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Speech: Ryall - Clinical Governance Assessment Project

Hon Tony Ryall
Minister of Health

6 December 2012 Speech Notes
Speech notes: launching the Clinical Governance Assessment Project final report
Good morning.

It is a pleasure to be here to open your seminar on clinical governance and help you launch the report of the Clinical Governance Assessment Project.

The Project’s goal is to assess the progress New Zealand is making in improving clinical governance and leadership in our public health service….to see how we are doing in re-engaging frontline clinicians in the running of the public health service.

This is the largest research project of its kind in the history of the New Zealand public health service.

Over 10,000 DHB health professionals participated in this project. That’s a quarter of the workforce.

Over 3,500 written submissions were received.

Site visits and interviews with key personnel were held at 19 of the 20 DHBs.

The project’s authors conclude that “there is good reason to be proud and celebrate progress with clinical governance development in New Zealand’s district health boards”. They describe the results as “very positive, albeit with variations”.

They go on to say they found solid and in many cases extremely impressive commitment and growth in building clinical governance and leadership.

I am sure you too find that very heartening.

May I express appreciation to Professor Peter Crampton, Professor Robin Gauld and the University of Otago for the work they’ve put into completing this report.

And also acknowledge the organisations that have supported and funded this work: the Centre for Health Systems, the National Health Board, the Health Quality and Safety Commission, the District Health Boards together with District Health Boards Shared Services.

My remarks today will touch on the importance of clinical leadership, some specific examples, the report results, and challenges for the future.


It is this Government's firm belief that strong clinical leadership is essential to improving our public health service. There are very clear links between clinical leadership, morale, quality and efficiency.

Globally, clinical leadership is recognised as the fundamental driver of improved patient outcomes.

But here in New Zealand, we inherited a health service where many clinicians were concerned their influence on decision making affecting patient outcomes was diminishing.

Cast your mind back four years, and there was significant disengagement between clinicians and managers. You read it in the newspapers almost every day.

This failure to fully engage the very people with the right expertise – doctors, nurses and other health professionals - the people who know the patients' needs best – was seriously eroding their ability to provide patients with the care they needed.

So our government sought to develop a new partnership with the health professions.

In Good Hands

And in 2009 the National Government commissioned “In Good Hands” from a Task Force Group on Clinical Leadership.

Produced by clinicians and managers, “In Good Hands” provided strong guidance to DHBs on how they could re-engage doctors, nurses and other health professionals in the running of frontline health services.

The Group recommended systems that ensured effective partnerships between clinicians and managers, and shared responsibility for both clinical and financial performance.

This is not to say doctors and nurses stop doing what they were educated to do and become managers.

But we did want to use the wealth of frontline experience nurses and doctors have accumulated to improve quality of care and rebuild confidence in the public health system.

And hence why this report has been commissioned…to inform us on the progress that’s been made, where we can do better, and how we might do that.

Clinicians in the driving seat

Engaging clinicians in the running of the health service is not something we expect only of the District Health Boards. The Government has backed its commitment with action.

I would like to acknowledge the considerable contribution of the many health leaders who serve on some of the key entities helping to improve our public health service.

The National Health Board primarily consists of highly respected doctors and nurses who bring a wealth of experience and respect to their role guiding much of the work we are doing.

In the Ministry of Health our clinical champions are playing a pivotal role in helping the public health service achieve the six national health targets.

We are privileged to have Dr Alan Merry – an internationally recognised quality leader – heading the independent Health Quality and Safety Commission.

Having the input of clinicians at the centre of much of our decision-making and agenda has been pivotal to the progress we’ve made in very difficult and constrained financial times.

What is clinical governance?

As Professor Gauld says in this report: “At the heart of clinical governance is the idea that doctors, nurses and other health professionals are best placed to encourage performance improvement amongst peers and should be involved in leadership”.

This report uses clinical governance and leadership variously side by side, and interchangeably. That’s not a bad thing as I see clinical governance and clinical leadership as two sides of the same coin. They are very complementary and intersect.

Clinical governance is about practice and performance, quality and safety. It’s about how standards, quality and processes are promoted and enforced generally within - but not limited to - a specific health delivery environment.

But it’s not sufficient to have structures alone. Clinical governance processes must be able to influence decision making within organisations and within the professions.

Just as there are clear responsibilities, duties and expectations on the corporate governance side of a hospital, so there needs to be on the clinical side.

We need good clinical governance to ensure health professionals can and are using their expertise to maintain and improve quality and safety, and assure safe practice within their autonomous practice but also their wider workplace.

This matters because clinical professionalism underpins the trust the public has in the health service and the people who work in it.
Every hospital should have strong clinical governance processes.

On the other side of the coin, clinical leadership could be described as a more outward looking approach focused on performance improvement, engagement in change, and the future of services and health care.

It better reflects clinicians’ partnership with management in a whole range of activities including planning, implementation and the allocation of resources.

Specific Examples of Clinical Leadership

Over the past four years there have been a number of examples of how clinical leadership has produced effective improvements to patient care and services.

National Cardiac Surgery Clinical Network

Access to cardiac surgery among regions in New Zealand was identified as a major point of concern in 2008.

The Central Region required a 28 percent increase, Canterbury a 25 percent increase and Northern Region required a 15 percent increase. The Midland Region was identified as requiring the largest increase to access of 68 percent.

In 2009 the National Cardiac Surgery Clinical Network was formed.

Who better to do the planning to improve the rate and availability of cardiac operations across the country than the experts in this area – the cardiac teams themselves?

This Network had clinicians and management informing and making the decisions needed to address the issue.

With the assistance of this Network there has been significant improvement in all regions and impressively, Midland Region which was identified as requiring the most improvement, has achieved the full 68 percent increase.

Across New Zealand, DHBs have delivered 400 more cardiac surgery procedures in 2012 than they had at the same point in 2011. DHBs are working within a maximum waiting list and they are monitoring the urgency scores to ensure patients are getting their operations in a timely manner.

Example # 2 Midland Regional Trauma System

Clinicians are also providing ongoing professional support and advice for each other through the new Midland Regional Trauma System.

It was established in 2010 to integrate care for serious accident victims across the Taranaki, Bay of Plenty, Waikato and Lakes DHBs. A core group is based at Waikato Hospital and provides the ongoing support to the other DHBs in the group.

One of the major strengths of the Midland Regional Trauma system is a high degree of decision making by clinicians at the four DHBs and regular communication of viewpoints between all parties. This is a successful governance structure that incorporates the principles of clinical leadership effectively.

Example #3 Counties Enhanced Recovery After Surgery Programme

This programme aims at improving patient outcomes and reducing in-patient length of stay, A multi-disciplinary team including a consultant surgeon, a ward charge nurse, a colorectal nurse specialist and a full time ward doctor are involved in the process.

Their leadership has resulted in significant reduction in the total hospital stay, through multiple interventions involving anaesthesia, nursing and pre and postoperative care. And this work saves almost $7000 per patient.

Example #4 3 DHBs

Wairarapa, Hutt Valley and Capital and Coast DHBs decided in early 2010 that it would benefit them all to have more collaborative clinical and corporate arrangements.

This approach was developed to address increasing workforce pressures and demand across all levels of health service delivery, concerns about the sustainability of some vulnerable services and increased financial pressure.

The Clinical Leaders Group has been established across these three DHBs to ensure clinical leadership is central to this process.

Report Results

The Assessment Project has provided us with assurance we are making progress but there’s more to do in promoting and embedding Clinical governance and leadership.

The report finds all DHBs have worked to proactively promote and provide an environment for clinical leadership. The survey finds that 78% of respondents believed that the DHB worked to enable strong clinical leadership throughout the organisation.

This is a very positive indication of the encouragement provided within DHBs for clinicians to contribute.

The report suggests that DHB employees participate in operation and procedural decision making to change systems for the benefit of patients. The survey found 75% of respondents reported they sought to take up opportunities to some or a greater extent to work with other DHB staff to change systems to benefit patients.

Additionally, 71% of respondents felt that health professionals in their DHBs were involved with management in shared decision making, responsibility and accountability to some extent.

I think this is perhaps the best indication that DHBs are effectively supporting and implementing clinical leadership.

The vast majority of respondents believe that quality and safety was a goal of every clinical resourcing or support initiative in their DHB to some or a great extent.

One result I will draw to your attention is 69% of respondents agree that it is easy to speak up when they see problems with patients care.

And the reason I do so is because this is becoming an over-riding theme of much of the commentary by the Health and Disability Commissioner Anthony Hill.

Mr Hill is increasingly saying in his speeches and reports that patient safety is being affected by members of the health care team who know that something is not right but do not speak up.

He has advised me that in many complaint cases someone in the health care team knew something that could have prevented harm but did not share that.

The introduction of the surgical safety checklist is helping address some of this reticence by some health professionals not to question or alert colleagues to potential or actual problems.

But it is timely for people to reflect on Commissioner Hill’s concerns and recognise that speaking up is a professional responsibility… and should be recognised as such by those who are being spoken to.


Overall the Clinical Governance Assessment Project report suggests that DHBs and DHB staff have done a great deal to improve opportunities for clinical leadership since the early days of In Good Hands.

DHB implementation of clinical leadership and governance principles has flowed over into improved healthcare quality and safety.

There are still areas that can be improved and this improvement will occur as more engagement takes place between staff and management.

I would like to recognise the strong contributions of DHB Boards, CEOs and Senior Leadership Teams to the current stage and further contributions in the future.

The engagement of senior medical officers is also vital to the success of clinical leadership in DHBs due to their level of influence over clinical processes and services.

I am confident that the DHBs’ work in this area will continue to contribute to health outcomes for the New Zealand public going into the future.

The National government remains strongly committed to putting clinicians at the centre of leading and improving our health system.

We must continue to make it easier for people to do the work for which they are skilled and employed, and make best use of the experience and expertise those people possess.

Going by the results from the Clinical Governance Assessment Project report today we are on track to achieving that goal.

It gives me great pleasure to officially launch the Project Report. I am sure the discussions you plan to have at the seminar today will be interesting.

Thank you

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