1. Clinical Governance

Governance, leadership and culture

Action 1.1

The governing body:

a. Provides leadership to develop a culture of safety and quality improvement, and satisfies itself that this culture exists within the organisation

b. Provides leadership to ensure partnering with patients, carers and consumers

c. Sets priorities and strategic directions for safe and high-quality clinical care, and ensures that these are communicated effectively to the workforce and the community

d. Endorses the organisation’s clinical governance framework

e. Ensures that roles and responsibilities are clearly defined for the governing body, management, clinicians and the workforce

f. Monitors the action taken as a result of analyses of clinical incidents

g. Reviews reports and monitors the organisation’s progress on safety and quality performance

Intent

The governing body must assure itself that a culture of safety and quality improvement operates in the organisation.

Reflective questions

How does the governing body understand and promote safety and quality within the health service organisation?

How does the governing body set strategic direction, and define safety and quality roles and responsibilities within the health service organisation?

What information does the governing body use to monitor progress and report on strategies for safe and high-quality clinical care?

Key tasks

  • Identify the governing body - this is the group of people or individuals with ultimate responsibility and accountability for decision making about safety and quality.

  • Ensure that the roles, responsibilities and accountabilities for safety, quality and clinical governance within the organisation are clearly articulated.

  • Review the organisational structure, and the position descriptions and contracts for managers, and ensure that roles, responsibilities and accountabilities for safety (including clinical safety) and quality are clearly defined and articulated at all levels in the organisation.

  • Endorse the organisation’s clinical governance framework and strategic plans such as the safety and quality improvement plan, and the plan for partnering with consumers.

  • Review the template or calendar for reporting to the governing body on safety and quality indicators and data, and ensure that it covers all services, locations, major risks, dimensions of quality and key elements of the quality improvement system.

  • Regularly review quality indicators to ensure that they are relevant and comprehensive.

  • Review relevant data from clinical incidents and reports of complaints and other incidents.

  • Review the processes for providing feedback to the workforce, patients, consumers, and the community about the organisation’s safety and quality performance.

  • Review the organisation’s audit program to ensure that it has enough safety and quality content.

  • Ensure that mitigation strategies are in place to manage all major risks.

  • Ensure that systems are in place to regularly survey and report on organisational culture.

Strategies for improvement

Hospitals

Leaders, managers and clinicians have an important role in influencing the safety and quality of care by shaping culture within the organisation, setting direction, providing support to the workforce, and monitoring progress and improvement in safety and quality performance. 1, 2

Define safety culture

There are many definitions of a safety culture. It involves the interaction of members of the workforce that influence their commitment to the organisation's safety management.  

A common interpretation of safety culture — which is perhaps more meaningful — is ‘the way things are done around here’.3

Positive safety cultures in health care have strong leadership to drive and prioritise the safety of all. Commitment from leadership and management in this context is important because their actions and attitudes influence the perceptions, attitudes and behaviours of members of the workforce throughout the organisation.

Organisations with positive safety cultures have:

  • Strong leadership to drive the safety culture

  • Strong management commitment, with safety culture a key organisational priority

  • A workforce that is engaged and always aware that things can go wrong

  • Acknowledgement at all levels that mistakes occur

  • Ability to recognise, respond to, give feedback about, and learn from, adverse events.

Define governance processes

The governing body has ultimate responsibility for the clinical governance of the organisation. It has obligations to ensure that effective safety and quality systems and robust governance practices are in place and performing well. The governing body must ensure that safety and quality are consistently and effectively monitored, and that responses to safety and quality matters are prompt and appropriate.

The governing body should define its expectations about the safety and quality performance of the organisation, and the behaviours expected from its workforce. It should also be clear about how and when the safety and quality culture of the organisation will be measured and monitored.

The governing body and management need to regularly assess the systems in place to help them perform their clinical governance roles, such as:

  • Identifying the appropriate structures and processes to manage and monitor clinical performance

  • Describing the expected outcomes in safety and quality through the organisation’s vision, mission and goals

  • Setting the requirements for time frames, targets and reporting on safety and quality performance

  • Monitoring implementation and compliance with strategic, business, or safety and quality improvement plans.

Involve consumers and define patient experience

The governing body should ensure that effective partnerships are developed, and promote the organisation’s engagement with patients and consumers. Strategies may involve:

  • Allocating time in meeting agendas to hear and discuss patient stories or consumer feedback

  • Ensuring that resources are available to support activities such as collecting patient experience data, engaging with consumers and local communities, supporting workforce training in person-centred care, and developing or adapting shared decision support tools

  • Including consumer representatives on committees or working groups.

The governing body should define the expected quality of the patient experience. Setting priorities and targets for safety and quality enables the organisation to define the roles and responsibilities of the workforce to achieve these goals, and to set up systems that support quality patient experiences.

Information about the expected quality of the patient’s experience can be communicated to the workforce by:

  • Incorporating it into strategic plans that are translated into operational statements, policies, procedures or protocols

  • Including it in workforce news bulletins and presentations in regular and ad hoc communication to the workforce

  • Discussing it during executive rounds or as standing items on meeting agendas.

Endorse the clinical governance framework

The responsibility of a governing body (such as a board) for clinical governance is an integrated element of its overall responsibility and accountability to govern the organisation. As a component of broader systems for corporate governance, clinical governance involves a complex set of leadership behaviours, policies, procedures, and monitoring and improvement mechanisms that are directed towards ensuring good clinical outcomes.

The clinical governance system of a health service organisation therefore needs to be conceptualised as a system within a system – a clinical governance system within a corporate governance system.

Under this model, it is important to recognise the following points:

  • Clinical governance is of equivalent importance to financial, risk and other business governance

  • Decisions regarding other aspects of corporate governance can have a direct impact on the safety and quality of care, and decisions about clinical care can have a direct impact on other aspects of corporate governance, such as financial performance and risk management

  • Governing bodies are ultimately responsible for good corporate (including clinical) governance

  • Governing bodies cannot govern clinical services well without the deep engagement of skilled clinicians working at all levels of the organisation

  • Clinicians, managers and members of governing bodies have individual and collective responsibilities for ensuring the safety and quality of clinical care. As well as being reflected in the NSQHS Standards, many of these are also specified in relevant professional codes of conduct.

Clinical governance relies on well-designed systems that deliver, monitor and account for the safety and quality of patient care. Although it is ultimately the responsibility of a governing body to set up a sound clinical governance system and be accountable for outcomes and performance within this system, implementation involves contributions by individuals and teams at all levels of the organisation.

The Commission has developed the National Model Clinical Governance Framework.1  Health service organisations can adapt and implement the framework to best meet the needs of their patients and the local situation, and to ensure that systems are regularly evaluated to improve safety and quality. See Action 1.3 for establishing and maintaining a clinical governance framework.

The National Model Clinical Governance Framework is based on the NSQHS Standards, in particular the Clinical Governance Standard and the Partnering with Consumers Standard.

The Clinical Governance Standard and the Partnering with Consumers Standard together ensure the creation of clinical governance systems within health service organisations that:

  • Are fully integrated within overall corporate governance systems

  • Are underpinned by robust safety and quality improvement systems

  • Maintain and improve the reliability, safety and quality of health care

  • Improve health outcomes for patients and ensure the safety and quality of care.

Together these two Standards constitute a complete and robust clinical governance framework.

Support the governance system

The governing body should describe the roles and accountabilities for the safety and quality of care within the health service organisation.

The governance system should provide:

  • A clear definition for safety and quality that articulates reporting lines, responsibilities and accountabilities

  • Position descriptions for all members of the workforce that clearly document responsibilities and accountabilities for the safety and quality of clinical care

  • Position descriptions, or similar documents, and, if appropriate, contracts for senior clinicians that describe their roles, responsibilities and accountabilities, including supervising the performance of the junior clinical workforce

  • Safety and quality policies, procedures or protocols that describe how patient safety is embedded in the operation of the organisation

  • A structured performance development system for clinicians and managers that incorporates a regular review of their engagement in safety and quality activities, including peer review and audit, supervision of the junior workforce, and goal-setting for future activities.

Monitor and review performance

The governing body is responsible for reviewing reports and monitoring the organisation’s safety and quality performance. The governing body should regularly review a selection of the organisation’s most important quality metrics, which may include:

  • Key national priority indicators and regulatory requirements

  • A selection of measures covering safety, clinical effectiveness, patient experience, access, and efficiency and appropriateness of care

  • Trends in complaints from patients and the workforce, and action taken to resolve complaints

  • Trends in reported adverse events, incidents and near-misses, and actions taken

  • Workforce surveys to monitor the organisational culture

  • Risk ratings

  • Compliance with best-practice pathways

  • Comparisons with peer organisations, and state and territory or national performance data.

In addition to monitoring indicators and trends, governing bodies should review relevant clinical and organisational systems to ensure that they are fit for purpose and being used in the organisation.

Day Procedure Services

Leaders, managers and clinicians have an important role in influencing the safety and quality of care by shaping culture within the organisation, setting direction, providing support to the workforce, and monitoring progress and improvement in safety and quality performance.1, 2

Define safety culture

There are many definitions of a safety culture. It involves the interaction of attitudes, beliefs and behaviours of members of the workforce that influence their commitment to the organisation’s safety management.

A common interpretation of safety culture – which is perhaps more meaningful – is ‘the way things are done around here’.3

Positive safety cultures in health care have strong leadership to drive and prioritise the safety of all. Commitment from leadership and management in this context is important because their actions and attitudes influence the perceptions, attitudes and behaviours of members of the workforce throughout the organisation.

Organisations with positive safety cultures have:

  • Strong leadership to drive the safety culture
  • Strong management commitment, with safety culture a key organisational priority
  • A workforce that is engaged and always aware that things can go wrong
  • Acknowledgement at all levels that mistakes can occur
  • The ability to recognise, respond to, give feedback about, and learn from, adverse events.

Define governance processes

The governing body has ultimate responsibility for the clinical governance of the organisation. It has obligations to ensure that effective safety and quality systems, and robust governance practices are in place and performing well. The governing body must ensure that safety and quality are consistently and effectively monitored, and that responses to safety and quality matters are prompt and appropriate.

The governing body should define its expectations about the safety and quality performance of the organisation, and the behaviours expected from its workforce. It should also be clear about how and when the safety and quality culture of the organisation will be measured and monitored.

The organisational structure for day procedure services varies from small, owner–operator models of service delivery to large corporations. The governance arrangements for smaller organisations may be less formal than those of large ones, but owners still have a responsibility to ensure that appropriate systems are in place so that they can provide safe and high-quality care.

The governing body and management need to regularly assess the systems in place to help them perform their clinical governance roles, such as:

  • Identifying the appropriate structures and processes to manage and monitor clinical performance
  • Describing the expected outcomes in safety and quality through the organisation’s vision, mission and goals
  • Setting the requirements for time frames, targets, and reporting on safety and quality performance
  • Monitoring implementation and compliance with strategic, business, or safety and quality improvement plans.

Involve consumers and define patient experience

The governing body should ensure that effective partnerships are developed, and promote the organisation’s engagement with patients and consumers. Strategies may involve:

  • Allocating time in meeting agendas to hear and discuss patient stories or consumer feedback
  • Ensuring that resources are available to support activities such as collecting patient experience data, engaging with consumers, supporting workforce training in person-centred care, and developing or adapting shared decision support tools.

The governing body should define the expected quality of the patient experience. Setting priorities and targets for safety and quality enables the organisation to define the roles and responsibilities of the workforce to achieve these goals, and to set up systems that support quality patient experiences.

Information about the expected quality of the patient’s experience can be communicated to the workforce through strategic plans, policy documents or newsletters.

Endorse the clinical governance framework

The responsibility of a governing body (such as a board) for clinical governance is an integrated element of its overall responsibility and accountability to govern the organisation. As a component of broader systems for corporate governance, clinical governance involves a complex set of leadership behaviours, policies, procedures, and monitoring and improvement mechanisms that are directed towards ensuring good clinical outcomes.

The clinical governance system of a health service organisation therefore needs to be conceptualised as a system within a system – a clinical governance system within a corporate governance system.

Under this model, it is important to recognise the following points:

  • Clinical governance is of equivalent importance to financial, risk and other business governance
  • Decisions regarding other aspects of corporate governance can have a direct impact on the safety and quality of care, and decisions about clinical care can have a direct impact on other aspects of corporate governance, such as financial performance and risk management
  • Governing bodies are ultimately responsible for good corporate (including clinical) governance
  • Governing bodies cannot govern clinical services well without the deep engagement of skilled clinicians working at all levels of the organisation
  • Clinicians, managers and members of governing bodies have individual and collective responsibilities for ensuring the safety and quality of clinical care. As well as being reflected in the NSQHS Standards, many of these are also specified in relevant professional codes of conduct.

Clinical governance relies on well-designed systems that deliver, monitor and account for the safety and quality of patient care. Although it is ultimately the responsibility of a governing body to set up a sound clinical governance system and be accountable for outcomes and performance within this system, implementation involves contributions by individuals and teams at all levels of the organisation.

The Commission has developed the National Model Clinical Governance Framework.1 Health service organisations can adapt and implement the framework to best meet the needs of their patients and local circumstances, and to ensure that systems are regularly evaluated to improve safety and quality. See Action 1.3 for establishing and maintaining a clinical governance framework.

The National Model Clinical Governance Framework is based on the NSQHS Standards – in particular, the Clinical Governance Standard and the Partnering with Consumers Standard.

The Clinical Governance Standard and the Partnering with Consumers Standard together ensure the creation of clinical governance systems within health service organisations that:

  • Are fully integrated within overall corporate governance systems
  • Are underpinned by robust safety and quality improvement systems
  • Maintain and improve the reliability, safety and quality of health care
  • Improve health outcomes for patients, and ensure the safety and quality of care.

Together, these two standards constitute a complete and robust clinical governance framework.

Support the governance system

The governing body should describe the roles and accountabilities for the safety and quality of care within the health service organisation.

The governance system should provide:

  • A clear definition of safety and quality that articulates reporting lines, responsibilities and accountabilities
  • Position descriptions for all members of the workforce that clearly document responsibilities and accountabilities for the safety and quality of clinical care
  • Safety and quality policies, procedures or protocols that describe how patient safety is embedded in the operation of the organisation
  • A structured performance development system for clinicians and managers that incorporates a regular review of their engagement in safety and quality activities.

Monitor and review performance

The governing body is responsible for reviewing reports, and monitoring the organisation’s safety and quality performance. The governing body should regularly review a selection of the organisation’s most important quality metrics, which may include:

  • Key national priority indicators and regulatory requirements
  • A selection of measures covering safety, clinical effectiveness, patient experience, access, and efficiency and appropriateness of care
  • Trends in complaints from patients and the workforce, and action taken to resolve complaints
  • Trends in reported adverse events, incidents and near misses, and actions taken
  • Workforce surveys to monitor the organisational culture
  • Risk ratings
  • Compliance with best-practice pathways
  • Comparisons with peer organisations, and state and territory or national performance data.

In addition to monitoring indicators and trends, governing bodies should review relevant clinical and organisational systems to ensure that they are fit for purpose and being used in the organisation.

Examples of evidence

Select only examples currently in use:

  • Policy documents that describe the
    • roles and responsibilities of the governing body
    • health service organisation’s clinical governance framework
    • processes for partnering with consumers
  • Strategic, business or risk management plans that describe the priorities and strategic directions for safe and high-quality clinical care that are endorsed by the governing body
  • Committee and meeting records in which clinical governance, leadership, safety and quality culture, or partnering with consumers are discussed
  • Documented clinical governance framework that is endorsed by the governing body
  • Audit framework or schedule that is endorsed by the governing body
  • Safety and quality performance data, compliance reports and reports of clinical incidents that are monitored by the governing body, managers or the clinical governance committee
  • Annual report that includes information on the health service organisation’s safety and quality performance
  • Terms of reference or letter of appointment to the governing body that describes members’ safety and quality roles and responsibilities
  • Communication with the workforce or consumers on the health service organisation’s clinical governance framework for safety and quality performance.
MPS & Small Hospitals

The governing body of MPSs or small hospitals that are part of a local health network or private hospital group will be responsible for endorsing and monitoring the established clinical governance framework and safety and quality systems.

The governing body of small hospitals that are not part of a local health network or private hospital group will need to set up a clinical governance framework using the National Model Clinical Governance Framework1and:

  • Ensure that the roles, responsibilities and accountabilities for safety, quality and clinical governance within the organisation are clearly articulated
  • Review the organisational structure, and the position descriptions and contracts for managers, and ensure that roles, responsibilities and accountabilities for safety (including clinical safety) and quality are clearly defined and articulated at all levels in the organisation
  • Endorse the organisation’s strategic plans, such as the safety and quality improvement plan, and the plan for partnering with consumers
  • Review the template or calendar for reporting to the governing body on safety and quality indicators and data, and ensure that it covers all services, major risks, dimensions of quality and key elements of the quality management system
  • Regularly review quality indicators to ensure that they are relevant and comprehensive
  • Review relevant data from clinical incidents, and reports of complaints and other incidents
  • Review the processes for providing feedback to the workforce, patients, consumers and the community about the organisation’s safety and quality performance
  • Review the organisation’s audit program to ensure that it has enough safety and quality content
  • Ensure that mitigation strategies are in place to deal with all major risks
  • Ensure that systems are in place to regularly survey and report on organisational culture.

Action 1.2

The governing body ensures that the organisation’s safety and quality priorities address the specific health needs of Aboriginal and Torres Strait Islander people

Intent

The health needs of Aboriginal and Torres Strait Islander people are identified in partnership with local communities, and improvement actions are supported by the governing body.

Reflective questions

What information from the organisation’s performance, external sources, and the local Aboriginal and Torres Strait Islander community does the governing body use to identify and prioritise the specific health needs of Aboriginal and Torres Strait Islander patients?

How are Aboriginal and Torres Strait Islander people involved in the governance of the organisation?

Key tasks

  • Establish partnerships with local Aboriginal and Torres Strait Islander communities to identify priority health needs and any barriers to accessing health services.

  • Endorse priorities and identified targets, and have mechanisms in place to review strategies to improve the safety and quality of health care.

  • Routinely review progress against Aboriginal and Torres Strait Islander safety and quality improvement strategies.

  • Collect relevant data to inform planning and future decision making relating to service development.

Strategies for improvement

Hospitals

Setting organisational goals to consider the specific health needs of Aboriginal and Torres Strait Islander people can focus the whole organisation on the elements of care that need to be provided.

The governing body and management should review the demographic profile of the patient population, and consider the health issues facing Aboriginal and Torres Strait Islander people who use their services. This will help to inform their decisions on which strategies might be used to best meet the needs of Aboriginal and Torres Strait Islander patients and consumers.

To understand the safety and quality issues facing Aboriginal and Torres Strait Islander people and the priorities for improving care, the governing body may need to:

  • Consult with Aboriginal and Torres Strait Islander health service providers and communities with established referral processes
  • Review information on the number and needs of Aboriginal and Torres Strait Islander patients using the health service
  • Review performance data relating to Aboriginal and Torres Strait Islander patients, such as discharges against medical advice or unplanned readmissions within 28 days; these data may also include information on neonatal birth weight, or records of participation in chronic care and other programs
  • Review feedback, outcome data, incidents and complaints to identify potential barriers for Aboriginal and Torres Strait Islander people in using the organisation’s services
  • Review workforce indicators such as the proportion of the workforce who identify as being of Aboriginal or Torres Strait Islander origin, as well as the effectiveness and coverage of cultural competency training for the workforce
  • Discuss the safety and quality issues facing Aboriginal and Torres Strait Islander patients with the workforce, especially members of the Aboriginal and Torres Strait Islander health workforce, and Aboriginal and Torres Strait Islander consumers or community representatives
  • Review the scope and effectiveness of strategies in place to improve care for Aboriginal and Torres Strait Islander people
  • Review the appropriateness and effectiveness of models of care for Aboriginal and Torres Strait Islander people.

The governing body should review how this information is incorporated into organisational strategies to improve the care and experience for Aboriginal and Torres Strait Islander patients and consumers, and receive routine reports on the implementation of these strategies.

Further strategies are available in User Guide for Aboriginal and Torres Strait Islander Health.

Day Procedure Services

This action applies to day procedure services that commonly provide care for Aboriginal and Torres Strait Islander people. These services should refer to the advice for hospitals and the User Guide for Aboriginal and Torres Strait Islander Health for detailed implementation strategies and examples of evidence for this action.

Day procedure services that rarely provide care for Aboriginal and Torres Strait Islander people, or when the risk of harm for these patients is the same as for the general patient population, should manage the specific risk of harm, and provide safe and high-quality care for these patients through the safety and quality improvement systems that relate to their whole patient population.

Day procedure services need to implement strategies to improve the cultural awareness and cultural competency of the workforce under Action 1.21, and identify Aboriginal and Torres Strait Islander patients under Action 5.8.

MPS & Small Hospitals

The governing body of MPSs or small hospitals that are part of a local health network or private hospital group will be responsible for setting safety and quality priorities to cover the specific needs of Aboriginal and Torres Strait Islander people who use the organisation’s services.

The governing body of small hospitals that are not part of a local health network or private hospital group will need to set organisational goals to cover the specific health needs of Aboriginal and Torres Strait Islander people and focus the whole organisation on the elements of care that need to be provided.

The governing body and management should review the demographic profile of the patient population, and consider the health issues facing Aboriginal and Torres Strait Islander people who use their services. This will help to inform their decisions on which strategies might be used to best meet the needs of Aboriginal and Torres Strait Islander patients and consumers.

To understand the safety and quality issues facing Aboriginal and Torres Strait Islander people and the priorities for improving care, the governing body may need to:

  • Consult with Aboriginal and Torres Strait Islander health service providers and communities with established referral processes
  • Review information on the number and needs of Aboriginal and Torres Strait Islander patients using the health service
  • Review performance data relating to Aboriginal and Torres Strait Islander patients, such as discharges against medical advice or unplanned readmissions within 28 days; these data may also include information on neonatal birth weight, or records of participation in chronic care and other programs
  • Review feedback, outcome data, incidents and complaints to identify potential barriers for Aboriginal and Torres Strait Islander people in using the organisation’s services
  • Review workforce indicators such as the proportion of the workforce who identify as being of Aboriginal or Torres Strait Islander origin, as well as the effectiveness and coverage of cultural competency training for the workforce
  • Endorse priorities and identified targets, and have mechanisms in place to review strategies to improve the safety and quality of health care for Aboriginal and Torres Strait Islander people
  • Routinely review progress against Aboriginal and Torres Strait Islander safety and quality improvement strategies
  • Review relevant internal and external data to inform planning and future decision-making relating to service development.

The governing body should review how this information is incorporated into organisational strategies to improve the care and experience for Aboriginal and Torres Strait Islander patients and consumers, and receive routine reports on the implementation of these strategies.

Further strategies are available in the User Guide for Aboriginal and Torres Strait Islander Health.

Last updated 21st June, 2018 at 10:08pm
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References

Bismark MM, Studdert DM. Governance of quality of care: a qualitative study of health service boards in Victoria, Australia. BMJ Qual Saf 2014;23(6):474–82.

Taylor N, Clay-Williams R, Hogden E, Braithwaite J, Groene O. High performing hospitals: a qualitative systematic review of associated factors and practical strategies for improvement. BMC Health Serv Res 2015;15:244.

Australian Commission on Safety and Quality in Health Care. Windows into safety and quality in health care 2011. Sydney: ACSQHC; 2011:46–55.