 2- Draft indicators were evaluated by experts through Delphi technique and expert panels, 3- The indicators were assessed through data collection at three sampling levels of hospitals, patients and community. All Tabriz hospitals (n=21) with various ownerships were included in the study. Moreover, 3000 patients (inpatients and outpatients) as well as 1050 Tabriz households were investigated. The TCGRP protocol is designed to provide basic performance information for policymakers as well as the researchers in field of clinical governance. Results from TCGRP are assumed to identify the weaknesses and facilitate the development of effective interventions to improve the clinical governance practice.

Applying and developing health service theory: an empirical study into clinical governance

PurposeThis paper aims to examine an organisation's enactment of clinical governance through applying and advancing a theoretical model.Design/methodology/approachThe research site was a large organisation within an autonomous jurisdiction. The study focused on one organisational division. There were nine interviews and 15 focus groups (118 participants). Ethnographic observations totalled 60.5 hours. Document analysis was conducted with organisational reports and website. Data were examined against the model's four attributes and 24 elements, and used to conduct an organisational culture analysis.FindingsAnalysis showed that a majority of elements, 17 of 24, were strongly identifiable. The remainder were identifiable but not strongly so. Analysis suggested two additions to the model: the inclusion of two elements to an existing attribute and a new attribute and defining elements. This showed that the organisation was working towards, but not yet having achieved, a positive quality and safety culture. In particular, a schism in understanding between managers and frontline staff was noted.Research limitations/implicationsThe study empirically applied and refined a health service theory. The new model, the “clinical governance practice model”, can be broadly applied, and can continue to be developed to expand the evidence base for the field.Practical implicationsSubstantively, the study accounts for differences in managerial and frontline staff actions in applying clinical governance. Investigations to understand and identify strategies to bridge the differences are required.Originality/valueThe study is an original application and refinement of a health service theory. The study identifies that the interpretation of clinical governance, whilst different in different places, gives rise to similar disagreements.

An investigation of change management processes involved in the implementation of clinical governance by allied health professionals in Scotland

AbstractPurpose and relevance. Clinical Governance (CG) has been a major ‘change’ initiative for facilitating quality accountability in health care. Responsibilities of Allied Health Professionals (AHPs) within CG have included the application of evidence into practice, risk management, audit, team‐ship and an engagement in the learning underpinning quality‐based care. The purpose of this study was to enlighten change management processes concerning the implementation of CG within AHP practice through: 1) examining the current ‘context of change’ surrounding AHPs and CG; and 2) determining the factors influencing AHP engagement in CG. Methods. A CG questionnaire was devised, peer‐reviewed and piloted in Wales. Subsequently a national survey of 3901 AHPs from 16 Scottish Trusts was undertaken. The sample consisted of a representative grouping of the six largest disciplines (Radiography, Occupational Therapy, Physiotherapy, Dietetics, Speech and Language Therapy and Podiatry). Analysis. Responses from 1714 participants (RR = 44%) were analysed (SPSS, Version 12). Content Analysis was undertaken on the textural data, analysis of variance to compare responses and Multiple Regression to predict the factors influencing AHP engagement in CG. Results. While AHPs were positive about and partially involved in CG, they did not have the appropriate skill, attitude or support to fully engage or take leadership roles in CG. AHPs experienced barriers to instigating change in practice, sharing and putting evidence into practice and to engaging in CG. Differences in perceptions of CG support and attitudes existed between the professions and grades. Certain professions felt significantly more positive and supported in their practice of CG than others. Levels of engagement, awareness, skill, attitude and perceptions of support for CG increased with grade. Part‐timers and newly qualified AHPs were less aware of CG than their full‐time or longer‐qualified AHP colleagues. Five predictors of engagement in CG were found: 1) perception of support for CG; 2) values and belief towards CG; 3) knowledge and skill in CG; 4) grade; and 5) hours of service. Conclusion. A multifaceted ‘change management’ approach, which would increase levels of CG knowledge and skill, provide support and enable positive attitudinal change among AHPs, would be the most successful strategy to facilitate future engagement of Scottish AHPs in CG. Copyright © 2008 John Wiley &amp; Sons, Ltd.

Diretrizes clínicas e outras práticas voltadas para a melhoria da qualidade assistencial em operadoras de planos de saúde sob a perspectiva dos seus dirigentes, no Brasil

This study aimed to characterize the implementation of clinical guidelines and other instruments and practices for health care quality improvement among health plan operators in Brazil. It was a national cross-sectional descriptive study, initially considering 1,573 health plan operators registered in the National Agency for Supplementary Health Care. The sample design was complex, stratified by macro-region, market segment, and number of beneficiaries. Ninety health plan operators agreed to participate and were interviewed. To obtain estimates for the universe of health plan operators, a sample expansion factor attributed per stratum was considered. Only 32.3% of the health plan operators implemented clinical guidelines, with important variation across regions and market segments. Clinical governance practices are still in the very initial stages. Challenges are presented with regard to health care incorporation as a dimension of management within health care organizations, including health plan operators. Initiatives to improve quality of care need to be integrated and conducted at the organizational level.

Talking towards excellence: a theoretical underpinning of the dialogue between doctors and managers

PurposeTo explore theoretically the reasons for the modest uptake of clinical governance practices by taking the literature on the origin of tensions between doctors and managers as the starting‐point.Design/methodology/approachThe approaches of doctors and managers to the division and coordination of medical work are analysed theoretically from a twofold perspective that combines insights from sociologists' theories on “professionalism” and administrative scientists' theories on “management science”.FindingsThe combined perspective theoretically explains the problems between doctors and managers that frustrate the uptake of clinical governance practices. By inference from this theoretical analysis, a twofold agenda for a constructive dialogue is proposed. Doctors and managers must develop a shared vision of the division and coordination of medical work as well as discussing the values, norms and goals underlying patient care. It is questionable, however, whether this agenda is currently adequately addressed.Originality/valueThis paper provides a theoretical underpinning for the dialogue between doctors and managers. It may be enlightening for all doctors and managers working in the field.