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Table 1 OPTIGOV analysis areas; first 3 questions of each form, including an example of weighted scores

From: OPTIGOV - A new methodology for evaluating Clinical Governance implementation by health providers

ANALYSIS AREAS Items First 3 items of each form     
CG structural and functional prerequisites:       
A. Resources and Services Management 17 Do you have a planning and control system in place? Yes, completely Yes, partially No  
   If so, does the attribution of objectives and resources to the single units occur by means of a formalised contractual process? Yes No   
   Is the planning process supported by a computerised procedure? Yes No   
B. Learning Culture 9 Have you defined a training plan? Yes No   
   If so, have health professionals been involved in the detection of training needs? Yes, completely Yes, partially No  
   If so, are the training programs specifically targeted to the different professionals and responsibility levels? Yes, completely Yes, partially No  
C. Research and Development 5 Are there units performing scientific research in the health care organization? Yes No   
   If so, are the research results shared with the other health care units? Yes, always Yes, sometimes No, never  
   If so, are the research results used to modify health care protocols? Yes, always Yes, sometimes No, never  
D. Information Technology 6 Is there a computerised system for management of clinical records? Yes, completely Yes, partially No  
   Are legal and scientific references reported on the clinical records? Yes, always Yes, in most of the cases No  
   Is there a computerised system for the outpatient clinical record management? Yes, completely Yes, partially No  
CG Areas:       
1. Evidence-Based Medicine 21 In the process of taking decisions on patients, do doctors integrate their clinical experience with the best available scientific evidence? Yes, always Yes, sometimes Yes, rarely No, never
   If so, through which tool is this integration realised? Exclusively by referring to databases (e.g. Cochrane Library) Mainly by referring to databases (e.g. Cochrane Library) Mainly by referring to scientific literature on paper) = 1,3888 Exclusively by referring to scientific literature on paper)
   If the source of information is computerised, where does the consultation occur? In a handheld pc, at the bedside, = 4,1666 In a computer located within the unit = 2,0833 In a computer located within the department = 1,3888 In a computer located somewhere else within the hospital = 1,0416
2. Accountability 9 A. Are medical activities accountable? [A question = 4 Cs] Yes, always = 19,0476 Yes, sometimes = 9,5238 No, never = 0  
   B. If so, is there a formalised accountability procedure? [B question = 2 Cs] Yes = 9,5238 No = 0   
   C. If so, on what kind of support? [C question = base] Both = 4,7619 Computerised = 2,3809 Paper = 2,3809  
3. Clinical Audit 22 Is clinical audit performed within the units? Yes, always Yes, sometimes = 3,9214 No, never = 0  
   If so, how frequently is it performed ? Weekly Fortnightly Monthly Other
   Is there a formal documentation of the audits? Yes No   
4. Measurement of Clinical Performances 13 Is there an organizational structure specifically devoted to clinical performance measurement within the organization? Yes No   
   Are there professionals specifically devoted to clinical performance measurement within the organization? Yes No   
   If so, what kind of skills have they? Both Health care expertise Management expertise  
5. Appraisal and Improvement of Clinical Activities 10 Do you use the measurement results in order to improve health care activity? Yes, always Yes, sometimes No, never  
   Do you involve external high-level professionals in performance appraisal? Yes, always Yes, sometimes No, never  
   Does the appraisal involve only the heads of the units or even doctors individually? Even doctors individually Only the heads of the units   
6. Health Technology Assessment 21 Is there a structure specifically devoted to Health Technology Assessment within the organization? Yes No   
   Are there professionals specifically devoted to Health Technology Assessment within the organization? Yes No   
   If so, what kind of skills have they? (multiple choice possible) Management expertise Health care expertise Technical expertise  
7. Quality Systems 14 Do you have a quality system? Yes No   
   If so, is it certified by an accreditation and certification organization (certifying authority)? Yes No   
   If so, is the accreditation and certification organization specialised in certifying health care organizations? Yes No   
8. Risk Management 15 Have you performed a mapping of the existing risks in the units? Yes No   
   If so, has the risk mapping been communicated to all health professionals working within the unit? Yes No   
   Do you have an incident reporting system? Yes No   
9. Information, Citizen/Patient Involvement 17 Do you inform the patient of the clinical, diagnostic, therapeutic procedures he will undergo? Yes, always Yes, sometimes No, never  
   If so, is the information supported by any documentation on paper (leaflets, brochures, forms) to be handed to the patient? Yes No   
   Are there case managers within the units? Yes No   
TOTAL 13 179