A Director’s Duty

For this special episode of Safeguarding Healthcare, we've prepared a written summary of the key points. You can find a link to download the PDF in the show notes. Medical administration is a rewarding profession, but it comes with challenges. So what is it like and what should you do if confronted with a monumental administrative difficulty? That takes unfortunate scenarios.

and explores the essentials of clinical governance to find solutions. I'm Dr. David Rankin, a very experienced medical administrator and lead fellow with the Royal Australasian College of Medical Administrators. And this is safeguarding healthcare, the essentials Today, looking at the director's role in clinical governance.

To start, let's consider the following scenario. How did it happen? Could it have been prevented? And can you be sure it would not happen in your hospital? An 84-year-old lady is admitted to hospital with an infection to her shin following an encounter with a rosebush in her immaculately maintained extensive garden. She lives alone following the death of her husband several years ago.

As she requires bed rest and continuous elevation of her leg, it is decided to insert an indwelling urinary catheter. Unfortunately, she develops a urinary tract infection which results in confusion and disorientation. While attempting to get out of bed, she falls and breaks her hip. After surgery she receives a relatively high dose of opioid medication, resulting in delirium.

Though the delirium rapidly resolves after her dose is reduced, it has left her with reduced self-confidence and a feeling of dependence. Her meal trays are left on the bedside table just out of her reach. She is hesitant to ask the busy nurses for assistance and so misses a number of meals leading to malnutrition and dehydration, which impact her mobility after surgery.

She develops pressure injury on her buttock. After several weeks in hospital she is transferred to a rehabilitation facility with the expectation that she will be unlikely to return home. While the patient seems resigned to her unfortunate outcome and believe the nurses were all lovely, her children are furious with the hospital and raise a formal complaint with the implied intent of exploring legal action. The hospital quality and safety team investigates the fall and the pressure injury.

The investigation focuses on the physical aspects of false prevention and skin integrity and concludes that the hospital's protocols were largely followed. The hospital recently underwent and passed accreditation under the National Safety and Quality Health Service standards. The organization has all the required policies in place and undertakes regular audits to ensure the policies are complied with.

Under activity-based funding, the hospital realizes an effective loss of over twelve thousand dollars and faces further financial penalties from the patient's hospital-acquired complications. The organization faces a potential huge reputational risk when the family raises their concerns with the National Social Issues TV program. This scenario should never have happened. However, it outlines an unfortunate outcome that is not uncommon in both public and private hospitals in Australia.

So what is clinical governance? Clinical governance has been defined by Scallion Donaldson. as a system through which organizations are accountable for continually improving the quality of services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. I asked some of Australia's most senior medical administrators what they saw as the definition of clinical governance.

doctor Helen Parsons is the president of the Royal Australasian College of Medical Administrators. Clinical governance to me is all about our responsibility and accountability as health professionals. firstly, but it's also about the responsibility of the organisation, hospitals, the Ministry of Health to ensure that we provide safe, high quality, effective and efficient care.

to our patients and to our community. Professor Gavin Frost is the former Dean of Medicine at the University of Notre Dame, Australia. It's ensuring that the right people are doing the right thing. almost all or most of the time, that you know if things are not going well and that you encourage those who are doing well to do even better. Dr. Paul Douglas is the Executive Director Health Protection with the New South Wales Ministry of Health.

For me, clinical governance is something where we as clinicians partner with consumers to ensure that we have a safe environment. And where we find it's not safe that we have process in place to improve it. And that we are reporting and measuring and responding to that as much as we would to our financial situation. That's where clinical government assistants me and probably leads healthcare rather than comes behind the other components of it.

doctor Peter Lothian is the former Group Director Medical Services and Clinical Governance at Cabrini Health and a Board Director of a Large Private Hospital Group. I have a fairly simplistic approach to clinical governance. Clinical governance is that set of relationships, policies, whatever you want to call it. that links everybody in the organization, from the patient through the staff, through the management, through to the board, and out.

And which to improve patient safety and performance of our clinical services and by collecting and utilizing data we're able to continually improve the service that we provide. So, clinical governance should be an organizational culture rather than compliance with a set of policies and procedures. The aim of good clinical governance is to create a culture where every person involved in delivering care is accountable for their patients' clinical outcomes.

experience of care and the efficient delivery of that care.

Clinical governance has traditionally been focused on the investigation of major incidents and a system of audits to ensure compliance with protocols and standards. Unfortunately, this approach is retrospective and does not appear to have improved rates of avoidable incidence over the past 25 years. It looks at what has happened rather than how incidents could be prevented. Medical staff are often overlooked in an incident investigation. Patient and family experience is not included in feedback.

While multiple recommendations are often made, these are not explored adequately with the impacted staff and as a result not followed through. Once the formal quality improvement cycle is closed, the change and improvement initiatives lapse. By focusing on major and catastrophic incidents as reported by hospital staff. Clinical governance can overlook apparently minor, high frequency complications, trends in patient outcomes, and poor patient experience.

It also ignores much more frequent near misses. It does not see the bigger picture. It also misses those occasions where staff have spoken up for patient safety but were unheard. It misses staff attitude and commitment to improve care and overlooks leadership and cultural issues. To achieve high quality clinical governance, every person involved in a patient's care needs to demonstrate. First, curiosity about the way they personally deliver care and how it compares to best practice.

Secondly, an understanding of the reporting and incident management processes. Thirdly, a courage to recognize opportunities to improve, and finally, a commitment to change practice and improve the value of care that they personally provide. The consequence of these behaviors needs to be measured in clinical outcomes through demonstration that complications are minimized.

The aim of good clinical governance is to create a culture where every person involved in delivering care is accountable for their patients' clinical outcomes. experience of care, and the efficient delivery of that care. These dimensions of care need to be routinely monitored and reported at all levels within the organization, from the doctors and nurses and support staff through to management and directors.

So the organization must have a robust monitoring system that provides an accurate picture of how the organization is performing, what is being done, what needs to improve, and what the risks are. Clinical governance must encompass leadership, consumer participation, workforce, clinical practice and risk management.

So what's the role of directors and board members in clinical governance? Board directors have a fiduciary duty to act in good faith. in the best interests of the organization. In healthcare, this duty extends to ensuring the organization provides safe and effective care to the patients that it treats.

In their publication, Crossing the Quality Chasm, a New Health System for the Twenty First Century, the Institute of Medicine defined the board director's role as To ensure that the organization is providing safe, effective, patient-centred, timely, efficient, and equitable health care. So, a director or board member needs to be provided with information that assures them that the risk of the organization are identified and monitored.

That action plans are in place to contain or eliminate any material risk, and that the organizations are providing care within appropriate regulatory parameters. To achieve this assurance, each director should consider the following questions. What evidence do you have that the leadership team is committed to quality and safety? What is the governance structure to monitor and support critical care? How is it supported by the leadership team?

Does the organization have a set of indicators that identify the level of safety and quality of care that the organization provides? Key performance measures should include clinical outcomes such as incident rates, infection rates, discharge destination, unplanned ICU admissions, deaths, readmissions, relief of symptoms. level of independence at discharge.

The KPI measures should include efficiency, measures such as length of stay, day of surgery admissions, same day procedures, theatre utilization. The KPIs should also include patient reported experience from survey results, monitoring complaints, and the type of issues that patients raise. Other questions include has the board set tolerance limits against each of these KPIs? What are the enterprise risks associated with the failures to meet these KPIs?

What are the patient safety and outcome risks? What are the reputational risks for the hospital? What are the regulatory risks? And what are the financial risks? Does the board receive regular reports against each of these KPIs? Does the data in these reports they receive make sense? Are the reports comparing apples with apples? Does the executive provide commentary on the trends, progress and exceptions in each of the reports?

Are the organization's performance indicators benchmarked with similar organizations to identify comparable performance? Are all staff and directors made aware of their own and their units' comparative performance against the indicators? Do staff understand the reports and use them for reflection and improvement? Has the organization clearly identified four to six top clinical risks for targeted action and improvement?

Does the board have assurance that there are clear strategies and action plans to address these priority risks at the organizational, team and individual clinician level? Are these targeted action areas aligned with the current strategic plan? What is the accountability framework for individuals and teams primarily responsible for generating clinical incidents?

Does the organization have clear scopes of practice for all clinical staff? And can the board be assured that each clinician is working within their scope of practice? Are all significant incidents appropriately investigated and our recommendations followed through and implemented? Are there appropriate incentives for all staff tailored to their role to encourage reflection and improvement? Are staff empowered to make changes that will enhance quality and safety?

Are teams encouraged to collaborate in resolving interdisciplinary challenges? Is there an appropriate interdisciplinary committee structure to monitor the trends, facilitate action plans, and oversee improvement? And is good performance and significant improvement recognized and celebrated? The board may take comfort that the organization has been assessed as complying with the National Safety and Quality Health Service standards.

Particularly standard one, clinical governance, standard two, partnering with consumers, standard three, preventing and controlling infections. Standard four, medical safety, and standard six, communicating for safety. The organization has shown that it has all the required policies and undertakes regular audit to ensure the policies are complied with.

Yet, the underlying quality and safety culture within the organization allowed this unfortunate scenario for the 84-year-old lady to play out. The board needs to be assured that all staff accept individual and team accountability for the outcomes for the patients they care for and understand their individual contribution to those outcomes. Let's go back and have a look at the scenario. Who are the players in this scenario?

The doctors and nurses in the emergency department who inserted the catheter. The physician under whose care the patient was admitted for the shin infection. the nurses who cared for the lady on the ward. The nurse assistants who provided hygiene care and made her bed. The surgeon who operated on the fractured hip. The anaesthetist who provided the anesthetic and charted post operative pain relief.

the doctors in training and the junior medical staff who were involved in her care, the food service staff who delivered her meals, the dietitians who planned and monitored her nutrition. The physiotherapists who provided rehabilitation care. The cleaners who cleaned her room. Each of these people interacted with the patient and had the opportunity to raise concerns about her care and identify risks that may have avoided the most unfortunate outcome. Yet,

None of these players talked to each other or shared their concerns. The food services staff did not raise concerns with the dietitian or the nursing staff about the uneaten meals. The physiotherapist did not raise concerns about her slow mobilization with the dietitian or the nurses. The admitting physician lost track of the patient once they were transferred to the orthopedic surgeon's care. The orthopedic surgeon did not feel accountable for the pressure injury.

The anesthetist was not informed of the impact of their post operative medication orders. no one met with the relatives to explain the patient's needs, or consider the contribution the family could have made to her care. Then we have the leaders and the directors who fail to set the culture of the organization. The safety net for good clinical governance should underpin each player's decisions.

This framework places staff on the front foot, enabling them to make appropriate, patient-focused decisions. This framework of clinical governance should include Training staff on speaking up about patient safety so that the food services staff and the physiotherapist felt empowered to raise their concerns with senior staff. Interdisciplinary clinical handovers within and between teams so that continuity of care is ensured.

In this way, the admitting physician remains involved in the care despite the patient's transfer to orthopedics and then to rehabilitation. and can coordinate timely management of a urinary tract infection and postoperative confusion. educating frontline staff on the indicators of patient deterioration and pathways for escalation so the patient's adverse events are headed off before they occur. Embracing robust procedures that prevent falls and pressure injuries in patients at risk.

Encouraging patient-centered care by involving patients and their families or carers in all decisions and acting on their reported experiences. Engagement with this patient and her family at all important points of care may have led to person centered decisions about catheters, post-off analgesia, meals, and access, and ultimately to better outcomes and increased safety for the patient during her hospital stay.

The clinical governance framework is overseen by the organization's leaders, and that includes directors and board members. This framework sets the culture of the organization, determines the organization's priorities, authorizes remedial action plans, and monitors trends in outcomes.

So what's the conclusion? Developing a culture of clinical governance is a challenge. The safety culture emerges from the governance framework which is embedded into clinical business as usual and is not to capture and investigate adverse events after they occur. It involves every member of staff, the patients It is front-footed and focuses on keeping patients safe. through quality care.

Thinking about outcomes, experience, and efficiency. In this way, we move from a focus on compliance and investigation to a culture of individual knowledge, individual accountability. Individual empowerment.