Clinical governance breakdown: Australian cases of wilful blindness and whistleblowing

BACKGROUND

After their attempts to have patient safety concerns addressed internally were ignored by wilfully blind managers, nurses from Bundaberg Base Hospital and Macarthur Health Service felt compelled to 'blow the whistle'. Wilful blindness is the human desire to prefer ignorance to knowledge; the responsibility to be informed is shirked.

OBJECTIVE

To provide an account of instances of wilful blindness identified in two high-profile cases of nurse whistleblowing in Australia.

RESEARCH DESIGN

Critical case study methodology using Fay's Critical Social Theory to examine, analyse and interpret existing data generated by the Commissions of Inquiry held into Bundaberg Base Hospital and Macarthur Health Service patient safety breaches. All data was publicly available and assessed according to the requirements of unobtrusive research methods and secondary data analysis.

ETHICAL CONSIDERATIONS

Data collection for the case studies relied entirely on publicly available documentary sources recounting and detailing past events.

FINDINGS

Data from both cases reveal managers demonstrating wilful blindness towards patient safety concerns. Concerns were unaddressed; nurses, instead, experienced retaliatory responses leading to a 'social crisis' in the organisation and to whistleblowing.

CONCLUSION

Managers tasked with clinical governance must be aware of mechanisms with the potential to blind them. The human tendency to favour positive news and avoid conflict is powerful. Understanding wilful blindness can assist managers' awareness of the competing emotions occurring in response to ethical challenges, such as whistleblowing.

[EFQM Model in the hospitals of Madrid Regional Health Service: full self-assessment cycle]

AIM

To analyse a complete cycle of self-assessment using the European Foundation for Quality Management (EFQM) Model in the hospitals of the Madrid Health Service as regards the fundamental concepts of excellence (FCE).

METHOD

Descriptive study of the EFQM self-assessments of the entire public hospital sector identifying the methodology and the information on strengths, weaknesses, evidence, RADAR matrix (Results, Approach, Deployment, Assessment and Review), and the related FCEs in the enabling criteria and in the prioritised action plans.

RESULTS

The self-assessment was carried out in 85% of the hospitals (29/34), 86% of them required specific training (25/29), with a total of 329 teaching hours and 833 people in training. Multidisciplinary working groups were required in 83% of the hospitals (24/29), with 123 groups and 857 people involved. There were 3,686 strengths and 3,197 weaknesses identified: strengths and weaknesses were 78% (2,869) and 74% (2,355), respectively, for the enabling criteria and 22% (817) and 26% (842), respectively, for the results criteria. The mean score was 404 points with a median of 399. The main FCEs were managing with agility, developing organisational capability, sustaining outstanding results, creating a sustainable future, succeeding through the talent of people, and adding value for customers, with harnessing creativity/innovation and leading with vision, inspiration and integrity being placed in lower positions. A total of 113 action plans were identified for all the hospitals.

CONCLUSION

A complete EFQM self-assessment cycle of the entire public hospital sector of a Regional Health Service is provided, linking the analysis and action plans with the FCE of the EFQM Model.

Uncomfortable realities: the challenge of creating real change in Europe's consolidating hospital sector

BACKGROUND

This article examines uncomfortable realities that the European hospital sector currently faces and the potential impact of wide-spread rationalization policies such as (hospital) payment reform and privatization.

METHODS

Review of relevant international literature.

RESULTS

Based on the evidence we present, rationalization policies such as (hospital) payment reform and privatization will probably fall short in delivering better quality of care and lower growth in health expenses. Reasons can be sought in a mix of evidence on the effectiveness of these rationalization policies. Nevertheless, pressures for different business models will gradually continue to increase and it seems safe to assume that more value-added process business and facilitated network models will eventually emerge.

CONCLUSIONS

The overall argument of this article holds important implications for future research: how can policymakers generate adequate leverage to introduce such changes without destroying necessary hospital capacity and the ability to produce quality healthcare.

Quality and impact of appraisal for revalidation: the perceptions of London's responsible officers and their appraisers

BACKGROUND

To evaluate NHS England London region's approach to the revalidation appraisal of responsible officers in London, exploring perceptions of the quality and impact of the appraisal process. Revalidation is the process which aims to ensure doctors in the UK are up-to-date and fit to practice medicine thus improving the quality of patient care. Revalidation recommendations are largely premised on the documentation included in annual appraisals, which includes the professional development a doctor has undertaken and supporting information about their practice.

METHODS

A pan-London qualitative study exploring the views of responsible officers and their appraisers about the revalidation appraisal process. The study aimed to gain an in-depth understanding of the experiences and perceptions of the participants. Responsible officers were purposefully sampled to represent the broadest range of designated bodies. Data analysis generated themes pertaining to quality and impact of appraisal for revalidation with the potential to feed into and shape the evolving system under investigation.

RESULTS

The central importance of highly skilled appraisers was highlighted. Both groups reported educational opportunities embedded within the appraisal process. Independent appraisers, not matched by clinical speciality or place of work, were considered to take a more objective view of a responsible officer's practice by providing an 'outsider perspective'. However, covering the breadth of roles, in sufficient depth, was challenging. Participants reported a bias favouring the appraisal of the responsible officer role above others including clinical work. Appraisal and revalidation was perceived to have the potential to improve the healthcare standards and support both personal development and institutional quality improvement.

CONCLUSIONS

Responsible officers play a central role in the revalidation process. Getting responsible officer appraisal right is central to supporting those individuals to in turn support doctors and healthcare organisations in continuous quality improvement. The complexity and importance of the role of responsible officer may make achieving an appraisal of all roles of such individuals problematic. This evaluation suggests responsible officer appraisal was perceived as educational and effective.

The Francis Report--implications for the regulator

The professional regulators were identified in the Francis Report as having a central role in maintaining fundamental standards of care. This paper describes the key themes in the Report and the importance of regulatory powers to ensure that the serious failings in patient care highlighted by the Mid-Staffs Inquiry cannot be repeated. The central role of the GDC Standards in the profession's response to the Francis Report is stressed. Clinical Relevance: The importance of our professional regulator in ensuring adherence to fundamental standards of care is a central tenet of clinical dentistry.

Role clarity and clinical governance: keeping irish hospitals efficient and effective

The notion of role clarity, and its impact on clinical governance, has not been previously considered within academic literature. The purpose of this research article was to add to theoretical knowledge surrounding the clinical governance and the effect that role clarity has on governance operationally. The context of Irish health care and Irish hospital boards is used to explore this phenomenon. A mixed-methods approach was used to appreciate the central phenomenon. The doctoral dissertation this article was drawn from identified that the adoption of similar or consistent structures and processes between Irish acute care hospitals would aid efficiencies, both human and cost, on multiple levels. Ultimately, the article concludes that role clarity is a significant component in the determination of effective health care. Hospital boards and their individual members should be cognizant of the implications of role clarity and its impact on effective and efficient clinical governance.

Is mandatory research ethics reviewing ethical?

Review boards responsible for vetting the ethical conduct of research have been criticised for their costliness, unreliability and inappropriate standards when evaluating some non-medical research, but the basic value of mandatory ethical review has not been questioned. When the standards that review boards use to evaluate research proposals are applied to review board practices, it is clear that review boards do not respect researchers or each other, lack merit and integrity, are not just and are not beneficent. The few benefits of mandatory ethical review come at a much greater, but mainly hidden, social cost. It is time that responsibility for the ethical conduct of research is clearly transferred to researchers, except possibly in that small proportion of cases where prospective research participants may be so intrinsically vulnerable that their well-being may need to be overseen.

Improving governance to improve oral health: addressing care delivery systems

The evolving role of the state in the provision of health care has seen the adoption of new management philosophies to ensure that goals set for the system are reached. In particular, the term New Public Management (NPM) has tended to dominate reforms to help address perceived shortcomings in public sector services. NPM is based on the use of freemarket type arrangements as a mechanism to solve problems, the control of which provides new challenges. One particular challenge that has arisen from the combination of NPM with the large number of agencies involved in care provision is that of addressing the issues arising from the improved understanding of the determinants of health. This has led to the evolution of differing care arrangements across differing sectors at all levels. If resources are to be used as intended, the control of delivery systems to oversee their use must exist. The overarching term for such activity is â governance. This paper provides an overview of the issues that arise for addressing governance of oral health care and the subsequent challenges that face those responsible for ensuring compliance.

NMC 'lacks clear vision of role': CHRE publishes interim report

Professor Alan Glasper discusses the interim report published by the Council for Health Care Regulatory Excellence (CHRE) of its strategic review of the Nursing and Midwifery Council (NMC)

Performance. Twelve steps to perfect competence

The NHS Information Centre's director of commissioning Sandra Hills on the key characteristics of strong PCTs.

Information sources. Ahead of the pack

The new data support for world class commissioning promises to be online, interactive and more user-friendly than ever. But what does that mean for PCTs?

Assessors' views. Health data is not enough

Experts who sat on the world class commissioning assessment panels share their views on how primary care trusts are performing - and their top tips

[Clinical governance and continuous quality improvement in surgical organizations]

Recently the awareness had progressively strengthened that the main interest of health care organizations is effectiveness and appropriateness of clinical performance. They have a statutory duty to seek quality improvement through clinical governance. All health care operators are involved in clinical governance implementation, in respect of their organizational positions toward continuous quality improvement. In this way health care organizations, professionals and patients will benefit of outcomes of the change.

[Evolution and practical application of the concept of clinical governance in Italy]

Clinical Governances' roots in the United Kingdom's National Health Service and the following introduction of "Governo Clinico" in Italy are analyzed. Some definitions of Clinical Governance and "Governo clinico" are presented and discussed, by highlighting the main characteristics and differences, both conceptual and semiological. Finally, legal bases for the official empowerment of Healthcare Governance in Italy are described, by focusing on the Region Emilia-Romagna, whose recent Social and Sanitary Plan for 2008-2010 has developed concepts of integration, multidisciplinarity, responsibility and quality of socio-sanitary services.