Clinical governance in primary care. Improving quality in the changing world of primary care.

Publication of A First Class Service placed quality improvement at the centre of the health policy stage. The term clinical governance was used to capture the range of activities required to improve the quality of health services. Central among these were the need for all NHS organisations to develop processes for continuously monitoring and improving the quality of health care and to develop systems of accountability for the quality of care that they provided. Evidence based practice, audit, risk management, mechanisms to monitor the outcomes of care, lifelong learning among clinicians, and systems for managing poor performance will all contribute to the development of effective clinical governance. In addition, the term combines an emphasis on improving care for individual patients with quality improvement targeted at whole populations. This wide ranging approach creates a challenge for those leading the implementation of clinical governance. Primary care groups and trusts are the organisations through which clinical governance will be developed at a local level and local priorities identified. Yet the nitty-gritty work of clinical governance will be undertaken by the members of individual practices and primary care teams. The articles in this series explore the meaning of clinical governance in primary care. They focus on the roles of primary care groups and trusts; the knowledge, skills, and support needed by individual practitioners; and the emerging requirements for accountability between practitioners, the public, and the wider NHS hierarchy. This article examines definitions of quality, the values underlying them, and early approaches to implementing clinical governance in primary care. Without consensus on these issues it will be difficult to develop a shared view of what clinical governance is and of how to implement it. Recognising the fragmented organisational structure of primary care and the traditional independence of general practitioners, the second article in the series will focus on accountability for quality. The need for organisational and professional development to facilitate changes in the culture of primary care, and improvements in clinical knowledge, skills, and leadership, will be covered in the third and fourth articles respectively. The final article will consider the extensive range of knowledge and information required for the successful implementation of clinical governance.