2Clinical Governance is : "A framework through which health care 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." (NHS)
3Effective Clinical Governance ensures: continuous improvement of patient services and carea patient centred approach that includes treating patients courteously, involving them in decisions about their care and keeping them informeda commitment to quality, which ensures that health professionals are up to date in their practices and properly supervised where necessarya reduction of the risk from clinical errors and adverse events as well as a commitment to learn from mistakes and share that learning with othersThe goal of clinical governance is for all staff to be striving to continuously improve care.
4The term ‘clinical governance’ may seem to imply that it is the exclusive responsibility and domain of clinical staff – but this is not the case.It is everyone’s concern – the nurse, the GP, the dentist, the pharmacist, the receptionist, the cleaner – everyone in fact whose work impacts on the patient’s experience of healthcareSo what does clinical governance really mean? Quite simply it is about:‘HIGH QUALITY, ACCOUNTABLE CARE’
5Clinical Governance requires changes at three levels:Individual health care professionals need to embrace change, adopting reflective practice which places patients at the centre of their thinking.Teams need to become true multi-disciplinary groups, where understanding about roles, about sharing information and knowledge and about support for each other becomes part of their everyday practice.The Healthcare organisation is also committed to embracing the changes required by putting systems and local arrangements in place to support you as an individual and the teams within which you work.
6There are seven key components of Clinical Governance, known affectionately as 'The 7 Pillars' :Risk ManagementClinical AuditEducation, training and continuing personal and professional developmentResearch and DevelopmentInformationPatient and Carer experience and involvementStaffing and staff management
7PATIENT – PROFESSIONAL PARTNERSHIP PATIENT AND PUBLICINVOLVEMENTINFORMATIONUSE OFRISK MANGEMENTRESEARCH ANDEFFECTIVENESSCLINICAL AUDITSTAFF MANAGEMENTSTAFF ANDPROFESSIONAL DEVELOPMENTEDUCATION,TRAININGSTRATEGIC CAPACITYSYSTEMSAWARENESSTEAMWORKCOMMUNICATIONOWNERSHIPLEADERSHIP
8Patient and Public Involvement Involving patient groups and local communities in all aspects of planning, provision, monitoring and evaluation of care is one of the key underpinning principles of clinical governance – and one that represents a fundamental culture shift for the HOSPITALPatient and Public Involvement includes:Appointing a Patient Advice & Liaison ManagerProviding patients with information about the services we provideActively seeking patients views on those services, and making changes as a resultInvolving patients in the planning and delivery of services.Working with GP practices to establish Patient Participation Groups
9Use of ‘Intelligent’ Information Use of ‘Intelligent’ InformationAccurate and appropriate information is vital. It can help identify the priority health needs of the local population, and assure the safety and quality of current clinical provision of care.Information we need includes:Robust and reliable public health informationRobust and reliable comparative national dataRobust and reliable clinical informationSome of the work includes: Ensuring we have a Data Protection Officer to oversee the confidentiality and security of informationMonitoring the accuracy of performance and activity information received from secondary care providersStarting to collect community data with scanned formsRoutinely making information on activity available to clinicians and staff
10Risk ManagementEnsuring the safety of everyone who comes into contact with the health services is one of the most important challenges facing healthcare today.There are three important things we can do which will help promote patient safety:Put systems and processes in place to proactively identify clinical and non-clinical risk Implement a systematic strategy to minimise them, monitor them and learn from themPromote a ‘fair blame’ culture, so that staff are willing to report their mistakes and near misses. Some of the steps to take include:Introducing an electronic Incident Reporting System in order that we can record, analyse and monitor incidents and complaints.Introducing staff training on incident reporting and ‘Root Cause Analysis’Disseminating learning from incidents across staff groups will be a key priority.Ensuring the Complaints Procedure is in place within the hospital.
11Research and Clinical Effectiveness All clinical decisions and actions initiated by or on behalf of the HOSPITAL should be based upon a reliable, robust and ever developing evidence base. In order to promote this the HOSPITAL needs to develop systems to: Promote and monitor clinical effectivenessEncourage and monitor the use of evidence based practiceSome of the steps include:Developing and agreeing evidence based protocols of careEnsuring that the standards and guidelines are implemented throughout the HOSPITALProviding training on searching for evidence is available to all staff.Developing systems to determine whether clinically effective practice is being implemented at grass roots level.Ensuring that research governance arrangements are in placeEnsuring that evidence based prescribing is implemented
12Some of the steps include: Clinical AuditClinical Audit is a structured process, which ensures we are carrying out best practice by reviewing what we are doing, compared with that which we should be doing.It is seen as an essential component of professional practice and can demonstrate efforts being made to deliver high quality care to all patients.Some of the steps include:The development of a Clinical Audit StrategyThe establishment of a Register to monitor Clinical Audit activity, progress and evaluation across all areas of the Services.Support, advice, guidance and training to all individuals or groups undertaking audits.The production of a Clinical Audit Guide for distribution to all interested parities.Providing a quarterly review of clinical audit activity to the Clinical Governance Committee.
13Staffing and staff management The quality of clinical care is intimately related to the quality and morale of the staff – and the way they are managed and supported.The ultimate aim is to have a staff group that is:Highly motivatedFully cohesive and effective in relation to current needs and demandsFlexible enough to respond positively to changing need and patterns of careSome of the work includes:Introducing a corporate induction programme for all new employeesAchieving Improving Working Lives Practice statusDeveloping a range of Human Resources (HR) policies.Undertaking an Annual Staff SurveyDeveloping the Hospital Newsletter, website and intranet site to help keep staff informed of key issues and associated informationHolding a regular programme of open meetings so that staff can raise issues with the Chief Executive, directors and non-executive directors
14Workforce Planning, Education and Training Workforce Planning, Education and TrainingStaff are the most important resource in all HEALTHCARE organisations.Thoughtful and imaginative investment in staff development shows a real commitment to clinical governance.The importance of life long learning and leadership development is important not only for individuals and the teams in which they work, but also for the ongoing development of the HOSPITALSome of the steps include:Developing a system to ensure equity of access to training and development opportunities via the Education Links system and by .Ensuring processes are in place to support a range of internal and external learning opportunities, higher and further education.Developing new roles and changes to work patterns to ensure we have the right workforce for future requirements.
16PERAN Pimpinan RS : Koordinator : Penanggung Jawab Prioritas “Patient Care”Menentukan KoordinatorMembentuk Subkomite Clinical GovernanceKoordinator :Koordinasi dan monitorDukungan terhadap Tim DepartemenReview Kemajuan
17Pengendali : Bertanggung Jawab kegiatan “day-to-day” Mendukung Tim Clinical Gov DepartemenAnggota terdiri dari :Perwakilan Tim DepartemenOrganisasi PendidikanManajemen ResikoInformasi
18Pelaksana : Tiap Departemen membentuk tim Clin Gov Melaksanakan arahan dari PengendaliAsessment kemampuan DepartementIdentifikasi kelemahan dan kekurangan pelayananPerencanaan tahunan DepartemenKomunikasi dan Disseminasi informasi intra maupun inter departemenKebutuhan pendidikan
20Langkah-Langkah Pengembangan Clinical Governance Tiap departemen harus menyediakan waktu untuk mendiskusikan implikasi dari clinical governance.Bagaimana situasi di Departemen? Contoh pelayanan yang baik dan yang buruk?Di bagian mana perlu perbaikan dengan sumber daya yang tersedia? Bagaimana perbaikan dapat dicapai?Bagaimana dukungan nyata (staf,IT,perpustakaan,dsb) yang dibutuhkan?Bagaimana keterlibatan multidisipliner secara efektif dapat dicapai
21Tiap departemen harus memiliki penanggung jawab untuk Nursing Clin Gov dan Medical Clin Gov Tiap departemen mengembangkan programnya sendiri meliputi tujuan dan sasaran dengan azas prioritasProgram departemen harus diketahui Pengendali, Koordinator dan PimpinanKebutuhan pelatihan untuk pengembangan kepemimpinan dan keterampilan khususPertemuan rutin antar DepartemenKembangkan jejaring dengan institusi kesehatan lain.
22“Unwritten Rules” yang Menghambat Status Quo We know bestMy own work has no effect on others areasClinician don’t need managersThe more senior you are the more you know !Don’t admit to mistakesEven though we talk about quality we only assess on the quantityBut I’ve always done it this way
23There are no rewards for doing well Everyone understands the jargon It is wrong to seek answers / consult othersDon’t fix it if it’s not bustDoctors time is more valuable than nursesNothing ever changesEverything is changing all the timeThe pass was much better( Adapted from : Cullen et al. British Journal of Clinical Governance 2000; 5(4): )
24HARUS DI INGATClinical Governance suatu perkembangan yang evolusioner, bukan revolusioner.Cinical Governance sudah dijalankan bertahun-tahun tetapi dalam bentuk “fragmented,haphazard & instropectiveClinical Governance is NOT just about systems, it is also about the CULTURE of an organization.