An Exploration Of Clinical Governance Interventions In The Western Cape Department Of Health Over The Past Twenty Years

Abstract

The tension between the increasing cost of healthcare provision and the need to

provide a quality level of care to a rising number of people is a global phenomenon.

A focus on one over the other could result in a rise in adverse patient outcomes, or

a health system too costly to be sustainable. Clinical governance is an approach

policymakers can use to walk the middle line of creating a healthcare service that

meets quality of care standards in a cost-effective manner, as has been done in

Australia, Burundi, Egypt, Spain, UK and Yemen (Goyet et al, 2019; Abd El Fatah et

al, 2019, Mannion et al, 2015; Aguilar Martin et al, 2019).

This study examines the practice of clinical governance in one LMIC setting that has

been able to successfully do this balancing walk for 20 years. Understanding how

this was done in the Western Cape province of South Africa helps inform how

clinical governance can be used to continue adding value as the health system

moves towards universal healthcare.

A mixed methods qualitative design was used for data collection and involved three

phases: (1) a document review of all policies in the province to identify clinical

governance structures; (2) observation of these structures in action, comparing

lived to written experience of clinical governance; and (3) interviews with key

stakeholders in the province to get their perspectives on past, present and future

forms of clinical governance. The Donabedian model was used to frame analysis

into three dimensions of care, viz. structure, process and outcome.

Beyond a comprehensive policy framework, collaborative structures and

consultative leadership styles facilitated strengthened clinical governance. For

example, clinical audits and M&E events become punitive and corrosive without

communication and supportive relationships between colleagues. Family

physicians have become the champions of clinical governance in a decentralized

health system and when supported in this by policy and management, the quality

of care in health systems thrive. Clinical governance is an effective strategy or tool LMICs can use to ensure quality of care is maintained or improved upon, even in resource-challenged settings. But while some structures, processes and outcomes may be borrowed from other LMIC or HIC settings, these need to be contextualized to local conditions. Appropriate clinical governance champions need to be identified and given the appropriate

mandate. Human relationships are key to the successful implementation of

interventions of this nature and space needs to be created in policy for this to be cultivated.