101. "To improve health care we require not better professions, but better systems of work. A "system" in this sense is a set of elements inter-acting to achieve a shared aim. Here is the trick: to improve the performance of the system you need to attend more to the inter-actions than to the elements. Great (mental) health professionals do not make great health care. Great (mental) health professionals inter-acting well with all of the other elements of the health care system make great health care. Professional associations that wish to lead socially responsive improvements in technical care, service, outcomes and costs have no real choice but to invest in improving inter-dependency among individuals, professions and organisations" (Don Berwick (1997).23
102. Any discussion of better care occurring even in part within a health service context cannot ignore the introduction of clinical governance.5 It has been defined as "the means by which organisations ensure provision of quality care, by making individuals accountable for setting, maintaining and monitoring performance standards". The central change is that the Chief Executive of the Trust will be made equally accountable for the delivery of quality of care to the previous requirement to maintain the fiscal integrity of the organisation. As pointed out by Berwick, one of the themes emerging is that management will expect individuals from different disciplines to work together to take corporate responsibility for service improvement. The components of clinical governance - risk management, quality assurance, clinical effectiveness, audit, and continuing professional development have been around for a while. Clinical governance acts as the higher order context to make these components more than the sum of the parts. It is expected that clinical governance will be delivered within the existing budget. Here is the difficulty - is the glass half full, or is it half empty? On the one hand integrating all the components takes time to implement and for staff to contribute. The staff resources available to an organisation are finite and time spent in this way has a cost. On the other hand, systems which are efficient, effective and get it right first time save money. Particularly in the management of risk the cost, personal and fiscal, of not getting it right first time can be very high. There may be no second chances.
Vignette- Extract from the determination of the Sheriff after a Fatal Accident Inquiry
"The evidence revealed a casual or indifferent attitude on the part of some of the staff at 'the Unit' to the monitoring of unaccompanied time out. Having regard to the fact that 'the Unit' is for acutely unwell patients, it is not acceptable that such an attitude should exist. While I accept that the Trust has devised and published policies and guidelines in relation to the management of acutely unwell patients, they are of worth only if they are known about, acknowledged, understood and followed by all those involved in the care and control of acutely unwell patients. In order to secure such awareness, recognition, comprehension and practice, it is essential that staff at every level are provided with appropriate training. For such training to be of practical use and benefit, there obviously needs to be in place proper facilities and procedures. I consider that this Inquiry has revealed a need for a review to take place at 'the Unit' in relation, in particular, to the recording and monitoring of unaccompanied time out. While I accept that it is difficult to strike a balance which properly weighs the interests of individual freedom, therapy and responsibility against intervention, and while I accept that staffing levels and the recruitment, deployment and attitude of staff are difficult issues, I take the view that a real need for reassessment at 'the Unit' has been demonstrated by this Inquiry."
103. Mental health care involves a partnership between different agencies, with different traditions and cultures; is clinical governance a health service driven imposition which partner agencies, and their staff, have no option but to go along with? In one sense, there can be no argument that the aims of clinical governance would be subscribed to by most health care and associated organisations. Quality assurance, effectiveness, continuous staff development, risk management and fiscal prudence are generally desirable. A source of comfort to partner agencies is that while clinical governance is a term which has been in use for 2 years, at the time of writing, nowhere can it be seen to be fully implemented. The concept is still evolving. This is because it is a revolutionary way of doing things. Instead of standards being imposed from above, with no local ownership, necessarily resulting in partial adoption and implementation at best, clinical governance can only work by a partnership between service users, carers, members of clinical and care teams and management. This allows partner agencies in the climate pervading the NHS in Scotland to contribute on the grounds of a shared set of aspirations for better services and care for people.
104. The essence of accountability is the identification and acceptance of the mutual roles and responsibilities of each clinical or care staff member and manager. The complex nature of mental health care and the services which provide it, dictates a new approach to this task. The setting of clear standards for practice, training, communication, recording and risk assessment is crucial. Standard setting from the top down does not work well in any care system, without continuing strenuous efforts being made to persuade workers of their appropriateness. Bottom-up standard setting, where service users and front-line workers have a major input, is much more likely to succeed. However, both staff and organisations will need to be able to demonstrate the reasonableness of the standards set, the monitoring arrangements used, and the actions taken to remedy poor service provision. Professionals will be expected to participate in internal and external peer review, and management will be expected to ensure the use of a mix of internal and external audit methods. External audit in this context might mean the Scottish Health Advisory Service, the Clinical Standards Board for Scotland, or the planned Scottish Commission for the Regulation of Care. Internal audit can be achieved by a process known as Controls Analysis or Assurance. This is a process by which the Board of a Trust or other mental health service provider can be satisfied that systems are in place to identify and manage risk.
Implementing Clinical Governance
105. The central elements are the people, the mechanisms, communication, effective care and clinical practice, the right processes and accountability.
106. The essential people issues are:
107. The mechanisms will include:
108. Communication means that all parts of the organisation find out where the risks are and what is happening by:
109. Effective clinical practice means:
110. The processes will:
The Critical Incident Review
111. There are 2 essential tasks - to develop and maintain practice in a way which minimises risk and to use untoward incidents constructively to show where the existing system has not worked as well as it should.
112. Critical incident reviews (CIR) often shed light on difficult areas and indeed demonstrate from life how systems function when under pressure. An organisation's errors may well be its "greatest treasure" That treasure has to be used constructively, with a culture of sharing it responsibly throughout the service. It is only when all involved in the organisations - Chief Executive, senior managerial, clinical and care staff, and front-line workers - feel mutually supported, working to a common goal that good practice can develop reliably and consistently.
113. There are no national NHS in Scotland guidelines which CIRs should follow. In each of its annual reports the Mental Welfare Commission for Scotland exhorts clinicians to review thoroughly the circumstances surrounding a patient's suicide, or other similar untoward incidents, but does not provide a model of practice for clinicians to follow. It is open to each Trust to produce its own protocol.
114. However, having a CIR protocol as part of Trust procedures is not enough in itself. The CIR should be part of a system of clinical risk management which is supported at every level within the Trust, from the executive board through the medical and nursing directors, the clinical governance committee, individual professional groups, down to multi-disciplinary clinical teams, working either in the wards or in community settings. Important features of such a system, which too often are ambiguous at present, include:
a clear definition of what constitutes a critical incident;
capture of "near misses" (analysis of which reveal just as much about potential deficiencies in care processes) ensured by;
full reporting of critical incidents and "near misses" by staff who should be confident that the organisation's response will not be retributive;
support for the CIR process by senior clinical staff and relevant management;
systematic distribution of the outcomes of the CIR through the rest of the organisation in a "What can we all learn from this?" mode;
action taken to remedy any unmet training requirements revealed by the CIR, across the Trust;
explicit mechanisms for support of staff, other patients or relatives or members of the public who may have been affected by the critical incident with follow up; to ensure a satisfactory outcome (this does not imply an automatic instigation of "post trauma debriefing" or counselling);
commitment at all levels in the Trust to implement Integrated Care Pathways for the management of processes (assessment, admission, management of psychosis etc). These allow standards of practice to be developed locally in the light of prevailing good practice;
exception analysis conducted on a regular basis to detect when care pathways have not been complied with, and why (this allows staff to remedy the deficiencies for an individual and to amend practice to make the omission less likely to occur);
an information system, paper based or electronic, within the organisation which captures all of the above and can yield it in a form useable for both local clinical purposes and for review by Trust management;
an expectation of continuing effort by local teams and managers to improve practice.
115. The protocol (Appendix D) for the conduct of CIRs is a good model derived from practical experience and, if implemented appropriately, should result in a thorough, open examination of the circumstances surrounding a particular episode.
116. A system of risk management, based on openness and the clear assumption of responsibility should not have to rely on "whistle blowing" by an individual concerned about a particular matter. A confidential system which allows a staff member with a concern about an episode or procedure to point to the issue can be valuable. There are obligations. The system breaks down if it is used to pursue grievances. It has to involve the staff member revealing a name. The people raising issues have to accept that their views may not prevail when balanced up against the risk management committee's perspective. Staff have the right to careful consideration of the issue, with a senior clinical manager, a member of the risk management committee, assessing issues and reporting regularly to it. Confidential means just that and a person using the system should be protected from retribution by others whose practice may be questioned as a result of the report. If trust in the system can be generated by how it is seen to operate, it allows the organisation to start to learn to do better. Only if the system is failing is an individual justified in following a route to outside agencies, such as the Mental Welfare Commission for Scotland.
117. The sub-group's remit was to cover mental health services. The first point in the Service Element section of the Framework covered the interface between primary and secondary health care, and social work. General practice has a major role to play in the provision of comprehensive mental health services. All members of the primary health care team, including receptionists, are involved. The continuing assessment of risk and its management is an ever present task. The existence of the Primary Care Trust with mental health services firmly embedded is an indication of the determination to move to a community focused service. The sub-group hopes that the points outlined above will be helpful to local healthcare co-operatives in working out and implementing management of risk policies. It will be for individual Primary Care Trusts to decide with their component co-operatives on whether there should be one risk management committee for the organisation, or several, one for each component. Because boundaries seem to make risk management more difficult, there is something to be said for having just one.