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Standards for general practices (4th edition)

including Interpretive guide for Aboriginal and Torres Strait Islander health services

Appendix B

Clinical governance

Introduction

There are several concepts in the RACGP Standards for general practices 4th edition that are multifaceted and which are reflected in different parts of the Standards. Clinical governance is one of these.

This appendix outlines what makes clinical governance important to the Standards, and provides an overview of the aspects of the Standards which contribute to good clinical governance. The RACGP defines clinical governance as a framework through which clinicians and health service managers are jointly accountable for patient safety and quality care. The Australian Commission on Safety and Quality in Health Care describes a model of governance18 that includes both corporate and clinical governance where corporate governance provides a structure through which corporate objectives (social, fiscal, legal and human resources) are set and achieved and performance is monitored.

The concept of clinical governance

Clinical governance as a concept may seem daunting to some people, especially people who are new to the healthcare environment or general practice. In the discussion below we outline how it is just a pragmatic approach to producing quality care.

Clinical governance involves the establishment of long term and trusting relationships. It requires respect and ongoing open communication. Some aspects involve mentoring and nurturing. Others involve encouraging self discipline and the willingness to be responsible for one’s actions. There is a component in clinical governance which involves being mindful of risk and opportunity. Although clinical governance can involve some personally and professionally challenging times, it is also a framework in which many people thrive.

The environment for clinical governance

The Australian Standard on corporate governance19 says ‘the essence of good governance is accountability’.

One side of this accountability reflects the longstanding dictum ‘do no harm’. This side of accountability is being accountable for preventing harm and appropriately managing harm where it occurs. The other side of this accountability is concerned with grasping opportunities to improve the quality of care and the working environment. These opportunities occur, for example, when new treatments become available or when new knowledge is discovered about existing treatments. Other opportunities are arising from the capability of new electronic information systems to ease the process of clinical coding and thus create better information for making quality improvements in the practice.

In broad terms, there are two areas of accountability that require an environment that is transparent, supportive and just. The first area is accountability to patients to prevent harm or manage harm when it occurs, including the disclosure of harm to patients by people who care for them. The second area of accountability is to the clinical team, to provide a safe, supportive and just work place and culture.

While a distinction is sometimes made between a focus on patients and a focus on the health team which cares for patients, in terms of clinical governance it is useful to see the situation more like a symbiosis, where an environment of accountability creates the opportunity for people to share their enthusiasm and insights and maintain a momentum of quality improvement.

There is a substantial focus in the RACGP Standards on taking a patient centred focus. Such criteria as 2.1.2 Patient feedback reflect this. Additionally, the RACGP has responded to the profession’s increasing concern for the health and wellbeing of the people who work within general practice, by complementing this patient centred concern with one for the people who work in the field.

The environment needs to be one that is active, rather than passive – one in which there is ongoing attention to the opportunity for harm.20 The Australian Commission on Safety and Quality in Health Care21 (ACSQHC) says effective clinical governance includes:

  • recognisably high standards of care
  • transparent responsibility and accountability for maintaining those standards
  • a constant dynamic of quality improvement.

Rather than a constant hypervigilance, the environment needs to cultivate an ongoing present mindedness to the risk of safeguards failing and harm occurring. The Standards focus on a number of mechanisms that bring potential and actual lapses in quality to the attention of the people who can prevent harm or manage its ongoing impact.

The link between quality and clinical governance

Phillips et al22 explored the link between quality and clinical governance in the Australian primary healthcare sector and found seven key areas to support clinical governance.

These, together with aspects of the RACGP Standards which reflect them, are:

Making clinical governance work

In a review of the literature on clinical governance, Braithwaite and Travaglia23 identified a number of issues as key to effective governance:

  • links between a health service’s clinical and corporate governance
  • the use of clinical governance to promote quality and safety through a focus on quality assurance and continuous improvement
  • clinical governance structures designed to improve safety and quality and manage risk and performance
  • strategies to ensure the effective exchange of data
  • knowledge and expertise
  • a patient centred approach to service delivery.

This suggests that it is critically important for the owners of a general practice (and others involved in its corporate governance) to play an active role in cultivating clinical quality. This concept is reflected, for example, in Criterion 1.4.2 Clinical autonomy for general practitioners. This work also suggests it is important to remember that clinical governance is not an end in itself. The purpose of clinical governance is the promotion of safety and quality.

The structures which form the clinical governance model within a general practice need to be designed with this aim in mind. As the RACGP Standards reflect there is an important role for pragmatism – for a practice structure that will really work to improve quality.

The RACGP Standards contain a number of criteria which focus on the effective exchange of information and data. These range from criteria about information collection, storage and transfer to criteria which encompass practice meetings to discuss the healthcare provided by a practice. In this way, the Standards reflect the general findings of Braithwaite and Travaglia.

Conclusion

Although the area of clinical governance can seem complex and sometimes onerous, the RACGP Standards provide a framework which allows clinical governance to become a vital and useful part of practice life.

References

  1. Australian Commission on Safety and Quality in Health Care. Draft National Safety and Quality Healthcare Standards. Sydney: ACSQHC, 2009.
  2. Standards Australia International. AS 8000–2003 Corporate governance – good governance principles. Sydney: Standards Australia International, 2004.
  3. Reason J. Human error: models and management. BMJ 2000;320:768–70.
  4. Australian Commission on Safety and Quality in Health Care. Draft National Safety and Quality Healthcare Standards. Sydney: ACSQHC, 2009.
  5. Phillips C, Hall S, Pearce C, et al. Improving quality through clinical governance in primary healthcare. Canberra: Australian Primary Healthcare Research Institute, 2010.
  6. Braithwaite J, Travaglia F. An overview of clinical governance, policies, practices and initiatives. Aust Health Review 2008;32:10–22.

Appendix B

Continuous quality improvement

This additional section has been included to provide a brief overview of continuous quality improvement (CQI). We recommend that you read this in conjunction with the relevant sections of the Standards and the RACGP QI&CPD program.           

The section gives a general description of CQI and then provides examples for the provision of clinical services. If, through the process of obtaining accreditation against the Standards, you identify any omissions, gaps or even patches of mediocrity in the processes of your health service, it may be appropriate to use a CQI process to address these.

For more information, refer to the Useful resources section of Standard 3.1 Safety and quality. In particular, GPs and other health professionals participating in the RACGP QI&CPD program should refer to the section on quality improvement at https://www.racgp.org.au/education/qicpd-program/

What is continuous quality improvement?

Most of us choose to work in healthcare to improve quality of life for the members of our community. How can we be sure that we are making a difference?

The glossary in the Standards for general practices defines quality improvement as:

An activity undertaken within a general practice, where the primary purpose is to monitor, evaluate or improve the quality of healthcare delivered by the practice. Ethics approval is not required for quality improvement activities, including clinical audits using a tool such as CAT or ‘plan, do, study, act’ cycles, undertaken within a general practice.

Continuous quality improvement is the process through which we can, on a regular basis, look at our health service and demonstrate that we are making a difference. Best practice is constantly changing and CQI systems enable us to ensure that we are providing the most effective service possible and that our work is impacting on the community positively.

We cannot call ourselves effective health professionals unless we take part in CQI to continually improve the delivery of those health services.

The RACGP Standards

Continuous quality improvement is illustrated by Criterion 3.1.1 in the Standards for general practices, which looks for evidence of quality improvement in a practice. Auditing, which is one of the components of CQI, is also recognised as a category 1 QI&CPD activity, with points awarded.

Blame-free culture

The days of finding someone to blame following a significant event are a thing of the past. CQI is not a tool to affix blame. Our training ensures that our practices are safe and ethical. Nevertheless, keeping up with the pace of continually evolving evidence-based medicine means that we all, at some point, will be practicing medicine that is out of synch with the latest evidence. Such is the nature of healthcare work. It is therefore vital that we understand this and appreciate the benefits of CQI as a learning tool.

Whose responsibility?

CQI is the responsibility of all clinical and non-clinical staff, although this needs to be driven by a CQI plan. The process is continuous and relies on everyone contributing.

Putting the theory into practice

There are many ways of evaluating the service provided. Health services need to ensure that staff have adequate time during work hours to do this.

The next section explains some of the ways in which the theory of CQI could be put into practice for clinical services.

A pre-requisite to good CQI is consistent coding

See also the RACGP publication Clinical indicators and the RACGP (2010) at www.racgp.org.au/your-practice/business/tools/standards/indicators

If health services do not use standardised coding then searching the database for information on the presentations you wish to study is going to be a difficult task.

Coding chronic obstructive pulmonary disease (COPD) as wheezing, bronchitis, emphysema, asthma etc. will make running a search for individuals with COPD very difficult. It is therefore important that you consistently use internationally accepted standard codes.

The cornerstone of CQI is good records. If the data entered in your health service’s electronic records system is poor quality, the information that you extract will be useless. Brief note keeping might appear to save you time, but in the long run it will cost you time and quality.

Clinical audit

A clinical audit is the gold-standard way of assessing and improving clinical services. It should be an on-going process that is relatively quick and easy to perform. The aim of an audit is to see how your service compares to nationally accepted evidence-based standards.

Choosing a topic for a CQI project

You need to choose a topic that is relevant to your community. This can be identified by looking at your chronic disease registers, from issues raised in your staff meetings, or from other sources such as patient feedback data. Several independent bodies also provide suitable audit topics for general practice. These bodies include:

Criteria for comparison

Once you have chosen a suitable clinical topic, appropriate criteria need to be selected for
comparison with nationally accepted standards. For example, if the topic you have chosen is the quality of asthma management, a criterion that could be used for comparison could be: people above the age of 7 with asthma should be offered spirometry at diagnosis.

You can choose your criteria by reviewing the current evidence. In the case of asthma, the easiest way of doing this is by looking at the guidelines published by the National Asthma Council of Australia or the second edition of the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. This resource was developed by the RACGP and NACCHO and provides guidelines for the prevention and management of a broad range of chronic diseases in the Aboriginal and Torres Strait Islander population.

Similarly, depending on what the audit topic is, you may choose to review the guidelines published, for example, by:

  • National Prescribing Service
  • One 21 Seventy
  • Diabetes Australia
  • Kidney Health Australia
  • National Heart Foundation.

Such guidelines can help you to choose your audit criteria.

Standards for benchmarking

Once the criteria have been selected, a benchmark needs to be set. Continuing with the example of asthma, the benchmark used might look something like this: at least 80% of adults with asthma have been offered spirometry.

The benchmark selected may be arbitrary, or a comparison can be made with other health services in the area. For example, if another health service in the area has demonstrated that 90% of their asthma patients have had spirometry, you can use 90% as your standard.

Using the National Asthma Council to set the criteria, the initial stages of your audit may, therefore, look like this:

  • topic: adults with asthma
  • criteria:
    • adults with asthma who have had spirometry at diagnosis
    • smoking status has been documented
    • inhaler technique education has been documented in the notes
  • the standards against which to benchmark could be set at 80% for each of the above criteria.

Data collection

Ideally, an audit would include all patients who fit the selection criteria. In the example above, this would include all adult patients at your service with asthma. However, this would be very cumbersome and doing this regularly would be time-consuming. An alternative and more effective way of looking at your data is by randomly sampling 20–40 patients who fit the selection criteria. You then need to look at each person’s notes to see if they have had spirometry at diagnosis, smoking status documented and inhaler technique documented as having been discussed. The results may look something like this:

  • number of adult patients with asthma randomly selected: 30
  • criterion 1: spirometry done at diagnosis 15/30 (50%)
  • criterion 2: smoking status documented 27/30 (90%)
  • criterion 3: inhaler technique documented as discussed 3/30 (10%).

Analysis

For criterion 2, consistency with best-practice guidelines is clearly demonstrated; however, the health service could be doing better in criteria 1 and 3.

How can the service improve care in these areas? This needs to be discussed in your service meeting; just being aware of the issues might result in more spirometry and more education. Additionally, the answer might be better documentation, or the service may feel that it would benefit from a dedicated nurse-led asthma clinic, which could focus on carrying out more
spirometry as well as providing patient education.

Analysis of the audit data is service-specific. What works in one service may not necessarily work in another.

Re-audit

Once changes to clinical practice have been implemented, their effectiveness needs to be demonstrated by performing a re-audit. This is usually done 6–12 months after the changes are implemented, but time frames can vary depending on the nature of the changes made.

Other continuous quality improvement activities

Significant event analysis (SEA)

SEA is a tool for recording unexpected events and attempting to minimise their risk of occurring again. Such events need to be recorded in a way that preserves the anonymity of the individuals involved, and an analysis needs to be conducted on what went well and what could have been done better. SEA links in with auditing and quite often identifies further areas that require auditing. SEA is particularly good at highlighting issues for improvement that you might have not otherwise thought about. For example:

You receive a letter from the hospital stating that a patient who attends your service has been discharged following an overdose of benzodiazepines. You note that the patient was seen the day before with insomnia and was prescribed benzodiazepines but suicide risk was not assessed. As a consequence of the analysis your health service may decide that the guidelines on benzodiazepine prescribing and suicide-risk assessment need to be reviewed and incorporated into practice. An audit could then demonstrate that the change in practice has indeed improved outcomes.

Remember that the application of SEA is not just limited to clinical issues. It can be used for any unexpected event in the practice.

Inter-service visit

The aim of a national health system is to improve outcomes for the population. Individual services are not in competition but should work in harmony to improve health outcomes. If an area for improvement has been identified by your CQI program, you may want to see how another health service deals with the same problem. This could then be implemented by your service. The RACGP CQI website provides guidance on organising an inter-service visit.

Other activities

CQI can also include collecting and using patient feedback, video analysis of consultations, participation in accredited learning activities, journal clubs and many other activities.

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