Clinical Governance Differently (Part 1)

Practical ways to move beyond compliance and towards continuous improvement

Introduction?

The somewhat itinerant life of a healthcare improvement consultant affords a few benefits, one of which is that I sometimes get to engage in the lives of several organisations simultaneously. While the fast-switching can be a little taxing, I’ve discovered that working with different levels in organisations (across regions and sectors), makes the subtle commonalities across them a little more apparent.

For instance, over the past year, I’ve worked on a range of initiatives linked (or at least adjacent) to questions of clinical governance*. Although clinical governance is widely (and correctly) regarded as a critical high-priority activity, most leaders and practitioners will readily express a multitude of frustrations with it - too much reporting and analysis for too little return (in terms of actionable intel), not having enough time to pursue real improvement, a lack of buy-in from frontline teams, unreasonable expectations from regulators, a perceived lack of trust from boards or senior management, a constant pattern of playing catch up with risks, low morale, a sense of resentment from clinical colleagues, so on and so forth. Most leaders are also prone to a gnawing anxiety from overseeing quite complicated systems without having a good handle on emerging risks or the sufficiency of mitigation efforts deployed.

There is a good chance that if you have worked in the field, you would have some experience with these issues yourself. With a decade spent in the churn of safety and quality work in the early years of my career, I wholeheartedly empathise!

Yet, the mere fact that similar stories emerge from organisations separated by time, space and service contexts suggests that these are perhaps a natural expression of something deeper, a ‘shaping’ influence that exists across organisations rather than merely some coincidental pattern of recurrent operational, technical or even cultural failures. The more I work with diverse organisations, the more I see this as a byproduct of the shared model of clinical governance^ adopted by many healthcare organisations.

I realise that what follows will be a discomforting read for some. This is not designed as a polemic against the obvious value of good governance systems in healthcare. Many tasks exist to make regulatory compliance easier or to demonstrate a visible commitment to safety and quality. These are important organisational priorities, no doubt. There is even the view that the resource cost of the extra administrative burden is offset by the promise of legal protection if failures do happen. While each of these assumptions can be debated, this is besides the point.

The essence of clinical governance has been described as simply to “integrate activities that support continuous quality improvement”1 , in other words, in supporting the learning and response cycles that?make healthcare safer.

If the ‘essential’ work of governance starves us of time, space and the required clarity to attend to the ‘essence’ of governance, isn’t this as compelling a reason as any to bring such conversations out of the shadows? If the muddled systems that we find ourselves enslaved to are complicit in creating this situation, then untangling those knots must be part of the conversation too.

Deconstructing clinical governance

Typical clinical governance activities tend to be viewed as an obligatory, non-negotiable exercise that organisations needn’t enjoy but just muscle through as efficiently and uncritically as possible. While these are complicated undertakings already, every other year something new is stirred into the pot, a new multiplicative numeral here, an added national standard there, another dimension of safety or quality to be fractionated out of the turbid slurry of clinical work.

When this happens, there is often little tolerance for (perhaps even a degree of fear of) entertaining questions that might go against the grain. In many organisations, to play the devil’s advocate by querying exactly how a given quality activity improves care is a sure-fire path to being labelled a contrarian or to even be uninvited from subsequent committee meetings (an observation not lost to many a clinical colleague). Yet, conversations about the relative value of various activities should be the most obvious first step in an era of resource rationing. A line of sight to the higher goal should not be sacrificed in pursuit of the immediate task.

What I often find is that governance teams tread this path not out of fear of regulators or due to a misplaced devotion to procedure. For many, it is the only system of practice they know.

So how did we even get here?

The form of institutionalised clinical governance that is now so familiar to us emerged in the United Kingdom as a reform priority - in response to a spate of serious patient safety failures where deficiencies in the governance of clinical risks were identified as contributing factors (such as the Bristol Royal Infirmary Inquiry).

Well-meaning efforts in the early 2000s gave us the foundations of the current model that many organisations continue to support today. We could describe this as a ‘rationalist’ (systematic, rules-based, empirical, analytical and compliance-centric) orientation to governance or as a rationalist ethos that permeates much of this work. In the absence of precedence, it would have made perfect sense to pursue this path, given that there were similar moves underway around the same time in the public service sector across the UK and Australia under the banner of ‘modernisation’.

In many ways, the intentional formalisation of this approach (as opposed to something that might have emerged over time) offered us a testable hypothesis - a proposition the adoption of this rationalist model would a) elevate the focus on safety and quality, b) create a culture of continuous improvement and c) make healthcare demonstrably safer and of higher quality. While ‘a’ was achieved rapidly (a massive win on a global scale), ‘b’ and ‘c’ have not been borne out by the evidence after three decades of strenuous effort.

Global patient safety and quality clearly did not experience the step changes in outcomes that were anticipated at the start of this journey. By extension, even if formalised governance systems conferred some local benefits in terms of an improvement culture, it certainly hasn’t manifested as a widespread pattern of continuous improvement at scale (otherwise things would have undoubtedly improved).

But there is an even more troubling aspect to all this.

A case of salting the wound?

One only needs to scan reports of major safety and quality failures in health and social care over the past two decades to see a consistent pattern emerge - a sampling of UK / Australian events are represented in the graphic below. Behind the tragic human costs, these examples highlight the repeated failures of governance systems to identify and engage with serious internal signals of risk. It also implies that whatever governance structures were in place in these institutions, they oversaw activities that did not pick up that the safety and quality of operations were degrading to dangerous levels.

The fact that the engine rooms of governance can become so disconnected from the very priorities they exist to serve should keep healthcare executive and boards awake at night. At the same time, we should not accept the salve that these case studies are some how blips on an otherwise high quality landscape.

At minimum, they represent one end of a continuum that most organisations will find a place on. Over the years, I have become more inclined to believe that this pattern of growing disconnect might well be an outcome of the rationalist governance approach and the mental models and practices it entrains: A ‘feature’ of the design of these systems rather than a ‘bug’.

If the current paradigm of clinical governance actually impedes true assurance and improvement - how does this happen?

The Dynamics of Degradation

There is a lot of possible territory to cover here. The safety science, sociology and organisational psychology literature is rich with examples, theories and counter-theories of how organisations incubate the necessary conditions for large scale failures within their management systems and institutional logics.

While we cannot touch on all the relevant material, I think it is worth highlighting certain negative patterns that predictably emerge from an over-reliance on the rationalist toolbox and go on to undermine the overall efficacy of clinical governance systems within organisations.

1. Reification and the Streetlight Effect

Just like in the high-school biology class with the eviscerated lab specimen, dissecting everyday clinical work with a rationalist lens makes us adept at describing what structures we see, while teaching us very little on how these parts work together.

When dealing with the behaviours of systems composed of living components with shifting, intangible linkages between them, it is natural to fall back on the visible and countable in lieu of a true understanding of how the desired behaviours are produced. These simplified models of safety and quality with their multiple categories and matrices lead us to feel some sense of control over the problem without creating a true sense of how these end points are produced in the real world practice.

Unfortunately, over time, these models can go through a process of what is called ‘reification’ - making us more prone to mistake the abstract for the real.

In time, the work of clinical governance can become like the metaphor of ‘drunkard’s search’ (or the ‘streetlight’ effect) - where we seek the markers of quality in the most convenient spots (the two-hundred page board report and the multitude of run charts) rather than where it is most likely to be found.

Worse, we gradually lose the ability to tell the map from the territory.

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2. A Rising Administrative Burden

In a resource constrained environment, an increasing burden of administrative work (documentation, auditing, reporting and administrative/managerial responses to complex risks) will take resources away from something else. The closer we get to the frontline, the more likely it takes away from time to care. This much is self-evident.

However by framing administrative work as a core safety and quality activity (arguably to raise its importance enough to promote sufficient compliance), it quickly becomes the main game in town - creating some truly weird maladaptations that do nothing to enhance quality. Think “high-risk” wristbands on every patient in the ward, inpatient fall risk assessments that run into five pages, or mandates to deploy them with every “at-risk” group including labouring mums (a class of short-term admission and a patient group where these older-person specific fall screening tools have zero predictive value but often get in the way of personal choice).

If the lack of utility of these measures were not enough, it also diverts enthusiasm and energy away from actual improvements that might be of practical benefit to our patients - because teams (despite their deeper intuitions) can begin to accept that they have done their bit for keeping patients safe by these exercises in procedural compliance.

3. Increasing Fragmentation

Increasing administrative burden and the “more is better” mindset also makes the clinical governance systems much more of a wicked problem to manage. Little organelles of work (checklists or procedural changes) often float away from direct control of the initiatives that implemented them and hide away in various pockets of the organisation, only to be discovered five years later in the next wave of implementation programs to address the issues (if ever). Other times, local and global initiatives can be at cross purposes to each other, spawning all sorts of undetected gremlins at their margins of contact.

The main issue is that the templates available to the rationalist governance model - its modes of interpreting data, designing solutions and intervening in work - all make the system more complex in ways that reduce an organisation's capacity to understand and manage the many runaway effects that these actions create.

We end up creating a more fragmented system sometimes as a result of the very efforts we deploy to defragment it.

4. Burgeoning Complexity

Another problem is that complex systems can produce complexity for no cost while compartmentalised efforts to deal with this complexity comes at a very high cost. For instance, while there is an analytical end point to a decomposition of a car, there is no such end point to clinical work. We could quite easily come up with a thousand indicators for safety and an equivalent number of quality dimensions, with highly sophisticated statistical models to integrate these and yet be no closer to “ground truth” in any real sense.

Practically speaking, there is absolutely no reason to believe that a governance system that is an order of magnitude more complicated than the one you have right now will produce even a smidgen more safety or quality for patients.

No matter what any vendor tells you the end goal is not a function of the multitude of metrics that you track but a function of how relationally connected you are to everyday operations.

5. A Focus on Safety Work versus the Safety of Work

Rae and Provan’s 2019 paper on the distinction between ‘safety work’ (all of the work that goes into demonstrating safety) and the ‘safety of work’ (the remaining activities that go towards making work safer) should be on high on your reading list if you haven’t discovered it already, ideally chased down with a couple of episodes of their highly regarded “Safety of Work” podcast.

Centrally, the two notions are presented as counterpoints that, although complementary in one sense, also exist in tension with each other. Further, the authors describe the phenomenon through which safety work can supplant the ‘safety of work’ because of the comparative ease with which one can be demonstrated over the other.

While the paper is concerned with occupational health and safety, its observations are very applicable to clinical governance.

6. Growing Operational Cynicism

As clinical governance activities become progressively decoupled from operations, it can amplify cynicism of safety and quality priorities among frontline clinicians and operational leaders. This is a strange paradox because few clinicians would express anything but enthusiastic support for efforts to make it easier to provide safer and higher quality care - yet the model they associate with the capitalised version of ‘Safety and Quality’ does not elicit the same interest.

That some Australian health services have chosen to stand up whole new “Innovation and Improvement” departments outside the reach of their safety and quality functions is a telling indicator as to how far the horse has bolted in this part of the world. While I don’t see these developments are problematic necessarily, some thoughtful integration is warranted so that critical risks are not missed in the newfound gaps between the oversight and change-making arms of healthcare organisations.

Equally, if these shifts end up relegating clinical governance teams to mere compliance monitoring, leaders who depend on these functions for insights on safety and quality might find themselves at the risk of being seriously misinformed as to what is actually going on.

Can Clinical Governance be done Differently?

While the aforementioned dysfunctions plague more organisations than we would like to admit, the path ahead is far from pre-determined. It does not need to be more of the same. We are already witnessing systematic shifts within the UK’s National Health Service to get at heart of these very issues. Across the dutch, the Kiwis seem to be blazing their own way forward.

Further afield, there are valuable lessons to be learnt from agencies as diverse as the Southcentral Foundation (the Nuka system of care), Médecins Sans Frontières and Buurtzorg Home Care and how they are translating principles of community partnerships, decentralised decision-making, adaptability, self-managing teams and rapid cycles of multi-level learning into effective models of governance.

These journeys are available to most organisations, regardless of how new this all sounds, how constrained the legislative environment is or how intolerant regulators and accreditation bodies appear. There are almost certainly things you can do now to rebalance and refocus in your given environment today.

In the next issue, I look forward to sharing some of practical tips and strategies I have used over the years to help safety and quality teams as well as board-level committees gradually create sustainable forward movement by coming back to a few key organising principles, by creating opportunities for novel conversations and by supporting intentional catalytic activities.

See you in a fortnight.

Come along for Healthcare Human Factors 2025 in Melbourne!

The first Monash University Human Factors and Patient Safety Conference will be held March 27 and 28, 2025 at Monash College in Docklands, Melbourne, Australia.?

*Regular readers might be a little perplexed as to why we are discussing clinical governance in the middle of a series on learning (keen readers will note that this particular edition of The Human Stream was slated to be focused on practical methods for learning from everyday work).

Well it so happens that my focus across current work and various recent interactions with colleagues has caused me to reflect on clinical governance systems more so than usual. Over the past few weeks, I've realised that a discussion about organisational learning is largely incomplete without talking about the ‘architecture’ that supports it - namely, our clinical governance models.

Of course, the sensible thing to do would have been to wait till end of the series to add it on as an addendum. Not known to be the most sensible sort, I instead followed the advice of one of my favourite authors, who suggests that it is good practice to get out of your own way when you have a strong intuition to write something! So clinical governance it will be for two issues.

Apologies to anyone experiencing a touch of mental whiplash! I will come back to ‘learning from everyday work’ in the New Year and wrap up the series.

^To our North American and Asian readers, clinical governance is an umbrella term used (more commonly in the UK and Australia) to describe the various systems and frameworks that codify, inform and help manage safety, quality and clinical risk management activities in healthcare organisations.

The Human Stream is a fortnightly newsletter for clinician improvers, safety and quality professionals, governance teams and healthcare leaders. The Human Stream compiles insights, topic overviews and practical tips from contemporary safety and systems sciences, all in an easy-to-read, information-rich package. Explore past issues at www.thehumanstream.com

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References

1? van Som, 2005 in UK Healthcare - Clinical Governance: Clinical Governance, edited by Group Emerald, Emerald Publishing Limited, 2005.?ProQuest Ebook Central, https://ebookcentral.proquest.com/lib/qut/detail.action?docID=282925.