PhD Thesis Title: The Practice of Accountability for “Clinical Governance”: A Life-and-Death Setting
Supervisor: Professor Niamh Brennan
Professor Irvine Lapsley, Professor of Accounting Emeritus, University of Edinburgh
This three-paper dissertation investigates clinical governance and the practice of accountability in a potentially life-and-death setting. The overall objective of my programme of research is to clarify what clinical governance really means and how the practice of accountability for clinical governance best operates. Each paper builds on the previous one and uses a different form of analysis: written word (paper one); spoken word (paper two); and narrative of critical clinical incidents (paper three).
Paper one reviews prior definitions of the umbrella term “clinical governance”. The research question is: do clinical governance definitions adequately distinguish between governance, management, and practice functions? Content analysis is applied to analyse 29 definitions (written words) of clinical governance from the perspective of the roles and responsibilities of those charged with governance, management, and practice. For effective governance, it is important that there be division of duties between practice roles, management roles, and governance roles. The analysis indicates that definitions of the umbrella term “clinical governance” comprise a mixture of activities relating to governance, management, and practice, which is confusing for those expected to execute those roles. I propose three new definitions to replace the umbrella term “clinical governance”.
Paper two examines how practitioners interpret “clinical governance” in praxis. While clinical governance is assumed to be part of organisational structures and policies, implementation of clinical governance in practice (the praxis) can be markedly different. This paper draws on spoken words of clinicians, managers, and governors on how they interpret the term “clinical governance”. The analytical lens is practice theory. The research is based on 40 in-depth, semi-structured interviews with hospital clinicians, managers, and governors. Interview transcripts are analysed for keywords/terms to explore how practitioners interpret the term “clinical governance”. I find that interpretation of “clinical governance” in praxis is quite different from best-practice definitions. Practitioner roles held, experience of practitioner, and hospital of practitioner all influence interpretation.
Paper three considers the practice of accountability in healthcare settings. The research question is: what are practitioner insights into accountability for clinical governance, in life-and-death, high-consequence healthcare settings? I draw on the distinction in the prior literature between formal “imposed accountability” and front-line “felt accountability”, as well as Mintzberg’s idea of “on-the-ground management”. I interview 41 clinicians, managers, and governors in two hospitals, who share their experiences responding to critical clinical incidents (where unintended mistakes or harm happen). As a peer, I obtain unique access to senior staff, which elicits responses of an honesty and depth impossible for outsiders. In high-consequence, hospital settings, I find a more nuanced, subtle and sensitive approach, compared with traditional considerations of accountability. I propose a new emergent concept of “grounded accountability”, described by 22 characteristics drawn from responses in the research data, as potentially more suitable to healthcare settings. I believe some of these insights could also lead to improved accountability in a business context.
Keywords: clinical governance, definitions, accountability, practice theory, hospital, life-and-death, highconsequence.