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Making space for clinical governance

Creating clinical governance systems for the Regional Forensic Psychiatric Service at Langdon Hospital in Devon

What prompted the initiative?
What has been done?
Clinical Governance afternoons
Is it working?
Tips for success
For more information contact

What prompted the initiative?

When the Government introduced the concept of clinical governance it echoed feelings within the Regional Forensic Psychiatry Service at Langdon Hospital that there was a need to improve systems to support the development of good clinical practice. Clinical audit had been rolling forward with mixed success, but there was no coordination with other areas such as risk management and evidence-based practice. There was a strong desire to take the opportunity to create a better system that would get away from the prevailing ad-hoc, last minute approach. The time seemed right to create a multidisciplinary pro-active approach delivered in a way that enabled all staff to participate.

What has been done?

In common with many other hospitals the starting point at Langdon was to review the senior committee structure. These discussions were guided by four basic principles:

  1. leadership would be essential at different levels
  2. it should be multidisciplinary in style
  3. all elements would be actively coordinated
  4. work involved would be shared across the service

The latter point was particularly important given scarcity of resources. There was a new challenge but no new money.

Predictably two senior committees are the centrepiece of the new arrangements. One is a Trust Clinical Governance Committee chaired by the Medical Director. The other is a Forensic Mental Health Clinical Governance Committee chaired by a Specialist Registrar rotating on a yearly basis. Other developments include individual service committees for each sub speciality and annual professional standards reviews between the Medical Director and individual consultants. A training group is charged with supporting continued professional development across all disciplines. The key innovations within the new arrangements are however five multidisciplinary steering groups at local service level that report to the main clinical governance committee and the introduction of clinical governance afternoons.

The five multidisciplinary steering groups are charged with investigating practice and developments which might be applicable at Langdon Hospital and proposing how those should be taken forward. Each group is led from different disciplines

The groups take a proactive approach to develop and roll forward a programme of work. As separate tasks are completed the work is presented at the clinical governance afternoons.

Clinical Governance afternoons

This arrangement was seen as a means of tying together the separate elements of the new system and ensuring that all staff are involved. The aim was to set aside time for presentation and discussions on topics that were important to the development of practice. The idea was to build on the model of previous clinical audit sessions but design them in a way that would give staff more of an incentive to attend. To support this approach there is an obligation on all professional heads to ensure that members of their discipline are able to attend. For example, the rosters for nursing staff have been amended to ensure that they are able to attend while cover on the wards is maintained.

The five multidisciplinary steering groups are involved in creating the programme for the sessions. The programme is circulated well in advance and professional accreditation obtained. There are ten sessions each year avoiding the holiday months of August and December. Lunch and a lucky door prize is provided courtesy of the local representative of a pharmaceutical company. The Table shows the basic framework for these meetings.

Table: Structure of clinical governance afternoons
Time Training
13.00 - 14.00 Evidence-based practice presentation
14.00 - 14.45 Policy and procedure - alternating with clinical audit
15.00 - 15.55 Risk management - alternating with User and Complaint issues

Is it working?

There are encouraging signs that the new coordinated approach is working and there is some anecdotal evidence that practice has changed. The discussions have been very productive. Guidelines have been agreed for the treatment of resistant schizophrenia and high dose neuroleptic medication. Integrated care-pathways are being developed for alcohol related and sexual offender treatment issues. In addition a policy and procedure on racism is being developed following a presentation in a clinical governance afternoon. A new risk prediction instrument is also being piloted.

Since the Clinical Governance afternoons were launched in May 1999 they have all taken place as planned. Attendance is encouraging with about three times the level for the old clinical audit sessions (up from about 10-15 to about 30-35). Debate has been lively and staff from most disciplines have been involved. An attendance register is maintained, as well as a record of presentations and discussions. Staff say they enjoy the meetings. The programme is now an important element of the continuing professional development of staff.

But it is not all plain sailing. A number of difficulties have arisen as the new approach has evolved. The will remains however to make sure that the opportunity created by the implementation of clinical governance is not lost. The problems include funding for the new arrangements because effective coordination does not just happen. Similarly, maintaining the right balance between team development and the needs of individual disciplines is proving difficult. Discussions are also in hand to ensure that all disciplines are involved, particularly singleton professional groups like speech therapy.

Tips for success

For more information contact

Adrian James
Consultant Forensic Psychiatrist
Devon and Cornwall Forensic Psychiatric Service
Exeter and District Community Health Service NHS Trust
Prentice House, Langdon Hospital
Exeter Road, Dawlish EX7 0NR
Telephone 01626 888372
Fax 01626 888373

The following material is available:

Clinical governance and mental health: a system for change. Adrian James - Clinician in Management 1999:8 : 92-100

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