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Review
Clinical governance development: learning from the New Zealand experience Robin Gauld Correspondence to Professor Robin Gauld, Department of Preventive and Social Medicine, University of Otago, PO Box 913, Dunedin 9054, New Zealand; [email protected] Received 3 September 2012 Revised 9 September 2013 Accepted 17 October 2013 Published Online First 6 November 2013
ABSTRACT The development of clinical governance in New Zealand has been pivotal to the country’s health policy since 2009. Some of the key findings from one component of a national assessment project, which involved interviews with health professionals and managers at 19 of the country’s 20 district health boards, are reviewed here. Key lessons for clinical governance are that: clinical governance needs to be clearly defined; it requires robust management–clinical partnerships along with a multilayered developmental strategy and investment in training; and it also requires organisational arrangements such as a clinical board. The New Zealand emphasis on clinical governance has been positive for health professionals but, at this stage, it is not possible to assess its broader impact.
INTRODUCTION
To cite: Gauld R. Postgrad Med J 2014;90:43–47.
The concept and terminology of ‘clinical governance’ has been central to healthcare policy and service development in several countries since at least the late 1990s, and defined in various ways in the literature.1–7 The classic Scally and Donaldson definition suggests: “Clinical governance is a system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish”.8 What this and other definitions appear to have in common is the idea that medical and other professionals have a responsibility to step up and change the systems and processes of care that they contribute to in order to improve patient safety and quality, but also that they should be accountable for the quality of care delivered. In this sense, health professionals have two jobs: improving the system through which care is delivered, as well as providing care. Governing boards and managers of health care organisations, meanwhile, have a responsibility for ensuring that clinical service quality and financial performance are given equal emphasis. It might be reasonable to conclude that ‘clinical governance’ is an indistinct concept that could have multiple meanings to different players in the health system. However, drawing from the literature and the policies of various countries, in practical terms, one might expect to see health professionals leading the way in quality improvement efforts, engaging in clinical audit and peer review, ensuring that clinical and organisational practices are evidence based, working to build team based and systematised services delivery processes, and encouraging performance improvement among their peers.6 An emerging body of research
Gauld R. Postgrad Med J 2014;90:43–47. doi:10.1136/postgradmedj-2012-131198
provides support for this. A 2010 multi-country study showed that clinically-led hospitals were more likely to have standard processes in place and better quality of care.9 A 2011 study of US hospitals added further weight to the argument, again showing a superior performance on financial and quality measures in clinically-led institutions.10 Then there are clinically-led organisations such as the Pennsylvania based Geisinger Health System which has worked to systematise services. For example, in pursuing best practice, its clinical staff agreed to 40 critical steps in the process of coronary artery bypass graft surgery. Results show significant improvements in performance across a range of cost and quality measures.11 While it is evident that clinical governance is an important policy and organisational pursuit, less clear is how it might be developed or the challenges that may be encountered along the way. This article, therefore, considers lessons from the case of New Zealand where, since 2008, the government has placed clinical governance and leadership at the centre of all health policy. The article looks at how the country has approached clinical governance and reports on some findings from an assessment project which involved information-gathering site visits to 19 of New Zealand’s 20 district health boards (DHBs) (the health system is described in box 1). In doing so, the article reflects on some challenges and complexities in developing clinical governance.
CLINICAL GOVERNANCE POLICY DEVELOPMENT IN NEW ZEALAND Since their election in 2008 the current (2013) New Zealand government has pursued various health system reforms.12 In the context of the government’s desire to promote clinical governance, a Ministerial Review Group featuring several clinical leaders made recommendations which have underpinned the reforms.13 This has led to the creation of: a new National Health Board to drive improved DHB performance; a Health Quality and Safety Commission to stimulate and coordinate quality and safety improvement efforts across the DHBs; and various other groups which concentrate on particular issues (eg, health IT, workforce, technology assessment). A number of health professionals have been appointed to the boards of each of these new agencies. In 2009, the Minister of Health commissioned a working party to provide advice on clinical governance chaired by the president of the national public hospital specialists union with, again, a clinically oriented membership. The working party drew strongly on concepts developed for the English NHS, particularly the Leadership Qualities Framework.14 43
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Review The resulting report entitled In Good Hands sought to bring a balance to the considerable prior effort across the 20 DHBs, especially their hospitals, into developing corporate governance structures and systems for reporting corporate outcomes.15 To do so, clinical governance was required. Following Scally and Donaldson, this was defined as ‘the system’ in which leadership, ‘by clinicians and others’, was a core component. The challenge, said the report, was to create distributed leadership at service delivery, hospital and national levels with clinicians (ie, health professionals) at the centre to “transform clinical governance into an everyday reality at every level of the system, to ensure the whole system is in good hands” (italics added).15 The following specific recommendations were included: ▸ the 20 DHBs should create governance structures that ensure an effective partnership between clinical and corporate management, with quality and safety at the top of all meeting agendas ▸ each of the 20 DHB chief executive officers (CEOs) should enable strong clinical leadership and decision making throughout their organisation ▸ clinical governance should cover the entire patient journey, with clinicians actively involved in all decision making processes and with shared responsibility and accountability with corporate management for both clinical and financial performances ▸ decision making should be devolved to the appropriate clinical unit or teams within DHBs and their hospitals ▸ DHBs should identify and support actual and potential clinical leaders and invest in training and mentoring. On release of In Good Hands, the Minister of Health announced that DHBs would be expected to implement its recommendations, saying: “This is not about massive structural upheaval, it is about operating differently to develop and support strong clinical leadership and governance throughout the health system”.16 Since then, the 20 DHBs have invested considerable effort into developing clinical governance.
LESSONS FROM CLINICAL GOVERNANCE ASSESSMENT IN NEW ZEALAND The Health Minister’s instructions were clear. However, implementation requires DHB and health professional commitment. Thus, in 2010, a year after In Good Hands was released, I led a survey project which aimed to investigate senior doctors’
awareness of clinical governance activities—in particular, whether key recommendations from In Good Hands were being acted upon. The findings were published elsewhere,17 and are summarised in box 2. The 2010 findings suggested limited progress had been made, with notable variation between the 20 DHBs. The Clinical Governance Development Index (CGDI) scoring method did, however, create an impact, especially as key components measured aspects of government policy. I was subsequently approached by the government to conduct a follow-up study with a broader scope, including a survey of all health professionals employed in DHBs (doctors, nurses, midwives, and allied health workers). The project also involved DHB site visits in which 165 interviews with key individuals involved in clinical governance development were conducted in order to learn about approaches and experiences. Alongside the site visits, each DHB produced a brief self-review for which a standard template was developed. In this, they outlined their strategy for clinical governance, their ‘three most important initiatives’ and experiences with these, and future plans. We found that all DHBs were committed to implementing clinical governance, but there were as many different approaches as DHBs.18 Virtually all had redesigned their corporate and service management structures. Typically, health professionals had been brought onto the executive leadership team working in partnership with the chief executive and other managers. The next tier of management tended to involve a partnership with joint responsibility between the chief operating officer, chief medical advisor, chief nurse, chief of allied health, and others as appropriate. Below this tier tended to be clinical directorates, responsible for clusters of clinical departments or services, with either a medical clinical director or partnership leadership model again, with joint responsibility among the partners. Many DHBs had created a clinical governance board with wide professional representation aimed at facilitating discussion of issues around service design, quality improvement, and patient safety. One DHB had included general practitioners as well as hospital specialists in its clinical directorate leadership teams (eg, medical and surgical services; mental health) to emphasise primary/secondary care integration. From the site visits it emerged that some key themes were common to the clinical governance development process in many DHBs, with associated lessons. These are discussed in the following sections.
Box 2 2010 survey findings Box 1 The New Zealand health system With similarities to the English NHS, New Zealand has a tax funded system with public institutions dominating hospital care. Around 80% of total health expenditure is from government. This is allocated on a population basis to 20 geographically based district health boards (DHBs) which plan and fund a full spectrum of services. DHBs own and run public hospitals which are free of charges and universally accessible. Public hospitals employ specialists and other staff on salary. Around 40% of public specialists are in dual practice so they also work in the private sector. Primary medical care is provided by general practitioners in private practice, but around half their income is from public sources with the remainder from direct patient charges. 44
52% of 3402 invited senior doctors responded Of these, just over half were very familiar/familiar with the concept of ‘clinical governance’ 60% felt management was working to develop clinical governance 48% believed structures were in place to support clinical governance Only 20% had enough time to engage in clinical governance activities The mean score for clinical governance development was 47.3%, as measured via the Clinical Governance Development Index (CGDI) of seven survey items The best performing district health board scored 55.3% on the CGDI Gauld R. Postgrad Med J 2014;90:43–47. doi:10.1136/postgradmedj-2012-131198
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Review The concept of clinical governance needs clear definition and communication Many were comfortable with the idea that clinical governance is about bringing professionals into ‘the system’ of governance and management, and getting professionals more involved in peer review, clinical audit and system improvement efforts. Others felt that it was necessary to show what specific outcomes clinical governance aimed for. This, of course, speaks to the problems inherent in having a wide variety of definitions of clinical governance in the published literature, as previously noted.6 7 It also implies that it is important for policymakers at different levels of a health system (ie, at central government and the local level) pursuing clinical governance to exactly outline what is intended and to collaborate with health professionals to produce a working definition. Notably, the working definitions used by DHBs that had developed these tended to differ from one another, but reflected principles and goals of importance to their specific situations. Most DHBs faced challenges in communicating ‘clinical governance’ to the broader health professional workforce. Many said their doctors and other professionals working at the frontline of care delivery may not recognise the organisational activities, nor care much about what clinical governance may be in theoretical or organisational terms, but were constantly seeking to improve service quality and care processes in their daily work. Clearly, this has implications for how a health organisation packages clinical governance and communicates this to staff. It also relates closely to the process of defining clinical governance in partnership with staff. Several DHBs had used or adapted the Scally and Donaldson definition of clinical governance outlined above and often linked this to a broader quality improvement plan such as the Triple Aim framework from the Institute for Healthcare Improvement.19 The ‘triple aims’ include working to improve the health of a defined population; improving the quality of care; and reducing costs as a result of the first two aims. In bringing together the definition and framework, the DHBs had created an overarching strategy for which clinical governance provided the organisational fuel. A good example of the above is a DHB that had made considerable progress with clinical governance compared with other DHBs, in which interviewees felt they had a very clear understanding of the goals and their roles. The DHB had produced detailed documentation outlining proposed structures, and launched an internal communications drive around this, stating: “The fundamental concept of effective clinical leadership to be a success for [DHB A] would be as follows”. A definition from the Darzi report of 2008, paraphrased in In Good Hands, was then listed: “Clinical leadership is a mechanism for effecting change and enhancing quality… It requires a new obligation to step up, work with other leaders, both clinical and managerial, and change the system where it would benefit patients”.20
well as budgetary decision making.9 In some DHBs interviewees suggested that, where generic managers had continued to hold the balance of power, and a partnership based on trust and mutual working relationships not been established, this undermined health professional confidence in and commitment to clinical governance. The incapacity to create an effective partnership was the key reason for perceived failure in implementing clinical governance in the couple of DHBs that reported this. The challenge of creating partnerships has also been experienced in the English NHS.22
Developing effective clinical governance requires a multi-layered strategy As indicated above and elsewhere,23 24 this must commence with organisational re-development from the top level. Of course, leadership from the board and chief executive is pivotal and has been shown to result in improved health care delivery performance.25 26 Senior management and clinical leaders also have a fundamental role in outlining the rationale and structures for clinical governance, leading by example and, once again, communicating this to staff. For all of the DHBs, clinical governance development has demanded considerable consultation among staff and sometimes convoluted organisational structures (outlined in general terms above) to facilitate the broad involvement of both professional and administrative leaders. For example, one DHB had created a ‘clinical council’ that featured representatives of the well over 20 health professional groups it employed. This had overarching power over all decisions, including capital expenditure on and design of new buildings. Early on, the clinical council had vetoed a major building project plan as it “made no sense to clinical leaders” as the building design had not been developed to cater for a future model of care. The result of such arrangements, for many DHBs, has been a slower pace of decision making but, ultimately, a more intelligent and widely endorsed process for this that is clinically supported. In this regard, several DHB experiences highlight that clinically-led structures can be especially effective around sensitive issues such as budget setting, service prioritisation and technology assessment in a context, such as New Zealand’s, of limited government funding yet potentially unlimited patient demand.
Do not overlook the importance of training for clinical governance and leadership
This is particularly important where there has been a history of mistrust between hospital management and health professionals, as was the case in New Zealand.21 In practice, a clinical–management partnership means clinical leaders and groups must be equally involved with management in all decision making, service planning and resource allocation processes. Indeed, the lines between clinical and managerial domains should eventually dissolve and, as noted elsewhere, there are strong arguments that clinicians are well placed to preside over both clinical as
A strong viewpoint from all DHBs was that such training should commence in medical and other health professional schools. As Leape et al argue, training for quality improvement and leadership should be considered a core skill so that graduates have an understanding of their role and obligations in health system improvement, how to work with other professionals in leading for improvement,27 and which quality and safety improvement strategies should be adopted.28 Governance and leadership should also be integral to advanced clinical training and professional registration processes. We heard from many doctor interviewees who had stepped into leadership roles that they may have what it takes to ‘lead’ but specific training in areas such as human resources, communications, accounting, and quality improvement would be especially useful. In this regard, New Zealand’s clinical leaders are not alone.29 New Zealand’s two medical schools are working to enhance the teaching of quality improvement and leadership in their curriculum and various DHBs offer leadership training for health professionals. Professional colleges and workforce unions also recognise the importance of such training.30 However, there is no national
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45
Effective clinical governance requires robust management– clinical partnerships
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Review plan for, nor coordination of, the various activities at present. There is considerable scope, therefore, to draw lessons from others who have invested in curriculum development and early career training.31
A ‘clinical governance board’ can play an important role Most DHBs had a clinical governance board composed of representatives from different professional groups and service areas as well as finance and planning staff and, usually, the chief executive. Most emphasised the important role these boards played when appropriately empowered. But the clinical governance boards differed between the DHBs. Some appeared to be vehicles for announcing policy and strategy. As a consequence, where health professionals had been initially sanguine at the prospect of involvement in governance, they had quickly become disengaged. Some boards were bogged down in overseeing and coordinating the activities of various hospital quality and standards committees in areas such as laboratory services and mortality review, and found it difficult to find time to focus on building clinical governance and leadership. Other DHBs had worked hard to create genuine clinically-led governance arrangements, in turn, building clinical oversight of the organisation and breathing life into the idea of clinical governance. Several had the chief medical officer or chief nurse as board chair or co-chairs. In one DHB, the clinical board had the capacity to veto any planning and funding decisions that did not fulfil clinical expectations around quality, safety and service design. This had led to a much closer and effective working relationship between clinical and managerial staff.
CONCLUSION Our clinical governance assessment project confirmed what is well known by New Zealand’s DHBs and health policymakers elsewhere: that clinical governance is complex and to promote and support it requires a multifaceted approach.32 This includes: structural components such as organisational redesign; training and support for health professionals interested in leadership and for general management staff; encouraging professionals to get involved in governance activities and to work in different ways, for example, as partners with professional and managerial colleagues; and developing a focus for clinical governance. Extracting from the New Zealand experience and the literature highlighted in this article, the focus for clinical governance development should arguably be around improving the quality and safety of care and the patient experience from a system perspective, as well as engendering health professional involvement in all aspects of service planning, decision making and budgeting. The New Zealand assessment project has revealed a great deal of enthusiasm among health professionals and managers for developing clinical governance, positive progress in organisational terms, and some useful lessons as discussed above. However, it is too early to tell yet whether clinical governance has resulted in improved health outcomes, quality of care or financial performances. The multifaceted nature of clinical governance development means assessment of progress is complex, as noted elsewhere,4 18 while measuring the impact on outcomes and other performance indicators is a longer term undertaking that could also be complicated by various confounding factors. Thus, a final lesson from the New Zealand experience is, perhaps, that those developing clinical governance need to consider carefully the aims of clinical governance along with the parameters and expectations for measurement and the methods used to achieve this. 46
Main messages ▸ The arguments and evidence in favour of clinical governance are strong. ▸ Clinical governance has been pivotal to health policy in New Zealand since 2009. ▸ An assessment of progress in New Zealand shows that: – clinical governance needs to be clearly defined – it requires robust management–clinical partnerships along with a multi-layered developmental strategy and investment in training – it also requires new organisational arrangements such as a clinical board. ▸ The New Zealand emphasis on clinical governance has been positive for health professionals but, at this stage, it is not possible to assess its broader impact.
Current research questions ▸ Should the definition of ‘clinical governance’ be site-specific or generic? ▸ What sorts of organisational arrangements might best facilitate the clinician–management partnerships and is there an ideal structure for this? ▸ What core topics should be included in a clinical governance curriculum for postgraduate medical training?
Key references ▸ Gauld R, Horsburgh S. Clinical governance assessment project: final report on a national health professional survey and site visits to 19 New Zealand DHBs. Dunedin: Centre for Health Systems, University of Otago, 2012. ▸ Scally G, Donaldson L. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998;317:61–5. ▸ Brennan N, Flynn M. Differentiating clinical governance, clinical management and clinical practice. Clin Governance 2013;18:114–31. ▸ Leape L, Berwick D, Clancy CM, et al. Transforming healthcare: a safety imperative. Qual Saf Health Care 2009;18:424–8. ▸ Paulus RA, Davis K, Steele GD. Continuous innovation in health care: implications of the Geisinger experience. Health Aff 2008;27:1235–45.
Acknowledgements The author is grateful to the National Health Board, Health Quality and Safety Commission and the DHBs for commissioning the study discussed in this article; to the 165 interviewees for their input into the study; and to the editor and three anonymous reviewers for comments on a prior draft of the article. The interpretations presented in this article are the responsibility of the author. Funding Joint commissioners as listed in the Acknowledgements. Competing interests None. Provenance and peer review Commissioned; externally peer reviewed. Gauld R. Postgrad Med J 2014;90:43–47. doi:10.1136/postgradmedj-2012-131198
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Nicholls S, Cullen R, O’Neill S, et al. Clinical governance: its origins and its foundations. Br J Clin Governance 2000;5:172–8. Shaw K, MacKillop L, Armitage M. Revalidation, appraisal and clinical governance. Clin Governance 2007;12:170–7. Som CV. Making sense of clinical governance at different levels in NHS hospital trusts. Clin Governance 2009;14:98–112. Specchia ML, La Torre G, Siliquini R, et al. OPTIGOV—a new methodology for evaluating clinical governance implementation by health providers. BMC Health Serv Res 2010;10:174. Staniland K. A sociological ethnographic study of clinical governance implementation in one NHS hospital trust. Clin Governance 2009;14:271–80. Travaglia J, Debono D, Spigelman A, et al. Clinical governance: a review of key concepts in the literature. Clin Governance 2011;16:62–77. Brennan N, Flynn M. Differentiating clinical governance, clinical management and clinical practice. Clin Governance 2013;18:114–31. Scally G, Donaldson L. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998;317:61–5. Dorgan S, Layton D, Bloom N, et al. Management in healthcare: why good practice really matters. London: McKinsey and Company/London School of Economics, 2010. Goodall AH. Physician-leaders and hospital performance: is there an association? Soc Sci Med 2011;73:535–9. Paulus RA, Davis K, Steele GD. Continuous innovation in health care: implications of the Geisinger experience. Health Aff 2008;27:1235–45. Gauld R. New Zealand’s post-2008 health system reforms: toward re-centralization of organizational arrangements. Health Policy 2012;106:110–13. Ministerial Review Group. Meeting the challenge: enhancing sustainability and the patient and consumer experience within the current legislative framework for health and disability services in New Zealand. Wellington: Minister of Health, 2009. NHS Institute for Innovation and Improvement. NHS leadership qualities framework. London: National Health Service Institute for Innovation and Improvement, 2005. Ministerial Task Group on Clinical Leadership. In good hands: transforming clinical governance in New Zealand. Wellington: Ministerial Task Group on Clinical Leadership, 2009. Ryall T. Clinical Leadership “In Good Hands”. Ministerial Press Release. 12 March. Wellington: Minister of Health, 2009.
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Gauld R, Horsburgh S, Brown J. The Clinical Governance Development Index: results from a New Zealand study. BMJ Qual Saf 2011;20:947–53. Gauld R, Horsburgh S. Clinical governance assessment project: final report on a national health professional survey and site visits to 19 New Zealand DHBs. Dunedin: Centre for Health Systems, University of Otago, 2012. Berwick D, Nolan T, Whittington J. The Triple Aim: care, health, and cost. Health Aff 2008;27:759–76. Secretary of State for Health. High quality care for all: NHS next stage review final report. Surrey: Office of Public Sector Information, 2008. Hornblow A. New Zealand’s health reforms: a clash of cultures. BMJ 1997;314:1892–4. Hogan H, Basnett I, McKee M. Consultants’ attitudes to clinical governance: barriers and incentives to engagement. Public Health 2007;121:614–22. James BC, Savitz LA. How Intermountain trimmed health care costs through robust quality improvement efforts. Health Aff 2011;30:1185–91. Bohmer RMJ. Fixing health care on the front lines. Harvard Bus Rev 2010: 62–9. Jha AK, Epstein AM. Hospital governance and the quality of care. Health Aff 2010;29:182–7. Conway J. Getting boards on board: engaging governing boards in quality and safety. Jt Comm J Qual Patient Saf 2008;34:214–20. Leape L, Berwick D, Clancy CM, et al. Transforming healthcare: a safety imperative. Qual Saf Health Care 2009;18:424–8. Shekelle P, Pronovost P, Wachter R, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med 2013;158:365–8. Morrow G, Burford B, Redfern N, et al. Does specialty training prepare doctors for senior roles? A questionnaire study of new UK consultants. Postgrad Med J 2012;88;558–65. Association of Salaried Medical Specialists. The public hospital specialist workforce: entrenched shortages or workforce investment? Wellington: Association of Salaried Medical Specialists, 2013. The King’s Fund. Leadership and engagement for improvement in the NHS. London: The King’s Fund, 2012. Greenfield D, Nugus P, Fairbrother G, et al. Applying and developing health service theory: an empirical study into clinical governance. Clin Governance 2011;16:8–19.
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Clinical governance development: learning from the New Zealand experience Robin Gauld Postgrad Med J 2014 90: 43-47 originally published online November 6, 2013
doi: 10.1136/postgradmedj-2012-131198 Updated information and services can be found at: http://pmj.bmj.com/content/90/1059/43
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Review
Clinical governance development: learning from the New Zealand experience Robin Gauld Correspondence to Professor Robin Gauld, Department of Preventive and Social Medicine, University of Otago, PO Box 913, Dunedin 9054, New Zealand; [email protected] Received 3 September 2012 Revised 9 September 2013 Accepted 17 October 2013 Published Online First 6 November 2013
ABSTRACT The development of clinical governance in New Zealand has been pivotal to the country’s health policy since 2009. Some of the key findings from one component of a national assessment project, which involved interviews with health professionals and managers at 19 of the country’s 20 district health boards, are reviewed here. Key lessons for clinical governance are that: clinical governance needs to be clearly defined; it requires robust management–clinical partnerships along with a multilayered developmental strategy and investment in training; and it also requires organisational arrangements such as a clinical board. The New Zealand emphasis on clinical governance has been positive for health professionals but, at this stage, it is not possible to assess its broader impact.
INTRODUCTION
To cite: Gauld R. Postgrad Med J 2014;90:43–47.
The concept and terminology of ‘clinical governance’ has been central to healthcare policy and service development in several countries since at least the late 1990s, and defined in various ways in the literature.1–7 The classic Scally and Donaldson definition suggests: “Clinical governance is a system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish”.8 What this and other definitions appear to have in common is the idea that medical and other professionals have a responsibility to step up and change the systems and processes of care that they contribute to in order to improve patient safety and quality, but also that they should be accountable for the quality of care delivered. In this sense, health professionals have two jobs: improving the system through which care is delivered, as well as providing care. Governing boards and managers of health care organisations, meanwhile, have a responsibility for ensuring that clinical service quality and financial performance are given equal emphasis. It might be reasonable to conclude that ‘clinical governance’ is an indistinct concept that could have multiple meanings to different players in the health system. However, drawing from the literature and the policies of various countries, in practical terms, one might expect to see health professionals leading the way in quality improvement efforts, engaging in clinical audit and peer review, ensuring that clinical and organisational practices are evidence based, working to build team based and systematised services delivery processes, and encouraging performance improvement among their peers.6 An emerging body of research
Gauld R. Postgrad Med J 2014;90:43–47. doi:10.1136/postgradmedj-2012-131198
provides support for this. A 2010 multi-country study showed that clinically-led hospitals were more likely to have standard processes in place and better quality of care.9 A 2011 study of US hospitals added further weight to the argument, again showing a superior performance on financial and quality measures in clinically-led institutions.10 Then there are clinically-led organisations such as the Pennsylvania based Geisinger Health System which has worked to systematise services. For example, in pursuing best practice, its clinical staff agreed to 40 critical steps in the process of coronary artery bypass graft surgery. Results show significant improvements in performance across a range of cost and quality measures.11 While it is evident that clinical governance is an important policy and organisational pursuit, less clear is how it might be developed or the challenges that may be encountered along the way. This article, therefore, considers lessons from the case of New Zealand where, since 2008, the government has placed clinical governance and leadership at the centre of all health policy. The article looks at how the country has approached clinical governance and reports on some findings from an assessment project which involved information-gathering site visits to 19 of New Zealand’s 20 district health boards (DHBs) (the health system is described in box 1). In doing so, the article reflects on some challenges and complexities in developing clinical governance.
CLINICAL GOVERNANCE POLICY DEVELOPMENT IN NEW ZEALAND Since their election in 2008 the current (2013) New Zealand government has pursued various health system reforms.12 In the context of the government’s desire to promote clinical governance, a Ministerial Review Group featuring several clinical leaders made recommendations which have underpinned the reforms.13 This has led to the creation of: a new National Health Board to drive improved DHB performance; a Health Quality and Safety Commission to stimulate and coordinate quality and safety improvement efforts across the DHBs; and various other groups which concentrate on particular issues (eg, health IT, workforce, technology assessment). A number of health professionals have been appointed to the boards of each of these new agencies. In 2009, the Minister of Health commissioned a working party to provide advice on clinical governance chaired by the president of the national public hospital specialists union with, again, a clinically oriented membership. The working party drew strongly on concepts developed for the English NHS, particularly the Leadership Qualities Framework.14 43
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Review The resulting report entitled In Good Hands sought to bring a balance to the considerable prior effort across the 20 DHBs, especially their hospitals, into developing corporate governance structures and systems for reporting corporate outcomes.15 To do so, clinical governance was required. Following Scally and Donaldson, this was defined as ‘the system’ in which leadership, ‘by clinicians and others’, was a core component. The challenge, said the report, was to create distributed leadership at service delivery, hospital and national levels with clinicians (ie, health professionals) at the centre to “transform clinical governance into an everyday reality at every level of the system, to ensure the whole system is in good hands” (italics added).15 The following specific recommendations were included: ▸ the 20 DHBs should create governance structures that ensure an effective partnership between clinical and corporate management, with quality and safety at the top of all meeting agendas ▸ each of the 20 DHB chief executive officers (CEOs) should enable strong clinical leadership and decision making throughout their organisation ▸ clinical governance should cover the entire patient journey, with clinicians actively involved in all decision making processes and with shared responsibility and accountability with corporate management for both clinical and financial performances ▸ decision making should be devolved to the appropriate clinical unit or teams within DHBs and their hospitals ▸ DHBs should identify and support actual and potential clinical leaders and invest in training and mentoring. On release of In Good Hands, the Minister of Health announced that DHBs would be expected to implement its recommendations, saying: “This is not about massive structural upheaval, it is about operating differently to develop and support strong clinical leadership and governance throughout the health system”.16 Since then, the 20 DHBs have invested considerable effort into developing clinical governance.
LESSONS FROM CLINICAL GOVERNANCE ASSESSMENT IN NEW ZEALAND The Health Minister’s instructions were clear. However, implementation requires DHB and health professional commitment. Thus, in 2010, a year after In Good Hands was released, I led a survey project which aimed to investigate senior doctors’
awareness of clinical governance activities—in particular, whether key recommendations from In Good Hands were being acted upon. The findings were published elsewhere,17 and are summarised in box 2. The 2010 findings suggested limited progress had been made, with notable variation between the 20 DHBs. The Clinical Governance Development Index (CGDI) scoring method did, however, create an impact, especially as key components measured aspects of government policy. I was subsequently approached by the government to conduct a follow-up study with a broader scope, including a survey of all health professionals employed in DHBs (doctors, nurses, midwives, and allied health workers). The project also involved DHB site visits in which 165 interviews with key individuals involved in clinical governance development were conducted in order to learn about approaches and experiences. Alongside the site visits, each DHB produced a brief self-review for which a standard template was developed. In this, they outlined their strategy for clinical governance, their ‘three most important initiatives’ and experiences with these, and future plans. We found that all DHBs were committed to implementing clinical governance, but there were as many different approaches as DHBs.18 Virtually all had redesigned their corporate and service management structures. Typically, health professionals had been brought onto the executive leadership team working in partnership with the chief executive and other managers. The next tier of management tended to involve a partnership with joint responsibility between the chief operating officer, chief medical advisor, chief nurse, chief of allied health, and others as appropriate. Below this tier tended to be clinical directorates, responsible for clusters of clinical departments or services, with either a medical clinical director or partnership leadership model again, with joint responsibility among the partners. Many DHBs had created a clinical governance board with wide professional representation aimed at facilitating discussion of issues around service design, quality improvement, and patient safety. One DHB had included general practitioners as well as hospital specialists in its clinical directorate leadership teams (eg, medical and surgical services; mental health) to emphasise primary/secondary care integration. From the site visits it emerged that some key themes were common to the clinical governance development process in many DHBs, with associated lessons. These are discussed in the following sections.
Box 2 2010 survey findings Box 1 The New Zealand health system With similarities to the English NHS, New Zealand has a tax funded system with public institutions dominating hospital care. Around 80% of total health expenditure is from government. This is allocated on a population basis to 20 geographically based district health boards (DHBs) which plan and fund a full spectrum of services. DHBs own and run public hospitals which are free of charges and universally accessible. Public hospitals employ specialists and other staff on salary. Around 40% of public specialists are in dual practice so they also work in the private sector. Primary medical care is provided by general practitioners in private practice, but around half their income is from public sources with the remainder from direct patient charges. 44
52% of 3402 invited senior doctors responded Of these, just over half were very familiar/familiar with the concept of ‘clinical governance’ 60% felt management was working to develop clinical governance 48% believed structures were in place to support clinical governance Only 20% had enough time to engage in clinical governance activities The mean score for clinical governance development was 47.3%, as measured via the Clinical Governance Development Index (CGDI) of seven survey items The best performing district health board scored 55.3% on the CGDI Gauld R. Postgrad Med J 2014;90:43–47. doi:10.1136/postgradmedj-2012-131198
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Review The concept of clinical governance needs clear definition and communication Many were comfortable with the idea that clinical governance is about bringing professionals into ‘the system’ of governance and management, and getting professionals more involved in peer review, clinical audit and system improvement efforts. Others felt that it was necessary to show what specific outcomes clinical governance aimed for. This, of course, speaks to the problems inherent in having a wide variety of definitions of clinical governance in the published literature, as previously noted.6 7 It also implies that it is important for policymakers at different levels of a health system (ie, at central government and the local level) pursuing clinical governance to exactly outline what is intended and to collaborate with health professionals to produce a working definition. Notably, the working definitions used by DHBs that had developed these tended to differ from one another, but reflected principles and goals of importance to their specific situations. Most DHBs faced challenges in communicating ‘clinical governance’ to the broader health professional workforce. Many said their doctors and other professionals working at the frontline of care delivery may not recognise the organisational activities, nor care much about what clinical governance may be in theoretical or organisational terms, but were constantly seeking to improve service quality and care processes in their daily work. Clearly, this has implications for how a health organisation packages clinical governance and communicates this to staff. It also relates closely to the process of defining clinical governance in partnership with staff. Several DHBs had used or adapted the Scally and Donaldson definition of clinical governance outlined above and often linked this to a broader quality improvement plan such as the Triple Aim framework from the Institute for Healthcare Improvement.19 The ‘triple aims’ include working to improve the health of a defined population; improving the quality of care; and reducing costs as a result of the first two aims. In bringing together the definition and framework, the DHBs had created an overarching strategy for which clinical governance provided the organisational fuel. A good example of the above is a DHB that had made considerable progress with clinical governance compared with other DHBs, in which interviewees felt they had a very clear understanding of the goals and their roles. The DHB had produced detailed documentation outlining proposed structures, and launched an internal communications drive around this, stating: “The fundamental concept of effective clinical leadership to be a success for [DHB A] would be as follows”. A definition from the Darzi report of 2008, paraphrased in In Good Hands, was then listed: “Clinical leadership is a mechanism for effecting change and enhancing quality… It requires a new obligation to step up, work with other leaders, both clinical and managerial, and change the system where it would benefit patients”.20
well as budgetary decision making.9 In some DHBs interviewees suggested that, where generic managers had continued to hold the balance of power, and a partnership based on trust and mutual working relationships not been established, this undermined health professional confidence in and commitment to clinical governance. The incapacity to create an effective partnership was the key reason for perceived failure in implementing clinical governance in the couple of DHBs that reported this. The challenge of creating partnerships has also been experienced in the English NHS.22
Developing effective clinical governance requires a multi-layered strategy As indicated above and elsewhere,23 24 this must commence with organisational re-development from the top level. Of course, leadership from the board and chief executive is pivotal and has been shown to result in improved health care delivery performance.25 26 Senior management and clinical leaders also have a fundamental role in outlining the rationale and structures for clinical governance, leading by example and, once again, communicating this to staff. For all of the DHBs, clinical governance development has demanded considerable consultation among staff and sometimes convoluted organisational structures (outlined in general terms above) to facilitate the broad involvement of both professional and administrative leaders. For example, one DHB had created a ‘clinical council’ that featured representatives of the well over 20 health professional groups it employed. This had overarching power over all decisions, including capital expenditure on and design of new buildings. Early on, the clinical council had vetoed a major building project plan as it “made no sense to clinical leaders” as the building design had not been developed to cater for a future model of care. The result of such arrangements, for many DHBs, has been a slower pace of decision making but, ultimately, a more intelligent and widely endorsed process for this that is clinically supported. In this regard, several DHB experiences highlight that clinically-led structures can be especially effective around sensitive issues such as budget setting, service prioritisation and technology assessment in a context, such as New Zealand’s, of limited government funding yet potentially unlimited patient demand.
Do not overlook the importance of training for clinical governance and leadership
This is particularly important where there has been a history of mistrust between hospital management and health professionals, as was the case in New Zealand.21 In practice, a clinical–management partnership means clinical leaders and groups must be equally involved with management in all decision making, service planning and resource allocation processes. Indeed, the lines between clinical and managerial domains should eventually dissolve and, as noted elsewhere, there are strong arguments that clinicians are well placed to preside over both clinical as
A strong viewpoint from all DHBs was that such training should commence in medical and other health professional schools. As Leape et al argue, training for quality improvement and leadership should be considered a core skill so that graduates have an understanding of their role and obligations in health system improvement, how to work with other professionals in leading for improvement,27 and which quality and safety improvement strategies should be adopted.28 Governance and leadership should also be integral to advanced clinical training and professional registration processes. We heard from many doctor interviewees who had stepped into leadership roles that they may have what it takes to ‘lead’ but specific training in areas such as human resources, communications, accounting, and quality improvement would be especially useful. In this regard, New Zealand’s clinical leaders are not alone.29 New Zealand’s two medical schools are working to enhance the teaching of quality improvement and leadership in their curriculum and various DHBs offer leadership training for health professionals. Professional colleges and workforce unions also recognise the importance of such training.30 However, there is no national
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Effective clinical governance requires robust management– clinical partnerships
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Review plan for, nor coordination of, the various activities at present. There is considerable scope, therefore, to draw lessons from others who have invested in curriculum development and early career training.31
A ‘clinical governance board’ can play an important role Most DHBs had a clinical governance board composed of representatives from different professional groups and service areas as well as finance and planning staff and, usually, the chief executive. Most emphasised the important role these boards played when appropriately empowered. But the clinical governance boards differed between the DHBs. Some appeared to be vehicles for announcing policy and strategy. As a consequence, where health professionals had been initially sanguine at the prospect of involvement in governance, they had quickly become disengaged. Some boards were bogged down in overseeing and coordinating the activities of various hospital quality and standards committees in areas such as laboratory services and mortality review, and found it difficult to find time to focus on building clinical governance and leadership. Other DHBs had worked hard to create genuine clinically-led governance arrangements, in turn, building clinical oversight of the organisation and breathing life into the idea of clinical governance. Several had the chief medical officer or chief nurse as board chair or co-chairs. In one DHB, the clinical board had the capacity to veto any planning and funding decisions that did not fulfil clinical expectations around quality, safety and service design. This had led to a much closer and effective working relationship between clinical and managerial staff.
CONCLUSION Our clinical governance assessment project confirmed what is well known by New Zealand’s DHBs and health policymakers elsewhere: that clinical governance is complex and to promote and support it requires a multifaceted approach.32 This includes: structural components such as organisational redesign; training and support for health professionals interested in leadership and for general management staff; encouraging professionals to get involved in governance activities and to work in different ways, for example, as partners with professional and managerial colleagues; and developing a focus for clinical governance. Extracting from the New Zealand experience and the literature highlighted in this article, the focus for clinical governance development should arguably be around improving the quality and safety of care and the patient experience from a system perspective, as well as engendering health professional involvement in all aspects of service planning, decision making and budgeting. The New Zealand assessment project has revealed a great deal of enthusiasm among health professionals and managers for developing clinical governance, positive progress in organisational terms, and some useful lessons as discussed above. However, it is too early to tell yet whether clinical governance has resulted in improved health outcomes, quality of care or financial performances. The multifaceted nature of clinical governance development means assessment of progress is complex, as noted elsewhere,4 18 while measuring the impact on outcomes and other performance indicators is a longer term undertaking that could also be complicated by various confounding factors. Thus, a final lesson from the New Zealand experience is, perhaps, that those developing clinical governance need to consider carefully the aims of clinical governance along with the parameters and expectations for measurement and the methods used to achieve this. 46
Main messages ▸ The arguments and evidence in favour of clinical governance are strong. ▸ Clinical governance has been pivotal to health policy in New Zealand since 2009. ▸ An assessment of progress in New Zealand shows that: – clinical governance needs to be clearly defined – it requires robust management–clinical partnerships along with a multi-layered developmental strategy and investment in training – it also requires new organisational arrangements such as a clinical board. ▸ The New Zealand emphasis on clinical governance has been positive for health professionals but, at this stage, it is not possible to assess its broader impact.
Current research questions ▸ Should the definition of ‘clinical governance’ be site-specific or generic? ▸ What sorts of organisational arrangements might best facilitate the clinician–management partnerships and is there an ideal structure for this? ▸ What core topics should be included in a clinical governance curriculum for postgraduate medical training?
Key references ▸ Gauld R, Horsburgh S. Clinical governance assessment project: final report on a national health professional survey and site visits to 19 New Zealand DHBs. Dunedin: Centre for Health Systems, University of Otago, 2012. ▸ Scally G, Donaldson L. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998;317:61–5. ▸ Brennan N, Flynn M. Differentiating clinical governance, clinical management and clinical practice. Clin Governance 2013;18:114–31. ▸ Leape L, Berwick D, Clancy CM, et al. Transforming healthcare: a safety imperative. Qual Saf Health Care 2009;18:424–8. ▸ Paulus RA, Davis K, Steele GD. Continuous innovation in health care: implications of the Geisinger experience. Health Aff 2008;27:1235–45.
Acknowledgements The author is grateful to the National Health Board, Health Quality and Safety Commission and the DHBs for commissioning the study discussed in this article; to the 165 interviewees for their input into the study; and to the editor and three anonymous reviewers for comments on a prior draft of the article. The interpretations presented in this article are the responsibility of the author. Funding Joint commissioners as listed in the Acknowledgements. Competing interests None. Provenance and peer review Commissioned; externally peer reviewed. Gauld R. Postgrad Med J 2014;90:43–47. doi:10.1136/postgradmedj-2012-131198
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Clinical governance development: learning from the New Zealand experience Robin Gauld Postgrad Med J 2014 90: 43-47 originally published online November 6, 2013
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