NHS support team Clinical governance: its origins and its foundations

S. Nicholls R. Cullen S. O'Neill and A. Halligan

The history of quality

In 1948 the National Health Service was established with no particular agenda for quality. It was assumed appropriate quality would result from the provision of an infrastructure and the training and education of staff. ``Quality was seen as inherent in the system, sustained by the ethos and skills of the health professionals working within it'' (Donaldson and Gray, 1998). There were attempts at quality improvement over the next two decades, but effort during this period was focused on rearranging tangible components of the service developing more and better equipment, renewing buildings and facilities, re-training and re-deploying staff. With responsibility for each of these elements separately apportioned it was inevitable that a lack of ``connectedness'' revealed itself in inefficiency, duplication, and the generation of complicated processes. (For example, a clinical team (Homa and Bejan, 1995) which reviewed its outpatient process in the early 1990s was able to reduce an eightstep process to one step by reviewing and adjusting clerical support. The resulting service was more efficient, more patientcentred and provided increased staff satisfaction. It also reduced costs by 15 per cent.) By the 1970s analysts and thinkers were working to define and explain the meaning and relevance of components of quality (criteria, standards, norms, etc.) as the importance of understanding the relationship between structures, processes and outcomes was recognised (Lembcke, 1956, 1959; Donabedian, 1981; Donabedian et al., 1982). In 1983 the Griffiths Report (1983) described a lack of clarity in accountability at local level, it overturned consensus management and resulted in the appointment of general managers to lead health care units. Medical staff were involved within management teams and this arrangement introduced an element of personal accountability for services provided. Since 1982 (Honigsbaum, 1994) managers had been accountable for output measures. Targets were revisited in Health of the Nation (Department of Health, 1992) and in Our Healthier Nation (Department of Health, 1998). However, targets remained related to financial and workload concerns, quality was

The authors S. Nicholls is a Researcher, R. Cullen is Programme Director, S. O'Neill is Communications Director and A. Halligan is Head, all of the National Clinical Governance Support Team. Keywords Clinical governance, Health care, National Health Service Abstract This article from the NHS Clinical Governance Support Team (NCGST) outlines the development of quality concerns since the NHS was founded in 1948. It traces the development of clinical governance as a means of achieving continuous quality improvement and describes what the implementation of clinical governance means for patients and professionals. It analyses features of the cultural shift necessary to underpin quality improvement initiatives and describes with practical examples the constituents of the culture necessary for successful clinical governance. Future articles in this series will address other issues around clinical governance and will explain the model being followed by delegates to the NCGST's Clinical Governance Development Programme as they implement clinical governance ``on the ground''. Electronic access The current issue and full text archive of this journal is available at http://www.emerald-library.com

Clinical Performance and Quality Health Care Volume 8 . Number 3 . 2000 . pp. 172178 # MCB University Press . ISSN 1063-0279

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``subsumed under the heading of organisational performance'' (Leatherman and Sutherland, 1998). ``Cost containment'' became an increasing problem in a service which was demand-led. Application of an understanding of the link between processes and outcomes in terms of quality had singularly failed to deliver improvement. A study which reviewed purchaser-provider contracts as a means of addressing quality issues, for example, found little evidence of a systematic approach to quality improvement (Gray and Donaldson, 1996).

Quality in the 1990s

There is a growing agreement that the NHS must make best use of available resources, and a general consensus that improved use of research based evidence will secure improved outcomes and consistency of approach. However, the rapid development of health technologies, and advances in the clinical management of specific conditions, has increased the complexity involved in defining and delivering clear and consistent quality in health care. A number of prominent service failures in bone tumour diagnosis in Birmingham, in paediatric cardiac surgery in Bristol, in cervical screening in Kent and Canterbury have helped bring quality improvement firmly to the top of the agenda. As public ``perception'' of the quality of health care performance fell for the first time below ``actual performance'', the 1990s heralded a requirement to revisit and review health service quality.

care. Based on 12 years of research, and more that 450,000 interviews, patients have identified eight ``dimensions of care'' which reflect their most important concerns. The list is perhaps quite different from one which professionals may have compiled on a patient's behalf: . respecting a patient's values, preferences and expressed needs; . access to care; . emotional support; . information, communication and education; . co-ordination of care; . physical comfort; . involvement of family and friends; . continuity and transition. As we define quality in the context of clinical governance initiatives we must embrace professional and patient perspectives and priorities and we must determine each in a spirit of ``authentic curiosity''.

Responses to the quality agenda

In 1997 New NHS Modern & Dependable (Secretary of State for Health, 1997) addressed the issue of health care quality directly. Quality was to become ``a prevailing purpose rather than a desirable accessory'' (Leatherman and Sunderland, 1998). The government introduced for the first time a statutory duty in respect of quality and the concept of corporate governance, previously applicable only to financial and workload affairs, was extended to the provision of quality. Supporting Doctors, Protecting Patients (Secretary of State for Health, 1999), with its proposals for professional regulation, provided ``additional strands within the Government's new strategy for quality improvement in the NHS''. The NHS Executive has set out a minimum series of actions with which NHS Trusts and Health Authorities must ensure that structures are in place to implement controls assurance (NHS Executive, 1999). This year ``An organisation with a memory'' (Department of Health, 2000), with its candid review of adverse events in the health service, has illustrated how cultural change and new systems are vital to address existing inadequacies. The establishment of the

What is quality?
Professionals and patients would no doubt define quality in different ways. Clinicians may justifiably focus on ``doing the right things, for the right people, at the right time, and doing them right first time'' (Donaldson and Gray, 1998). Patients, however, ``do not feel qualified to judge technical quality they assess their health care by other dimensions which reflect what they personally value'' (Kenagy et al., 1999). The Picker Institute[1] specialises in measuring patients' experiences of health

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National Institute for Clinical Excellence (NICE) in April 1999 and the Commission for Health Improvement (CHI) in April 2000 has formed part of a structured response at national level to ensuring quality improvement. As a requirement for rigour and accountability is imposed on individual practitioners, NHS Trusts, Primary Care Groups and Health Authorities, clinical governance is proposed as a means by which accountable quality will be achieved. Clinical governance is becoming ``the main vehicle for continuously improving the quality of patient care'' (Scally and Donaldson, 1998).

Davies et al. (2000) have identified the difficulty of achieving a ``cultural fit'' where subcultures exist both within different occupational or professional groups and between such groups. Sandra Dawson (1997), when she reviews the difficulties inherent in putting research into practice, finds at least ``four different cultures F F F different worlds'' within the NHS. The dependent relationship between achieving quality improvement and changing organisational culture has been understood in business and industry for many years. The importance of changing culture in order to achieve clinical governance was recognised as the Government set out its vision for quality in the new NHS:
F F F achieving meaningful and sustainable quality improvements in the NHS requires a fundamental shift in culture, to focus effort where it is needed and to enable and empower those who work in the NHS to improve quality locally (Secretary of State for Health, 1997).

Quality and clinical governance?

Clinical governance has been formally defined as:
F F F 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 (Donaldson and Gray, 1998).

Clinical governance can be viewed as a whole system cultural change which provides the means of developing the organisational capability to deliver sustainable, accountable, patient focused, quality assured healthcare. The National Clinical Governance Support Team has developed one model for embedding organisational capability in health care units. This model, as it is delivered via the Clinical Governance Development Programme, will be explained in detail in a future article in this series. The fundamental requirement for successful implementation of clinical governance by any model is to generate a shift in existing culture.

The complex hierarchy which arose to deal with the different worlds within the health service has frequently precluded effective communication and has contributed to poor and inefficient planning. It has meant that in the past there has been little opportunity to ``join things up'', and service quality has suffered. The means by which we chose to implement clinical governance may be an invaluable opportunity to begin a cultural shift.

How implementation of clinical governance may ``shift the culture''

Clinical governance is a chance to find ways to move people out of the comfort zone of the status quo towards a more challenging culture where there is active learning, talking with ``hearing and listening'' and where questions are asked in the spirit of learning and development. The means by which clinical governance is introduced could create the initial momentum required to begin to ``change the way things are done around here'' (Davies et al., 2000) so that we move towards a reflective, non-blame culture where ``what went wrong?'' not ``who went wrong?'' is the first response to a problem, and where the same mistakes are not repeated by different people on a regular basis.

Why change culture?

In the past a complex environment which was often too hierarchical and inflexible made efforts to provide quality service exhausting and unworkable. There were rigid barriers and blockages which kept professional groups separate and isolated so that integrated development often happened only at the margins of service.

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Patients first and last

At the centre of clinical governance must be a real partnership between patients and professionals. It is patients who can best tell it ``as it really is'' and professionals need to develop the mechanisms and the skills to listen to patients with ``authentic curiosity''.
F F F the task is not so much to see what no one yet has seen, but to think what nobody yet has thought, about that which everybody sees (Arthur Schopenhauer).

Only when we can see ``through the patients' eyes'' can we be confident that we are building into organisations and systems deliverables which are really meaningful for patients at their centre.

measurement tools centred around the seven ``pillars'' which provide the support for the patient-professional partnership at the heart of clinical governance (see Figure 1). Underpinning the successful implementation of clinical governance is an awareness of the need for solid foundations to establish an enabling culture. The five cultural components systems awareness, teamwork, communication, ownership and leadership represent the areas in which we need to share ``beliefs, attitudes, values and norms of behaviour'' (Davies et al., 2000) in order to deliver sustainable quality improvement in health care. Systems awareness Health care organisations comprise myriad systems whose complex interactions can generate unplanned consequences because ``every system is perfectly designed to achieve the results it achieves'' (Berwick, 1996).
Systems awareness F F F ``What went wrong?'' not ``who went wrong?''

Recognising the most valuable asset of all

As we implement clinical governance we must recognise that ``the key resource for the NHS is its staff'' (Harrison and Dixon, 2000). The health service is a multitude of highly skilled, highly motivated, hard working and creative individuals. In the past the inevitable unpredictability which such a rich mix of talent creates has sometimes encouraged organisations to design complex rules, to build in check on check to insulate in order to protect. Example of an overly complex system with ``non-value adding steps'':
The requirement for a medical signature on investigation request forms has been found to be unnecessary F F F by making a simple adjustment to the system we have eliminated a previously unpredictable delay and cause of unnecessary frustration for patients, increased efficiency, and improved ``patient flow'' (delegate to NCGST Clinical Governance Development Programme).

Systems failures Systems usually grow up over time to contain multiple defences against accidents or untoward events. Some defences may be termed ``hard'' builtin barriers such as automatic switches, warning lights, computer programmes which do not allow mismatched data entry, etc. Some defences are ``soft'' they involve people and administrative controls checklists, systems for double checking drug dispensing,

Figure 1 The temple paradigm

Clinical governance is a chance to harness and value the talents and skills of our staff to recognise the need to mobilise knowledge from the front line. Health care professionals who work in teams to review their own service, who are empowered to ask ``Where do we want to go?'' and ``How are we going to get there?'' will engage with a new agenda on quality and act as pathfinders to create a tried and tested route to quality improvement. The CGST uses a temple model to capture the components necessary for successful clinical governance. In future contributions to this journal we will look at performance 175

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etc. Ideally, hard and soft defences create an impregnable barrier and eliminate error. In reality some defences will be flawed and may fail. When defences fail sequentially a ``gap'' or ``channel'' is created via which a hazard meets a victim (Figure 2) (Department of Health, 2000). Most often it is a system which fails, not a human. There is rarely a single causal element in a failure: when there is a ``near miss'' or an ``untoward incident'' the first response should always be to examine the systems involved. In the past the tendency has been to concentrate on perfecting the components of systems. We have tried ``to make doctors better at doctoring, to make nurses better at nursing to give equipment more functions F F F to replace one drug with a better one'' (Berwick, 1996). While ``discipline-specific'' improvement is important, it is more productive, and more sustaining, to see the pattern of professional interaction and to redesign the overall flow of work using a ``systems view''. Understanding the flow of systems Effective management aligns itself naturally with people and patient flows, reinforcing their centrality. Berwick (1996) describes ``continuous flow'' as the alternative to ``batching''. Batching is ``making stacks of things to be worked on in due time''.
We stack things everywhere in health care F F F patients in waiting rooms, forms and equipment in bins, laboratory specimens for processing, and phone calls on hold (Berwick, 1996).

There were two set times during the day when tissue specimens would be cut. All specimens would then be processed overnight as a batch; embedded in paraffin wax the following day, as a batch; cut and sent to the Histopathologist as a batch (and arriving at 5pm) and reported the following day as a batch (the reports arriving with administration staff for typing at 5pm). By adjusting the ``cut up'' times, maximising the use made of the automated part of the process, and using smaller processing runs by understanding and improving the flow of the system the laboratory achieved an 80 per cent increase in the number of results returned within 24 hours. There were no extra costs involved.

Understanding the interconnections of systems It is important to anticipate and analyse the ``connected-ness'' of events and actions. It may not be immediately apparent that the broken wheelchair in A&E is contributing to the waiting time in Xray, or that insisting on taking all patients to theatre on their beds means two less patients per operating list. The NHS has generated hugely complex system matrices over the years, and many have rarely been re-evaluated. Clinical governance is an opportunity to review and streamline, to cut out components which at best add no value (which detract from, or delay, the provision of quality service) and at worst cause harm. Teamwork On a day-to-day basis, as we work alongside each other, we recognise the interdependence of existing working methods; there are not many of us who can provide a service alone. Moss et al. (1998) suggest that a patient with a probable diagnosis of lung cancer will have contact with about 20 hospital professionals. ``The time spent with the consultant will be where the patient learns about the probable diagnosis and the treatment options. But the decisions about care cannot be made without the contributions from the 19 others''. Properly developed, multidisciplinary teams will have the potential to become prime levers for change; as teams grow and develop they will be able to both drive and deliver quality improvement initiatives. Communication In a system as complex as the health service much effort is necessarily concentrated in passing information from those who have it to those who need it.

When a pathology laboratory in the Midlands set out to solve problems with prolonged turn-around of diagnostic histology specimens it analysed the system:
Figure 2 Swiss cheese

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Clinical Performance and Quality Health Care Volume 8 . Number 3 . 2000 . 172178

As we redesign systems we need to build in communication mechanisms which enable the transmission of accurate, accessible and timely information. The information needs to reflect the appropriate parameters and reality; it must be presented in an easily understood format, and it must be delivered to the person or team which will use it on time.
Rumours illustrate the truism that the most effective way to communicate is informally, face to face, one-to-one with individual people (Garside, 1998).

contribution carried equal weight and every opinion was valued. It was clinic co-ordinators/clerks who, in the new clinic, took the lead on sorting clinic referrals, and it was they who offered the solution to a problem with laboratory turnaround times which threatened delaying receipt of histology results following dilatation and curettage. They suggested the 0730h clinic start which meant that patients were investigated, and received results and treatment if appropriate at their first clinic visit.

Effective communication will enhance service quality and will enable, for example: . effective hand-over sessions; . informal one to one dialogues to learn from and with individual patients who have experienced difficult episodes of care; . sensible oral and written information and clear handover mechanisms for locums; . habitual, informal team reviews after clinics/surgeries; . regular contact with and surveys of patients to hear their views and ideas. Ownership Ownership is about real participation of staff in all developments. It is about creating a working environment where structures are in place to support individuals so that professionals and teams are empowered to own, and therefore to solve, problems. The Ritz-Carlton Hotel quality award The Ritz-Carlton hotel, which has twice won the prestigious Baldrige Award[2] for quality, understands that the concept of ``ownership'' must be high on the agenda of essentials necessary to deliver quality:
At The Ritz-Carlton our staff are the most important resource in our service commitment to our guests. All employees have the right to be involved in the planning of work that affects them. Each employee is empowered. Whoever receives a complaint from a guest will own it and resolve it to the guest's satisfaction.

A project team which neglected to include clinic co-ordinators would have suffered by the omission. A team which values all of its members, which encourages equality, freedom to think aloud and be creative, will often find that the best ideas and the most imaginative solutions arise from staff who have never before been asked. Leadership An effective leader understands the reality of the present, but can focus followers on the future to achieve commitment to an agreed vision. Living systems health care systems embrace constant flux, unpredictability, individual creativity, interdependence, the jostling of co-operation and competition. People working within living systems need to be empowered, encouraged to grow, supported as they develop wisdom, and learn and apply lessons from experience: effective leadership is crucial.
Resistance to change is potentially so strong that without consistent, unswerving commitment from leaders, programmes for change are unlikely to be successful (Garside, 1998).

An example from an improvement project to create a ``single visit (referral to diagnosis) menstrual disorders clinic'' may serve to make the point:
All members of the small project team were involved from the beginning, and all were united in their determination to improve what had been clearly demonstrated to be a poor service. Project meetings were round-table; every

Changing culture will help accelerate quality development A shift in culture is a prerequisite for successful clinical governance; we all want to work in a learning organisation, one which values our contribution, where systems are supportive, safe and efficient, where errors are seen as learning opportunities, and where the focus is firmly on quality assured patient care. If, as we work on implementing clinical governance, we can begin to shift ``the way things are done around here'' we will accelerate the development of health care services which have the organisational capability to deliver patient centred, systematic, accountable and sustainable quality assured health care.

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Notes
1 The Picker Institute, Suite 100, 1295, Boylston Street, Boston, MA 02128. http://www.picker.org 2 The Malcolm Baldrige National Quality Award, established 1988.

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