Clinical and corporate governance: delivering quality reliably

Clinical governance: delivering quality

Few, if any, of the world’s healthcare leaders would claim that their organizations are fully ‘in control.’ Even those widely acknowledged as shining examples of best practice admit that they have some way to go in understanding what drives outcomes, and how to measure quality and avoid harm to patients.

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“Compared to the average, we’re doing pretty well; we score on the top of most lists. But are we ‘in control’ yet? No. Are we where we want to be? No. But we’re on our way.” - Mike Harper, Executive Dean of Clinical Practice, Mayo Clinic, US

Mike Harper, Executive Dean of Clinical Practice of the US-based Mayo Clinic, explains: “Compared to the average, we’re doing pretty well; we score on the top of most lists. But are we ‘in control’ yet? No. Are we where we want to be? No. But we’re on our way. We score very high on all of these measures, yet we can do better.”

In a high-risk environment such as healthcare (and, indeed, in aviation, chemical processing and nuclear power), the aim is to become a ‘high reliability’ provider that is focused on consistently excellent outcomes along with prevention of failure. Such organizations align their leadership, core processes and measurement systems, with clear lines of accountability and a common mind-set from the ground floor to the boardroom.

The predominant culture within many providers is one of individual professional autonomy, where clinical excellence is the sole responsibility of doctors, and boards have little influence over quality. Consequently, processes are error-free only 80 percent of the time, outcomes are variable, and patients frequently suffer harm. And without formal monitoring of outcomes, such a state is either unknown or tolerated as the norm. Conversely, once safety and clinical excellence are given higher priority, and responsibility for quality shifts from individuals to multifunctional teams, outcomes improve dramatically and harm rates decline. High reliability organizations typically experience zero errors in more than 99.5 percent of care processes.

‘High reliability’ organizations

The definition of a high reliability organization extends beyond patient safety to encompass quality care – and ultimately value.

Four building blocks towards a ‘high reliability’ healthcare organization

Many healthcare providers lack even the basic building blocks of culture, responsibilities and accountability, process optimization and standardization, and measurement. As they progress to a state of high reliability, each of these blocks has to mature individually and become interdependent with the others, which is no small task, even for the more renowned organizations.

“We are moving towards a more fully integrated operating model, fighting the disintegrating pull of continuous specialization,” says Mayo Clinic’s Mike Harper.

These sentiments are echoed by Ralf Kuhlen, Chief Medical Officer of Helios Kliniken, a German hospital chain with an explicit, public focus on clinical excellence. “Much of this isn’t very sexy. It is the small stuff that matters the most, and it is sometimes hard to get everyone to focus on that.”

What distinguishes these providers is their willingness to push back the frontiers to integrate necessary changes encompassing the building blocks.

The four building blocks are:

  1. A culture devoted to quality: All the leaders involved in this report highlighted the importance of a quality-oriented culture, not just among leaders but throughout the organization.
  2. Responsibility and accountability: Without a clear vision of how to use measurements, even the best metrics are of little value.
  3. Optimizing and standardizing processes: With a higher level of scrutiny and double checks, processes become far more resilient.
  4. Measurement: Leading healthcare organizations measure quality relentlessly, with systematic reporting and monitoring, real-time feedback and regular benchmarking against peers and best practices.

The journey towards a ‘high reliability’ organization

Despite representing many of the world’s foremost healthcare organizations, none of the leaders interviewed for this paper were confident that their institutions had reached a state of high reliability, which entails a journey through four stages:

Phase 0

In this initial phase, care may be excellent but not consistently so, with no real board oversight over quality and a lack of control over clinical risks. Outcomes are not uniformly measured nor reported, and quality is not central to the culture. Responsibility for outcomes is poorly defined, with few protocols centered around patients.

Phase 1

Many providers in developed markets are at this stage, where safety and clinical excellence enters the agenda, along with a growing acknowledgment that progress is dependent upon systems rather than individuals. Measurement of outcomes is more common but not yet standard, and attention to quality is becoming more systematic, from the board down to the ground floor, with higher prevalence of (and adherence to) protocols and checklists, to improve outcomes.

Phase 2

Only the most advanced organizations have reached Phase 2, where key outcomes and their drivers are routinely measured and reported, and aligned with the board’s quality objectives. The culture is intolerant of breaking basic rules, yet also takes a blame-free, learning approach to errors. Individuals have clear responsibility for care paths, while departments handling parts of care also have their own measures, and monitor the impact of their performance upon overall patient outcomes.

Phase 3

Phase 3, ‘high reliability’ care, is achieved only in some instances, where the standards become so high that preventing failures becomes the leading drive. In healthcare, probably only high-risk environments like the OR, ICU and the ED require such a mind-set and corresponding ‘failsafe’ organization of the work.

Becoming a Phase 2 or even Phase 3 organization is a high ambition – but the public demands it, and the business case is clear for both those delivering and receiving or contracting the care. Becoming ‘in control’ of quality, we see time and time again, creates a much stronger grasp on expenditures as well. Ultimately, delivering high-quality care is why most providers and professionals stepped into the business in the first place.

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