Clinical governance and the role of NHS boards: learning lessons from the case of Ian Paterson

Keeping institutional logics in arm’s length: emerging of rogue practices in a gray zone of everyday work life in healthcare

We set out to explore the practice-level cognitive structures and associated practices characterizing the daily routine work of physicians by conducting a qualitative study in the Turkish healthcare field, in which a recent government-led healthcare reform was implemented causing logic multiplicity. Contrary to the accumulated knowledge in institutional logics literature, a bulk of which suggests that actors craft and enact various practices in managing plural and at times conflicting institutional templates strictly within the confines of higher order societal logics, this study shows that while ground level actors may not exercise complete freedom and maneuverability in relation to pre-established social structures, they do incorporate unconventional schemas of action; namely rogue practices, into their embodied practical activity, which over time become routinized in their day-to-day work lives. Unraveling the dynamics of micro-level practices of highly professionalized ground level actors as they pertain to atypical logical orientations substantially advances our understanding of the unknown or unseen side of how and under which conditions certain or various combinations of institutional logics are employed during day-to-day activities.

Healthcare scandals and the failings of doctors

PURPOSE

The purpose of this paper is to explore whether official inquiries are an effective method for holding the medical profession to account for failings in the quality and safety of care.

DESIGN/METHODOLOGY/APPROACH

Through a review of the theoretical literature on professions and documentary analysis of key public inquiry documents and reports in the UK National Health Service (NHS) the authors examine how the misconduct of doctors can be understood using the metaphor of professional wrongdoing as a product of bad apples, bad barrels or bad cellars.

FINDINGS

The wrongdoing literature tends to present an uncritical assumption of increasing sophistication in analysis, as the focus moves from bad apples (individuals) to bad barrels (organisations) and more latterly to bad cellars (the wider system). This evolution in thinking about wrongdoing is also visible in public inquiries, as analysis and recommendations increasingly tend to emphasise cultural and systematic issues. Yet, while organisational and systemic factors are undoubtedly important, there is a need to keep in sight the role of individuals, for two key reasons. First, there is growing evidence that a small number of doctors may be disproportionately responsible for large numbers of complaints and concerns. Second, there is a risk that the role of individual professionals in drawing attention to wrongdoing is being neglected.

ORIGINALITY/VALUE

To the best of the authors' knowledge this is the first theoretical and empirical study specifically exploring the role of NHS inquiries in holding the medical profession to account for failings in professional practice.

The challenges of implementation of clinical governance in Iran: a meta-synthesis of qualitative studies

Background

Policy- and decision-makers seek to improve the quality of care in the health sector and therefore aim to improve quality through appropriate policies. Higher quality of care will satisfy service providers and the public, reduce costs, increase productivity, and lead to better organisational performance. Clinical governance is a method through which management can be improved and made more accountable, and leads to the provision of better quality of care. In November 2009, the Iranian Ministry of Health and Medical Education implemented new clinical guidelines to standardise and improve clinical services as well as to increase efficiency and reduce costs. The purpose of this study was to assess the challenges of implementing clinical governance through a meta-synthesis of qualitative studies published in Iran.

Methods

Ten databases, including ISI/Web of Sciences, PubMed/MEDLINE, Embase, PsycINFO, the Cochrane Library, CINAHL, Scopus, Barakatns, MagIran and the Scientific Information Database, were searched between January 2009 and May 2018. The quality of the included studies was assessed using the Critical Appraisal Skills Programme tool. This study was reported according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research guidelines. Thematic synthesis was used to analyse the data.

Results

Ten studies were selected and included based on the inclusion/exclusion criteria. In the first stage, 75 items emerged and were coded, and, following comparison and combination of the codes, 32 codes and 8 themes were finally extracted. These themes included health system structure, management, person-power, cultural factors, information and data, resources, education and evaluation.

Conclusion

The findings of the study showed that there exist a variety of challenges for the implementation of clinical governance in Iran. To successfully implement a health policy, its infrastructure needs to be created. Using the views and support of stakeholders can ensure that a policy is well implemented.

Trial registration

CRD42017079077. Dated October 10, 2017.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0399-5) contains supplementary material, which is available to authorized users.

Has Publishing Surgeon-Specific Outcomes Had an Impact on Training in Cardiac Surgery?

BACKGROUND

Surgeon-specific outcome data are now published for most surgical specialties in the United Kingdom. There are concerns that this initiative has had a negative impact on training. The primary objective of this study was to assess whether training activity has changed since the publication of surgeon-specific outcomes in cardiac surgery.

METHODS

Prospectively collected data for cardiac surgical procedures performed at a single center from 2004 to 2016 were analyzed. The cohort was split into two halves according to operation date. Multivariable logistic regression was used to assess whether training activity had increased from the first to the second part of the study and to identify whether trainee first operator was associated with adverse outcomes.

RESULTS

A total of 14,054 cardiac surgical procedures were included, of which 1,777 (12.6%) had a trainee as first operator. Despite an increase in the risk profile of patients undergoing surgical procedures, the proportion of cases performed by trainees increased from 11.7% (786 of 6,708) in the first half of the study to 13.5% (991 of 7,346) in the second half of the study (p = 0.002). This effect remained after adjustment for confounding variables. Trainee first operator was not significantly associated with an increased risk of any adverse short-term outcome.

CONCLUSIONS

Since surgeon-specific outcome publication began in United Kingdom, cardiac surgical training activity has significantly increased at the study center despite an increase in the risk profile of patients. This study demonstrates that it is possible to maintain or even increase training activity with good outcomes in the era of surgeon-specific outcome publication.