TO THE EDITOR: Braithwaite and Travaglia make some telling points in their article "An overview of clinical governance policies, practices and initiatives".1 However, while they have identified many of the key components of clinical governance, they have underplayed the role that collaborations and partnerships have in ensuring the quality of clinical care. Braithwaite and Travaglia suggest that corporate governance is about what happens in the board room and clinical governance is what happens at the clinical level of the organisation.
The governors (in some cases this is the Boards; sometimes, the executive group) and the clinicians are equally responsible for the quality of clinical care that is provided in the organisation. They have different roles and use different strategies, but for many initiatives they must combine forces. We should not see governance in hierarchical but in partnership terms.
Clinical governance was first defined for an Australian health care setting in the New South Wales Health clinical governance policy2 "A Framework for Managing the Quality of Health Services in NSW". This framework clearly identifies the structures and processes that the governors need to have in place at the organisational level (which of course also relate to the clinical level) for ensuring effective clinical governance. The companion document to this policy, "The Clinicians Toolkit for Improving Patient Care"3 then identified the clinician-level processes and activities that must be in place to ensure that clinicians discharge their responsibility for achieving, maintaining and improving the quality of clinical care. Together, these became the seminal documents for expressing clinical governance in Australia, were influential throughout the country and were relied on by others in international jurisdictions to shape their policy processes.
Another elegant framework that was published subsequently, and followed the principle of collaborative responsibility, is that which is contained in the Australian Council on Healthcare Standards EQuIP 4th edition standards.4 These standards and their organisation provide a practical means of achieving good governance in a health care organisation. The standards are divided into three categories.
* The first contains the clinical standards; the standards for which (mostly) clinicians are mostly responsible
* The third contains the corporate standards; the standards for which (mostly) the governors or managers of the organisation are mostly responsible
* The middle category contains the support standards; those standards for which they are together responsible.
The combination of the first two categories, clinical and support, represents clinical governance and the combination of the second two categories, support and corporate, represents corporate governance. This is one of the easiest ways of describing corporate and clinical governance.
Clearly, there are many models by which to conceptualise clinical governance. Braithwaite and Travaglia have done us a great service in analysing relevant literature and providing a model which can be used to appreciate many of the strategies to achieve effective clinical governance. The key is to complement what they have given us by having both a framework to set the scene and a set of tools by which to implement their core ideas.
Maureen E Robinson
Director
Communio
Sydney, NSW
Maureen.Robinson@communio.com.au
1 Braithwaite J, Travaglia JF. An overview of clinical governance policies, practices and initiatives. Aust Health Rev 2008; 32: 10-22. Available at: http:// 203.147.135.205/publications/articles/issues/ahr_32_ 1_0208/ahr_32_1_010.asp (accessed Jun 2008).
2 NSW Health. A framework for managing the quality of health services in NSW. Sydney: NSW Health, 1999. Available at: http://www.health.nsw.gov.au/quality/ pdf/framework.pdf (accessed Jun 2008).
3 NSW Health. The clinician's toolkit for improving patient care. 2001. Available at: http:// www.health.nsw.gov.au/pubs/2001/pdf/clinicians_ toolkit.pdf (accessed Jun 2008).
4 Australian Council on Healthcare Standards. The ACHS EQuIP 4 Guide. Part 1. Accreditation, standards, guidelines. Sydney: ACHS, 2006.
IN REPLY: Robinson raises an important issue in her response to our article "An overview of clinical governance policies, practices and initiatives."1 Her statement "there are many models by which to conceptualise clinical governance" strikes at the heart of both the question at hand, and the intent of our paper.
The main objective of our paper was to explore the concept of clinical governance, as outlined in the current literature, for the benefit of governing boards and bodies. As with any complex construct, multiple perspectives are possible. In examining the literature from this point of view we were seeking to fill a gap in the review literature and provide directors and executives with a framework for discussion about this relatively new, but well accepted, concept.
Robinson is right to draw our attention to the importance of the partnership between directors and clinicians to the quality of care. Clinical governance brings together two fundamental operating principles of health care: corporate governance and professional responsibility. It is in the connection between these two that clinical governance is enacted, or it ought to be. Our paper analysed the literature on clinical governance from the perspective of governing boards, but it is the structural, organisational and managerial relationships between these bodies and clinicians that makes clinical governance something more than another top-down management strategy.
This is the point we believe Robinson is making by drawing attention to documents such as the NSW Health clinical governance framework2 and the Australian Council on Healthcare Standards' EQuIP 4.3 It is publications such as these which make visible the mutual dependence of boards, clinicians and most importantly, patients. We hope in future papers to re-examine the clinical governance literature from these perspectives.
Joanne F Travaglia
Research Fellow
Jeffrey Braithwaite
Professor and Director
School of Public Health and Community Medicine
and Centre for Clinical Governance Research
University of New South Wales
j.travaglia@unsw.edu.au
1 Braithwaite J, Travaglia JF. An overview of clinical governance policies, practices and initiatives. Aust Health Rev 2008; 32: 10-22. Available at: http:// 203.147.135.205/publications/articles/issues/ahr_32_ 1_0208/ahr_32_1_010.asp (accessed Jun 2008).
2 NSW Health. A framework for managing the quality of health services in NSW. Sydney: NSW Health, 1999. Available at: http://www.health.nsw.gov.au/quality/ pdf/framework.pdf (accessed Jun 2008).
3 Australian Council on Healthcare Standards. The EQuIP 4 Guide. Sydney: ACHS, 2006.
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