Clinical governance is defined as a systematic approach to the maintenance and improvement of the quality of healthcare provision within a health organizations and system. Clinical governance is helpful in carrying out the foster teamwork in the Primary Health Organizations, is supportive to both clinical, as well as, non-clinical staff, helps in meeting the PHO’s performance management requirements, and most significantly helps in improving the outcomes of healthcare for the enrolled populations of these organizations (O’Neill, 2014). Clinical governance framework can be described as a framework with the help of which the health organizations are responsible for improving the standards and quality of their healthcare services, as well as, safe guarding the high sets and standards of care in continuity by adopting an environment which will lead to the provision of excellent clinical care (Stonehouse, 2013). This framework is basically in support of an internationally recognized framework and defines the healthcare quality in six main domains, which are safety, efficiency, effectiveness, appropriateness, patient-centricity, and equity (O’Connor & Paton, 2008).

Concept of governance and management: Governance requires the recognition of the roles by the teams and the accountability for their actions. As individuals, everyone is accountable for their own practices, including their managers and colleagues. If there is any kind of concerns regarding the performance of their co-workers, it should be immediately raised and addressed to the appropriate managers (McKeown & Thompson, 2001). One must act sensitively and responsibly when questioning about the practices of any other team member and should ensure the presence of an explicit framework, and a culture where counseling, as well as, support are optional to disciplinary action. The responsibilities of the management should be clear, and policies should identify any kind of arrangements for the delegation, deputation, and cover for the absentee (Arya & Callaly, 2005). Each member should be aware of the mechanisms about reporting the incidents and how to cope up with a situation. This involves procedures for the team staff for alerting the more senior managerial or clinical staff in case the team disagrees with the management plan for the patient (Williamson, Benjamin, Devine, Katz, & Pink, 2015).

Concept of clinical governance: Clinical governance can be viewed and described as an umbrella concept that contributes towards the challenges in the identification of the concept (Singh, 2009). The proliferation of various mixed metaphors like umbrella, framework, model,  represents an inherent ambiguity regarding the clinical governance’s precise nature (Cowan, 2000). In New Zealand, the clinical governance term has only being implemented since 1999 and the most advanced kind of clinical governance is observed in PCOs.  Clinical governance within the health and human services/DHBs are more tentative and recent. The main elements of New Zealand’s clinical governance system are the following:

• Development of joint professional accountability for managing the clinical activity for the improvement of the quality and for making better use of all the primary healthcare resources, management of relationships between members of primary and secondary care.
• Implementation of the infrastructure of the primary care including appointments of staff, an information system for computerizing, managing and merging the practice registers, to analyse the pharmaceutical and laboratory data and to provide feedbacks to the healthcare members.
• Formulating peer group of various clinical guidelines, as well as, monitoring the performance for evidence-based and better quality practice.
• Management of increasing resources of primary and secondary care for achieving effective health outcomes for both patients, as well as, communities
• Establishment of community’s new form and consumer participation (Gauld & Horsburgh, 2014).

For instance, Counties Manakau DHB has formed a Clinical Board including broad ranging membership, which is focused on the continuous quality improvement, effectiveness, clinical safety, and commitment towards the consumer participation. Further, the Health Waikato has formed a Clinical or Shared Governance Framework for the provision of clinical staff involvement in comprehensive quality improvement, decision-making, clinical audit, etc. Moreover, the Quality Health New Zealand is known as to be New Zealand Council’s trading name on Health Care Standards. This is the national accreditation body that is formed by the health sector for improving the standards, as well as, performance of health services and disability services. QHNZ is formed to undertake audits and surveys, as well as, awards accreditation to DHBs, rest homes, hospitals, community services, mental health services, home  care services, disability services, Maori health providers, primary care services, and non-profit organizations (Gauld, 2013). Hence, the clinical governance framework helps in attaining all these elements and aims to drive behaviors at the organizational, as well as, at the individual level, which will result in better and effective patient care (Owen & Grealish, 2006).

Delivery of health services: The provision of New Zealand’s public health services is mainly carried out through district health board (DHBs), mainly through the network of 12 DHB, which are owned Public Health Units, consisiting of both communicable and environmental disease control, services related to health promotion and prevention. Since 2001, there has been a coordination of the primary health care (PHC) via the Primary Health Organisations (PHOs) that gets the capitation funds for the enrolled populations. Moreover, they also contracts the GP practices, as well as, other health practitioners to deliver primary health care services (“New Zealand Health System Review”, 2014). Health, as well as, disability services are delivered by using a composite network of people and organizations. Everyone plays an equal role while working with each other across the network to achieve effective and better health outcomes of patients (Kinney, Lima, McKeever, Twomey, & Newall, 2012). The health care specialists and surgeons deliver ambulatory care to the people either in the community-based private or private clinics or also provide in the hospital outpatient units. The specialists are mostly hired by public-sector hospitals. However, many of them also keep their own private clinics. Hospital inpatient and outpatient services are primarily delivered by public hospitals, which are either administered and owned, or are DHB funded. The outpatient or inpatient treatment in the public hospitals are not charged. Individuals are prioritized to have full access of the publicly funded health services. Mental health care in New Zealand is largely outpatient- and community-based. While, provision of maternity services are carried by a Lead Maternity Carer, where 75% are midwives. There is free provision of basic dental care for children below 18 years. However, there is only little publicly funded dental services for adults, except in case of emergencies (“New Zealand Health System Review”, 2014). The ACC is a government-funded, comprehensive, no-fault personal injury system that provide funds for treatment, rehabilitation, as well as, compensation for the individuals who gets injury in New Zealand. Moreover, New Zealand’s present health system is also responsible for providing services to the individuals with disabilities (Davis, 2003). While the Ministry of Health provides funds to the services for the individuals aged below 65 years, the DHBs provides fund to the services meant for individuals of 65 years and above.  According to the Health and Disability Services Eligibility Direction, 2011 each and every resident of New Zealand have rights to access the public services. A strong recognition is observed in New Zealand on the cultural and social acceptability of various health services, which are primary aspects of the accessibility of the health services (Edozien, 2013).

Reflection: As being the health care practitioner, I benefited from the clinical governance framework. As the clinical governance framework focuses on different parameters, it has helped me to understand the basic requirements of the healthcare provision to the patient. The communication skills, ability to work in teamwork and leadership qualities are being inculcated due to this framework. Clinical auditing and effectiveness of this framework leads to the improved patient care and increases the professional satisfaction. The adherence to the framework has made me efficient and effective in providing healthcare. Though there are various advantages linked to the clinical governance framework, but during the provision of healthcare services, I experienced certain drawbacks resulting from this framework. As this framework includes various clinical audits and supervision, I experienced that many team members of my multidisciplinary team were reluctant in taking clinical ownerships despite of the fact that they were very good in dealing the health conditions of the people. Hence, this could restrict people in providing care and can lead to the professional isolation. Further, I noticed that everyone was more interested in taking a multidisciplinary approach instead of participating individually during the provision of the healthcare. Clinical audits were considered as an extra undertaking by various healthcare practitioners. Moreover, as the framework consists of different components like education, clinical audits, clinical effectiveness, clinical supervision, patient-centered healthcare approach, and risk management, there was a lack of resources mostly in terms of time. Due to the insufficient time and resources, a great tension in the environment was being generated, which affected the performance of the individuals in my teamwork. Various overwhelmed healthcare providers had the feeling that they have insufficient time, which made them feel frustrated and low. This, in turn, would affect their performance. Further, I observed that the fear of litigation and suspicions due to hierarchy, generated negative attitudes and unwillingness to actively participate in the provision of the healthcare. On the other hand, those individuals who were ready to undertake the responsibility were not allowed to play their professional roles just because the main focus was on audit, as well as, compliance. This attitude in return caused the crisis of trust amongst the individuals. During the provision of the healthcare services, I also noticed that the main emphasis was given to the quality assurance programs, and there was no emphasis on the ethical and moral principles and aspects in decision-making. Moreover, as the main focus is on quality assurance, it masks the other aspects and its operationalisation, mainly regarding transparency, fiduciary duty, and accountability. The main focus on the clinical audits at certain times overruled the basic and main purpose of the healthcare organizations. Hence, irrespective of various advantages that the clinical governance framework provides, there are ample of drawbacks that are restricting the provision of the better and effective provision of healthcare directly or indirectly.

Clinical governance during the provision of the healthcare services is multifaceted. The concept of clinical governance is underpinned by various generic principles based on the accountability, transparency, probity, and fiduciary duty (Som, 2011). However, these principles are not actually followed by some due to the fear and negative attitudes generated amongst them because of clinical audits and supervision. The main focus of the clinical governance on audit and quality has obscured various other dimensions and parameters of the governance, as well as, their application in the process of decision making during the carrying of healthcare and clinical activity (Harrop & Gillies, 2013).  No doubt, the clinical governance framework is a useful idea and concept in the health care industry and focuses on the quality and management of risk associated with the provision of the healthcare services to the patient, but still it is failing to achieve it completely (Kazanjian & Green, 2004). Hence, steps should be taken to overcome the negative outcomes of the clinical governance framework.

The generation of the negative attitudes and reluctance to participate individually because of the fear of audits and supervisions leads to an ineffective development of the practice skills, especially amongst those who are new in the healthcare field. Hence, it should take initiatives and provide more education that will generate the feeling of self-confidence in the individuals. Moreover, it should provide certain measures and methods of overcoming the tension and stress due to the conductance of various clinical audits and clinical supervisions. Health organizations should also focus on the moral and ethical consideration while decision-making and should educate the members that the main aim should be an effective provision of the healthcare services than just passing the audit (Moore & McAuliffe, 2012).

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