Clinical governance one size does not fit all!

24 June 2021


By Heidi Bubendorfer, Principal Quality Programmes Advisor

Clinical governance evolved in the UK in the late 1990s in response to the vast differences in the quality of healthcare delivery throughout Britain. 

In fact, the quality of health services being delivered throughout the world, range from excellent to those with serious unresolvable problems.

Apart from the outliers at each end of the spectrum, most healthcare providers sit comfortably in the middle of the ‘quality curve’. 

New Zealand’s Health Quality and Safety Commission (HQSC) have published a comprehensive guidance document for all health and disability providers in this country, which summarises clinical governance as, “An organisation-wide approach to the continuous quality improvement of clinical services. It is larger in scope than any single quality improvement initiative, committee, or service. It involves the systematic joining-up of all patient safety and quality improvement initiatives within a health organisation.”

Put simply, clinical governance is a combination of activities and relationships that connect governance with management in the four core health areas. It consolidates and focusses much of the positive quality and safety work already underway in general practice, and its flexible framework allows for the adaptation of clinical governance systems within practices of all shapes and sizes.

Research shows that quality of care is influenced by under-resourcing, social determinants, infrastructure, systems, culture, and attitudes. Consequently, many people are missing out on the quality of care they are entitled to under the Human Rights Act, 1993 and Te Tiriti o Waitangi.  

Governance systems have long been established in commercial businesses. Here, governance involves a set of relationships between a company's management, its board, its shareholders, and other stakeholders.

Clinical governance in health takes it a step further by adding the four core elements of healthcare.

With the evolution of general practice over the years, its increasing size and complexity has seen the introduction of practice managers into the business.

Practice managers are well placed to implement clinical governance, often orchestrating, organising, and overseeing the management and integration of the core health elements within the practice. 

Currently, primary care is groaning under the strain of GP shortages, burnout, an increase in chronic diseases and a global pandemic. Implementing a governance process may feel daunting or even excruciating to some. Nonetheless, the increasing accountabilities for healthcare providers as well as expectations from patients means integrating clinical governance has become a necessity to streamline processes and fulfil healthcare obligations.

Practices of differing shapes and sizes have been seen to adapt the flexible framework to suit the character and construct of their business.

To illustrate, large corporate health organisations under which multiple practices operate, often appoint a medical director with clinical governance roles and responsibilities at each site.  These clinics are then supported by organisational clinical governance with clinical directors meeting monthly to discuss risks, incidents, clinical audits of note, detect trends and changes, review policies and protocols, and generally act as a safety net for the individual practices and the organisation as a whole.

Medium sized general practices have been seen to incorporate clinical governance into their existing systems without adding the burden of additional meetings. For example, individual teams (GPs, nurses, admin) may meet at scheduled intervals and discuss items related to clinical governance. This may then pass through the practice manager, who applies their critical eye, before adding to the standing agenda item for the quarterly practice meeting.  

If necessary, an emergency clinical governance meeting, with core members, may be called for events/ complaints/sensitive issues or policy sign-off. 

Small practices comprising of very few team members may simply assign clinical roles and responsibilities and discuss clinical governance at every team meeting.

In delivering health services that are safe, effective, integrated, high quality and continuously improving, clinical governance has shown it can inspire leadership and creativity.  

The challenge is to apply the strategy into reality in the best way possible for time poor practices. If this challenge is met, the beneficial consequences will flow, taking us all closer to our collective health care goals. 

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