Document Type : Original Article
1 Research Center for Patient Safety, Mashhad University of Medical Sciences, Mashhad, Iran.
2 Health Management and Economics Research Center, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
Clinical governance which was introduced by the National Health Services of England is a term to describe a systematic approach to maintain and promote the patient care process in the health system. The first movement for improving the health services quality began in England in 1948 with the establishment of the National Health System (NHS) (1).
Excellence of clinical services generally means improving clinical services quality and increasing the accountability of providers and custodians regarding the quality of health services presented to people (2).
Quality and patient safety should be considered in all stages from the most basic health services to the highest professional levels.
Clinical governance is a new and comprehensive mechanism used to permanently promote the services quality with respect to the highest standards in the organization. The purpose of clinical governance is to provide an environment where the staffs of Health Departments regularly think about how they can better work.
Also, clinical governance is a framework in which the organizations providing health services are bound to regard the principles of excellence in clinical services. In this way, they are responsive to wards maintaining and improving the quality of the providing services. Every quality improvement system has to consider the requirements, the society’s cultural conditions and its health system to be labeled as the so-called native (3).
Optimizing health care governance is a method for assessing the level of clinical governance establishment in the health care system and its aim is to track health care quality through integrity in all activities affecting the patient and to direct them toward a single goal (4). The question is what factors will lead the clinical governance towards improving the quality of patient care?
There are three factors which if well considered, would lead to the successful performance of clinical governance in primary care:
1- Designers of clinical governance and the conditions in which the clinical governance will be established in (change environment) (5).
2- The people who are responsible for performing the clinical governance (change responsive).
3- The people whom clinical governance is a part of their daily activities (change implementers and users). The employees of health departments cannot be changed in order to establish clinical governance leadership. Nevertheless, all employees are expected to use clinical governance and all patients are required to take part in this process. Therefore, we must be patient and allow this process to be established and a culture to be formed gradually
(6, 7). Clinical governance attempts to create an environment in which under such conditions, the patient quality would be flourishing. Of course, the standards and goals (both for organizations and individuals) should be realistic and practical.
Moreover, clinical governance mostly emphasizes on quality improvement (8, 9).
Checking the improvement rate of the health system quality is a way to evaluate the level of clinical governance efficacy. Its aim is to maintain the quality of health services at the highest level.
Moreover, clinical governance leaders must identify inappropriate care and also those employees whom despite supporting them are not able to improve the healthcare quality. Clinical Governance recipients (patients and staff) as well as all those who use clinical governance in health services should not be afraid of the punishment which may be imposed against them; it is even rather recommended to support the punishments in such conditions (10).
In other words, there should be a sense of ownership and belonging towards the clinical governance programs from the highest to lowest levels of the organization in all groups and individuals. Since, clinical governance is a framework for improving health care quality in hospitals and medical centers; it is essential that the hospitals move towards the establishment of clinical governance and thoroughly perform its axes especially in clinical departments. The aim of this study was to assess Mashhad hospitals before and after the establishment of clinical governance in 2011.
Materials and Methods
This descriptive-analytic-interventional study was performed in hospitals of Mashhad during the time interval between summer and autumn 2011. Data collection was performed through specially designed questionnaires and observation. The questionnaire was a standard checklist of the Department of Health and Medical Education including 7 pillars (management, risk management and patient safety, clinical effectiveness, clinical audit, patient and relatives and community interaction, the use of information and personnel management and training) and 214 questions in the Likert scale. Four hospitals (Ommul-banin, Imam Reza, Ghaem, and Kamyab) were randomly selected among 12 public teaching hospitals. The checklist was completed before the establishment of clinical governance in summer 2011 and after its establishment in autumn of the same year at the selected hospitals with respect to the clinical governance data. The same evaluations were performed by a single team monitoring each hospital. The assessors’ team consisted of two experts who had been trained in a 2-day course on completing checklists before study initiation. Data were collected by check lists and were then analyzed by the One way ANOVA test and Paired sample t-test. The SPSS software version 16 with a coefficient confidence level of 95% was also applied.
Comparing the range of clinical governance’s pillars of selected hospitals showed that the most effective part was the clinical audit pillar with the range of 59.09% and personnel management and training axis with a range of 58.03%. The least effectiveness belonged to the patient and community interaction axis with a range of 24.13% (table 1).
Scores of clinical governance pillars, before and after the establishment of clinical governance, were significantly different in Ommul-banin, Imam Reza, Ghaem and Shahid Kamyab hospitals. Also, there
There was no substantial difference when comparing the total scores of studied hospitals after the establishment of clinical governance (P=0.925).
According to Table 3, no significant difference was observed between Ommul-banin and Shahid Kamyab (two single specialty hospitals) with the two hospitals of Imam Reza and Ghaem (two general hospitals) (P=0.917).
was considerable difference in the total mean scores of studied hospitals before and after the establishment of clinical governance (P<0.000) (table 2).
Regarding the great importance of health care quality improvement in health systems and despite the great efforts made in the recent years, Iran’s health system still has a long way to achieve the aimed national and global standards (10, 11).
Previous experiences of quality improvement models in health services each had their own strength and weakness points which have resulted in this unintended status of disintegration in the process of quality improvement. The only model shown to have favorable capacity, no conflict with the implementation of other quality improvement programs and aimed at continuous improvement of health services quality, is clinical governance.
The successful implementation of clinical governance requires cultural and organizational changes, increase in the number of supportive systems, application of monitoring systems and regular evaluation of quality (12). Accordingly, following the establishment of clinical governance as a pivotal seven models in the health care system, including the hospitals of Mashhad University of Medical Sciences, this study was conducted in order to evaluate Mashhad hospitals before and after the establishment of clinical governance. The obtained results showed significant improvement in all studied axes following the establishment of clinical governance. The highest effectiveness was related to clinical audit, staff management and training axes whereas the least effectiveness was achieved from the interaction with patients and their relatives and the community. In all the studied hospitals, a statistical difference was observed when comparing the mean scores before and after the establishment of clinical governance.
Considering the progress taken place in the studied pillars after the establishment of clinical governance, this quality improvement model can be ultimately effective in improving health system services. The mean scores after the establishment of clinical governance were not significantly different between the two hospitals of Omolbanin and Shahid Kamyab (two single-specialty hospitals) with the two hospitals of Imam Reza and Ghaem (two general hospitals). Therefore, it could be concluded that the establishment of clinical governance with similar interventions has equal efficacy and can play an important role in all medical centers, either specialized or public, in improving the quality of health services. According to the study by Moll in France, feeling the need for creating a system of systematic monitoring of health services was associated with an order for hospitals between 2005_2006.
This system was improved in 2010 and the guidelines were given to hospitals including the seven axes of clinical governance in addition to the possibility of diagnosing the progress of the health promotion process. Final evaluation of this program showed that modifying the hospital management training and determining the priorities and annual operational programs requires further follow-up (13). In another vast investigation, Dorgan studied 1200 hospitals in seven countries (England, America, France, Italy, Canada, Germany, and Sweden) and concluded that competent managers have a key role in improving the quality of health services. Excellence in clinical services and approaching the aimed standards are related to management systems with high quality and efficiency (14). Given the importance of this issue, one of the axes of clinical governance is management.
After the establishment of clinical governance in Mashhad University of Medical Sciences, and the efforts made in this field, the mean score of the axis of management which forms the basis of other axes, changed from 38% to 81%. This shows the effectiveness of clinical governance in the progress and improvement of management systems in the studied hospitals which could establish a reliable background for the development and promotion of health care quality.
In the study of Campbell in England, lack of supported supervision and audit systems was introduced as one of the main challenges ahead in the field of clinical governance establishment (12).
This type of audit that aims to improve the quality of health services without tagging is a systematic and holistic approach, as with determining one indicator of the service providers, proportional services would be provided. Therefore, periodic evaluation and audit is an effective step to approach national and global standards and reduce the errors and finally increase health service quality. Also, Scott et al. In 2008 reported that the health and safety quality system in Australia has offered 20 programs to improve patient safety, but without evaluation none of these models would be reliable enough to determine the quality of patient safety programs (15); However, many studies have demonstrated that the improvement of health care systems and reaching to the aimed standards are related to the establishment of clinical governance and the implementation of its axes.
In this study, we evaluated seven axes of clinical governance (management, risk and patient safety management, clinical effectiveness, clinical audit, patient and community interaction, the use of information and personnel management and training) before and after the establishment of clinical governance in 4 hospitals related to Mashhad University of Medical Sciences. The results showed that there is a statistically significant difference in the mentioned indices before and after the establishment of clinical governance in all studied hospitals. This shows the effectiveness of the interventions performed towards the establishment of clinical governance and the possibility of improving service quality in this way.
Of course, more studies are required in order to further generalize these results to other hospitals.