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Principles of Audit and Governance in Ophthalmology
Corporate liability„Walsh (1998) detailed the concept of corporate liability for both competence and performance within the NHS, and delineated impelling reasons for institutionalised audit procedures.
Risk Management„In the light of high profile system failuresin Bristol and elsewhere, the government is understandably concernedto reassure the public. „If clinical governance is driven solelyby an agenda of control and risk management, the result couldbe compliance rather than commitment.
Relevant Bodies„Medical Royal Colleges, the General Medical Council, the NHS Executive and NHS trusts all have their roles. Other statutory bodies such as the National Institute for Clinical Excellence (NICE), the Commission for Health Improvement (CHI) in England and Wales, and the Clinical Resource and Audit Group (CRAG) and the National Clinical Standards Board (NCSB) in Scotland and the relevant bodies in Northern Ireland, will be crucially important. Clinical governance depends not only on self regulation by clinicians but also requires support for clinicians from managers and involvement of clinicians in management.
“system failure”„„Underpinning contemporary theories of quality improvement is the axiom that poor individual performance usually reflects wider"system failure" or the absenc1e of an organisation-wide systemof quality assurance.In healthcare organisations, criticalincidents can lead to death, disability, or permanent discomfort.This, together with clinicians' tendency to protect their individualautonomy and reputation, can promote a culture of blame and secrecythat inhibits the organisational learning necessary to preventsuch incidents in future.
Systematic approach to qualityassurance and improvement„Introducing clinical governance to primary care, the government stated that it "must be seen as a systematic approach to qualityassurance and improvement within a health organisation ...Aboveall clinical governance is about changing organisational culture...away from a culture of blame to one of learning so thatquality infuses all aspects of the organisation's work.
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Governance„The current definition of governance is thus…‘A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.’
The Audit CycleTheAuditCycleAgreecriteria(settarget)PlanCareInvolveObservepractice(ImplementChange)the(CollectData)maetEvaluatePerformance(PerformancevsTargets)
Outcome MeasurementCondition/ProcedureCataract extraction and LOICorneal graftDacryocystorhinostomyRetinal detachmentCLINICAL OUTCOME MEASUREMENTDataQuality IndicatorsPre-op best corrected VA. Post-op: % achieve 6/12 Post-op VA at discharge or better in eyes without from hospital. Post-op VA co-morbidity or % gain>2 at final refraction (or 3 lines ofSnellenVAmonths). Co-morbidity (additional diagnoses)Graft survivalClear graftEpiphora(absent, % free ofepiphoraat improved no change)hospital discharge or 3 monthsAnatomical re-attachment %at ... weeks after first time surgeryEvidence/ReferenceRCOphthNational Cataract Audit 1998/99UKTSSA follow-up dataRCOphthaudit
„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„„MEASUREMENT OF SERVICE PROVISIONConditionataDQuality Indicators ÝEvidence/ReferenceCataract extraction and IOLTime on waiting list for elective surgerymedian time on waiting list. % waiting 12 months or moreDoHreport on outcome indicators for cataract 1997GlaucomaOrganisation and range of servicesspecial clinics/screening arrangementsWaiting time for hospital appointment% within ... weeksAvailability next visual field appointment% within ... weeksDiabetic retinopathyOrganisation and range of servicesspecial clinics/screening arrangementsWaiting time for hospital appointment% within ... weeksWaiting time for PRP% within ... weeksAge related macular degenerationWaiting time for hospital appointment% within ... weeks
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