Clinical governance was first described in a government White Paper in 1996 as 'a new system in NHS Trusts and primary care to ensure that clinical standards are met, and that processes are in place to ensure continuous improvements, backed by a new statutory duty for quality'.1
As such, clinical governance provides a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of patient care, by creating an environment in which excellence in clinical care will flourish.2
For practitioners, it creates a framework through which they are accountable for improving the quality of their clinical care and ensuring a high standard of practice.3
Having clinical governance structures in place can help OH practitioners working outside the NHS to demonstrate that their policies and practices are sound and effective. This article examines the constituents of clinical governance and suggests ways in which it can be adapted for use within any OH setting.
The key elements required to ensure the continual improvement required by clinical governance are:
- Accountability and responsibility
- Quality improvement
- Risk management.4
Accountability and responsibility for clinical governance in the NHS rests with the trusts' boards who are required to implement systems and procedures to ensure continuing improvements in clinical care. These include the appointment of clinical lead, risk assessment, development planning, annual reporting and review.5
Quality improvement is a continuous process that aims to maintain and improve standards of care, which are achieved by setting standards, monitoring and auditing the standards, improving performance and re-auditing.5
Standards are written statements of professionally agreed, evidence-based levels of performance and service delivery. Clinical decisions cannot be based on opinion alone and practice must be based on sound evidence.6
The first building block in evidence-based clinical decision-making is the knowledge that flows from comprehensive, sound research.1
Standards must be acceptable, observable, achievable and measurable and should:
- Be clinically sound
- Take into account current research
- Take into account professional guidance and standards
- Be realistic in their expectations
- Be specific
- Be reviewed periodically in the light of new research or changing practices or procedures
- Meet legislative requirements
- Be written in a clear, understandable, unambiguous style.7
Clinical audit is a process of improving the quality of clinical practice through the review of clinical performance, the measurement of performance against agreed standards and the refining and improvement of clinical practice as a result.6
An effective audit programme will help provide the necessary reassurance to clients, practitioners and managers that an agreed quality of service is being provided within the resources available.8 Properly conducted audits will ensure performance meets the criteria in the written standards, ensure the needs of the organisation are met, increase client/organisational satisfaction and highlight any action needed to improve performance.
There is a range of risks inherent in the provision of healthcare in any setting. These include risks to the patient/client, risks to the practitioner and risks to the organisation providing the care.
These risks need to be managed effectively by assessing the potential risks and as far as possible preventing or reducing them, using the experience from near misses, incidents, complaints and compensation claims to prevent recurrence and improve performance and by providing support systems for staff to enable them to reflect on and develop their clinical practice.9
Clinical risk management includes creating and maintaining safe systems of care and minimising the risk to patients/clients and others in the organisation, which helps to contribute to an improved quality of care. Risk management involves systems for identifying risk, which may include a variety of reporting or data monitoring activities including:
- Risk assessment & prevention/reduction
- Incident reporting
- Handling complaints
- Clinical supervision
- Managing poor performers
- Continual professional development
- Professional self-regulation.8
A clinical incident is 'any occurrence not consistent with the professional standards of care of a patient/client or the routine operations/policies of the organisation'.6 Reporting of incidents allows for investigation and procedures put in place to prevent recurrence.
Complaints may range from grumbles about the standard of service delivery to the standard of client/patient care. Complaints can result in stress and anxiety for staff involved, yet properly handled they offer an opportunity to learn and improve the quality of care.
Poorly performing healthcare staff are a risk, not only to patients/clients, but also to the organisation for which they work. Under clinical governance NHS organisations are required to have procedures in place to support professional staff in identifying and tackling poor performance. This includes learning from critical incidents, learning from complaints, having performance management procedures which help the individual improve performance and ensuring there are clear procedures for reporting concerns about colleagues' professional conduct and performance.10
Supervision is a formal process consisting of an exchange between practising professionals to enable the development of professional skills, knowledge and competence and to assume responsibility for their own practice.11 Supervision should benefit the practitioner and clients and also contribute to the business objectives of the employing organisation.12 There is a range of benefits attributed to the introduction of clinical supervision, which includes:
- Improved clinical practice
- Enhanced service provision
- Personal and professional growth
- Reduction of stress and improved communication.12
Whereas clinical supervision is not yet mandatory for nurses, the Nursing and Midwifery Council (NMC) strongly supports the principles and provision of supervision for all practitioners.12 There are a number of models for clinical supervision and ways in which it can be provided. The way it is delivered will depend on the needs of the practitioner and the organisation.
For example, it may be provided via one-to-one supervision with a more experienced practitioner in the same speciality or field, or as one-to-one supervision with the supervisor in a related/allied profession. Alternatively, it may be provided in a facilitated group supervision setting, as one-to-one supervision with the practitioner's line manager as part of a combined package of appraisal and support or with peer supervision in a one-to one relationship.13
Continual professional development
Continual professional development (CPD) is a process of lifelong learning that supports clinical governance by ensuring skills and knowledge are up-to-date and effective and appropriate for the service being delivered.
Nurses are already required by the NMC's Post-Registration, Registration, Education and Practice programme to re-register every three years,14 undertake at least five days of learning activity every three years, reflect on their practice and maintain a professional portfolio. As well as meeting the NMC's requirements for practice, CPD also helps practitioners to:
- Remain in touch with issues relevant to their role
- Develop existing skills
- Consider how to develop new skills
- Broaden knowledge and understanding
- Develop personally within the job.15
Reflective practice, which reviews progress and enables the practitioner to identify areas of practice that are in need of further development is essential to good professional practice.16 Professional self-regulation involves exercising professional accountability and the use of professional knowledge and skills to interpret and apply professional standards in practice.17
It is also worth noting that in its Code of Professional Practice for Nurses, Midwives and Health Visitors,9 the NMC requires employees to maintain and improve professional knowledge and competence and decline duties and responsibilities unless able to perform them in a safe and skilled manner.
Implementing a system for clinical governance in an OH setting
Occupational health advisers (OHAs) will already be familiar with quality improvement initiatives, such as clinical audit, evidence-based practice, standard setting and risk management. These all make up the framework of clinical governance as described above.
The processes for ensuring clinical governance are now well established in the NHS and OHAs working in the NHS will already be working to local clinical governance protocols. However, OHAs working in organisations outside the NHS may often be the only OHA employed in the organisation, or be part of a small team of two or three practitioners. They may also report to a manager who may have little or no knowledge of OH. OHAs working in these situations will find that the implementation of the systems that make up the cohesive approach of clinical governance allows them to demonstrate a transparent, high level of service delivery based on rigorously researched, regularly audited standards that benefit employer and client.
Many OHAs may be able to identify existing structures and systems in the organisation that may already reflect some of the requirements of clinical governance. For example, one of the key concepts of clinical governance is responsibility at board level.
The systems for ensuring accountability and responsibility for clinical governance are well documented in the NHS. Within other organisations, this should not be very difficult to establish. Many organisations will by now have appointed a director with responsibility for health and safety, and because of the close and overlapping relationship between health and safety and OH, this would seem a natural area to place responsibility for clinical governance.
Most organisations will have in place systems for auditing the quality of their product or service and will recognise the value of audit in raising standards and ensuring customer satisfaction. There may also be a formal system for dealing with complaints. OHAs may not be the only professionals in the organisation for whom CPD is a requirement for membership of a professional body.
The prospect of implementing a system for clinical governance may seem daunting for OHAs working in organisations outside of the NHS, but it is not insurmountable. But securing the support of managers at all levels is vital in implementing clinical governance, not least because there are cost implications for the employer as continual professional development, reflective practice, audit and supervision will all carry a financial cost. There will also be a cost in terms of the time taken up by the practitioner and other staff.
Presenting a clear, balanced business case to managers by setting out the rationale, costs and benefits of the proposals is the most effective way of approaching this issue. It is essential to convince the employer that implementing a process for clinical governance will improve performance through the regular auditing of evidence based standards. The support mechanisms of governance such as supervision and continued professional development will help the practitioner continue to develop professionally, which will in turn enhance practice and add value to the organisation. It will also benefit all the employees, for whose safety and well-being OH is delivered.
1. Health Service Circular (1999) Clinical Governance; Quality in the New NHS, Stationary Office 1999
2. Onion, C,W.R. (2000) Principles of Clinical Governance, Journal of Evaluation in Clinical Practice, 6,4, 405-412
3. NMC (2000). A Statement on Clinical Governance, London
4. RCN (1998) Information Guidance for Nurses on Clinical Governance, London
5. Scally, G and Donaldson, J (1998) Clinical Governance and the Drive for Quality, British Medical Journal, 317: 61-65
6. Starey, N (2001) What is Clinical Governance? London: Hayward Medical Communications
7. Sale, D (1990) Quality Assurance, Basingstoke: Macmillan
8. Wilson, J (1998) Incident Reporting, British Journal of Nursing, 7 (11) 670-671
9. RCN (2000) Clinical Governance - how nurses can get involved, London
10. Hale, C. (1999) Providing Support for nurses in general practice through clinical supervision. A key element of the clinical governance framework. Journal of Clinical Governance, December 7, 162-165
11. AOHNP (2002) Statement for Employers on Professional Supervision. AOHNP Peterhead
12. NMC (1996) Statement on Clinical Supervision, London
13. AONP (2001) Guidance on Professional Supervision, Peterhead: AONP
14. NMC (1997) Prep and You, London
15. Chartered Institute of Library Information Professionals (2002) Continuing Professional Development (website)
16. North Bristol NHS Trust (2004) Portfolio Management and Professional Practice - Introductory Guidelines (website)
17. NMC (2002) Code of Professional Conduct, London
Mary Guinness is Principal occupational health and safety adviser, The Prison Service