A statutory ‘duty of quality’ for all providers of NHS services was introduced in 1999 (Health Act) following the tragic Shipman, Bristol Royal Infirmary and Alder Hey cases. This statutory duty of quality, is largely discharged through clinical governance. Clinical governance is a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care. This approach sees quality and safety not only as the professional responsibility of individuals, but also as a responsibility to be embedded at all levels of an organisation. Whilst such measures cannot guarantee that cases such as Shipman will never happen again, having the right systems, processes and culture in place makes it easier for them to be detected, and provide assurance to patients that the services they receive are safe and of sufficient quality.
It is well recognised that performing artists are likely to have health needs which prevent them from performing. Performing arts organisations which commission or provide health services for artists or are considering doing so, should aim to comply with quality standards for healthcare to ensure the best service for beneficiaries, use resources effectively and help to manage any liabilities if things should go wrong.
This paper explains the concept of clinical governance and how it works. At BAPAM, we recommend that any performing arts organisation delivering or commissioning health services should have an appropriate clinical governance framework.
Clinical governance is the framework within an organisation through which the organisation achieves and maintains a high quality of clinical services, along with a commitment to continuous improvement of those services, whether it provides services directly or commissions them, or buys them in, from other individuals or organisations.
‘Clinical services’ includes any health or wellbeing services in which a healthcare professional provides treatment, care, health promotion or health advice to an individual or group of individuals. However there are grey areas in considering the scope or reach of clinical governance e.g. into areas of health and wellbeing such as exercise and fitness, or welfare advice.
Principles of Clinical Governance
Clinical governance frameworks are often said to rest on seven principles or “pillars”:
- Clinical effectiveness – ensuring that the clinical services involved are effective in delivering benefit to patients or service users, for example by ensuring they are evidence-based, by auditing them, or by measuring outcomes.
- Risk management – ensuring that services are safe and the risk of harm is minimised.
- Patient experience – ensuring that patient and service user experience is at the centre of service design and delivery, including accessibility, equality of provision, consent, dignity and respect.
- Cost effectiveness – avoiding unnecessary waste of resources by delivering services that are clinically effective and provide value for money.
- Strategic effectiveness – ensuring that clinical services fit with the organisation’s strategic aims in providing them.
- Communications – services are underpinned by high quality communications, both within and between organisations and individuals, providing a culture of openness and transparency.
- Learning – ensuring a culture of continuous improvement through both organisational learning and individual professional development.
NB In a situation where an organisation is commissioning clinical services for its members or beneficiaries, both the commissioning organisation and the service provider will need to have some form of clinical governance framework in order to ensure the provision of safe and effective services.
Clinical Governance Policies
A Clinical Governance framework will generally include policies in the following areas:
- Staff management – policies that ensure skilled and appropriately trained clinical and non-clinical staff, including recruitment practices, safeguarding practices, DBS checks, staff appraisal and performance monitoring.
- Education and training – all staff who might come into contact with patients or service users will need training in confidentiality, safeguarding, equality and diversity and Data Protection/Data Transmission. Clinical practitioners should be engaged in continuing professional development (CPD) according to their professional requirements.
- Public and patient involvement – patient/service-user feedback is an important part of quality assurance and service monitoring. A mechanism should be in place to encourage routine feedback, along with a clear complaints procedure. Feedback and complaints need to be routinely monitored and reported. Staff should also be encouraged to report poor quality services or behaviour via a Public Interest Disclosure Policy (“Whistleblowing”).
- Risk management – the risk of harm to patients/service-users, staff and the organisation should be considered and minimised. In particular a robust Incident Policy and incident reporting mechanism should be in place so that all adverse events and ‘near misses’ can be assessed and learned from. Poor patient/service-user feedback and complaints should automatically be logged as incidents, as should Data Protection/Information Governance breaches. Other specific policies that might need to be developed or modified to reduce risk include Lone Working, Chaperoning and Safeguarding.
- Clinical effectiveness – best practice in clinical services is assured by using evidence-based treatments, adhering to national guidelines where they are present, encouraging clinical staff to maintain their skills and knowledge, and following up patients/service-users to assess treatment outcomes.
- Information management – confidentiality and consent should be central to all situations involving patients/service-users. Clinical data and records are regarded as Special Data under GDPR, so Data Protection and Data Transmission Policies will need to be reviewed to take into account personal data collected in the context of clinical encounters, including preliminary patient registration data. Policy and procedures around clinical records will need to cover record creation, storage and destruction, as well as details of access rights for both staff and patients. Any service monitoring or reporting that requires the collection of patient data should ensure that it is anonymised. Data protection breaches require a reporting mechanism as part of Incident Reporting.
- Audit – periodic data collection and analysis designed to monitor the quality of service provision and appropriateness of service design.
Commissioning clinical services – how to ensure and monitor quality
A non-clinical organisation that is commissioning or purchasing clinical services on behalf of its members or beneficiaries will want to ensure that:
1. The services it commissions are the right ones for its client group, by understanding the needs of that group and making some assessment of the suitability of the care options that are available.
2. Services are of a high quality. During the commissioning process, it is important to check that the clinical service provider:
- Has a clinical governance framework
- Has a named lead for quality and clinical governance
- Is indemnified
- Uses professionals and practitioners with appropriate qualifications and registration with a body approved by the Professional Standards Authority (see below)
- Requires practitioners to have ongoing training and CPD
- Has appropriate Information Governance processes and Consent/Confidentiality Policies in place
- Has Policies and Procedures in place specifically for: Complaints, Incident management, Feedback and Safeguarding
- Charges private fees which are appropriate and in keeping with the location and type of practice.
3. Ongoing management and monitoring of services is in place. This might include agreements over:
- Standards and outcome measures
- Data protection and data transmission arrangements between the parties
- Procedures for investigating any complaints or serious incidents – who would be responsible?
- Reporting arrangements
- How poor performance by a healthcare practitioner would be managed.
Professional Standards for Healthcare Practitioners
It is important to know that any healthcare practitioner that an organisation works with, or signposts, is practising to a high standard of expertise and professionalism. Professional standards in the UK are overseen by the Professional Standards Authority, via Regulators in some professions, or by acceptance onto an Accredited Voluntary Register in others.
“Regulated Professions”: some healthcare practitioners in the UK are statutorily regulated: qualifications are standardised and are of degree level or above, and there is a statutory requirement to maintain professional standards and professional development. Regulated professions include doctors, dentists, nurses, osteopaths, chiropractors, physiotherapists, speech therapists and clinical psychologists.
“Unregulated professions”: in other healthcare professions in the UK there are no standardised qualifications and no obligation on individuals to comply with registration arrangements to guarantee professional standards, although practitioners in these professions have the option of applying for and registering with an Accredited Voluntary Register if they meet the right criteria. It is a good idea to use only practitioners who are registered with one of these Accredited Registers as it guarantees that they have completed an accredited qualification and have accepted (and can be held to) certain standards of behaviour, ethics and ongoing professional education. Examples include Accredited Registers for counsellors and psychotherapists, acupuncturists, alexander technique teachers, and massage therapists.
How BAPAM can help
BAPAM is a clinically led organisation working in the performing arts sector. We have a clinical governance framework in place and are registered with the Care Quality Commission (CQC).
Our team can support performing arts organisations who are delivering or commissioning health services themselves to ensure that care is safe and effective and meets quality standards. We are available to:
- Discuss quality issues in relation to an existing or planned service
- Develop policy documents and reporting systems that allow you to continually monitor the quality of service delivery
- Support the scrutiny of your service
Contact firstname.lastname@example.org 0207 404 5888