Article Title

Do inquiries into health system failures lead to change in clinical governance systems?


Aim: This paper reports the first part of a case study investigation to examine the changes at King Edward Memorial Hospital (KEMH) following an inquiry established to review the quality of obstetric and gynaecological services.

Background: Common findings from a range of health inquiries in recent times include that there have been inadequate adverse event reporting systems, the absence of transparent systems for staff and patients to report concerns about quality of patient care, and an ineffective medical credentialing and performance review system. The similarity of findings from many health inquiries raises the question of whether an inquiry does lead to changes to improve patient care and safety. There has been very little reported in the literature about this.

Method: Using a case study strategy the areas of medical credentialing, performance review and involvement of consumers in care were chosen as the KEMH clinical governance processes to be examined for changes post inquiry. Documents, archives and interviews were used as data sources for this case study. Documents were examined using a normative analytic approach and the Miles and Huberman framework was used for data analysis of the interviews.

Findings: There were significant changes in the area of credentialing and performance review evident in analysis of all sources of data. There were some improvements in the processes of involving consumers in care, but deficits were identified in regard to the provision of training and upskilling for clinicians to improve their communication skills and interactions with patients and families.


peer-reviewed, health inquiry, clinical governance, patient safety, clinical credentialing, consumer involvement

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