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Clinical governance might not be in the forefront of everyone’s mind 24/7 but it is key to continuous quality improvement which is important for patient care at all levels.
Our patients rightly ask: why should the safety or responsiveness of my care be different if I’m in a large teaching hospital or attending a community clinic? And we agree. In this article I’m going to set out a series of problems relating to clinical governance and then give a solution which has worked for us in my trust and is continuing to yield positive results.
After a decade in clinical leadership and management I can still be caught out by the unexpected.
Clinical incidents will always occur while imperfect human factors are involved and we will continue to learn from our mistakes. But clinical governance spans so many issues. When an investigation into a drug administration error tells me the cause was a timetabling problem with Foundation doctor training, I know I need a better system to visualise what’s going on.
Question: What could such a helicopter view look like?
The Five Year Forward View sets out the triple aim of improving health and wellbeing, care and quality and funding and efficiency and has a strong emphasis on integrating services.
And mirroring this I think we should have shared clinical governance because patients should experience seamless joined up care. Much of the learning we are generating from the Vanguard new models of care, where we are often joining up services, tells us that clinical teams need to work together differently. Phrases like “trusted assessor” can create issues among colleagues who actually don’t “trust” the assessment being made and want to repeat it – but unnecessary duplication doesn’t help our patients.
Question: What sort of shared clinical governance tool could provide the safety net and confidence clinical teams need to truly work differently?
I come to work because I want to provide a service that is safe, effective, caring, responsive and well led. I think colleagues of any background can readily agree that those are good reasons “why” they come to work. Where it gets messier is when we start to consider all the different factors that affect the quality of our services. Before long we feel like we’re spinning plates and every organisation seems to spin different plates in different ways.
Question: If we can agree “why” we’re at work, then why can’t we agree “what” we need to pay attention to in order to achieve high quality services?
If your organisation or service has been inspected by the Care Quality Commission you will remember the huge amount of preparatory work involved. Many of us will have wondered exactly how we evidence that we are “caring”, or if our infection control procedures are “well led”. I also have experience of working as a CQC inspector and I know how difficult it can be to reach a balanced judgement that is as evidential as possible. Regulation and inspection are right and proper mechanisms for public services to be held to account and provide assurance.
Question: However, wouldn’t it be easier and simpler if the methodology for that quality assurance was transparently comparable?
If we had a system that answered all of those questions we’d start to feel less like we were spinning plates and more like we had a neat way to organise our assurance.
My own organisation has formally approved the use of a methodology for clinical governance through our Quality Committee chaired by Sir Stephen Moss.
The idea is to combine the five domains of quality with the seven pillars of clinical governance into a matrix framework. That 5 x 7 table gives you 35 cells in the matrix. Each of those cells can be populated with the relevant measure or evidence giving assurance of quality. This framework methodology is adaptable and flexible for use with any team, department, service or organisation and beyond. My published paper “The clinical governance of multidisciplinary care” in the International Journal of Health Governance describes this in more detail.
Our Division of Integrated Care includes Business Units for paediatrics, maternity, gynaecology, GU medicine, rehabilitation and elderly care, pharmacy and therapy services. Each service has agreed relevant measures for each cell of their high level clinical governance matrix. We are developing our ability to draw information into the matrix in real time and work to achieve balance across the framework.
The next time CQC come calling we want a system ready to demonstrate assurance of high quality services that are safe, effective, caring, responsive and well led across each of the seven pillars of clinical governance.