The issue of quality of care for older patients has been in the limelight for about three decades now. Wells (1980) first described this problem. He noted that geriatric nurses worked very hard and were indeed busy, but they were very engaged in the wrong things. As a result, older people continued to receive suboptimal care. For instance, patients who suffered strokes would be catheterized unnecessarily or catheters were left on site for patients who were immobile after orthopedic surgery despite the need to remove them. Moreover, when there was a shortage in time for physiotherapy, the older patient population would suffer (Nazarko, 2004). This issue of poor rehabilitation for older people is still prevalent in many healthcare institutions, resulting in poor quality of care for this vulnerable population. As a result, this paper explores how effective evidence-based quality care could be provided to this population. Clinical governance helps to achieve this outcome.
Past Policy Agendas for Geriatric Patients
Previously, quality issues were not considered as part of healthcare delivery (Gray & Donaldson, 1996), but this has since changed. The Department of Health introduced national policies requiring the improvement of care in healthcare settings. Healthcare quality outcomes would be delivered to the patient using the concept of clinical governance (Nazarko, 2004). Underlying frameworks under this concept involved scrutiny of organizations as well as clinical audits (Lugon & Secker-Walker, 2001). Clinical governance was, therefore, put in place to curb underperformance, benchmark excellent organizations and improve quality of care at local sites (Scally & Donaldson, 1998). Patients were no longer viewed as the passive recipients in the care environment, but active partners in the delivery of quality care.
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Clinical governance requires management skills and brought about significant changes in nursing culture. Moreover, it reconciled the expectations from management with learning objectives (Ferguson & Lim, 2001), thereby resolving conflicts arising from a central command line and an antagonistic localized culture. These effects affected the innovation and responsiveness to the needs of the patient.
Research has voiced concerns of quality of care provided for older people since the early sixties. After about 50 years, the Health Advisory Service identified eight issues largely affecting the geriatric population (Nazarko, 2004). Even so, the geriatric population continue to receive substandard care. Older people find it more difficult to access health services compared with younger populations. Some health services have explicit age restrictions, whereas others are restricted unofficially. For example, studies have found that there are age limits placed on some procedures such as renal dialysis and coronary artery bypass surgery. High dependency care is prescribed for post-operative care of people over 90. Nevertheless, only 4 percent of the geriatric population is admitted to high-dependency units (Gray, Hoile, Ingram, & Sherry, 1998).
Clinical Governance for this Population
The introduction of the internal market into the NHS led to limited inter-agency cooperation and thus inequitable access to services (Robinson & Le Grand, 1994). Despite the fact that modernization requires the NHS to become more responsive to the needs of its clientele, bureaucratic structures make it difficult to achieve this objective. Clinical governance presents the need for central targets, similar to those provided in national service frameworks but also address the service needs for local sites. The gold standard for the NHS to provide excellent service would be to ensure that its target population, geriatric patients, receive quality care.
Research indicates that recent services have been reactive in nature, where two-thirds of geriatric patients were admitted as emergencies and up to 57,000 operations were canceled. 70% of these cancelations were the result of bed shortages arising from unplanned admissions (Berwick, 2002). Moreover, 20 percent of geriatric patients admitted in 2000 were admitted inappropriately and another 50 percent were admitted for a wrong description of their condition (Nazarko, 2004). Where older people were served by reactive means, their condition often worsened leading to expensive and intensive care needs. Moreover, geriatric populations have three times the likelihood of being admitted as emergencies because they are vulnerable to situations such as loss of muscle strength and inability to carry out their normal daily activities (Nazarko, 2004). In light of this, the Department of Health notices that adverse events are frequent in geriatric patients and could have serious consequences for these patients. Because of the confusion present in older people due to their condition, they may not notice service mishaps and failures, including receiving wrong medication or inappropriate dosages (Nazarko, 2004). Thus, the delivery of best-quality care for this population requires that this service becomes proactive.
Clinical governance is different from previously used systems because it provides a coherent framework. Unlike previous frameworks, it is not a number of unrelated initiatives. Clinical governance requires collaboration and commitment at different levels of the organization, with the service being transformed from a reactive to proactive and effective one. As a result, those leading the change are at the bedside of the patient.
Clinical Governance and Change Management
Previously, managers were charged with control, with roles such as quality control, minimizing complains and optimizing budgets and ensuring sickness absence. Clinical governance provides a different measurement standard for management – employees are required to improve and innovate, which is different from the style adopted in traditional styles. In modern care environments, nurses are in charge of others and facilitate their colleagues’ change. Because of the abundance of theories of change in different organizations, care staff can learn from the lessons and failures of individuals who introduced change within their settings in different times. As a result, these lessons will enable care professionals to understand the diversity of change and its relation to the time, culture of the organization and the people experiencing the change.
Clinical governance thus focuses on the integration of change into the organization. Although managing staff may be tempted to use their power to force through change, this approach is not well advised, since it is a misconception of power within the organization. Staff equally hold the power to resist and block change and where leaders do not use their power wisely, staff could wield this power against them. Using manipulative, dictatorial and paternalistic methods to achieve change have become outdated. Instead, value-based approaches are required so that the leader with the welfare of followers in mind achieves the best results. Clinical governance provides leaders with the opportunity to create self-reflecting and change-embracing organizations, where new thinking and open-mindedness are acceptable concepts. Clinical governance thus implement a set of core values within any overall strategy of change, where essentials such as recognition of the two-way nature of change and reciprocity are set out. Additionally, adaptability is key with regards to change management, as well-intentioned actions could lead to unforeseen changes within the organization. Leaders must then be able to see new possibilities and work in an agile manner for the delivery of best services.
Clinical governance also sets a standard for continuous professional improvement, where caregivers must work consistently and coherently with multidisciplinary teams to provide top-notch care. Organizations need to perform audits of staff skill levels and qualifications and to organize staff appraisals, training and additional education for the purpose of improving quality of care delivered to patients (Nazarko, 2004). It is possible that staff could require additional non-clinical time to full participate in appraisals. An active investment in quality improvement is required to improve outcomes associated with providing good quality care.
Conclusion
Care professionals have come a long way in ensuring that services provided to older patients are still rated as high quality. Although no practitioner goes to the hospital to provide poor care, there has been trends that indicate that there is still improvement required in service delivery to geriatric patients. The reason behind this is not the lack of knowledge on the part of nurses or that they do not consider the consequences of their failures. Instead, clinical governance provides a framework for the transformation of service provision in care settings. Nurses have received standards to guide their practice in dispensing best-quality care. There is some recognition that older patients require specialized care teams. Perhaps the only challenge to this development is overcoming poor attitudes for bedside staff and the impact of poor-quality care histories.
References
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