1. Introduction to Clinical Governance
Dr Lee Gruner
BSc, MBBS, BHA, FRACMA, MBA (Executive) GAICD
Dr Lee Gruner Management for Clinicians 2008

2. Dr Lee Gruner Management for Clinicians 2008
Origins
What was the catalyst?
Why this terminology?
Clinical governance
Dr Lee Gruner Management for Clinicians 2008

3. What is corporate governance?
Corporate governance is the system by which companies are directed and managed. It influences how the objectives of the company are set and achieved, how risk is monitored and assessed, and how performance is optimised. Good corporate governance structures encourage companies to create value and provide accountability and control systems commensurate with the risks involved.
Dr Lee Gruner Management for Clinicians 2008

4. The King Edward Memorial Hospital Story
Dr Lee Gruner Management for Clinicians 2008

5. Lessons from King Edward Memorial Hospital
Issues relating to poor child and maternal outcomes dating back over 10 years
Three reviews in 3 years culminating in the Douglas Enquiry in 1999
Douglas Enquiry focused on areas for improvement and high risk cases
Findings related to management / medical staff and clinical practice issues
Dr Lee Gruner Management for Clinicians 2008

6. Dr Lee Gruner Management for Clinicians 2008
Findings
Lack of safety and quality systems at state, board and hospital level :
Ineffective accreditation and credentialing systems, inadequate incident reporting systems,
Poorly performing statutory mortality reporting and investigation systems
Non-existent inter-hospital comparative data analysis.
Dr Lee Gruner Management for Clinicians 2008

7. Dr Lee Gruner Management for Clinicians 2008
Findings
Significant leadership, management and clinical performance problems
A culture of blame, unsupportive of open disclosure of errors and adverse events;
Lack of clarification of senior staff responsibilities and accountability;
Non-existent “safety nets” or systems to effectively monitor performance and respond to performance issues;
Ineffective or non-existent systems to ensure staff had the right credentials, training, support and performance management to meet the demands and skill requirements of their roles and responsibilities;
Dr Lee Gruner Management for Clinicians 2008

8. Dr Lee Gruner Management for Clinicians 2008
Findings
Failure to meet the emotional needs of many women and their families, excluding them from decisions about care or failing to give them honest, complete and timely information when things went wrong; and
Failure to address serious and ongoing management and clinical problems that resulted in serious adverse events and poor outcomes for women and their families
Dr Lee Gruner Management for Clinicians 2008

9. Dr Lee Gruner Management for Clinicians 2008
Findings - Management
Management failed to:
Make important decisions
Create an open and transparent culture
Monitor safety and quality
Ensure proper supervision/ training of staff
Define accountability and reporting responsibility
Address serious issues relating to adverse pt outcomes
Respond adequately to complaints
Dr Lee Gruner Management for Clinicians 2008

10. Findings- Clinical Practice
Senior doctor procedures deficient:
Insufficient involvement in complex cases
Inadequate decisions
Inadequate credentialing and appointment procedures
Inadequate performance management
Inadequate supervision of junior staff
Failed to provide timely analysis of staffing needs
Dr Lee Gruner Management for Clinicians 2008

11. Findings- Clinical Practice
Junior doctor work practices:
Did much of the complex work
Poorly supervised
Requests for help ignored
Blamed for errors
Sink or swim culture
Inadequate orientation and training
Ad hoc performance management
Dr Lee Gruner Management for Clinicians 2008

12. Findings- Clinical Practice
Clinical practice issues:
Little best practice
Poor outcomes
No benchmarking
Dr Lee Gruner Management for Clinicians 2008

13. Dr Lee Gruner Management for Clinicians 2008
Lessons
To assure safe, quality care, governments, boards, health care leaders and managers must create an open and transparent culture, where people willingly discuss and address errors and systems problems.
Effective organisations have people at all levels doing the right thing.
Organisational structures are only effective if people know and aim to meet their responsibilities and are held accountable for their actions.
Effective management ensures that their organisation has systems that effectively monitor the key aspects of its performance and ensure timely and appropriate responses to performance issues.
Dr Lee Gruner Management for Clinicians 2008

14. Dr Lee Gruner Management for Clinicians 2008
Lessons learned
To do a good job, people need the right credentials, training, support, performance management and development consistent, with the demands and skills requirements of their roles and responsibilities.
A caring, concerned health care service recognises the importance of involving patients and their families in care, provides information about care options, involves them indecisions about care and advises them openly and honestly when things go wrong.
Dr Lee Gruner Management for Clinicians 2008

15. Dr Lee Gruner Management for Clinicians 2008
Implementing change
In the 9 years since the Douglas Enquiry:
How far have we come?
What have we really learnt?
Dr Lee Gruner Management for Clinicians 2008

16. What is Clinical Governance?
Dr Lee Gruner Management for Clinicians 2008

17. Dr Lee Gruner Management for Clinicians 2008
Clinical governance
A governance system for health care organisations that promotes an integrated approach towards management of inputs, structures and processes to improve outcomes in health care service delivery where staff work in an environment of greater accountability for clinical quality
Dr Lee Gruner Management for Clinicians 2008

18. Clinical Governance – what does the definition mean?
A governance system for health care organisations that promotes an integrated approach towards management of inputs, structures and processes to improve outcomes in health care service delivery where staff work in an environment of greater accountability for clinical quality
Dr Lee Gruner Management for Clinicians 2008

19. An integrated approach
Considers the whole patient experience
Considers all quality variables not just the medical care
Reliability- doing what is promised
Empathy- respect/ concern
Tangibles- environment/ food
Responsiveness- response to needs
Assurance- credible service/ seamless organisation / good equipment
Dr Lee Gruner Management for Clinicians 2008

20. Dr Lee Gruner Management for Clinicians 2008
inputs
Financial resources
Buildings and equipment
Staff
Policies
Dr Lee Gruner Management for Clinicians 2008

21. Dr Lee Gruner Management for Clinicians 2008
Structures
Clinical Governance Committee
Procedures/ guidelines
Education and training of staff
Reporting system for adverse events
System for patient feedback
Dr Lee Gruner Management for Clinicians 2008

22. Dr Lee Gruner Management for Clinicians 2008
Process
Implementation of risk management
Job descriptions
Multidisciplinary management of clinical care
Communication
Management of patient information
Collection of data on clinical care
Acting on patient feedback
Dr Lee Gruner Management for Clinicians 2008

23. Dr Lee Gruner Management for Clinicians 2008
Clinical governance
Aims to ensure that:
systems to monitor the quality of clinical practice are in place and functioning properly
clinical practices are reviewed and improved
clinical practitioners meet standards set by regulatory bodies
Dr Lee Gruner Management for Clinicians 2008

24. Elements of clinical governance
Human resource systems
Review of clinical practice
External assessment of practice
Commitment to ongoing education
Dr Lee Gruner Management for Clinicians 2008

25. Human resource systems
Medical appointments and credentialing systems
Management and support of the clinical performance of colleagues , developing guidelines and protocols
Effective management of poorly performing colleagues
Dr Lee Gruner Management for Clinicians 2008

26. Review of clinical practice
Clinical audit
Evidence based clinical practice
Implementation of clinical effectiveness evidence
Risk management
Dr Lee Gruner Management for Clinicians 2008

27. Commitment to ongoing education
Continuing education for all clinical staff
Development of clinical leadership skills
Continuing professional development for all staff
Dr Lee Gruner Management for Clinicians 2008

28. External assessment of practice
External accreditations
Consumer feedback audits
Internal audit
Dr Lee Gruner Management for Clinicians 2008

29. Engaging medical staff
What motivates medical staff?
What methods can we use to get medical staff involved?
Engaging medical staff
Dr Lee Gruner Management for Clinicians 2008

30. Key elements of a clinical governance culture
Identify 4 barriers to developing a robust clinical governance culture
Which of these are most important?
Key elements of a clinical governance culture
Dr Lee Gruner Management for Clinicians 2008

31. Barriers to a good Clinical Governance system
Lack of leadership
Inadequate Time and resources
Inadequate training and education
Lack of accountability of staff
Negative organisation culture
Resistance to change
Poor systems and processes
Fear of repercussions
Dr Lee Gruner Management for Clinicians 2008

32. Identifying knowledge and skills of medical leaders
What knowledge and skills do medical leaders require to support a robust clinical governance system?
What behaviour should they display?
How can they acquire the skills and knowledge?
What strategies do we put in place to support this and to overcome the barriers?
Identifying knowledge and skills of medical leaders
Dr Lee Gruner Management for Clinicians 2008

33. Overcoming the barriers
Building systems and processes:
Reporting
Implementation of change following analysis of incidents
Appropriate committee structure
Appropriate policies
Feedback systems
Dr Lee Gruner Management for Clinicians 2008

34. Success of Clinical Governance depends on:
Educated and committed leadership
A vision of what Clinical Governance will deliver in the context of organisational strategy
Education of key staff
Provision of appropriate resources – people/ time / funding
A working coordination mechanism with appropriate systems- data/ reporting/ feedback/ policies
A change management environment
Dr Lee Gruner Management for Clinicians 2008

35. Overcoming the barriers
Education and training
Structured education program
Adequate resources for education
Management led education of all staff
Leadership
Education of Board and executive
Involvement of executive to drive the process
Appropriate resources
Dr Lee Gruner Management for Clinicians 2008

36. Overcoming the barriers
Resistance to change:
Develop staff champions
Adopt a change management approach
Openly address the culture of blame
Positive reinforcement of change
Reward and recognition systems
Dr Lee Gruner Management for Clinicians 2008

37. Major implications in introducing clinical governance
Development of leadership skills and knowledge amongst clinicians.
Development of mechanisms to ensure the 'audit loop' is closed - to ensure that change in clinical practice takes place in the light of audit, research, evidence, risk management and complaints findings
Development of appropriate accountability structures
Dr Lee Gruner Management for Clinicians 2008

38. Major implications in introducing clinical governance
Implementation of evidence-based practice across organisations.
Development of effective multidisciplinary and inter-agency working.
Integration of continuing education and continuing professional development into quality improvement programs.
Dr Lee Gruner Management for Clinicians 2008

39. Major implications in introducing clinical governance
Development of leadership skills and knowledge amongst clinicians.
Development of mechanisms to ensure the 'audit loop' is closed - that is, to ensure that change in clinical practice takes place in the light of audit, research, evidence, risk management and complaints findings.
Development of appropriate accountability structures
Dr Lee Gruner Management for Clinicians 2008

40. Major implications in introducing clinical governance
Implementation of evidence-based practice across organisations.
Development of effective multidisciplinary and inter-agency working.
Integration of continuing education and continuing professional development into quality improvement programs.
Dr Lee Gruner Management for Clinicians 2008

41. Clinical Governance Principles
Dr Lee Gruner Management for Clinicians 2008

42. Clinical Governance Principles
Integrated approach
Integral part of everyone’s job
Obligation to seek to improve what we do by continuously examining our work
Obligation to advise on improvements
Management has an obligation to ensure staff have skills and tools to do their work
Dr Lee Gruner Management for Clinicians 2008

43. Clinical Governance Principles
Consistent approach
Standardised structures and processes
Support of active collaboration in all activities
Integration of clinical and non clinical functions that contribute to standards of clinical care
Respect individuals and teams contributing to care, education and research
Dr Lee Gruner Management for Clinicians 2008

44. Clinical Governance Principles
Strategic focus
Led by CEO of the health service
Top down approach
Integral part of strategic planning
Dr Lee Gruner Management for Clinicians 2008

45. Clinical Governance Principles
Provides assurance on standards of care
Quality Control measures
Appropriate Quality Assurance activities
Evidence of improvement in care
Evidence of regular policy review and improvement
Evidence of service improvement
Evidence that risks are identified and managed
Dr Lee Gruner Management for Clinicians 2008

46. Defining the gaps in health services in 2008
What needs to be done better?
What still needs to be put in place- structure and process?
Are there still gaps in the inputs?
Defining the gaps in health services in 2008
Dr Lee Gruner Management for Clinicians 2008