June 02, 2007
Prompted by outrageous incidents like the Bristol incident and in a bid to improve its quality of care and accessibility to all patients the National Health Service (NHS) issued its White Paper of 1997 with an agenda, “A First Class Service”, set to connect clinical judgement of individual practicing clinicians with clear agreed national standards for health care.9 A new concept of clinical governance was introduced; NHS defined it as 1a framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. 9
In other words it is a system whereby healthcare organisations themselves are responsible and accountable for implementing standards of healthcare excellence, continuously reviewing and improving them when necessary to maintain uniform excellence. These standards were to be set by the National Services Frameworks and process evidence provided by the National Institute for Clinical Excellence on clinical and cost effectiveness and develops the best ways of providing services.9 This is not entirely new concept, because its pillars all have links with the Society's Code of Ethics and Standards.
CPD is one of the key pillars as it as major responsibility for a pharmacist to keep up to date. A pharmacists needs to be aware of new developments in medicine like more effective medicines being developed, “changes in morning after pill” regulations, or changes of indications for a drug or know which drugs have been removed from the Drug Tariff. This is vital for a pharmacist to know what is happening around them and be able to offer the most relevant information to patient or when making clinical decisions. During my placement visit, the head pharmacist said he updated his CPD files every few weeks to help him “stay on top of things”.3 This relates well with Part 2 of the Code of Ethics, which states that pharmacists must ensure that "…they undertake continuing professional development relevant to their professional duties…"
Over the years evidence based practice has become mainstay in pharmacy practice, this comes mainly in the form of evidence based medication. Partly as a bid to cut down on wastage costs and achieve best therapeutic outcome , instead of stocking ten different brands stock two or three that are known to be effective thus the use of formularies and cutting down on poly pharmacy. During my first PBL this was put in practice when the group decided not give Mrs Wilson aspirin to prevent DVT on flight as there was no evidence for its effectiveness but recommended muscle flexing and special compression socks that had been proven to be effective in preventing DVT.11
In order to be able to monitor progress and performance records should be kept. This makes it easier to compare the actual practice to the set standards. A lot of this was evidenced at NAPP pharmaceuticals where every step in the production of medicine from procurement to shipment was rigorously recorded and double checked.6This will make it easy for anyone analysing the process to see if the standards are being adhered to at each stage. The distruction of expired methadone tablets on my visit to Boots was well documented for the same reason.4 In community pharmacy clinical care is monitored to use the information they have about patients to improve healthcare. On the dispensing computers at Boots a warning automatically comes up if a new prescription interacts with current medication. This is achieved through the use and regular updating of Patient Medication Records. 4
But this is not complete without input from the patient. In order to have comprehensive records patient views on their care should be taken aboard like having complaints system or suggestion box for their perceptions of their care. As a result groups like Age Concern’s health care policy representing the elderly.1 Encouraging concordance also empowers the patient as opposed to passive consent when deciding on medication.5
In order to analyse the progress of the practice pharmacists need to conduct audits. This is usually a five day period in which clinical practice is reviewed against set standards; this is facilitated by the documented practice. This process identifies areas that can be appraised and should be shared with other practices because of their effectiveness. At the same time the process reveals areas of care that need improvement, either they did not meet set standards or the set standard did not comply fully with patient needs. After identifying the problems, changes can then be implemented to address these short falls. The Berkshire Audit Group did one such audit on preventive treatment on stokes heart disease.7
Updating or adding standards according to patient care needs brings about an improvement in service but this is not always the case. Mistakes cannot be absolutely waved out by existing SOPs. In such cases risk management is the way forward and pharmacist should be competent in applying of Root Cause Analysis10 which provides the ability to identify the primary cause of a problem not its manifestation. At Ipswich Hospital Pharmacy where robots handle the medicine in an accurate, predictable way that ensures its integrity, there are less likely to be breakages, occupational accidents and mix ups as compared to humans.6 Log books of patient/staff incidents are still kept and filed to the National Patient Safety Agency which reviews them and produces solutions (SOPs).8 This could be done locally, for example at Boots; the pharmacist put notices on shelves under medicines that were often mistaken for the other either by similar name or packaging. Such SOPs are in use at practices like Boots.4
This comes down to the next pillar, staff management. This involves recruitment and training of staff that can provide a service comparable to the set standards or, in the favourable case surpass them. The pharmacist at Boots kept records of staff qualifications and cyclical training in order to keep skills at their “fingertips” and update them on changes due to audit and advancing clinical practices. The pharmacist reviews them, discussing their progress and setting new performance goals that will improve their service4. It also includes effective methods of working and good working conditions as defined by Maslow’s Hierarchy2
Clinical governance in healthcare has past the setting up systems phase and I intend not only use it in my practice but to implement it in helping healthcare become fully integrated by interprofessional working amongst clinicians by more effective management of healthcare teams and continuous vertical learning that ensures cooperation and ultimately improved patient care.