CLINICAL GOVERNANCE
Dr. ADIB A. YAHYA,MARS
Clinical Governance is :
"A framework through which health care organisations
are accountable for continuously improving the quality of
their services and safeguarding high standards of care,
by creating an environment in which excellence in clinical
care will flourish." (NHS)
Effective Clinical Governance ensures:
continuous improvement of patient services and
care
a patient centred approach that includes treating
patients courteously, involving them in decisions
about their care and keeping them informed
a commitment to quality, which ensures that health
professionals are up to date in their practices and
properly supervised where necessary
a reduction of the risk from clinical errors and
adverse events as well as a commitment to learn
from mistakes and share that learning with others
The goal of clinical governance is for all staff to be
striving to continuously improve care.
The term ‘clinical governance’ may seem to
imply that it is the exclusive responsibility and
domain of clinical staff – but this is not the case.
It is everyone’s concern – the nurse, the GP,
the dentist, the pharmacist, the receptionist, the
cleaner – everyone in fact whose work impacts
on the patient’s experience of healthcare
So what does clinical governance really mean?
Quite simply it is about:
‘HIGH QUALITY, ACCOUNTABLE CARE’
Clinical Governance requires changes at three levels:
Individual health care professionals need to embrace
change, adopting reflective practice which places
patients at the centre of their thinking.
Teams need to become true multi-disciplinary groups,
where understanding about roles, about sharing
information and knowledge and about support for each
other becomes part of their everyday practice.
The Healthcare organisation is also committed to
embracing the changes required by putting systems and
local arrangements in place to support you as an
individual and the teams within which you work.
There are seven key components of Clinical
Governance, known affectionately as
'The 7 Pillars' :
Risk Management
Clinical Audit
Education, training and continuing personal
and professional development
Research and Development
Information
Patient and Carer experience and involvement
Staffing and staff management
SYSTEMS
AWARENESS
TEAMWORK
COMMUNICATION
OWNERSHIP
EDUCATION,TRAINING
PROFESSIONAL DEVELOPMENT
STAFF AND
STAFF MANAGEMENT
CLINICAL AUDIT
RESEARCH AND
EFFECTIVENESS
RISK MANGEMENT
USE OF
INFORMATION
PATIENT AND PUBLIC
INVOLVEMENT
PATIENT – PROFESSIONAL PARTNERSHIP
STRATEGIC CAPACITY
LEADERSHIP
Patient and Public Involvement
Involving patient groups and local communities in all
aspects of planning, provision, monitoring and evaluation
of care is one of the key underpinning principles of
clinical governance – and one that represents a
fundamental culture shift for the HOSPITAL
Patient and Public Involvement includes:
– Appointing a Patient Advice & Liaison Manager
– Providing patients with information about the services we provide
– Actively seeking patients views on those services, and making
changes as a result
– Involving patients in the planning and delivery of services.
– Working with GP practices to establish Patient Participation
Groups
Use of ‘Intelligent’ Information
Accurate and appropriate information is vital. It can help identify the
priority health needs of the local population, and assure the safety
and quality of current clinical provision of care.
Information we need includes:
– Robust and reliable public health information
– Robust and reliable comparative national data
– Robust and reliable clinical information
Some of the work includes:
– Ensuring we have a Data Protection Officer to oversee the
confidentiality and security of information
– Monitoring the accuracy of performance and activity information
received from secondary care providers
– Starting to collect community data with scanned forms
– Routinely making information on activity available to clinicians and
staff
Risk Management
Ensuring the safety of everyone who comes into contact with the
health services is one of the most important challenges facing
healthcare today.
There are three important things we can do which will help promote
patient safety:
– Put systems and processes in place to proactively identify clinical and
non-clinical risk
– Implement a systematic strategy to minimise them, monitor them and learn
from them
– Promote a ‘fair blame’ culture, so that staff are willing to report their
mistakes and near misses.
Some of the steps to take include:
Introducing an electronic Incident Reporting System in order that we
can record, analyse and monitor incidents and complaints.
Introducing staff training on incident reporting and ‘Root Cause
Analysis’
Disseminating learning from incidents across staff groups will be a
key priority.
Ensuring the Complaints Procedure is in place within the hospital.
Research and Clinical Effectiveness
All clinical decisions and actions initiated by or on behalf
of the HOSPITAL should be based upon a reliable,
robust and ever developing evidence base. In order to
promote this the HOSPITAL needs to develop systems
to:
– Promote and monitor clinical effectiveness
– Encourage and monitor the use of evidence based practice
Some of the steps include:
– Developing and agreeing evidence based protocols of care
– Ensuring that the standards and guidelines are implemented
throughout the HOSPITAL
– Providing training on searching for evidence is available to all
staff.
– Developing systems to determine whether clinically effective
practice is being implemented at grass roots level.
– Ensuring that research governance arrangements are in place
– Ensuring that evidence based prescribing is implemented
Clinical Audit
Clinical Audit is a structured process, which ensures we are carrying
out best practice by reviewing what we are doing, compared with
that which we should be doing.
It is seen as an essential component of professional practice and
can demonstrate efforts being made to deliver high quality care to all
patients.
Some of the steps include:
– The development of a Clinical Audit Strategy
– The establishment of a Register to monitor Clinical Audit activity,
progress and evaluation across all areas of the Services.
– Support, advice, guidance and training to all individuals or groups
undertaking audits.
– The production of a Clinical Audit Guide for distribution to all
interested parities.
– Providing a quarterly review of clinical audit activity to the Clinical
Governance Committee.
Staffing and staff management
The quality of clinical care is intimately related to the quality and
morale of the staff – and the way they are managed and supported.
The ultimate aim is to have a staff group that is:
– Highly motivated
– Fully cohesive and effective in relation to current needs and
demands
– Flexible enough to respond positively to changing need and patterns
of care
Some of the work includes:
–
–
–
–
–
Introducing a corporate induction programme for all new employees
Achieving Improving Working Lives Practice status
Developing a range of Human Resources (HR) policies.
Undertaking an Annual Staff Survey
Developing the Hospital Newsletter, website and intranet site to help
keep staff informed of key issues and associated information
– Holding a regular programme of open meetings so that staff can
raise issues with the Chief Executive, directors and non-executive
directors
Workforce Planning, Education and Training
Staff are the most important resource in all HEALTHCARE
organisations.
Thoughtful and imaginative investment in staff development shows a
real commitment to clinical governance.
The importance of life long learning and leadership development is
important not only for individuals and the teams in which they work,
but also for the ongoing development of the HOSPITAL
Some of the steps include:
– Developing a system to ensure equity of access to training and
development opportunities via the Education Links system and by email.
– Ensuring processes are in place to support a range of internal and external
learning opportunities, higher and further education.
– Developing new roles and changes to work patterns to ensure we have the
right workforce for future requirements.
PENGORGANISASIAN
PENANGGUNG JAWAB :
– PIMPINAN RS / CEO
KOORDINATOR:
– DIREKTUR MEDIK / KOMITE KLINIK
PENGENDALI :
– SUBKOMITE CLINICAL GOVERNANCE
PELAKSANA :
– DEPARTEMEN / PERORANGAN
PERAN
Pimpinan RS :
– Penanggung Jawab
– Prioritas “Patient Care”
– Menentukan Koordinator
– Membentuk Subkomite Clinical Governance
Koordinator :
– Koordinasi dan monitor
– Dukungan terhadap Tim Departemen
– Review Kemajuan
Pengendali :
– Bertanggung Jawab kegiatan “day-to-day”
– Mendukung Tim Clinical Gov Departemen
– Anggota terdiri dari :
Perwakilan Tim Departemen
Organisasi Pendidikan
Manajemen Resiko
Informasi
Pelaksana :
–
–
–
–
–
–
Tiap Departemen membentuk tim Clin Gov
Melaksanakan arahan dari Pengendali
Asessment kemampuan Departement
Identifikasi kelemahan dan kekurangan pelayanan
Perencanaan tahunan Departemen
Komunikasi dan Disseminasi informasi intra maupun
inter departemen
– Kebutuhan pendidikan
Penanggung Jawab
(CEO)
Koordinator
(DirMed / KomKlin)
7 PILLARS
internal
Pengendali
drivers (SubKom.Clin Gov)
Pelaksana
(Dept / Perorangan)
external
drivers
Standards
Regulations
Authority
Langkah-Langkah Pengembangan
Clinical Governance
Tiap departemen harus menyediakan waktu
untuk mendiskusikan implikasi dari clinical
governance.
1.
•
•
•
•
Bagaimana situasi di Departemen? Contoh
pelayanan yang baik dan yang buruk?
Di bagian mana perlu perbaikan dengan sumber
daya yang tersedia? Bagaimana perbaikan dapat
dicapai?
Bagaimana dukungan nyata
(staf,IT,perpustakaan,dsb) yang dibutuhkan?
Bagaimana keterlibatan multidisipliner secara efektif
dapat dicapai
2.
3.
4.
5.
6.
7.
Tiap departemen harus memiliki penanggung jawab
untuk Nursing Clin Gov dan Medical Clin Gov
Tiap departemen mengembangkan programnya sendiri
meliputi tujuan dan sasaran dengan azas prioritas
Program departemen harus diketahui Pengendali,
Koordinator dan Pimpinan
Kebutuhan pelatihan untuk pengembangan
kepemimpinan dan keterampilan khusus
Pertemuan rutin antar Departemen
Kembangkan jejaring dengan institusi kesehatan lain.
“Unwritten Rules” yang Menghambat  Status Quo
We know best
My own work has no effect on others areas
Clinician don’t need managers
The more senior you are the more you know !
Don’t admit to mistakes
Even though we talk about quality we only
assess on the quantity
But I’ve always done it this way
There are no rewards for doing well
Everyone understands the jargon
It is wrong to seek answers / consult others
Don’t fix it if it’s not bust
Doctors time is more valuable than nurses
Nothing ever changes
Everything is changing all the time
The pass was much better
( Adapted from : Cullen et al. British Journal of Clinical Governance
2000; 5(4):233-239)
HARUS DI INGAT
Clinical Governance suatu perkembangan
yang evolusioner, bukan revolusioner.
Cinical Governance sudah dijalankan
bertahun-tahun tetapi dalam bentuk
“fragmented,haphazard & instropective
Clinical Governance is NOT just about
systems, it is also about the CULTURE
of an organization.