Clinical Governance - Essay Example

?Introduction Clinical governance is a very complex and systematic approach to outline the maintenance and improvement of patient healthcare. Clinical governance has its roots in the increasing number of deaths due to pediatric surgery at the Bristol Royal Infirmary during 1995. Since then National Health Service (NHS) has been active in defining and outlining best practices for clinical governance in order to improve the delivery of overall health care to patients. Clinical governance as a mechanism therefore emerged in order to improve the overall healthcare standards in NHS organizations. It not only makes organizations accountable but also put through a systematic process of improving the overall quality at the health care service providers. By implementing the concepts of clinical governance, NHS therefore attempted to introduce a radical framework to improve the quality of health care on consistent base. The overall model of clinical governance is based upon certain components and critically following all the standards and criteria mentioned under such components also need to be followed. By opening up the overall clinical governance to the public scrutiny also increases the element of accountability and makes it mandatory for NHS trusts to actually look for continuous improvement of the system. This paper will present a literature review on the clinical governance and two of its important components i.e. clinical audit and evidence based practice. By providing a review and critique of the existing literature, this paper will discuss how clinical governance can be evaluated in the extended scope of practice. Clinical Governance Clinical governance is considered as an umbrella term used to define the broader level of standards to sustain and improve the overall health care standards for patients. First introduced through a Government Whitepaper, clinical governance was advocated as a new system within NHS Trusts to ensure that all the clinical standards are met and that effective processes are in place. The new system was believed to be rapidly evolving and it was expected that the improvements will be incremental and that the future will be reasonable enough to predict that NHS trusts will be able to maintain and improve their performance. (Badham, Wall, Sinfield & Lancaster, 2006) The origins of term clinical governance can be traced back to the White Paper “The new NHS Modern, dependable”. This document was also considered as the overall vision and plan of labor government to actually improve the quality of healthcare services and improve the ability and capability of NHS to deliver such quality services. (Nicholls, Cullen, & O’Neill Halligan, 2000). Its origins are in that of the corporate governance and Cadbury Report on Corporate governance served as one of the key strategic inputs in developing a comprehensive framework for clinical governance.( Maxwell, 1984) It is also critical to note that the term clinical governance, as initially defined in the original White Paper has actually changed. It has now assumed a global acknowledgment and most of the clinicians have actually embraced clinical governance as a recognized framework. Differences however have emerged in terms of how clinicians have actually internalized the term in relation to their specific profession. These differences in the overall perception of what actually clinical governance is and how it can be properly implemented therefore may not result into development of specific models or standard frameworks for corporate governance. (Halligan, Wall, & O’Neill, 2002) Clinical governance actually puts in new statutory responsibility on the NHS and its trusts to actually put in place an established framework for improving quality of healthcare service. There were three important elements which were basically to be implemented and improved upon i.e. safeguarding of the standards, promotion of continuous improvement and overall encouragement of the excellence. (Hothi, 2004) Introduction of clinical governance has actually redefined the relationship between State and medical professionals. This view suggests that State has actually put an extra bar over medical professionals to actually improve the way operate and also put into practices the processes which can improve the governmentality of the medical institutions. This view therefore outlines that State has actually put in extra control and surveillance of medical professionals. By putting into practice additional responsibilities and enhancing the accountability of medical professions, State, through NHS has actually attempted to assert its control and improve the way they perform their duties. (Vanu, 2004) It is critical to note that in order to effectively implement clinical governance; NHS trusts have to implement organizational culture and strategies to affect the behavior of clinicians. There is also a growing debate regarding the overall effectiveness and benefits of implementing corporate governance within the NHS trusts. (Sheps, 2006). Increasingly, literature indicates about the implementation of various organizational strategies by NHS trusts to actually influence the behavior. Research also indicates that NHS trusts need to develop learning strategies which can actually help them to improve the overall patient outcome through effective clinical governance. It has also been argued that the lack of ideal model or standards for implementing the effective frameworks for clinical governance, many NHS trusts is actually utilizing what is called trial and error method. (Lewis, Saunders & Fenton, 2002). This research also suggests that clinical practioners actually face structural issues in terms of properly following any framework or model for the clinical governance. It may therefore be critical to assume that NHS and its trusts actually fail to comprehend with the development of methodologies which can improve overall clinical governance mechanism. It has also been argued that the overall quality of the given to the patients and the overall perception of the patients as to whether they have been able to receive quality healthcare service largely depends upon interpersonal care. Understanding overall quality of patient healthcare from the perspective of the patients is therefore of critical importance. As such existing research has actually failed to take into consideration the overall perception of patients regarding the quality of healthcare services. Barriers to Implementation of Clinical Governance Framework While implementing clinical governance, various research studies have outlined the barriers to proper implementation of the framework. It has been suggested that the clinicians and NHS trusts believe that clinical governance was actually forced upon them by the government. Harvey (1998) however argues that clinical governance is much more than just a system of bureaucracies as it allows nurses, doctors and other healthcare services providers an opportunity to pursue excellence in medical practice. Harvey’s view is radically different from what is generally perceived in practice because it counters the impression that medical professionals have been put through additional and external burden to comply with the requirements to meet standards lay down in the clinical governance framework. It has also been suggested that clinicians and other health professionals may have to unlearn many things in order to properly understand a help implement clinical governance framework. Though clinical governance framework was implemented with an aim to improve the overall clinical outcomes for patients however, it is also evident that increasing number of healthcare professionals is viewing it as a forced imposition by the government to comply with the criteria and standards which may be hard to change in time. This perception therefore may serve as one of the key barriers for clinicians and medical professionals to actually follow clinical governance framework in its entirety. Components of Clinical Governance The overall clinical governance framework is based upon certain important components which combine together to provide NHS trusts a practical and implementable framework. The main components of Clinical governance include Risk Management, Clinical Audit, Education and continuous development, evidence based care, patient and carer experience and involvement as well as staffing and staff management. These components are considered as necessary to implement in order to ensure that NHS trusts follow a broad level methodology and framework for consistently sustaining and improving the healthcare services. Literature review will however, focus more on existing research on clinical audit and evidence based practice. The overall focus of this literature review however, will be on providing critique of the existing literature on the clinical audit and evidence based practices. Clinical Audit & Effectiveness Clinical Audit is one of the important components of overall clinical governance framework and requires a continuous quality improvement and compliance with explicit external criteria and best practices. Clinical audit can also be carried out by the practioners involved in the treatment of patients. It is basically a measurement of practice against the acceptable standards and criteria against which the performance can also be measured. Audit is therefore considered as a quality assurance tool and requires significant amount of research in order to ensure compliance with the established standards. Various research studies have critically established the link between clinical audit and research. Areas such as ethical considerations during audit, ethical review of the audit as well as highlighting the responsibilities of clinicians towards other stakeholders therefore make considerable amount of research on the topic of clinical audit. Hughes (2005) however is of the view that both audit and research however cannot be used for similar purposes as both tend to serve different purposes and should be used for their original purposes. Clinical audit has also been viewed from the perspective of quality assurance which Audit in its strict sense may not be. Quality assurance is relatively a different phenomenon requiring compliance with set down quality standards however the element of improving healthcare quality. The perceived benefits of clinical audit include improve communication, better healthcare services for patients, increased professional satisfaction as well as better administration. Clinical audit therefore is a diversified concept which requires implementation of cross sectional tools in order to actually effectively perform it and yield the results desired under overall clinical governance. Above benefits however may not fully translate into effective clinical audit and clinical governance as clinicians face different barriers which actually restrict the ability of NHS trusts and clinicians to effectively ensure quality assurance through clinical audit. Few of the key barriers to performing clinical audit include lack of resources, experience as well as conflict of interest groups’ group members. These barriers to performing clinical audit effectively may therefore restrict the ability of clinical governance framework to implement desired level of change in quality. An important issue involved in the clinical audit is that of the service user involvement as various NHS trusts seems to put in place relevant policies as well as structure to improve the service user involvement. There still exists barriers where the overall involvement of the users is limited to just providing feedback with little or no active involvement in the overall audit process. This is despite the fact that many NHS trusts have actually been able to put in place relevant structures and policies to implement clinical audit frameworks. It is however, critical to note such lesser involvement can actually result into low effectiveness of the overall audit and resultantly may not provide the desired results. In order to increase the overall effectiveness, it is critical that an organizational culture of user involvement must be developed in order to ensure increased participation of service users. Clinical Audit Process actually allows the practioners to improve upon their extended scope of practices. By continuously engaging into the process of improvement and quality assurance, clinicians need to ensure that they engage into continuous professional development. Clinical audit therefore must be used as a tool for extended scope practices for clinicians and other medical professionals. Clinicians have to assume larger roles when implementing clinical audit because under extended scope practices they must continue to ensure that they offer range of services which often go beyond their traditional roles. Issues such as education, training as well as advice can be included in the overall corporate governance mechanism to provided extended scope services. Evidence Based Practice Evidence based practice is also a critical component of overall clinical governance. Evidence based practice is considered as a radical shift away from traditional medical practices wherein decisions were made on the opinion and past practices. Evidence based practice made it mandatory for clinicians to improve the scope of their practice and base their decisions on research as well as evidence. It is however, not necessary that the use of research can actually enhance overall outcome for clinicians. It has also been suggested that the use of judicious current best evidence may also contribute towards the cause of evidence based practice. (Gray, 1997) The above discussion outlines that the use of research may not be necessary in terms of initiating and planning evidence base practice. There are different other approaches to evidence based practice which critically differ from the official view. It has been argued that other approaches may be less stringent and may support criteria which are less extensive as compared to the laid down criteria in the official definition for evidence based practice. The critical differences between the overall perception and views about evidence based practice indicate that clinicians may face difficulties in terms of overall patient outcome. (Hughes, 2005). Various approaches to evidence based practice actually lack a clear direction towards defining various patient outcomes and how they can be correlated with improved evidence based practices. Various approaches discuss about the use of research and evidence in making the decisions but fail to outline as to how such approaches can actually result into better patient outcome. There is also a general perception that evidence based practice is basically focused upon doing rather than the results of doing. This approach requires that clinicians and other medical professionals must take into consideration the overall impact of clinical effectiveness. It is critical therefore that the evidence based practice must also result into better and more effective clinical outcomes in order to implement evidence base practice. It is also critical to dispel the myth that evidence based practice is same as that of the research based practice. The absence of any research cannot replace the opinions based upon past evidence besides relying on having best evidence rather than availability of the best evidence. (Kelly & Swann, 2004) Evidence based practice along with the extended scope practices will actually require clinicians to engage extensively into research and development. Evidence based practice requires constant upgradation of knowledge base for performing evidence based practice. Defining of roles under extended scope practices as well as contribution of other medical professionals needs to be taken into consideration while engaging into evidence based practices. The existing research on connecting the dots between the extended scope of practices and evidence based practices is not robust yet. There has been considerable debate regarding initiating a robust research framework in order to evaluate the overall expansion of the extended practices roles and how they fit into the evidence based practice. There are also some barriers to the evidence based research as research studies clearly established the link between different barriers and the inability of clinicians to implement evidence based practice effectively. Various research studies have highlighted the overall interest of medical professionals in using the latest research and evidence to improve overall healthcare service delivery. However, issues such as workloads are considered as barriers to allow medical professionals to actually divert their time and energy to pursue new research and evidence in order to improve their overall clinical outcomes.( Smith, 2003) The overall purpose of evidence based practice is to rather guide the medical professionals rather than dictate them. As such, evidence based practice may not be the only option available to clinicians and other medical professionals. Balancing available research with overall ethical standing of the medical professional may be one of the delicate acts to perform. This view therefore should substantiate the fact that evidence based practices shall be there only to guide the clinicians rather than actually dictating them. This view also gives them a little flexibility in terms of differentiating between best practices and where and how to use the personal and professional judgment. The use of evidence based practices may not allow clinicians to use their own professional judgment especially in cases where clinicians face certain ethical dilemmas and will have to make a decision based upon their own professional judgment.( Mynors-Wallis, Cope, & Suliman,2004) Conclusion Clinical governance emerged as a result of the changes in the corporate governance mechanism in UK. Borrowed from Cadbury report on corporate governance, Labor Government initiated the task of improving overall effectiveness and efficiency of NHS and as a result of this introduced the framework for clinical governance. Clinical governance is a very complex and systematic approach to outline the maintenance and improvement of patient healthcare. Clinical governance has its roots in the increasing number of deaths due to pediatric surgery at the Bristol Royal Infirmary during 1995. Since then National Health Service (NHS) has been active in defining and outlining best practices for clinical governance in order to improve the delivery of overall health care to patients. By discussing evidence based practice as well as clinical audit as two of the most important components of clinical governance, this literature discussed about how both the clinical audit as well as evidence based practice can actually contribute towards the improvement in overall health service quality. Since the over-arching goals of clinical governance is to improve the overall patient outcome and the quality of delivery of healthcare services therefore it is of critical importance that the healthcare service providers must use the various standards and policies prescribed under these frameworks. This literature review also discussed about some of the potential barriers which could restrict the effective implementation of clinical governance framework. References Badham, J, Wall, D, Sinfield, M & Lancaster, J, 2006 "The Essence of Care in clinical governance", Clinical Governance: An International Journal, 11(1), p.22 – 29 Gray, M, 1997 Evidence-based Health Care. Edinburgh, Churchill Livingstone. Halligan, A, Wall, D & O’Neill, S, 2002 "Clinical governance: sharing practical experiences – developing a national clinical governance resource", British Journal of Clinical Governance, 7(1), p.53 – 56 Hothi, D, 2004 "Challenges to improving patient safety in the NHS", Clinical Governance: An International Journal, 9(3), p.143 – 146 Hughes, R, 2005 "Is audit research? The relationships between clinical audit and social research", International Journal of Health Care Quality Assurance, 18(4), p.289 – 299 Kelly, M & Swann, C, 2004 "Evidence into practice and health inequalities", Health Education, 104(5), p.269 – 271 Lewis, S, Saunders, S & Fenton, K, 2002 "The magic matrix of clinical governance", British Journal of Clinical Governance, 7(3), p.150 - 153 Maxwell R, 1984 Quality assessment in health. British Medical Journal. 288, 1470-1472. Mynors-Wallis,L Cope, D & Suliman,S, 2004 "Making clinical governance happen at team level: the Dorset experience", Clinical Governance: An International Journal, 9(3), p.162 – 166 Nicholls, S, Cullen, S. & O’Neill, A. Halligan, 2000 "Clinical governance: its origins and its foundations", British Journal of Clinical Governance, 5(3), p.172 – 178 Sheps, S, 2006 "New frontiers and approaches to clinical governance", Clinical Governance: An International Journal,11(2), p.141 – 147 Smith, W, 2003 "An explanation of theories that guide evidence-based interventions to improve quality", Clinical Governance: An International Journal, 8(3), p.247 – 254 Vanu, C, 2004 "Clinical governance: a fresh look at its definition", Clinical Governance: An International Journal, 9(2), p.87 – 90 Read More