Patient Safety

Clinical Governance Tools

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Clinical governance is the primary means through which healthcare organisations discharge their statutory duty of quality. Quality protects the patients, clinicians, reputation and good standing of all healthcare professions. Quality services can reduce the levels of human suffering, professional stress and the drain on valuable resources arising from clinical negligence or systematic error. Clinical governance underpins and informs the work of healthcare services at every level and in every capacity.

Clinical governance is everybody's business. Through forging co-ordination and interconnection between different component elements clinical governance becomes a powerful lever for change and improvement.

Healthcare organisations exist to improve the health of the population and to provide as far as is possible seamless, effective and safe care within its financial resources. This is done by working in partnership with patients, staff, visitors, stakeholders and other healthcare organisations. A healthcare organisation's vision should be that patients will enjoy the best state of health and will have access to first class health services when it's needed. Healthcare organisations should measure their achievement of this aspiration by their ability to:

create sustainable healthcare systems in terms of it's environmental impact and the models of care
develop a diverse workforce which is responsive to the needs of patients
actively engaged in the development and delivering of first class services
ensure that evidence based care, cost effective and safe care and working in partnership are embedded

The Care Quality Commission (CQC), the NHS Litigation Authority and the National Patient Safety Agency, promote Patient Safety and Quality within the NHS by the:

Implementation and Compliance against Care Quality Standards,
Implementation of Risk Management Standards and Systems,
Development and Maintenance of Systems to Report and Investigate all Incidents
Implementation and Review of National Patient Safety Initiatives
Use of Patient Feedback Questionnaires, Surveys, Compliments, Comments and Complaints

Ensuring the safety of everyone who comes into contact with healthcare services is one of the most important challenges facing health care today. Improving patient safety involves assessing how patients may be harmed, preventing or managing risks, reporting and analysing incidents, learning from such incidents and implementing solutions to minimise the likelihood of them reoccurring.

Serious failures are uncommon. Where these occur, they are often due to weak systems rather than the fault of any one individual. The advances in technology and knowledge in healthcare in recent decades have created an immensely complex healthcare system. This complexity brings risks, and evidence shows that things will and go wrong in healthcare; that patients are sometimes harmed and that the effects of harming a patient are widespread.

Patient safety is now recognised in many countries, with global awareness fostered by the World Health Organisation's World Alliance for Patient Safety. And yet there continue to be significant challenges to implementing patient safety policies and practices. Patient safety events incur costs through litigation and extra treatment and concerns everyone within any healthcare organisation, whether they are working in a clinical or a non-clinical role. It is increasingly clear that patient safety has become a discipline, complete with an integrated body of knowledge and expertise, and that it has the potential to revolutionise healthcare. Therefore, tackling patient safety collectively and in a systematic way can have a positive impact on the quality of care and efficiency of healthcare organisations. The key components of patient safety are:

Limiting Blame

It is important that healthcare organisation realise that adverse events often occur because of system breakdowns, not simply because of individual ineptitude prompted the change. A traditional approach assumes that well-trained, conscientious practitioners do not make errors. That error is equated with incompetence and regarded punishment as both appropriate and effective in motivating individuals to be more careful. The use of this kind of blame would have a toxic effect. Sometimes, practitioners do not reveal mistakes as a result patients are frequently kept in the dark. Low reporting rate would result in learning from errors nearly impossible, legal counsel sometimes supports and encourages this approach in order to minimise the risk of litigation. This mind-set lent a wary, antagonistic backdrop to the therapeutic interaction and creates demoralising effect on all concerned. Thinking started to change when preventable medical injury was acknowledged as occurring far more often than actually realised and that active errors happening when practitioners interacted with patients or equipment resulted in "latent" errors. Latent errors are defects in the design of the organisation's systems, management, training and equipment that leads to an individual(s) to make mistakes. Therefore, to punish individuals for such mistakes would make little sense, as the errors are bound to continue until the underlying causes are resolved.

Systems Thinking

Errors could be reduced by redesigning systems and processes using human factors principles. This in turn could reduce mistakes through design features, including standardisation, simplification, and the use of constraints. In the earlier phases of medical history, different forms of systems thinking were more dominant than others. However, these forms focused on the systems within the individual patient, rather than on care and interactions between individuals in the environment of care. Healthcare systems should be seen as an open, not closed, system and policy to begin to be thought of as a feature of the system

Transparency and Learning

Adverse events yielding information is nothing new, but it's newly applied in healthcare. This has made sharing information about medical errors urgent and essential for effective patient safety outcome. The more error-related information are shared, the better lessons can be implemented organisation-wide

This Website aims to provide an overview of what healthcare organisations' Clinical Governance responsibilities should be and the management of those responsibilities in terms of the following:

Leadership and Accountability
Identification of Priorities: the priorities for the duration an organisation's clinical governance strategy could be linked to the prevailing healthcare organisation's corporate objectives. This can be within the framework of the Care Quality Commission's Regulations and Standards and additionally Patient Experience feedback received from which the priorities for delivery of safe, effective, high quality service are determined. Performance against these standards would affect the organisation's overall Performance Rating. Clinical governance including Clinical Audit, should continue to feature as a priority and recommendations from the findings of clinical audit should be fed back into an informed service development processes.
Clinical Governance Objectives could be to ensure there is a focus on delivering the highest standards of quality patient care within the available resources across the organisation; ensure that the components of clinical governance as identified by the Care Quality Commission (CQC) are addressed; to maintain a culture of continual improvement, professional learning and sharing of best practice.
Monitoring and Evaluation: clinical governance activities could be monitored through an organisation's reporting structures where reasonability will be taken for overseeing implementation. Reports on progress against clinical governance agenda and priorities should be made to the organisation's Board. Clinical governance reports should outline participation and outcomes across the organisation's services and within teams within the scope of the clinical audit programme and identified any remedial actions which may be required to be taken; demonstrate how and where clinical governance is being undertaken giving examples of good practice.