Applying and developing health service theory: an empirical study into clinical governance

Clinical Governance in Musculoskeletal Care-An Online Cross-Sectional Survey of What Allied Health Professionals Participate in, and What They Value

RATIONALE

Clinical governance (CG) is a systematic approach to improving care quality, ensuring healthcare organisations and professionals are accountable for safe, effective, and continuously advancing practice. Traditionally, CG frameworks follow the 'seven pillars' model: risk management, education and training, patient and carer experience, information management, clinical effectiveness, clinical audit, and staff management. However, optimal CG may also require additional elements. Despite its importance, research on CG, and clinicians' views, remains limited, particularly in musculoskeletal (MSK) care where calls for reform are growing.

AIM

To explore the views of NHS MSK Allied Health Professionals (AHPs) on CG, establishing what activities are undertaken and valued. An additional objective was to identify any differences between clinical leads and non-leads.

METHODS

This exploratory study used an anonymous online cross-sectional survey built with Qualtrics software. Questions were informed by evidence and MSK think-tank discussions, enhancing content validity. The survey evaluated general opinions as well as perspectives on the seven pillars and 23 additional CG activities, including teamwork, culture, and leadership. It was disseminated via social media (X) and Interactive CSP (iCSP) to maximise the response rate. Predominantly ordinal data were analysed using descriptive statistics, with qualitative comments examined using content analysis.

RESULTS

Data from 52 participants were analysed. 96.15% were physiotherapists, 90.38% worked in the NHS, and 53.85% held clinical leadership roles. Respondents viewed CG positively, with 73.08% strongly agreeing it was essential for care quality. Most participated in and valued both the seven pillars and additional activities. No substantial variance was observed between clinical leads and non-leads.

CONCLUSION

MSK AHPs in this study strongly supported CG and valued a broader range of activities than the seven pillars model asserts. Findings suggest current approaches may not fully reflect the scope of CG as perceived by clinicians, highlighting the need for more inclusive CG frameworks.

Has the clinical governance development agenda stalled? Perceptions of New Zealand medical professionals in 2012 and 2017

Clinical governance is a key policy and organisational foundation for health care quality improvement. This study sought to measure progress with clinical governance development from the perspective of practicing medical professionals in the New Zealand public health system. A short fixed-response survey, with questions derived from a government policy statement, was sent in 2012 and 2017 to all registered medical professionals in ongoing employment in New Zealand's public health system. Respondents, therefore, worked across New Zealand's 20 District Health Boards (DHBs), which own and manage public hospital and health care services. The survey sought to gauge medical professionals' perspectives around performance on, and implementation of, key clinical governance components. The overall performance in clinical governance development declined or stalled between the two survey periods across eight out of 10 key survey questions. There were improvements on two questions relating to respondent familiarity with clinical governance concepts, and to management support for clinical leadership development, but no change in areas such as having a structure to support clinical governance, or working in partnership with management. Limited government and DHB policy attention to clinical governance may well have contributed to stalled development across the New Zealand health system. If so, this finding has lessons for other countries and health systems in which there has been varying government support for the clinical governance agenda with ramifications around expectations for clinical leadership on, and involvement in, quality improvement.

Calling for confirmation, reassurance, and direction: Investigating patient compliance after accessing a telephone triage advice service

Understanding the influence of a telephone triage advice service (TTAS) on patients seeking care is critical to realize enhancements in patient care, functioning of emergency departments (EDs), and effectiveness of the health system. This study addresses the question: what influence does a TTAS have on a patient's attendance at an ED and the wider health system? Records from 2016 to 2017 of 12,741 calls from a national TTAS were linked to 72,577 ED presentations to a hospital in regional Australia, retrospectively. Matching criteria included patient within the hospital's statistical local area code, age, gender, and ED attendance within 8 hours of TTAS call. Five statistical analyses of the data were conducted. There were 2857 matches. TTAS patients accessing the ED had a slightly higher proportion of women and a greater proportion of children under 4 years than usual. When TTAS confirmed callers' inclination for ED care, however only up to 69% subsequently attended the ED. When TTAS redirected others initially less inclined to more urgent care, up to 62% attended the ED. TTAS empowers vulnerable patients to access appropriate and timely services and promotes clinical and functional integration of care. Improvements of TTAS can come through investigation of callers' compliance factors.

A strategic and good governance perspective on handling patient complaints

Purpose

The patient complaint is one of the main procedures of exercising patient’s rights in the Finnish health care system. Such complaints typically concern the quality of care and/or patient safety. The purpose of this paper is to examine the types of patient complaints received by a specialized medical care organization and the kinds of responses given by the organization’s personnel. The organization’s strategy and good governance principles provide the framework for understanding the organization’s action.

Design/methodology/approach

This study’s data comprise patient complaints and the responses from personnel of a specialized medical care organization from the start of 2012 to the end of January 2014. The data were analyzed through qualitative data analysis.

Findings

The results show many unwanted grievances, but also reveal the procedures employed to improve health care processes. The results are related to patients’ care experiences, provision of information, personnel’s professional skills and the approach to patient complaints handling. The integrative result of the analysis was to find consensus between the patients’ expectations and personnel’s evaluation of patients’ needs.

Originality/value

Few prior studies have examined patient complaints related to both strategy and good governance. Patient complaints were found to have several confluences with an organization’s strategic goals, objectives and good governance principles. The study recommends further research on personnel procedures for patient complaints handling, with a view to influencing strategic planning and implementation of strategies of organizations.

Implementing Barcode Medication Administration Systems in Public Sector Medical Units

Medication errors in healthcare have a high cost since it is one of the main causes of harming a patient; it leads to inefficient utilization of healthcare organization resources. The barcode medication administration system helps in improving the patients' safety. The purpose of this article is to determine preparatory needs for introducing a Barcoding Medication Administration System (BCMA) in the medical units in one of the largest tertiary hospital in Abu Dhabi City, United Arab Emirates. Analytical Hierarchical Process (AHP) has been employed to describe systematic decision-making by prioritizing different factors that affect the implementation of BCMA and how technology plays a role in helping to reduce or prevent human errors by promoting safety in the health care sectors. Five major domains are identified: leadership, technology, process, education, quality and safety. Leadership was found to be the most important factor oppositely of technology was the least important.

Delivering safe and effective test-result communication, management and follow-up: a mixed-methods study protocol

INTRODUCTION

The failure to follow-up pathology and medical imaging test results poses patient-safety risks which threaten the effectiveness, quality and safety of patient care. The objective of this project is to: (1) improve the effectiveness and safety of test-result management through the establishment of clear governance processes of communication, responsibility and accountability; (2) harness health information technology (IT) to inform and monitor test-result management; (3) enhance the contribution of consumers to the establishment of safe and effective test-result management systems.

METHODS AND ANALYSIS

This convergent mixed-methods project triangulates three multistage studies at seven adult hospitals and one paediatric hospital in Australia.Study 1 adopts qualitative research approaches including semistructured interviews, focus groups and ethnographic observations to gain a better understanding of test-result communication and management practices in hospitals, and to identify patient-safety risks which require quality-improvement interventions.Study 2 analyses linked sets of routinely collected healthcare data to examine critical test-result thresholds and test-result notification processes. A controlled before-and-after study across three emergency departments will measure the impact of interventions (including the use of IT) developed to improve the safety and quality of test-result communication and management processes.Study 3 adopts a consumer-driven approach, including semistructured interviews, and the convening of consumer-reference groups and community forums. The qualitative data will identify mechanisms to enhance the role of consumers in test-management governance processes, and inform the direction of the research and the interpretation of findings.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the South Eastern Sydney Local Health District Human Research Ethics Committee and Macquarie University. Findings will be disseminated in academic, industry and consumer journals, newsletters and conferences.

It Takes Two to Tango: Customization and Standardization as Colluding Logics in Healthcare Comment on "(Re) Making the Procrustean Bed Standardization and Customization as Competing Logics in Healthcare"

The healthcare context is characterized with new developments, technologies, ideas and expectations that are continually reshaping the frontline of care delivery. Mannion and Exworthy identify two key factors driving this complexity, 'standardization' and 'customization,' and their apparent resulting paradox to be negotiated by healthcare professionals, managers and policy makers. However, while they present a compelling argument an alternative viewpoint exists. An analysis is presented that shows instead of being 'competing' logics in healthcare, standardization and customization are long standing 'colluding' logics. Mannion and Exworthy's call for further sustained work to understand this complex, contested space is endorsed, noting that it is critical to inform future debates and service decisions.

Perspectives of rural and remote primary healthcare services on the meaning and goals of clinical governance

Definitions of clinical governance are varied and there is no one agreed model. This paper explored the perspectives of rural and remote primary healthcare services, located in North Queensland, Australia, on the meaning and goals of clinical governance. The study followed an embedded multiple case study design with semi-structured interviews, document analysis and non-participant observation. Participants included clinicians, non-clinical support staff, managers and executives. Similarities and differences in the understanding of clinical governance between health centre and committee case studies were evident. Almost one-third of participants were unfamiliar with the term or were unsure of its meaning; alongside limited documentation of a definition. Although most cases linked the concept of clinical governance to key terms, many lacked a comprehensive understanding. Similarities between cases included viewing clinical governance as a management and administrative function. Differences included committee members' alignment of clinical governance with corporate governance and frontline staff associating clinical governance with staff safety. Document analysis offered further insight into these perspectives. Clinical governance is well-documented as an expected organisational requirement, including in rural and remote areas where geographic, workforce and demographic factors pose additional challenges to quality and safety. However, in reality, it is not clearly, similarly or comprehensively understood by all participants.

Quality improvement in large healthcare organizations

PURPOSE

The purpose of this paper is to investigate the obstacles and challenges associated with organizational monitoring and follow-up (M & F) processes related to health care quality improvement (QI) and development.

DESIGN/METHODOLOGY/APPROACH

A longitudinal case study of a large health care organization during a system-wide QI intervention. Content analysis was conducted of repeated interviews with key actors and archival data collected over a period of four years.

FINDINGS

The demand for improved M & F strategies, and what and how to monitor were described by the respondents. Obstacles and challenges for achieving M & F strategies that enables system-wide and coherent development were found in three areas: monitoring, processing, and feedback and communication. Also overarching challenges were found.

PRACTICAL IMPLICATIONS

A model of important aspects of M & F systems is presented that can be used for analysis and planning and contribute to shared cognition of such systems. Approaches for systematic analysis and follow-up of identified problems have to be developed and fully incorporated in the organization's measurement systems. A systematic M & F needs analytic and process-oriented competence, and this study highlights the potential in an organizational function with capacity and mandate for such tasks.

ORIGINALITY/VALUE

Most health care systems are flooded with a vast amount of registers, records, and measurements. A key issue is how such data can be processed and refined to reflect the needs and the development process of the health care system and how rich data can be used for improvement purposes. This study presents key organizational actor's view on important factors to consider when building a coherent organizational M & F strategy.

Gaps in governance: protective mechanisms used by nurse leaders when policy and practice are misaligned

BACKGROUND

Due to large geographical distances, the telephone is central to enabling rural Australian communities to access care from their local health service. While there is a history of rural nurses providing care via the telephone, it has been a highly controversial practice that is not routinely documented and little is known about how the practice is governed. The lack of knowledge regarding governance extends to the role of Directors of Nursing as clinical leaders charged with the responsibility of ensuring practice safety, quality, regulation and risk management. The purpose of this study was to identify clinical governance processes related to managing telephone presentations, and to explore Directors of Nursing perceptions of processes and clinical practices related to the management of telephone presentations to health services in rural Victoria, Australia.

METHODS

Qualitative documentary analysis and semi structured interviews were used in the study to examine the content of health service policies and explore the perceptions of Directors of Nursing in eight rural health services regarding policy content and enactment when people telephone rural health services for care. Participants were purposively selected for their knowledge and leadership role in governance processes and clinical practice. Data from the interviews were analysed using framework analysis. The process of analysis resulted in the identification of five themes.

RESULTS

The majority of policies reviewed provided little guidance for managing telephone presentations. The Directors of Nursing perceived policy content and enactment to be largely inadequate. When organisational structures failed to provide appropriate governance for the context, the Directors of Nursing engaged in protective mechanisms to support rural nurses who manage telephone presentations.

CONCLUSIONS

Rural Directors of Nursing employed intuitive behaviours to protect rural nurses practicing within a clinical governance context that is inadequate for the complexities of the environment. Protective mechanisms provided indicators of clinical leadership and governance effectiveness, which may assist rural nurse leaders to strengthen quality and safe care by unlocking the potential of intuitive behaviours. Kanter's theory of structural power provides a way of conceptualising these protective mechanisms, illustrating how rural nurse leaders enact power.

Achieving patient-centred care: the potential and challenge of the patient-as-professional role

BACKGROUND

The patient-as-professional concept acknowledges the expert participation of patients in interprofessional teams, including their contributions to managing and coordinating their care. However, little is known about experiences and perspectives of these teams.

OBJECTIVE

To investigate (i) patients' and carers' experiences of actively engaging in interprofessional care by enacting the patient-as-professional role and (ii) clinicians' perspectives of this involvement.

DESIGN, SETTING AND PARTICIPANTS

A two-phased qualitative study. In Phase 1, people with chronic disease (n = 50) and their carers (n = 5) participated in interviews and focus groups. Phase 2 involved interviews with clinicians (n = 14). Data were analysed thematically.

FINDINGS

Patients and carers described the characteristics of the role (knowing about the condition, questioning clinicians, coordinating care, using a support network, engaging an advocate and being proactive), as well as factors that influence its performance (the patient-clinician partnership, benefits, barriers and applicability). However, both patients and carers, and clinicians cautioned that not all patients might desire this level of involvement. Clinicians were also concerned that not all patients have the required knowledge for this role, and those who do are time-consuming. When describing the inclusion of the patient-as-professional, clinicians highlighted the patient and clinician's roles, the importance of the clinician-patient relationship and ramifications of the role.

CONCLUSION

Support exists for the patient-as-professional role. The characteristics and influencing factors identified in this study could guide patient engagement with the interprofessional team and support clinicians to provide patient-centred care. Recognition of the role has the potential to improve health-care delivery by promoting patient-centred care.

Clinical Governance Infrastructures and Relational Mechanisms of Control in Healthcare Organizations

This review paper aims to identify and discuss the dominant themes surrounding the governance initiatives in the context of medical markets relying on the two most common search strategies, namely the keyword search technique and the ancestry approach. In an in-depth examination of the recently published research in the field we uncover an emergent decoupling between the governance initiatives formulated at the macro- and micro-levels in today’s institutions of healthcare provision. The macro-level initiatives are associated with clinical governance infrastructures directed towards the attainment of medical performance targets, whereas the micro-level endeavors refer to relational governance mechanisms for overseeing the relationship between the patient and the physician. Acknowledging the importance of monitoring micro-level interactions that may contribute to the achievement of macro-level objectives, a more comprehensive integration of relational governance devices under the broader system of clinical governance is advocated in this paper with the purpose of enhancing the effectiveness of healthcare organizations.

On a wing and a prayer: an assessment of modularized crew resource management training for health care professionals

INTRODUCTION

Evidence suggests that Crew Resource Management (CRM), a form of team training, is beneficial. In CRM training, participants learn individual portable team skills such as communication and decision making through group discussion and activities. However, the usual 1-day course format is not always compatible with health care organizational routines. A modular training format, while theoretically sound, is untested for interprofessional team training. The aim of this study was to explore the potential for modularized CRM training to be delivered to a group of interprofessional learners.

METHOD

Modularized CRM training, consisting of two 2-hour workshops, was delivered to health care workers in an Australian tertiary hospital. Kirkpatrick's evaluation model provided a framework for the study. Baseline attitude surveys were conducted prior to each workshop. Participants completed a written questionnaire at the end of each workshop that examined their motivations, reactions to the training, and learner demographics. An additional survey, administered 6 weeks post training, captured self-assessed behavior data.

RESULTS

Twenty-three individuals from a range of professions and clinical streams participated. One in 5 participants (22%) reported that they translated teamwork skills to the workplace. While positive about the workshop format and content, many respondents identified personal, team, and organizational barriers to the application of the workshop techniques.

DISCUSSION

CRM training when delivered in a modular format has positive outcomes. Following the training, some respondents overcame workplace barriers to attempt to change negative workplace behavior. This progress provides cautious optimism for the potential for modular CRM training to benefit groups of interprofessional health staff.

A four-year, systems-wide intervention promoting interprofessional collaboration

Background

A four-year action research study was conducted across the Australian Capital Territory health system to strengthen interprofessional collaboration (IPC) though multiple intervention activities.

Methods

We developed 272 substantial IPC intervention activities involving 2,407 face-to-face encounters with health system personnel. Staff attitudes toward IPC were surveyed yearly using Heinemann et al's Attitudes toward Health Care Teams and Parsell and Bligh's Readiness for Interprofessional Learning scales (RIPLS). At study's end staff assessed whether project goals were achieved.

Results

Of the improvement projects, 76 exhibited progress, and 57 made considerable gains in IPC. Educational workshops and feedback sessions were well received and stimulated interprofessional activities. Over time staff scores on Heinemann's Quality of Interprofessional Care subscale did not change significantly and scores on the Doctor Centrality subscale increased, contrary to predictions. Scores on the RIPLS subscales of Teamwork & Collaboration and Professional Identity did not alter. On average for the assessment items 33% of staff agreed that goals had been achieved, 10% disagreed, and 57% checked neutral. There was most agreement that the study had resulted in increased sharing of knowledge between professions and improved quality of patient care, and least agreement that between-professional rivalries had lessened and communication and trust between professions improved.

Conclusions

Our longitudinal interventional study of IPC involving multiple activities supporting increased IPC achieved many project-specific goals. However, improvements in attitudes over time were not demonstrated and neutral assessments predominated, highlighting the difficulties faced by studies targeting change at the systems level and over extended periods.