Organisational strategies for changing clinical practice: how trusts are meeting the challenges of clinical governance

Objectives-To describe the use, perceived effectiveness, and predicted futu re use of organisational strategies for influencing clinicians' behaviour i n the approach of NHS trusts to clinical governance, and to ascertain the p erceived benefits of clinical governance and the barriers to change. Design and setting-Whole population postal survey conducted between March a nd June 1999. Subjects-Clinical governance leads of 86 NHS trusts across the South West a nd West Midlands regions. Method-A combination of open questions to assess the use of strategies to i nfluence clinician behaviour and the barriers to clinical governance. Close d (yes/no) and Likert type ratings were used to assess the use, perceived e ffectiveness, and future use of 13 strategies and the predicted outcomes of clinical governance. Results-All trusts use one or more of 13 strategies categorised as educatio nal, facilitative, performance management, and organisational change method s. Most popular were educational programmes (96%) and protocols and guideli nes (97%). The least popular was performance management such as use of fina ncial incentives (29%). Examples of successful existing practice to date sh owed a preference for initiatives that described the use of protocols and g uidelines, and use of benchmarking data. Strategies most frequently rated a s effective were facilitative methods such as the facilitation of best prac tice in clinical teams (79%), the use of pilot projects (73%), and protocol s and guidelines (52%). The least often cited as effective were educational programmes (42%) and training clinicians in information management (20%); 8% found none of the 13 strategies to be effective. Predicted future use sh owed that ah the trusts which completed this section intended to use at lea st one of the 13 strategies. The most popular strategies were educational a nd facilitative. Scatter-plots show that there is a consistent relationship between use and planned future use. This was less apparent for the relatio nship between planned use and perceived effectiveness. Barriers to change i ncluded lack of resources, mainly of money and staff time, and the need to address cultural issues, plus infrastructure support. The anticipated outco mes of clinical governance show that most trusts expect to influence clinic ian behaviour by improving patient outcomes (78%), but only 53% expect it t o result in better use of resources, improved patient satisfaction (36%), a nd reduced complaints (100%). Conclusions-Clinical governance leads of trusts report using a range of str ategies for influencing clinician behaviour and plan to use a similar range in the future. The choice of methods seems to be related to past experienc e of local use, despite equivocal judgements of their perceived effectivene ss in the trusts. Most expect to achieve a positive impact on patient outco mes as a result. It is concluded that trusts should establish methods of le arning what strategies are effective from their own data and from external comparison.