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Clinical governance: learning and changing practice.

S Ingram1, S Randall

  • 1Ella Gordon Unit, St Mary's Hospital, Portsmouth, Hampshire, PO3 6AD, UK.

The Journal of Family Planning and Reproductive Health Care
|November 30, 2002
PubMed
Summary
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A simple "pink slip" system effectively improved communication by allowing staff to anonymously share learning points and suggestions. This non-threatening method was highly accepted and useful, leading to practice changes.

Area of Science:

  • Healthcare communication strategies
  • Quality improvement in clinical practice
  • Workforce learning and development

Background:

  • Effective communication is crucial for healthcare quality.
  • Sharing learning points and identifying system failures can enhance practice.
  • A non-threatening method was needed to encourage open reporting.

Purpose of the Study:

  • To evaluate the acceptability and utility of an anonymous reporting system for clinical staff.
  • To determine if sharing 'less than optimum' practice and helpful hints improves communication.
  • To assess staff willingness to contribute to a shared learning system.

Main Methods:

  • Implementation of a 'pink slip' system for staff to report on practice.
  • Anonymous submission option for all staff across multiple venues.

Related Experiment Videos

  • Monthly collation and feedback of reports by a senior nurse.
  • Post-implementation survey to gauge staff opinion and system effectiveness.

    • Main Results:

    • 139 'pink slips' submitted over 22 months, with 56% of 'less than optimum' events identified as system failures.
    • Over 95% of surveyed staff found the scheme helpful, with 62% response rate.
    • A third of respondents contributed, and most felt comfortable contributing in the future.

    Conclusions:

    • The 'pink slip' system facilitated sharing of best practices and areas for improvement in a large, distributed healthcare service.
    • The scheme was perceived as non-threatening and highly acceptable to staff, including doctors and nurses.
    • The system led to positive changes in clinical practice and is recommended for similar settings.