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Clinical Governance and the Drive for Quality Improvement in the New NHS in England

Author(s): Gabriel Scally and Liam J. Donaldson
Source: BMJ: British Medical Journal, Vol. 317, No. 7150 (Jul. 4, 1998), pp. 61-65
Published by: BMJ
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1993. and monitoring. Clinical governance and the drive for quality improvement in the new NHS in England Gabriel Scally. Ann Intern Med 1998. 24 May 2017 12:42:07 UTC All use subject to http://about. chance to focus their time and energies on exactly Randomised comparison of guided self management and traditional those technical. Rethinking medicine improving health outcomes with doctors.) they wish. eds. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. and other healthcare professionals the cost-effective psychosocial interventions Psychosom Med 1995. taking the best as its norm. care system. and with some important midcourse comes and lower cost for both teachers and students. and remain 5 Nolan T.125. and respecting every patient as an cally ill adults to provide care and education to other individual. Splaine ME. Lean thinking. Herrala J. sis. Lime Kiln Close. Kiviranta K.289-92. nurses. Med demean their expertise. 1996. achieving better health status out right in 1948. Continually improving the health and value of health care for a popula making. Greenfield S. Patient Educ Counsel 1992.11 I am sure you will help them if they ask. et al.bmj. The new NHS.33 on Wed. London: Stationery Office. treatment. much of their care in their own homes. 12 Nelson EC. Plume SK. service performance. and humanitarian tasks that treatment of asthma over one year. The resonance of the two terms is important. Schall M. in which financial control. BMJ 1996.13 NHS patients today 1998. Baker GR.27:S 110-27. (Cm 3807. banish waste and create wealth in At first. The NHS's 50th anniversary sugar and adjust their insulin doses.312. The government's Gabriel Scally. write in and read their own medical records. cultures are particularly important NHS Executive The new concept has echoes of corporate govern (Northern and Yorkshire) ance.128. and data collection into medical practice. et al. 6 WomackJP. and as it will be in 2048. You are not by any means 13 Gerteis M. In the past many Summary points Westwood House. health professionals have watched as board agendas and Stoke Gifford. dealing with poor professional performance) Durham University seek quality improvement through clinical governance. Jones DT. management meetings have become dominated by Bristol BS34 8SR Clinical governance is to be the main vehicle for financial issues and activity targets. this reformulation of the 8 Devine EC. San Francisco:Jossey-Bass.748-52. Shared decision 3 Batalden PB. Edgman-Levitan S. Involving patients in everyone?giving patients and their families the chance medical decision making. Batalden PB. Diane Plampingjo By the early 21st century. well managed organisations will be those Durham DH1 3YG It requires an organisation-wide transformation. illnesses to become experts in their own care whenever 1997. the NHS was becoming a Bufford.5(l):5-7. Rockefeller R. regional director. Kuusisto P. for if clinical governance is to be successful New approaches are needed to enable the BMJ 1998. Science Park. Ware JE Jr. receive 4 Berwick DM. Nelson EC. your doctors resisted this trend? . to establish control over their own lives and giving 10 Sobel DS.19:129-42. In the future. Through the achieving far bet 2023 seek the continual improvement of an NHS full ter control than when the doctor was making the insu of knowledge. you remain well on track. Daley J.9 You learned from Dr David Sobel at capacity as a full and integrated system of shared effort.5:41-51. is now the norm. growing its lin adjustments. 1995.128:460-6. the heart of everyday clinical practice. and Jan Filotowski for helpful comments. truly patient centered clinical care system. and clinical leadership and positive organisational Liam J Donaldson. Building measurement they are in the best position to pursue. to undue the NHS). 7 Kaplan SH.jstor. Boston: Institute for Healthcare Improvement. able to participate fully in their own diagno 2 Rogers E. Nolan TW.12 The author thanks Paul Plsekjohn Oldham. 9 Mulley A. Staker L. These principles endure. Kaiser Permanente in America. New York: Simon & Schuster. you in patients eyes. Physicians as leaders in improving health care. hypertension treatment. and positive BMJ VOLUME 317 4JULY 1998 www. that it would relegate them to second fiddle.1 For the first and developing the capacity of the NHS in public health England to maintain high standards (including time. incorporating every patient's values and tion of patients: the panel management process. accountable in its delivery. and self diagnosis of urinary tract 61 This content downloaded from 202. Delbanco TL. Liam J Donaldson NHS Executive A commitment to deliver high quality care should be at (South and West). clinical quality are fully integrated at every level.57:234-44.317:61-5 it must be underpinned by the same strengths as recognition and replication of good clinical corporate governance: it must be rigorous in its appli practice to ensure that lessons are reliably learned from failures in standards of care cation. Maybe some day You built your programmes on evidence of the benefits healthcare leaders in the United States will catch up. who trained chroni wasting little. Ann Intern Med 1998. organisation-wide in its emphasis. 1996. New York: Free Press. The empha sis today is on helping people with acute and chronic 1 Secretary of State for Health. of patient self care in studies of asthma treatment. Kava T. Wasson JH. 4th ed. Mohr JJ. Mendoza G. Plume SK. Qual Manage Health Care circumstances. Effects of psychoeducational care for adult surgical patients: a respective roles of doctor and patient has helped metaanalysis of 191 studies.103.10 corrections. You continue to know that you started off chronically ill adults. Quality Connection 1996. 11 Lahdensuo A. all health organisations will have a statutory duty to John Snow House. Reducing delays and waiting times throughout the health fully connected with their loved ones and communities. Haahtela T. perhaps. and perhaps subject patients Car* 1989. your corporation. pastoral. continuously improving the quality of patient care white paper on the NHS in England outlines a new style regional director of of NHS that will redress this imbalance. an initiative originally aimed at redressing failed Local professional self regulation will be the key standards in the business world through the Cadbury to dealing with the complex problems of poor Correspondence to: Dr Scally report2 and later extended to public services (including performance among clinicians gscally@doh. developmental in its thrust. As in 1998. Instead. Diffusion of innovations.

is by e * Average far the most ambitious quality initiative that will ever have been implemented in the NHS. Failures in 62 BMJ VOLUME 317 4 JULY 19 This content downloaded from 202. Variations in Fig 1 Variation in the quality standards of care between different services have been well documented.103. it will also be seen as a way of addressing concerns about the quality of health Potential problems Exemplar care.5 It divides quality into four aspects: are also important Professional performance (technical quality) In the NHS a key Resource use (efficiency) philosophy of quality Risk management (the risk of injury or illness asso how clinical audit fits ciated with the service provided) Although the concept o Patients' satisfaction with the service provided. audit. and flow of informati . on subst clear policies and approaches. in the United Kingdom These dimensions of quality are taken a stage audit in the NHS is no further in the components identified in the new NHS have focused on the fa white paper as being the attributes of an organisation and moderate significa providing high quality clinical care.6 64.6 88. 24 May 2017 12:42:07 UTC All use subject to http://about.8 84.8 West Midlands 74. The introduction of clinical governance. Northwest 75.The NHS's 50th anniversary in its connotations. o / ??? x^ ?\ ^^^^^ ?f* CP ^V "^ s -11* Origins of clinical governance Although clinical governance can be viewed generally Leatti KX as positive and developmental. if the mean of th high standards of care by creating an environment in necessitate a more which excellence in clinical care will flourish principles and methods ment initially developed later applied to health Clinical quality has always engendered a multiplic organisation-wide appr ity of approaches. both locally and nation The process of learnin and problem services h What is clinical governance? tematically in the NHS. Under the previous government's market driven system for the NHS.1 South and West 80. Region or country Each organisation will have to work out these account Anglia and Oxford _73 ability arrangements in detail and ensure that they are North Thames 68.8 72.7 address the whole range of performances. many felt that the standards of care?wh quality of professional care had become subservient to plaints. and universalise often fragmented and far from aging services.6 75. Moreover.125.2 74.3 At any one time. and some have even con simplifying and imp sidered the term too subjective to be useful. Universally accepted definitions with emphasis on preve have been difficult to achieve. Some changes in healthcare organisations have been prompted by failings of such seriousness that Low quality H they have resulted in major inquiries. surveillance?represent some serious clinical failures?for example. unto price and quantity in a competitive ethos.8 Northern Ireland 82. and on in which the final accountability for clinical governance amounts to a significan rests with the chief executive of the health organisation?with regular reports to board meetings Table 1 Percentage of quest (equally as important as monthly financial reports)? national confidential inquiry and daily responsibility rests with a senior clinician. aimed as it is at improving the quality of clinical care at all levels of healthcare provision. The development plete participation (tab of clinical governance is designed to consolidate.2 communicated throughout the organisation.5 Quality improvement philosophy South Thames 75. team wor clinical governance.0 _ 72. in breast sations that are exempl and cervical cancer screening programmes3?have present once good prac been widely publicised and helped to make clinical more general applicabi quality a public confidence issue. Quality improvement must Wales _75.jstor. improved quality will oc Clinical governance is a system through which NHS in the middle range of organisations are accountable for continuously improving the quality of their services and safeguarding that is.3 Northern and Yorkshire 80.33 on Wed.1 service show variation in their performance against quality criteria (fig 1).4 The World Leadership and comm Health Organisation is helpful in exploring the idea of organisation. the organisations making up a health Trent 77.1 74. to create organisations regional audit.3 80.

Although this change professional 63 This content downloaded from 202. There have been two chief be defensive if the full benefits of these important addi executives in the past four years.jstor. for publicly advertised and are invested with significant example. response times and budgetary control?are showing up example) will find themselves leading clinical govern badly. uncer longer be comfortably based on opinion alone.103. which serves a small city and its surrounding county they are viewed by local services. such as the introduction of problem based learn quality ethos?a fact that is recognised by the new chief ing and joint education with other professional executive.9 Clinical governance offers the opportunity for the New approaches to undergraduate medical educa hospital to look at itself afresh and start to rebuild its tion. hospitals and primary care groups of the future. However. disciplines.125. a feature of the pre directorship of Gridstone Royal Infirmary at her inter vious eight years. and voluntary organisations. The role of the two new bodies could contain members of the senior medical staff have regularly used the local elements of all these functions.10 Culture. tainty exists about how best to appraise it critically. BMJ VOLUME 317 4JULY 1998 www. where currendy the on a model of wise authority rather than of authority infrastructure to support evidence based practice is not conferred by virtue of position. newly appointed chief tions to the national scene are to be realised. and where blame is tant too. such as general practitioners' ance strategies within their organisations. The Case study: Gridstone Royal Infirmary NHS Trust style of working of the Commission for Health Gridstone Royal Infirmary NHS Trust has advertised for a new medical Improvement and the National Institute for Clinical director with specific lead responsibility for developing clinical governance Excellence will be important. The most obvious is information tech clinical and medical directors in NHS trusts has nology to enable access to specialist databases (such as changed this approach dramatically.The NHS research and development programme Most observers would identify leadership as an has helped with the production and marshalling of the equally important ingredient in successful organisa evidence needed to inform clinical decision making tional change. The applicant for the medical ration would begin. Other indicators.12 professions expected to take on these posts.bmj. Any external body population. However. The strength of the view recognises that an organisation that creates a working relationship between senior managers and working environment which is open and participative. Medical referral preferences and the inability to fill vacant directors of NHS trusts may recognise that they have posts. Accessing and appraising evidence is rapidly some of the panel members at the medical director's becoming a core clinical competency. Other partnerships will be impor cation and research are valued. little effort has been expended in English region has shown wide variation in funding for developing leadership skills among members of the and access to library services. The challenge for universities. Day to day and longer term developmental used exceptionally is likely to be one where clinical progress will depend on effective partnerships with governance thrives (box next page). undoubtedly be preferable. 24 May 2017 12:42:07 UTC All use subject to http://about. Conventional indicators of performance?for example.33 on Wed. facilitating. or providing access many who hold such posts (as in the Gridstone to . is a necessary condition for adopting new practices. targets for inpatient waiting times ing. and teams One of the strongest statements in the recent NHS The feature that distinguishes the best health organisa white paper for England was that a new era of collabo tions is their culture. leadership too is a rather and service planning. A confidential survey of general practitioners' opinions conducted which will be based (at least in their initial approach to for the community health council showed that many were referring to local organisations) on facilitating improvement and hospitals outside the county because of concerns about standards of care in encouraging evaluation. was to be ended. Posts may well be the Cochrane collaboration). Competition. evidence on how to define a "good" culture and on the methods required to promote one is largely Evidence and good practice lacking in the healthcare field. She states that the key to creating an organisation with a reputation for The case study (box) describes an imaginary hospi high quality is successful implementation of clinical governance. investigat financial deficit has increased each year. and a recent review in one has taken place. But although the management neither clinical decisions nor health policy can any literature deals with such subjects extensively. Moreover. health professionals will be at the heart of successful where ideas and good practice are shared. suggest that all is not well with the quality of care skill deficits. and ing. the importance of teamworking has been emphasised by the General Medical Council. should in time improve team working skills. local authorities. a proactive approach would between doctors and management is dysfunctional. Although presenting evidence. Increasingly. The introduction of always in place. The NHS's 50th anniversary Two new external bodies will facilitate and reinforce the local duty for quality in the NHS. interview at Gridstone. are a basic requirement for access to responsibilities and authority. where edu clinical governance. patients' representative the NHS is the active creation of such cultures in most groups. supplying expertise. leadership. executive is the first woman senior manager ever appointed to the hospital's staff. Health organisations must not some of the local hospital's clinical departments. advising. but although these may be addressed provided. libraries. It is obvious too that the relationship when someone is in post. The hospital has had a troubled past four years: a recurrent can add value in different ways: inspecting. tal (Gridstone) that is ailing as an organisation. However. Clinical governance will require vague concept Among professionals it is often based a greater emphasis at local level. as will the way in which in its hospital. How ever. it will be newspaper to criticise decisions by the trust's management The hospital has a higher number of medical posts filled by locums than any hospital in the important that they establish an overall philosophy region. The fact that those lead The evidence based medicine movement11 has always ing health services do not traditionally think along had a major influence on many healthcare systems of these lines perhaps explains the initial scepticism of the world. accredit agreed in annual performance plans have repeatedly not been met. The current.

It would be wrong. Council to deal with most problems. and we do want to ask you about your attitude to criticism of a fellow professional.15 The introduction of new performance why I emphasise leadership and culture and why I will eat "mother pie" if I am wrong. has yet to develop a simple way to allow the important. A new major strand in the NHS research and earlier. high governance is to sort out problem doctors (see quality service for patients attending your accident and emergency interview (box)). I see a positive culture they work for. by the clinical directors of each service.125. A small proportion of hospital based department depends just as much on the leadership skills of the staff nurse medical staff are likely to have sufficient deficiencies in in the department as it does on the clinical skills of the trauma surgeon or their performance to warrant consideration of discipli the management skills of the medical director at trust board level. A safe. access to evidence. it is vital that poor performance is recognised and dealt with better than it has problems?are concerned. their as one in which doctors. the people we are doing correctly putting the protection of patients first. and education and training. managers. and other healthcare professionals work existence. doesn't it? I mean. That is nary action. Local professional it is vital that die right infrastructure is in place for clinical governance: regulation needs to be developed so that satisfactory information technology. It will also Changes to the NHS complaints procedure in mean having better data to review quality in each clinical service. being clearer about the skills and competencies openness and lay participation. after all. while more than we have in the past?they are. as and timely solutions can be found to what can be com well as some protected time for individuals and teams to think about the quality of their services. through which it is becoming clear that single take the lead on implementation of clinical governance. it is much more difficult to been in the past That's what people mean when they talk of local self identify the benficial elements and replicate them else regulation. through mechanisms like making sure everyone takes part in development programme?addressing so called serv effective clinical audit. and inde performance than sorting out the bad apples. I see the first and most important task as an organisational one?to on clinical incidents which are the subject of internal create the kind of service where high quality is assured and improvement and external inquiries is generated. and the tenacity with which the problem is closely together with a minimum of hierarchies and boundaries. Here is an extract from her measures (such as general feedback) are not effective interview and multifaceted strategies are needed?using tech Q: In your vision of clinical governance will our doctors be more niques such as input from a respected colleague. I think the concept is much more fundamental than that Certainly. BMJ VOLUME 317 4 JULY 1998 www. 24 May 2017 12:42:07 UTC All use subject to http://about. and individual audit and feedback.14 The health service needed in each area of service. but just two points for now. It would addressed. generalisable lessons to be extracted from the Q: Okay. but there is no takes place month on month. to rely on a body such as the General Medical A: There is a great deal more I could say. ance is also expected to address how good practice can Q: Isn't clinical governance just a more formal way for us to weed out the be recognised in one service and transferred to others. This will mean learning where possible from failures in standards of care?for example. a wealth of other information A: Yes. could you be a bit more specific? How will we recognise a good culture in the hospital if we see it? Poorly performing doctors and other health staff are a risk not only to patients but also to the organisation A: It is because the leadership and the culture have been wrong that you have had so many problems over the past four years. looking at our record of complaints and untoward incidents. Clinical govern \ possibly suggest anything else? ance has the opportunity to address this weakness A: I think you mean "motherhood and apple pie. You are surely not going to tell me that establishing the right leadership and culture are not keys to successful organisations are you? Dealing with poor performance Q: Okay. procedures by the General Medical Council has signalled a change in approach?away from a Q: Are there any other points about clinical governance you would like to reluctance to do anything that might be seen as make? Time is short. however. you and the chairman run private companies. ice delivery and organisation?is intended to tackle this But we must also try to prevent many of these problems. Firsdy. The controversy generated by this subject can through the leadership of the chief executive and the board (including me lead some to believe that the sole purpose of clinical as medical director if I am appointed). poor performers? Where whole services?for example. appraise evidence. but you say there is also more pendent judgment which now underpin the handling to the concept of clinical governance? of complaints. and having more open communication within teams. a community dia betic service or a service for women with menstrual A: No. and being willing to change things to make them better. how could you prevent similar errors from recurring. If she is appointed she will be expected to base. We need to identify problems of poor performance much where.bmj. information gathering. ensuring 1996 reduced the fragmentation and inconsistency of that clinical teams work more effectively so that individuals are taking fewer previous arrangements as well as introducing more decisions in This content downloaded from 202. year on year. is very important to the standing of the also be one with an environment in which learning and evaluation are NHS and the healthcare professions in the eyes of the encouraged and blame is rarely used This will be brought about only . and by individual team leaders in every clinical area.13 A: I think the scope of professional responsibility will be much broader Much of the evidence based work to improve clini than at present?covering commitment not just to delivery of a safe and cal decision making has centred on specific interven effective service but to the quality goals of the organisation as a whole and tions and clinical policies. you've convinced us that there's more to addressing poor extensive analysis. Moreover. Secondly. The test will be whether such cases can improvements. 64. also deal fairly with experienced and highly trained professionals. accountable than they are now? academic detailing. However. we must find ways of involving patients much be dealt with in a sympathetic manner which. consultants having reserved spaces in the car park.The NHS's 50th anniversary it is not sufficient The field of behaviour change among A consultant rheumatologist is an external applicant for the post of medical director health professionals is itself developing an evidence of Gridstone Royal Infirmary NHS Trust. by problem. review data.103. and plan plex problems. obvious route for this information to be channelled to i Q: Sounds a litde "mother pie/' doctor.33 on Wed. will this for.jstor. clinical govern to the clinical team. Though relatively few in number." don't you? I know that requiring organisational as well as individual learning.

9 Wood TJ.268:1111-7. The NHS's 50th anniversary Professional development ^s^* Risk avoidance^^^^ The staff of a healthcare organisation will be the key to /aV Well trained staff 7/\^S. To do this requires the drawing together of many strands of professional endeavour and managerial commitment into a Data quality cohesive programme of action in each healthcare The importance of clinical record keeping is well organisation in England.8 procedure. 7 Gallimore SC. health professionals and managers alike?is to turn this new concept into reality (fig 2). BMJ VOLUME 317 4JULY 1998 www.2 0. assessed. At the outset. The change masters. and costs of care. valuing staff and letting them know that they are valued?easily espoused but often overlooked?is a common feature of organisations that TO^ ^Z/participatlvoNX // / //// show sustained excellence in other sectors1617 \% \%% %** //Good leadershipNA ^# f ^f ? / \%. In: There are substantial failings in the completeness of Nuffield Provincial Hospitals Trust Towards a measure of medical care.0 1995. access to evidence are all important Thirdly. JAMA 1992. Clinical effectiveness indicators: a consultation document. Leeds: NHS . The human side of the enterprise. Management knowledge and skills required by UK and US Medical Directors. 1997. 1997. 1984. New York: McGraw Hill. Systematic reviews are beginning to inform the design of training and continuing professional development programmes for Conclusion doctors. 24 May 2017 12:42:07 UTC All use subject to http://about. the emphasis in data collection was on the 3 NHS Executive (South Thames). Firstly. Operational research on the health services?a symposium.153:1423-31. Can Med Assoc J Northern and Yorkshire 4.9 0. / /$ \\ Clear procedures // \*j\ good recruitment. 1990 and 1997) was seen as highly dependent on the 1997. 1960. Copenha gen: WHO. (Cm 3807. Continuous improvement as an ideal in health care. retention.33 on Wed. Evidence-based medicine: a Table 2 Percentage of hospital episodes in which the primary new approach to teaching the practice of medicine. 1983. South and West 1.) ness. Thomas MA. 1998.320:53-6. BMJ 1994. Secondly. staff must be / ^/^^ \\ Safe environment // % ^\% \ supported if they are to practise well: skills training. (Report by the comptroller and auditor general. South Thames .18 Designing programmes that help to advance the quality goals of every organisation and which draw Clinical governance is a big idea that has shown that it on an evidence base will also be part of the principles can inspire and enthuse. modern information technology. 8 Clinical Audit in England HC 2 7 Session 1995-96. 10 General Medical Council. If this challenge is met the beneficial patient data has been a central part of the health serv consequences will flow to every hospital. staff must participate in developing quality strategies and be encouraged to look critically at existing processes of care and improve them. Hayes RB.2 ness of CME: a review of 50 randomised controlled trials. 1996. appropriateness. length of stay. 268:2420-5. exchange of data about the quality of care provided. 17 Kanter RM. London: National Audit so unsatisfactorily dealt with in the past that they will Office. London: Allen and Unwin.7_0_ 18 Davis DA. practice. ice's planning and administration.103.X%%^// Educationand \\ ? ^f^/ In the NHS the development of educational \ 7s? \ ^ // research valued \\\P &f ?/ consortiums has for the first time given NHS trusts and >w \ // Patient partnership \\^/ / health authorities direct control over the type of train N^ V/ Ethos of teamwork \ V >^ ing received by large numbers of professional staff. Hoile RW. The principles of quality assurance. JAMA North West_t9_04_ 1992. Good medical practice: guidance from the General Medical Council. number of treatments.) 2 Report of the Committee on the Financial Aspects of Corporate Governance. Sherry KM.125.bmj.7 14 NHS Executive.jstor. N Engl required if judgments about clinical quality are to be J Med 1989. (Report on a WHO meeting. London: GMC. Hayes RB. Scally G. how it rises to the challenges of the new agenda. Review of cervical cancer screening services at Kent and Canterbury hospitals. 4 Brotherston HHF. However.4 1. Doctors with problems in an NHS workforce. and analysis of healthcare information will be 6 Berwick DM. London: NHS Executive. London: NCEPOD. mitment to the accuracy. diagnosis or primary operative procedure is unknown. London: Gee. 15 Donaldson LJ. (A report to the NHSE Regional Office for the South and West) Primary operative 13 Oxman AD. This will need leadership and established. The report of the national made and the impact of clinical governance is to be confidential enquiry into perioperative deaths 1994/1995. complete 5 World Health Organisation. Finally. Oxford: Oxford some of the vital clinical data (table 2). the internal market in the NHS (which operated between 1 Secretary of State for Health. England_4J5_2J_ 19 NHS Executive. North Thames_3^_^4_ 308:1277-82. O'Neill D. Bristol: NHS Executive. and development of staff will make a major contribution. 1995. Guidance on implementation of the NHS complaints Anglia and Oxford 2. Leeds: NHSE. Davis DA.) need to be addressed nationally not only locally. The challenge for the NHS? of good clinical governance._^5_1. Medical care investigation in the health services. Evidence for the effective West Midlands 2. 11 Evidence-based Medicine Working Group. No magic bullets: a Region Primary diagnosis procedure systematic review of 102 trials of interventions to help health profession als deliver services more effectively and efficiently. London: Stationery Office. and patient in the country. The collection and analysis of routine creativity. The new NHS. Thomas MA. 1995.8 16 McGregor D.21(8):26-9. Trent 21. Physician Executive 1995.2 2. These issues are so important and have been 1997. The ^\^^ Culture ^^s^ alignment of this new system to the goals of clinical Fig 2 Integrating approaches of clinical governance governance will be essential. 1962. England 1995-619 12 Access to the knowledge base: a review of libraries. Oxman 65 This content downloaded from 202. 1992. Ingram GS. A renewed com University Press.