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In this month’s edition of Healthcare Review – OnlineTM, we are pleased to present the proceedings from the Clinical Governance in Healthcare forum held in Auckland, New Zealand, on 4 April 2000.
The one-day forum, convened by RH Penny Ltd, examined the concept and experience of clinical governance with the objective of more fully defining the concept and its relevance to New Zealand in terms of quality care and professional practice.
Clinical governance involves organisational accountability for the effective use of resources, clinical practice and performance, as well as health outcomes. It arises from the need to ensure patient safety.
Patient safety has traditionally been viewed as the individual responsibility of health professionals and clinicians. However, international concern about the broader dimensions of quality and patient safety has led to the emergence of the concept of clinical governance. Recent problems with clinical performance in the UK and New Zealand have demonstrated the need for robust organisational systems and accountabilities.
Questions exist in relation to the structures, systems and culture that need to be established to empower clinical staff in the leadership and management of quality health in a context of limited resources.
Clinical governance was introduced by the Blair Government in the UK in response to concern over adverse incidents and the need to increase clinical accountability.
The concept initially involved directors and chief executives having clinical as well as financial responsibility for their institutions. This has been extended to include clinicians and managers. Clinical governance is being implemented throughout England, driven by the NHS (National Health Service) Board.
In 1993 the New Zealand government established commercially focussed health services. This has led to health purchasing arrangements and service structures focussed on products of health care such as volumes of outputs rather than integration and quality outcomes. This environment has required managers to focus on commercial goals, often in conflict with the professional cultures and priorities of clinicians. Clinical leadership, sidelined during this period of emphasis on financial viability, is now being revitalised, as evidenced by the emergence of independent practitioner associations (IPAs), credentialling and a shift towards increased involvement of clinicians in decision-making in many hospital and health services.
The Clinical Governance in Healthcare forum opened with a welcome from Dr Michael Powell, Professor of Health Management, The University of Auckland, and opening remarks from the Chair, Mr Rex Paddy, General Manager, Starship Hospital, Auckland.
Professor Aidan Halligan, Professor of Fetal Medicine, Leicester Royal Infirmary, England, described the nature of clinical governance and reviewed key elements of the concept and related issues experienced in the UK. Using his UK experience as Director of the NHS Clinical Governance Support Team (CGST), he focussed on key issues in the implementation of clinical governance, approaches to the management of cultural and attitudinal change, and the education and training requirements of implementation.
The CGST is responsible for designing and delivering a clinical governance development programme to manage the implementation of clinical governance in England. This involves boosting the profile of clinical governance in the NHS, providing a practical clinical governance development programme for health care professionals, capturing best practice and disseminating the lessons learned. The Clinical Governance Development Programme is a shared learning programme that aims to empower and equip health care professionals to lead and achieve real improvements in the delivery and outcomes of health care. The ultimate aim is to "make a difference" to patients and their experience of the health services provided.
Successful achievement of the CGST’s goals depends on the professional–patient partnership being supported by five key elements:
- systems awareness
- teamwork
- communication
- ownership
- leadership.
The programme will provide support and guidance to programme delegates as well as the knowledge and skills required to continually improve patient care and to make "a real and owned difference" within an organisation. This process lies at the heart of any meaningful implementation of clinical governance.
[View Professor Halligan’s presentation, The Meaning of Clinical Governance]
Mr Ron Paterson, Deputy Director-General, Safety and Regulation, Ministry of Health, reviewed legal and ethical issues arising from incompetent practice by health professionals.
Mr Paterson considered professional collegiality and the reasons why doctors may be slow to report colleagues they believe to be incompetent. He set out the ethical and legal responsibilities of medical practitioners in this area, the role of the Health and Disability Commissioner and the rights of patients as set out in the Code of Rights.
[View Mr Paterson’s presentation, Incompetent Health Professionals]
Dr David Rankin, CEO, ACC Healthwise, reviewed ACC benchmarking and evaluation.
Dr Rankin outlined ACC’s purchasing directive, which sets out treatment requirements, for example, that treatment must be necessary and appropriate, of a quality appropriate for the purpose, and delivered at a time appropriate for the purpose. He described the various roles of ACC – Healthwise, including work with health service providers to define service delivery models, and identifying and encouraging best practice and optimal purchasing frameworks.
He considered the monitoring and evaluation of providers, reviewing prerequisites to evaluation such as defined outcome expectations.
[View Dr Rankin’s presentation, Evaluation of Clinical Practice]
Dr Peter Gow, Chairman, Clinical Board, South Auckland Health, considered physician peer review and the credentialling process at South Auckland Health (SAH).
He outlined the quality structure at SAH, highlighting key relationships, and described quality improvement activities at SAH including accreditation policies, guidelines and clinical pathways, clinical audits and the credentialling process.
Dr Gow defined credentialling, as per SAH Clinical Board policy: "Individual credentialling is the establishment of the range of activities that health workers can undertake in disciplines where specialised knowledge and skill is required. The skills of individuals need to be determined to ensure they do not practise outside their range of competencies." Clinical Board policy also sets out the principles behind credentialling: peer review occurs; external assessors are involved in the process; confidentiality for credentialling data is crucial; agreement to participate is in the contract and; professional groups in each service shall develop a framework. He went on to describe the structure used in credentialling, and, using rheumatology as an example, outlined the process of credentialling.
[View Dr Gow’s presentation, Peer Appraisal – Physician Credentialling at South Auckland Health]
In his presentation, "Evidence-based Health Care and Clinical Governance", Professor Rod Jackson, Professor of Epidemiology, Faculty of Medical and Health Sciences, The University of Auckland, began by defining clinical governance as "when management is clinically as well as financially accountable."
Professor Jackson focussed on evidence-based decision-making: "using more epidemiological and economic evidence (on risks, benefits and costs) more critically, more systematically and more quantitatively (probabilities) to inform decisions made by patients and health care professionals."
He emphasised that the "evidence" in evidence-based health care is "probabilistic" evidence about risks, benefits and harms (and costs) that quantifies uncertainty. He highlighted the issues associated with training health professionals to use "probabilistic" evidence, given that they are trained to believe that health outcomes are produced by a causal chain of events (deterministic).
Professor Jackson went on to use a number of examples to illustrate evidence-based decision-making.
Summarising why evidence-based decision-making is required, Professor Jackson pointed to the wide variation in clinical practice, the increasing numbers of effective interventions and an unknown number of ineffective interventions. He highlighted the need to stop ineffective interventions and to prioritise effective interventions, and observed that this requires valid, reliable and relevant probabilistic evidence of risks, benefits, harms (and costs).
He noted that new evidence is constantly being generated but is not accessed. As a result, knowledge and performance deteriorates over time. It is evidence-based practice, not traditional continuing education programmes, that improve performance.
Professor Jackson concluded that evidence-based decision-making is the foundation on which clinical governance must be built. It is the responsibility of health care management to ensure the practitioners in their organisations are supported to make evidence-based decisions.
[View Professor Jackson’s presentation, Evidence-based Health Care and Clinical Governance]
Presenters’ Profiles
Professor Aidan WF Halligan is a graduate of Trinity College Dublin and became Professor of Fetal Maternal Medicine at the University of Leicester and Leicester Royal Infirmary in October 1997. Professor Halligan’s main research interests are hypertensive disorders of pregnancy and health services research. As Obstetric Head of Service, Professor Halligan led a process redesign project team that facilitated the reconfiguration of maternity services to implement clinical governance at the Leicester Royal Infirmary. Professor Halligan has been appointed to the post of Director of Clinical Governance for the NHS and Head of the NHS Clinical Governance Support Team. This is a two-year secondment and he will retain a regular clinical and research commitment at Leicester Royal Infirmary and the University of Leicester during that time.
[View Professor Halligan’s presentation, The Meaning of Clinical Governance]
Mr Ron Paterson taught at the Faculty of Law, The University of Auckland, 1986–99. He has published papers and given conference addresses on a wide range of topics in health care law and ethics, including HIV and AIDS, confidentiality, rationing and human rights, and patients’ rights.
Mr Paterson was Fulbright Visiting Professor of Biomedical Ethics at Case Western Reserve University in Cleveland, Ohio, in 1993. He was contracts manager for medical/surgical services at North Health in 1994–95, and worked for the Ministry of Health in various roles related to mental health, public health, and consumer protection, from 1995–98. In 1998–99 he was a Harkness Fellow in Health Care Policy at Georgetown University in Washington DC, and completed a research project on implementation of patients’ rights legislation in the United States. He took up an appointment as Deputy Director-General, Safety & Regulation, at the Ministry of Health, in December 1999.
[View Mr Paterson’s presentation, Incompetent Health Professionals]
Dr David Rankin is the Chief Executive Officer of ACC – Healthwise, a wholly owned subsidiary of the Accident Compensation Corporation, where he has worked since January 1998. This position has responsibility for purchasing health services for the 1.5 million New Zealanders who suffer accident-related injuries each year. These services range from physiotherapy and ambulance services through primary, secondary and tertiary care. With a health services purchasing budget of $640 million, Healthwise maintains a register of over 11,500 providers. Currently Healthwise administers over 750 contracts for some 35 different types of health service. Dr Rankin holds a Masters in Health Administration and a Masters in Public Health, from Lorna Linda University in California. He gained a Diploma in Obstetrics from The University of Auckland in 1985 and a MBChB from the University of Otago in 1982.
[View Dr Rankin’s presentation, Evaluation of Clinical Practice]
Dr Peter Gow is a practising rheumatologist and Clinical Director of Rehabilitation at South Auckland Health (SAH). He has a longstanding interest in quality improvement and has presented at conferences in Australia, New Zealand and Europe and published articles in the quality literature. Since 1998 he has been the Chairman of the SAH Clinical Board which has delegated responsibility for clinical governance. He has been involved in the development of national clinical guidelines and the implementation of local clinical pathways, and is at present on CLANZ/Ministry of Health and CCMAU working parties looking at a balanced scorecard approach to performance management. From 1993 to 1998 he was Clinical Director of Medical and Rehabilitation Services and in this role was responsible for the credentialling of physicians at SAH. He is the New Zealand Quality Assurance Convenor, and a member of the Maintenance of Professional Standards and Quality Assurance Committee and the Royal Australasian College of Physicians.
[View Dr Gow’s presentation, Peer Appraisal – Physician Credentialling at South Auckland Health]
Professor Rod Jackson is Professor of Epidemiology and Head of the Department of Community Health in the Faculty of Medicine and Health Science at The University of Auckland. He is also the director of the Effective Practice Institute, which was established in the Faculty of Medicine and Health Science in 1999 to undertake teaching, research and consultancies in evidence-based health care practice. His main research area has been cardiovascular disease epidemiology, and over the last 10 years his major interest has been getting research into practice, both in public health and clinical practice. He is the "architect" of current New Zealand guidelines on the management of raised blood pressure and dyslipidaemia in clinical practice.
[View Professor Jackson’s presentation, Evidence-based Health Care and Clinical Governance]
