Assessment 3: Clinical Governance Practice Issue Report

This report provides an in-depth analysis of clinical governance practices, focusing on patient safety, healthcare accountability, and the investigation of adverse events. It examines the policies, professional standards, and reporting mechanisms related to clinical incidents. The report delves into the principles of clinical governance, identifies barriers to effective implementation, and highlights the role of healthcare leaders in ensuring high levels of safety and quality. It includes a case study of a medication error and discusses organizational, regulatory, and legal reporting requirements for adverse events. The report also explores various investigation methodologies, such as Root Cause Analysis and local investigations, and outlines the steps involved in the clinical incident investigation process. Additionally, it emphasizes the importance of patient and public involvement, information technology, and other key principles in minimizing adverse events and improving healthcare services.

Assessment 3 Report of a
clinical governance practice
issue investigation and
remedial action plan

EXECUTIVE SUMMARY
Clinical governance can be defined as approach for maintaining care in the hospitals. It is
also referred as framework by the National Health Service organisation across the country are
making improvements in their quality of services and safety of patients. It also involves the
safeguarding the standards of care in the healthcare organisations by creating the environment
that results in the excellent clinical care in various healthcare organisations of the country. This
report will include the policies and professional standards which are related to healthcare
accountability and patients safety. This report also includes the investigation process of clinical
incidents in the healthcare and will also discuss the principle of clinical governance, it will also
identify the barriers for implementation of plan. This report will also, role of healthcare leaders
which they play in achieving high levels of safety and quality.

INTRODUCTION
Clinical Governance is the approach that can help in maintaining care in the health care
organisation so that patients can get quality care. It has become an important part for improving
standards of healthcare within the country. It can also be referred as a set of relationships as well
as responsibilities which are set by the health services organisations that exists between the
department of health, executive force, governing bodies, patients and consumers, and
stakeholders in order to deliver the high quality and safe healthcare services. Present report
discusses adverse events or clinical incidents or the organisational factors which influence safety
of patients (Kluetz & et.al., 2016). It also includes the regulatory or organisational or legal
reporting for adverse clinical incidents and also appraises the clinical incident investigation
process and identifies the ethical, legal as well as professional issues which relate to clinical
incidents in the healthcare. A person 75 years patient had some health issues at home and was
suffering from chest pain and was admitted to hospital by its family members for treatment. He
was given some medicines by physician which further worsened his health conditions due to
which he suffered a lot and resulted in death. Present report also discusses various principles of
clinical governance and also discusses the accountability in the health practices. It also includes
the barriers of implementation of effective governance process and role of health leaders in
applying the principles.
There may be many clinical adverse events which may occur in the clinical trials due to
negligence from healthcare or form the nurses or even due to patient itself. Adverse events are
such accidents which occur due to negligence of hospital staff. These can be clinical trials etc. It
can be illustrated with an example during the medical trail a patient is checked for blood pressure
and is cuffed with a period of 10 minutes which might seem innocuous and there may exist a
patient's skin to be irritated by the device. Patents during the study may also die within a 10-
minute period. So, both irritation of skin and sudden death can be considered as adverse events.
There can also be various influencing factors which can influence adverse events like negligence
from the doctors or form the nursing departments lack of patients previous medication
knowledge or inexperienced staff may be the contributory factor which may result in the adverse
events (Bernstein & et.al., (2017). There may also be some organisational factors which may can
influence the adverse events may inadequate document review of patients, inadequate automated
surveillance of patients treatment data and inability of the hospital to monitor the progress of
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patients which may lead to the adverse events. So, these are some influencing factors which may
cause adverse events during the treatment of patients or during the clinical trials. A person 75
years old had some health issues and was suffering from chest pain and was admitted to hospital
for care, and he was given some medicines which further worsened his health conditions due to
which he suffered a lot. There has been a grave medication error from the hospital which resulted
in harm to patient.
MAIN BODY
Organisational, regulatory as well legal reporting mechanism for Adverse Events
A mechanism which is followed by the hospital for reporting the adverse or clinical
events starts with the Case recognition and there should be an ideal system for recording the case
adverse events and that should be reliable, valid and cost effective. There should be a direct
observation of the case identifying the rate of error or injury which has occurred while providing
the medical care. After recognising the case then next step involves the reporting procedure.
Reporting procedures includes the ease of reporting like the systems that would be online or
which are user friendly and secure. Reporting should be done in such a way that it is fast and
provide the accurate results (Tamma & et.al., 2017). Also, the medium of reporting should be
effective like using the electronic data capture for recording of adverse events. Various exemplar
forms which are applicable to secondary and primary care and carer reporting is being developed
initially within a document form with a aim using it electronically through NHSnet or through
internet. Once the information is submitted the its comprehensively analysed in order to identify
the action which could minimise the risk which reported events recur. Then feedback and
information is provided like sharing of patient safety information within various healthcare
organisation. Finally in the reporting mechanism, reporting system itself is subjected to
monitoring as well as evaluation which is done by an identified independent body.
Policies and professional standards which relate to patient safety and healthcare accountability
In the field of patients safety in Australia many unwanted incidents take place in care
hospitals. It has been emphasised from the high profile inquires which where made in some
specific hospitals. Within the study it was analysed that there were issue which resulted in the
lack of patient safety or lack of accountability (SAFE PATIENT CARE AND Nurses and
Midwives’ Professional Obligations, 2017). Within Australia there are various large
organisations which play an important role in providing the quality and safety within primary
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healthcare and there are various standards and policies in place in order to improve safety of
patients (Buja. & et.al., 2018). There are various policies and standards related to safety and
quality of healthcare for patients some of them are mentioned below:
1. Governance for quality as well as safety within the healthcare service organisation which
includes the quality of framework that is required for healthcare organisations for implementing
them safely.
2. Prevention and controlling of healthcare associated infections, this involves the strategies as
well as systems for preventing the infections of patients in a healthcare organisation or system. It
also includes managing of infections in effective manner in order to minimise the consequences.
3. Organisations should provide the proper medication safety to patients that should ensure that
clinical safety of the organisation is prescribing, administering, dispensing and appropriate
medicines to the patients.
4. Procedure matching or patient identification that describes the type of strategies or systems for
identifying the patients correctly whenever responsibility and accountability of a patient's care is
being transferred.
5.Clinical handover of the patient which discusses about various strategies in order to protect
patients. People are able to get blood immediately whenever require.
6. Another policy or standards related to patients safety and accountability is the prevention of
pressure injuries and managing them (Chandraharan & Arulkumaran, 2016).
7. Another policy is related to recognition as well as responding to clinical deterioration and in
this it includes the systems and the strategies as well as processes which is to be implemented by
the healthcare firms for responding towards the medical problems of patients immediately.
8. Prevention of falls and any sort of harm form falls that includes the strategies or systems for
reducing the incidence of patient's fall within the healthcare service organisation and providing
the best healthcare management services when a fall occurs to a patient.
9. Also, healthcare organisations should partner with the consumer that includes the involvement
of strategies as well as the systems as designing the better quality of healthcare services within
the organisation.
The contents which are provided in NSQHS standards are being applied in the wide
variety of healthcare services in Australia which is mainly due to variable structure, size and the
complexity of the health services delivery models and the degree of flexibility which is to be
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required within the application standards. Core actions which is to be taken in the healthcare
organisation should be considered as fundamentally safe and also, organisations have to focus on
the areas or identify the areas where healthcare service which are provided requires time and
investments for improving the safety as well as accountability of the patients. Australian Health
Minister have charged ACSQHC for maintaining the standards after their full implementation,
also these standards are continuously been evaluated and reviewed. Also, health service
organisations are kept regularly updated when any amendment is made within the policies or the
standards in order to offer better security for the patients within the health service organisation
across the country.
Investigation of adverse events
National South Wales (NSW) Health Staff are required to provide all the incidents and
complaints in order to recognise the risks associated with the patient and can take actions
accordingly in order to prevent recurrence. Nation South Wales Ministry of health has notified of
SAC1 as well as other signifuicant clinical events through Reportable Incident Brief System and
all incidents are been outline in the National South Wales Health Incident Management Policy.
Investigation of clinical incidents is considered as the important components for an
effective incident management system in a country. All the incidents are being notified within
the Victorian Health Incident Management System which is also known as (VHIMS) which is
allocate in an incident severity rating and which also requires the investigation process or review
process (Singh, Durani & Dias, 2019). Within any clinical investigation process there are three
methodologies which are involved or are available for health services in order to investigate the
clinical incidents and there of them are mentioned below:
Root Cause Analysis
In-depth case review
Local investigation and aggregate review.
Following is the procedure which is involved in the investigation of clinical incident:
1. Hospitals provide confirmation letter before participating in any kind of investigation, they
discuss rules related to the same so that no future complications take place.
2. In a given time frame hospitals need to analyses the problems so that rout cause of any event
can be identified effectively.
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3. In the nest step all the agencies which are involved in the investigation conduct meeting and
they discuss regarding outline of this investigation, also system level vulnerabilities is to be
identified as well as agreed upon.
4. After the joint review session health services will be provided an opportunity for reviewing
and refining any quality improvements actions which they want to implement in the future.
5. Conducting a second meeting if necessary and agencies have to take responsibilities for
tracking their own implementations.
6. Final report is to be provided which incorporates the recommendations for the quality of
improvement.
For every doctor and nurse it is very important to be aware as well as understand the
principles of clinical governance and also they should about their duties and responsibilities.
clinical governance principles and how does they align to accountability which can help in
minimising the likelihood of adverse events is mentioned below:
Patient and Public Involvement: It is majorly concerned with improving the healthcare
services by involving the patients and public in the development of healthcare strategies and this
can be done by gathering feedback from them in relation to care and treatment (Pelzang &
Hutchinson, 2018). This can help in minimising the adverse events it will help the organisation
to improve their services and will also make the staff accountable for their actions.
Information and IT: Making the correct use of information in order to provide better service
and this is the best making the responsible for their action also patients information can decrease
adverse events in the health service.
Managing risk: This is best way of reducing clinical incidents in the organisation which can be
done by viable and comprehensive audit process which is necessary for monitoring and clinical
service delivery (Churchill, 2008). Risk management will also increase the accountability of staff
for their action due to effective monitoring process.
Education and training: By offering training and education to staff will improve the skills and
knowledge of the staff which can help the staff knowing their duties and responsibilities which
can minimise the risks of adverse events in the health services.
Effective clinical care: This is also the best way of decreasing the likelihood of adverse events
as by providing the effective clinical care which requires commitment for providing the best out
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to every patient. For this it is also important that a staff should be accountable for its actions
which can also helps in minimising the adverse events.
Staff management: It is related with need of clinical governance with respect to selecting the
effective staff for the organisation which knows the sense of accountability and which
experienced and knowledgeable enough to minimise the adverse events in the health service.
CONCLUSION
There are various legal, ethical and professional issues which relate to adverse events or
clinical incidents in the healthcare. One of the major issues is the failure of healthcare
professionals as well as health care service providers to address the problems. Another issue
which is faced is inability to make the disclosure easier but not riskier for the healthcare
practitioners. There is another issue related to implementation of ethical guidelines. There is also
lack of good communication skills and effective tactics for disclosing of negative consequences
(Ten Cate & et.al., 2016). Also, there are health services within the country which fail to follow
the NSQHS which gives rise to clinical incidents in the country. Also, some professional are
totally unaware of these standards due to which they are totally unable to minimise the issues of
clinical incidents in their organisations. Also, another legal issue which are faced while
minimising the adverse events is the lack of proper training and development programs within
organisation which results in lack of skills and knowledge especially in the nursing staff. Also,
there some ethical issues which pertain to adverse events such inadequate data in relation to
incidence of adverse events, inadequate protocols or practise guidelines or poor outcome
analysis. Also, there may exist a culture of blame within the healthcare organisations and
ignoring the compensation for injured patients also there may be an issue of telling the truth.
Within some systems there may exist non-flexibility due to which they may be inability get
adjusted with the health standards which has been set by the government of Australia
(Sanlorenzo & et.al., 2015). Also, some organisations are unable to keep record on the updates
which are made by the Health Ministry of Australia due to which they are unable to reduce the
adverse events while taking care of patients. So, these are some legal, professional and ethical
issue which relate to adverse events in the healthcare. In case of any medical error many
physicians applies the ethical imperative of non-maleficence in which physicians only provide
half the ethical answers in case of medical error but it is the ethical duty of physician to disclose
the errors to their patients. In the common law of Australia, it has been clearly defined that any
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physician who does a medical error has a legal duty to disclose the error to patients family or its
guardian.
Remedial quality improvement plan
Quality Improvement Plan
Goals: To improve quality of healthcare services in order to minimise the adverse events in
health services in Australia.
Objectives:
 To improve healthcare services across the healthcare departments of Australia.
 To minimise the adverse events across healthcare services providers in a country.
Quality Improvement Framework
In order to achieve the goal there should be a proper clinical governance which forms
the central element for the framework and supports in delivering the quality healthcare services
within the country. There should be proper polices for dealing the poor practitioner performance
and they should continuously learn from adverse events and errors which has been already
added in the clinical governance structure in order to enhance the safety patients within the
health care organisations of Australia. Also, national systems of rapid assessment of the country
should be examine various concerns in relation to doctors practices that engage in the poor
performance which can be recognised earlier and which can be tackled with the range of
flexible interventions (Cho & et.al., 2016). Also, getting the patients and their families involved
in the development of a system and healthcare strategies within the organisation. All healthcare
organisation should make sure that they comply all the standards and keep themselves updated
regularly. It should also include the new approaches of leadership as well as strategic planning
for improving the quality of healthcare services within the organisation. Also, there should be
proper information analysis as well as proper management of staff and process management
which help in increasing the quality of health services and reducing the adverse events.
Barriers
There are some barriers which can cause hindrances in achieving the goal and some of
them are mentioned below:
 One of the major barriers can low involvement of clinical staff in the participation with
management which can result in inadequately implementation of plan in the healthcare
organisations.
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 Another barrier can lack of clear guidance as well as guidelines and policies which is
needed for the support for the implementation of the plan. There may be lack of
comfort process or failure to accept patients as partner of system can be one of the
challenging factor for implementation of the plan effectively.
 There may also lack of time from physicians, personnels and may the financial barriers
which can result in the hindrances in implementation of the plan.
Recommendations
 Providing the proper management support as well as structure for the implementation of
the plan.
 Motivating, providing training and development to staff which can be help in
implementing the plan effectively.
 Also, facilitating active participation of staff and personnel such as physicians to
increase their involvement.
 Making use of software and hardware in order to record the medical data quickly and
easily. Also, storing and retrieving of the information and personal medical records,
personal training and using of information technology which can be help in effective
implementation of plan.
Role of health Leaders
Health leaders play an vital role in applying the principles of quality improvement as
well as evaluation for organisation in order to achieve high levels of quality and safety. As
healthcare leaders are experienced and knowledgeable they can provide guidelines to
organisation and the staff for implementation of plan in an effective manner. Also, they can
play an important role in setting a proper communication process which can help to address
various issue of patents effectively. Also, they can provide an training and development
programs to their staff member which can increase their skills and knowledge in relation to
increase the safety of patients within the healthcare organisation. Also, they play an important
role in minimising the barriers which are faced in increasing the safety standards of patients in
the country.
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