In April 2015, the Australian Commission on Safety and Quality in Health Care (ACSQHC) produced the Guide to the National Safety and Quality Health Service Standards for Health Service Organisation Boards, outlining practical strategies for health consumer engagement and partnerships, and effective systems of assurance, accountability and clinical risk management. More than one year on, many boards will be reviewing their performance against the standards in relation to “ensuring that management has systems and processes in place to support clinicians in providing safe, high-quality care”.
As part of their review, here are a number of key points for boards to consider.
Best practice clinical governance is critical to the quality of patient care, trust between health partners and the reputation of all health related entities.
Public and private hospital boards are well aware of the impact of clinical errors on patients and the reputation of their entities. In the last few months, prominent media reporting of catastrophic clinical governance failures in New South Wales, Victoria, South Australia and beyond, has brought into sharp focus the accountability of boards and management teams for breaches in quality and safety.
The ongoing media attention to the public debate between private health insurers and private hospitals about paying for “avoidable” adverse events, has raised community awareness to apparent quality and safety issues in private health care.
As patient care is increasingly provided in out-of-hospital settings, there is also a growing recognition of the negative consequences of inadequate clinical quality systems, structures and policies in community-based settings.
The board’s role
The rapid growth of the health industry has been associated with an increasing diversity in the governance and size of health-related entities, including corporate primary care, private mental health services, residential aged care providers, disability services, e-health technology companies, large and small hospitals, private health insurers, and others providing direct and indirect health care. In view of this diversity, board endorsed clinical governance frameworks should be tailored to the unique needs of the entity, outlining the values, principles, codes of conduct, culture, clinical and e-health standards, guidelines and policies, and the roles, responsibilities and accountabilities for clinical quality and clinical risk management, at all levels of the organisation.
Clearly, documents in themselves do not guarantee excellence in patient care, and boards must continually monitor the implementation of their framework, by receiving detailed reports on health consumer feedback, clinical quality outcomes, mitigation plans for clinical risks, root cause analyses of clinical incidents and benchmarking of morbidity and mortality data. Specific indicators for hospitals are outlined in the National Health Reform Performance and Accountability Framework.
Ongoing education on clinical governance should be seen as essential as corporate governance education for all board members.
Asking the right questions
Is your board asking the right questions of senior management, including chief medical and nursing administrators? In the last few decades, there has been considerable progress in strengthening the corporate governance of health related entities, resulting in a more diverse skills mix of non-clinical board members and health consumer and carer representatives than in the past. If there is a lack of clinical skills among board members, boards must seek external advice or rely on quality reporting by chief medical and nursing administrators, who have varying degrees of engagement with clinicians working at the coalface.
Sometimes a “clinical skills gap” at governance level is addressed by appointing prominent external medical and nursing academics or clinical opinion leaders/experts to boards, audit and risk committees or clinical management committees, to provide independent questioning of medical and/or nursing administration in relation to clinical governance. While these appointments can be very valuable, a sole appointment will not lead to significant improvements in quality systems, unless there is also improved board communication with internal and external clinical leaders.
Of course, boards do not have a role in operational clinical matters, but all board members have a responsibility to gain deeper understanding of the core clinical business of a health related entity.
How can a board nurture a culture where excellence in clinical care flourishes? It is difficult to reconcile the growing disconnect between governance and clinical leadership in the current environment of increasing external scrutiny of boards and management teams. The disconnect is often evidenced by poor clinician response rates and scores on engagement surveys, non-compliance with clinical frameworks and guidelines, and disengagement of clinicians with “bureaucratic” committees and accreditation processes.
The external and internal practising clinical members of the overarching clinical management committee should be regarded as valuable sources of clinical information for the board, and their board reports should be prioritised accordingly. Clinical leaders usually have credibility among a wide range of clinicians, whom they can engage in the development of a clinically relevant framework and meaningful quality and clinical risk reporting requirements.
Every clinician has ideas on how to continually improve the standard of health care, but annual engagement and quality surveys often do not capture this valuable information. However, by using new secure mobile communication technologies, boards and management teams can gain deeper insights into clinical culture, provide timely feedback and improve transparent two-way communication with clinical leaders and their teams.
Why must our board continually strengthen its leadership role in clinical governance? Health care has a profound impact on peoples’ lives, and everyone involved in the health system has a duty to ensure the highest standards of quality and safety – including board members.
And why must boards continually strengthen their role in clinical governance whether the entity is a global private metropolitan hospital network or a small remote government-funded community telemedicine service?
As the wife of a plaintiff with a catastrophic injury said to me: “They seemed to be too busy to listen to our complaint about the delay in treatment. Why did they wait until someone was harmed before they took any action? Why do we have to take legal action before communication failures will be taken seriously?” Why indeed?
Establishing and maintaining a clinical governance framework
The Australian Securities and Investment Commission (ASIC) identified a key duty of boards as “know what your company is doing”. For health service organisations, this requires the board to understand the clinical performance of its organisation, among other things. Good clinical governance requires strong strategic and cultural leadership of clinical services. The board should focus on:
- Reviewing plans providing cultural leadership.
- Ensuring the appropriate allocation of resources.
- Ensuring there is appropriate delegation.
- Maximising staff engagement.
- Using data and information effectively to monitor and report on performance across the health service organisation, to the governing body.
- Ensuring well-designed and integrated systems are in place for identifying and managing clinical risk.
The board should comprise people with an appropriate mix of skills to fulfil its governance roles, responsibilities and accountabilities. The board may also seek input from appropriately skilled individuals.
Source: Guide to the National Safety and Quality Health Service (NSQHS) Standards for Health for health service organisation boards, Australian Commission on Safety and Quality in Health Care April 2015