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Objectives: This study investigated whether the attitudes of physicians towards justified and unjustified litigation, and their perception of patient pressure in demanding care, influence their use of defensive medical behaviours., Design: Cross-sectional survey using exploratory factor analysis was conducted to determine litigation attitude and perceived patient pressure factors. Regression analyses were used to regress these factors on to the ordering of extra tests or procedures (defensive assurance behaviour) or the avoidance of high-risk patients or procedures (defensive avoidance behaviour)., Setting: Data were collected from eight Dutch hospitals., Participants: Respondents were 160 physicians and 54 residents (response rate 25%) of the hospital departments of (1) anaesthesiology, (2) colon, stomach and liver diseases, (3) gynaecology, (4) internal medicine, (5) neurology and (6) surgery., Primary Outcome Measures: Respondents' application of defensive assurance and avoidance behaviours., Results: 'Disapproval of justified litigation' and 'Concerns about unjustified litigation' were positively related to both assurance (β=0.21, p<0.01, and β=0.28, p<0.001, respectively) and avoidance (β=0.16, p<0.05, and β=0.18, p<0.05, respectively) behaviours. 'Self-blame for justified litigation' was not significantly related to both defensive behaviours. Perceived patient pressures to refer (β=0.18, p<0.05) and to prescribe medicine (β=0.23, p<0.01) had direct positive relationships with assurance behaviour, whereas perceived patient pressure to prescribe medicine was also positively related to avoidance behaviour (β=0.14, p<0.05). No difference was found between physicians and residents in their defensive medical behaviour., Conclusions: Physicians adopted more defensive medical behaviours if they had stronger thoughts and emotions towards (un)justified litigation. Further, physicians should be aware that perceived patient pressure for care can lead to them adopting defensive behaviours that negatively affects the quality and safety of patient care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Objective: Although the guiding principle of clinical governance states that healthcare professionals are the leading contributors to quality and safety in healthcare, little is known about what healthcare professionals perceive as important for clinical governance. The aim of this study is to clarify this by exploring healthcare professionals' views on clinical governance., Design: Based on a literature search, a list of 99 elements related to clinical governance was constructed. This list was refined, extended and restricted during a three-round Delphi study., Setting and Participants: The panel of experts was formed of 24 healthcare professionals from an academic hospital that is seen as a leader in terms of its clinical governance expertise in the Netherlands., Main Outcome Measures: Rated importance of each element on a four-point scale., Results: The 50 elements that the panel perceived as most important related to adopting a bottom-up approach to clinical governance, ownership, teamwork, learning from mistakes and feedback. The panel did not reach a consensus concerning elements that referred to patient involvement. Elements that referred to a managerial approach to clinical governance and standardisation of work were rejected by the panel., Conclusions: In the views of the panel of experts, clinical governance is a practice-based, value-driven approach that has the goal of delivering the highest possible quality care and ensuring the safety of patients. Bottom-up approaches and effective teamwork are seen as crucial for high quality and safe healthcare. Striving for high quality and safe healthcare is underpinned by continuous learning, shared responsibility and good relationships and collaboration between healthcare professionals, managers and patients., Competing Interests: Conflicts of Interest: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Rationale, Aims and Objectives: This study aims to provide in-depth insight into the emotions and thoughts of physicians towards malpractice litigation, and how these relate to their incident disclosure behaviour., Methods: Thirty-one Dutch physicians were interviewed and completed short questionnaires regarding malpractice litigation. We used hierarchical cluster analysis to identify physician clusters. Additional qualitative data were analysed., Results: Physicians vary largely in their attitude towards malpractice litigation, and their attitude is not straightforward related to their disclosure behaviour. Based on their responses physicians could be divided into two clusters: one with a positive and one with a negative attitude. Physicians with a negative attitude showed often, but also 6 out of 15 not, a reluctance to disclose, whereas the majority in the positive attitude cluster (12 out of 16) showed no reluctance. If, what and how physicians disclose incidents depends on a complex interplay of their emotions and thoughts regarding litigation, and not only on their fear of litigation as many studies assume., Conclusions: Due to the variation among physicians in their litigation attitude and behaviour in terms of incident disclosure the oft-heard call for 'openness' about medical incidents will not be easy to achieve. A coaching system in which physicians can share and discuss their differing attitudes and disclosure principles, teaching medical students and junior physicians about disclosure, and explaining how to organize emotional and legal support for oneself in case of litigation could decrease stress feelings and support open disclosure behaviour., (© 2014 John Wiley & Sons, Ltd.)