Does Clinical Governance influence the quality of medical records? Andrea Poscia, Elena Azzolini, Pasquale Cacciatore, Antonio Giulio de Belvis, Massimo Volpe, Andrea Cambieri, Gianfranco Damiani, Walter Ricciardi and Maria Lucia Specchia [PDF - 92.58 kbytes]

摘要

Background. Clinical Governance (CG) is a validated framework for continuous qualityimprovement in health care settings. Quality medical records may reflect the quality ofcare delivered and are a viable tool to implement CG skills.Aim. Aim of this study is to investigate the correlation between the level of implementationof CG dimensions and the quality of medical records.Material and methods. A cross-sectional study was carried out in an Italian TeachingHospital. CG implementation levels were quantified through a systematic methodology(OPTIGOV.). The overall quality of medical records was measured through a revisedversion of a National-validated scale. A multiple linear regression model was used totest the likely influence of all the variables constituting the OPTIGOV evaluation on thequality of medical records. 47 hospital wards and 1458 medical records were assessed.Results. A significant and positive association between the quality of medical recordsand the accountability score (β = 0.15; p < 0.01) and the clinical audit score (b = 0.11; p= 0.02), was found. Conversely, the risk management score shown a negative and significantcorrelation (b = -0.17; p < 0.01). This study confirms that CG plays a central rolein driving quality improvement and advocates a systematic implementation of such anapproach within healthcare organizations.