70 Accountability and Clinical Governance: a Policy Perspective
for monitoring and improving practice and services. Examples of such systems and processes include: clinical audit, risk management, education, training, continuing personal and professional development, and staffing and staff management.
However, greater emphasis is now placed upon involvement of patients and service users and the integration of existing quality initiatives to form a coherent whole. Gone are the days when departments such as risk man-agement, audit and training could operate in relative isolation (if in fact they ever did so successfully). Integration and working together are seen as the keys to high quality healthcare. It is also recognised that co-operation rather than the competition of previous years (and reinforced through the internal market) must be promoted, if individuals and organisations are to share best practice and learn from each other’s mistakes. This leads to the crux of the change: what clinical governance appears to represent, moreover require, is a whole cultural shift from a situation where when things went wrong the question asked was ‘who was to blame?’ to one where the major challenge is to find out ‘what went wrong?’
The requirement for a ‘no blame’ culture and more integrated working arrangements are not the only major changes associated with clinical gov-ernance (Figure 6.1). For the first time since the inception of the NHS in 1948, accountability for the quality of clinical care rests firmly at organisational level; final legal responsibility being placed with the chief executives of NHS trusts (Department of Health, 1998).
Accountability and clinical governance 71
• clear lines of accountability and responsibility for the quality of services
• an extensive programme of quality improvement initiatives and activities
• clear policies aimed at managing risks
• procedures for all professional groups to identify and remedy poor per-formance in all professional groups.
The organisation’s chief executive was given ultimate responsibility for assuring the quality of services provided and a designated senior clinician (usually the medical or nursing director) was charged with ensuring that systems were in place to support clinical governance and to monitor effect-iveness. Formal arrangements for trust boards to discharge their respons-ibilities for clinical quality were required and an annual reporting process instituted.
A concept allied to clinical governance is that of controls assurance.
Based upon best governance practice (NHSE, 1999b), controls assurance completes the governance picture by assuring, through the introduction of
CULTURE (No blame/learning)
EFFECTIVE CLINICAL GOVERNANCE STRUCTURES and SYSTEMS
(Cohesive, based upon partnership and cooperation, patient focused, standardised)
ACCOUNTABILTY
(Political, organisational, individual)
Figure 6.1 Effective clinical governance: dominant policy themes.
72 Accountability and Clinical Governance: a Policy Perspective
18 standards, the quality of non-clinical support services such as health and safety and waste management. By doing so it recognises that the success of processes to maximise clinical and non-clinical quality are to some extent interdependent.
Clinical governance, which is essentially about accountable and depend-able local delivery of clear national standards of service, is unsurprisingly also monitored by the centre. The Commission for Health Improvement (CHI) was established to perform just such a function, and builds upon the work of other monitoring strategies such as the national performance framework and national patient and user survey (Department of Health, 1997/1998).
CHI was established to support and scrutinise local clinical governance arrangements independently through scheduled programmes of review.
Originally depicted as a watchdog not dissimilar to the Office for Standards in Education (OFSTED), more recent conceptualisations have portrayed a more developmental, softer touch organisation. Nonetheless there are some similarities between CHI and OFSTED. It has statutory powers and is accountable to Government for its work, although operating independently and collaborating with other bodies such as the Royal Colleges, regulatory and voluntary organisations (OFSTED, 2002; Department of Health, 1997/
1998, CHI, 2001).
CHI is keen to emphasise that the patient experience is at the heart of its work. Its main functions are said to be:
• to independently scrutinise the local clinical governance arrangements of NHS trusts
• to conduct or assist in the investigation of serious service failures and inter-vention to put things right
• to monitor and review the implementation of national service frameworks, National Institute for Clinical Excellence (NICE) guidance and other key NHS policy priorities
• to provide leadership, identify and share best practice related to clinical
governance (adapted from CHI, 2001)
Accountability implies visibility. Walsh (2000) argues that nurses cannot be accountable unless there are unambiguous outcomes and standards against which performance can be measured. His point, that expectations must be clear if one is to be expected to explain how or why they have not been met, would appear to apply equally well at an organisational level too.
NHS trusts could reasonably expect to be informed of the remit for which they are required to account. The ‘bold type’ of Government policy makes this clear too. Arguably the guidance produced by NICE, the publication of national service frameworks and performance indicators, and clear policy priorities serve to fulfil this function. Organisations know they will be measured, know what they will be measured against and furthermore what they will be expected to account for if they are perceived to fall short of requirements.
Accountability and clinical governance 73 Individual accountability
The implication of the above changes in organisational accountability for individual practitioners is not difficult to calculate. The success of the clinical governance process demands that the responsibilities and sphere of accountability of individuals within an organisation are explicit too. Put simply, as a chief executive with ultimate responsibility for clinical quality, most of us would wish to ensure that doctors, nurses and other healthcare professionals were clear on the role they were required to fulfil in order to make the organisation a success. That said, accountability is a two-way pro-cess. Those holding nurses to account must remember their half of the contract and make sure the resources (whether equipment or training and education) and authority are available to allow them to function in an accountable manner. This responsibility, which has received limited atten-tion in the past, appears to have been underlined by recent reforms.
In reality then, accountability can occur at different levels. For example, in the event of a serious incident resulting from failure to follow identified best practice, organisations would be expected to account for the structure and systems they have in place to support the dissemination and execution of best practice. However, individual clinicians would be expected to account for their decision to employ or reject the use of a particular practice or intervention in an individual case.
Political accountability
There is no doubt that NHS trust chief executives face two very daunting tasks. First, in ensuring that requirements associated with financial account-ability and clinical accountaccount-ability do not come in to conflict. Second, in fos-tering a no blame culture in a climate where the personal and professional accountability of individual employees is explicitly reinforced.
At first sight it would appear that responsibility and accountability for the quality of clinical care rests solely at the local level and that the Government have somehow managed to distance themselves from public accountability in all but their role as the monitor, evaluator and reporter of progress.
However, an alternative view is possible. As discussed earlier, successive Governments have striven to achieve a balance between devolution and cent-ral control. Whilst the ‘how’ of clinical governance is to some extent left to local interpretation (although even this is subject to question given the level of detail provided by central guidance) the Government appears to have retained a great deal of authority and power over NHS trusts. In fact Government policy, through national service frameworks and the work of NICE and CHI, has extended its influence into areas previously regarded as the exclusive domain of managers and clinicians.
Accountability involves responsibility, knowledge and being able to jus-tify your actions. It also involves the ability to make decisions and carry them through into practice – autonomy and authority (Walsh, 2000). In exercising a greater degree of central control over practice and services, the
74 Accountability and Clinical Governance: a Policy Perspective
Government must accept some accountability for clinical quality. Thus whilst the quality reforms in general terms have served to emphasise both the accountability of individual professionals and the organisations for which they work, they can equally be viewed as making policy makers more explicitly accountable too. By taking greater control, policy makers have also assumed greater responsibility for clinical performance, and made it more difficult for any distinction to be drawn between the domains of policy and practice in the future (Walshe et al., 2000). This is good news when things are progressing well, less so when healthcare is perceived to be in decline.