The Clinical Governance Research and Development Unit (CGRDU) was launched in April 1999. It is the successor to the Eli Lilly National Clinical Audit Centre, an organisation that had provided support to primary care audit groups (also called medical audit advisory groups) since 1992. It is core funded by Leicestershire Health Authority with some pump priming funds from Eli Lilly and Co. Ltd.
Clinical governance can be defined as a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.
Many GPs are weary of change in general, and suspicious about clinical governance in particular, and may thus have doubts about the need for research into clinical governance. But because it is such a new concept, practitioners are in urgent need of guidance about how to make it both practical and effective. Past efforts to improve clinical practice have not always been as successful as was hoped, so it is essential that we make clinical governance work.
At the same time, the pressures on practitioners and primary care groups (PCGs) are growing rapidly – certainly much faster than the resources that are available to help deal with them. New ideas should therefore be practical to implement, and aim to make working lives easier as well as more effective.
While providing support to primary care audit groups, we have discovered much about improving practice. This can be a complex challenge, but the need for simple tools and approaches is paramount, because time and resources are not – and probably never will be – sufficient.
As the Lilly Audit Centre, we provided practical tools such as audit protocols and methods for investigating patient opinion. These tools were issued to all primary care audit groups and have been used by large numbers of practices throughout the country.
With the introduction of clinical governance, a wider range of tasks is required of primary care teams and PCGs and the need for support is even greater. For example, practical methods of appraisal and risk assessment are needed.
Effective links between audit and education have often failed to materialise in the past. Clinical governance offers an opportunity to bring this about in the context of professional development plans, although the most effective methods have still to be determined.
Despite numerous attempts to implement guidelines, the number of successes is depressingly low. There is thus a strong argument for providing practical support and tools.
CGRDU is a relatively small organisation within the Department of General Practice & Primary Health Care at the University of Leicester. However, we can draw on the support of other members of the Department and University, so we punch above our weight.
We also collaborate with other experts in the field. For example, together with Martin Roland of the National Primary Care Research & Development Centre at the University of Manchester, we have developed a practical guide to clinical governance for primary care teams.1
The guide recognised the enormous challenge that clinical governance might present to a primary care team. Our response was to emphasise the long period over which it will be introduced, and to break the elements of clinical governance down into small steps. Different teams may tackle different steps, according to their needs and priorities.
A prime task of CGRDU is to undertake research into aspects of clinical governance. We are thus involved in submitting proposals for funding and undertaking studies. The principal funders of our research are the NHS R&D programme, DoH and Regions.
However, the CGRDU focuses on the practical. Its aim is to produce practical products from studies, as well as increase the body of knowledge about quality improvement and clinical governance. For example, in past studies we have produced tools for facilitators of primary care teams and methods of evaluating team culture and use of clinical audit.2
The CGRDU has introduced the idea of obstacles to change that need to be addressed when trying to implement changes through the introduction of guidelines or clinical governance. We have tried to show that this can be a practical approach to use as part of implementation.3
We have also used the findings of our research in providing courses. In the past most of our training has been developed for support staff working with primary care audit groups. Now we are in the process of reviewing our objectives for education and training and it is likely that plans will be developed for supporting PCGs and their clinical governance staff.
In promoting EBM, we have devoted considerable time to the development of evidence-based audit protocols. Many people with an interest in EBM seem to forget that the fifth stage of the process is audit of current practice to check that appropriate care has been implemented.
It sometimes seems that talking about evidence is easier than implementing it. When we do get around to audit, we often find that implementation has not been successful.
Our audit protocols are designed to overcome this problem. Each audit protocol includes a set of evidence based review criteria and instructions for the audit. The criteria are developed from evidence following a systematic process, with those that are most strongly supported by evidence and having greatest impact on outcome being categorised as 'must do'.
As a result, the number of criteria in an audit is reduced to the minimum, and efforts to change performance can be concentrated on those elements of care that are most important. In several studies we have shown that this approach can lead to improved performance in large numbers of practices.
The CGRDU website includes several protocols that can be downloaded (www.le.ac.uk/cgrdu/protocol.html). Others are available from local primary care audit groups, and yet more can be found in the book Evidence-based Audit in General Practice.4
clinical governance research & development unit
|Set up||1st April 1999|
|Objectives||To undertake research & development within the field of clinical governance|
|Funding||Principally Leicestershire Health Authority, with some pump priming support from Eli Lilly & Co. Ltd|
|Key personnel||Director:||Professor Richard Baker|
|Deputy Director & Senior Lecturer:||Dr Francine Cheater|
|Clinical Lecturers:||Dr Kamlesh Khunti & Dr Mayur Lakhani|
|Contact details||Address:||Dept of General Practice & Primary Health Care, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW|
- For further information about the CGRDU, please contact Professor Richard Baker at the Department of General Practice & Primary Health Care, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW (tel 0116 2584873 or email firstname.lastname@example.org).
- Roland M, Baker R. Clinical Governance – a practical guide for primary care teams. Manchester: University of Manchester, 1999.
- Reddish S, Sorrie R, Darling L, Hearnshaw H, Peddie D. Foundations for Quality Improvement: A facilitator's programme guide. Leicester: Leicestershire MAAG, 1995.
- Baker R, Hearnshaw H, Robertson N (Eds). Implementing Change with Clinical Audit. Chichester: John Wiley & Sons, 1999.
- Fraser RC, Lakhani MK, Baker RH (Eds). Evidence-Based Audit in General Practice: from principles to practice. Oxford: Butterworth-Heinemann, 1998.