Elsevier

Public Health

Volume 121, Issue 8, August 2007, Pages 614-622
Public Health

Original Research
Consultants’ attitudes to clinical governance: Barriers and incentives to engagement

https://doi.org/10.1016/j.puhe.2006.12.013Get rights and content

Summary

Objective

To explore medical specialists’ attitudes to clinical governance in acute hospitals and factors influencing these attitudes.

Methods

A semi-structured interview study with a purposeful sample of 24 medical specialists from two contrasting hospitals. Hospital A had a low level of consultant involvement in quality improvement initiatives and Hospital B had higher levels of engagement.

Results

Specialists from both hospitals acknowledged that quality improvement was a major part of their role. Among specialists from Hospital A, the lack of a commonly held focus on quality-improvement, poor inter-professional relationships and little clinical engagement in management were the main factors generating negative attitudes towards clinical governance. Effective communication of the hospital's goal of continuous quality improvement to all staff groups, a sense of being able to get issues affecting the quality of care heard by senior management, and a perception that there were clear structures and processes to support clinical governance, were factors that resulted in a more positive attitude to clinical governance among specialists in Hospital B. Specialists from both hospitals identified lack of time across all professional groups and availability of accurate data as barriers to involvement in clinical governance activities.

Conclusion

The cultural context, level of technical support available, ability to communicate clear goals and strategies and the presence of structures to support delivery, all contribute to shaping specialists’ attitudes to clinical governance and in turn influence levels of engagement and ultimately the success of quality improvement initiatives.

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.

References (29)

  • N. Black et al.

    Obstacles to medical audit: British doctors speak

    Soc Sci Med

    (1993)
  • N. Fulop et al.

    Changing organisations: a study of the context and process of mergers of health care providers in England

    Soc Sci Med

    (2005)
  • R. Smith

    All changed, all changed utterly

    BMJ

    (1998)
  • A first class service: quality in the new NHS

    (1998)
  • Clinical governance in the new NHS, HSC 1999/065

    (1999)
  • L. Wallace et al.

    Organisational strategies for changing clinical practice: how trusts are meeting the challenges of clinical governance

    Qual Health Care

    (2001)
  • S.M. Campbell et al.

    Implementing clinical governance in English primary care groups/trusts: reconciling quality-improvement and quality assurance

    Qual Saf Health Care

    (2002)
  • G. Johnston et al.

    Reviewing audit: barriers and facilitating factors for effective clinical audit

    Qual Health Care

    (2000)
  • J. Hayward et al.

    Clinical governance: thin on the ground

    Health Serv J

    (1999)
  • T. Freeman et al.

    Achieving progress through clinical governance? A national study of health care managers’ perceptions in the NHS in England

    Qual Saf Health Care

    (2004)
  • B. Weiner et al.

    Promoting clinical involvement in hospital quality-improvement efforts: the effects of top management, board and physician leadership

    Health Serv Res

    (1997)
  • D. Blumenthal et al.

    A report card on continuous quality-improvement

    Milbank Q

    (1998)
  • P. Morrison et al.

    Why do health practitioners resist quality management?

    Qual Prog

    (1992)
  • C. Ham et al.

    Redesigning work processes in health care: lessons from the National Health Service

    Milbank Q

    (2003)
  • Cited by (0)

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