A detailed presentation on clinical governance in hospital set up, with its pillars and foundation stones.

1. By
GROUP- H( MBA HOM)
Shilpa Singh Shreosee Mukherjee
Shivangi Das Shruti Aggarwal
Shivani Shakti Rao Shweta Bisht
Shivani Vishwakarma Shweta Shastri
Shreeparna Das Sonal Jain
Sonali Taggar
CLINICAL GOVERNANCE
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2. S.No TOPICS
1. Clinical Governance
2. Need for Clinical Governance
3. Elements of Clinical Governance
2. Importance
3. Case Study
4. Hospital System
5. Components of Quality System
6. Culture
7. Temple Model
TABLE OF
CONTENTS
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3. CLINICAL GOVERNANCE
• Organisation-wide approach
• Continuous improvement of healthcare quality
• The intention of CG is to ‘safeguard the high standards of care by creating an
environment in which excellence in clinical care will flourish’
• Quality is the heart of health services and quality with regards to clinical services is
defined as- patient safety, clinical effectiveness and patient experience
• The main elements of CG are clinical audits, risk management, patient
involvement and lifelong learning
• The patient–professional relationship is seen as central to high-quality healthcare
• Clinical governance promotes a learning culture, and develops a system to deal with
and learn from errors, mistakes, incidents, claims, complaints, and to identify and
manage risk in healthcare organizations
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4. What was the need of Clinical Governance?
BRISTOL HEART SCANDAL
• In England, around 1990s, babies died at high rates after cardiac surgery at
the Bristol Royal Infirmary
• Overall 170 children died in the Bristol unit between 1986–1995
• The reasons identified were shortages of key surgeons and nurses, and a
lack of leadership, accountability, and teamwork
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5. ELEMENTS OF CLINICAL GOVERNANCE
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6. IMPORTANCE OF CLINICAL GOVERNANCE
Corruption in
public
healthcare
systems
Corruption in
staffing of
healthcare
delivery
Corruption in
flow of funds
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7. CORRUPTION
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8. HEALTHCARE GOVERNANCE FRAMEWORK
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9. A hospital is a regulated organization with multiple departments. The organizational model defines
the framework, line of duty, communication roles and resource allocation. It also reflects the ethos of
the organization
NARAYANA HRUDALAYA- BENGALURU
Private Hospital Tertiary care Hospital
20 years old
AWARD & ACHIEVEMENT
• In year 2008, NH became first hospital in state to be awarded
with NABH accreditation in the Karnataka state.
• In 2011, NH was awarded as India Shining Star CSR Award
for exceptional CSR work done.
• In year 2018, NH was awarded to be hospital as Quality
Beyond accreditation.
• In year 2018, NH was awarded as World's Most
Innovative Companies By Fast Company by avoiding
surgeries with nuclear medicine.
• Narayana Institute Of Cardiac Sciences, Bangalore is JCI
approved.
• & many more.....
WHAT IS HOSPITAL ?
CASE STUDY
Multi-specialty hospital with 3000 beds & 30
specializations & 11 centers across Bangalore
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10. RIPPLE EFFECT : A situation in which one event produces effects which spread and produce
further effects
What changes? How to implement?
What are the impact or
results of change?
OBJECTIVES
Measurable
Related to present situation
& problem
Quality maintain
Resource oriented
Realistic
Accessibility &
Affordability to
surgeries
Pay-Per-Model
Reuse equipment
Without compromising
quality
Increase in number of
surgeries with better
outcomes.
10
https://www.commonwealthfund.org/publications/case-study/2017/nov/expanding-access-low-cost-high-quality-
tertiary-care

11. Customer
wants/ needs
Measures-
Audit, surveys
Review-
customer sati
sfaction
Access & pre
paration (
execution)
Service
delivery
Resource
management
Identify gaps
Further
improvement
Clinical Governance
Audit
• Objectives
• Review
evidences
• Set standards
• Data analysis
• Findings
STEPS
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12. Expending Access to Low-Cost, High Quality Tertiary Care
Organizational Objective -
 Optimize Productivity
 Minimize Cost
Customer Requirement -
• Accessibility
 Affordability
Departmental Objective - (Clinical)
•Leveraging economies of scale
• Using assembly line concepts for surgery​
•Reducing the average length of stay​
•Reengineering the design, materials, and use of medical
equipment to reduce the cost of ownership.
Spreading the Narayana Health Model Beyond India
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13. • Utilizing a pay-per-use model with suppliers for
some diagnostic equipment, it minimizes capital costs
• A production-line approach to surgery, combined with
task-shifting among staff, create an extremely
efficient operating theater, resulting in many more
procedures completed per day than is typical in the
U.S. and elsewhere. Each surgeon performs 400 to
600 procedures annually, compared with 100 to 200
in the U.S.
• The average cost of open-heart surgery, as reported
by Narayana Health, is less than $2,000. The same
procedure at a U.S. research hospital typically costs
more than $100,000
RESULTS
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14. Case Study-Challenge
Integrate a growing
Provider
Halton Healthcare
when the
organization planned
to open new two
hospitals it realize
they existing
infrastructure
required more
unified,strategic
approach .
Solution
A Single Platform
for all healthcare
delivery
Results
Extended real time
communications
across two new large
healthcare facilities
to enhance
healthcare delivery
and patient
outcomes
Halton Healthcare Builds a Foundation for Smart Hospitals with Cisco
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15.  Optimize the average length of stay in the hospitals
The average length of stay in hospitals (ALOS) is often used as an indicator of
efficiency in the hospitals. All other things being equal, a shorter stay will reduce
the cost per discharge and shift care from inpatient to less expensive post-acute
settings. The ALOS refers to the average number of days that patients spend in
hospital. It is generally measured by dividing the total number of days stayed by
all inpatients during a year by the number of admissions or discharges(including
deaths). Day cases are excluded.
 Improving the bed occupancy rate
BOR represents the percentage of all licensed and installed beds within a given
year, and it is used as an indicator of utilization and productivity. ALOS is
considered as an indicator driving the BOR. A lower value means a better quality
of service, which is helpful in making more beds available to incoming patients.
Evidence suggests that significantly lower levels of ALOS and greater number of
admissions indicate sound management. This implies that higher BOR which
results from higher admissions will have negative correlation with ALOS. Hence,
its coefficient is expected to be negative.
Improving the utilization of services.
ORGANISATIONAL OBJECTIVES
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16.  Improving the utilization of services
PD(patient days) refers to units of measure denoting accommodating facilities
provided, and services rendered to inpatients within the census-taking period. It
reflects the volume of services provided by each hospital within a given year. PD
impacts the BOR by changing both output and input amounts. So, under the same
conditions, higher PD would mean higher utilization and higher BOR. It is assumed
that because admission has a potential utilization of hospital resources, increasing
PD may generate a larger increasing effect of BOR, and thus can increase the rate of
utilization. For these reasons, PD is considered an important factor of BOR. PD
captures the number of days in totality that patients stay in hospitals as inpatients
within a given time period.
There was a study done on the public hospitals of Malaysia during the period of
2006 to 2013. The data used in this study were obtained from the Ministry of Health
(MOH), Malaysia, and consist of all public hospitals in Peninsular Malaysia to
study the impact of ALOS on BOR and it was found that ALOS is inversely
correlated with BOR, Hence, reducing ALOS can help raise performance of public
hospitals in Malaysia. It showed a need to reduce ALOS in public hospitals to
improve BOR. The evidence provided in this study suggests that targeted efforts at
increasing utilization rates of public hospitals can increase their overall
performance, which is in sync with a previous study that showed that reducing
hospitalization rates leads to an improvement in efficiency.[41] Therefore, health care
policy-makers should ensure a coordinated action plan toward the promotion of
health care facility utilization to enhance overall health care delivery.
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ORGANIZATIONAL OBJECTIVES (contd…)

17. 17
 Increasing the empowerment of the hospital staffs.
 Improving the patient satisfaction index
A study utilized data collected between January 2007 and June 2008 from 32
hospitals representing a large, national private not-for-profit hospital system. The
patient satisfaction survey included the Consumer Assessment of Healthcare
Providers and Systems, Hospital version questionnaire items, and there are
31,471 cases. It was found that patients' highest priority is to be treated with
courtesy and respect by nurses and physicians. An effective intervention
programme to improve patient satisfaction would include a training programme,
where care providers understand that patients want them to show courtesy and
respect. Then, well-trained and empathetic nurses and staff members can comfort
patients, and consequently improve patient satisfaction index.
ORGANIZATIONAL OBJECTIVES (contd…)

18.  Reducing the cancellation of surgeries and increasing the number of
operations
There was study done in a Portuguese public hospital to study the reasons for the
cancellation of scheduled surgeries and how to reduce them. For the study the
cancellation rate ranges from 19% and 21% in 2011 and 2012 and an increase to 29%
in 2013.the root cause of cancellation was found to be related to the patients changing
state of health, delay in previous surgeries, refusal to undergo a surgery, bed
unavailability, patient not contactable, lack of equipment's, lack of professionals and
many others. The improvements proposed focused on the causes that could be
avoided by the establishment of pre assessment clinics before operation monitoring
and auditing the utilization of operating room time, improving the efficiency of the
services related to surgical care provision, monitoring the time of operating room that
is used for emergency operations and confirming the attendance for the surgery with
the patients the day before the operations .
 Reducing the medication error
Medication errors are any error in the process of giving a medication. It includes 5
stages that is ordering , transcription, pharmacy where it is dispensed, order comes
back to the unit where the nurse administers it and finally when the patient gets the
medication. Roughly half of the medication errors occur at the ordering stage. The
single most powerful intervention for reducing it is computerizing prescribing or
putting in place computerized order entry. If we just suggest the right default dosage
for medications, then its helpful in reducing the error rate.
DEPARTMENTAL OBJECTIVES
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19.  Focusing on enhancing the soft skills of the technical staffs
In the Soft skill communication skills both verbal and non-verbal are essential
However role of non -verbal skill is even more important as body language,
dress code help in forming impression even before any verbal communication
is started. This is important for all the cadre of staff including housekeeping,
nursing, doctors, paramedical and office staff. Soft skills are required Pan
hospital. Patient must be counseled and attended with soft skills by each
department like Front office, Admission Desk & Guest Relations, IPD,
Nursing, Medical Services and marketing for excellent patient care. Empathy
is critical attribute for the effective handling of patients & attendants as they
are at higher stress level.
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DEPARTMENTAL OBJECTIVES (contd…)

20. 20
 Reduction in the inventory .There are certain ways to ensure
that we can improve the efficiency of the hospital inventory
management while keeping a handle on the supply costs
• Collect data from supply chain
• Assign team responsibilities clearly
• Frequently analyze usage vs order frequency
• Organize the supply room more efficiently
• Improve record keeping
• Consider new hospital inventory management technology
DEPARTMENTAL OBJECTIVES (contd…)

21. • Make people to think about the topic, plan and
what to achieve
• Building interpersonal relationships can help to
promote teamwork and collaboration.
• Quality awareness among the staff
• Catching practice management problem
at early stage
• Identify hospital bottleneck and helps to
overcome through continual improvement
ADVANTAGES PROBLEMS
• Maintaining protocol compliance
• To much time is spent
in sharing simple information(limit to
10% information and sharing and 90% action and
decision).
• Difficulty in understanding the concept.
• Difficulty in defining objectives.
• We should not revisit and rehash (same meeting
should not be done over and over again)
• Lack of accountability and follow through.
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ADVANTAGES & PROBLEMS

22. HOSPITAL SYSTEM
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23. COMMPONENTS of INTERNAL QUALITY SYSTEM
• Patients
• Equipment
• Supplies
• Training
• Environment
INPUTS
• Patient Satisfaction
• Cost
OUTCOME
• Inventory Method
• Coordination
• Physician orders
• Nursing Care
• Ancillary Staff
• Housekeeping
• Transport
STEPS
• Physiologic Parameters
• Functional Status
OUTPUTS
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24. QUALITY OF CARE
• What & How care is delivered
• Evidence-based guidelines
• Infection prevention
• Infection control
PROCESS MEASURES
• Facility infrastructure
• Water sanitation
• Hygiene
• Human resources
STRUCTURAL INPUTS
• Health status of the
patient/population
OUTCOMES
Dependent on 3 Inter-linked Factors
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25. CLINICAL GOVERNANCE and DRIVE for QUALITY IMPROVEMENT
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26. DUTY of QUALITY
• Health Act 1999
LEGAL
OBLIGATIONS
CLEAR ROLES
and
RESPONSIBILITIES
• Clinical Governance
Board/ Committee
• Annual Reports
• All staff
ACCOUNTABLE
CHIEF
EXECUTIVES
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27. Culture for Clinical Governance to flourish
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28. • Attitudes to Innovation and Risk taking
• Internal or External focus
• Team Orientation
• Effective Communication
• Shared Decision Making
• Communication with stake Holders
OTHER CULTURAL QUALITIES
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29. The Temple Model Of Clinical Governance
• The first widely used clinical governance framework was developed within
the NHS in the late 1990’s
• The framework was the Temple Model Of Clinical Governance,
• It used the concept of Seven Pillars comprising patient experience, and
effectiveness in the clinical area, risk management, communication,
resources, strategy, and learning.
• The pillars rely on the foundations of systems awareness, teamwork,
communication, ownership and leadership
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30. THE FOUNDATION STONES
• System awareness
• Teamwork
• Communication
• Ownership
• Leadership
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31. SYSTEM AWARENESS
• Healthcare systems involve the human dimension to care delivery as well
as technology and processes
• Systems approach not only addresses the individual incident and risks
but also aims to further reduce the risks and chance of reoccurrence across an
organization through the implementation of risk management solutions
• Hence the clinical governance takes a broad approach to problem solving
and requires to view the whole situation rather than dealing with certain
aspects in isolation
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32. TEAMWORK
• Effective teamwork is required to implement and sustain clinical governance
• Teamwork enables greater flexibility, sharing of information, problem solving and
the acknowledgement of strengths and limitations within the work environment, all
of which contribute to quality assurance
• Effective teamwork can overcome barriers to cross-boundary working, whereby
team members aim to promote optimum patient care in an environment that fosters
openness, respect, trust and co-operation
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33. COMMUNICATION
• Effective communication systems are crucial to the implementation of
clinical governance and are at the centre of a quality service
• Communication in health care is often complex and is the cause of many
patient complaints
• To be effective, good communication is required among team members,
departments and patients
• Also listening skills are crucial to effective communication, it is important
for colleagues and patients to actively listen so that all can learn from their
experiences
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34. OWNERSHIP
• Ownership involves ensuring that there are systems and structures in place
within the workplace so that staff feel supported and empowered to solve
problems
• Without ownership the development of a culture that embraces and embeds
clinical governance will not happen
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35. LEADERSHIP
• Effective leadership is recognized as being critical to the development of
the NHS
• Effective leaders not only provide direction and empower staff, they also
ensure employment practices have the best performance outcomes for
staff
• Good leadership not only empowers staff but creates a culture that is open
to change and innovation, and one that incorporates clinical governance in
everyday practice
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36. PILLARS OF CLINICAL GOVERNANCE
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37. CLINICAL EFFECTIVENESS
• Clinical effectiveness is an umbrella term which constitutes a wide range
of activities that aid a healthcare professional to improve the quality of
patient care
• Adopting evidence-based approach for better outcomes while treating
patients
• Reviewing current practices, if found inadequate, then adopting newer
guidelines and protocols
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38. RISK MANAGEMENT & EFFECTIVENESS
• Risk Management involves having robust systems in place to understand, monitor
and minimize the risks to patients and staff and to learn from mistakes.
• Identification of risks is the major hurdle in risk management.
• To have an effective risk management, incident reporting should be encouraged.
• Assessing the risks, their probability and the impact they could have should be
acknowledged.
NEAR MISS
Near miss is an unplanned event that did not result in injury, damage or illness but
had the potential to do so.
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39. PATIENT EXPERIENCE
• Patient’s perspective via feedback is very important to assess the quality of care
received
• Involvement of the patient in handling issues should be carried out
• Taking information through local patient’s forum and understanding the problems
faced by them during treatment
• Patient surveys are important in learning about their perspectives
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40. COMMUNICATION EFFECTIVENESS
• Communication is a process of sharing understanding between people. It
can be verbal or non-verbal communication
• Communication is vital to maintain constant flow of information around
the department
• Communication is essential among healthcare professional as well between
healthcare professional and patients
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41. RESOURCE EFFECTIVENESS
• In terms of resources effectiveness, empowerment of staff may lead
staff to have sense of ownership to the organization
• Sense of ownership, in turn, may lead staff to be responsible for
resources utilization to achieve goals effectively
• To ensure resources are being used optimally without wastage
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42. STRATEGIC EFFECTIVENESS
• Strategic management is the process of “managing the pursuit of the organizational
mission while managing the relationship of the organization to its environment”
• Strategic management should focus on patient- professional relationship in order to
improve quality
• It should also reflect the mission of the organization and its intention to pursue patient
centered care
• It focuses on the external environment and involve long term organizational issues and
provide guidelines for the organization
• An excellent leadership is essential for good strategic effectiveness
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43. LEARNING EFFECTIVENESS
• Learning is a continuous process. The organization evolves with technology
• The importance of the learning process is that it provides an opportunity to
obtain and implement new skills and knowledge
• To improve quality of clinical care, workshops and seminars should be
conducted
• A learning environment helps gain knowledge and skills
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44. THANK YOU
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