The beautiful world of governance
The next topic on our journey is one that people either love or hate, quite often people hate it because they just don’t understand it, it’s fine not to like it but we now need you to understand it. So, if you haven’t already go grab yourself a brew, sit back and let’s talk about GOVERNANCE.
First things first, let’s be really clear, good governance is the entity that will allow you to sleep at night, without it your services won’t be safe, you won’t know what’s going on and this will only add to the pressure. I work for 400 staff, I serve a population of 180k and have in the region of about 8k individuals currently receiving care from one or more of my services. I sleep at night not because I’m any ‘better’ than those reading this blog but because I have sound governance structures in place that stand up to scrutiny and that offer me oversight.
What is governance?
Clinical governance is a system which organisations are accountable for, continuously improving the quality of their services and safeguarding high standards of care (Scally and Donaldson, 1998). So in a nut shell Clinical Governance is a system that you need to put in place to ensure that you have oversight and assurance of the care that you deliver.
What is good governance?
Good Clinical Governance allows you to see what’s going on, it allows you to know what training your staff have completed, it allows you to know what the quality of your Care Plans look like, it tells you what your risks are and what you are doing to mitigate them.
When our friends at the CQC come they will look at the following when they are assessing you:
Your systems must either have or provide the following:
· Assess, monitor and improve the quality and safety of the services that you provide, this must include the experience of those using your services
· Assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity
· Maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided
· Maintain securely such other records as are necessary to be kept in relation to
Persons employed in the carrying on of the regulated activity, and
The management of the regulated activity
· Seek and act on feedback from relevant persons and other persons on the services provided in the carrying on of the regulated activity, for the purposes of continually evaluating and improving such services
· Evaluate and improve their practice in respect of the processing of the information
Straight forward right? Let’s break this all down now, but please remember this blog will only offer a general overview, if you’d like something tailored specifically for your organisation please visit me at www.racheljamesconsultancygroup.com or contact me on 07909693177 and I will tailor this for you.
Assess, monitor and improve the quality and safety of the services that you provide, this must include the experience of those using your services
So you must have a system in place whereby you have sight of the quality of work that you and your services are delivering. Most people will opt for some sort of audit, this maybe to monitor training which staff have completed, it maybe for the notes that staff are writing or it might be that you want to audit the number of care plans and risk assessments you have in place whilst assuring yourself both of the quality but also when these need updating. To capture the feedback from those using your services you should think about a couple of approaches. You could for example send out a questionnaire every 3 months which is anonymous, you could call people up and ask for their feedback you could also have a link on your page for feedback. Whatever you do think about those that are using your service and how you can reach out to make it as easy for them as possible. N.B Don’t send someone a questionnaire to fill out if they have arthritis and can’t see, call them up and check in, record the conversation so you have an audit trail etc
These systems need to talk to each other and link into your board/performance meetings. For example if you’ve completed your training compliance matrix and your staff haven’t been completing the training that you’ve set them then this needs to be added to your ‘Risk Register’. A risk register is simply that, a register of risk but also the mitigation and how you’re going to get out of the risk. When CQC turn up please show them the risk register, if offers more assurance than you’ll ever know. Remember, no service is perfect.
Assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity
So as previously mentioned risk and how you mitigate risk is very important. Every service needs to have a risk register with the following titles:
Name of risk
Details
Mitigation
Action
Date of review
Close?
To really be well led make sure you share these risks with your staff at your monthly business meeting, make sure staff can also raise concerns and put things on the risk register too. Again, don’t be afraid of putting things on your risk register.
Other types of risk that need monitoring are those that are presented in the form of the environment. When you complete your assessment of a new individual please ensure you’re completing risk assessments of the environment and that you’re sharing these with staff.
Your other types of risk will be with the individual you’re supporting. Clearly these risks can be anything from pressure sores through to verbal aggression or physical health difficulties, I’m not going to write down every risk known to us healthcare professionals but do feel confident in asking someone what their risks are, It’s ok to ask,
Maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided
So I’m sure you’re all aware of what type of notes need to be kept. We know we need a care plan and risk assessment and we all know that we need to keep contemporaneous notes. I’d never want to patronise anyone but what I would say is let’s be really clear with what Contemporaneous notes actually mean (I’ve had Nurses ask me). So contemporaneous notes are notes that have been made at the time or shortly after an event has occurred, so for us the event is ‘a visit’. Whilst these a legal notes they are also a valuable way of passing information over to the next person.
A challenge over the years that I’ve faced is the quality of notes as well as the presenting issue as to the consistency amongst staff. We ended up putting in headings that staff would need to follow, this way we would have consistency, it also ended that dreaded language that you read ‘optimal mental health’ or even staff copying what was said from the day before. Think about what headings would help you.
Remember that we live in the 21st century now, we can go paperless! In the organisation that I set up we moved to an online cloud system whereby staff could type their notes and we could then audit them remotely, it also gave families the opportunity to monitor (with permission) what was happening.
Please remember that I’m giving highlights of each section, there are further elements such as recording Mental Capacity that we will go into at a later date.
Maintain securely such other records as are necessary to be kept in relation to
i. persons employed in the carrying on of the regulated activity, and
ii. the management of the regulated activity
When keeping details of those you’ve recruited please make sure that again you’ve got a robust system that stands up to scrutiny. What details are you recording? Where people live, their demographic details such as ethnicity, gender, DOB, what about their DBS check? If I walk into your office this afternoon I need to pick up a file that paints a picture of who you have recruited. Remember your workforce should represent the population that you serve! Don’t just recruit those people that look and sound like you, seek out those with different voices, as leaders we must never get stuck in the echo chamber (I think I’ve just thought of the next blog).
The second point to this is the anything that is relevant to you running your services, your governance structures for example, policies and procedures, service maintenance records, audits and reviews.
Seek and act on feedback from relevant persons and other persons on the services provided in the carrying on of the regulated activity, for the purposes of continually evaluating and improving such services
So how do you know if the service that you’re offering is one of high quality? At a commissioning level this isn’t being recorded properly yet. The success of some of my services are based on Key Performance Indicators which as you know can mean that you tick a box but it doesn’t mean the quality is there.
There are lots of ways that you can collect feedback. Just remember, the more you listen the more you know! Give people the platform to tell you of their experience, too many managers I know shy aware from these conversations. Maybe it’s because they worry, maybe it’s because they don’t have time, I don’t know, what I do know is that if you reach out and listen it will save you so much time in the long run. All of my managers, have to call x amount of patients each week and give them the opportunity to talk to them about their experiences. Our Ward Managers and Matrons have ‘Ward Manager’ and ‘Matron’ surgeries where patients and staff can talk to them about the good, the bad and the ugly! If you haven’t started collecting feedback start with a questionnaire, send it out to clients and staff but please make sure you do something with the information. If you’re staff tell you something isn’t working make sure that you have an agenda item called ‘you said, we did’ in your monthly business meeting, talk about the issues that have been raised, what you’re going to do about them, this closes the loop in terms of governance. When your clients feedback back make sure it’s captured either on your website or in your monthly newsletter (you do have a monthly newsletter don’t you?!)
Evaluate and improve their practice in respect of the processing of the information
So you’ve got the intel, what are you going to do with it? Hopefully a Quality Improvement piece. As a qualified QI coach through the Institute of HealthCare Improvement I’ve specialised for many years in QI projects. My advice would be to identify something that you want to improve and create a Driver Diagram with both primary and secondary drivers that support you to achieve your overall aim.
So there you have it, easy right? Governance will either make you or break you, don’t struggle with it though, get in touch and we’ll do it together.
So what have we learnt?
1) Governance is a system that gives you oversight and assurance around the quality of the services that you offer
2) We’ve looked at the 6 key areas that CQC will assess against
3) We know that Governance structures must link up and talk to each other, ie if your audit identifies a risk then this risk needs to go onto your risk register which Is discussed at your board meetings
Remember that governance is here as a friend, it’s that friend that we all have who can be annoying at times but you know deep down they have your best intentions at the centre of their thoughts. Make sure that your structures are clear, concise and that they link into all areas of your business. Those elements that we’ve discussed today will ensure that you are patient focussed, that you are focussed on the information, that quality improvement is embedded within your organisation, that there is a clear focus on staff and that your leadership is sound, meaning your company is well led.
Until next time
Mark
