Quality improvement in New Zealand healthcare Part 7: clinical governance - an attempt to bring quality into reality Rod Perkins, Allan Pelkowitz, and Mary Seddon Summary and HTML coding for brilliant New Zealand Ltd by Malcolm Macpherson Abstract In this seventh and final article, Perkins et al discuss clinical governance, describing it as clinicians accepting transparent accountability, teamwork rather than individualism, a systems view and the need to share power with others in the clinical domain. And in return, being given the autonomy to do the job they are trained for and the necessary resources. Without these, clinical governance will not be effective. With it, there will be a sound basis for clinicians and managers to work together in contemporary healthcare organisations. The previous six articles identified the need to improve safety and quality of care, examined how quality can be measured, monitored, and improved, and looked at the monitoring interests of the State and District Health Boards and the notion of patient-centred care. This final article looks at how all this could come together in a system that places joint responsibility on clinicians and healthcare managers: frequently referred to as clinical governance. The meaning of clinical governance Clinical governance attempts to link clinical and managerial paradigms, and has been central to the health reform efforts in the UK since the Blair Government took office in the late 1990s. Leaders in medicine defined it at the time as: A framework through which NHS 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. Clinical governance is about process. It is not a method for managers to govern or control doctors, nor is it a method for doctors to govern or control managers or other clinicians. It is quite different from governance in other contexts, such as corporate governance or the sort of governance that goes on in a DHB board meeting. It is not a top-down process, nor is it dominated by the financial imperatives that drive many other business management models. Clinical governance depends on doctors and managers working together, each realising that they have the potential to gain from such collaboration. The elements of clinical governance The reason for investing in clinical governance is to improve quality of care. However, this principle causes a clash of ideologies between those who believe that each patient deserves the best care (typically doctors with a sense of duty towards their patients) and those who have to distribute funding and relate to a population (characteristically board directors and managers within an ethic of utilitarianism, the greatest good for the greatest number). Within the NHS, its introduction was politically and financially supported by the Blair Government. At the same time, a refereed publication The Journal of Clinical Governance was launched and an agency was created for its promotion and development: The NHS Clinical Governance Support Team. In New Zealand and Australia, clinical governance appeared on the agenda because of its promotion by interested doctors and academics. One of the latter, Pieter Degeling, has consistently identified four elements of the process as central to its implementation. This requires doctors to think differently about accountability and autonomy; to accept that their clinical work should be subject to scrutiny by their peers; that teams rather than individuals should be dominant in the delivery of healthcare; and further to accept that decision-making about clinical matters has resource implications that doctors need to manage. Four elements their role in clinical governance 1 Money All clinical decisions have resource implications 2 Autonomy/accountability Balance clinical autonomy with transparent accountability 3 The systems view Support the systematisation of clinical work 4 Power sharing Subscribe to the power sharing implications of team based approaches to clinical work The four propositions may challenge traditional attitudes, beliefs, and behaviours of doctors who in response could ask, what are the managers and funders doing as their contribution to clinical governance? The four elements focus on doctors’ responsibilities primarily because clinicians take a central role in clinical governance by virtue of the fact that they do the clinical work. The attitude required of managers is to acknowledge that the doctor is in charge of decisions that result in cost and income for the organisation, and to facilitate quality systems. How can clinical governance based on these propositions be operationalised. Degeling proposed that hospitals and other providers move away from the traditional quality silos (risk management, quality assurance, accreditation, adverse event reporting, and so on), which characterise existing healthcare organisations to a new structure which would be built around the work of groups of clinical staff who work within a particular service. In the management of heart failure, for example, this might include cardiologists, gerontologists, general physicians, general practitioners, clinical nurse specialists, nurse practitioners, practice nurses, dieticians, community nurses, smoking cessation educators, occupational therapists, psychologists, and others. Clinical governance accepts the multidisciplinary nature of much of modern medical endeavour. Supporters of clinical governance also advocate the use of clinical pathways, evidence-based clinical practice, and clinical audit backed up by appropriate resources to drive quality improvement. There are reasons why clinical governance has struggled to gain standing in New Zealand: Money While it is axiomatic that clinical decisions have resource implications, accepting this first proposition infers some responsibility on clinical staff and doctors, in particular to take the leadership role in the rationing process. This will be acceptable only when the legitimate concerns of doctors on behalf of their patients are given standing. If managers do not support clinical staff when advocating reasonable positions, then doctors will not take difficult rationing decisions. The decision of the Canterbury DHB to remove 5,000 patients who had exceeded the 6-month waiting list limit to satisfy Ministry of Health requirements is a case in point. In a letter from 74 of the Board’s 80 surgeons, it was accepted that healthcare funding was limited but they criticised the Ministry’s waiting list policy that ranked certainty of operation as the prime driver in waiting list management. The letter went on to say that the relative level of funding for the provision of healthcare for patients in our community and who require surgical care in particular is not adequate. CDHB could have handled the process better, especially that it was a mistake not to involve the surgeons in the decision about who should be cut from the waiting list. Here we have a case where it appears that the Government wishes to give patients certainty (about having or not having an operation within 6 months) ahead of prioritising cases according to need. Furthermore, there is a financial penalty for those DHBs that do not comply with this MOH directive. Doctors have come to accept rationing, but not arbitrary rationing which fails to give priority to the most urgent cases. The case illustrates a lack of clinical governance and the resulting disaffection of doctors and patients. Autonomy/accountability The profession adopts high clinical standards via accountability systems that stand up to scrutiny. Doctors practice in an open system that demands public levels of accountability against the backdrop of some members of the public favouring a culture of blaming and shaming. This means that managers, the Ministry of Health, and others including the Health and Disability Commissioner must continue to support a no-blame culture and must support and fund strategies such as clinical audit that enable clinical professionals to be accountable. Doctors need to participate in these programmes and take leadership roles in their management. The systems view A systems view examins how care is delivered, and how it can be redesigned to improve patient experience and outcomes, while understanding the cause of errors and latent system weaknesses. It recognises that healthcare is a complex adaptive system. James Reason has identified three key symptoms of the vulnerable system syndrome that predicts a high risk of error and failure. These are: 1 Blaming front-line individuals 2 Denying the existence of systematic error, provoking weakness 3 Blinkered pursuit of productive and financial indicators By this definition, most of the large healthcare systems in New Zealand are vulnerable to systems failures, trapped in a never-ending cycle of reacting to problems (not training staff to prospectively identify and remedy deficiencies) and ignoring quality problems to focus only on financial bottom-lines. A systems view also focuses attention on the movement of patients across care settings, both horizontally (from one specialist or general practitioner to another) and vertically (from secondary care to primary care and vice versa). Doctors are central to this sort of systematisation and when given the opportunity and training, will take the lead in other types for example with root cause analysis. However, there are examples of doctors standing aside from efforts to systematise. For example, they often leave the development of clinical pathways to nurses and allied health professionals. While managers are attracted to systems, they are in no position to lead their development in clinical settings because they lack the necessary knowledge. This is an area where doctors must increasingly take the lead and where doctors can learn from nurses. Power sharing The training, clinical knowledge, and experience of doctors makes them natural candidates to lead clinical teams. Indeed, historically, they have dominated other members of the healthcare workforce. Clinical governance requires all members of the clinical team to be able to participate as equals. If it is to gain traction in healthcare organisations, doctors will be required to share some of their power. They can do this by encouraging nursing and other colleagues to join key committees and other influential groups. Adopting clinical governance in New Zealand requires attention and energy on four fronts: Managers and doctors knowing what one another are talking about. Recognition on the part of funders and managers of the need for responsible funding of the service where clinical governance is sought. Recognition on the part of clinicians that the four items identified in Table 1 are legitimate. Provision of suitable structures, such as a clinical board and supporting infrastructure. Communication Doctors and managers need to work collaboratively and recognise that they use the same words but often mean different things. For example, doctors and managers frequently use the word accountability; which to the doctor means personal responsibility for their actions (in connection with a patient) and realising that any shortfall may lead to censure, legal action, and (at worst) patient harm. To a manager, the word is used in connection with resources. Managers view accountability in terms of living within budget, achieving output targets, and so on. Clinical governance requires an engagement in conversation and an awareness of different languages. Funding The key is balance. If Governments are to adopt the position of the Secretary of State in the UK (which required managers to put financial management ahead of clinical objectives), then doctors will fail to engage. In contrast, if they adopt agendas that recognise responsible funding, doctors may engage in responsible resource use. Where doctors are employees in healthcare organisations they will recognise as legitimate the four elements. Each is consistent with sound clinical practice and sound management practice. Clinical governance needs infrastructure. In some places it is given direction and standing by having a clinical board. Such a board can develop and support appropriate clinical policy Does clinical governance work? The obvious question: has it has been implemented anywhere and is there any evidence that it improves patient care and outcomes? While it makes intuitive sense, it has not been subject to the sort of critical evaluation that doctors would find convincing. A review of the relevant literature suggests that most articles on this topic appeared before 2002. Clinical governance has been described as building on existing processes for improvement, requiring leadership to integrate processes and drive change at the highest level. However, investigation of the types of improvement methodologies used indicate limited application because of ambivalence among doctors about the impact of clinical governance. While there was often a lot of activity around setting up the structures for clinical governance, little has been reported on improved outcomes. In fact, clinical governance has struggled in most settings to gain the approval and commitment of doctors generally, and has been described as a yet another management tool to control clinicians and a further rehash of previous failed attempts. Clinical governance might be better thought of as a system of management peculiar to health systems where those with the funds and those with clinical skills can work together. Perhaps the answer lies in improving relationships so that each views the other with trust and accepts that each has a valuable role in improving patient care with the judicious use of available funding. Conclusion For clinical governance to work, both doctors and managers have no alternative but to recognise that the values and objectives of each have standing: Doctors need to accept that every clinical decision they make carries an economic consequence that they are using up money for one person that will then not be available for others Managers need to value quality as well as financial risk management. They have to accept that doctors know more about what works for patients than they do. And they have to accept that the doctors make the decisions that cost money. The way clinical governance operates in one locale may be different from the way it functions in another. Irrespective of whether an activity is called clinical governance, the items identified above require appreciation and consideration. Without resources, clinical governance will founder. The articles in this Series have touched on the separate but linked dimensions of healthcare quality: safe, timely, effective, efficient, equitable, and patient-centred. They have identified how to develop indicators or benchmarks, and measure, monitor, and improve the quality of care. Sustainable quality improvement requires leadership from doctors with a continued commitment to work in multidisciplinary teams, and an interest in acquiring the relevant skills.