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

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?

Step 1 – IDENTIFY THE PROBLEM(S)

Briefly state the Scenario: 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?

List the Issues that arise from the scenario

• What is the meaning of ‘clinical governance’?

• How to standardise medical care across a medical system? - This is even more complex in a multi-national environment.

Identify Critical Information required and Assumptions to be made

• Variation in ‘standard of care’ across nations.

• 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?

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

Step 2 – ANALYSE

Patient: It is in the patient's best interest to receive the highest standard of care, grounded in the principles of beneficence (doing good) and non-maleficence (avoiding harm). For patients, clinical governance ensures that the healthcare system is structured to safeguard and prioritise their health, safety, and overall well-being while fostering an environment of continuous improvement and learning to enhance the quality of care provided.

Clinical: Clinical governance helps to ensure that the care patients receive is based on the best available evidence, follows established guidelines, and is delivered by competent healthcare professionals.

“A PHYSICIAN SHALL always exercise his/her independent professional judgment and maintain the highest standards of professional conduct.” - WMA. ‘International Code of Medical Ethics’ Revised October 2022. At: https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/

“Healthcare 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.” - WMA. ‘Ethical principles of health care in times of armed conflict and other emergencies’. At: https://www.wma.net/policies-post/ethical-principles-of-health-care-in-times-of-armed-conflict-and-other-emergencies/

Legal: Some organisations establish mutually agreed policies and procedures for medical support, such as the United Nations or NATO, which provides some key documents to facilitate this process, e.g. NATO Medical Standardisation Agreements. At: https://www.coemed.org/resources/stanag-search

Countries can participate in providing medical support to a multinational force in different ways, enabling each nation to choose an approach that aligns with its specific situation and national policies. Nations can adjust or discontinue their level of involvement at any point, as long as it does not affect forces already deployed, in which case any changes must be communicated in advance. - NATO Medical Standardisation Agreements. ‘Allied Joint Medical Support doctrine’ AJP 4.10. At: https://www.coemed.org/files/stanags/01_AJP/AJP-4.10_EDC_V1_E_2228.pdf

Societal/Military: There is a military necessity for a system that supports and ensures global combat medical readiness that ensures military personnel are ready for active duty, as well as improve combat casualty care. - Smith J, Hodgetts T, Mahoney P, et al. ‘Trauma governance in the UK defence Medical Services.’ J R Army Med Corps 2007;153:239–42. 10.1136/jramc-153-04-04

Mary Ann Spott, PhD, MPA, MSIS, MBA, RHIA, Cynthia R Kurkowski, BJ, Zsolt Stockinger, MC, USN, The Joint Trauma System: History in the Making, Military Medicine, Volume 183, Issue suppl_2, 1 September 2018, Pages 4–7. At: https://doi.org/10.1093/milmed/usy166

US Joint Trauma System. At: https://jts.amedd.army.mil/

Kashuk, J.L., Peleg, K., Glassberg, E. et al. ‘Potential benefits of an integrated military/civilian trauma system: experiences from two major regional conflicts.’ Scand J Trauma Resusc Emerg Med 25, 17 (2017). At: https://doi.org/10.1186/s13049-017-0360-6

Step 3 – FUSE

● Summarise conclusions

● Insert citations to key reference sources for your analysis

● Determine the exact Decision(s) to be made

Medical care should be provided to the highest standards of professional practice. This question 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.

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 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 includes; clinical governance, clinical audit, mortality and morbidity review, and continuous improvement in healthcare support on operations.

For further reading, see:

- Schweizer, M.A., Janak, J.C., Stockinger, Z.T. et al. Description of trauma among French service members in the Department of Defense Trauma Registry: understanding the nature of trauma and the care provided. Military Med Res 6, 7 (2019). At: https://doi.org/10.1186/s40779-019-0197-6

- R. Linwood, N. Duff, A. Stewart, Flint, M. Reade, P. Krohn, A. Williams, B. McCall. Application of Clinical Governance in a Role 2E Hospital: The 2nd General Health Battalion Experience. Journal of Military and Veterans Health. 2017;1. At: https://jmvh.org/article/application-of-clinical-governance-in-a-role-2e-hospital-the-2nd-general-health-battalion-experience/

Step 4 – DECIDE

• What is your Decision?

• Why (can you justify it)?

• Residual uncertainly, need for review?

When addressing concerns about a medical facility, several steps should be considered. Initially, a formal case review should be conducted with national clinicians to establish the facts. This may be complemented by informal consultations with the leadership of the medical facility in question to gain further insight. A formal case review in collaboration with the clinical team at the facility can also provide valuable perspective. Additionally, offering clinical exchanges between medical facilities can help facilitate the sharing of best practices and improve overall care. - Frassini J. Continuous improvement in healthcare support on NATO operations. BMJ Mil Health. 2020 Aug 4:bmjmilitary-2020-001543. doi: 10.1136/bmjmilitary-2020-001543. Epub ahead of print. PMID: 32753533

MCM Bricknell, RF Cordell (UK). ‘Continuous Improvement in Healthcare Support to Operations’. 20 June 2019. At: https://military-medicine.com/article/3718-continuous-improvement-in-healthcare-support-to-operations.html

In terms of allocating cases, if the concerns about clinical acceptability are substantiated, it could influence where cases are directed. Patient safety and the quality of care should always be the primary considerations when determining where to allocate cases. If the other nation's facility is found to have significant issues, it may be prudent to avoid sending cases there until the problem is addressed. However, decisions should be based on objective data and not just on hearsay, ensuring that all actions taken are in the best interest of patient care.

See examples of features of low standards in a medical facility described in; ICRC. ‘Health Care in Danger: The Responsibilities of Healthcare Personnel Working in the Armed Conflicts and Other Emergencies, 6.4. Recognising an unacceptable standard of health care’. 2020. At: https://healthcareindanger.org/wp-content/uploads/2015/09/icrc-002-4104-the-responsibilities-health-care-personnel.pdf

Reviewed and formatted by:

Adriana Salas Yeguez, MBBS Year 3 King’s College London

December 2024