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The clinical governance development index: results from a New Zealand study
  1. Robin Gauld1,
  2. Simon Horsburgh1,
  3. Jeff Brown2
  1. 1Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
  2. 2Department of Pediatrics, MidCentral District Health Board, Palmerston North, New Zealand
  1. Correspondence to Dr Robin Gauld, Department of Preventive and Social Medicine, University of Otago, Dunedin 9054, New Zealand; robin.gauld{at}


Background Clinical governance is seen as pivotal to improving healthcare quality, yet there are few available tools for tracking progress on its implementation. With this in mind, the authors developed a Clinical Governance Development Index (CGDI) designed to track performances between healthcare organisations and over time.

Methods A survey on implementation of government policy on clinical governance was sent to 3402 New Zealand public hospital specialists. Responses to seven survey items were weighted and combined to form the CGDI. Final scores for each of New Zealand's 21 District Health Boards were converted to percentages.

Results The mean CGDI score was 47.3%, with significant differences in performances across the 21 District Health Boards (F(20, 1178)=3.233, p=0.0000). Scores were higher in boards where respondents perceived governing boards and management worked to support clinical leadership.

Conclusion The CGDI offers a simple method for measuring the extent to which a healthcare organisation is working to develop clinical governance. Its use in New Zealand provides a baseline for tracking clinical governance over time. The CGDI could be easily adapted for use in other healthcare systems.

  • Clinical governance
  • survey
  • hospital specialists
  • New Zealand
  • governance
  • healthcare quality improvement
  • leadership

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‘Clinical governance’ is often cited as being pivotal to improving healthcare quality.1–3 An indistinct concept, clinical governance involves healthcare professionals leading the way in quality-improvement efforts, ensuring practices are evidence-based, and working to build team-based and systematised service delivery processes. Central to clinical governance is the idea that clinicians, including doctors, nurses and allied health professionals, are best placed to encourage performance improvement among peers.

There have been a number of published studies on clinical governance, mostly involving the UK National Health Service. These have a range of methods and foci, not uncommonly case-study approaches. Consistent conclusions are that opportunities for professionals to partner in leadership activities are lacking, with management providing insufficient support for clinical governance implementation.4–6 As far as we can ascertain, only one study has reported on a method for tracking clinical governance development. This provides a conceptual framework for evaluation, but has yet to be used in practice.7

To aid implementation of clinical governance, there is a need for tools that can be used consistently and over time to compare performances among healthcare providers and provide an indication of commitment to clinical governance and its development. This article introduces the Clinical Governance Development Index (CGDI), designed for such purposes. The setting is the government-dominated health system of New Zealand where, in early 2009, the government commissioned a working party to provide advice on clinical governance.8 Based on a wide-ranging review of the theory and practice of clinical governance internationally, including the UK National Health Service's Leadership Qualities Framework,9 the working party's report made several practical policy recommendations. These included that: District Health Boards (that own and run public hospitals) must establish governance structures ensuring a partnership of clinical and corporate management; these Boards and their Chief Executives must enable strong clinical leadership and decision-making, and promote this throughout the organisation; clinical governance must cover the whole patient journey, with decision-making devolved to the appropriate level; and management must identify clinical leaders and support their development.

The Minister of Health announced the working party's recommendations were government policy with implementation by District Health Boards an immediate priority. We therefore sought to measure the extent to which clinical governance was being implemented by surveying public hospital medical specialists. Although representing only one group of health professionals involved in clinical governance development, specialists are finely attuned to the nuances of clinical governance and likely to be aware of changes in leadership and organisational structures. From this project, we developed the CGDI. This article outlines the survey method, results, derivation of the index, and implications for utilising the CGDI.


We developed a fixed-response 11-item survey, with an additional eight background questions and a comments box. Survey items related directly to the key policy statements in the clinical governance working party's report.8 Thus, respondents were asked to rate the extent of familiarity with clinical governance concepts and policy. In a series of related questions, they rated the extent to which they perceived their employer organisation was working to develop and support clinical governance and partner with clinicians, from the level of the board and senior management through to front-line services. The survey was peer-reviewed through the development process by six researchers and medical professionals as well as the 10 members of the National Executive of the Association of Salaried Medical Specialists (ASMS) (all practising hospital specialists). A draft was then piloted among two groups of hospital specialists (22 in total) with further adjustments following feedback. Therefore, the survey questions and design met the standards for both ‘face’ and ‘construct’ validity.10

All New Zealand public hospital specialists are salaried employees of one of the District Health Boards for which they work. Ninety-one per cent of specialists are members of the ASMS, a national union. The self-completed survey was distributed in paper form by ASMS to its 3402 members in June 2010, with two follow-up reminders. In August 2010, a web-based survey sought participation with an email invite to those who had not responded to the paper version, with two subsequent email reminders. Data from paper surveys were converted into electronic form and merged with data from the web survey, with no significant differences in response patterns for survey items between the two response modalities found.

The CGDI was formed by combining responses from seven survey items that represent related aspects of processes involved in implementing clinical governance. The remaining core survey items were precluded from the index, as they were used as either control or predictive variables as further described below. Responses to each item were assigned a value and then summed for each individual. The mean of these summed scores became the index score for each of the 21 District Health Boards (a merger means there are now 20 of these Boards). For items with responses of ‘a great extent,’ ‘some extent’ and ‘no extent,’ the responses were scored as 2, 1 or 0, respectively. Items with binary responses were scored 1 if a response of ‘yes’ was recorded, and 0 for ‘no’ or ‘don’t know.' The index had a range of 0–13, converted to a percentage as it was felt it would be easier to work out how well an organisation was faring on a scale of 0–100. All items displayed good correlations with the final index score, with Pearson correlations ranging from 0.60 to 0.75. The index was found to be internally consistent, with a Cronbach α of 0.80.

The data were analysed using R statistical system version 2.12.11 Differences between District Health Boards for count data (such as responses to survey items) were analysed using the χ2 goodness-of-fit test. For continuous data, a one-way ANOVA was used. Finally, a generalised estimating equation (GEE), using a Gaussian link function, was applied to quantify the association between fostering support for the development of clinical leadership by the District Health Board governing board and hospital management, and the CGDI. The GEE was used to adjust for correlation in CGDI scores between respondents within a Board. A GEE model with item 1 (board) and item 2 (management) in table 1 as predictor variables and the CGDI score as the dependent variable was fitted. Respondent District Health Board was used as the grouping variable. The items ‘Extent which Chief Executive has sought to enable strong clinical leadership and decision-making’ and ‘Do you feel you have enough time to engage in clinical leadership or development programmes?’ were also included in the model as possible confounders. GEEs were used to adjust for within-District Health Board correlation, with an exchangeable (constant) correlation structure within Boards assumed.

Table 1

Key survey items


A total of 1761 completed surveys were returned, for a 52% response. Respondents were 66% male (compared with 69% male in the total ASMS membership). Response rates across the 21 District Health Boards ranged from 39 to 70% (mean=51%, SD=7%). We asked respondents whether they had any specific clinical leadership or management responsibilities: 52% listed none, 22% had <4 h per week, 10% had 4 to 7 h, and 12% had 8 h or more. Respondents were asked whether they had enough time to engage in clinical leadership/governance activities. Only 20% felt they did, with a range of 10 to 41% across District Health Boards (χ2=40.60, df=20, p=0.0042). Familiarity with the concept of clinical governance stated in the working party report8 ‘as an obligation to step up, work with other leaders and change the system where it will benefit patients’ was probed, with 51% saying they were ‘very familiar’ or ‘familiar’ with the concept, and 49% saying they were ‘unfamiliar’ or ‘very unfamiliar.’ The level of familiarity varied by District Health Board, with a range of 43 to 77% (χ2=33.69, df=20, p=0.0283).

Responses to key survey items are listed in the table 1. Notable were the proportions of respondents indicating that their organisation's governing board and management were not fostering clinical leadership or that they did not know whether this was the case. There were differences in the extent respondents saw quality and safety as the goal of all clinical and all administrative initiatives. A majority believed management–clinician partnerships were in place to some or a great extent, but only 48% said a governance structure was in place to support this.

CGDI scores for 506 (30.0% of total) respondents could not be calculated due to ‘don’t know' Likert scale responses. The CGDI scores naturally reflect responses to key survey items. The mean CGDI score was 47.3%, showing considerable scope for improvement. Differences in District Health Board performances were significant (F(20, 1178)=3.233, p=0.0000), ranging from a low of 38.1% contrasted with the best-performing board scoring only 55.3%. CGDI scores were significantly and independently related to scores for the first two items in table 1; that is, CGDI scores were higher where respondents perceived boards and management had worked to support clinical leadership. Both board and management (as described in the Methods) were found to have statistically significant associations with CGDI score (table 2).

Table 2

Generalised Estimating Equation results showing association between certain factors and Clinical Governance Development Index score


The CGDI offers a simple yet effective means of measuring the extent to which a healthcare organisation is working to facilitate clinical leadership and partner with clinicians in this. In keeping with the notion that well-developed clinical governance requires managerial support as well as clinical involvement in leadership activities, the CGDI draws its measures from the perspective of clinicians. Importantly, the CGDI mixes items that probe both management and clinician activities; in our study, these items sought to measure the implementation of stated policy. The CGDI can be used as a yardstick for assessing performances on clinical governance over time as well as between organisations which can be useful for applying pressures for improvement.

Our application of the CGDI implies considerable effort is required if New Zealand's health boards are to put robust systems of clinical governance in place. Responses to individual CGDI items highlight where efforts might be directed. Clearly, governing boards and corporate management need to do more. Indeed, it could be argued that the majority of responses to individual items on managerial processes of ‘don’t know' and ‘to some extent’ are a failure and that success in clinical governance development should be judged by clinicians perceiving support and development to be occurring to ‘a great extent.’ That between a third and a fifth of respondents to some individual survey items ticked ‘don’t know' and therefore could not provide knowledgeable answers should, in itself, be a deep concern.

Various options are available for those seeking to promote clinical governance. Central to these is seeking to identify and support clinical leaders and developing structures through which decision-making is the result of a partnership between management and clinical staff. Competency to engage in clinical governance may play a part in developing clinical leaders. Indeed, there is a strong argument that leadership training should feature early in health-professional education and be promoted more widely.12 Of course, it is important to ensure that decisions are based on best available evidence, including around how services should be configured and delivered.13 Recent research also indicates that, where possible, responsibility for decision-making (including budgets) should be devolved to the clinical leaders of specific services, with appropriate training to support such responsibilities.14 However, any organisational development process is contingent on support for and understanding of new directions among all involved parties. That only around half of our survey respondents were familiar with the basic concept of clinical governance implies that health professionals also need to increase their level of engagement. This is where incorporating leadership and team-based approaches to clinical work in training and workforce development programmes could be useful.15 16 Equally useful would be clinicians with leadership responsibilities working to promote clinical governance activities and encouraging colleagues that they have an obligation, to their patients and to one another as professionals, to become involved in these.

We found a significant association between organisations whose boards and management had been more active in promoting clinical governance and scores on the CGDI. This is in line with research indicating that hospital performances on quality are better where governing boards are proactive.17–19 It also adds to calls from healthcare quality advocates for getting ‘boards on board’ as central to the quality-improvement mix.20 The role of management, for its part, in clinical governance implementation is to some degree contingent on individuals in leadership positions and their leadership styles, but leadership is a similarly important component in organisational and quality improvement. What is clear is that leaders need support, of governing boards, as well as resources.21 Research also suggests that hospitals with clinical leaders have better clinical governance processes in place and superior health outcomes.14 Yet New Zealand, with its mediocre performance on clinical governance, is not alone. Elsewhere, studies show that the struggle continues with attempting to bridge the managerial–clinical divide and build entities with strong clinical leadership focused on quality and safety.2 22 23 The reasons for this may, again, be due to leadership capacity, as well as the context-dependent nature of any management project which means that it is difficult to simply transplant a well-functioning model of clinical governance from one organisation into another.

The research in this article has limitations. First, the self-completed survey method relies on individual perceptions and has associated biases. However, response patterns were consistent across the 1761 returned surveys from 21 districts. Second, a response rate above 52% would have been desirable but was around the level obtained in comparable studies. A review of research in a related field concluded that 55% is considered to be ‘one of the best response rates.’24 While we lack knowledge of the non-responders, informal feedback received at presentations to New Zealand medical specialist conferences gives us no reason to believe that a higher participation rate would have significantly altered the findings. That said, it is possible that the 48% of non-responders featured a larger proportion of clinicians who feel disenfranchised. If so, then the results in our study could indicate a higher level of clinical governance development than the reality. Third, our survey included only medical specialists. Albeit a pivotal group, a larger study might also include nurses and allied health professionals who have important roles in the management of health services. Fourth, we were unable to measure whether the higher-scoring organisations, with more supportive boards and management, had stronger clinical governance mechanisms in place. It is possible that respondents may have simply perceived a higher level of clinical governance activities due to management espousal of key concepts. Further research might look for relationships between CGDI scores and indicators such as devolved lines of responsibility, investment in training, and shared decision-making structures.

Despite these caveats, the CGDI and our use of it in the New Zealand context provide a baseline for further research. This might involve additional work on validating the questionnaire and CGDI, and addressing questions such as the time period over which we might expect to see changes in index scores. In the meantime, the CGDI could be easily adapted for use in other countries and healthcare settings. It could also be used to measure ongoing progress in New Zealand District Health Boards towards improved clinical governance and therefore improved patient quality, safety and outcomes.


We are grateful to the three anonymous reviewers, for their very useful and insightful comments on a prior draft, and to the survey respondents, for their participation.



  • Funding University of Otago; Association of Salaried Medical Specialists.

  • Competing interests JB is President, Association of Salaried Medical Specialists and Chaired the Ministerial Task Group on Clinical Leadership.

  • Ethics approval Ethics approval was provided by the National Executive of the Association of Salaried Medical Specialists.

  • Provenance and peer review Not commissioned; externally peer reviewed.