Organisaitons providing clinical care to consumers are required to implement a clinical governance framework, the efficetivenss of which is overseen by the Boards who are accountaible for safety and quality across the organisaiton. Fair enough, but where to start and how to manage and maintain the clinical governance system is the hard part.
At OneVault, we help our clients get on top of clinical governance using a number of stategies. One of these is the OneVault recipe for good clinical governance. Here are the main dot points with some key tips:
1. GAP analysis
Do a gap analysis against each requirement of the Standards. Be brutal. Assume nothing. Assign work to people with the skills and time to complete the task.
2. RISK analysis
Review your risk register and ensure you look at the clinical and corporate risks. dont forget the risk associated regarding your governance structure. if the governance and committee structure needs reworking, then do this as a priority. The priority of what work gets done first is based on risk assessment, so start with your high risk areas and work down.
3. POLICY and procedures
Review all policy and procedure against Standards and in according to risk. Yes, policy should be risk rated. This determines how often they need to be reviewed. Ensure your systems of document and version control are robust and that all staff have rapid access to this informaiton.
4. MONITOR feedback, audits, incidents and complaints
Review your survey and audit scedule. Make sure you are auditing the 3 core areas. Legislative requirments, Standards requirements and areas of identified high risk. Ensure that exising processes match your newly reviewed policy and procedure regarding Feedback, incidents and complaints and if not, update them. Make sure your documentation clearly explains what quality improvements have been linked to audit results, complaints or other feedback. Close the communication loop with staff and share the lessons learnt.
5. QUALITY improvement
The reason we analyse the incoming information from audit, survey, incidents, feedback, recommendations and risk analysis is to improve and reduce risk. Small improvements must be captured and large projects well managed. Track your large QI projects to make sure they deliver otherwise they will consume costly time and effort for zero benefit.
6. TRAINING and upskilling
Back to risk...identify the training needs in priority of risk. Like monitoring, there is "must do" training. This includes training to uphold legislative requirements and training to ensure compliance to Standards. It also includes any training needed to address areas of identified high risk. Training for the leadership team is also included in this "must do" space. Do research on what free onlnine learning is available, there is more available each day. Just ensure they are provided by reputable sources.
Finally, there is little use doing all this without good communication. This includes providihng meaningful reports to the Board and keeping in touch with the workforce.
A final word of advice:
If, as a board member, a director or a manager, you really want to know what is going on....go for a walk, closely observe the people both those recieveing care and those providing it, talk to these people, look at their living and working environment, imagine yourself as someone being cared for or providng the care and then ask yourself...would it be good enough for me?
In 2014, the Australian Commission on Safety and Quality in Health Care released a Strategic Planning Report where healthcare providers were interviewed regarding their thoughts in relation to the work they do for accreditation and monageing clinical governance generally. Here are some of their comments from page 6 - 13.
In particular, health services wanted to:
"have uniformity of information across sectors (so people are getting the same messages)"
"share information and knowledge between health services, especially in relation to initiatives where there is evidence that these initiatives have resulted in good patient outcomes, know where to access information, or which organisation to go to if they are struggling and need assistance"
"..have a repository of best practice examples, so that other services can leverage the good work that has already been done” “….
"system just doesn’t seem to have that flexibility or adaptability to keep up with things that are changing” -
Do any of these comments resonate with you?
We work in silos, that is why there is so much duplication and rework in the clinical governance and accreditation space. Between us, we have an incredible pool of knowledge. The big picture organisaitons, like the ACSQHC or the CEC are great but wouldnt it be fantastic if all of us could easily helpone another. Whether it is a large or small care provider, people are usually very open and willing to share their information, expertise and lessons learnt. The problem is there is no easy way to do this.
That is why OneVault created "Share Network"
If you would like to know more about how you can share information between sites or between other organisatios while protecting your IP and getting the acknowledgement you deserve, flick us an email and we will organise a time to chat.