Journal of Public Health Advance Access published April 12, 2015 Journal of Public Health | pp. 1–8 | doi:10.1093/pubmed/fdv045
Are some health professionals more cognizant of clinical governance development concepts than others? Findings from a New Zealand study Robin Gauld, Simon Horsburgh Centre for Health Systems, Department of Preventive and Social Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand Address correspondence to Robin Gauld, E-mail: [email protected]
Background Clinical governance has been promoted in recent years as core to improving patient safety. Effective clinical governance requires partnerships between ‘management’ and health professionals as well as equal involvement of all professional groups. Professionals must also be willing to engage in clinical governance activities such as working to improve care systems and patient safety. There is limited research into the relative understanding of core clinical governance concepts amongst different professional groups or the extent to which professionals are prepared to take up opportunities to ‘change the system’. Methods A 2012 national survey study of health professionals employed in New Zealand health boards sought to probe understanding of and commitment to clinical governance following introduction of a 2009 policy. Results Respondent data showed only limited policy implementation had occurred. Regression analyses revealed statistically significant differences in perceptions of knowledge of clinical governance concepts and structures by gender, age, experience and profession, as well as in seeking opportunities to change the system. Conclusions These findings have implications for policy makers in terms of ensuring that clinical governance implementation provides equal opportunity for engendering involvement of different health professionals. Keywords clinical governance, health professionals, New Zealand, patient safety, proportional odds mixed modelling, survey
Background ‘Clinical governance’ emerged in the late-1990s in the UK NHS and has since been applied in a range of countries. Recent studies show that clinically governed health organizations deliver superior care quality and financial performances.1 – 5 In many countries, there is a history of clinical governance rooted in ‘triumvirate’ models which involve administrative and clinical leaders working in partnership. The contemporary resurgence of clinical governance in the NHS was partly in response to management-clinical divides in the running of hospitals, an outcome of ‘managerialism’ which saw installation of generic managers. Clinical governance was also a response to concerns for patient safety; that health professionals had an obligation to get involved in leadership for safety improvement.6
There are various definitions of ‘clinical governance’.7 In general, this might be considered ‘the system’ for governing, organization and leadership. Obviously, the expansive nature of these definitional categories makes for uncertainty.7 In a general sense, clinical governance involves health professionals leading the way in quality and safety improvement efforts, ensuring practices are evidence-informed, and working to build team-based service delivery processes.6 Central to clinical governance is the idea that clinicians are best placed to encourage performance and safety improvement amongst peers.4 Clinical
Robin Gauld, Professor of Health Policy Simon Horsburgh, Lecturer in Epidemiology
# The Author 2015. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: [email protected].
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A B S T R AC T
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Box 1: The New Zealand health system New Zealand’s health system, which caters to its 4.4 million population, is around 80% government-funded from general taxes. The institutional arrangements are not dissimilar to those of other government-funded jurisdictions.15,16 The public sector dominates hospital care which is provided via 20 District Health Boards. Primary medical care, in contrast, is largely privately provided, albeit with considerable government subsidies to offset patient co-payments.
In response, in 2009, the government established a Ministerial Task Group on Clinical Leadership. Its report, In Good Hands,22 became government policy.23 This included that District Health Boards (hereafter termed ‘Boards’) create structures that ensure partnerships between clinical and corporate management; Boards should enable strong clinical leadership; and clinicians should be involved in all decision making. Thus, since 2009, Boards have worked to develop clinical governance with a range of initiatives implemented as described elsewhere.24,25 In 2010, we sought to assess implementation of clinical governance by surveying public hospital medical specialists as they would likely be aware of changes in policy, leadership and organizational structures.26 From this survey, the Clinical Governance Development Index (CGDI) was created which provides a method for rating a health organization’s level of development from a health professional perspective.26 In 2012, we undertook a follow-up study encompassing the full range of health professionals employed in New Zealand’s public health care system. This included not only the spectrum of doctors—consultants, registrars and house surgeons—but also nurses, midwives and allied professionals. The next section outlines the methods for the 2012 study.
Methods A fixed-response 11-item survey was developed for the 2010 study, with additional background questions. The 11 items related directly to policy statements in the clinical governance working party’s report22 with respondents asked to rate familiarity with the developmental process in their Board. The CGDI included seven weighted survey items. This allowed for respondent scores to be aggregated giving an index score out of 100 for each of the Boards.26 The survey underwent minor modifications for the 2012 study through consultation with government policy makers, Board managers and more than 200 health professional employees. One question was dropped from the 2010 survey,
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governance may therefore be expressed in terms of health professionals having two roles: improving the care delivery system with a focus on quality and safety, as well as providing care. Extracting from this, clinical governance might be seen in both organizational structures and processes, with an expectation that improved patient outcomes will be delivered. Research into clinical governance development has been largely focused on the UK NHS. Mostly, studies conclude that there are considerable challenges in developing leadership models featuring genuine health professional involvement; they also find often limited opportunities and variable management backing for clinical governance.8 – 10 However, these studies also reveal challenges in getting health professionals to see governance and leadership as an ‘important calling’ above and beyond health service delivery. In contrast with many other health services and management fields, there is a dearth of clinical governance research aimed at assessing development of structures and processes. A 2010 study presented such a method but was not put to use.11 Others have developed proprietary measures12,13 and checklists.14 There has been a shortage of studies investigating both top-down policy and management support as well as professional commitment to clinical governance. Previous studies have also not investigated the perspectives of different professional groups. While doctors might often be seen as pivotal to clinical governance development, other professionals have equally important contributions to make if effective quality and safety improvement are an aim. If so, it is important to probe levels of knowledge of core clinical governance concepts amongst health professionals. It is important, also, to consider the willingness amongst different professions to engage in clinical governance development. This article contributes to filling the aforementioned gaps by probing two questions: are there different levels of knowledge of clinical governance concepts and processes amongst different health professions; and different levels of willingness to get involved in clinical governance activities? The article presents results from a study of clinical governance implementation in New Zealand’s health system (Box 1) where, in 2009, the government issued a national policy. The New Zealand case is noteworthy as, in the early-1990s, the government swiftly implemented what was possibly the most pure example in the world at the time of an ‘internal market’, along with a managerially led structure for public hospitals.17,18 Controversially, there was an explicit effort to remove health professionals from positions of leadership.19 – 21 Despite subsequent efforts to reverse these policies, their impact endured including on engagement of health professionals in leadership.
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Results The survey response was 25%, or 10 303 respondents from the 19 Boards. Respondents included 19% of nurses, 22% of midwives, 25% of doctors and 38% of allied professionals. There were discrepancies between some respondent groups and the broader public sector health professional workforce (Table 1). Narrow 95% confidence intervals suggested a high level of precision with which the survey represented the population value. Table 2 presents responses from all Boards combined to the survey items of relevance to this article. As illustrated in the right column, the mean score on item 1 suggests that 70% of respondents reported that their Board had established a partnership governance structure. Items 2, 3 and 6, probing dimensions of clinical governance structures, were lower compared with items 4 and 5 which asked whether quality and safety were goals of clinical and resourcing initiatives. They were also lower than the final item about taking up opportunities to change the system. Table 3 contains the POMM results. Findings for item 1 show females were more likely to perceive their Board had established partnership governance structures, while nurses and midwives were less likely than doctors; the likelihood of reporting this increased with age but not years of experience.
There were no age associations for item 2. However, respondents with 5 –15 years of experience were less likely to report a partnership with management, while midwives were less likely than other professionals. For item 3, perceptions of participation in organizational design processes were more positive with age, while respondents with 5 – 15 years of experience and midwives both had reduced odds. On item 4, females were slightly more likely than males to report that quality and safety were goals of every clinical initiative, those aged 60 and over had higher odds than the reference group, and there were lower odds for those with more than 5 years of work experience. Compared with doctors, all of the other professional groups were more likely to report quality and safety as goals for clinical initiatives. Item 5 illustrates increasing likelihood with age, but a decrease with years of experience, to agree quality and safety was a goal of every clinical resourcing or support initiative. Compared
Table 1 Comparison of survey respondent demographics (n ¼ 4988) and those of the total DHB workforce (n ¼ 41 030) Survey Coding
Combined DHBs Respondents
Coding
Workforce
(%)
(if different)
(%)
Gender Male
26
20
Female
74
80
Doctor
21
18
Nurse
44
56
Professional group
Midwife Allied health
3
4
32
22
professional/other Age group 20– 29
7
30– 39
17
25–34
23
40– 49
33
35–44
25
50– 59
34
45–54
27
60 and over
10
55–64
16
,25
65 or over
6
3
Length of service ,5 years
15
,5 years
53
5– 15 years
36
5–14 years
32
More than 15 years
49
15 and over
15
years Note that age group and length of service were categorized differently between the two data sources.
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three new quality and safety questions added in and a further question reworded. A total of 41 030 professionals were invited by their Board to participate in the web-based survey (one Board did not participate). Inclusion criteria were that invitees must be registered health professionals, in on-going employment, full- or part-time, with their Board. Invites, containing a link to the survey web site, were sent via email with three follow-ups sent a week apart. Due to modifications, only six of the original CGDI questions were included in the 2012 survey. These six, plus an item probing whether respondents had sought opportunities to get involved in working with other staff to change the system where it would benefit patients, underpin the research reported in this article. Means of the mean responses from each of the 19 participating Boards were calculated for respondents who had completed all included survey items. To clarify how different demographic and professional groups responded to survey questions, a proportional odds mixed modelling (POMM) method was used for the six CGDI questions and the additional question on getting involved in clinical governance. POMM allowed examining whether certain groups were more likely to give responses to survey items at the positive end of the response ranges provided. This was quantified using odds ratios in the ordinal package for the R statistical environment.27,28
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Table 2 Mean DHB ratings (i.e. mean of the DHB means) for each of the CGDI items, with higher scores indicating more positive mean responses Item
Survey item (scoring range)
number 1
DHB mean (SD)
To your knowledge, has your DHB established
0.70 (0.08)
governance structures that ensure a partnership between health professionals and management? (0– 1) 2
To what extent are health professionals in your
1.02 (0.09)
DHB involved in a partnership with management with shared decision making, responsibility and To what extent are health professionals in your
0.92 (0.08)
DHB involved as full active participants in the design of organizational processes? (0 – 2) 4
To what extent do you believe that quality and
1.39 (0.09)
safety is a goal of every clinical initiative in your DHB? (0 –2) 5
To what extent do you believe that quality and
1.21 (0.08)
safety is a goal of every clinical resourcing or support initiative in your DHB? (0 –2) 6
To what extent has your DHB sought to give
1.06 (0.13)
responsibility to your team for clinical service decision making in your clinical areas? (0– 2) (Not in
To what extent have you sought to take up
CGDI)
opportunities to work with other DHB staff, both
1.25 (0.06)
clinical and managerial, to change the system where it would benefit patients? (0 –2) There were 4988 respondents across all of the 19 DHBs included who completed all of the CGDI items. The distribution of responses for all respondents is also given. SD, standard deviation.
with doctors, the likelihood increased with all of the other professional groups ( particularly nurses). For item 6, the only statistically significant findings were that, compared with doctors, nurses and allied/other staff were slightly more likely to report their team being given responsibility for clinical service decision making. The last item, probing whether respondents had sought to take up clinical governance opportunities, shows females less likely to report this. Likelihood increased with age and years of experience, although the increase disappeared for the over 60 group, while decreasing for nurses compared with doctors.
What is already known on this topic
A growing literature shows that clinical governance can improve patient safety, care quality and financial performances. Prior studies of clinical governance development have mostly been qualitative, focused largely on relationships between management and professionals—predominantly doctors—or deployed checklists designed for organizational self-evaluation.
Discussion Main findings of this study
What this study adds
Three years after introduction of national policy, this study revealed variable knowledge of core clinical governance
First, in contrast with other studies of clinical governance, this study quantitatively measured development through the lens
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accountability? (0– 2) 3
concepts amongst New Zealand health professionals in public employment. Given the government policy drive and engagement by Boards with all professionals, it could be posited that higher knowledge levels and less variation between respondent groups should have been found. It is possible that the findings could be seen as the result of a struggle to traverse the management – professional divide which, as noted, had been embedded by prior policy. Such a divide, and the challenges reversing this, has been reported elsewhere.2,29,30 Policy embeddedness, or ‘path dependency’, meaning institutional arrangements in place frequently pose barriers to the introduction of new policy directions, is also often cited as an explanation for limited policy implementation.31,32 The performance could also be considered a consequence of inadequate attention to core components of successful implementation, such as sufficient resourcing, communications and performance indicators, which have been found to be behind difficulties in other settings.33,34 The study also highlighted differences in the levels of knowledge of, and potential contribution to, clinical governance development amongst different health professional groups. In particular, it illustrated that in some areas of importance one or more professional groups had more knowledge or felt that they were more involved in processes which are pivotal to robust clinical governance. Similarly, there were important and statistically significant differences in perceptions by gender, years of experience and age. While such differences may not be unexpected, it is crucial that different groups within the health professional workforce are treated equally and perceive their contribution is as valued as the next group. This is as a central aim of clinical governance is quality of care and patient safety improvement.35 In turn, this requires clinically led teamwork and inter-professional approaches in what are often complex organizational environments where patients will encounter a range of different professionals in the care delivery process.36,37
Table 3 Results from the multivariable proportional odds mixed models for the relationships between demographic variables and the survey items listed in Table 2 (n ¼ 4988) Item 1 OR
95% CI
Item 2 P
OR
95% CI
Item 3 P
OR
95% CI
Item 4 P
OR
95% CI
Item 5 P
OR
95% CI
Item 6 P
OR
95% CI
Sought opportunities P
OR
95% CI
P
Gender Male
Reference
Female
1.28 1.11 – 1.48 0.001 1.06 0.93 –1.21 0.408 1.07 0.94– 1.22 0.336 1.14 1.02 –1.28 0.024 1.11 0.98 –1.26 0.087 1.02 0.91 – 1.15 0.711 0.77 0.68 –0.86 0.000
Age 20–29
Reference
30–39
1.17 0.92 – 1.50 0.209 0.95 0.77 –1.19 0.680 1.12 0.90– 1.39 0.303 0.85 0.71 –1.01 0.069 0.90 0.74 –1.09 0.296 1.04 0.86 – 1.26 0.651 1.39 1.16 –1.68 0.000
40–49
1.47 1.15 – 1.87 0.002 1.00 0.80 –1.23 0.966 1.14 0.92– 1.41 0.229 0.91 0.76 –1.09 0.299 1.04 0.86 –1.26 0.671 0.97 0.80 – 1.16 0.718 1.80 1.50 –2.16 0.000
50–59
1.75 1.36 – 2.25 0.000 1.14 0.91 –1.42 0.265 1.31 1.05– 1.64 0.017 1.14 0.95 –1.37 0.175 1.35 1.11 –1.64 0.003 1.09 0.90 – 1.32 0.383 1.65 1.36 –1.99 0.000
60 and over
1.87 1.38 – 2.53 0.000 1.16 0.89 –1.52 0.269 1.49 1.15– 1.94 0.003 1.30 1.04 –1.61 0.020 1.78 1.41 –2.25 0.000 1.06 0.84 – 1.33 0.639 1.19 0.95 –1.49 0.129
Years of experience Reference
5–15 years
0.92 0.77 – 1.09 0.323 0.78 0.67 –0.91 0.002 0.83 0.71– 0.97 0.018 0.79 0.70 –0.90 0.000 0.72 0.63 –0.82 0.000 0.86 0.75 – 0.98 0.027 1.27 1.12 –1.45 0.000
More than 15 years 1.13 0.94 – 1.37 0.201 0.96 0.81 –1.14 0.646 0.89 0.75– 1.05 0.168 0.81 0.70 –0.93 0.003 0.65 0.56 –0.75 0.000 0.88 0.76 – 1.02 0.092 1.59 1.38 –1.84 0.000 Professional group Doctor
Reference
Nurse
0.83 0.71 – 0.98 0.031 0.93 0.79 –1.08 0.317 1.00 0.86– 1.16 0.984 1.61 1.42 –1.84 0.000 2.11 1.83 –2.43 0.000 1.19 1.04 – 1.36 0.012 0.81 0.71 –0.92 0.001
Midwife
0.60 0.44 – 0.83 0.002 0.64 0.48 –0.87 0.004 0.58 0.43– 0.77 0.000 1.43 1.10 –1.85 0.008 1.74 1.32 –2.31 0.000 1.07 0.81 – 1.40 0.640 0.81 0.62 –1.05 0.111
Allied/Other
1.07 0.91 – 1.27 0.408 0.96 0.82 –1.12 0.581 0.99 0.85– 1.15 0.902 1.57 1.38 –1.79 0.000 1.84 1.60 –2.12 0.000 1.17 1.02 – 1.34 0.026 1.00 0.88 –1.14 0.978
Each of the models included all of the demographic variables.
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Under 5 years
5
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professionals having two jobs: clinical practice, and system improvement. Perhaps this is where health professional training institutes have a role to play in incorporating system and quality improvement into their curriculum and supporting junior professionals’ activities in these areas.42 Registration bodies, professional colleges, policy makers and employers could be similarly proactive. Following the above, the finding that years of experience was a predictor of less likelihood to agree with some survey items seems counterintuitive. Possible explanations could be that those with longer service had not noted anticipated changes in clinical governance structures compared with what they saw as being the ‘reality’ at the time they responded to the survey. Notably, those with more experience were more likely to have sought opportunities to change the system. Perhaps ‘pushback’ from management, such as not supporting new initiatives due to constrained funding in the New Zealand health system, drove negative responses. Austerity may also explain the differences between doctors and other professionals in responses to the two quality and safety questions, with doctors less likely to agree that quality and safety underpinned clinical and resourcing initiatives. It may be that doctors see more of the direct implications of funding limitations affecting patients in terms of access to services.43 They also may be more involved in discussions around prioritization in a context of restricted funding. Doctors had reduced odds of believing they had been given responsibility for decision making. It is possible, despite higher odds of reporting stepping up to change the system, that doctors simply felt they should have more control over clinical resource decisions, which can improve care quality and financial performances.4,5 It is possible also that they felt there should be more ‘medical engagement’, which is important for getting traction on health system improvement.44 – 46
Limitations of this study
First, there are potential biases in self-completed surveys. However, response patterns were consistent across returned surveys from the 19 Boards. Second, a response rate of 25 percent is undesirable but for a national workforce survey may not be unexpected and there is increasing recognition that high response rates are difficult to attain.47 – 49 While we do not know whether non-responders had different perspectives from respondents, feedback received on a report of wider study findings provided no reason to believe increased participation would have altered the findings.24 That said, it is possible that the non-responders featured a larger proportion of professionals who felt un-engaged. If so, then our results could indicate a higher level of clinical governance development
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of practicing health professionals. As such, it provides baseline information and a benchmark for measuring ongoing progress. While the setting was New Zealand, the study findings could be used comparatively with routine questions asked of health professionals and providers in different countries now commonplace.38,39 The study also validates the questions reported in this article which could be used elsewhere with minimal adaptation. In this way, the study extends development of methods for tracking clinical governance development. Second, the study included all health professionals working in public hospitals and is the first to reveal relative levels of knowledge and the contribution of different professions to clinical governance. Previous studies have only considered the contribution of a single profession.8,40 It is important to understand knowledge levels within particular professional groups, which is critical both for understanding where additional developmental work is needed and for gauging commitment to clinical governance and improving patient care systems. However, a broader understanding of different professional groups’ knowledge of and contribution to clinical governance is demanded. This study, therefore, has illustrated some important differences. The gender difference in perceptions that partnership governance was in place, and quality and safety the goals of clinical initiatives, might be explained with reference to females having a propensity to prefer collaborative, consensus-building organizational arrangements, as described elsewhere.41 If so, female respondents may have perceived in a more positive light management endeavours to induct professionals into partnership governance arrangements. That they were less likely than males to have sought opportunities for involvement in clinical governance, which might be considered an individualistic activity if not otherwise promoted, could be seen as corresponding with the collaborative tendency. If these findings translate beyond New Zealand, then policy makers may need to redouble efforts to ensure a gender balance around involvement in governance and leadership activities. Clinical governance may also need to be promoted as a collaborative effort. This study found older age was a significant predictor of perceptions of clinical governance partnership structures being in place. Older respondents were also more likely to see themselves as active participants in design of organizational processes, and to see quality and safety as goals of clinical initiatives. In contrast, younger respondents (aged 20 –29 years) were less likely to have sought to take up opportunities to change the system. These patterns may be explained with reference to experience that younger professionals are more focused on developing clinical practice skills. If this explanation is valid, then it has implications for the notion of health
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than the reality. Third, the survey method means we were unable to probe why professional group perceptions differed from one another. Answers to these questions might be explored through key informant interviews.
Conclusion
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4 Dorgan S, Layton D, Bloom N et al. Management in Healthcare: Why Good Practice Really Matters. London: McKinsey and Company/ London School of Economics, 2010. 5 Goodall AH. Physician-leaders and hospital performance: is there an association? Soc Sci Med 2011;73:535 – 9. 6 Scally G, Donaldson L. Clinical governance and the drive for quality improvement in the New NHS in England. Br Med J 1998;317:61– 5.
Clinical governance requires partnerships between health professionals and managers but also inter-professional collaboration, with different professional groups having equal potential to contribute to decision making around work organization. This study found significant differences in understanding of core clinical governance policy concepts and willingness amongst professionals to get involved in clinical governance. This could have implications for patient safety where one professional group has potentially less capacity to influence decision making. Policy makers and organizational leaders, therefore, need to ensure that clinical governance implementation provides equal opportunity for engendering involvement of different health professionals.
7 Brennan N, Flynn M. Differentiating clinical governance, clinical management and clinical practice. Clin Govern Int J 2013;18:114 – 31.
Ethical approval
13 Spurgeon P, Barwell F, Mazelan P. Developing a medical engagement scale (MES). Int J Clin Leadership 2008;16:213 – 23.
Funding This study was funded by the National Executive of the National Health Board, the Health Quality and Safety Commission, and the 19 participating DHBs.
Conflict of interest statement The authors declare no conflicts of interest.
9 Som CV. Making sense of clinical governance at different levels in NHS hospital trusts. Clin Govern Int J 2009;14:98– 112. 10 Staniland K. A sociological ethnographic study of clinical governance implementation in one NHS hospital trust. Clin Govern Int J 2009; 14:271– 80. 11 Specchia ML, La Torre G, Siliquini R et al. OPTIGOV—a new methodology for evaluating clinical governance implementation by health providers. BMC Health Serv Res 2010;10:174:1– 10. 12 Spurgeon P, Mazelan P, Barwell F. Medical engagement: a crucial underpinning to organizational performance. Health Serv Manage Res 2011;24:114– 20.
14 Clark J, Nath V. Medical Engagement: A Journey Not An Event. London: King’s Fund, 2014. 15 Okma K, ed. Six Countries, Six Reform Models: The Healthcare Reform Experience of Israel, the Netherlands, New Zealand, Singapore, Switzerland and Taiwan. Singapore: World Scientific Publishers, 2010. 16 Tenbensel T, Eagle S, Ashton T. Comparing health policy agendas across eleven high income countries: islands of difference in a sea of similarity. Health Policy 2012;106:29– 36. 17 Gauld R. Big bang and the policy prescription: health care meets the market in New Zealand. J Health Polit Policy Law 2000;25:815– 44. 18 Cumming J, Mays N. How sustainable is New Zealand’s latest health system restructuring? J Health Serv Res Policy 2002;7:46– 55. 19 Upton S. Your Health and the Public Health: A Statement of Government Health Policy. Wellington: Government Print, 1991. 20 Scott G, Bushnell P, Sallee N. Reform of the Core Public Sector: New Zealand Experience. Governance 1990;3:138– 67. 21 Gauld R. The attitudes of senior official in the ‘new’ New Zealand health sector. Polit Sci 1995;47:191 – 214.
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The study protocol and survey tool was reviewed, including for ethical considerations, and approved by the National Executive of the National Health Board, Board and executive team of the Health Quality and Safety Commission and CEO and leadership teams of the participating DHBs.
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29 Benson LA, Boyd A, Walshe K. Learning from regulatory interventions in healthcare: the Commission for Health Improvement and its clinical governance review process. Clin Govern Int J 2006;11: 213 – 24.
37 Pathak S, Holzmueller CG, Haller KB et al. A mile in their shoes: interdisciplinary education at the Johns Hopkins University School of Medicine. Am J Med Qual 2010;25:462 – 7.
Are some health professionals more cognizant of clinical governance development concepts than others? Findings from a New Zealand study Robin Gauld, Simon Horsburgh Centre for Health Systems, Department of Preventive and Social Medicine, University of Otago, PO Box 56, Dunedin 9054, New Zealand Address correspondence to Robin Gauld, E-mail: [email protected]
Background Clinical governance has been promoted in recent years as core to improving patient safety. Effective clinical governance requires partnerships between ‘management’ and health professionals as well as equal involvement of all professional groups. Professionals must also be willing to engage in clinical governance activities such as working to improve care systems and patient safety. There is limited research into the relative understanding of core clinical governance concepts amongst different professional groups or the extent to which professionals are prepared to take up opportunities to ‘change the system’. Methods A 2012 national survey study of health professionals employed in New Zealand health boards sought to probe understanding of and commitment to clinical governance following introduction of a 2009 policy. Results Respondent data showed only limited policy implementation had occurred. Regression analyses revealed statistically significant differences in perceptions of knowledge of clinical governance concepts and structures by gender, age, experience and profession, as well as in seeking opportunities to change the system. Conclusions These findings have implications for policy makers in terms of ensuring that clinical governance implementation provides equal opportunity for engendering involvement of different health professionals. Keywords clinical governance, health professionals, New Zealand, patient safety, proportional odds mixed modelling, survey
Background ‘Clinical governance’ emerged in the late-1990s in the UK NHS and has since been applied in a range of countries. Recent studies show that clinically governed health organizations deliver superior care quality and financial performances.1 – 5 In many countries, there is a history of clinical governance rooted in ‘triumvirate’ models which involve administrative and clinical leaders working in partnership. The contemporary resurgence of clinical governance in the NHS was partly in response to management-clinical divides in the running of hospitals, an outcome of ‘managerialism’ which saw installation of generic managers. Clinical governance was also a response to concerns for patient safety; that health professionals had an obligation to get involved in leadership for safety improvement.6
There are various definitions of ‘clinical governance’.7 In general, this might be considered ‘the system’ for governing, organization and leadership. Obviously, the expansive nature of these definitional categories makes for uncertainty.7 In a general sense, clinical governance involves health professionals leading the way in quality and safety improvement efforts, ensuring practices are evidence-informed, and working to build team-based service delivery processes.6 Central to clinical governance is the idea that clinicians are best placed to encourage performance and safety improvement amongst peers.4 Clinical
Robin Gauld, Professor of Health Policy Simon Horsburgh, Lecturer in Epidemiology
# The Author 2015. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: [email protected].
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A B S T R AC T
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Box 1: The New Zealand health system New Zealand’s health system, which caters to its 4.4 million population, is around 80% government-funded from general taxes. The institutional arrangements are not dissimilar to those of other government-funded jurisdictions.15,16 The public sector dominates hospital care which is provided via 20 District Health Boards. Primary medical care, in contrast, is largely privately provided, albeit with considerable government subsidies to offset patient co-payments.
In response, in 2009, the government established a Ministerial Task Group on Clinical Leadership. Its report, In Good Hands,22 became government policy.23 This included that District Health Boards (hereafter termed ‘Boards’) create structures that ensure partnerships between clinical and corporate management; Boards should enable strong clinical leadership; and clinicians should be involved in all decision making. Thus, since 2009, Boards have worked to develop clinical governance with a range of initiatives implemented as described elsewhere.24,25 In 2010, we sought to assess implementation of clinical governance by surveying public hospital medical specialists as they would likely be aware of changes in policy, leadership and organizational structures.26 From this survey, the Clinical Governance Development Index (CGDI) was created which provides a method for rating a health organization’s level of development from a health professional perspective.26 In 2012, we undertook a follow-up study encompassing the full range of health professionals employed in New Zealand’s public health care system. This included not only the spectrum of doctors—consultants, registrars and house surgeons—but also nurses, midwives and allied professionals. The next section outlines the methods for the 2012 study.
Methods A fixed-response 11-item survey was developed for the 2010 study, with additional background questions. The 11 items related directly to policy statements in the clinical governance working party’s report22 with respondents asked to rate familiarity with the developmental process in their Board. The CGDI included seven weighted survey items. This allowed for respondent scores to be aggregated giving an index score out of 100 for each of the Boards.26 The survey underwent minor modifications for the 2012 study through consultation with government policy makers, Board managers and more than 200 health professional employees. One question was dropped from the 2010 survey,
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governance may therefore be expressed in terms of health professionals having two roles: improving the care delivery system with a focus on quality and safety, as well as providing care. Extracting from this, clinical governance might be seen in both organizational structures and processes, with an expectation that improved patient outcomes will be delivered. Research into clinical governance development has been largely focused on the UK NHS. Mostly, studies conclude that there are considerable challenges in developing leadership models featuring genuine health professional involvement; they also find often limited opportunities and variable management backing for clinical governance.8 – 10 However, these studies also reveal challenges in getting health professionals to see governance and leadership as an ‘important calling’ above and beyond health service delivery. In contrast with many other health services and management fields, there is a dearth of clinical governance research aimed at assessing development of structures and processes. A 2010 study presented such a method but was not put to use.11 Others have developed proprietary measures12,13 and checklists.14 There has been a shortage of studies investigating both top-down policy and management support as well as professional commitment to clinical governance. Previous studies have also not investigated the perspectives of different professional groups. While doctors might often be seen as pivotal to clinical governance development, other professionals have equally important contributions to make if effective quality and safety improvement are an aim. If so, it is important to probe levels of knowledge of core clinical governance concepts amongst health professionals. It is important, also, to consider the willingness amongst different professions to engage in clinical governance development. This article contributes to filling the aforementioned gaps by probing two questions: are there different levels of knowledge of clinical governance concepts and processes amongst different health professions; and different levels of willingness to get involved in clinical governance activities? The article presents results from a study of clinical governance implementation in New Zealand’s health system (Box 1) where, in 2009, the government issued a national policy. The New Zealand case is noteworthy as, in the early-1990s, the government swiftly implemented what was possibly the most pure example in the world at the time of an ‘internal market’, along with a managerially led structure for public hospitals.17,18 Controversially, there was an explicit effort to remove health professionals from positions of leadership.19 – 21 Despite subsequent efforts to reverse these policies, their impact endured including on engagement of health professionals in leadership.
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Results The survey response was 25%, or 10 303 respondents from the 19 Boards. Respondents included 19% of nurses, 22% of midwives, 25% of doctors and 38% of allied professionals. There were discrepancies between some respondent groups and the broader public sector health professional workforce (Table 1). Narrow 95% confidence intervals suggested a high level of precision with which the survey represented the population value. Table 2 presents responses from all Boards combined to the survey items of relevance to this article. As illustrated in the right column, the mean score on item 1 suggests that 70% of respondents reported that their Board had established a partnership governance structure. Items 2, 3 and 6, probing dimensions of clinical governance structures, were lower compared with items 4 and 5 which asked whether quality and safety were goals of clinical and resourcing initiatives. They were also lower than the final item about taking up opportunities to change the system. Table 3 contains the POMM results. Findings for item 1 show females were more likely to perceive their Board had established partnership governance structures, while nurses and midwives were less likely than doctors; the likelihood of reporting this increased with age but not years of experience.
There were no age associations for item 2. However, respondents with 5 –15 years of experience were less likely to report a partnership with management, while midwives were less likely than other professionals. For item 3, perceptions of participation in organizational design processes were more positive with age, while respondents with 5 – 15 years of experience and midwives both had reduced odds. On item 4, females were slightly more likely than males to report that quality and safety were goals of every clinical initiative, those aged 60 and over had higher odds than the reference group, and there were lower odds for those with more than 5 years of work experience. Compared with doctors, all of the other professional groups were more likely to report quality and safety as goals for clinical initiatives. Item 5 illustrates increasing likelihood with age, but a decrease with years of experience, to agree quality and safety was a goal of every clinical resourcing or support initiative. Compared
Table 1 Comparison of survey respondent demographics (n ¼ 4988) and those of the total DHB workforce (n ¼ 41 030) Survey Coding
Combined DHBs Respondents
Coding
Workforce
(%)
(if different)
(%)
Gender Male
26
20
Female
74
80
Doctor
21
18
Nurse
44
56
Professional group
Midwife Allied health
3
4
32
22
professional/other Age group 20– 29
7
30– 39
17
25–34
23
40– 49
33
35–44
25
50– 59
34
45–54
27
60 and over
10
55–64
16
,25
65 or over
6
3
Length of service ,5 years
15
,5 years
53
5– 15 years
36
5–14 years
32
More than 15 years
49
15 and over
15
years Note that age group and length of service were categorized differently between the two data sources.
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three new quality and safety questions added in and a further question reworded. A total of 41 030 professionals were invited by their Board to participate in the web-based survey (one Board did not participate). Inclusion criteria were that invitees must be registered health professionals, in on-going employment, full- or part-time, with their Board. Invites, containing a link to the survey web site, were sent via email with three follow-ups sent a week apart. Due to modifications, only six of the original CGDI questions were included in the 2012 survey. These six, plus an item probing whether respondents had sought opportunities to get involved in working with other staff to change the system where it would benefit patients, underpin the research reported in this article. Means of the mean responses from each of the 19 participating Boards were calculated for respondents who had completed all included survey items. To clarify how different demographic and professional groups responded to survey questions, a proportional odds mixed modelling (POMM) method was used for the six CGDI questions and the additional question on getting involved in clinical governance. POMM allowed examining whether certain groups were more likely to give responses to survey items at the positive end of the response ranges provided. This was quantified using odds ratios in the ordinal package for the R statistical environment.27,28
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Table 2 Mean DHB ratings (i.e. mean of the DHB means) for each of the CGDI items, with higher scores indicating more positive mean responses Item
Survey item (scoring range)
number 1
DHB mean (SD)
To your knowledge, has your DHB established
0.70 (0.08)
governance structures that ensure a partnership between health professionals and management? (0– 1) 2
To what extent are health professionals in your
1.02 (0.09)
DHB involved in a partnership with management with shared decision making, responsibility and To what extent are health professionals in your
0.92 (0.08)
DHB involved as full active participants in the design of organizational processes? (0 – 2) 4
To what extent do you believe that quality and
1.39 (0.09)
safety is a goal of every clinical initiative in your DHB? (0 –2) 5
To what extent do you believe that quality and
1.21 (0.08)
safety is a goal of every clinical resourcing or support initiative in your DHB? (0 –2) 6
To what extent has your DHB sought to give
1.06 (0.13)
responsibility to your team for clinical service decision making in your clinical areas? (0– 2) (Not in
To what extent have you sought to take up
CGDI)
opportunities to work with other DHB staff, both
1.25 (0.06)
clinical and managerial, to change the system where it would benefit patients? (0 –2) There were 4988 respondents across all of the 19 DHBs included who completed all of the CGDI items. The distribution of responses for all respondents is also given. SD, standard deviation.
with doctors, the likelihood increased with all of the other professional groups ( particularly nurses). For item 6, the only statistically significant findings were that, compared with doctors, nurses and allied/other staff were slightly more likely to report their team being given responsibility for clinical service decision making. The last item, probing whether respondents had sought to take up clinical governance opportunities, shows females less likely to report this. Likelihood increased with age and years of experience, although the increase disappeared for the over 60 group, while decreasing for nurses compared with doctors.
What is already known on this topic
A growing literature shows that clinical governance can improve patient safety, care quality and financial performances. Prior studies of clinical governance development have mostly been qualitative, focused largely on relationships between management and professionals—predominantly doctors—or deployed checklists designed for organizational self-evaluation.
Discussion Main findings of this study
What this study adds
Three years after introduction of national policy, this study revealed variable knowledge of core clinical governance
First, in contrast with other studies of clinical governance, this study quantitatively measured development through the lens
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accountability? (0– 2) 3
concepts amongst New Zealand health professionals in public employment. Given the government policy drive and engagement by Boards with all professionals, it could be posited that higher knowledge levels and less variation between respondent groups should have been found. It is possible that the findings could be seen as the result of a struggle to traverse the management – professional divide which, as noted, had been embedded by prior policy. Such a divide, and the challenges reversing this, has been reported elsewhere.2,29,30 Policy embeddedness, or ‘path dependency’, meaning institutional arrangements in place frequently pose barriers to the introduction of new policy directions, is also often cited as an explanation for limited policy implementation.31,32 The performance could also be considered a consequence of inadequate attention to core components of successful implementation, such as sufficient resourcing, communications and performance indicators, which have been found to be behind difficulties in other settings.33,34 The study also highlighted differences in the levels of knowledge of, and potential contribution to, clinical governance development amongst different health professional groups. In particular, it illustrated that in some areas of importance one or more professional groups had more knowledge or felt that they were more involved in processes which are pivotal to robust clinical governance. Similarly, there were important and statistically significant differences in perceptions by gender, years of experience and age. While such differences may not be unexpected, it is crucial that different groups within the health professional workforce are treated equally and perceive their contribution is as valued as the next group. This is as a central aim of clinical governance is quality of care and patient safety improvement.35 In turn, this requires clinically led teamwork and inter-professional approaches in what are often complex organizational environments where patients will encounter a range of different professionals in the care delivery process.36,37
Table 3 Results from the multivariable proportional odds mixed models for the relationships between demographic variables and the survey items listed in Table 2 (n ¼ 4988) Item 1 OR
95% CI
Item 2 P
OR
95% CI
Item 3 P
OR
95% CI
Item 4 P
OR
95% CI
Item 5 P
OR
95% CI
Item 6 P
OR
95% CI
Sought opportunities P
OR
95% CI
P
Gender Male
Reference
Female
1.28 1.11 – 1.48 0.001 1.06 0.93 –1.21 0.408 1.07 0.94– 1.22 0.336 1.14 1.02 –1.28 0.024 1.11 0.98 –1.26 0.087 1.02 0.91 – 1.15 0.711 0.77 0.68 –0.86 0.000
Age 20–29
Reference
30–39
1.17 0.92 – 1.50 0.209 0.95 0.77 –1.19 0.680 1.12 0.90– 1.39 0.303 0.85 0.71 –1.01 0.069 0.90 0.74 –1.09 0.296 1.04 0.86 – 1.26 0.651 1.39 1.16 –1.68 0.000
40–49
1.47 1.15 – 1.87 0.002 1.00 0.80 –1.23 0.966 1.14 0.92– 1.41 0.229 0.91 0.76 –1.09 0.299 1.04 0.86 –1.26 0.671 0.97 0.80 – 1.16 0.718 1.80 1.50 –2.16 0.000
50–59
1.75 1.36 – 2.25 0.000 1.14 0.91 –1.42 0.265 1.31 1.05– 1.64 0.017 1.14 0.95 –1.37 0.175 1.35 1.11 –1.64 0.003 1.09 0.90 – 1.32 0.383 1.65 1.36 –1.99 0.000
60 and over
1.87 1.38 – 2.53 0.000 1.16 0.89 –1.52 0.269 1.49 1.15– 1.94 0.003 1.30 1.04 –1.61 0.020 1.78 1.41 –2.25 0.000 1.06 0.84 – 1.33 0.639 1.19 0.95 –1.49 0.129
Years of experience Reference
5–15 years
0.92 0.77 – 1.09 0.323 0.78 0.67 –0.91 0.002 0.83 0.71– 0.97 0.018 0.79 0.70 –0.90 0.000 0.72 0.63 –0.82 0.000 0.86 0.75 – 0.98 0.027 1.27 1.12 –1.45 0.000
More than 15 years 1.13 0.94 – 1.37 0.201 0.96 0.81 –1.14 0.646 0.89 0.75– 1.05 0.168 0.81 0.70 –0.93 0.003 0.65 0.56 –0.75 0.000 0.88 0.76 – 1.02 0.092 1.59 1.38 –1.84 0.000 Professional group Doctor
Reference
Nurse
0.83 0.71 – 0.98 0.031 0.93 0.79 –1.08 0.317 1.00 0.86– 1.16 0.984 1.61 1.42 –1.84 0.000 2.11 1.83 –2.43 0.000 1.19 1.04 – 1.36 0.012 0.81 0.71 –0.92 0.001
Midwife
0.60 0.44 – 0.83 0.002 0.64 0.48 –0.87 0.004 0.58 0.43– 0.77 0.000 1.43 1.10 –1.85 0.008 1.74 1.32 –2.31 0.000 1.07 0.81 – 1.40 0.640 0.81 0.62 –1.05 0.111
Allied/Other
1.07 0.91 – 1.27 0.408 0.96 0.82 –1.12 0.581 0.99 0.85– 1.15 0.902 1.57 1.38 –1.79 0.000 1.84 1.60 –2.12 0.000 1.17 1.02 – 1.34 0.026 1.00 0.88 –1.14 0.978
Each of the models included all of the demographic variables.
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Under 5 years
5
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professionals having two jobs: clinical practice, and system improvement. Perhaps this is where health professional training institutes have a role to play in incorporating system and quality improvement into their curriculum and supporting junior professionals’ activities in these areas.42 Registration bodies, professional colleges, policy makers and employers could be similarly proactive. Following the above, the finding that years of experience was a predictor of less likelihood to agree with some survey items seems counterintuitive. Possible explanations could be that those with longer service had not noted anticipated changes in clinical governance structures compared with what they saw as being the ‘reality’ at the time they responded to the survey. Notably, those with more experience were more likely to have sought opportunities to change the system. Perhaps ‘pushback’ from management, such as not supporting new initiatives due to constrained funding in the New Zealand health system, drove negative responses. Austerity may also explain the differences between doctors and other professionals in responses to the two quality and safety questions, with doctors less likely to agree that quality and safety underpinned clinical and resourcing initiatives. It may be that doctors see more of the direct implications of funding limitations affecting patients in terms of access to services.43 They also may be more involved in discussions around prioritization in a context of restricted funding. Doctors had reduced odds of believing they had been given responsibility for decision making. It is possible, despite higher odds of reporting stepping up to change the system, that doctors simply felt they should have more control over clinical resource decisions, which can improve care quality and financial performances.4,5 It is possible also that they felt there should be more ‘medical engagement’, which is important for getting traction on health system improvement.44 – 46
Limitations of this study
First, there are potential biases in self-completed surveys. However, response patterns were consistent across returned surveys from the 19 Boards. Second, a response rate of 25 percent is undesirable but for a national workforce survey may not be unexpected and there is increasing recognition that high response rates are difficult to attain.47 – 49 While we do not know whether non-responders had different perspectives from respondents, feedback received on a report of wider study findings provided no reason to believe increased participation would have altered the findings.24 That said, it is possible that the non-responders featured a larger proportion of professionals who felt un-engaged. If so, then our results could indicate a higher level of clinical governance development
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of practicing health professionals. As such, it provides baseline information and a benchmark for measuring ongoing progress. While the setting was New Zealand, the study findings could be used comparatively with routine questions asked of health professionals and providers in different countries now commonplace.38,39 The study also validates the questions reported in this article which could be used elsewhere with minimal adaptation. In this way, the study extends development of methods for tracking clinical governance development. Second, the study included all health professionals working in public hospitals and is the first to reveal relative levels of knowledge and the contribution of different professions to clinical governance. Previous studies have only considered the contribution of a single profession.8,40 It is important to understand knowledge levels within particular professional groups, which is critical both for understanding where additional developmental work is needed and for gauging commitment to clinical governance and improving patient care systems. However, a broader understanding of different professional groups’ knowledge of and contribution to clinical governance is demanded. This study, therefore, has illustrated some important differences. The gender difference in perceptions that partnership governance was in place, and quality and safety the goals of clinical initiatives, might be explained with reference to females having a propensity to prefer collaborative, consensus-building organizational arrangements, as described elsewhere.41 If so, female respondents may have perceived in a more positive light management endeavours to induct professionals into partnership governance arrangements. That they were less likely than males to have sought opportunities for involvement in clinical governance, which might be considered an individualistic activity if not otherwise promoted, could be seen as corresponding with the collaborative tendency. If these findings translate beyond New Zealand, then policy makers may need to redouble efforts to ensure a gender balance around involvement in governance and leadership activities. Clinical governance may also need to be promoted as a collaborative effort. This study found older age was a significant predictor of perceptions of clinical governance partnership structures being in place. Older respondents were also more likely to see themselves as active participants in design of organizational processes, and to see quality and safety as goals of clinical initiatives. In contrast, younger respondents (aged 20 –29 years) were less likely to have sought to take up opportunities to change the system. These patterns may be explained with reference to experience that younger professionals are more focused on developing clinical practice skills. If this explanation is valid, then it has implications for the notion of health
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than the reality. Third, the survey method means we were unable to probe why professional group perceptions differed from one another. Answers to these questions might be explored through key informant interviews.
Conclusion
7
4 Dorgan S, Layton D, Bloom N et al. Management in Healthcare: Why Good Practice Really Matters. London: McKinsey and Company/ London School of Economics, 2010. 5 Goodall AH. Physician-leaders and hospital performance: is there an association? Soc Sci Med 2011;73:535 – 9. 6 Scally G, Donaldson L. Clinical governance and the drive for quality improvement in the New NHS in England. Br Med J 1998;317:61– 5.
Clinical governance requires partnerships between health professionals and managers but also inter-professional collaboration, with different professional groups having equal potential to contribute to decision making around work organization. This study found significant differences in understanding of core clinical governance policy concepts and willingness amongst professionals to get involved in clinical governance. This could have implications for patient safety where one professional group has potentially less capacity to influence decision making. Policy makers and organizational leaders, therefore, need to ensure that clinical governance implementation provides equal opportunity for engendering involvement of different health professionals.
7 Brennan N, Flynn M. Differentiating clinical governance, clinical management and clinical practice. Clin Govern Int J 2013;18:114 – 31.
Ethical approval
13 Spurgeon P, Barwell F, Mazelan P. Developing a medical engagement scale (MES). Int J Clin Leadership 2008;16:213 – 23.
Funding This study was funded by the National Executive of the National Health Board, the Health Quality and Safety Commission, and the 19 participating DHBs.
Conflict of interest statement The authors declare no conflicts of interest.
9 Som CV. Making sense of clinical governance at different levels in NHS hospital trusts. Clin Govern Int J 2009;14:98– 112. 10 Staniland K. A sociological ethnographic study of clinical governance implementation in one NHS hospital trust. Clin Govern Int J 2009; 14:271– 80. 11 Specchia ML, La Torre G, Siliquini R et al. OPTIGOV—a new methodology for evaluating clinical governance implementation by health providers. BMC Health Serv Res 2010;10:174:1– 10. 12 Spurgeon P, Mazelan P, Barwell F. Medical engagement: a crucial underpinning to organizational performance. Health Serv Manage Res 2011;24:114– 20.
14 Clark J, Nath V. Medical Engagement: A Journey Not An Event. London: King’s Fund, 2014. 15 Okma K, ed. Six Countries, Six Reform Models: The Healthcare Reform Experience of Israel, the Netherlands, New Zealand, Singapore, Switzerland and Taiwan. Singapore: World Scientific Publishers, 2010. 16 Tenbensel T, Eagle S, Ashton T. Comparing health policy agendas across eleven high income countries: islands of difference in a sea of similarity. Health Policy 2012;106:29– 36. 17 Gauld R. Big bang and the policy prescription: health care meets the market in New Zealand. J Health Polit Policy Law 2000;25:815– 44. 18 Cumming J, Mays N. How sustainable is New Zealand’s latest health system restructuring? J Health Serv Res Policy 2002;7:46– 55. 19 Upton S. Your Health and the Public Health: A Statement of Government Health Policy. Wellington: Government Print, 1991. 20 Scott G, Bushnell P, Sallee N. Reform of the Core Public Sector: New Zealand Experience. Governance 1990;3:138– 67. 21 Gauld R. The attitudes of senior official in the ‘new’ New Zealand health sector. Polit Sci 1995;47:191 – 214.
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The study protocol and survey tool was reviewed, including for ethical considerations, and approved by the National Executive of the National Health Board, Board and executive team of the Health Quality and Safety Commission and CEO and leadership teams of the participating DHBs.
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29 Benson LA, Boyd A, Walshe K. Learning from regulatory interventions in healthcare: the Commission for Health Improvement and its clinical governance review process. Clin Govern Int J 2006;11: 213 – 24.
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