Clinical governance in primary care: participating in clinical governance

Establishing clinical governance model in primary health care: A systematic review

Clinical governance is a systematic approach to enhancing the quality of primary health care and ensuring high clinical standards, responsiveness to performance, and continuous improvement in service quality. The objective of the current study was to investigate the global experiences of clinical governance in primary health care. In the present systematic review, relevant articles from different countries were searched in various databases such as MD PubMed from Medline portal, Emerald Springer link, ProQuest, Cochrane, Scopus, Web of Science, and Consult until April 2019. The searched articles were checked through CASP and PRISMA checklists, and their results were extracted. Of the 17 selected studies, 16 belonged to developed countries, including England (13), Australia, Italy, and New Zealand, and one was from Turkey. The findings were divided into three general categories: (1) principles of effectiveness and risk management, (2) deployment requirements such as structural and organizational needs, resource and communication, and information management, and (3) barriers of clinical governance toward providing primary health care. it is recommended that a suitable framework or model be developed and designed adapted to the local culture and taking into account all effective dimensions for a proper establishment and implementation of clinical governance in primary health care.

Ten-Year Follow-Up of Clinical Governance Implementation in Primary Care: Improving Screening, Diagnosis and Control of Cardiovascular Risk Factors

Current improvement strategies for the control of cardiovascular risk factors (CRFs) in Europe are based on quality management policies. With the aim of understanding the effect of interventions delivered by primary healthcare systems, we evaluated the impact of clinical governance on cardiovascular health after ten years of implementation in Catalonia. A cohort study that included 1878 patients was conducted in 19 primary care centres (PCCs). Audits that comprised 13 cardiovascular health indicators were performed and general practitioners received periodic (annual, biannual or monthly) feedback about their clinical practice. We evaluated improvement in screening, diagnosis and control of the main CRFs and the effects of the feedback on cardiovascular risk (CR), incidence of cardiovascular disease (CVD) and mortality, comparing baseline data with data at the end of the study (after a 10-year follow-up). The impact of the intervention was assessed globally and with respect to feedback frequency. General improvement was observed in screening, percentage of diagnoses and control of CRFs. At the end of the study, few clinically significant differences in CRFs were observed between groups. However, the reduction in CR was greater in the group receiving high frequency feedback, specifically in relation to smoking and control of diabetes and cholesterol (Low Density Lipoprotein (LDL) and High Density Lipoprotein (HDL)). A protective effect of having a cardiovascular event (hazard ratio (HR) = 0.64, 95% confidence interval (CI) = 0.44-0.94) or death (HR = 0.55, 95% CI = 0.35-0.88) was observed in patients from centres where general practitioners received high frequency feedback. Additionally, these PCCs presented improved cardiovascular health indicators and lower incidence and mortality by CVD, illustrating the impact of this intervention.

[Factors facilitating and impairing implementation of integrated care]

BACKGROUND

Better integration of healthcare is the focus of many current reforms in Western countries. The goal is to reduce fragmentation of health and social care delivery for patients with chronic diseases. In France, Alzheimer autonomy integration experimentations (Maison Autonomie Intégration Alzheimer [MAIA]) were introduced as part of the 2008-2012 National Alzheimer Plan. To date, implementation of such organizations remains challenging. It is thus paramount to identify factors obstructing, and on the contrary facilitating, implementation of integrated care.

METHODS

After an in-depth literature review of qualitative studies published from January 1995 to December 2010. We selected 10 qualitative studies on health care professionals' perceptions of barriers and facilitators to the implementation of integrated care.

RESULTS

Barriers and facilitating factors linked to the implementation of integrated care were identified at several levels: leadership; collaboration between services and clinicians; and funding and policy making. The operative strategy applied to change care delivery and the role of the leading pilot are key elements during the implementation phase.

CONCLUSION

Strong leadership and active involvement of a broad spectrum of professionals from clinical practitioners to healthcare managers is crucial for a successful implementation of integrated care services.

Shifting clinical accountability and the pursuit of quality: aligning clinical and administrative approaches

This paper presents a narrative review of the literature on clinical accountability, and draws particularly on England's experience establishing "clinical governance" as a base to examine the establishment of a clinical accountability framework for cancer services in Ontario. The review suggests that clinical governance and accountability approaches that actively mesh clinical and administrative approaches at both system and local levels are more likely to be effective in improving quality of care.

Groups or teams in health care: finding the best fit

RATIONALE

In the evolution of the team concept, clear distinctions between 'groups' and 'teams' were made. In this paper we argue that these distinctions were not made explicit in the translation of team structures to health care. Even though teams are appropriate for many health care settings, this paper explores the notion that when teams may not be working, it is the concept of team that may not be appropriate, not the functioning of the team itself.

METHODS

This paper reviews the differences between teams and groups, and identifies how these differences are expressed in health care settings using urban and rural examples from the UK and Australia.

RESULTS

Some suggestions about matching structures to suit the unique nature of health care provision, particularly in community health settings, are made.

DISCUSSION

Instead of concentrating on improving the process of teams, the focus could be better directed to ensure that whatever structure is utilized best facilitates the necessary outcomes in the most effective way. The team approach may not always be the best approach, and sometimes referring to a number of people working together as a group is sufficient.

Revalidation of general dental practitioners in Scotland: The results of a pilot study Part 1 – feasibility of operation

AIM

To devise and operate a pilot scheme of revalidation for general dental practitioners.

METHOD

A representative group of dental practitioners was convened to advise on an approach to piloting revalidation. Ten general dental practitioners volunteered and completed portfolios of evidence of fitness to practise. The portfolios were assessed by a panel of three calibrated experts, using a specially developed assessment tool. A single decision "evidence presented allowed revalidation to be recommended" was made. A timesheet was used to record the time spent producing the portfolio.

RESULTS

Eight portfolios were assessed as sufficient for revalidation purposes. Two dentists were required to make supplementary submissions of evidence before they were found to be acceptable. An average of eight hours of dentist time and six hours of delegated time was spent producing the portfolios.

CONCLUSIONS

The small number of dentists in this pilot were able to use the portfolio satisfactorily. The dentists were all volunteers and so may not necessarily be fully representative of the profession. The time spent completing the portfolio was not considered excessive. The assessors were adequately prepared and calibrated for their work.

[Impact on cardiovascular health results of the introduction of the clinical governance contract into primary care in Tarragona]

OBJECTIVE

The objectives of this study are: 1) to determine the improvement in the cardiovascular health of the population after the introduction of the clinical governance contract for primary care team professionals in Tarragona-Reus and the Terres de l'Ebre area (Tarragona province, Spain); 2) to identify the factors predictive of better cardiovascular health after the introduction of the clinical governance contract. The introduction of the clinical governance contract, which is based on professional leadership, feed-back of care information, and monitoring of indicators of cardiovascular risk based on scientific evidence and concretised in clinical practice guidelines, will improve the cardiovascular health results of the reference population. Improvements in indicators of procedure and result are specified in "Material and methods."

DESIGN

This is a before-and-after, multi-centre study.

SETTING

Primary health care.

PARTICIPANTS

Thirty health centres (all the primary care Centres in the area).

MAIN MEASUREMENTS

Characteristics of the centre. Variables in procedures: indicators of good care practice, calculation of cardiovascular risk, application of clinical practice guidelines (hypertension, diabetes, lipaemia, tobacco and cardiovascular risk) and quality standards for drug prescription. Result variables: cardiovascular risk figures, number of ongoing care visits, hospital emergencies and admissions for angina, heart attack or stroke, and risk factor screenings of the population.

DISCUSSION

This study is useful, in that clinical governance aims to be a dynamic device to bring professionals into the leadership of health care management and, through monitoring indicators and feeding the findings back to the professionals, to improve health care quality. The study aims to show that management strategy can improve the population s cardiovascular health. The originality of the study lies in the development of a new tool of evaluation based on a novel management strategy for measuring cardiovascular health findings.

Attitudes and knowledge of primary care professionals towards evidence-based practice: a postal survey

OBJECTIVES

To describe the attitudes, awareness and use of evidence across key professional groups working in primary care.

METHODS

A postal questionnaire was sent to all lead/chairs, general managers, clinical governance leads, lead nurses, lead pharmacists and public health practitioners working in local health care cooperatives in Scotland.

RESULTS

289 (66.1%) health care professionals responded, ranging from 51% of general managers to 80% of lead nurses. All professional groups supported evidence-based practice. General practitioners (GPs) were less likely to agree that they had the skills to carry out literature reviews or appraise evidence compared to nurses and public health facilitators (36% vs. 75% vs. 80%; 51% vs. 64% vs. 70%). Access to the internet and bibliographic databases was good for all groups but GPs used a narrower spectrum of evidence-based journals, relying mainly on medical literature. Only nurses and public health practitioners appeared to have any understanding of qualitative research terms. Public health practitioners were also least likely to view guidelines or protocols developed by others as the best source of evidence for primary care. The major perceived barrier to practising evidence-based practice was time. Consequently the most important facilitator was protected time, but increased resources (financial and staff) and training were also cited. Professional groups other than GPs perceived inter-professional boundaries as a barrier and suggested multi-professional teamworking and learning as potential supports for evidence-based practice.

CONCLUSIONS

While all professional groups welcome and support evidence-based practice, there are clear differences in the starting point and perspectives across the groups. These need to recognized and addressed to ensure that learning the skills of evidence-based practice and implementing evidence are effective. This will also enhance the ability of primary care organizations to develop robust mechanisms for supporting key aspects of clinical governance.

Research methods used in developing and applying quality indicators in primary care

Quality indicators have been developed throughout Europe primarily for use in hospitals, but also increasingly for primary care. Both development and application are important but there has been less research on the application of indicators. Three issues are important when developing or applying indicators: (1). which stakeholder perspective(s) are the indicators intended to reflect; (2). what aspects of health care are being measured; and (3). what evidence is available? The information required to develop quality indicators can be derived using systematic or non-systematic methods. Non-systematic methods such as case studies play an important role but they do not tap in to available evidence. Systematic methods can be based directly on scientific evidence by combining available evidence with expert opinion, or they can be based on clinical guidelines. While it may never be possible to produce an error free measure of quality, measures should adhere, as far as possible, to some fundamental a priori characteristics (acceptability, feasibility, reliability, sensitivity to change, and validity). Adherence to these characteristics will help maximise the effectiveness of quality indicators in quality improvement strategies. It is also necessary to consider what the results of applying indicators tell us about quality of care.

Chiropractors' attitudes to, and perceptions of, the impact of continuing professional education on clinical practice

OBJECTIVES

As with other health care professions, there is a need for chiropractors to maintain their clinical competencies through continuing professional education (CPE) and development (CPD). This study set out to evaluate chiropractors' attitudes to, and opinions of, current CPE provision, and their perceived needs for the future. In particular, their perceptions of the impact of CPE on clinical practice were assessed.

DESIGN

A survey in which primary quantitative and secondary qualitative data were collected using a self-administered questionnaire. The questionnaire concentrated on four areas: (i) attitudes to CPE; (ii) impact of current CPE on practice; (iii) modes of delivery most likely to change practice; and (iv) future learning needs from continuing education programmes.

RESPONDENTS

A random sample of chiropractors registered with the British Chiropractic Association.

RESULTS

Overall, chiropractors were positive to CPE and cognisant of the need to keep up to date. However, in spite of several benefits, chiropractors did not perceive current CPE to be instrumental in changing practice. As might be expected, chiropractors perceived clinical updates and hands-on practical workshops to be most effective in changing clinical practice.

DISCUSSION

There is currently considerable debate surrounding the ability of CPE and CPD to actually make a difference to the way clinicians practice. This study describes a method of evaluating the impact of CPE/D in changing clinical practice from the viewpoint of the practitioners themselves.