A report by the Tax Payers Alliance on a statistical analysis of NHS performance in a European context since 1981sets out ‘the ongoing failure of the NHS to match European levels of healthcare performance and the inability of new money, since 1999, to rectify the situation.’ With a foreword by renowned NHS oncologist Professor Karol Sikora, the report ‘uses mortality amenable to healthcare – the number of deaths from certain conditions, and at certain ages, that healthcare can reasonably be expected to avert – to compare NHS performance with that of four European peer countries: France, Germany, the Netherlands and Spain.
Amenable mortality is a widely respected metric for healthcare performance described in the British Medical Journal and currently being studied for implementation by the Office for National Statistics.’ The report finds that ‘In 2004, the latest year for which data is available, higher rates of mortality amenable to healthcare in the United Kingdom relative to the average of European peers led to 17,157 deaths in that year. This is equivalent to over five times the total number of deaths in road accidents and over two and a half times the number of deaths related to alcohol.’ [and, interestingly, although not mentioned in the report, this figure is approximately equivalent to half the number of avoidable pateint safety deaths every year in the NHS - Ed.].
In order for the NHS to match the performance of its European peers, the report says that urgent reform is needed. In particular, the NHS needs ‘….decentralisation, competition and professional management….’. The report can be downloaded at: http://tpa.typepad.com/home/files/wasting_lives.pdf
Research carried out by Stuart Emslie, editor, Healthcare Governance Review, has found a clear association between board and organisational performance in NHS foundation trusts. The research involved 21 foundation trust boards of directors and compared the effectiveness of the board, as measured using a robust validated tool developed for non-profit boards, including hospital boards, in the USA, and various measures of financial and non-financial organisational performance.
The research found a strong and highly statistically significant association between board performance and both financial performance and key performance metrics relating to staff satisfaction. Unfortunately, no association was found between board performance and a range of clinically oriented performance indicators, including the Healthcare Commission’s quality ratings.
The research was carried out to produce a dissertation in partial fulfilment of the degree of Master of Science by Research in Corporate Governance and Ethics at Birkbeck, University of London. A copy of the dissertation can be freely downloaded here.
The Department of Health’s Integrated Governance Handbook, issued in February 2006, was an unfinished publication – perhaps more aptly described as ‘work in progress’. In this new book published by the Healthcare Financial Management Association (HFMA), the Integrated Governance handbook has been ‘finished’ and updated. The majority of the approach to Integrated Governance is highly reminiscent of the Department of Health’s NHS Controls Assurance project which, in 1999, officially introduced the term ‘governance’ (as opposed to clinical or corporate governance) and published guidance on ‘converging’ (as opposed to ‘integrating’) the various governance strands and on rationalising board and organisation committees.
The authors of this book have kept faithful to the key Controls Assurance requirement of a board assurance framework and a Statement on Internal Control, but have added additional useful guidance around board functioning and etiquette, as well as providing useful vignettes and case studies. Whilst there are some errors and omissions, particularly in relation to the development of governance in the NHS, the book should be regarded as a key reference document in the ongoing development of NHS governance principles and practices.
The Royal college of Obstetricians and Gynaecologists (RCOG) is urging all maternity units to consider the use of a ‘Maternity Dashboard’ to plan and improve their maternity services.
The Maternity Dashboard serves as a clinical performance and governance score card to monitor the implementation of the principles of clinical governance on the ground.
According to the RCOG, this may help to identify patient safety issues in advance so that timely and appropriate action can be instituted to ensure a woman-centred, high-quality, safe maternity care. The RCOG says that use of the Maternity Dashboard has been shown to be beneficial in monitoring performance and governance to reassure the ‘health’ of maternity units.
The RCOG has developed guidance on producing a practical Maternity Dashboard, which can be accessed here.
As reported in Director of Finance online, 31 January 2008, the actions of “a tiny minority of people who defraud the NHS” are estimated to cost the service up to one per cent of the NHS budget annually. As a consequence, a new strategy has been launched by NHSScotland to fight fraud.
Steve Walker, Chief Executive of the NHS Litigation Authority, has apparently joined the campaign for ‘open disclosure’ of ‘medical errors’. In an Observer interview with Steve, he said that ‘The message to doctors is: if you’re aware of an error, or a shortfall in what’s been delivered, you should feel free, indeed you should feel under an obligation, to tell your patients and to apologise and to explain, either verbally or in writing, even if the patient is likely to sue. The explanation bit is really important to many, many claimants. It doesn’t matter if it heads off a claim or encourages a claim, people as human beings and patients are entitled to this and they should be getting it. Some patients are dissatisfied by not getting this information already. Some patients and patients’ relatives feel short-changed by the system. They believe there’s a lack of honesty, of frankness and of candour.’
The Centre for Innovation in Health Management (CIHM) at Leeds University Business School has identified a number of aspects of fit for purpose Governance in the NHS that warrant clarification and development. These come from their work with Boards, and discussions at the CIHM bi-annual network, where NHS Trusts identified questions about governance for which they were seeking answers. The areas of Inquiry that CIHM are seeking to follow are:
- The impact of governance on changing behaviours in a public system, and on the effectiveness of the organisation
- How to generate local accountability and local ownership within a national service, with national regulation frameworks.
- The nature of governing service versus products.
- The relationship between governance of individuals (e.g. the clinical decision-making of a consultant) and governance of collectives (e.g. teams/professional groups) in an organisation
- Fit-for purpose design – what structures work?
- What tools and processes are effective in supporting governance?
And specifically in relation to Boards:
- How to design a Board that knows what to do for the whole.
- How governance creates alignment across the whole organisation.
- On whose behalf is the Board working?
- The role and function of the Board and Chair.
- What value for money does the Board offer?
The Inquiry aims to build on the growing acknowledgement that nationally there needs to be a way of governing that is not driven by targets; that locally in the NHS the growth of Foundation Trusts challenges the traditional models of governance and the ‘membership’ model is still to make its mark in terms of increasing local accountability and local engagement; the need to make more of the potential of governors and of governance processes within the public sector (for it to demonstrably add value); and that there needs to be more clarity about ‘whose in charge’. A range of workshops and meetings have been arranged between January and April 2008 and a report is expected to be produced later in 2008.
The tragic and avoidable death of a teenager at Sydney’s Royal North Shore Hospital has prompted an inquiry into the governance of the area health services in New South Wales. This follows coronial findings that the hospital ‘had made every conceivable error’ in the treatment of Vanessa Anderson, who died after being given the wrong dose of painkillers following admission for a skull fracture sustained after being hit with a golf ball. According to ABC News, ‘The Royal North Shore Hospital was the focus of a parliamentary inquiry last year, sparked when a woman miscarried in an emergency department toilet after waiting two hours for treatment.There were revelations about live cockroaches in operating theatres and beds collapsing during surgery during the inquiry. The report made 45 recommendations and identified problems including an unacceptable tolerance of workplace bullying, a disconnect between management and staff, and a shortage of nurses.’ The full ABC News article can be viewed at: www.abc.net.au/news/stories/2008/01/25/2146296.htm?section=justin
NHS Quality Improvement Scotland (NHSQIS) has subjected itself to independent assessment against its own clinical governance and risk management standards issued for compliance by the NHS in Scotland. Given that NHSQIS does not engage in direct patient care, the standards are not wholly relevant. However, many standards can be interpreted in the context of NHSQIS’s working and the combination of self-assessment and independent peer review reveals a number of areas for improvement. These include:
- A lack of clarity around NHSQIS’s Board’s role in developing and reviewing the risk profile for the organisation.
- No clinical governance strategy or overarching framework in place across the organisation
- Business continuity plans are developed, but need to be formally adopted and cascaded throught the organisation
Reports for all Scottish Health Boards, together with a copy of the ‘National standards for clinical governance and risk management standards – achieving safe, effective, patient-focused care and services’, can be accessed at: www.nhshealthquality.org/nhsqis/3426.html
Patient safety, as well as the safety of staff and others, is likely to benefit from the imminent implementation of the Corporate Manslaughter and Corporate Homicide Act on 6 April 2008. From that date any death resulting from poor health and safety management is a potential candidate for a police and/or Health and Safety Executive (HSE) investigation into ‘corporate manslaughter’. Such an investigation is likely to be traumatic for any healthcare organisation, involving very invasive reviews of safety management systems and overall organisational ’safety culture’. If convicted of an offence under the Act, an organisation potentially faces a unlimited fine and significant loss of reputation. The best way to minimise the likelihoood of an organisation being prosecuted under the Act is to ensure compliance with relevant health and safety laws and regulations and to develop a culture of safety across the organisation. Further information including a 10-step action plan for healthcare organisations to ensure compliance with the Act is presented in the slideshow below, which was used by the Editor in a talk by him at a recent HSJ conference on preparing for the corporate manslaughter act (see Events page).
The Chief Medical Officer for England, Sir Liam Donaldson, who, along with Gabriel Scally developed the concept of clinical governance, has provided us with some of his most notable quotes relating to clinical governance and quality. Read them all here.
The NHS in Scotland has for several years led the way in best practice in ‘human resources management’ in healthcare with its approach to ’staff governance’. Staff governance is defined as ‘a system of corporate accountability for the fair and effective management of all staff” and ‘makes up the third pillar of the governance framework (alongside clinical and financial governance) within which [the NHS in Scotland] must operate.’ The 3rd and latest edition of the NHS Scotland Staff Governance Standard for NHSScotland employees can be downloaded at: http://openscotland.gov.uk/Resource/Doc/179320/0051009.pdf
The ‘Master of Healthcare Management and Healthcare Governance’ is a collaborative venture between the Arabian Gulf University and the French University Denis Diderot – Paris 7.
The programme aims to reinforce candidates’ mastery of new tools (hospital risk management / patient safety, performance, assessment and measures, etc.), as well as deepen their understanding of new technical management tools, and strategic diagnosis within the complex healthcare system. Candidates are also given the opportunity to apply newly acquired concepts through strategic actions responding to real healthcare issues (Business Problems, Quality Improvement, Marketing, Risk Management, Communication, Information System Design), as well as new topics, and new stakeholder mindsets and interests.
At the end of January, 2008, the US Leapfrog Group will host a national conference designed to address the critical role that hospital and health system boards play in driving quality and value in American health care. The Leapfrog Conference on the Future of Hospital Governance: Quality at the Leading Edge will take place January 28-29, 2008 at the Fairmont Miramar Hotel in Santa Monica CA. For further information, click here.
Healthcare Governance Review (HGR) is a free public blog site and e-mail newsletter for anyone concerned with governance issues in healthcare, including board members, senior managers, clinicians, assurance providers, policy makers and regulators. HGR is published by Healthcare Governance Limited and kindly supported by ECRI Institute (Europe). The site is edited by Stuart Emslie, Director of Healthcare Governance Limited. Stuart is internationally known for his work in healthcare governance and healthcare risk management, including patient safety, having lectured and/or consulted in several countries, including Australia, China, Hong Kong, Ireland, Malaysia, Singapore and the USA, in addition to the UK. He is visiting fellow in healthcare governance and risk at Loughborough University Business School (where he developed and currently leads a ‘World-first’ postgraduate programme on healthcare governance – see the Education page), is visiting lecturer in risk management and clinical governance at Flinders University Medical School in South Australia, and is formerly Department of Health head of controls assurance for the NHS in England. Stuart holds a masters degree, with distinction, in corporate governance and ethics from the University of London and a bachelors degree, with honours, in mechanical engineering from the University of Strathclyde. He is a chartered mechanical engineer and a member of the Institute of Healthcare Management (IHM).
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