9. PHC Clinical Governance

Clinical Governance Standard

Healthcare services have a responsibility to the community for continuous improvement of the safety and quality of their services, and ensuring they are person centred, safe and effective.

Consumer outcome

I am confident the healthcare service is well run and that I will receive safe, high-quality health care.

Intention of this standard

To implement a clinical governance framework that ensures that patients and consumers receive safe and high-quality health care.

Criteria

Governance, leadership and culture

The healthcare service sets up and uses clinical governance systems to improve the safety and quality of health care for patients.

Consumer outcome: The healthcare service is high quality and continuously makes improvements.

Item	Action
Governance, leadership and culture	1.01 The healthcare service: Has a culture of safety and quality improvement Partners with patients, carers and consumers Sets priorities and strategic directions for safe and high-quality clinical care, and ensures that these are communicated effectively to the workforce Establishes and maintains a clinical governance framework Clearly defines the safety and quality roles, responsibilities and accountabilities of those governing the healthcare service, management, and the workforce Monitors and reviews the safety and quality performance of the healthcare service Considers the safety and quality of health care for patients in its business decision-making Establishes and maintains systems for integrating care with other service providers involved in a patient’s care

Item

Action

Governance, leadership and culture

1.01 The healthcare service:

Has a culture of safety and quality improvement
Partners with patients, carers and consumers
Sets priorities and strategic directions for safe and high-quality clinical care, and ensures that these are communicated effectively to the workforce
Establishes and maintains a clinical governance framework
Clearly defines the safety and quality roles, responsibilities and accountabilities of those governing the healthcare service, management, and the workforce
Monitors and reviews the safety and quality performance of the healthcare service
Considers the safety and quality of health care for patients in its business decision-making
Establishes and maintains systems for integrating care with other service providers involved in a patient’s care

Patient safety and quality systems

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

Consumer outcome: I know the health care I receive is well organised and my feedback will be heard and dealt with.

Item	Action
Policies and procedures	1.02 The healthcare service uses a risk management approach to: Establish and maintain policies, procedures and protocols Make policies, procedures and protocols easily available to the workforce Monitor and take action to improve adherence to policies, procedures and protocols Ensure compliance with relevant safety and quality legislation, regulation and jurisdictional requirements
Measurement and quality improvement	1.03 The healthcare service uses a range of data to: Identify priorities for safety and quality improvement Implement and monitor safety and quality improvement activities Measure changes in safety and quality outcomes Provide timely information on safety and quality performance to patients, carers and families and the workforce
Risk management	1.04 The healthcare service:: Supports the workforce to identify, mitigate and manage safety and quality risks Documents and routinely monitors safety and quality risks Plans for, and manages, ongoing service provision during internal and external emergencies and disasters
Incident management and open disclosure	1.05 The healthcare service has an incident management system that: Supports the workforce to recognise and report incidents Supports patients, carers and families to communicate concerns or report incidents Involves the workforce in the review of incidents Provides timely feedback on the analysis of incidents to the workforce and patients, carers and families who have communicated concerns or incidents Uses the information from the analysis of incidents to improve safety and quality Incorporates risks identified in the analysis of incidents into the risk management system Regularly reviews and acts to improve the effectiveness of the incident management and investigation systems
Incident management and open disclosure	1.06 The healthcare service uses the Australian Open Disclosure Framework when a patient is harmed through the delivery of health care
Feedback and complaints management	1.07 The healthcare service: Seeks feedback from patients, carers and families about their experiences and outcomes of health care Has processes to regularly seek feedback from the workforce on their understanding and use of the safety and quality system Uses feedback to improve safety and quality
Feedback and complaints management	1.08 The healthcare service: Provides opportunities for its patients to report complaints Has processes to address complaints in a timely way Uses information from the analysis of complaints to improve safety and quality
Patient populations and social determinants of health	1.09 The healthcare service identifies patient populations using its service at greater risk of avoidable differences in health outcomes, including: People of Aboriginal and Torres Strait Islander origin People with disability People with diverse backgrounds
Patient populations and social determinants of health	1.10 The healthcare service uses information on its patient populations to inform planning and delivery of health care for patients
Healthcare records	1.11 The healthcare service has a healthcare record system that: Makes the healthcare record available to healthcare providers at the point of care Supports healthcare providers to maintain accurate and complete healthcare records Complies with privacy and security regulations Supports audits of healthcare records Facilitates a patient’s access to their healthcare record
	1.12 The healthcare service has processes to: Receive and review reports on patients Recall patients and communicate about reports and health care options Take action on reports in a timely manner Document reports in a patient’s healthcare record
	1.13 The healthcare service using My Health Record has processes to: Use national healthcare identifiers for patients and healthcare providers Use standard national terminologies Support healthcare providers to use My Health Record to optimise the safety and quality of health care for patients
	1.14 The healthcare service providing clinical information to the My Health Record system has processes to: Comply with legislative requirements Ensure the accuracy and completeness of information uploaded

Clinical performance and effectiveness

The workforce has the right qualifications, knowledge and skills to provide safe, high-quality health care to patients.

Consumer outcome: I get the healthcare services that I need from people who are qualified to provide my health care.

Item	Action
Safety and quality training	1.15 The healthcare service: Provides its workforce with orientation and training to their safety and quality roles on commencement with the service, when safety and quality responsibilities change and when new healthcare services are introduced Identifies the training needs of its workforce to meet the requirements of these standards Ensures its workforce completes training to meet its safety and quality training needs
Safety and quality training	1.16 The healthcare service supports its workforce to provide culturally safe services to meet the needs of its Aboriginal and Torres Strait Islander patients
Safety and quality roles and responsibilities	1.17 The healthcare service has processes to support its workforce to understand and fulfil their assigned safety and quality roles and responsibilities
Evaluating performance	1.18 The healthcare service has valid and reliable review processes for the workforce that: Are used to regularly review their performance Identify needs for training and development of safety and quality
Scope of clinical practice	1.19 The healthcare service has processes to ensure that healthcare providers have the qualifications, knowledge and skills required to perform their role by: Describing the scope of clinical practice for healthcare providers practising in the healthcare service Monitoring healthcare providers’ practices to ensure they are operating within their designated scope of clinical practice Reviewing healthcare providers’ scope of clinical practice when a clinical service, procedure or technology is introduced or substantially altered
Evidence-based care	1.20 The healthcare service: Provides its healthcare providers with ready access to best practice guidelines and available evidence, clinical care standards developed by the Australian Commission on Safety and Quality in Health Care and decision support tools relevant to their clinical practice Supports its healthcare providers to use best practice guidelines and available evidence, clinical care standards developed by the Australian Commission on Safety and Quality in Health Care and decision support tools relevant to their clinical practice to deliver best practice care
Variation in care delivered and health outcomes	1.21 The healthcare service supports its healthcare providers to: Monitor and review care delivered against relevant best practice care Explores reasons for variation of health care from best practice Uses information on unwarranted variation from best practice to improve health care

Safe environment for the delivery of care

The environment in which services are delivered enables safe and high-quality health care for patients.

Consumer outcome: I feel safe and comfortable accessing health care.

Item	Action
Safe environment	1.22 The healthcare service maximises safety and quality of health care: Through the design of the environment and management of the location where health care is provided By providing access to an environment, devices and equipment that are fit for purpose and well maintained By ensuring patients’ privacy when health care is provided
	1.23 The healthcare service identifies areas that have a high risk of unpredictable behaviours and develops strategies to minimise the risks of harm to patients, carers, families, consumers and the workforce
	1.24 The healthcare service supports patients to access health care, including patients from diverse backgrounds and patients with disability
	1.25 The healthcare service provides a culturally safe environment that recognises the importance of the cultural beliefs and practices of Aboriginal and Torres Strait Islander people

Explanatory notes

Clinical governance

Clinical governance is the set of relationships and responsibilities established by a healthcare service between regulators and funders, managers, owners and governing bodies (where relevant), healthcare providers, the workforce, patients, consumers and other stakeholders to ensure optimal clinical outcomes.¹ It ensures that:

The community can be confident there are systems in place to deliver safe and high-quality health care
There is a commitment to continuously improve services

Everyone is accountable to patients and the community for ensuring the delivery of safe, effective and high-quality health care. This includes healthcare providers, other members of the workforce and managers, owners and governing bodies (where they exist). Depending on the size of the healthcare service, multiple roles may be carried out by the same individual.¹

Clinical governance framework

A healthcare service’s clinical governance framework describes the safety and quality systems and processes that need to be in place to ensure the delivery of safe, high-quality health care. The existence of a robust clinical governance framework provides assurances to patients and the community of safe health care as well as driving improvements in services.

Healthcare services implementing the Clinical Governance Standard together with the Partnering with Consumers Standard will establish a clinical governance framework. This will provide a foundation to support the implementation of the third Clinical Safety Standard, which considers high-risk areas commonly encountered in primary and community healthcare services.

Reference

Australian Commission on Safety and Quality in Health Care. National Model Clinical Governance Framework. Sydney: ACSQHC; 2017.

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National Safety and Quality Primary and Community Healthcare Standards

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