Health Education Research, Vol. 15, No. 4, 505-506,
August 2000
© 2000 Oxford University Press
Book Review |
Clinical Governance in Primary Care
Institute of Nursing & Midwifery, University of Brighton
How do you produce a book that covers in sufficient detail, but not so detailed that it loses portability, the various components that constitute clinical governance? Answer—assign each component to a chapter, introduce the main concepts by means of clear headings and judicious use of boxes and tables, and then enable the reader to access additional information when they want to by providing sources, references and websites. This book is one of those rare examples of a well thought out book, exhilarating when you find them. It is prefaced by a clear strategy on what to include and how to cope with inevitable limitations.
Clinical governance is not so much a case of combining the ingredients necessary to make the quality cake; it is more that each ingredient takes up an entire aisle in the supermarket of the quality industry. With the enormity of this challenge, van Zwanenberg and Harrison seem to have delivered a strict script to their contributors; make this readable, educational, logical but interesting. [I almost said entertaining there, but for that we need a Gareth Morgan and an entirely unique way of looking at organizations (Morgan, 1986). This may not be unique, but then again useful, clear and thorough are also good adjectives.] Each chapter has set prescriptions which aid readability and comprehension:
- Boxes with clear messages. Each chapter begins with an introductory box with no more than two sentences summarizing the chapters' content. Practical points boxes at the end of chapters provide bulleted key points.
- A liberal smattering of headings provide a map to milestones of key issues in each chapter.
- Coverage of the key elements of clinical governance is delivered in a rational and logical way.
- References and sources to take it all that step further.
Right from the outset the agenda is clearly spelt out in the form of `10 Commandments of Clinical Governance' with the relevant chapter assigned to each `commandment'. This in itself is a useful guide to answer that tricky question that most people think they know, but then again find it difficult to answer when confronted with the question with any semblance of certainty—what is clinical governance? For the record, and for those who really want to know the answer but might not get round to reading the book, these are the 10 commandments according to van Zwanenberg and Edwards:
- Evidence-based practice with the infrastructure to support it.
- Good practice, ideas and innovations systematically disseminated.
- Quality improvement processes, e.g. clinical audit.
- High quality data to monitor clinical care.
- Clinical risk reduction programmes.
- Adverse events detected and openly investigated, and the lessons learned promptly applied.
- Lessons for clinical practice systematically learned from complaints made by patients.
- Problems of poor clinical performance recognized at an early stage and dealt with.
- All professional development programmes reflect principles of clinical governance.
- Leadership skill development at clinical team level.
The manner of dealing with issues of scale is seen in the evidence-based practice (EBP) chapter, where again boxes showing useful sources are identified. This chapter provides an example of political tender footing that would make hardened politicians smile. The biggest debate in EBP still seems to be associated with randomized controlled trials (RCTs) and is known to provoke great passion amongst our medical colleagues, apart from others. Ian Watt, whilst wishing to include a hierarchy of evidence which places RCTs indomitably at the top, gently inserts the following sentence: `Even when undertaken correctly, some study designs are more susceptible than others to bias'.
Almost inevitably, in a book of this nature, we would expect to find some overlap. Although relatively little, there is some that almost occurs negligently. An example of this can be seen in the two consecutive chapters on `EBP' and `Dissemination and implementation of EBP'. This is a shame as both chapters would invariably be read together. Where overlap is more acceptable, i.e. where readers may skip chapters for personal relevance, is seen in the chapters where accreditation is discussed; `Tackling poor performance' and `EBP'.
This book is essential reading for those in general practice, but useful too for any interested in clinical governance generally. Case studies, for example, which are set in local practice have more extensive significance. In particular, I found the case studies on complaints, or significant event auditing, invaluable. Clinical governance, although an umbrella term for an awful lot that is happening, is clearly more than the sum of its part and integrating all the parts into an effective whole incorporates many of the problems associated with introducing cultural as well as generic change management issues. The section on leadership and management shows that leadership is about dealing with change and coping with the complexity that inevitably follows.
I was interested in the final two chapters and the manner with which they chose to bring the book to an end. They decided to take clinical governance back to square one and talk about what health is, issues of rights and responsibilities, a rounding of the circle to illustrate the non-ending nature of clinical governance. In essence they decided to place clinical governance in the centre of the ring, surrounded by all the stakeholders, patients as well as clinicians, in partnership. A neat ending for a neat book.
Notes
T. Van Zwanenberg and J. Harrison (eds), Radcliffe Medical Press, Abingdon, Oxford, 2000, 224 pp. ISBN 1857753968
Reference
Morgan, G. (1986) Images of Organizations. Sage, London.
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