Assurance and governance

Quality assurance within a healthcare context can be conceptualised as the process by which care is objectively and systematically monitored for the appropriateness and quality of patient care to inform continuous improvement efforts (73, 74). Quality assurance efforts have become key policy agenda items for healthcare systems worldwide, including the UK with recent publications emphasising quality and excellence initiatives within the NHS (75-77). In response to the Vale of Leven Inquiry, in which care quality was found to be significantly eroded, NHS Scotland has prioritised efforts to ensure consistent high-quality care across healthcare boards, with particular focus on the important role of nurses and midwives (78).

EiC will assure care quality first through quality assessment using the CAIR dashboard, developing a suite of valid and reliable measures informed by scientific literature that are indicative of high-quality healthcare (79). In line with the Institute of Medicine, EiC have highlighted patient experience, safety, effectiveness, efficiency, and sustainability as fundamental domains of care quality, and thus the measures selected for the CAIR dashboard will reflect these priorities (80).

Historically governance structures in the NHS have been aligned with a hierarchical model, in which managers have had a dominant control over nursing care (81, 82), however there have been recent reforms towards clinical governance in which control is devolved from managers towards frontline staff (83). This shared governance perspective was developed as a strategy to facilitate nurses’ control over their care practice, reducing the inequalities between management and frontline staff, with core principles of accountability, recognition for the decision making role of nurses, and the facilitation of collaboration with staff to promote working conditions that reflect this shared authority (83-85).

Governance strategies that promote shared decision making and empower staff have been recognised by professional nursing bodies as key components of healthcare system structure that ensure a high-quality of care, with the literature demonstrating an association between shared, clinical governance and positive outcomes for patients and staff (83, 85). Conversely, inadequate professional autonomy–as perceived by healthcare professionals–is correlated with high levels of burnout, job dissatisfaction, stress and turnover. These negative impacts on staff subsequently influence the quality of care provided (82, 86). There is evidence that nurses within the NHS perceive a discrepancy between their expectations of professional autonomy and the way in which their work was governed; reporting a lack of significant control over their nursing practice and that management enacted inappropriate levels of control over their work (87). Therefore, the EiC framework recognises the importance of healthcare governance structures that emphasise the perspectives of staff across all levels of the organisation, aligning this aspect of the framework with a positive workplace culture and prioritising staff wellbeing.