Clinical Governance

Question: Essay on Clinical Governance – Improving the quality of Healthcare



Safety, equitability and efficiency are concepts which are inherently associated with today’s healthcare and all of these aspects depict “quality” (Friend & Kohn, 2014). Quality in healthcare through quantitative as well as qualitative means have gained immense importance as the sector is increasingly becoming complex and requirements of new and improved means are becoming inevitable. The concept of clinical governance makes an appearance here. Clinical governance is defined as the systematic approach to maintain and improve the quality of the patient care within the framework of every health service provider. Though the concept of clinical governance was initially developed by the National Health Service of United Kingdom, today the system is widely used by leading healthcare institutions worldwide. Clinical governance is composed of the following aspects – training and education, clinical audit, clinical effectiveness, R&D, transparency, risk management and lastly information technology (Aveyard, 2010). 
Clinical governance is built on the concept of continuous quality improvement, which is also the key concept of TQM or Total Quality Management. Clinical governance procedure should be aligned as a TQM system as that would help in the creation of high quality procedures and will aim at continuous improvement of such. This will also ascertain maximum value creation, reduction of wastage and errors to a great extent and will uplift the quality of healthcare for the maximum benefit of the patients (Devettere, 2009). Clinical governance received significance in the Hong Kong’s Hospital Authorities Annual Plan for 2017 – 2018 and as a part of it, the authority is determined to improve the status of healthcare services through aligning the system with effective procedures of quality control. Offering high quality healthcare services to patients is the main agenda for the hospital. This paper would be divided into three core segments – the introduction which presented the rationale of the paper and its background, the main body would delve into the chosen situation of incidence and commonality of needle stick injuries in healthcare settings to be analyzed on the basis of Ishikawa’s Fish Bone model and Lewin’s Force Field Analysis and finally the third segment which will summarize the key findings and present the scope for this paper. 


For the purpose of this report, Scenario 3 was chosen where it showed how common needle stick injuries are occurring amongst staffs associated in healthcare all around the globe. Within the time period of 1999 to 2013, as high as 87% of 1525 healthcare workers in Hong Kong had suffered from a needle stick injury. This situation would be analyzed with the help of Ishikawa’s Fish Bone Model, to find out the plausible causes and identify strategies to reduce such occurrences. Lewin’s Force Field Model would be used to understand the drivers and the resistors of such a phenomenon and finally three clinical governance strategies would be implemented to reduce the occurrence of such needle stick injuries. 

Ishikawa’s Fish Bone Model

Also known as the Cause and Effect Diagram, Ishikawa’s Fish bone diagram depicts the causes of any specific event. Developed by Kaoru Ishikawa, this diagram is mainly used in product designing and prevention of quality defects by identifying the plausible aspects causing the occurrence of such effects (Ginter, Duncan, & Swayne, 2018). Causes after identification are then grouped into main categories to classify the sources of variation.
The main strengths of Fish Bone Diagram are that it accurately identifies the cause and effect aspects in a specific situational problem; it helps in creation of brainstorming of ideas and helps in identifying out of the box ideas; it displays the causal effects clearly and very logically and simultaneously depicts all the related causes; it stimulates problem solving and also aids the team to maintain its focus on the issue (McSherry & Pearce, 2011). On the other hand, the Fish Bone Diagram also has some key limitations. These are – the brainstorming often leads to identification of causes which are irrelevant along with the relevant ones, resulting in loss of energy and time; there is no means of understanding which cause is more important than the other ones through the diagram as all the causes are given the same importance in it; the complex interaction and relationships of a large number of factors are difficult to be depicted in a fish bone diagram and lastly, the diagram is not subjective (Breathnach & Lane, 2017). The situational analysis of Needle Stick Injuries is presented in a Fish Bone Diagram in later segments of this paper. 
Needle-stick injuries or a percutaneous injury is an injury occurring from accidental penetration of the skin by a sharp object or generally needle, which has previously been in contact with tissue, blood or other body fluids (Muralidhar, Singh, Malhotra, & Bala, 2010). As per WHO’s World Health Report in 2002, out of 35 million health workers worldwide, 2 million of them experience such needle-stick injuries and get exposed to infectious diseases every year. 37.6% of the Hepatitis B, 4.4% of HIV/AIDs and 39 % of the Hepatitis C occurrence in healthcare workers around the globe is due to the needle-stick injuries (WHO, 2018). Hence, the gravity of the situation can be well understood from the statistics provided and it is of crucial importance that the causes be identified of such occurrence so that corrective strategies can be taken to reduce the occurrence of needle-stick injuries. 
The main causes which result in the occurrence of needle-stick injuries are when healthcare staff draws blood, or administers the application of an IM (Intramuscular) or IV (Intravenous) drug, or performs a procedure which involves handling of sharp tools, accidents can occur and result in the transmission of blood borne diseases. These injuries can also occur during the recapping of needles, or the improper disposal of such in a poorly located container for used sharps or when such is overfilled. Lack of protective gear or lack of access to such, or the failure of an employee to use such equipment also increases risk of such occurrences (Devettere, 2009). Injuries pertaining from needle-sticks commonly occur when needles are passed in between personnel or when sutures are sown while being connected to the needles. It has also been witnessed that human factors, of exhaustion, fatigue and sleeplessness for long also has resulted in the occurrence of needle-stick injuries (Siegrist & Rodel, 2006). Chaotic environment in the Operation Theatre often disrupts the concentration of highly trained personnel and can lead to the occurrence of such injuries. High work pressure, low perception of risk, ill trained people etc all result in the high probability of needle stick injuries (Cousins, Mackay, Clarke, Kelly, Kelly, & McCaig, 2004). Lack of awareness about the gravity of the situation is also another aspect which can lead to serious outcome of needle-stick injuries. Hence, the key causes can be identified as follows; 
-Accidents which can occur while drawing blood, or administering IM /IV Drugs 
-Ill managed workplaces, improper hospital management ( no provision for protective gear / ill placed protective gear which cannot be accessed on need ) 
-Ill trained staff ( do not know the use of protective gear / does not understand the gravity of such a situation / is not trained to handle sharp objects carefully) 
-Improper manpower planning ( permitting low trained staff to administer drugs / assist in surgeries / to draw blood ) 
-Human Factors ( Fatigue / Exhaustion ) and chaotic environment in the OT can result in such occurrences 
-Improper scheduling of work hours (which result in stress / high work pressure )
Therefore the Fish Bone Diagram which can be construed from the above mentioned causes are as follows; 


Strategies to reduce the Occurrence

To devise strategies to counter the causes for such occurrences of NSI (Needle – stick Injuries) one must take help of clinical governance. Clinical governance, as mentioned at the start of this paper, is the comprehensive framework which the healthcare industry utilizes to continuously improve its system in terms of quality and sustaining such quality to be able to provide the highest care to its patients. Clinical governance has gained immense importance as healthcare institutions are accountable to its communities and society for providing the highest quality of service possible. Clinical governance is formed of five key factors – the focus on patients, spotlight on information; quality improvement; aim to improve the KSA (Knowledge, Skills and Attitudes) of personnel employed and lastly pro-leadership which singularly focuses on the planning and implementation of improved efforts (Goldenhar, 2014). Together these factors form the framework which brings a marked quality difference to healthcare. 
As there were six causes identified which leads to the occurrence of NSI, we would identify specific six strategies which will help in counter these causes. Primarily, NSI is a resultant of accidents which occur in hospitals. Though being cautious and careful and taking care of the other five causes will reduce the occurrence of a large number of these accidents, a portion of such can always occur as accidents are beyond anyone’s control. However, attempts should be made by the hospital management as well as the healthcare staff to reduce the chances of occurrences of such accidents to the minimal (Alli, 2008). Secondly, improper equipment placement by the hospital management can also act as a leading cause. To counter this, hospital management should refocus its attention of equipment placements in different parts of the floor, so that in times of need the staff can get hold of the specific protective gear and conduct their work safely (Champoux & Brun, 2003). And care must be taken in repeated servicing and maintenance of such equipments as well so that they are fit to use and do not have any quality issues when handled by trained staff (Champoux & Brun, 2003). Thirdly, ill trained staff is a big issue for the occurrence of NSI. Staff members who do not have expertise in handling sharp objects, who do not understand the gravity of the situation resulting from a NSI on their health and who due to poor knowledge bring about NSIs in their working partners, all need to be trained effectively by the management. Handling of sharp objects when the patient is around, is a very minute and accurate job and should be handles by individuals who have steady hands and strong expertise. Therefore, effective training would help in reducing the risks which arise from low confidence regarding the procedure and lack of effective knowledge about the safe practices. Improper manpower planning basically consists of two causes - which involves in assigning ill trained staff for operations or complicated drug administrations and in assigning more work- hours to the same individuals, resulting in extreme pressure and stress (Healy & Dugdale, 2009). Therefore, job assignment and personnel assignment are tasks which hospital management should do with care to avoid wrong assignments to wrong people, and to lower the build up of stress and pressure. Lastly human factors like fatigue and exhaustion plays is role in the occurrence of NSI. Human resource management of hospitals, must take care that the highly stressed individuals are not assigned tasks regularly and every staff must get free time to de-stress. Also the stressful environment in the operation theatre though is highly probable, but still management should take active efforts to assign only highly skilled staff so that they can better handle such stressful situations. Management can also assign a backup of skilled staff in case of taking care on wrong turn of events. Therefore after analyzing the individual strategies of the NSI causes, it can be said that instead of making individual changes, a holistic change has to be brought about by the hospital management which will ensure significant reduction of such cases. Therefore, the need for Clinical Governance can be felt which will help improvement of such situation comprehensively.

Lewin’s Force Field Analysis(FFA)

Change is known as the only constant factor in today’s environment. So healthcare is no exception to this rule. Change does not automatically occur in organizations and institutions – there must be strategies which will implement change. These are the drivers of change. And during any change process, there will be factors resisting such, and these are known as the Resistors of such change phenomenon (Runy, 2008). Kurt Lewin, effectively analyzed any change mechanisms by the friction of these two sets of factors – drivers and resistors. The Force Field Analysis by Lewin is an effective and powerful tool to understand the need for change in both the personal and institutional environment. The model depicts that, to bring about any desired change, the very balance between the two opposing forces has to be changed – that is the resistors need to be toned down or the drivers need to adhere a higher force either of which will upset the equilibrium of the opposing forces, and change will occur. 
One uses the FFA, by defining the change one wants to see; mind map the resistors and the drivers; evaluate the drivers and resisters; review the forces; strategize and prioritize. The main advantages of the FFA are that a visual summary of all the forces for and against can be identified and it also helps in identifying potential obstacles. FFA can be used as a visual aid and can thereby simplify the communication and assist a group in developing a common understanding. The key disadvantages of FFA are it requires every individual in the group to participate which will help in better analysis but it is a difficult task to achieve and required time; it is difficult to obtain the complete picture and lastly, this FFA can have a negative influence on team work as this leads to identifying individuals who promote and who resist change and this leads to division in the group. For this specific situation of NSI, the drivers are – need to reduce the occurrence of NSI; need for improvement of the quality; more resources in terms of funding and manpower; improved human resource management; pro-change top management and clinical governance. The resistors of this situation are – aging manpower ; lack of interest and motivation ; high work pressure and low skilled manpower ; low funding and lack of resources ; unconvinced top management ; human nature etc.  

Clinical Governance Strategies

The two clinical governance strategies chosen for this case are –clinical care pathways as Strategy 1 and Risk Management as Strategy 2. 

Strategy 1 - Integrated Care Pathways

Integrated care Pathways (ICP) are specific structured multidisciplinary plans which highlight the essential steps required in the care of patients having specific clinical issues (Warrington, Absolem, & Velikova, 2015). They have been designed as a means of encouraging the translation of different national guidelines into that of local procedures and their effective application to regular clinical practice. These care pathways are means of setting out a specific guideline based on a best practice to be followed when a specific patient having a specific condition or with particular needs are admitted. These ICPs are basically the distillation of all the best available practices on the specific care process of such a disease. Though this seem like a highly unlikely strategy for dealing with NSIs, it is effective as NSIs become fatal when these sharp objects touch an infected patients’ blood, tissue or other body fluids and infect others. Hence, when patients come with distinct diseases, then ICPs must be built so that, only trained professionals having full knowledge of the condition and the probable issue with the patient handles the latter. This conscious knowledge and the ICP protocol will lead to admission of only extremely trained professionals in dealing with these patients and the ICP would ensure that healthcare professionals are wearing protective gear while handling such patients. Therefore, this will significantly reduce the occurrence of such NSIs in future. 

Strategy 2 - Risk Management

Risk Management in healthcare is of critical importance as it deals with safety of patients, and identifies the risk aspects which can impact the staff members, the visitors, the employees etc and device means by which such risks can be averted and not recurs in future (Hasle & Limborg, 2006).  Risk management as a clinical governance strategy to reduce the occurrence of NSI makes sense, as it brings about the required regulatory changes, management changes, recruitment and allocation of job changes and suggests alternative means. It is through Risk Management, that the future policies of the hospital management can be built in a manner that NSI occurrence be reduced to the maximum. Risk Management can also help in improving the overall atmosphere and work culture of the hospital and significantly reduce the stress built up and chaotic environment (Healy & Dugdale, 2009). Integrated Care Pathways can ascertain the rigorous following of specific schedules for patients having specific diseases, so that staff members handling such patients are aided enough to avoid NSIs in such cases and Risk Management overall aims to reduce the causes for occurrence of general NSI related events. 

SMART Standards

The SMART Standards build for these two strategies are; 
Strategy 1 – By the end of 2018, ICPs must be in operation regarding all the leading infectious diseases which patients bring in the hospital and every staff members and job allocation team must be made knowledgeable about the ICPs and provide training.
Strategy 3 – By the end of 2018, risk management teams will ascertain proper floor management and job allocation/ manpower training to reduce the NSI occurrences stemming from poor management and poor training. 

Strategy 3 – Audit

Audit is a clinical governance strategy which ascertains quality improvement procedures in patient care, patient safety and overall promotes an environment of care and safety in the hospitals. Audit in healthcare is crucial as this process is used to assess and evaluate and continuously thereby improve the patient care efficiently and systematically (Al-Busaidi, 2008). Audit basically measures the present status of operations in comparison to the desired state of operations and undertakes strategies to fill the gap. Audit helps in the actual understanding of the situation of patient care and thereby can devise realistic goals which will practically help a hospital (Huber, 2017).     
A typical audit cycle is divided into five sub-stages : preparation stage, which is concerned with choosing a relevant high priority topic and identify the associated available resources; criterion selection, where standard or target is identified; measuring the present level of performance; making improvements and lastly, maintaining improvements (Kaynak, Toklu, Elci, & Toklu, 2016). For Scenario 3, the audit would be conducted in, firstly by gathering information regarding the occurrences of NSIs in specific hospital setting and understanding which diseases were involved when NSIs had occurred; secondly, identifying the reasons which have led to the NSIs – that is, identification of personnel who were involved and the reasons which resulted in such NSIs, that is, lack of protective gear, lack of skills, human issues etc ; developing a standard that 50% of such cases need to be eradicated by the end of this year ; taking strategies like changing the equipment plan per floor, conducting training and skill tests, allocation of more humane work pressure and establishing ICPs and lastly, conducting analysis of whether the standard has been achieved at the end of the audit session. Audit is an ongoing process so the second cycle of audit can being at the end of the first cycle and so on and so forth. 


In this paper, the occurrences of NSIs have been introduced and the severity of such for the health and safety of hospital workers have been identified. Ishikawa’s fish bone diagram has been used to identify the plausible causes – improper hospital management, human factors, improper manpower planning, lack of training etc. Lewin’s Force Field Analysis have been conducted and found that, the main drivers are continuous improvement, funding and management support, health worker safety whereas the resistors are age and experience, lack of motivation, lack of funding and wrongly directed management. Two strategies of clinical governance were chosen to counter the problem of NSI – these were ICPs or Integrated Care Pathways and Risk Management. ICPs would help, as such would ensure that patients with specific infectious diseases are handled differently and only very skilled manpower be only dedicated to such cases. This would help in reduction of such NSI cases which stem from inexperience and less training. Risk Management strategy would overall help in improving the management of hospitals and reduction of such cases. The third strategy of Audit was also implemented and was found that through repeated audit cycles, specific hospitals can reduce the occurrence of NSIs in their vicinities. 


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