Original ResearchConsultants’ attitudes to clinical governance: Barriers and incentives to engagement
Introduction
Reforming how health care is organized and monitored has become a political imperative in most industrialized countries owing to the growing costs of such care, the lack of proven effectiveness of many healthcare interventions and concerns related to the medical professions’ ability to ensure accountability among its members.1 Seven years ago, the English Department of Health introduced a strategy to improve quality of healthcare services.2 ‘Clinical governance’ was identified as the mechanism to systematically improve standards of clinical care. Early guidance3 identified its components: evidence-based practice, audit, risk management, mechanisms to monitor the outcomes of care, lifelong learning among clinicians and systems for managing poor performance. Healthcare providers were required to identify a clinician at board level with responsibility for clinical governance, supported by a board-level clinical governance committee.
Initial studies among managers and clinicians revealed some scepticism, especially as some components, such as clinical audit, were already perceived as having a limited effect on quality.4, 5, 6 Key barriers to successful implementation were identified: lack of time, staff support and financial resources and issues related to organizational culture.7 In 2002, a survey of over 1000 Trust (National Health Service provider) managers reported progress in establishing clinical governance structures and processes, including at board level, but less evidence of coherent planning or of effect on clinical practice.8
Involvement of physicians at strategic and operational levels is widely viewed as essential for the success of quality improvement initiatives.9, 10 However, scepticism and resistance to these initiatives has been shown to be widespread among this group of professionals.11 Research points to a training that inculcates strong professional pride and individualism,10, 11, 12 the power and control that physicians command,13 a culture heavily influenced by peers and collegial processes,14 and experience of earlier initiatives15 as reasons for these negative attitudes and resulting lack of involvement. In contrast, healthcare organizations that have been successful in implementing quality improvement programmes highlight the importance of active involvement of doctors and point to factors such as effective clinical and managerial leadership, preservation of clinician autonomy, support for training, and peer pressure as important in changing attitudes and increasing commitment.10, 16, 17 The situation is, however, dynamic as norms evolve in society and within the health professions. It remains important to understand doctors’ attitudes to clinical governance in different settings and contexts to illuminate why and how interventions succeed or fail, and to identify interventions that are more likely to succeed.18 In this paper, we describe attitudes to clinical governance in two neighbouring acute healthcare providers in South East England. In one, senior managers felt that many senior physicians (consultants) had negative attitudes to clinical governance and found it difficult to increase involvement in quality improvement activities (Hospital A). In the second, consultants were felt to have a more positive attitude and were more engaged with management (Hospital B).
Section snippets
Method
Interviews were carried out between September 2004 and January 2005 in two acute hospitals in South East England. The study was initiated by managers in Hospital A, who sought to understand the challenges they faced. In subsequent discussions, it was agreed that it would be important to compare Hospital A's experience with another hospital in which clinical governance was considered to be successfully embedded. Hospital A was established in 2001 after the merger of two smaller hospitals. It had
The consultant's role in clinical governance
Most consultants across both hospitals accepted that improving quality of health care should be integral to their role. Reviewing clinical care against defined standards, monitoring and improving patient outcomes and comparing performance with peers were seen as legitimate activities. For some, in both hospitals, ‘clinical governance’ was simply a new name for existing quality improvement activities, although these individuals readily agreed that these activities had not necessarily been
Clinical governance and team work
Many doctors from both hospitals identified the development of functional multidisciplinary teams as a key contributor to improving the quality of care. Clinical governance activities were more effective if all members of the team accepted their importance, contributed to their design and participated in them. There were, however, obstacles to the development of teamwork in some specialties, the principle one being protected time. Consultants also felt that some professional groups needed to
Effectiveness of clinical governance
Medical audit was the first type of quality improvement activity to be implemented widely in the National Health Service. Opinions about its effectiveness were mixed at both hospitals. Many saw audit solely as an educational exercise for junior doctors. Its contribution was limited by lack of methodological rigour and the poor quality of recommendations that resulted. Moreover, the junior doctors who undertook audits had often moved on before the recommendations could be implemented, resulting
Discussion
This study has highlighted several factors that influence consultants’ attitudes to clinical governance in two acute hospitals. Before discussing the results, some limitations must be considered. First, the study included only two hospitals. However, many of the issues that emerged resonated with findings from earlier studies,6, 11, 17 suggesting that these hospitals were not atypical. Second, there is a risk that the more positive views on clinical governance expressed in Hospital B reflected
Acknowledgements
We would like to thank the staff and senior management at both hospitals for their involvement in this study.
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