Action 1.03

Health service organisations are responsible for designing and implementing the systems to operationalise an effective clinical governance system as directed by the governing body.

Management should ensure that well-designed and integrated systems are in place that provide safe and high-quality health care. This may include systems and processes for:

• Identifying and managing risk
• Testing and influencing organisational culture
• Ensuring quality improvement
• Managing clinical practice
• Managing workforce performance and skills
• Managing incidents and complaints
• Ensuring patients’ rights and engagement.

To ensure the effectiveness of these systems and processes, managers should use the clinical governance framework to:

• Monitor, analyse and report on performance
• Collect, analyse and report on feedback
• Recommend actions to improve the safety and quality of care, and provide advice to the governing body about the issues identified and actions taken.

Strategies may include:

• Establishing a committee that is responsible for overseeing the clinical governance framework
• Implementing policies, procedures and protocols that describe the clinical governance framework
• Clearly defining and articulating the roles and responsibilities of clinical leaders and members of the workforce at all levels in improving safety and quality
• Reviewing the implementation of the clinical governance framework
• Reviewing audit findings of compliance with policies, procedures and protocols.

See the

Day procedure services are responsible for designing and implementing the systems for an effective clinical governance system, as directed by the governing body. These systems and processes include:

• Identifying and managing risk
• Testing and influencing organisational culture
• Ensuring quality improvement
• Managing clinical practice
• Managing workforce performance and skills
• Managing incidents and complaints
• Ensuring patients’ rights and engagement.

To ensure the effectiveness of these systems and processes, managers should use the clinical governance framework to:

• Monitor, analyse and report on performance
• Collect, analyse and report on feedback
• Recommend actions to improve the safety and quality of care, and provide advice to the governing body about the issues identified and actions taken.

Strategies may include:

• Establishing a group or committee that is responsible for overseeing the clinical governance framework
• Implementing policies, procedures and protocols that describe the clinical governance framework
• Clearly defining and articulating the roles and responsibilities of clinical leaders and members of the workforce at all levels in improving safety and quality
• Reviewing the implementation of the clinical governance framework
• Reviewing audit findings of compliance with policies, procedures and protocols.

See the

Examples of evidence

Select only examples currently in use:

• Documented clinical governance framework
• Documented safety and quality goals and performance indicators for the health service organisation
• Documented organisational and committee structure that is aligned to the clinical governance framework
• Audit results of compliance with the health service organisation’s clinical governance framework, and management of safety and quality risks
• Reviews or evaluation reports on the effectiveness of the health service organisation’s safety and quality systems.

For MPSs or small hospitals that are part of a local health network or private hospital group for which the clinical governance framework has been described, managers should ensure that well-designed and integrated systems are in place that provide safe and high-quality health care.

Small hospitals that are not part of a local health network or private hospital group will need to document the clinical governance framework using the

All organisations will need to ensure systems and processes for:

• Policy development and maintenance
• Risk identification and management
• Testing organisational culture
• Clinical practice management
• Workforce performance and skills management
• Incidents and complaints management
• Patients’ rights and engagement.

To ensure the effectiveness of these systems and processes, managers should use the clinical governance framework to:

• Monitor, analyse and report on performance
• Collect, analyse and report on feedback
• Recommend actions to improve the safety and quality of care, and provide advice to the governing body about the issues identified and actions taken.

Strategies may include:

• Identifying an individual or group responsible for overseeing the clinical governance framework; this could be an extra responsibility for a current committee
• Informing the workforce about the key aspects of the clinical governance framework and their roles and responsibilities for clinical leadership and improving safety and quality at all levels in the organisation
• Conducting performance reviews
• Reviewing results of clinical audits and system evaluation reports for compliance with the clinical governance framework.