Editorial

Citation

Harrop, N. and Gillies, A. (2011), "Editorial", Clinical Governance: An International Journal, Vol. 16 No. 2. https://doi.org/10.1108/cgij.2011.24816baa.001

Editorial

Article Type: Editorial From: Clinical Governance: An International Journal, Volume 16, Issue 2

Would you participate as a subject in a clinical trial? Would you be confident to manage the risk safely as a researcher or as an ethics committee member? Would you allow your institution to carry the risk? In the paper that opens this issue of Clinical Governance International Journal, Brown makes proposals for the better assessment and control of risk in clinical research interventions. He argues the need for a normative definition of “reasonable risk”, the delineation of its boundaries and the specification of practical tests that can warn when transgression of these boundaries is imminent. These three steps are to be supplemented by the derivation of an action plan that can contain the risks revealed.

Risk is distributed differentially between the research subject, the research team and the research institution. Different forms of risk pertain to each of these categories. In the model the authors present, the impact / likelihood matrix is amplified by an assessment of each category to participate safely, so that safeguards can be tailored.

Within the governance of the United Kingdom health service, clinical audit has become enshrined as a governance tool. But has clinical audit become a Shibboleth: a “sacred cow”, revered and conducted for its own sake rather than making a real contribution to clinical practice?

Komuravelli and Smith point to the disconnect between audit conducted as an exercise within regional post-graduate clinical training programmes, audit conducted within the local R&D and quality programme of a hospital, and the translation of audit activity into real changes in the ethos and working practices of the clinical “shop-floor”.

DNAR (Do Not Attempt Resuscitation) orders are intended to protect those who are dying naturally from futile and intrusive intervention (cardiopulmonary resuscitation) at the end of life. What are the implications of a DNAR order for a patient who still ought to receive humane and sensitive management as life draws to its close?

Stewart and Baldry suggest that DNAR orders may be subject to over-interpretation, such that patients spared unwelcome intervention are also denied aspects of management they ought to receive. They raise an important concern that needs to be explored in more detailed studies. Meanwhile we must recognise that DNAR has strictly limited scope. Clinicians must draw a thoughtful balance, rather than making a crude switch, between realistic optimism and nihilism. These authors introduce the concept of a “realistic ceiling” on care.

The clinical ward round is the occasion when this concept can be reviewed, within the overall plan of clinical management. The ward round is always a professionally stimulating stroll through the clinical landscape. Herring et al. show how its purposeful conduct can be focused and made efficient, yet sensitive to the cues that emanate from each patient.

Their “considerative” checklist goes beyond rigidly formalising a “standard operating procedure” for an encounter “done to” the patient, by catering equally for emergent aspects “done with” the patient. It is a conscious reflection of specific concerns outlined in key documents from key agencies and it is a prompt rather than a substitute for thought.

Where planned and codified arrangements introduce comfort, stability and predictability, the reverse is true when decision making is totally disaggregated. Following the white paper, Liberating the NHS (United Kingdom Department of Health, 2010) the United Kingdom NHS is on the brink of another phase of market-led reform, intended to promote disinvestment from the traditional secondary care sector in favour of alternatively configured services, focused on the primary care sector.

Ferguson and Cook recognise the de-stabilising impact of this policy evolution on what has been one example of a stable relationship between a primary care-based and a secondary care-based service.

They describe a Primary Care Orthopaedic Interface Service, originally intended to complement the local orthopaedic service by providing an alternative form of relevant expertise (physiotherapists) without impeding access to the surgical service when needed. They ask whether such a service is sustainable in a changing political and healthcare environment.

Traditional services are highly compartmentalised. The participation of each service in the care of an individual patient has tended to be sequential and fragmented. Communication between participants has tended not to be intense. The shift from a planned to a market environment for the commissioning and delivery of care threatens to exacerbate this situation.

The resilience of the service these authors describe stems from intensity of collaboration rather than competition with its neighbour service. The two partners in the interface relationship are mutually supportive and focused on patients rather than on the maintenance of their own business. Communication is relatively intense: a consultation rather than a referral model.

Finally, back to safety. What has prevented healthcare from becoming an “ultrasafe” enterprise? The North American perspective, provided by Sheps and Cardiff, provides a startling answer.

Healthcare organisations try to defend themselves and their patients from human error by formalising codified procedures: protocols, procedures, guidelines and standard operating procedures. These isolate a problem and apply the simple cause and effect logic that, if human judgement can be disciplined, constrained and eliminated, accountability will be enhanced and error will be prevented, by the closed system of logic enshrined in the instrument.

All well and good, except that as codified, simple systems of rules proliferate, they begin to interact unpredictably. Each becomes part of the other’s external environment. Contradictions and complexity emerge and substantial human work is consumed in the effort to reconcile the simple system with its environment. What began as a set of closed logical rule systems rapidly becomes a complex of open systems, adjudicated by people who interact knowledgeably within the prevailing context of governance, practice and operational constraint.

These authors argue that human failure is inherent in such a milieu and they protest against a narrow view of quality that over-emphasises specification, standards and conformance. Human error is a symptom of organisational failure, not a diagnosis and they argue that, rather than seek to blame human actors, clinical governance procedures have not sufficiently aimed to determine those factors and the circumstances in which they operate, that make it possible for human error to occur, and those factors and circumstances that make it possible for human error to cause harm.

In this issue of our journal, we are pleased to present a mix of papers that, each in their own way, emphasise a discursive relationship between theory and practice on an academic level, yet individually present useful insights into a range of clinical governance issues that are highly important at a practical level.

Nick Harrop and Alan GilliesUK