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This chapter presents an overview of clinical governance. It discusses the meaning of clinical governance, origins of clinical governance, and the regulatory bodies tasked with the assessment of clinical governance by regulatory bodies. It then describes the Patient Safety First Campaign, which was launched within the National Health Service (NHS) in England in 2008 to make the safety of patients the highest priority and make all avoidable death and harm unacceptable.

There is currently no universal model of clinical governance (CG) at service delivery level. This chapter discusses a simple approach that allows the concepts of CG to be tailored to various clinical settings. The cycle is designed to ensure clinical services provide care to an acceptable quality. It seeks to compare current practices to reference standards, emphasizing that CG activities are undertaken iteratively, with considerable overlap of each component of the cycle, which may be entered at any point.

This chapter focuses on the evolving and volatile UK National Health Service (NHS) regulatory and governance frameworks, and considers their impact upon healthcare organization and clinical practice. It reviews the inquiry culture that has influenced government policies on accountability and transparency in health care delivery, and critically assesses the central place accorded to clinical governance. The rise and function of audit and risk management, and the escalatory relationship between risk and regulation, are explored. The paradox that regulatory failures engender tighter controls which, in turn, generate further regulatory failures, is illustrated by reference to several case studies, including that of the death of ‘Baby Peter’, and its aftermath. The chapter concludes with a consideration of the limitations of regulatory control, highlighting the potential for constant review and reform to exacerbate gaps between policy and practice.

Clinical networks are described as linked groups of health professionals and organizations from primary, secondary, and tertiary care, working in a co-ordinated manner, unconstrained by existing professional (and organizational) boundaries to ensure equitable provision of high-quality and clinically-effective services. This chapter discusses the types of networks, engagement in clinical networks, and clinical governance and improving patient safety across a network.

This chapter considers how Labour put in place a series of organisational changes based around the goal of achieving greater ‘central control’ over implementation (or ‘delivery’, as it became known) during the 2000s. It considers the use of performance management systems in both hospitals and GP surgeries, but with, the authors argue, very important differences that affected the relative successes of such systems in those different contexts. It also suggests modifications to performance management and clinical governance systems in order to improve their effectiveness.

In the 1980s, the UK experienced an explosion of monitoring, evaluating, and assessing activity, and organisations found themselves subject to increasing scrutiny and accountability for performance. By the late 1990s, the emphasis had changed to quality, performance, and excellence. Clinical audit is at the centre of the reinvention of clinical governance in the UK health care system, and the use of appropriate performance measures and standards is central to audit. Audit aims to improve care for patients and families by assessing whether people are doing the right thing well. This chapter provides an overview of the principles of audit in palliative day care and gives guidance for implementing audit into routine practice.

This chapter reviews the broad literature on public services and health policy reforming over the last thirty years and the particular contribution of New Labour in the UK NHS. It starts by reprising two well known models: professional dominance and the NPM. It then asks: did New Labour achieve a break from either of these well established models? It draws in basic ideas of network governance which at least in theory did offer an alternative reform narrative to the NPM. It then offers an analytic history of health policy reforms during the New Labour period which presents a mixed picture. Review of New Labour health policy found a cluster of strands (clinical governance; patient safety; Evidence-Based Medicine and Policy; managed networks in arenas covered by evidence-based NSF) which all displayed novel and distinctive conditions of ‘decentralised centralisation’ and of surveillance, self-surveillance and high levels of managerial commitment.

This chapter discusses performance management, which is important in ensuring high standards of clinical governance, which in turn drives improvement in patient safety. Performance management is based on self-assessment, combined with inspections and cross-checking with other sources. It covers compliance with standards, use of a variety of indicators from across the healthcare spectrum, and the meeting of national targets.

One of the more prominent features of modern governance is its increasing reliance on guidelines. Sometimes they acquire such an aura of authority that they are assumed to be part of the general law. This misperception is not uncommon among health-care personnel; it is likely to become more widespread as a result of new arrangements for ‘clinical governance’ in the NHS, as further extended and reinforced by the Health Act 1999. This chapter discusses the limits to implementation of guidelines, the legal status of guidelines, and the impact on medical practice and the doctor-patient relationship.

Planning is an integral part of dental care provision that can operate at many different levels. At a national level, government NHS policy impacts upon dental services in different ways. For example, in the General Dental Service, patient charge bands in England are currently set by the government. In the future, at the national level, the National Health Service Commissioning Board (NHSCB) will determine national policy and national delivery requirements. The NHSCB will be responsible for commissioning primary dental services and contractual arrangements with dentists. At the Health and Wellbeing Board (HWB) level in England, planners (in conjunction with general medical practioner (GMP) consortia/clinical care commissioning groups (CCGs)) will make decisions over the priorities for local services, and the types and range of services offered locally. Within a dental practice, dental practitioners and their team members may develop a range of practice policies aimed at improving the services provided. Finally, every day clinicians develop treatment plans for individual patient care based upon their oral health needs. All these activities are planning in action. This chapter will examine the basic principles of planning, and review the different steps in the planning process. At the most basic level, planning aims to guide choices so that decisions are made in the best manner to reach the desired outcomes. Planning provides a guide and structure to the process of decision-making to maximize results within the limited resources available. Is planning really necessary when there are so many other demands on practitioners’ time? Planning can be justified for the following reasons: . . . ● It provides an opportunity to be proactive in decision-making rather than constantly reacting to pressures and demands. . . . . . . ● It enables priorities to be set. . . . . . . ● It identifies where resources can be directed to have the greatest impact. . . . Various planning models have been proposed to act as a guide to the different steps in the planning process. The rational planning model provides a basic guide to the process (McCarthy 1982), and involves the following steps: . . . 1 Assessment of need: e.g. identification of the oral health problems and concerns of the population. . . . . . . 2 Identifying priorities: agreeing the target areas for action. . . .

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This task assesses the following clinical skills: Patient safety Communication with colleagues Applied clinical knowledge In Box 4.1 are the findings of an audit on Service provision of Termination of Pregnancy. Your task is to: • Go through the findings in the first six minutes • In the next six minutes you will be asked to critically appraise the methodology and results of the audit You have 12 minutes for this task. Use the 2 minute initial reading time to start going through the article findings. Instructions for Assessor The candidate has six minutes to prepare for this station. Please do not interrupt them in this time. Ask them to critically appraise the audit. If you need to prompt, adjust the marks accordingly. You may need to prompt them to comment on why the audit was done, the appropriateness and limitations of the methodology, findings, and the implications for change in practice. Patient safety • Are any of the practices harmful/ affecting adversely the patient’s safety? Has this been recognized and changes made before the completion of audit? • Is patient service user included in the audit? (Type a quote from the document or the summary of an interesting point. You can position the text box anywhere in the document.) • Is it a patient survey questionnaire? • Is the confidentiality maintained Communication with colleague • Explains why a particular topic was chosen • Explains which national/ local standards are chosen • Explains if data is collected appropriately • Explains where the results were discussed • Explains if any robust plans for re- audit are in place • Explains if re- audit results are presented in this presentation Applied clinical knowledge • Understands what a clinical audit is and the cycle. • Understands what an audit is not about • Understands the difference between audit and research • Selecting a topic—service evaluation • Standards of best practice (audit criteria).

This chapter looks at the topic of health services quality from a commissioning and whole population perspective. Quality is noted to be a multidimensional concept and dimensions of quality are considered. The role of the commissioner in maintaining and improving quality of services is explored, and this is seen within a wider backdrop of a health system with commissioner and provider functions (if there are such distinctions in the system). Commissioners need to know whether they are securing quality care for their population for the money spent. They also need an understanding of how this dovetails with the provider perspective on this topic. Commissioners also need to be able to articulate what they wish to assess in practice under the guise of quality. Finally, at a system level there are also bearings on how to compile and interpret a picture of a population’s health if needed.

By the end of this chapter you should be able to:… ● Understand the responsibilities and accountability of the student and trained nurse with regards to medicines management ● Understand the reasons for policy to support medicines management ● Interpret the role of the nurse in relation to policies and standards for medicines management ● Understand the role of the nurse in relation to key standards and drivers for the safer administration and management of medicines…. The aims of this chapter are to support you to interpret the responsibility that you already carry as a student and will carry as a registrant when giving medicines to patients and to help you to understand what is meant by accountability and how this relates to your role now and in the future in the management of medicines. Medicines management occurs wherever there is a patient and is carried out in a variety of settings which include:… ● acute hospitals ● community hospitals ● care homes, both residential care homes and nursing homes ● the patient’s own home ● schools ● community clinics…. The National Patient Safety Agency (NPSA, 2004 ) has produced guidance for organizations on supporting patient safety. They suggested the implementation of seven steps as follows:… 1 Build a safety culture. 2 Lead and support your staff. 3 Integrate your risk management activity. 4 Promote reporting. 5 Involve and communicate with patients and the public. 6 Learn and share safety lessons. 7 Implement solutions to prevent harm…. When interpreted in relation to medicines management and nursing care this means that the employing organization has a duty of care to its employees and patients to ensure that medicines are dispensed, supplied, and administered safely and that procedures are in place to support this. Managers need to be made aware of anything that might prevent this, and must ensure that checks are in place to prevent harm from occurring. The clear and prompt reporting of concerns, risk, and errors to management is pivotal to patient safety and medicines management in nursing and, from an organizational point of view, patient consultation and involvement is vital. Lessons must be shared in a ‘low blame culture’ and changes made to support the reduction of risk and potential harm. For more on communication and on risk reduction please see Chapters 1 and 10.

This chapter examines the Total Place Programme applied to hospitals. It discusses the key factors that lead to hospital reconfiguration; general trends in Europe and in the US; patterns of change in the UK since the mid-1960s; and a review of the material using governments as placemakers (GAP) model. Hospital management has remained focused on the application of generic management techniques and broad and somewhat abstract organizational approaches, such as benchmarking, clinical governance, and business process re-engineering. What is additionally and equally important is recognizing the issues that have components which are embedded locally and specific to the community.