Clinical governance

Clinical governance is the term used to describe a systematic approach to maintaining and improving the quality of patient care within a health system. It was originally elaborated within the United Kingdom National Health Service (NHS), and its most widely cited formal definition describes it 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." (Scally and Donaldson, 1998)

This definition is intended to embody three key attributes: recognisably high standards of care, transparent responsibility and accountability for those standards, and a constant dynamic of improvement.

The concept has some parallels with the more widely known corporate governance, in that it addresses those structures, systems and processes that assure the quality, accountability and proper management of an organisation's operation and delivery of service. However clinical governance applies only to health and social care organisations, and only those aspects of such organisations that relate to the delivery of care to patients and their carers; it is not concerned with the other business processes of the organisation except in so far as they affect the delivery of care. The concept of "integrated governance" has emerged to refer jointly to the corporate governance and clinical governance duties of healthcare organisations.

Prior to 1999, the principal statutory responsibilities of UK NHS Trust Boards were to ensure proper financial management of the organisation and an acceptable level of patient safety. Trust Boards had no statutory duty to ensure a particular level of quality. Maintaining and improving the quality of care was understood to be the responsibility of the relevant clinical professions. As of 1999, Trust Boards assumed a legal responsibility for quality of care that is equal in measure to their other statutory duties. Clinical governance is the mechanism by which that responsibility is discharged.

"Clinical governance" does not mandate any particular structure, system or process for maintaining and improving the quality of care, except that designated responsibility for clinical governance must exist at Trust Board level, and that each Trust must prepare an Annual Review of Clinical Governance to report on quality of care and its maintenance. Beyond that, the Trust and its various clinical departments are obliged to interpret the principle of clinical governance into locally appropriate structures, processes, roles and responsibilities.

The elements of clinical governance
Clinical governance is composed of the following elements:
 * Education and Training
 * Clinical audit
 * Clinical effectiveness
 * Research and development
 * Openness
 * Risk management

Education and Training
It is no longer considered acceptable for any clinician to abstain from continuing education after qualification - too much of what is learnt during training becomes quickly outdated. In NHS Trusts, the continuing professional development of clinicians has been the responsibility of the Trust. It has also been the professional duty of clinicians to remain up-to-date.

Clinical audit
Clinical audit is the review of clinical performance, the refining of clinical practice as a result and the measurement of performance against agreed standards - a cyclical process of improving the quality of clinical care. In one form or another, audit has been part of good clinical practice for generations. Whilst audit has been a requirement of NHS Trust employees, in primary care clinical audit has only been encouraged, where audit time has had to compete with other priorities.

Clinical effectiveness
Clinical effectiveness is a measure of the extent to which a particular intervention works. The measure on its own is useful, but it is enhanced by considering whether the intervention is appropriate and whether it represents value for money. In the modern health service, clinical practice needs to be refined in the light of emerging evidence of effectiveness but also has to consider aspects of efficiency and safety from the perspective of the individual patient and carers in the wider community.

Research and development
Good professional practice has always sought to change in the light of evidence from research. The time lag for introducing such change can be very long and reducing time lag and associated morbidity requires emphasis not only on carrying out research, but also on using and implementing such research. Techniques such as critical appraisal of the literature, project management and the development of guidelines, protocols and implementation strategies are all tools for promoting the implementation of research practice.

Openness
Poor performance and poor practice can too often thrive behind closed doors. Processes which are open to public scrutiny, while respecting individual patient and practitioner confidentiality, and which can be justified openly, are an essential part of quality assurance. Open proceedings and discussion about clinical governance issues should be a feature of the framework.

Any organisation providing high quality care has to show that it is meeting the needs of the population it serves. Health needs assessment and understanding the problems and aspirations of the community requires the cooperation between NHS organisations, public health departments, local authorities and community health councils.

The system of clinical governance brings together all the elements which seek to promote quality of care.

Risk management
Risk management involves consideration of the following components:

Risks to patients: compliance with statutory regulations can help to minimise risks to patients. In addition, patient risks can be minimised by ensuring that systems are regularly reviewed and questioned - for example, by critical event audit and learning from complaints.

Risks to practitioners: ensuring that clinicians are immunised against infectious diseases, work in a safe environment and are helped to keep up-to-date are important parts of quality assurance.

Risks to the organisation: poor quality is a threat to any organisation. In addition to reducing risks to patients and practitioners, organisations need to reduce their own risks by ensuring high quality employment practice (including locum procedures and reviews of individual and team performance), a safe environment (including estates and privacy), and well designed policies on public involvement.