1. The pursuit of excellence in clinical care
9/19/2018
Clinical Governance
The pursuit of excellence in clinical care
Clinical Governance is not new…….in a sense it has been part of Medicine since Hippocrates
“To cure sometimes, to relieve often and to comfort always”
The recent emphasis is an attempt to bring the different strands together
Audit, Risk, Quality,Education and Research and to knot them together for the whole is greater than the sum of its parts
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2. Making better sense of Clinical Medicine
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Making better sense of Clinical Medicine
Peter Sims
Professor of Public Health Medicine
The School of Medicine
University of Papua New Guinea
Clinical Governance became a new mantra in Britain in the late 1990’s.
Suddenly Managers were responsible not just for the budgets,the waiting lists and the complaints but for the Patient Care delivered
Medicine was too important to be left to the doctors and systems were necessary to monitor and evaluate work, to correct problems effectively and to measure the impact of that medical service.
Increasingly clinical care would be judged , the world of league tables was here, a hospital ,a clinic, even a doctor could be given a ***** rating.
The doctors were puzzled, uncertain and suspicious. Plainly there had o be a better partnership with Management and better understanding of the joint task-hence this lecture
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3. Clinical Governance is Performance Management for Clinicians
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Clinical Governance is Performance Management for Clinicians
The components are
Clinical Audit, Risk Management, Quality, Continued Professional Development and Research and development
Clinical Governance requires that all these aspects are in place and practiced
They are quantified in terms of Input,Process and Outcome
This seems daunting and difficult to the busy clinician.
Where will the time and money for this activity come from?
Where to start?
The answers are that it is difficult, costly and hard to fit in unless there is real dialogue with Management.
It should start small and simple and not try too much too soon
One area in each of the components,
Every year,
Input and Process initially
e.g.
Risk management- (Input and Process)
Fire Policy
Fire extinguishers in place, checked, dated and staff trained
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4. Clinical Governance Part1
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Clinical Governance Part1
Concepts and definitions
Clinical Audit
Risk Management
Continued Professional Development (CPD)
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5. Performance Management
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Performance Management
Performance Management is about
1.Setting standards
2.Achieving standards on time and within budget
3.Active monitoring and evaluation
4.Sensitive use of resources
4.Setting higher standards
…….for all aspects of an organisations work
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6. Corporate and Clinical Governance
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Corporate and Clinical Governance
Corporate Governance Clinical Governance
Systems for Systems for
Information Clinical Audit
Finance Risk Management
Personnel Quality
Planning Continued Professional Development
Research and Development
…..are the two pillars of a Clinical Organisation
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7. RESEARCH& DEVELOPMENT RISK MANAGEMENT
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RESEARCH& DEVELOPMENT
RISK MANAGEMENT
QUALITY
AUDIT
What is the right balance?
All are necessary and the whole of Clinical Governance is greater than the sum of its parts
Each aspect can be considered in terms of
INPUT-OUTCOME-PROCESS
CONTINUED PROFESSIONAL DEVELOPMENT
& INDEPENDENT PERFORMANCE REVIEW
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8. The Systematic and continuous review of clinical practice and process
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The Systematic and continuous review of clinical practice and process
The concept is that positive criticism is invaluable if there is to be some chance of continuous improvement.
A staff that are doing well.performing above standard, take pride in their work; they work hard; they are well motivated and are fiercely patriotic about their organisation.
Only by continuous review is it possible to demonstrate to staff that targets are being met or where there are particular difficulties. It then becomes everyone’s problem and not just management’s
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9. Take action-Resources, Training
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The Audit Cycle
Set Standards
Repeat Audit
Conduct Audit
Clinical audit enables clinicians to examine practice critically and constructively.
Audit is about examining how well-or badly common conditions and procedures are managed.
It is not appropriate for rare things. Here the experience is insufficient to design an agreed protocol/standard to allow for comparison of practice
It is important to repeat the audit, after taking action on the findings of the first audit, to see if there has been an improvement
Take action-Resources, Training
Identify Problems
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10. The Audit Cycle-a helix
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The Audit Cycle-a helix
A series of interconnected audits, with action taken as appropriate, is a powerful indicator of a quality service.
It is important to establish a climate and a culture of audit in any health organisation .
Then it is accepted as completely normal practice ,funded and staffed accordingly.
It is seen that its results are taken seriously and appropriate action taken-staffing, training, resources…..
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11. 9/19/2018
Audit versus Research
1-off, Research design, Type1 & Type 2 errors, Sample size, Significance, Power, Controls, Publish
RESEARCH
Normal work (common problems) Repeated several times, Action taken Not published but a tool
Research is “audit,one at a time” but although there is overlap Audit and research are Qualitatively and Quantitatively different.
Research is about new knowledge while audit is mainly about the better application of existing knowledge
AUDIT
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12. Risk Management 9/19/2018 www.petersims.co.uk 9/19/2018
All work of Organisations carries risk
e.g. Fire, Staff sickness, Drug shortages
It is helpful to quantify the probability of an event occurring
(1:10,1:100,1:1000,1:10,000,1:1,000,000)
and the hazard (Major, +++Intermediate,++ minor +)
The Consequence is the Probability x The Hazard
Risk Management is about examing possible risks and then prioritising them in terms of their consequences.
There are never sufficient resources to cope with all the risks adequately. A Manager has to make choices and through Risk management can examine the consequences of each risk in terms of its hazard and probability.
It is then possible to reach working priorities
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13. The Risk can be Quantified-as the Consequence
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The Risk can be Quantified-as the Consequence
It is the product of The seriousness of the HAZARD x
The PROBABILITY of Occurrence
E.g. The Hazard of Lightening is considerable but it is a very rare event and therefore the Consequence is quite small
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14. Hospital Risk Management
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Hospital Risk Management
Factor
Hazard
Risk
Consequence
Fire
++++
1 in 100,000
Considerable
MRSA +
1 in 100
Fair
The slide illustrates a Risk Management calculation for three areas in a Hospital.
Plainly the risk of fire is not high but the consequence considerable, hence fire drills, fire extinguishers, fire brigade priority, staff training
MRSA is a problem world wide, it may necessitate closing a hospital. There needs to be a system and protocol for
1.antibiotic policies
2.management of positive cases
Bed sores are common but can be largely avoided by good nursing, the problem is relatively minor for the hospital-some increase in length of stay , but major for the patient
Bed +
1 in 10
Minor
sores
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15. Teach, Learn, and Develop Staff
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Teach, Learn, and Develop Staff
Performance review for Strengths, Weaknesses and an Agenda for Action
Continued Professional Development or Education for Life
Health care changes all the time-yesterday’s heterodoxy can be today’s orthodoxy and tomorrow’s heresy………..
Staff are the key factor in organisational performance.
Staff have to keep existing skills up to date, with adequate experience to maintain competence
.e.g. number of procedures per year per person
At the same time Staff need to learn new skills
Education is for life and educating people is “like lighting a fire”, and a fire needs to have fuel to remain alight giving out heat and warmth!
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16. Continued professional development (CPD)
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Continued professional development (CPD)
Maintaining existing skills
Developing new skills
Keeping “up to date”
Sustaining enthusiasm
The idea is that each of us develops a Personal Learning portfolio which is reviewed and altered in line with new tasks, responsibilities and interests.
E.g. A Clinician who becomes a Clinical Director may spend time on a Management Course
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