The development of clinical governance in the UK: its implications for rehabilitation medicine

Abstract

-Clinical governance has been introduced in the UK as a mechanism to improve the quality of health services, and the professional performance of clinicians. Specialist societies have a pivotal role to play in developing systems to support its implementation in clinical practice. Rehabilitation medicine is a specialty characterised by closely integrated interdisciplinary teamwork. The particular issues that this poses for clinical governance may also be relevant to other specialities. This paper presents an overview of the development of audit and clinical governance procedures in the UK and their specific implications for rehabilitation medicine. It also summarises the work undertaken to date by the British Society for Rehabilitation Medicine towards implementation of clinical governance, to improve the quality of care offered to patients. KEY WORDS: clinical audit, clinical governance, clinical standards, rehabilitation medicine Clinical governance in the UKThroughout the 1990s, clinical audit was the hallmark of quality assurance in the UK. Essential features of clinical audit were the systematic assessment of clinical practice, against agreed standards, to ensure the best quality of care. Implementation of change was then followed by re-audit to complete the audit cycle.However, audit had no real teeth. There was no statutory duty applicable to NHS hospital trusts with respect to quality of care. In a competitive openmarket health system, the only statutory requirement for hospital managers was to maintain financial balance. In 1998, the UK Government introduced reforms for 'modernisation' . 1 Clinical governance was the framework through which NHS organisations would be 'accountable for continuously improving the quality of their services' . The audit cycle became the audit spiral (Fig 1), 2 and hospital trust boards now had statutory responsibility for the quality of services, as well as financial management. 3 Nationally agreed standards and guidelinesA central tenet of clinical governance is the elimination of unnecessary variation in practice. 'Benchmarking' is now required against nationally agreed standards which are based on research evidence or consensus of widely gathered expert opinion.The terms 'standards' and 'guidelines' are sometimes used interchangeably, but this is incorrect.Standards define the quality of service delivery, while guidelines provide guidance to the clinician for individual patient care. A 'standard' is therefore interpreted at the level of a population, while a 'guideline' is interpreted at the level of the individual. Nevertheless there is a close relationship between the two, illustrated in Box 1. 4 If guidelines are to become 'compulsory' practice, the advice must be correct and up to date. Guideline developers carry a major responsibility and the process must be meticulous. In the UK, the Scottish Intercollegiate Guidelines Network (SIGN) pioneered guideline development with a rigorous system of gathering and evaluating evidence, achieving consensus through consu...

Payment by Results or Payment by Outcome? The History of Measuring Medicine

“…The essential part of using outcomes to improve care is to complete the 'audit cycle' by examining the deficiencies noted, implementing changes and then reassessing the changes to see if they have resulted in the anticipated result. [29][30][31] Furthermore, audit should measure the enhancement in patients' quality of life and functioning that is brought about by the medical care using the appropriate measurement tools. 32 …”