Importance Of Clinical Governance In Healthcare Essay Paper

Ishikawa’s Fishbone Analysis

Clinical governance is an ‘umbrella term’ that refers to a system through which healthcare organization develop the responsibility for continuous quality improvement and maintain high quality care by fostering an environment that can facilitate excellence and flourishing clinical care (Scally and Donaldson 2015; rcn.org.uk 2018). Clinical Governance ensures proper care for everyone seeking healthcare, facilitates the best practice by staff, maintenance of the best possible standards (Qotba 2018). The importance of clinical governance is supported by the duty of healthcare organisations in the maintenance of quality and safety of care. Because of such aspects, clinical governance has been implemented in the UK by the National Health Service (NHS) and involves 5 key themes:  patient focus, information focus, quality improvement, staff focus, leadership (rcn.org.uk 2018). This can be considered as a part of Total Quality Management (TQM) which is an approach towards long term success through customer satisfaction, where the members of the organization are involved in the improvement of the process, services or products as well as the work culture (asq.org 2018). Such aspects of TQM have been incorporated into the HA Annual Plan framework 2017-2018 that included three strategies: a) providing patient centered care b) developing competency and commitment in workforce c) improve financial sustainability (Ha.org.hk 2018). Al-Shdaifat (2015) suggested that the most important factor in the implementation of TQM was to maintain a customer focus as the first priority, attributed through interviews with nurses. Hong Kong uses the clinical governance model utilized by the UK because of two reasons a) similarity in the professional training systems between UK and Hong Kong and b) the developmental stage of the UK model allows scope for learning through their experiences (Leng 2005)

In this essay, the importance of clinical governance will be discussed briefly, and then the causes of the selected scenario (scenario 2) will be visualised using the Fishbone model. After this, the strategies to address such causes will be discussed to identify appropriate clinical governance strategies. In the conclusion, the key aspects of the discussion will be highlighted.  Importance Of Clinical Governance In Healthcare Essay Paper

Ishikawa’s Fishbone Analysis is a universal model that can be used in the identification of cause and effects associated with a given problem and represented in a structured format. This visual tool allows several contributing factors to be changed simultaneously and helps to fully comprehend the identification of multiple factors associated with a situation or problem. It allows scope for team discussions and solving problems, and facilitates systematic discourse while maintaining focus on the problem. IN the fishbone model, the problems are categorised into different groups like: people (the involved personnel in the process); process (any important pasrt6 of the process); equipment (used in the process); material used and management (evaluation of quality through evaluation of data) and environment (Vetter et al. 2016).

• Allows a comprehensive analysis of the causes of a problem without the possibility of overlooking any root cause
• Easy implementation of the model.
• Easy to comprehend due to the visual representation of the cause-effect relation.
• Enables focussing on the big picture in relation to the influences of the identified factors on the problem or issue being discussed.
• It also allows identification of areas of weakness, and therefore the scope of further improvement and rectifications.

Disadvantages Of This Model

• Complex situations, involving interrelation of several different factors might be difficult to represent on the fish bone.
• Lack of space while drawing the fishbone can leave inadequate scope for the exploration of cause-effect relation properly.
• The model only focuses in analysing the causes of a problem but not on any solutions.

The Annual report on sentinel and serious untoward events– 1 October 2013 to 20 September 2014 published by Hospital Authority Hong Kong on January 2015, showed 19 cases of death of an inpatient due to suicide (that included 10 patients on home leave and 2 patients reported missing. The report showed that most of the Sentinel Events in the hospitals were contributed by retained instruments or materials during surgery (20 events) and due to inpatient suicides (19 events). However, the suicide cases accounted for most of the severity of the consequences compared to other sentinel events (Ha.org.hk 2015).

Communication: The study showed an inadequate communication taking place between the patient, staff and the patient’s family. Due to this, the patient’s mental health status was not properly understood, and any plans of the patient to commit suicide went unnoticed by either staff or the patient’s family.

Environment: Presence of environmental risks in the hospital environment (like in the patient’s toilet or bathroom) for any point of anchorage for hanging was not thoroughly assessed. Also, presence of sharp objects that could be used by the patient for self inflicted injuries by stabbing and bleeding was not properly analysed, due to which such items might have been used by the patients to commit suicides.

Policies/Procedures/Guidelines: There was a delay in the activation or reactivation of suicide precautionary strategies for patients with unstable emotional state or identified at risk of committing suicide or self harm. Inadequate follow-up on patients on home leave and ineffective actions to identify if any patient went missing during this time.

Poor communication (between patients, staff and patient’s family), because of which the staff was unable to identify or recognise any propensity of patients to commit suicide and subsequently any plans of the patient to commit suicide went unnoticed and unreported. Communication skills as well as cultural and clinical competencies of the healthcare professionals can be improved through education and training programs that can allow the professionals to have a better communication with the patients and their families. Moreover, integrated care pathways that involves professionals from different disciplines (clinical, pharmacological, psychological, social and spiritual or religious guides). The multidisciplinary team can ensure the physical, mental, psychological as well as spiritual well being of the patient and therefore might be effective in dissuading them from committing suicide.

Proper Risk Analysis was not done, which allowed the presence of hazardous or risky environment to persist in the toilets or bathrooms like potential anchorages for hanging inside toilets and bathrooms or any sharp objects used to inflict self harm. The patients consequently were able to use the curtain rails, door beam, and metal rods in toilets and or bathrooms as a point of anchorage and waist belts, cloth strips from bed linen, plastic chains or nylon ropes for hanging. Few patients also committed suicide by stabbing and bleeding, showing that they had access to sharp objects that can inflict serious and fatal injuries. This highlights the necessity of conducting a risk management to identify and eliminate any factors that can increase the risk of self harm done by the patient.

Communication

Delay in the activation or inactivation of suicide prevention strategies for patients identified at risk for committing suicide was another significant factor that allowed such events to occur. This can be caused due to a lack of understanding of mental health issues which can increase risks of suicides, and the inability of staff to identify such patients at risk of committing suicide, for example identification of patients who might show emotional instability. This highlights the necessity of an improvement in the understanding of different mental health issues that can push a patient towards suicide, and therefore help in the early identification of patients showing signs of mental instability, and suicidal tendencies. Education and training provided to healthcare professionals can equip them with such important knowledge, and allow timely activation or reactivation of precautionary and preventative strategies for the patients. Development of research based practice and clinical competency can also allow the application of effective strategies to prevent suicide. Research based practices can lead to an improved clinical competency, and therefore foster proper clinical decisions to be made, based on evidence and best practice guidelines, that can benefit the patient.

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Lack of proper follow-up with patients who are on home leave can be related to the inability of the management to identify missing patients. Additionally, due to a lack of proper follow-up the patients at risk of committing suicide could not be intervened and helped. Proper follow-up with patients on home leave can be achieved through the involvement of a multidisciplinary team (through integrated care pathways) that consists of social care workers, psychological and spiritual counsellors who can provide psychological, emotional and spiritual support to the patients at risk. Additionally, education and training can also equip the professional with the correct protocols for the follow-up with the patients. Considering the implications of the root causes that allowed the suicide events by hospital inpatients, it is important that a change in the current status quo be implemented to address and mitigate the risk factors. Using the Lewin’s Force Field Model, the resistors and drivers for the change can be identified, and therefore help to understand what needs to be done to facilitate the implementation of a change in the system.

The Lewin’s Model was developed by Kurt Lewin, and it studied how the interaction between two opposing forces can hold a particular issue or problem in its place therefore either facilitating or challenging a shift from the status quo. These forces have been identified as driving forces and restraining forces. The driving forces works towards facilitating a change, while the restraining forces works towards the maintenance of the current state of matter. These forces are in a state of dynamic equilibrium, and change can be facilitated when the driving forces overpowers the restraining forces. This model can be used in different levels like personal, project, network or an organization to understand factor that can facilitate or resist a change (Valuebasedmanagement.net 2018).

• The analysis requires the participation of all the members of the group, which can be challenging.
• Without a full participation, a thorough analysis and the formation of a full picture of the issue cannot be performed.
• Can lead to a fork force division due to differentiated opinions about the implementation of the process.

Environment

In the given scenario, the force field model can e constructed by identifying the restraining forces as: poor communication, lack of knowledge, problems in the process and improper follow-up and the driving forces as knowledge and competency, strong leadership, evidence based practice (EBP) and proper risk analysis and involvement of integrated care pathways.

The force field diagram (figure 6) helps to visualise the key driving and restraining forces that helps in the maintenance of status quo. In order for change to be implemented, it is important to have an idea about the factors that resist change, so that the change policies and strategies can address such factors and attempt to reduce them, so they no longer overpower the collective driving forces. Additionally, strengthening the driving forces can help to ensure it exerts more collective power than the restraining forces, thereby causing a change in the status quo. For example, training and education, evidence based practice can help to reduce communication barriers between patient and healthcare professionals, as well as improve knowledge and cultural competencies of the nurse. Using Evidence based practice can help to maintain best known practice guidelines, and help in adequate risk assessment and identification of patients at risk of committing suicide. Moreover, an integrated care pathway can also help in the effective follow-up with the patient as well as facilitating better care for the patient.

Two clinical governance strategies can be suggested that can address the key requirements highlighted by the Fishbone Model and the Force Field Model. These strategies include: education and training (on clinical and cultural competencies as well as on evidence based practices) and integrated care pathways (involving a multidisciplinary team).

Pijl-Zieber et al. (2014) suggested that through education and training, the competencies of the nurses can improve, and can strengthen their knowledge therefore helping to make better clinical judgements. It can therefore be assumed that such competency can also help the healthcare professionals to identify patients with signs of emotional and mental distress and showing signs of self harm or committing suicide. Through training, the cultural awareness as well as skills and knowledge to comfort the patients can also be developed, which can improve communication with the patient. Studies by Samuelsson and Åsberg (2012) showed that training programs in psychiatric suicide prevention given to nurses can help to improve the understanding and willingness of the nurses to care of the patients who attempted suicide. Brown et al. (2012) pointed out that knowledge and attitudes related to evidence based practice as significant barriers towards the promotion of best nursing practices. However education can help to assess evidence, support evidence based practice, and changes the attitude of nurses to utilize EBP.

Policies/Procedures/Guidelines

Integrated Care Pathway (ICP) can help in the continuity of care beyond the boundaries of the healthcare centres (hospitals or clinics), and ensures uninterrupted care for the patients. It provides a patient cantered model for care (Evans et al. 2015).  Additionally, ICP can also help to ensure proper follow-up with patients outside healthcare facilities (Smith-Strøm et al. 2016; Evans et al. 2015). Studies by Malakouti et al. (2015) suggested that integrating suicide prevention program in primary care program can also help to maintain a better depression and suicide surveillance, and therefore in better identification of patients at risk of committing suicide. Hogan and Gurmet (2016) also supported such a suggestion, mentioning that such can integration can improve mental healthcare of suicidal patients. They pointed out that isolation can increase the risks of suicide, and therefore timely and routine supportive contact (through calls, letters, texts and visits) can be implemented after acute care visits or during interruptions in healthcare service (like for patients on home leave). The studies show that the risks of suicide attempt is the highest in the first month after discharge and that 70% of patients discharged from Emergency Department after a suicide attempt never actually attend their first follow-up visit (Knesper 2011; Luxton, June and Comtois 2013).

SMART criteria can help in the identification of objectives in the implementation of a change. Each letter represents different aspects of the objective, like Specificity, Measurability, Achievability, Relevance and Timeframe (Haughey 2018). MacLeod (2012) explained each of these aspects, which shall be explained briefly next.

Specificity of the objectives helps in a clear identification of the proposed actions, and leaves little scope for misunderstanding or misinterpretation. Measurability helps in the quantification of the objectives and the extent of the achievements can be measured. Achievability helps to understand if the recommended steps are reasonably achievable, and maintain practicality of the steps. Relevancy ensures that the implemented process is relevant to the problems being addressed. Timeframe helps in the timely execution of steps and ensures they are bound to a given timeframe (McLeod 2012). The SMART goal settings help to improve focus, motivation, and group cohesion as well as cooperation. It can additionally help to improve job satisfaction as they would be able to quantify6 their performance and development as a professional, and help to maintain a productive environment and orientation towards organizational goals or objectives.

For education and training program, the specific objectives can be development and improvement in cultural and clinical competencies, usage of evidence based nursing process, development in the understanding of mental health conditions that can increase risks of suicide attempts and implement psychiatric suicide prevention strategies. The outcomes of these strategy can be measured through an improved communication between patients (and their families) and nurses, and an improved competency and skills acquired by healthcare professionals to identify mental health risks and usage of evidence based practice (to support the best professional practice). Such steps are achievable through continuous education and training, and have been evidenced by different studies. The relevance of the strategy can be attributed by its effect in the reduction of suicide cases by hospital inpatients. Since education and training is a continuous process, it can continue thought the year, and progress being measured periodically.

Improving Communication Skills

In the implementation of Integrated Care Plan, the objectives can specifically involve the setting up of multidisciplinary team of care professionals (like primary healthcare, general physicians, pharmacologists, psychologists, social care workers and even spiritual counselors. The efficacy of the ICP can be measured through the diversity of the involved professionals, in their respective domains, which can allow an uninterrupted and continuous care for the patient both within and outside the care facility. Such aspect is practically feasible, since multidisciplinary teams have been incorporated in several healthcare facilities with positive results. The relevance of such as aspect can be highlighted by the ability of different care professionals to provide care under different settings. For example, home visits by nurses or counselors (psychological or spiritual) or social workers can help in the extension of support and care outside the care facility, and help in the routine follow-up with the patient, monitoring any change in the patients health condition. The implementation of ICP for the care of patient should start from the admission of the patient until the patient, and should ideally continue until the full recovery.

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The third important governance strategy that needs to be implemented is the process of auditing changes. The audit can help to identify whether the outlined strategies have been properly implemented and complied to, and if they fulfilled the SMART goals attributed to each of the strategy. The audit can also help to develop care programs, appraisals, revalidation, and information governance, ensure compliance to National Recommendation guidelines and service frameworks, help in research and development, evaluation of services, as well as designing internal control policies (Hqip.org.uk 2018).

In the current scenario, Bespoke audits can be used that can be used to determine if the controls selected in the reduction of suicide cases have been properly implemented, and keep focus on the change being implemented. The audit will have 2 phases: collection and collation of evidence of controls and testing the controls (Bristol.ac.uk 2018).

Conclusion:

The Annual Report on Sentinel and Untoward Incidents (2013-2014) in Hong Kong reported 19 cases of inpatient suicide. The factors that led to such event have been discussed and visualised using the Ishikawa’s model that showed that poor communication, improper risk analysis, improper or untimely activation or reactivation of suicide precautionary steps and improper follow-up with patients being the root causes of the problems. However such problems can be addressed by the implementation of education and training programs and the involvement of integrated pathways, apart from proper risk management strategies and utilisation of evidence based learning and practice.

Proper Risk Analysis

Successful change can be driven through improving the knowledge and competency of the nurse, effective leadership and management, risk analysis and integrated pathways, while lack of knowledge, poor communication, and improper follow-up and risk assessment can be resistors for the change.

Two selected clinical governance strategies like Education and Training and Integrated Care path can help in the development of competencies and knowledge by the staff, help in the continued and uninterrupted care of the patients and help to maintain the best practice in the car4e facility that is centered on the patient. These can also help to improve the quality of care and employee satisfaction.

References:

Asq.org., 2018. Total Quality Management (TQM): What is TQM? | ASQ. [online] Asq.org. Available at: https://asq.org/learn-about-quality/total-quality-management/overview/overview.html [Accessed 22 Feb. 2018].

Bristol.ac.uk., 2018. Cite a Website – Cite This For Me. [online] Bristol.ac.uk. Available at: https://www.bristol.ac.uk/safety/media/po/safety-health-audit-strategy-po.pdf [Accessed 27 Feb. 2018].

Brown, C.E., Wickline, M.A., Ecoff, L. and Glaser, D., 2012. Nursing practice, knowledge, attitudes and perceived barriers to evidence?based practice at an academic medical center. Journal of advanced nursing, 65(2), pp.371-381.

Evans, J.M., Matheson, G., Buchman, S., MacKinnon, M., Meertens, E., Ross, J. and Johal, H., 2015. Integrating cancer care beyond the hospital and across the cancer pathway: a patient-centred approach. Healthc Q, 17, p.28.

Ha.org.hk., 2015. Annual report on sentinel and serious untoward events- 1 October 2013 to 20 September 2014. [online] Ha.org.hk. Available at: https://www.ha.org.hk/haho/ho/psrm/ESEREPORT.pdf [Accessed 25 Feb. 2018].

Ha.org.hk., 2018. Cite a Website – Cite This For Me. [online] Ha.org.hk. Available at: https://www.ha.org.hk/haho/ho/ap/AP17-18Eng.pdf [Accessed 22 Feb. 2018].

Haughey, D., 2013. SMART goals. Project Smart.

Hogan, M.F. and Grumet, J.G., 2016. Suicide prevention: an emerging priority for health care. Health Affairs, 35(6), pp.1084-1090.

Hqip.org.uk., 2018. Developing a clinical audit strategy. [online] Hqip.org.uk. Available at: https://www.hqip.org.uk/public/cms/253/625/19/620/HQIP%20Developing%20a%20clinical%20audit%20strategy.pdf?realName=Iiv6In.pdf&v=0 [Accessed 27 Feb. 2018].

Knesper, D.J., 2011. Continuity of care for suicide prevention and research: suicide attempts and suicide deaths subsequent to discharge from an emergency department or an inpatient psychiatry unit. Suicide Prevention Resource Center.

Luxton, D.D., June, J.D. and Comtois, K.A., 2013. Can postdischarge follow-up contacts prevent suicide and suicidal behavior?. Crisis.

MacLeod, L., 2012. Making SMART goals smarter. Physician executive, 38(2), pp.68-72.  Importance Of Clinical Governance In Healthcare Essay Paper