Preparation and priority setting of clinical governance performance indicators in dimensions of risk management and clinical effectiveness from the healthcare staff viewpoints

Background: Evaluating the performance in clinical governance activities requires specific and appropriate national indicators. The aim of this study was to develop clinical governance performance indicators in dimensions of risk management and clinical effectiveness using viewpoints of healthcare staff who were working in various hospitals in East Azerbaijan, Iran. Materials and Methods: Through an extensive literature review, 135 indicators were selected for assessment by using comments of the staff working in all 41 hospitals of East Azerbaijan. Two hundred and eighty-eight people participated in four sessions in National Public Health Management Center (NPMC). Participants evaluated the indicators through 36 Focus Group Discussions. Through their discussions they completed predesigned forms with respect to title of indicators, methods of calculating the indicators, total score of importance and its feasibility, data collection method, data sources, and the level of indicator's evaluation. Results: Patients' safety and cardiovascular care unit (CCU) each by 16 indicators had the highest number of indicators. Pathology, ophthalmology, and radiology each by three indicators had the lowest number of indicators. The median score of the importance and the feasibility were both calculated in eight. Only 36.3% of the indicators were collected from hospitals. Most of the suggestions for gathering the indicators were from medical records and hospital information system (HIS), supervisors, statisticians, and admissions department. Sixty-nine indicators were designed by the participants that patient's safety had the highest number of them. Conclusion: A total of 204 indicators were evaluated and proposed by hospitals staff and stakeholders in clinical governance that can be useful in the quality of hospitals services promotion.