Clinician’s Impression of Clinical GovernanceDr Emma Glanville

Consultant Psychiatrist

Mental Health ACT.

Clinical governance background High profile problems in health. Increasing emphasis. Structures evolving. Evidence base evolving. Local context.

Barriers 1. Health is different. Business as usual after a major incident. Person injured is patient rather than staff. Death and disease is normal. Negative consequences (eg coroner’s case,

litigation) occur sporadically, inconsistently & a long time after the event.

Lack of perceived benefits.

Barriers: 2. Psychiatry is different? Not as different as we like to think. Clear differences between wrong site surgery. But many parallels with other problems eg

type II diabetes.

Barriers3. ‘No blame culture’? Our culture is a blame culture.

‘In the aftermath of such a disaster there must be an assignment of blame’.

Runciman 2003 Medicine is a blame culture. Finding a balance between fatalism &

persecuting scapegoats.

Barriers 4. Issue of evidence

‘No sound evidence currently exists to support the claim that clinical governance will improve service quality’

(Thomas M 2002)

Barriers4. The issue of evidence

‘…audit and feedback can be effective in improving clinical practice. When it is effective the effects are generally small to moderate. The relative effectiveness… is likely to be greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively.’

Cochrane Collaboration 2008.

Barriers4. The issue of evidence

As the natural heterogeneity of an intervention increases, experimental methods become progressively less helpful in understanding its effectiveness.

Walshe 2007. Heterogeneous & evolving activities in

heterogeneous organisations in heterogeneous populations – there will never be the definitive study.

Barriers5. Managers vs clinicians?

“clinical governance committees provide a ‘theatrical’ function, reassuring the board that all is well while allowing business as usual at lower levels within the organisation”.

Freeman 2004

My project - Aims Focuses on clinicians and their opinions of

our clinical review process for serious adverse incidents – eg suicides, serious self harm, serious assaults (incl sexual assaults).

Clinical review process aims to identify systems issues (rather than performance management issues).

Report RatingCRC

discussion

InvestigationFindings &

RecommendationsFeedback

Incident

My project: aims My aim is to investigate what clinicians feel

about this process:

-is it worth putting in an incident report?

-how do they experience the investigation?

-what do they think of our findings & recommendations?

-do they think we make a difference?

-how could they be more involved?

My project: further aims Better understanding of evidence around

governance. Better understanding of research process –

particularly qualitative research. Better understanding of staff responses when

things go wrong. Learning to provide leadership in clinical

governance.

Methods Interview with CATT clinicians. Questions around:

-their knowledge of CRC.

-their experience of CRC processes.

-their thoughts on our recommendations.

-suggestions re learning about adverse events. Taped.

Data Analysis Themes analysis conducted independently by

two researchers. Key words and concepts.

Where am I up to? Support from clinical director of service. Support from team leader and psychiatrist on

CATT. Literature review. Questions designed. Ethics approval.

Questions?