National Model

Clinical Governance
Framework
Published by the Australian Commission on Safety and Quality in Health Care
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Email: [email protected]
Website: www.safetyandquality.gov.au
ISBN: 978-1-925665-18-5

© Australian Commission on Safety and Quality in Health Care 2017

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Australian Commission on Safety and Quality in Health Care. National Model Clinical Governance Framework.
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Disclaimer
The content of this document is published in good faith by the Australian Commission on Safety and Quality
in Health Care for information purposes. The document is not intended to provide guidance on particular
healthcare choices. You should contact your healthcare provider on particular healthcare choices.
This document includes the views or recommendations of its authors and third parties. Publication of
this document by the Commission does not necessarily reflect the views of the Commission, or indicate a
commitment to a particular course of action. The Commission does not accept any legal liability for any injury,
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Acknowledgement
The Commission would like to thank all of our partners for their contributions to the development of the NSQHS
Standards and their continuing commitment to improving safety and quality across the Australian healthcare
system.
This document was released in November 2017.
Contents
Foreword    ii
Summary    iii
Introduction    1
Corporate (organisational) governance of health service organisations    3
Key concepts    3
Responsibilities of governing bodies for corporate governance    3
Clinical governance and the National Model Clinical Governance Framework    5
Clinical governance as an integrated component of organisational governance    5
Components of the Clinical Governance Framework    6
Importance of culture in clinical governance    8
Roles and responsibilities for clinical governance    9
Governance, leadership and culture    11
Patient safety and quality improvement systems    12
Clinical performance and effectiveness    14
Safe environment for the delivery of care    16
Partnering with consumers    17
Appendix: NSQHS Standards    19
Acknowledgements    30
Glossary    31
References    35

National Model Clinical Governance Framework i

Foreword
Australians enjoy good health outcomes, and The National Model Clinical Governance
generally trust health service organisations and Framework has been developed to improve
clinicians to provide safe and high-quality health these issues. It provides a consistent national
care. However, safety and quality lapses continue to framework for clinical governance that is based
occur that can have a major affect on people’s lives on the National Safety and Quality Health Service
and on the broader health system. Standards. It supports a shared understanding of
clinical governance among everyone working in
Since 2015, a number of state and territory
health service organisations, including clinicians,
governments have engaged the Australian
managers and members of the governing body.
Commission on Safety and Quality in Health
This will ensure that clinical governance systems
Care to review identified patient safety problems.
are implemented effectively, and support safer and
These reviews have shown that some health service
better care for patients and consumers.
organisations have problems implementing key
clinical governance processes. Issues that have been We take this opportunity to thank members of
identified include problems with: the Advisory Panel who provided expert advice in
• Implementing an open disclosure response the development of the National Model Clinical
consistent with national and local standards Governance Framework for their time and expertise.
• Ensuring that incident management and
investigation systems can provide adequate Ms Wendy Harris QC
surveillance to recognise major safety failures or Chair
risks National Model Clinical Governance Framework
• Implementing corrective action in response to Advisory Panel
identified patient safety risks and failures Professor Villis Marshall AC
• Establishing complaint management systems Chair
that include a partnership with patients and Australian Commission on Safety and Quality in
carers Health Care
• Ensuring a robust and positive safety culture
• Clearly understanding the roles and
responsibilities of boards, the executive, clinical
teams and clinicians in clinical governance.

ii National Model Clinical Governance Framework

Summary
Patients, consumers and the community trust The elements in the Clinical Governance
clinicians and health service organisations to Framework are also mandatory for health service
provide safe, high-quality health care. organisations that need to meet the requirements
of the NSQHS Standards when they are accredited.
Clinical governance is the set of relationships
As with the NSQHS Standards, however, the
and responsibilities established by a health
Clinical Governance Framework does not specify
service organisation between its state or territory
how a health service organisation should develop
department of health, governing body, executive,
or implement its clinical governance systems. Each
workforce, patients, consumers and other
health service organisation needs to put in place
stakeholders to ensure good clinical outcomes.
strategies to meet the requirements of the NSQHS
It ensures that the community and health service
Standards for clinical governance that consider
organisations can be confident that systems are in
its local circumstances. The Clinical Governance
place to deliver safe and high-quality health care,
Framework builds on the NSQHS Standards,
and continuously improve services.
providing more information about corporate and
Clinical governance is an integrated component clinical governance, and roles and responsibilities
of corporate governance of health service for people within a health service organisation.
organisations. It ensures that everyone – from Further resources will also be available to support
frontline clinicians to managers and members of the Clinical Governance Framework for specific
governing bodies, such as boards – is accountable target audiences and settings.
to patients and the community for assuring the
delivery of health services that are safe, effective,
integrated, high quality and continuously
improving.
To support the delivery of safe and high-quality
care for patients and consumers, the Australian
Commission on Safety and Quality in Health
Care has developed the National Model Clinical
Governance Framework (the Clinical Governance
Framework). The Clinical Governance Framework
is based on the National Safety and Quality Health
Service (NSQHS) Standards – in particular, the
Clinical Governance Standard and the Partnering
with Consumers Standard. The Clinical Governance
Framework has five components:
• Governance, leadership and culture
• Patient safety and quality improvement systems
• Clinical performance and effectiveness
• Safe environment for the delivery of care
• Partnering with consumers.

National Model Clinical Governance Framework iii

Introduction
Health care in Australia is provided by teams of Although the safety and quality of health care
clinicians working in partnership with patients, provided to each patient are highly dependent on
families and carers. It is delivered in a wide variety the skills and performance of individual clinicians,
of public and private organisations, ranging from safety and quality are also a professional and
sole proprietorships to large statutory corporations organisational responsibility. They rely on effective
and public companies. governance and management processes, and the
establishment of systems involving a large number
Patients, consumers and the community trust
of contributors in health service organisations and
clinicians and health service organisations
across the health system.
to provide safe, high-quality health care, and
most Australians have access to such care. To support the delivery of safe and high-quality
Australia’s clinicians are highly regarded as skilled health care, and the best possible outcomes
professionals who are committed to meeting the for patients in this complex environment, the
healthcare needs of their patients. Key safety and Australian Commission on Safety and Quality in
quality risks have been identified, and strategies Health Care (the Commission) has developed this
exist to improve the safety and quality of health National Model Clinical Governance Framework
care. Although there is a strong system-wide (Clinical Governance Framework) for public and
commitment to continuous improvement, delays private healthcare organisations in the acute sector.
and problems with implementation mean that
The Clinical Governance Framework is based on
failures in safety and quality continue to occur.
the National Safety and Quality Health Service
Australia generally performs well in international (NSQHS) Standards (second edition), particularly
comparisons about health.1 However, although the Clinical Governance Standard and the
most health care in Australia leads to good Partnering with Consumers Standard.7 As part of
outcomes, patients do not always receive the care the complete set of NSQHS Standards, these two
that is most appropriate for them, and preventable standards constitute a complete and robust clinical
adverse events occur across the Australian governance framework.
healthcare system.2 Lapses in safety and quality,
and unwarranted variation in health care provided
to different populations within Australia have Purpose of the Clinical
substantial costs, in terms of both the effect on
people’s lives and financially.2,3
Governance Framework
The delivery of health care is a complex endeavour.
The purpose of the Clinical Governance Framework
Contemporary models of care are sophisticated and
is to ensure that patients and consumers receive
rapidly changing, as are the expectations of patients
safe and high-quality health care by describing the
and consumers. Health service organisations such
elements that are essential for acute health service
as hospitals sit within intricate webs of different
organisations to achieve integrated corporate and
types of services across tertiary, secondary and
clinical governance systems. Through these systems,
primary sectors. Patients and consumers move
organisations and individuals are accountable
between these services and sectors, and safety and
to patients and the community for continuously
quality risks exist at all points on these journeys.4-6
improving the safety and quality of their services.
Traditionally, ensuring an acceptable standard of The Clinical Governance Framework:
safety and quality was viewed as predominantly • Defines clinical governance
the responsibility of individual clinicians. Now, the
• Provides the context for clinical governance
importance of the individual and collective roles and
being an integrated component of corporate
responsibilities of patients, consumers, clinicians,
governance
healthcare teams, managers, directors, governing
bodies and departments of health is well recognised.

National Model Clinical Governance Framework 1

• Describes the key components of a clinical support effective clinical governance and improve
governance framework, based on the NSQHS the safety and quality of care.
Standards
The Clinical Governance Framework will
• Discusses the role of culture in supporting good be supported by resources developed by the
clinical governance Commission for specific target audiences, including
• Outlines the roles and responsibilities of, and members of governing bodies (such as boards),
essential partnership between, patients and clinicians and consumers. Resources will also be
consumers, clinicians, managers, and governing developed to support application of the Clinical
bodies (such as boards) in implementing effective Governance Framework in specific settings, such as
clinical governance systems in health service private hospitals and day procedure services.
organisations.
The Clinical Governance Framework applies to
public and private health services in the acute sector.
As noted earlier, however, the delivery of health
Application and use of care in Australia is complex, and patients move
the Clinical Governance between different types of services across acute
and primary sectors. Because of this complexity,
Framework and the safety and quality risks that exist at these
transition points4-6, there is a need to work towards
It is mandatory for all Australian hospitals and an integrated system of clinical governance for
day procedure services to be assessed through an the whole health system. The Clinical Governance
independent accreditation process to determine Framework is a starting point for future work that
whether they have implemented the NSQHS will explore clinical governance in primary care.8
Standards. Therefore, the elements in the Clinical
Governance Framework are also mandatory for
these health service organisations. Definition of clinical
As with the NSQHS Standards, the Clinical governance
Governance Framework does not specify how
a health service organisation should develop or The definition of clinical governance that underpins
implement its clinical governance systems. Rather, the Clinical Governance Framework is as follows:
it outlines the components of a clinical governance
Clinical governance is the set of relationships
framework to enable health service organisations
and responsibilities established by a health
to develop and implement their own governance
service organisation between its state or
systems, considering local needs, values and the
territory department of health (for the public
context in which services are provided. sector), governing body, executive, clinicians,
The Clinical Governance Framework builds on the patients, consumers and other stakeholders
NSQHS Standards, providing more information to ensure good clinical outcomes.9 It ensures
about corporate and clinical governance, and roles that the community and health service
and responsibilities relating to clinical governance organisations can be confident that systems
for people within a health service organisation. are in place to deliver safe and high-quality
health care, and continuously improve services.
Detailed guidance about strategies to meet the
requirements of the NSQHS Standards is included Clinical governance is an integrated component
of corporate governance of health service
in the guides for hospitals and other types of
organisations. It ensures that everyone
health service organisations that are currently
– from frontline clinicians to managers
being developed by the Commission. The Clinical
and members of governing bodies, such as
Governance Framework should be used with these boards – is accountable to patients and the
documents. community for assuring the delivery of health
The Clinical Governance Framework can be used by services that are safe, effective, integrated,
clinicians, managers, executives, governing bodies, high quality and continuously improving.
and state and territory departments of health to

2 National Model Clinical Governance Framework

Corporate (organisational) governance
of health service organisations
Clinical governance is an integrated component Management, on the other hand, is concerned
of corporate governance. This section provides with doing – with coordinating and managing the
an overview of key concepts and elements of day-to-day operations of the business.11
corporate governance, particularly regarding the
responsibilities of governing bodies such as boards.
Responsibilities of
Key concepts governing bodies for
corporate governance
A large proportion of Australian health care
is delivered in public sector and private sector Good governance is clearly recognised as a
organisations governed by bodies such as boards responsibility of governing bodies such as boards:
of directors. Boards are generally well versed in the
It is the board’s responsibility to ensure good
concepts and practices of corporate governance,
governance and to account to [shareholders]
which is recognised as a responsibility of governing
for their record in this regard.12
bodies, and is distinguished from responsibility for
management and service delivery. Management has an operational focus, whereas
governance has a strategic focus. Managers run
The concept of clinical governance is best
organisations, whereas their boards ensure that
understood as founded in, and consistent with,
organisations are run well and in the right direction.
broader concepts of corporate or organisational
governance.* The governing body derives its authority to conduct
the business of the organisation from the enabling
Robert Tricker is credited with creating the term
legislation and the organisation’s constitutional
‘corporate governance’. According to Tricker10:
documents, where applicable. The board ‘governs’
The governance role is not concerned with the organisation by establishing a ‘governance
the running of the company, per se, but with system’, elements of which are implemented by the
giving overall direction to the enterprise, with board itself, leaders and the workforce at all levels of
overseeing and controlling the executive actions the organisation. As part of its governance system,
of management and with satisfying legitimate the governing body:
expectations of accountability and regulation
by interests beyond the corporate boundaries.
• Establishes a strategic and policy framework
• Delegates responsibility for operating the
Corporate governance encompasses the organisation to the chief executive officer, who,
establishment of systems and processes that shape, in turn, delegates specific responsibilities to
enable and oversee management of an organisation. members of the workforce
It is the activity, undertaken by governing bodies
such as boards, of formulating strategy, setting • Supervises the performance of the chief executive
policy, delegating responsibility, overseeing officer
management, and ensuring that appropriate • Monitors the performance of the organisation
risk management and accountability arrangements and ensures that there is a focus on continuous
are in place throughout the organisation. quality improvement.

* In the public sector, since not all health service organisations
are corporations with a governing board, the term
‘organisational governance’ can be used, rather than ‘corporate
governance’.

National Model Clinical Governance Framework 3

The model described by Tricker for the role and • Reviewing and monitoring performance of the
functions of governance highlights both the control framework to ensure that major risks are
forward-looking (leadership and performance) identified and managed
and retrospective (accountability and conformance) • Ensuring that there is an ongoing focus on
elements of good governance (Figure 1).10 quality improvement
The generally accepted governance duties and • Evaluating reports, and reviewing feedback,
responsibilities of a governing body such as a board suggestions and complaints
include: • Ensuring the continuing development of the
• Appointing a chief executive officer, supporting executive management team
them to lead the organisation and evaluating • Planning for succession
their performance
• Communicating with, and being accountable to,
• In consultation with management, setting and internal and external stakeholders.
reviewing organisational plans and strategies
• Endorsing and approving budgets, and major Although it is ultimately the governing body’s
financial and organisational decisions responsibility to ensure good corporate governance,
many governance responsibilities are distributed
• Ensuring that the organisation is being properly
throughout the organisation. For example, people
managed, including that
at all levels of a health service organisation help
–– systems of production or service delivery are to design and implement risk management,
well designed and fit for purpose performance monitoring and audit programs, which
–– services meet desired standards are key elements of good governance systems. It
–– the organisation meets its compliance is the board’s responsibility, however, to ensure
obligations that the overall governance system is implemented
• Challenging the assumptions of management effectively, and that the board is accountable for the
outcomes and performance of the organisation.

Figure 1: Role and functions of governing bodies in governance

4 National Model Clinical Governance Framework

Clinical governance and the National
Model Clinical Governance Framework
This section describes how clinical governance • Clinicians, managers and members of
is an integrated component of broader corporate governing bodies have individual and collective
governance and sets out the key elements of the responsibilities for ensuring the safety and
Clinical Governance Framework, based on the quality of clinical care; as well as being
NSQHS Standards. reflected in the NSQHS Standards, many of
these responsibilities are specified in relevant
professional codes of conduct.
Clinical governance as an
integrated component of Figure 2: Corporate governance
responsibilities
organisational governance
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 (Figure 2).
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:
• Clinical governance is of equivalent importance
to financial, risk and other business governance
• Decisions about other aspects of corporate Although it is ultimately the responsibility of a
governance can have a direct affect on the safety governing body to set up a sound clinical governance
and quality of care, and decisions about clinical system, and be accountable for outcomes and
care can have a direct affect on other aspects performance within this system, implementation
of corporate governance, such as financial involves contributions by individuals and teams at
performance and risk management all levels of the organisation. There is also reliance
• Governing bodies are ultimately responsible for on well-designed systems that deliver, monitor and
good corporate (including clinical) governance account for the safety and quality of patient care.
• Governing bodies cannot govern clinical services
well without the deep engagement of skilled
clinicians working at all levels of the organisation

National Model Clinical Governance Framework 5

The application of clinical governance systems to To achieve a complete and robust clinical
achieve good clinical outcomes requires a focus governance system, actions to meet the Clinical
on both what happens within a health service Governance Standard and the Partnering with
organisation, and the integration and linkages of Consumers Standard need to be supported by
the health service organisation within a network actions to meet the other six NSQHS Standards.
of other health service organisations in the acute As reflected in the NSQHS Standards, the Clinical
and primary care sectors. This network may include Governance Framework has five components
general practitioners, other specialists, allied health (Figure 3). The central component relates to patients
providers and aged care homes. and consumers, who are at the centre of the Clinical
Governance Framework. The five components of the
Clinical Governance Framework are as follows:
Components of the Clinical • Governance, leadership and culture – integrated
Governance Framework corporate and clinical governance systems are
established, and used to improve the safety and
quality of health care for patients
The Clinical Governance Framework is based on
the NSQHS Standards (2nd ed.) – in particular, the • Patient safety and quality improvement systems
Clinical Governance Standard and the Partnering – safety and quality systems are integrated with
with Consumers Standard. governance processes to actively manage and
improve the safety and quality of health care for
The NSQHS Standards were developed by the patients
Commission in consultation and collaboration with
• Clinical performance and effectiveness – the
states and territories, the private sector, executives
workforce has the right qualifications, skills and
and managers, clinical experts, patients, and carers.
supervision to provide safe, high-quality health
The primary aims of the NSQHS Standards are to
care to patients
protect the public from harm and to improve the
quality of health service provision. Since 2013, it • Safe environment for the delivery of care – the
has been mandatory for all Australian hospitals environment promotes safe and high-quality
and day procedure services to be assessed through health care for patients
an independent accreditation process to determine • Partnering with consumers – systems are
whether they have implemented the NSQHS designed and used to support patients, carers,
Standards. families and consumers to be partners in
healthcare planning, design, measurement and
To fully apply the NSQHS Standards in a evaluation; elements of this component include
health service organisation, governing bodies, –– clinical governance and quality improvement
management, patients, consumers, clinicians systems to support partnering with consumers
and clinical teams need to be engaged in the
–– partnering with patients in their own care
implementation of actions set out in the NSQHS
–– health literacy
Standards.
–– partnering with consumers in organisational
In the context of the complete set of NSQHS design and governance.
Standards, the Clinical Governance Standard and
the Partnering with Consumers Standard together Detailed information about each component of
ensure the creation of clinical governance systems the Clinical Governance Framework, including
within healthcare organisations that: strategies for improvement, is available in the
• Are fully integrated within overall corporate guides developed by the Commission to support the
governance systems NSQHS Standards.
• Are underpinned by robust safety and quality The actions specified in the NSQHS Standards
management systems for the Clinical Governance Standard and the
Partnering with Consumers Standard are in the
• Maintain and improve the reliability, safety and
Appendix. These actions comprise the Clinical
quality of health care
Governance Framework.
• Improve health outcomes for patients.

6 National Model Clinical Governance Framework

Figure 3: National Model Clinical Governance Framework

National Model Clinical Governance Framework 7

Importance of culture in clinical
governance
The NSQHS Standards specify the actions that a To put in place the requirements of the NSQHS
health service organisation needs to take to develop Standards that are the basis of the Clinical
and set up systems for good clinical governance. Governance Framework, health service
Culture, however, is just as important in clinical organisations need to have a culture that has16:
governance in ensuring that patients and consumers • Strong strategic and cultural leadership of
receive safe and high-quality care. clinical services, focusing on
Culture is a complex and contested concept that has –– effective planning to enable development and
many different definitions. Central to most of these improvement opportunities to be captured
definitions is that culture consists of: –– cultural leadership that requires, and gives
… the values, beliefs and assumptions shared priority to, safety and quality, and supports
by occupational groups. These shared ways continuous improvement
of thinking are then translated into common –– allocating resources to support the delivery of
and repeated patterns of behaviour: patterns high-quality care
of behaviour that are in turn maintained and • Clear responsibilities for managing the safety and
reinforced by the rituals, ceremonies and
quality of care, and delegation of the necessary
rewards of everyday organisational life.13
management authority for this purpose
Factors that have been identified as being important • Reliable processes for ensuring that systems for
for sustaining cultures that ensure safe and high- delivery of care are designed and performing
quality care include14-15: well, and clinicians are fully engaged in the
• Leaders articulating a vision for high-quality, design, monitoring and development of these
compassionate and safe care, and acting on this systems
vision throughout the organisation • Effective use of data and information to monitor
• Translating the vision into clear objectives for and report on performance, through the health
safety and quality at all levels of the organisation, service organisation to the governing body
and establishing measures to assess progress • Well-designed systems for identifying and
• Providing a supportive and positive working managing clinical risk.
environment for the workforce
• Ensuring that members of the workforce are
engaged in their work
• Having an organisation that is transparent about
performance, open to learning and continuously
improving
• Supporting multidisciplinary teams to work
together effectively.

8 National Model Clinical Governance Framework

Roles and responsibilities for clinical
governance
Good clinical governance provides confidence In addition to these roles, state and territory
to the community and everyone who works in a departments of health provide centralised and
health service organisation that systems are in coordinated oversight of the performance of health
place to support the delivery of safe, high-quality service organisations, and create a common set of
health care. Within a well-governed healthcare safety metrics that report meaningful safety and
organisation, everyone, including frontline quality outcomes.
clinicians, managers and the governing body, is
Implementation of an organisation’s clinical
accountable for their contribution to the safety and
governance system involves contributions
quality of care delivered to patients. Broadly, these
by individuals and teams at all levels of the
roles are as follows (Figure 4):
organisation. Roles and responsibilities for
• Patients and consumers clinical governance at all levels of the system are
Patients and consumers participate as summarised in the following sections.
partners to the extent that they choose. These
partnerships can be in their own care, and in
organisational design and governance.
• Clinicians
Clinicians work within, and are supported
by, well-designed clinical systems to deliver
safe, high-quality clinical care. Clinicians are
responsible for the safety and quality of their
own professional practice, and professional codes
of conduct include requirements that align with
the Clinical Governance Framework.17
• Managers
Managers (including clinical managers) advise
and inform the governing body, and operate
the organisation within the strategic and policy
parameters endorsed by the governing body.
They are primarily responsible for ensuring that
the systems that support the delivery of care are
well designed and perform well.
• Governing body
The governing body is ultimately responsible for
ensuring that the organisation is run well and
delivers safe, high-quality care. It does this by
establishing a strong safety culture through an
effective clinical governance system, satisfying
itself that this system operates effectively, and
ensuring that there is an ongoing focus on
quality improvement.

National Model Clinical Governance Framework 9

Figure 4: Clinical governance roles

10 National Model Clinical Governance Framework

Governance, leadership and culture
The roles and responsibilities for this component of the Clinical Governance Framework relate to the
establishment of, and participation in, corporate and clinical governance systems.

Role Responsibilities

Patients and • Use organisational systems and processes to contribute to the planning, design and
consumers operation of the health service organisation
• Identify opportunities for improvement of the health service organisation and
communicate these to relevant individuals or bodies
• Consider taking an active role in the governance of the health service organisation,
when opportunities exist

Clinicians • Actively take part in the development of an organisational culture that enables, and
gives priority to, patient safety and quality
• Actively communicate their profession’s commitment to the delivery of safe, high-
quality health care
• Model professional conduct that is consistent with a commitment to safety and
quality at all times
• Embrace opportunities to learn about safety and quality theory and systems
• Embrace opportunities to take part in the management of clinical services
• Encourage, mentor and guide colleagues in the delivery of safe, high-quality care
• Take part in all aspects of the development, implementation, evaluation and
monitoring of governance processes

Managers • Actively communicate the commitment of the health service organisation to the
(including delivery of safe, high-quality care
clinical • Create opportunities for the workforce to receive education in safety and quality
theory and systems
managers)
• Model the safety and quality values of the health service organisation in all aspects
of management
• Support clinicians who embrace clinical leadership roles
• Lead the development of business plans, strategic plans, and organisational policies
and procedures relevant to safety and quality
• Integrate safety and quality into organisational plans, policies and procedures
• Set up effective relationships with relevant health services to support good clinical
outcomes

National Model Clinical Governance Framework 11

Role Responsibilities

Governing • Lead development of a common organisational language in safety, quality and

bodies clinical governance
• Actively communicate the commitment of the governing body to the delivery
of safe, high-quality care
• Are satisfied that an effective culture of safety and quality exists within the health
service organisation
• Lead the organisation towards achieving a ‘blame-free’, accountable and learning
culture
• Are aware of how the health service organisation sits within a wider network of
local and other health services and providers
• Set up an effective relationship with the chief executive officer, founded on
a mutual commitment to safety and quality of care
• Ensure that the organisation has a comprehensive suite of plans, strategies and
policies that support safety and quality of care
• Ensure that organisational resources are allocated to support safety and quality
of care
• Create relevant education and training opportunities for managers and executives
• Allocate enough board time and attention to safety and quality of care
• Monitor organisational culture, and identify and capture improvement opportunities
and ensure that they are acted on

Patient safety and quality improvement systems

Roles and responsibilities for this component of the Clinical Governance Framework relate to the various
patient safety and quality processes that are part of effective clinical governance systems.

Role Responsibilities

Patients and • Provide feedback, complaints and compliments about experiences in the health
consumers service organisation, including
–– participating in patient experience surveys
–– communicating with the organisation about any opportunities for improving
services and systems
–– communicating with the organisation about potential safety and quality risks
• Consider being involved in quality improvement projects within the health service
organisation
• Consider advocating for, or representing, other patients in focus groups and
meetings to improve the health service organisation and the care that is delivered
• Consider reviewing and commenting on reports on safety and quality of the health
service organisation
• Consider participating in the review of safety and quality incidents or other serious
adverse events, when opportunities exist

12 National Model Clinical Governance Framework

Role Responsibilities

Clinicians • Contribute to the design of systems for the delivery of safe, high-quality
clinical care
• Provide clinical care within the parameters of these systems
• Communicate with clinicians in other health service organisations to support good
clinical outcomes
• Ensure contemporary knowledge about safe system design
• Maintain vigilance for opportunities to improve systems
• Ensure that identified opportunities for improvement are raised and reported
appropriately
• Educate junior clinicians in the importance of working within the organisational
systems for the delivery of clinical care
• Take part in the design and implementation of systems within the health service
organisation for
–– quality improvement and measurement
–– risk management
–– incident management
–– open disclosure
–– feedback and complaints management
• Comply with professional regulatory requirements and codes of conduct

Managers • Coordinate and oversee the design of systems for the delivery of clinical care
(including • Engage with clinicians on all system design issues
clinical • Allocate appropriate resources to implement well-designed systems of care
managers) • Respond to identified concerns about the design of systems
• Periodically, systematically review the design of systems for safety and quality
• Set up an operational policy and procedure framework, with the active engagement
of clinicians
• Ensure availability of data and information to clinicians to support quality assurance
and improvement
• Ensure that safety and quality systems reflect the role of the health service
organisation within a wider network of local and other health services and providers
• Implement and resource effective systems for management of
–– quality improvement and measurement
–– risk management
–– incident management
–– open disclosure
–– feedback and complaints
• Systematically monitor performance across all safety and quality systems
• Report to the health service organisation and governing body

National Model Clinical Governance Framework 13

Role Responsibilities

Governing • Ensure that all systems for the delivery of care are regularly reviewed for their ability
bodies to support safe, high-quality care
• Incorporate systematic audits of safety and quality systems in the
whole-of-organisation audit program
• Ensure availability of data and information to support quality assurance and review
across the organisation
• Monitor system performance, and consider implications for system design and
opportunities for improvement
• Ensure that the following safety and quality systems are in place, involve
all members of the clinical workforce and are subject to periodic review of
performance
–– quality improvement and measurement
–– risk management
–– incident management
–– open disclosure
–– feedback and complaints management

Clinical performance and effectiveness

Roles and responsibilities for this component of the Clinical Governance Framework relate to the
processes that exist in effective clinical governance systems for ensuring that the workforce has the right
qualifications, skills and supervision to deliver safe and high-quality care.

Role Responsibilities

Patients and • Provide feedback, complaints and compliments about experiences in the health
consumers service, including
–– p articipating in patient experience surveys
–– communicating with the organisation about any opportunities for improving
services and systems
–– communicating with the organisation about potential safety and quality risks
• Consider sharing experiences through patient stories, information sessions, letters,
pictures, patient journeys, or presentations at meetings or training sessions for the
workforce
• Consider participating in recruitment processes for the workforce, when
opportunities exist

14 National Model Clinical Governance Framework

Role Responsibilities

Clinicians • Maintain personal professional skills, competence and performance

• Contribute to relevant organisational policies and procedures
• Comply with professional regulatory requirements and codes of conduct
• Monitor personal clinical performance
• Supervise and manage the performance of junior clinicians
• Ensure that specific performance concerns are reported appropriately
• Work constructively in clinical teams
• Take part in the design and implementation of the organisation’s systems for
–– credentialing and defining scope of clinical practice
–– clinical education and training
–– performance monitoring and management
–– clinical, and safety and quality education and training

Managers • Maintain personal professional skills, competence and performance

(including • Set up an operational policy and procedure framework
clinical • Implement and resource effective systems for management of
managers) –– credentialing and defining scope of clinical practice
–– clinical education and training
–– performance monitoring and management
–– clinical, and safety and quality education and training
• Respond in a prompt and effective way to indications of clinical underperformance
• Systematically monitor safety and quality performance across all clinical

Governing • Ensure that the following organisational systems are in place, involve all members
bodies of the clinical workforce and are subject to periodic review of system performance
–– credentialing and defining scope of clinical practice
–– clinical education and training
–– performance monitoring and management
–– whole-of-organisation clinical, and safety and quality education and training

National Model Clinical Governance Framework 15

Safe environment for the delivery of care
Roles and responsibilities for this component of the Clinical Governance Framework relate to the creation of
an environment that supports safety and quality.

Role Responsibilities

Patients and • Provide feedback, complaints and compliments about experiences of the
consumers environment of the health service organisation, including
–– participating in patient experience surveys
–– communicating with the organisation about any opportunities for improving the
environment
–– communicating with the organisation about potential safety and quality risks
• Consider being involved in quality improvement projects within the health service
organisation

Clinicians • Contribute to planning and development activities regarding the environment of

the health service organisation
• Provide clinical care within the parameters of this environment
• Maintain vigilance for opportunities to improve the environment
• Ensure that identified opportunities for improvement are raised and reported
appropriately

Managers • Coordinate and oversee planning and development of the health service
(including environment to support safety and quality
clinical • Engage with clinicians on the environment of the health service organisation
managers) • Allocate appropriate resources to ensure that the environment supports safety
and quality
• Respond to identified concerns about the environment

Governing • Ensure that the environment of the health service organisation promotes safe and
bodies high-quality care

16 National Model Clinical Governance Framework

Partnering with consumers
Roles and responsibilities for this component of the Clinical Governance Framework relate to the way in
which patients and consumers are involved in partnerships in their own care, and in organisational design
and governance.

Role Responsibilities

Patients and • Are involved in planning and sharing decisions about individual health care
consumers • Ask for more information, information in different formats or a translator, if required
• Let the workforce know who should be involved in sharing decisions about
their care
• Provide feedback to the health service organisation or clinician about care
experiences
• Consider being involved in the governance of the organisation, when opportunities
exist
• Consider being involved in the development and review of health information for
consumers, when opportunities exist

Clinicians • Understand the evidence on consumer engagement, and its contribution to the
safety and quality of health care
• Understand how health literacy might affect the way a consumer gains access to,
understands and uses health information
• Support patients to have access to, and use, high-quality, easy-to-understand
information about health care
• Support patients to share decision-making about their own health care, to the
extent that they choose
• Work with consumer representative groups to ensure that systems of care are
designed to encourage consumer engagement in decision-making
• Assist consumer access to their own health information, and complaints and
feedback systems
• Implement and fully take part in the organisation’s open disclosure policy

Managers • Understand the barriers for patients and consumers to understand and use health
(including services, and develop strategies to improve the health literacy environment of the
health service organisation
clinical
• Ensure that patients and consumers have access to high-quality, easy-to-
managers)
understand information about health care
• Set up organisational systems to enable consumers to fully engage in
–– planning and sharing decisions about their own health care
–– planning, designing, reviewing and evaluating clinical systems, and safety and
quality of care
• Collect and review patient experience information as part of quality improvement
processes
• Create opportunities for consumer involvement in relevant operational committees
• When appropriate, set up specific consumer advisory committees

National Model Clinical Governance Framework 17

Role Responsibilities

Governing • Show leadership and commitment to partnerships with consumers

bodies • Set up high-level policies and procedures that support partnerships with consumers
• Ensure that the organisation has effective systems for consumer complaints and
open disclosure, and monitor performance of these systems
• Ensure consumer input to decisions of the governing body
• Create opportunities for consumer involvement in subcommittees of the
governing body
• Ensure that organisational systems support consumer engagement in
decision-making
• When appropriate, set up a specific consumer advisory committee to the board

18 National Model Clinical Governance Framework

Appendix: NSQHS Standards
The second edition of the NSQHS Standards has Patient safety incidents can be associated with
eight standards: adverse outcomes for the patient, such as pain,
1. Clinical Governance delays in care, short-term and permanent disabilities
(both physical and psychological), and death. They
2. Partnering with Consumers can also be associated with increased healthcare
3. Preventing and Controlling Healthcare- costs due to longer hospital stays, extra treatments
Associated Infection and readmissions.2
4. Medication Safety Although it is difficult to measure the costs directly
attributable to lapses in safety and quality in
5. Comprehensive Care
health care, estimates indicate that the costs are
6. Communicating for Safety considerable. Almost a decade ago, the National
Health and Hospitals Reform Commission
7. Blood Management
estimated that ‘adverse events cost around $2 billion
8. Recognising and Responding to Acute annually’.23
Deterioration.
The case for investing in improvements in the safety
Within the context of all of these standards, the and quality of care in the Australian healthcare
Clinical Governance Framework comprises the system is strong. A rigorous safety and quality
Clinical Governance Standard and the Partnering framework that addresses system-level issues can
with Consumers Standard. This appendix lists the reduce the cost of poor care and reduce harm to
actions in these two standards, and provides some patients.
background information about the rationale and
A systematic approach to quality improvement
context for each standard.
identifies those accountable for specific actions in
health service organisations, and focuses on safety
1. Clinical Governance and quality risks to ensure that the necessary
monitoring and actions are taken to improve
Standard services. Safe and high-quality care requires the
vigilance and cooperation of the whole healthcare
Although most health care in Australia is associated workforce.
with good clinical outcomes, patients do not always In recent years, health service organisations have
receive the care that is recommended, and adverse used the NSQHS Standards as a framework for
events continue to occur across the Australian investing in safety and quality improvement
healthcare system.2 activities, such as developing and implementing
Estimates of the proportion of patients who policies, educational materials and improvement
experience patient safety incidents in hospital range processes (including credentialing, mortality
from 3% to 15% of admissions.18-21 This variation reviews, incident monitoring and root-cause
occurs because of differences in definitions and analysis). These changes have improved the safety
methods of collecting information. Even if the and quality of health care for patients.24
lower, more conservative, rate of 3% is used, this
means that almost 300,000 people were affected by
a patient safety incident in a hospital in Australia in
2013–14.22

National Model Clinical Governance Framework 19

Governance, leadership and culture
Leaders at all levels in the organisation set up and use clinical governance systems to improve the safety and
quality of health care for patients.

Item Action

Governance, 1.1 The governing body:

leadership and a. Provides leadership to develop a culture of safety and quality
culture 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

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

Organisational 1.3 The health service organisation establishes and maintains a clinical
leadership governance framework, and uses the processes within the framework to
drive improvements in safety and quality

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

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

Clinical leadership 1.6 Clinical leaders support clinicians to:

a. Understand and perform their delegated safety and quality roles and
responsibilities
b. Operate within the clinical governance framework to improve the
safety and quality of health care for patients

20 National Model Clinical Governance Framework

Patient safety and quality systems
Safety and quality systems are integrated with governance processes to enable organisations to actively
manage and improve the safety and quality of health care for patients.

Item Action

Policies and 1.7 The health service organisation uses a risk management approach to:
procedures a. Set out, review, and maintain the currency and effectiveness of,
policies, procedures and protocols
b. Monitor and take action to improve adherence to policies, procedures
and protocols
c. Review compliance with legislation, regulation and jurisdictional
requirements

Measurement 1.8 The health service organisation uses organisation-wide quality

and quality improvement systems that:
improvement a. Identify safety and quality measures, and monitor and report
performance and outcomes
b. Identify areas for improvement in safety and quality
c. Implement and monitor safety and quality improvement strategies
d. Involve consumers and the workforce in the review of safety and
quality performance and systems

1.9 The health service organisation ensures that timely reports on safety and
quality systems and performance are provided to:
a. The governing body
b. The workforce
c. Consumers and the local community
d. Other relevant health service organisations

Risk management 1.10 The health service organisation:

a. Identifies and documents organisational risks
b. Uses clinical and other data collections to support risk assessments
c. Acts to reduce risks
d. Regularly reviews and acts to improve the effectiveness of the risk
management system
e. Reports on risks to the workforce and consumers
f. Plans for, and manages, internal and external emergencies and
disasters

National Model Clinical Governance Framework 21

Item Action

Incident 1.11 The health service organisation has organisation-wide incident

management management and investigation systems, and:
systems and open a. Supports the workforce to recognise and report incidents
disclosure b. Supports patients, carers and families to communicate concerns or
incidents
c. Involves the workforce and consumers in the review of incidents
d. Provides timely feedback on the analysis of incidents to the governing
body, the workforce and consumers
e. Uses the information from the analysis of incidents to improve safety
and quality
f. Incorporates risks identified in the analysis of incidents into the risk
management system
g. Regularly reviews and acts to improve the effectiveness of the incident
management and investigation systems

1.12 The health service organisation:

a. Uses an open disclosure program that is consistent with the Australian
Open Disclosure Framework25
b. Monitors and acts to improve the effectiveness of open disclosure
processes

Feedback and 1.13 The health service organisation:

complaints a. Has processes to seek regular feedback from patients, carers and
management families about their experiences and outcomes of care
b. Has processes to regularly seek feedback from the workforce on their
understanding and use of the safety and quality systems
c. Uses this information to improve safety and quality systems

1.14 The health service organisation has an organisation-wide complaints

management system, and:
a. Encourages and supports patients, carers and families, and the
workforce to report complaints
b. Involves the workforce and consumers in the review of complaints
c. Resolves complaints in a timely way
d. Provides timely feedback to the governing body, the workforce and
consumers on the analysis of complaints and actions taken
e. Uses information from the analysis of complaints to inform
improvements in safety and quality systems
f. Records the risks identified from the analysis of complaints in the risk
management system
g. Regularly reviews and acts to improve the effectiveness of the
complaints management system

22 National Model Clinical Governance Framework

Item Action

Diversity and 1.15 The health service organisation:

high-risk groups a. Identifies the diversity of the consumers using its services
b. Identifies groups of patients using its services who are at higher risk of
harm
c. Incorporates information on the diversity of its consumers and higher-
risk groups into the planning and delivery of care

Healthcare 1.16 The health service organisation has healthcare records systems that:
records a. Make the healthcare record available to clinicians at the point of care
b. Support the workforce to maintain accurate and complete healthcare
records
c. Comply with security and privacy regulations
d. Support systematic audit of clinical information
e. Integrate multiple information systems, where they are used

1.17 The health service organisation works towards implementing systems that
can provide clinical information into the My Health Record system that:
a. Are designed to optimise the safety and quality of health care for
patients
b. Use national patient and provider identifiers
c. Use standard national terminologies

1.18 The health service organisation providing clinical information into the My
Health Record system has processes that:
a. Describe access to the system by the workforce, to comply with
legislative requirements
b. Maintain the accuracy and completeness of the clinical information
the organisation uploads into the system

National Model Clinical Governance Framework 23

Clinical performance and effectiveness
The workforce has the right qualifications, skills and supervision to provide safe, high-quality health care
to patients.

Item Action

Safety and quality 1.19 The health service organisation provides orientation to the organisation
training that describes roles and responsibilities for safety and quality for:
a. Members of the governing body
b. Clinicians, and any other employed, contracted, locum, agency,
student or volunteer members of the organisation

1.20 The health service organisation uses its training systems to:
a. Assess the competency and training needs of its workforce
b. Implement a mandatory training program to meet its requirements
arising from these standards
c. Provide access to training to meet its safety and quality training needs
d. Monitor the workforce’s participation in training

1.21 The health service organisation has strategies to improve the cultural
awareness and cultural competency of the workforce to meet the needs
of its Aboriginal and Torres Strait Islander patients

Performance 1.22 The health service organisation has valid and reliable performance review
management processes that:
a. Require members of the workforce to regularly take part in a review of
their performance
b. Identify needs for training and development in safety and quality
c. Incorporate information on training requirements into the
organisation’s training system

Credentialing and 1.23 The health service organisation has processes to:
scope of clinical a. Define the scope of clinical practice for clinicians, considering the
practice clinical service capacity of the organisation and clinical services plan
b. Monitor clinicians’ practices to ensure that they are operating within
their designated scope of clinical practice
c. Review the scope of clinical practice of clinicians periodically
and whenever a new clinical service, procedure or technology is
introduced or substantially altered

1.24 The health service organisation:

a. Conducts processes to ensure that clinicians are credentialed, where
relevant
b. Monitors and improves the effectiveness of the credentialing process

24 National Model Clinical Governance Framework

Item Action

Safety and 1.25 The health service organisation has processes to:
quality roles and a. Support the workforce to understand and perform their roles and
responsibilities responsibilities for safety and quality
b. Assign safety and quality roles and responsibilities to the workforce,
including locums and agency staff

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

Evidence-based 1.27 The health service organisation has processes that:

care a. Provide clinicians with ready access to best-practice guidelines,
integrated care pathways, clinical pathways and decision support tools
relevant to their clinical practice
b. Support clinicians to use the best available evidence, including relevant
clinical care standards developed by the Australian Commission on
Safety and Quality in Health Care

Variation in 1.28 The health service organisation has systems to:

clinical practice a. Monitor variation in practice against expected health outcomes
and health b. Provide feedback to clinicians on variation in practice and health
outcomes outcomes
c. Review performance against external measures
d. Support clinicians to participate in clinical review of their practice
e. Use information on unwarranted clinical variation to inform
improvements in safety and quality systems
f. Record the risks identified from unwarranted clinical variation in the
risk management system

National Model Clinical Governance Framework 25

Safe environment for the delivery of care
The environment promotes safe and high-quality health care for patients.

Item Action

Safe environment 1.29 The health service organisation maximises safety and quality of care:
a. Through the design of the environment
b. By maintaining buildings, plant, equipment, utilities, devices and other
infrastructure that are fit for purpose

1.30 The health service organisation:

a. Identifies service areas that have a high risk of unpredictable
behaviours and develops strategies to minimise the risks of harm for
patients, carers, families, consumers and the workforce
b. Provides access to a calm and quiet environment when it is clinically
required

1.31 The health service organisation facilitates access to services and facilities
by using signage and directions that are clear and fit for purpose

1.32 The health service organisation admitting patients overnight has

processes that allow flexible visiting arrangements to meet patients’
needs, when it is safe to do so

1.33 The health service organisation demonstrates a welcoming environment

that recognises the importance of the cultural beliefs and practices of
Aboriginal and Torres Strait Islander people

26 National Model Clinical Governance Framework

2. Partnering with Delivering care that is based on partnerships
provides many benefits for patients, consumers,
Consumers Standard clinicians, health service organisations and the
health system. There is evidence for links between
Effective partnerships exist when people are treated the existence of effective partnerships, a positive
with dignity and respect, information is shared experience for patients, and high-quality health care
with them, and participation and collaboration in and improved safety.27-29 As well, the involvement
healthcare processes are encouraged and supported of patients and consumers in planning, delivery,
to the extent that people choose.26 monitoring and evaluation can have a positive
impact on service planning and development,
The health system includes different types of information development and dissemination, and
partnerships, which are not mutually exclusive. the attitudes of healthcare providers.27,30,31 Specific
Partnerships are necessary at all levels to ensure studies in the United States have found that
that a health service organisation achieves the best delivering health care that is based on partnerships
possible outcomes for all parties.27 can result in reduced hospital costs, lower cost per
At the level of the individual, partnerships relate case and reduced length of stay.32,33
to the interaction between clinicians and patients
when care is provided. At this level, a partnership
involves providing care that is respectful; sharing
information in an ongoing way; working with
patients, carers and families to make decisions and
plan care; and supporting and encouraging patients
in their own care.
At the level of a service, department or program
of care, partnerships relate to the organisation and
delivery of care within specific areas. At this level,
a partnership involves the participation of patients,
carers, families and consumers in the overall design
of the service, department or program. This could
be as full members of quality improvement and
redesign teams, and participating in planning,
implementing and evaluating change.
At the level of the health service, partnerships
relate to the involvement of consumers in overall
governance, policy and planning. This level
overlaps with the previous level, since a health
service is made up of various services, departments
and programs. At the level of the health service,
partnerships relate to the involvement of consumers
and consumer representatives as full members
of key organisational governance committees
in areas such as patient safety, facility design,
quality improvement, patient or family education,
ethics and research. This level can also involve
partnerships with local community organisations
and members of local communities.

National Model Clinical Governance Framework 27

Clinical governance and quality improvement systems to support
partnering with consumers
Systems are designed and used to support patients, carers, families and consumers to be partners in
healthcare planning, design, measurement and evaluation.

Item Action

Integrating clinical 2.1 Clinicians use the safety and quality systems from the Clinical Governance
governance Standard when:
a. Implementing policies and procedures for partnering with consumers
b. Managing risks associated with partnering with consumers
c. Identifying training requirements for partnering with consumers

Applying quality 2.2 The health service organisation applies the quality improvement system in
improvement the Clinical Governance Standard when:
systems a. Monitoring processes for partnering with consumers
b. Implementing strategies to improve processes for partnering with
consumers
c. Reporting on partnering with consumers

Partnering with patients in their own care

Systems that are based on partnering with patients in their own care are used to support the delivery of care.
Patients are partners in their own care to the extent that they choose.

Item Action

Healthcare rights 2.3 The health service organisation uses a charter of rights that is:
and informed a. Consistent with the Australian Charter of Healthcare Rights34
consent b. Easily accessible for patients, carers, families and consumers

2.4 The health service organisation ensures that its informed consent
processes comply with legislation and best practice

2.5 The health service organisation has processes to identify:

a. The capacity of a patient to make decisions about their own care
b. A substitute decision-maker if a patient does not have the capacity to
make decisions for themselves

Sharing decisions 2.6 The health service organisation has processes for clinicians to partner with
and planning care patients and/or their substitute decision-maker to plan, communicate, set
goals, and make decisions about their current and future care

2.7 The health service organisation supports the workforce to form

partnerships with patients and carers so that patients can be actively
involved in their own care

28 National Model Clinical Governance Framework

Health literacy
Health service organisations communicate with consumers in a way that supports effective partnerships.

Item Action

Communication 2.8 The health service organisation uses communication mechanisms that are
that supports tailored to the diversity of the consumers who use its services and, where
relevant, the diversity of the local community
effective
partnerships
2.9 Where information for patients, carers, families and consumers about
health and health services is developed internally, the organisation involves
consumers in its development and review

2.10 The health service organisation supports clinicians to communicate with

patients, carers, families and consumers about health and health care so
that:
a. Information is provided in a way that meets the needs of patients,
carers, families and consumers
b. Information provided is easy to understand and use
c. The clinical needs of patients are addressed while they are in the health
service organisation
d. Information needs for ongoing care are provided on discharge

Partnering with consumers in organisational design and governance

Consumers are partners in the design and governance of the organisation.

Item Action

Partnerships 2.11 The health service organisation:

in healthcare a. Involves consumers in partnerships in the governance of, and to
governance design, measure and evaluate, health care
planning, design, b. Has processes so that the consumers involved in these partnerships
reflect the diversity of consumers who use the service or, where
measurement
relevant, the diversity of the local community
and evaluation
2.12 The health service organisation provides orientation, support and
education to consumers who are partnering in the governance, design,
measurement and evaluation of the organisation

2.13 The health service organisation works in partnership with Aboriginal and
Torres Strait Islander communities to meet their healthcare needs

2.14 The health service organisation works in partnership with consumers to

incorporate their views and experiences into training and education for the
workforce

National Model Clinical Governance Framework 29

Acknowledgements
The Clinical Governance Framework was developed with input from the National Model Clinical
Governance Advisory Panel. Members of this panel are listed below. The Commission thanks the members
of the panel for their time and expertise.

Name Position

Ms Wendy Harris QC, Chair Australian Commission on Safety and Quality in Health Care

Dr Richard Ashby AM Chief Executive, Metro South Hospital and Health Service,
Queensland

Dr Tarun Bastiampillai Representative, Australian Medical Association (South Australia)

Adjunct Professor Cheyne Chalmers Chief Nursing and Midwifery Officer, Monash Health

Dr Michael Coglin Representative, private sector provider

Ms Karen Crawshaw PSM Deputy Secretary, NSW Ministry of Health

Mr Martin Fletcher Chief Executive Officer, Australian Health Practitioner Regulation

Agency

Professor Phillip Harris Chair, South Western Sydney Local Health District

Ms Sally-Anne Jones Federal President, Australian Nursing and Midwifery Federation

Professor Anthony Lawler President, Australasian College for Emergency Medicine; and
Principal Medical Advisor, Tasmanian Department of Health and
Human Services

Dr Len Notaras AM Chief Executive, Northern Territory Department of Health

Ms Jenny Richter Deputy Chief Executive, SA Health

Mrs Cheryle Royle General Manager, St Vincent’s Private Hospital, Queensland

Professor David Watters OBE President, Royal Australasian College of Surgeons

Ms Jennifer Westacott Chief Executive, Business Council of Australia

Associate Professor Andrew Wilson Chief Medical Officer, Victoria Health

Dr Chris Zappala President, Australian Medical Association (Queensland)

30 National Model Clinical Governance Framework

Glossary
If appropriate, glossary definitions from external consumer: a person who has used, or may
sources have been adapted to fit the context of the potentially use, health services, or is a carer for a
NSQHS Standards. patient using health services. A healthcare consumer
may also act as a consumer representative, to
adverse event: an incident that results, or could have
provide a consumer perspective, contribute
resulted, in harm to a patient or consumer. A near
consumer experiences, advocate for the interests of
miss is a type of adverse event. See also near miss
current and potential health service users, and take
Australian Charter of Healthcare Rights: specifies part in decision-making processes.35
the key rights of patients when seeking or receiving
credentialing: the formal process used by a health
healthcare services. It was endorsed by health
service organisation to verify the qualifications,
ministers in 2008.34
experience, professional standing, competencies
Australian Open Disclosure Framework: endorsed and other relevant professional attributes of
by health ministers in 2013, it provides a framework clinicians, so that the organisation can form a view
for health service organisations and clinicians to about the clinician’s competence, performance and
communicate openly with patients when health care professional suitability to provide safe, high-quality
does not go to plan.25 healthcare services within specific organisational
clinical governance: an integrated component environments.36
of corporate governance of health service environment: the physical surroundings in which
organisations. It ensures that everyone – from health care is delivered, including the building,
frontline clinicians to managers and members of fixtures, fittings, and services such as air and water
governing bodies, such as boards – is accountable supply. Environment can also include other patients,
to patients and the community for assuring the consumers, visitors and the workforce.
delivery of safe, effective and high-quality services.
governance: the set of relationships and
Clinical governance systems provide confidence to
responsibilities established by a health service
the community and the healthcare organisation
organisation between its executive, workforce and
that systems are in place to deliver safe and high-
stakeholders (including patients and consumers).
quality health care.
Governance incorporates the processes, customs,
clinical leaders: clinicians with management or policy directives, laws and conventions affecting the
leadership roles in a health service organisation way an organisation is directed, administered or
who can use their position or influence to change controlled. Governance arrangements provide the
behaviour, practice or performance. Examples are structure for setting the corporate objectives (social,
directors of clinical services, heads of units and fiscal, legal, human resources) of the organisation
clinical supervisors. and the means to achieve the objectives. They
clinician: a healthcare provider, trained as a also specify the mechanisms for monitoring
health professional, including registered and non- performance. Effective governance provides a clear
registered practitioners. Clinicians may provide care statement of individual accountabilities within the
within a health service organisation as an employee, organisation to help align the roles, interests and
a contractor or a credentialed healthcare provider, actions of different participants in the organisation
or under other working arrangements. They to achieve the organisation’s objectives. In the
include nurses, midwives, medical practitioners, NSQHS Standards, governance includes both
allied health practitioners, technicians, scientists corporate and clinical governance.
and other clinicians who provide health care, and
students who provide health care under supervision.

National Model Clinical Governance Framework 31

governing body: a board, chief executive officer, having low health literacy; being homeless; or being
organisation owner, partnership or other highest of diverse gender identities and experiences, bodies,
level of governance (individual or group of relationships and sexualities (currently referred to as
individuals) that has ultimate responsibility for lesbian, gay, bisexual, transgender and intersex, or
strategic and operational decisions affecting safety LGBTI).
and quality in a health service organisation.
incident (clinical): an event or circumstance that
health care: the prevention, treatment and resulted, or could have resulted, in unintended or
management of illness and injury, and the unnecessary harm to a patient or consumer; or a
preservation of mental and physical wellbeing complaint, loss or damage. An incident may also be
through the services offered by clinicians, such as a near miss. See also near miss
medical, nursing and allied health professionals.25
informed consent: a process of communication
healthcare record: includes a record of the patient’s between a patient and a clinician about options for
medical history, treatment notes, observations, treatment, care processes or potential outcomes.
correspondence, investigations, test results, This communication results in the patient’s
photographs, prescription records and medication authorisation or agreement to undergo a specific
charts for an episode of care. intervention or participate in planned care.38 The
health literacy: the Australian Commission on communication should ensure that the patient has an
Safety and Quality in Health Care separates health understanding of the care they will receive, all the
literacy into two components – individual health available options and the expected outcomes, including
literacy and the health literacy environment. success rates and side effects for each option.39

Individual health literacy is the skills, knowledge, jurisdictional requirements: systematically

motivation and capacity of a consumer to access, developed statements from state and territory
understand, appraise and apply information to governments about appropriate healthcare or
make effective decisions about health and health service delivery for specific circumstances.40
care, and take appropriate action. Jurisdictional requirements encompass a number
of types of documents from state and territory
The health literacy environment is the governments, including legislation, regulations,
infrastructure, policies, processes, materials, people guidelines, policies, directives and circulars. Terms
and relationships that make up the health system, used for each document may vary by state and
which affect the ways in which consumers access, territory.
understand, appraise and apply health-related
information and services.37 leadership: having a vision of what can be achieved,
and then communicating this to others and evolving
health service organisation: a separately constituted strategies for realising the vision. Leaders motivate
health service that is responsible for implementing people, and can negotiate for resources and other
clinical governance, administration and financial support to achieve goals.41
management of a service unit or service units
providing health care at the direction of the local community: the people living in a defined
governing body. A service unit involves a group of geographic region or from a specific group who
clinicians and others working in a systematic way receive services from a health service organisation.
to deliver health care to patients. It can be in any near miss: an incident or potential incident that
location or setting, including pharmacies, clinics, was averted and did not cause harm, but had the
outpatient facilities, hospitals, patients’ homes, potential to do so.42
community settings, practices and clinicians’ rooms.
open disclosure: an open discussion with a patient
higher risk (patients at higher risk of harm): and carer about an incident that resulted in harm to
a patient with multiple factors or a few specific the patient while receiving health care. The criteria
factors that result in their being more vulnerable of open disclosure are an expression of regret, and a
to harm from health care or the healthcare system. factual explanation of what happened, the potential
Risk factors may include having chronic clinical consequences, and the steps taken to manage the
conditions; having language barriers; being of event and prevent recurrence.43
Aboriginal or Torres Strait Islander background;

32 National Model Clinical Governance Framework

organisation-wide: intended for use throughout the quality improvement: the combined efforts of
health service organisation. the workforce and others – including consumers,
patients and their families, researchers, planners
outcome: the status of an individual, group of
and educators – to make changes that will lead
people or population that is wholly or partially
to better patient outcomes (health), better system
attributable to an action, agent or circumstance.44
performance (care) and better professional
partnership: a situation that develops when development.46 Quality improvement activities may
patients and consumers are treated with dignity be undertaken in sequence, intermittently or on a
and respect, when information is shared with continual basis.
them, and when participation and collaboration
risk: the chance of something happening that will
in healthcare processes are encouraged and
have a negative impact. Risk is measured by the
supported to the extent that patients and consumers
consequences of an event and its likelihood.
choose. Partnerships can exist in different ways
in a health service organisation, including at the risk assessment: the assessment, analysis and
level of individual interactions; at the level of a management of risks. It involves recognising
service, department or program; and at the level which events may lead to harm in the future, and
of the organisation. They can also exist with minimising their likelihood and consequence.47
consumers and groups in the community. Generally,
risk management: the design and implementation
partnerships at all levels are necessary to ensure
of a program to identify and avoid or minimise risks
that the health service organisation is responsive to
to patients, employees, volunteers, visitors and the
patient and consumer input and needs, although the
organisation.
nature of the activities for these different types of
partnership will vary depending on the context of safety culture: a commitment to safety that
the health service organisation. permeates all levels of an organisation, from the
clinical workforce to executive management.
patient: a person who is receiving care in a health
Features commonly include acknowledgement
service organisation.
of the high-risk, error-prone nature of an
patient safety: prevention of errors and adverse organisation’s activities; a blame-free environment
effects on patients associated with health care. in which individuals are able to report errors or near
misses without fear of reprimand or punishment;
policy: a set of principles that reflect the
an expectation of collaboration across all areas
organisation’s mission and direction. All procedures
and levels of an organisation to seek solutions to
and protocols are linked to a policy statement.
vulnerabilities; and a willingness of the organisation
procedure: the set of instructions to make policies to direct resources to deal with safety concerns.48
and protocols operational, which are specific to an
scope of clinical practice: the extent of an
organisation.
individual clinician’s approved clinical practice
process: a series of actions or steps taken to achieve within a particular organisation, based on the
a particular goal.45 clinician’s skills, knowledge, performance and
program: an initiative, or series of initiatives, professional suitability, and the needs and service
designed to deal with a particular issue, with capability of the organisation.16
resources, a time frame, objectives and deliverables standard: agreed attributes and processes designed
allocated to it. to ensure that a product, service or method will
protocol: an established set of rules used to perform consistently at a designated level.44
complete tasks or a set of tasks.

National Model Clinical Governance Framework 33

system: the resources, policies, processes and
procedures that are organised, integrated, regulated
and administered to accomplish a stated goal.
A system:
• Brings together risk management, governance
and operational processes and procedures,
including education, training and orientation
• Deploys an active implementation plan; feedback
mechanisms include agreed protocols and
guidelines, decision support tools and other
resource materials
• Uses several incentives and sanctions to influence
behaviours and encourage compliance with
policy, protocol, regulation and procedures.

The workforce is both a resource in the system and

involved in all elements of systems development,
implementation, monitoring, improvement and
evaluation.
training: the development of knowledge and skills.
workforce: all people working in a health service
organisation, including clinicians, and any other
employed or contracted, locum, agency, student,
volunteer or peer workers. The workforce can
be members of the health service organisation
or medical company representatives providing
technical support who have assigned roles and
responsibilities for care of, administration of,
support of, or involvement with, patients in the
health service organisation. See also clinician

34 National Model Clinical Governance Framework

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Telephone: (02) 9126 3600
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