Clinical Governance

Author: Jo Davies RMN, CPN Cert., Pg Dip. Education, MA

This paper outlines the basics of the clinical governance framework within the context of key national policies. It will also provide brief explanations of some of the associated language and describes key issues for consideration by mental health nurses in relation to clinical practice and the delivery of mental health services. Whilst these contexts are punctuated by reference to policies pertaining to the National Health Service (NHS) in England, the principles do reflect the healthcare quality agendas within Scotland, Wales and Northern Ireland. Some brief examples are given, suggesting how clinical governance may be or is currently manifested in practice and further sources of information and reading are recommended.

The expectations of the general public are changing. Not only is there a rising expectation of good quality services but also that those responsible for providing those services can demonstrate effective management of public funds and do so in an open and transparent way. In other words, and public service should be accountable for good governance. The NHS particularly exposed to this degree of public expectation given the public’s increasing knowledge and awareness of health, consumerism, legislation and human rights. No longer can it be assumed that professionals know what is best for users of services who have a right to be active, rather than passive participants in the care they receive. Indeed the government’s modernisation agenda has maintained this emphasis throughout (Department of Health, 1997). Individual challenges to existing structures often through the legal system commonly provide newsworthy articles for the media to highlight the public’s demand for confidence in a service that we can all depend and rely upon.

A First Class Service (Department of Health, 1998) stipulated geographical variations in the service provided was no longer acceptable in terms of service options, patient experience, accessibility, performance and treatment effectiveness. So, the quality of service should be assured and consistent throughout the health service and not dependent upon regional or local configuration or individual professional inclinations. Care and treatment should be based on the best available evidence and demonstrate a clear commitment to the delivery of a high quality service.

Hence the establishment of the National Institute for Clinical Excellence (NICE) who will provide guidance on best practice and the National Service Frameworks (NSF) which will stipulate standards for service delivery. Those standards will be subsequently monitored by the Commission for Health Improvement (CHI), the National Performance Framework and the National Patient and User survey. Overall, these quality standards will be delivered through patient and public involvement, professional self-regulation, life-long learning and NHS clinical governance frameworks.

Setting quality standards
NICE (National Institute for Clinical Excellence). Promotes clinical and cost effectiveness by issuing specific guidance and advice on evidence-based treatment and best practice. It also reviews and appraises new treatment and interventions prior to utilisation within service settings. Essentially, NICE will assist clinical judgement and decision making.
NSF (National Service Framework). Sets service standards and milestones for service improvements that service providers must adhere to. Coronary heart disease and mental health services (Department of Health, 1999a) were the first NSFs introduced with the NSF for older people’s imminent.

Delivering quality standards
Life-long Learning and Continuing Professional Development (CPD). This refers to individual and organisational commitment to continuous learning throughout each and every individual’s NHS career. This has been re-emphasised within the nursing strategy Making a Difference (Department of Health, 1999b), and the consultation document on the review of workforce planning. A Health Service for all the talents (Department of Health, 2000a).
Professional Self-Regulation. The public has a right to scrutinise and expect the highest possible professional standards of conduct, practice and accountability. This ultimately strengthens public confidence in the professionals who deliver care (Department of health, 2000b). therefore monitoring and maintenance of these standards must be done openly and in collaboration with the public. Regulatory bodies must work together to ensure consistent standards (Department of Health, 1999b) as well as:
Stipulate clear standards of conduct, competence and practice
Take account of feedback from users and professionals when reviewing and updating those standards
Remain accountable to the public and the government
Ensure prompt action when necessary to protect patients from harm
Ensure non-discriminatory, open and sensitive procedures
Stipulate clear standards for standards of professional education

So self-regulation is primarily guided by three principles (UKCC, 1999):
Promoting good practice
Preventing poor practice
Intervening in unacceptable practice

Monitoring quality standards

CHI (Commission for health Improvement). CHI will monitor and review the implementation of the NSFs and the guidance disseminated from NICE. CHI activities will include review vists to NHS Trusts and has the authority to instigate investigations into organisations that demonstrate poor performance
National Performance Frameworks. The performance of every NHS organisation will be assessed and monitored against six quality areas: effective delivery, access, health improvement, efficiency, health outcomes and user and carer experience
National Patient Survey. This will be carried out on a yearly basis in order to ascertain users and carers’ views and experiences of healthcare services

Key principles of clinical governance

Service user and carer feedback is systematically incorporated into practice and service development programmes
Clear lines of accountability and responsibility
Risk Management systems are robust and systematic ensuring all adverse events and ‘near misses’ are reported and investigated and are used to inform practice and service development (Department of Health, 2000c)
Leadership development occurs at all levels of the organisation
Evidence-based practice is implemented and supported at service level
Organisational processes support quality improvement by creating quality data and feedback that can be used to assess performance and implement change programmes, such as clinical audit, CPD, complaints procedures, clinical supervision, evidence-based practice and research and development
Robust systems of data collection are sued to monitor care delivery
Sharing and disseminating good practice takes place within organisations
Poor performance is dealt with appropriately and promptly

Examples of what clinical governance means in practice

Clinical Practice Benchmarking. This process involves standards of best practice being agreed by users and professionals, that can be used to compare, share and develop practice in a structured way (Department of Health, 1999b). in Spring 2001 the Department of Health plans to launch benchmarks based on eight fundamental and essential aspects of care:
Privacy and dignity
Personal and oral hygiene
Food and nutrition
Pressure ulcers
Continence and bladder and bowel care
Safety of clients with mental health needs in acute mental health and general hospital settings
Record keeping
Principles of self care

Each aspect will have an overall statement or outcome, which expresses what users want from practice. This is supported by a list of factors that have been identified as essential to achieving this outcome. For each factor, a statement describing best practice is given. Best practice has been identified from:

User and professional involvement
Research evidence
Other publications that identify standards of excellence
Examples of best practice known to the Department of Health

Each factor includes a scoring structure which practitioners or services can utilise in awarding their own practice or service a score against the best practice identified. Each factor also includes a number of statements suggesting how scores can be justified. These examples of practice can also be used to assist development of action plans.

Clinical supervision. Whilst not a statutory requirement for nurses and health visitors, clinical supervision is an essential professional and organisational process which supports quality improvement (UKCC, 1996). Particularly in relation to the following:

Continuing professional development and identification of education and training needs which relate to organisational objective
Clinical risk management
Professional accountability
Promoting and maintaining high standards of care
Support for clinical staff
Contribution to management appraisal systems
Facilitates reflection and practice development

Integrated Care Pathways (ICP). A mulit-disciplinary process of care which facilitates the service user’s journey through the service in a timely and structured way. ICPs can be either diagnosis or outcome focussed or process-specific but ultimately based on locally agreed standards or evidence based best practice. They can encompass the detailed activities and interventions of all the professionals along the continuum of care within one care document (Jones and Kamath, 1998). Essentially ICPs:
Ensure that the care process is user focused
Involve collaboration and development of partnership with users and carers
Support integrated, multidisciplinary and holistic approached to care, complementing the Care Co-ordination process
Contribution to team development and support effective communication
Support integrated clinical records with the needs of the service user as the focus and not the needs of professional groups
Reduce duplication
Highlights deficits in the evidence base
Assist service managers in identifying service requirements in order to support the agreed outcomes
Provide data which can be utilised by clinical teams to inform service and practice development and education and training
Allow analysis of variations from agreed standards
Facilitate critical review and improvement of practice and continuous monitoring of performance

Summary
Essentially clinical governance is about accountability for quality. That is, professional and organisational accountability to the public for the continuous improvement of NHS services. Organisations must also safeguard ‘high standards of care by creating an environment on which excellence in clinical care will flourish’ (Department of health, 1998). So perhaps the biggest challenge of all is the culture change necessary to achieve this kind of responsive, reflective and learning environment throughout the NHS.