Emerald

This paper aims to examine the impact of a number of audits on clinical practice within a large mental health NHS trust. It aims to consider all audits that had been reaudited by psychiatry trainees and to compare the adherence to various standards before and after reaudit.

The authors examined all available clinical audits undertaken by psychiatry trainees that had been reaudited within Mersey Care NHS Trust. The results were analysed using SPSS version 16.0 for Windows. Differences between the results before and after reaudit were tested for using Pearson chi‐squared and Fisher's exact tests, both two‐tailed.

Significant improvements were noted in five of the 35 standards compared before and after reaudit. Only one reaudit, that of the assessment of physical health and of metabolic and cardiovascular risk in inpatients in Ashworth Hospital, showed significant deteriorations in adherence to the standards which was seen in seven of the nine parameters.

The reaudits demonstrated only a limited improvement in practice. This highlights the need for a more structured approach to involvement of junior doctors in clinical audit and more robust methods of dissemination and implementation of recommendations.

This study aims to give an account of how stakeholders in one NHS Hospital Trust responded to the clinical governance initiative, the effects on quality improvement and the practical accomplishment of legitimacy.

Sociological new institutionalism theory was utilised to explain the political and ceremonial conformity that marked the clinical governance process. A case study was employed using ethnographic methods. The qualitative data were obtained by documentary analysis, observation of meetings and ward activity and 28 semi‐structured interviews. A grounded theory approach was adopted in the analysis of the interviews.

Errors and inconsistencies were found in Trust documentation and reporting systems were poor. In practice clinical governance was inadequately understood and the corporate goals not shared. Nevertheless, during the same period the Trust obtained recognition for having appropriate structures and systems in place resulting in external legitimacy.

The results only relate to the Trust considered but the study has identified that, although the organization responded to isomorphic governmental pressures in the production of appropriate institutional documentation, the impact of clinical governance to improve the quality in practice was found to be inconsistent.

The Trust promoted and endorsed clinical governance success but the lack of organizational processes and knowledge management equally promoted its failure by denying the resources to implement the desired actions.

Whilst the study identified that clinical governance had been a “ceremonial success”, it is argued that the practical accomplishment in the improvement of quality of care for patients will remain a paper exercise until organizational and practice issues are addressed.

The current risk management system for community mental health patients in England is based around the Care Programme Approach (CPA). This system is not responsive to changes in risk for community patients. This paper aims to introduce a practical system to manage risk that has been developed for an Early Intervention Service in East London on the basis of need.

Coding of red, amber and green is associated with specific criteria agreed by all disciplines in the team. The change of a code leads to a rapid change in risk level and management. An agreed clinical and non‐clinical action plan leads to a whole team response. The limitation of use is dependent on the size of the case load and the number of clinical staff attending a daily clinical briefing.

Zoning according to the traffic lights system could complement the CPA system and support a clinical governance structure utilising a whole team response.

The risk management system described has not been tested empirically. Currently it has been used in early intervention mental health teams but will need to be adapted for other teams with bigger case loads.

This practical risk management system is aligned with the statuary CPA requirements. A dynamic and flexible management of risk is central to early intervention in psychosis teams but the risk management system described can suit any community mental health team and fits well with the distributed responsibility model of functionalised teams according to new ways of working.