Making clinical governance work
http://www.100md.com
《英国医生杂志》
1 Centre for Clinical Management Development, University of Durham, Stockton on Tees TS17 6BH, 2 Centre for Clinical Governance Research, University of New South Wales, Sydney, Australia, 3 School for Health, University of Durham
Correspondence to: D J Hunter d.j.hunter@durham.ac.uk
The current focus on quality and safety means most doctors have negative views about clinical governance. But done properly, clinical governance has the power to improve NHS performance
Introduction
The failure to take account of variations in clinical work has two main effects on clinical governance. Firstly, it is removed from the day to day concerns of clinical staff. For example, clinical governance is incapable of tackling questions such as: "How can we improve our procedures for a normal delivery?" or "how we provide a year of care for a patient with diabetes?" Secondly, by divorcing issues of risk and safety from the specifics of providing care to a nominated patient group, the prevailing model encourages clinicians to view clinical governance as a management driven exercise that has exploded their paperwork to the detriment of patient care.6 7 This perception has resulted in many staff rejecting clinical governance as yet another misconceived attempt by politicians to extend their control over frontline care.6 7
What needs to be done?
The self governance of clinical performance and organisation by multidisciplinary teams requires structures and practices that will encourage multidisciplinary teams to engage in conversations that are focused on the detailed composition of care for specific conditions. Such conversations would deal with questions such as:
Are we doing the right things? (Given assessed health needs and existing resource constraints, are we delivering value for money? For common conditions, how appropriate and effective are the services we offer?)
Are we doing things right? (Are we managing clinical performance according to national codes of clinical practice? For common conditions, how systematised are our care processes and how are we performing on risk, safety, quality, patient evaluation, and clinical outcomes?)
Are we keeping up with new developments and what are we doing to extend our capacity to undertake clinical work in these areas? (What strategies are in place for service and professional development for each condition? What are we doing about clinical mentoring, leadership development, and staff appraisal and review?)
Enabling these conversations requires action at the level of both clinical practice and organisational structure. At the practice level, it requires the development and implementation of integrated care pathways for high volume case types—for example, normal deliveries, hip replacements, patients with chronic obstructive pulmonary disease. These pathways describe the diagnostic and therapeutic events that will appreciably affect the quality, outcomes, and cost of care. Use of integrated care pathways for systematising care extends the evidence base, strengthens service integration, and improves clinical effectiveness, quality, and technical efficiency as well as patients' satisfaction and clinicians' work experience.8-12
Integrated care pathways are not immutable documents setting out inviolable treatment regimens. Variation remains an expected feature of clinical practice. What is at stake is the learning a clinical team can derive from these variations. When variation occurs, documentation of the variances can become part of structured interprofessional conversations. It is neither realistic nor useful to consider systematising all clinical work. Nevertheless, about half of a hospital's clinical workload is accounted for by a relatively small number of conditions that are amenable to systematisation (box)13.
Patient activity of four NHS trusts in England during 2000-213 categorised into 547 health related groups
30 health related groups accounted for 46% of all emergency inpatient episodes and 39% of all emergency generated bed days
30 groups accounted for 53% of inpatient elective episodes and 47% of elective bed days
30 groups accounted for 75% of day elective episodes
At the level of structure, we need to set in place clinical governance arrangements along the lines depicted in figure 3. In this model, clinical governance becomes a mechanism for encouraging and supporting clinicians in specialist units to systematically and routinely review their unit's performance on its high volume case types. For example, figure 3 depicts an orthopaedics unit reviewing its care for patients with fractured neck of femur. This review would involve surgeons, nurses, rehabilitation physicians, physiotherapists, occupational therapists, mental health specialists, and social workers. The same structure could apply in primary care, with each clinical unit (a general practice or community nursing service) reporting on the year of care provided to patients with conditions such as diabetes, chronic obstructive pulmonary disease, or chronic heart disease. The reports for each clinical condition would include data on evidence, cost, outcomes, clinical effectiveness, quality, safety, adverse events, variance, and complaints.
Fig 3 Pathway focused clinical governance in acute settings
Where we are and where we want to be
Leatherman S, Sutherland K. The quest for quality in the NHS: a mid-term evaluation of the ten-year quality agenda. London: Nuffield Trust, 2003.
Gray A, Harrison S, eds. Governing medicine: theory and practice. Buckingham: Open University Press, 2004. (Chapters 2, 6, 8, 11, 12.)
Scally G, Donaldson LJ. Looking forward: clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998;317: 61-5.
Secretary of State for Health. A first class service. Quality in the new NHS. Leeds: NHS Executive, 1998. www.nhshistory.net/a_first_class_service.htm (accessed 3 Sep 2004).
Degeling P, Maxwell S, Macbeth F, Kennedy J, Coyle B. The impact of CHI: some evidence from Wales. Qual Primary Care 2003;11: 147-57.
Degeling P, Macbeth F, Kennedy J, Maxwell S, Coyle B, Telfer B. Professional subcultures and clinical governance implementation in NHS Wales: a report to the National Assembly for Wales. Durham: Centre for Clinical Management Development, University of Durham, and College of Medicine, University of Wales, 2002.
Degeling P, Kennedy J, Macbeth F, Telfer B, Maxwell S, Coyle B. Practitioner perspectives on objectives and outcomes of clinical governance: some evidence from Wales. In: Gray A, Harrison S, eds. Governing medicine: theory and practice. Buckingham: Open University Press, 2004: 60-77.
Gregory C, Pope S, Werry D, Dobek P. Reduced length of stay and improved appropriateness of care with a clinical path for total knee or hip arthroplasty. J Qual Improvement 1996;22: 617-27.
Johnson S. Pathways of care: what and how? J Managed Care 1997;1: 15-7.
Flynn AM. Case management: a multidisciplinary approach to the evaluation of cost and quality standards. J Nurs Care Qual 1993;1: 58-66.
Guiliano KK, Poirier CE. Nursing care management: critical pathways to desirable outcomes. Nurs Manage 1991;22: 52-5.
Poole DL. Care profiles, pathways and protocols. Physiotherapy 1994;80: 256-66.
Degeling P, Maxwell S, Kennedy J, Coyle B. Commissioning for performance—but what is the work? An analysis of the commissioning implications of activity data in four health economies in northern England. Public Manage Money (in press).
Edwards N, Marshall M. Doctors and managers. BMJ 2003;326: 116-7.
Marnoch G. Doctors and management in the National Health Service. Buckingham: Open University Press, 1996.
Degeling P. Reconsidering clinical accountability. An examination of some dilemmas inherent in efforts to bolster clinician accountability. Int J Health Plann Manage 2000;15: 3-16.
Degeling P, Kennedy J, Hill M. Mediating the cultural boundaries between medicine, nursing and management—the central challenge in hospital reform. Health Serv Manage Res 2001;14: 36-48.
Rose N. Identity, genealogy, history. In: Hall S, du Gay P, eds. Questions of cultural identity. London: Sage, 1996: 128-50.(Pieter J Degeling, profes)
Correspondence to: D J Hunter d.j.hunter@durham.ac.uk
The current focus on quality and safety means most doctors have negative views about clinical governance. But done properly, clinical governance has the power to improve NHS performance
Introduction
The failure to take account of variations in clinical work has two main effects on clinical governance. Firstly, it is removed from the day to day concerns of clinical staff. For example, clinical governance is incapable of tackling questions such as: "How can we improve our procedures for a normal delivery?" or "how we provide a year of care for a patient with diabetes?" Secondly, by divorcing issues of risk and safety from the specifics of providing care to a nominated patient group, the prevailing model encourages clinicians to view clinical governance as a management driven exercise that has exploded their paperwork to the detriment of patient care.6 7 This perception has resulted in many staff rejecting clinical governance as yet another misconceived attempt by politicians to extend their control over frontline care.6 7
What needs to be done?
The self governance of clinical performance and organisation by multidisciplinary teams requires structures and practices that will encourage multidisciplinary teams to engage in conversations that are focused on the detailed composition of care for specific conditions. Such conversations would deal with questions such as:
Are we doing the right things? (Given assessed health needs and existing resource constraints, are we delivering value for money? For common conditions, how appropriate and effective are the services we offer?)
Are we doing things right? (Are we managing clinical performance according to national codes of clinical practice? For common conditions, how systematised are our care processes and how are we performing on risk, safety, quality, patient evaluation, and clinical outcomes?)
Are we keeping up with new developments and what are we doing to extend our capacity to undertake clinical work in these areas? (What strategies are in place for service and professional development for each condition? What are we doing about clinical mentoring, leadership development, and staff appraisal and review?)
Enabling these conversations requires action at the level of both clinical practice and organisational structure. At the practice level, it requires the development and implementation of integrated care pathways for high volume case types—for example, normal deliveries, hip replacements, patients with chronic obstructive pulmonary disease. These pathways describe the diagnostic and therapeutic events that will appreciably affect the quality, outcomes, and cost of care. Use of integrated care pathways for systematising care extends the evidence base, strengthens service integration, and improves clinical effectiveness, quality, and technical efficiency as well as patients' satisfaction and clinicians' work experience.8-12
Integrated care pathways are not immutable documents setting out inviolable treatment regimens. Variation remains an expected feature of clinical practice. What is at stake is the learning a clinical team can derive from these variations. When variation occurs, documentation of the variances can become part of structured interprofessional conversations. It is neither realistic nor useful to consider systematising all clinical work. Nevertheless, about half of a hospital's clinical workload is accounted for by a relatively small number of conditions that are amenable to systematisation (box)13.
Patient activity of four NHS trusts in England during 2000-213 categorised into 547 health related groups
30 health related groups accounted for 46% of all emergency inpatient episodes and 39% of all emergency generated bed days
30 groups accounted for 53% of inpatient elective episodes and 47% of elective bed days
30 groups accounted for 75% of day elective episodes
At the level of structure, we need to set in place clinical governance arrangements along the lines depicted in figure 3. In this model, clinical governance becomes a mechanism for encouraging and supporting clinicians in specialist units to systematically and routinely review their unit's performance on its high volume case types. For example, figure 3 depicts an orthopaedics unit reviewing its care for patients with fractured neck of femur. This review would involve surgeons, nurses, rehabilitation physicians, physiotherapists, occupational therapists, mental health specialists, and social workers. The same structure could apply in primary care, with each clinical unit (a general practice or community nursing service) reporting on the year of care provided to patients with conditions such as diabetes, chronic obstructive pulmonary disease, or chronic heart disease. The reports for each clinical condition would include data on evidence, cost, outcomes, clinical effectiveness, quality, safety, adverse events, variance, and complaints.
Fig 3 Pathway focused clinical governance in acute settings
Where we are and where we want to be
Leatherman S, Sutherland K. The quest for quality in the NHS: a mid-term evaluation of the ten-year quality agenda. London: Nuffield Trust, 2003.
Gray A, Harrison S, eds. Governing medicine: theory and practice. Buckingham: Open University Press, 2004. (Chapters 2, 6, 8, 11, 12.)
Scally G, Donaldson LJ. Looking forward: clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998;317: 61-5.
Secretary of State for Health. A first class service. Quality in the new NHS. Leeds: NHS Executive, 1998. www.nhshistory.net/a_first_class_service.htm (accessed 3 Sep 2004).
Degeling P, Maxwell S, Macbeth F, Kennedy J, Coyle B. The impact of CHI: some evidence from Wales. Qual Primary Care 2003;11: 147-57.
Degeling P, Macbeth F, Kennedy J, Maxwell S, Coyle B, Telfer B. Professional subcultures and clinical governance implementation in NHS Wales: a report to the National Assembly for Wales. Durham: Centre for Clinical Management Development, University of Durham, and College of Medicine, University of Wales, 2002.
Degeling P, Kennedy J, Macbeth F, Telfer B, Maxwell S, Coyle B. Practitioner perspectives on objectives and outcomes of clinical governance: some evidence from Wales. In: Gray A, Harrison S, eds. Governing medicine: theory and practice. Buckingham: Open University Press, 2004: 60-77.
Gregory C, Pope S, Werry D, Dobek P. Reduced length of stay and improved appropriateness of care with a clinical path for total knee or hip arthroplasty. J Qual Improvement 1996;22: 617-27.
Johnson S. Pathways of care: what and how? J Managed Care 1997;1: 15-7.
Flynn AM. Case management: a multidisciplinary approach to the evaluation of cost and quality standards. J Nurs Care Qual 1993;1: 58-66.
Guiliano KK, Poirier CE. Nursing care management: critical pathways to desirable outcomes. Nurs Manage 1991;22: 52-5.
Poole DL. Care profiles, pathways and protocols. Physiotherapy 1994;80: 256-66.
Degeling P, Maxwell S, Kennedy J, Coyle B. Commissioning for performance—but what is the work? An analysis of the commissioning implications of activity data in four health economies in northern England. Public Manage Money (in press).
Edwards N, Marshall M. Doctors and managers. BMJ 2003;326: 116-7.
Marnoch G. Doctors and management in the National Health Service. Buckingham: Open University Press, 1996.
Degeling P. Reconsidering clinical accountability. An examination of some dilemmas inherent in efforts to bolster clinician accountability. Int J Health Plann Manage 2000;15: 3-16.
Degeling P, Kennedy J, Hill M. Mediating the cultural boundaries between medicine, nursing and management—the central challenge in hospital reform. Health Serv Manage Res 2001;14: 36-48.
Rose N. Identity, genealogy, history. In: Hall S, du Gay P, eds. Questions of cultural identity. London: Sage, 1996: 128-50.(Pieter J Degeling, profes)