1. Clinical Governance

Organisational leadership

Action 1.3

The health service organisation establishes and maintains a clinical governance framework, and uses the processes within the framework to drive improvements in safety and quality

Intent

The clinical governance framework is comprehensive and effective in improving safety and quality.

Reflective questions

Does the health service organisation have a documented clinical governance framework?

How is the effectiveness of the clinical governance framework reviewed?

Key tasks

  • Develop a clinical governance framework
  • Educate the workforce about the key aspects of the clinical governance framework, and their responsibilities for improving safety and quality
  • Review policies, procedures and protocols to ensure that they align with the clinical governance framework
  • Review results of clinical audits and system evaluation reports for compliance with the clinical governance framework.

Strategies for improvement

Hospitals

Health service organisations are responsible for designing and implementing the systems to operationalise an effective clinical governance system as directed by the governing body.

Management should ensure that well-designed and integrated systems are in place that provide safe and high-quality health care. This may include systems and processes for:

  • Identifying and managing risk
  • Testing and influencing organisational culture
  • Ensuring quality improvement
  • Managing clinical practice
  • Managing workforce performance and skills
  • Managing incidents and complaints
  • Ensuring patients’ rights and engagement.

To ensure the effectiveness of these systems and processes, managers should use the clinical governance framework to:

  • Monitor, analyse and report on performance
  • Collect, analyse and report on feedback
  • Recommend actions to improve the safety and quality of care, and provide advice to the governing body about the issues identified and actions taken.

Strategies may include:

  • Establishing a committee that is responsible for overseeing the clinical governance framework
  • Implementing policies, procedures and protocols that describe the clinical governance framework
  • Clearly defining and articulating the roles and responsibilities of clinical leaders and members of the workforce at all levels in improving safety and quality
  • Reviewing the implementation of the clinical governance framework
  • Reviewing audit findings of compliance with policies, procedures and protocols.

See the National Model Clinical Governance Framework for more information.1

Day Procedure Services

Day procedure services are responsible for designing and implementing the systems for an effective clinical governance system, as directed by the governing body. These systems and processes include:

  • Identifying and managing risk
  • Testing and influencing organisational culture
  • Ensuring quality improvement
  • Managing clinical practice
  • Managing workforce performance and skills
  • Managing incidents and complaints
  • Ensuring patients’ rights and engagement.

To ensure the effectiveness of these systems and processes, managers should use the clinical governance framework to:

  • Monitor, analyse and report on performance
  • Collect, analyse and report on feedback
  • Recommend actions to improve the safety and quality of care, and provide advice to the governing body about the issues identified and actions taken.

Strategies may include:

  • Establishing a group or committee that is responsible for overseeing the clinical governance framework
  • Implementing policies, procedures and protocols that describe the clinical governance framework
  • Clearly defining and articulating the roles and responsibilities of clinical leaders and members of the workforce at all levels in improving safety and quality
  • Reviewing the implementation of the clinical governance framework
  • Reviewing audit findings of compliance with policies, procedures and protocols.

See the National Model Clinical Governance Framework1 for more information.

Examples of evidence

Select only examples currently in use:

  • Documented clinical governance framework
  • Documented safety and quality goals and performance indicators for the health service organisation
  • Documented organisational and committee structure that is aligned to the clinical governance framework
  • Audit results of compliance with the health service organisation’s clinical governance framework, and management of safety and quality risks
  • Reviews or evaluation reports on the effectiveness of the health service organisation’s safety and quality systems.
MPS & Small Hospitals

For MPSs or small hospitals that are part of a local health network or private hospital group for which the clinical governance framework has been described, managers should ensure that well-designed and integrated systems are in place that provide safe and high-quality health care.

Small hospitals that are not part of a local health network or private hospital group will need to document the clinical governance framework using the National Model Clinical Governance Framework.1

All organisations will need to ensure systems and processes for:

  • Policy development and maintenance
  • Risk identification and management
  • Testing organisational culture
  • Clinical practice management
  • Workforce performance and skills management
  • Incidents and complaints management
  • Patients’ rights and engagement.

To ensure the effectiveness of these systems and processes, managers should use the clinical governance framework to:

  • Monitor, analyse and report on performance
  • Collect, analyse and report on feedback
  • Recommend actions to improve the safety and quality of care, and provide advice to the governing body about the issues identified and actions taken.

Strategies may include:

  • Identifying an individual or group responsible for overseeing the clinical governance framework; this could be an extra responsibility for a current committee
  • Informing the workforce about the key aspects of the clinical governance framework and their roles and responsibilities for clinical leadership and improving safety and quality at all levels in the organisation
  • Conducting performance reviews
  • Reviewing results of clinical audits and system evaluation reports for compliance with the clinical governance framework.

Action 1.4

The health service organisation implements and monitors strategies to meet the organisation's safety and quality priorities for Aboriginal and Torres Strait Islander people.

Intent

Strategies to improve the safety and quality of care provided to Aboriginal and Torres Strait Islander people are implemented and monitored for effectiveness.

Reflective questions

What strategies are used to improve outcomes for Aboriginal and Torres Strait Islander patients?

How are these strategies monitored, evaluated and reported?

Key tasks

  • Review data for Aboriginal and Torres Strait Islander patients relating to safety and quality outcomes, patient experience and engagement, and complaints
  • Engage with Aboriginal and Torres Strait Islander patients and communities to review safety and quality information to set priorities for safety and quality improvement
  • Implement, monitor and report on strategies to improve health outcomes for Aboriginal and Torres Strait Islander patients.

Strategies for improvement

Hospitals

Although the governing body is responsible for ensuring that the organisation’s priorities consider the specific health needs of Aboriginal and Torres Strait Islander people, management is responsible for designing, implementing and monitoring the strategies to achieve these priorities. Strategies for improvement may include:

  • Forming sustainable partnerships with local Aboriginal and Torres Strait Islander people by working with local communities to understand and acknowledge their healthcare needs, and the risks and barriers to accessing health care, and developing strategies and priorities for improved care delivery
  • Providing flexibility in health service delivery and the patient journey; flexible health service organisations are more likely to be person centred and, as a result, increase patient engagement and participation in their care
  • Employing Aboriginal and Torres Strait Islander people at all levels of the health service, and supporting and empowering them, which can improve the cultural competency of an organisation; Aboriginal and Torres Strait Islander liaison officers are key to supporting and advocating for Aboriginal and Torres Strait Islander patients, and with Aboriginal and Torres Strait Islander clinicians and interpreters
    • improve the quality of care provided
    • reduce the rate of discharge against medical advice
    • provide cultural mentors for non-Indigenous members of the workforce
  • Monitoring safety and quality for Aboriginal and Torres Strait Islander people; health service organisations should have goals or targets in place for the care of their Aboriginal and Torres Strait Islander patients, and should routinely measure and report on specific performance indicators related to those goals and targets.

Identify and develop strategies

Strategies have the greatest chance of being effective when:

  • The Aboriginal and Torres Strait Islander community is actively engaged in the development, implementation and evaluation of strategies
  • Interventions are multidisciplinary and operate across services
  • The organisation promotes collaboration with Aboriginal and Torres Strait Islander community controlled health services and adopts a holistic model of health and wellbeing.

To develop appropriate strategies, organisations need to:

  • Accurately identify the Aboriginal and Torres Strait Islander people who are accessing care
  • Agree on measures for analysing health outcomes and risks facing Aboriginal and Torres Strait Islander patients
  • Engage with the workforce in planning, designing and implementing improvement strategies
  • Evaluate the effectiveness of the changes that are put in place
  • Routinely report on improvement initiatives to the governing body, clinicians and the local Aboriginal and Torres Strait Islander communities.

Examples of strategies may include:

  • Establishing mechanisms to review and develop tailored care plans for Aboriginal and Torres Strait Islander people who frequently use the health service
  • Reviewing the appropriateness and effectiveness of models of care for Aboriginal and Torres Strait Islander people, including options to provide care using outreach services
  • Developing a workforce and employment strategy that sets targets and identifies how to increase or maintain the participation of Aboriginal and Torres Strait Islander people in the health workforce across clinical, managerial, support and advocacy roles
  • Coordinating early discharge planning that considers the need for community social and health services
  • Providing information materials in Aboriginal and Torres Strait Islander languages, if appropriate
  • Coordinating service provision using flexible hours of service delivery (that is, outside a 9-to-5 working day).2, 3

Further strategies are available in the 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

Health service organisations are responsible for designing, implementing and monitoring the strategies to achieve the priorities set by the governing body to improve the health of Aboriginal and Torres Strait Islander people. Strategies for improvement may include:

  • Forming sustainable partnerships with local Aboriginal and Torres Strait Islander people by working with local communities to understand and acknowledge their healthcare needs, and the risks and barriers to accessing health care, and developing strategies and priorities for improved care delivery
  • Providing flexibility in health service delivery and the patient journey; flexible health service organisations are more likely to be person centred and, as a result, increase patient engagement and participation in their care
  • Employing Aboriginal and Torres Strait Islander people at all levels of the health service, and supporting and empowering them, which can improve the cultural competency of an organisation
  • Monitoring safety and quality for Aboriginal and Torres Strait Islander people; health service organisations should have goals or targets for the care of their Aboriginal and Torres Strait Islander patients, and should routinely measure and report on specific performance indicators related to those goals and targets.

Other specific strategies may include:

  • Establishing mechanisms to review and develop tailored care plans for Aboriginal and Torres Strait Islander people who often use the health service
  • Reviewing the appropriateness and effectiveness of models of care for Aboriginal and Torres Strait Islander people, including options to provide care using outreach services
  • Developing a workforce and employment strategy that sets targets and identifies how to increase or maintain the participation of Aboriginal and Torres Strait Islander people in the health workforce across clinical, managerial, support and advocacy roles
  • Coordinating early discharge planning that considers the need for community social and health services
  • Providing information materials in Aboriginal and Torres Strait Islander languages, if appropriate
  • Coordinating service provision using flexible hours of service delivery (that is, outside a 9-to-5 working day)2, 3
  • Discussing 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
  • Reviewing the scope and effectiveness of strategies in place to improve care for Aboriginal and Torres Strait Islander people.

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

Action 1.5

The health service organisation considers the safety and quality of health care for patients in its business decision-making

Intent

Decisions relating to equipment, plant, building works, consumables, staffing and other resources consider the safety and quality implications for patients.

Reflective questions

How are patient safety and quality issues considered when making business decisions?

How are decisions about patient safety and quality of care documented?

Key tasks

  • Review the organisation’s strategic planning and business planning processes to ensure that they explicitly capture safety and quality improvement strategies and initiatives, including those articulated in the organisation’s clinical safety and quality plan
     
  • Review templates for submitting business proposals to the governing body and management, and ensure that they take account of impacts on safety and quality.

Strategies for improvement

Hospitals

Include safety and quality goals, objectives and strategies prominently in business and strategic plans. This will ensure that all strategic and decision-making processes consider the safety and quality of all services being provided.

If a proposal for service development or a change in scope of clinical practice explicitly identifies implications for patient safety and quality of health care, adopt policies, procedures or protocols to explain how clinical risks will be managed.

Train the workforce to consider safety and quality issues when developing business cases or influencing business decisions.

Other strategies may include ensuring that:

  • The terms of reference for committees (for example, finance and audit committees, strategic planning committees) consider safety and quality implications when making business decisions
  • Decisions about the procurement of building, plant, consumables and equipment are informed, and that products and services are fit for purpose, comply with relevant standards, and take into consideration safety and quality issues such as multiple chemical sensitivity.
Day Procedure Services

Include safety and quality goals, objectives and strategies prominently in business and strategic plans. This will ensure that all strategic and decision-making processes consider the safety and quality of all services being provided.

If a proposal for service development or a change in scope of clinical practice explicitly identifies implications for patient safety and quality of health care, adopt policies, procedures or protocols to explain how clinical risks will be managed.

Other strategies may include ensuring that:

  • The terms of reference for committees (for example, finance and audit committees, strategic planning committees) consider safety and quality implications when making business decisions
  • Decisions about the procurement of building, plant, consumables and equipment are informed, and that products and services are fit for purpose, comply with relevant standards, and take into consideration safety and quality issues such as multiple chemical sensitivity.

Examples of evidence

Select only examples currently in use:

  • Committee and meeting records, such as for finance and audit committees, and strategic planning committees, that show that safety and quality of health care are considered in business decision-making
  • Strategic plans, operational plans or business plans that outline the potential impact of decisions on patient safety and quality of care
  • Business proposal templates that include consideration of safety and quality risks
  • Register of safety and quality risks that includes actions to manage the identified risks.
MPS & Small Hospitals

For MPSs or small hospitals that are part of a local health network or private hospital group, business decisions may be the responsibility of the Local Hospital Network or state or territory health department.

For small hospitals that are not part of a local health network:

  • Include safety and quality goals, objectives and strategies prominently in business and strategic planning; this will ensure that all strategic and decision-making processes consider the safety and quality of all services being provided
  • Consider the safety and quality implications when making business decisions in the terms of reference for committees (for example, finance and audit committees, strategic planning committees)
  • Ensure that decisions about the procurement of building, plant, consumables and equipment are informed, and that products and services are fit for purpose, comply with relevant standards, and take into consideration safety and quality issues
  • Review templates for submitting business proposals to the governing body and management, and ensure that they take account of effects on safety and quality.
Last updated 21st June, 2018 at 10:15pm
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