Exploring clinical governance in rural and remote primary health care: an embedded multiple case study approach

Abstract

Evolving from major failures in health care services, clinical governance is a system by which organisations are accountable for continuously working to improve quality and safety using a multifaceted, systematic and integrated approach. Most research on clinical governance in Australia has been conducted in hospitals. In primary health care, most studies have been in the general practice setting. Consequently, little is known about clinical governance in rural and remote publicly managed primary health care services and organisations. The broad aim of this study was to investigate the understanding and implementation of clinical governance in publicly managed rural and remote primary health care settings in Australia to make a contribution to the knowledge base for the future development of organisational frameworks and supporting policy. Specifically, the research objectives included an exploration of clinical governance with different stakeholders across multiple settings and the proposal of recommendations on the future development of clinical governance processes and systems. The study applied an embedded multiple case study approach with six case studies comprising two overarching committees and four health facilities located in Queensland. Data management and analysis was supported by QSR NVIVO 10 and followed an iterative process using both content and thematic analysis of findings from three qualitative data collection methods: non-participant observation; 61 semi-structured interviews; and analysis of 310 documents. The findings from the study contribute to current knowledge and have important implications for future practice. Clinical governance is a well-documented and expected organisational requirement; however, in reality it is not clearly, similarly or comprehensively understood by all participants. The primary implementation approach is top-down with motivations for participation being primarily led by external pressures. Within this there are different patterns of implementation between health facility staff, managers and committee members, offering insights into opportunities to bridge the gap between organisational levels. Identified enablers and areas working well, such as functioning teams and targeted resourcing, have potential to strengthen clinical governance, as do significant findings related to drivers for clinical governance, risks associated with organisational culture and impacts of restructures and reforms on services.