April, 2011 - SUPPORT Summary of a systematic review | print this article |

Can clinical governance improve the quality of general practice and primary care?

Clinical governance is a systematic and integrated approach to ensuring that service providers are accountable for delivering quality healthcare.

Key messages

The current evidence base for clinical governance is limited, and focuses mainly on process rather than outcomes
Most of the evidence originates from high-income countries and support governance models that use targeted, peer-led feedback on clinician practice
There is limited information on the impact of clinical governance on chronic disease management, care of the elderly, and mental healthcare

Who is this summary for?

People making decisions about improving quality of care in general practice and primary care.

This summary includes:

Key findings from research based on a systematic review
Considerations about the relevance of this research for low income countries

Not included:

Recommendations
Additional evidence not included in the systematic review
Detailed descriptions of interventions or their implementation

This summary is based on the following systematic review:

Phillips CB, Pearce CM, Hall S, Travaglia J, de Lusignan S, Love T, Kljakovic M. Can clinical governance deliver quality improvement in Australian general practice and primary care? A systematic review of the evidence. Med J Aust. 2010 Nov 15;193(10):602-7. See in Medical Journal of Australia

What is a systematic review?

A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.

SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.

Glossary of terms used in this report

Background references on this topic

Background

Clinical governance is seen as a systematic, integrated approach to ensuring safe, good quality healthcare. It is a systematic and multi-faceted approach to quality improvement using a range of locally implemented strategies, instead of single strategies. Clinical governance is delivered through a combination of strategies. These include: ensuring clinical competence, clinical audits, patient involvement, education and training, risk management, the [better?] use of information, and [improved?] staff management. A wide range of resources and guidelines are used for clinical governance in primary care. Therefore, there is a need to clarify models of clinical governance and to evaluate evidence relating to their impact on quality improvement. Clinical governance models operate on a number of different levels, including the national level, regional level, service level or multiple combinations of these.

How this summary was prepared

After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low-income countries. The methods used to assess the reliability of the review and to make judgements about its relevance are described here

Knowing what’s not known is important

A reliable review might not find any studies from low-income countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known.

A lack of evidence does not mean a lack of effects. It means the effects are uncertain. When there is a lack of evidence, consideration should be given to monitoring and evaluating the effects of intervention, if it is used.

About the systematic review underlying this summary

/	What the review authors searched for	What the review authors found
Review Objectives: To explore the relevance of different models of clinical governance to Australian primary healthcare, and their potential contributions on quality and safety
Interventions	Clinical governance operating at any level	19 studies exploring the outcomes of clinical governance were included
Participants	Not specified
Settings	In hospital settings globall	In hospital setting. The location of the trial was not stated in the Systematic review.
Outcomes	Capability, safety, continuity, appropriateness of care, responsiveness, accessibility, safety, efficiency and effectiveness	The included studies addressed capability (16 studies); safety (4 studies); responsiveness (6); accessibility (5); efficiency (4); effectiveness (8); and sustainability (1 study)
Date of most recent search: Not mentioned
Limitations: This is a good quality systematic review with only minor limitations

About the certainty of the  evidence (GRADE)

High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.

Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.

Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.

Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.

* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.

† Substantially different = a large enough difference that it might affect a decision.

See last page for more information.

Summary of findings

The review summarised 19 studies: 7 randomised controlled studies, 11 longitudinal observational studies, and 1 case study. Most of the studies were conducted in high-income countries, including the United Kingdom (UK), the United States of America (USA), Australia, New Zealand, Spain, Belgium, Holland and Germany. One study was conducted in the Philippines. The included studies addressed capability (16 studies); safety (4 studies); responsiveness (6); accessibility (5); efficiency (4); effectiveness (8); and sustainability (1 study).

	Type of model	May improve	Conflicting evidence on impact	May worsen
National Level	National benchmarking with regional level development support	Accessibility, capability	Responsiveness
National Level	National external benchmarking with no regional support		Sustainability, responsiveness, capability	Accessibility
Regional Level	Collaboration with other GPs with targeted feedback to improve practice	Capability, safety	Effectiveness, capability, accessibility
	Collaboration with other GPs without targeted feedback to improve practice	Efficiency	Capability, accessibility, effectiveness
	Collaboration with community to set clinical priorities and/or monitor services	Accessibility
Service Level	Practice-determined organisation of quality management, using targeted feedback to healthcare workers with supported reflection	Effectiveness, safety, responsiveness, efficiency, capability	Capability, effectiveness, responsiveness
Multilevel	National level benchmarking and incentive-setting, regional network support, and support for practice-level organisation using targeted feedback	Efficiency, capability	Effectiveness, safety

Relevance of the review for low-income countries

Findings	Interpretation*
APPLICABILITY
Only 1 out of the 19 studies included was conducted in a low-income setting. The rest were conducted in high-income countries using different strategies and models of clinical governance	There is limited evidence on the impact of clinical governance from low- and middle-income countries. The findings of the review may not be applicable in such settings
EQUITY
There was no information in the included studies on the differential effects of the interventions in resource-limited settings	The degree to which clinical governnance strategies are effective will determine the extent to which they are able to improve the quality of care in general practice and primary healthcare settings and reduce inequities in access to quality care, especially in resource-constrained settings
ECONOMIC CONSIDERATIONS
The review provided insufficient data to determine the cost of the different models and strategies of clinical governance	There is a need for research to identify the most cost-effective strategies used in models of clinical governance
MONITORING & EVALUATION
There is little or no evidence on the impact of clinical governance on quality of care in low- and middle-income countries	There is a need for studies of strategies and models of clinical governance in low- and middle-income settings. There is also a need for the careful monitoring of strategies of clinical governance on quality of care in such settings
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low- and middle-income countries. For additional details about how these judgements were made see: http://supportsummaries.org/support-summaries/how-support-summaries-are-prepared/

Additional information

Related literature

Tait AR. Clinical governance in primary care: a literature review. Journal of Clinical Nursing 2004; 13:723-30.

This summary was prepared by

Charles I. Okwundu, South African Cochrane Centre, South African Medical Research Council, Cape Town, South Africa

Conflict of interest

None. For details, see: Conflicts of interest

Acknowledgements

This summary has been peer reviewed by: Christine Phillips, Australia; Nyokabi Musila, Kenya

This summary should be cited as

Okwundu CI. Can clinical governance improve the quality of general practice and primary care? A SUPPORT Summary of a systematic review. April 2011.

About certainty of evidence (GRADE)

The “certainty of the evidence” is an assessment of how good an indication the research provides of the likely effect, i.e. the likelihood that the effect will be substantially different from what the research found. By “substantially different” we mean a large enough difference that it might affect a decision. These judgements are made using the GRADE system, and are provided for each outcome. The judgements are based on the study design (randomised trials versus observational studies), factors that reduce the certainty (risk of bias, inconsistency, indirectness, imprecision, and publication bias) and factors that increase the certainty (a large effect, a dose response relationship, and plausible confounding). For each outcome, the certainty of the evidence is rated as high, moderate, low or very low using the definitions on page 3.

For more information about GRADE

SUPPORT collaborators:

The Cochrane Effective Practice and Organisation of Care Group (EPOC) is part of the Cochrane Collaboration. The Norwegian EPOC satellite supports the production of Cochrane reviews relevant to health systems in low- and middle-income countries . www.epocoslo.cochrane.org

The Evidence-Informed Policy Network (EVIPNet) is an initiative to promote the use of health research in policymaking in low- and middle-income countries. www.evipnet.org

The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration that promotes the generation and use of health policy and systems research in low- and middle-income countries. www.who.int/alliance-hpsr

Norad, the Norwegian Agency for Development Cooperation, supports the Norwegian EPOC satellite and the production of SUPPORT Summaries. www.norad.no

The Effective Health Care Research Consortium is an international partnership that prepares Cochrane reviews relevant to low-income countries. www.evidence4health.org

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