Major failures in patient safety often lead to high profile inquiries set up to establish the facts, and to identify areas of improvement to prevent further failures. In order to learn from inquiries, we need to be able to identify if, and how, the inquiry process influences improvements. Using a case study strategy, this research study examined the perceptions of external stakeholders in regards to the impact or influence of the Douglas Inquiry on KEMH’s clinical governance systems. The research focused on two areas that were highlighted in the final Inquiry report as requiring reform. These systems deal with the clinical credentialing and performance review and the involvement of consumers in care. Several sources of data collection were employed. Firstly, document and archive analysis identified the procedures and processes employed by the Inquiry, and the changes that had occurred at the hospital. Secondly, semi-structured interviews ascertained participants’ perceptions of changes in clinical governance systems at KEMH post Inquiry, and the influence of the Inquiry on the changes that have taken place. The document and archives were analysed using an analytic approach described by Neuendorf (2002). The Miles and Huberman (1994) framework was used for the analysis of the interviews. The findings were then compared and with the literature. The study conclusions identified critical factors within the Inquiry process, which influenced improvement in the clinical governance systems examined. These factors were the Terms of Reference (TOR) and the investigative and inquisitorial processes employed by the Inquiry. Absence of one of these critical factors resulted in the Inquiry reinforcing existing barriers and thus, in those areas there was no change. Lewin’s (1951) model of change specifically informed the analytic process, with the outcome resulting in the development of a conceptual model of organisational clinical governance change.
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机译：患者安全方面的重大失误通常会引起高调的调查，以建立事实并确定需要改进的方面，以防止进一步的失误。为了从查询中学习，我们需要能够确定查询过程是否以及如何影响改进。本研究使用案例研究策略，研究了外部利益相关者对道格拉斯咨询对KEMH临床治理系统的影响或影响的看法。该研究集中在最终调查报告中突出强调的两个领域，需要进行改革。这些系统处理临床认证和性能审查以及消费者对护理的参与。使用了几种数据收集来源。首先，文件和档案分析确定了调查所采用的程序和过程，以及医院发生的变化。其次，半结构化访谈确定了参与者对KEMH询问后临床管理系统的变化的看法，以及该询问对已经发生的变化的影响。使用Neuendorf（2002）描述的分析方法对文档和档案进行了分析。 Miles and Huberman（1994）框架用于访谈的分析。然后将发现与文献进行比较。研究结论确定了询问过程中的关键因素，这些因素影响所检查的临床管理系统的改进。这些因素是职责范围（TOR）以及调查所采用的调查和调查过程。这些关键因素之一的缺乏导致调查增加了现有的障碍，因此，在那些地区没有变化。 Lewin（1951）的变革模型专门为分析过程提供了依据，其结果导致组织临床治理变革概念模型的发展。
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