Action 1.25

Implement the governance arrangements determined by the governing body and ensure that the workforce understands their roles, responsibilities and accountabilities for safety and quality.

Ensure that foundational educational programs include:

• Clinical risk from the patient’s perspective
• Clinical governance responsibilities for safety and quality
• Legislative responsibilities related to patient harm and reportable incidents
• Incident investigation methods
• Human error and human factors principles
• Principles of teamwork and leadership style
• Open disclosure
• Creating and sustaining a patient safety culture that has person-centred care at its centre
• Applying evidence-based practices to develop and support effective multidisciplinary teams.

The clinical governance system should be supported by:

• Clear definition and delegation of reporting lines and responsibilities for safety and quality
• Clearly documented accountabilities for safety and quality of clinical care within the position descriptions and contractual responsibilities of the chief executive, management and clinicians
• Descriptions of roles, responsibilities and accountabilities for supervising the performance of the junior clinical workforce within the position descriptions and contractual responsibilities of senior clinicians
• Safety and quality policies, procedures or protocols that allocate responsibility to specific roles within the organisation
• A structured performance development system for all clinicians and managers, incorporating regular review of
  • their engagement in safety and quality, and in specific activities such as peer review and audit
  • supervision of the junior workforce.

Consider the following strategies when implementing delegated roles and responsibilities in the workforce:

• Ensure that safety and quality roles and responsibilities are clearly defined by
  • reviewing workforce position descriptions
  • discussing safety and quality responsibilities in routine performance management processes
  • providing information to the workforce about their safety and quality roles and responsibilities
• Educate and train members of the workforce in their governance roles, responsibilities and accountabilities
• For managers and senior clinicians, identify professional development opportunities in clinical safety and quality, leadership and risk, and schedule training in clinical governance
• Ensure that contractual arrangements are in place for the agency and locum workforce, and verify that credentialing and scope of clinical practice are undertaken before or after they start
• Provide agency and locum members of the workforce with an orientation to safety, quality and clinical governance that includes access to policies and procedures that outline roles and responsibilities
• Provide support material to help the workforce orientate agency and locum members of the workforce.

Examples of evidence

Select only examples currently in use:

• Policy documents that outline the delegated safety and quality roles and responsibilities of the workforce
• Employment documents that describe the safety and quality roles, responsibilities and accountabilities of the workforce
• Contracts for locum and agency workforce that specify designated roles and responsibilities, including for safety and quality
• Organisational chart and delegations policy that demonstrates clinical governance reporting lines and relationships
• Training documents about safety and quality roles and responsibilities of the workforce
• Communication to the workforce about their safety and quality roles and responsibilities
• Performance appraisals that include feedback to the workforce about delegated safety and quality roles and responsibilities
• Results of workforce surveys or feedback regarding their safety and quality roles and responsibilities.

Ensure that members of the workforce understand their roles, responsibilities and accountability for ensuring the safety and quality of care.

The clinical governance system should be supported by:

• Clear definition and delegation of reporting lines, and responsibilities for safety and quality
• Clearly documented accountabilities for safety and quality of clinical care within the position descriptions and contractual responsibilities of the chief executive, management and clinicians
• Safety and quality policies, procedures or protocols; responsibilities should be allocated through the organisational management system
• A structured performance development system for all clinicians and managers, incorporating regular review of their engagement in safety and quality, and in specific activities such as peer review and audit.

Consider the following strategies when implementing delegated roles and responsibilities in the workforce:

• Ensure that safety and quality roles and responsibilities are clearly defined by
  • reviewing workforce position descriptions
  • discussing safety and quality responsibilities in routine performance management processes
  • providing information to the workforce about their safety and quality roles and responsibilities
• Educate and train members of the workforce in their governance roles, responsibilities and accountabilities
• For managers and senior clinicians, identify professional development opportunities in clinical safety and quality, leadership and risk, and schedule training in clinical governance
• Ensure that contractual arrangements are in place for the agency and locum workforce, and verify that credentialing and scope of clinical practice are undertaken before or after they start work
• Provide agency and locum members of the workforce with an orientation to safety, quality and clinical governance that includes access to policies and procedures that outline roles and responsibilities
• Provide support material to help the workforce orientate agency and locum members of the workforce.

Examples of evidence

Select only examples currently in use:

• Policy documents that outline the delegated safety and quality roles and responsibilities of the workforce
• Employment documents that describe the safety and quality roles, responsibilities and accountabilities of the workforce
• Contracts for locum and agency workforce that specify designated roles and responsibilities, including for safety and quality
• Organisational chart and delegations policy that demonstrates clinical governance reporting lines and relationships
• Training documents about safety and quality roles and responsibilities of the workforce
• Communication to the workforce about their safety and quality roles and responsibilities
• Performance appraisals that include feedback to the workforce about delegated safety and quality roles and responsibilities
• Results of workforce surveys or feedback regarding their safety and quality roles and responsibilities.

MPSs or small hospitals that are part of a local health network or private hospital group should implement and use the established processes for describing workforce roles and responsibilities for safety and quality.

Small hospitals that are not part of a local health network or private hospital group should:

• Ensure that the governing body appropriately delegates responsibility for governance
• Review the organisation’s performance development policy, and ensure that it incorporates leadership in safety and quality management and governance for all managers and clinicians
• Review the organisational structure, position descriptions and contract templates of managers, clinicians and other members of the workforce to ensure that responsibility for safety and quality is clearly defined at all levels.

Consider the following strategies when implementing delegated roles and responsibilities in the workforce:

• Ensure that safety and quality roles and responsibilities are clearly defined by
  • reviewing workforce position descriptions
  • discussing safety and quality responsibilities in routine performance management processes
  • providing information to the workforce about their safety and quality roles and responsibilities
• Educate and train members of the workforce in their governance roles, responsibilities and accountabilities
• For managers and senior clinicians, identify professional development opportunities in clinical safety and quality, leadership and risk, and schedule training in clinical governance
• Ensure that contractual arrangements are in place for the agency and locum workforce, and verify that credentialing and scope of clinical practice are undertaken before or after they start work
• Provide agency and locum members of the workforce with an orientation to safety, quality and clinical governance that includes access to policies and procedures that outline roles and responsibilities
• Provide support material to help the workforce orientate agency and locum members of the workforce.

Examples of evidence

Select only examples currently in use:

• Policy documents that outline the delegated safety and quality roles and responsibilities of the workforce
• Employment documents that describe the safety and quality roles, responsibilities and accountabilities of the workforce
• Contracts for locum and agency workforce that specify designated roles and responsibilities, including for safety and quality
• Organisational chart and delegations policy that demonstrates clinical governance reporting lines and relationships
• Training documents about safety and quality roles and responsibilities of the workforce
• Communication to the workforce about their safety and quality roles and responsibilities
• Performance appraisals that include feedback to the workforce about delegated safety and quality roles and responsibilities
• Results of workforce surveys or feedback regarding their safety and quality roles and responsibilities.