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Table 3 The themes and subthemes in this study

From: The challenges of implementation of clinical governance in Iran: a meta-synthesis of qualitative studies

Themes

Subthemes

Quotation

Health system structure

Rules related to clinical governance implementation

Having an appropriate legislation allows the policy to be implemented in a better and more suitable way. There was a motivation for implementing clinical governance, but there were not many very good laws to guarantee its implementation” [30]

Formal structure for clinical governance affairs in the governance arrangement of the health system

When clinical governance began, many managers set up a unit to show their interest in running the program, but the unit’s performance was unclear” [31]

Inter-sectoral collaboration in the health system

The implementation of clinical governance was left to the hospital staff alone. Cooperation with other parts of the Ministry of Health was also needed to implement this program. For example, the support and procurement of some equipment required the cooperation of other deputies” [33]

Policy issues

Over the time, the Ministry of Health was not interested in the implementation of clinical governance. Financial and manpower [person-power] problems have led the managers to pursue other programs” [31]

Management

Administrator support of clinical governance

In the hospitals in which managers were interested in the implementation of clinical governance, they supported activities and employees also had a good incentive to provide services. Good results were obtained” [36]

The commitment of managers to clinical governance

If they (managers) had the necessary training before running the program, they would surely have had much more support. Employees expected the managers to support the program, but this did not actually happen. Over the time, commitment of managers to run the program has decreased” [32]

Planning

Having a clear program in mind is very important. The Ministry of Health expects to achieve the goals quickly with the implementation of clinical governance. The [MOHME Ministry of Health and Medical Education] should consult all parties to implement the program” [35]

Change of managers

In Iran, hospital administrators frequently change. The hospital administrators were planning to implement clinical governance as efficiently as possible. It was a matter of time. But as soon as the manager was close to success, it changed, and with the arrival of the new manager, the staff was faced with a new condition for the implementation of clinical governance” [32]

Delegation of authority

Some managers believe that they are doing things better than others. And it's better to do all the work themselves. They have a lot of tasks and they have not much time to monitor the program. Because of lack of trust in other employees, this has slowed down the activities” [39]

Person-power

Participation in the implementation of clinical governance

Many employees, including physicians, resist against the implementation of the program. They think that the implementation of this program needs many years to achieve its results. They also consider the implementation of clinical governance as opposed to offering their services” [35]

Resistance to implementation of clinical governance

When a new program should be implemented, a lot of people in all parts of the health sector are opposed to its implementation. Many believe that these programs cannot solve the problems” [34]

High workload

In addition to my daily activities, I also have services related to clinical governance. I really have no time to do all this and I’m tired” [33]

Cultural factors

Cultural structures governing the health system of Iran

When there is a change to be made, it should be completely clear to everyone. Really, the need for implementation must be clear to the staff. A few months after the program was implemented, many people asked about the tasks and meaning of clinical governance. One of our problems is that there is no consultation with the staff for implementing a program, and the culture of accepting programs is often not provided for staff” [36]

Attitude towards clinical governance

When serious support is not given to health sector programs, employees do not like it, and they do not make much effort to run programs. Indeed, if the authorities were trying to explain the benefits of this program, then surely the staff would have had a positive attitude toward the program” [37]

The role of other stakeholders in the implementation of clinical governance

When clinical governance began, many people believed that the implementation of any new program caused more demands from the authorities and, therefore, did not want to cooperate. Moreover, the lack of funding for programs and low motivation has led to a lot of the staff to be strongly critic towards the program” [36].

Medical error reporting

Many employees are afraid to report medical errors.

Physicians and nurses, especially physicians, are not likely to report medical errors” [37].

Information and data

Access to required information

With regard to many of the indicators needed to implement clinical governance, we did not have the correct information on the status quo of these indicators. So many programs were not based on reality. The goals that were set were not real” [30]

Development of health information system

There is no accurate and interconnected hospital information system with adequate equipment; it is not possible to use a variety of fragmentary data to examine the state of implementation of clinical governance programs” [32]

Documentation of activities

Employees were told that clinical governance activities should be documented. Everyone tried to record the services they were doing. But the equipment was not good for this” [36]

Instructions

In my opinion, the instructions were very general and ambiguous. If for clinical governance activities the details were correctly stated in the instructions, many of the staff would have been more transparent” [33]

Resources

Equipment

If we want to ensure that clinical governance is implemented in all its dimensions effectively, then there should be various equipment. The hospital was not able to provide all the equipment due to the lack of funds, which greatly affected the correct implementation of the program” [36]

Human resources

For the implementation of clinical governance, a special human resources unit should be assigned. All hospitals are facing shortage of manpower. Many people, in addition to carrying out activities related to clinical governance, have to do some other work, and therefore their motivation for doing their work is reduced” [39]

Financing

An adequate budget should be considered for the implementation of this program, and all the activities that the staff members provide should be rewarded. Even for the purchase of some items needed for basic patient safety, there was not enough money” [30]

Education

Teaching programmes

Many hospital managers do not have much knowledge about clinical governance, and because of this, they have little interest in training the rest of the staff. Training classes should be provided before running this program” [32]

Clinical governance-related training in medical universities

If employees who provide health services in their careers receive training in clinical governance goals, their performance will be better” [30]

Patient knowledge and awareness of clinical governance

In many hospitals, patients did not know about this program. In some cases, they did not cooperate because they were not aware” [36]

Evaluation

Evaluation criteria

Evaluators need to be scientifically trained to evaluate the performance of the staff in a transparent manner” [32].

Issues related to the evaluators

Each evaluator has his own criteria and applies his own personal views” [37]