Clinical Governance Framework: Governance, leadership and culture

Patients and consumers

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

Clinicians

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

Managers (including clinical managers)

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

Governing bodies

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