Clinical Governance: The Monitoring of Ambulance Services - Term Paper Example

Clinical Governance 03 November 2009 Introduction Clinical governance has lately gained the attention of academics and professionals in the medical health services. This new attention has been brought about by the new focus on the use of emergency services, especially ambulance services, as an integral part of the health care team. More importantly, the people involved have endeavored to bring professionalism to this vital component of the health care delivery team. Legal challenges to the emergency units response to medical emergencies have highlighted the need for professionalism and improved clinical governance to bring some measure of standardization to ambulance service and avoid the oft-repeated complaints of negligence or incompetence in the rendition of service. Governance, as defined, pertains to certain expectations within an organization that is applicable to all its members. It is therefore a leadership and management process that is more concerned with the observance of certain standards to monitor desired performance. Clinical governance, as used in this paper, will refer to the systematic approach that is applied in the monitoring, maintenance and improvement of the quality level of patient care within a health system. In this case, it refers in particular to ambulance services, a crucial component in the delivery of pre-hospital care from the home to the hospital or to transfers between hospitals. This renewed focus on clinical governance is primarily intended to enhance patient safety and raise the level of quality of ambulance services. The new atmosphere is featured as one of accountability and transparency with some policy implications for those involved in ambulance services such as the emergency health care personnel. Paramedics in particular are concerned about the effects of this new direction with regards to a blame-free environment. Discussion In the past, paramedics were seen as necessary adjuncts to the health care team but not necessarily treated as professionals themselves. There are some reasons for this view and they are due to the lack of certain standards required in other professions like law or accounting. It is also thought that paramedics are the new kids on the bloc who need sometime to prove their credibility alongside the other health professions. But these views are changing rapidly due to a series of exciting developments on many fronts. Lately, paramedics have undergone changes in clinical practice, academic training, educational attainment and increased participation in the field of research. All these augur well for paramedics in general but these has also raised a few concerns from its practitioners. Paramedics are slowly developing their very own identity but still have a long way to achieve their aim of being recognized as a separate but legitimate profession. In general, public expectations of paramedics are changing but the overall theme is that they are expected to behave and act as professionals. Among the changes occurring today concerning paramedics are in education, with new undergraduate degrees being developed even up to the university level. Educational training is the single biggest defining factor for paramedics to attain the respect of being a professional if they can prove it is a legitimate career path that requires extensive academic preparation. This focus on education can be augmented by increased levels of scholarly activities like research and field studies that emphasize at the same time a greater community-based role for them. Paramedics also need to explore other areas used by other professions to enhance their community standing such as greater autonomy by establishing a body that will draft a code of ethics for all practitioners to abide by, accreditation bodies, professional associations geared towards addressing common concerns and the formation of linkages with other international organizations that will help update its knowledge database and current best practices. There are some important questions that paramedics themselves have to answer before their dream of being treated as professionals can be achieved. Among them are the education standards, who will do the accreditation, what is the scope of their practice, does it have its own code of ethics and what licences are required for practice. In short, there is a need for the rationalization of their practice and the reason why the principles of clinical governance are being applied today to paramedics. Depending on which definition is used such as the four perspectives by Andrew Abbot (1988), it is important that paramedics view their practice as an occupation (Wueste, 1994) that demands some aspects social responsibility. Or they can choose to be guided by the five dimensions of Freidson (2001) such as clear-cut division of labour, a well-defined set of knowledge and skills, a career path, sophisticated training and an ideology to distinguish themselves as professionals in the true sense of the word. This was the case before for similar professions like nursing, the military and the clergy that had undergone the same process before they came to be called as professionals in their own right (Thompson & Boyd, 2006). The overarching aim before a professional status can be attained is the formulation of a set standard criteria with which to judge performance. Paramedics must also strive, as a group, to justify the considerable privileges it offers to those who embrace its principles by effectively advocating social policies that will benefit everybody in society (Watson, 2003). In other words, paramedics must devise their strategy as a group when dealing with the government whether as employees or as fee-paid practitioners. It can use a combination of self-interest and concern for others similar to what doctors used in their dealings, as a mediator between the individual professional (a paramedic) and the client. This may involve some trade union tactics but the point is to act collectively as an occupation. It must also increase its members status, provide autonomy and emphasize altruistic service. However, before all these can be achieved, paramedics must also address academic issues such as sponsoring scholarly activities like academic research studies, publication of peer-reviewed journals, submit position papers to relevant government agencies and holding of conferences. An important aspect of academia is that work done by this sector can greatly influence public policy formulation that will be favourable to the paramedics as a whole by taking their concerns and issues into consideration before new legislation is approved. There is a need to go beyond mere images or symbolism and go for the traits of true professionals. Paramedics must also guard against the twin threats of bureaucracy and consumerism which Eliot Freidson had described in his book “Professionalism: The Third Logic” that also wants to claim the body of knowledge that professionals are supposed to have exclusively to some extent for use in doing good (Duyvendak, Knijn & Kremer, 2006). Paramedics can lobby as a group for an increase in budget allocations for paramedic professors and academics by increasing their pay relative to those offered by other courses. Additionally, they must also strive to dispel the wrong notions that becoming a professional is a threat to the other members of the health care team. Moreover, they should also remove the biases that attach to obtaining higher education and getting a college degree. Paramedics must dispel their own limiting mentality that their occupation is merely vocational or technical. In other words, paramedics themselves must lead the way about feeling good as professionals. The emergency medical services can use paramedics to compile health data about the localities in which they operate. This way, health issues are treated as social concerns and not purely medical considerations. This new perspective gives rise to health sociology that is not a part of the usual medical analysis of illnesses having a biological etiology (Germov, 2005). It can be likened to epidemiology in some respects, looking for certain patterns in the social aspects of diseases and develop effective preventive measures before these can worsen. In conjunction with efforts to inject a sense of professionalism into the mindsets of paramedics, the government of New South Wales has also embarked on clinical governance to enhance patient safety. Its hallmarks are openness, transparency on the cause of failures, an emphasis on learning, an obligation to act according to the best interests of the public and in good faith, accountability and teamwork. This means there are now standards by which to measure performance, mainly through the use of key performance indicators or KPI. These new KPIs are used in all aspects of emergency care service such as protocol application, data gathering on age groups, incidence reports, adverse events and even pharmacology protocols. This way, paramedics are guided as to the limits of their responsibility and avoid litigation in the performance of their duties. It means there is not much leeway or flexibility involved. The principles of best practices in clinical governance are being applied to such areas as the correct cardiac care (whether myocardial ischemia or infarction), trauma and mental health cases, cardiac arrest incidents (resuscitation measures needed) and the use of medically based research produced by the Ambulance Research Institute regarding correct procedures when using adrenaline or sodium bicarbonate. It has also issued guidelines on the correct response procedures regarding airway blockages, pain management and stroke mitigation. The clinical governance focus today has emphasized the need for acute care services such as hiring more intensive-care paramedics and ambulance retrieval paramedics. All these various threads related to emergency medical services have been linked all together by Germov, whose main contribution is the belief that health and illnesses often have a social basis. Factors like gender, ethnicity, race, economic status and crime rates have great bearing on the diseases of a certain locality that is particular or distinctive to local Australian society (Germov & Poole, 2007). Germov suggests paramedics must be allied with the other professionals like dieticians and nutritionists to be effective (Germov & Williams, 1999). One important aspect of the new emphasis on clinical governance is how it looks at medical errors committed in the performance of duty by paramedics. It had changed the way medical errors are perceived from who caused the accident to what caused the accident. This has taken the burden of disproof from the paramedics who are constantly worried about the effects of their actions on the field can affect life-or-death outcomes. It has given paramedics new faith in themselves by not jumping to conclusions; that mistakes do happen not because of carelessness, misconduct or negligence of the individual but the result of several factors. A very good example of this new concept is the Swiss cheese model where several defences are in place and when mistakes happen, a system is reviewed and not the individual right away. An objective is to foster and cultivate a blame-free environment where paramedics can exercise their best judgement sometimes under very trying circumstances. The beauty of this model is the admission that humans are not perfect and mistakes happen occasionally. A new attitude like this goes a long way to reassure anxious paramedics how they will turn out if something goes wrong despite their best efforts in the course of performing their duties. An important article about clinical governance was the one published by Braithwaite and Travaglia (August 2008) that defined key components of a good clinical governance. In it, they discussed the model to be used when crafting strategies for clinical governance. They had however, missed a few points, such as emphasizing cooperation and collaboration when trying to achieve good governance within a healthcare organization between both corporate governance (composed by board of directors) and clinical governance (at the clinical level) . One aspect of clinical governance that is encouraged to be prevented or avoided at all times is the so-called hindsight bias. This bias tends to cloud the more important issues that surround an incident or medical error by limiting a more thorough investigation from being conducted because hindsight bias tends to blame the individual instead of the system itself. This new openness in the paramedics professional culture has some benefits to patients such as encouraging emergency medical service personnel to render their best efforts as they are not to be blamed any more. In other words, they will not be so hesitant in rendering much needed service. This change in culture also encourages mistakes to be announced more openly that will help investigators avoid similar mistakes in the future. In a sense, it encourages the paramedics to tell everything rather than hide errors and mistakes on the field. This is what the new blame-free environment tells them, that they will be blameless as long as they did the job properly, regardless of the circumstances and the outcomes. Actual experiences by medical personnel in the field will be discussed openly so that new measures can be designed to avoid mistakes or somehow improve service the next time. It is hoped that the new openness will benefit the paramedics as well as the patients by having new knowledge imparted to the paramedics from the experiences of other paramedics with the sharing of important medical information. Paramedics also perform an important additional function: the gathering of data for studies on the epidemiology of Australians health, factors and determinants of health, relationships between disease patterns and socio-economic status of local populations and make some preliminary conclusions regarding the continued welfare state of Australia and epidemiological data, given its unique country characteristics of sparse populations and vast distances between cities and settlements (Willis & Reynolds, 2008). One possible drawback for this new proposed no-blame environment will be perceived increase in carelessness or negligence by some personnel who now expect to be absolved of any criminal wrongdoing if something goes horribly wrong in the field. They will most likely put the blame now on the system put in place for emergency medical services rather than on themselves specifically. This finger-pointing could encourage a temporary rise in some people who might skip some procedures or commit shortcuts in the delivery of medical services. Conclusion The practice and profession of paramedics in Australia is undergoing massive changes due to several factors that interplay with each other. These are the desire of paramedics to be considered as a legitimate profession with its own professional code of ethics alongside other medical health practitioners like nurses and doctors. New legislation had also been passed that were designed to protect paramedics from the hazards of the profession such as lawsuits from malpractice or negligence. Academia has also been helpful towards this end by implementing new courses or integrating them into their curricula with advanced degrees in some instances. An example is the National Ambulance Competencies endorsed back in 2002. A big concern among paramedics is the unique legal situation prevailing in NSW that is not implemented in other states or jurisdictions. The legal experts opine that political reality often intrude on patient safety considerations (Freckelton, 2006) and the state of NSW moved away from autonomous peer review, one of the critical elements for a professional body. In a nutshell, the cause of all these were the Camden and Campbelltown Hospitals as examples of the failure and deficiencies of using the no-blame systems approach to clinical governance. It seems that NSW had discarded the concept of autonomous self-regulation regarding ethics and deviant behavior among health care professionals and leans towards some intervention. There have been encouraging signs of competency-based standards of professional practice intended for paramedics and NSW was the first to implement them back in 1994. The certificate-level programme for ambulance personnel is now a degree programme which now signifies acceptance by the tertiary educational sector of the growing complexity of the job of paramedics. The growing body of knowledge and skills required for this profession resulted in greater flexibility because employment opportunities have been widened (Velde, 2009). Most paramedics can now apply for a job in any state ambulance service or authority in Australia. Reference List Braithwaite, J. & Travaglia, J. F. (August 2008). “An Overview of Clinical Governance Policies, Practices and Initiatives.” Australian Health Review. 23(1): 1022. Duyvendak, J. W., Knijn, T. & Kremer, M. (2006). Policy, People and the New Professional: De-professionalisation and Re-professionalisation in Care and Welfare. Amsterdam, the Netherlands: Amsterdam University Press. Freckelton, I. R. (2006). Regulating Health Practitioners. Annandale, NSW, Australia: Federation Press. Germov, J. (2005). Second Opinion: An Introduction to Health Sociology. Melbourne, Australia: Oxford University Press. Germov, J. & Poole, M. (2007). Public Sociology: An Introduction to Australian Society. St. Leonards, Australia: Allen & Unwin. Germov, J. & Williams, L. (1999). Get Great Information Fast. St. Leonards, Australia: Allen & Unwin. Thompson, I. E. & Boyd, K. M. (2006). Nursing Ethics. Chatswood, NSW, Australia: Elsevier Health Sciences. Velde, C. R. (2009). International Perspectives on Competence in the Workplace: Implications for Research, Policy and Practice. New York, USA: Springer. Watson, T. J. (2003). Sociology, Work and Industry. Florence, KY, USA: Routledge. Willis, E. & Reynolds, L. (2008). Understanding the Australian Health Care System. Chatswood, NSW, Australia: Elsevier Health Sciences. Wueste, D. E. (1994). Professional Ethics and Social Responsibility. Lanhan, MA, USA: Rowman & Littlefield. Read More