Good Governance for technology supported healthcare

Governance is tricky no doubt about it.

This is my attempt to begin to think it through

Governance concerns are one of those things that you often start to hear be voiced when folk are unsure of whether or not a new way of doing things should be adopted. This is especially true when dealing with highly complex systems such as healthcare and in many ways I appreciate the cautious approach, as complexity is a very close friend of the law of unintended consequences.

A large part of the answer needed to address the governance concerns should include consideration of the type of governance that needs to be addressed, and time to think it though in a constructive collaborative environment. A framework to consider definitions, scope, and hierarchies may also be extremely helpful as a means of providing re-assurance that guard against unintended consequences.  The result should make available a transparent explicit summary of the mandates, responsibilities and accountability that will provide clarity whilst underpinning good governance.

In healthcare systems there are 3 main domains to consider: Corporate, Clinical and Information Governances they distinct but markedly interdependent. Additionally when technology based tools and applications are to be applied in service delivery Corporate Governance will direct IT governance and Data governance as separate discreet sub-domains. Each different domain has specific subject matter experts whose professional disciplinary background maps directly to the relevant domain.

Definitions

Corporate Governance: Procedures and processes according to which an organisation is directed and controlled. The corporate governance structure specifies the distribution of rights and responsibilities among the different participants in the organisation – such as the board, managers, shareholders and other stakeholders – and lays down the rules and procedures for decision-making. (OECD 2005)

Information Technology Governance specifies the decision rights and accountability framework to encourage desirable behaviour using IT (Weill&Ross 2004)

Data Governance is the processes and controls within an organisation that ensure that data is of high quality. (OECD2015)

Clinical Governance is a framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. (NHS ClinGov Supp Team)

Information Governance is the activities and technologies that organisations employ to maximise the value of their information while minimising associated risk and costs (IGI2014)

Clearly good governance permits permission and rule setting that is critical in providing for order and clarity that describe the lines of accountability within an organisation. Rules come in many guises, such as policies, guidance, and standards all orientated to meet the business aims and objectives of the organisation. Within healthcare the rules will apply to a multiplicity of processes, and procedures and may be generated internally in response to the business operating environment and resource constraints. There are however many rules that are external to an organisation but must be adopted to meet legal and regulatory requirements.  These rules must be adopted, and implemented within the most appropriate part of an organisations structure, in a way that is capable of providing appropriate evidence of compliance with that external requirement.

When it comes to new ways of doing things conflicting or potentially conflicting with external regulation these are often the most difficult areas to work through, ownership of the policies and guidance that satisfy the legal or regulatory requirements will often sit outside of the remit, expertise or awareness of those wishing to make the process or procedure change. It is not within the gift of the organisation no matter how big or powerful to deviate from the legal or regulatory requirements for compliance.

Sharing technology solutions or services between distinct legal organisational entities brings with it additional complexity in addressing individual positional accountabilities and evidence of compliance in considering the 3 domains of governance. The potential for a federated model of governance probably presents the best attempt to develop solutions that address this. (More on this later)

I believe that it is completely possible to get the right balance with sensible workable solutions in relation to these difficulties. However it must be recognised that the appropriate subject matters experts within the respective governance domains need time together, they need conceptual models that can be stretched and strained to develop and maintain transparent frameworks that provide assurance that compliance is deliverable.