Clinical Governance and Risk Management

Clinical Governance and Risk Management have become increasingly important over the last decade in the various fields of nursing. The development of the concept of clinical governance will be discussed and how it can be facilitated into practice with relation to learning disabilities nursing. Clinical Governance was first introduced in the White Paper ‘The New NHS: Modern, dependable’ (DoH, 1997). Donaldson (1998) viewed clinical governance as the vehicle to achieve, locally, continuous improvements in clinical quality, which will aid the government’s agenda for modernisation of the NHS.

This modernisation includes improving services such as clinical audit, clinical effectiveness programmes and risk management. Donaldson was among many authors in 1998 that contribute to literature, which supported the need for clinical governance at a time when the standards and quality of healthcare provision were in decline. Risk management and assessment will be discussed in relation to learning disabilities to include disabled children in the child protection system. High quality risk assessments and risk management strategies are essential for children and adolescents with disabilities.

It will be shown that barriers faced in the assessment process often lead to disabled children being discriminated against in the child protection system. To understand the development of clinical governance, we must firstly gain knowledge of its origins. During the early 1990’s, government documents and a series of high profile medical disasters such as the National Health Service (NHS) failures in bone tumour diagnosis and in paediatric surgery in Bristol helped to bring quality improvement to the top of the White Paper agenda (Nicholls, S et al 2000).

The Patient’s Charter (1992) and The Citizen’s Charter (1993) are documents that drew the publics attention towards the quality and standards of care been delivered by the NHS. Both these charters gave rise to informing and empowering patients to the standard of care they found acceptable. Upon the deliver of these charters, healthcare professionals and the public became better informed and educated, thus demanded a higher quality of healthcare. The decline in the quality and standard of care by the NHS was now made public. The government had to act upon this.

As mentioned, the term clinical governance became prominent following the publication of the first White Paper report, in which the government set out its agenda for the modernisation of the NHS. Succeeding this a year later was a new White Paper report, A First Class Service – Quality in the new NHS (DoH, 1998) which defines clinical governance as ‘A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish’.

The evolution of clinical governance, promoted the various sectors of the NHS to embrace and define this new system to their specific field. Dewar (2000) suggests that the official definition has deliberately been left incomplete so that health professionals can define their own systems of clinical governance in their own way. An explosion of clinical governance definitions were circulated through the health sector in relation to specific fields such as, doctors, GPs, nurses, physiotherapists, pharmacists etc.

The Royal Collage of Nursing (1998) defines clinical governance as ‘a framework, which helps all clinicians including nurses to continuously improve quality and safeguard standards of care’. McSherry and Pearce (2007) argue that even though the majority of healthcare professionals welcomed the initial definition, individuals have interpreted, internalised and transferred the meaning of clinical governance to their specific profession.

The definitions supplied by the individual sectors, are in agreement that this is a framework, which pulls all the ranges of organisational departments together, and were individuals and organisations are accountable for clinical quality, service and patient safety. The Health Act (1999) gave chief executives of NHS trusts a statutory responsibility for clinical governance; they are accountable for the successful implementation. However, to achieve the daily high standards of care all staff must acknowledge and understand the components that support clinical governance into their practice.

Boden and Kelly (1999) view these components as Clinical audit, Clinical effectiveness, Clinical Risk management, Quality assurance and Organisational and staff development. Some of the components may or may not be new but they are now placed in an overall framework for quality and assurance. Each element mentioned, must be scrutinised to ensure it is serving both the patient and the organisation. McSherry and Pearce (2007a pg. 59) state that ‘to ensure that an organisation and staff deliver a high quality service, they need to have sound knowledge and well developed skills and competencies to perform their roles efficiently and effectively’.

To attain this, it is essential that each component is lead by a clinician who has respect and confidence in healthcare staff and has the ability to influence, guide and lead through change. Walshe (2000) recognise the growing number of research articles on clinical governance that identify the many challenges that organisations face in its implementation. The barriers affecting the implementing process originate from internal and external sources, which can affect the organisation, teams and individuals (McSherry and Pearce 2007b).

Key themes linked to the barriers affecting the implementation are culture, management, leadership, communication, education and training, knowledge and support (McSherry and Pearce 2007c pg 121). A study by Currie and Loftus-Hills (2002) found that clinicians were aware of the importance of creating a culture in which clinical governance could thrive but felt that they still exist in a blame culture, which seeks to address mistakes and apportion blame to individuals. Creating a culture that inhibits staff to voice their concerns or report when mistakes are made.

This culture that seeks to apportion blame only leads to secrecy, mistrust and a failure to report mistakes, which hinders staff development and learning. For clinical governance to be accepted and practiced with in healthcare, a shift in attitudes and culture is needed. T o achieve this Cullen et al (2000) states that we need to unlearn some old habits and develop some new ones in order to develop a new healthcare culture that works under the guidance of clinical governance. This new cultural will guide staff in reporting mistakes, without prejudice, to the appropriate staff member and reducing clinical risk through learning by mistakes.

Improving the patients experience in healthcare is seen as the central purpose of clinical governance. Roberts (2002) report that each year nearly 28,000 written complaints are made about aspects of clinical treatment in hospitals and the NHS pays out around ? 400 million in settlements of clinical negligence claims. As part of the government’s efforts to improve quality assurance and patient’s safety, the Department of Health (2000) published ‘An organisation with a memory’ which identified areas of healthcare practice that requires change.

Clinical governance and risk management are included in the contents, as they are part of the government’s current strategy for modernisation in the NHS. Risk management is a statutory duty to be carried out by every NHS and other health organisations. It has been defined as ‘ a means of reducing the risk of adverse events occurring in an organisation by systematically assessing, reviewing and then seeking ways to prevent their occurrence. Clinical Risk management takes place in a clinical setting’ (NHS Executive, 2001).

All healthcare professionals must ensure that risk management is a process for identifying the risks that have adverse effects on the quality, safety and effectiveness of service delivery. A risk management strategy provides the framework for assessing and evaluating those risks and takes positive action to eliminate or reduce them. Within a clinical healthcare setting the elimination of risk is paramount, however it will now be argued that the complete elimination of risk for people with a learning disability is not always preferable.

Many definitions of risk are negative and this often leads to the assumption that risks should be completely eliminated. Giddens (1998) argues that risk taking “is a core element in the creation of a dynamic economy and innovative society” (cited in Denney 2005 p. 11). From a more individualist perspective risk can be seen as an opportunity to learn about the implications of our decisions (Sellars 2002). This is particularly true for people with disabilities. Often people with disabilities are over-protected and consequently do not have opportunities for experimentation and learning (Sellars 2002a).

When a person with disabilities is empowered to take risks it can give them a sense of achievement and independence. Taking risks is part of leading a normal life and people with disabilities should be empowered to take risks. Risk in this context is positive. The complete elimination of risk would deny people the opportunity of personal development and learning from mistakes (Sellars 2002b). Therefore it is argued that the complete elimination of risk is undesirable. The Disability Discrimination Act was a key development for people with disabilities.

The Act was a major step forward in determining how statutory services should respond to the aspirations of disabled people (Russell 1996). The Local Authority as a service provider has responsibility for the discriminatory attitudes or omissions of its employees. Another key policy document was The Same as You, a review of services for people with learning disabilities. The publication of this document is to be applauded since it strengthened the view that people with disabilities should be empowered to lead a normal life. There is much emphasis on empowering people to take risks as it is recognised as part of leading a normal life.

Although there has been many improvements in the way in which society views disabled people there is still evidence that they discriminated against. This is clearly evident in the child protection system. There has been an overwhelming body of research conducted in the United States which highlights that children with disabilities are more vulnerable to abuse. A study by Sulivan and Knutson (2000) found disabled children were more likely to be abused and neglected than non-disabled children (cited in Miller 2003). They discovered that “disabled children are 3. times more likely to be neglected, 3. 8 times more likely to be physically abused, 3. 1 times more likely to be sexually abused and 3. 9 times more likely to be emotionally abused. Overall they found that 31% of disabled children had been abused compared to 9% among the non-disabled population” (Miller 2003a pg. 19). Therefore it has been well established in research from the United States that children with disabilities experience an increased risk of abuse. Research in the UK which explores the safeguarding and abuse of children with disabilities is limited (Millar 2003b).

The very fact that there has been little research in the UK seems very telling of the attitudes and cultural norms of British society. This seems to point out that disabled children are less worthy of being protected from abuse. Research literature can be divided into three main categories which indicate increased vulnerability factors for the disabled child. Miller (2003c pg. 20) describes these as: “attitudes and assumptions held by others, inadequacies in service provision and factors associated with the impairment”. Middleton (1996) argues that there is a widespread belief that children with disabilities are not subjected to abuse.

This can lead to a failure to report abuse. Poorly developed services can also increase a disabled child’s vulnerability to abuse (Miller 2003d). For example, disabled children are often taught to be compliant and when their behaviour is seen as non-compliant they are often subject to techniques which ensure compliance. Also, disabled children may not have access to support with communication (Miller 2003e). Lack of support services can leave children with disabilities and their families feeling isolated and Miller (2003f pg. 22) argues “isolation is widely recognised to be a factor for abuse”.

When a child does have access to services they may be more vulnerable to abuse simply because of the multitude of people in their lives (Middleton 1996a). Another concerning problems highlighted by Miller (2003g) is organisational and skills gaps between professionals who work with disabled children and those who work in the child protection system which creates barriers to effective child protection. Also when a disabled child is behaving in a way which may indicate unhappiness more often than not it is associated with the impairment rather than being taken as a sign of abuse (Middleton 1996b).

These factors create barriers in the assessment of risk for children with disabilities. Calder (2002) argues the DOH framework for assessment has changed the focus of assessment. It is based on an ecological approach and expects that assessments are grounded in evidence based practice. The practice guidance for this framework suggests that it has been designed to be inclusive of all children in need and states that it is the duty of social services to ensure that “every child is assessed in a way that recognises the child’s individuality and particular needs” (Department of Health 2000 pg. 73).

The assessment process will involve the systematic collection of information which results in the identification of risks, what they are, and the likelihood of their future occurrence, if there is a need for intervention and if so what that will be (Calder 2002a). Calder (2002b) argues that whilst this framework which was research driven is better than a framework which involves professional consensus he argues that it struggles to ‘embrace the diversity of practice situations’. Calder (2002c) argues that professionals must acknowledge that this framework is merely a tool and it can only aid professional judgement.

This appears to be particularly true when it is applied to the assessment of children with disabilities who face abuse. Some criticism can be applied to the use of this model of assessment in work with children with disabilities. One of the expectations of the assessment process is that it is grounded in evidence based practice (Calder 2002d). As previously mentioned research in relation to the abuse and safeguarding of children with disabilities is limited. This makes the expectation that assessments are grounded in evidence based research almost impossible to achieve.

Middleton (1996c) argues that there is a lack of confidence among disability specialists in the child protection system. Lack of familiarity with the child’s disability can often get in the way of social workers using their child protection expertise (Richardson & Edwards 2003). An adequate assessment will often require the social worker to work in collaboration with many different professionals and other significant people in the child’s life. It may also be important to gather information from a specialist on the child’s impairment (Richardson & Edwards 2003a).

Sufficient time will be required to complete a holistic assessment (Richardson & Edwards 2003b). However, Richardson and Edwards (2003c) argue the current child protection system does not allow for the additional time that may be required to complete a good assessment. Paul and Cawson (2002 pg. 270) argue “it is society’s response to disability that may lead to the increased abuse of disabled people”. This is evidenced in the belief that parents with disabled children are under more pressure than most parents and therefore abuse is seen as more excusable (Middleton 1996d).

Attitudes such as this could lead to reticence in challenging parents which will be detrimental to the risk assessment process. Another major problem in the assessment process is that disabled children are often in contact with many people and it may be difficult to identify the perpetrator (Richardson & Edwards 2003d). Richardson and Edwards (2003e pg. 39) argue “this should not inhibit action to safeguard a child although in our experience it often does”. Sobsey and Doe (1991) argue that disabled children have as much right as any body to experience a safe environment.

They argue that while any environment cannot be totally risk free steps can be taken to reduce risk and any failure on the part of the agency to implement risk management techniques is negligence. Considering the increased risk that children with disabilities face it is essential that risk assessment strategies are identified and implemented. Sobsey and Doe (1991a) identify a number of risk management strategies which could be implemented. For example, “people with disabilities should be taught to discriminate appropriate occasions for compliance and for assertiveness” (Sobsey & Doe 1991b pg. 41). Appropriate sex education is also essential. The belief of keeping sex a secret from people with disabilities is discriminatory. Sobsey and Doe (1991c) found that sexual offences against people with disabilities appear to be similar to other sex crimes. For example the offenders are predominantly male and victims are predominantly female. Sobsey and Doe (1991d) found that there was a similarity in relationships between offenders to victims. There was evidence of an underlying abuse of power (Sobsey & Doe 1991e).

They found that differences such as the increase of incidence were found to ‘exist as extremes on a continuum rather than fundamental differences’ (Sobsey & Doe 1991f pg. 251). Given that offences against disabled children appear to be similar to those against non-disabled children it would seem that developing risk management strategies would be similar. Risk management strategies for non-disabled children appear to have been well established. It follows then that these can be used with disabled children.

Services need to be developed in order to be inclusive of children with disabilities. Support for families and children with disabilities are essential. It will be helpful if “family assessment centres and other support services provide a service for families with disabled children as indeed they are required to do under the Disability Discrimination Act” (Richardson & Edwards 2003f pg. 42) Victims who cannot speak for themselves should be provided with assistance so that the risk of abuse may be decreased (Sobsey & Doe 1991g).

Most importantly our cultural beliefs that often devalue people with disabilities should be challenged and disregarded. It should be brought to the public attention that people with disabilities do add value to our society. Also where people have been subjected to abuse treatment programmes should be provided (Sobsey & Doe 1991h). This will be no easy task and there will be many challenges. In order to protect children increased collaboration between disability specialists and child protection specialists is also of the utmost importance.

Increased awareness of the abuse of disabled children and research will also be essential. The development of risk management strategies is recognition that abuse does occur and is a step forward in countering cultural attitudes towards children with disabilities. It is clear from research that disabled children are more vulnerable to abuse. Currently the child protection system appears to deny the abuse of disabled children. There are many barriers in assessing and managing risk but this does not mean that disabled children should not be provided with the same protection as non-disabled children.

Cultural attitudes need to be challenged and there needs to be recognition that disabled children are victims of abuse. Research about the abuse and safeguarding of disabled children should be conducted in the UK and risk management strategies should be developed. What will it take to get the abuse of disabled children onto the policy agenda, another public inquiry perhaps? Until it is recognised that disabled children are discriminated against in the child protection system there can be no hope of reducing their vulnerability. Word count 3, 186