Clinical governance and infection control in the United Kingdom

The recent organizational changes in the NHS have at their core the concept of clinical governance. Although initially poorly defined and understood this term has now taken on a clear identity, placing quality alongside fiscal probity and corporate governance at the top of NHS priorities. Integral to clinical governance are the basic elements of clear national standards for services and treatments that are to be locally delivered through assured, monitored, high quality healthcare. It is within this framework that workers in infection control must develop their own methods of applying clinical governance. This review explores the implications that the strategy of clinical governance holds for the speciality of infection control, emphasizing the benefits its active adoption can bring and highlighting the key relevance of clinical risk management in this setting. It illustrates clinical governance as a tool to engage colleagues on a multi-disciplinary front, most particularly the crucial link to senior Trust management.     

Clinical governance: its origins and its foundations

This article from the NHS Clinical Governance Support Team (NCGST) outlines the development of quality concerns since the NHS was founded in 1948. It traces the development of clinical governance as a means of achieving continuous quality improvement and describes what the implementation of clinical governance means for patients and professionals. It analyses features of the cultural shift necessary to underpin quality improvement initiatives and describes with practical examples the constituents of the culture necessary for successful clinical governance. Future articles in this series will address other issues around clinical governance and will explain the model being followed by delegates to the NCGST's Clinical Governance Development Programme as they implement clinical governance "on the ground".     

Trust relations in health care: developing a theoretical framework for the "new" NHS

PURPOSE: This paper seeks to address how and why trust relations in the NHS may be changing and presents a theoretical framework for exploring them in future empirical research. DESIGN/METHODOLOGY/APPROACH: This paper provides a conceptual analysis. It proposes that public and patient trust in health care in the U.K. appears to be shaped by a variety of factors. From a macro perspective, any changes in levels of public trust in health care institutions appear to derive partly from top-down policy initiatives that have altered the way in which health services are organised and partly from broader social and cultural processes. A variety of policy initiatives, including the introduction of clinical governance and the resulting use of performance management to scrutinise and change clinical activity, increasing patient choice and involvement in decision-making regarding their care, are examined for how they have changed the context for trust relations within the NHS. FINDINGS: It is argued that these policy initiatives have produced a new context for trust relations within the NHS, shifting the inter-dependence and distribution of power between patients, clinicians, and mangers and changing their vulnerability to each other and to health care institutions. The paper presents a theoretical framework based on current policy discourses which illustrates how new forms of trust relations may be emerging in this new context of health care delivery, reflecting a change in motivations for trust from affect based to cognition based trust as patients, clinicians and managers become more active partners in trust relations. The framework suggests that trust relations in all three types of relationship in the "new" modernised NHS might, in general, be particularly characterised by an emphasis on communication, providing information and the use of "evidence" to support decisions in a reciprocal, negotiated alliance. ORIGINALITY/VALUE: The paper examines the drivers for change in trust in health care relations in the U.K. and develops a theoretical framework for the emergence of new trust relations that can be subsequently explored through empirical research.     

Clinical governance for public health professionals

This paper examines the issues specific to clinical governance for public health professionals. It highlights three levels at which public health is capable of promoting clinical governance: within the specialty of public health, across other National Health Service (NHS) organizations and as part of the public health responsibilities of health authorities. Current work is reviewed, and its focus on hospital and community NHS Trusts is noted. Current thinking on the introduction of clinical governance into clinical practice is interpreted to provide a framework for its development in public health professional practice.     

Clinical risk--minimising harm in practical procedures and use of equipment

The article discusses some of the clinical negligence problems and risk management issues arising from training of health professionals (predominantly junior hospital doctors) in practical procedures. There continue to be incidents, claims and complaints in the NHS arising from the clinical practice of doctors or other health professionals who are not perceived to be competent in some of the practical skills they are undertaking. This article addresses some aspects of this training, where it should best be started and who should have responsibility for ensuring that doctors, in particular, continue to work under appropriate supervision. Also acknowledges the current problems facing NHS trusts in trying to ensure that risk management standards are met for training health professionals in the use of medical equipment--a task that has not previously needed to be documented or accounted for on a formal basis. There are considerable resource implications attached to the introduction of systems that can assess and monitor the training provided in the use of medical equipment but the introduction of a baseline assessment is an essential part of sound clinical governance and risk management. It is suggested that risk management exercises of this nature are worthwhile in reducing the potential for harm to patients.     

Outcomes,Outcomes Research and Disease Management

The UK National Health Service (NHS) is in the process of further reforms aimed at restoring a national focus to its activities and also at enhancing the quality of the service it provides. Key features are: (i) the formation of primary care groups to replace general practitioner (GP) fundholders, holding a single devolved budget for the majority of NHS services; (ii) a move towards defining outcome and performance indicators for the NHS; (iii) the establishment of new bodies to develop and monitor the implementation of clinical guidelines; (iv) the evaluation of new technologies including pharmaceuticals; and (v) a new framework termed ‘clinical governance’ for the long term maintenance of quality.This approach to quality and outcomes may start to move the NHS away from its focus on processes, but in the short term at least, the ability to make this change is limited by the performance indicators available. Many of these indicators are process markers rather than true outcomes, but given the poor outcomes data currently collected by the NHS, it may be all that is possible for the moment.The commitment to better quality in the NHS may make underfunding of the NHS more obvious and lead to further political difficulties for the government. Disease management systems which have in-built markers of their quality, both in terms of the service provided and its outcomes, may look increasingly attractive to the NHS. Outcomes research in the NHS will remain clinically focused for the moment but, with the explicit consideration of cost effectiveness underlying clinical guidelines in the future, a gradual move to the US type of outcomes research is possible in the future.     

Exploring the human resource implications of clinical governance

In 1998, clinical governance was introduced in the National Health Service, UK (NHS) as a major policy initiative to improve the quality of clinical care. The implementation of clinical governance is crucially dependent on the skills, competencies and willingness of the NHS staff. In turn, clinical governance influences the way people work in health care organisations. Therefore, it is no surprise that the introduction of clinical governance has thrown-up new challenges for human resource management. However, what are these human resource management challenges under the clinical governance framework? The current literature on the subject provides no answer. This article attempts to fill this gap in the literature. A qualitative approach influenced by phenomenological case study approach has been adopted. A heterogeneous group of 33 persons identified through a purposive sampling procedure were interviewed using a semi-structured format. The results indicate that the staff members appreciate the crucial role of human resources management in the implementation of clinical governance. However, there is little evidence to suggest that senior management is paying attention to develop the human resources function around the clinical governance agenda. The seven major human resource implications of clinical governance that emerged from the data analysis are discussed. The author argues that a more proactive HR approach is needed to make clinical governance everyone's business in the NHS organisations.     

Auditing the implementation of SIGN (Scottish Intercollegiate Guidelines Network) clinical guidelines

Clinical practice guidelines are increasingly being recognised as integral to the clinical effectiveness agenda. According to the recent Scottish White Paper, Scotland "leads the way in clinical effectiveness". The Scottish Intercollegiate Guidelines Network (SIGN), established in 1993, has produced over 20 clinical practice guidelines, and plans to produce at least as many more, while reviewing existing guidelines at a minimum of every two years. This represents a substantial investment of NHS resources. This paper investigates whether this investment is being recouped in Scottish NHS acute trusts via the implementation of SIGN guidelines, and whether their implementation is being audited properly. It is argued that without clinical audit, guideline implementation is unlikely to succeed. This has important ramifications for the implementation of clinical governance.     

Comparing patients' experience of mental health services in England: a five-Trust survey

The implementation of the Care Programme Approach (CPA) in English mental health services has been slow to proceed despite general support, both in England and in other countries, of its principles of good practice. This study set out to evaluate the implementation of the CPA directly from patients' experience using the "Your Treatment and Care" assessment tool. The results of a survey of 503 patients across five NHS Trusts in England showed that many patients did not have a copy of their care plan and had not been involved in the care planning procedure. Many reported shortcomings in their experience of their key worker and their psychiatrist. However, there was substantial variation in experience across services. "Your Treatment and Care" showed good internal reliability, was acceptable to users, and appeared to be able to access actual experiences better than a traditional "satisfaction" item. It appears to be very useful as a benchmarking tool and is now being used in services across the UK, the USA and Australia.     

英国国民卫生服务制度(NHS)的结构性改革与治理模式

基于英国NHS在管理体制与机制上所实施的结构性改革措施,从完善法律、建立问责机制、完善财务管理和经营模式4个维度,系统阐述了NHS的结构性改革与治理模式的特点;作为一种"公共利益公司",NHS所属公立医院基于公私伙伴关系的原则,在坚持公益性的前提下,引入企业经营行为组建了信托基金医疗联合体,并根据NHS的核心原则,免费医疗、需求导向、可负担性等,基于购买合同向辖区患者或居民提供医疗保健服务。随着相关改革措施的逐步实施,NHS信托基金医疗联合体的法人地位和自主决策权得到明显提升,能真正做到对自身的发展负责;同时,随着对提供者行为的规范,以及医疗服务市场竞争与规制机制的完善,也极大的促进了医疗机构之间的有序竞争和医疗服务供给的多元化发展。     

Information governance standards for managing e-health information

Integrity of patient information, from both a quality and a security perspective, is critical to patient care. In the UK, the information governance initiative of the National Health Service (NHS) provides a framework to monitor and control the management of confidential patient data. Information governance standards grew out of the Data Accreditation Programme, first proposed in the 1998 NHS document Information for Health. The Data Accreditation Programme was based on a three-stage assessment of data quality in acute hospitals. Stage one required internal review of policy and procedures for data input into computerized patient administration systems. Stage two involved an external audit to verify compliance with the standards. Stage three mandated audits of data outputs, focusing on clinical coding quality. Before stage three of the programme was fully implemented, the standards were incorporated into the information governance initiative, in which standards were expanded to include primary care and other health-care settings. These standards address many information management issues, including security and data quality, which are key concerns in telemedicine and e-health applications. Compliance is essential for the successful implementation of the NHS Care Records Service, which will allow sharing of electronically stored patient information across the UK.     

Clinical governance in accident and emergency services

Owing to NHS managers' preponderance with financial issues, the present Government made improving the quality of health services a statutory requirement in 1997. In this article, one means of improving the quality of health services, clinical governance, is examined in detail before some issues related to its implementation are described. The Trust's A&E services, the context for interpreting and applying clinical governance, are briefly described before introducing a force-field analysis that demonstrates the different elements when changing services broadly and clinical governance specifically. The final section concentrates on implementing and improving clinical governance in A&E departments.     

Implementation of statutory occupational respiratory health surveillance

Health surveillance is required by UK regulations in certain circumstances, and is usually provided through an occupational health organization. Although there are studies assessing the provision of health surveillance across the country, there are no published studies addressing the practical application of legislation, guidelines and medical research to respiratory health surveillance programmes. An audit of a multidisciplinary health surveillance programme was carried out, using review of occupational health records, occupational hygiene reports and managers' risk assessments, to compare the implementation of health surveillance in different organizations and under different contractual relationships. Sixty-six per cent of National Health Service (NHS) and 56% of industrial workplaces were able to provide risk assessments but were unable to link these with appropriate health surveillance. Twenty-seven per cent of NHS employees potentially exposed to respiratory sensitizers had baseline surveillance, compared with 87% in industry. Fifty-five per cent of Medical Research Council questionnaires were inappropriately administered by the employee themselves, rather than an interviewer as recommended. Other follow-up questionnaires in use had not been formally validated. Non-regular lung function assessment using spirometry was the predominant tool used for follow-up surveillance. There was no overall strategic approach to respiratory health surveillance in the organization studied. Health surveillance programmes should focus on disease prevention without becoming a repetitious application of unvalidated tools. Clinical governance demands quality assurance standards that will effectively implement a coordinated approach to health surveillance.     

The usefulness of the NHS Economic Evaluation Database to researchers undertaking technology assessment reviews

OBJECTIVES: Health-care technology reviews now increasingly include outcome costs as well as clinical effects. This study reports the findings and implications of a survey to explore the usefulness of the National Health Service Economic Evaluation Database (NHS EED) within this process. METHODS: Postal survey of lead authors of Technology Assessment Reviews (TARs) commissioned by the United Kingdom's National Institute for Clinical Excellence (NICE). The questionnaire investigated the usefulness of NHS EED in terms of (a) search strategy, (b) data extraction, (c) quality assessment, and (d) determining requirements for new modeling studies. Qualitative data were requested, including opinions regarding NHS EED. RESULTS: NHS EED was used in 90 percent of all identified reviews (n = 46). The questionnaire response rate was 63 percent. The percentage of scores 3 or above (most useful), 2 or below (least useful), or N/A were, respectively, (a) search strategy= 62 percent, 23 percent, 15 percent; (b) data extraction = 23 percent, 27 percent, 50 percent, (c) quality assessment= 38 percent, 19 percent, 42 percent; (d) determining requirements for new modeling studies = 27 percent, 23 percent, 50 percent. The results were expanded further in the qualitative data from the respondents. CONCLUSIONS: NHS EED is a useful tool for a variety of tasks in the NICE/TAR process but not, unsurprisingly, as a replacement for understanding primary studies. There is, however, a need to reduce the impact of time lags between the publication of economic evaluations and the appearance of abstracts relating to them on NHS EED. The results will inform future developments of the NHS EED database, which should increase its usefulness to researchers.     

Clinical governance: a convincing strategy for quality improvement?

Clinical governance is a new policy introduced by the UK government to improve quality of care in the National Health Service; it imposes a "duty of quality" on all NHS organisations, and aims to bring together managerial, organisational and clinical approaches to improving quality of care. Infrastructures have been established to support quality improvement in NHS organisations and priorities for quality improvement have been established. Initial approaches are largely educational. However, information on quality of care is starting to be shared, and experiments are being conducted with a range of financial and contractual incentives for quality improvement. For widespread cultural change to occur, a "no blame" approach to quality improvement will be necessary; this may be incompatible with the need to identify and eliminate bad practice. Other tensions include the rapid pace of change being centrally driven and uneven development of the infrastructure to support clinical governance. What has not yet been shown is that quality of care has improved. It is too early to say this yet. Given the magnitude both of the vision and the work required, it is unlikely that change will be rapid, or seen on a widespread scale.     

An evaluation of clinical governance in the public health departments of the West Midlands Region

STUDY OBJECTIVES: (1) To evaluate the development of clinical governance within public health departments. (2) To assess two models for examining clinical governance in public health departments. DESIGN: Semi-structured interviews carried out during the annual visits of the regional director of public health to the health authority public health departments. SETTING: West Midland Region, England. PARTICIPANTS: Directors of public health plus other members of public health departments. Main results: These visits demonstrated that there is already a substantial amount of clinical governance activity taking place in the region's public health departments. There was also a need to reclassify many routinely occurring activities and include them under the clinical governance heading. CONCLUSIONS: The two models both proved useful for examining clinical governance in public health departments, however combining them into a matrix provided the best results. This matrix will still be useful after the reorganisation of the NHS and could be used to assess any public health department in the world. The West Midland public health departments find the visits valuable as they provide a source of external peer review of their activities. The public health departments have ownership of the process.     

A study of the attitudes and perceived barriers to undertaking clinical governance activities of dietitians in a Welsh National Health Service trust

Background  Previous studies of National Health Service (NHS) employees have identified barriers to undertaking clinical governance activities. Little of this research has investigated dietitians; however, where dietitians were included, generally positive attitudes towards research and evidence-based practice were reported alongside the identified barriers.
Methods  A quantitative, whole population census was undertaken via a questionnaire distributed to 54 dietitians employed by Gwent Healthcare NHS Trust.
Results  Dietitians reported positive attitudes towards clinical governance; however, barriers to undertaking clinical governance activities were identified. The main barriers included lack of time, inadequate funding, the view that direct patient care should always be prioritised over clinical governance activities and inadequate research and critical evaluation skills.
Conclusions  Findings were similar to those reported in previous studies of NHS staff. Where comparison was possible, all of the barriers identified were reported at lower levels than in previous studies. As the study was purely quantitative in nature, no understanding was gained regarding the nature of identified barriers or what factors influenced the dietitians' attitudes and perceptions. For further in-depth analysis of these factors, a qualitative study is recommended. As the study comprised a whole population census, the findings cannot be generalized to the dietetic profession as a whole, or to other staff groups within or outside of the study Trust.