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In the spotlight: Clinical Governance  

First published in The Business Time on 25 April 2014
Medical accidents in healthcare have made news headlines globally. Beyond complaints over poor service and long waiting times, medical mishaps are not uncommon.

Such adverse incidents – on both clinical and service fronts - have put the quality of patient care under the microscope. Many healthcare organisations all over the world, Singapore included, may still be using outdated and inadequate care delivery approaches.

A recent KPMG healthcare report about clinical governance based on interviews with C-level leaders of healthcare providers in countries such as the United States, the United Kingdom, Australia, India and Singapore indicates that medical accidents are a source of concern.

Indeed, the healthcare sector, especially at the leadership and regulatory levels, should continually explore how best to provide oversight and govern, as well as how to go about measuring and monitoring quality and safety.

Towards high reliability

High reliability is expected of industries such as civil aviation and nuclear power generation, where even one rare error can lead to catastrophic consequences.

In healthcare, where decisions can lead to outcome of patients' treatments, a premium is placed on medical professionals' autonomy (""doctor know best") and because every patient is different.

While risks are part and parcel of major procedures or operations, healthcare providers must take conscious effort to reduce such risks.

Rather, in a 'high reliability' healthcare organisation, excellence is planned. Outcomes are methodically measured and safety is an absolute priority. Quality is a thread running through the entire institution from the emergency room floor to the boardroom.

How exactly should healthcare providers be in control over clinical governance and build a highly reliable system? There are four areas they must consider:

  • methodical measurements of care outcomes
  • clinical outcome responsibility and accountability
  • standardised processes
  • creating a culture devoted to quality

Measuring care outcomes

Top organisations share an obsession with measurement. Without measurements, healthcare organisations will not be able to fully evaluate its work.

Measurements can be set up for a whole range of processes and outcomes including quality outcomes, prevention practices, re-admissions and patient satisfaction by way of compliments and complaints.

A reliable healthcare provider should have measurements embedded within its culture - the search for new, simpler and more effective ways to measure never ceases. They should also tap on rapidly evolving technologies to enhance the way they measure.

The Mayo Clinic in Minnesota, for example has developed a bank of care processes, which it mandates should be used at least 80 percent of the time, and this is measured.

These pathways or guidelines are agreed upon by experts and doctors, and then integrated into the day-to-day workflow. As these measures become increasingly automated and real-time, they can be fed to professionals, higher management tiers and even the board. Data is also fed back to the owners of clinical pathways to enable continuous improvement.

At Fortis Healthcare hospitals in India, measurement and tracking is very much integrated into everyday work. All acute myocardial infarction (AMI) cases are measured based on 30-day outcomes, one-year outcomes and revascularisation outcomes. For hip or knee replacement, outcomes are evaluated after one year.


Without a clear vision of how to use measurements however, even the best metrics are of little value.

While some hospitals have existing measurement protocols, they lack the discipline to consciously review and document their measurements, as well as take corrective actions to ensure that lapses do not recur.

To address this issue, medical professionals must lead and take accountability for clinical outcomes.

Existing outcome and reporting structures in hospitals should be enhanced further so that the board and regulators can better identify who is accountable.

As a starting point, patient pathways through a healthcare organisation should have identifiable owners and teams, pretty much the same way that units such as wards, intensive care and emergency have clear lines of responsibility.

When these owners are accountable for and measured by their performance, the organisation has a basis for continuous quality and cost improvement.

For Salford Royal Foundation Trust in the UK, an integrated provider of hospital, community and primary care, clinical governance mirrors financial governance. Risks are rated, and responsibility for monitoring and management allocated on the basis of the level of risk involved, with the most critical sitting with the board, then the chief executive and so on.

Standardised processes

In a 'high reliability' organisation, measurement, roles and culture are all aligned with standard pathways and operating procedures. Doing so reduces complexity and variation, improves cooperation and communication, and enhances quality.

Standardised processes are also necessary to ensure execution. Are outcomes of deliberation communicated effectively down the line? Are there conscious efforts to carry out recommended practices?

Even though every patient, condition and treatment needs customisation, many activities performed in the hospital can benefit from a higher level of scrutiny and double-checks. Processes can become far more resilient.

For example, front line professionals should be responsible for confirming that guidelines and individual orders are being followed, and have the capability and will to intervene should there be concerns that this is not happening.

At Intermountain Healthcare based in Utah, guidelines have been blended into the flow of clinical work and added to checklists, order sets and clinical flow sheets that are used by clinicians routinely to deliver care. Such ‘automated pathways’ ensure that guidelines are not forgotten, and standardised processes are being followed.

A culture devoted to quality

All the leaders interviewed for KPMG's clinical governance report highlighted the importance of a quality-oriented culture, not just among leaders but throughout the organisation.

The activities and habits discussed in this article are seen as intrinsic values rather than imposed obligations.

This manifests in: trust and respect for each other’s roles (especially between managers and professionals); a constructive approach to errors that does not seek to blame individuals; and a sense of belonging to a team coupled with a drive to excel and not accept complacency.

Building a culture tuned to quality takes time and calls for collective effort and common goals. Such a culture is also vital to a hospital’s reputation and the satisfaction levels of patients, their family and hospital staff.

Patients, governments and regulators across the world are demanding to know more about care delivery and quality. The need for strong system governance assuring quality and safety will only increase over time.

Leaders of healthcare organisations have a choice - act now to perhaps sleep easier, or ignore these demands at their own (and their patients') peril.

This article is contributed by Tan Wah Yeow, Head of Asia Pacific Healthcare Practice, KPMG in Singapore and Allan Yeo, Principal Advisor, Healthcare Practice, KPMG in Singapore. The views and opinions expressed herein are those of the authors and do not necessarily represent the views and opinions of KPMG in Singapore.