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Background In Victoria, Australia, public hospitals are administered through a system of devolved governance. Overall, Victoria's public health system has a record of good performance when comparing measurable safety outcomes to the rest of Australia. However, in 2015 a cluster of preventable perinatal deaths were identified at a health service in Melbourne's outer fringes. Questions What were the factors that contributed to these preventable deaths, and what were the outcomes of the four key inquiries commissioned by the Victorian government after the identification of the cluster? What can be learnt by comparing this crisis in one Victorian health service to similar events at other health services in Australia and the United Kingdom? Methods This paper discusses the crisis at the Victorian health service and expands on the factors that contributed to the crisis, the inquiries, subsequent recommendations, and the response from the Victorian state government. Similarities between this case and others in Australia and the United Kingdom are discussed. Findings A common theme in the four inquiries into the crisis at the health service in Victoria was that inadequate clinical governance was a key factor that led to these events. As a result, a number of significant changes were implemented across the state to improve patient safety across all areas of health care. When comparing this Victorian crisis to similar events at other health services across the world, inadequate clinical governance consistently appears as a key contributing factor to poor clinical outcomes. Discussion All cases discussed had a delay in the identification of clusters of poor clinical outcomes. This was found to be a direct result of inadequate clinical governance structures at both a local and government level. Conclusion A robust clinical governance framework that is enacted at both the government and the health organisation level is essential to deliver high quality and safe patient care.

Enterprise imaging governance is an emerging need in health enterprises today. This white paper highlights the decision-making body, framework, and process for optimal enterprise imaging governance inclusive of five areas of focus: program governance, technology governance, information governance, clinical governance, and financial governance. It outlines relevant parallels and differences when forming or optimizing imaging governance as compared with other established broad horizontal governance groups, such as for the electronic health record. It is intended for CMIOs and health informatics leaders looking to grow and govern a program to optimally capture, store, index, distribute, view, exchange, and analyze the images of their enterprise.

Background With increasing workload and reducing length of stay, a robust system was needed to keep track of outstanding clinical jobs regarding patients whose early discharge was made possible by the on-site presence of senior decision makers. A paper based diary initially proved successful and results were presented as a (P) at the RCPCH annual conference 2015. However, this system did not keep up with demands and posed several clinical governance challenges. Therefore, a computerised network based system (PaedsTMS) was developed with help of employees of a multinational technology firm as a charity project. Aims To assess the effectiveness and quality of jobs recording and completion, before and after the introduction of PaedsTMS. Methods PaedsTMS was introduced in June 2017 after an initial audit of the existing paper based system. The project was led by a registrar under guidance of a consultant paediatrician. A team of champions from medical, nursing and clerical background was assembled. Team discussions were done on messaging apps. Training was accomplished face to face and by video tutorial on YouTube. PaedsTMS was run parallel to the existing system for two weeks. Two audits were completed after introduction of PaedsTMS in July and September 2017. We looked at the percentage of tasks added to PaedsTMS, percentage of tasks added with sufficient clinical information, percentage of outstanding tasks completed and percentage of tasks completed within due date. The results were compared with pre-PaedsTMS introduction audit. Results The re-audit showed significant improvements as depicted in table 1 below: Conclusion The computerised system has significantly increased the quality of clinical details recorded with jobs as well as their timely completion whilst providing a clear audit trail to satisfy clinical governance standards.

Background A portfolio of supporting information (SI) reflecting a doctor’s entire medical practice is now a central aspect of UK appraisal for revalidation. Medical revalidation, introduced in 2012, is an assessment of a doctor’s competence and passing results in a five yearly license to practice medicine. It assesses of a doctor’s professional development, workplace performance and reflection and aims to provide assurance that doctors are up-to-date and fit to practice. The dominant assessment mechanism is a portfolio. The content of the revalidation portfolio has been increasingly prescribed and the assessment of the SI is a fundamental aspect of the appraisal process which ultimately allows Responsible Officers (ROs) to make recommendations on revalidation. ROs, themselves doctors, were the first to undergo UK revalidation. This qualitative study explored the perceptions of ROs and their appraisers about the use of this portfolio of evidence in a summative revalidation appraisal. Methods 28 purposefully sampled London ROs were interviewed following their revalidation appraisal and 17 of their appraisers participated in focus groups and interviews. Thematic analysis was used to identify commonalities and differences of experience. Results SI was mostly easy to provide but there were challenges in gathering certain aspects. ROs did not understand in what quantities they should supply SI or what it should look like. Appraisers were concerned about making robust judgements based on the evidence supplied. A lack of reflection from the process of collating SI and preparing for appraisal was noted and learning came more from the appraisal interview itself. Conclusions More explicit guidance must be available to both appraisee and appraiser about what SI is required, how much, how it should be used and, how it will be assessed. The role of SI in professional learning and revalidation must be clarified and further empirical research is required to examine how best to use this evidence to make judgments as part of this type of appraisal.

Background Dashboards can support data-driven quality improvements in health care. They visualize data in ways intended to ease cognitive load and support data comprehension, but how they are best integrated into working practices needs further investigation. Objective This paper reports the findings of a realist evaluation of a web-based quality dashboard (QualDash) developed to support the use of national audit data in quality improvement. Methods QualDash was co-designed with data users and installed in 8 clinical services (3 pediatric intensive care units and 5 cardiology services) across 5 health care organizations (sites A-E) in England between July and December 2019. Champions were identified to support adoption. Data to evaluate QualDash were collected between July 2019 and August 2021 and consisted of 148.5 hours of observations including hospital wards and clinical governance meetings, log files that captured the extent of use of QualDash over 12 months, and a questionnaire designed to assess the dashboard’s perceived usefulness and ease of use. Guided by the principles of realist evaluation, data were analyzed to understand how, why, and in what circumstances QualDash supported the use of national audit data in quality improvement. Results The observations revealed that variation across sites in the amount and type of resources available to support data use, alongside staff interactions with QualDash, shaped its use and impact. Sites resourced with skilled audit support staff and established reporting systems (sites A and C) continued to use existing processes to report data. A number of constraints influenced use of QualDash in these sites including that some dashboard metrics were not configured in line with user expectations and staff were not fully aware how QualDash could be used to facilitate their work. In less well-resourced services, QualDash automated parts of their reporting process, streamlining the work of audit support staff (site B), and, in some cases, highlighted issues with data completeness that the service worked to address (site E). Questionnaire responses received from 23 participants indicated that QualDash was perceived as useful and easy to use despite its variable use in practice. Conclusions Web-based dashboards have the potential to support data-driven improvement, providing access to visualizations that can help users address key questions about care quality. Findings from this study point to ways in which dashboard design might be improved to optimize use and impact in different contexts; this includes using data meaningful to stakeholders in the co-design process and actively engaging staff knowledgeable about current data use and routines in the scrutiny of the dashboard metrics and functions. In addition, consideration should be given to the processes of data collection and upload that underpin the quality of the data visualized and consequently its potential to stimulate quality improvement. International Registered Report Identifier (IRRID) RR2-10.1136/bmjopen-2019-033208

Aims and methodTo establish whether a dementia intensive support (DIS) service that is part of a crisis resolution and home treatment team for older people is preventing admissions to acute hospital and psychiatric wards. The number of referrals in 2017 to the DIS service was established and those admitted to hospital ascertained. Senior doctors examined 30 sets of notes in detail and reached a conclusion on whether DIS had contributed to admission prevention. This information was then re-examined in two meetings with at least eight senior psychiatrists present. A consensus opinion was then reached as to whether DIS had contributed to admission prevention in each case.ResultsOver 12 months, 30/171 patients (18%) referred were admitted to hospital. For the subset of 30 referrals examined in detail, DIS contributed to admission avoidance in 21 cases (70%).Clinical implicationsOur evaluation demonstrates that the DIS service is an effective way of preventing admission.

Aims and methodTo compare and contrast the burden of comorbidity in a population receiving in-patient treatment for substance misuse with that of a cohort admitted to the same unit 4 years previously. The Charlson Comorbidity Index (CCI) was used to quantify patients' comorbidity and predict 10-year survival.ResultsThere was a marked reduction in predicted 10-year survival: in 2014, 22% of patients had a predicted 98% chance of 10-year survival, whereas only 2% in the 2018 cohort had a predicted 98% chance. Additionally, in 2014 only 9% of patients had a Clinical implicationsIn-patient substance misuse units are known to serve individuals with complex illnesses. With service funding cuts, subsequent bed reductions and increased waiting times, this complexity is increasing, with a considerably higher burden of comorbidity. The consequential increased mortality risk highlights the ongoing need for adequate community and in-patient services with integrated care of mental and physical health alongside social work.

Aims and methodTo describe the functions of the Aneurin Bevan University Health Board Risk Reference Panel and characterise the typical referrals presented and outcomes from the panel. A structured thematic analysis was performed on verbatim transcripts of 48 panel sessions.ResultsThe 79 codes identified were grouped into 16 subthemes. Four principal themes were identified: two characterising cases brought to the panel (childhood risk factors and current presenting difficulties) and two describing advice given (risk management and wider organisational issues). Quotations are given to illustrate cases presented and advice given by the panel.Clinical implicationsThe panel provides a valuable source of special expertise in the management of complex and exceptional cases where risk of harm is significant and clinical teams have ongoing concerns. This paper describes a model of peer-working to support staff and may further reduce the risk of harm associated with mental illness.Declaration of interestNone.

This paper gives a narrative account of how the Oxford Healthcare Improvement Centre has embedded continuous quality improvement (CQI) across both mental health and community services in Oxford, UK. The aim of the centre is to develop capability across healthcare services, with frontline staff leading CQI independently. The paper discusses the various methods employed to achieve this aim, including the provision of training, mentoring and support to those undertaking improvement work, alongside developing the required governance for CQI.

Introduction\ud Videofluoroscopy (VFSS) is a frequently used radiological investigation for dysphagia and is conducted within a radiology setting by speech and language therapists (SLTs) working alongside imaging personnel (radiologists and/or radiographers). Previous surveys of SLT practice have reported variability in VFSS protocols and procedures. The aim of this study was to explore current clinical practice for VFSS from the perspective of imaging personnel engaged in VFSS within the United Kingdom.\ud \ud Methods\ud A comprehensive online survey enabled exploration of current practices of imaging professionals. Target participants were diagnostic imaging personnel (radiographers and radiologists) with experience of working in VFSS clinics. Descriptive statistics describe and summarise the data alongside inferential statistics where appropriate.\ud \ud Results\ud 54 survey participants represented 40 unique acute healthcare organisations in the UK, in addition to two respondents from the Republic of Ireland. The survey demonstrated high variance in clinical practice across all stages of the VFSS procedure. Clinicians were not always compliant with current UK guidelines and the roles and responsibilities of different professionals working within the clinics were often not clearly defined.\ud \ud Conclusion\ud Further research is required to develop new international, interprofessional VFSS guidelines to standardise service delivery for VFSS, improving diagnostic accuracy, efficiency and patient experience.\ud \ud Implications for practice\ud In the absence of VFSS guidelines for imaging personnel, practitioners should familiarise themselves with the UK Royal College of Speech and Language Therapists VFSS Position paper; IR (ME)R guidelines and DRLs for the client groups with which they work to guide clinics and improve practice. Clinicians should revisit protocols and clinical governance regarding safe practice in order to improve the quality of care within the VFSS clinic.

The worldwide coronavirus pandemic has forced health services to adapt their delivery to protect the health of all concerned, and avoid service users facing severe disruption. Improving Access to Psychological Therapies (IAPT) services in particular are having to explore remote working methods to continue functioning. Australian IAPT services have utilised remote delivery methods and disruptive technologies at their core from inception. This was to maintain fidelity and clinical governance across vast distances but has allowed training, supervision and service delivery to continue virtually uninterrupted through coronavirus restrictions. On this basis, key recommendations for remote working are outlined. Remote methods are defined as (1) real time delivery, (2) independent delivery and (3) blended delivery. These are applied across three broad areas of remote training, remote clinical supervision and remote service delivery. Recommendations may be of great benefit to IAPT training institutions, clinical supervisors and service providers considering a move towards remote delivery. Challenges, adaptations and examples of applying remote methods are outlined, including case examples of methods applied to low-intensity and high-intensity cognitive behavioural therapy. Remote methods can safeguard service continuity in times of worldwide crisis and can contribute to reducing the impact of increased mental health presentations post-COVID-19. Key learning aims (1) To understand the core areas of remote training, clinical supervision and service delivery. (2) To review and distinguish between three broad methods of remote working. (3) To understand how to plan remote working via key recommendations and case examples.

Background Clinical governance of medical mobile apps is challenging, and there is currently no standard method for assessing the quality of such apps. In 2018, the National Institute for Health and Care Excellence (NICE) developed a framework for assessing the required level of evidence for digital health technologies (DHTs), as determined by their clinical function. The framework can potentially be used to assess mobile apps, which are a subset of DHTs. To be used reliably in this context, the framework must allow unambiguous classification of an app’s clinical function. Objective The objective of this study was to determine whether mobile health apps could be reliably classified using the NICE evidence standards framework for DHTs. Methods We manually extracted app titles, screenshots, and content descriptions for all apps listed on the National Health Service (NHS) Apps Library website on July 12, 2019; none of the apps were downloaded. Using this information, 2 mobile health (mHealth) researchers independently classified each app to one of the 4 functional tiers (ie, 1, 2, 3a, and 3b) described in the NICE digital technologies evaluation framework. Coders also answered contextual questions from the framework to identify whether apps were deemed to be higher risk. Agreement between coders was assessed using Cohen κ statistic. Results In total, we assessed 76 apps from the NHS Apps Library. There was classification agreement for 42 apps. Of these, 0 apps were unanimously classified into Tier 1; 24, into Tier 2; 15, into Tier 3a; and 3, into Tier 3b. There was disagreement between coders in 34/76 cases (45%); interrater agreement was poor (Cohen κ=0.32, 95% CI 0.16-0.47). Further investigation of disagreements highlighted 5 main explanatory themes: apps that did not correspond to any tier, apps that corresponded to multiple tiers, ambiguous tier descriptions, ambiguous app descriptions, and coder error. Conclusions The current iteration of the NICE evidence standards framework for DHTs did not allow mHealth researchers to consistently and unambiguously classify digital health mobile apps listed on the NHS app library according to their functional tier.

Introduction: Health care organizations are highly specialized and complex. Thus we may expect the adverse events will inevitably occur. Building a medical error reporting system to analyze the reported preventable adverse events and learn from their results can help to prevent the repeat of these events. The medical errors which were reported to the Clinical Governance’s office of Mazandaran University of Medical Sciences (MazUMS) in years 2011-2012 were analyzed. Methods and Materials: This is a descriptive retrospective study in which 18 public hospitals were participated. The instrument of data collection was checklist that was designed by the Ministry of Health of Iran. Variables were type of hospital, unit of hospital, season, severity of event and type of error. The data were analyzed with SPSS software. Results: Of 317966 admissions 182 cases, about 0.06%, medical error reported of which most of the reports (%51.6) were from non- teaching hospitals. Among various units of hospital, the highest frequency of medical error was related to surgical unit (%42.3). The frequency of medical error according to the type of error was also evaluated of which the highest frequency was related to inappropriate and no care (totally 37%) and medication error 28%. We also analyzed the data with respect to the effect of the error on a patient of which the highest frequency was related to minor effect (44. 5%). Conclusion: The results showed that a wide variety of errors. Encourage and revision of the reporting process will be result to know more data for prevention of them.

Effective handover between shifts is vital to protect patient safety and assist doctors with clinical governance. Poor quality, or inadequate handover can lead to serious harm for both patients and doctors. The weekend medical handover system among junior doctors at Tunbridge Wells Hospital in Pembury, UK was cumbersome, inadequate and poor, restricting the ability to provide good patient care. 78.6% of doctors felt that the introduction of an electronic weekend handover system would address the issues in order to improve communication between the medical teams and thus improve patient care. A five week trial of an excel based electronic weekend handover system was conducted. 87.5% of the doctors surveyed felt that the new electronic weekend handover was better or significantly better than the old paper based handover system. The effectiveness rating of the weekend medical handover, with 1 (least effective) - 10 (most effective), rose from 6.14 to 7.31 after introduction of the electronic weekend medical handover system. As a result, this project has become part of the junior doctors medical induction, ensuring permanence of electronic weekend medical handover. This project takes a step towards improved patient safety as well improving the working conditions for junior doctors in a busy acute medical unit. There is always a need to refine and optimise systems and though this project is not perfect, it is a step toward electronic handover that is available now and free of cost.

Clinical governance was the centrepiece of an NHS white paper introduced soon after the Labour government came into office in the late 1990s.1 The white paper provides the framework to support local NHS organisations as they implement the statutory duty of quality, which was placed on them through the 1990 NHS act.2 Clinical governance provides the opportunity to understand and learn to develop the fundamental components required to facilitate the delivery of quality care—a no blame, questioning, learning culture, excellent leadership, and an ethos where staff are valued and supported as they form partnerships with patients. These elements have perhaps previously been regarded as too intangible to take seriously or attempt to improve. Clinical governance demands the re-examination of traditional roles and boundaries—between health professions, between doctor and patient, and between managers and clinicians—and provides the means to show the public that the NHS will not tolerate less than best practice. In 1998 Scally and Donaldson set out the vision of clinical governance: “A framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.”3 In this paper we take the story forward. Two years on, how is clinical governance faring in the NHS, and, with the advent of the national plan for the NHS,4 how is it being developed in practical terms? #### Summary points Clinical governance represents the systematic joining up of initiatives to improve quality Since the introduction of governance in the NHS, structures have been put in place to set standards and ensure that they are met New approaches are needed to leadership, strategic planning, patient involvement, and management of staff and processes The NHS Clinical Governance Support Team is providing task based …

standards are met, and that processes are in place to ensure continuous improvement in clinical practice within trusts. This concept, although currently loosely defined, is to be backed up by a new statutory duty for quality within the National Health Service (NHS). The arrangements are such that chief executives will carry ultimate responsibility for assuring the quality of services provided by trusts and will be accountable officers, much in the same way that they are accountable officers for the proper use of resources. The White Paper suggests that "Chief Executives will be expected to ensure

The government document A First Class Service – Quality in the New NHS (Department of Health, 1998) stated that one of the key strategies for achieving quality was the introduction of clinical governance, and as Scott noted (above) this would require a fundamental change in culture. Sadly, while there has been a significant change in culture it has had little to do with quality, as recent media coverage in the South of England, and numerous anecdotes testify. It is important to remember, when despairing over such displays of the most blatant abrogation of standards, that there are people doing fine work in the NHS, but it is also important to scrutinise carefully that which has put management and nursing in a very bad light, and to consider how this might have been avoided. What are the lessons to be learned? One wonders why qualified nurses with an accountability to both their profession and to the State struggle on when conditions for patients are so appalling? A misguided notion of not letting people down? A fear of whistle-blowing? Whatever the reasons – and no doubt they are as varied as the staff involved – the highly exposed weakness of nursing need to be examined. It is highly relevant to note that in the recent White Paper (Secretary of State for Health, 2007) proposals are made to strengthen continuing professional development, amongst other measures aimed at improving performance in general, as well as eliminating poor performance more effectively than in the past.These proposals must be welcomed and concur with the views of Scott (1999: 173) who stated that for clinical governance to be successful

In the short months following the result of the UK 2010 General election,\ud a new Government White Paper has been released entitled: Equity and\ud Excellence: Liberating the NHS (Department of Health (DH), 2010a). It strives\ud to distance itself from previous health-care proposals (DH, 2009), yet if the\ud initiatives of this latest paper are combined against previous initiatives,\ud also using high impact declarative terms, such as competition and choice,\ud it is clear that little has changed and more important principles than saving\ud money are at risk.

Objective: The purpose of this study was investigating situation and presenting a conceptual model for clinical governance information system by using UML in two sample hospitals. Background: However, use of information is one of the fundamental components of clinical governance; but unfortunately, it does not pay much attention to information management. Material and Methods: A cross sectional study was conducted in October 2012- May 2013. Data were gathered through questionnaires and interviews in two sample hospitals. Face and content validity of the questionnaire has been confirmed by experts. Data were collected from a pilot hospital and reforms were carried out and Final questionnaire was prepared. Data were analyzed by descriptive statistics and SPSS 16 software. Results: With the scenario derived from questionnaires, UML diagrams are presented by using Rational Rose 7 software. The results showed that 32.14 percent Indicators of the hospitals were calculated. Database was not designed and 100 percent of the hospital’s clinical governance was required to create a database. Conclusion: Clinical governance unit of hospitals to perform its mission, do not have access to all the needed indicators. Defining of Processes and drawing of models and creating of database are essential for designing of information systems.

Objectives—To describe the use, perceived eVectiveness, and predicted future use of organisational strategies for influencing clinicians’ behaviour in the approach of NHS trusts to clinical governance, and to ascertain the perceived benefits of clinical governance and the barriers to change. Design and setting—Whole population postal survey conducted between March and June 1999. Subjects—Clinical governance leads of 86 NHS trusts across the South West and West Midlands regions. Method—A combination of open questions to assess the use of strategies to influence clinician behaviour and the barriers to clinical governance. Closed (yes/ no) and Likert type ratings were used to assess the use, perceived eVectiveness, and future use of 13 strategies and the predicted outcomes of clinical governance. Results—All trusts use one or more of 13 strategies categorised as educational, facilitative, performance management, and organisational change methods. Most popular were educational programmes (96%) and protocols and guidelines (97%). The least popular was performance management such as use of financial incentives (29%). Examples of successful existing practice to date showed a preference for initiatives that described the use of protocols and guidelines, and use of benchmarking data. Strategies most frequently rated as eVective were facilitative methods such as the facilitation of best practice in clinical teams (79%), the use of pilot projects (73%), and protocols and guidelines (52%). The least often cited as eVective were educational programmes (42%) and training clinicians in information management (20%); 8% found none of the 13 strategies to be eVective. Predicted future use showed that all the trusts which completed this section intended to use at least one of the 13 strategies. The most popular strategies were educational and facilitative. Scatterplots show that there is a consistent relationship between use and planned future use. This was less apparent for the relationship between planned use and perceived eVectiveness. Barriers to change included lack of resources, mainly of money and staV time, and the need to address cultural issues, plus infrastructure support. The anticipated outcomes of clinical governance show that most trusts expect to influence clinician behaviour by improving patient outcomes (78%), but only 53% expect it to result in better use of resources, improved patient satisfaction (36%), and reduced complaints (10%). Conclusions—Clinical governance leads of trusts report using a range of strategies for influencing clinician behaviour and plan to use a similar range in the future. The choice of methods seems to be related to past experience of local use, despite equivocal judgements of their perceived eVectiveness in the trusts. Most expect to achieve a positive impact on patient outcomes as a result. It is concluded that trusts should establish methods of learning what strategies are eVective from their own data and from external comparison. (Quality in Health Care 2001;10:76‐82)

N Barber, professor of the practice of pharmacy M Schachter, senior lecturer and honorary consultant physician Objective—To develop a practitioner led definition of a prescribing error for use in quantitative studies of their incidence. Design—Two stage Delphi technique. Subjects—A panel of 34 UK judges, which included physicians, surgeons, pharmacists, nurses and risk managers. Main outcome measures—The extent to which judges agreed with a general definition of a prescribing error, and the extent to which they agreed that each of 42 scenarios represented a prescribing error. Results—Responses were obtained from 30 (88%) of 34 judges in the first Delphi round, and from 26 (87%) of 30 in the second round. The general definition of a prescribing error was accepted. The panel reached consensus that 24 of the 42 scenarios should be included as prescribing errors and that five should be excluded. In general, transcription errors, failure to communicate essential information, and the use of drugs or doses inappropriate for the individual patient were considered prescribing errors; deviations from policies or guidelines were not. Conclusions—Health care professionals are in broad agreement about the types of events that should be included and excluded as prescribing errors. A general definition of a prescribing error has been developed, together with more detailed guidance regarding the types of events that should be included. This definition allows the comparison of prescribing error rates among different prescribing systems and different hospitals, and is suitable for use in both research and clinical governance initiatives. (Quality in Health Care 2000;9:232–237) Key Words: prescribing errors; medication errors; definition of error

EDITOR—With these words, we were introduced to the idea of clinical governance: “A commitment to deliver high quality care should be at the heart of everyday clinical practice. In the past many health professionals have watched as board agendas and management meetings have become dominated by financial issues and activity targets. The government's white paper on the NHS in …

Background The detection, assessment, and management of primary care poor performance raise difficult issues for all those involved. Guidance has largely focused on managing the most serious cases where patient safety is severely compromised. The management of primary care poor performance has become an increasingly important part of primary care trust (PCT) work, but its modes of presentation and prevalence are not well known. Aim To report the prevalence, presentation modes, and management of primary care poor performance cases presenting to one PCT over a 5-year period. Design of study A retrospective review of primary care poor performance cases in one district. Setting St Helens PCT administered 35 practices with 130 GPs on the performers list, caring for 190 110 patients in North West England, UK. Method Cases presenting during 2002–2007 were initially reviewed by the chair of the PCT clinical executive committee. Anonymised data were then jointly reviewed by the assessor and another experienced GP advisor. Results There were 102 individual presentations (20 per year or one every 2–3 weeks) where clinician performance raised significant cause for concern occurred over the 5-year period. These concerns related to 37 individual clinicians, a range of 1–14 per clinician (mean 2.7). Whistleblowing by professional colleagues on 43 occasions was the most common presentation, of which 26 were from GPs about GPs. Patient complaints (18) were the second most common presentation. Twenty-seven clinicians were GPs, of whom the General Medical Council (GMC) were notified or involved in 13 cases. Clinicians were supported locally, and remedying was exclusively locally managed in 14 cases, and shared with an external organisation (such as the GMC or deanery) in another 12. Conclusion Professional whistleblowing and patient complaints were the most common sources of presentation. Effective PCT teams are needed to manage clinicians whose performance gives cause for concern. Sufficient resources and both formal and informal ways of reporting concerns are essential.

“The Mental Health Act Commission (MHAC) has a major role in protecting the interests of patientswho are subject to the provisions of the 1983 Act. Its principal functions are to:• appoint Second Opinion Appointed Doctors• review treatments given under sections 57(2) or 58(3)(b) of the Act, ie treatment that requires a second opinion• visit detained patients and investigate complaints• keep under review the exercise of statutory powers relating to detained patients• submit proposals for a code of practice• look into matters relating to informal patients, when directed to do so by the Secretary of State,and• report to the Secretary of State every two years on the operation of the Act.”This is the summary of the functions of the MHAC contained in the Green Paper on Reform of the Mental Health Act 1983. In this brave new world of the Modern NHS, with much enhanced arrangements for local quality assurance and clinical governance, the Commission for Health Improvement, the Commission for Care Standards, the National Institute for Clinical Excellence, the establishment of Patient Advocate and Liaison Services, and the numerous other ways of increasing patient participation which are outlined in the National Plan for England, is a successor body to the Mental Health Act Commission really necessary ?

Editorial by James Papers p 1330 Clinical governance requires evidence based standards of clinical relevance to assess performance. The recommended interval between the decision to perform an “emergency” caesarean section and the procedure is 30 minutes 1 2 but there is little objective evidence to support this recommendation. We conducted a prospective 12 month study in a large consultant obstetric teaching unit to examine whether the time between the decision to perform a caesarean section to actual delivery affects the success of the delivery. Time intervals between a decision to deliver and actual delivery were collected prospectively for all caesarean sections from 1 January 1996 to 31 December 1996. Clinical staff were not aware of the audit since by April 1995 all staff had been required to record these times with the guidelines expecting all deliveries within 30 minutes. Caesarean sections were classified as emergency (decision made during labour because of evolving fetal distress, failing …

The management of corticosteroid-induced osteoporosis in rheumatology outpatients in the West Midlands was audited in relation to the 2002 Royal College of Physicians (RCP) Guidelines and re-audited in relation to the 1998 National Osteoporosis Society (NOS) Guidance. Practice was assessed from prospective data on all follow-up patients over a 2-week period in 13 rheumatology units. Data were analysed on 2,609 patients. Of the 626 patients fulfilling criteria for assessment against the RCP Guidelines, 351 (56.1%) were treated appropriately. The results do not allow for availability of, or wait for, DEXA scanning. Of 197 patients fulfilling the criteria for assessment against the NOS Guidance, 137 (69.5%) were treated appropriately, compared to 63% in a similar audit undertaken in 2000. Regional audit may facilitate clinical governance. These audits will inform discussion on both improving local practice and strengthening cases for improved osteoporosis services.

The very notion of academic general practice is problematic for some—conjuring up images of ivory towers, and GPs working in sheltered environments, protected from the demands of ‘real’ or ‘front-line’ practice. The academic section of any discipline is marked out by its responsibilities for its ‘futures’ component, i.e. education and research for future practice. Academic general practice is still a relatively new discipline. Its role is to support the development of general practice and primary care through the education and training of medical undergraduates, GPs and primary care staff, and through research activities that will contribute to the evidence base for health care in the community. It works in partnership with networks of teaching and research active practices, and has a multi-professional approach illustrated by the variety of disciplines currently working within academic departments of general practice. These include doctors, nurses, managers, social scientists, anthropologists, statisticians, psychologists and others. 1,2 While departments within Universities must account for their existence by satisfactory contributions to research and teaching, the base of academic general practice needs to be broader than this. As we enter the Millennium, general practice and primary care are facing some of the most radical organizational changes that have been encountered in the lifetime of the NHS. The associated political and service pressures place new demands and responsibilities on individual professionals, related health care organizations and the academic world that assists them. The aspirations of Government for the development of primary care, as set out in the White Paper The New NHS, Modern, Dependable 3 and in the Department of Health’s publication A First Class Service: Quality in the New NHS, 4 place particular emphasis on clinical effectiveness, clinical governance and the application of evidencebased medicine. The evidence base underpinning this hive of activity and decision making is inadequate, as is the current capacity of primary care to generate it. The 1997 Report of an Independent Task Force on Clinical Academic Careers stated

PurposeThe paper examines interviewee insights into accountability for clinical governance in high-consequence, life-and-death hospital settings. The analysis draws on the distinction between formal “imposed accountability” and front-line “felt accountability”. From these insights, the paper introduces an emergent concept, “grounded accountability”.Design/methodology/approachInterviews are conducted with 41 clinicians, managers and governors in two large academic hospitals. The authors ask interviewees to recall a critical clinical incident as a focus for elucidating their experiences of and observation on the practice of accountability.FindingsAccountability emerges from the front-line, on-the-ground. Together, clinicians, managers and governors co-construct accountability. Less attention is paid to cost, blame, legal processes or personal reputation. Money and other accountability assumptions in business do not always apply in a hospital setting.Originality/valueThe authors propose the concept of co-constructed “grounded accountability” comprising interrelationships between the concept’s three constituent themes of front-line staff’s felt accountability, along with grounded engagement by managers/governors, supported by a culture of openness.

Objectives—To test the feasibility of deriving comparative indicators in all the practices within a primary care group. Design—A retrospective audit using practice computer systems and random note review. Setting—A primary care group in southern England. Subjects—All 18 general practices in a primary care group. Main outcome measures—Twenty six evidence-based process indicators including aspirin therapy in high risk patients, detection and control of hypertension, smoking cessation advice, treatment of heart failure, raised cholesterol levels in those with established cardiovascular disease, and the treatment of atrial fibrillation. Feasibility was tested by examining whether it was possible to derive these indicators in all the practices; the problems and constraints incurred when collecting data; the variations in indicator values between practices in both their identification of diseases and in the uptake of various interventions; the possible reasons for these variations; and the cost of generating such indicators. Results—It was possible to derive eight indicators in all practices and in three practices all 26 indicators. The median number of indicators derived was 12 with two practices able to generate eight. There was considerable variation in the use of computers between practices and in the ability and ease of various practice computer systems to generate indicators. Practices varied greatly in the identification of diseases and in the uptake of eVective interventions. Variation in identification of ischaemic heart disease could not be explained by a higher prevalence in practices with a more deprived population. The cost of generating these indicators was £5300. Conclusion—Comparative evidencebased indicators, used as part of clinical governance in primary care groups, could have the potential to turn evidence into everyday practice, to improve the quality of patient care, and to have an impact on the population’s health. However, to derive such indicators and to be able to make meaningful comparisons primary care groups need greater conformity and compatibility of computer systems, improved computer skills for practice staV, and appropriate funding. (Quality in Health Care 2000;9:90‐97)

Objectives—To categorise senior health professionals’ experience with poor medical practice in hospitals and in general practice, to describe perceptions which senior NHS staV have of good medical practice, and to describe how problems of poor medical practice are currently managed. Design—A postal questionnaire survey. The questionnaire sought perceptions of good medical practice, asked participants to characterise deviations from good practice, and to describe experience with managing poor performance at the time of the introduction of the General Medical Council (GMC) performance procedures. Setting—A range of NHS settings in the UK: hospital trusts, health authorities/ boards, local medical committees, community health councils. Subjects—Senior health professionals involved in the management of medical professional performance. Main measures—Perceptions of what constitutes good medical practice. Results—Most respondents considered that persistent problems related to clinical practice (diagnosis, management, and outcome and prescribing) would require local management and, possibly, referral to the GMC performance procedures. Informal mechanisms, including informal discussion, education, training, and work shifting, were the most usual means of handling a doctor whose performance was poor. Many took a less serious view of deficiencies in performance on manner and attitude and communication, although consultation skills rather than technical skills comprised the greatest number of complaints about doctors. Conclusions—Senior NHS professionals seem reluctant to consider persistently poor consultation skills in the same critical light as they do persistently poor technical practice. These attitudes may need to change with the implementation of clinical governance and updated guidance from the GMC on what constitutes good medical practice. (Quality in Health Care 1999;8:213‐218)

Aims—To identify a model to assess general practitioner use of pathology services that could be applied to assess specific interventions designed to promote best practice. Methods—A database containing standardised requesting data for 22 general practices was constructed. The database contained 28 tests covering 95% of general practitioner activity, distributed across pathology, and it was evaluated during two sequential six month periods. A comparison of ranks of requesting activity between different time periods was undertaken by calculating Pearson rank correlation coefficients. Requesting numbers were also adjusted for patients' age and sex distributions within the 22 practices for a sample of three high volume tests. The effects of distributing requesting guidelines and details of requesting activity were assessed during two sequential three month periods. Results—Requesting activity was extremely stable during the two baseline periods for most tests (r > 0.80 for 20 of the 28 tests). Several less discriminatory tests were identified. Age and sex adjustment had minimal impact on the ranks of requesting activity. Requesting activity during the two three month periods after distributing guidelines and comparative details of individual requesting activity showed little change (overall correlation coefficient, 0.844 between baseline and intervention periods). Conclusion—Ranking general practitioners requesting activity adjusted for practice list size provides a reproducible means of measuring requesting activity for most pathology tests performed in general practice. Activity was not influenced by age or sex of patients on the practice list. Distributing requesting guidelines and individual requesting activity on their own do not have any measurable impact on requesting activity. More innovative (possibly multiple) interventions might be required to influence general practitioner requesting practice. Key Words: benchmarking • appropriateness • clinical governance

Clinical governance has been introduced as a new approach to quality improvement in the UK national health service. This article maps clinical governance against a discussion of the four main approaches to measuring and improving quality of care: quality assessment, quality assurance, clinical audit, and quality improvement (including continuous quality improvement). Quality assessment underpins each approach. Whereas clinical audit has, in general, been professionally led, managers have driven quality improvement initiatives. Quality assurance approaches have been perceived to be externally driven by managers or to involve professional inspection. It is discussed how clinical governance seeks to bridge these approaches. Clinical governance allows clinicians in the UK to lead a comprehensive strategy to improve quality within provider organisations, although with an expectation of greatly increased external accountability. Clinical governance aims to bring together managerial, organisational, and clinical approaches to improving quality of care. If successful, it will define a new type of professionalism for the next century. Failure by the professions to seize the opportunity is likely to result in increasingly detailed external control of clinical activity in the UK, as has occurred in some other countries.

When representatives from 10 British hospital trusts met last September to tackle the issue of why clinical audit has failed to bring about change, the NHS white paper and the term “clinical governance” had not been born. It is now clear, however, that the Action on Clinical Audit project, which brought these trusts together, was conceived in the same camp—and with the same aim, to improve clinical services. Action on Clinical Audit is a two year project, funded by the NHS Executive, that is devised to unravel the complex relationships that seem to render audit unworkable.* On paper, clinical audit takes the form of a neat cycle of events, leading to harmonious improvement in the activity under scrutiny.1 In the gritty world of doctors, patients, and managers, the cycle can all too easily lose its shape, stop short, or simply vanish. The promised improvement never materialises. The founders of …

Bruce mentions the climate of fear and the culture of defensive practice created by increasing regulation of doctors.1 The government white paper on which his editorial is based recognises that there has been managerial over-reaction in NHS trusts.2 It also concedes that more should be done to ensure clinical …

Objective To identify and summarize the current internal governance processes adopted by hospitals, as reported in the literature, for selecting, optimizing, and evaluating clinical decision support (CDS) alerts in order to identify effective approaches. Materials and methods Databases (Medline, Embase, CINAHL, Scopus, Web of Science, IEEE Xplore Digital Library, CADTH, and WorldCat) were searched to identify relevant papers published from January 2010 to April 2020. All paper types published in English that reported governance processes for selecting and/or optimizing CDS alerts in hospitals were included. Results Eight papers were included in the review. Seven papers focused specifically on medication-related CDS alerts. All papers described the use of a multidisciplinary committee to optimize alerts. Other strategies included the use of clinician feedback, alert data, literature and drug references, and a visual dashboard. Six of the 8 papers reported evaluations of their CDS alert modifications following the adoption of optimization strategies, and of these, 5 reported a reduction in alert rate. Conclusions A multidisciplinary committee, often in combination with other approaches, was the most frequent strategy reported by hospitals to optimize their CDS alerts. Due to the limited number of published processes, variation in system changes, and evaluation results, we were unable to compare the effectiveness of different strategies, although employing multiple strategies appears to be an effective approach for reducing CDS alert numbers. We recommend hospitals report on descriptions and evaluations of governance processes to enable identification of effective strategies for optimization of CDS alerts in hospitals.

Good medication adherence is directly proportional to good health recovery and general improvement of a patient’s health condition. Although many good medication adherence monitoring methods/techniques exist, the level of medication adherence for some chronic diseases by patients in rural settings is still suboptimal. Hence, the need for healthcare organisations to devise viable governance frameworks that will facilitate effective medication adherence monitoring and improved adherence by patients. This paper presents the conceptual overview of a governance framework for medication adherence monitoring and improvement that enables the collaboration of multiple stakeholders and data analytics (MUCODAF) in support of the patient in the treatment journey. The framework allows relevant stakeholders such as Healthcare workers (HCW), family members, and close friends to collaborate in support of a patient through the engagement of critical human factors such as empathy, motivation, encouragement, flexibility, and negotiation. The use cases of the framework, its technical composition, and the implementation plan are discussed in this paper. A concrete example of the application of the governance framework for medication adherence monitoring and improvement for a Tuberculosis patient in the African Country of Lesotho is presented to highlight the plausibility of the framework.

The current purchaser efficiency index has resulted in perverse incentives and a distortion of clinical priorities.1 In the name of increased efficiency, cost saving measures have been rewarded while few attempts have been made to assess the quality of care provided. When attempts have been made, variation has often been shown in the quality of care delivered and the outcomes achieved by different providers. In a significant and welcome change from the previous administration, the new government recognises these problems and proposes several measures to deal with them—at every level of the NHS. At the centre, a National Institute of Clinical Excellence will promote clinical and cost effective care by producing research based guidelines. National service frameworks will also set out the patterns and levels of service which should be provided for major …

BackgroundThere are few examples of the practical application of the concepts of social accountability, as defined by the World Bank and WHO, to health system change. This paper describes a robust approach led by First Nations Health Authority and the Rural Coordination Centre of British Columbia. This was achieved using partnerships in British Columbia, Canada, where the health system features inequities in service and outcomes for rural and Indigenous populations. Social accountability is achieved when all stakeholders come together simultaneously as partners and agree on a path forward. This approach has enabled socially accountable healthcare, effecting change in the healthcare system by addressing the needs of the population.InnovationOur innovative approach uses social accountability engagement to counteract persistent health inequities. This involves an adaptation of the Boelen Health Partnership model (policymakers, health administrators, health professionals, academics and community members) extended by addition of linked sectors (eg, industry and not-for-profits) to the ‘Partnership Pentagram Plus’. We used appreciative inquiry and deliberative dialogue focused on the rural scale and integrating Indigenous ways of knowing along with western scientific traditions (‘two-eyed seeing’). Using this approach, partners are brought together to identify common interests and direction as a learning community. Equitable engagement and provision of space as ‘peers’ and ‘partners’ were key to this process. Groups with varying perspectives came together to create solutions, building on existing strengths and new collaborative approaches to address specific issues in the community and health services delivery. A resulting provincial table reflecting the Pentagram Plus model has fostered policies and practices over the last 3 years that have resulted in meaningful collaborations for health service change.ConclusionThis paper presents the application of the ‘Partnership Pentagram Plus’ approach and uses appreciative inquiry and deliberative dialogue to bring about practical and positive change to rural and Indigenous communities.

In one of the numerous documents I have received on the NHS white paper for England I read the following: “Clinical governance encompasses all the processes needed to achieve the highest quality clinical practice possible within available resources.” The last subordinate clause of that sentence is a killer and holds within it the reason this initiative may well be stillborn. In order to achieve the “highest quality of clinical practice” I need certain things. I need good quality information. l want this from a source I trust and respect. It should be easy to assimilate and have realistic goals. It also needs to address a commonly encountered clinical scenario. Local sources are best, preferably from someone occupying a similar post in a similar hospital to my own. I will look with the utmost cynicism on poorly written reports or recommendations handed down from ivory towers concerning diseases I hardly knew existed. Does anyone know whether this good quality information exists? In obstetrics and gynaecology it is quite hard to find data of sufficiently high quality to help …

The election of a Labour government under Tony Blair in 1997 brought to an end 18 years of Conservative government under Margaret Thatcher and John Major and appeared to offer the prospect of a return to quieter times for the NHS. In practice, this was not to be as the Blair government developed its own policies for the modernisation of the NHS and in the process published proposals which were just as radical as those contained in Working for Patients. These proposals centred on what ministers described as a ‘third way’ of reform, different from both the internal market of the Thatcher government and the application of centralised planning by previous Labour governments. The aim of this chapter is to analyse this third way and to explore variations in its application to different parts of the United Kingdom at a time when the devolution of power opened up increasing differences of approach between England, Northern Ireland, Scotland and Wales.

Purpose Governance of healthcare organisations and health systems requires many different competencies, with a great emphasis on evidence and information governance, which are traditional fields of librarians’ expertise. However, stakeholders are unaware of how health and hospital libraries are contributing with specific activities and what are the trends in library support for health/clinical governance in Europe, mainly because traditional methods of measuring impact are restricted to specific library activities or are not showing direct impact long term. The paper aims to discuss these issues. Design/methodology/approach A model combining components of clinical and health governance (C/HG), related library activity types, and the possible impact was developed based on a literature review and tested by a European expert panel. A web-based survey was offered to the members of the European Association for Health Information and Libraries (EAHIL) to offer further insight into activities and examples of contribution to C/HG. Findings Librarians from 25 European countries participated in the survey. The model proves that librarians in Europe are involved in supporting most identified components of C/HG, with examples of clinical effectiveness and research, education and training, patient and public involvement, partnership engagement, formulating strategic direction, etc. Research limitations/implications The authors were unable to cover the roles of libraries in all European countries in this paper, but dialogue and research will continue within the EAHIL group. Originality/value No such comparative research has been undertaken before, looking at what activities and tasks libraries undertake to support C/HG. This research has highlighted valuable services and tools that can be replicated in libraries across health care organisations and at the same time promote libraries and librarians as significant actors in organisational governance.

Background During the global COVID-19 pandemic, there has been guidance concerning adaptations that physical healthcare services can implement to aid containment, but there is relatively little guidance for how mental healthcare services should adapt service provision to better support staff and patients, and minimise contagion spread. Aims This systematic review explores service adaptations in mental health services during the COVID-19 pandemic and other contagions. Method The Allied and Complementary Medicine database (AMED), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Medline, PsycINFO and Web of Science were systematically searched for published studies from database inception to April 2020. Data were extracted focusing on changes to mental health services during contagion outbreaks. Data were analysed with thematic analysis. Results Nineteen papers were included: six correspondence/point-of-view papers, five research papers, five reflection papers, two healthcare guideline documents and one government document. Analysis highlighted four main areas for mental health services to consider during contagion outbreaks: infection control measures to minimise contagion spread, including procedural and practical solutions across different mental health settings; service delivery, including service changes, operational planning and continuity of care; staff well-being (psychological and practical support); and information and communication. Conclusions Mental health services need to consider infection control measures and implement service changes to support continuity of care, and patient and staff well-being. Services also need to ensure they are communicating important information in a clear and accessible manner with their staff and patients, regarding service delivery, contagion symptoms, government guidelines and well-being.

Background Health system governance is widely recognised as critical to well-performing health systems in low- and middle-income countries. However, in 2008, the Alliance for Health Policy and Systems Research identified governance as a neglected health systems research issue. Given the demands of such research, the Alliance recommended applying qualitative approaches and institutional analysis as well as implementing cross-country research programmes in engagement with policy-makers and managers. This Commentary reports on a 7-year programme of work that addressed these recommendations by establishing, in partnership with health managers, three district-level learning sites that supported real-time learning about the micro-practices of governance – that is, managers’ and health workers’ everyday practices of decision-making. Paper focus The paper’s specific focus is methodological and it seeks to prompt wider discussion about the long-term and engaged nature of learning-site work for governance research. It was developed through processes of systematic reflection within and across the learning sites. In the paper, we describe the learning sites and our research approach, and highlight the set of wider activities that spun out of the research partnership, which both supported the research and enabled it to reach wider audiences. We also separately present the views of managers and researchers about the value of this work and reflect carefully on four critiques of the overall approach, drawing on wider co-production literature. Conclusions Ultimately, the key lessons we draw from these experiences are that learning sites offer particular opportunities not only to understand the everyday realities of health system governance but also to support emergent system change led by health managers; the wider impacts of this type of research are enabled by working up the system as well as by infusing research findings into teaching and other activities, and this requires supportive organisational environments, some long-term research funding, recognising the professional and personal risks involved, and sustaining activities over time by paying attention to relationships; and working in multiple settings deepens learning for both researchers and managers. We hope the paper stimulates further reflection about research on health system governance and about co-production as a research approach.

Good medication adherence is directly proportional to good health recovery and general improvement of a patient’s health condition. Although many good medication adherence monitoring methods/techniques exist, the level of medication adherence for some chronic diseases by patients in rural settings is still suboptimal. Hence, the need for healthcare organisations to devise viable governance frameworks that will facilitate effective medication adherence monitoring and improved adherence by patients. This paper presents the conceptual overview of a governance framework for medication adherence monitoring and improvement that enables the collaboration of multiple stakeholders and data analytics (MUCODAF) in support of the patient in the treatment journey. The framework allows relevant stakeholders such as Healthcare workers (HCW), family members, and close friends to collaborate in support of a patient through the engagement of critical human factors such as empathy, motivation, encouragement, flexibility, and negotiation. The use cases of the framework, its technical composition, and the implementation plan are discussed in this paper. A concrete example of the application of the governance framework for medication adherence monitoring and improvement for a Tuberculosis patient in the African Country of Lesotho is presented to highlight the plausibility of the framework.

Purpose In North America, delegated practice “medical direction” models are often used as a proxy for clinical quality and safety in paramedic services. Other developed countries favor a combination of professional regulatory boards and clinical governance frameworks that feature paramedics taking lead clinician roles. The purpose of this paper is to bring together the evidence for medical direction and clinical governance in paramedic services through the prism of paramedic self-regulation. Design/methodology/approach This narrative synthesis critically examines the long-established North American Emergency Medical Services medical direction model and makes some comparisons with the UK inspired clinical governance approaches that are used to monitor and manage the quality and safety in several other Anglo-American paramedic services. The databases searched were CINAHL and Medline, with Google Scholar used to capture further publications. Findings Synthesis of the peer-reviewed literature found little high quality evidence supporting the effectiveness of medical direction. The literature on clinical governance within paramedic services described a systems approach with shared responsibility for quality and safety. Contemporary paramedic clinical leadership papers in developed countries focus on paramedic professionalization and the self-regulation of paramedics. Originality/value The lack of strong evidence supporting medical direction of the paramedic profession in developed countries challenges the North American model of paramedics practicing as a companion profession to medicine under delegated practice model. This model is inconsistent with the international vision of paramedicine as an autonomous, self-regulated health profession.

Bioethics can be considered as a topic, an academic discipline (or combination of disciplines), a field of study, an enterprise in persuasion. The historical specificity of the forms bioethics takes is significant, and raises questions about some of these approaches. Bioethics can also be considered as a governance practice, with distinctive institutions and structures. The forms this practice takes are also to a degree country specific, as the paper illustrates by drawing on the author’s UK experience. However, the UNESCO Universal Declaration on Bioethics can provide a starting point for comparisons provided that this does not exclude sensitivity to the socio-political context. Bioethics governance practices are explained by various legitimating narratives. These include response to scandal, the need to restrain irresponsible science, the accommodation of pluralist views, and the resistance to the relativist idea that all opinions count equally in bioethics. Each approach raises interesting questions and shows that bioethics should be studied as a governance practice as a complement to other approaches.

Aims and methodThis paper analyses how practice varied between patients aged ResultsData on 3959 patients were analysed. Those aged v. 67%) and more likely to receive a functional, psychiatric or no diagnosis. Younger patients were more likely to have magnetic resonance imaging; use of dementia biomarkers was low in both groups. Frontotemporal dementia and functional cognitive disorder were diagnosed infrequently. Use of dementia navigators/advisors and carer psychoeducation was similar between groups; younger patients were less likely to be offered but more likely to accept cognitive stimulation therapy.Clinical implicationsMemory services seeing younger people need expertise in functional cognitive disorder, alongside clinical skills and technologies to diagnose rarer forms of dementia. Further work is needed to understand why cognitive stimulation therapy is less frequently offered to younger people.

All human service sectors experience turning points. The 1990s was a decade of revelation about poor healthcare quality, identified and reported in major studies of adverse events and public inquiries across the world. The initial shock waves evolved into a care safety revolution, supported by the introduction of clinical governance. A quarter of a century later, the outcomes of the Aged Care Quality and Safety Royal Commission is having a similar impact in aged care, with a stream of legislation and innovations challenging aged care providers to re-set their approach to creating and maintaining quality care. The financial cost of suboptimal care to consumers and organisations is significant (ACSQHC, 2019.) Ineffective clinical governance processes also waste time, energy and resources. Expectations are growing that aged care will develop more sophisticated, whole-of-organisation approaches to improving point of care quality. The sector can short-cut development time and increase implementation effectiveness by learning from the healthcare sector’s clinical governance path. Healthcare has developed many useful and innovative approaches to clinical governance. There have also been many missteps that slowed or misdirected progress. This paper highlights four key clinical governance implementation ‘rabbit holes’, derived from the healthcare experience: 1. Activity without purpose 2. Process before people 3. Prioritising passivity 4. Confusing fads with foundations. These are not the only clinical governance traps to avoid, but are useful to be aware of, because: " most health services have fallen into these traps on their implementation path at some stage " they align with the literature on clinical governance failures and fault lines " they are avoidable; aged care provider organisations have it within their power to bridge these clinical governance chasms because they are not government policy or funding dependent, but require boards and executives to cultivate the right mindset, knowledge and leadership to chart a better course. Stepping over, rather than into, each of these rabbit holes will help aged care to reduce clinical governance evolution time and increase positive point of care impact.

Purpose Clinical leadership, researcher capacity and a culture of clinical inquiry are needed in the clinical workforce. The purpose of this paper is to report on a program which was used to develop and support clinicians to explore practice, implement innovation, translate evidence and build researcher capacity. Design/methodology/approach This pragmatic paper presents a case study of a nursing and midwifery clinician-researcher development program. The multi-site, multi-modal program focused on education, mentoring and support, communication networks, and clinician-university partnerships strategies to build workforce capacity and leadership. Findings Over 2,000 staff have been involved in the program representing a range of health disciplines. The study day program has been delivered to 500 participants with master classes having over 1,500 attendees. The research mentor program has demonstrated that participants increased their confidence for research leadership roles and are pursuing research and quality assurance projects. Communication strategies improved the visibility of nursing and midwifery. Research limitations/implications This case study was conducted in one health district, which may not have relevance to other geographical areas. The small numbers involved in the research mentor program need to be considered when reviewing the findings. Practical implications The program has been a catalyst for developing a research culture, clinical leadership and research networks that strengthen workforce capacity. Building researcher skills in the workforce will better support quality healthcare and the examination of everyday practice. Social implications Building a culture of healthcare that is based on inquiry and evidence-based practice will lead to more appropriate and consistent healthcare delivery. Consumers have the right to expect health clinicians will challenge everyday practice and have the skills and capability to translate or generate best evidence to underpin professional and service delivery. Originality/value This paper provides strategies for building workforce researcher capacity and capability. The program provides opportunity for building research networks and role modeling the value and importance of research to practice and quality improvement.

ObjectiveTo explore patient involvement in the implementation of infection prevention and control (IPC) guidelines and associated interventions.DesignScoping review.MethodsA methodological framework was followed to identify recent publications on patient involvement in the implementation of IPC guidelines and interventions. Initially, relevant databases were searched to identify pertinent publications (published 2013–2018). Reflecting the scarcity of included studies from these databases, a bidirectional citation chasing approach was used as a second search step. The reference list and citations of all identified papers from databases were searched to generate a full list of relevant references. A grey literature search of Google Scholar was also conducted.ResultsFrom an identified 2078 papers, 14 papers were included in this review. Our findings provide insights into the need for a fundamental change to IPC, from being solely the healthcare professionals (HCPs) responsibility to one that involves a collaborative relationship between HCPs and patients. This change should be underpinned by a clear understanding of patient roles, potential levels of patient involvement in IPC and strategies to overcome barriers to patient involvement focusing ontheprofessional–patient relationship (eg, patient encouragement through multimodal educational strategies and efforts to disperse professional’s power).ConclusionsThere is limited evidence regarding the best strategies to promote patient involvement in the implementation of IPC interventions and guidelines. The findings of this review endorse the need for targeted strategies to overcome the lack of role clarity of patients in IPC and the power imbalances between patients and HCPs.