Clinical supervision sits at the heart of the UK Government's agenda for improving the quality of service delivery (Department of Health, 1997, 1998, 1999). The practice in the workplace was introduced as a way of using reflective practice and shared experiences as a part of continuing professional development. Clinical supervision has ensured that standards of clinical care remain a key mechanism for monitoring the performance of Trusts, with clinical performance measures being given equal weight to financial and accounting measures. Each Trust is required to have a clinical supervision lead and a clinical supervision committee. The clinical supervision process within Trusts is performance managed through annual reports scrutinised by Strategic Health Authorities. (Kohner 1994; Faugier 1992) The Commission for Health Improvement review teams focus, during their visits, on the clinical supervision process. There are therefore several mechanisms for monitoring the delivery of clinical supervision.
Clear national standards for services and treatment support the development of high-quality services. The National Institute for Clinical Excellence Guidelines and technology appraisals are sent to all Trusts with a requirement that they be implemented. Other key drivers for clinical supervision include National Service Frameworks, Effective Healthcare Bulletins, Cochrane reviews and national audits including Suicide and Perinatal Mortality. Trusts are expected to establish robust management mechanisms to ensure that this national guidance is implemented.
In addition to the implementation of national standards, a further requirement for clinical supervision is to ensure that good ideas are facilitated locally, and form an integral part of clinical improvement. (Butterworth 1992; (Farrington 1995)) This requirement recognises that many improvements that will make a real difference to patient care will be identified by clinicians working directly with patients. Clinicians and patients together are often able to identify local factors, which will make a real difference to the local delivery of care. Establishing a mechanism whereby these bottom-up changes can occur alongside the implementation of the more top down requirements is a real challenge for clinical supervision teams within Trusts. This paper sets out how Dorset Healthcare NHS Trust (a specialist mental health and learning disability Trust) has met and responded to this challenge.
The clinical supervision structure
Clinical work in health care is largely delivered by teams of staff rather than by individuals or hospitals as a whole. It is recognised that training whole teams can often be more effective than training individuals within the team. Hence, real quality improvements are most likely to be delivered by teams rather than by individuals. (Johns 1993; Faugier 1994) The first priority, therefore, for Dorset Healthcare's clinical supervision programme was to identify all the clinical teams delivering patient care. These teams are largely multidisciplinary and include hospital inpatient wards, community mental health teams, and specialist treatment teams. Each team is part of one of the Trust's four supervision teams (directorates): adult, older people, learning disability, and child and adolescent mental health. Trust priorities for clinical supervision are agreed and monitored through the Trust Clinical Supervision and Risk Management Committees and Subcommittees of the Trust Board.
Clinical supervision portfolios
The Trust had an established mechanism of recording training, appraisal, supervision, etc. for individuals, and also recording audits and patient and public involvement activity at Trust and directorate level, but no clear mechanism for recording and developing such activity at team level. In order to monitor and record team clinical supervision activity, Dorset Healthcare NHS Trust provided each clinical team with a clinical supervision...
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