The Clinical Governance Assessment Project (CGAP) was jointly commissioned by the National Health Board, Health Quality and Safety Commission and the DHBs through DHBSS. The research work for the project was led by the Centre for Health Systems, University of Otago, and so is both an assessment of the present situation with clinical governance in DHBs as well as an independent study designed to promote discussion and debate. The project represented a partnership arrangement in that various activities associated with the research were undertaken by the DHBs themselves, in collaboration with the Centre for Health Systems, with facilitation and support from DHBSS.
The research detailed in this report was conducted from April-November 2012 with considerable preparation beforehand. The CGAP involved one of the largest and most complex workforce surveys conducted in the New Zealand health sector, coupled with site visits and interviews with key personnel at 19 of the 20 DHBs. The final component of the project was a ‘wrap-up’ meeting on 6 December 2012 at which this report was delivered and the project findings discussed, with a focus on cross-sector learning and the clinical governance developmental process.
The CGAP followed on from earlier work led by the Centre for Health Systems which sought to gauge the implementation of the 2009 In Good Hands report of the Ministerial Task Group on Clinical Leadership. That project involved a survey of ASMS members (mostly public hospital medical specialists, but also public hospital dentists and some public health physicians employed in public health services) and compared DHB performances via the Clinical Governance Development Index. In contrast, the focus of the CGAP was the entire health professional workforce, including all doctors, nurses, midwives and allied health professionals employed by DHBs. Again, these professionals are mostly public hospital employees. The intent was to gather quantitative data via a follow-up to the ASMS survey and, through the individual DHB case studies, learn how DHBs have approached and facilitated the development of clinical governance and leadership.
This report presents the findings from the CGAP. It is structured as follows. First, it overviews ‘clinical governance’ and places New Zealand’s activities in an international context. Second, it provides a brief background to the earlier survey and introduces the present project. Third, the project methods are detailed. The bulk of this report is in the fourth and fifth sections which present the findings of the survey followed by the case studies. Last, the discussion section outlines implications of the research and a series of points for further consideration.
Key points of note include:
- There is good reason to be proud of and to celebrate progress with clinical governance development in New Zealand’s DHBs. Especially so, given the nascent nature of activities inmany DHBs and complexity of clinical governance which requires a pan-organisational approach, often a range of objectives and projects, and building of partnerships and new methods of working between all components of the workforce at all levels. The survey data show very positive results, albeit with variations. The DHB case studies revealed solid and, in many cases, extremely impressive commitment and growth, along with a range of highly-innovative approaches to building clinical governance and leadership;
- A survey response rate of 25 percent. Respondent characteristics were broadly representative of the registered health professional workforce. Response rates varied between the DHBs from 7.5 to 49 percent (section 3.1);
- Some 3500 written comments were received from survey respondents. A snapshot is provided in this report (section 4.4). Further analysis of these is planned for 2013;
- The survey data portray positive development around several issues (section 4). A healthy proportion of respondents see:
- Themselves as ‘involved in a partnership with management, with shared decision making, responsibility and accountability’;
- That their DHB has worked to ‘enable strong clinical leadership’; and to ‘foster and support development of clinical leadership’;
- That quality and safety are goals of both clinical service and clinical resourcing and support (managerial/financial) initiatives in their DHB;
- That their DHB had ‘sought to give responsibility’ to their team for ‘clinical service decisions in their service area’;
- A separate report contains more detailed analysis of three quality and safety survey questions. In brief:
- Fifty-seven percent of respondents believe health professionals in their DHB work together in well-coordinated teams;
- Seventy percent of respondents agree that health professionals involve patients and families in efforts to improve patient care;
- Sixty-nine percent of respondents agree that it is easy to speak up when they see problems with patient care;
- The survey data suggest it could be useful to put more effort into:
- Explaining what is meant by ‘clinical leadership’ and, in this regard, requested of clinicians;
- Providing information to staff about the ‘governance structures that ensure a partnership between health professionals and management’;
- Providing support for professionals to engage in clinical leadership activities;
- Comparison of CGAP data from SMO respondents with data from the earlier ASMS SMO survey suggests solid progress on clinical governance almost without exception. According to this analysis, some DHBs have demonstrated considerable and very positive improvement in a short space of time (section 4.1.15);
- Proportional odds mixed modelling of responses (section 4.3) to each of the survey questions reveals that females, younger or older respondents and those with longer service in the New Zealand health sector have higher or lower odds of responding positively to various questions. These findings have various implications;
- The 19 DHB case studies revealed concentrated activity without exception but, again, to varying degrees. Many DHBs havemade bold steps in terms of implementing structures to facilitate and advance clinical governance and leadership. There is considerable potential to learn from the often unique approaches taken by different DHBs. Readers of this report should be aware that clinical governance development is a recent focus for many DHBs, so the assessment is of initial progress. Several themes around DHB leadership, Senior Medical Oficer engagement, opportunities for cross-sector learning, the role of clinical boards, training, and connecting clinical governance and quality improvement, emerged from the site visits (section 5);
- The discussion (section 6) highlights areas that warrant further consideration:
- ‘Clinical Governance’ demands tighter definition. This should be a national project so that DHBs and health professionals receive consistent information. Tools to assist with clinical governance development and assessment could be linked to this;
- There is a strong case for an arrangement to facilitate essential cross-sector fertilisation of information around clinical governance and leadership development, so that themultitude of excellent examples of clinical governance can bemore widely shared;
- Dedicated training for clinical governance and leadership is needed and should be tied to the specific requirements of clinical governance as well as to training in the tools of quality improvement;
- How to get health professionals, especially doctors, engaged in clinical governance and leadership, as well as how to achieve a balance between the various professional groups (doctors, nurses, midwives, allied professionals) demands attention.
Professional training institutes, including tertiary institutes and professional colleges, have a crucial role to play. How to better support ‘clinical leaders’, often in part-time posts, and to engender the participation of colleagues often on part-time contracts, also requires further discussion.