Implementation of Clinical Governance in the NHS

1. Establishing leadership from the NHS Trust Board down through each organisation together with accountability and working arrangements, eg, establishment of quality, clinical governance and accountability structures.
2. Carrying out a baseline assessment of the organisational capability and capacity of each organisation in relation to its current performance vis-à-vis the quality of the care it offered.
3. Putting together a plan for developing clinical governance within each organisation such as closing gaps in performance as against standards, developing a suitable infrastructure and identifying and responding to related staff development needs.
4. Clarifying reporting arrangements to NHS Trust Boards, Health Authorities, primary care trusts and ensuring appropriate reporting mechanisms were in place.

Freeman et al surveyed the NHS Trusts’ early development of clinical governance across the Southwest and West Midland regions in mid 1999 ¹. Both results were very similar and showed that, while there was encouraging evidence about the successful implementation of the four key steps, in that much had been achieved, there was considerable variation in the rate of progress of different NHS Trusts. The data suggested that change had occurred at the corporate level in response to the implementation of clinical governance but change was not consistent at a department or directorate level. Nor had resources been allocated to systems for quality improvement at the middle management level.

The reviewers noted widespread concern from those surveyed at the need for change when resources were so constrained and cautioned the NHS Executive and the Commission for Health Improvement (CHI) of the need to make available significant incentives, and possibly sanctions, to maintain momentum. (This need for incentives appears to have been accepted, as details in the new NHS plan for Investment and Reform spell out financial and performance incentives to be made available to high performing NHS organisations ².

Other issues that were highlighted in these reviews centred on potential barriers to the full development of clinical governance and the implementation of quality systems, particularly in bringing together risk management and continuous quality improvement systems and making them work at the ground level. Those staff surveyed within NHS Trusts expressed concern at the necessity of changing the culture in the face of professional boundary keeping and identified existing barriers to teamwork. As well, there was a general lack of confidence and knowledge at all levels within NHS Trusts in relation to implementing clinical governance. This was particularly relevant given that existing systems intended to improve the quality of health care were only partially operative or, in some cases, non-effective.

These results were consistent with two further studies performed in 1999. Firstly, Wright et al reported on 14 one-to-one interviews with representatives of primary care trusts in four different English counties ³. The interviews focused on the four key steps, the implementation of clinical governance and the structures/resources that existed to support the implementation. The reviewers concluded that the cultural and attitudinal changes required to be made in order to implement such a concept as clinical governance were vast. These included issues of developing trust and a "no blame" culture, changing work practices at the ground floor level to incorporate team work, as well as developing shared understanding and ownership between professional groups. The report concluded that these cultural changes needed to occur at the earliest opportunity and that sufficient resources committed to enable staff to effect these cultural changes.

Secondly, Fitz-Cohens interviewed and/or surveyed 220 health service staff across all key professions, including chief executives, to ascertain their individual development needs in terms of clinical governance ⁴. The response showed that clinical governance was being implemented within a climate of goodwill but that detailed knowledge of clinical governance was rare. Clinical staff needed clinical audit skills (review processes), risk management skills and team leadership skills. Principal barriers to implementation by this group were lack of time, lack of knowledge about clinical governance and evidence-based practice together with isolation from their colleagues. Chief executives needed other developing partnerships against which to benchmark their own progress, clinical governance systems approaches and knowledge of how to develop a no-blame culture as well as how to involve the public in providing feedback on the quality of service received. Clinical governance co-ordinators needed communication and information dissemination skills, knowledge about developing a no-blame culture, risk management skills, team development training and change management skills.

That NHS staff were having difficulty grappling with the implementation of clinical governance, with the initial four steps, is not surprising given the government’s short timeframe from policy announcement to policy implementation. The concept and policy were first announced in the paper entitled "A First Class Service" by the NHS Executive in August 1998 and were implemented within eight months via an NHS Executive circular in March 1999.

Baker et al described the agenda as ambitious and saw that considerable resources must be allocated to underpin the scheme so as to prevent failure from the outset⁵. Garside from the Judge Institute, Cambridge University, has demonstrated that change is not a sequential programmed approach, rather it includes elements of rationality and irrationality, variability between individual people’s responses, uptake of change, learning and decision-making, and often fails because leaders and their employees have differing views of change ⁶. For leaders it is opportunistic, while for staff it can be disruptive and intrusive. Garside, using lessons from organisational development and change theory for quality improvement in health care, identified three key elements for successful change:

1. Change should be driven by a vision with the context of why, when and what is to be achieved spelt out;
2. The culture of an organisation needs to be receptive for change to occur. Perceptions and behaviours of individual stakeholders and recipients acknowledged and buy-in achieved. Change itself should be supported by a learning environment; and
3. Attention needs to be focused on the implementation process of change in that there should be a flexible approach to managing the process.

The report concluded with recommendations to involve staff in the process of change, to communicate effectively and to train and develop individual people for their new roles as well as encouraging them to promote and be involved in the outcomes of change.

The NHS Executive’s response to the need for providing additional support, training and development for organisations and staff involved in the implementation of clinical governance was to establish a Clinical Governance Support Team in August 1999.

The team, based in Leicester and covering the whole of England, was established with three key aims: eg, to heighten the awareness of clinical governance by the provision of information; to provide a practical development programme for health care professionals; and to aid in the acceleration of the implementation clinical governance.

Clinical Governance Support Team

Introduction

The Clinical Governance Support Team’s (CGST’s) initiative focuses on change at the ground level within the health services. The team offers practical support, training programmes, a helpline to deal with general enquiries and to provide information on its activities, as well as a website with up-to-date information on clinical governance and its implementation, examples of best practice and online access to the CGST ^7,8.

The Clinical Governance Development Programme receives most emphasis within this initiative.

The programme is open to all NHS organisations providing health care in England. Self-referrals to undergo the development programme are received from members of multidisciplinary teams within NHS Trusts and can arise from any service delivery specialty, e.g. primary, community, secondary or tertiary. Teams are comprised of two or three people are usually made up of lead medical, nursing or allied health clinicians, together with their immediate manager. The team’s referral is endorsed by their Chief Executive and each team selects from their own service area an issue on which they will work.

Formal learning sessions are spaced as five separate days within a nine-month period and are based on the principles of transformational change using leadership, systems awareness, teamwork, communication and ownership to develop solutions to the achievement of high quality care and patient-focused service delivery. Ideally delegates should be those whom their organisations "need" rather than those they can "spare" and health professionals and/or managers who can influence, motivate and lead change within their area of work. Delegates need approval from their chief executive prior to applying for a place on the programme ^7,8.

Focus of the Development Programme

The focus of the programme is on providing a developmental approach of shared learning, mentoring and coaching to participating teams ^7,8.

This approach is intended to empower and equip frontline health professionals and their immediate managers to lead and achieve actual improvement in the delivery, the quality, clinical accountability and outcome of patient health care.

The action-based learning process underpinning these changes incorporates, initially, the teams gaining buy-in from key stakeholders in their service area or organisation. This is followed by a review of current service delivery, gaining agreement on the changes required to improve the service, implementing the changes and bedding down success. This process is described by the CGST as RAID, ie, Review, Agree, Implement and Demonstrate. The learning days are based on a concept of shared learning and take place prior to commencing the next phase; they are highly interactive. The learning sessions equip participants at all levels to facilitate and manage transformational change.

The programme provides the knowledge and skills to establish a learning environment in the workplace, to change the organisational culture, to continually improve the clinical accountability for and quality of health care as well as integrating and co-ordinating the client care pathway.

Between the learning days, participants are mentored and coached by their team’s project managers to assist them to put into practice what they have learned and to achieve time-framed action goals related to the review process.

The programme includes: ⁹

• Achieving buy-in for change internally and externally with their organisations;
• Preparing for a grass-roots review of their current grass-roots service;
• Reviewing their current service, using leadership, communication and ownership skills;
• Utilising best practice evidence-based practice guidelines in developing recommendations;
• Gaining widespread agreement and commitment to the recommendations;
• Setting up an implementation team;
• Implementing change, measuring success, overcoming barriers/resistance, prioritising developments; and
• Demonstrating/evaluating the success and sharing the lessons learnt.

Structure of the Programme ^7,8

Day One - (of five spread across nine months)
	Change is made possible by:
		establishing a learning culture valuing people influencing people emoving barriers to change preparing for a review achieving buy-in from key stakeholders.
	Key interval actions
		ensure commitment of the board and senior management within the organisation to supporting the team and the change process secure time, resources and support for the proposed programme of change.
Day Two -
	Review processes:
		doing a grass-roots review defining leadership, communication and ownership distilling the key messages.
	Key interval action:
		undertake a review of the current service within the organisation.
Day Three -
	Achieving agreement:
		ongoing communication and ownership leadership styles planning and monitoring preparing for implementation.
	Key interval actions:
		gain widespread agreement and commitment to the review recommendations development of the implementation team(s).
Day Four -
	Implementation:
		making it happen measuring and monitoring for success troubleshooting and overcoming barriers prioritising developments identifying achievements.
	Key interval action:
		develop a number of projects to implement the recommendations.
Day Five -
	Demonstrate the benefits:
		determining whether the programme has made a difference? ascertaining whether these benefits continue? identifying lessons learnt sharing the learning bedding down the changes with ongoing monitoring.
	Key interval actions:
		demonstrate the success bed the changes down into ongoing service delivery undertake ongoing monitoring for quality.

 

The Clinical Governance Support Team and its Role

Considerable resources have been committed to this team. It is led by a senior clinician, Professor Aidan Halligan who, in his role as Professor of Foetal Medicine, has successfully implemented this type of change in the Leicester Royal Infirmary. A nurse manager manages the team on a day-to-day basis. Other team members include: a director of education, who delivers the training; a programme director, responsible for the development of the training programme; a communications manager; an information manager; a researcher; four project managers (coaches and mentors during the intervals between training); and five administration/personal assistants.

Professional team members have all been seconded from their parent organisations for an initial two-year period, which ends August 2001. The key roles which team members undertake externally are training, influencing, networking, communicating and informing throughout all levels of the NHS system. Strategic communication and networking links with other key NHS initiatives, such as the Commission for Health Improvement (CHI), National Institute for Clinical Excellence (NICE) and Primary Health Care Initiatives ^7,8 are well developed.

Professor Halligan is currently a member of the NHS executive and his dual roles provide a means of strategic co-ordination between the national NHS plan and the process for change.

Communicating the team’s role and functions involves the team manager and project managers "marketing" these to NHS trusts and health care professionals in meetings and other forums. The communications and information managers also assist by providing audio-visual material and written handouts.

As at June 2000 the team’s outputs were as follows: ^7,8

• 70 teams from acute/ambulance/primary/mental health were engaged in the learning/action programmes.
• 804 enquiries had been received from the helpline since its inception
• 11,000 people had been talked to in 20 separate public engagements.