clinical governance research articles

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v.19(6); 2019 Jun

What is clinical governance?

A.j.r. macfarlane.

1 Glasgow Royal Infirmary, Glasgow, UK

2 University of Glasgow, Glasgow, UK

Clinical governance may be defined as ‘the framework through which healthcare organisations are accountable for continuously improving the quality of their services and safeguarding high quality of care’. 1 Improving quality should be a core value of healthcare institutions worldwide; indeed, following the Health Care Act 1999 there is a statutory ‘duty of quality’ for healthcare providers in the UK. 2 Several clinical governance ‘frameworks’ or ‘pillars’ exist, but all focus ultimately on delivering safe, effective, and person-centred care to every patient, all of the time . This article aims to provide an introduction to clinical governance and is based on UK practice.

In NHS organisations, the chief executive has overall responsibility for clinical governance. Each hospital has a clinical governance lead (often the medical director) and depending on the size and structure of the organisation, governance may be configured into several multidisciplinary tiers. UK Anaesthesia Clinical Services Accreditation (ACSA) standards mandate that every department of anaesthesia should have a clinical governance lead. 3 Generally, anaesthesia governance meetings would include as a minimum the clinical director and senior managerial and nursing staff. Leadership is required to ensure that clinical governance processes are embedded within service provision.

Several methods are used to safeguard patients' care, and systems to minimise and manage risk should be in place. 4 When problems are identified, or occur, there needs to be an open, transparent, and blame-free reporting system. The goal is to understand the issue and allow lessons to be learned, shared, and acted upon constructively in order to prevent recurrence. Organisations that manage risk effectively and efficiently are more likely to achieve safe and effective care. 5

Incident reporting

An incident is any event or circumstance that led to unintended or unexpected harm, loss, or damage. A near miss is an event or occurrence which, but for skilful management or a fortunate turn of events, would have led to harm, loss, or damage. Most incidents can be investigated locally: the seniority of the investigating team depends on the severity of the incident. A significant incident is an event sufficiently serious to warrant a formal root cause analysis investigation and usually involves death or serious injury/ill health, major damage to property, loss of a service, a major health risk, or a threat to the strategic objective(s) of the organisation. In England, these must be reported via the Strategic Executive Information System but also via the National Reporting and Learning system (NRLS) if patient safety is involved. The recent UK Duty of Candour legislation requires that every healthcare professional must be open, honest, and supportive when a patient suffers as a result of treatment received. 6 An apology and support should be offered, and an explanation that there will be an investigation (by definition usually a significant incident investigation) after which the results will be shared. A never event is a serious incident that in theory is wholly preventable, because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented. 7 In England, these must be reported via the NRLS. Sharing of lessons learned from other incidents through the RCoA Safe Anaesthesia Liaison Group (SALG) is voluntary. Meaningful safety recommendations relevant to anaesthesia and critical care have also emerged from the recently formed Healthcare Safety Investigation Branch. Finally, certain work-related injuries must be reported under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013, including those where the result is that the employee is unable to work for more than 7 days subsequently. 8

Morbidity and mortality

An effective morbidity and mortality (M&M) meeting should identify events that have resulted in adverse outcomes, foster discussion, and lead to the dissemination of learning. Ideally this should be multidisciplinary and within a ‘safe’, non-critical environment where staff are encouraged to share and ‘speak up’, and focus on systems and process variations rather than individuals and blame. Cases that may be discussed include any deaths arising from elective surgery; deaths involving an unscheduled period in intensive care; deaths where it was necessary for the patient to return to the operating theatre within 14 days of initial surgery; deaths where a significant incident has been identified; or patients who suffered major complications but did not die. The Scottish Audit of Surgical Mortality was a nationwide process involving an external review of all perioperative deaths in Scotland. This no longer exists, but the structured judgement review is a national process introduced by the Royal College of Physicians using validated methodology to learn from mortality. 9 SALG summaries of anaesthesia-related incidents should also be reviewed at M&M meetings.

Risk register

This is a systematic record of risks to the organisation, with a description and severity rating of the risk, along with the impact and consequences. Many risks cannot be eliminated and therefore it must be decided whether to accept, manage, or possibly avoid (i.e. cease a certain procedure) the risk. The risk register should be reviewed regularly.

Effective care

Effective care for patients should be based on good quality evidence from research, and incorporates the use of guidelines, standards, and quality improvement (QI) processes. Guidelines and standards do not replace the need for experienced clinical judgement exercised by individual anaesthetists in the best interests of their patients, but they are very much intended to support this.

Where there is variation in practice that affects patient outcomes, and research demonstrates evidence of effective practice, guidelines such as those published by the RCoA, the Association of Anaesthetists, the National Institute for Health and Care Excellence, or the Scottish Intercollegiate Guidelines Network may assist practitioners in making decisions. Appropriately implemented, guidelines may potentially improve the quality of care for patients and increase the efficiency of healthcare organisations through standardisation. 10 , 11 However, although guidelines are usually developed systematically and with rigour, they can be open to interpretation. Hence they should still be scrutinised, and decisions made on how best to adopt them locally.

A standard is a statement, reached through consensus, which clearly identifies the desired outcome. Standards should be measurable, often through the use of audit, and also achievable. By meeting standards such as the voluntary ACSA standards, the quality of service provision should improve.

Quality improvement

The purpose of QI is to bring about measurable improvements by applying systematic change methods and strategies within a healthcare setting. QI has recently been described in more detail in this journal. 12

Person-centred care

Patients, along with their relatives where appropriate, should be equal partners in planning, developing, and assessing care to ensure that it is the most appropriate for their needs. A safe experience may not be a person-centred one and a good experience might not be a safe one. Person-centred care also includes complaints and a process whereby these are reviewed and responded to in a timely fashion. Surveys of patients can form an important part of person-centred care, although these can be more difficult in the field of anaesthesia, where many other factors influence the experience of a patient undergoing surgery.

Assured care

Assured care is the process of ensuring that safe, effective, person-centred care occurs. Care may be assured either through voluntary (e.g. the ACSA standards) or involuntary (e.g. the Care Quality Commission in England, Healthcare Inspectorate Wales, and Healthcare Improvement in Scotland) mechanisms. Such inspections may be planned or unannounced. Failure to meet standards can, rarely, lead to suspension of services. The process of regular clinical governance meetings, and the dissemination of work and any changes undertaken is also part of the assured care process.

Declaration of interest

The author declares that they have no conflict of interest.

Alan Macfarlane BSc (Hons) MRCP FRCA EDRA is a consultant anaesthetist at Glasgow Royal Infirmary where he is clinical governance lead for anaesthetics and theatres. He is also an Honorary Clinical Associate Professor at the University of Glasgow. His major clinical and research interests are regional anaesthesia; he is treasurer of Regional Anaesthesia-UK, a member of the ESA scientific subcommittee for regional anaesthesia and an editor of BJA Education.

Matrix codes: 1I01, 3J00

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Improving the quality...

Improving the quality of care through clinical governance

Related content
Peer review
Stephen Campbell , research fellow ,
Martin Roland , professor, general practice ( m.roland{at}man.ac.uk ) ,
David Wilkin , professor, health services research
National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL
Correspondence to: M Roland

This is the third in a series of five articles

The UK government has set a challenging agenda for monitoring and improving the quality of health care. It is based on a series of national standards and guidelines, a strategy for quality improvement termed “clinical governance,” and a framework for monitoring the quality of care in and performance of NHS organisations (box). Clinical governance is “a framework through which NHS organisations are accountable for continually improving the quality of their services, safeguarding high standards by creating an environment in which excellence in clinical care will flourish.” 1 To be successful this strategy requires effective leadership by clinicians who have responsibility for improving quality; it must engage the doctors and nurses who provide care on a daily basis; and it must have commitment and support from managers within the NHS.

Summary points

Primary care groups and trusts are responsible for implementing clinical governance, including monitoring and improving the quality of care

In their first two years they have concentrated on educating and supporting health professionals and encouraging shared learning

Information about the quality of care provided in general practice is being shared between practices and with the public, often in a form that permits practices to be identified

Many groups and trusts are offering incentives to practices to promote improvements in the quality of care

Sanctions and disciplinary action are rarely used when dealing with poor performance

Limited resources and the pace of change are potential obstacles to future success in improving the quality of care

Goals of quality improvement strategies in the NHS

National service frameworks, National Institute for Clinical Excellence —set standards, develop guidelines

Clinical governance —deliver care, improve quality

National performance framework, annual appraisal of doctors, Commission for Health Improvement, national surveys of patients —monitor quality and performance

Clinical governance

Primary care groups and trusts are responsible for implementing clinical governance in primary care. These new organisations bring together general practitioners, nurses, other primary care professionals, and managers to develop services, raise quality standards, commission hospital services, and improve the health of populations of about 100 000 people. Operating initially as subcommittees of existing health authorities, all are expected to become free standing primary care trusts controlling their own budget for the health care of their populations by 2004. 2 In the past, primary and community services in the NHS have been fragmented, and general practices have not usually worked together as part of a larger organisation. One of the challenges facing primary care groups and trusts in implementing clinical governance is to develop a more corporate culture in which quality improvement becomes a shared enterprise. This will entail greater use of shared learning—that is, joint education and training during which different professions working in primary care learn together and from each other—and a greater openness and willingness to exchange information about quality. It will require the development both of incentives and methods for tackling poor performance.

Primary care groups were established in England in April 1999. Progress in clinical governance during their first year was largely confined to putting in place an appropriate infrastructure, conducting baseline assessments, and establishing priorities. 3 At the end of their second year we can begin to assess how they are implementing clinical governance. In this article we concentrate on the broad approaches to quality improvement that are being adopted; we use evidence from a recent survey. 4

National tracker survey

The national tracker survey is a longitudinal survey of 72 of the 481 primary care groups established in England; it aims to evaluate their achievements and identify features associated with success in performing their core functions, including quality improvement. The first survey was completed in December 1999 3 and the second in December 2000. 4 By October 2000, two of the groups in our original sample had merged with each other, and five had become trusts. Details of the survey were summarised in the first article in this series. 5 The evidence cited in this article is derived from postal questionnaires returned by 49 (68%) of those who were in charge of clinical governance for their group or trust in 1999 and by 58 (81%) of those who were in charge in 2000. Forty eight (83%) of those responsible for clinical governance were general practitioners, but 20 (34%) groups and trusts had a general practitioner and a nurse who shared lead responsibility for implementing clinical governance. In these cases, only one of them completed the questionnaire.

Shared learning and partnerships

Primary care groups and trusts are using education to improve quality. By December 2000, 54 of 58 (93%) were actively encouraging development plans for their practices and implementing personal learning plans for general practitioners, compared with only two (4%) of those surveyed in 1999. Many of the initiatives created opportunities for learning to be shared and partnerships to be developed with other organisations (table 1 ).

Most common clinical governance schemes for sharing learning and developing partnerships among primary care groups and trusts, October 2000 4

View inline

Half day educational events organised for the whole primary care group were a notable initiative, promoting shared learning and reducing the isolation of practices. The commonest model used was for all practices in a primary care group to close for one afternoon a month, with emergency cases being covered by doctors from a neighbouring group. Sometimes these meetings were attended only by doctors and sometimes by the entire primary care team. In some cases regular attendance rates were higher than 95%.

These activities will represent a new point of departure for general practice in the United Kingdom. Before primary care groups were established, general practitioners worked largely independently of each other and may never have needed even to speak to doctors practising nearby. General practitioners and other practice staff are reported to be keen to take up opportunities to meet and learn together even though participation is voluntary. Similarly, encouraging cross practice audits of clinical care and working to develop local guidelines provide opportunities for health professionals to work together on quality improvement.

As well as facilitating shared learning between members of the group, many of those responsible for clinical governance also reported engaging in initiatives with other groups, including hospital trusts and providers of community health services.

Sharing information

To be successful, shared learning and other joint activities require a willingness to exchange information about quality of care. Successfully implementing clinical governance requires developing this willingness. In the past, information about the quality of care provided by doctors and nurses in general practice may not even have been shared with colleagues in the same practice depending, for example, on whether the practice undertook a clinical audit. However, information from a clinical audit was hardly ever shared outside a practice. This is changing rapidly. Primary care groups and trusts already have access to routine data on practice activities, such as rates of cervical cytology and immunisation, and will increasingly have access to the results of cross practice audits.

(Credit: SUE SHARPLES)

There is an increasing move towards making information about quality of care more widely available. Virtually all groups and trusts surveyed were making anonymised information on quality available, but many were also providing information—to board members and other practices—that permitted individual practices to be identified (table 2 ). This represents an important change in both the practice and culture of primary care, where even sharing information with professional colleagues has been rare. Making such information available to the public is an even more radical step, and while plans to do this are much less advanced, some primary care groups and trusts are beginning to take tentative steps in this direction.

Providing incentives

Promoting shared learning and disseminating information help improve quality by increasing the acceptability of the need for improvement and through peer pressure. Although the surveys showed that some practices are still hostile to these changes, the majority reported that they had at least acquiesced to the new agenda if not enthusiastically embraced it.

Additionally, primary care groups and trusts are using financial incentives to promote quality improvement. Excluding prescribing incentive schemes, 50% (29/58) reported using specific quality incentive schemes in 2000, compared with 29% (14/49) in 1999. In general, these were associated with participating in audit activities or rewarding those who met targets.

During the past three years the government has been experimenting with new types of contracts for general practice (for example, the personal medical services pilot scheme) in which the nature and quality of services to be provided can be more closely specified. Altogether, 29% (17/58) of those responsible for clinical governance reported using contractual arrangements to improve quality. It seems likely that this trend will continue, and modifications to the main contract for general practitioners are likely to include specific payments linked to the quality of the care provided.

Primary care groups and trusts sharing information on quality of care, October 20004

Dealing with poor performance

The approaches taken by groups and trusts to deal with poor performance in practices have been supportive and educational. Those responsible for clinical governance described their strategies as including having informal discussions, providing training for practices, and allocating resources to give extra to poorly performing practices. Conducting clinical audit and sharing information were also used as means of addressing poor performance; these approaches were taken to try to engage poorly performing practices with the quality improvement strategies being used by their peers.

Only 3% (2/58) of those responsible for clinical governance said that they intended to withdraw resources from poorly performing practices, and only 9% (5/58) had established any formal disciplinary procedures.

During 1999 and 2000, the NHS established formal procedures to identify poorly performing general practitioners. In most cases, these operate at the level of the health authority (that is, among several primary care groups in a geographical area). Because of this, groups and trusts have been able to adopt a supportive role, leaving disciplinary procedures to a higher tier of the NHS. Many of those responsible for clinical governance told us that in order to engage health practitioners in quality improvement, it is essential for them to be seen as helpful to and supportive of practices. However, this may become more difficult as groups become primary care trusts, a move that will ensure that they take on more responsibility for the quality of care provided by clinicians in their area.

Can groups and trusts improve quality?

The strategy developed by the UK government to improve the quality of health care is ambitious and wide ranging. Reports on progress in implementing this strategy come from those with responsibility for it, so their views may not fully reflect the activity under way or the views of grass roots primary care doctors and nurses. However, our research in primary care suggests that the strategy is resulting in substantial activity that is beginning to bring about a significant cultural change among both managers and clinicians in primary care. In many cases clinical governance is building on previous initiatives, such as the work of medical audit advisory groups. Nevertheless, the changes that have taken place have been impressive given that clinical governance and primary care groups were only 18 months old at the time of the survey reported in this paper.

What has not yet been shown is that any of this activity has improved the quality of care because it is still too early to tell. However, the educational approaches being taken, which emphasise engaging practitioners in regular quality improvement activities, are soundly based. Furthermore, the managerial agenda is relatively well aligned with what primary care practitioners themselves wish to achieve—that is, better care for important health problems such as coronary heart disease. Again, this is likely to encourage clinicians to participate in quality improvement.

Implementing clinical governance is not without its problems. Limited time and resources remain important constraints restricting the speed at which change can take place. Altogether, 41% (24/58) of those responsible for clinical governance did not have a budget to support the implementation of clinical governance and 35% (20/58) said that they had little or no support. In some respects general practitioners seem to have engaged enthusiastically with shared learning activities, but our research suggests that the pace of reform in the NHS risks making them feel disengaged.

There is also a significant tension between the desire to engage practices in quality improvement and the need to ensure that poor performance is addressed. Primary care groups and trusts are focusing their energies on facilitating shared learning and offering support to practices. Where such supportive approaches fail to improve performance, it may be necessary to adopt other tactics. If responsibility for poor performance moves from health authorities to primary care trusts, the conflict between these two roles is likely to become more evident to those who are responsible for clinical governance.

Much has been achieved by primary care groups and trusts in their first 18 months. The elements of clinical governance, while varying according to local needs, are now mostly in place and changes are beginning to take effect. However, the task is formidable and the barriers should not be underestimated. Quality improvement cannot be imposed by decree but needs to be maintained and developed by adequately funded infrastructures. There remains a risk that the organisational structures that have been developed are not sufficiently established or funded to ensure that the expected improvements in the quality of health care can be delivered.

Series editor: David Wilkin

Funding The national tracker survey is funded by the Department of Health and carried out by the National Primary Care Research and Development Centre in collaboration with the King's Fund.

Competing interests None declared.

Secretary of State for Health
Dowswell T ,

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What is clinical governance?

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Macfarlane AJR 1

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Macfarlane AJR | 0000-0003-3858-6468

BJA Education , 20 Mar 2019 , 19(6): 174-175 https://doi.org/10.1016/j.bjae.2019.02.003 PMID: 33456887 PMCID: PMC7808043

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Abstract

Free full text , a.j.r. macfarlane.

1 Glasgow Royal Infirmary, Glasgow, UK

2 University of Glasgow, Glasgow, UK

Incident reporting

Morbidity and mortality

Risk register

Effective care

Quality improvement

Person-centred care

Assured care

Declaration of interest

The author declares that they have no conflict of interest.

Matrix codes: 1I01, 3J00

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Does clinical governance influence the appropriateness of hospital stay?

Maria Lucia Specchia 1 ,
Andrea Poscia 1 , 2 ,
Massimo Volpe 2 ,
Paolo Parente 1 ,
Silvio Capizzi 1 ,
Andrea Cambieri 2 ,
Gianfranco Damiani 1 ,
Walter Ricciardi 1 ,
OPTIGOV© Collaborating Group &
Antonio Giulio De Belvis 1 , 2

BMC Health Services Research volume 15 , Article number: 142 ( 2015 ) Cite this article

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Metrics details

Clinical Governance provides a framework for assessing and improving clinical quality through a single coherent program. Organizational appropriateness is aimed at achieving the best health outcomes and the most appropriate use of resources. The goal of the present study is to verify the likely relationship between Clinical Governance and appropriateness of hospital stay.

A cross-sectional study was conducted in 2012 in an Italian Teaching Hospital. The OPTIGOV © ( Optimizing Health Care Governance ) methodology was used to quantify the level of implementation of Clinical Governance globally and in its main dimensions. Organizational appropriateness was measured retrospectively using the Italian version of the Appropriateness Evaluation Protocol to analyze a random sample of medical records for each clinical unit.

Pearson-correlation and multiple linear regression were used to test the relationship between the percentage of inappropriate days of hospital stay and the Clinical Governance implementation levels.

47 Units were assessed. The percentage of inappropriate days of hospital stay showed an inverse correlation with almost all the main Clinical Governance dimensions. Adjusted multiple regression analysis resulted in a significant association between the percentage of inappropriate days and the overall Clinical Governance score (β = −0.28; p < 0.001; R-squared = 0.8). EBM and Clinical Audit represented the Clinical Governance dimensions which had the strongest association with organizational appropriateness.

Conclusions

This study suggests that the evaluation of both Clinical Governance and organizational appropriateness through standardized and repeatable tools, such as OPTIGOV © and AEP, is a key strategy for healthcare quality. The relationship between the two underlines the central role of Clinical Governance, and especially of EBM and Clinical Audit, in determining a rational improvement of appropriateness levels.

Peer Review reports

The need to improve health care quality while pursuing costs’ rationalization and reduction is currently a common topic in the discussion about health systems efficacy and effectiveness.

Clinical Governance (CG) is a key drive towards quality improvement in health care [ 1 ] and enhancement of the corporate responsibility for the quality of care [ 2 ]. In fact, CG provides a framework for bringing together all local activities for improving and assessing clinical quality into a single coherent program which encourages everyone in the organization to be a part of and work to improve quality and safety of patient care [ 3 ].

With the aim of assessing and measuring the implementation level of CG within health care organizations, in 2006 the Department of Public Health of the Catholic University of the Sacred Heart developed “OPTIGOV © ” (Optimizing Health Care Governance), a methodology consisting of a hospital audit based on a structured and systematic approach and on an improvement operational plan. OPTIGOV © allows to: analyze the CG structural and functional prerequisites and areas and assign to each of them a score; identify the organization strengths and weaknesses; provide suggestions and indications to be implemented by the Hospital management and monitor the health care services quality improvement [ 4 ].

The application of OPTIGOV © within several Italian hospitals resulted in a realistic representation of the effective CG implementation both at the Board level (top management) and the Unit level (each single ward) [ 5 ]. Furthermore, the concept of appropriateness in healthcare has progressively become one of the guiding principles of health systems with more and more attention being given to both quality improvement and effectiveness of health care [ 6 ].

The continuous evaluation of the efficient hospital utilization is an essential issue that must be considered to increase the quality of health care providers. In fact, unjustified hospital admissions and stays not only increase costs, but are also related to poor health services [ 7 ].

The Appropriateness Evaluation Protocol (AEP) is a widely used assessment tool that identifies and measures the inappropriateness variables of hospital healthcare related to unjustified admission and/or length of stay [ 8 ]. Moreover, the AEP has been designed to determine the reasons of inappropriate use of hospitals with the aim of strengthening health care professionals’ awareness and supporting decision-making [ 9 ].

Several studies have shown that the application of CG tools, as Clinical Audit or Health Technology Assessment, could positively impact on organizational appropriateness in hospital settings [ 9 , 10 ]. However, despite the progressive increase of health professionals’ interest in appropriateness and CG themes [ 11 ], no practical study about their connection is available.

The purpose of this study was to verify the likely relationship between the appropriateness of hospital stay and the CG implementation level, by comparing the results of OPTIGOV © methodology and AEP applications within a large Teaching Hospital.

The study was conducted between July and December 2012 in an Italian Teaching Hospital with the aim to simultaneously represent CG implementation levels, as measured through OPTIGOV © , and organizational appropriateness, as measured through AEP.

The OPTIGOV © methodology is aimed at assessing the CG implementation level within a health care organization by assigning an overall CG score and partial scores referred to the single CG areas (min = 0 – max = 100). OPTIGOV © constitutive elements, characteristics and steps have been previously described in detail [ 4 ].

A joint project team from the Department of Public Health and the Hospital Top Management, consisting of 4 public health experts and 2 health economists, assessed the CG implementation at the Unit level (47 clinical wards) in each of the 10 Departments of the Teaching Hospital.

The CG areas analyzed were represented by: Evidence Based Medicine (EBM), Accountability, Clinical Audit, Risk Management, Performance Evaluation, Patient Involvement. These areas were assessed through hospital audits, supported by an assessment tool: the OPTIGOV © Scorecard.

The EBM area was assessed as the practice of medicine based on the integration of the physician’s clinical experience with the best scientific proof available applied to each patient’s unique features and values.

The Accountability area was tested as the availability within the organization of univocal systems of identification of those responsible for the clinical procedures (doctors, nurses and other health professionals).

The Clinical Audit area was estimated as the organizational level and the quality of organized and structured peer reviews, aimed at systematically examining one’s own activity and results by comparing these with explicit standards, with the purpose of improving healthcare quality and outcomes.

The Performance Evaluation area was assessed by evaluating the ability of the healthcare organization and units to systematically monitor the results of clinical practice in terms of efficacy, suitability, efficiency, quality and time.

The techniques and methods to manage risk, the existence of insurance coverage, the identification of risks, the procedures to prevent risks and medical errors have been evaluated in the “Risk Management” area.

Finally, for the “Patient Involvement” area the structured and systematical methods of discussion and dialogue with the patient/citizen about clinical decisions taken in healthcare wards were assessed.

A CG global score and 6 partial scores referred to the above mentioned CG areas were obtained by applying the OPTIGOV © Scorecard [ 4 ].

At the end of the OPTIGOV © evaluation a feedback to the Heads of the Departments and of the Units was given through specific written reports. Moreover several meetings with health professionals were organized to display and discuss the overall results.

The AEP evaluation is part of a hospital program started in 2012 to improve appropriateness levels. The methodology used for the AEP evaluation is described in detail in a methodological paper [ 12 ] and briefly summarized below.

An evaluation team, consisting of one medical doctor and one nurse, carried out independently a retrospective assessment of the organizational appropriateness of the Teaching Hospital. The assessment was performed by analyzing a random sample of medical records through the application of the Italian version of the AEP [ 13 ]. Both the physician and the nurse were trained by a physician expert in Public Health with certified know-how in the use of PRUO in Italy [ 14 , 15 ]. However, the physician was already familiar with AEP given his collaboration with the Italian research group on the obstetric PRUO [ 16 ]. The PRUO manual was used for training and for reference during reviews. The reviewers only used the criteria included in the PRUO manual. The override criteria were not used (neither positive, nor negative). Each day of hospital stay was considered appropriate if it met one of the AEP criteria. Both the physician and the nurse reviewed all the records without the knowledge of the other’s decision. In case of different judgment, a final agreement about appropriateness was reached by the two evaluators through the discussion and comparison of the different points of view.

1371 records from 47 Units, that represented about 3% of the whole hospital activity as suggested for the regional standard about appropriateness evaluation [ 17 ], was sampled. Organizational appropriateness of hospital stay was measured as the frequency of inappropriate days on the whole days of hospital stay.

At the end of the AEP evaluation, the hospital management gave a feedback to the Heads of Departments/ Units through specific written reports and several meetings with health professionals were organized during which the results of the assessment were shown and discussed.

Statistical analysis

A bivariate analysis was carried out between the outcome variable (frequency of inappropriate days) and each variable included in OPTIGOV © and AEP surveys. Pearson pairwise correlation was used: if the p value was lower than 0.25, the variable was tested for association with a multiple linear regression model which was used to test the likely influence of the selected variables on organizational appropriateness of hospital stay. Since type of admission (elective/urgent), type of hospital ward (surgical/medical) and appropriateness in admissions (as measured by AEP) are likely to influence hospital appropriateness [ 18 , 19 ], these were included as covariates in the regression analysis. The regression equation was:

Where Y i = organizational appropriateness of hospital stay; β 0 = constant; β 1–4 = weights of the variables; X 1 = selected variable dealing with OPTIGOV © (CG overall score in Table 1 , EMB score in Table 2 and Clinical audit score in Table 3 ); X 2 = percentage of urgency admissions; X 3 = type of hospital ward; X 4 = appropriateness in admissions.

A p- value less than 0.05 was considered statistically significant. Statistical analysis was performed by using STATA 12 software.

Ethics statement

Approval of the ethics committee was not required for the study because the Italian legislation concerns only clinical research studies and does not provide statements on observational studies on aggregated data collected from administrative databases without the patient’s involvement. For the present study anonymous data about AEP were extracted from routinely collected administrative databases and there was no need to obtain additional data from individual patients. Indeed, in 2012 the Management of the Teaching Hospital involved in this project decided to launch a quality improvement program. The assessment of appropriateness with AEP was carried out by the Medical Direction as a part of this improvement program. For the present study, researchers had access only to an anonymous dataset containing aggregated data (Unit level), which ensured patients’ privacy. For these reasons, no personal informed consent to the present analysis was requested from study participants.

CG and organizational appropriateness were evaluated in 47 hospital wards (24 surgical and 23 medical wards). The results of OPTIGOV © and AEP applications are shown in Tables 1 and 2 .

By means of a multiple regression analysis, we found a statistically significant association between the overall CG score and the percentage of inappropriate hospital stay (days) (β = −0.28; p < 0.001; R-squared = 0.82) (Table 3 ). Our model suggests that for each unitary increase of the overall CG score, a mean reduction of about 0.3 inappropriate days resulted. Furthermore, the most important variable predicting the inappropriateness rate was the percentage of appropriate admissions, as for a unitary increase in appropriate admission, a mean reduction of about 0.7 inappropriate days resulted, too. Medical wards seemed to be related to a decrease of hospital stay appropriateness, but this correlation did not approach statistical significance (Table 3 ).

The percentage of inappropriate days of hospital stay was inversely correlated with all the CG dimensions, except for Risk Management (rho = 0.12, p = 0.38). However, among the CG dimensions inversely correlated with inappropriateness, a significant correlation was only found with respect to EBM (rho = 0.34, p < 0.05), while a trend was found with respect to Clinical Audit (rho = 0.27, p = 0.06).

By applying the multiple regression analysis, a significant association between the percentage of inappropriate days and the EBM score (β = −0.33; p < 0.01; R-squared = 0.83) and the Clinical Audit score (β = −0.11; p = 0.02; R-squared = 0.81), was found (Table 4 and 5 ). Such association was stronger for EBM, as for a unitary increase of the EBM score, a mean reduction of about 0.3 inappropriate days resulted, while for a unitary increase of the Clinical Audit score, the mean reduction was about 0.1.

Our study is the first aiming to explore and detect the relationship between the appropriateness of hospitalization and the CG implementation level. Our results showed an association between CG implementation and appropriateness in hospital care. CG scores, as measured with OPTIGOV © , in particular EBM and Clinical Audit, were found to be inversely correlated with appropriateness, as measured with the AEP protocol.

Since CG is a system through which health care organizations 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” [ 1 ], each intervention aimed at improving CG is likely to positively influence healthcare quality and consequently appropriateness of care. In fact, healthcare quality – that is pursued by CG - consists of several measurable dimensions (safety, accessibility, acceptability, appropriateness, provider competence, efficiency, effectiveness and outcomes), one among which is appropriateness of care [ 20 , 21 ]. EBM and Clinical Audit represented the Clinical Governance dimensions mostly associated with organizational appropriateness.

Our main findings can be interpreted as follows. When health care professionals’ activity is based on the integration of their own clinical experience with the best scientific proof available applied to each patient (EBM) and when an organized and structured peer review process (Clinical Audit) is carried out in a rigorous and systematic way, hospital care is more likely to comply with the criteria underlying the concept of appropriateness. Strengthening scientific knowledge and attitude towards its continuous improvement makes clinicians more prone to systematically reflect on the way they supply care, apply protocols, guidelines and, consequently, to reach a better level of appropriateness.

In our Teaching Hospital, the overall CG score, measured through the application of the OPTIGOV © methodology, was 48.8, thus meaning that about half of the theoretical highest score was satisfied in our survey. These CG values are comparable with the results of other experiences carried out within several Italian Hospitals by using the same methodology [ 5 ], although CG is widely implemented across the Italian healthcare system [ 22 ].

By measuring the level of hospital stay appropriateness through PRUO, we found a mean rate of inappropriateness of 27.6%, ranging from 0.0% to 70.1%. Such inappropriateness rate is similar to that reported by previous studies, even though other papers showed lower (14%) or higher (40%) rates [ 23 , 24 ]. Some studies reported a large heterogeneity in the inappropriateness rates among different hospitals of the same Italian Region, with values ranging from 17.9% to 57.9% [ 25 ], while others demonstrated different inappropriateness levels even in the same hospital in different time periods [ 26 ].

We adjusted hospital stay appropriateness for appropriateness in admission, type of admission (urgent vs elective) and type of ward (surgical vs medical): a recently published study [ 27 ] confirms the importance of inappropriateness in admission which accounts for 14% of acute hospitalizations. In our study such percentage was 27%, and, by applying the regression model, it represented the first predictor of inappropriateness rate.

Nevertheless, our study shows some limits. The first one concerns the psychometric properties of OPTIGOV. Indeed, although the results of its application within several Italian Hospitals lead to hypothesize the validity and reliability of the methodology, carrying out of further studies would be advisable in order to confirm these properties. However, the previous applications of OPTIGOV showed its potential to produce a realistic representation of the CG implementation level of a hospital, highlighting both criticisms and transferable best practices and providing concrete plans for organizational change and quality improvement [ 4 , 5 ]. On the other hand, the validity and reliability of the AEP have been tested extensively. Indeed, in their first work, Gertman and Restuccia found an overall agreement rate between pairs of reviewers from 92 to 94% (73 to 79% if the case was judged inappropriate by at least one of the reviewers) [ 8 ]. Moreover, as reported by McDonagh MS et al., reliability testing shows a specific agreement rate of 24–75% for admissions and 64–85% for days of hospital stay [ 28 ]. These ranges have been confirmed by Lorenzo et al. for the European version of the AEP [ 29 ]. Finally, validity specific agreement rate has been reported to range from 39 to 80% for admissions and 59–91% for days of hospital stay [ 28 ]. Unfortunately, we did not test the inter-rater reliability in our study.

Furthermore, both OPTIGOV and AEP are based on the detection of process indicators which can be considered a proxy measure of overall quality in healthcare. Anyway, other studies already showed that improvements in CG can drive the organization to better performance [ 30 ]. Moreover, we have to point out that the study design is cross-sectional. Therefore the huge variability among hospital wards both for CG (27-85%) and appropriateness rates (0-70%), confirmed by the literature [ 19 , 23 - 26 ], may be due both to health professionals’ attitudes and behaviors, as well to organizational barriers. Such hypothesis can be confirmed through appropriate longitudinal studies.

In addition, further studies would be useful to investigate the effectiveness of specific CG tools and processes in improving appropriateness in hospital care, particularly referring not only to EBM and Clinical Audit, but also to the application of targeted training programs for healthcare professionals and the development of clinical pathways.

In this sense, considering that monitoring represents one of the pillars of continuous healthcare quality improvement, our study has been aimed at investigating the impact of the application of an integrated approach to the evaluation of hospital performance consisting of the combined implementation of rigorous tools. A systematic implementation of such an approach within healthcare organizations would be desirable in the future. It could also play an important role in the definition of hospital financial strategies and incentive systems for healthcare professionals based on pay for performance.

Improving healthcare efficiency needs awareness and control of unnecessary and inappropriate hospitalization. Both healthcare quality and appropriateness should be pursued through a systemic approach based on CG principles, tools and processes. This study suggests that CG plays a central role in determining a rational improvement of appropriateness levels and recommends the systematic, structured and integrated implementation of standardized and repeatable tools to monitor healthcare quality improvement.

Abbreviations

( OptimizingHealthCareGovernance )

Clinical Governance

Appropriateness Evaluation Protocol

Standard Deviation

Confidence Interval

Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ. 1998;317:61–5.

Article CAS PubMed PubMed Central Google Scholar

Allen P. Accountability for clinical governance: developing collective responsibility for quality in primary care. BMJ. 2000;321:608–11.

Dickinson A. Clinical Governance Strategy 2009–2012. NHS Leeds 2009. Available on http://www.leeds.nhs.uk

Specchia ML, La Torre G, Siliquini R, Capizzi S, Valerio L, Nardella P, et al. OPTIGOV - A new methodology for evaluating Clinical Governance implementation by health providers. BMC Health Serv Res. 2010;10:174.

Article PubMed PubMed Central Google Scholar

Specchia ML, Nardella P. Capizzi, Donno S, La Torre G, Siliquini R, Ibba N, Campana A, Rabacchi G, Bertetto O, Ricciardi W. [OPTIGOV: strumento per la misura della Clinical Governance. Risultati di una sperimentazione in Regione Piemonte]. Clin Governance. 2008;4:19–25.

Google Scholar

Poppa P, La Torre G, Mannocci A, Specchia ML, Rabacchi G, Vaschetto C, et al. Appropriateness of admission and stay in obstetric wards: a new tool assessing unnecessary days of hospital care. Ital J Public Health. 2009;4:341–51.

Anton P, Peiro S, Aranaz JM, Calpena R, Compan A, Leutscher E, et al. Effectiveness of a physician-oriented feedback intervention on inappropriate hospital stays. J Epidemiol Community Health. 2007;61:128–34.

Gertman PM, Restuccia JD. The appropriateness evaluation protocol: a technique for assessing unnecessary days of hospital care. Med Care. 1981;19:855–71.

Article CAS PubMed Google Scholar

Soria-Aledo V, Carrillo-Alcaraz A, Flores-Pastor B, Moreno-Egea A, Carrasco-Prats M, Aguayo-Albasini JL. Reduction in inappropriate hospital use based on analysis of the causes. BMC Health Serv Res. 2012;12:361.

Tagliaferri S, Ippolito A, Cuccaro P, Annunziata ML, Campanile M, Lieto AD. Governance of Innovation and Appropriateness of Hospitalization for High-Risk Pregnancy: The TOCOMAT System. Telemed J E Health. 2013;19:542–8.

Article PubMed Google Scholar

Finocchiaro G, Paparo D, Gitto G, Caruso R, Parisi A. Clinical governance and continuous quality improvement in surgical organizations. G Chir. 2009;30(1–2):58–60.

CAS PubMed Google Scholar

Poscia A, Cambieri A, Tucceri C, Ricciardi W, Volpe M. Audit as a tool to assess and promote the quality of medical records and hospital appropriateness: methodology and preliminary results. Ig e San Pubbl. 2015;71(2). In press.

Fellin G, Apolone G, Tampieri A. Appropriateness of hospital use: an overview of Italian studies. Int J Quality Health Care. 1995;7:219–26.

D'Andrea G, Capalbo G, Volpe M, Marchetti M, Vicentini F, Capelli G, et al. Evaluation of the appropriateness of hospital admissions using the iso-gravity classification systems. APR-DRG and Disease Staging and the Italian version of Appropriateness Evaluation Protocol (AEP). Ann Ig. 2006;18(1):49–62.

Capalbo G, D’Andrea G, Volpe M, Cambieri A, Cicchetti A, Ricciardi G. Appropriateness evaluation of short hospital admissions using Appropriateness Evaluation Protocol (Italian version): experience of a teaching hospital. Ann Ig. 2004;16(6):759–65.

Mannocci A, Specchia ML, Poppa G, Boccia G, Cavallo P, De Caro F, et al. La Torre G; Collaborative Group. A multicenter study on the appropriateness of hospitalization in obstetric wards: application of Obstetric Appropriateness Evaluation Protocol (Obstetric AEP). J Matern Fetal Neonatal Med. 2014;29:1–7.

Lazio Region. DCA n 40 26/03/2012 and DCA n. 58/2009: Sistema dei controlli dell’attività sanitaria ospedaliera e specialistica - L. 133/08, art. 79, comma 1 septies. Available at: www.regione.lazio.it/binary/rl_main/tbl_delibere/223386.doc

Angelillo IF, Ricciardi G, Nante N, Boccia A, Bianco A, La Torre G, et al. Appropriateness of hospital utilisation in Italy. Public Health. 2000;114(1):9–14.

Pérez-Rubio A, Santos S, Luquero FJ, Tamames S, Cantón B, Castrodeza JJ. [Evaluation of the appropriateness of stays in a third level hospital]. An Sist Sanit Navar. 2007;30(1):29–36.

Royal College of Physicians and Surgeons of Canada. Health and Public Policy Committee and Office of Health Policy. Position statement. The art and science of high-quality health care: Ten principles that fuel quality improvement. November 2, 2012. Avaliable online at: http://www.royalcollege.ca/portal/page/portal/rc/common/documents/policy/quality_improvement_e.pdf .

Maxwell RJ. Dimensions of quality revisited: from thought to action. Qual Health Care. 1992;1(3):171–7.

de Belvis AG, Biasco A, Pelone F, Romaniello A, De Micco F, Volpe M, et al. [Diffusion of clinical governance among the Italian Local Health Units (LHUs). Analysis of the Health Surveys, the Firm Acts and the Health Plans]. Ann Ig. 2009;21:117–26. Italian.

PubMed Google Scholar

Fontaine P, Jacques J, Gillain D, Sermeus W, Kolh P, Gillet P. Assessing the causes inducing lengthening of hospital stays by means of the Appropriateness Evaluation Protocol. Health Policy. 2011;99:66–71.

Panis LJ, Verheggen FW, Pop P. To stay or not to stay. The assessment of appropriate hospital stay: a Dutch report. Int J Qual Health Care. 2002;14:55–67.

Sticca G, Filocamo A, Di Domenicantonio R, Prota F, Di Falco C, Materia E, et al. Guasticchi G [Evaluation of the appropriateness of hospital admissions with the Italian version of the AEP in a university hospital]. Ann Ig. 2006;18:63–73.

Barisonzo R, Wiedermann W, Unterhuber M, Wiedermann CJ. Length of stay as risk factor for inappropriate hospital days: interaction with patient age and co-morbidity. J Eval Clin Pract. 2013;19:80–5.

Jepsen HK, Hendriksen C, Nielsen H, Nybo B, Perrild H. Every seventh acute medical admission is preventable. Dan Med J. 2013;60:A4595.

McDonagh MS, Smith DH, Goddard M. Measuring appropriate use of acute beds A systematic review of methods and results. Health Policy. 2000;53(3):157–84.

Lorenzo S, Lang T, Pastor R, Tampieri A, Santos-Eggimann B, Smith H, et al. Reliability study of the European appropriateness evaluation protocol. Int J Qual Health Care. 1999;11(5):419–24.

West E. Management matters: the link between hospital organisation and quality of patient care. Qual Health Care. 2001;10:40–8.

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Acknowledgements

Partial and preliminary results of this study have been presented at the BMJ 18th Annual International Forum on Quality and Safety in Healthcare, London, 2013 (Specchia ML, Lazzari A, Parente P, Guido D, Damiani G, Guizzardi M, Ricciardi W, de Belvis AG. How to combine clinical governance and performance evaluation within a large teaching hospital. Results of an italian experience). The authors would like to thank Chiara Tucceri for her valuable contribute in the analysis through “PRUO” of a great sample of medical records. The authors are grateful to Vincenzo Di Gregorio for the language revision of the paper.

OPTIGOV © collaborating group

Basso D, Cadeddu C, Carovillano S, Di Nardo F, Di Giannantonio P, Ferriero AM, Furia G, Gliubizzi D, Ianuale C, Iodice L, Lazzari A, Marino M, Mancuso A, Raponi M, Santoro A, Silenzi A, Department of Public Health, Catholic University of Sacred Hearth, Largo F.Vito, 1, 00168 Rome, Italy.

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Maria Lucia Specchia, Andrea Poscia, Paolo Parente, Silvio Capizzi, Gianfranco Damiani, Walter Ricciardi & Antonio Giulio De Belvis

Clinical Directorate “A. Gemelli” Teaching Hospital, Largo Gemelli 8, 00168, Rome, Italy

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Authors’ contributions

AGdB, AP, MLS & MV conceived of the study and performed the statistical analysis; OPTIGOV Collaborating Group performed OPTIGOV interviews; AGdB, GD, MLS, PP & SC performed the analysis of the results of the OPTIGOV application; AC, AP & MV assessed the organizational appropriateness; AGdB, AP, MLS, MV, PP, SC & WR drafted the manuscript. All authors read and approved the final manuscript.

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Specchia, M.L., Poscia, A., Volpe, M. et al. Does clinical governance influence the appropriateness of hospital stay?. BMC Health Serv Res 15 , 142 (2015). https://doi.org/10.1186/s12913-015-0795-2

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Mapping clinical governance to practitioner roles and responsibilities

Journal of Health Organization and Management

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Article publication date: 18 December 2020

Issue publication date: 17 December 2021

While clinical governance is assumed to be part of organisational structures and policies, implementation of clinical governance in practice (the praxis) can be markedly different. This paper draws on insights from hospital clinicians, managers and governors on how they interpret the term “clinical governance”. The influence of best-practice and roles and responsibilities on their interpretations is considered.

Design/methodology/approach

The research is based on 40 in-depth, semi-structured interviews with hospital clinicians, managers and governors from two large academic hospitals in Ireland. The analytical lens for the research is practice theory. Interview transcripts are analysed for practitioners' spoken keywords/terms to explore how practitioners interpret the term “clinical governance”. The practice of clinical governance is mapped to front line, management and governance roles and responsibilities.

The research finds that interpretation of clinical governance in praxis is quite different from best-practice definitions. Practitioner roles and responsibilities held influence practitioners' interpretation.

Originality/value

The research examines interpretations of clinical governance in praxis by clinicians, managers and governors and highlights the adverse consequence of the absence of clear mapping of roles and responsibilities to clinical, management and governance practice.

Clinical governance

Practice theory

Practitioners

Flynn, M.A. and Brennan, N.M. (2021), "Mapping clinical governance to practitioner roles and responsibilities", Journal of Health Organization and Management , Vol. 35 No. 9, pp. 18-33. https://doi.org/10.1108/JHOM-02-2020-0065

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Introduction

The term “clinical governance” was first used in 1998 ( Department of Health, 1998 ; Scally and Donaldson, 1998 ) to promote a system for delivery of safe quality care. Since then, practitioners, managers, researchers and policymakers have used the term “clinical governance” in ways that reflect different meanings and interpretations. Cleary and Duke (2019) highlight the continuing need for a clinical-governance agenda using a case of clinical-governance breakdown; while Gopal and Ahmad Kamar (2020) focus on the importance of clinical governance during the COVID-19 pandemic. Arising from their bottom-up study of clinical governance with healthcare professionals at one Dutch hospital, Veenstra et al. (2017 , p. 1) recommend further research “involving the perspectives of managers and policy makers”. This study answers their call by exploring in 40 interviews with clinicians, managers and governors their understanding of clinical governance at two large Irish academic hospitals.

Practice theory is useful in envisaging how practitioners take and shape (best) practices to create their clinical governance roles and responsibilities in praxis. Practice theory and its core tenets, practices, practitioners and praxis, provide a suitable analytical lens, particularly for studies using interpretive, interview-based methods.

Brennan and Flynn's (2013) analysis of 29 best-practice definitions of clinical governance, to examine interpretations of clinical governance in praxis.

Veenstra et al. (2017) by including managers and governors, as well as clinicians, in the sample of participants.

The findings highlight confusion and uncertainty for practitioners seeking to apply clinical governance (best) practices in their daily hospital activities. Using a single umbrella (catch-all) term compounds the problem and does not assist in explaining (best) practice. Findings confirm the need for clearer distinction in praxis between clinical practice, clinical management and clinical governance roles and responsibilities originally proposed in Brennan and Flynn (2013) . Findings reveal how the lack of clarity between the three categories of roles and responsibilities inhibits consistent interpretation of and implementation of clinical governance, clinical management and clinical practice in praxis.

Given the variation in interpretation by clinicians, managers and governors, the study points to an opportunity to strengthen interpretation of the term by clarifying clinical governance by reference to roles and responsibilities. Such a clarification would help each practitioner role-and-responsibility category to understand how practitioners contribute to clinical governance arrangements for the hospital.

Literature review

This section examines prior research on clinical governance, the theoretical lens – practice theory – and what might influence practitioners' interpretations of clinical governance.

What is clinical governance?

The United Kingdom (UK) Department of Health (1998) and Scally and Donaldson (1998 , p. 61) define clinical governance as “a system 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 excellence in clinical care will flourish”. Clinical governance is not a unitary concept, with variation in application and many constituent parts (e.g. Baker, 2003 ; Gauld, 2014 ; Som, 2009 ; Walshe, 1998 ). Prior research indicates that the concept, as well as the practice, of clinical governance has undergone significant development, leading to complexity and confusion.

The original clinical governance definition does not distinguish between how the system might apply across three categories of practitioner roles and responsibilities: Clinicians, managers and governors ( Baker, 2003 ; Degeling et al. , 2004 ; Som, 2004 , 2009 ; Veenstra et al. , 2017 and Walshe, 1998 ). To address this confusion, Brennan and Flynn (2013) apply content analysis to 29 definitions of clinical governance from the perspective of those charged with practice, management and governance, reflecting the importance of clear division between practice, management and governance roles, leading to more effective implementation of clinical governance in praxis.

Practice theory seeks to explain the relationship(s) between human action, on the one hand, and “the system” on the other ( Ortner, 2006 ). Whittington (2006) identifies the core tenets of practice theory: “practices”, “practitioners” and “praxis”. Figure 1 illustrates the relationships between these three core tenets, (best) practices, practitioners and praxis (activities in practice). Practitioners draw upon (best) practices to act which, in turn, generates praxis ( Jarzabkowski et al. , 2007 , p. 10). (Best) practices influence practitioners who combine, coordinate and adapt practices to their needs and context and convert these into praxes. In turn, through a feedback-loop adaptation process, praxis can shape (best) practices.

Practice theory is suitable for analysing the practice of clinical governance in hospitals due to the complexity of the relationships and the number of practitioners involved ( Feldman and Worline, 2016 ). We use the term “practitioner” throughout, to refer to the collective of clinicians, managers and governors, i.e. people engaged in clinical practice, clinical management and clinical governance. We also use the term “practitioner” to refer to interviewees, the participants in this research.

Factors influencing practitioner interpretations

The original Department of Health (1998) / Scally and Donaldson (1998) definition of clinical governance is silent on “how”, “by whom” and at “what levels” clinical governance is to be achieved. Factors influencing clinical governance in praxis include best practice, practitioner role-and-responsibility category and practitioner hospital.

Practices refer to the shared understandings, rules, languages and procedures that guide and enable human activities. These shared understandings can be referred to as “best practice”. The Irish health services operate through a national body, the Health Service Executive (HSE). National policy and guidance documents assist service providers in applying clinical governance frameworks (Health Information and Quality Authority (HIQA), 2012 ; HSE, 2014 ; Flynn et al. , 2015 ; Gauld et al. , 2017 ). Unlike the UK, these do not have legislative backing ( Committee on the Future of Healthcare, 2017 ).

By reference to roles and responsibilities, Brennan and Flynn (2013) differentiate between three categories of practitioner roles and responsibilities: front-line practitioners, managers and governors. Practitioner influence has been found to be important in the interpretation of clinical governance. Davies et al. (2000) identify the different professional cultures (backgrounds / experience) of health service managers and medical professionals and point to the importance of a degree of “cultural fit” between these two key groups in clinical governance cultural transformation. Clinical governance is central to clinical directors' [1] work ( Gafoor et al. , 2020 ). Som (2009 , pp. 108-109) finds that “depending on their organisational level, the directorate in which they are working, their professional background and the responsibilities they have handled and their current job, staff vary in their interpretation of clinical governance”. Freeman and Walsh (2004 , p. 335) find directorate-level manager perceptions of achievement in 54 clinical governance items to be significantly lower than those of their board-level colleagues on all domains other than improving clinical governance performance. Jones et al. (2017) highlight the importance of board members in clinical governance.

Type of hospital has also been found to influence clinical governance ( Hogan et al. , 2007 ; Pronovost et al. , 2018 ). Karassanvidou et al. (2011 , p. 236) find type of hospital relevant in terms of its organisational culture. While not directly examining hospital influence, Brault et al. (2015) identify the hospital accountability structure as a clinical-governance lever.

Research questions and research methodology

Extending the work of Brennan and Flynn (2013) , this research examines what the term “clinical governance” means to practitioners in their everyday activities, i.e. their interpretation of clinical governance in praxis by comparison with clinical governance best practice.

How does the interpretation of clinical governance in praxis compare with best-practice definitions?

Keywords/terms used in definitions but not used by practitioners?

Keywords/terms in common between best-practice definitions and those used by practitioners?

Keywords/terms used by practitioners in praxis but not in definitions?

The frequency of usage of keywords/terms in definitions compared with by practitioners in praxis?

How does the interpretation of clinical governance in praxis map to practitioner roles and responsibilities?

Interviewees

The research conducts 40 in-depth semi-structured interviews, informed by the research questions and Brennan and Flynn's (2013) content analysis of 29 definitions of clinical governance. Interviews focus on practitioners' understanding of the term “clinical governance”. Pilot interviews ( n = 4) validate the data collection methods. Pilot study data is not included in these research findings.

Practitioners ( n = 40) from two sites, Hospital A ( n = 20) and Hospital B ( n = 20), participate in the study. The hospitals are large university tertiary referral hospitals, providing acute medicine, surgery and national speciality services. The research selects the two hospitals on the basis that the hospital (1) has a hospital board, (2) is an acute general hospital and (3) is a large academic university hospital. Seven of the 48 publicly funded hospitals in Ireland meet the three inclusion criteria. The three categories of practitioner roles and responsibilities comprise: (1) front-line clinicians, (2) managers and (3) governors (see Table 1 ). Clinicians include medical doctors, advanced nurse practitioners, pharmacists and therapy professionals. Through a nominated link person, the interviewer (first-named author) invites hospital managers with single roles (e.g. CEO, Director of Nursing, Director of Human Resources, Director of Finance) to participate. The link person purposively connects with clinician participants and non-executive board members for their experience using a snowball approach ( Richards and Morse, 2013 ).

The interviewer asks practitioners two open-ended interview-guide questions: (1) what do you understand by the term “clinical governance”? and (2) to what extent has clinical governance featured in your roles?. The interviewer audio records and transcribes the interviews, along with interviewer notes drafted during and after the interviews. The interviewer returns transcripts to participants for checking. The interviewer uploads interview transcripts in NVivo 10 for coding and reviews interview transcript responses line-by-line.

Operationalising the constructs

The research includes two constructs: (1) clinical governance best practice and (2) interpretation of clinical governance in praxis. For RQ1 , the research applies a coding architecture using a priori keywords/terms from Brennan and Flynn's (2013) 29 clinical governance definitions. The research catalogues the 1,000 most frequent keywords used by practitioners to describe clinical governance. To operationalise best practice, the study identifies keywords relating to roles and responsibilities in Brennan and Flynn's (2013) 29 definitions of clinical governance. The research operationalises praxis through the keywords/terms spoken by practitioners to describe their clinical governance roles and responsibilities. The research analyses interview transcripts using keyword and keyterm content analysis ( Krippendorff, 2013 ). The unit of analysis is “words” (single word) and “terms” (combination of words) interviewees use to describe their clinical governance roles and responsibilities. During the analysis, minor variations in a priori keywords/terms and new emerging keywords/terms are added to the architecture. Understandably, interviewees use the words “clinical” (115) and “governance” (102) most commonly. As these two words are the kernel of the concept being described, they are not included in the content analysis counts.

Analysis of the data

This research uses rank orders of the frequency of usage (i.e. number of mentions) by practitioners of keywords/terms as proxy indicators of the prominence for practitioners of the various clinical governance roles or responsibilities (as direct observation was not feasible). Rank ordering of ordinal data is more robust to outliers (by ignoring step changes created by frequencies) ( Kerlinger and Lee, 2000 ).

Discussion of findings

This section provides the study findings by reference to the two research questions.

Comparison of best-practice keywords/terms and usage in praxis (RQ1)

The number of keywords/terms used by practitioners to describe clinical governance evidences the impact of including a wide number of activities and functions within one concept. Table 2 shows that practitioners use 71 keywords/terms in their interpretations of clinical governance in praxis.

Of the 40 keywords in definitions, six are not used by practitioners (see Table 2 ) ( RQ1a ). These keywords are not commonly used in the definitions. We believe this is because practitioners do not favour command-and-control (“regulated professional”, “compliance”, “obligation”) and business-orientated terms (“inputs”). However, we acknowledge this is a broad interpretation based on our assumption which others may not share. Mintzberg (2017 , p. 94) concurs with our view when he observes: “The field of health care may be appropriately supplied by businesses, but in the delivery of its most basic services, it is not a business at all, nor should it be run like one. At its best, it is a calling”. It is somewhat surprising that “customer participation” or the more common term “patient involvement” is not used by the practitioners. Practitioners use 34 keywords/terms in common with the 40 (85%) keywords/terms in Brennan and Flynn's (2013) 29 clinical governance definitions (best practice) (see Table 2 ) ( RQ1b ). Practitioners add extensively to keywords in definitions with 37 additional keywords/terms of their own (see Table 2 ) ( RQ1c ).

Addressing RQ1b and RQ1d , Figure 2 rank orders the frequency of practitioner usage of the 34 keywords/terms and compares it with the rank ordering of usage of the 34 keywords/terms in Brennan and Flynn's 29 clinical governance definitions. The keywords “1. quality”, “3. accountability”, “5. system” and “12. continual improvement” feature most prominently in the definitions, while “2. safety”, “4. processes/procedures”, “7. structures” and “5. system” are most prominent in practitioners' descriptions of clinical governance.

Figure 3 rank orders the frequency of practitioner usage of the 37 keywords/terms added by practitioners. Many of these keywords/terms reflect the practical outputs of the application of clinical governance, such as “2. reporting”, “6. outcomes”, “8. patient safety”, “10. trust”, “12. openness”, “13. transparency” and “18. change” – again, potentially signifying practitioners' wish to move away from command-and-control language. However, practitioners also add more negative keywords/terms such as “9. ensure”, “22. control”, “28. blame”, and “36. Blame culture”, evidence of an “on top” hierarchical, command-and-control environment ( Mintzberg, 2012 , p. 6). There is a strong focus in the new keywords on people-related aspects of clinical governance such as “14. support”, “16. training”, “17. recruitment”, “20. induction”, “26. confidence” and “27. competence”.

Addressing RQ1d , Figure 4 compares the 24 most-frequent keywords/terms in the definitions with the 24 most-frequent keywords/terms used by practitioners. These 24 keywords/terms represent the top 50% of keywords most frequently used by practitioners. If clinical governance definitions influence practitioner interpretation, the rank order of definitions/practitioner terms in both columns in Figure 4 should be similar. However, Figure 4 shows that the frequency of clinical governance keywords/terms used by practitioners does not appear to be influenced by best-practice clinical governance definitions. It may be that the norms and expectations observed and experienced during practitioners' careers have a stronger influence, perhaps because the definitions are found to be somewhat vague and limited when considering practical application of practitioner roles and responsibilities. This suggests that practitioners' interpretation of clinical governance may be obtained more from the ground rather than from official policy and definitions. Practitioners “pick-up” the idea of clinical governance by observing peers, from experience, and from their own, what can be called, on-the-ground practice. As Mintzberg (2013 , p. 174) suggests, “if we really want to understand what has happened to management, then we would do well to get down on the ground […]”.

Influences of practitioner roles and responsibilities on interpretation of clinical governance in praxis (RQ2)

RQ2 examines influences of practitioner roles and responsibilities on the interpretation of clinical governance in praxis. Keywords/terms spoken by practitioners are analysed by reference to the three categories of practitioner roles and responsibilities (see Tables 2 and 3 ). Table 2 shows that the 71 keywords/terms are used, with managers using fewer keywords/terms. Table 3 analyses the frequency of usage (748 usages in total) across the three categories of practitioner roles and responsibilities and by reference to individual keywords/terms. Frequency of usage by practitioners varies from 43 times (“safety”) to 1 time (six keywords/terms). The rank ordering in Table 3 shows marked variation between the frequency of usage of keywords/terms.

The 71 keywords/terms used by interviewees are allocated between front-line delivery, management and governance roles and responsibilities. The purpose is to map clinical governance to the three categories of roles and responsibilities (see Table 3 ). As previously acknowledged, the classification of keywords/terms into three role-and-responsibility categories involves judgement; some terms (e.g. “risk management”, “leadership”, “blame”, “information”) may fit under more than one heading. The subjective nature of the analysis is such that other researchers might produce different analyses.

Summary of findings

The insights suggest that, while there is some awareness of clinical governance, there is still much confusion and uncertainty about who is responsible and how to activate the system at various hospital role-and-responsibility levels.

In total, 77 unique keywords/terms are used across the definitions and descriptions of clinical governance in praxis. The research finds that practitioners use many more keywords/terms in their own descriptions of clinical governance (71) than provided in definitions (40). Practitioners include 37 additional keyword/terms not in Brennan and Flynn's (2013) 29 definitions of clinical governance. Of note, most keywords/terms (34–85%) in best-practice definitions are included by practitioners in their personal description of what clinical governance means to them, even though several indicate that they are not aware of or do not refer to definitions. There are a small number (6–15%) of keywords/terms in definitions (best practices) describing clinical governance not used by practitioners, such as “registered professional”, “compliance”, “obligation”, “inputs”, “customer participation” and “clinical judgement”. Practitioners are possibly more conscious of best-practice governance arrangements evident in the commonality of use of clinical governance keywords/terms between practitioners' and Brennan and Flynn's (2013) clinical governance definition, for example, “structures” and “system” of “accountability”, “responsibility”, “culture”, “audit” and “oversight”. Of note, the lowest number (6 – Table 2 ) of new keywords/terms pertains to the governance role category. A larger number of new keywords/terms pertain to front-line-delivery roles and management (15/14 respectively – Table 2 ). The study reveals that the umbrella term has not been mapped to people and roles and responsibilities within Hospital A and Hospital B.

Almost all participants (36–90%) talk about the extent that clinical governance features in their role, be they clinician, manager or governor. Practitioners describe clinical governance activities as “absolutely” a feature of their role, “central”, “huge”, “permeates”, “a lot”, “part and parcel”, “a feature of day-to-day professional life”, incorporated in “every part of my role”, “it's ever present, it's every single day, many nights and some weekends” and “it's a massive part of my working life now here”. All clinical directors mentioned the constraints of time impacting on the extent they can focus on clinical governance due to their clinical work commitments. Thus, implicitly, they see clinical work and clinical governance as separate activities. This is sub-optimal. Clinical practice and clinical governance should be hand-in-glove connected, for clinical governance to operate effectively.

In praxis, practitioners are only partially influenced by definitions of clinical governance because of the “picked-up” nature of their construction of clinical governance. Practitioners are aware of, but confused by, clinical governance. They emphasise trust and the calibre of people more than accountability and independent review. However, despite this, clinical governance is ever present in their work and thinking.

The findings affirm variation in interpretation, understanding and confusion around the use of the term clinical governance. The findings signal the disparity and confusion among practitioners, particularly around front-line clinical practice and management roles and responsibilities. Findings support the differentiation between front-line delivery, management and governance roles and responsibility and support using Brennan and Flynn's (2013) three separate definitions.

Limitations

Gaining insights from hospital practitioners' experiences answers the call for exploratory research reflecting the context of clinical governance ( Veenstra et al. , 2017 ). The findings are limited to experiences of practitioners in the healthcare services where they have worked. Some interviewees have overlapping roles, whereas the study categorises them into one of three role categories. For example, some clinicians are also clinical directors ( n = 10), while some clinicians ( n = 4) have roles as governors (members of the board of directors). Because many interviewees do not fall uniquely into the three role categories (clinician, manager or governor), it is not possible to map the words they use into the three role categories. This reflects the complexity of healthcare with multiple overlapping roles and responsibilities. In addition, clinical directors experience the predicament of their management role affecting relationships with colleagues. All suggest that they need more time to focus on clinical governance (perceived as management functions) but, for clinical credibility among colleagues and managers, they also indicate (unlike other countries where clinical directors are full-time) that the best arrangement would be to retain some clinical practice, but for something less than the current 50% of their time. Practitioners identify systems of accreditation (voluntary or required by regulators) as one positive initiative assisting clinical directors in bringing attention to clinical governance and its execution. Despite some confusion, ambivalence and juggling a myriad of roles, this study reveals that clinical governance is ever present in practitioners' work and thinking. In this environment, there is a risk of practitioners suffering from role confusion and conflict. The scope of the study does not provide for the inclusion of the perspectives of patients or the public on the praxis of clinical governance. However, careful attention is given to identifying clinicians’, managers’ and governors’ thoughts on patient perceptions and experiences during the analysis.

Implications for theory and practice

The confusion around the definition of clinical governance and its application in practice is evident in the absence of a standardised approach to interpretation by practitioners participating in this research. The findings indicate that some practitioners are hesitant and, on occasion, find it difficult to articulate their role in clinical governance. Despite this, their personal descriptions reflect several features of clinical governance set out in (best) practice definitions. Achieving effective clinical governance requires a collaborative effort between clinicians, managers and governors being clear about their separate and distinct roles. Use of “catch-all” understanding of clinical governance, regardless of roles/responsibilities or by whom within the hospital it is to be applied, compounds the confusion. For effective clinical governance, it is important that there be division of duties between front-line delivery roles, management roles and governance roles. It is a fundamental principle of governance that governors cannot oversee and monitor their own work. The praxis of clinical governance described by practitioners in this study does not distinguish between front-line delivery, management and governance functions. To embed clinical governance fully in hospitals, it is necessary to clearly articulate the roles and responsibilities relating to clinical governance. Providing three separate definitions provides clarity on the operation of clinical governance in each role (as set out in Brennan and Flynn, 2013 ). These distinctions will help to clarify roles and responsibilities in the accomplishment of clinical governance and concomitant increase in patient safety.

The difference in understanding this study reveals is an important consideration for executive management teams and boards. Heretofore, most attention has been given to independence in thinking and challenge by having both internal and external non-executive membership of hospital boards of directors. This study suggests that it is also important to consider further diversity by having a combination of those who have the benefit of clinical experience during their career and those with no clinical experience among both the executive and non-executive board member groups.

Concluding comment

There is an absence of mapping of clinical governance to the roles and responsibilities of the parties expected to execute clinical governance. The absence of mapping, and therefore discernibility of clinical governance roles and responsibilities, leads to confusion for those expected to execute them. The use of the term clinical governance is losing prominence. Gauld and Horsburg (2020) provide evidence that the clinical governance agenda has stalled. Alternatives are being proposed for example “governance for quality” and “governance of quality and safety” ( Flynn et al. , 2015 ). Variations of the term are equally problematic.

The study findings show that best-practice definitions of clinical governance are not alone in influencing practitioners in their interpretation of clinical governance. It is apparent that providing a “catch-all” definition is not enough, particularly when available definitions are considered confusing. It is evident that the calibre of staff providing role models, and a culture supportive of clinical governance, are equally a way of developing the norms and expectations that construct practice. In the praxis of clinical governance, practitioners do not adequately distinguish between practice, management and governance functions, particularly when they are “juggling roles”. Obtaining enough independent review to seek assurance and inform board oversight is a priority. However, how accountability (a core element of clinical governance) is executed has the potential to affect the creation of cultures of reporting and openness or not and, ultimately, the “north star” of quality and safety for patient care in hospitals. There is an increasing awareness in financial services of the importance of precisely mapping people's roles and responsibilities. This is aided by arrangements such as the UK's senior managers' regime or the forthcoming Irish Senior Executive Accountability Regime ( KPMG, 2018 ). The regime provides a tool that helps senior leaders to be crystal clear about their responsibilities and can therefore better manage their duties. Mapping clinical governance to clinician, manager and governor roles and responsibilities has the potential to enable responsive cultures of person-centred healthcare.

Core tenets of practice theory

Rank order of clinical governance keywords/terms in common between definitions (best-practice) and used by practitioners in praxis ( RQ1b , RQ1d )

Rank order of new keywords/terms used by practitioners in their interpretation of clinical governance (praxis) not in best-practice definitions ( RQ1c )

Comparison of rank ordering of most common usage of keyword/terms in definitions (best-practice) and used by practitioners (praxis) ( RQ1d )

Overview of interviewees

Keywords/terms in 29 definitions of clinical governance (best-practice) and practitioner descriptions of clinical governance (praxis)

Frequency/ranking of keywords/terms used by practitioners to describe the practice of clinical governance, grouped by front-line delivery, management and governance ( RQ2 )

A medical doctor who has a leadership role for one or more specialties within a hospital. The primary role is to manage and plan how services are delivered and contribute to the process of strategic planning, influencing and responding to organisational priorities.

Baker , M. ( 2003 ), “ Accountability and responsibility: clinical governance beyond the institution ”, Clinical Governance: An International Journal , Vol. 8 No. 4 , pp. 288 - 289 .

Brault , I. , Denis , J.L. and Sullivan , T.J. ( 2015 ), “ Using clinical governance levers to support change in a cancer care reform ”, Journal of Health Organisation and Management , Vol. 29 No. 4 , pp. 482 - 497 .

Brennan , N.M. and Flynn , M.A. ( 2013 ), “ Differentiating clinical governance, clinical management and clinical practice ”, Clinical Governance: An International Journal , Vol. 18 No. 2 , pp. 114 - 131 .

Cleary , S. and Duke , M. ( 2019 ), “ Clinical governance breakdown: Australian cases of wilful blindness and whistleblowing ”, Nursing Ethics , Vol. 26 No. 4 , pp. 1039 - 1049 .

Committee on the Future of Healthcare ( 2017 ), Sláintecare Report , Houses of the Oireachtas , Dublin .

Davies , O.H. , Nutley , S.M. and Mannion , R. ( 2000 ), “ Organisational culture and quality of healthcare ”, Quality in Health Care , Vol. 9 No. 2 , pp. 111 - 119 .

Degeling , P. , Maxwell , S. , Iedema , R. and Hunter , D. ( 2004 ), “ Making clinical governance work ”, British Medical Journal , Vol. 329 No. 7469 , pp. 679 - 681 .

Department of Health ( 1998 ), A First-Class Service: Quality in the New NHS , Department of Health , London .

Feldman , M. and Worline , M. ( 2016 ), “ The practicality of practice theory ”, Academy of Management Learning and Education , Vol. 15 No. 2 , pp. 304 - 324 .

Flynn , M. , Burgess , T. and Crowley , P. ( 2015 ), “ Supporting and activating clinical governance development in Ireland: sharing our learning ”, Journal of Health Organization and Management , Vol. 29 No. 4 , pp. 455 - 481 .

Freeman , T. and Walshe , K. ( 2004 ), “ Achieving progress through clinical governance? A national study of healthcare managers' perceptions in the NHS in England ”, Quality and Safety in Health Care , Vol. 13 No. 5 , pp. 335 - 343 .

Gafoor , A. , Thaker , S. , Gupta , H. and Botchu , R. ( 2020 ), “ Life as a clinical director: an insight ”, Clinical Radiology , Vol. 75 No. 8 , pp. 640.e13 - 640.e16 .

Gauld , R. ( 2014 ), “ Clinical governance development: learning from New Zealand experience ”, Postgraduate Medical Journal , Vol. 90 No. 1 , pp. 43 - 47 .

Gauld , R. and Horsburgh , S. ( 2020 ), “ Has the clinical governance development agenda stalled? Perceptions of New Zealand medical professionals in 2012 and 2017 ”, Health Policy , Vol. 124 No. 2 , pp. 183 - 188 .

Gauld , R. , Horsburgh , S. , Flynn , M.A. , Carey , D. and Crowley , P. ( 2017 ), “ Do different approaches to clinical governance development and implementation make a difference? ”, Journal of Health Organization and Management , Vol. 31 Nos 7/8 , pp. 682 - 695 .

Gopal , K.S. and Ahmad Kamar , A. ( 2020 ), “ Clinical governance and ethics during a pandemic ”, in Tan , H.S. and Tan , M.K.M. (Eds), Bioethics and COVID-19: Guidance for Clinicians , 1st ed. , Malaysian Bioethics Community , pp. 7 - 9 , available at: http://csamm.org.my/files/Bioethics%20&%20COVID-19%20-%20Guidance%20for%20Clinicians.pdf .

Health Information and Quality Authority (HIQA) ( 2012 ), National Standards for Safer Better Healthcare , Health Information and Quality Authority , Dublin .

Hogan , H. and BasnettMcKee , I.M. ( 2007 ), “ Consultants' attitudes to clinical governance: barriers and incentives to engagement ”, Public Health , Vol. 121 No. 8 , pp. 614 - 622 .

Health Service Executive (HSE) ( 2014 ), Report of the Clinical Governance Development Initiative: Sharing Our Learning , Quality and Patient Safety Division, Health Service Executive , Dublin .

Jarzabkowski , P. , Balogun , J. and Seidl , D. ( 2007 ), “ Strategizing: the challenge of a practice perspective ”, Human Relations , Vol. 60 No. 1 , pp. 5 - 27 .

Jarzabkowski , P. and Spee , A. ( 2009 ), “ Strategy-as-practice: a review and future directions for the field ”, International Journal of Management Reviews , Vol. 11 No. 1 , pp. 69 - 95 .

Jones , L. , Pomeroy , L. , Robert , G. , Burnett , S. , Anderson , J.E. and Fulop , N.J. ( 2017 ), “ How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England ”, British Medical Journal Quality and Safety , Vol. 0 , pp. 1 - 9 , doi: 10.1136/bmjqs-2016-006433 .

Karassanvidou , E. , Glaveli , N. and Zafiropoulos , K. ( 2011 ), “ Assessing hospitals' readiness for clinical governance initiatives through organisational climate ”, Journal of Health Organisation and Management , Vol. 25 No. 2 , pp. 214 - 240 .

Kerlinger , F.N. and Lee , H.B. ( 2000 ), Foundations of Behavioral Research , 4th ed. , Hercourt College Publisher, Holt , New York .

KPMG ( 2018 ), Individual Accountability. Global Regulatory Developments in Financial Services , KPMG , Dublin .

Krippendorff , K. ( 2013 ), Content Analysis: An Introduction to its Methodology , Sage , Los Angeles .

Mintzberg , H. ( 2012 ), “ Managing the myths of health ”, World Hospitals and Health Services , Vol. 48 No. 3 , pp. 4 - 7 .

Mintzberg , H. ( 2013 ), Simply Managing: What Managers Do – and Can Do Better , Berrett-Koehler Publishers , San Francisco .

Mintzberg , H. ( 2017 ), Managing the Myths of Health Care: Bridging the Separations between Care, Cure, Control and Community , Berett-Koehler Publishers, Inc , Oakland California .

Ortner , S. ( 2006 ), Anthropology and Social Theory: Culture Power and the Acting Subject , Duke University Press , Durham, NC .

Pronovost , P. , ArmstrongDemski , M.R. , Peterson , R.R. and Rothman , P.B. ( 2018 ), “ Next level of board accountability in health care quality ”, Journal of Health Organization and Management , Vol. 32 No. 1 , pp. 2 - 8 .

Richards , L. and Morse , J. ( 2013 ), Qualitative Methods , 3rd ed. , Sage , Los Angeles .

Scally , G. and Donaldson , L. ( 1998 ), “ Clinical governance and the drive for quality improvement in the new NHS in England ”, British Medical Journal , Vol. 317 No. 7150 , pp. 61 - 65 .

Som , C.V. ( 2004 ), “ Clinical governance: a fresh look at its definition ”, Clinical Governance: An International Journal , Vol. 9 No. 2 , pp. 87 - 90 .

Som , C.V. ( 2009 ), “ Making sense of clinical governance at different levels in NHS hospital trusts ”, Clinical Governance: An International Journal , Vol. 14 No. 2 , pp. 98 - 112 .

Veenstra , G. , Ahaus , K. , Welker , G. , Heineman , E. , van der Laan , M. and Muntinghe , F. ( 2017 ), “ Rethinking clinical governance: healthcare professionals' views: a Delphi study ”, British Medical Journal Open , Vol. 7 , e012591 , doi: 10.1136/bmjopen-2016-012591 ( accessed July 2017 ).

Walshe , K. ( 1998 ), “ Clinical governance what does it really mean? ”, Health Services Management Centre Newsletter , Vol. 4 No. 2 , pp. 1 - 2 .

Whittington , R. ( 2006 ), “ Completing in the practice turn of strategy research ”, Organization Studies , Vol. 27 No. 5 , pp. 613 - 634 .

Acknowledgements

The authors thank the Chair of the hospital board and CEO of Hospital A and Hospital B for facilitating this research, their nominated link person and the 40 practitioners who generously shared their experiences and observations while participating in this study.

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Published: 28 April 2021

Clinical Governance: A simple guide

Bhavisha Mistry 1

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Audit, event analysis, peer review. As a dental student, these words can sound confusing and may not feel relevant to you at first. In reality, clinical governance is a crucial part of our day-to-day practice on clinic. Most of us follow it without realising. This guide will simplify clinical governance: explaining what it is, why it is important and provide a breakdown of its major components.

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Scally G, Donaldson L. Looking forward: Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998; 317 : 61-65.

General Dental Council. Standards for the Dental Team. Online information available at https://standards.gdc-uk.org/Assets/pdf/Standards%20for%20the%20Dental%20Team.pdf (Accessed March 2021).

Faculty of General Dental Practice. Ideas for audit- developing local guidelines. Online information available at www.fgdp.org.uk/selection-criteria-dental-radiography/92-ideas-audit---developing-local-guidelines (Accessed March 2021).

General Dental Council. Enhanced CPD guidance. Online information available at www.gdc-uk.org/docs/default-source/enhanced-cpd-scheme-2018/enhanced-cpd-guidance-for-professionals.pdf?sfvrsn=edbe677f_4 (Accessed March 2021).

National Institute for Health and Care Excellence. Glossary. Online information available at www.nice.org.uk/glossary?letter=p (Accessed March 2021).

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