title: Do inquiries into health system failures lead to change in clinical governance systems?
abstract: OBJECTIVE
  This paper reports the first part of a case study investigation to examine the changes at King Edward Memorial Hospital (KEMH) following an inquiry established to review the quality of obstetric and gynaecological services.
  
  
  BACKGROUND
  Common findings from a range of health inquiries in recent times include that there have been inadequate adverse event reporting systems, the absence of transparent systems for staff and patients to report concerns about quality of patient care, and an ineffective medical credentialing and performance review system. The similarity of findings from many health inquiries raises the question of whether an inquiry does lead to changes to improve patient care and safety. There has been very little reported in the literature about this.
  
  
  METHODS
  Using a case study strategy the areas of medical credentialing, performance review and involvement of consumers in care were chosen as the KEMH clinical governance processes to be examined for changes post inquiry. Documents, archives and interviews were used as data sources for this case study. Documents were examined using a normative analytic approach and the Miles and Huberman framework was used for data analysis of the interviews.
  
  
  RESULTS
  There were significant changes in the area of credentialing and performance review evident in analysis of all sources of data. There were some improvements in the processes of involving consumers in care, but deficits were identified in regard to the provision of training and upskilling for clinicians to improve their communication skills and interactions with patients and families.
authors.affiliation: School of Nursing & Midwifery, Murdoch University, Education Drive, Mandurah, WA 6210, Australia. h.gluyas@murdoch.edu.au
authors.forename: Heather
authors.initials: H
authors.lastname: Gluyas
authors.forename: Selma
authors.initials: S
authors.lastname: Alliex
authors.forename: Paul
authors.initials: P
authors.lastname: Morrison
mesh_terms: D054869:Clinical Audit; D054976:Clinical Governance; D003406:Credentialing; D004650:Employee Performance Appraisal; D006801:Humans; D009775:Obstetrics and Gynecology Department, Hospital / Q000458:organization & administration*; D019982:Organizational Case Studies; D009936:Organizational Innovation; D010358:Patient Participation; D061214:Patient Safety; D012308:Risk Management / Q000458:organization & administration*; D014904:Western Australia