Differentiating clinical governance, clinical management and clinical practice

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.

Implementing high-value, cost-conscious care: experiences of Irish doctors and the role of education in facilitating this approach

BACKGROUND

Adopting high-value, cost-conscious care (HVCCC) principles into medical education is growing in importance due to soaring global healthcare costs and the recognition that efficient care can enhance patient outcomes and control costs. Understanding the current opportunities and challenges doctors face concerning HVCCC in healthcare systems is crucial to tailor education to doctors' needs. Hence, this study aimed to explore medical students, junior doctors, and senior doctors' experiences with HVCCC, and to seek senior doctors' viewpoints on how education can foster HVCCC in clinical environments.

METHODS

Using a mixed-methods design, our study involved a cross-sectional survey using the Maastricht HVCCC-Attitude Questionnaire (MHAQ), with a subset of consultants engaging in semi-structured interviews. Descriptive analysis provided insights into both categorical and non-categorical variables, with differences examined across roles (students, interns, junior doctors, senior doctors) via Kruskal-Wallis tests, supplemented by two-group analyses using Mann-Whitney U testing. We correlated experience with MHAQ scores using Spearman's rho, tested MHAQ's internal consistency with Cronbach's alpha, and employed thematic analysis for the qualitative data.

RESULTS

We received 416 responses to the survey, and 12 senior doctors participated in the semi-structured interviews. Overall, all groups demonstrated moderately positive attitudes towards HVCCC, with more experienced doctors exhibiting more favourable views, especially about integrating costs into daily practice. In the interviews, participants agreed on the importance of instilling HVCCC values during undergraduate teaching and supplementing it with a formal curriculum in postgraduate training. This, coupled with practical knowledge gained on-the-job, was seen as a beneficial strategy for training doctors.

CONCLUSIONS

This sample of medical students and hospital-based doctors display generally positive attitudes towards HVCCC, high-value care provision, and the integration of healthcare costs, suggesting receptiveness to future HVCCC training among students and doctors. Experience is a key factor in HVCCC, so early exposure to these concepts can potentially enhance practice within existing healthcare budgets.

Attitudes Toward Safety and Teamwork: Benchmarking Australian Surgeons and Nurses

OBJECTIVES

This study aimed to investigate the safety attitudes of surgeons and nurses working in Australian operating rooms and establish a baseline of their general safety attitudes, as well as to compare the safety attitudes of surgeons and nurses working in operating room settings.

METHODS

A modified version of the Safety Attitudes Questionnaire (Operating Room version) was distributed to operating room personnel across Australia via their relative colleges and unions. A total of 261 surgeons and registered nurses completed the online survey.

RESULTS

An above-average safety focus was reported, with participants tending to be more positive on all subscales of the Safety Attitudes Questionnaire (Operating Room version) than reported by previous studies, which measured those working in intensive care units, ambulatory settings, and operating rooms. Participants had the most positive attitudes toward Teamwork Climate and Job Satisfaction, and the least positive attitudes toward Perceptions of Management and Work Conditions. There were some occupational differences in attitudes toward the various aspects of safety, with surgeons having more positive attitudes toward all aspects of safety except in relation to stress recognition, compared with nurses.

CONCLUSIONS

This study provides a baseline of general safety attitudes for Australian surgeons and nurses against which the effectiveness of future interventions can be interpreted. The occupational differences found in this study support the notion that safety interventions should be occupationally tailored. Interventions should target individual professional groups, taking into account the specific differences within each occupation to maximize their impact and effectiveness.

Grounded accountability in life-and-death high-consequence healthcare settings

Purpose

The paper examines interviewee insights into accountability for clinical governance in high-consequence, life-and-death hospital settings. The analysis draws on the distinction between formal “imposed accountability” and front-line “felt accountability”. From these insights, the paper introduces an emergent concept, “grounded accountability”.

Design/methodology/approach

Interviews are conducted with 41 clinicians, managers and governors in two large academic hospitals. The authors ask interviewees to recall a critical clinical incident as a focus for elucidating their experiences of and observation on the practice of accountability.

Findings

Accountability emerges from the front-line, on-the-ground. Together, clinicians, managers and governors co-construct accountability. Less attention is paid to cost, blame, legal processes or personal reputation. Money and other accountability assumptions in business do not always apply in a hospital setting.

Originality/value

The authors propose the concept of co-constructed “grounded accountability” comprising interrelationships between the concept’s three constituent themes of front-line staff’s felt accountability, along with grounded engagement by managers/governors, supported by a culture of openness.

Clinical governance in New Zealand: perceptions from registered health professionals in health care delivery compared with social insurance

ObjectiveEffective clinical governance can improve delivery of health outcomes. This exploratory study compared perceptions of clinical governance development held by registered health professionals employed by two different but interrelated health organisations in the broader New Zealand (NZ) health system. Most staff in public sector healthcare service delivery organisations (i.e. District Health Boards (DHBs)) are registered health professionals, whereas these clinical staff represent a small minority (5%) in social insurance organisations (i.e. the Accident Compensation Corporation (ACC)). Given these different contexts, comparison of results from three surveys of clinical governance perceptions identified key learnings for the development of clinical governance.MethodsThe Clinical Governance Development Index (CGDI) was administered to registered health professional staff in NZ DHBs and ACC, at different time points. The data were explored, compared and reported.ResultsResponses to survey items completed by NZ DHB staff and registered health professionals employed by ACC were compared. For each administration, there was a similar profile of positive responses across the seven CGDI items. The 2020 ACC survey results for one item were clearly different. This item asked about perceptions of full and active involvement in organisational processes and decision making (i.e. clinical engagement).ConclusionsPerceptions of registered health professionals working in the NZ public sector delivering health services were compared with those held by staff employed by a NZ social insurer predominantly commissioning and influencing care. The results indicated similar levels of clinical governance development. Clinical governance development in the ACC context can benefit from clear communication, building strong supporting structures and greater management-clinical provider partnerships. Clinical governance development drives health outcomes and regular measurement of developmental progress can provide momentum. There is room across the NZ health system to raise awareness and leverage clinical governance to deliver improved health outcomes.What is known about the topic?Little is known about the perceptions held by registered health professionals employed by social insurance organisations. There are no published comparative studies exploring differences in perceptions between registered health professionals across two different organisational contexts, both with a goal of improving health outcomes.What does this paper add?Effective clinical governance drives coordinated, quality systems that promote optimal health outcomes. Social insurance organisations predominantly commission healthcare providers to deliver health outcomes. Although registered health professionals employed by social insurance organisations represent a small total number of staff, their perspective on clinical governance, as reported via survey, indicated there is most to be gained in the development of partnerships between management and clinical providers. This exploratory study fills a gap in the existing clinical governance development literature and evidence base.What are the implications for practitioners?Any health organisation can leverage clinical governance to deliver improved health outcomes. Effective clinical governance interventions are targeted to specific organisational context and culture. For ACC, a clear definition, enhanced management-clinical provider partnerships and strong supporting structures or organisational arrangements can be further developed. The survey results indicated that a focus on management-clinical provider partnerships is a clear priority for ACC clinical governance development. Partnerships based in empowered collaboration require greater clinical engagement, as well as increased capability for aligning with organisational priorities. Effective clinical governance development requires attention to context and culture. It can improve delivery of health outcomes.

Governance of maternity services: Effects on the management of perinatal deaths and bereavement services

BACKGROUND

External inquiries are carried out following adverse maternal/perinatal events, to examine the care provided and make recommendations to improve it. Clinical governance ensures that organisations promote high-quality care and are accountable for the care they provide, thus contributing to its improvement.

OBJECTIVE

This study examined how Irish perinatal bereavement services and the management of perinatal deaths (including events leading up to the deaths) were affected by developments in maternity services governance as described in ten Irish enquiry reports published over 14 years (2005-18).

METHODS

Two clinicians collected data from the ten enquiry reports by using a specifically designed review tool. Thematic analysis was carried out, following the steps of familiarising, coding, identifying, grouping and revising themes.

FINDINGS

Seven main themes were identified: workforce, leadership, management of risk, work environment, hospital oversight, national documents, data collection. Eight reports noted shortcomings in staffing levels, with a workforce that was under-resourced, and at times carried excessive workloads. The absence of 24/7 midwifery-shift leaders in maternity units resulted in problems with care at times not being escalated appropriately. The absence of a widely-owned, understood strategic plan for the management of the maternity services was mentioned in the reports from 2013. Conclusions and implications for practice The National Bereavement Care Standards were published in 2016 to address deficiencies identified in the enquiry reports and to standardise perinatal bereavement care across Irish maternity units. Though the first Irish Maternity Strategy (2016-26) was published in 2016, its implementation is incomplete. Inconsistencies remain in the definition and collection of national perinatal data, as well as concerns regarding the lack of local audit activities on pregnancy outcomes. Greater focus on hospital oversight, implementation of national documents and reliable data collection is required. To be effective and initiate positive changes in clinical services, documents such as incident reviews, national strategies and national reports including inquiries, need to include realistic recommendations with clear timelines and responsibilities for implementation.

Mapping clinical governance to practitioner roles and responsibilities

Purpose

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.

Findings

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.

Research on hospital-based shared governance: a scoping review

Purpose

The purpose of this study is to review research on hospital-based shared governance (SG), focussing on its core elements.

Design/methodology/approach

A scoping review was conducted by searching the Medline (Ovid), CINAHL (EBSCO), Medic, ABI/INFORM Collection (ProQuest) and SveMed+ databases using SG and related concepts in hospital settings as search terms (May 1998–February 2019). Only original research articles examining SG were included. The reference lists of the selected articles were reviewed. Data were extracted from the selected articles by charting and then subjected to a thematic analysis.

Findings

The review included 13 original research articles that examined SG in hospital settings. The studied organizations had implemented SG in different ways, and many struggled to obtain satisfactory results. SG was executed within individual professions or multiple professions and was typically implemented at both unit- and organization-levels. The thematic analysis revealed six core elements of SG as follows: professionalism, shared decision-making, evidence-based practice, continuous quality improvement, collaboration and empowerment.

Practical implications

An SG framework for hospital settings was developed based on the core elements of SG, the participants and the organizational levels involved. Hospitals considering SG should prepare for a time-consuming process that requires belief in the core elements of SG. The SG framework can be used as a tool to implement and strengthen SG in organizations.

Originality/value

The review resumes the tradition of systematically reviewing SG literature, which had not been done in the 21st century. General tendencies of the research scene and research gaps are pointed out.

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.

Can institutional entrepreneurship strengthen clinical governance and quality improvement: a case study of a district-based clinical specialist team in South Africa

We present an interpretive qualitative account of micro-level activities and processes of clinical governance by recently introduced district-based clinical specialist teams (DCSTs) in South Africa. We do this to explore whether and how they are functioning as institutional entrepreneurs (IE) at the local service delivery level. In one health district, between 2013 and 2015, we carried out 59 in-depth interviews with district, sub-district and facility managers, nurses, DCST members and external actors. We also ran one focus group discussion with the DCST and analysed key policies, activities and perceptions of the innovation using an institutional entrepreneurship conceptual lens. Findings show that the DCST is located in a constrained context. Yet, by revealing and bridging gaps in the health system, team members have been able to take on certain IE characteristics, functioning-more or less-as announcers of reforms, articulating a strategic vision and direction for the system, advocating for change, mobilizing resources. In addition, they have helped to reorganize services and shape care practices by re-framing issues and exerting power to influence organizational change. The DCST innovation provides an opportunity to promote institutional entrepreneurship in our context because it influences change and is applicable to other health systems. Yet there are nuanced differences between individual members and the team, and these need better understanding to maximize this contribution to change in this context and other health systems.

Quality patient care: challenges and opportunities

There are several interlocking elements integral to the delivery of safe patient care, including clinical governance, efficient communication, teamwork, risk assessment, inter-professional education and effective leadership. Each element can be challenging to understand, develop, or act on, but it is essential that nurses use these as opportunities to ensure their specialty or service delivers safe and high-quality care. This article discusses each of these elements and its relationship to quality patient care, with specific reference to the role of children's nurses.

Impact of organisational change for leaders in mental health

PURPOSE

The purpose of this paper is to examine the impact of organisational and structural change on the evolution of quality and safety in health organisations, specifically in mental health services.

DESIGN/METHODOLOGY/APPROACH

Data were gathered through semi-structured interviews. In total, 25 executive management team members in both public and private mental health services were interviewed and data were analysed using Burnard's framework.

FINDINGS

Three overarching themes emerged: organisational characteristics, leadership and accountability; sustaining collaboration and engagement with stakeholders; and challenges to and facilitators of quality and safety. Taken together, the findings speak to the disruptive and disorienting impact of on-going organisational change and restructuring on leaders' ability to focus on, and advance, the quality and safety agenda.

RESEARCH LIMITATIONS/IMPLICATIONS

Typical with qualitative research of this nature, the potentially limited generalisability of the findings must be acknowledged.

PRACTICAL IMPLICATIONS

There is a need for strategies to implement change that are informed by evidence and theory and informed by decades of research on this topic, rather than introduced ad hoc. Change agents must pair effective change management and implementation science strategies to specific contexts, depending on what is being implemented and ensure appropriate evaluation of organisational change to bolster the evidence base around quality and safety and inform future decision-making.

ORIGINALITY/VALUE

The study explores an identified gap in the literature on the impact of on-going organisational re-structuring and transformation on the evolution of quality and safety in mental health services.

Implementation of district-based clinical specialist teams in South Africa: Analysing a new role in a transforming system

BACKGROUND

Improving the quality of health care is a national priority in many countries to help reduce unacceptable levels of variation in health system practices, performance and outcomes. In 2012, South Africa introduced district-based clinical specialist teams (DCSTs) to enhance clinical governance at the lowest level of the health system. This paper examines the expectations and responses of local health system actors in the introduction and early implementation of this new DCST role.

METHODS

Between 2013 and 2015, we carried out 258 in-depth interviews and three focus group discussions with managers, implementers and intended beneficiaries of the DCST innovation. Data were collected in three districts using a theory of change approach for programme evaluation. We also embarked on role charting through policy document review. Guided by role theory, we analysed data thematically and compared findings across the three districts.

RESULTS

We found role ambiguity and conflict in the implementation of the new DCST role. Individual, organisational and systemic factors influenced actors' expectations, behaviours, and adjustments to the new clinical governance role. Local contextual factors affected the composition and scope of DCSTs in each site, while leadership and accountability pathways shaped system adaptiveness across all three. Two key contributions emerge; firstly, the responsiveness of the system to an innovation requires time in planning, roll-out, phasing, and monitoring. Secondly, the interconnectedness of quality improvement processes adds complexity to innovation in clinical governance and may influence the (in) effectiveness of service delivery.

CONCLUSION

Role ambiguity and conflict in the DCST role at a system-wide level suggests the need for effective management of implementation systems. Additionally, improving quality requires anticipating and addressing a shortage of inputs, including financing for additional staff and skills for health care delivery and careful integration of health care policy guidelines.

Self-regulation and medical direction

Purpose

The purpose of this paper is to describe and analyse two approaches to paramedic service clinical governance and quality management from the perspective of two groups of paramedics and paramedic managers working in North America.

Design/methodology/approach

A case study approach was utilised to describe and analyse paramedic service medical direction in North America and contrast this with the professional self-governance and clinical governance systems operating in other high-income countries. Researchers interviewed participants at two remote North American sites, then completed transcription and thematic analysis.

Findings

Participants identified three themes: first, resourcing, regulatory frameworks and fragmentation; second, independent practice facilitators and barriers; and third, paramedic roles and professionalisation. Those trained outside North America tended to identify self-regulation and clinical governance as the preferred approach to quality management. Few participants had considered paramedicine becoming a self-regulating health profession.

Originality/value

In North America, the “medical direction” model is the dominant approach employed to ensure optimal patient outcomes in paramedic service delivery. In contrast, other comparable countries employ paramedic self-regulatory systems combined with clinical governance to achieve the same ends. This is one of two studies to examine medical direction from the perspective of paramedics and paramedic managers.

Clinical leadership in paramedic services: a narrative synthesis

Purpose

In North America, delegated practice “medical direction” models are often used as a proxy for clinical quality and safety in paramedic services. Other developed countries favor a combination of professional regulatory boards and clinical governance frameworks that feature paramedics taking lead clinician roles. The purpose of this paper is to bring together the evidence for medical direction and clinical governance in paramedic services through the prism of paramedic self-regulation.

Design/methodology/approach

This narrative synthesis critically examines the long-established North American Emergency Medical Services medical direction model and makes some comparisons with the UK inspired clinical governance approaches that are used to monitor and manage the quality and safety in several other Anglo-American paramedic services. The databases searched were CINAHL and Medline, with Google Scholar used to capture further publications.

Findings

Synthesis of the peer-reviewed literature found little high quality evidence supporting the effectiveness of medical direction. The literature on clinical governance within paramedic services described a systems approach with shared responsibility for quality and safety. Contemporary paramedic clinical leadership papers in developed countries focus on paramedic professionalization and the self-regulation of paramedics.

Originality/value

The lack of strong evidence supporting medical direction of the paramedic profession in developed countries challenges the North American model of paramedics practicing as a companion profession to medicine under delegated practice model. This model is inconsistent with the international vision of paramedicine as an autonomous, self-regulated health profession.

Do different approaches to clinical governance development and implementation make a difference? Findings from Ireland and New Zealand

Purpose

Clinical governance (CG) is an important foundation for a high-performing health care system, with many countries supporting its development. CG policy may be developed and implemented nationally, or devolved to a local level, with implications for the overall approach to implementation and policy uptake. However, it is not known whether one of these two approaches is more effective. The purpose of this paper is to probe this question. Its setting is Ireland and New Zealand, two broadly comparable countries with similar CG policies. Ireland’s was nationally led, while New Zealand’s was devolved to local districts. This leads to the question of whether these different approaches to implementation make a difference.

Design/methodology/approach

Data from surveys of health professionals in both countries were used to compare performance with CG development.

Findings

The study showed that Ireland’s approach produced a slightly better performance, raising questions about the merits of devolving responsibility for policy implementation to the local level.

Research limitations/implications

The Irish and New Zealand surveys both had lower-than-desirable response rates, which is not uncommon for studies of health professionals such as this. The low response rates mean the findings may be subject to selection bias.

Originality/value

Despite the importance of the question of whether a national or local approach to policy implementation is more effective, few studies specifically focus on this, meaning that this study provides a new contribution to the topic.

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.

The pre-eminence of patient safety in health care governance

Purpose

The purpose of this paper is to identify a common theme linking the articles in this issue of IJHG. The review editor elucidates on this topic while presenting key findings from the articles which comprise the current issue.

Design/methodology/approach

The design is a general review describing the articles under review while expanding on the subject matter through reference to other authors.

Social implications

The Review provides readers with a brief overview of the current articles enabling them to select the ones which reflect their needs or interests.

Originality/value

IJHG is the only Emerald journal providing a Review section of this type.

The theory and practice of integrative health care governance

Purpose

The purpose of this paper is to outline the theory and practice of governance for integrated care, using the case of New Zealand’s healthcare alliances.

Design/methodology/approach

This is descriptive analysis.

Findings

Alliance governance provides considerable scope for bringing health professional together to focus on whole system approaches to care design. As such, it facilitates care integration.

Research limitations/implications

This is a descriptive review.

Originality/value

Descriptions of alliance governance in New Zealand and in general are rare in the literature. This paper fills this gap.

Community paramedicine model of care: an observational, ethnographic case study

Background

Community paramedicine programs have emerged throughout North America and beyond in response to demographic changes and health system reform. Our aim was to identify and analyse how community paramedics create and maintain new role boundaries and identities in terms of flexibility and permeability and through this develop and frame a coherent community paramedicine model of care that distinguish the model from other innovations in paramedic service delivery.

Methods

Using an observational ethnographic case study approach, we collected data through interviews, focus groups and field observations. We then applied a combination of thematic analysis techniques and boundary theory to develop a community paramedicine model of care.

Results

A model of care that distinguishes community paramedicine from other paramedic service innovations emerged that follows the mnemonic RESPIGHT: Response to emergencies; Engaging with communities; Situated practice; Primary health care; Integration with health, aged care and social services; Governance and leadership; Higher education; Treatment and transport options.

Conclusions

Community engagement and situated practice distinguish community paramedicine models of care from other paramedicine and out-of-hospital health care models. Successful community paramedicine programs are integrated with health, aged care and social services and benefit from strong governance and paramedic leadership.

Fiery Spirits in the context of institutional entrepreneurship in Swedish healthcare

PURPOSE

Clinical governance and leadership concepts can lead to more or less successful implementations of new clinical practice. The purpose of this paper is to examine how Fiery Spirits, as institutional entrepreneurs can, working in a team, implement sustained change in hospital clinical practice.

DESIGN/METHODOLOGY/APPROACH

This paper describes two case studies, conducted at two Swedish hospitals over a period of two years, in which changes in clinical practice were implemented. In both cases, key-actors, termed Fiery Spirits, played critical roles in these changes. The authors use a qualitative approach and take an intra-organizational perspective with semi-structured in-depth interviews and document analysis.

FINDINGS

The new clinical practices were successfully implemented with a considerable influence of the Fiery Spirits who played a pivotal role in the change efforts. The Fiery Spirits persuasively, based on their structural and normative legitimacy and the adoption of learning processes, advocated, and supported change.

PRACTICAL IMPLICATIONS

Fiery Spirits, given flexibility and opportunity, can be powerful forces for change outside the trajectory of management-inspired and management-directed change. Team members, when inspired and encouraged by Fiery Spirits, are less resistant to change and more willing to test new clinical practices.

ORIGINALITY/VALUE

The paper complements literature on how the Fiery Spirit concept aligns with concepts of clinical governance and leadership and how change can be achieved. Additionally, the findings show the effects of legitimacy and learning processes on change in clinical practice.

Supporting and activating clinical governance development in Ireland: sharing our learning

Purpose

– The purpose of this paper is to present a description of the Irish national clinical governance development initiative and an evaluation of the initiative with the purpose of sharing the learning and proposing actions to activate structures and processes for quality and safety. The Quality and Patient Safety Division of the Health Service Executive established the initiative to counterbalance a possible focus on finances during the economic crisis in Ireland and bring attention to the quality of clinical care.

Design/methodology/approach

– A clinical governance framework for quality in healthcare in Ireland was developed to clearly articulate the fundamentals of clinical governance. The project plan involved three overlapping phases. The first was designing resources for practice; the second testing the implementation of the national resources in practice; and the third phase focused on gathering feedback and learning.

Findings

– Staff responded positively to the clinical governance framework. At a time when there are a lot of demands (measurement and scrutiny) the health services leads and responds well to focused support as they improve the quality and safety of services. Promoting the use of the term “governance for quality and safety” assisted in gaining an understanding of the more traditional term “clinical governance”. The experience and outcome of the initiative informed the identification of 12 key learning points and a series of recommendations

Research limitations/implications

– The initial evaluation was conducted at 24 months so at this stage it is not possible to assess the broader impact of the clinical governance framework beyond the action project hospitals.

Practical implications

– The single most important obligation for any health system is patient safety and improving the quality of care. The easily accessible, practical resources assisted project teams to lead changes in structures and processes within their services. This paper describes the fundamentals of the clinical governance framework which might serve as a guide for more integrative research endeavours on governance for quality and safety.

Originality/value

– Experience was gained in both the development of national guidance and their practical use in targeted action projects activating structures and processes that are a prerequisite to delivering safe quality services.

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.

Healthcare professionals' perceptions of clinical governance implementation: a qualitative New Zealand study of 3205 open-ended survey comments

OBJECTIVES

To investigate healthcare professional perceptions of local implementation of a national clinical governance policy in New Zealand.

DESIGN

Respondent comments written at the end of a national healthcare professional survey designed to assess implementation of core components of the clinical governance policy.

SETTING

The written comments were provided by respondents to a survey distributed to over 41 000 registered healthcare professionals employed in 19 of New Zealand's government-funded District Health Boards. Comments were analysed and categorised within emerging themes.

RESULTS

3205 written comments were received. Five key themes illustrating barriers to clinical governance implementation were found, representing problems with: developing management-clinical relations; clinicians stepping up into clinical governance and leadership activities; interprofessional relations; training needs for governance and leadership; and having insufficient time to get involved.

CONCLUSIONS

Despite a national policy on clinical governance which New Zealand's government launched in 2009, this study found that considerable effort is required to build clinical governance at the local level. This finding parallels with other studies in the field. Two areas demand attention: building systems for organisational governance and leadership; and building professional governance arrangements.

Measuring progress with clinical governance development in New Zealand: perceptions of senior doctors in 2010 and 2012

Background

Clinical governance has become a core component of health policy and services management in many countries in recent years. Yet tools for measuring its development are limited. We therefore created the Clinical Governance Development Index (CGDI), aimed to measure implementation of expressed government policy in New Zealand.

Methods

We developed a survey which was distributed in 2010 and again in 2012 to senior doctors employed in public hospitals. Responses to six survey items were weighted and combined to form the CGDI. Final scores for each of New Zealand’s District Health Boards (DHBs) were calculated to compare performances between them as well as over time between the two surveys.

Results

New Zealand’s overall performance in developing clinical governance improved between the two studies from 46% in 2010 to 54% in 2012 with marked differences by DHB. Statistically significant shifts in performance were evident on all but one CGDI item.

Conclusions

The CGDI is a simple yet effective method which probes aspects of organisational commitment to clinical governance, respondent participation in organisational design, quality improvement, and teamwork. It could be adapted for use in other health systems.

Clinical governance in the Irish health system – a review of progress

Purpose

– The purpose of this paper is to explain the path that the Irish health system has taken towards achieving good clinical governance, exploring the historical influences on its’ development, some of the major initiatives that have been implemented and the obstacles that have been encountered.

Design/methodology/approach

– The paper draws on the author's experience researching and teaching in health systems and healthcare management.

Findings

– The paper offers some explanations for why earlier attempts failed to change the system as well as why recent attempts have met with more success. Greater efforts need to be made to progress clinical governance in the primary care services. In addition it is argued that there is a need to institute systems that enable learning form errors, to involve the public and patient groups and to invest in research that enables answers to the how and why questions that are so often neglected in the reform process.

Originality/value

– The paper discusses clinical governance in the Irish Health system and identifies some of the challenges yet to be addressed, many of which are common to clinical governance efforts in other jurisdictions.