“Everybody involved in overseeing, planning, delivering and supporting healthcare services in Scotland has a role to play in ensuring that our governance procedures improve, assure and result in necessary remediation to drive the quality of our healthcare services”
Extracted from ‘Governance for Quality Healthcare in Scotland – An Agreement’, Scottish Government Health and Social Care Directorates, NHSScotland. Available at: http://tinyurl.com/qualitygovernance (Accessed 17th December 2013)
From 2010-2013 I worked as Assistant Director in the Medical and Nurse Directorates of NHS Ayrshire and Arran, supporting and advising on the Board’s Clinical and Healthcare Governance activity. A significant amount of time (as you would expect given the role) was spent in dialogue regarding ideas and requirements for changes in systems and processes – a common thread across all governance, learning and improvement work.
I was recently asked by colleagues in NHS Ayrshire and Arran’s Mental Health Services Directorate to speak at their annual clinical governance and improvement symposium. My talk focused on ‘ten things that I have learned about governance’.
These are outlined below:
1 – What have you done about it?
Governance is about being able to identify what action is required and demonstrate that this has been effectively implemented.
2- Adopt an open ‘questioning’ mindset
Engage and support questions that drive forward a focus on understanding systems, making sense of contributors and understanding relationships between people, processes and wider organisational climate and culture.
3- It’s not about you
Systems, processes, organisational climate and cultures are more powerful than any one individual. It’s not personal, even though there may be many who think it is and try to make it so. Stay focused on the people who we are employed ‘to serve’ – this is the ‘key’ unifying factor in terms of focusing on what matters to the people that use services being provided.
4- Defensiveness is dangerous
Defensive and dismissive reactions can significantly weaken good governance – energy is taken away from learning, dialogue, and the generation of ideas for change, development and, most importantly, the implementation of plans for improvement.
5-That’s not your job/that’s my job
There needs to be clear, shared and accepted understanding of what individual roles and responsibilities are. Delivery of ‘best in class’ governance practices is always more effective when roles and responsibilities were clear and understood in practice.
6-Clarify your intentions
Personal and organisational custom and practice can mean that intention/personal meaning that is attached to actions is incorrect. I quickly learned that if colleagues had not had the opportunity to consider the same theoretical models of healthcare governance as I had, they would sometimes attach meanings about intent of my actions that then became unproductive.
This could lead to perceptions of unjustified interference, thankfully often addressed by making sure intent was clarified – for example, saying ‘My intent in asking about how this action has been progressed is to provide an update to Mr Jones’ widow who is frightened to come into hospital herself now in case we have not improved the systems’ would often help focus action around what mattered.
7-It’s all about measurement and change
Governance, improvement and performance have more in common than people think or believe that they have. Data for dialogue – to understand systems, inform ideas for change and examine whether changes have resulted in improvements or delivery of a stated aim is what matters.
8-Some people don’t “get it”
A well-developed understanding of the legal, professional, moral and policy imperatives regarding governance does not always seem to have been an essential recruitment criterion. It’s insufficient to issue policies and guidance and hope that actions will be effectively taken as a result. Good governance also depends on a grounded and comprehensive understanding of what matters most to the people using services.
9-Impact is everything
The impact of getting it right (even after getting it horribly wrong) can be profound for everyone involved. Trust can be restored when there is an authentic and honest ‘reaching out’ to connect with the lived experience of all who are touched by the encounters that are reflected in governance and improvement conversations.
10-Did I say impact is everything? – I meant transparency is everything
People who use services, people who might need to use them and the staff who work within them have a fundamental right to know what is happening – what is going well, what hasn’t gone well, what has been done, whether it worked and how they can become involved with efforts to continuously improve service quality.
Some closing remarks…..
Governance and assurance doesn’t need to stifle improvement activity. The following simple model for healthcare governance process was based on the work of the late Avis Donabedian and, I believe, demonstrates how governance process can be entirely resonant with improvement focused thinking and action.
- Information on the quality of care is collected (through a range of sources)
- Information is then interpreted to identify what action is needed
- Agreed actions are then documented
- The impact of taking these actions is then monitored through agreed measurement and reporting processes
- The information on this impact is then considered against agreed aims, this in turn again provides information for further interpretation:
- Has this made a difference?
- Are things better?
- What have we learned?
- What do we need to next to make this more reliable?
Good governance consists of a set of simple steps. Although they are often difficult to implement consistently and reliably they can be powerful enablers to support a learning and improvement focused approach to governance and accountability.
The views outlined in this blog are personal views based on professional experience while Assistant Director (Healthcare Governance and Assurance), NHS Ayrshire and Arran 2010-2013.
About the Author
Professor Craig White is now Divisional Clinical Lead (Quality and Planning), The Quality Unit, Health and Social Care Directorates, Scottish Government.
Email: firstname.lastname@example.org Twitter: @craigwhitephd