OPTIGOV - A new methodology for evaluating Clinical Governance implementation by health providers

Specchia, Maria Lucia; La Torre, Giuseppe; Siliquini, Roberta; Capizzi, Silvio; Valerio, Luca; Nardella, Pierangela; Campana, Alessandro; Ricciardi, Walter

doi:10.1186/1472-6963-10-174

BMC Health Services Research

Table 1 OPTIGOV analysis areas; first 3 questions of each form, including an example of weighted scores

From: OPTIGOV - A new methodology for evaluating Clinical Governance implementation by health providers

ANALYSIS AREAS	Items	First 3 items of each form
CG structural and functional prerequisites:
A. Resources and Services Management	17	Do you have a planning and control system in place?	Yes, completely	Yes, partially	No
		If so, does the attribution of objectives and resources to the single units occur by means of a formalised contractual process?	Yes	No
		Is the planning process supported by a computerised procedure?	Yes	No
B. Learning Culture	9	Have you defined a training plan?	Yes	No
		If so, have health professionals been involved in the detection of training needs?	Yes, completely	Yes, partially	No
		If so, are the training programs specifically targeted to the different professionals and responsibility levels?	Yes, completely	Yes, partially	No
C. Research and Development	5	Are there units performing scientific research in the health care organization?	Yes	No
		If so, are the research results shared with the other health care units?	Yes, always	Yes, sometimes	No, never
		If so, are the research results used to modify health care protocols?	Yes, always	Yes, sometimes	No, never
D. Information Technology	6	Is there a computerised system for management of clinical records?	Yes, completely	Yes, partially	No
		Are legal and scientific references reported on the clinical records?	Yes, always	Yes, in most of the cases	No
		Is there a computerised system for the outpatient clinical record management?	Yes, completely	Yes, partially	No
CG Areas:
1. Evidence-Based Medicine	21	In the process of taking decisions on patients, do doctors integrate their clinical experience with the best available scientific evidence?	Yes, always	Yes, sometimes	Yes, rarely	No, never
		If so, through which tool is this integration realised?	Exclusively by referring to databases (e.g. Cochrane Library)	Mainly by referring to databases (e.g. Cochrane Library)	Mainly by referring to scientific literature on paper) = 1,3888	Exclusively by referring to scientific literature on paper)
		If the source of information is computerised, where does the consultation occur?	In a handheld pc, at the bedside, = 4,1666	In a computer located within the unit = 2,0833	In a computer located within the department = 1,3888	In a computer located somewhere else within the hospital = 1,0416
2. Accountability	9	A. Are medical activities accountable? [A question = 4 Cs]	Yes, always = 19,0476	Yes, sometimes = 9,5238	No, never = 0
		B. If so, is there a formalised accountability procedure? [B question = 2 Cs]	Yes = 9,5238	No = 0
		C. If so, on what kind of support? [C question = base]	Both = 4,7619	Computerised = 2,3809	Paper = 2,3809
3. Clinical Audit	22	Is clinical audit performed within the units?	Yes, always	Yes, sometimes = 3,9214	No, never = 0
		If so, how frequently is it performed ?	Weekly	Fortnightly	Monthly	Other
		Is there a formal documentation of the audits?	Yes	No
4. Measurement of Clinical Performances	13	Is there an organizational structure specifically devoted to clinical performance measurement within the organization?	Yes	No
		Are there professionals specifically devoted to clinical performance measurement within the organization?	Yes	No
		If so, what kind of skills have they?	Both	Health care expertise	Management expertise
5. Appraisal and Improvement of Clinical Activities	10	Do you use the measurement results in order to improve health care activity?	Yes, always	Yes, sometimes	No, never
		Do you involve external high-level professionals in performance appraisal?	Yes, always	Yes, sometimes	No, never
		Does the appraisal involve only the heads of the units or even doctors individually?	Even doctors individually	Only the heads of the units
6. Health Technology Assessment	21	Is there a structure specifically devoted to Health Technology Assessment within the organization?	Yes	No
		Are there professionals specifically devoted to Health Technology Assessment within the organization?	Yes	No
		If so, what kind of skills have they? (multiple choice possible)	Management expertise	Health care expertise	Technical expertise
7. Quality Systems	14	Do you have a quality system?	Yes	No
		If so, is it certified by an accreditation and certification organization (certifying authority)?	Yes	No
		If so, is the accreditation and certification organization specialised in certifying health care organizations?	Yes	No
8. Risk Management	15	Have you performed a mapping of the existing risks in the units?	Yes	No
		If so, has the risk mapping been communicated to all health professionals working within the unit?	Yes	No
		Do you have an incident reporting system?	Yes	No
9. Information, Citizen/Patient Involvement	17	Do you inform the patient of the clinical, diagnostic, therapeutic procedures he will undergo?	Yes, always	Yes, sometimes	No, never
		If so, is the information supported by any documentation on paper (leaflets, brochures, forms) to be handed to the patient?	Yes	No
		Are there case managers within the units?	Yes	No
TOTAL 13	179

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ISSN: 1472-6963

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