Clinical governance is not equal across organisations; how might you r · Medical

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9 Clinical governance is not equal across organisations; how might you respond to an allegation that care in another nation’s medical facility is not clinically acceptable? Would it/should it affect where you allocate cases?

Specific Topic(s):

• Meaning of ‘clinical governance’ and method of standardising care in military medical systems.

• Variation in ‘standard of care’ between nations.

• This may also apply to local medical facilities – see 8 Spades

Key references:

‘Ethical principles of health care in times of armed conflict and other emergencies’ –

2. Health-care personnel shall at all times act in accordance with relevant international and national law, ethical principles of health care and their conscience. In providing the best available care, they shall take into consideration the equitable use of resources.

Geneva Conventions:

Not applicable

Customary IHL:

Not applicable

Ethical principles:

WMA INTERNATIONAL CODE OF MEDICAL ETHICS - https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/

A PHYSICIAN SHALL always exercise his/her independent professional judgment and maintain the highest standards of professional conduct.

Discussion:

Review of the question: this question raises the issue of how to standardise medical care across a medical system, which is even more complex in a multi-national environment. There are international variations in clinical culture, techniques of clinical practice, employment of healthcare professionals, naming and use of drugs etc. This also applies at the national level and between individual clinicians. However, a medical evacuation chain – military or civilian – requires standardised treatment protocols so as to minimise the risk of miscommunication or misunderstanding between referring and receiving clinicians. It is also necessary to have a system of organisational learning and consensus building so that clinical staff have confidence in the process of setting these standards. Finally, the system requires clinical data and case reviews so that the clinical performance of the whole system can be evaluated and that everyone learns from patients with poor clinical outcomes. The exact term for this whole process varies between nations and include: clinical governance, clinical audit, mortality and morbidity review, continuous improvement in healthcare support on operations. The question then considers the implications of differences in clinical performance between medical facilities. Ultimately, nations or employers are responsible for the suitability of the medical treatment system for their personnel.

Interpretation of the principles/policy from the references: medical care should be provided to the highest standards of professional practice.

Framework for answering the scenario/question:

• What is the evidence for poor clinical performance in the medical facility of concern?

• What are the agreed standards/clinical protocols in use across the medical system?

• What is the agreed system for monitoring clinical performance and raising issues?

• Consider:

o A formal case review using national clinicians to establish the facts

o Informal consultation with the leadership of the medical facility of concern

o A formal case review in partnership with the clinical team of the medical facility of concern

o Offer clinical exchanges between medical facilities to share clinical practice

o Decide if your personnel could avoid being treated in the medical facility of concern

Further discussion points

• Discuss examples of integrated national military trauma systems such as the US Joint Trauma System, UK, France, Israel identify the features that are essential to the system.

• Discuss the role of multi-national organisations, such the United Nations or NATO in establishing mutually agreed policies and procedures for medical support. Identify the key documents (such as NATO Standardisation Agreements) that facilitate this process.

• What does NATO mean by continuous improvement in healthcare support on operations (CIHSO) and how is this implemented? [tip – go to Chapter 1, page 27 of Allied Joint Medical Support doctrine AJP 4.10 (C)]

• What are the implications if you are transferring patients to local medical units and you have clear evidence of poor clinical outcomes?

Author: Professor Martin Bricknell