Dr Rachel McEnery GP trainer Kilmeny Group Medical Practice CLINICAL GOVERNANCE Dr Rachel McEnery GP trainer Kilmeny Group Medical Practice

Aims and Objectives To understand the role and significance of Clinical Governance in General Practice Highlight potential areas that may come up in your AKT Inspire you to become Clinical Governance leads in your future practice! Mention learning needs questionnaire Sian – verbal requests for general overview and linking to AKT questions Thanks To Katie Lazenby for useful email highlighting areas of the curriculum that we’ll have time to touch on today but really are HDR sessions in themselves e.g. appraisal and revalidation, CPD, assessing quality of clinical guideline etc Long shot inspiring you to become clinical governance leads in the future

Agenda Introduction What is Clinical Governance? Small group work looking at cases, SEAs or Audits Discussion Interactive session!

Clinical Governance - Definition ‘a framework through which NHS organisations are accountable for continuously 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 So what is Clinical Governance? This is the official definition. Umbrella term which encompasses a range of activities in which clinicians should become involved in order to maintain and improve the quality of care they provide to patients and to ensure full accountability of the system to patients. Designed to prevent serious problems arising. Came as a result of various health scandals of the 1990s including Alder Hey, Bristol paed surgeons, Shipman and more recently mid staffs hospital.

Clinical Governance – History 1997: The New NHS – modern, dependable 1998: A First Class Service: Quality in the New NHS GMC: Duties of a Doctor and Good Medical Practice RCGP: Good Medical Practice for General Practitioners 2008: Lord Darzi High Quality Care For All – NHS next stage review CG was introduced as a concept in 1997. Nothing new. This white paper placed a duty of quality on all health organisations. GMC – Duties of a Doctor and Good Medical Practice – (Need to know these on curriculum) – Keep up to date, regularly monitor their performance, ensure their actions always serve the best interests of their patients. This last statement was made more explicit – if you believe a drs or other colleagues health conduct or performance is a threat to patients your overriding duty is to protect the patient. Have been other papers in the intervening years the most recent of which was by Lord Darzi in 2008 following on from the NHS plan 2000 who defined quality in terms of 3 core areas – pt experience, patient safety and clinical effectiveness.

Clinical Governance Structure Individual Practice PCT SHA DoH Independent regulators CQC and Monitor National Quality Board RCGP GMC There’s no real structure to CG very confusing! I’d advise you to think of it as an idea of continuous demonstrable improvement rather than a particular mandated set of structures. Especially now with the NHS being restructured and the PCTs and SHA’s going. This is a list of a few of the people/agencies that are involved. Involves everyone at practice level not just clinicians. Did anyone get a chance to speak to their CG lead? Any written policy's? PCT don’t seem to have anyone overall responsible for CG. Have separate areas for Risk Management, Audit etc. CQC – independent regulator of health and social care in England. All practices will need to register with them – details are coming out in October 2011. Produce quality accounts. Others - National quality board ensures alignment of quality through the different levels. NPSA have the National Clinic Assessment Authority dealing with poor performance. NHS commissioning board – Support local consortia of GP practices will be held accountable for quality RCGP QPA – voluntary accreditation process GMC AKT – mention e.g. EMQ here

7 Pillars of Clinical Governance C……….. E……….. & R……….. A…. R… M……… E…….. & T…….. P…… & P….. I……… U…. I…….. & I. S……. & S……. M……… Health organisations also need L………, T… W…, A…………. and a C…… of openness for Clinical Governance to be effective. What are the key components to CG? Flip chart – temple model

7 Pillars of Clinical Governance Clinical Effectiveness and Research Audit Risk Management Education and Training Patient and Public Involvement Using Information and IT Staffing and Staff Management Health organisations also need Leadership, Team work, Accountability and a Culture of openness for Clinical Governance to be effective. These are HDR sessions in themselves. I’ll only have time to do a brief overview

Clinical Governance key components video Short video to reinforce CG 7 pillars (note the difference in cultural components)

Leadership Establish direction or vision Persuade people to share the vision Communication/listening skills Innovate Responsibility, respect, integrity, authority Ability to inspire and motivate Ability to interpret data Good and fair judgement High standards Firstly what needs to be in place for CG to be effective? Leadership - ?skills of a CG lead

Accountability Answerability Responsibility Blameworthiness Liability Accountability – ability to give an account of what has happened. Implies honest, factual, straightforward account, free from justifications, rationalisation though after an account has been given, the question often arises ‘why did it happen?’ and the above will inevitably creep in.

Culture No blame Patient first Safety Desire for quality improvement Openness Learning Education and reflection Supportive Staff are valued and motivated. When things go wrong inquiries often describe institutional or systemic failures, so the culture required is one in which all members of the organisation take on board the values of CG.

Clinical Effectiveness and Research The Right person doing: The Right thing (evidence based practice) In the Right way (skills and competence) At the Right time (providing treatment or services when the patient needs them) In the Right place (location of treatment/services) With the Right result (clinical effectiveness/maximising health gain) A quick run through of the 7 pillars Clinical effectiveness - In practice it means Adopting an evidence based approach in the management of patients Changing your practice, developing new protocols or guidelines based on experience and evidence if current practice is shown to be inadequate (through SEA, near misses, complaints, pt and staff views) Implementing NICE guidelines, NSFs and other national standards (royal colleges) or local GL (pace) to ensure optimal care. Katie was asking in her email where to get ebm from now with cks not being kept upto date – any ideas? Conducting research to develop the body of evidence available and therefore enhancing the level of care provided to patients in future

Audit Aim of the audit process is to ensure that clinical practice is continuously monitored and that deficiencies in relation to set standards of care are remedied At practice and national levels Assuming everyone knows the audit cycle. Who’s bought one to discuss later? Prescribing and referral audits

Education and Training CPD Appraisal and Revalidation Before professionals were assumed to be performing acceptably unless evidence came to light that showed there were problems, relying on an ageing certificate of graduation or admission to a professional body displayed on the consulting room wall. Now professionals will have to prove that their performance is acceptable, education must continue after qualification, life long learning. e.g. mrcgp, attending courses, other relevant exams Revalidation GMC 2 elements Since 2009 Dr have to hold a licence from the GMC describing a Drs area of licensed activity All licensed Drs will be subject to Revalidation – late 2012. All Drs will have to demonstrate they are practising in accordance with the generic standards of practice set by the GMCs Good Medical Practice. Supportive information will be generated from within the practice and brought together through what will be an annual appraisal for all Drs.

Patient and Public Involvement Patient and public feedback to improve services, for development of services and monitoring treatment outcomes PALS LINKs Local feedback questionnaires Patient participation groups Patient satisfaction surveys local and national Suggestion boxes Lay members on interview panels, complaints hearings and trust boards Applies to individual dr’s communication skills with patients and relatives, treating them with respect as individuals and involving them in their own care. Then at a service level ensuring that the services provided suit patients, that patient and public feedback is used to improve services into day to day practice to ensure an increased level of quality and suitability, that patients and the public are involved in the development of services and the monitoring of treatment outcomes PALS – Patient Advice and Liaison service (handle issues with patients) LINKs – Local Involvement Networks (used to be called patient forums) to enable communication to influence healthcare services at a local level NHS choices website for public to use when comparing quality patientopinion.org.uk and iwantgreatcare.org.uk – patients can rate directly their experience of GP

Using Information and IT Patient data is accurate and up to date Data protection QOF To ensure that Patient data is accurate and up to date Confidentiality of patient data is respected Full and appropriate use of the data is made to measure quality of outcomes and to develop services tailored to local needs Full and appropriate use of the data is made to measure quality of outcomes

Staffing and Staff Management Appropriate recruitment and management of staff Organising a programme of education, training and appraisal of all in the service to motivate and develop staff and encourage retention. Systems to identify poor performance Implementation of strategies to correct poor performance To provide good working conditions. Identify poor performance. If persistent and individual refuses to deal with it then they must be reported to management structure or appropriate professional body e.g. GMC

Risk Management 2 stage process Includes infection control Risk Assessment Risk Management Includes infection control Reporting of incidents via SEA Promote a blame free culture www.nhstaps.org.uk www.npsa.nhs.uk www.nrls.npsa.nhs.uk MaPSAF Primary care trigger tool RM involves having robust systems in place to understand, monitor and minimise the risks to patients and staff and to learn from mistakes. When things go wrong in the delivery of care doctors and other clinical staff should feel safe admitting it and be able to learn and share what they have learnt. Includes Complying with protocols (hand washing, discarding sharps, identifying patients correctly) Learning from mistakes and near misses Reporting and Significant Adverse Events via critical incident forms, looking closely at complaints Assessing the risks identified for their probability of occurrence and the impact they could have if an incident did occur. Implementing processes to decrease the risk and its impact Promoting a blame free culture to encourage everyone to report problems and mistakes Identify things before they happen Risk Assessment – identifying areas which have the highest possibility of going wrong and which of those have the highest possibility of doing harm Risk management – how can we reduce the likelihood of a mistake (protocols etc) Split further into Risk to patients – health and safety, infection control, data protection act, sea, responding to complaints, reflecting on clinical practice, audit Risk to clinicians – ensuring clinicians are immunised, work in a safe environment, management of aggression Risks to organisations – all the above, high quality employment practice accrediting teams and individuals Nhstaps – local patient safety Yorkshire and the Humber NPSA and part of that is the NRLS – note low incidence of reporting from GPs. Why is this? Does anyone have experience of reporting an incident nationally? Describe video camera incident – e.g. serious untoward incident Where else can you get info from if no one is reporting incidents? – defence organisations, data from hospital admissions MaPSAF and primary care trigger tool

Risk Management Risk management video - Bodies series 1 7 min video Make note of the elements of clinical governance that are/are not demonstrated here and have a think about what should have happened

Risk Management What key elements of Clinical Governance were and were not demonstrated here? What should have happened? Pt involvement Risk management Processes in place to check right pt not right op Near miss Leadership, culture, Team work, accountability Any member of staff could have reported the incident but didn’t why? What barriers could there be in place? Drs can sort it out themselves, reflection of their ability

Small Group Work Discussing Audits, SEA or cases. How many have brought Audits/SEAs? I have four cases. ?Split into groups of four depending on room availability. 20min discussion then coffee then back to big group for final discussion

Conclusions Nothing new Opportunities and threats Can support us Might make us feel better! Please fill out evaluation sheets