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Clinical Governance & Risk Management

Clinical Governance & Risk Management. Mr Kerry Walsh Head of Clinical Governance Support & Development 24 th June 2009: Audit Committee Forum. Any fool can spot a hazard…. Ayrton Senna, Imola, 1994. National context. Patient Safety Alliance Increase importance of quality improvement

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Clinical Governance & Risk Management

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  1. Clinical Governance & Risk Management Mr Kerry Walsh Head of Clinical Governance Support & Development 24th June 2009: Audit Committee Forum

  2. Any fool can spot a hazard… Ayrton Senna, Imola, 1994

  3. National context • Patient Safety Alliance • Increase importance of quality improvement • Clinical Governance is maturing at all levels • Limited knowledge of Clinical Governance & Patient Safety • Assurance & accountability

  4. What is Clinical Governance • ‘ 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 clinical care will flourish.’ A First Class Service (1998)

  5. Origins of clinical governance • White Paper ‘Designed to Care’ 1997 • NHS MEL(1998)75 & NHS MEL(2000) 29 • Our National Health: A Plan for Action, A Plan For Change (2000) • Partnership for Care Scotland’s Health White Paper (2003) • http://www.show.scot.nhs.uk • Chief Executives given corporate accountability for clinical performance. • Robust frameworks required to deliver this objective

  6. What is this in practice ? • Statutory Duties- clinical governance as part of corporate governance • Structure & Accountability- Board, Chief Executive, clinical governance committee • Processes- Quality improvement activities, risk management, professional performance and involvement of users / patients • Support- Work force planning, information, management & Technology, professional development

  7. Clinical Governance is…. • Moving from doing things to people, to doing things with and for people • Shifting from “service driven” to “needs led” approaches • Assessment of “outcomes and results” in order that we can identify what “processes” need changed • Delivery of appropriate, responsive and effective services

  8. What does this mean for you? • How does this relate to your practice? • What difference will it make to your clients? • Who are the key contacts in your organisation that can help you? • Where do you start? • Why?

  9. How big is the problem? • 44,000 to 98,000 incidents were the result of medical error in the United States of America. • Resulted in a million injured to medical error • Cost is estimated to be $9 billion. • Medical errors were the 8th commonest cause of death. • Not all adverse incidents are recognised or reported. • Recommended adverse incident recording and reporting systems. Kohn et al.,(1999) Institute of Medicine, To Err is Human,

  10. An international issue • 400 people die or are seriously injured in adverse events involving medical devices. • Nearly 10,000 people are reported to have experienced serious adverse reactions to drugs. • Around 1,150 people who have been in recent contact with mental health services commit suicide. • Nearly 28,000 written complaints are made about aspects of clinical treatment. Department of Health Report (2000) An Organisation with a Memory

  11. What is Risk Management ? ‘ …as a field of activity seeking to eliminate, reduce and generally control risks (patient safety, financial, security, environmental, human resources, IT, and threats to the organisational) and to enhance the benefits and avoid detriment’ (Waring & Glendon 1998)

  12. Purpose • Understand which aspects of the problem needs to be solved • Realize the nature of the problem and its consequences • Identity's the participants and ask questions • Collect, sort and analyze • Assemble a group and review the information

  13. Problem Understanding • Gather all the documentation • Collection information from internal and external processes • Make notes and reflect • Can you describe the timeline • Use a flowchart as a picture of the process

  14. Action Plan to manage the risk • Link recommendations to actions • Who is going to do it • When do you wish this to be done by? • Can you collect the evidence that this has been done? • Could this happen again?

  15. Learning & improvement • Compare the seriousness of the problems and causes • Identify individual & organisation issues • Make recommendations to improve service • Write up the finding and conclusions • Share the information

  16. Use of Evidence & Accountability • Risk Management Annual Report • Clinical Governance Annual Report • Link patient outcomes • Use evidence as part of communication process- Mind the Gap • Dashboard monitoring • Identify trends & associated action plans • Regular reports internal & external • Share what has been learned • Is there evidence of lack of integration?

  17. but it takes professionals to manage the risk Ralf Schumacher, Melbourne, 2002

  18. Thank you kerry.walsh@nhs.net

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