1. INTRODUCTION

1.1 The principles and policy framework for clinical governance in the speciality of Geriatric Medicine have been set out in a joint position paper of the British Geriatrics Society and the Royal Colleges of Physicians of the UK, endorsed by the Councils (or equivalent) of these bodies [1].

1.2 This paper prepared by the same joint working group (see Appendix for membership) develops the recommendations for implementation within the speciality. It sets out the minimum implementation requirements within a Trust, to meet the standards set in the position paper.

1.3 The cornerstones of implementation are considered to be the following:

1.3.1 Each department of Geriatric Medicine (or group of consultant physicians specialising in Geriatric Medicine) should have a nominated lead consultant in organisational service quality.

1.3.2 The appropriate participation of consultants in Geriatric Medicine in processes covering each element of the clinical governance cycle [1] should be clearly demonstrable.

2. IMPLEMENTATION MANPOWER AND RESOURCES

2.1 The lead consultant in organisational service quality (who might logically be the clinical director or equivalent) should lead the implementation. This commitment will require at least 1 session per week. This minimum level of funded sessional consultant manpower is an absolute prerequisite for the competent delivery of clinical governance in the speciality as outlined in this paper. Training for lead consultants in clinical governance will be required. The Royal Colleges of Physicians in collaboration with the British Geriatrics Society will prepare guidelines, which will inform and complement the necessary training provided by Trusts.

2.2 All consultants should participate. A minimum of 1 session per month of protected time should be identified and set aside specifically for this process (not in place of other Continuing Medical Education [CME]/Continuing Professional Development [CPD] activities). The protected time required must be written into job plans.

2.3 The resources for 2.1 and 2.2 will require the identification by government of the required sessions for clinical governance within the current contract renegotiations.

2.4 Specialist registrars should be involved. In so far audit is an integral component of clinical governance, the existing mandatory training in audit should be broadened to include training in other elements of clinical governance.

2.5 Senior departmental managerial staff should be appropriately involved alongside clinicians in completing the department's clinical governance agenda, which will also require administrative/clerical support.

2.6. For consultants with parallel responsibilities in General Medicine the arrangement and content of clinical governance should (as for other medical subspecialities) be organised in such a way as to avoid duplication.

2.7 The diversity of departmental service profiles and manpower resources will dictate an evolutionary approach in a significant proportion of centres.

3. IMPLEMENTATION CONTENT

3.1 Each department should comprehensively investigate at least one selected area of specialist knowledge within the remit of Geriatric Medicine per annum. The basis of this model is the integration of one or more aspects of required theoretical specialist knowledge within an evaluation of professional consultant practice and service delivery. (The approach is distinct from a mere revision of the theory required for qualification, which provides no measure of subsequently acquired experience. It also goes beyond putative “lowest common denominator” measures of substandard practice, which lack both specificity and sensitivity in defining the nature and origin of any perceived problem)(See Section 7). It is therefore complementary to the broader and equally mandatory pursuit of other aspects of CME/CPD.

3.2. The Royal Colleges of Physicians and the British Geriatrics Society have identified an initial primary list of topics, on which the following list (with some modification) is based. One (or more) areas of specialist knowledge should be chosen from the list, alongside other topics of key relevance to the speciality.

Management and prevention of falls and syncope

• Management of stroke in older patients
• Management of delirium
• Management of dementia and depression
• Management of continence problems in older patients
• Management of Parkinson's disease and syndromes in older patients
• Prevention and management of pressure sores
• Decision making and communication with respect to resuscitation and end-of-life issues
• Rehabilitation after fractured femur
• Evidence-based prescribing

3.3 At least one area from the primary list should be included in the content of clinical governance service level activities. Other areas of practice can be included and the primary list will require periodic review.

4. IMPLEMENTATION PROCESS

4.1 The underlying philosophy is that service clinical governance processes should be designed to lead to continuing professional and organisational development. They should provide a mechanism to prevent, rather than primarily to redress, shortcomings.

4.2 All, or as many as possible, of the recognised clinical governance tools should be incorporated into the process, namely:

• Clinical and service audit
• Complaints
• Risk assessment
• Critical incident review
• National patient surveys
• Service agreement performance monitoring
• National indicators
• Peer review of accepted standards of care

4.3 Departments should in any case ensure that they have in place a supportive culture where individual clinical cases are openly and freely discussed amongst colleagues.

4.4 When the service clinical governance tool relates to significant concerns involving individual patients as opposed to aggregated populations (e.g. a critical incident review), or entails a systematic review of normal care, it is recommended that two reviewers are utilised, each blind to the other's review. A reviewer may be from inside or outside the department but should have the competence to review the case(s). The review should follow a predetermined template. An example is shown in Table 1.

4.5 All such reviews should be presented anonymously (i.e. the identities of health care professionals and patients should be undisclosed at the meeting). The participants in the meeting and the reviewers should agree on the final completed template. It should be axiomatic that problems identified in individual case review may be caused not only by deficiencies on the part of individuals but also by deficiencies of the system in which they work. [See Sections 5 & 7]

5 IMPLEMENTATION OUTCOMES

5.1 Unless a service clinical governance process identifies absolutely no deficiencies, it should always be accompanied by a clear action plan, which includes:

• the action
• the person responsible for ensuring the action happens
• the date by which the action should have happened

5.2 Individual or team professional development. Individual or team professional development is a likely outcome of these processes. For this reason the identities of those health care professionals involved should be held solely by the department's clinical governance lead.

5.2.1 It should be his or her responsibility to undertake the following:

• Give detailed feedback to individuals and teams on the wide range of service clinical governance processes.
• Give this detailed feedback in a non-threatening way.
• Work with the individual and or team to ensure they have a clear and agreed method of improving performance.
• Ensure that if this improvement is through education it becomes the priority for that individual or team in the next year, and is directly linked to the local appraisal process of the individual or team.

5.2.2 Either the clinical governance lead for the Trust or a nominated member of the department should undertake these responsibilities for the individual appointed as the department's clinical governance lead.

5.3 Service development. Service development is the other likely outcome. The service development need should be explicitly stated and those responsible for it clearly identified. The actual service development itself should follow local policy and procedure but a clear audit trail of accountability and responsibility for its delivery should be available to the Trust's clinical governance lead or outside agency e.g. Commission for Health Improvement, Clinical Standards Board for Scotland.

5.4 Three less likely scenarios may emerge.

• The need for change in another organisation, because of an issue that has emerged within the department's service clinical governance processes.
• That several service clinical governance processes reveal serious concerns about an individual's competence and patient safety.
• That several service clinical governance processes reveal serious concerns about systematic service issues and the management of clinical services.

Clearly defined lines of procedure should be in place to address each of these, involving the departmental clinical governance lead, the clinical governance lead of the trust and the clinical governance lead of any related organisation.

6. CLINICAL GOVERNANCE REPORTING AND RECORD KEEPING

6.1 It is essential that all clinical governance activity reports be kept for at least 7 years with agreed procedures for confidentiality

6.2 Clinical Governance activities and the responsibilities therein should be auditable by appointed professional or NHS bodies. It is therefore recommended (1) that there is a summary report (see illustrative example - Table 2) which can be produced once or twice yearly, and (2) that the individual service clinical governance process reports are kept in a secure area by the department’s clinical governance lead.

6.3 Processes that use technologies to cross reference and interrogate clinical governance data across the organisation or within the organisation over time are likely to emerge and should be seriously considered if shown to be feasible, practicable and cost effective.

7. CLINICAL GOVERNANCE INDICATORS OF MINIMUM STANDARD

7.1 The processes of clinical governance outlined above, if appropriately implemented allow for the sensitive and specific detection of standards below which both professional practice and service delivery may be deemed unacceptable by agreed criteria. They also enable preventative and remedial measures to be initiated at an early stage.

7.1.1 Individual Level: The following are the minimum acceptable requirements as defined by clinical governance activity at the individual level:

• Completion of 50 hrs CPD per annum, the component of geriatric medicine being proportional to its content in the job plan.
• Participation in an annual appraisal linked to the setting of personal development objectives.
• The subjects in the personal learning objectives and clinical governance processes include one or more specific components of the JCHMT curriculum for specialist training
• Personal development objectives to include personal CME topics
• 50% of planned personal development objectives addressed by the next annual appraisal.
• Content of completed CPD activities to included CME activities reflecting the previous years’ personal CPD objectives.
• Evidence of active participation in more than one clinical governance process.

An unacceptable standard is defined by failure to meet any of the above requirements.

7.1.2 Service Level: The following are the minimum requirements as defined by clinical governance activity at the service level:

• There is summary written evidence that either the minimum requirements for acceptable clinical governance activity at the individual level have been met by all career grade medical staff or that action has been taken if this is not the case.
• There is a clear, written 2-5 year speciality service development and improvement plan, the annual progress and review of which takes into account the outputs of clinical governance processes, namely:

Audit

Indicators

National Service Framework / SIGN Guidelines

Consensus documents

Performance Management Framework

Complaints in Health Ombudsman Reports

Critical Incident Review

Patient Surveys etc.

• There is an audit trail for decisions taken by senior provider and commissioning managers to achieve the annual timetabled elements of the service development plan
• There is evidence that the service shows demonstrable year on year improvement in terms of the targets set within the development plan.

An unacceptable standard is defined by failure to meet any or all of the above requirements.