International Journal of Health System and Disaster Management

: 2013  |  Volume : 1  |  Issue : 1  |  Page : 16--21

Preparation and priority setting of clinical governance performance indicators in dimensions of risk management and clinical effectiveness from the healthcare staff viewpoints

Saber Azami Aghdash1, Homayoun Sadeghi-Bazargani2, Babollah ghasemi3, Ameneh Mirzaei3, Leila Abdollahi1, Gholshan Asghari3,  
1 Department of Health Service Management,Tabriz Health Services Management Research Center, Faculty of Management and Medical Informatics, Tabriz, Iran
2 Department of Statistics and Epidemiology, Traffic Injury Research Center, Tabriz, Iran
3 Treatment affair, Tabriz University of Medical Sciences, Tabriz, Iran

Correspondence Address:
Homayoun Sadeghi-Bazargani
Department of Statistics and Epidemiology, Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz


Background: Evaluating the performance in clinical governance activities requires specific and appropriate national indicators. The aim of this study was to develop clinical governance performance indicators in dimensions of risk management and clinical effectiveness using viewpoints of healthcare staff who were working in various hospitals in East Azerbaijan, Iran. Materials and Methods: Through an extensive literature review, 135 indicators were selected for assessment by using comments of the staff working in all 41 hospitals of East Azerbaijan. Two hundred and eighty-eight people participated in four sessions in National Public Health Management Center (NPMC). Participants evaluated the indicators through 36 Focus Group Discussions. Through their discussions they completed predesigned forms with respect to title of indicators, methods of calculating the indicators, total score of importance and its feasibility, data collection method, data sources, and the level of indicator«SQ»s evaluation. Results: Patients«SQ» safety and cardiovascular care unit (CCU) each by 16 indicators had the highest number of indicators. Pathology, ophthalmology, and radiology each by three indicators had the lowest number of indicators. The median score of the importance and the feasibility were both calculated in eight. Only 36.3% of the indicators were collected from hospitals. Most of the suggestions for gathering the indicators were from medical records and hospital information system (HIS), supervisors, statisticians, and admissions department. Sixty-nine indicators were designed by the participants that patient«SQ»s safety had the highest number of them. Conclusion: A total of 204 indicators were evaluated and proposed by hospitals staff and stakeholders in clinical governance that can be useful in the quality of hospitals services promotion.

How to cite this article:
Aghdash SA, Sadeghi-Bazargani H, ghasemi B, Mirzaei A, Abdollahi L, Asghari G. Preparation and priority setting of clinical governance performance indicators in dimensions of risk management and clinical effectiveness from the healthcare staff viewpoints.Int J Health Syst Disaster Manage 2013;1:16-21

How to cite this URL:
Aghdash SA, Sadeghi-Bazargani H, ghasemi B, Mirzaei A, Abdollahi L, Asghari G. Preparation and priority setting of clinical governance performance indicators in dimensions of risk management and clinical effectiveness from the healthcare staff viewpoints. Int J Health Syst Disaster Manage [serial online] 2013 [cited 2020 Jun 1 ];1:16-21
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Quality and its lasting improvement are of the discussions which have been attended in scientific and executive circles in recent years. Various approaches have been designed and extended in order to its settlement. [1] One of these approaches in the health system is clinical governance. [2] Clinical governance is an effective, new, and comprehensive framework in order to assure policymakers from the conformity of services presentation with recorded standards and lasting promotion of health services. [3] This approach has merged the clinical and subclinical attentions in order to achieve a comprehensive quality management. Such mergence can result in organizational coordination, cooperation, and communication between organizational units and finally caused to high quality presentation of surveillances. [4],[5] Clinical governance has seven compasses form the selective model of the health care and medical education ministry point of view consisting: Risk management, clinical effectiveness, education and instruction, manpower management, association of patient and society, information usage, and clinical examination. [6] In order to evaluate the clinical governance revenue and its rate of success in the hospitals of Iran, having no alternative of performance indicators usage which is showing the rate of success and improvement in clinical governance performance. Performance indicators are systems which are measures medical activities in the field of medicine and other related disciplines. [7] Such indicators present quantitative amount of measures as a standard and guideline for services quality improvement and also supportive services. [8] Although performance indicators do not measure the services quality directly, but define the aspects and parts which need more attention and improvement. [9],[10] Preparation, improvement, and report of performance indicators have been widely used as a method of services quality improvement and responsibility increase in many countries through recent years. [11],[12],[13],[14] Consultant association indicators of the health and therapeutic cares of Australia is of the most important experiences of improvement and usage of performance indicators that prepared in 1993 for accreditation or reaccreditation of Australia's hospitals. Through this preparation, 185 indicators from more than 500 centers were collected. [14],[15] The international project of performance indicators preparation for six patients had started in 2000 in Denmark and lasted for 2 years. [16] India has been driven to prepare performance indicators for this country's second level in 2008 with the aim of health services quality improvement. [17] In many other advanced countries like US, England, Holland, other European association countries, and performance indicators usage have been used currently. [18],[19],[20],[21] Despite of the expansion of these indicators usage, their collection and usage has been neglected in Iran. The aim of this research is to collect and design the clinical governance performance indicators in 43 hospitals and four organizations and ministries of the East Azerbaijanin risk management and clinical accreditation scopes.

 Materials and Methods

In this research data has been gathered by using systematic and widespread review in PubMed, Medline, Science Direct, Google Scholar, SID databases, websites, related journals, and other related resources through searching Clinical Governance, Risk management, Clinical effectiveness, Performance indicators, Clinical indicators, Hospital indicators keywords, and their Persian alternatives. Finally, 135 indicators presented for the survey of this scope in a native version by the staff's views of all of the province's hospitals and administrations. These persons were selected from 43 province's hospitals consisting educational, private, suburban, and four organizations consisting healthcare relief of Tabriz University of Medical Sciences, province's administration of events and medical urgencies, and province's administration of laboratories and province's nursing administration. They consisted of matron, clinical governance expert, hospital expert, statistician, and medical document expert, educational and clinical supervisor, clinical governance educational team, emergency, and other unit's supervisors. Two hundred and eighty-eight persons from these hospitals participated through four meetings in national public health management system (NPMC). They were divided into 36 concentrated discussion groups with 7-10 persons in each group in order to evaluate the achieved indicators using designed form (form 1).

This form consisted of the below mentioned columns:

First column: Title of the index gathered and translated from various resources

Second column: Manner of indicators' calculation in fractional, percentage, mean ratios, yes and no questions, and … calculation quality

Third column: People's suggestions for title modification and calculation quality

Fourth column: The importance of index in a nine step scale.

Fifth column: Executive capabilities meant accurate and reliable data gathering easily in the present system in a 1-9 scale

Sixth column: Index gathering in the hospitals with the source and method of gathering each of the items; first they were pointed to their definite index gathering and then they were recorded their suggestions about the method of index gathering

Seventh column: The smallest level of indicators gathering; consists of five levels including patient, patient companion, the unit, hospital, and university.

At the end of this form, participants were take action to new indicators designing in their specialized field and through discussion groups. They completed the whole of mentioned matters except the third column for their indicators designed by themselves.

In each session, one of the team members presented a lecture about performance evaluation indicators and method of indicators' evaluation and collection. Indicators had been collected in two scopes of risk management and clinical effectiveness and presented to people. Risk management was consisting of patient's safety, staff's safety, equipment safety, and physical environment safety. Clinical effectiveness was consisting of 11 parts: Hospital's infection indicators, indicators of special care unit, cardiac special care unit, hospital's mortality indicators, gynecology indicators, psychotics' indicators, surgeries indicators, pediatric indicators, ophthalmology indicators, pathology indicators, and radiology indicators. Risk management is consisting of 47 indicators and clinical effectiveness was consisting of 88 indicators. Excel 2007 software has been used for data analysis. Internal analysis has been used in gathering departments and information gathering resource.


One hundred and thirty-five indicators gathered through literature review of published resources. These indicators modified by 43 hospitals' staff of the East Azerbaijan (13 educational hospitals, 18 suburban hospitals, and 12 private hospitals) and four organizations' staff in the scope of healthcare (province's administration of events and medical urgencies, province's administration of laboratories, and province's nursing administration). Instead of these indicators, several indicators were designed by staff in consistent with their work environment. The results presented separately in [Table 1] and [Table 2].{Table 1}{Table 2}

The most number of evaluated indicators were in patient's safety and cardiovascular care unit (CCU), each of them with 16 indicators. The least evaluated indicators were related to pathology, ophthalmology, and radiology (from clinical accreditation); each of them with three indicators. Median score of the importance and indicators' feasibility were 8. 36.33% of the cases were collected from province's hospitals. Most of the suggestions were gathered from patients' files, supervisors of the units, hospital information system (HIS), statisticians, and receptions. The hospital level and the unit level were the appropriate levels for indicators' gathering.

After omission of the shared, unrelated, and defective matters; 69 indicators were selected from the participants' designed indicators. Patient safety with 13 indicators, hospital's infection, and mortality with nine indicators have the most number of indicators. Equipment safety and CCU departments with one index has the least number of indicators. Median score of the importance and feasibility were both equaled to 9. Only 36.27% of the indicators are that of designed by staff. The most common suggestions in data gathering were consisted of hospital's files completion, indicators' gathering by supervisors, and responsibles and checklists usage.

The above tables have been totalized in the [Table 3].{Table 3}


Performance indicators have critical role in providing more transparency, responsibility, and quality. Another important efficacies of the indicators are revenue evaluation and measurement and the rate of aims' accessibility. [22],[23] One hundred and thirty-five indicators that had extracted through systematic review, evaluated by the staff of 43 province's hospitals and four related organizations in the healthcare scope point of view. Then modified and improved in accordance to our country situation and finally 69 indicators prepared by their point of view. Totally 214 indicators have been studied in order to clinical governance evaluation.

The survey on the published literature and resources has been shown that designing and usage of performance indicators was neglected. Designing and usage of performance indicators has been more common in European and developed countries and has a vast of application. Azami et al., [24] in a similar study, designed critical governance evaluation indicators through performing experts panel and private interviews. The 361 extracted indicators after five panels and four interviews had decreased to 169 indicators. Information system weakness and lack of hospitals' awareness were of the main causes of most of the indicators omission. Files' incompleteness, information systems' weakness, and inattentive to indicators are of the reasons of lack of indicators gathering in the present study. Reinforcement of hospitals' information systems, appropriate completion of medical files, and emphasis of the hospitals' managers on indicators gathering and usage can be effective on the indicators usage in hospitals.

In the risk management and its related subjects, scattered studies have been occurred but in clinical accreditation this weakness is more swaggered. Azami et al., [25] gathered and collected 512 clinical indicators by their literature review and also referred to the necessity of clinical indicators designing and usage in order to evaluate the clinical governance operation.

The World Health Organization (WHO) in Europe in the project of "Performance assessment tool for quality improvement in hospitals (PATH)" and by using the expert panel and systematic review of literature prepared 100 indicators of performance measurement with cooperation of 20 European countries in six scopes consists of clinical effectiveness, safety, patient, staff, services effectiveness, and responsibility; and performed it in eight countries. [26] The more number of indicators in this research may arise from dilated view and broad study of surveyed indicators. This matter instead of its effectiveness, in state of time and power deficit, has its own offensiveness. So, appropriate policy in this study indicators usage should be applied.

A study in Netherlands [27] has produced 22 indicators in two scopes of patient safety and clinical effectiveness for hospitals' revenue evaluation. Researchers of this study used literature review, experts, and stakeholders' views for preparing indicators. In comparison of these two studies, the people's views and the number of indicators of the present study is more than that in the mentioned studies.

In this study, the patient safety scope with 16 selected indicators and 13 designed indicators have the most number of indicators which shows high importance of patient's safety and its applications. Azami et al., [28] have been focused on the importance and usage of patients' safety indicators. One of the most famous organizations in the context of patients' safety is the Agency for Healthcare Research and Quality (AHRQ). This organization introduced 20 indicators as the most important and universal indicators for patients' safety evaluation through a vast study in 2007 entitled in "Patients' safety indicators of the Agency for Healthcare Research and Quality". [29]

Organization for Economic Cooperation and Development (OECD) has extracted patients' safety indicators in five main scopes via experts' panel and proficient's cooperation in 2004 and throughout 21 membered countries and other international organizations. These main scopes are hospital acquired infections, surgical and after surgical charges, important and critical incidents, partiuritional, and other terrific incidents related to patients' safety indicators. Through this research, the 59 primary extracted indicators decrease to 21 final indicators. [30] These broad studies in such dimensions and with huge formations shows the necessity of these performance indicators attendance especially in critical scopes such as patients' safety.

Of the other important scopes that researchers had designed 16 indicators for, that was the indicators related to the CCU that despite of its high importance, just one useable indicator has been designed for this scope. The reasons of such matter could be caused by the low awareness and knowledge of the hospitals' staff of this unit and the high expertness of this scope. Ulla has produced 17 indicators for quality measurement of services presented to cardiovascular diseases throughout the membered countries in the OECD. Referring to this matter that cardiovascular diseases have a vast mortality and are different in presented services between various countries, he indicated that performance indicators usage is one of the most important strategies for declining such differences and universal standards observance. [31]

In attendance to this fact that cardiovascular diseases are one of the most important agents in mortality, it's necessary to delivery of high quality health services to people with cardiovascular diseases, in this regarding performance indicators are appropriate tools for evaluation of this services.

The limitations of this research were lack of hospitals' managers' attendance, information systems problems, lack of reliable indicators in hospitals and units, lack of supervisors, responsible of medical documents and statisticians' attendance, and lack of their motives. Lack of reliable and valid indicators, lack of staff' motives, and software problems in the performance indicators usage have been referred in Freeman's systematic review in England. [32]

Weaknesses of this research were few numbers of meetings and their tightness of time because of the lack of equipment and time and the extensive number of indicators. The number of participants from all the hospitals and four organizations of this province were of the strengths of this study.


We needed reliable and valid indicators coordinated to our health system in order to evaluate the clinical governance and operations of Iranian's hospitals. Utilization of other countries' successful experiences in consistent with the status of hospitals in our country are very necessary. Systematic review in order to recognizing and gathering such indicators and using the experts and stakeholders' views is a very effective approach.

According to the limit of number of surveys and the methodology of the study, we cannot claim that these survey indicators are applicable in the health system of our country. So, more studies in larger levels and with more supports are being needed.

Suggestions for more effective usage of performance indicators:

Hospitals' information systems modification and improvement, and equip them for gathering and analyzing indicators and their information.Effective system establishment in hospitals for gathering, analyzing, and reporting hospitals' indicators.Hospitals' managers assumption for performance indicators usage in policy and decision making.Conducting educational courses for staff in order to concentrate on the performance indicators method of gathering and reporting.Ordering hospitals' units in order to gather and report performance indicators.


The writers of this article are acknowledged of:

Clinical governance staff of the Tabriz University of Medical Sciences (clinical governance responsible and experts).National Public health Management Center (NPMC) for meeting attendance.Therapy relief of the Tabriz University of Medical Sciences (for coordination).All staff and managers of Tabriz province's hospitals and participated organizations.


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