1. Clinical Governance

Safety and quality roles and responsibilities

Action 1.25

The health service organisation has processes to:

a. Support the workforce to understand and perform their roles and responsibilities for safety and quality

b. Assign safety and quality roles and responsibilities to the workforce, including locums and agency staff

Intent

Every member of the workforce understands and enacts their safety and quality roles and responsibilities.

Reflective question

How are members of the workforce informed about, and supported to fulfil, their roles and responsibilities for safety and quality of care?

Key tasks

  • Ensure that the governing body appropriately delegates responsibility for governance.

  • Review the organisation’s performance development policy, and ensure that it incorporates leadership in safety and quality management and governance for all managers and clinicians.

  • Review the organisational structure, position descriptions and contract templates of management, clinicians and other members of the workforce to ensure that responsibility for safety and quality is clearly defined at all levels

Strategies for improvement

Hospitals

Implement the governance arrangements determined by the governing body and ensure that the workforce understands their roles, responsibilities and accountabilities for safety and quality.

Ensure that foundational educational programs include:

  • Clinical risk from the patient’s perspective
  • Clinical governance responsibilities for safety and quality
  • Legislative responsibilities related to patient harm and reportable incidents
  • Incident investigation methods
  • Human error and human factors principles
  • Principles of teamwork and leadership style
  • Open disclosure
  • Creating and sustaining a patient safety culture that has person-centred care at its centre
  • Applying evidence-based practices to develop and support effective multidisciplinary teams.

The clinical governance system should be supported by:

  • Clear definition and delegation of reporting lines and responsibilities for safety and quality
  • Clearly documented accountabilities for safety and quality of clinical care within the position descriptions and contractual responsibilities of the chief executive, management and clinicians
  • Descriptions of roles, responsibilities and accountabilities for supervising the performance of the junior clinical workforce within the position descriptions and contractual responsibilities of senior clinicians
  • Safety and quality policies, procedures or protocols that allocate responsibility to specific roles within the organisation
  • A structured performance development system for all clinicians and managers, incorporating regular review of
    • their engagement in safety and quality, and in specific activities such as peer review and audit
    • supervision of the junior workforce.

Consider the following strategies when implementing delegated roles and responsibilities in the workforce:

  • Ensure that safety and quality roles and responsibilities are clearly defined by
    • reviewing workforce position descriptions
    • discussing safety and quality responsibilities in routine performance management processes
    • providing information to the workforce about their safety and quality roles and responsibilities
  • Educate and train members of the workforce in their governance roles, responsibilities and accountabilities
  • For managers and senior clinicians, identify professional development opportunities in clinical safety and quality, leadership and risk, and schedule training in clinical governance
  • Ensure that contractual arrangements are in place for the agency and locum workforce, and verify that credentialing and scope of clinical practice are undertaken before or after they start
  • Provide agency and locum members of the workforce with an orientation to safety, quality and clinical governance that includes access to policies and procedures that outline roles and responsibilities
  • Provide support material to help the workforce orientate agency and locum members of the workforce.

Examples of evidence

Select only examples currently in use:

  • Policy documents that outline the delegated safety and quality roles and responsibilities of the workforce
  • Employment documents that describe the safety and quality roles, responsibilities and accountabilities of the workforce
  • Contracts for locum and agency workforce that specify designated roles and responsibilities, including for safety and quality
  • Organisational chart and delegations policy that demonstrates clinical governance reporting lines and relationships
  • Training documents about safety and quality roles and responsibilities of the workforce
  • Communication to the workforce about their safety and quality roles and responsibilities
  • Performance appraisals that include feedback to the workforce about delegated safety and quality roles and responsibilities
  • Results of workforce surveys or feedback regarding their safety and quality roles and responsibilities.
Day Procedure Services

Ensure that members of the workforce understand their roles, responsibilities and accountability for ensuring the safety and quality of care.

The clinical governance system should be supported by:

  • Clear definition and delegation of reporting lines, and responsibilities for safety and quality
  • Clearly documented accountabilities for safety and quality of clinical care within the position descriptions and contractual responsibilities of the chief executive, management and clinicians
  • Safety and quality policies, procedures or protocols; responsibilities should be allocated through the organisational management system
  • A structured performance development system for all clinicians and managers, incorporating regular review of their engagement in safety and quality, and in specific activities such as peer review and audit.

Consider the following strategies when implementing delegated roles and responsibilities in the workforce:

  • Ensure that safety and quality roles and responsibilities are clearly defined by
    • reviewing workforce position descriptions
    • discussing safety and quality responsibilities in routine performance management processes
    • providing information to the workforce about their safety and quality roles and responsibilities
  • Educate and train members of the workforce in their governance roles, responsibilities and accountabilities
  • For managers and senior clinicians, identify professional development opportunities in clinical safety and quality, leadership and risk, and schedule training in clinical governance
  • Ensure that contractual arrangements are in place for the agency and locum workforce, and verify that credentialing and scope of clinical practice are undertaken before or after they start work
  • Provide agency and locum members of the workforce with an orientation to safety, quality and clinical governance that includes access to policies and procedures that outline roles and responsibilities
  • Provide support material to help the workforce orientate agency and locum members of the workforce.

Examples of evidence

Select only examples currently in use:

  • Policy documents that outline the delegated safety and quality roles and responsibilities of the workforce
  • Employment documents that describe the safety and quality roles, responsibilities and accountabilities of the workforce
  • Contracts for locum and agency workforce that specify designated roles and responsibilities, including for safety and quality
  • Organisational chart and delegations policy that demonstrates clinical governance reporting lines and relationships
  • Training documents about safety and quality roles and responsibilities of the workforce
  • Communication to the workforce about their safety and quality roles and responsibilities
  • Performance appraisals that include feedback to the workforce about delegated safety and quality roles and responsibilities
  • Results of workforce surveys or feedback regarding their safety and quality roles and responsibilities.
MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should implement and use the established processes for describing workforce roles and responsibilities for safety and quality.

Small hospitals that are not part of a local health network or private hospital group should:

  • Ensure that the governing body appropriately delegates responsibility for governance
  • Review the organisation’s performance development policy, and ensure that it incorporates leadership in safety and quality management and governance for all managers and clinicians
  • Review the organisational structure, position descriptions and contract templates of managers, clinicians and other members of the workforce to ensure that responsibility for safety and quality is clearly defined at all levels.

Consider the following strategies when implementing delegated roles and responsibilities in the workforce:

  • Ensure that safety and quality roles and responsibilities are clearly defined by
    • reviewing workforce position descriptions
    • discussing safety and quality responsibilities in routine performance management processes
    • providing information to the workforce about their safety and quality roles and responsibilities
  • Educate and train members of the workforce in their governance roles, responsibilities and accountabilities
  • For managers and senior clinicians, identify professional development opportunities in clinical safety and quality, leadership and risk, and schedule training in clinical governance
  • Ensure that contractual arrangements are in place for the agency and locum workforce, and verify that credentialing and scope of clinical practice are undertaken before or after they start work
  • Provide agency and locum members of the workforce with an orientation to safety, quality and clinical governance that includes access to policies and procedures that outline roles and responsibilities
  • Provide support material to help the workforce orientate agency and locum members of the workforce.

Examples of evidence

Select only examples currently in use:

  • Policy documents that outline the delegated safety and quality roles and responsibilities of the workforce
  • Employment documents that describe the safety and quality roles, responsibilities and accountabilities of the workforce
  • Contracts for locum and agency workforce that specify designated roles and responsibilities, including for safety and quality
  • Organisational chart and delegations policy that demonstrates clinical governance reporting lines and relationships
  • Training documents about safety and quality roles and responsibilities of the workforce
  • Communication to the workforce about their safety and quality roles and responsibilities
  • Performance appraisals that include feedback to the workforce about delegated safety and quality roles and responsibilities
  • Results of workforce surveys or feedback regarding their safety and quality roles and responsibilities.

Action 1.26

The health service organisation provides supervision for clinicians to ensure that they can safely fulfil their designated roles, including access to after-hours advice, where appropriate

Intent

The clinical workforce is appropriately supervised as and when required to ensure the provision of safe, high-quality care.

Reflective question

How does the health service organisation monitor and support clinicians to safely fulfil their designated roles?

Key task

  • Identify clinicians who require supervision, including junior clinicians, clinicians in training, clinicians who are expanding their scope of clinical practice and clinicians who require oversight of their performance.

Strategies for improvement

Hospitals

Effective clinical supervision enables health professionals to practise effectively and enhances patient safety.

Supervision is a key safeguard for safe and high-quality care. Supervision of junior clinicians should be appropriate to their assessed capabilities, and be consistent with organisational policies, procedures and protocols. A key goal of supervision is to safely develop a clinician’s capabilities.

Formally document the roles and responsibilities of clinicians who are in training in their position description and training program. Monitor compliance with training requirements as part of the clinician’s training program and performance reviews.1

As trainees gain experience, they achieve greater independence. Some organisations approve trainees undertaking increasingly higher levels of performance. In such circumstances, define and regularly review the trainee’s scope of clinical practice as part of their training program to assess competence.1

Define who is responsible for monitoring trainees’ performance and confirming they operate within their scope of clinical practice or training portfolio requirements. Ensure that this information is readily available to other clinicians working with the trainee. Provide regular feedback to trainees on their performance.

Clearly define clinical supervision responsibilities in the contracts of employment or engagement of all senior clinicians, and in relevant organisational policies, including those that apply to the performance development system. This will help to ensure that junior clinicians develop their skills, while protecting the safety and quality of patient care.

Ensure that clinicians who supervise other clinicians1:

  • Have the qualifications and skills necessary to 
    supervise in the nominated area of clinical practice
  • Have experience at the appropriate level of practice
  • Have the training and experience necessary to provide supervision
  • Are located appropriately to provide adequate supervision
  • Participate in the process of reviewing the supervised clinicians’ scope of clinical practice.

Examples of evidence

Select only examples currently in use:

  • Individual performance reviews for the clinical workforce, including requirements for supervision
  • Audit of the extent and effectiveness of supervision
  • Observation of clinical practice
  • Mentoring or peer-review reports
  • Audit results of members of the clinical workforce who have completed performance reviews, including supervision that is required, and actions taken to deal with identified training and development needs.
Day Procedure Services

Supervision is a key safeguard for safe and high-quality care. Supervision of junior clinicians should be appropriate to their assessed capabilities, and be consistent with organisational policies, procedures and protocols. A key goal of supervision is to safely develop a clinician’s capabilities.

Formally document the roles and responsibilities of clinicians who are in training in their position description and training program. Monitor compliance with training requirements as part of the clinician’s training program and performance reviews.1

Clearly define clinical supervision responsibilities in the contracts of employment or engagement of all senior clinicians, and in relevant organisational policies, including those that apply to the performance development system. This will help to ensure that junior clinicians develop their skills, while protecting the safety and quality of patient care.

Ensure that clinicians who supervise other clinicians1:

  • Have the qualifications and skills necessary to supervise in the nominated area of clinical practice
  • Have experience at the appropriate level of practice
  • Have the training and experience necessary to provide supervision
  • Are located appropriately to provide adequate supervision
  • Participate in the process of reviewing the supervised clinicians’ scope of clinical practice.

Examples of evidence

Select only examples currently in use:

  • Individual performance reviews for the clinical workforce, including requirements for supervision
  • Audit of the extent and effectiveness of supervision
  • Observation of clinical practice
  • Mentoring or peer-review reports
  • Audit results of members of the clinical workforce who have completed performance reviews, including supervision that is required, and actions taken to deal with identified training and development needs.
MPS & Small Hospitals

Supervision is a key safeguard for safe and high-quality care. Supervision of junior clinicians should be appropriate to their assessed capabilities, and be consistent with organisational policies, procedures and protocols. A key goal of supervision is to safely develop a clinician’s capabilities.

MPSs and small hospitals will need to identify clinicians who need supervision, including junior clinicians, clinicians in training, clinicians who are expanding their scope of clinical practice and clinicians who need oversight of their performance.

Formally document the roles and responsibilities of clinicians being supervised and define the supervising clinicians responsibilities for monitoring performance.

Ensure that clinicians who supervise other clinicians1:

  • Have the qualifications and skills necessary to supervise in the nominated area of clinical practice
  • Have experience at the appropriate level of practice
  • Have the training and experience necessary to provide supervision
  • Are located appropriately to provide adequate supervision
  • Participate in the process of reviewing the supervised clinicians’ scope of clinical practice.

Examples of evidence

Select only examples currently in use:

  • Individual performance reviews for the clinical workforce, including requirements for supervision
  • Audit of the extent and effectiveness of supervision
  • Observation of clinical practice
  • Mentoring or peer-review reports
  • Audit results of members of the clinical workforce who have completed performance reviews, including supervision that is required, and actions taken to deal with identified training and development needs.
Last updated 31st May, 2018 at 10:43pm
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References

Australian Commission on Safety and Quality in Health Care. Credentialing health practitioners and defining their scope of clinical practice: a guide for managers and practitioners. Sydney: ACSQHC; 2015.