Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 46, Num. 3, 2000, pp. 240-241

Journal of Postgraduate Medicine, Vol. 46, No. 3, July-September, 2000, pp. 240-241

Book Review

Clinical Governance in Health Care Practice

C.A.K. Yesudian

Professor and Head, Department of Health Sciences, Tata Institute of Social Sciences, Mumbai, India

Code Number: jp00081

Clinical Governance in Health Care Practice
Written By:
Thoreya Swage MBBS (Lond), MA Oxon, MIHM
Independent Consultant, National Health Service, UK
Reviewed By:
C.A.K. Yesudian
Professor and Head, Department of Health Sciences
Tata Institute of Social Sciences, Mumbai, India
Book Details:
ISBN 0750644532: 272 pp: 234 x 156 mm: 20 line illustrations
Paperback: March 2000: £17.99
Butterworth Heinemann Ltd, London

On the whole, the author has dealt with the subject of clinical governance in the National Health Service (NHS) in detail and has explained the concepts in detail and every aspect of the clinical governance with illustrations, examples and cases. From the book, one understands the comprehensiveness of quality initiative in the NHS. It explains that quality is not merely the clinical quality but it includes the technical quality of all the health personnel in the health system. In addition, quality also means efficient use of resources and the positive perception of the user about the health care. Further, from the top executive to everyone downward are accountable for the quality of care. The clinical governance identifies the role of every one in ensuring the quality of care in terms

Considering the importance and probable utility of the system in our settings a summary from the book is presnted below.

In the late nineties, the Labour government in England took initiatives to improve the NHS with emphasis on "quality at heart" and implementation of quality standards consistently with the participation of the public, through clinical governance. On the whole, it is a system-wide change implemented at the local level with equal responsibilities on health professionals, clinicians and managers.

The Concept

The four elements of clinical governance are professional management (technical quality), resource use (efficiency), risk management and patient satisfaction. Clinical governance guarantees quality of care through a number of processes of clinical effectiveness, clinical risk management, complaints, professional development, outcomes of care, and good quality clinical data.

Quality Mechanism

Setting up of national standards is a challenge to reduce inequalities and concerns in the provision of health care. This has been achieved through National Service Frameworks (NSF) and the National Institute for Clinical Excellence (NICE). The NSF addresses the issue of equity and set national standards to ensure standardisation of NHS care for everyone. The NICE was set-up to asses the clinical effectiveness as well as the cost effectiveness and to provide evidence based guidelines for local adaptation. The Commission for Health Improvement or CHI is the statutory auditing body and reviews every NHS trust regarding the working of the clinical governance arrangements. It ensures that the standards produced by the NICE are adhered to. Further, NHS Performance Assessment Framework is set up as a mechanism for health authorities to monitor the delivery of health services against the plans for improvement. It has identified six areas, where performance can be measured. The six areas are health improvement, fair access, effective delivery of appropriate health care, efficiency, patient/carer experience and health outcomes. The purpose of the Performance Assessment Framework is "to improve the health of the population, and to provide better care and outcomes for people who use the NHS."

of technical quality, economic efficiency and user perception. Clinical governance is developed keeping in mind the present on-going quality initiative in the NHS. Therefore, it is not something entirely new, which the health personnel may find it difficult to adapt. It is built on what is existing. Another important feature of the clinical governance is that it is not a quality initiative in a health care institution but it is a quality initiative of the whole system. It comprehensively deals with the health of the population in terms of health promotion, prevention and treatment. It is a system introduced in a public sector health system, which has a lot of relevance to our country. Our large public sector or government health services can learn a lesson or two from the clinical governance of the NHS and improve the quality of care, which is the major concern today in our health system.

From the book, it appears that the NHS has developed an excellent system of developing and sustaining quality in the entire health care system. Since the clinical governance was introduced in 1999, the author was not in a position to find out the impact of the clinical governance in improving the quality of health care in the NHS. The NHS suffers from certain quality issues such as long waiting time for admission, investigation and treatment. We have to wait and see how for the quality initiatives of the clinical governance has solved or minimised these problems.

Quality Initiatives

The author discusses the quality initiatives undertaken to ensure clinical effectiveness. Clinical effectiveness means efficacy and cost effectiveness of the intervention achieving greatest possible health within the available resources.

Research and Development: The process of clinical effectiveness is based on the production of clinical evidence from research, production and dissemination of clinical guidelines based on the evidence, implementation of the evidence based practice through education, training and change management and assessment of compliance to the guidelines and the evaluation of patient outcomes. Clinical guidelines are prepared to achieve clinical effectiveness and to ensure appropriate healthcare for specific clinical circumstances. However, patients do vary in their response to treatment and recognition that clinical guidelines provide general reference point for the minimum standards of care is key to the quality initiative of the clinical governance.

Evidence-based Practice: The process of clinical effectiveness is achieved through evidence-based practice. It aims at providing the means by which the best evidence from research can be applied in the prevention, detection and care of health disorders.

Dealing with Complaints: A three-tier system was developed where a complaint is dealt with at the local level immediately through a local response, by a complaints manager is readily available to the public. If the complaint is not resolved, the complainant has the right to request an independent review panel consisting of three members: a lay chair, the convenor of the relevant health authority and a representative of the purchaser or another independent person. The report of this panel is submitted to the concerned board of the health authority for discussion and action. If this fails, the matter is referred to ombudsman.

Risk Management: Risk management involves preventing and managing adverse incidents to patients in the health care system. The strategy of risk management involves risk identification, risk analysis, risk treatment and evaluation of risk treatment strategies.

Support for Clinical Governance

Training and development and timely and accurate information for clinical and managerial decisions are the two main areas of support. For training and development, clinical governance adopts a strategy of lifelong learning and continuous professional development (CPD). The lifelong learning process ensures that the staff maintains up-to-date skills and knowledge to deliver quality care at the local level. The CPD is "an individual taking responsibility for the development of his/her own career." Professional self-regulation by professional bodies and external accreditation such as ISO 9000 and Quality Practice Award regulate professional behaviour and ensure quality health care.

The comprehensive quality improvement programme depends on good information. The NHS strategy of information management and technology involves electronic lifelong health records, round-the-clock on-line access to records, public access to information and effective use of information for the NHS managers. For these purposes, the infrastructure developed includes electronic patient records, NHSnet, National Electronic Library for Health and so on.

User Perspective

The NHS document on A First Class Service says, "modern and dependable treatment must be delivered with a real understanding of patients fears and worries." The users' perspective is an integral thread of clinical governance. In commissioning health services, the users' views are sought to a great extent and are involved in reviewing services and developing plans and strategies.

Evidence-based Management

Clinical governance emphasises on evidence-based decision making in all the levels of health care system. One of the areas where evidence is effectively used is commissioning of health care and monitoring these outcomes. Commissioning of health care in the NHS is assessing health needs, purchasing of health care and evaluation to ensure maximum health gain. Here the managers need research evidence to support their commissioning decisions. First the needs of the target population are quantified to determine the quantum of resources needed to achieve the best value health care to patients. From the information obtained through the need assessment exercise, it is possible to accomplish evidence-based tasks, allocation of resources, managing innovations and controlling costs.

Legal and Ethical Principles

Clinical governance has to follow certain legal and ethical principles. There are Code of Conduct issued by professional and regulatory bodies. The legal aspect of clinical governance deals with the issue of medical negligence. Expert opinion is sought to find out the good practice and is substantiated by the use of evidence-based clinical guidelines.

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