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PubMed2002

The role of clinical governance as a strategy for quality improvement in primary care.

This power considers the process of implementing clinical governance in primary care and its impact on quality improvement. It discuss how clinical governance is being implemented both at the level of Primary Care Organisations and general practices, and the challenges to implementing clinical governance. It also suggests a model for promoting the factors that will help clinical governance improve quality of care. The experience of implementing clinical governance is broadly positive to date. However, the government needs to match its commitment to a ten-year programme of change with realistic timetables to secure the cultural and organisational changes needed to improve quality of care.

Efficiency, Organizational↗
PubMed2005

Asthma prescribing practices of government and private doctors in Malaysia--a nationwide questionnaire survey.

A self-answered, anonymously completed questionnaire survey was performed between June 2002 and May 2003 where doctors from government and private sectors in Malaysia were invited to participate by post or during medical meetings. One hundred and sixteen government doctors and 110 private doctors provided satisfactorily completed questionnaires (effective respondent rate: 30.1%). The most preferred medications for 'first-line', 'second-line' and 'third-line' treatment were for government doctors: inhaled short-acting beta2-agonist (SABA) (98%), inhaled corticosteroids (CS) (75%), and leukotriene antagonist (52%); and for private doctors: oral SABA (81%), inhaled CS (68%), and oral CS (58%). The first choice inhaler device for most government and private doctors were metered dose inhalers, with cost and personal preferences (for private doctors), and technical ability (for government doctors) as the key considerations when deciding on the choice of device. This benchmark data on the asthma prescribing practices of a healthcare delivery system fully dichotomized into government and private sector, provides evidence for practice differences affected by the nature of the healthcare system, and might have implications on healthcare systems of other countries that share similarities with that of Malaysia.

Administration, Inhalation↗
PubMed2005

Trends in global protected area governance, 1992-2002.

Governance refers to the interactions among structures, processes, and traditions that determine direction, how power is exercised, and how the views of citizens or stakeholders are incorporated into decision-making. Governance is now recognized as a critical aspect of effective conservation and is a prominent part of the Convention on Biological Diversity's work program on protected areas. This study reports on a global survey to assess changes in governance of protected area systems between 1992 and 2002 based on responses from 41 countries. Results indicate that substantial changes have taken place with overall trends towards increased participation of more stakeholders, greater use of formal accountability mechanisms, and a wider range of participatory techniques. Many of these changes are supported by legislative and policy requirements and 75% of respondents reported changes in legislation over the past decade. Protected areas are becoming more influenced by global forces. A majority of respondents reported increased involvement of the private sector. Funding is coming from a broader range of sources, with a smaller proportion of income coming from government sources in 2002. Absolute funding amounts have increased, but almost two-thirds report that budgets fall short of requirements. Almost 90% of respondents felt that protected area governance had improved over the last decade; 67% felt that this had also led to improved management effectiveness. Respondents felt that secure funding, capacity building, and increased community involvement were the main governance needs for the future.

Conservation of Natural Resources↗
PubMed1984

Survey of the previous investigation and treatment by private practitioners of patients with pulmonary tuberculosis attending government chest clinics in Hong Kong. Hong Kong Chest Service/British Medical Research Council.

A questionnaire was applied to 159 consecutive patients with smear-positive and 187 with smear-negative pulmonary tuberculosis attending the 8 full-time Government chest clinics in Hong Kong for the first time for their current illness, who had already attended a private practitioner at a private general practice, a private clinic, or an independent hospital, outside the Government or Government-subsidised Service. The aim was to obtain details of management by private practitioners, and in particular of the antituberculosis chemotherapy prescribed. The great majority (86%) of the patients had originally attended a private practitioner because of symptoms. Only 18% had had their sputum examined, although 76% had had a chest radiograph; 65% of the smear-positive and 71% of the smear-negative patients had been told that they had, or might have, tuberculosis. For 40% there was an interval of more than a month between their first attendance at a private practitioner and at a Government chest clinic. Only 11% of the patients were referred without delay to a Government chest clinic, and another 21% once tuberculosis had been diagnosed or suspected. The patients were asked to name the drugs they had been prescribed, to produce samples, or to identify them from a perspex board containing samples of all 49 antituberculosis tablets and capsules known to be available in Hong Kong at the time. In the event, only 11% of the patients could name some or all of their medicaments and only 7% could produce samples, although a further 76% were able to describe them with or without the aid of the perspex board. In all, 19% of the patients were definitely or probably prescribed an antituberculosis regimen, although this was not always an adequate regimen. The findings suggest that there is considerable scope for active case-finding aimed at encouraging patients who are likely to have tuberculosis to attend a Government chest clinic.

Adolescent↗
PubMed2002

Governing nursing conduct: the rise of evidence-based practice.

Drawing on the Foucauldian concept of 'governmentality' to analyse the evidence-based movement in nursing, we argue that it is possible to identify the governance of nursing practice and hence nurses across two distinct axes; that of the political (governance through political and economic means) and the personal (governance of the self through the cultivation of the practices required by nurses to put evidence into practice). The evaluation of nursing work through evidence-based reviews provides detailed information that may enable governments to target and instruct nurses regarding their work in the interest of preserving the health of the population as a whole. Political governance of the nursing population becomes possible through centralised discursive mechanisms, such as evidence-based reviews that present nursing practice as an intelligible field whose elements are connected in a more or less systematic manner. The identity of the evidence-based nurse requires the modern nurse to develop new skills and attitudes. Evidence-based nursing is an emerging technology of government that judges nursing research and knowledge and has the capacity to direct nursing practice at both the political and personal level.

Australia↗
PubMed2003

Research governance: implications for health library and information professionals.

The Research Governance Framework for Health and Social Care published by the Department of Health in 2001 provides a model of best practice and a framework for research in the health and social care sector. This article reviews the Department of Health Research Governance Framework, discusses the implications of research governance for library and information professionals undertaking research in the health- and social-care sector and recommends strategies for best practice within the information profession relating to research governance. The scope of the Framework document that covers both clinical and non-clinical research is outlined. Any research involving, amongst other issues, patients, NHS staff and use or access to NHS premises may require ethics committee approval. Particular reference is made to the roles, responsibilities and professional conduct and the systems needed to support effective research practice. Issues such as these combine to encourage the development of a quality research culture which supports best practice. Questions arise regarding the training and experience of researchers, and access to the necessary information and support. The use of the Framework to guide research practice complements the quality issues within the evidence-based practice movement and supports the ongoing development of a quality research culture. Recommendations are given in relation to the document's five domains of ethics, science, information, health and safety and finance and intellectual property. Practical recommendations are offered for incorporating research governance into research practice in ways which conform to the Framework's standards and which are particularly relevant for research practitioners in information science. Concluding comments support the use of the Research Governance Framework as a model for best practice.

Benchmarking↗
PubMed2001

Clinical governance and infection control in the United Kingdom.

The recent organizational changes in the NHS have at their core the concept of clinical governance. Although initially poorly defined and understood this term has now taken on a clear identity, placing quality alongside fiscal probity and corporate governance at the top of NHS priorities. Integral to clinical governance are the basic elements of clear national standards for services and treatments that are to be locally delivered through assured, monitored, high quality healthcare. It is within this framework that workers in infection control must develop their own methods of applying clinical governance. This review explores the implications that the strategy of clinical governance holds for the speciality of infection control, emphasizing the benefits its active adoption can bring and highlighting the key relevance of clinical risk management in this setting. It illustrates clinical governance as a tool to engage colleagues on a multi-disciplinary front, most particularly the crucial link to senior Trust management.

Decision Making, Organizational↗
PubMed2026

Access to maternity services for women asylum seekers and refugees: A transnational document analysis of international, European regional, and United Kingdom governance.

Women asylum seekers and refugees face persistent barriers to maternity care (antenatal, intrapartum and postnatal care) across high-income countries, yet the upstream governance shaping access remains under-examined. Although legally distinct, both groups share protection-seeking experiences and are addressed jointly in governance documents. This study examined and synthesised how international (macro), European regional (meso), and United Kingdom (UK, micro) governance documents frame and operationalise maternity service access. Sixty-four documents were analysed using the READ framework. Inductive analysis of macro and meso documents identified six access dimensions: universal coverage; cultural and linguistic adaptation; rights-based approaches; multi-agency collaboration; data, monitoring and accountability; and quality of care. These dimensions structured assessment of UK governance, with jurisdictions rated strong, moderate or weak. Alignment was fragmented: Wales, Scotland and Northern Ireland exempted asylum seekers from charging, whereas England retained charging provisions. Multi-agency collaboration was consistently articulated, yet none of the 35 UK government documents focused on maternity access for this population, and none required outcome monitoring disaggregated by asylum or refugee status. UK governance appears coordinated in form but fragmented in substance. UK-wide minimum standards and routine recording of these data, with safeguards against immigration-related use, could strengthen coherence and accountability and improve visibility of inequities.

Refugees↗
PubMed2002

Closing the gap: building the capacity of non-government organizations as advocates for health equity.

Seeking achievement of health equity has underpinned national government and global health policies for decades. However, major difficulties and challenges faced in the practice of achieving 'Health for All' has led to a recognition of the need to broaden the focus of efforts to improve health equity. Civil society groups have been identified as key stakeholders in attempts to achieve health equity, and the importance of strengthening their capacity to influence relevant government policy and practice has been highlighted. This paper presents the results of a qualitative study which examined the role of organizations outside government in advocating for health equity, and the capacities and conditions that were related to their success. In-depth, unstructured interviews were conducted with 26 non-government organizations (NGOs) who were active in three important health policy debates in Australia. The grounded theory method was used to direct data collection and analysis, and member checking was employed to ensure soundness and build ownership of the findings. Effective advocacy was found to be a dynamic process characterized by flexibility and opportunism within a framework of longer term goals. Two key ways of working were identified--in partnership and in conflict with government, with shifts in emphasis in response to organizational strengths and a changing environment. A number of domains of capacity, which together are termed 'capacity for advocacy', were also identified. It is clear that NGOs can learn a great deal from each other, but there needs to be investment by governments, international agencies and NGOs themselves if advocacy for health equity is to be strengthened.

Australia↗
PubMed2006

Clinical governance in practice: closing the loop with integrated audit systems.

Clinical governance has been acknowledged as the driving force behind National Health Service (NHS) reform since the government white paper outlined a new style of NHS in the UK in 1997. The framework of clinical governance ensures that NHS organizations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will develop. A major component of a clinical governance framework requires utilizing audit procedures, which assess the effectiveness of current systems and ultimately direct continual quality improvement. This paper describes the audit component of a local clinical governance framework designed for a unit based within an NHS trust, which has utilized a multidisciplinary approach to assess the effectiveness of a newly commissioned service and its impact on the residents and staff. The unit is a 12-bedded, low-secure-intensive rehabilitation unit for clients with severe and enduring mental illness. Using recognized and standardized psychometric outcome measures, information was collected on clinical symptoms, social functioning, social behaviour, quality of life, relationship quality with named nurses and medication side-effects. Additionally, confidential staff measures were included to assess levels of burnout, identify expressed emotion and assess staff perception of models of illness. The paper includes a comprehensive account of how managerial commitment, teaching processes and application of technology ensured prompt data collection and maintained the momentum through the audit timescale. Data analysis and presentation of data in both clinical reviews and in senior management meetings within the unit are discussed. Findings highlight the full integration of the audit system into the processes of the unit. Clinically, the paper highlights the enhancement of the knowledge base of the client group and the influence on clinical decision-making processes and care delivery as a result of the audit. Brief clinical examples are given. In conclusion, the impact of the audit on unit strategy and organizational efficiency are discussed to highlight the importance of closing the audit loop and completing the cycle of clinical governance. The audit system has positive implications for replication in other services.

Commission on Professional and Hospital Activities↗
PubMed2005

Work-based learning: a leadership development example from an action research study of shared governance implementation.

AIM: An empowering action research study was undertaken to evaluate and strengthen the implementation of shared governance. One aim was to identify factors that acted as aids or barriers to effective decision-making by clinical leaders. As a work-based learning approach, action research was expected to lead to integration of learning into practice by researcher and participants alike. BACKGROUND: Shared governance replaces traditional hierarchies and requires and develops clinical leaders. Strategies are needed to maximize learning from introduction of such initiatives at the individual, group and organizational level. METHODS: Participant-observations and interviews were undertaken with shared governance council members from one model in north-west England. RESULTS: Leadership skills and knowledge and shared governance practices were significantly enhanced. Preparation for council roles was considered inadequate. Increased structured time for reflection and action planning was indicated. CONCLUSIONS: Implementation of shared governance has succeeded in developing leadership capacity. Evaluation findings have led to improvements in the overall shared governance model. Action research has been found to have great utility at optimizing work-based learning. Nurse Managers need to develop their coaching and facilitating skills and recognize there is no "quick fix" for developing clinical leaders. Implications include the need to support learners in identifying and implementing changes arising from work-based learning activities, the significant resource implications and the need to optimize the organizational climate if work-based learning approaches to leadership and management development are to succeed.

Decision Making, Organizational↗
PubMed2002

Implementing clinical governance in English primary care groups/trusts: reconciling quality improvement and quality assurance.

OBJECTIVES: To investigate the concept of clinical governance being advocated by primary care groups/trusts (PCG/Ts), approaches being used to implement clinical governance, and potential barriers to its successful implementation in primary care. DESIGN: Qualitative case studies using semi-structured interviews and documentation review. SETTING: Twelve purposively sampled PCG/Ts in England. PARTICIPANTS: Fifty senior staff including chief executives, clinical governance leads, mental health leads, and lay board members. MAIN OUTCOME MEASURES: Participants' perceptions of the role of clinical governance in PCG/Ts. RESULTS: PCG/Ts recognise that the successful implementation of clinical governance in general practice will require cultural as well as organisational changes, and the support of practices. They are focusing their energies on supporting practices and getting them involved in quality improvement activities. These activities include, but move beyond, conventional approaches to quality assessment (audit, incentives) to incorporate approaches which emphasise corporate and shared learning. PCG/Ts are also engaged in setting up systems for monitoring quality and for dealing with poor performance. Barriers include structural barriers (weak contractual levers to influence general practices), resource barriers (perceived lack of staff or money), and cultural barriers (suspicion by practice staff or problems overcoming the perceived blame culture associated with quality assessment). CONCLUSION: PCG/Ts are focusing on setting up systems for implementing clinical governance which seek to emphasise developmental and supportive approaches which will engage health professionals. Progress is intentionally incremental but formidable challenges lie ahead, not least reconciling the dual role of supporting practices while monitoring (and dealing with poor) performance.

Attitude of Health Personnel↗
PubMed1994

Government intervention in cardiovascular disease--help or hindrance? The pharmaceutical industry viewpoint.

The health of its people is a matter of importance for any responsible government. This is primarily achieved through ensuring adequate standards of nutrition, housing, and hygiene. The government has additionally to ensure the provision of an effective and affordable health care system. This must deliver adequate medical resources that are readily available for those who fall ill. Cardiovascular disease is the major cause of mortality in the Western world. Thus, it is incumbent on the government to provide health care for those who suffer from cardiovascular disease. There is a further obligation to promote a healthy life-style in the community by providing dietary advice and discouraging avoidable risk factors (e.g., smoking). Life-style changes are not easy and may be insufficient to beneficially influence the risk factors for cardiovascular disease. The pharmaceutical industry, therefore, plays an integral role in health care delivery by providing doctors with the medicines to manage those patients who suffer from cardiovascular disease, for whom life-style changes have not provided the answer. In most european countries, the pharmaceutical industry operates within tight government regulatory confines which define efficacy and safety of medicines. In those countries where there is a socialized health care policy, the prices of medicines are regulated by the government. Thus government intervention in most European countries is a fact of life for the industry, and the manner in which it exercises its powers will have a critical effect on whether the intervention is a help or hindrance.

Cardiovascular Agents↗
PubMed2004

Soft governance and attitudes to clinical quality in English general practice.

OBJECTIVES: English primary care organisations (primary care groups and trusts - PCGs, PCTs) were, and are, responsible for the quality of general practice but lack hierarchical structures and, frequently, contractual relationships through which to influence it. The theory of soft governance describes how managers can influence professional practice by other means. This study examines the hypothesis that PCG/Ts have used 'soft' clinical governance. METHODS: Survey in 2000/01 of general practitioners' (GPs') attitudes, opinions and self-reported activity in six PCGs and six PCTs using a semi-structured mailed questionnaire. To assess how representative respondents were of English GPs generally, four questions from a national sample survey of English GPs were included and the results compared. RESULTS: Responses were obtained from 437 (52%) GPs. They most often mentioned the technical aspects of clinical governance. Managerial, policy and resourcing implications were next most frequently mentioned, usually in unfavourable terms. Most GPs reported that their clinical practice had changed because of clinical governance activities, although nearly 40% also reported little difference in the quality of care provided. The National Service Framework for coronary heart disease influenced practice independently of PCG/T activities. CONCLUSION: English primary care organisations are exercising soft governance (although not by that name) over some but not all aspects of GPs' clinical practice. However, this soft governance is complex, not easy to sustain and appears hard to extend beyond essentially clinical domains.

Attitude of Health Personnel↗
PubMedDate not supplied

Clinical governance.

Clinical governance has marked a significant shift towards involving clinicians in the assurances of both quality and accountability in healthcare delivery. The White Paper (Department of Health (DoH), 1997) stated that: 'The Government will require every NHS trust to embrace the concept of clinical governance, so that quality is at the core, both of their responsibilities as organizations, and of each of their staff as individual professionals.' In order to achieve this the Government will bring forward legislation to give NHS trusts a new duty for maintaining quality care. Under these arrangements, chief executives will carry ultimate responsibility for assuring the quality of the services provided by their NHS trust, just as they are already accountable for the proper use of resources. In 'A First Class Service Quality in the NHS' (DoH, 1998), clinical governance is defined as 'a framework through which NHS organizations 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'. The principles of clinical governance apply to all those who provide or manage patient care services in the NHS. It requires staff to work in partnerships, breaking down boundaries by providing integrated care within health and social care teams (Wilson, 1996), and between practitioners and managers and between the NHS, patients and the public.

Decision Making, Organizational↗
PubMed2000

Out-of-pocket expenses borne by the users of obstetric services at government hospitals in Karachi, Pakistan.

OBJECTIVE: Financing health services is a challenge for health policy makers world over, especially in developing countries. Alternate mechanisms such as user fees are being proposed. However, there is a feeling that in developing countries, users of government hospitals spend appreciable personal income to obtain "free services" at these facilities. METHODS: This study aimed to measure the extent and the factors associated with of out-of-pocket expenses borne by the users of obstetric care at government hospitals. It also aimed to determine willingness of consumers to bear out of pocket expenses. It was conducted in three government hospitals in Karachi. RESULTS: Seven hundred cases were registered in the study. Sixty-five percent of them had a monthly household income of less than Rupees (Rs.) 3000. Overall, users spent mean of Rs. 590 as out-of-pocket expenses for obstetric services. Of this Rs. 330 was spent on drugs and Rs. 24 on user fees. Thirty-nine percent of the patients were willing to spend out of pocket for services provided at government hospital and 39% declined to do so. Of the patients indicating willingness to spend, 98% agreed to do so for drugs. CONCLUSION: The results suggest that considerable expenses are borne out of pocket by the users of government hospitals for supposedly "free services". If user fees are to be increased the government needs to provide services for which the people will pay, such as drugs, otherwise increase in this fees will simply add to financial burden on the users.

Adult↗
PubMed2005

The ownership elephant: ownership and community-governance in primary care.

Ownership of primary care is an often neglected but important health systems design parameter. The New Zealand Primary Health Care Strategy has established Primary Health Organisations (PHOs) as non-profit umbrella organisations, however in most instances their constituent general practices are for-profit small businesses. This viewpoint paper aims to: (a) define ownership and community participation; (b) summarise some of the evidence from the NatMedCa study pertaining to ownership-related differences; and (c) discuss the policy implications of different ownership forms in primary care, and the implications of merging different ownership forms under the umbrella of PHOs. Ownership confers governance responsibility (ultimate control) for an organisation, and accountability for its actions. Community governance involves vesting overall control of resources in users and the community, rather than with health service managers or health professionals. Results from three studies using the NatMedCa survey indicate that community-governed non-profits in New Zealand differ in a number of respects from their for-profit counterparts. As non-profit and for-profit ownership forms have different social roles, and as meaningful community participation in governance is determined in large part by ownership structures, there is a need for ownership frameworks to be used more widely in health policy making. Because of the ownership boundary that exists between non-profit community-governed PHOs and their constituent for-profit general practices PHOs may have little real ability to effectively govern their practices.

Community-Institutional Relations↗
PubMed1997

[A comparative study of local mental health and welfare policies in Japan: Cases of Tokyo Metropolitan Government and Yamaguchi Prefecture].

In this article the mental health and welfare policies of the Tokyo Metropolitan Government and Yamaguchi Prefecture were analyzed, and the features of their development and problems were discussed. The results are as follows: a) The emphasis of the mental health and welfare policies both of Tokyo and Yamaguchi experienced changes according to national policies and is to be divided into the following four periods and key concepts. The 1st period (1950-1964): no policy or increase of psychiatric beds The 2nd period (1965-1975): dawn of "from hospital to community" The 3rd period (1976-1987): workplace for the mentally ill The 4th period (1988-present): accommodation for the mentally ill b) During the 2nd period, in terms of increase in psychiatric beds, the Tokyo Metropolitan Government tried to limit increase, whereas Yamaguchi Prefecture accommodated it. c) In the field of community mental health, the most remarkable development in Tokyo in recent years is that the number of workshops and group homes grew dramatically. The original policy of the Tokyo Metropolitan Government to subsidize such small institutions was recommended in the report of Local Advisory Council on Mental Health and Welfare (Chiho-Seishinhokenhukushi-shingikai). As a result many voluntary groups operate those institutions with help of subsidy. On the contrary the development in Yamaguchi is slow, because the establishment of institutions for rehabilitation was mainly implemented by the regulation of national law which demands high costs for its building and land. d) The original policies of the Tokyo Metropolitan Government, however, is based on the premise that a shortage exists of institutions for rehabilitation regulated by Mental Health and Law. In this situation, therefore, the development of community mental health depends on a subsidy from local government, development of community mental health depends on a subsidy from local government, development of voluntary groups, and accessibility to social services.

Community Mental Health Services↗