Clinical governance is a systematic approach to maintaining and improving
the quality of patient care within a health system. Clinical governance
became important in health care after the Bristol heart scandal in 1995,
during which an anaesthetist, Dr Stephen Bolsin, exposed the high mortality rate
for paediatric cardiac surgery at the Bristol Royal Infirmary. It was
originally elaborated within the United Kingdom National Health Service, and its
most widely cited formal definition describes it as:
A framework through which NHS 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. This definition is intended to embody
three key attributes: recognisably high standards of care, transparent
responsibility and accountability for those standards, and a constant dynamic
of improvement. The concept has some parallels with the
more widely known corporate governance, in that it addresses those structures,
systems and processes that assure the quality, accountability and proper
management of an organisation's operation and delivery of service.
However clinical governance applies only to health and social care organisations,
and only those aspects of such organisations that relate to the
delivery of care to patients and their carers; it is not concerned with the
other business processes of the organisation except insofar as they
affect the delivery of care. The concept of "integrated governance" has emerged
to refer jointly to the corporate governance and clinical governance
duties of healthcare organisations. Prior to 1999, the principal statutory
responsibilities of UK NHS Trust Boards were to ensure proper financial
management of the organisation and an acceptable level of patient safety.
Trust Boards had no statutory duty to ensure a particular level of quality.
Maintaining and improving the quality of care was understood to be the
responsibility of the relevant clinical professions. In 1999, Trust Boards
assumed a legal responsibility for quality of care that is equal in measure
to their other statutory duties. Clinical governance is the mechanism by
which that responsibility is discharged. "Clinical governance" does not mandate
any particular structure, system or process for maintaining and improving
the quality of care, except that designated responsibility for clinical
governance must exist at Trust Board level, and that each Trust must prepare
an Annual Review of Clinical Governance to report on quality of care and its
maintenance. Beyond that, the Trust and its various clinical departments are
obliged to interpret the principle of clinical governance into locally
appropriate structures, processes, roles and responsibilities.
Elements of clinical governance Clinical governance is composed of at
least the following elements: Education and Training
Clinical audit Clinical effectiveness
Research and development Openness
Risk management Information Management
= Education and training = It is no longer considered acceptable
for any clinician to abstain from continuing education after qualification
- too much of what is learned during training becomes quickly outdated. In
NHS Trusts, the continuing professional development of clinicians has been the
responsibility of the Trust and it has also been the professional duty of
clinicians to remain up-to-date. = Clinical audit =
Clinical audit is the review of clinical performance, the refining of clinical
practice as a result and the measurement of performance against agreed standards
- a cyclical process of improving the quality of clinical care. In one form or
another, audit has been part of good clinical practice for generations.
Whilst audit has been a requirement of NHS Trust employees, in primary care
clinical audit has only been encouraged, where audit time has had to compete with
other priorities. = Clinical effectiveness =
Clinical effectiveness is a measure of the extent to which a particular
intervention works. The measure on its own is useful, but decisions are
enhanced by considering additional factors, such as whether the
intervention is appropriate and whether it represents value for money. In the
modern health service, clinical practice needs to be refined in the light of
emerging evidence of effectiveness but also has to consider aspects of
efficiency and safety from the perspective of the individual patient
and carers in the wider community. = Research and development =
Good professional practice has always sought to change in the light of
evidence from research. The time lag for introducing such change can be very long
and reducing time lag and associated morbidity requires emphasis not only on
carrying out research, but also on using and implementing such research.
Techniques such as critical appraisal of the literature, project management and
the development of guidelines, protocols and implementation strategies are all
tools for promoting the implementation of research practice.
= Openness = Poor performance and poor practice can
too often thrive behind closed doors. Processes which are open to public
scrutiny, while respecting individual patient and practitioner
confidentiality, and which can be justified openly, are an essential part
of quality assurance. Open proceedings and discussion about clinical governance
issues should be a feature of the framework.
Any organisation providing high quality care has to show that it is meeting the
needs of the population it serves. Health needs assessment and
understanding the problems and aspirations of the community requires
the cooperation between NHS organisations, public health
departments, local authorities and community health councils.
The system of clinical governance brings together all the elements which seek to
promote quality of care. = Risk management =
Risk management involves consideration of the following components:
Risks to patients: compliance with statutory regulations can help to
minimise risks to patients. In addition, patient risks can be minimised by
ensuring that systems are regularly reviewed and questioned - for example,
by critical event audit and learning from complaints. Medical ethical
standards are also a key factor in maintaining patient and public safety
and well-being. Risks to practitioners: ensuring that
clinicians are immunised against infectious diseases, work in a safe
environment and are helped to keep up-to-date are important parts of
quality assurance. Risks to the organisation: poor quality
is a threat to any organisation. In addition to reducing risks to patients
and practitioners, organisations need to reduce their own risks by ensuring high
quality employment practice, a safe environment, and well designed policies
on public involvement. Balancing these risk components may be
an ideal that is difficult to achieve in practice. Recent research by Fischer and
colleagues at the University of Oxford finds that tensions between 'first
order' risks and 'second order' risks can produce unintended contradictions,
conflict, and may even precipitate organisational crisis.
= Information management = Information management in health:
Patient records proper collection, management and use of information within
healthcare systems “will determine the system’s effectiveness in detecting
health problems, defining priorities, identifying innovative solutions and
allocating resources to improve health outcomes.
Applying clinical governance in the field
If clinical governance is to truly function effectively as a systematic
approach to maintaining and improving the quality of patient care within a
health system, it requires advocates. It also requires systems and people to be
in place to promote and develop it. The system has found supporters outside
of the UK. The not-for-profit UK hospital accreditation group the Trent
Accreditation Scheme base their system upon NHS clinical governance, and apply
it to hospitals in Hong Kong and Malta. Notes
References G. Scally and L. J. Donaldson, Clinical
governance and the drive for quality improvement in the new NHS in England
BMJ: 61-65 N. Starey, 'What is clinical
governance?', Evidence-based medicine, Hayward Medical Communications, What is
clinical governance? External links
UK NHS Clinical Governance Support Team Primary Care Training Centre
Stephen Bolsin [1]
[2]