Introduction 

The somewhat itinerant life of a healthcare improvement consultant affords a few benefits, one of which is that I sometimes get to engage in the lives of several organisations simultaneously. While the fast-switching can be a little taxing, I’ve discovered that working with different levels in organisations (across regions and sectors), makes the subtle commonalities across them a little more apparent.

For instance, over the past year, I’ve worked on a range of initiatives linked (or at least adjacent) to questions of clinical governance*. Although clinical governance is widely (and correctly) regarded as a critical high-priority activity, most leaders and practitioners will readily express a multitude of frustrations with it - too much reporting and analysis for too little return (in terms of actionable intel), not having enough time to pursue real improvement, a lack of buy-in from frontline teams, unreasonable expectations from regulators, a perceived lack of trust from boards or senior management, a constant pattern of playing catch up with risks, low morale, a sense of resentment from clinical colleagues, so on and so forth. Most leaders are also prone to a gnawing anxiety from overseeing quite complicated systems without having a good handle on emerging risks or the sufficiency of mitigation efforts deployed.

There is a good chance that if you have worked in the field, you would have some experience with these issues yourself. With a decade spent in the churn of safety and quality work in the early years of my career, I wholeheartedly empathise!

Yet, the mere fact that similar stories emerge from organisations separated by time, space and service contexts suggests that these are perhaps a natural expression of something deeper, a ‘shaping’ influence that exists across organisations rather than merely some coincidental pattern of recurrent operational, technical or even cultural failures. The more I work with diverse organisations, the more I see this as a byproduct of the shared model of clinical governance^ adopted by many healthcare organisations.

I realise that what follows will be a discomforting read for some. This is not designed as a polemic against the obvious value of good governance systems in healthcare. Many tasks exist to make regulatory compliance easier or to demonstrate a visible commitment to safety and quality. These are important organisational priorities, no doubt. There is even the view that the resource cost of the extra administrative burden is offset by the promise of legal protection if failures do happen. While each of these assumptions can be debated, this is besides the point.

The essence of clinical governance has been described as simply to “integrate activities that support continuous quality improvement”¹ , in other words, in supporting the learning and response cycles that make healthcare safer.

If the ‘essential’ work of governance starves us of time, space and the required clarity to attend to the ‘essence’ of governance, isn’t this as compelling a reason as any to bring such conversations out of the shadows? If the muddled systems that we find ourselves enslaved to are complicit in creating this situation, then untangling those knots must be part of the conversation too.

Deconstructing clinical governance

Typical clinical governance activities tend to be viewed as an obligatory, non-negotiable exercise that organisations needn’t enjoy but just muscle through as efficiently and uncritically as possible. While these are complicated undertakings already, every other year something new is stirred into the pot, a new multiplicative numeral here, an added national standard there, another dimension of safety or quality to be fractionated out of the turbid slurry of clinical work.

When this happens, there is often little tolerance for (perhaps even a degree of fear of) entertaining questions that might go against the grain. In many organisations, to play the devil’s advocate by querying exactly how a given quality activity improves care is a sure-fire path to being labelled a contrarian or to even be uninvited from subsequent committee meetings (an observation not lost to many a clinical colleague). Yet, conversations about the relative value of various activities should be the most obvious first step in an era of resource rationing. A line of sight to the higher goal should not come at the cost of the immediate task.

What I often find is that governance teams tread this path not out of fear of regulators or due to a misplaced devotion to procedure. For many, it is the only system of practice they know.

So how did we even get here?

Well-meaning efforts in the early 2000s gave us the foundations of the current model that many organisations continue to support today. We could describe this as a ‘rationalist’ (systematic, rules-based, empirical, analytical and compliance-centric) orientation to governance or as a rationalist ethos that permeates much of this work. In the absence of precedence, it would have made perfect sense to pursue this path, given that there were similar moves underway around the same time in the public service sector across the UK and Australia under the banner of ‘modernisation’.

In many ways, the intentional formalisation of this approach (as opposed to something that might have emerged over time) offered us a testable hypothesis - a proposition the adoption of this rationalist model would a) elevate the focus on safety and quality, b) create a culture of continuous improvement and c) make healthcare demonstrably safer and of higher quality. While ‘a’ was achieved rapidly (a massive win on a global scale), ‘b’ and ‘c’ have not been borne out by the evidence after three decades of strenuous effort.

Global patient safety and quality clearly did not experience the step changes in outcomes that were anticipated at the start of this journey. By extension, even if formalised governance systems conferred some local benefits in terms of an improvement culture, it certainly hasn’t manifested as a widespread pattern of continuous improvement at scale (otherwise things would have undoubtedly improved).

But there is an even more troubling aspect to all this.

A case of salting the wound?

One only needs to scan reports of major safety and quality failures in health and social care over the past two decades to see a consistent pattern emerge - a sampling of UK / Australian events are represented in the graphic below. Behind the tragic human costs, these examples highlight the repeated failures of governance systems to identify and engage with serious internal signals of risk. It also implies that whatever governance structures were in place in these institutions, they oversaw activities that did not pick up that the safety and quality of operations were degrading to dangerous levels.

The fact that the engine rooms of governance can become so disconnected from the very priorities they exist to serve should keep healthcare executive and boards awake at night. At the same time, we should not accept the salve that these case studies are some how blips on an otherwise high quality landscape.

At minimum, they represent one end of a continuum that most organisations will find a place on. Over the years, I have become more inclined to believe that this pattern of growing disconnect might well be an outcome of the rationalist governance approach and the mental models and practices it entrains: A ‘feature’ of the design of these systems rather than a ‘bug’.

If current paradigm of clinical governance actually impedes true assurance and improvement - how does this happen?

The Dynamics of Degradation

There is a lot of possible territory to cover here. The safety science, sociology and organisational psychology literature is rich with examples, theories and counter-theories of how organisations incubate the necessary conditions for large scale failures within their management systems and institutional logics.

While we cannot touch on all the relevant material, I think it is worth highlighting certain negative patterns that predictably emerge from an over-reliance on the rationalist toolbox and go on to undermine the overall efficacy of clinical governance systems within organisations.

1. Reification and the Streetlight Effect

Just like in the high-school biology class with the eviscerated lab specimen, dissecting everyday clinical work with a rationalist lens makes us adept at describing what structures we see, while teaching us very little on how these parts work together.

When dealing with the behaviours of systems composed of living components with shifting, intangible linkages between them, it is natural to fall back on the visible and countable in lieu of a true understanding of how the desired behaviours are produced. These simplified models of safety and quality with their multiple categories and matrices lead us to feel some sense of control over the problem without creating a true sense of how these end points are produced in the real world practice.