Making sense of clinical governance
In the second of a series of articles,
Catherine Dewsbury, the Royal Pharmaceutical Society's clinical governance
pharmacist, explains how clinical governance, far from introducing new
requirements, reflects much of the Society's Code of Ethics
I hold the belief that clinical governance is not
new to pharmacy, because its individual components all have links with
the Society's Code of Ethics and Standards. Clinical governance should
therefore be a part of everyday practice.
The history of clinical governance in the National
Health Service begins in 1998, when the Department of Health published
"A first class service: quality in the NHS", setting out for the first
time the Government's policy for raising quality for NHS patients and
services. The policy involved setting standards through the National Institute
for Clinical Excellence and the national service frameworks, and monitoring
standards through the Commission for Health Improvement, patient forums
and national patient satisfaction surveys. Central to this process would
be delivering higher quality services through better self-regulation and
through clinical governance. "A first class service" gave a complex definition
of clinical governance: "A framework through which NHS organisations are
accountable for continuously improving the quality of their services and
safeguarding high standards of care, by creating an environment in which
excellence in clinical care will flourish".
The Society was quick off the mark with its policy
document "Achieving excellence in pharmacy through clinical governance"
(1999) in which it welcomed clinical governance and set a framework through
which pharmacists might deliver clinical governance. Since that time much
work has been done in pharmacy by both local groups and individuals. There
is, however, evidence that much more work is needed if pharmacists are
to participate fully in clinical governance.
Since "Achieving excellence", the focus of clinical
governance has changed significantly in the light of reports such as "Organisation
with a memory" (1999), the Kennedy report on Bristol children's hospital
(2001), the Toft report on intrathecal chemotherapy (2001) and "Building
a safer NHS for patients" (2001). These, and the launch of the National
Patient Safety Agency in September, have mapped out the quality agenda
in terms of the NHS plan's objective of a patient-centred NHS. In addition,
the new National Health Service Reform and Health Care Professionals Bill
spells out even more clearly that in future regulatory bodies such as
the Society will have to focus on improving their systems to involve more
lay people and re-emphasise their role in protecting patients and the
public.
Where are we now?
Although the Government's wordy definition of clinical
governance does not exactly trip off the tongue, its commitment to improvements
and excellence is clear. What helps us understand what is required of
us as individuals, and in our workplaces, is to consider the component
processes of clinical governance. These processes help us to build the
links between clinical governance and the Society's Code of Ethics.
Clinical governance consists of a series of processes
for improving quality and ensuring that professionals are accountable
for their practice. These processes have been identified as continuing
professional development, evidence-based practice, audit, dealing with
poor performance, managing risk, monitoring clinical care and patient
involvement.
Let us consider each clinical governance process
in turn.
CPD One of the key responsibilities
of a pharmacist is to keep up to date. Part 2 of the Code, which sets
out standards of professional practice, states that pharmacists must ensure
that "they undertake continuing professional development relevant to their
professional duties".
Evidence-based practice The need for
evidence-based practice is highlighted in the Code's "key responsibilities
of a pharmacist", which state: "Pharmacists must ensure that their knowledge,
skills and performance are of a high quality, up to date, evidence based
and relevant to their field of practice."
Audit Pharmacists' participation in
audit is outlined in the Code's standards for professional competence:
"Pharmacists must continually review the skills and knowledge required
for their field of practice, identifying those skills or knowledge most
in need of development or improvement and audit their performance as part
of the review."
Dealing with poor performance Identifying
poor practice and remedying it is inherent in the Code's section on personal
responsibilities of a pharmacist, which begins: "Pharmacists' prime concern
must be for the wellbeing and safety of patients and the public.
Risk management In terms of managing
risk, the introduction to the Code's standards for personal responsibilities
says: "Pharmacists must ensure their own working practices are safe and
effective." There are additional responsibilities for superintendents
and chief pharmacists in hospitals and pharmacy owners who "must ensure
that procedures designed to minimise risk are formulated and applied"
in the workplace.
Monitoring clinical care The key to
monitoring clinical care is the way in which pharmacists manage and use
the information they have about patients. Guidance on these responsibilities
is given in the Code in the service specification for patient medication
records. The requirements for adequate records is repeated in specifications
for diagnostic services, advice to nursing and residential homes and domiciliary
oxygen services.
Patient involvement Part of the Code's
key responsibilities of a pharmacist is that: "Pharmacists must respect
patients' rights to participate in decisions about their care and must
provide information in a way in which it can be understood."
Accountability
Above all these processes is the requirement for
professionals to be accountable for their work, as is made clear in "Building
a safer NHS for patients", the Kennedy report and "A first class service".
The Society takes this requirement seriously. Part 1 of the Code, which
covers pharmacists' ethics, requires that "when faced with ethical dilemmas
pharmacists are expected to use their professional judgement in deciding
the most appropriate course of action. They must be able to justify their
decisions to their peers, and to any person or organisation which may
be affected by their actions, including individual patients, the public,
the NHS, their employers, and other healthcare professionals. Pharmacists
may be accountable to any of these".
A new year's resolution
At this time of year many of us review the past
year and consider our actions for the coming year. I hope that, having
read this article, readers will now agree that participation in clinical
governance is a substantive part of good professional practice. Let us
make 2002 the year in which we resolve to do the right things right, to
the right people, in the right way and at the right time, and to take
responsibility for doing it.
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