Time for a new set of clinical governance (definition) wheels?

Ever had a lightbulb moment about clinical governance? Yes, I may be the only person in Australia (or the world) pondering this deeply today. (Or most days!)? But a little stubbornly missing piece of my CG puzzle popped into place this week.? As a result, I’m going to redefine clinical governance – for me, at least.?

I’ve been banging on about CG not quite doing itself justice for a few years now. Everywhere I look across human services, there are many reminders that although the clinical governance workload is increasing, we’re not seeing a corresponding improvement in care quality. ?You would think that as effort goes up, so should care quality.? But inconsistent care is still the norm - a mix of brilliance, harm and mediocrity - ?despite the seemingly endless compliance, auditing, training and incident reporting etc, etc that goes on.? Frankly, I think we’ve reached the limit of what a focus on CG systems alone can achieve in our complex environments.

Many of you will know that I’ve become a bit obsessed with purposeful clinical governance, and how the purpose should be to enhance the human and care interactions between staff and consumers. People create care quality in these interactions. But I don’t think this gets anywhere near enough airplay.?

Clinical governance has become an end in itself.? It’s like mixing all our favourite foods together in a bowl and ‘hoping’ a nice meal emerges.? Well, sometimes it will, sometimes it won’t.? But this approach feeds inconsistent quality care. CG should be our 'means to an end' go-to recipe where we know exactly what we want to make, we know exactly what we have to do, if there’s a team of us we all know our roles, we feel supported and united in the common goal, we focus and we get it done; and it gets us a great result ?nine times out of ten (even the best chefs have off days!)? And we get a sense of satisfaction from producing that great ‘meal’ yet again.

Recently I had a bit of a lightbulb moment about all this. (One day I might talk about it in an AICG ‘Lightbulbs’ session!) ?Sometimes a lightbulb is learning something new, and sometimes it’s seeing something you’ve been thinking about expressed in a new way. Scanning the IHI newsletter, I was struck by a headline: Staff Are the Change: How Focusing on Staff Engagement Got Results.(1) Of course, my first reaction was – ‘no kidding!’ Then I read the opening paragraph: ‘Previously, only 50% of elective surgeries at Barts Health NHS Trust started within half an hour of their scheduled time. A recent initiative increased that number to 70–75%. Yet the work did not focus directly on increasing efficiency. Instead, it focused on engaging staff first.'

Hmmm.? Once again, no brainer.? But when I read further, the big flag unfurled in front of me, patiently waiting for me to notice it: ‘It sounds counter-intuitive, but a recent initiative to improve elective surgery start times did not focus directly on increasing punctuality and efficiency. Instead, it emphasized improving staff experience and ensuring that they had what they needed to flourish.’

Bang! So this is not just making sure staff feel clear, supported and equipped as we implement the new processes and solutions for improving elective surgery start times (all still very important!) This is next-level prioritising the staff experience as the basis for improving a process and outcome. Before diving into the usual technical nuts and bolts of driver diagrams and flowcharts and new procedures and training (if you then even need them!) ?

The project was led by Eva Fiz, Deputy Director, Improvement and Transformation at Barts Health NHS Trust (London, UK), who said: ‘“We are not numbers. We are people and patients. We want to make sure that the time we spend in theatres is as good as it can be.”? She noted that they had tried to improve start times in the past, focusing on the usual process inefficiencies, ?with not much impact. But this approach was different – with a very different result.

OK.? Imagine if all improvement started with this premise.? And beyond that, if day-to-day care delivery was designed for a great staff experience, not just to get things done. I don’t know for sure, but I bet that a whole lot of other things would improve off the back of it; culture, outcomes, efficiency, satisfaction.? ?Satisfied staff, satisfied consumers.? No brainer again.

In light of this lightbulb, I examined a couple of my favourite clinical (or quality – depending on the sector) governance definitions to see what messages they're sending.

The first we might call a traditional ‘nuts and bolts’ definition – but a good one; not too long, straightforward, says what it means, with purpose:

‘The integrated systems, processes, leadership and culture that are at the core of safe, effective, connected, person-centred (community) services underpinned by continuous improvement.’??(Victorian Community Services Quality Governance Framework, 2018. https://www.dffh.vic.gov.au/publications/community-services-quality-governance-framework)

Then there’s this, expressed slightly more inspirationally (and a classic):

“A framework through which organisations are accountable for improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in care will flourish.” (Scally G, Donaldson LJ. Looking forward: clinical governance and the drive for quality improvement in the new NHS in England.?BMJ1998;317:?61-5.)

Hmmmm.? Both close. But, I realised in the light of my new bulb, no cigar. These definitions are still a bit abstract - like CG makes all this happen by itself. Something is missing – and that thing - bingo! - is the people who make it all happen.? If this is how we define clinical (quality) governance, no wonder we get preoccupied with the mechanics.? These definitions ( and every other one I’ve seen) are telling us to do exactly that. While not bad, could it be that these are now not serving us as they once did, as we evolve our understanding of how quality care is truly created?

So, perhaps it's time for the next set of CG definition 'wheels' to speed us up the hill toward consistently great. After all that revelation, I have no choice, of course, ?but to put my money where my mouth is, so here goes:

‘A framework of leadership, accountability and systems, implemented to support staff to fulfil their responsibility and potential for creating excellent care and services with consumers.’? (Balding, 2023)

Cigar?? You be the judge.

(BTW, if you’re wondering, ?this definition is completely AI-free!)

1. Staff Are the Change: How Focusing on Staff Engagement Got Results. IHI, Nov 17, 2023. Find it here.