Clinical Governance to Enhance User Involvement in Care: A Canadian Multiple Case Study in Mental Health

Document Type : Original Article

Authors

1 Ingram School of Nursing, McGill University, Montreal, QC, Canada

2 McGill University Health Centre, Montreal, QC, Canada

3 Department of Health Policy, Management and Evaluation, School of Public Health, University of Montreal, Montreal, QC, Canada

Abstract

Background
Individuals with serious mental illness face challenges in managing their health, leading to the need for integrating their needs and preferences in care decisions. One way to enhance collaboration between users and providers is to improve clinical governance; a shared responsibility between managers and providers, supported by healthcare organizations (HCOs), policies, and standards. We applied the concept of clinical governance to understand (1) how managers and providers can enhance the involvement of users in mental health, (2) the contextual and organizational factors that facilitate user involvement in care, and (3) the users’ perceptions of their involvement in care.
 
Methods
We conducted two, in-depth case studies from two clinical teams in Canada offering outpatient care for users with acute mental illness. A total of 25 interviews were carried out with managers, and four focus groups were held with providers. A measure of patient-reported experience was used to evaluate the users’ perceptions of their involvement in care.
 
Results
The providers used two methods to involve users in the care planning process: encouraging users to identify their life goals and supporting them to define recovery-oriented objectives. To encourage the adoption of collaborative practices, the managers used various practices such as revising care protocols, strengthening providers’ knowledge of best practices and integrating peer-support workers (PSWs) in the team. Compliance with organizational and external commitments/requirements for user involvement, access to specific training and the institutionalization of a culture promoting user involvement facilitated the adoption of collaborative practices. We found that mental health teams that adopt recovery and collaborative practices with users show a high degree of user-perceived involvement in care.
 
Conclusion
This is the first study to apply the concept of clinical governance to understand how managerial and clinical practices, and other organizational and contextual factors, can enhance the involvement of mental healthcare users.

Keywords


  1. Crawford MJ, Rutter D, Manley C, et al. Systematic review of involving patients in the planning and development of health care. BMJ. 2002;325(7375):1263. doi:10.1136/bmj.325.7375.1263
  2. Trotti A, Colevas AD, Setser A, Basch E. Patient-reported outcomes and the evolution of adverse event reporting in oncology. J Clin Oncol. 2007;25(32):5121-5127. doi:10.1200/jco.2007.12.4784
  3. Hibbard JH, Greene J, Tusler M. Improving the outcomes of disease management by tailoring care to the patient's level of activation. Am J Manag Care. 2009;15(6):353-360. 
  4. Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff (Millwood). 2013;32(2):207-214. doi:10.1377/hlthaff.2012.1061
  5. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002;288(19):2469-2475. doi:10.1001/jama.288.19.2469
  6. Dixon LB, Holoshitz Y, Nossel I. Treatment engagement of individuals experiencing mental illness: review and update. World Psychiatry. 2016;15(1):13-20. doi:10.1002/wps.20306
  7. World Health Organization (WHO). The World Health Report 2001: Mental Health: New Understanding, New Hope. Geneva: WHO; 2001.
  8. Chisholm D, Flisher AJ, Lund C, et al. Scale up services for mental disorders: a call for action. Lancet. 2007;370(9594):1241-1252. doi:10.1016/s0140-6736(07)61242-2
  9. United Nations. Convention on the Rights of Persons with Disabilities. https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities/convention-on-the-rights-of-persons-with-disabilities-2.html.  Accessed October 3,  2020. Published 2020.
  10. Grande SW, Faber MJ, Durand MA, Thompson R, Elwyn G. A classification model of patient engagement methods and assessment of their feasibility in real-world settings. Patient Educ Couns. 2014;95(2):281-287. doi:10.1016/j.pec.2014.01.016
  11. Carman KL, Dardess P, Maurer M, et al. Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Aff (Millwood). 2013;32(2):223-231. doi:10.1377/hlthaff.2012.1133
  12. Pomey MP, Flora L, Karazivan P, et al. Le “Montreal model”: enjeux du partenariat relationnel entre patients et professionnels de la santé. Sante Publique. 2015;1 Suppl:41-50.
  13. Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med. 1999;49(5):651-661. doi:10.1016/s0277-9536(99)00145-8
  14. Barry MJ, Edgman-Levitan S. Shared decision making--pinnacle of patient-centered care. N Engl J Med. 2012;366(9):780-781. doi:10.1056/NEJMp1109283
  15. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361-1367. doi:10.1007/s11606-012-2077-6
  16. Flynn D, Knoedler MA, Hess EP, et al. Engaging patients in health care decisions in the emergency department through shared decision-making: a systematic review. Acad Emerg Med. 2012;19(8):959-967. doi:10.1111/j.1553-2712.2012.01414.x
  17. Légaré F, Witteman HO. Shared decision making: examining key elements and barriers to adoption into routine clinical practice. Health Aff (Millwood). 2013;32(2):276-284. doi:10.1377/hlthaff.2012.1078
  18. Gravel K, Légaré F, Graham ID. Barriers and facilitators to implementing shared decision-making in clinical practice: a systematic review of health professionals' perceptions. Implement Sci. 2006;1:16. doi:10.1186/1748-5908-1-16
  19. Pomey MP, Ghadiri DP, Karazivan P, Fernandez N, Clavel N. Patients as partners: a qualitative study of patients' engagement in their health care. PLoS One. 2015;10(4):e0122499. doi:10.1371/journal.pone.0122499
  20. Karazivan P, Dumez V, Flora L, et al. The patient-as-partner approach in health care: a conceptual framework for a necessary transition. Acad Med. 2015;90(4):437-441. doi:10.1097/acm.0000000000000603
  21. Mental Health Commission of Canada. Guidelines for Recovery-Oriented Practice. Ottawa: Mental Health Commission of Canada; 2015:1-97.
  22. Jacob KS. Recovery model of mental illness: a complementary approach to psychiatric care. Indian J Psychol Med. 2015;37(2):117-119. doi:10.4103/0253-7176.155605
  23. Davidson L, Tondora J, Pavlo AJ, Stanhope V. Shared decision making within the context of recovery-oriented care. Ment Health Rev (Brighton). 2017;22(3):179-190. doi:10.1108/mhrj-01-2017-0007
  24. Dahlqvist Jönsson P, Schön UK, Rosenberg D, Sandlund M, Svedberg P. Service users' experiences of participation in decision making in mental health services. J Psychiatr Ment Health Nurs. 2015;22(9):688-697. doi:10.1111/jpm.12246
  25. Accreditation Canada. Client- And Family-Centered Care in the Qmentum Program. Ottawa: Accreditation Canada; 2015.
  26. Ministère de la Santé et des Services sociaux. Plan d'action en santé mentale 2015-2020. Québec: Gouvernement du Québec; 2015.
  27. Buetow SA, Roland M. Clinical governance: bridging the gap between managerial and clinical approaches to quality of care. Qual Health Care. 1999;8(3):184-190. doi:10.1136/qshc.8.3.184
  28. Brault I, Roy DA, Denis JL. Introduction à la gouvernance clinique: historique, composantes et conceptualisation renouvelée pour l’amélioration de la qualité et de la performance des organisations de santé. Prat Organ Soins. 2008;39(3):167-173.
  29. Gray C. What is clinical governance? BMJ. 2005;330(7506):S254. doi:10.1136/bmj.330.7506.s254-b
  30. O'Connor N, Paton M. 'Governance of' and 'Governance by': implementing a clinical governance framework in an area mental health service. Australas Psychiatry. 2008;16(2):69-73. doi:10.1080/10398560701799266
  31. Halligan A, Donaldson L. Implementing clinical governance: turning vision into reality. BMJ. 2001;322(7299):1413-1417. doi:10.1136/bmj.322.7299.1413
  32. Pomey MP, Denis JL, Contandriopoulos AP. A conceptual framework for analysing clinical governance in healthcare establishments. Prat Organ Soins. 2008;39(3):183-193.
  33. Som CV. Clinical governance: a fresh look at its definition. Clinical Governance: An International Journal. 2004;9(2):87-90. doi:10.1108/14777270410536358
  34. Scally G, Donaldson LJ. The NHS's 50 anniversary. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ. 1998;317(7150):61-65. doi:10.1136/bmj.317.7150.61
  35. Yin RK. Case Study Research: Design and Methods. Thousand Oaks, CA: SAGE Publications; 2009.
  36. Mills A, Durepos G, Wiebe E. Encyclopedia of Case Study Research. Thousand Oaks, CA: SAGE Publications; 2010. doi:10.4135/9781412957397
  37. Calman L, Brunton L, Molassiotis A. Developing longitudinal qualitative designs: lessons learned and recommendations for health services research. BMC Med Res Methodol. 2013;13:14. doi:10.1186/1471-2288-13-14
  38. Gerring J. Case Selection for Case‐Study Analysis: Qualitative and Quantitative Techniques. In: Box-Steffensmeier JM, Brady HE, Collier D, eds. The Oxford Handbook of Political Methodology. Oxford: Oxford University Press; 2008.
  39. Elwyn G, Edwards A, Wensing M, Hood K, Atwell C, Grol R. Shared decision making: developing the OPTION scale for measuring patient involvement. Qual Saf Health Care. 2003;12(2):93-99. doi:10.1136/qhc.12.2.93
  40. Elwyn G, Hutchings H, Edwards A, et al. The OPTION scale: measuring the extent that clinicians involve patients in decision-making tasks. Health Expect. 2005;8(1):34-42. doi:10.1111/j.1369-7625.2004.00311.x
  41. Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods. 2006;5(1):80-92. doi:10.1177/160940690600500107
  42. Crabtree B, Miller W. Doing Qualitative Research. 2nd ed. SAGE Publications; 2002.
  43. Boyatzis RE. Transforming Qualitative Information: Thematic Analysis and Code Development. Thousand Oaks, CA: SAGE Publications; 1998.
  44. Stein LI, Santos AB. Assertive Community Treatment of Persons with Severe Mental Illness. New York, NY: W. W. Norton & Company; 1998.
  45. Livingston JD, Nijdam-Jones A, Lapsley S, Calderwood C, Brink J. Supporting recovery by improving patient engagement in a forensic mental health hospital: results from a demonstration project. J Am Psychiatr Nurses Assoc. 2013;19(3):132-145. doi:10.1177/1078390313489730
  46. Canadian Mental Health Association. Family mental health alliance. Caring Together: Families as Partners in the Mental Health and Addiction System. Toronto: Canadian Mental Health Association; 2006.
  47. Repper J, Carter T. A review of the literature on peer support in mental health services. J Ment Health. 2011;20(4):392-411. doi:10.3109/09638237.2011.583947
  48. Pelletier JF, Tourette-Turgis C. Recovery-oriented medical training: a narrative literature review for the university of recoveryas a new concept of co-learning between patients and (future) healthcare providers. J Community Med Health Educ. 2016;6(6):495. doi:10.4172/2161-0711.1000495
  49. Pelletier JF. Civic recovery mentorship: an online undergraduate medical training program to transform experience into expertise, and attitudes into competencies. Ann Med Health Sci Res. 2017;7(1):73-75.
  50. Hess JZ, Lacasse JR, Harmon J, Williams D, Vierling-Claassen N. “Is there a getting better from this, or not?” examining the meaning and possibility of recovery from mental disorder. Child Youth Serv. 2014;35(2):116-136. doi:10.1080/0145935x.2014.924344
  51. Pelletier JF, Corbière M, Lecomte T, et al. Citizenship and recovery: two intertwined concepts for civic-recovery. BMC Psychiatry. 2015;15:37. doi:10.1186/s12888-015-0420-2
  52. Scott T, Mannion R, Davies HT, Marshall MN. Implementing culture change in health care: theory and practice. Int J Qual Health Care. 2003;15(2):111-118. doi:10.1093/intqhc/mzg021
  53. Stacey D, Légaré F, Col NF, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014(1):CD001431. doi:10.1002/14651858.CD001431.pub4
  54. Giguere A, Légaré F, Grad R, et al. Decision boxes for clinicians to support evidence-based practice and shared decision making: the user experience. Implement Sci. 2012;7:72. doi:10.1186/1748-5908-7-72
  55. Elwyn G, Lloyd A, Joseph-Williams N, et al. Option Grids: shared decision making made easier. Patient Educ Couns. 2013;90(2):207-212. doi:10.1016/j.pec.2012.06.036
  • Receive Date: 07 January 2020
  • Revise Date: 09 October 2020
  • Accept Date: 11 October 2020
  • First Publish Date: 07 November 2020