Suhail Anwar ( Department of General and Colorectal Surgery, Huddersfield Royal Infirmary, UK. )
In 1998, the British medical regulatory body, the General Medical Council (GMC), severely disciplined 3 doctors after inquiring into the deaths of 29 infants and children at Bristol Royal Infirmary, a hospital in the south west of England. The deaths had resulted from open-heart operations for atrioventricular septal defect or transposition of the great arteries. According to the Council\\\'s adjudication, the 2 surgeons had continued to operate when their mortality rates were too high, and the medical chief executive (CEO), despite ample cause for alarm, had failed in his duty to intervene.
The "Bristol scandal" generated enormous outrage and in 1998, a public inquiry was set up under the chairmanship of Professor Ian Kennedy, a lawyer. His report1 suggested that between 1988 and 1994, the mortality rate for open-heart surgery in children younger than one year at Bristol Royal Infirmary was about double of that in England as a whole. At the conclusion of the GMC case in June 1998, James Wisheart, the senior surgeon, and John Roylance, former chief executive of the hospital, were struck off the medical register. Janardan Dhasmana, the second surgeon, was banned from operating on children for three years and later sacked by the hospital.
However the story just did not end there, lessons were learned and a new concept was born; the concept of Clinical governance.
Clinical governance2 is the term used to describe a systematic approach to maintaining and improving the quality of patient care within a health system. Its most widely cited formal definition describes it as:
"A framework through which health 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."
The four major factors that underpin the concept of Clinical Governance are recognisably high standards of care, transparent responsibility, accountability for those standards, and a constant dynamic of improvement. Clinical governance is how health services and hospitals are held accountable for the safety, quality and effectiveness of clinical care delivered to patients.
Clinical governance applies only to health and social care organisations, and only to 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 referred to as Corporate Governance. As of 1999, in the UK, 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 applies to all treatments and services. The three most recognisable components of clinical governance and those which involve health professionals in quality improvement are
Clinical effectiveness activities including audit and redesign
Risk management including patient safety
Patient focus and public involvement
Clinical Governance in Pakistan:
Like all existing health care systems, the Pakistani health care scene can immensely benefit from application of Clinical Governance and that includes health care professionals, trainees and above all patients. The lack of accountability is the single most important factor allowing health care professionals to behave irresponsibly and cause serious morbidity whereas the sole purpose of medicine as described in the Hippocratic oath is Primum non nocere "first do no harm".
So how do we go about it? No single system can cover the reforms in a health care system in its entirety. However a good start would be to set standards which can guide and support the processes of clinical and service change. Standards and their mere existence in the public domain means that decision makers cannot ignore them. They will lead to a more informed debate about service configuration and about performance. Standards need to be clearly defined based on best care evidence available. They need to be debated, agreed upon, published, distributed and looked upto as standards of excellence for delivery of care. It should be the responsibility of the ministry of health and the professional bodies that standards should be adhered to and any non compliance should be remprimanded.
A fundamental concept of Clinical Governance is that all health care professionals are required to keep their knowledge, skills and professional competencies up-to-date.
Learning and development happens in a number of ways:
Continuing professional development of clinical skills and competencies
Organisational support for leadership and/or clinical skills
Ongoing supervision and appraisal
Personal development plans
Mentoring, tutoring or training opportunities
Protected time for learning either as an individual, team or practice
Support to carry out research
Accountability is more than responsibility. To be accountable you need to have the ability, responsibility and authority for your actions. Different levels of corporate and individual accountability exist in relation to management structures and professional practice. The Duty of Care and Codes of Professional Conduct will provide clarity around the professional accountability of individual regulated clinicians.
How can Clinical Indicators help?
A Clinical indicator4 is an integral part for application of Clinical Governance. It is a tool that can help identify possible problems and/or opportunities for improvement within a service or treatment. A clinical indicator is simply a measure of the clinical management and/or outcome of care. A well-designed indicator should \\\'screen\\\', \\\'flag\\\' or \\\'draw attention\\\' to a specific clinical issue. Usually rate based, indicators identify the rate of occurrence of an event. Indicators do not provide definitive answers; rather they are designed to indicate potential problems that might need addressing, usually demonstrated by statistical outliers or variations within data results. They are used to assess, compare and determine the potential to improve care. Indicators are therefore, tools to assist in assessing whether or not a standard in patient care is being met. Used appropriately, indicators can be utilized to compare variations in how the same services are provided in different areas or against national benchmarks. Indicators can be used as a basis for reflection on current practice and act as the starting point for improvements in the quality of patient care.
What can we learn from the Kennedy report?
The Kennedy\\\'s report concluded that a "club culture" existed at the Bristol hospital; there was an imbalance of power, with too much control in the hands of a few individuals. Disturbing local results were kept under wraps. He called for a more open and accountable health service in which patients are seen as partners in decision-making, physicians surrender their dominance and become team players, standards for clinical and hospital practice are set and monitored, and local success rates are published.
For those working in the Pakistani health care system the conclusions of Kennedy\\\'s report are more than reminiscent of what is happening locally. The "you scratch my back, I scratch yours" culture has to be shunned for a greater good. Clinical Governance is not about a blame culture, it is about a transparent system where the sole and combined goal is improving the standards of care. This can only be achieved if individuals own up to their short comings, accept responsibility and strive for self and system improvement.
However human beings are inherently biased toward their own ideas and goals and even the most selfless of individuals can be lead stray with emotions and subjectivity. That\\\'s where Clinical Governance brings in the concept of accountability, a 360 degree system where individuals and groups are responsible to each other and no body holds the absolute power.
In summary a lot can be learned from this concept. Applied in an objective and true manner our system and patients can immensely benefit from this approach.
1.The Kennedy Report 2001. (Online) (Cited 2009 Feb 2). Available from URL: http://www.bristol-inquiry.org.uk/final_report/Summary.pdf.
2.Department of health. (Online) (Cited 2009 Feb 2). Available from URL: http://www.dh.gov.uk/en/Publichealth/Patientsafety/Clinicalgovernance/index.htm.
3.Bergman R. Accountability - Definition and Dimensions. Int Nursing Review 1981; 28: 2.
4.The Australian Council of Health Care standards. (Online) (Cited 2009 Feb 2). Available from URL: http://www.achs.org.au/ClinicalIndicators.