The current issue and full text archive of this journal is available on Emerald Insight at:
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Relationship between clinical Psychiatrichospitals in
governance and hospital Ghana
performance: a cross-sectional
study of psychiatric hospitals 225
in Ghana Received 29 April 2020
Revised 27 September 2020
29 November 2020
Joshua Cobby Azilaku 25 February 2021
College of Health, Kintampo, Ghana Accepted 23 March 2021
Patience Aseweh Abor
Department of Public Administration and Health Services Management,
University of Ghana, Accra, Ghana
Aaron Asibi Abuosi
Public Administration and Health Services Management, University of Ghana,
Accra, Ghana
Emmanuel Anongeba Anaba
Department of Public Administration and Health Services Management,
School of Social Sciences, University of Ghana, Accra, Ghana, and
Abraham Titiati
College of Health, Kintampo, Ghana
Abstract
Purpose – Clinical governance (CG) is crucial for healthcare quality of care improvement and safeguarding
high standards of care. Little is known about CG in sub-Saharan Africa. The authors assessed health workers’
perceptions of CG and hospital performance in Ghana’s psychiatric hospitals.
Design/methodology/approach – A cross-sectional survey was conducted among 230 health workers
across two psychiatric hospitals in Ghana. Data were collected with a structured questionnaire and analyzed
with Statistical Package for Social Sciences (SPSS), version 23.0.
Findings –Themajority (59.5%) of the respondents were females. The authors found that less than five in ten
respondents felt that the hospitals have adopted measures to promote quality assurance (43.2%) and research
and development (43.7%). However, a little above half of the respondents felt that the hospitals have adopted
measures to promote education and training (57.7%); clinical audit (52.7%); risk management (50.7%) and
clinical effectiveness (68.6%). The authors also found a statistically significant association between CG and
hospital performance (p < 0.05).
Research limitations/implications – There was a positive relationship between CG and hospital
performance. Therefore, investing in CG may help to increase hospital performance.
Originality/value – This is the maiden study to investigate CG and hospital performance in Ghana’s
psychiatric hospitals and one of the few studies inAfrica. This studymakes amodest contribution to the global
discourse on the subject matter.
Keywords Clinical governance, Hospital performance, Psychiatric hospitals in Ghana, Clinical effectiveness,
Quality assurance
Paper type Research paper
International Journal of Health
Governance
Vol. 26 No. 3, 2021
pp. 225-236
The authors would like to thank the management of Pantang and Accra Psychiatric Hospitals for the © Emerald Publishing Limited
2059-4631
warm reception and support during the data collection. DOI 10.1108/IJHG-04-2020-0042
IJHG Introduction
26,3 Clinical governance (CG) is gaining recognition among health professionals and researchers
worldwide. Healthcare managers are investing in measures to improve quality of care and
safeguard high standards of care (Nmai et al., 2015). CG refers to the measures adopted by
health institutions to promote clinical quality and high standards through the creation of a
supportive environment. It focuses on promoting clinical effectiveness, risk management,
clinical audit and quality assurance as well as research and capacity building through
226 education and training (Khayatzadeh-Mahani et al., 2013).
CG bridges the gap between managerial and clinical approaches to quality healthcare
improvement (Buetow and Roland, 1999). Effective implementation of CG enhances
responsible and continuous improvement in the quality of care (Crook, 2002; Halligan and
Donaldson, 2001). It has been underscored that investing in measures to improve the
quality of care enhances the effectivemanagement of health institutions (Taboli et al., 2014).
In addition, adopting effective risk management and clinical audit measures enhances
efficiency and reduces financial losses (Rodella et al., 2018). Implementing CG helps to
reduce the incidence of adverse events and nosocomial infections in health institutions
(Gillam and Siriwardena, 2018). Also, evidence suggests that health institutions that adopt
measures to safeguard high standards of care are more likely to perform better
(Gauld, 2017).
CG has received much research attention in developed countries (Fardazar et al., 2015).
However, little is known about the subject matter in sub-Saharan Africa, including Ghana.
Poor quality of care is a major concern in Ghana (Atinga, 2012). In addition, health workers in
Ghana, including mental health workers, have embarked on a series of industrial actions,
largely due to poor conditions of service (Fournier, 2011; Agyapong et al., 2015).
Ghana has only three large mental health or psychiatric hospitals situated in two of the
now 16 administrative regions (Gloria et al., 2018) coupled with five smaller psychiatric units
in five regional hospitals. The bed to population ratio stands at six beds per 100,000 people
(Roberts et al., 2014). Themajority of people in Ghana accessmental health services at district
hospitals and private health institutions. Studies have shown that mental health facilities in
Ghana are underresourced and understaffed (Aikins and Koram, 2017; Harrison et al., 2018).
In addition, mental health services are highly fragmented, poorly coordinated and low in
quality (Eaton and Ohene, 2016; Roberts et al., 2014).
In the quest to strengthen the capacities of mental health institutions, the Government of
Ghana passed the Mental Health Law in 2012. This law led to the establishment of the Ghana
Mental Health Authority, which is responsible for regulating mental health institutions.
Despite these efforts, the quality of mental health services has not improved significantly. In
addition, there is a paucity of literature on CG in Ghana, especially in the context of mental
healthcare. To the best of our knowledge, this is the maiden study in Ghana that investigates
CG in psychiatric hospitals. Studies of this nature are crucial for healthcare quality
improvement and policy purposes. The objectives of this study were to assess health
workers’ perceptions of CG and examine the relationship between CG and hospital
performance.
Review of theoretical and empirical literature
This study was underpinned by the United Kingdom National Health Service (NHS) version
of the Temple Model of CG (Braine, 2006; Levy and Rockall, 2009). According to Scally and
Donaldson (1998) “clinical governance is a framework through which NHS organisations are
accountable for continually improving the quality of their services and safeguarding high
standards of care by creating an environment in which excellence in clinical care will
flourish.”
The overall purpose of CG is to ensure that patients receive the highest standard of care Psychiatric
possible (Braine, 2006). This can be achieved by implementing measures to promote clinical hospitals in
effectiveness; clinical audit; risk management; education and training; research and Ghana
development; and quality assurance (Braine, 2006). Clinical audit focuses on ensuring that
clinical practices meet acceptable standards by measuring and reviewing current practices
against best practices. This enhances transparency and accountability in the clinical
setting. In addition, clinical effectiveness seeks to ensure that clinical decisions are based on
rigorous and comprehensive scientific evidence to help improve healthcare outcomes, while 227
clinical risk management emphases managing risk on day-today basis (Briner and Manser,
2013). In addition, the Temple Model underlines that capacity building and continuous
professional development are crucial for improving quality of care. This can be achieved by
implementing measures that enhance continuity in education, training and development.
Last but not least, the proponents of the Temple Model posit that implementing continuous
monitoring and evaluation mechanisms (quality assurance) may improve the quality
of care.
CG has been widely investigated in developed countries. For example, prior studies found
a positive association between CG and quality of care and overall hospital performance
(Mousavi et al., 2014; Veenstra et al., 2017). Sarchielli et al. (2016) also found that
implementation of CG was positively associated with clinical efficiency, including bed
occupancy rate, bed turnover interval and reduced mortality. Studies have also shown that
there is a positive relationship between CG and job satisfaction. For instance, Gurdogan and
Alpar (2016) found that Turkish nurses who perceived a supportive environment were more
likely to be satisfied with their job.
However, the implementation of CG remains problematic. Previous studies identified
multiple barriers to effective implementation of CG. Som (2005) revealed that the majority of
doctors in the United Kingdom were less enthused about CG coupled with little support. The
doctors felt that there was inadequate stakeholder consultation during the implementation of
CG. Wilks and Boniface (2004) found that health workers demonstrated a good
understanding of CG. However, their participation in continuous professional development
activities was low due to inadequate resources (Hogan et al., 2007; Shakeshaft, 2008) and poor
leadership and management styles. It has also been found that the lack of shared goals on
quality improvement among clinicians posed a challenge to the successful implementation
of CG.
Further, the lack of a good relationship between different cadres of health workers and the
noninvolvement of clinicians in health services management pose a threat to CG
implementation (Hogan et al., 2007). Suggesting that participation and broader stakeholder
consultation are crucial for effective implementation of CG. Evidence also suggests that there
is low awareness of CG among health professionals in developing countries. For instance,
Ravaghi et al. (2014) found that health workers lacked a comprehensive understanding of the
concept of CG. Health workers limited CG to continuous quality improvement, medical errors
and patient safety. Other barriers to the effective implementation of CG include lack of proper
management and leadership, lack of support, inappropriate organizational culture, lack of
knowledge, poor communication systems and insufficient training (Ravaghi et al., 2014;
Gauld and Horsburgh, 2015).
In the quest to increase commitment to CG, stakeholders have argued that there is the need
to raise awareness among clinicians. There is also the need for a supportive culture which
enhances partnership among various stakeholders (Currie and Loftus-Hills, 2002). Factors
associated with positive attitudes toward CG include effective communication of hospital
goals on continuous quality improvement, effective communication of safety concerns to
senior management and availability of clear structures and processes to support CG (Hogan
et al., 2007).
IJHG Methods
26,3 Study setting
We invited all the three psychiatric hospitals in Ghana to participate in this study;
however, only two hospitals accepted our invitation. The two hospitals are located in the
Greater Accra Region: Ghana’s capital city. The hospitals provide both outpatient and
inpatient health services. They have a total staff capacity of 960 and patient capacity
of 1,041.
228
Study design and sampling
A cross-sectional survey was conducted among health workers in the two selected hospitals.
Our target population were doctors, physician assistants, nurses, occupational therapists,
psychologists, biomedical scientists and social workers. National service persons and
students were excluded from this study. The simple random sampling technique was
employed to select the respondents. A sample size of 272 was determined using a population
size of 960, design effect of 1 and a confidence level of 95%. To cater for nonresponse, 10%
(n5 28) of the sample size was added, summing up to 300 participants. Sample size formula:
n 5 [DEFF*Np (1
p)]/[(d2/Z21
α/2*(N
1) þ p*(1
p)].
Instrumentation and data collection
Data were collected using a structured questionnaire. The questionnaire was categorized
into three main sections. The first section collected data on participants’ characteristics,
including age, sex, position, qualification and work experience. The second section of the
questionnaire assessed health workers’ perceptions of CG. This section had 23-items,
categorized into six dimensions, namely clinical effectiveness (4 items), clinical audit
(4 items), risk management (4 items), quality assurance (4 items), research and development
(4 items), and education and training (3 items). All the items were coded on a five-point
Likert scale ranging from (15 strongly disagree to 55 strongly agree). This section of the
questionnaire was adapted from Spaeth-Rublee et al. (2010). The scale had a reliability score
of 0.9, which is above the recommended threshold of 0.7 (Pallant, 2013). The third section of
the questionnaire measured health workers’ perceptions of overall hospital performance on
a five-point Likert scale ranging (1 5 very poor to 5 5 very good). The design of
questionnaire was guided by the research objectives, NHS framework for CG and empirical
literature. Prior to data collection, the questionnaire was pilot-tested. We computed factor
analysis during the testing stage, and items that had good factor loadings were maintained
in the final instrument.
The questionnaire was self-administered to healthworkers, and a period of three dayswas
agreed upon for pick-up. Data collection was done by the first author and a trained research
assistant. Data collection took place between the month of May and June 2019. On average, a
respondent needed 15 min to complete the questionnaire. In all, three hundred (300)
questionnaires were administered but 230 completed questionnaires were retrieved,
representing a 77% response rate.
Ethical considerations
This study received the approval of the Ghana Health Service Ethical Review Committee
(GHS-ERC 086/04/19). In addition, permission was sought from the managers of the hospitals
prior to data collection. Participation was voluntary and no respondent was induced or
coerced to participate. Participants were only required to respond to the questionnaire; hence,
this study was associated with minimal harm. Above all, the respondents signed a consent
form which was provided by enumerators.
Statistical analysis Psychiatric
Data were analyzedwith the aid of Statistical Package for Social Sciences (SPSS) version 23.0. hospitals in
Data were analyzed in three stages, including univariate, bivariate and multivariable Ghana
analyses. At the univariate level, descriptive statistics, such as frequencies, percentages,
means and standard deviations, were computed.We also computed the percentage of positive
response by summing percentages of “agree” and “strongly agree”. The mean score was
calculated by dividing the sum of positive responses by the total number of items under each
dimension or pillar. At the bivariate level, Pearson’s correlation was computed to ascertain 229
the relationship between CG pillars and hospital performance. At this level, items under each
dimension were computed to generate a composite index. At the multivariable level, multiple
linear regression was computed to identify significant predictors of overall perception of
hospital performance. Independent variables included: clinical effectiveness; clinical audit;
risk management; quality assurance; research and development; and education and training.
Overall perception of hospital performance was the dependent variable, controlling for
participants’ characteristics. Assumptions underlying multiple regression, such as
collinearity, outliers and normality, were satisfied. All the results were reported at a 95%
confidence interval.
Results
Characteristics of respondents
It was found that the majority (59.5%) of the respondents were females, 76.5% of the
respondents were less than 36 years old, with a mean age of 32.2 years, and a standard
deviation (SD) of 6.4. It was also found that the majority (78.7%) of the respondents were
nurses, while 49.1% of the respondents had a diploma. Concerningwork experience, 61.7% of
the respondents had less than six years of work experience with a mean work experience of
6.3 years and a SD of 4.5. (Details are provided in Table 1).
Descriptive statistics of clinical governance pillars
Less than seven in ten respondents thought that the selected hospitals have implemented
measures to promote clinical effectiveness, while five in ten respondents perceived that there
were measures in place to promote clinical audit. In addition, half of the respondents felt that
the hospitals have adopted measures to minimize risk. Concerning education and training,
about six in ten respondents did think that the hospitals have implemented measures to
promote it. The dimensions or pillars that were rated very low included quality assurance and
research and development. Less than half of the respondents thought that the selected
hospitals have adopted measures to promote these pillars of CG. Details are provided in
Table 2.
Relationship between clinical governance pillars and hospital performance
It was found that of the 230 respondents, 2.6% perceived hospital performance to be very
poor and 13.5% perceived hospital performance to be poor. Exactly 43.5% rated hospital
performance as average. Regarding positive response, 36.5% of the respondents perceived
hospital performance to be good, while 3.9% of respondents perceived hospital performance
to very good.
We found a positive significant relationship between clinical effectiveness and hospital
performance. Clinical audit correlated positively with hospital performance. The results
showed that risk management had a positive relationship with hospital performance. In
addition, we found a significant relationship between quality assurance and hospital
IJHG
Characteristic n %
26,3
Sex
Female 137 59.5
Male 93 40.4
Age (years) M (±SD) 32.2 ± (6.4)
230 18–25 29 12.6
26–30 77 33.5
31–35 70 30.4
36–40 35 15.2
≥41 19 18.3
Job position
Doctor 16 7.0
Physician assistant 33 14.3
Nurse 181 78.7
Work experience M (±SD) 6.3 ± (4.5)
≤1–2 years 50 21.7
3–4 years 45 19.6
4–5 years 47 20.4
6–7 years 35 15.2
8–9 years 25 10.9
≥10 years 28 12.2
Qualification
Table 1. Diploma 113 49.1
Characteristics of Degree 106 46.1
respondents Postgraduate 11 4.8
performance. The other pillars of CG also correlated positively with hospital performance
(p > 0.001). The strength of the associations was either weak or moderate (0.29–0.42).
Predictors of perceived hospital performance
The findings showed that of the six CG pillars, only quality assurance was found to be a
significant predictor (β 5 0.195, p 5 0.027) of hospital performance, controlling for
respondents’ characteristics. This means that for every unit increase in quality assurance,
perception of hospital performance would increase by two units, holding other factors
constant. Details are provided in Table 3.
Discussion
This study sought to assess health workers’ perceptions of CG and hospital performance in
two psychiatric hospitals. Generally, hospital performance was perceived to be poor as well
as the implementation of CG. Quality assurance and research and development were rated
very low. In addition, we found a positive significant association between CG and hospital
performance.
Specifically, clinical effectiveness recorded the highest average positive response. This
means that healthcare was delivered using appropriate procedures, promptly and produced
positive outcomes. This suggests that patient waiting time in psychiatric hospitals is
relatively short. This finding is contrary to findings in general hospital settings. Studies in
Ghana have shown that patients in general hospitals experience long waiting time (Atinga,
2012; Turkson, 2009). For instance, Abuosi and Braimah (2019) revealed that long waiting
Psychiatric
Pillar/dimension n % of positive response
hospitals in
Clinical effectiveness Mean 5 68.6 Ghana
There is an evidence-based approach to client management 230 78.7
Services produce desired results 230 67.9
Services are delivered in God time 230 60.4
Services are delivered using appropriate methods 230 67.4
Clinical audit Mean 5 52.7 231
There are constant peer review activities 230 67.4
Staff are involved in clinical evaluation activities 230 55.2
There are regular performance review meetings 230 54.4
There are systems in place to control financial leakages 230 33.9
Risk management Mean 5 50.7
There are strategies in place to address clinical risk 230 51.3
Incidence register is always provided 230 61.3
There are systems in place to reduce risk 230 44.4
The systems promote learning lessons from adverse events 230 45.6
Quality assurance/openness Mean 5 43.2
There are quality improvement initiatives 230 43.9
There are measures in place to protect the safety of staff 230 37.4
There is frequent staff training on medication safety 230 42.2
There are measures in place to promote patient safety 230 49.2
Research and development Mean 5 43.7
There is a knowledge pool that staff can easily accessed 230 32.6
Staff are regularly trained on best practices 230 49.6
There are opportunities to apply new skills learned 230 51.7
The hospital supports continuous professional development 230 40.9
Education and training Mean 5 57.7
There are training and educational programs available 230 53.9 Table 2.
Every staff is aware of the selection criteria for training 230 47.8 Descriptive statistics
Managers of the hospital conduct a regular appraisal 230 71.3 for pillars of CG
Predictors B SD error Beta t p-value
Clinical effectiveness 0.051 0.032 0.111 1.622 0.106
Clinical audit 0.029 0.020 0.114 1.415 0.159
Risk management 0.029 0.021 0.116 1.373 0.171
Quality assurance 0.043 0.019 0.195 2.232 0.027
Research and development 0.028 0.026 0.087 1.086 0.279
Education and training 
0.002 0.025 
0.007 
0.085 0.932
Position of participant 
0.042 0.097 
0.030 
0.434 0.665
Work experience of participant 0.004 0.020 0.021 0.193 0.847
Table 3.
Qualification of participant 
0.097 0.095 
0.068 
1.016 0.311 Multiple linear
Sex of participant 0.094 0.104 0.055 0.905 0.367 regression of
Age of participant 0.000 0.014 0.004 0.034 0.973 predictors of perceived
Note(s): R2 5 0.23, adjusted R2 5 0.19, F-value 5 5.9, p-value 5 0.000 hospital performance
time was an intractable problem at various service delivery units of health facilities and
constituted amajor source of patient dissatisfaction with care. The differences in the findings
may be attributed to differences in patient attendance. General hospitals delivered many
types of health services, including general medicine, pediatric care and maternal care. Hence,
they record overwhelming patient attendance, which contributes to long patient waiting time.
This implies that patients in psychiatric hospitals have access to prompt care. This can help
IJHG reduce further complications or death that may occur due to delays in providing care. More
26,3 importantly, persons with psychiatric disorders can be very aggressive and violent, hence
providing care at the opportune time is crucial. Moreover, prompt delivery of care is an
indicator of quality of care as well as increases patient satisfaction with care.
In addition, education and training scored the second highest average positive response.
The majority of the respondents perceived that the hospitals have implemented measures to
promote continuity in education and training aswell as regular performance appraisal. These
232 findings are expected because the hospitals are state-owned and regulated by the Ghana
Health Service. The service has a policy on performance appraisal, education and training.
And it is expected that all public health institutions would adhere to these policy guidelines.
For instance, a nurse whoworks for at least four consecutive years is qualified for study leave
with full salary (Kwamie et al., 2017). In addition, performance appraisal is compulsory in all
public health facilities in Ghana. It is a tool for assessing health workers performance for
promotional purposes and also helps to identify their training needs. This finding implies that
psychiatric hospitals adhere to national policy guidelines. This is crucial for safeguarding
high stands of care and promoting employee performance and job satisfaction. There is
however a need for a comparative study between general hospitals and psychiatric hospitals.
This would help stakeholders to understand the level of adherence to national policy
guidelines by different healthcare providers.
On the contrary, quality assurance scored the lowest average positive response. The
majority of the respondents felt that the hospitals have not adopted measures to promote
quality of care, patient safety, medication safety and health workers safety. This finding
suggests that some pillars of CG were of less priority to the managers of the hospitals. A
similar study in Iran found that health managers demonstrated low interest in CG (Fardazar
et al., 2015). These findings suggest that health workers in psychiatric hospitals may be
exposed to many occupational hazards. The findings also suggest that patient safety may
be compromised in psychiatric hospitals. This contradicts with the overall purpose of
CG, which seeks to ensure that patients receive the best of care. In addition, medication
errors pose a threat to patient safety and quality of care. It is a major risk factor to adverse
events in health facilities, which may lead to disability or death (Lisby et al., 2005; Thomas
et al., 2000).
The findings also showed that the majority of the respondents perceived hospital
performance to be suboptimal. This finding may be explained by the poor implementation of
CG in the hospitals. For instance, the majority of the respondents indicated that there was a
lack of regular training on best practices coupled with lack of support for continuous
professional development. These may contribute to poor performance of health workers,
which may, in turn, affect overall hospital performance. It was, however, interesting to find
that there was a positive association between CG and hospital performance. This finding is
supported by previous studies in Iran and Italy (Taboli et al., 2014; Sarchielli et al., 2016). This
means that investing in CG may help increase hospital performance.
Implications for findings
These findings have implications for health service management; hence, they require urgent
attention of stakeholders. For instance, the lack of safety mechanisms may expose health
workers to danger since persons with psychiatric disorders can be very aggressive and
violent. Grey literature shows that mental health workers in Ghana experience verbal and
physical assaults from patients. This may contribute to psychological distress, job
dissatisfaction and high employee turnover. Ghana’ mental health sector already lacks
adequate health workforce; hence, more professionals leaving the sector may have dire
consequences.
Further, an unsafe work environment may negatively affect health workers performance. Psychiatric
Health workers who feel unsafe or are assaulted may experience injuries, which may hospitals in
contribute to job stress, burnout and absenteeism. Moreover, the cost of losing experienced Ghana
personnel as well as replacing and training new employees cannot be miscalculated. It is
therefore recommended that healthcare managers in their quest to increase performance as
well as the quality of care should invest in CG.
233
Limitations of the study
Although this study provides valuable information for health service management, it is not
devoid of limitations. One main limitation was our inability to involve many cadres of mental
health workers, including biomedical scientists, occupational therapists, social workers and
psychologists. These cadres of health workers were few in the hospitals, hence had a very
busy schedule. Understanding the subject matter from the perspectives of these stakeholders
would have been more insightful. Therefore, the findings must be interpreted with caution.
Another limitation of this study was the small sample size and low response rate. This
study presents the views of a few health workers in Ghana; hence, these findings cannot be
generalized to the larger population. Future studies should consider sampling many health
workers across professional groups and geographical locations. Also, this study employed a
cross-sectional design, hence cannot explain the intricate views of participants. Future
studies should explore the views of patient relatives and healthcare managers on the subject
matter.
We also acknowledge limitations in the model underpinning this study. Hence, the
interpretation of the findings must be done with caution. Further studies should consider
employingmore recentmodels. Also, the self-reported approach to data collection is subject to
survey bias, including social desirability bias. Therefore, the views of patient relatives or
caregivers should be considered in future studies to help confirm or refute some of the
findings. Notwithstanding, this is the maiden study to investigate the implementation of CG
in Ghana’s psychiatric hospitals. It, therefore, serves as valuable reference material for future
studies.
Conclusion
This study demonstrates that the implementation of CG in Ghana’s psychiatric hospitals was
perceived to be suboptimal. There was a positive relationship between CG and hospital
performance. This study has highlighted aspects of CG that require urgent attention.
Healthcaremanagers can leverage this evidence to help improve hospital performance aswell
as improve quality of care and increase patient satisfaction. This study makes a modest
contribution to the global literature on CG by looking at Africa’s perspective.
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Corresponding author
Patience Aseweh Abor can be contacted at: pabor@ug.edu.gh
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