current systems of quality assurance and clinical audit based on evaluation of
clinical standards, better utilisation of evidence based practice and learning the
lessons from poor performance. The clinical governance framework builds on
professional self-regulation and performance review; it takes account of existing
systems of quality control and includes all activity and information for quality
improvements.
11.9.9 Clinical and cost effectiveness
Clinical audit should be an activity that aims to produce change where change is
necessary and share lessons to be learnt, as well as working towards the delivery of
services of the highest possible standard to individual patients and to populations.
However, the debate about clinical versus cost effectiveness and affordability is
part of the same spectrum of activity and must be considered. The criteria for
doing this are outlined in Fig. 11.2 which shows the areas which need to be
considered and balanced in order to provide the most appropriate care. The bal-
ance needs to be struck between effectiveness, appropriateness and acceptability
which inevitably, when dealing with health care, cannot be audited as perfect when
judged against all these different criteria, and a judgement will be required about
what is reasonable. Resources will always be limited, and clinical audit should play
aleading part in ensuring optimal use of resources.
11.10 Conclusions
In order to obtain both organisational and professional governance all of the
clinical professions must have structures and systems of clinical governance to
maintain professional accountability. These must be integrated and reconciled
with NHS accountability systems and structures at all levels. The key to successful
implementation of clinical governance is to be able to demonstrate the develop-
ment of an accountability structure which ensures that monitored changes in
clinical practice as a result of identification of failures in quality are judged against
the defined standards and their outcomes. Health care organisations now have to
show clear lines of accountability, reporting mechanisms, risk management and
ongoing quality measures to meet the governance agenda.
Clinical audit focuses on the patient and his or her use of resources, the care
given and the outcomes achieved. Quality improvements cover three main areas:
more flexible access to services; greater sensitivity to individual treatment needs;
and improvement in technical competence. Audit provides the systematic reviews
of treatments, and lessons learned will improve standards, reduce clinical risk
exposure and raise the quality of care. This is exactly what clinical governance
needs to achieve in enhancing lifelong learning through education and developing
clinical excellence through processes, systems and outcomes of healthcare deliv-
ery. However, it must be remembered that clinical audit is a continuous process
and a means to an end and not an end in itself. In order to be effective the audit
loop must be closed and there must be ongoing re-evaluation for assurance of best
and up-to-date practices.
238 Nursing Law and Ethics