1. Module 3. Session 3 3.1 DCST Clinical governance
Prepared by J Moorman

2. What is clinical governance
Clinical governance is a framework which helps all clinicians to continuously improve the quality of their services and safeguard standards of care – by creating an environment in which excellence in clinical care will flourish Systematic approach to and central to quality assurance and quality improvement

3. Why is clinical governance needed
Quality of care varies across all facilities, levels of care.
Quality of care in many facilities is not as good as we would like it to be.
Health care providers are accountable to “public service” and so we need be able to show what we do well – and acknowledge where we can do better

4. What does that actually mean
CG is about every member of staff recognising their role in providing quality of care
CG is about improving care using whatever method is the most suitable
So – find aspects of care that need improvement, making plans to improve them and monitoring your success
To stress here that clinical governance is NOT someone else's problem – its about their role in ensuring good quality ca care.

5. What's good about clinical governance
Can demonstrate what is good (this is not always about identifying what is wrong)
Earn and retain trust of patients and colleagues
CLINICAL GOVERNANCE NOT ALL ABOUT IDENTIFYING WHAT IS WRONG

6. Traditionally there have been five pillars of CG

7. Three key domains Clinical effectiveness Evidence based practice
Clinical audits
Clinical guidelines
Patient safety
Risk management
Adverse event
Patient experience
Complaints management
Patient information
Patient involvement
Each domain includes many components – highlighted here the ones that are most important for DCST’s – also in line with the national core standards. Clearly not all will be covered BUT WILL FOCUS ON MOST IMPORTANT AND NOTE THAT LITERATURE AVAILABLE ON CD.

8. Pillar 1. Clinical effectiveness 6 R’s
Clinical effectiveness is ensuring the right care is provided to the right patient who is informed and involved in their care at the right time by the right clinician with the right skills in the right way.

9. What does “right care” mean
Production and dissemination of evidence-based clinical guidelines

10. What does “right way "mean
Evaluation of compliance to these guidelines
Audit
performance of clinical care processes and clinical outcomes are measured.
These performance measures, as well as peer review and clinical audit, are used to evaluate and improve performance.
quality improvement activities are reviewed externally.

11. Other clinical effectiveness strategies
Quality improvement activities are coordinated, planned, prioritised and have sustainability strategies in place.
Involvement of clinicians in designing and planning systems and services so that they are efficient and improve delivery and clinical outcomes.
Clinicians actively involve consumers as partners in their care.
Other strategies that ensure good clinical performance are to make sure that all quality improvement activities are coordinated. We will come back to this but many things are happening about quality of care and these activities are often very diverse and not will coordinated planned.
In many institutions, quality assurance officers are being employed who may not have the experience to coordinate activities – and also may not have the seniority to manage clinicians who are critical in all these activities. Many of them focus on patient satisfaction surveys and complaints and core standards.
The second bullet point is about engaging those involved in delivering care in the planning of the care
The third point is about engaging consumers in decisions about their care. Of course this needs well educated patients. This is not the same as community participation

12. Pillar 2 – Risk management
Providing health care is risky
Risk to patients
Risk to health care providers
Risk to organisation

13. Ensuring the safety of everyone who comes into contact with healthcare services is one of the most important challenges facing health care today. 
Health care is risky and mistakes are common

14. Common risks Failure / delay in diagnosis
Inadequate treatment / management
Attitude of staff
Medication errors
Administration errors
Inadequate examination
Failure to communicate with patients!!

15. How do we do manage risks?
Assess how patients may be harmed – identify at risk patients – foreigners, elderly, mentally ill, institutionalised.
Prevent or manage risks - checking credentials of staff and training
Report and analyse incidents – critical events, complaints, reviews (documents for example)
Learn from such incidents – morbidity and mortality meetings
Implement solutions to minimise the likelihood of them re- occurring.
The things in italics are examples. The examples come from the national core standards so you can refer back to them

16. Critical event auditing
"individual cases in which there has been a significant occurrence (not necessarily involving an undesirable outcome for the patient) are analysed in a systematic and detailed way to ascertain what can be learnt about the overall quality of care and to indicate changes that might lead to future improvements".
Adverse / critical / significant events – many different names.
There is some adverse event auditing going on already so ask them what they know. Mainly mortality but they may have other lists.

17. Aim of adverse event monitoring
Identify events in individual cases that have been critical (beneficial or detrimental) to the outcome
Instigate a culture of openness and reflective learning
Enable identification good practice

18. Seven steps to critical event monitoring
Identify adverse event
Information gathering
Team meeting – honest, non-threatening, respectful atmosphere
Analysis of event
What happened
Why did it happen
What has been earned
What has been changed
Agreement, implementation and monitoring change
Write it up
Report, share and review

19. Barriers to the process
Time
Honesty
Potential for emotionally uncomfortable experience
Group dynamics
Conflict of loyalties for staff
Motivation
Concerns about confidentiality
Lack of challenge and insularity

20. Complaints
Complaints can be an indicator of problems with the care you are giving
Isolated complaints aren’t always the issue – its the patterns of complaints
System should enable complaints to be dealt with positively and constructively
Complaints should inform future planning
Complaints is the second way to manage risks
Most institutions now have a way of allowing patients to complain – again this is in the core standards.
Try to find out what is happening already and what they know.
Are they aware – can the system be strengthened

21. Pillar 3. Patient experience
Providing information to patients about quality
So that consumers are empowered to participate in their care
Need to have clear, open and respectful communication
More than education – what they can expect
Ensuring their experience is good
Services respond to the diverse needs of consumers with humanity
Rights and responsibilities of patients are promoted to community, consumers, carers and clinicians
Improving the way services are delivered by increasing awareness and understanding of the consumer perspective, their needs and what matters to them most
Again – some of these activities are happening already. Need to engage and find out., the check list at the beginning would also have helped with this.

22. Pillar 3. Patient experience (2)
Monitoring their experience
Complaints management
Client satisfaction surveys
Ensuring participation in planning, improvement and monitoring of services
Consumers provide feedback on clinical care and services learn from it

23. Approaches to engaging communities
Focus groups
Interviews
Patient satisfaction surveys
The insert is from the South African Quality of Care Policy and just highlights some things you can do