2026 National Model for Clinical Governance

The 2026 National Model for Clinical Governance (national model) aims to drive high-quality care and better outcomes for patients in Australian hospitals.

The national model is a short, simple, principles-based document that describes key actions and clarifies roles within health services to achieve high-quality care. It signals a strategic shift in how clinical governance is understood, led and embedded in all health services.

The model:

elevates clinical governance to the highest level of organisational leadership and oversight, highlighting the crucial role of boards and executives in governing for high-quality care
reshapes Australia’s approach to clinical governance, shifting the main focus from complying with accreditation requirements to building the culture of the organisation to one in which delivery of high-quality care is the core focus of everyone in a health service, every day.

The national model is accompanied by a practical guide to implementation and tools.

Health services can use the guide to review their organisation’s clinical governance arrangements, identify gaps, develop an implementation plan, and monitor delivery of high-quality care.

The national model replaces the 2017 National Model Clinical Governance Framework.

Download the National Model for Clinical Governance

Or use the menu on the left to explore the model.

Download the practical guide to implementation

Or use the menu on the left to explore the guide.

About the national model

Clinical governance establishes the conditions for high-quality care. It builds an environment and culture where everyone in a health service works together and with patients and consumers to deliver high-quality care.

The National Model for Clinical Governance (national model) provides updated national guidance on clinical governance that is clear, relevant and effective in helping health services to strive for consistently high-quality care.

Health service leaders can use the national model to review and strengthen their clinical governance systems and to identify and monitor what their organisation needs to achieve consistently high-quality care.

The national model provides a definition of high-quality care and describes the six foundations of clinical governance required to achieve this care:

Leading systems and organisational culture
Partnering with patients, carers and consumers
Building a healthy workforce culture
Enabling high-quality and integrated clinical practice
Managing and reducing risk
Using data for better care

Who this model is for

The national model is for public and private health services in the acute sector, including day hospitals.

It is primarily intended for health service board members and executives or equivalent who are responsible for directing and implementing clinical governance systems essential for high-quality care. At the same time, the national model is designed to be understood by all the workforce as everyone has a role in providing or supporting the delivery of high-quality care.

“When board members, executives and clinical leaders champion clinical governance as fundamental to achieving high-quality care, it sets the tone for the rest of the organisation.”
Professor Christine Kilpatrick AO, Board Chair, Australian Commission on Safety and Quality in Health Care

How to use the national model

Boards and executives (or equivalent) can use the model to govern, lead and plan for high-quality care through:

building a shared language and understanding across the workforce of the definition of high-quality care and the six foundations of clinical governance required to support it
designing systems and processes and shaping organisational culture to achieve consistently high-quality care
enhancing accountability and clarifying roles and responsibilities
guiding their approach to meeting safety and quality standards.

State and territory health departments and private hospital groups can use the national model to inform clinical governance systems and to shape detailed guidance for health services.

“The national model provides a structured way for me to conduct a gap analysis with the board and executive team to sharpen our clinical governance strategy – to visualise and articulate where we need to be.”
Lynne Walker, Chief Executive Officer, Perth Clinic, Western Australia

Implementing the national model

The national model is a principles-based document. Health services can apply the six foundations of clinical governance in a way that meets the needs of their organisation, no matter their size, type or location. An implementation guide offers practical steps for how health services can adapt the model.

Applying the national standards with purpose

The national model describes the systems, structures and culture for effective clinical governance in health services. As a principles-based document, the national model supports health services to review and strengthen their clinical governance arrangements and address the requirements of both the current and next edition of the National Safety and Quality Health Service (NSQHS) Standards. The six foundations of clinical governance will form the structure of the Clinical Governance Standard in the third edition.

Boards and executives should use the six foundations of clinical governance to check that their organisation’s strategy, systems and culture are aligned to deliver care that is consistently high quality and improving, no matter which safety and quality standards are in place.

The national model guides health services’ approach to applying NSQHS Standards in a meaningful way. By orienting every role and every system in the organisation to focus on high-quality care, and allocating resources to enable effective action, everyone in a health service can be confident that standards are being met every day – not just during accreditation assessments.

This fact sheet describes what the new national model means for assessment to the National Safety and Quality Health Service (NSQHS) Standards.

About clinical governance

What is clinical governance?

Clinical governance is central to providing the best possible outcomes for patients. It is the combination of organisational culture, systems and structures that enables everyone in a health service to deliver care that is consistently high quality and improving.

Effective clinical governance means that boards, executives, clinical leaders and the workforce are clearly accountable to patients and the community for providing high-quality care – care that is person-centred, safe, effective, accessible and integrated, provided in a way that is equitable, efficient and sustainable.

When done well, clinical governance builds trust across a health service. Patients experience care that better meets their needs. The workforce is confident that their organisation backs them with the right culture, structures, support and leadership to provide consistently high-quality care. Boards and executives have the oversight and tools they need to realise their strategy for achieving high-quality care.

Public inquiries into suboptimal care show that weak clinical governance can result in normalisation of poor care, ignored patient concerns, a culture of blame, a disengaged workforce, and overemphasis on legal and financial matters at the expense of care quality and patient outcomes.

Good governance

Corporate governance refers to the systems that direct and control – or govern – an organisation, including financial and legal functions.

Clinical governance and corporate governance are interdependent in a health service. Every board member and executive needs to understand that the core business of a health service is providing high-quality care, and that financial and operational decisions determine how resources are allocated to deliver that care.

“There is no corporate governance without clinical governance, because we are in the business of providing clinical care.”

Adjunct Professor Frank Tracey, Chief Executive, Children’s Health Queensland

Clinical governance for digitally enabled care

Robust clinical governance is needed for all types of care, whether delivered face to face or digitally enabled. Digitally enabled care includes virtual care, remote monitoring, and decision-making supported by artificial intelligence. Governance structures and systems must adapt to allow for changes in digitally enabled models of care, clinical workflows and technical requirements.

Clinical governance systems and frameworks must continue to evolve to harness the benefit of digitally enabled care – such as enhanced diagnostic accuracy, seamless information exchange across settings and support for personalised care – while safeguarding the safety and quality of care for patients.

High-quality care

The central aim of clinical governance is to deliver care to patients that is consistently high quality and improving. The Commission defines high-quality care as person-centred, safe, effective, accessible and integrated, provided in a way that is equitable, efficient and sustainable (Figure 1).

Cultural safety, as determined by Aboriginal and Torres Strait Islander people, is necessary for high-quality care. Cultural safety must be embedded in each domain of high-quality care to improve health outcomes for Aboriginal and Torres Strait Islander people.

Figure 1: Diagram of domains of high-quality care. High quality care is when patients receive care that is: person-centred, safe, effective, accessible and integrated, and provided in a way that is: equitable, efficient and sustainable.

^{Figure 1:}^{Diagram of domains of high-quality care. High quality care is when patients receive health care that is: person-centred, safe, effective, accessible and integrated, and provided in a way that is: equitable, efficient and sustainable.}

Roles in supporting high-quality care

Everyone in a health service – whether directly or indirectly involved in patient care – is responsible for achieving consistently high-quality care for every patient. To be effective, clinical governance needs to involve the board, executive and the workforce at all levels in a health service (Figure 2). Engagement and partnerships with patients, carers and consumers are critical to achieving high-quality care and better patient outcomes.

Figure 2: Diagram of roles supporting high-quality care. Consumer and patient representatives are empowered as partners. Boards or equivalent set the organisational culture, expectations and strategy. Executives or equivalent implement clinical governance activities. Managers and clinical leaders create the environment for consistency high-quality care. Clinicians provide consistently high-quality care. Non clinical staff create the environment and systems that contribute to high-quality care.

^{Figure 2:}^{Diagram of roles supporting high-quality care in a health service. Everyone has a role in achieving high-quality care. Consumer and patient representatives are empowered as partners in the planning, delivery and evaluation of health care. Boards or equivalent set the organisational culture, expectation and strategy for high-quality care, providing resourcing and support for the executive to implement clinical governance systems. Executives or equivalent implement clinical governance activities by enabling people and systems, they lead and improve the health service to provide high-quality care, fostering the desired culture. Managers and clinical leaders create the environment for consistently high-quality care, they support, organise and develop the workforce to create high-quality and improving care using guidance tools such as standards and systems. Clinicians provide consistently high-quality care, they create high-quality care through their behaviour and skills by monitoring and improving the care experience. Non clinical staff create the environment and systems that contribute to high-quality care, non-clinical staff include human resources, food services and ICT teams. (This illustration has been adapted from an Australasian Institute of Clinical Governance resource – ‘I take responsibility’)}

“Our CEO promotes all the time that our vision of best care is everyone’s business. You may not be providing direct clinical care, but you’re still providing best care, and everything you do contributes to providing best care.”

Alison Rule, Director Best Care Governance Compliance and Assurance, Western Health, Victoria

A note about patients and consumers

This model uses the term ‘patient’ for the person receiving care. It uses ‘consumer’ when referring to a consumer advocate or representative involved in clinical governance activities.

The six foundations of clinical governance

Clinical governance is the set of organisational systems aimed at supporting health services to deliver high-quality care. In this national model, these systems are structured into six foundations of clinical governance (Figure 3) that, when combined, underpin an organisational approach to delivering consistently high-quality and improving care.

The six foundations are connected and interdependent. As a health service’s priorities change, continuous monitoring, evaluation and improvement are required to check that activities are aligned with each foundation and achieve the purpose of providing consistently high-quality care.

Of the six foundations, leadership is a critical enabler of effective clinical governance. The board and executive provide clear strategic direction while creating an organisational culture in which there is leadership and accountability for providing high-quality care at all levels of the organisation.

^{Figure 3:}^{Diagram of the six foundations of clinical governance and high-quality care. 1: Leading systems and organisational culture. 2: Partnering with patients, carers and consumers. 3: Building a healthy workforce culture. 4: Enabling high-quality and integrated clinical practice. 5: Managing and reducing risk. 6: Using data for better care.}

Cultural safety for Aboriginal and Torres Strait Islander patients and health service staff

All foundations of clinical governance emphasise that cultural safety is essential in achieving high-quality care for Aboriginal and Torres Strait Islander patients and communities and in creating and maintaining a safe environment for Aboriginal and Torres Strait Islander health service staff.

Good practice and warning signs

The foundations of clinical governance set out key examples of good practice. The examples are not a complete list – rather they are designed so that health services can assess their performance in each foundation area. Each foundation also includes warning signs that can alert boards and executives to weaknesses in their clinical governance systems. Practical resources are available on the website.

1. Leading systems and organisational culture

Leadership of a health service’s systems and organisational culture is central to how care is delivered and the outcomes of that care.

Inquiries into safety and quality failings in health services have highlighted that leadership actions – or lack of action – have a major impact on the culture of a health service and how it operates. Ineffective systems and negative organisational culture contribute to suboptimal care, poor staff morale and higher costs, while robust systems and positive organisational culture are associated with a satisfied and motivated workforce and better patient outcomes.

The board and executive are accountable for establishing, maintaining and continually improving systems for high-quality care. They set the strategy and culture for high-quality care, and support the workforce and patients, carers and consumers to achieve better patient outcomes and experiences. The board and executive have a legal duty to provide a psychosocially safe environment for the workforce and patients.

What good practice looks like

Key examples
The board and executive have a clear vision and strategy for high-quality care that is communicated and understood across the organisation. They use a clinical governance framework to achieve the strategy. Board members understand their responsibilities for high-quality care as part of their governance role and receive education and training to fulfil their responsibilities. The board and executive lead an organisation-wide approach to continuous systems improvement, driven by high-quality data that support decision-making and high-quality care. The board, executive and committees establish the systems and organisational culture to achieve consistently high-quality care and provide adequate resources for collaboration and accountability. The board and executive monitor the organisation’s safety culture, including patient and workforce perception of safety culture, and findings inform improvement strategies. Clinicians have leadership roles in establishing and maintaining the safety culture. Board decision-making considers the perspectives of patients, carers and community members, including people with lived experience. The board and executive are accountable for cultural safety in governance and across the organisation. Health care is culturally safe for Aboriginal and Torres Strait Islander patients, and the workplace is culturally safe for Aboriginal and Torres Strait Islander staff. Aboriginal and Torres Strait Islander leadership roles are embedded in governance structures. Partnerships with Aboriginal and Torres Strait Islander patients, staff, communities and organisations enable Aboriginal leadership and self-determination that achieves culturally safe health care that is free from racism. Clinical governance activities are inclusive and representative. Systematic engagement with, and representation from, patients, carers and consumers of diverse cultures, identities and experiences is used to improve care. The board and executive lead strategies to deliver environmentally sustainable health care through minimising unwarranted healthcare variation and low-value care. The board and executive have oversight of digitally enabled models of care, including digital tools and technologies that support those tools. They are accountable for enabling a trusted environment that ensures data privacy and security and the safe and ethical use of automated systems, such as artificial intelligence, in clinical decision-making and patient care.

Key examples

The board and executive have a clear vision and strategy for high-quality care that is communicated and understood across the organisation. They use a clinical governance framework to achieve the strategy.
Board members understand their responsibilities for high-quality care as part of their governance role and receive education and training to fulfil their responsibilities.
The board and executive lead an organisation-wide approach to continuous systems improvement, driven by high-quality data that support decision-making and high-quality care.
The board, executive and committees establish the systems and organisational culture to achieve consistently high-quality care and provide adequate resources for collaboration and accountability.
The board and executive monitor the organisation’s safety culture, including patient and workforce perception of safety culture, and findings inform improvement strategies. Clinicians have leadership roles in establishing and maintaining the safety culture.
Board decision-making considers the perspectives of patients, carers and community members, including people with lived experience.
The board and executive are accountable for cultural safety in governance and across the organisation. Health care is culturally safe for Aboriginal and Torres Strait Islander patients, and the workplace is culturally safe for Aboriginal and Torres Strait Islander staff.
Aboriginal and Torres Strait Islander leadership roles are embedded in governance structures. Partnerships with Aboriginal and Torres Strait Islander patients, staff, communities and organisations enable Aboriginal leadership and self-determination that achieves culturally safe health care that is free from racism.
Clinical governance activities are inclusive and representative. Systematic engagement with, and representation from, patients, carers and consumers of diverse cultures, identities and experiences is used to improve care.
The board and executive lead strategies to deliver environmentally sustainable health care through minimising unwarranted healthcare variation and low-value care.
The board and executive have oversight of digitally enabled models of care, including digital tools and technologies that support those tools. They are accountable for enabling a trusted environment that ensures data privacy and security and the safe and ethical use of automated systems, such as artificial intelligence, in clinical decision-making and patient care.

Warning signs

Board meeting agendas have a disproportionate focus on legal and financial matters without due consideration of clinical governance.
There is high turnover in key leadership roles.
The board does not engage with clinical issues, e.g. the board rarely or never hears from clinicians and there are no board directors with clinical backgrounds.
The board, executive and workforce do not reflect the community they serve.
Responsibility for digital tools is siloed within Information and Communications Technology (ICT) functions and is not integrated with clinical governance systems.

2. Partnering with patients, carers and consumers

Partnering with consumers in clinical governance – and with patients in their own care – is critical to achieving high-quality care and contributes to better outcomes and experiences for patients, carers and consumers.

Governance systems at all levels of the health service enable patients, carers and consumers to shape their care. The board and executive lead systems that build a culture of person-centred care so that everyone in a health service partners with patients, carers and consumers to provide or support the delivery of high-quality care.

What is person-centred care?

Person-centred care is health care that respects the patient, their family and carers, and responds to the person’s preferences, needs and values.

Person-centred care is equitable, culturally safe and free from racism and all other forms of discrimination. Patients, carers and consumers are treated with dignity, respect and kindness.

What good practice looks like

Key examples
There are meaningful and active partnerships with patients, carers and consumers at all levels of the health service. The consumer voice informs board and executive strategic priorities and decision-making. An engagement strategy outlines how consumers are recruited, trained and supported. Consumers partner in planning, designing (including co-design where possible) and reviewing health service activities. As part of a learning culture, the board and executive act on patient-reported experience and outcome measures, alongside other measures of quality, and allocate resources to improve care. The organisation’s systems, structures and culture enable clinicians and patients to share decision-making about the patient’s care. Clinicians communicate with patients, families, carers and consumers in a way they understand. The organisation partners with consumers who reflect the diversity of the wider community, including priority groups who are at higher risk of poor health outcomes. Partnerships with Aboriginal and Torres Strait Islander people and communities prioritise self-determination and cultural authority and use community-led engagement methods. Insights from patients, carers and consumers, including people with lived experience are used to improve care. Patients, carers and consumers are encouraged and supported to speak up for safety. Their concerns about deterioration during clinical care are escalated. The organisation encourages positive feedback, complaints and suggestions for improvement. There are systems to use patient and consumer feedback to improve care. Patients, carers and consumers receive information about the outcomes of their feedback. Open disclosure processes are championed, supported and embedded at all levels of the organisation. The organisation partners with patients, carers and consumers to share decision-making about ways to achieve environmentally sustainable health care through minimising low-value care. Consumers are partners in the design, implementation and governance of digitally enabled systems and are supported to build their digital health literacy.

Key examples

There are meaningful and active partnerships with patients, carers and consumers at all levels of the health service. The consumer voice informs board and executive strategic priorities and decision-making.
An engagement strategy outlines how consumers are recruited, trained and supported. Consumers partner in planning, designing (including co-design where possible) and reviewing health service activities.
As part of a learning culture, the board and executive act on patient-reported experience and outcome measures, alongside other measures of quality, and allocate resources to improve care.
The organisation’s systems, structures and culture enable clinicians and patients to share decision-making about the patient’s care. Clinicians communicate with patients, families, carers and consumers in a way they understand.
The organisation partners with consumers who reflect the diversity of the wider community, including priority groups who are at higher risk of poor health outcomes.
Partnerships with Aboriginal and Torres Strait Islander people and communities prioritise self-determination and cultural authority and use community-led engagement methods.
Insights from patients, carers and consumers, including people with lived experience are used to improve care.
Patients, carers and consumers are encouraged and supported to speak up for safety. Their concerns about deterioration during clinical care are escalated.
The organisation encourages positive feedback, complaints and suggestions for improvement. There are systems to use patient and consumer feedback to improve care. Patients, carers and consumers receive information about the outcomes of their feedback.
Open disclosure processes are championed, supported and embedded at all levels of the organisation.
The organisation partners with patients, carers and consumers to share decision-making about ways to achieve environmentally sustainable health care through minimising low-value care.
Consumers are partners in the design, implementation and governance of digitally enabled systems and are supported to build their digital health literacy.

Warning signs

Consumers are engaged to satisfy representation requirements for committees rather than to meaningfully inform clinical governance decisions.
Patient-reported measures and outcomes are not monitored or, if monitored, areas for improvement are not identified or acted on.
There are consistently low scores in patient experience surveys. Patient and consumer feedback is not acted on.
The organisation fails to recognise diverse cultures, identities and experiences and to tailor responses and models of care to meet patients’ unique needs.

3. Building a healthy workforce culture

A supported, engaged and empowered workforce is essential for delivering high-quality care and improving patient outcomes. A positive workforce culture in which staff feel respected, valued and safe to speak up for safety is a critical factor in boosting workforce morale and enabling staff to provide or support consistently high-quality care.

Constraints such as workforce shortages and turnover and fewer senior staff mean it is more important than ever to build and support an effective and engaged workforce.

Many factors contribute to building and maintaining a workforce culture in which all staff feel responsible for the care provided and feel that they can raise issues. These factors include a physically, psychosocially and culturally safe workplace, effective supervision, development and performance management systems, management of workload and adequate staffing.

What good practice looks like

Key examples
The board and executive define the workforce’s responsibilities for delivering high-quality care and provide appropriate and effective workforce planning and resourcing to meet them The board, executive, clinical leaders and managers are responsible for workforce health and wellbeing. They understand the link between workforce wellbeing and quality of care and systematically measure workforce culture, including psychosocial safety and cultural safety, and act on the findings. All members of the workforce, regardless of role or seniority, feel safe to speak up for safety. A just and learning culture encourages identifying and reporting risks, incidents and complaints and acting to improve care. There is accountability without blame. There are systems to respond to staff concerns appropriately and transparently to reduce risks and learn from mistakes. Cultural safety is embedded in workforce recruitment and training processes, including in orientation, supervision and performance review. The organisation measures indicators of cultural safety, has culturally safe processes for the workforce to escalate concerns, and acts on racism and culturally unsafe behaviour. The organisation attracts, recruits and retains a diverse workforce that reflects the community it serves. Everyone in the organisation acknowledges, respects and accommodates difference. Racism and discrimination are not tolerated. The board receives regular reports on workforce risks and gaps. There is regular succession planning to fill key roles with minimum delay. Operational systems and rostering enable the workforce to provide high-quality care by balancing clinical responsibilities with protected time for non-clinical responsibilities. Tailored education and training programs, high-quality supervision, competency frameworks and performance reviews enable the workforce to provide, support and be accountable for high-quality care. Strong leadership and mentorship enable the workforce to work effectively in teams and to reach their potential by fostering emerging talent and strengthening capability, confidence and career pathways. The workforce receives practical support to select, develop, integrate and evaluate digital tools and technologies into their practice.

Key examples

The board and executive define the workforce’s responsibilities for delivering high-quality care and provide appropriate and effective workforce planning and resourcing to meet them
The board, executive, clinical leaders and managers are responsible for workforce health and wellbeing. They understand the link between workforce wellbeing and quality of care and systematically measure workforce culture, including psychosocial safety and cultural safety, and act on the findings.
All members of the workforce, regardless of role or seniority, feel safe to speak up for safety. A just and learning culture encourages identifying and reporting risks, incidents and complaints and acting to improve care. There is accountability without blame.
There are systems to respond to staff concerns appropriately and transparently to reduce risks and learn from mistakes.
Cultural safety is embedded in workforce recruitment and training processes, including in orientation, supervision and performance review. The organisation measures indicators of cultural safety, has culturally safe processes for the workforce to escalate concerns, and acts on racism and culturally unsafe behaviour.
The organisation attracts, recruits and retains a diverse workforce that reflects the community it serves. Everyone in the organisation acknowledges, respects and accommodates difference. Racism and discrimination are not tolerated.
The board receives regular reports on workforce risks and gaps. There is regular succession planning to fill key roles with minimum delay.
Operational systems and rostering enable the workforce to provide high-quality care by balancing clinical responsibilities with protected time for non-clinical responsibilities.
Tailored education and training programs, high-quality supervision, competency frameworks and performance reviews enable the workforce to provide, support and be accountable for high-quality care.
Strong leadership and mentorship enable the workforce to work effectively in teams and to reach their potential by fostering emerging talent and strengthening capability, confidence and career pathways.
The workforce receives practical support to select, develop, integrate and evaluate digital tools and technologies into their practice.

Warning signs

There is inadequate board oversight of workforce indicators, such as engagement surveys, feedback about cultural safety, retention rates and absenteeism.
Workplace culture issues, such as low response rates to staff surveys and poor engagement with safety culture questions, are not recognised as risks to patient safety.
The workforce is not encouraged to report problems and does not feel empowered to make change to improve outcomes.
The organisation has a high priority on meeting financial targets at the expense of workforce wellbeing and quality of care.
Digital health systems do not support clinical workflows, leading to workarounds and inefficiency.

4. Enabling high-quality and integrated clinical practice

The primary purpose of a health service is to provide clinical care to achieve the best possible patient outcomes. Patients are likely to have the best outcomes when their clinical care respects their needs and preferences, is informed by the best available evidence, and is integrated across clinical care providers and settings, both in the health service and in the community, including in general practice.

Clinicians are enabled to provide care that achieves the best possible outcomes for patients across the continuum of care. They use insights gained from data to improve care. Clinicians communicate clearly and respectfully and work collaboratively. Clinicians contribute to, and participate in, the organisation’s clinical governance systems. Leaders and managers create the systems and environment that support clinicians to provide consistently high-quality care.

What good practice looks like

Key examples
There are effective systems that support clinicians to use evidence-based clinical guidance and standards at the point of care. The organisation is accountable for coordinating a patient’s care across providers and settings, including the seamless sharing of information, particularly at transitions of care. Clinicians communicate clearly with patients, within teams and between providers to reduce risks and improve care. The board and executive recognise that racism and a lack of cultural safety are risks to clinical care, and lead strategies to eliminate systemic, structural and institutional racism, discrimination and bias throughout the organisation. The organisation’s culture, systems and structure reinforce and support clinicians’ dual roles – as healthcare professionals and stewards of system improvement. Clinicians participate in peer review systems and quality improvement activities. Clinicians’ leadership, teamwork and communication skills are developed to enable them to work in multidisciplinary clinical teams and with non-clinical staff to deliver high-quality care and system improvements. There are robust and transparent systems to protect patient safety through credentialing, re-credentialing and defining scope of practice within the organisation, and the effectiveness of these systems is monitored. A range of clinician groups is represented in clinical governance roles. The reporting system provides the board and executive with an accurate view of clinical perspectives on care quality. Clinicians in training receive the supervision they need to feel supported and to provide safe clinical care. Their work schedules support education and ongoing training. Clinical teams are supported to adopt evidence-based, environmentally sustainable models of care that reduce emissions while improving patient outcomes. Clear governance arrangements ensure digital tools and technologies are selected and used to address clinical needs and to enhance the quality of care. Clinical and information and communications technology (ICT) teams work together for quality, safety and accountability in the use of these tools.

Key examples

There are effective systems that support clinicians to use evidence-based clinical guidance and standards at the point of care.
The organisation is accountable for coordinating a patient’s care across providers and settings, including the seamless sharing of information, particularly at transitions of care. Clinicians communicate clearly with patients, within teams and between providers to reduce risks and improve care.
The board and executive recognise that racism and a lack of cultural safety are risks to clinical care, and lead strategies to eliminate systemic, structural and institutional racism, discrimination and bias throughout the organisation.
The organisation’s culture, systems and structure reinforce and support clinicians’ dual roles – as healthcare professionals and stewards of system improvement. Clinicians participate in peer review systems and quality improvement activities.
Clinicians’ leadership, teamwork and communication skills are developed to enable them to work in multidisciplinary clinical teams and with non-clinical staff to deliver high-quality care and system improvements.
There are robust and transparent systems to protect patient safety through credentialing, re-credentialing and defining scope of practice within the organisation, and the effectiveness of these systems is monitored.
A range of clinician groups is represented in clinical governance roles. The reporting system provides the board and executive with an accurate view of clinical perspectives on care quality.
Clinicians in training receive the supervision they need to feel supported and to provide safe clinical care. Their work schedules support education and ongoing training.
Clinical teams are supported to adopt evidence-based, environmentally sustainable models of care that reduce emissions while improving patient outcomes.
Clear governance arrangements ensure digital tools and technologies are selected and used to address clinical needs and to enhance the quality of care. Clinical and information and communications technology (ICT) teams work together for quality, safety and accountability in the use of these tools.

Warning signs

There is inadequate use of comparative data on clinical performance, e.g. how healthcare use, clinical outcomes and patient experiences compare with similar organisations or trends over time.
The organisation tolerates poor outcomes with no clear improvement actions or systematic monitoring of their effectiveness.
There are problems in the culture of escalation – e.g. junior staff are hesitant to raise concerns and have variable access to senior clinician support; there is a tendency to minimise or dismiss red flags instead of triggering escalation pathways.
There is a lack of systems and structures that allow clinicians to raise concerns with management.
Digital solutions are implemented before the clinical problem is clearly defined or are used to replicate paper-based workflows rather than improve care.

5. Managing and reducing risk

Health services are, by their nature, high-risk environments. A strategic approach to risk management informs monitoring, planning and allocation of resources across all parts of the organisation. Risk management involves oversight of clinical, financial, digital, operational and strategic risks, because all affect each other and the quality of care delivered. It also involves review and analysis of risks to look for trends and drive improvement.

Effective risk management requires systems and a culture in which everyone in a health service understands how the organisation defines risk and is accountable for identifying circumstances in which patients or the workforce could be harmed and acting to prevent or control those risks. The health service promotes a safety culture that allows people to openly share lessons from safety investigations, and to contribute to responses to reduce risk. Risk management systems need to be robust and adaptable as new technologies and digitally enabled health care evolve.

What good practice looks like

Key examples
The organisation’s approach to managing risk aligns with key strategic priorities. The board agrees on the risk appetite – the level of risk the organisation is willing to tolerate to achieve its strategic vision for high-quality care. A systematic approach to risk management focuses on risks to quality of care across all clinical and business functions. The board understands risks to patient safety at the point of care, including at transitions of care. Issues that patients and the workforce identify are included in the risk register, and management addresses these issues. The organisation identifies, reports on and acts to minimise risk and harm to patients and the workforce, including anticipating emerging risks. The effectiveness of risk management systems is regularly reviewed. Investigations into safety incidents identify contributing factors and draw together findings from related investigations to develop systematic and effective responses. Clinical and technical incidents, near misses, risk reports and complaints are analysed to look for trends and drive improvement efforts. Results of investigations into safety incidents and risk reports are communicated throughout the workforce to share lessons and improve practices. Clinicians receive feedback about incidents they are involved in. The organisation recognises that racism is a clinical and organisational risk. It monitors and reports on that risk and embeds anti-racist practices and cultural safety in clinical governance systems and processes. Governance structures and reporting processes help to identify and reduce risk: Committees are structured to increase communication about risk, e.g. the chair of the safety and quality committee sits on the audit and risk committee The board receives summarised risk reports that enable a strategic response. The organisation has a comprehensive approach to maintaining healthcare delivery during emergencies. It assesses and integrates climate-related risks – such as floods, heatwaves, bushfire smoke and supply chain disruptions – into emergency preparedness and response frameworks. A risk management plan is used to assess and mitigate risks before introducing digital tools and technologies, including cyber security and artificial intelligence tools, and implementation of the risk management plan is monitored.

Key examples

The organisation’s approach to managing risk aligns with key strategic priorities. The board agrees on the risk appetite – the level of risk the organisation is willing to tolerate to achieve its strategic vision for high-quality care.
A systematic approach to risk management focuses on risks to quality of care across all clinical and business functions.
The board understands risks to patient safety at the point of care, including at transitions of care. Issues that patients and the workforce identify are included in the risk register, and management addresses these issues.
The organisation identifies, reports on and acts to minimise risk and harm to patients and the workforce, including anticipating emerging risks. The effectiveness of risk management systems is regularly reviewed.
Investigations into safety incidents identify contributing factors and draw together findings from related investigations to develop systematic and effective responses. Clinical and technical incidents, near misses, risk reports and complaints are analysed to look for trends and drive improvement efforts.
Results of investigations into safety incidents and risk reports are communicated throughout the workforce to share lessons and improve practices. Clinicians receive feedback about incidents they are involved in.
The organisation recognises that racism is a clinical and organisational risk. It monitors and reports on that risk and embeds anti-racist practices and cultural safety in clinical governance systems and processes.
Governance structures and reporting processes help to identify and reduce risk:
- Committees are structured to increase communication about risk, e.g. the chair of the safety and quality committee sits on the audit and risk committee
- The board receives summarised risk reports that enable a strategic response.
The organisation has a comprehensive approach to maintaining healthcare delivery during emergencies. It assesses and integrates climate-related risks – such as floods, heatwaves, bushfire smoke and supply chain disruptions – into emergency preparedness and response frameworks.
A risk management plan is used to assess and mitigate risks before introducing digital tools and technologies, including cyber security and artificial intelligence tools, and implementation of the risk management plan is monitored.

Warning signs

Clinical care risks emerge ‘without warning’ – the board spends more time reacting to emergencies than on anticipating and addressing potential risks.
There is a focus on individual incidents rather than identifying patterns or system issues.
Excessive reporting of risks dilutes the focus on key risks and leads to a significant reporting burden.
There is a failure to respond to incident reports, complaints and suggestions for improvement from the workforce.
The organisation implements major programs of work without a risk-based approach.

6. Using data for better care

Collecting, analysing and acting on data about health service systems and performance, patient and workforce experience and patient outcomes is fundamental to providing high-quality care. Data are key to a planned and systematic program for continuous improvement across the health service.

Responsive governance is needed to use findings across the health service to inform learning, improvement and accountability. The board and executive champion a data-driven improvement culture by making data-informed decisions and providing information to all who need it.

High-quality data are used to identify areas for improvement and to provide feedback to the workforce to prompt behaviour change.

Insights from multiple data sources (quantitative and qualitative performance, experience and outcome measures, and patient and workforce feedback) are triangulated to provide a deeper understanding of the quality of health care and the impact of efforts to improve care. The organisation learns from other health services and sectors to improve their systems and quality of care.

What good practice looks like

Key examples
The board and executive systematically use data to determine whether the organisation is providing all the dimensions of high-quality care. They allocate resources to improve care based on the findings. The board receives quality and risk data that are summarised and communicated so that trends and issues are clear to all, including managers and board members who do not have a clinical background. Multiple sources of trend and comparative data are used to identify and reduce unwarranted healthcare variation, manage risk, monitor workforce culture, measure performance and drive innovation to promote high-quality care. Improvement efforts are monitored and evaluated. The organisation develops the capability of all parts of the organisation to use data to improve care. Clinicians receive timely information about the quality of care they provide and patient outcomes so they can improve care. Priority areas and outcomes of improvement efforts are reported to the board. The organisation works with Aboriginal and Torres Strait Islander people and communities to collect, interpret and respond to data, including data on racism, in a culturally appropriate way. Aboriginal and Torres Strait Islander people and communities have the right to govern the collection, ownership, application and reporting of data about their communities (data sovereignty). Data on markers of equity are used to identify and act on disparities in care. The organisation measures and reports on how effectively patient care is integrated within the health service and with providers outside the health service, and acts to improve that care. The organisation collects and analyses data on the environmental impact of clinical care to inform improvement and sustainability initiatives, including reducing low-value care. The board and executive are accountable for the governance, quality and appropriateness of data generated by digital systems to support high-quality care, and relevant data are provided to clinicians for improving quality of care.

Key examples

The board and executive systematically use data to determine whether the organisation is providing all the dimensions of high-quality care. They allocate resources to improve care based on the findings.
The board receives quality and risk data that are summarised and communicated so that trends and issues are clear to all, including managers and board members who do not have a clinical background.
Multiple sources of trend and comparative data are used to identify and reduce unwarranted healthcare variation, manage risk, monitor workforce culture, measure performance and drive innovation to promote high-quality care. Improvement efforts are monitored and evaluated.
The organisation develops the capability of all parts of the organisation to use data to improve care.
Clinicians receive timely information about the quality of care they provide and patient outcomes so they can improve care. Priority areas and outcomes of improvement efforts are reported to the board.
The organisation works with Aboriginal and Torres Strait Islander people and communities to collect, interpret and respond to data, including data on racism, in a culturally appropriate way. Aboriginal and Torres Strait Islander people and communities have the right to govern the collection, ownership, application and reporting of data about their communities (data sovereignty).
Data on markers of equity are used to identify and act on disparities in care.
The organisation measures and reports on how effectively patient care is integrated within the health service and with providers outside the health service, and acts to improve that care.
The organisation collects and analyses data on the environmental impact of clinical care to inform improvement and sustainability initiatives, including reducing low-value care.
The board and executive are accountable for the governance, quality and appropriateness of data generated by digital systems to support high-quality care, and relevant data are provided to clinicians for improving quality of care.

Warning signs

A compliance mindset leads to excessive data collection (‘drowning in data’). There is a high reporting burden but lack of flexibility to respond to key risks and emerging issues.
Data reports to the board are high on detail and lack insights, key messages and visualisations.
The board and executive focus on positive data rather than pursuing data that reveal inconvenient truths, missing opportunities for improvement.
Security controls do not keep pace with increasing volume and sources of data, resulting in data breaches.

Glossary

Accreditation A formal program where trained independent reviewers assess evidence of implementation for specified standards. In this document, the relevant standards are the National Safety and Quality Health Service (NSQHS) Standards.

Artificial intelligence Computer systems able to perform tasks that normally require human intelligence, such as visual perception, speech recognition, decision making and translation between languages.

Board or equivalent Directors (or key decision-makers/accountable people) whose responsibilities include governing, directing and monitoring a health service’s business, affairs and operations, including overall organisational performance and compliance.

Carer A person who provides personal care, support and assistance to another individual who needs it because they have a disability, medical condition (including a terminal or chronic illness) or mental illness, or they are frail or aged. An individual is not a carer merely because they are a spouse, de facto partner, parent, child, other relative or guardian of an individual, or live with an individual who requires care. A person is not considered a carer if they are paid, a volunteer for an organisation, or caring as part of a training or education program. For Aboriginal and Torres Strait Islander people, there may be a collective approach to carer responsibilities.

Clinical governance Clinical governance is central to providing the best possible outcomes for patients. It is the combination of organisational culture, systems and structures that enables everyone in a health service to deliver care that is consistently high quality and improving. Effective clinical governance means that boards, executives, clinical leaders and the workforce are clearly accountable to patients and the community for providing high-quality care – care that is person-centred, safe, effective, accessible and integrated, provided in a way that is equitable, efficient and sustainable.

Clinician A trained health professional who provides direct clinical care to patients. Includes registered and non-registered practitioners, nurses, midwives, medical practitioners, allied health professionals, paramedics and other professionals who provide health care, and students who provide health care under supervision.

Co-design A process where people who are traditionally considered experts in a field work in partnership with patients, consumers or other users to design a policy, process, service or service improvement.

Consumer A consumer advocate or representative who provides a consumer perspective, contributes consumer experiences, advocates for the interests of current and potential health service users, and takes part in decision-making processes.

Corporate governance The framework of rules, relationships and processes that directs and controls the overall direction of an organisation. It includes clinical governance, financial and legal functions, and stakeholder accountability.

Credentialing A process that verifies the qualifications and experience of a clinician to determine their ability to provide safe, high-quality healthcare services within a specific healthcare setting and role.

Cultural safety Cultural safety is determined by Aboriginal and Torres Strait Islander individuals, families and communities. Culturally safe practice is the ongoing critical reflection of health practitioner knowledge, skills, attitudes, practising behaviours and power differentials in delivering safe, accessible and responsive health care free from racism.

Data sovereignty Indigenous data sovereignty is the right of Aboriginal and Torres Strait Islander people, communities and organisations to maintain, control, protect, develop and use data as it relates to them.

Digital health The use of technology to help Australians live healthier lives with greater control and better access to their information. It includes My Health Record, electronic prescriptions and telehealth.

Digital health literacy The ability to access, understand, critically evaluate, and use digital tools and technologies to make informed health decisions and engage effectively with health services.

Digitally enabled care The appropriate integration and application of digital health in clinical settings to deliver, augment or coordinate patient care.

Environmentally sustainable health care Health care that minimises environmental impact and reduces emissions while providing high-quality care.

Equity The absence of unfair, avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically or by other dimensions of inequality (e.g. sex, gender, ethnicity, disability or sexual orientation).

Evidence-based practice Health care that integrates the best available research evidence with clinical expertise and the patient’s unique values and circumstances.

Executive or equivalent The executive team, or key decision-makers/accountable people, who manage the day-to-day operations of the organisation, its people and resources. It is headed by the chief executive officer (or equivalent), who implements the strategy approved by the board.

Foundations of clinical governance A set of organisational systems that enable health services to deliver high-quality care.

High-quality care Health care that is person-centred, safe, effective, accessible and integrated, provided in a way that is equitable, efficient and sustainable.

Integrated care Where all parts of the health system work together to deliver person-centred care that is seamless, comprehensive, coordinated and efficient across the continuum of care.

Just culture A just culture looks beyond human error as a root cause to identify system-based improvements that address contributing factors across all levels of the organisation.

Learning culture An environment that actively encourages curiosity, growth and knowledge sharing, in which everyone feels empowered to ask questions, learn from mistakes, and discuss ways to improve care.

Lived experience Someone with personal experience of ill-health, including mental, chronic or acute illness.

Low-value care Care that provides little or no benefit, may cause patient harm, or yields marginal benefits at a disproportionately high cost.

National Safety and Quality Health Service (NSQHS) Standards Accreditation standards operated by the Commission as a quality assurance mechanism. The Standards test whether relevant systems are in place to ensure that expected standards of safety and quality are met.

Open disclosure An open discussion between a healthcare provider and a patient when things go wrong that have harmed or had the potential to cause harm to the patient. The discussion may include an expression of regret by the provider, an explanation of what happened and its consequences, and steps to prevent it happening again.

Organisational culture A set of values, expectations, formal and informal practices, and behaviours that define the unique organisational environment. ‘The way things are done around here.’

Patient A person receiving health care.

Patient outcome The status of a patient that is wholly or partially attributable to an action, agent or circumstance.

Patient-reported experience and outcome measures Information collected directly from patients about their experience of health services, and the outcomes of health services.

Patient-reported experience measures (PREMs) include patients’ views and observations on matters such as the accessibility and physical environment of services and aspects of the patient–clinician interaction.
Patient-reported outcome measures (PROMs) are used to obtain information from patients on their health status such as overall health and wellbeing, the severity of symptoms such as pain, measures of daily functioning and psychological symptoms.

Person-centred care Health care that respects the patient, their family and carers, and responds to the person’s preferences, needs and values. Person-centred care is equitable, culturally safe and free from racism and all other forms of discrimination.

Priority group Specific population group at elevated risk of poorer health outcomes, including Aboriginal and Torres Strait Islander people, people with mental health conditions, those living in rural/remote or lower socioeconomic areas, and people identifying as gay, lesbian, bisexual, transgender or intersex.

Psychosocial safety Protection from hazards and risks in the workplace that may negatively influence mental health and emotional wellbeing.

Remote monitoring A system that uses software and medical devices to allow healthcare professionals to assess, monitor and care for patients virtually (such as in the home or remote areas).

Safety culture A culture in which everyone enables and cares for each other to adopt patient safety as part of routine business, with the wellbeing of the workforce and consumers at the centre.

Safe workplace A workplace that is physically, psychosocially and culturally safe.

Transitions of care A transition of care is when all or part of a person’s health care is transferred between care providers.

Triangulated data Using multiple sources of data, with awareness of their strengths and limitations for specific purposes (as in taking bearings from at least two reference points on a map).

Unwarranted healthcare variation Differences in clinical practices, treatments, or outcomes that cannot be explained by differences in patient needs, preferences or evidence-based guidelines.

Virtual care Any interaction between a patient and clinician, or between clinicians, occurring remotely with the use of information technologies.

Workforce All people working in a health service, including clinicians and any other employed or contracted, locum, agency, student, volunteer or peer workers.

References

Australasian Institute of Clinical Governance. Creating an upward spiral of staff satisfaction and care quality – Together. Melbourne: AICG; 2024.
Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. 2nd ed. Sydney: ACSQHC; 2017.
Australian Commission on Safety and Quality in Health Care. Review of the key attributes of high-performing person-centred healthcare organisations. Sydney: ACSQHC; 2018.
Australian Commission on Safety and Quality in Health Care. The state of clinical governance in Australia: A needs analysis. Sydney: ACSQHC (unpublished).
Australian Commission on Safety and Quality in Health Care. National Model Clinical Governance Framework. Sydney: ACSQHC; 2017.
Australian Digital Health Agency. Clinical governance framework for digital health. Sydney: 2023.
Australian Institute of Company Directors. Not-for-profit governance principles. 3rd ed. AICD; 2024.
Balding C, Leggat S. Making high quality care an organisational strategy: Results of a longitudinal mixed methods study in Australian hospitals. Health Serv Manage Res. 2020;34(3):148–157. doi: 10.1177/0951484820943601.
Bismark MM, Studdert DM. Governance of quality of care: a qualitative study of health service boards in Victoria, Australia. BMJ Qual Saf. 2014 Jun;23(6):474–82. doi: 10.1136/bmjqs-2013-002193.
Braithwaite J, Herkes J, Ludlow K, et al. Association between organisational and workplace cultures, and patient outcomes: systematic review. BMJ Open. 2017 Nov 8;7(11):e017708. doi: 10.1136/bmjopen-2017-017708.
DPV Health. Excellent Care. DPV Health’s Clinical & Quality Governance Framework. DPV Health; 2021.
Flynn MA, Burgess T, Crowley P. Supporting and activating clinical governance development in Ireland: sharing our learnings. J Health Organ Manag. 2015;29(4):455–81. doi: 10.1108/JHOM-03-2014-0046.
Fulop NJ, Ramsay AIG. Governance and Leadership. Elements of improving quality and safety in healthcare. Cambridge University Press; 2023. doi: 10.1017/9781009309578
Department of Health and Human Services Victoria. Community services quality governance framework. State of Victoria; 2018.
Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the quality chasm: A new health system for the 21st Century. Washington (DC): National Academies Press (US); 2001. doi: 10.17226/10027
Kellner P, Tsering D, Ngo CL et al. Clinical governance definitions and themes from safety and quality and incidents. A rapid literature review and environmental scan. Sydney: ACSQHC (unpublished).
Leggat SG, Balding C. Bridging existing governance gaps: five evidence-based actions that boards can take to pursue high quality care. Aust Health Rev. 2019 Apr;43(2):126–132. doi: 10.1071/AH17042.
Leggat SG, Balding C. Effective quality systems: implementation in Australian public hospitals. Int J Health Care Qual Assur. 2018 Oct 8;31(8)1044-1057. doi: 10.1108/IJHCQA-02-2017-0037.
Ngo CL, Kellner P, Tsering D et al. Contemporary definitions of quality health care: A rapid literature review. Sydney: ACSQHC (unpublished).
Safer Care Victoria. Delivering high-quality care: Victorian clinical governance framework. Melbourne: State of Victoria; 2024.
Scally G, Donaldson LJ. The NHS's 50 anniversary. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ. 1998 Jul 4:317(7150):61–5. doi: 10.1136/bmj.317.7150.61.
Western Health. Best Care Framework 2024. Melbourne: Western Health; 2024.

Practical guide to implementation

This guide is designed to support health services to apply the new National Model for Clinical Governance (the national model) as an enabler of consistently high-quality care.

It proposes five high-level steps to guide planning for effective implementation of the national model. Health services can use the national model to strengthen current clinical governance arrangements.

The guide supports integrating the national model into governance structures and processes.

It is based on extensive feedback gathered during development and refinement of the national model, as well as implementation evidence and consultation with a broad range of health services on what works well when implementing new guidance on clinical governance.

We thank Dr Cathy Balding for her leadership and expertise in developing this guide. Dr Balding specialises in designing and implementing quality and clinical governance systems for impact at the point of care. The guide and practical tools draw on her research and decades of experience working with boards and health system leaders in these areas.

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How to use this guide

Everyone begins implementation in a different place. The guide should be used with your existing systems, implementation processes and state, territory and corporate requirements. You may choose to follow the steps in order, or use some of the steps as building blocks to help align your clinical governance system with the national model.

If your clinical governance system is well evolved, you might use the guide as a high-level status check of your own framework and approach. Alternatively, you may decide to use the national model as an opportunity to perform a large-scale review and evolution of your clinical governance system.

Wherever you’re starting, a key to productive implementation of the national model is to agree on a definition of success that can guide planning and assessment of progress and results. Without this, implementation can become an end in itself, rather than a means to achieving the quality of care your organisation wants to be known for.

Effective implementation that makes a real difference to care requires leadership, planning and sustained focus. Board and executive ownership is a cornerstone of success. Allocate sufficient time and resources to get it right.

Clinical governance success can be defined as the extent to which it achieves the central aim stated in the national model: ‘delivering care to patients that is consistently high quality and improving’.

What are the implementation steps?

1. Compare

Compare the national model with your clinical governance system:

identify what to introduce and what to adapt.

2. Develop

Develop and approve an implementation plan:

engage consumers and the workforce (including staff and contractors)
prioritise changes
assign leaders and timelines
align with strategic and operational plans.

3. Introduce

Introduce the national model and implementation plan:

discuss your approach with the board, executive, senior leaders, managers, consumers and the workforce.

4. Roll out

Roll out the implementation plan:

update roles, routines and committee terms of reference and agendas to integrate changes into governance and systems that support everyday work.

5. Monitor

Monitor and report on progress:

track measures of progress and output
periodically review clinical governance maturity.

What is included in each step?

Suggested activities

To be applied as relevant alongside local, state, territory or corporate clinical governance and implementation processes.

Outputs

Desired results and deliverables for the step.

Questions for reflection on implementation

Prompts for boards and executives to review their role and progress in each step.

Tools

Companion tools to support the steps (recognising that organisations will also use local, state, territory and corporate implementation tools):

Snapshot of key changes: key changes in the national model to help you form a big picture view of the implementation scope for your organisation
Implementation maturity scale: a guide for assessing and evolving your clinical governance model implementation governance and progress
Foundations of clinical governance maturity worksheets: templates to rate implementation maturity in the examples of good practice in each foundation
Implementation plan structure: suggestions for structure, content and progress measures
Clinical governance framework planning template: a template for those who choose to redevelop their current framework to reflect the national model
Example key messages: core statements that organisations can use as relevant to explain what is different about the national model and how the national model is being implemented
Case study: a real-world example of how the steps can be applied.

The tools are examples only and should be adapted for local needs.

Step 1: Compare the national model with your clinical governance system

The first step for many organisations will be to identify the key gaps between the national model and their internal clinical governance system.

The gap analysis should be done using your usual processes for assessing any external framework or policy to be implemented. For example, in some organisations, the clinical governance manager or team will produce an initial gap analysis before planning starts. For others, the executive, a committee or a working group may identify key changes required and will plan the organisational approach. Multi-site health services may rely on a corporate office assessment and local reviews. The foundations of clinical governance in the national model may be allocated to subject matter experts.

Whatever approach is taken, the analysis will only be useful if it is based on the reality of how well your current clinical governance system supports consistently high-quality care.

Use the assessment to reflect on opportunities as well as gaps, asking these questions:

What do you do well?
What could you stop doing?
Could you fix some clinical governance pain points for your clinicians and managers?
How could implementing the national model make it easier and more beneficial for the workforce to engage with the clinical governance system?

Use evidence to assess the status of your clinical governance system against the national model and seek feedback from patients, carers, consumers and clinicians where required to confirm gaps and strengths.

Top tips
DO: focus on clarity: describe the changes in concrete and measurable terms. DON’T: change or replace things you already do well.

Top tips

DO: focus on clarity: describe the changes in concrete and measurable terms.

DON’T: change or replace things you already do well.

Suggested activities

Use the snapshot of key changes to compare the intent and content of the national model with your current internal clinical governance system. This will give you a big-picture view of any significant changes required to align your system with the national model and help you assess your implementation scope.
Conduct a more detailed comparison of your clinical governance system to compare it to content in the national model, such as roles in high-quality care, examples of good practice and warning signs.
Identify changes required to align with the national model. Consider classifying these, for example:
- What will you introduce (requires development and implementation)?
- What will you adapt (update or improve the current system)?
- Which of these changes are major (e.g. significant gap, policy and practice change, poses a key risk) and which are minor (e.g. document changes)?
- What will you stop doing (e.g. activities not aligned with the national model and not adding value)?
Use the implementation maturity scale to establish your baseline status and to track and report progress.

Outputs

Organisational gaps are identified and classified as ‘introduce’ or ‘adapt’ activities with major or minor implementation impact.
The maturity status of your clinical governance model implementation is rated.

Tools

Implementing the national model is not only about enhancing your current processes; it is also an opportunity to streamline and simplify your clinical governance system.

Reflective questions

Board

Do we have evidence that supports the gaps and risks identified in the plan – and what risks should be included in the risk register?
Are we satisfied that the plan reflects the intention to better support high-quality care in our organisation?
Is there clear integration with existing processes, such as plans for workforce wellbeing, care quality, and diversity, equity and inclusion?
Have we identified how we will track and oversee progress?

Executive

What are our collective and individual implementation roles?
What do our leadership and management teams need from us to support effective implementation?
How can we guide implementation to have a positive impact for patients and the workforce at the point of care?

Step 2: Develop and approve an implementation plan

The gap analysis and planning process provide an opportunity to clarify the right big-picture aim for implementation in your organisation. Will you use the national model to enhance an already mature and well-functioning clinical governance system, or seize the opportunity for a major review and evolution of your clinical governance effectiveness? Clarity of purpose will support effective implementation.

The implementation plan should support your aim in a way that is useful for the workforce and achieves high-quality care with patients, as described in the national model (or as described in your organisation’s definition of high-quality care, aligned to the national model).

Use your usual processes to develop the plan. It may be drafted by the clinical governance manager or team, an executive or a working group; or may be developed or led by a corporate or regional office. Similarly, each organisation will have its own process for approving and monitoring the plan.

At a minimum, the plan will describe:

gaps
risks and priorities
key implementation actions
timelines and responsible leads.

The implementation plan may also identify oversight committees, measures of progress and outputs, and how these will be reported. For some services, the organisational business or quality plan (or equivalent) may be the implementation vehicle. Some organisations will include a communication plan while others will develop this separately.

Top Tips
DO: build implementation into existing roles and structures, shared across the executive team. DON’T: present implementation of the national model as a set of tasks with no benefit.

Top Tips

DO: build implementation into existing roles and structures, shared across the executive team.

DON’T: present implementation of the national model as a set of tasks with no benefit.

Suggested activities

Plan development

Involve those responsible for implementing the plan. Obtain input from consumer representatives and the workforce to reflect their perspectives on implementation. Clinical leaders and managers, in particular, should be consulted on practical implications of proposed changes.
Prioritise implementation activities to focus first on major gaps, particularly those that pose a risk to patients and/or the workforce. Add identified risks posed by gaps to your organisation’s risk register, where appropriate.
Set current and desired implementation maturity.
Note key changes to be made to your clinical governance framework.
Show where implementation links with existing processes such as quality and equity plans.
Incorporate measures of progress and how, when and where these will be reported.

Plan approval

Seek implementation plan approval using your usual governance channels. This may require:

developing shared executive and board understanding of the intent of the national model, how it supports strategic aspirations for high-quality care, and implications for your organisation’s clinical governance system (are you adjusting or renewing it?)
showing how the implementation plan will address gaps and associated risks and support high-quality care
clarifying board and executive roles in overseeing and operationalising implementation, and how reporting on the plan will integrate with existing processes for reporting care quality
appointing an executive implementation leader, operational steering group (existing or new) and board oversight committee.

Cultivate board support by linking model implementation with strategic and operational priorities. How can the national model drive your organisation’s aspiration for high-quality care and support your clinical governance system to be more purposeful?

Outputs

Shared board and executive understanding of intent, content and benefits of the national model is achieved.
Current and desired national model implementation maturity is identified.
Required changes to the internal clinical governance framework are documented.
The prioritised implementation plan is approved and executive leader is appointed.
The structure and process for governance and operational oversight of progress and reporting are established.

Tools

Reflective questions

Board

Do we have evidence that supports the gaps and risks identified in the plan – and what risks should be included in the risk register?
Are we satisfied that the plan reflects the intention to better support high-quality care in our organisation?
Is there clear integration with existing processes, such as plans for workforce wellbeing, care quality, and diversity, equity and inclusion?
Have we identified how we will track and oversee progress?

Executive

What are our collective and individual implementation roles?
What do our leadership and management teams need from us to support effective implementation?
How can we guide implementation to have a positive impact for patients and the workforce at the point of care?

Step 3: Introduce the national model and implementation plan

Introducing the national model and implementation plan should enable the workforce to understand and relate to their clinical governance role as described in the national model. Large organisations may use a communications team to do this, while others will develop their messaging through the executive lead and/or implementation steering group.

Use the example key messages to develop messaging on a mix of general information about the national model, targeted guidance on implementation in your organisation, and enacting clinical governance roles.

Focus on supplying workforce groups with the information they need to engage with clinical governance changes. Most people will not need to know all the details to enact their role.

Apart from the board, executive, clinical governance manager/team and senior clinical leaders who require detail on implementation intent and process, most of the workforce will want answers to questions such as:

Why is there a new national model?
Does this mean we have to change everything?
How will this help patients?
What will this mean for me in my everyday work?
What do I need to do now?

The purpose of sharing the national model and implementation plan goes beyond raising awareness; it is about achieving clarity on the required changes and building commitment to the changes.

Top Tips
DO: emphasise the benefits of the changes to patients, carers, consumers and the workforce. DON’T: overwhelm people with information they don’t need. Focus on people’s roles and how they will use the national model, and provide them with information that helps them enact their responsibilities.

Top Tips

DO: emphasise the benefits of the changes to patients, carers, consumers and the workforce.

DON’T: overwhelm people with information they don’t need. Focus on people’s roles and how they will use the national model, and provide them with information that helps them enact their responsibilities.

Suggested activities

Prepare and approve key messages:
- how the national model is different: what is changing and why, and how it can improve the quality of care
- what it means for patients, leaders, managers and the workforce: key changes, how they’ll be implemented and how roles will be supported
- implementation steps and where to get help or further information.
Identify and equip a network of subject matter experts in your organisation to introduce the national model, deliver and reinforce key messages and answer questions. These may be people who are already involved in clinical governance, clinical leaders, consumer representatives and other influential people.
Determine channels for distributing the information. These may include:
- messages from the CEO
- online and in-person meetings and forums such as grand rounds, team meetings and huddles
- information sessions
- existing education and onboarding sessions, information hubs and portals, reward and recognition processes and informal channels such as newsletters, competitions, quizzes and posters.
Gather feedback on messaging from consumer groups and the workforce.
- Are the messages landing well?
- Is the purpose of the national model clear?
- Do people understand the national model and the key changes that relate to their roles?
- Are clinical governance roles clear?

Outputs

Key messages and the distribution plan are developed and implemented.
A network of subject matter experts promotes the national model and internal implementation steps and roles.
Consumer committees and groups, senior leaders and managers provide feedback on their understanding of the intent of the national model and key changes.

Use messaging to position the national model as a positive and practical enabler of high-quality care.

Tools

Reflective questions

Board

Do we have a shared understanding of key messages about implementing the national model?
How will communication effectiveness be reported to us?

Executive

What is our process to make sure that different workforce groups receive the information they need?
How will we know how well the national model and the implementation plan are understood?
How will we align our implementation actions and key messages for consistency?

Step 4: Roll out the implementation plan

Your clinical governance framework will require modifications, either major or minor, to align with the national model. You are not expected to redevelop your framework to replicate the national model. The important thing is that the intent and content of the national model are clearly reflected in your clinical governance framework and are therefore integral to your clinical governance system.

Incorporate the national model content as required into your clinical governance system and processes, such as board, executive and consumer group agendas, executive business and quality plans, role descriptions, policies and procedures.

Operationalising the national model cannot happen without executive leadership and management. The executive team has both individual and collective implementation roles. Individually, executives are responsible for enabling and equipping their divisional leaders and managers to understand their clinical governance roles, including responsibilities for enacting any changes.

Collectively, the executive team models leadership that supports effective implementation and ensures that new and adapted clinical governance activities are integrated into organisational systems that support patient care.

If the workforce doesn’t perceive the changes as helping them to deliver high-quality care, they will view the changes as just more work. Implementation should aim to embed the content of the national model as business as usual, with the primary intention of supporting the workforce to deliver consistently high-quality care. Prioritise both systems improvement and areas of risk for patients and the workforce.

Top Tips
DO: emphasise with consumers and the workforce what you are doing well. Effective implementation of the national model doesn’t reinvent the wheel but builds on and enhances your clinical governance system. DON’T: create new clinical governance structures and committees if implementation of the national model can be integrated into existing mechanisms that support high-quality care.

Top Tips

DO: emphasise with consumers and the workforce what you are doing well. Effective implementation of the national model doesn’t reinvent the wheel but builds on and enhances your clinical governance system.

DON’T: create new clinical governance structures and committees if implementation of the national model can be integrated into existing mechanisms that support high-quality care.

Suggested activities

Develop an implementation support structure, led by the appointed executive lead, e.g. tap into existing working groups or committees, or convene a steering group to drive and monitor actions in the implementation plan.
Modify your internal clinical governance framework as required to encompass new content in the national model.
Allocate implementation actions to relevant executive, divisional and service improvement leaders and embed in their business and operations plans.
Update committee charters, terms of reference, standing agendas and reporting to reflect the intent of the national model. Clinical governance and quality-related committees, including consumer committees, should discuss the national model content for which they are responsible, and make changes to agendas and reporting required to fulfil this responsibility.
Adjust position descriptions where required to reflect roles as described in the national model for implementing and working with clinical governance systems to support high-quality care, and provide professional development where required.
Set up a process to recognise and reinforce individuals and teams who have made changes relating to the national model and have achieved improved clinical governance practice.
Collect and spread good news stories showing the benefits of clinical governance.

An overly ambitious program of change may result in implementation without impact, a disengaged workforce and wasted time and resources. Sustained improvement is likely to result from a well-paced process using a proven change-management approach that considers both people and processes.

Outputs

A manageable and sustainable implementation process is established.
Implementation actions are allocated to relevant leaders and managers with appropriate support.
Boards, executives, consumers and the workforce understand their clinical governance and implementation roles.
The internal clinical governance framework, systems and committees reflect the intent and content of the national model.

Tools

Reflective questions

Board

Do we understand and enact the implementation actions related to our governance role?
Are we monitoring unnecessary creation or duplication of clinical governance bureaucracy?

Executive

Are we clear on and enacting individual and collective roles in leading and supporting progress?
Do our behaviours show that implementing the national model is an organisational priority?
Are we providing the right support for clinical leaders and managers to put changes into practice, so they are as simple and practical as possible?

Step 5: Monitor and report on progress

Your implementation plan should describe a monitoring and reporting process that may include:

a limited set of measures on progress (are we doing what we said we would do, on time?)
implementation outputs (did the change produce concrete results? Are there any unforeseen negatives resulting from removing clinical governance components that are no longer relevant?)
feedback from consumers and the workforce (are the changes supporting high-quality care?)
progress with evolving clinical governance implementation maturity.

Reporting should allow the executive and relevant operational and governing body committees to track and guide implementation. Where possible, integrate regular implementation monitoring into existing clinical governance reporting to the board and executive. The information should support timely decisions to unblock barriers and accelerate progress.

Your organisation should decide the level of reporting required to drive progress. Boards will require less detail than executives and may decide to receive reports only on high-risk and major gaps, and feedback on the changes from consumers and the workforce. Executive information will include progress on closing all gaps. Depending on the size of the organisation, executives may choose to receive less frequent reporting on minor and low-risk gaps as these may be overseen by an implementation working group or equivalent.

In the short-term implementation window, suggested outputs described in the steps may be used as markers of progress and impact, and/or you may choose to develop progress measures specific to your organisation.

Use existing quality measures to track patient experience and care outcomes over the longer term, adding to these as required to reflect the definition of high-quality care in the national model. Your organisation may wish to set numerical targets for care quality improvement resulting from implementing the national model. Collaborate with clinicians and consumers to make these aspirational timelines and desired results realistic and useful.

Effective implementation of the national model aims to achieve consistently high-quality care. Improvements in clinical governance processes are likely to be seen first, with sustained improvements in care quality over the longer term.

The progress report may include:

summary of implementation progress and next steps
progress against timelines for high-risk and major gaps and barriers
management of clinical risks associated with clinical governance gaps
requests for implementation support
implementation outputs and impacts, including feedback from consumers and the workforce
periodic assessment of clinical governance maturity for each foundation in the national model and for roles and governance.

Top Tips
DO: make reporting brief and to the point: What’s on track? What’s stuck? What needs a decision? DON’T: let the implementation reality get lost in the data – tell a clear progress story first, then add detail if required to make a case for support or resources to drive progress.

Top Tips

DO: make reporting brief and to the point: What’s on track? What’s stuck? What needs a decision?

DON’T: let the implementation reality get lost in the data – tell a clear progress story first, then add detail if required to make a case for support or resources to drive progress.

Suggested activities

Identify and collect data on measures of implementation:
- progress (actions taken, progress against timelines)
- outputs (impact of changes based on data and feedback from consumers and the workforce; evidence of outputs achieved within each implementation step)
- outcomes (risk reduction and changes in care quality using subjective and objective data – likely to be seen over the longer term).
Set up regular progress reporting to the executive and governing body oversight committee, integrated into existing committee reporting and workplans where possible.
Provide timely feedback on progress to the workforce and consumer groups.

Outputs

Regular progress reports to the executive and relevant governing body committees, aligned with the implementation plan, are established.
Committees make timely decisions to support or accelerate progress (e.g. to reduce implementation or clinical risk, remove barriers, redirect effort and resources, increase implementation maturity).
Feedback from consumers and the workforce on the usefulness of changes in supporting high-quality care is reported and responded to.
Reporting provides evidence of active oversight of implementation progress and outcomes for accreditation.

Tools

Reflective questions

Board

Is the relevant board committee receiving regular implementation updates – and do these support board understanding and decision-making?
Are we making progress? Where we are not, do we ask the executive to act? Ź What evidence do we have that implementation is improving the patient and workforce experience?
Is implementation maturity evolving within each foundation in the national model, and for the board and executive roles?

Executive

Are we regularly reviewing progress and making decisions to drive effective implementation within realistic timeframes?
Where progress and outcome targets are set, are we providing the support required to achieve them?
How are we keeping the workforce and consumer groups engaged in, and informed of, progress?

Don’t measure implementation progress solely on task completion. Balance this with consumer and workforce satisfaction with the implementation process and outcomes to support sustainable change.

Implementation tools

Companion tools to support the steps (recognising that organisations will also use local, state, territory and corporate implementation tools):

Snapshot of key changes: key changes in the national model to help you form a big picture view of the implementation scope for your organisation
Implementation maturity scale: a guide for assessing and evolving your clinical governance model implementation governance and progress
Foundations of clinical governance maturity worksheets: templates to rate implementation maturity in the examples of good practice in each foundation
Implementation plan structure: suggestions for structure, content and progress measures
Clinical governance framework planning template: a template for those who choose to redevelop their current framework to reflect the national model
Example key messages: core statements that organisations can use as relevant to explain what is different about the national model and how the national model is being implemented
Case study: a real-world example of how the steps can be applied.

Topics

Clinical Governance

Better Care Everywhere hubs

Clinical topics

Systems and governance

National Standards

Accreditation

Clinical Care Standards

Clinical topics

Better Care Everywhere hubs

Clinical topics

Systems and governance

Data and measurement

Go to section

2026 National Model for Clinical Governance

Go to section

Download the National Model for Clinical Governance

Download the practical guide to implementation

About the national model

Who this model is for

How to use the national model

Implementing the national model

Applying the national standards with purpose

About clinical governance

What is clinical governance?

Good governance

Clinical governance for digitally enabled care

High-quality care

Roles in supporting high-quality care

A note about patients and consumers

The six foundations of clinical governance

Cultural safety for Aboriginal and Torres Strait Islander patients and health service staff

Good practice and warning signs

1. Leading systems and organisational culture

What good practice looks like

Warning signs

2. Partnering with patients, carers and consumers

What is person-centred care?

What good practice looks like

Warning signs

3. Building a healthy workforce culture

What good practice looks like

Warning signs

4. Enabling high-quality and integrated clinical practice

What good practice looks like

Warning signs

5. Managing and reducing risk

What good practice looks like

Warning signs

6. Using data for better care

What good practice looks like

Warning signs

Glossary

References

Practical guide to implementation

How to use this guide

What are the implementation steps?

1. Compare

2. Develop

3. Introduce

4. Roll out

5. Monitor

What is included in each step?

Suggested activities

Outputs

Questions for reflection on implementation

Tools

Step 1: Compare the national model with your clinical governance system

Suggested activities

Outputs

Tools

Reflective questions

Board

Executive

Step 2: Develop and approve an implementation plan

Suggested activities

Plan development

Plan approval

Outputs

Tools

Reflective questions

Board