The atmosphere in which the sunflower grows informs the views and attitudes that guide the actions of both health professionals and patients.įor each petal (ie, theme or topic), we searched for relevant interventions in the Cochrane Library from 2010 to the end of 2016, in the context of chronic care in the primary care setting.
The sunflower is rooted in the earth, from where its structural components receive inputs in the form of water and nutrients in healthcare, inputs from the ‘soil’ enable the provision of primary care, collaboration between service providers and resources from the outside world. The petals in turn represent the themes or topics that shape direct actions involving patients or caregivers (the bud of the system). We then devised a framework arranged like a sunflower, where the stem and leaves represent the structural components of the system needed to supply and support the petals. We ultimately selected five core elements from the original Chronic Care Model (delivery system design, decision support, clinical information systems, self-management support, the community) and six approaches (risk avoidance, coherence, infrastructure, culture, quality methods, poor performance) from the clinical governance framework described by Scally et al based on their relevance to primary care and chronic disease management. We then conceptualised a new framework, merging the relevant aspects of both, and also defining and implementing new themes in a way that is relevant for primary care. Our paper aims to conceptualise a clinical governance framework and the tools it needs for the effective management of chronic diseases in the primary care setting, allowing to drive an effective change in healthcare services and thereby systematically improving their quality and safety.įor the purposes of our analysis, we used the Chronic Care Model by Wagner et al 16 and Clinical Governance statement by Scally et al 17 for reference, carefully reviewing each of them and their various components. 14 Clinical governance for primary care, focusing on the management of chronic diseases, has specific features and relies on a network of different health professionals working together for their patients’ benefit. 10–13 Until now, it has focused largely on in-hospital care, and met with significant difficulties when transferred to primary care. Clinical governance was first established in the UK, 9 and has been implemented in many different countries. It encompasses the tools, methods and infrastructure devoted to assuring healthcare delivery, continuously improving the quality of the service and striving towards clinical excellence for patients. 8Ĭlinical governance is an umbrella for the systematic administration and coordination of different processes having a direct impact on healthcare delivery, including the management of patients with chronic conditions. 7 With these pressures, primary care systems may have difficulty ensuring a coordinated approach, and the lack of clarity concerning their goals has led to divergent approaches, and a slow and often disjointed adoption of changes and improvements. 5 6 In fact, it is now widely recognised that the care and support needed to live with a long-term condition requires a radical re-design of services, by allowing patients to drive the care planning process and by developing a new management of care for people that is proactive, holistic, preventive and patient-centred as for example defined by the ‘House of Care’ model. 4 There is currently a growing interest in high-income countries to redesign healthcare organisations, focusing on practices that improve the quality of care and guarantee the equitable, timely and effective management of patients with chronic diseases. 1–3 As a consequence, the organisation and provision of primary care now faces new challenges (eg, polypharmacy, multimorbidity, fragmentation of care, frequent transitions of care, a need for strong integration and pressure from patients). The dramatic increase in the burden of chronic diseases in the last 20 years represents a primary concern for health services, and global health system sustainability demands a massive shift to primary care.
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