Exploring the human resource implications of clinical governance

Health Policy 80 (2007) 281–296

Exploring the human resource implications of clinical governance Chandra Vanu Som Durham Business School, University of Durham, Mill Hill Lane, Durham City DH1 3LB, United Kingdom

Abstract In 1998, clinical governance was introduced in the National Health Service, UK (NHS) as a major policy initiative to improve the quality of clinical care. The implementation of clinical governance is crucially dependent on the skills, competencies and willingness of the NHS staff. In turn, clinical governance influences the way people work in health care organisations. Therefore, it is no surprise that the introduction of clinical governance has thrown-up new challenges for human resource management. However, what are these human resource management challenges under the clinical governance framework? The current literature on the subject provides no answer. This article attempts to fill this gap in the literature. A qualitative approach influenced by phenomenological case study approach has been adopted. A heterogeneous group of 33 persons identified through a purposive sampling procedure were interviewed using a semi-structured format. The results indicate that the staff members appreciate the crucial role of human resources management in the implementation of clinical governance. However, there is little evidence to suggest that senior management is paying attention to develop the human resources function around the clinical governance agenda. The seven major human resource implications of clinical governance that emerged from the data analysis are discussed. The author argues that a more proactive HR approach is needed to make clinical governance everyone’s business in the NHS organisations. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Health policy; Clinical governance; Human resource management; Quality improvement; Risk management; Evidence based practice

1. Background In response to several cases of well-publicised failures in clinical care [1], the Labour Government introduced clinical governance in the National Health Service (NHS) as a major policy initiative to improve the quality of clinical care in 1998. This quality initiative is crucially dependent on the performance of

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clinical staff, which in turn, is ‘determined by the policies and practices that define the number of staff, their qualifications, their deployment and their working conditions’ [2, p. 5]. In a sense, clinical governance is a framework that could be operationalised through NHS staff commitment, motivation and enthusiasm. Therefore, it is no surprise that the introduction of clinical governance has thrown-up new challenges for NHS human resource managers. However, what are these human resource management challenges in the context of clinical governance framework?

0168-8510/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2006.03.010

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In the last few years, clinical governance has emerged as a popular public discourse topic. But from the literature, it emerges that the human resource implications of health policies in general and clinical governance in particular remains largely unexplored. Most clinical governance discussion in the literature has focused on its definition [3–5], organisational strategies [6,7], leadership [8–11], professional development [12], clinical audit [13], role of chief executives [14], managerial and clinical approaches to quality [15], clinical guidelines [16], organisational culture [17], risk management [18,19], staff development needs [20], education [21] and information management [22,23]. Few of these publications pay attention to the human resource implications of clinical governance. This article attempts to fill a significant gap in the literature gap by exploring the human resource implications of clinical governance. The article reports part of a wider study conducted during the year 2003 in a NHS acute hospital trust.

2. Purpose and research question The purpose of this article is to contribute to the current debate on the role of human resource management in the implementation of health policy initiatives. The article attempts to address the following research questions that have been formulated within the framework of human resources implications of health policies: (a) What is the perceived role of human resource management in the implementation of clinical governance? (b) What are the human resource implications of clinical governance? (c) What is the role of staff members in the development of clinical governance framework in a NHS Trust? (d) What are the problems related to human resources that affect the implementation of clinical governance? An attempt has been made to answer the above questions through analysis of the empirical data collected from semi-structured interviews conducted in a NHS hospital trust (hereby referred to as the hospital trust), documents generated by Department of Health (DoH), Commission for Health Improvement (CHI,

now known as the Healthcare Commission) reports, case studies reported by NHS Clinical Governance Support Team (NHSCGST) and the internal documents generated by the study hospital trust.

3. Theoretical framework Unlike, the previous fragmented approaches to quality assurance where clinical audit, risk management and other quality activities were seen as separate, clinical governance promotes an integrated approach to quality improvement and attempts to bring all quality activities under one umbrella [3]. In a sense, clinical governance creates ‘an environment for organisation-wide approach to effectively manage healthcare quality improvement systems’ [5, p. 89]. Clinical governance is a framework to achieve continuous quality improvement by providing a uniform governance system for clinical care through which the health organisations can work towards achieving the excellent quality standards in patient’s care. The main elements of clinical governance as recognised by the Commission for Health Improvement are: involvement of patients/carer in delivery of services, risk management, clinical audit, evidence based practice, staff management, life long learning, training and CPD, leadership and information management. In an attempt to explore the human resource implications of clinical governance, a systematic approach would be to examine each element of clinical governance and unfold its human resource implications. The contribution of these elements towards continuous quality improvement is crucially dependent on the beliefs, perception, attitudes and values of organisational actors. The attempt by the researcher will be to look into the organisational processes, how the organisational actors relate to clinical governance and what they perceive as the role of human resources in clinical governance. In recognition of the fact that management of human resources has substantial influence on the organisational characteristics such as structure, strategy, size and culture [24], the term ‘human resource management’ has achieved much broader connotations and it is not restricted to the traditional ‘personnel’ functions of a particular department. Leopold et al. [25, p. 9] define human resources as follows:

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“Human resources are the efforts, knowledge, capabilities and committed behaviours which people contribute to a work organization as part of an employment exchange (or more temporary contractual arrangement) and which are managerially utilised to carry out work tasks and enable the organization to continue in existence”. Human resource policies and practices result from a dynamic process, which evolves through negotiations, decision-making and review process [26]. This dynamic nature of the employee–organisation relationship makes the human resource management a challenging task. Therefore, the human resources need to be treated with great care and the employees should be nurtured starting with a very careful selection process [27]. In the context of health service, human resources include all the necessary human ability, skills, competencies and knowledge required to deliver clinical care [28, p. 17] and human resource management has been defined as: “The mobilization, motivation, development and deployment of human beings in and through work in the achievement of health goals, which is based on the essential value assumption that people seek . . . certain satisfaction from their work” [29]. Under the clinical governance framework, ‘human resource’ would include any function, activity, practice, process, responsibility or role that would directly or indirectly impact upon the health staff’s ability to contribute to the process of continuous quality improvement. Since a diverse range of personnel such as medical, nursing, technical, administrative, managerial, catering, laundry, cleaning, estate management and other support staff are involved in delivering clinical care, management of human resources [28] for developing clinical governance could be quite a complex task. Thus, the HR strategy should be developed keeping in mind the organisation wide implications of clinical governance and the HR policies and practices should support the development of clinical governance framework. Human resource management is a strategic player in the clinical governance framework to achieve the objective of continuous quality improvement. Hence, human resource issues require special

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attention of decision makers at the strategic level (the chief executives and the senior management team) as well as the line managers. Ideally, the HR director should be a member of the board and HR managers should assist the clinical staff to steer the organisation towards its objectives and goals. But the implementation of human resource policies should not be left to the HR specialists only. The human resource management should engage everyone in the organisation and effective implementation of HR policies would require partnership between HR department with the line managers and other employees [24]. Line managers have a vital role to play in the effective management of human resources through organising team briefings, conducting appraisals, encouraging clinical audits and so on, where the line managers act as drivers of HR policies. At the heart of this thinking is a view that directly or indirectly, every person associated with patient care is also associated with the human resources function on a day-to-day basis. For example, the modern matron not only performs his/her duties as a clinical staff but also performs certain human resource functions (e.g. leave, sickness absence, roster and appraisal) while managing people working under his/her supervision. HRM and the management of organisational culture should coincide to become same project to encourage consensus, flexibility and commitment [27]. The main challenge here is to ensure that these basic HR functions are dealt with in a coherent manner to support clinical governance. This understanding of human resource management is crucial while implementing any change process designed to bring culture change, adopting new ways of working and developing quality improvement systems. Under these circumstances, a pragmatic approach that allows us to take a more holistic view of HR in healthcare organisations would enable us to explore the HR implications of an organisation-wide phenomenon like clinical governance.

4. Research methodology The choice of research method depends on the circumstances, research topic, research questions and the organisation where the research will be conducted [30]. Taking into account the fact that healthcare organisations are complex systems with multi-dimensional

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problems [31] there are several benefits to using qualitative research methods [30]. The advantage is that qualitative research adopts an interpretive, naturalistic and descriptive approach to the subject matter when researchers study things in their natural settings, attempting to make sense of, or interpret, phenomena in terms of the meanings that people bring to them [32]. It helps to develop an understanding of reality [33] as experienced from the personal perspective of informants [34] and describes their underlying motivation [35]. In other words, qualitative reflection helps to describe the essence of the lived world rather than providing a causal explanation of that experience [33]. This approach enables us to develop an insight into a phenomenon by moving away from an obsession with measurable outcomes and scientific explanations. Sanders [36] argues that from an organisational research point of view, qualitative research, influenced by phenomenology, helps to probe the deeper structures of organisations, emerging themes and underlying essences that are difficult to trace using quantitative research. Apart from being a flexible approach, it provides a new way of probing organisational research problems [36], and it helps to analyse ‘the collective experiences of a group of people’ [37]. In the present context, a qualitative perspective can enrich our understanding of how the senior managers, clinical professionals and frontline staff have responded to clinical governance and what they perceive as the major HR implications of clinical governance. This approach also has the added advantage of focusing upon a particular organisation (NHS hospital) for a detailed understanding of the reality, giving attention to the complexities of the phenomenon [38]. In turn, the qualitative approach will provide richness in the data and an in-depth understanding of the research topic. Qualitative approach was therefore adopted from a desire to be responsive to the phenomenon [39] and to explore, characterise, and interpret the HR resource implications of clinical governance from the perspective of the participants.

5. Triangulation While acknowledging that no observation or interpretation is perfectly repeatable, Denzin and

Lincoln [40] argue that triangulation serves to clarify meaning and verify the repeatability by looking at the phenomenon using multiple perceptions. Thus, triangulation is an important way of increasing the reliability and validity of a research study. The use of in-depth, semi-structured interviews coupled with document analysis [36] provides the necessary triangulation for verification and validation of the data. At the macro-level, triangulation has been achieved through literature review, secondary data and primary data and at the micro-level triangulation has been achieved through various methods as illustrated in the diagram below. The three different points of the triangles in Fig. 1 indicate the three different main perspectives. At the macro-level of triangulation, the three main perspectives are the literature, secondary data and the primary data. At the micro-level, triangulation is achieved through the review of literature on clinical governance, clinical practice and human resource management. Similarly, the micro-level triangulation for the secondary data emerges from the Department of Health documents, CHI reports, and the NHSCGST case studies. For the primary data, the micro-level triangulation is achieved through the semi-structures interviews, documents generated by the hospital trust itself and the documents generated by external agencies like CHI about this particular hospital trust. Accordingly, the data collection was planned for this research study.

6. Research design The important aspects of research design— sampling, data collection process and method of data analysis are illustrated below [36]. 6.1. Sampling Purposive sampling is more useful to decide who should be the subjects for the research study [30]. The choice of subjects for study is based on persons ‘who can give reliable information on phenomenon being researched’ [36, p. 356]. The sample size (i.e. how many subjects should be sufficient for the research study) was guided by the research design. Since considerable amount of time is required to conduct and

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Fig. 1. Triangulation at different levels.

interpret semi-structured interviews, usually a small number of participants are selected [36,39,41]. After obtaining permission to conduct this research from the Local Research Ethics Committee (LREC) and the study hospital trust research committee, a manager in the human resource department was contacted to obtain a list of board directors, clinical directors, directorate managers, consultants, modern matrons, senior nurses, HR managers and general managers. The participants for the research were selected from this list after consultation with senior managers associated with the implementation of clinical governance and a manager in the human resource department. This purposive sampling process helped to select the 42 key informants for the research based on their role in the implementing clinical governance, HR responsibilities or both. The selected sample included the Chairman, CEO, Executive Directors, Clinical Directors, Directorate Managers, Senior Consultants, Senior Nurses, HR Managers and General Managers.

6.2. Data collection Semi-structured interviews were used as they provide a loose structure to explore the ‘lived reality’ of people’s experiences [42]. A first-person description [43] enables the researchers to get closer to the participants’ experience of the phenomenon [40], with ‘the additional benefit of uncovering issues or concerns that had not been anticipated or considered by the researchers’ [30, p. 149]. The interviews were conducted in the participants’ workplace (a familiar environment) to make them feel relaxed and comfortable so that they are able to ‘respond honestly and comprehensively’ [44, p. 114]. While interviewing the participants, every attempt was made by the researcher to be a ‘non-directive’ listener (following Ref. [43], p. 139) and researcher’s views were withheld [37, p. 74] in order to comprehend the lived experience of participants [45]. The literature review helped to frame the research question [35] and generate the interview

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guide1 (a list of probable questions). However, the interview questions were revised following the pilot study. The interview guide helped to maintain the focus on the research topic during the interview [35,43]. The 42 prospective participants were contacted through letters (along with the information sheet and consent form) giving them the details of the research. The letters were followed-up with e-mails and phone calls requesting an appointment for the interview. The overall response from the participants was encouraging (75%) and 33 persons participated in this research. The 25% participants were unable to take part mainly because of their busy schedule. For example, interviews were cancelled when clinicians had to attend patients in the emergency ward. Analysis of participants’ professions revealed that 8 doctors, 13 nurses, 5 HR managers and 7 general managers took part in the research. Looking into the roles and responsibilities, 10 participants were currently handling clinical responsibilities, 5 were handling human resource management, 15 were in general management, whereas 3 participants were handling clinical as well as managerial responsibilities (e.g. Clinical Director). The analysis revealed that there was no mismatch in numbers of any staff groups from nonparticipation. All the interviews were tape recorded to obtain a full description of the participant’s experience [36,37]. The duration of each interview varied from 45 min to 1 h. These semi-structured interviews and various documents (mentioned earlier) provided a wealth of information to address the research questions. 6.3. Document analysis Using documented accounts along with semistructured interviews in a case study enables the researcher to crosscheck the status of the various statements made by the interviewees and to make sense of the interview data [46]. The purpose of document analysis in this research is three-fold. Firstly, it gives an overview of the organisation, thereby enabling the researcher to be acquainted with important features in the organisational context of the particular case under study. Secondly, it helps to build an interview guide relevant to the context for the semi-structured interview. 1 Copies of this interview guide could be obtained by contacting the author.

Finally, it provides necessary information for crosschecking and evaluating the findings of the research. For this purpose, the documents were selected based on two criteria: (1) their relevance directly or indirectly to clinical governance, human resource management or both and (2) their date of issue [47]. Only those documents that were produced between April 1998 (when the clinical governance was introduced) and September 2003 (when the first phase of review was nearing completion) were selected. In total 38 documents were initially identified as potentially relevant to the study and a subset of 14 documents (Appendix A) was then selected for detailed analysis (following Ref. [47]), because they appeared: • to provide detailed information on clinical governance; • to have significant implications for clinical governance; • to provide detailed information on HR; • to have significant implications for human resources; • to have potential HR implications for clinical governance. Documents provided a wealth of information and collective knowledge about the hospital trust (following Ref. [48]) that may be otherwise inaccessible. 6.4. Method of analysis Three methodological aspects, the emic approach, autonomy of the text, and bracketing [42, p. 140] guided the analysis. The ‘emic’ terms are the exact words used by the participants during an interview [41, p. 189]. In the emic approach, direct quotes from the interviews are used to reveal the ‘respondents’ depth of emotion, the ways they have organised their world, their thoughts about what is happening, their experiences, and their basic perceptions [49]. Further, treating the text as autonomous data without any theoretical preconceptions enables the researcher to describe the lived experience of the participants [42]. During the analysis, bracketing the researcher’s views played a vital role capturing the experience of the participants [37,45] without any interference from preconceived notions. Bracketing is essentially a self-reflective process that requires bringing participants’ viewpoint into focus [50] while other issues are temporarily left out of consideration [36]. Keeping in

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mind the above three methodological aspects helped to analyse the data with minimum bias where the researcher bracketed his opinion and permitted the data to speak for itself [51]. Potential bias to findings may arise from participants’ possible unwillingness to discuss sensitive issues. However, during this research none of the participants expressed unwillingness to discuss any of the questions put to them during the interview. The interviews were conducted in such a way that the participants direct the course of the interview and spoke freely about their experience. The audiotapes were transcribed verbatim [41,52] to preserve the informants’ original words/sentences. The initial analysis of the transcripts focused on the participants’ unique experience [51] of the phenomenon under study. The transcripts were read (and reread) adopting the process of going ‘back-and-forth’ relating a particular part of the text to the whole [41,43] while the interpretations were continuously revised to broaden the context as more of the text was analysed [52]. It was an iterative approach to analysing the data looking for similarities, differences, patterns in the informants’ experiences [37,52], and contradictions of the participants’ own understanding [41] to create a more holistic sense of the data. In this way, emerging themes were developed by repeatedly studying the interview transcripts.

7. Ethical issues Ethical issues arise because of the in-depth nature of the semi-structured interviews [43]. The sense of involvement felt by the researcher and the participant [51] in the semi-structured interviews is much greater (compared to postal survey, for example) because of the interaction between the two individuals during the interviewing process. Following strict ethical principles (and procedures) the prospective participants were contacted only after obtaining permission from the Local Research Ethics Committee and the Hospital Trust’s Research Committee to conduct this research. Each interview was started when the participant expressed satisfaction with the information provided and voluntarily agreed to participate in the research by signing the consent form. Participants’ identities are preserved throughout by omitting the hospital trust’s name and their names.

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8. Results The results indicate that participants appreciated the crucial role of human resource management in the implementation of clinical governance by putting right people in right positions, providing opportunities for skill up-gradation, preparing staff for advanced roles and ensuring adequate level of staffing in every department. However, there is little evidence to suggest that systematic efforts are being made by managers to work towards organisational integration, policy integration, functional integration or process integration [53] for the development of effective HR policies/practices that would support clinical governance. The seven major HR implications of clinical governance revealed by the data analysis are as follows: (a) role of human resources in improving risk management; (b) managing people to deliver patient focused clinical care; (c) supporting health staff to adopt evidence based practice; (d) role of HR in facilitating clinical audit; (e) managing HR information to support clinical governance; (f) systematic appraisal to manage individual performance; (g) HR problems in the implementation of new governance framework. Clinical governance (the quality improvement framework), corporate governance (focusing on financial standards and performance) and people governance (the way staff are organised and managed) are the important areas of governance. These three strands are closely inter-related and influence upon each other; they are not separate but each contributes to the overall organisation’s governance framework. Therefore, each aspect of clinical governance has some important human resource implications, as will be illustrated in the following paragraphs. 8.1. Role of human resources in improving risk management Clinical risk management is one of the clinical governance’s key areas. The hospital trust developed a Clinical Risk Management Strategy in 1999 (and

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revised it in 2001) that intends to promote a “fair blame” culture, where the incidents are investigated to determine and correct ‘systems faults and failings’ to improve patient care. The medical director is the designated leader for clinical risk management in this hospital trust. A clinical risk manager has been also appointed by the hospital trust to promote, monitor and evaluate the risk management activities. The risk manager reports to the medical director and works closely with the designated leads for risk management in the directorates to coordinate the implementation of the clinical risk management strategy. Efforts to establish a closer link between clinical governance and human resource management issues are clearly visible in some directorates. A project around medical devices and risk management is in progress in the trust. Explaining the benefits of this project one directorate manager said, “We have a nurse whose role is specifically around the medical devices and looking at how we use medical devices. Currently she works part-time, she is going to work full time, her role is to look at how we use medical devices what training people actually had and keeping people updated about medical devices alert. Whenever we get an incident that involves medical devices we pass that information to her and then we sort of collect the trends in different devices”. As part of the project, the nurse looks at the training needs analysis of the staff, to actually find out who needs to be trained in what sort of devices. Establishing this kind of linkage between HR issues and clinical governance to demonstrate the influence of HR on quality improvement would not only improve the quality of patients’ care but also make the benefits of clinical governance visible to the people. However, further research is necessary to explore how training to staff on risk management issues help in minimising the serious incidents. Some people feel that the prevailing culture makes the risk management system unworkable. Explaining a situation the risk manager, said, “we may have an incident where the consultant is very clearly in the wrong, but the people are unwilling to challenge him or her because of the hierarchy that exists within the ward team”. Supporting this view, one consultant argued, “I can’t see any trust where a CEO can afford to take

clinical governance and risk management so seriously that he risks antagonising the consultants – so I think that has been the basic flaw – lack of understanding of the power structures within the NHS Trusts”. Therefore, people going through risk management sincerely have realised that the management cannot afford to back them up. The present culture does not really support open discussion on clinical risk issues, particularly when it might involve a senior clinician. 8.2. Managing people to deliver patient focused clinical care The hospital trust has developed a patient user partnership strategy in 1999 so that patients and carers’ views could be used for service planning. Along with any strategy, it is necessary to put right people in place who can implement this strategy. As a part of this patient user initiative, a Patient Advocacy and Liaison Services (PALS) manager has been appointed in the hospital trust. The PALS manager works independently of the hospital’s managers and reports directly to the Chief Executive Officer. The role of the PALS manager is to deal with the patient/carer experience—regarding their treatment. There are times when the clinical staff may not be able to understand the patients’ perspective. It is the responsibility of the PALS manager to understand the patients’ viewpoint and communicate the same to the concerned staff. In a sense, the PALS manager acts as an advocate for the patients—asking questions on behalf of the patients regarding the quality of care. However, there could be problems when some staff “don’t like to be challenged about how they have treated people because they feel [that] what they have done, is right” said the PALS manager. The staff members need to be properly trained to be able to appreciate the viewpoint of the patients, reflect upon their complaints/suggestions and identify problems areas so that the patients’ feedback could be constructively used for improving the quality of care. In general, the staff members are aware of the procedures for engaging patients/carers in clinical decision-making. However, during the CHI inspection of this hospital trust it was found that, staff members get little feedback from the complaints procedure and there is little evidence of learning from complaints [54]. Similarly, there is a consent policy [i.e. taking prior consent of patients for treatment] in the hospital, but some

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clinicians are not aware on how to put the consent policy into practice. Training of clinicians is necessary to put the consent policy into practice so that patients get an opportunity to be involved in the clinical decisionmaking as envisaged under the clinical governance. 8.3. Supporting people to adopt evidence based practice Clinical governance recommends evidence-based practice to secure clinical risk reduction, improve outcomes and bring consistency in the quality of care through identification of best practices. To deliver high quality care under the new governance framework, health staff should learn “how to practice evidence based medicine being given the means by management and by their own colleagues to monitor their own activity and to prove it is evidence based” explained one consultant. In order to make the concept clinical governance workable, one consultant feels that staff members need skills in research evidence appraisal and time for critical appraisal of the research based evidence to ensure that their practice is evidence based. However, the pressures of clinical work sometimes make it very difficult for the clinical staff to find time for skill development activities that would support evidence based practice. In addition, describing the current situation one consultant said, “the most important element that is missing in the current clinical governance arrangements is that we have no protected time”. Moreover, this lack of time creates a kind of dilemma for people trying to do a balancing act. As one clinical director explained “yes, you have to work with greater quality, greater adherence to evidence base, audit that sort of thing, at the same time you have to meet all these targets”. Sometimes, it could be a daunting task for the clinicians (who are already hard pressed for time) to meet targets, reduce waiting times and at the same time make sure that the care that they are delivering is evidence based. By ensuring, that adequate time and resources for education, training and professional development are available, human resources department could support the staff in embracing evidence-based practice. 8.4. Role of HR in facilitating clinical audit Clinical audit provides a mechanism for monitoring the quality standards [13] set under the clinical gover-

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nance framework. In theory, clinical governance may provide the structure, systems and processes to deliver excellent clinical care but in practice, things could be different. In addition “that’s why it’s important to have some sort of audit process to make sure what you think is going on—is actually going on” argued the CEO. However, during the CHI inspection, there was no clinical audit strategy in this Trust [54], but at the time of this research, a draft Clinical Audit Strategy was ready. Trust regulations stipulate that the Clinical Audit Office approve all audit projects. Adequate number of staff was available in the clinical audit office to provide assistance to all grades of staff in clinical audit. The director of nursing is the designated lead for Clinical Audit (CA) and each directorate has a clinician designated as the CA lead. Although the clinical audit system is in place quite often the clinical audit is not delivering the desired results. One of the reasons why this is happening is that quite often junior doctors are doing an audit. According to one directorate manager the clinical improvement group in that particular directorate, found that they were having monthly audit meetings that was well attended but the junior doctors were doing the clinical audit most of the time. The problem was that the junior doctors rotate every 6 months so there were no follow-up actions being taken on the issues that were identified. The problem is compounded by the fact that in some departments, nobody was identified for taking the responsibility to complete the clinical audit cycle and sometimes the records of the audit are not kept properly. There is no systematic procedure in place to circulate the findings of an audit for other people to see later on, what has been done, what has been looked at and what were the actions taken. The human resource department could constructively support clinical audit by providing appropriate training, allotting sessions for clinical audit and rewarding those clinical audit teams that achieve quality improvement of care. 8.5. Managing HR information to support clinical governance Systematic data collection is necessary for effective human resource management. The trust’s Human Resource Strategy document (2003), acknowledges the need for improvement in the quality of HR information and it’s analysis in order to enable the

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senior management to identify the problems areas and take corrective action in a timely manner. Similarly, the HR Director expresses the view that in order to prepare a credible workforce plan, it is necessary to know certain basic workforce characteristics e.g. gender, age, ethnicity, length of service, turnover, training details, personal development plans, etc. However, the collection of human resources data in this hospital trust is not supported by any specific human resource software package and most of the systems are manual, paper based systems explained one personnel manager. The limited human resource data available electronically is collated by pulling out information from various sources—mainly the pay roll system, data that is generated by risk management, health and safety, serious incidents or near misses or accident report form. The trust does not have a software package to support human resources data collection and it is unclear whether the data/information produced is accurate [54]. In view of the deficiencies in the information system for human resource management, the CHI visit (in 2002) has recommended installation of more robust information systems for data collection and monitoring of staff management issues. As a solution to this problem, the Trust has purchased a Workforce Information System (WIS) that can download from the payroll a lot of HR related information. According to the HR director, “This software is capable of producing analysis at the trust board level, directorate level, and indeed at the department level or ward level”. In an effort to encourage the increased use of HR information for developing organisational strategy, the HR director plans to place before the trust board the first report on some of the workforce characteristics. This will also help to develop a better understanding of the overall human resource management capacity and capabilities in the Trust. 8.6. Systematic appraisal to manage individual performance One consultant who has earlier worked in senior management feels that “appraisal is quite fun, it is an enjoyable process to talk about your own job and what you want to do” and it is a very useful thing because “the point of having an appraisal is to agree on a job plan and careers development issues including

training”. Although recent research has found evidence that well managed appraisal makes a contribution to enhance the quality of patients’ care [55], in practice it could be very difficult to convince clinical staff to go through the appraisal process. The chief executive feels that carrying out appraisal needs sensitive management of the clinical professionals, because with hands on responsibilities for patients care their appraisal would involve looking at the fundamental part of their clinical work. And that could be a very sensitive issue for the individuals (particularly the consultant doctors) who may be reluctant to discuss about their clinical practice with others and often feel confident that they are delivering the highest standards of care. So managing the fallouts of the appraisal could be quite a difficult task and has a major implication for human resource management. The CHI Report [54]2 of this hospital trust has been critical of the consultant appraisal and has said in its report that, “The appraisal system is uncoordinated and in some areas is not being implemented”. Explaining why this happened a former executive director said, “lots of people were unable to agree on their job plans and they didn’t see any reason why they should get appraised for their job plan agreement”. Some of the other reasons why appraisals were not taking place could be lack of time, resources and issues related to the internal politics of the organisation. But the scenario might change with the implementation of new consultant contracts whereby each pay progression will be linked to the annual appraisal. Explaining the situation the former executive director explained, “consultants’ appraisal will be rolled out only when the people have to do it in order to get their pay progression under the new contract, otherwise it is seen as a nuisance”. However, things are gradually changing and the consultants’ appraisal is now part of the CHI action plan in the hospital trust. This issue is now regularly discussed in the trust board meetings. There has been considerable progress in the appraisal of consultants, since the CHI visit. Training sessions were organised for the appraisers and appraises and these trainings are still ongoing. The chief executive monitors the appraisal process and keeps a record of the same. It is the responsibility of the clinical directors to appraise 2 The name of the NHS hospital trust is not mentioned keeping in mind the ethical issues associated with the research.

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their colleagues. The crucial advantage of appraisal process and preparing job plans in justifying recruitment of additional staff is now being appreciated at the directorate level. Through this process of job plan preparation the workload in a department could be systematically assessed. One consultant pointed out that in one department they were able to get additional funding for the post of another consultant, demonstrating the advantages of the appraisal process (and job plan preparation) if it is taken-up seriously. 8.7. HR problems in the implementation of new governance framework Recruitment and retention problems, strict financial regimes, shortage of staff and rigid staffing patterns are some of the HR problems faced in the implementation of clinical governance framework. “Improvement in quality of care does not come cheap” said one former executive director. For example, under the clinical governance framework, NICE’s patient safety recommendations require introduction of new staff, more staff training on certain procedures and regular inspections of medical equipment explained one modern matron. It means allocating additional financial resources for human resources. But most of NHS organisations are facing “financial pressures and regimes” that make it difficult to increase staffing levels, explained one executive director. Even if the additional financial resources are made available, the problem is further complicated in some specialties where it is difficult to find a professionally qualified person to take up that position. As a consequence in most of the departments studied, shortage of staff is a problem. As one manager explained, “The biggest problem that we face is staffing and if you do a root cause analysis, a lot of the [serious] incidents that we actually get, inevitably come back to the number of nurses and doctors that we have”. This problem gets magnified when clinical services are over stretched—wards are at full capacity, staff members are working at full capacity and they are doing too much over time. In such a situation, sickness absence further aggravates the staffing problems. According to a directorate manager, “We do have an effective sickness absence policy where, we try to keep our sickness absence levels down to a minimum, because obviously that is an increased burden on

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other ward staff”. The trust’s comprehensive Sickness Absence Policy and Procedure (2003) recognises the adverse effects of frequent staff sickness on the quality of care. The policy document clearly defines the responsibility and procedures to be followed for managing people reporting frequent/persistent sickness. However, another manager expressed the opinion that sickness absence could be managed in a better manner. Under the present system, the managers have limited powers for handling the “problematic sick” [staff] and “the trust does not actively promote coming into work” felt one manager. Sometimes, the situation becomes difficult to handle and the staffing problems become visible. The staff shortages triggers a cycle of problems that affects the quality of care as illustrated in Fig. 2. The human cost of staffing shortages is that the moment people feel they are understaffed they feel tired, they go off sick and sometimes they resign. There are people who have left the NHS or left their clinical profession to take up other jobs. Therefore, staff shortages have short-term as well as long-term consequences for staff retention in the NHS. The NHS spends huge amount of money educating and training specialist clinical staff. When they leave one hospital and join another, it may be seen as a transfer of specialist staff within NHS. However, when people (particularly the specialists) leave NHS for private jobs, it is a great loss for the NHS. The human resource department have a vital role to play in retention of the staff so that the quality of patients’ care does not suffer. In an attempt to convince people to stay on, this hospital trust offers family-friendly policies (including flexible working hours, negotiated roster system, etc.). During periods of extreme staff shortage and full capacity in the hospital, incentives like overtime payment are offered to motivate the staff to work additional hours. However, these monetary rewards wear off soon when people become tired. This is particularly the case when they are doing too much overtime. In the long run, additional staffing is required to alleviate the pressures on the existing staff members, said a manager. With a diverse workforce like in the NHS, recruitment and retention is a difficult and challenging task. The recruitment problems arise mainly because: (a) sometimes many people retire or resign within a short period time;

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Fig. 2. Shortage of staff and its impact on the quality of patients’ care.

(b) there is clearly a shortfall in certain clinical staff category in UK (e.g. critical care nurses); (c) there are shortage of people for certain specialists clinical jobs (e.g. radiography). To deal with these problems, this hospital trust (like many other NHS trusts) sent recruitment teams to other countries to attract nurses. In addition, retiring staff members were re-employed to overcome shortage of clinical staff in some departments. The specialists’ posts are advertised in wide range of publications and internet web pages. In an attempt to attract qualified persons in those specialist areas, these adverts highlight the advantages of working for this trust. Another way the hospital trust deals with these problems is to call upon other hospitals and their departments to find out whether staff can work extra hours—but this is a short-term solution. Moreover, there are agencies that are able to provide qualified staff within a short notice. Nevertheless, employing temporary staff through local agencies has implications for continuity of care and the quality of care. The agency staff might not have the appropriate skills, competencies and training necessary to deliver the highest standards of care. On the other hand, under financial constraints not many hospital trusts are inclined to spend money educating and training temporary staff.

Therefore, every activity within clinical governance framework aim at improving the quality of clinical care has an element of people management. Hence, it is necessary to develop a HR approach that is “sympathetic to the clinical governance agenda” said one manager. This would mean developing human resource management practices that motivate people to participate in clinical governance, build confidence in the framework and provide them with necessary skills to perform their duties competently is the only way to drive the clinical governance agenda forward. 9. Discussion and recommendations In organisations like the NHS, where the majority staff are highly skilled, well-trained and qualified professionals, the workforce may not respond to the traditional personnel approach of the HR department. Fear of punishment, for example, may not necessarily help to deal with poor performance in clinical care because the current system accepts rationalisation/justification for mistakes as valid [56]. Under these circumstances, it is essential to develop a framework where clinical decision-makers can provide sufficient justification in advance for the expected outcome(s) of the proposed intervention. Further, any aspect of human resource management that is

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perceived to be compulsory (for example, appraisal) is likely to face resistance from professionals. A more proactive HR approach that understands the different professional groups, encourages them to participate in decision-making and creates an environment of harmony in the organisation is more likely to succeed. In terms of implementing clinical governance, a distinctive proactive HRM approach is required in the NHS to make it work. In the context of healthcare management, this paper recommends that a more proactive HR approach may include the following: 1. HR department should adopt a more systematic approach to recruitment and retention to ensure that the right people with the right skills are put in the right positions at the right time to deliver the expected high quality of clinical care. 2. Regular assessment of staffing levels based on the patients’ dependency level and the number of critical incidents, particularly in the wards where the workload is heavy and shortage of staff is likely to affect the patients’ care. 3. HR department should plan recruitment well in advance to avoid shortage of staff due to retirements, etc. 4. More team oriented learning opportunities needs to be created as part of on-the-job training to strengthen the team-working skills in the clinical staff and promote a culture of multidisciplinary teamwork. 5. HR managers and general managers need to be trained for at least once every year in the wards to get a better understanding of how their work affect the patients and the frontline staff. 6. Create a skill database of all staff and an information management system to ensure that they undergo regular training. Monitoring such information regularly to find out whether staff is appropriately qualified/trained to perform their specialised tasks. 7. As part of the early warning system, poor performance detection mechanisms should be clearly defined in the risk management strategy, so that major disasters could be averted. 8. Skill Escalator Progression system with welldefined incentives needs to be established to

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encourage people to undergo appropriate training that will help them take-up advanced roles. 9. Sufficient time should be provided in the employee’s job plan for quality improvement activities (e.g. clinical audit) when finalising employees’ contracts. 10. The sickness absence policy should actively encourage coming to work and enable the managers to effectively deal with the problematic staff. Since clinical governance is influenced by how staff are organised, their values and standards, how well trained they are, how staff members behave toward patients and how they communicate with their colleagues, it is necessary to adopt a more proactive HR approach (like the one described above) to support the integrated quality framework. The mantra for achieving continuous quality improvement is to engage all supervisory staff in various aspects of human resource management starting from the formulation of HR strategy to its implementation, so that managing human resources becomes part of everyday work for all supervisory staff and does not remain in the restricted domain of the HR department. It will not only raise the profile of HR but it will provide clinicians with the confidence to solve many problems on the shop floor without taking them to the HR department.

10. Limitations and suggestions for future research The main limitation of this research emanated from the difficulties in getting access to NHS organisations. As a social science researcher gaining access to NHS organisations have now become much more difficult partly because of the NHS Research Governance Framework published in 2001 [57]. Keeping in mind the welfare of the patients and the NHS staff members, the new research framework has laid down more strict guidelines for seeking permission from the Local Research Ethics Committee, which is excellent. However, the application procedures prescribed for seeking permission are designed around clinical trials. This causes a lot of inconvenience to the social science researchers, who have to fill in the same application forms as researchers conducting clinical trials. Then the LREC is likely to evaluate a social science research pro-

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posal on the same parameters as applicable to clinical trials. However, most of these parameters/precautions applicable to clinical trials may not be applicable to a social science research. For example, in this research there was no contact with the patients, no clinical procedures, no clinical tests or drug trials and thereby no possibility of injury to anybody. However, the procedure for seeking permission for social science research was as complicated as for any clinical trial. Even after getting the permission from LREC, getting appointments with NHS staff was an equally challenging task. Notwithstanding the limitations, this research was able to explore the HR implications of clinical governance. Further research is necessary to reveal the effect of issues like attendance, sickness and staffing levels on the quality of clinical care. In addition, we need to know: what is the motivation of health staff to implement clinical governance framework? Is it visible reward and punishment, opportunity to achieve excellence, increased job satisfaction, increased training opportunities or opportunities for advanced roles? All these questions remain unanswered and point to the need for further research to reveal the role of employee participation in establishing clinical governance in healthcare organisations. A comparative study of secondary and primary care NHS organisations would help to enhance our understanding of the HR implications of clinical governance. As a much larger research project, it will be interesting to know whether the HR implications of clinical governance in UK hospitals trusts and those in other countries (e.g. Australia, New Zealand) are the same or different, and the reasons for such similarities or differences. In this regard, it is worthwhile to investigate whether cross-cultural differences (as suggested by Hofstede [58]) hold true in the case of healthcare organisations also.

11. Conclusion Clinical governance is a vehicle to help staff and the organisation to improve the quality of care. This new quality framework is brought into practice by healthcare staff. Therefore, they must be well managed, well organised, well educated, well trained and well conversant with all aspects of clinical governance. In this regard, a more proactive HR approach is needed that

will make clinical governance everyone’s business in the NHS organisations. This HR approach will ensure the recruitment of staff who understand the essence of clinical governance, create enthusiasm for increased participation in clinical governance activities and facilitate development of an education and training strategy that is built around complying with the governance framework for continuously improving the quality of clinical care.

Appendix A List to 14 documents generated in the Hospital Trust that has been considered in this research: 1. Clinical governance strategy (2002). 2. Human resource strategy (personnel development strategy 2003). 3. Risk management strategy (2001). 4. A new structure for a new organisation: a discussion paper (July 2003). 5. CHI visit report (2002). 6. CHI compliance report (2003). 7. Clinical governance development plan—three directorates (medical and OPD, accident and emergency, and operating theatres) (2003). 8. Policy for the safe use and management of medical devices in the clinical environment (2003). 9. Lifelong learning directory (April 2003–March 2004). 10. Minutes of Heads of Department Meeting—June 2003. 11. Minutes of Heads of Department Meeting— September 2003. 12. PALS patient advice and liaison service—giving a helping hand (2003). 13. Ask the execs – your questions answered – 27 May 2003. 14. Sickness Absence Policy (2001).

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