Who Governs The Governors? by Sue Ieraci, MD

Sue Ieraci, MDIn the state of Australia where I work, the industry of Clinical Governance has invaded the public hospital system. Should be good, right? Reflective practice, external case review, incident reporting and analysis, standardisation of practice – shouldn’t that result in better quality and less adverse events? Well, that would be great – but how good is the governance system? Like any process within health care, quality and governance practices should be conducted according to a set of standards. Should the governers have audits and KPIs of their own?

First, there’s the incident reporting system – an electronic data base where all staff are encouraged to enter details of any event they consider to be an incident. An “incident” need not be an adverse event – it can be an error, a disagreement, a misunderstanding, a complaint. The idea is that the report goes to the department head, who investigates and takes appropriate action. On mass, this type of data can be analysed for trends and patterns, and can provide useful information on which to base policy or change processes. However, what frequently happens is that the people employed in clinical governance rush to micro-analyse each incident and reach conclusions BEFORE it has been investigated.

Then, there’s the root cause analysis process – or RCA. A formalised investigation occurs, involving people external to the clinical unit in which the incident happened, with varying knowledge or insight into the particular clinical area. A set of recommendations invariably results. These results are often not reality-checked, but there is direction to the department head to implement them. The process is not designed to find that the incident was not foreseeable or preventable – there will always be recommendations about how systems should be improved. More often than not, this involves writing a new policy, protocol or guideline – evidence that you have “done something”. The process is becoming more important than the outcome.

Next, there’s the External Review. This can be an asset – if the reviewer is on your side and makes recommendations that can assist you. On the other hand, it can just deliver foregone conclusions – find what they wanted it to find, recommend what they wanted to happen.

So, if we agree that we need good quality governance, why don’t we look at a quality system for the quality system? Here are some of my suggestions

An incident reporting system should allow full investigation of all incidents before any conclusions are made. Recommendations arising from the data should be backed up by the de-identified data, and should be reality-checked for feasibility. Prior to implementation, recommendations designed to prevent one type of incident should be checked to ensure that implementing them or changing the system doesn’t cause another type of incident somewhere else in the system.

RCAs and other incident reviews should include panel members who understand the nature of the practice involved. It should be emphasised in the process that the panel has the option of deciding that the incident was neither foreseeable nor preventable, and that no system changes need to be made. Where recommendations are made, they should be reality-checked with the department head. Again, thought should be given to whether the system change has the potential to disrupt outcomes in other parts of the system.

Departmental reviews need to be carried out by a team who has credibility to both the governance manager and the department head. There should be clarity about the process, the data supplied and the staff members to be interviewed. Draft findings and recommendations should be checked for accuracy and feasibility with the department head prior to final recommendations being made. In this way, there is a greater chance that the recommendations will be embraced, and therefore implemented.

Every process in health care delivery should be scrutinised for quality, effectiveness and appropriateness – not just the clinical process. If the clinical governers can’t optimise their own processes, how can they advise us on ours?

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