Clinical governance: a key, but under-researched, health system foundation

Clinical governance: a key, but under-researched, health system foundation

Article Type: Guest editorial From: Journal of Health Organization and Management, Volume 29, Issue 4.

What do we mean by “clinical governance and leadership”?

This special issue of the JHOM covers a topic of increasing and critical importance to health systems. It has now been some years since the introduction of the concept of clinical governance (CG) in the UK NHS, as described by Scally and Donaldson (1998), and many countries and health systems have since had CG firmly on the policy agenda (Gauld, 2014; Halligan and Donaldson, 2001; Nicholls et al., 2000; Shiwani, 2006). This is for several reasons. First, are concerns about health care quality improvement and patient safety, driven by various lapses in professional standards and the monitoring and promotion of these. These concerns have also been propelled by obvious gaps in the systems of care – gaps in the way in which professionals work together, and between the different professionals involved in patient care (Scally and Donaldson, 1998). Second, because of the so-called “management-clinician divide” which exists in many health systems and hospitals, especially in countries such as the UK and New Zealand where there has been a strong influence of “managerialism” in recent years (Gauld, 2000; Klein, 1995). A third reason relates to the obvious knowledge of front-line service delivery that health professionals can bring to the decision-making arena. This means decisions in a CG environment are derived from a knowledge base that encompasses more than just strategic and financial considerations.

CG promises to address these concerns as it entails building a system of management and leadership which features health professionals in the foreground. Scally and Donaldson defined CG as:

[…] a system through which health 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 (Scally and Donaldson, 1998).

In essence, and to tease out some of the tenets of this definition, CG involves health professionals working in partnership with “management”. Indeed, professionals are an integral part of the management and leadership system, with a focus on improving the quality and safety of patient care. It is through this that “health organisations” build accountability for outcomes. Following this, good CG ensures that there is joint professional-management accountability for quality of care as well as financial performances, therefore, creating the foundations for excellence in clinical care. CG goals also include building working systems in which professionals encourage clinical performance and quality improvement amongst their peers in order to provide all-important clinical oversight of standards and health system performance. Very importantly, good CG involves every health professional viewing their professional work in a different light, with dual and equally important responsibilities: providing excellent and high-quality health care; and improving the system within which care is delivered. Following this, CG may involve new structures for health system and hospital organisation, designed to give life to the concepts and aims outlined above.

If CG is “the system” of professionals and management working together for the same goals, then clinical leadership is an element of that system with professionals stepping up into leadership positions and leading for improvement by example. With CG, all professionals and managers may be expected to play a role. Fewer professionals may have specific “leadership” roles, but all should still take an active interest in leading improvement of patient services and the system in which they work.

Research into CG

The research-base for CG is gradually building, providing a strong rationale for making it a founding principle for any health system or service provider organisation. Studies have demonstrated links between clinically led organisations and superior performances on quality of care and financial indicators (Dorgan et al., 2010; Goodall, 2011). Yet despite its importance, CG remains under-researched when compared with other core policy issues facing today’s health systems.

There remain questions around how CG is defined and what exactly its scope is, leading some to question what the focus of it should be, how it should be designed and implemented, and health professionals themselves demanding more specific information (Brennan and Flynn, 2013; Gauld and Horsburgh, 2012). It could even be suggested that CG is a “fuzzy” management concept; that without crucial detail on the structures which should be aimed for, or the roles that should be created in a health system to support CG, it will always be challenging building clinically governed organisations. Furthermore, each organisation could end up building its own version of CG, possibly repeating mistakes made elsewhere. We, therefore, need more research into what works and why.

Questions also abound around how to measure CG and leadership. Various studies have looked at components of assessment, largely deploying qualitative and case study methods, although some have also sought to quantify developmental progress across different health organisations (Freeman and Walshe, 2004; Gauld and Horsburgh, 2014; Gauld et al., 2011; Greenfield et al., 2011; Hogan et al., 2007; Som, 2009). Some studies have developed frameworks for assessing different dimensions of CG (Specchia et al., 2010). There are also various self-assessment tools (Department of Health Western Australia, 2005; Health Service Executive, 2012). The divergence in approaches may be expected in a field of management and organisational research but also points to another important gap. This is the need for improved methods for researching CG, especially the approaches and tools which might be used for this, along with broader agreement on these.

What this issue covers

This special issue on CG and leadership is the result of an open call for submissions. We set a wide scope for this, including theoretical advancements, case studies of CG development and implementation, evaluations of CG performance, and methods for its assessment. We present here in this special issue a series of submissions that were accepted following peer-review. The collection reflects the diversity of research in the field but obviously only touches on a potentially much broader range of topics and research approaches. The papers cover:

• the factors motivating Australian medical professionals who undertake training in leadership which, of course, is a key component of building clinical governance;

• a study of female leaders of academic departments in US teaching hospitals, an area traditionally dominated by male leaders;

• the clinical governance “levers” deployed in cancer care services reform in Canada;

• the process of developing and implementing clinical governance across Ireland’s public hospitals;

• the role of “fiery spirits” (designated leaders) in working to change services configurations in a context of clinical governance in Sweden; and

• also from Sweden, the interaction between clinicians and politicians in setting priorities, an important clinical governance function.

As noted, many topics in CG and leadership require further investigation. There is also a notable gap in use of quantitative methods for CG research. These topics could perhaps be taken up in a future issue of the JHOM. Meantime, we are very pleased to present this collection. In doing so, we hope to raise interest amongst the research and policy communities in CG and leadership and give it the prominence that anyone who is a patient of health services would naturally expect. After all, we all want our health professionals to be constantly seeking to improve the system in which they work.

Robin Gauld and Simon Horsburgh - Guest Editors

References

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Freeman, T. and Walshe, K. (2004), “Achieving progress through clinical governance? A national study of health care managers’ perceptions in the NHS in England”, Quality and Safety in Health Care, Vol. 13 No. 5, pp. 335-343

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