Clinician’s Impression of Clinical Governance Dr Emma Glanville Consultant Psychiatrist Mental Health ACT. My name is Emma Glanville and I am a consultant psychiatrist at ACT Mental Health. I work in both community outpatients and a consultation liaison psychiatry. In addition to this I sit on our clinical review committee which is the committee charged with the responsibility of reviewing serious adverse incidents within ACT MH. My research is around clinician’s opinions of how we conduct our reviews of serious adverse incidents. Today I am going to talk about some of things that sparked my interest in this area, some of the barriers to effective clinical governance within the health system and then the details of my project.

Clinical governance background High profile problems in health. Increasing emphasis. Structures evolving. Evidence base evolving. Local context. For most areas the impetus for increased emphasis on clinical governance has been a high profile failure or problems within the health system. Clinical governance structures are evolving and the evidence base is also evolving. In Canberra the precipitant was a public review of neurosurgical services –which recommended a system for identifying and monitoring adverse events. This lead to our current clinical review process (discussed in article Mitchell 2008).

Barriers 1. Health is different. Business as usual after a major incident. Person injured is patient rather than staff. Death and disease is normal. Negative consequences (eg coroner’s case, litigation) occur sporadically, inconsistently & a long time after the event. Lack of perceived benefits. Major incident eg floor collapse in a building next door. Worksite shut down. Workers went home. Immediate investigation. Financial consequences. Workers deeply concerned and might strike – highly invested in safety. People come to us sick & deaths in hospital are normal. Used to seeing adverse outcomes and perhaps inurred to them. Incident reporting seen as being unsupportive of colleagues after an incident.

Barriers: 2. Psychiatry is different? Not as different as we like to think. Clear differences between wrong site surgery. But many parallels with other problems eg type II diabetes. Chronic complex conditions. No clear root causes. Multifactorial. Even with perfect management the event may still have occurred. Often a therapeutic nihilism around our patients and lack of reflection.

Barriers 3. ‘No blame culture’? Our culture is a blame culture. ‘In the aftermath of such a disaster there must be an assignment of blame’. Runciman 2003 Medicine is a blame culture. Finding a balance between fatalism & persecuting scapegoats. Quote is from a US newspaper in an article discussing media responses to a death after a heart lung transplant when the donor was ABO incompatible. Our media is no different. Our culture is a blame culture. Powerful incentives to blame when something goes wrong – financial etc. Heightened when someone is harmed in a setting where they expect to be helped. Cultural problems in health and particularly in my discipline – ‘good doctors do not make mistakes’. Shame, fear of liability, loss of reputation, peer disapproval (Leape). We know that doctors are less likely to report incidents than other disciplines and that the more senior you get the less likely you are to report (Evans 2006). Need to be infallible leads to the temptation to cover up mistakes rather than admit them. Use of incident reporting systems to express anger at colleagues. Two responses after an adverse incident – quick absolution without reflection. Incessant search for blame – hindsight bias. Both a means of denial, denying our own vulnerability to contributing to adverse events and reflect a desire to move away quickly from what is painful. Need to avoid both but to reflect carefully on the event and try to learn what we can. Hard to do in a ‘blame culture’. May involve painful conclusions.

Barriers 4. Issue of evidence ‘No sound evidence currently exists to support the claim that clinical governance will improve service quality’ (Thomas M 2002) This quote was the conclusion of a young doctor who performed an extensive literature search around clinical governance. A lot of time, effort and money put into clinical governance structures. Can be painful – clinicians wondering whether it is worth the time and effort. Cynicism.

Barriers 4. The issue of evidence ‘…audit and feedback can be effective in improving clinical practice. When it is effective the effects are generally small to moderate. The relative effectiveness… is likely to be greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively.’ Cochrane Collaboration 2008. Cochrane collaboration looked at randomised trials of audit and feedback that measured either professional practice or healthcare outcome. Needed to have objective measures. They came to this conclusion “quote”. This makes intuitive sense – if baseline adherance is low there is much more room to improve. Must be remembered that most clinical governance processes don’t come neatly packaged as stand alone interventions.

Barriers 4. The issue of evidence As the natural heterogeneity of an intervention increases, experimental methods become progressively less helpful in understanding its effectiveness. Walshe 2007. Heterogeneous & evolving activities in heterogeneous organisations in heterogeneous populations – there will never be the definitive study. The key issue in terms of research in this area is dealing with the heterogeneity not only of a clinical governance intervention but also of the precipitant for it, the organisational culture, the leadership styles of the people implementing the intervention and so on. This means that there will probably never be the definitive study. In health research where the RCT is king we are not used to doing this kind of research and this can lead people to conclude that there is no evidence. Other fields of social research are much better at dealing with this kind of complexity - for instance in studies looking at teaching disadvantaged children to read or mentoring teenagers who offend. The key question is not whether it works but how and why it works in this setting. Heterogeneity. Not whether it works but how and why they work. Again other fields of social research can inform us eg teaching children to read, mentoring teenagers (Walshe) Leadership, organisational culture, training, resources all likely to be important. Qualitative methods likely to be the most useful.

Barriers 5. Managers vs clinicians? “clinical governance committees provide a ‘theatrical’ function, reassuring the board that all is well while allowing business as usual at lower levels within the organisation”. Freeman 2004 This quote indicates the dangers of ‘top down’ clinical governance. Many clinicians are cynical about the purposes of clinical governance activities – they see them as serving the purposes of managers in terms of reducing the potential for adverse media coverage and litigation whilst imposing increasing burdens of paperwork and policies on clinicians without benefits for patients. Clinicians tend to see most problems as being fundamentally due to insufficient resources and can be reluctant to look at other possibilities. However clinicians also have a lot to offer – they have a grounded ‘real world’ perspective when reviewing an incident and can more readily identify possible issues and questions to ask. Managers tend to emphasise control and accountability and adherence to standards and are perhaps better at identifying performance management and cultural problems. In the end both the perspectives of clinicians and managers is required for a balanced governance process. Important to recognise both skill sets and expertise. Working together can be mutually enriching.

My project - Aims Focuses on clinicians and their opinions of our clinical review process for serious adverse incidents – eg suicides, serious self harm, serious assaults (incl sexual assaults). Clinical review process aims to identify systems issues (rather than performance management issues).

Incident CRC discussion Rating Report Feedback Findings & Currently undergoing a review. Processes outlined in Mitchell 2008 – MJA. Feedback Findings & Recommendations Investigation

My project: aims My aim is to investigate what clinicians feel about this process: -is it worth putting in an incident report? -how do they experience the investigation? -what do they think of our findings & recommendations? -do they think we make a difference? -how could they be more involved?

My project: further aims Better understanding of evidence around governance. Better understanding of research process – particularly qualitative research. Better understanding of staff responses when things go wrong. Learning to provide leadership in clinical governance.

Methods Interview with CATT clinicians. Questions around: -their knowledge of CRC. -their experience of CRC processes. -their thoughts on our recommendations. -suggestions re learning about adverse events. Taped. Qualitative study. Interview questions given before hand – in order to give people an opportunity to reflect on them. Open questions – designed to have a conversation about the processes and to get a sense of their opinions and feelings around these processes and their broad insights as to how things could be improved. Quite a different approach to research and quite challenging to find someone who could advise me on it. In the end I found a social researcher from the local University as the most helpful person. Taped – so that as interviewers we can engage in the process rather than taking notes and also so that we can go back and listen again to what people have to say.

Data Analysis Themes analysis conducted independently by two researchers. Key words and concepts. Immediately after the interview – jot down themes. Listen again independently coding useing words and concepts that they use. If we disagree – keep the tensions and disagreements in.

Where am I up to? Support from clinical director of service. Support from team leader and psychiatrist on CATT. Literature review. Questions designed. Ethics approval.

Questions?