Lida Karbalaee Salmanpour et al., Asian Journal of Pharmaceutical Technology & Innovation, 02 (05); 2014; 01-11
Asian Journal of Pharmaceutical Technology & Innovation ISSN: 2347-8810
Research Article Received on: 30-12-2013 Accepted on: 19-01-2014 Published on: 15-04-2014
Corresponding Author:
The Relationship between Clinical Governance and performance indicators in Iranian Hospitals Amir Ashkan Nasiripour 1, Lida KarbalaeeSalmanpourMamaghani*2, Pouran Raeissi3
*LidaKarbalaeeSalmanpourMamaghani PO Box 14515-775, Tehran, Iran. Phone No +98 21 44869701
ABSTRACT
*Email Id-
[email protected]
Key-words: Clinical Governance, Performance Indicator, Hospital
Introduction: Healthcare organizations are complicated and their structures, processes and management are of high significance for promoting the quality of clinical care. Clinical governance, as a healthcare quality improvement instrument, detects the complications and tries to solve some of the problems through providing integrated, comprehensive strategies and moving toward quality improvement. The main purpose of present study was to determine the relationship between clinical governance and performance indicators in Iranian hospitals. Methods: The present study was conducted at 16 hospitals (N=16) and their clinical governance performance was evaluated using the Treatment Deputy of Tehran University of Medical Sciences (TUMS) checklist containing all items of the seven clinical governance pillars and their scores; in the end, the total scores of the seven pillars were calculated and considered as the hospital’s score. Performance indicators were also obtained from the statistics department of the hospitals under study. The Pearson and Spearman correlation tests were used to determine the presence of a relationship between clinical governance and hospital performance indicators. Results: The mean score of the overall performance of clinical governance in the investigated hospitals was 817.93 of 1116 total score; the hospitals were at moderate level considering the performance indicators from March 2012 to March 2013. The maximum correlations belonged to risk management and patient safety(r=0.708, P=0.002)and the minimum was between management and leadership (r=0.505, P=0.046). Conclusion: There was no statistically meaningful relationship between clinical governance and performance indicators of the studied hospitals. Among the seven aspects, risk management and patient safety, use of information, management and leadership as well as clinical audit were positively and significantly associated with clinical governance performance.
Cite this article as: Amir Ashkan Nasiripour, Lida Karbalaee Salmanpour, Pouran Raeissi, The Relationship between Clinical Governance and performance indicators in Iranian Hospitals , Asian Journal of Pharmaceutical Technology & Innovation, 02 (05); 2014.
1
Associate professor, Department of Health Services Management, Tehran Science and Research Branch, Islamic Azad University, Tehran, Iran M.A. in Health Services Management , Tehran Science and Research Branch, Islamic Azad University, Tehran, Iran (Correspondence author) 3 Associate Professor, School of Management and Medical Information Services, Iran University of Medical Sciences, Tehran, Iran. 2
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Lida Karbalaee Salmanpour et al., Asian Journal of Pharmaceutical Technology & Innovation, 02 (05); 2014; 01-11 INTRODUCTION Health is contemporarily one of the most significant preoccupations of humans and new definitions and responsibilities of healthcare systems are playing a growing role in preserving and promoting people’s health from different aspects through policy making, intra-departmental governance and interdepartmental leadership1. In the meantime, the topic of service quality in hospitals, as the most important element of healthcare systems, has a particular position and without its effective role in maintaining quality, effective and efficient care, the health system cannot be complete. The major mission of the hospitals is providing quality care for patients as well as meeting their needs and expectations; this indeed requires the institutionalization of quality in hospitals so that all staff takes that as a responsibility and not a part of their duty2. Studies show that low quality of health services wastes resources that could be used for treating a larger number of patients; thus, people’s demand for higher quality of hospital care has a growing trend. Providing safety for patients and the staff in addition to improving the quality are among national objectives of all healthcare systems around the world3. In many developed and developing countries, health systems are busy with establishing new institutions, mechanisms and processes, the main aim of which is constant preservations and promotion of the quality of health services4. The quality of care is usually applied for evaluating the performance of medical organizations and most studies focus on the performance of hospitals with regard to service quality, particularly in the United States5. Designing appropriate structures and promoting quality of services in theory do not seem to be difficult; however, executing the strategies and putting the mechanisms into practice would be challenging. Various methods and instruments have been used in different countries to promote the quality of health care and clinical governance is a recent model that has demonstrated its capability following its administration in hospitals across the country4. Clinical governance was first suggested to the health system of England as a strategy recommended by the government to promote the quality of clinical care in 1998. It, in fact, is a framework through which National Health System (NHS) organizations are accountable for continuallyimprovingthe quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. Clinical governance should simultaneously concentrate on the accountability for preserving current level of care and promoting future services. This includes concepts like improving the quality of information, promoting cooperation and participation of patients, enhancing teamwork and executing evidence-based medicine that can cover all items contributing to preservation and promotion of patient care standards. It also covers all quality promotion activities that the clinical staff considers in providing daily medical services6. Clinical governance is an opportunity for finding ways to make individuals move from their present idle and lethargic condition toward a more challenging culture resplendent with active education, speaking along with hearing as well as listening and asking aiming at learning and development. The approach, through which clinical governance will be established, can be a start point for changing the manner of performing tasks to take people into an environment created based on intellection and is free from blame. In such a setting, the question of “Who does not work properly?” should be replaced with “What does not work properly?” as the first step in solving any problem; one single mistake should not be repeatedly made by different individuals. There are different models and patterns for defining and explaining clinical governance. One of the patterns applied in England National Health Service (NHS) is the7-pillarpattern that is also proposed by the Iranian Ministry of Health, Treatment & Medical Education considering its comprehensibility. The pillars include clinical risk management, service user, career and public involvement, use of information, education, training and development, staffing and staff management, clinical effectiveness and clinical audit6. Like other processes, performance assessment also includes a series of activities and purposeful measures in logical order and sequence; any model or pattern of choice take in common stages and the
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Lida Karbalaee Salmanpour et al., Asian Journal of Pharmaceutical Technology & Innovation, 02 (05); 2014; 01-11 second stage following aim identification will be devising indicators that is one of the most important steps because organizations review their extent of accessibility to aims and objectives by determining the criteria and key indicators and in most organizations, general indices are defined and a series of factors are considered for assessing the key indicators7. Key indicators are value instruments or a fixed desired quantity that describe a statistical population, remain fixed in specific conditions or change in others8.In fact, the indicators show the pathway to organizations to accomplish their goals. In order to assess the performance of hospitals, performance indicators should be determined. Hospital indicators are the most important performance markers in different areas. Hence, directing overall attention to these indicators is necessary for by viewing the hospital indicators, their performance status will be clear and further deliberation reveals their strong and weak points9. The present study aims at determining the relationship between clinical governance performance and amount of performance indicators of TUMS and IUMS hospitals.
METHODS The type of study was correlation and the statistical population include all TUMS and IUMS hospitals (N=26) from among which 16 (N=16) were selected. Clinical governance assessment was performed through the administration of TUMS Treatment Deputy Checklist containing all items of the seven pillars of clinical governance and their scores (or grades); scores of the clinical governance performance of each hospital was separately calculated by adding up each pillar’s score. Moreover, performance indicators of the hospitals were obtained from their statistics unit and then, the relationship between clinical governance performance and hospitals performance indicators scores was analyzed by SPSS. First, descriptive findings including the specifications of the hospitals under study, those obtained from the variables (clinical governance performance and hospital performance indicators) and their pillars were studied. Finally, Pearson-Spearman correlation test was used to determine the presence (or absence) of a relationship between clinical governance performance, its pillars and hospital performance indicators; matrix tables were provided for demonstrating analytical findings. Considering the normal distribution of clinical governance variables and its pillars in this study (management and leadership, Career& public involvement, staffing and staff management, risk management and patient safety, use of information, clinical effectiveness and clinical audit) as well as performance indicators of beds including occupancy rate (bed-day occupancy rate), bed turnover interval, net mortality, gross mortality, successful cardiopulmonary resuscitation (CPR) and leaving ER upon personal consent, Pearson correlation test and for other performance indicators with non-normal distribution (mean duration of hospital stay or hospitalization days), Spearman correlation test were used. The significance level was determined at Pvalue0.05, normal distribution condition), the major variable of the study, i.e. overall
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Lida Karbalaee Salmanpour et al., Asian Journal of Pharmaceutical Technology & Innovation, 02 (05); 2014; 01-11 clinical governance performance and its seven pillars were normally distributed and Pearson test was used for studying the correlation (Table 1). Table 1.Results of Smirnov-Kolmogorov normality test in clinical governance performance& its different pillars in hospitals under study Pillars
Risk management & patient safety Staffing & staff management Use of information Management & leadership Career& public involvement Clinical effectiveness Clinical audit Clinical governance performance
Total score
356
Min. score
185
Max. score
Mean
355
283.25
115
92.8
100
60.5
93.5
81.78
170
85
157
124.53
110
49.06
961.5
817.93
115
40
165
61.5
146.5
110.87
100
0
100
75.62
110 1116
0
620
SD
Z distributio n
Probabilit y rate
Result
(Vs. total Score)
46.17
0.716
0.684
Normal
20.73
0.792
0.557
Normal
9.01
19.82 21.63 27.90 28.45 89.3 1
0.519 0.413 0.612 0.882 0.967
0.445
Variable’s condition
0.950 0.996 0.848 0.418 0.307
0.989
Normal Normal Normal Normal Normal
Normal
Proper & good (79.5%) Proper & good (81.78%) Proper & good (80.78%) Average (73.25%) Average (67.19%) Fairly average (44.6%) Proper & good (75.62%) Average (73.29%)
*The status to the studied variable based on quartile classification is: 0%-25% of the total score (improper condition), 25%-75% of the total score (moderate condition), 75%-100% of the total
score (proper condition)
The comparative study of descriptive results of key performance indicators (according to 12-month data leading to 2012) in TUMS & IUMS hospitals indicate that among performance indicators, bed occupation rate with the mean of 77.27(±12.35) is in a proper and fairly good condition. Moreover, the comparison of bed occupation means in the hospitals show that the rate ranges between 46.67 and 92.09. The mean hospital stay or duration of hospitalization is 6.37(±7.33) and ranges from 1.37 to 33.02 that might be due to the specialized nature of the said hospitals. The mean bed turnover interval rate was 5.81(±3.75) ranging from 0.79 to 17.10; this wide range can also be explained like the former indicator. Overall, the mean bed turnover interval is 1.73(±1.61). Comparing net and gross mortality rates in the hospitals under study, a significant relative difference was observed among the hospitals that might probably be due to different specialties and nature of various diseases treated in hospitals. In a single-spatiality hospital, the indicator is measured at almost null (%) point while in some other, higher rates (>5%) could also be observed. The mean rate of successful CPR compared in TUMS & IUMS hospitals ranges from 3.80 to 76.90 with the mean and standard deviation of 37.15±21.21. Moreover, the descriptive results of leaving ER upon personal consent in the said hospitals reveal that during 12 months (from March 2012 to March 2013), the mean (±SD) of this indicator was 2.78(±3.34) ranging from 0.03 to 12.07. It is noteworthy that the data on key performance indicators of the hospitals were obtained from the Treatment Deputy of the medical universities. Considering Z distribution and probability rate (normal distribution, P>0.05), all indicators (including occupancy rate/bed-day occupancy rate, bed turnover interval, net mortality, gross mortality, successful CPR and leaving ER upon personal consent percentage) except the mean hospital stay had a normal
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Lida Karbalaee Salmanpour et al., Asian Journal of Pharmaceutical Technology & Innovation, 02 (05); 2014; 01-11 distribution; Spearman and Pearson tests were respectively used for indicators with normal and nonnormal distribution (Table 2). Table 2. Results of One-Sample Kolmogorov-Smirnov Test on 8 performance key indicators in hospitals under study Performance Key Indicator
Bed occupancy rate Mean hospital stay
Bed turnover rate Bed turnover interval rate Net mortality percentage Gross mortality percentage Successful CPR Leaving ER upon personal consent Clinical governance performance
Mean
SD
Min. score
Max. score
Z distributio n
Probabilit y rate
77.27
12.35
46.67
92.09
0.544
0.929
5.81 1.73 1.58 1.70 37.15
3.75 1.61 1.49 1.67 21.21
0.79 0.18 0.00 0.00 3.80
17.10 5.66 5.08 5.75 76.90
0.844 1.085 0.641 0.715 0.386
0.475 0.190 0.806 0.686 0.998
Normal Nonnormal Normal Normal Normal Normal Normal
1116
620
0.989
Normal
6.37
7.33
2.78
3.34
1.37
0.03
33.02
961.5
12.07
817.93
1.491
1.134
0.445
0.023
0.152
Result
Normal
Table 3. Results Correlation coefficients of clinical governance performance and hospital performance indicators in hospitals under study
Use of information Management & leadership Career& public involvement Clinical effectiveness
Clinical audit Clinical governance performance
Correlation Coefficient Probability rate Correlation Coefficient Probability rate Correlation Coefficient Probability rate Correlation Coefficient Probability rate Correlation Coefficient Probability rate Correlation Coefficient Probability rate Correlation Coefficient Probability rate Correlation Coefficient Probability rate
0.121
-0.192
-0.479
0.409
-0.020
0.231
0.148
0.231
-0.272
-0.214
-0.153
0.021
0.521
0.165
0.130
0.309
0.215
0.440
0.002 0.116 0.038 0.505 0.046 0.216 0.422
0.982 0.941
0.070 0.389
0.100 0.585
0.184 0.390
0.323
-0.051
0.451
-0.160
0.071
-0.279
0.365
0.360
0.014
0.041
0.540 0.081 0.164
0.223 0.555 0.170
0.850 0.793 0.960
0.631 0.295 0.879
0.014
-0.011
-0.011
-0.057
-0.103
0.518
-0.356
-0.218
-0.077
0.084
0.111
-0.163
0.200
0.960 0.40 1
0.968 0.175 0.682
0.969 0.418 0.547
0.835 0.776 0.458
0.704 0.757
-0.185 0.493
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0.554 0.328 0.262 0.292
Gross mortality percentage
0.166
Net mortality percentage
-0.350
Bed turnover interval rate
0.425
Bed turnover rate
-0.465
Mean hospital stay
0.006
Bed occupancy rate
Leaving ER upon personal consent
Staffing & staff management
0.708
Clinical governance performance
Variables
Risk management & patient safety
Successful PCR
Hospital performance indicators
0.655 0.426 0.423
0.596 0.672 0.203
0.071 0.943 0.247 0.375
0.337
-0.299
-0.246
-0.204
-0.112
-0.128
0.139
0.243
-0.349
0.096
0.055
-0.024
-0.212
0.185
0.185
-0.237
0.291 0.377 0.621 0.846 0.508
0.202 0.449 0.365 0.928 0.494
0.402 0.758 0.324 0.556 0.511
0.182 0.517 0.648 0.732 0.088 0.755
-0.122 0.666
Lida Karbalaee Salmanpour et al., Asian Journal of Pharmaceutical Technology & Innovation, 02 (05); 2014; 01-11 Clinical governance performance and its seven pillars were not significantly associated with any of the performance indicators (12 months from March 2012 to March 2013) of the hospitals under study (Pvalue>0.05). Also, correlation coefficients presented in table 3 show that among the seven pillars of clinical governance performance, only risk management and patient safety, use of information, management and leadership and clinical audit were positively and significantly related to clinical governance performance in TUMS and IUMS hospitals (P-value>0.05). The correlation range from 0.505 to 0.708 with the maximum and minimum correlation coefficient rates for risk management and patient safety (r=0.708, P=0.002) and management and leadership (r=0.505, P=0.046), respectively (Table 3).
DISCUSSION The results of this study showed that Clinical governance performance and its seven pillars were not significantly associated with any of the performance indicators (12 months from March 2012 to March 2013) of the hospitals under study (P-value>0.05). Also, correlation coefficients presented in table 3 show that among the seven pillars of clinical governance performance, only risk management and patient safety, use of information, management and leadership and clinical audit were positively and significantly related to clinical governance performance in TUMS and IUMS hospitals (P-value>0.05). The analytical findings of the present study on the relationship between management and leadership and the performance indicators seem to be the result of more concentration on the relevant tasks and responsibilities in addition to close supervision and monitoring of the managers. The results of this study consistent with results of research of Amerioun and et al10 as “Evaluating management approach of selected hospitals of armed forces and its relationship with hospital performance indicators" and as research of Hamidi11 in hospital managers of Iran University of Medical Sciences done. but the result of the Arab12 as “Relationship between leadership styles of hospital deans and managers and hospital performance indicators”were not statistically significant relationship, which is inconsistent with the results of the present study. The results of this study did not consistent with Mozaffari and et al13as "The importance of performance indicators in promoting the quality of hospitals including clinical governance factors” is clearly seen, which ultimately concluded that monitoring quality of care is impossible without the use of performance indicators. In this regard, the findings are not inconsistent with the results of external studies can be seen. In the study of Cormick and et al14 as "quality assurance,clinical governance,and a patient wants to die”showed that the main aim of clinical governance is ensuring the highest possible quality of clinical care for patients and quality assurance as a major responsibility of all managers and clinical governance as developed structure in the NHS system in order to implement this objective and a great opportunity for improving services provided to patients. also, Baker and et al15 in a study titled" a model for clinical governance in primary care groups" were showed that with regard to the clinical governance in the NHS system represents each person's tasks, individual accountability and quality improvement through effective ways of change in the performance. CONCLUSION The results of this study showed that Clinical governance performance and its seven pillars were not significantly associated with any of the performance indicators (12 months from March 2012 to March 2013) of the hospitals under study (P-value>0.05). Also, among the seven pillars of clinical governance performance, only risk management and patient safety, use of information, management and leadership and clinical audit were positively and significantly related to clinical governance performance in TUMS and IUMS hospitals (P-value>0.05) that seem to be the result of more concentration on the relevant tasks and responsibilities in addition to close supervision and monitoring of the managers which unveils the need for conducting further specialized research projects.
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