Introduction to Clinical Governance

1. Introduction to Clinical Governance Dr Lee Gruner BSc, MBBS, BHA, FRACMA, MBA (Executive) GAICD Dr Lee Gruner Management for Clinicians 2008

2. Origins What was the catalyst? Why this terminology? Clinical governance Dr Lee Gruner Management for Clinicians 2008

3. What is corporate governance? • Corporate governance is the system by which companies are directed and managed. It influences how the objectives of the company are set and achieved, how risk is monitored and assessed, and how performance is optimised. Good corporate governance structures encourage companies to create value and provide accountability and control systems commensurate with the risks involved. Dr Lee Gruner Management for Clinicians 2008

4. The King Edward Memorial Hospital Story Dr Lee Gruner Management for Clinicians 2008

5. Lessons from King Edward Memorial Hospital • Issues relating to poor child and maternal outcomes dating back over 10 years • Three reviews in 3 years culminating in the Douglas Enquiry in 1999 • Douglas Enquiry focused on areas for improvement and high risk cases • Findings related to management / medical staff and clinical practice issues Dr Lee Gruner Management for Clinicians 2008

6. Findings Lack of safety and quality systems at state, board and hospital level : • Ineffective accreditation and credentialing systems, inadequate incident reporting systems, • Poorly performing statutory mortality reporting and investigation systems • Non-existent inter-hospital comparative data analysis. Dr Lee Gruner Management for Clinicians 2008

7. Findings Significant leadership, management and clinical performance problems • A culture of blame, unsupportive of open disclosure of errors and adverse events; • Lack of clarification of senior staff responsibilities and accountability; • Non-existent “safety nets” or systems to effectively monitor performance and respond to performance issues; • Ineffective or non-existent systems to ensure staff had the right credentials, training, support and performance management to meet the demands and skill requirements of their roles and responsibilities; Dr Lee Gruner Management for Clinicians 2008

8. Findings • Failure to meet the emotional needs of many women and their families, excluding them from decisions about care or failing to give them honest, complete and timely information when things went wrong; and • Failure to address serious and ongoing management and clinical problems that resulted in serious adverse events and poor outcomes for women and their families Dr Lee Gruner Management for Clinicians 2008

9. Findings - Management • Management failed to: • Make important decisions • Create an open and transparent culture • Monitor safety and quality • Ensure proper supervision/ training of staff • Define accountability and reporting responsibility • Address serious issues relating to adverse pt outcomes • Respond adequately to complaints Dr Lee Gruner Management for Clinicians 2008

10. Findings- Clinical Practice • Senior doctor procedures deficient: • Insufficient involvement in complex cases • Inadequate decisions • Inadequate credentialing and appointment procedures • Inadequate performance management • Inadequate supervision of junior staff • Failed to provide timely analysis of staffing needs Dr Lee Gruner Management for Clinicians 2008

11. Findings- Clinical Practice • Junior doctor work practices: • Did much of the complex work • Poorly supervised • Requests for help ignored • Blamed for errors • Sink or swim culture • Inadequate orientation and training • Ad hoc performance management Dr Lee Gruner Management for Clinicians 2008

12. Findings- Clinical Practice • Clinical practice issues: • Little best practice • Poor outcomes • No benchmarking Dr Lee Gruner Management for Clinicians 2008

13. Lessons • To assure safe, quality care, governments, boards, health care leaders and managers must create an open and transparent culture, where people willingly discuss and address errors and systems problems. • Effective organisations have people at all levels doing the right thing. • Organisational structures are only effective if people know and aim to meet their responsibilities and are held accountable for their actions. • Effective management ensures that their organisation has systems that effectively monitor the key aspects of its performance and ensure timely and appropriate responses to performance issues. Dr Lee Gruner Management for Clinicians 2008

14. Lessons learned • To do a good job, people need the right credentials, training, support, performance management and development consistent, with the demands and skills requirements of their roles and responsibilities. • A caring, concerned health care service recognises the importance of involving patients and their families in care, provides information about care options, involves them indecisions about care and advises them openly and honestly when things go wrong. Dr Lee Gruner Management for Clinicians 2008

15. Implementing change • In the 9 years since the Douglas Enquiry: • How far have we come? • What have we really learnt? Dr Lee Gruner Management for Clinicians 2008

16. What is Clinical Governance? Dr Lee Gruner Management for Clinicians 2008

17. Clinical governance • A governance system for health care organisations that promotes an integrated approach towards management of inputs, structures and processes to improve outcomes in health care service delivery where staff work in an environment of greater accountability for clinical quality Dr Lee Gruner Management for Clinicians 2008

18. Clinical Governance – what does the definition mean? • A governance system for health care organisations that promotes an integrated approach towards management of inputs, structures and processesto improve outcomes in health care service delivery where staff work in an environment of greater accountabilityfor clinical quality Dr Lee Gruner Management for Clinicians 2008

19. An integrated approach • Considers the whole patient experience • Considers all quality variables not just the medical care • Reliability- doing what is promised • Empathy- respect/ concern • Tangibles- environment/ food • Responsiveness- response to needs • Assurance- credible service/ seamless organisation / good equipment Dr Lee Gruner Management for Clinicians 2008

20. inputs • Financial resources • Buildings and equipment • Staff • Policies Dr Lee Gruner Management for Clinicians 2008

21. Structures • Clinical Governance Committee • Procedures/ guidelines • Education and training of staff • Reporting system for adverse events • System for patient feedback Dr Lee Gruner Management for Clinicians 2008

22. Process • Implementation of risk management • Job descriptions • Multidisciplinary management of clinical care • Communication • Management of patient information • Collection of data on clinical care • Acting on patient feedback Dr Lee Gruner Management for Clinicians 2008

23. Clinical governance Aims to ensure that: • systems to monitor the quality of clinical practice are in place and functioning properly • clinical practices are reviewed and improved • clinical practitioners meet standards set by regulatory bodies Dr Lee Gruner Management for Clinicians 2008

24. Elements of clinical governance • Human resource systems • Review of clinical practice • External assessment of practice • Commitment to ongoing education Dr Lee Gruner Management for Clinicians 2008

25. Human resource systems • Medical appointments and credentialing systems • Management and support of the clinical performance of colleagues , developing guidelines and protocols • Effective management of poorly performing colleagues Dr Lee Gruner Management for Clinicians 2008

26. Review of clinical practice • Clinical audit • Evidence based clinical practice • Implementation of clinical effectiveness evidence • Risk management Dr Lee Gruner Management for Clinicians 2008

27. Commitment to ongoing education • Continuing education for all clinical staff • Development of clinical leadership skills • Continuing professional development for all staff Dr Lee Gruner Management for Clinicians 2008

28. External assessment of practice • External accreditations • Consumer feedback audits • Internal audit Dr Lee Gruner Management for Clinicians 2008

29. What motivates medical staff? What methods can we use to get medical staff involved? Engaging medical staff Dr Lee Gruner Management for Clinicians 2008

30. Identify 4 barriers to developing a robust clinical governance culture Which of these are most important? Key elements of a clinical governance culture Dr Lee Gruner Management for Clinicians 2008

31. Barriers to a good Clinical Governance system • Lack of leadership • Inadequate Time and resources • Inadequate training and education • Lack of accountability of staff • Negative organisation culture • Resistance to change • Poor systems and processes • Fear of repercussions Dr Lee Gruner Management for Clinicians 2008

32. What knowledge and skills do medical leaders require to support a robust clinical governance system? What behaviour should they display? How can they acquire the skills and knowledge? What strategies do we put in place to support this and to overcome the barriers? Identifying knowledge and skills of medical leaders Dr Lee Gruner Management for Clinicians 2008

33. Overcoming the barriers • Building systems and processes: • Reporting • Implementation of change following analysis of incidents • Appropriate committee structure • Appropriate policies • Feedback systems Dr Lee Gruner Management for Clinicians 2008

34. Success of Clinical Governance depends on: • Educated and committed leadership • A vision of what Clinical Governance will deliver in the context of organisational strategy • Education of key staff • Provision of appropriate resources – people/ time / funding • A working coordination mechanism with appropriate systems- data/ reporting/ feedback/ policies • A change management environment Dr Lee Gruner Management for Clinicians 2008

35. Overcoming the barriers • Education and training • Structured education program • Adequate resources for education • Management led education of all staff • Leadership • Education of Board and executive • Involvement of executive to drive the process • Appropriate resources Dr Lee Gruner Management for Clinicians 2008

36. Overcoming the barriers • Resistance to change: • Develop staff champions • Adopt a change management approach • Openly address the culture of blame • Positive reinforcement of change • Reward and recognition systems Dr Lee Gruner Management for Clinicians 2008

37. Major implications in introducing clinical governance • Development of leadership skills and knowledge amongst clinicians. • Development of mechanisms to ensure the 'audit loop' is closed - to ensure that change in clinical practice takes place in the light of audit, research, evidence, risk management and complaints findings • Development of appropriate accountability structures Dr Lee Gruner Management for Clinicians 2008

38. Major implications in introducing clinical governance • Implementation of evidence-based practice across organisations. • Development of effective multidisciplinary and inter-agency working. • Integration of continuing education and continuing professional development into quality improvement programs. Dr Lee Gruner Management for Clinicians 2008

39. Major implications in introducing clinical governance • Development of leadership skills and knowledge amongst clinicians. • Development of mechanisms to ensure the 'audit loop' is closed - that is, to ensure that change in clinical practice takes place in the light of audit, research, evidence, risk management and complaints findings. • Development of appropriate accountability structures Dr Lee Gruner Management for Clinicians 2008

40. Major implications in introducing clinical governance • Implementation of evidence-based practice across organisations. • Development of effective multidisciplinary and inter-agency working. • Integration of continuing education and continuing professional development into quality improvement programs. Dr Lee Gruner Management for Clinicians 2008

41. Clinical Governance Principles Dr Lee Gruner Management for Clinicians 2008

42. Clinical Governance Principles Integrated approach • Integral part of everyone’s job • Obligation to seek to improve what we do by continuously examining our work • Obligation to advise on improvements • Management has an obligation to ensure staff have skills and tools to do their work Dr Lee Gruner Management for Clinicians 2008

43. Clinical Governance Principles Consistent approach • Standardised structures and processes • Support of active collaboration in all activities • Integration of clinical and non clinical functions that contribute to standards of clinical care • Respect individuals and teams contributing to care, education and research Dr Lee Gruner Management for Clinicians 2008

44. Clinical Governance Principles Strategic focus • Led by CEO of the health service • Top down approach • Integral part of strategic planning Dr Lee Gruner Management for Clinicians 2008

45. Clinical Governance Principles Provides assurance on standards of care • Quality Control measures • Appropriate Quality Assurance activities • Evidence of improvement in care • Evidence of regular policy review and improvement • Evidence of service improvement • Evidence that risks are identified and managed Dr Lee Gruner Management for Clinicians 2008

46. What needs to be done better? What still needs to be put in place- structure and process? Are there still gaps in the inputs? Defining the gaps in health services in 2008 Dr Lee Gruner Management for Clinicians 2008