Looking at the whole picture

In 1998, the government placed a legal duty of quality on NHS institutions called clinical governance. It also set up the Healthcare Commission to monitor its implementation. This duty has been extended to private and voluntary health services although occupational health schemes are (arguably) still exempt (see footnote).

In the past, quality was regarded as an inherent feature of healthcare resulting from the professionalism of those who delivered the service. Quality management had become prominent in the 1980s mainly in the form of clinical audit.1 Yet its effectiveness is unknown, despite substantial investment of time and money in clinical audit.2

More recently there has been a significant shift in emphasis towards the patient’s perspective.3 Patients, like customers in other markets, buy the results they feel are important, and not products and services.4

When clinical governance quality was introduced it was described as “doing the right things, at the right time, for the right people, and doing them right first time” and it is “the patient’s experience as well as the clinical result – quality measured in terms of prompt access, good relationships and efficient administration”.5

There is a growing body of evidence that increasing the quality of patient ‘service’ can improve clinical outcome.4 In addition, there is evidence that improved patient satisfaction is associated with improved carer satisfaction.6

While the legal duty for clinical governance may not apply to many OH services, the principles are transferable. There is no reason for care of a lesser quality to be offered to those in work.

Clinical governance

Senior NHS directors G Scally and L Donaldson define clinical governance as: “A framework through which … organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish”.7 However, no single model or definition of clinical governance has been universally accepted.

Clinical governance embraces a combination of different processes and activities and its precise nature remains ambiguous.8 In essence, clinical governance provides an umbrella under which aspects of quality can be monitored.

There is still insufficient evidence that clinical governance increases service quality.9 As recently as 2003, the government watchdog the National Audit Office found that some NHS institutions were still to be convinced of its value. The great majority, though, had implemented many different aspects.10

It is rare to find reports on clinical governance being implemented in organisations that are not subject to inspection by the Healthcare Commission.11 The paper by A Cook described the benefit of external assessment and registration with the Health Quality Service (HQS), because “HQS is specifically concerned with healthcare and allows the company to focus on the quality systems it needs to support excellence in clinical care”.12

The most comprehensive reviews of the impact of clinical governance have been published by Walshe and the National Audit Office.10, 13, 14 They found that improvement actions were significantly more likely to be carried out if they were measurable and timed (irrespective of their priority). They also identified the need for leadership by senior clinical and non-clinical managers with overall sponsorship by a senior leader who understands clinical governance.

Leadership needs to be firmly founded in explicit organisational values.15 It should be characterised by teamwork, communication, and taking responsibility (ownership).16 Teamwork, in particular, has been identified as key to effective clinical governance. Freeman found an inverse relationship between what he called a ‘climate’ of clinical governance and hierarchical management culture.17

Mary Braine notes in her recent review that teamwork is “fundamental to the success of clinical governance because collaboration between teams and their members is required to deliver quality and improvement initiatives”. She goes on to add: “Teamwork enables greater flexibility, sharing of information, problem solving and the acknowledgement of strengths and limitations within the work environment, all of which contribute to quality assurance.”18

The need for teamwork in OH is considerable. The multidisciplinary team supporting patients often includes a broader range of participants than in many other areas of healthcare, including not only clinical disciplines, but also technical and management disciplines, ranging from safety engineering to human resources (HR).

Leadership and communication skills, and a willingness to take ownership are essential in OH. These attributes have been recognised as key competencies for all OH practitioners.19

The typical components of a clinical governance system are shown above. Most of these, such as clinical risk management, audit and training, have been extensively reviewed.15, 21, 22 Some, such as improving patients’ experiences, developing the effectiveness of practitioners, and managing information are challenging in OH. This is because of the tendency to work in relatively small clinical teams; the need to support patients who are adversely affected by health professionals’ opinions (for example, those who lose their employment); and the difficulty in obtaining and sharing meaningful information about clinical effectiveness.

Patient experience

A feature of clinical governance is the emphasis on the patient’s perspective of quality. Patients judge care differently to practitioners. Based on more than 450,000 interviews, the Picker Institute, which specialises in measuring patients’ experiences of healthcare, has identified eight dimensions of patient-centred care (see below).23

Improving clinical performance depends, in part, on measuring the components of practice that contribute to quality care. Feedback from clients and managers is an increasingly important input into performance assessment and development.

HR management

OH practitioners are accustomed to working alongside HR managers when supporting patients. However, clinical governance brings with it a keener focus on the application of HR management principles to OH, placing an emphasis on both encouraging clinical excellence and addressing under-performance. It is not enough to provide OH care; it should be demonstrably good care. This is founded on initial specialist training and continuing professionalism.

Use of information

There is a lack of good research evidence underpinning aspects of OH practice but it is incorrect to conclude that evidence is not available. In many cases evidence is available, although it may not be easy to identify and it takes investment of resources to assess it.24, 25

Good practice will continue to develop through sharing experience, engaging in debate and, where possible, reaching consensus. For this to happen, practitioners need to share insights into their practice with peers and take time to reflect and learn. Clinical supervision is one mechanism to achieve this, as well as participation in meetings, regional groups, e-mail forums, and reporting experiences in the literature.
It is rare for data to be published on clinical effectiveness although this is now becoming commonplace in the NHS (even if it is sometimes controversial).26

It is relatively straightforward to report surgical outcomes for a specific procedure, even if these don’t reflect the whole experience of healthcare. It is much more difficult to identify simple measures of OH intervention. How many employees who are exposed to noise retain good hearing because of effective health surveillance? How many long-term absentees resume productive work because of effective intervention and work adjustment?

It may seem that performance reports on OH services are a distant possibility. However, this may not be the case. Already the NHS Information and Social Care Information Centre, for example, publishes data on the performance of GPs. Patient expectations are rising and the same demands will no doubt be placed on occupational health in the future.

Care pathways are now being widely used to promote effective and consistent practice. These are being proposed for OH care.27 If practitioners are to develop, data will need to be gathered, shared and assessed.

Developments elsewhere suggest that the trend to gather and report information on clinical effectiveness will gradually affect occupational health.

Conclusions

Clinical governance has now been embedded into most of UK healthcare and its principles are applicable in OH. Patients in the workplace should be offered care with the same assurance of quality that they would get in any other setting.

The implementation of clinical governance in OH is not straightforward, but useful resources are available to facilitate it. Patient expectations are increasing and practitioners and teams should gather information to demonstrate and learn from their performance.

Implementation in a commercial healthcare setting: Atos Origin

Atos Origin is the largest commercial OH service provider in the UK. Clinical governance is led by the clinical leadership team and reports to a board chaired by the chief medical officer. The terms of reference of the clinical governance board and its annual report are published on the internet.

The Health Act 1999 placed duties only on the NHS. Atos Origin was keen to demonstrate high standards of care too: patients at work should get as good an assurance of quality as those not at work.

It committed significant resources to making sure that clinical governance is in place and is commercially viable. The clinical team is dispersed across the UK, so there is also a geographical challenge.

The clinical leadership team meets regularly to discuss clinical governance and improvement activity in a multidisciplinary forum. The multidisciplinary teams are organised into regions with clinical leaders responsible for co-ordinating supervision and peer support, and providing mentorship to team members.

Atos Origin regularly surveys the opinions and views of people who use the services and it prepares and implements action plans to improve the experience.

  • Clinical audit: an integrated audit system is used to measure quality and continual improvement. Each month a statistically significant random sample of cases is selected. This shows that more than 98% of the advice and examinations are satisfactory or better. The results of the audit are fed back to each practitioner by a designated mentor.
  • Risk management: clinical incidents are recorded and reported to the appropriate lead clinician. Complaints are overseen by managers using a well-understood framework and reporting system. Trends are noted and organisational action by way of training or process change instituted.
  • Continuing professional development: clinical supervision is provided regionally to all practitioners at a minimum of 3.5 hours every six weeks. Regular contact with professional peers ensures that clinical effectiveness is maintained and enhanced. Each practitioner has a personal development plan and the clinical leadership team leads a review of talent across the organisation and discusses its development with line managers. Continuing professional development of all practitioners is a priority. In the main, OH practitioners derive most benefit from training events and self-directed learning. Atos Origin organises an annual conference for practitioners and invites external speakers and participants.
    All practitioners are encouraged to participate fully in a professional association.
  • Use of information: being a larger employer with wide geographical spread, communication systems have to be well managed. Atos Origin is now using electronic records using secure systems so that practitioners can readily access patient information. The use of information technology means that practitioners can keep in touch with colleagues. A monthly clinical governance report is distributed electronically.
  • Clinical excellence: Atos Origin is promoting a model that rewards and encourages clinical excellence based on a balance of three dimensions of care: quality and client satisfaction, productivity, and clinically appropriate decision-making. Since 2005 OH practitioners have been provided with information on their work and the work of their teams with a focus on sharing with and learning from each other. The ability to explore differences in practices is already enabling practitioners to learn from each other and improve overall practice. In the past year an OH nurse, Caroline Cliff, has been appointed as lead OHA for professional development and coaching.
  • External registration: the clinical governance systems have been externally audited and registered with HQS.
  • Clinical governance board terms of reference
    – Aid business success and the achievement of financial objectives
    – Report on clinical governance to the leadership team
    – Ensure compliance with professional standards
    – Improve professional standards
    – Monitor clinical performance
    – Implement practice improvements
    – Ensure that arrangements are in place to deal effectively with poor performance
    – Receive, examine and act on reports on the components of clinical governance
    – Ensure conformity with medical norms
    – Facilitate and sponsor research and development.

Components of clinical governance (20)

  • Patient experience
  • Clinical effectiveness and research
  • Risk management
  • Clinical audit
  • Education and training
  • Use of information
  • Human resource management
  • Clinical accountability and support

Dimensions of patient care (23)

  • Access (including time spent waiting)
  • Respect for patient’s preferences
  • Co-ordination and integration of care
  • Information, communication, and education
  • Physical comfort
  • Emotional support and alleviation of anxiety
  • Involvement of family and friends
  • Continuity of care

Helen Kirk is an independent occupational health consultant, and Richard Preece is head of the clinical leadership team at Atos Origin.

References

  1. Buetow S A, Roland M (1999) Clinical governance: bridging the gap between managerial and clinical approaches to quality of care Quality in Health Care 8: 184-190
  2. Lester H, Alderslade R, Thompson A (1997) Reviewing the value of clinical audit: is now the time for a change? International Journal of Health Care Quality Assurance 10: 76–79
  3. Donaldson L J, Muir Gray J A (1998) Clinical governance: a quality duty for health care organizations Quality in Health Care 7 (Suppl): S37-44
  4. Kenagy J W, Berwick D M, Shore M F (1999) Service quality in health care Journal of the American Medical Association 281 (7): 661-665
  5. Department of Health (1997) The new NHS modern – dependable London: The Stationery Office
  6. Suchman A L, Roter D, Green M, Lipkin M (1993) Physician satisfaction with primary care office visits Medical Care; 31: 1083-1092
  7. Scally G, Donaldson L J (1998) Clinical governance and the drive for quality improvement in the new NHS in England British Medical Journal 4 July: 61-65
  8. Flynn R (2000) Clinical governance and governmentality Health, Risk and Society 4 (2): 155-173
  9. Thomas M (2002) The evidence base for clinical governance Journal of Evaluation in Clinical Practice 8 (2): 251-254
  10. National Audit Office (2003) Achieving improvement through clinical governance: a progress report on the implementation by NHS Trusts London: The Stationery Office
  11. Preece RM (2006) Clinical governance in UK commercial occupational health providers Occupational Medicine (in press)
  12. Cook A (2003) Governing principles Nursing Management 10 (8): 28-31
  13. Walshe K, Freeman T, Latham L, Wallace L, Spurgeon P (2000) Clinical governance from policy to practice University of Birmingham: Health Services Management Centre
  14. Benson L, Boyd A, Walshe K (2004) Learning from CHI: the impact of health regulation University of Manchester: Centre for Health Care Management
  15. Hackett M, Lilford R, Jordan J (1999) Clinical governance: culture, leadership and power – the key to changing attitudes and behaviours in trusts International Journal of Health Care Quality Assurance 12 (3) 98-104
  16. Guinness M (2005) Clinical governance: ensuring high standards Occupational Health 57 ( 1 ): 27 – 31 http://www.personneltoday.com/29006.article
  17. Freeman T (2003) Measuring progress in clinical governance Health Services Management Research 16 (4): 234-250
  18. Braine ME (2006) Clinical governance: applying theory to practice Nursing Standard. http://www.nursing-standards.co.uk/archives/ns/vol20-20/pdfs/v20n20p5664.pdf
  19. Royal College of Nursing (2005) Competencies: an integrated career and competency framework for occupational health nursing. http://www.rcn.org.uk//publications/pdf/occupational health competencies.pdf
  20. Nicholls S, Cullen R, O’Neill S, Halligan A (2000) Clinical governance: its origins and its foundations British Journal of Clinical Governance 5 (3): 172-178
  21. Whitaker S C (1998) Audit in Occupational Health in Occupational Health 4th edn, Harrington J M, Gill F S, Aw T C, Gardiner K Eds. Oxford, Blackwell Scientific Publications
  22. Agius R M (1999) Auditing Occupational Medicine Occupational Medicine 49: 261-264
  23. Jenkinson C, Coulter A, Bruster S (2002) The Picker Patient Experience Questionnaire: development and validation using data from in-patient surveys in five countries. International Journal of Quality in Health Care. Oct;14(5):353-358
  24. Waclawski E R, Maden I (2005) In the current era of evidence-based guidelines, do consensus-based guidelines still have a place? Occupational Medicine 55:343–344
  25. Verbeek J H, van Dijk F J, Malmivaara A, Hulshof C T, Räsänen K, Kankaanpää E E, Mukala K (2002) Evidence-based medicine for occupational health. Scandinavian Journal of Work, Environment and Health, June, Vol.28, No.3, p.197-204.
  26. BBC (2006) Lack of data ‘harms NHS choice’ 14 January 2006 http://news.bbc.co.uk/1/hi/health/4606180.stm
  27. Breen A, Langworthy J, Bagust J (2005) Improved early pain management for musculoskeletal disorders (2005) Health and Safety Executive 399 HSE Books Sudbury http:// hse.gov.uk/research/rrpdf/rr399.pdf

Footnote: The Private and Voluntary Health Care (England) Regulations 2001, Regulation 5: For the purposes of the [Care Standards] Act 2000, any undertaking which consists of the provision of medical services by a medical practitioner solely under arrangements made on behalf of the patients by their employer or another person shall be excepted from being an independent medical agency.

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