1 - clinial governance policy framework guide

Victorian clinical governance policy frameworkA guidebook

Victorian clinical governance policy framework — a guidebook i

Victorian clinical governance policy framework

A guidebook

ii Victorian clinical governance policy framework — a guidebook

If you would like to receive this publication in an accessible format,

please phone the Statewide Quality Branch using the National Relay Service

13 36 77 if required.

This document is also available in pdf format on the Internet

at www.health.vic.gov.au/clinrisk

Published by the Statewide Quality Branch, Rural and Regional Health and Aged Care Services,

Victorian Government, Department of Human Services, Melbourne, Victoria

2009

© Copyright State of Victoria, Department of Human Services, 2009.

This publication is copyright. No part may be reproduced by any process

except in accordance with the provisions of the Copyright Act 1968.

Authorised by the State Government of Victoria, 50 Lonsdale Street, Melbourne.

This document may also be downloaded from the Department of Human Services website

at www.health.vic.gov.au

(rcc_090406)

Victorian clinical governance policy framework — a guidebook iii

Contents

1. Introduction 1

2. Structure of the clinical governance framework 2

3. Governance system 4

3.1 Health service governance 4

4. Domains of quality and safety 16

4.1 Consumer participation 16

4.2 Clinical effectiveness 17

4.3 Effective workforce 18

4.4 Risk management 19

Attachments —

Attachment A: Key stakeholders in state-level priority setting 21

Attachment B: Legislative compliance 22

Attachment C: Committee structure reporting areas 23

Attachment D: Clinical database reporting 24

Attachment E: Quality and safety measurement framework 25

Attachment F: Example report to board 32

Attachment G: Roles and responsibilities 34

iv Victorian clinical governance policy framework — a guidebook

Accreditation an evaluation by an independent body of the degree of compliance by an organisation with

previously determined standards and, if adequate, the award of a certifi cate.

Adverse event an incident in which harm resulted to a person receiving health care.

Benchmarking a continuous process of measuring quality or performance specifi cally in relation

to effi ciency and effectiveness.

Clinical audit a quality improvement process that seeks to improve patient care and outcomes through

systematic review of care against explicit criteria and the implementation of change.

Aspects of the structures, processes and outcomes of care are selected and systematically

evaluated against explicit criteria. Where indicated, changes are implemented at an

individual team, or service level and further monitoring is used to confi rm improvement

in health care delivery.

Clinician health care staff involved in clinical aspects of patient care, mainly, but not restricted to,

allied health, nurses and doctors.

Clinical

governance

the system by which the governing body, managers, clinicians and staff share responsibility

and accountability for the quality of care, continuously improving, minimizing risks, and

fostering an environment of excellence in care for consumers/ patients/residents.1

Consumer people who are current or potential users of health services. This includes children,

women and men, people living with a disability, people from diverse cultural and religious

experiences, socioeconomic status and social circumstances, sexual orientations, health

and illness conditions.

Credentialling the formal process used to verify the qualifi cations, experience, professional standing

and other relevant professional attributes of medical practitioners, or other health

professionals for the purpose of forming a view about their competence, performance and

professional suitability to provide safe, high quality health care services within specifi c

organisational environments.

Framework a set of principles and long-term goals that form the basis of making rules and guidelines,

and to give overall direction to planning and development.

Incident an event or circumstance which could have, or did lead to, unintended and/or unnecessary

harm to a person and/or a complaint, loss or damage.

Open disclosure the open discussion with a patient or their carer when things go wrong with their health

care.

Performance

measures

measures of structures, processes and outcomes of quality and safety of care. Includes

clinical indicators as a subset which are measures of the effectiveness and effi ciency of

health providers in providing health care.

Quality doing the right things, for the right people, at the right time and doing them right the

fi rst time.

Safety a state in which risk has been reduced to an acceptable level.

Strategy a range of actions, programs, activities, and policies that provide a guide for

implementation to achieve a goal.

for footnote 11

1 This definition is based on Australian Council on Healthcare Standards (2004) ACHS News, Vol 12 1-2,

ACHS Sydney.

Glossary

Victorian clinical governance policy framework — a guidebook 1

Consumers have a right to safe, high quality health care and to the provision of the information

they need to participate in decisions about their care. They have the right to openness and honesty

of communication and to be cared for in an environment that fosters trust in those providing care.

Clinicians and clinical teams play a pivotal role in providing safe, high quality care to consumers

and require robust systems and processes to support them in providing that care.

There is widespread recognition that the direction and management of safety and quality systems

within health care would benefit from a more consistent, systematic approach. Service delivery

is complex and there are competing priorities, posing challenges for health services in the delivery

of care.

In Australia clinical governance has been defined as “the system by which the governing body,

managers and clinicians share responsibility and are held accountable for patient care, minimising

risks to consumers and for continuously monitoring and improving the quality of clinical care”

(Australian Council on Healthcare Standards, 2004).

The clinical governance policy framework (the policy) will provide a coordinated plan of action

for the department, key stakeholders and Victorian health services to develop the capacity of the

health system to deliver sustainable, patient focussed, high quality care.

1. Introduction

2 Victorian clinical governance policy framework — a guidebook

The consumers, their needs and their experience of the care that is provided are the focus

of health service provision. The interaction between consumers and clinicians, and their

partnership in care provision, determines the quality of care provided. Clinicians and clinical

teams are responsible and accountable for the safety and quality of the care they provide.

Clinicians and clinical teams are supported by management and health service boards to deliver

safe, high quality care. This support includes fostering an open and just culture, resourcing quality

and safety strategies, and empowering clinicians to improve clinical care delivery. Management

should actively engage clinicians in risk management and improvement activities.

Figure 1 represents the components of the clinical governance framework:

• Consumer and clinical team focus — Consumer (patient/resident/client/carer)2 experience and

health outcomes are at the centre of the clinical governance framework. Clinicians and clinical

teams have a fundamental role in the delivery of safe, high quality care.

• Governance system — There are a number of governance requirements at different levels of the

system in order to ensure that there are effective systems to safeguard and improve the quality

and safety of clinical care. These requirements are delivered at an operational level through

governance structures and processes.

• Domains of quality and safety — Consumer participation, clinical effectiveness, effective

workforce and risk management are the four domains of quality and safety and provide

a construct for strategies to enhance the delivery of clinical care. Within each domain, there

are a number of quality and safety management functions that require direction and oversight

by governing bodies.

• Strategies — Within each quality and safety domain, there are a range of strategies, formal

structures, processes, programs, activities and actions that should be in place. Some of these

strategies are considered an essential part of an effective governance system. Other functions

stretch the system to improve it and may be delivered through a number of different approaches

or incorporated into a planned, staged approach to develop the quality and safety governance

system of the organisation.

2 See glossary — Whenever the term consumer is used, it implies as relevant patient, resident, client,

family or carer.

2. Structure of the clinical governance framework


Figure 1: Components of the clinical governance framework

The policy has been designed to be relevant to a range of clinical service settings including

acute, subacute, community and aged care. It takes into account local, state and national

issues and provides mechanisms for determining direction at all organisational levels.

This policy acknowledges:

• the different stages of development that individual health services may be starting from

• the significant resourcing requirements for implementation of some strategies.

It allows a staged approach to implementation enabling the system to evolve, growing and

developing as evidence builds on the most effective approaches to quality and safety systems

and as resourcing allows.


3. Governance system

Governance is the system through which organisations are directed and managed. Governance

influences how strategic directions are set and achieved, risks are monitored and assessed, and

how optimal performance can be attained. Good governance systems provide accountability and

control systems which are proportional to the risks involved.3

3.1 Health service governance

Any system of governance of clinical care must operate within the health service’s overall system

of governance which includes financial and corporate functions with clinical governance being

equal in importance. The governance of clinical care occurs within the context of the broader

governance role of boards that includes setting strategic direction, managing risk, improving

performance and ensuring compliance with statutory requirements (Figure 2).4

Figure 2: Representation of governance context

Governance of an organisation requires a program of review and improvement of internal

processes and outcomes at every level of the organisation.

Ultimately, the health service board is accountable for the quality and safety of clinical services

to the Minister for Health, and through the Minister who is acting on their behalf, to the local

community. At the level of clinical service delivery, accountability for the quality of care is shared

among members of the multidisciplinary health care team consistent with their defined roles

and responsibilities.

3 Australian Stock Exchange. Principles of Good Corporate Governance and Best Practice

Recommendations. ASX Corporate Governance Council. May 2003

4 Achieving best practice corporate governance in the Public Sector. Chartered Secretaries Australia’s

Public Sector Governance Forum 2003


Effective governance of health services occurs with a combination of “bottom-up” and “top-down”

mechanisms. Governance will only occur at all levels of the organisation where delegation

of responsibility and accountability for performance goes hand in hand with empowerment

of staff through their involvement in planning, decision making and improvement activities.

The following list is an outline of the required elements of a robust clinical governance system.

These elements are explored in greater detail in the following section.

• Priorities and strategic direction are set and communicated clearly.

• Planning and resource allocation supports achievement of goals.

• Culture is positive and supports patient safety and quality improvement initiatives.

• Legislative requirements are complied with.

• Organisational and committee structures, systems and processes are in place.

• Measure performance and monitor quality and safety systems within the service.

• Report, review and respond to performance to support continuous improvement of quality

and safety within the service.

• Roles and responsibilities are clearly defined and understood by all participants in the system.

• Continuity of care processes ensure that there is continuity across service boundaries.

For each of these governance elements, there are specific issues that have been identified for

consideration at state level or at health service level.

3.1.1 Priorities and strategic direction

Good governance requires that goals, priorities and strategic direction for improving quality and

safety of clinical care are set and take into consideration national, state and key health care

professional policy and strategy.

Strategic directions should be set and provide a vision for health services over an agreed

timeframe. Quality and safety goals should be incorporated into strategic plans and relevant

agreements between the department and its agencies such as the annual statement of priorities.

Short and medium term goals and priorities for improvement of quality and safety should

be defined, reviewed and updated annually. Directions in safety and quality performance should

be given equal weight to financial and activity performance in the development of strategies and

goals. Priorities should include evidence-based strategies identified in policy that proactively

improve health service performance and respond to identified issues and risks.


• State level — boards, managers and clinicians recognise a number of key groups who provide

leadership, direction and, in some instances, governance of the safety and quality at state or

national level. Goals and priorities should be set jointly in collaboration with key stakeholders

(Attachment A), taking into consideration:

- international evidence and directions

- state and national government policy directions

- directions set by the Australian Commission on Safety and Quality in Health Care

- risks and system deficiencies identified at a state level.

• Health service level — Health services should include quality plans within their strategic plan and

their annual statement of priorities. Plans, goals and priorities should be reviewed with reference to:

- state government goals and priorities for quality and safety

- locally identified issues from consumers, community clinical teams and non-clinical staff.

3.1.2 Planning and resource allocation

Quality and safety initiatives and improvement strategies need to be planned and resourced

adequately at all organisational levels to ensure success, sustainability and achievement of positive

consumer outcomes.

Improvement strategies should be planned and funded with regard to medium and long

term quality and safety goals, targets and sustainability of improvement. Quality and safety

activities should be equitably resourced according to strategic priorities and incorporated into

business planning.

• State level — Planning should occur at a state level to ensure achievement of a range of short,

medium and long term objectives for improvement of quality and safety. Policy directions

should be in place to guide health service priorities, goals and actions. Policy should provide

imperatives and inform the development of priorities for funding strategies. Quality and safety

goals and priorities should be incorporated in a meaningful way into the annual Statement of

Priorities, with achievement linked to sanctions and rewards, including bonus payments.

• Health service level — Health services should develop and implement coherent strategic and

business plans to deliver high quality, safe services that are responsive to the community and

consumer need.

Quality business plans or improvement plans should be monitored and reviewed annually. A major

component of the business plan should be the quality and safety plan which is formulated with

consideration of state priorities and local issues. Input from community, consumers and clinicians

should be sought when developing these plans.


3.1.3 Culture

Culture is a key driver of organisational clinical governance capability and for delivering safe,

high quality care. Acknowledgement that errors occur and the frequency of adverse events

in health care, creation of a culture where open disclosure, reporting and learning from

adverse events is embedded, and empowerment and involvement of clinicians and consumers

in planning and implementing quality and safety initiatives are critical to improving quality and

safety of clinical care.

All levels of the health system should work towards establishing a just culture that fosters

a systems approach, consumer centred care, continuous improvement and innovation in delivery

of clinical care. Performance monitoring and risk management activities should focus on system

deficiencies rather than blaming individuals, so that staff are able to discuss concerns, incidents

and errors in a just, open and supportive environment. There should be acknowledgement that

errors and adverse events occur and the frequency with which they occur. Innovation at all levels

of the organisation should be encouraged and supported.

• State level — There should be visible commitment to quality and safety and acknowledgment

of the incidence of both positive and adverse outcomes for consumers. Policy and funding

should drive initiatives that increase understanding and uptake of quality improvement, open

disclosure, systems review, effective multidisciplinary teamwork, analysis of human factors, and

learning from problems and errors.

• Health service level — Support should be provided to clinicians and staff involved in clinical

incidents to openly discuss issues with consumers, the clinical team and management. There

should be strong leadership and positive examples of a just, open culture at all organisational

levels commencing with the board, the chief executive and the senior executive team.

A just culture is articulated in policies and operationalised in management processes.

Systems issues identified through incident analysis should be responded to promptly and

outcomes communicated in a timely manner to those who report them.

3.1.4 Legislative requirements

There are a number of parameters that are set through legislative and regulatory mechanisms

to provide assurance to the public on standards of health care provision.

Legislative, regulatory and ethical obligations should be fulfilled by the health service. The

legislative direction in relation to governance is delineated in the Health Services Act 1988,

as amended by the Health Services (Governance) Act 2000 and includes requirements for health

service boards of directors.

• State level — Where appropriate, legislative safeguards should be developed to protect the

public interest, and ensure safety and quality of care.

• Health service level — The board or board’s special committees should fulfil their governance

role as specified in the Health Services Act 1988, and amended by the Health Services

(Governance) Act 2000. Health services are required to manage risks and ensure compliance

with legislative and policy requirements. They are required to comply with and maintain currency


of compliance with a number of acts, including occupational health and safety legislation,

mandatory reporting requirements for aged care, children at risk and infectious diseases.

Legislation that should be considered in the governance of health services is listed

in Attachment B.

3.1.5 Organisational and committee structures and processes

Executive and senior management should ensure that management structures and processes are

in place to enable good governance and support clinical teams in providing high quality, safe care.

Chief executives and senior management should work with the board and its committees to give

effect to quality and safety plans, ensure performance monitoring systems are in place and ensure

that improvements are actioned. Chief executives and senior management should be supported

in this activity through management committees with managers and clinicians participating in

decision making and implementing planned activities at the consumer care level.

• State level — The department should provide guidance on responsibility and accountability

mechanisms for key quality and safety structures and processes and, where relevant, facilitate

opportunities to collaborate and share successful strategies within the system. Support

should be provided to boards by developing tools, templates and training programs for

directors in conjunction with other relevant stakeholders such as the Victorian Managed

Insurance Authority (VMIA).

• Health service level — Health services should have a policy, guideline or framework that

outlines the organisation’s commitment to quality and safety improvement, and the core

activities and processes that are in place within the organisation in relation to the four domains

of quality and safety.

Management committees should support and monitor implementation of quality and safety

policies and participate in decision making. Health service boards are required to establish

a Finance Committee, an Audit Committee, a Quality Committee and other committees as required

to assist in carrying out their functions. An example of the functions for direction, oversight and

management within a health service committee structure is outlined in Attachment C.

The clinical governance committee structure within health services should support improvement

of clinical care and provide an avenue for escalation of significant quality and safety issues

where indicated.

3.1.6 Measure performance

Measuring clinical performance should be used to determine if short term priorities and long term

strategic goals are being achieved. Measures should include:

• compliance with legislative, regulatory and policy requirements

• process indicators that have supporting evidence to link them to outcomes

• indicators of the outcomes of care.


A core set of measures of quality and safety should be developed and should include qualitative

and quantitative data that are analysed to provide timely and accurate information regarding

organisational performance. This set of quality and safety measures should have relevance for

specialist, as well as generalist, acute health services. The measures should be monitored on

an ongoing basis with a staged program to focus improvement in underperforming areas. Data

integrity should be tested and tools, such as Statistical Process Control, should be used to

recognise both good performance and under-performance. Use of performance measures should

occur within a culture of openness, trust, and improvement rather than blame and punishment.

Measuring the performance of activities listed within each of the governance domains of the

clinical governance framework should occur with Key Performance Indicators (KPIs) and targets

reflecting each of the dimensions of quality as set out in Better Quality, Better Health Care – A Safety

and Quality Improvement Framework for Victorian Health Services.

Clinical performance measures should be developed, updated and owned by clinical groups, either

through established national registry programs or Victorian clinical networks. These measures

should also be a part of the performance management system to monitor individual and clinical

unit performance.

Many core safety and quality measures are part of indicator sets that health services report

through the state clinical databases (Attachment D). These datasets may be used as a starting

point for development of the core quality and safety dataset. A proposed measurement framework

is outlined in Attachment E. Where appropriate, a flag to indicate outlier performance should

be established. Mechanisms for flagging and the establishment of statistical parameters will

depend on the indicator and the size of the service/volume of activity.

• State level — Core quality and safety measures, data definitions, collection and reporting

processes should be established in collaboration with clinical groups. These should be regularly

reviewed and updated. Meaningful quality of care measures should be incorporated into

agreements between the department and their agencies.

The core set of measures should represent all dimensions of quality and provide a range

of structure, process and outcome measures that facilitate benchmarking, where appropriate.

The department should coordinate regular (either monthly or quarterly as appropriate) performance

reports to health services that integrate indicators from all state databases. If outlier performance

flags are not in use, these should be developed, tested and implemented for all reported measures.

Technology supports should be developed to provide clinical teams with information on care

processes and their performance where and when it is needed.

• Health service level — All health services should qualitatively evaluate the implementation

of policy and priority quality and safety strategies set down in the policy. This should be reported

to the board and progress monitored over time. An example schedule for board reporting is set

out in Attachment F. Once fully implemented, ongoing reporting should be replaced with periodic

evaluation to minimise the burden of reporting. Health services should participate in state

coordinated data capture, reviewing performance reports, investigating outlier performance and

addressing any underlying data integrity issues.


Clinicians and managers should be provided with information on processes of care that allows

them to track and manage performance. Health services need to identify, from the core set of

statewide measures, a list of appropriate KPIs that accurately reflects the scope of the services

they deliver. In addition, health services may use other indicators that are relevant for their service.

Table 1: Potential sources of data

Data sources Clinical databases Administrative databases

Description Systematically collect health-related

information on an ongoing basis from

a defined population

Data collected as part of the

administration eg Victorian Admitted

Episodes Dataset (VAED)

Benefits Well accepted by target audience,

good clinical engagement, developed

for specific purpose

Readily available, reported against

agreed international definitions, are

existing, impose no extra reporting

burden

Limitations Lag time for reporting, data reporting

burden, consistency of application

of definitions, expensive to maintain,

limited to specific populations or

disease groups

Not established for clinical purpose,

lack of trust by clinicians, only suitable

for use as a screening tool

Uses Measuring performance of programs

and public reporting

Flag for potential areas of concern

or exceptional performance in health

care quality as a starting point for

further investigation

The following table lists activities that may comprise all or part of the health services approach

to achieving these strategic objectives. Measures of the performance of these activities should

be reported through management to the board as determined by the organisational focus and

degree of improvement or risk presented. This list is not exhaustive and there is no implication that

listed activities are mandatory for all health services.

Table 2: Monitoring performance activities

Consumer participation

Information resources are available to support active participation of consumers in their care.

Consumers participate in health service governance, priority setting, and strategic, business and quality planning.

Consumers participate in safety and quality initiatives.

Consumer experience and perspective is considered when undertaking safety and quality initiatives and in

designing service delivery.

Public reporting of safety and quality performance — Quality of Care Reports.


Clinical effectiveness

Set priority areas for safety and quality improvement.

Clinicians are involved and provide leadership in safety and quality governance and management.

Quality improvement programs and process redesign are used to improve service delivery.

Knowledge management strategies are in place to support evidence-based care and access to evidence-based

guidelines and tools.

Clinical care is provided in accordance with best practice evidence-based medicine.

Safety and quality indicators are defi ned, monitored, reported and managed.

Clinicians have the appropriate qualifi cations, training and experience to provide safe and high quality care.

A clinical audit program exists that measures the performance in providing care and compares it to best practice.

Innovation and research into safety and quality improvement is supported at all levels.

Health care organisations undergo accreditation against accepted health care standards.

IT system strategy to provide clinical management and decision support.

Effective workforce

Roles and responsibilities in relation to safety and quality of care are clearly articulated.

Performance management system includes review of safety and quality performance and participation in

improvement activities.

Providing comprehensive education and training of all staff in safety and quality skills and methods.

The organisational culture values staff and consumer input.

Work practices support safe, high quality care.

Supervision and training arrangements are in place for junior staff.

Leadership capability is developed and there is succession planning for key safety and quality positions.

Clinicians are provided with appropriate continuing education and skills training to provide high quality

and safe care.

Risk management

An integrated risk management system exists that detects risk, takes appropriate action to reduce the risk and

monitors the effectiveness of its action.

Clinical and corporate risks are regarded as equally important.

There is a system in place for clinical incident reporting, investigation (RCA or other method appropriate to the

severity of the incident) and clinical incident management.

A complaints and compliments management system is in place.

A risk register is in place to report risks and risk level through organisation.

There is a transparent and just culture that supports open disclosure and staff involved in clinical incidents.


Performance measurement in specialty health services

Many of the system wide measures developed may not be relevant to specialist hospitals.

Specialist services should develop their own set of indicators that are relevant to their casemix

and clinical risks. These include services such as the Peter MacCallum Cancer Institute, the Royal

Children's Hospital, the Royal Women's Hospital, Dental Health Services Victoria and the Royal

Victorian Eye and Ear Hospital.

3.1.7 Report, review and respond to performance

Reporting organisational performance is a critical activity in the governance of clinical care.

It provides a mechanism for monitoring and communicating safety and quality performance and

identifying areas that require improvement. A system for reporting performance measures and

progress against goals and priority strategies should be in place.

Rigorous internal and external monitoring and review of quality and safety activities should

be established. These should be underpinned by an escalated responsive regulatory mechanism.

There should be a move towards public reporting of KPIs where there is the capability to provide

these in a meaningful format that takes into account different levels of risk.

Responsive regulation acknowledges that one strategy or mechanism is not applicable across

all situations and uses a variety of mechanisms and levers to respond to under-performance and

ensure compliance with standards.

At an organisational level, health services are subject to review and regulation in line with their

accountability to the Minister and DHS for corporate, financial and clinical performance. External

regulatory mechanisms occur at an individual clinician level or at organisational level through

professional registration boards, accreditation agencies, professional colleges, universities and the

Office of the Health Services Commissioner.

Where significant under-performance is identified, an initial response should be triggered which

includes increased support, access to tools, education and expertise. Health services are required

to develop an improvement plan which will be included in the health service quality plan, with an

agreed timeframe for achievement of milestones. In exceptional circumstances, where there

is sustained non-implementation or under-performance in relation to governance, management

or quality of health services, sanctions or penalties for the board and chief executive may

be triggered. Different levels of a responsive regulation approach are depicted in Figure 3.

Where underperformance is identified, there is a defined response that includes:

• investigation and assessment of the significance of the flag

• identification of the root causes of performance and underlying safety and quality issues

• implementation of an improvement strategy

• escalation where performance continues to be outside acceptable levels.


Figure 3: Responsive regulatory mechanisms

Modified from Braithwaite J. et al5

• State level — Performance reports that include key quality and safety performance measures

and implementation status of priority clinical governance framework strategies is monitored.

Consideration is given to random auditing and auditing of outlier performance for priority

strategies where there are significant concerns about safety and quality of care. DHS reporting

requirements for health services are integrated and aligned to ensure that reporting is not

duplicated or burdensome to the system. Strategies to improve the quality of reporting to boards

should be developed and include best practice examples and reporting templates for reporting

to boards and community (Quality of Care reports).

• Health service level — Health services should develop or enhance existing self (internal)

regulation, ensuring that all priority quality and safety strategies are implemented and that

performance is measured, monitored and issues responded to. Organisational performance and

responses to under-performance on KPIs should be reported through management to the board

as appropriate to the level of risk presented. A hierarchy of measures may be developed that

allows reporting detail appropriate to the organisational level receiving the reports.

5 Braithwaite, J., Healy, J., Dwan, K., The governance of health safety and quality, Commonwealth

of Australia, 2005.


Health services should benchmark core safety and quality indicators and compare:

• performance over time

• performance in comparison with like health services.

Quality and safety programs and activities should be evaluated through approved accreditation

providers. Where an issue is identified and staff or management have been unable to achieve the

degree of improvement required, the executive or the board may instigate an external expert review.

3.1.8 Roles and responsibilities

A key element in implementation of an effective clinical governance system is strong leadership

and visible commitment to quality and safety at all levels of the health system including chief

executive, senior management and clinicians. Roles and responsibilities should be clearly defined

to reduce ambiguity in organisational processes, including clinical care processes, and to reduce

the risk of gaps within the system.

Roles and responsibilities should be established, clearly articulated and include specific leadership

expectations for quality and safety at each level of the health system. The governing body,

managers, clinicians and staff should each have differing but interdependent responsibilities and

should be individually accountable within their own scope of responsibility.

All staff within the Victorian health system should have a fundamental understanding

of governance, quality and safety and the appropriate skills and knowledge required

to fulfil their role and responsibilities. Overarching roles and responsibilities, based

on The Healthcare Board’s role in clinical governance6 are proposed in Attachment G.

This governance model requires that responsibility and accountability for safety and quality

is shared between boards, chief executives, clinicians and managers within an acknowledged

hierarchy of responsibility and accountability. Where there is a sharing of responsibility and

accountability, there also needs to be shared decision making and acknowledgement of risks

identified by all parties. Clinicians and managers should be allowed to speak up and make

decisions to undertake (or not undertake) activities if they deem that they present an unacceptable

risk to the quality or safety of patient care.

Consumers have a significant role informing and participating in governance and improvement

activities. This role is outlined in detail within the policy directive Doing it with us not for us.7

6 The Victorian Quality Council 2004 The Healthcare Board’s role in clinical governance – A supplementary

paper to the VQC document ‘Better Quality, Better Health Care – A Safety and Quality Improvement

Framework for Victorian Health Services’ 2003

7 Doing it with us not for us - Participation in your health service system 2006–09 Department of Human

Services 2006


Training and capacity building programs should be in place to ensure that boards, managers,

clinicians and consumers understand their role and have the skills and knowledge required

to fulfil their governance responsibilities.

• State level — Roles and responsibilities in relation to governance of safety and quality should

be periodically reviewed and updated.

• Health service level — A systematic and integrated program of training and development

should be developed to increase understanding of clinical governance and the respective roles,

responsibilities and accountabilities at each level of the health system.

Health services should develop leadership in quality and safety among clinicians and managers,

through mentoring, education and training. Health services have a responsibility to work with their

communities and actively seek their opinions through a range of strategies including participation

in quality committees and improvement activities.

3.1.9 Continuity of care

Health care consumers frequently move between different care settings and health providers

to access the care that they need. It is important that issues and risks that arise as a result

of these transitions are understood, managed and their impact minimised.

Arrangements should be in place to ensure that governance of clinical care is seamless across

different health care sectors and between health services. Mechanisms should ensure that

governance arrangements account for situations where patients are transferred between health

services or where consumers access services not available within their local area.

Where incidents or issues arise during transfer of care or when the consumer is in a period

of transition between sectors, the service that becomes aware of the issue should report it, both

through their own reporting channels as well as to the original service from which they were

referred. Where appropriate, joint investigations and improvement strategies should be initiated.

• State level — The department should clearly define arrangements for governance of clinical care

for consumers who move between services and sectors. Mechanisms to ensure understanding

should be developed, in collaboration with consumers and peak community organisations,

to guide health services where cross-boundary governance issues arise.

• Health service level — Governance (and therefore risk) is shared between services delivering

care. Health services should have a clear point of contact for reporting clinical incidents and

issues that is communicated to those outside the service, for example through a contact clearly

displayed on the health service website. Cross-boundary issues should be investigated and

responded to in a collaborative manner between the two services/sectors involved and with

consumer and community input.


4. Domains of quality and safety

The domains of quality and safety serve to provide a focus for implementation of the clinical

governance framework. Each of these domains comprises a number of structures, processes and

activities to support the consumer through their journey or to support the clinical teams to deliver

safe, high quality care.

Clinicians and clinical teams are responsible and accountable for the quality of care they provide.

Management and the board are responsible and accountable for ensuring the systems, structures

and processes are in place to support clinicians in providing safe, high quality care and for actively

engaging clinicians to participate in improvement and risk management activities.

4.1 Consumer participation

Consumer participation is about improving the way services are delivered by increasing awareness

and understanding of the consumer perspective, their needs, what matters most to them in their

journey through the health system and how the systems and processes of care can be designed

to enhance their participation, experience and health outcomes. It is also about understanding,

and working with consumers’ expectations of their health care.

Consumer participation should occur at multiple levels of the organisation through activities

such as community consultation and consumer partnership on governance and management

committees, and within improvement initiatives or clinical risk management activities. Consumer

participation should be sought in planning, policy development, health service management,

clinical research, training programs and guideline development. The organisation should use

consumer complaints, compliments, surveys and Freedom of Information (FOI) requests to inform

improvements. Consumer input should also be used in the development of information resources

and communication strategies for consumers, patients, residents and carers.

“Participation occurs when consumers, carers and community members are meaningfully involved

in decision making about health policy and planning, care and treatment, and the wellbeing

of themselves and the community. It is about having your say, thinking about why you believe

in your views, and listening to the views and ideas of others. In working together, decisions

may include a range of perspectives”.8

At an individual level, consumers can participate more effectively if they are well informed and

involved in decision making regarding their care. Improving an individual’s participation in care may

be achieved through self management programs, involvement in planning care, transparent care

processes, and provision of plain English information on the expected patient journey. Where care

does not go according to plan, an open and honest explanation of the reasons should be provided.

Increasing the health literacy of the population, and structuring information materials to lead

consumers through the decision making process, facilitates their active participation.

8 Doing it with us not for us - Participation in your health service system 2006–09: Victorian consumers,

carers, and the community working together with their health services and the Department of Human

Services 2006


Strategies should be in place to ensure:

• consumers are empowered to participate in their care

• consumers participate in organisational processes including planning, improvement

and monitoring

• there is clear, open and respectful communication between consumers and all levels of the

health system

• services respond to the diverse needs of consumers and the community with humanity

• consumers provide feedback on clinical care and service delivery and that services learn from it

• rights and responsibilities of ‘patients’ are promoted to community, consumers, carers, clinicians

and other health service staff.9

4.2 Clinical effectiveness

Clinical effectiveness is achieving:

• Right care – the right care is provided to the patient

• Right patient – right patient who is informed and involved in their care

• Right time – at the right time

• Right clinician – by the right clinician with the right skills

• Right way – in the right way.

Enhancement of clinical performance and the continuous improvement of the safety, effectiveness

and appropriateness of clinical care occurs through the introduction, use, monitoring and

evaluation of evidence-based best practice. Ongoing evaluation of organisational and clinical

performance is critical to good governance and involves the use of performance measures, clinical

indicators and clinical audit. Reporting organisational performance is central to governance

of clinical care and provides mechanisms for monitoring safety and quality performance and

flagging issues that require intervention.

Clinicians should provide input into prioritising improvement activities through identifying gaps

between evidence and practice. Improvement activities should be based on the science of safe

systems and human factors, and should incorporate lessons from other industries including mining,

aviation, nuclear and finance. Improvement activities should be underpinned by robust, proven

methodologies such as Clinical Practice Improvement, Lean Thinking and Six Sigma. Clinical

processes should be redesigned or new processes proactively designed to minimise waste and

make it easier for clinical teams to “do the right thing”.

Clinical audit is an essential tool for promoting clinical effectiveness. By undertaking a systematic

review of aspects of the structure, process or outcomes of care against explicit evidence-based

criteria, issues are identified, changes implemented and performance is monitored to ensure

improvement occurs.10

9 Doing it with us not for us - Participation in your health service system 2006–09 (as above)

10 Principles for Best Practice in Clinical Audit. NHS 2002 National Institute for Health and

Clinical Excellence


Health services should determine their own focus for improvement activities which will be informed

by statewide priorities and locally identified issues.


• clinicians are empowered to improve clinical care delivery

• clinicians actively involve consumers as partners in their care

• clinical innovation is fostered and supported

• clinical service delivery processes are streamlined and efficient

• clinicians participate in designing systems and processes

• quality improvement activities are planned, prioritised and have sustainability strategies in place

• clinical care delivery is evidence-based

• standards of clinical care are clearly articulated and communicated

• performance of clinical care processes and clinical outcomes are measured

• clinical performance measures are used to evaluate and improve performance

• quality improvement activities are reviewed externally

• new procedures and therapies are introduced in a manner that assures quality and safety issues

have been considered and acted upon.

4.3 Effective workforce

All staff employed within health services must have the appropriate skills and the knowledge

required to fulfil their role and responsibilities within the organisation. Support is required to ensure

clinicians and managers have the skills, knowledge and training to perform the tasks that are

required of them and that they understand the concept of governance. Processes should be

in place to support the appropriate selection and recruitment of staff, maintenance of professional

standards, monitoring scope of practice and to control the safe introduction of new therapies

or procedures.

Adequate access should be provided to tools such as computers, information technology, and

decision support systems necessary to function efficiently and effectively. Physical surroundings

should be supportive of clinical teams delivering care and should provide a safe work environment.

Clinical teams should have access to evidence-based guidelines and models of care.

Strategies for ensuring effective inter-professional or multidisciplinary team work should

be in place, and should include all members of the team as appropriate, including cleaners,

engineers and students.

Consideration should be given to skills, knowledge and attributes of the workforce that facilitate

good governance of the care provided. Health services should have consideration for cultural

aspects of quality and safety governance in staff recruitment and strategies to manage the impact

of the contracted workforce (eg visiting medical officers and agency nurses).



• workforce development is planned and ensures the availability of a health workforce with

appropriate skill and professional group mix

• the health workforce has the appropriate qualifications and experience to provide safe,

high quality care

• workforce development activities to improve quality and safety are coordinated and efficient

• expectations and standards of performance are clearly communicated

• workforce is supported in their roles through training, development and mentoring

• the health workforce is fulfilling its roles and responsibilities competently

• workforce competence is sustained, innovation is fostered and corporate knowledge

is passed on

• strategies to support effective multidisciplinary teamwork are in place.

4.4 Risk management

Health care organisations need to have in place a broad based risk management system which

integrates the management of organisational, financial, occupational health and safety, plant,

equipment and clinical risk.

Minimising clinical risk and improving safety of care requires a systems response which sustains

a health care environment and clinical processes where it is difficult to make errors. It also

requires a just culture where systems and processes are the focus of investigation rather than

blaming individuals. Clinical risk management and improvement strategies should be integrated

within improvement and performance monitoring functions.

Risks should be both proactively and reactively identified with responses determined by the level

of risk presented. Potential risks may be reactively identified or flagged through incident reporting,

screening medical records, or analysis of administrative data for clinical incident markers.

Investigation and analysis should be used to determine the significance of the flags. Risks should

be proactively identified through the review results of hospital enquiries and horizon scanning for

new or emergent risks.


• clinical incidents are identified and reported

• clinical incidents are investigated and underlying systems issues and root causes are identified

• risks are proactively identified, assessed and reported

• organisational culture supports open communication and a systems approach to learning

from incidents

• clinical processes and technology supports are designed to minimise error and ensure clear,

unambiguous communication

• known clinical risks are responded to proactively


• risk information is considered in setting goals, priorities and developing business

and strategic plans

• legislation is complied with

• policies and protocols are reviewed and managed

• risk management activities are reviewed externally

• methods to improve patient safety are researched and innovative interventions developed.


Goals and priorities for improvement of quality and safety should be set in collaboration with the following key

groups to facilitate engagement of those required to participate or lead implementation of quality and safety

strategies. In setting goals and priorities, international evidence and directions, national directions set by the

Australian Commission on Safety and Quality in Health Care and risks and system deficiencies identified at state

level should be taken into consideration.

The following list identifies a number of stakeholder groups that should provide input into determining priority

areas for improvement. While the list is not exhaustive, it aims to identify the key groups to involve. These groups

may provide leadership, be actively involved at all points in the process or be consulted where relevant. A level

of involvement is also proposed; however, this may depend on current issues.

Stakeholder group Leadership Involve Consult

Victorian Government

Minister

DHS — Statewide Quality Branch

DHS — Metropolitan and Rural divisions

Victorian Health Service Management Innovation Council

Victorian Managed Insurance Authority

Board chairs of public health services

Specialist quality and safety groups

Victorian Quality Council

Australian Commission on Safety and Quality in Health Care

National Institute of Clinical Studies

Clinical Networks

Consumer and community groups

Offi ce of the Health Services Commissioner

Consumer Health Forum

Other consumer advocacy groups

Clinical groups

Professional colleges

Registration boards

Victorian Consultative Councils (Anaesthetic, Obstetric and Paediatric, Surgery)

Chairs of clinical networks

Health services

Boards

CEOs

Clinical governance directors

Clinical leaders

Quality/Safety/Risk managers

Attachment A:

Key stakeholders in state-level priority setting


Legislation relevant to governance of health services includes but is not limited

to the following legislation.

• The Health Services Act 1988 as amended by the Health Services (Governance) Act 2000

• Occupational Health and Safety Act 2004

• Health Professions Registration Act 2005

• State and Federal Privacy legislation

• Environment Protection Act 1970

• Information Privacy Act 2000

• Public Health Records Act 2001

• Freedom of Information Act

• Whistleblowers Protection Act 2001

• Equal Opportunity Act 1995

• Associations Incorporation Act 1981

• Public Administration Act 2004

• Mental Health Act 1986 and Mental Health Regulations 1998

• Human Rights and Responsibilities Act 2006

Attachment B:

Legislative compliance


All health services are required to have in place an organisational and committee structure that

supports quality and safety.

Organisational structure is determined by the CEO and must provide lines of responsibility and

accountability for the areas of activity listed in the table below. How the organisational structure

is shaped is determined by many factors including size, role and capacity of the service. The table

below provides a starting point for health services to check to ensure that each major area

of activity is tied into responsibility and accountability lines.

Level Role Area

Health service

board

Oversight and direction

of all areas

Deliver strategic

directions and monitor

performance

Planning

Quality

Risk and audit

Human resources

Finance

Community participation


Board quality/

risk committee

(or equivalent)

Oversight and direction

in more detail and depth

than that of board

Quality improvement activities including safety, access,

effectiveness, appropriateness, equity, effi ciency and

acceptability

Risk management (all organisational and clinical)

Other functions listed below

Management

quality

committee

(or equivalent

and delegated

subcommittees)

Operational

management

Improvement and innovation initiatives

Clinical risk management:

• including incident reports, investigation and management

• response to known clinical risks eg infection control,

transfusion, medication safety

Selection, credentialling and scope of practice

Drugs and therapeutics

Clinical safety and quality including death review/morbidity and

mortality review

Drugs/therapeutics

New technologies and procedures

Consumer satisfaction and experience


Accreditation

Complaints and compliments

Clinical audit


Attachment C:

Committee structure reporting areas


Infection control — Victorian Hospital Acquired Infection Surveillance System (VICNISS)

Cleaning standards — Department of Human Services

Victorian Cardiac Surgery Database Project — Australian Society of Cardiac and Thoracic Surgeons

Victorian Vascular Surgery Database Project — Melbourne Vascular Surgical Quality Initiative

Intensive care — Australian and New Zealand Intensive Care Society

Clinical risk — sentinel event reporting within 3 days of event to Department of Human Services

Trauma — Victorian State Trauma Outcomes Registry and Monitoring Group

Pressure ulcers [New collection] — Department of Human Services

Consumer participation — Department of Human Services

Quality of care reports — Department of Human Services

Cultural diversity and language services — Department of Human Services

Attachment D:

Clinical database reporting


The clinical governance framework measurement strategy outlines a range of measures that

should be considered for inclusion to support governance of quality and safety. It is not designed

to be a comprehensive list and many specialist or tertiary referral services will have a significantly

larger set of measures in use. It is rather a point from which to develop a more formal list

of measures for use across the state. Many of the indicators are part of existing indicator lists

in use within the department and/or Victorian health services:

• structure and strategy measures

• process indicators

• outcome indicators

The list is a work in progress and it is anticipated that, as measures are used and refined,

information systems improve and priority areas are developed the list will change.

E.1 Structure and strategy

Structure and strategy measures will require development and testing. Health services should

review each of the strategies outlined in this framework to determine application, measure

progress in implementation.

Not appropriate — The strategies are not relevant to this health service either because of the scope

or types of services provided.

No action — The strategies are relevant but the strategies have not been implemented as yet.

This may be for a range of reasons such as it is a lower priority than others or implementation

of the strategy is reliant on other strategies, action at state level or development of materials

to support implementation.

Planned — A plan to implement strategies has been outlined in the health service strategic,

business and quality plans. The plans include a timeframe for implementation, risks and barriers

to implementation and strategies to overcome them articulated in the plan.

Partially implemented — The strategy has been implemented either in part across the whole service

or in parts of the health services.

Fully implemented — The strategy has been implemented in full across all areas of the

health service.

Evaluated — The effectiveness of implementation has been evaluated either through review

of performance or audit of processes and activities.

Attachment E:

Quality and safety measurement framework


Table

E1:

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E.2 Process measures

There are a number of process measures that have strong evidence links to clinical outcomes.

The following list offers a short list of basic process measures as a starting point. Health services

should review each to determine applicability within their service setting. The following have been

developed based on findings of consultation:

Table E2: Proposed list of process measures11

Area Process measures Dataset

Clinical Appropriate venous thromboembolism prophylaxis

Infection control Surgical antibiotic prophylaxis guideline — compliance with antibiotic timing Victorian DHS

Clinical Percentage with assessment complete for relevant known clinical risks.

(Focus on known clinical risks. Determined at local level and may rotate

through a defi ned list)

Clinical (subset

of the above)

Percentage risk rated patients/residents with appropriate use of pressure

relieving materials to prevent pressure ulcers

Clinical Time to thrombolysis for AMI (emergency) AHRQ

Clinical Medications at discharge for AMI and ACS — aspirin, beta blockers and

ACE inhibitors

Consumer

response

Percent of complaints responded to within 30 days

Consumer

participation

Consumer participation in health service quality committee

Consumer

experience

VPSM overall core index state mean for hospital category

Workforce Sick leave utilisation

Intensive care Proportion of after hours discharge Victorian DHS

Clinical Care planning in community health (under development)

Cleaning Performance against cleaning standards during audit (target 85%) Victorian DHS

11 The Agency for Healthcare Research and Quality (AHRQ) Safety Indicators

http://www.qualityindicators.ahrq.gov/psi_overview.htm


E.3 Outcome indicators

Table E3: Proposed list of clinical outcome indicators

Clinical area Existing indicators Dataset

Aged care Prevalence of pressure ulcers Victorian DHS

Prevalence of falls and fall-related fractures Victorian DHS

Incidence of use of physical restraint Victorian DHS

Incidence of residents using nine or more different medicines Victorian DHS

Prevalence of unplanned weight loss Victorian DHS

Mental Health Single seclusion episodes

(% of all separations from adult acute inpatient ward)

Victorian DHS

Multiple seclusion episodes

(% of all separations from adult acute inpatient ward)

Victorian DHS

Procedural safety Foreign body left in during procedure Victorian DHS

Complications of anaesthesia Victorian DHS

Postoperative hip fracture Victorian DHS

Postoperative haemorrhage or haematoma Victorian DHS

Postoperative respiratory failure Victorian DHS

Postoperative pulmonary embolism or deep vein thrombosis Victorian DHS

Postoperative sepsis Victorian DHS

Postoperative wound dehiscence in abdomino-pelvic

surgical patients

Victorian DHS

Accidental puncture and laceration Victorian DHS

Targeted areas of risk

— medication safety

Serious medication related clinical incidents

(Others to be developed based on NSW Therapeutic Advisory Group

indicator set-see below)

Victorian DHS

Targeted areas of risk

— pressure ulcers

The number of patients who develop one or more Stage 1 pressure

ulcer/s, during their admission, during the reporting quarter.

Victorian DHS



Victorian DHS



Victorian DHS



Victorian DHS

The number of patients who develop one or more pressure ulcer/s,

during their admission, during the reporting quarter.

Victorian DHS

The number of patients with a documented pressure ulcer

risk assessment.

Victorian DHS



Safety Death in low mortality diagnosis related groups (DRGs) Victorian DHS

Failure to rescue Victorian DHS

Iatrogenic pneumothorax Victorian DHS

Infection control —

large hospitals

Central line associated bloodstream infections in adult intensive

care units (ICU)

Victorian DHS

Central line associated bloodstream infections in neonatal intensive

care units (NICU)

Victorian DHS

Peripheral line associated bloodstream infections in NICU Victorian DHS

Surgical site infection rates Victorian DHS

i) coronary artery bypass grafts Victorian DHS

ii) cholecystectomy Victorian DHS

iii) colon surgery Victorian DHS

iv) Caesarean section Victorian DHS

v) hip arthroplasty Victorian DHS

vi) knee arthroplasty Victorian DHS

Other selected infections due to medical care Victorian DHS

Infection control —

small hospitals

Multi-resistant organism infection rate Victorian DHS

Laboratory-confi rmed bloodstream infections Victorian DHS

Deep and organ space infection rate Victorian DHS

Outpatient haemodialysis event rate Victorian DHS

Compliance with measles vaccination guidelines Victorian DHS

Compliance with hepatitis B vaccination guidelines Victorian DHS

Peripheral venous catheter compliance with guidelines Victorian DHS

Rate of infl uenza vaccination (staff) Victorian DHS

Occupational exposures Victorian DHS

Intensive care Standardised mortality ratio Victorian DHS

Crude mortality Victorian DHS

Readmission rate Victorian DHS



Trauma Number of hospitalised major trauma patients Victorian DHS

Death rates (overall and in-hospital) Victorian DHS

Time and day of injury Victorian DHS

Overall injury severity Victorian DHS

Head injury severity Victorian DHS

Proportion of patients receiving defi nitive care at an appropriate

trauma service

Victorian DHS

Transfers across the system Victorian DHS

Discharge status Victorian DHS

Observed versus unexpected deaths Victorian DHS

Maternity Outcomes for standard primiparae Victorian DHS

Term infants transferred or admitted to special care nursery (SCN)

or NICU for reasons other than birth defect

Victorian DHS

The rate of administration of antenatal corticosteroids to women

delivered or transferred before 34 weeks gestation

Victorian DHS

Vaginal births after a primary caesarean section Victorian DHS

Five-year gestation standardised perinatal mortality ratio Victorian DHS

The rate of women referred to postnatal domiciliary care Victorian DHS

The rate of women offered appropriate interventions in relation

to smoking

Victorian DHS

The provision of appropriate breastfeeding support and advice Victorian DHS

The rate of women receiving timely hospital antenatal clinic services Victorian DHS

The rate of women of non-English speaking background (NESB),

without profi ciency in English, who receive appropriate

interpreter services

Victorian DHS

Birth trauma -- injury to neonate AHRQ Patient

safety indicators

Obstetric trauma -- vaginal delivery with instrument AHRQ Patient

safety indicators

Obstetric trauma -- vaginal delivery without instrument AHRQ Patient

safety indicators

Obstetric trauma -- caesarean delivery AHRQ Patient

safety indicators

Cardiac surgery 30 day all-cause risk-adjusted mortality (coronary artery bypass

graft (CABG))

Victorian DHS

Postoperative deep sternal infections (CABG) Victorian DHS

Postoperative haemorrhage requiring return to theatre (CABG) Victorian DHS



Vascular surgery Stroke after carotid endarterectomy Victorian DHS

Mortality following abdominal aortic aneurysm repair elective

and ruptured

Victorian DHS

Graft complications after infrainguinal bypass surgery Victorian DHS

Mortality after endoluminal stents performed for aortic

aneurysmal disease

Victorian DHS

Dental Restorative retreatment within 6 months Victorian DHS

Unplanned returns within 28 days following emergency care Victorian DHS

Unplanned returns within 7 days following extraction Victorian DHS

Endodontic retreatment in permanent teeth within 6 - 12 months Victorian DHS

Denture remakes within 12 months Victorian DHS

Radiographs (number of orthopantomogram (OPG)/intraoral

radiographs taken for new patients in the relevant age group)

Victorian DHS

Dental Health Services Victoria (DHSV) provided regional and

statewide reports to agencies to enable them to benchmark

themselves and undertake professional development etc with the

results. The reports are not published

Victorian DHS

Clinical area Developmental indicators Dataset

Primary health In March 2007 the Australian Institute for Primary Care (AIPC)

completed a discussion paper for the Victorian DHS: Clinical

Governance in Community Health Services: Development

of a Clinical Indicator Framework. As a follow-up action a working

group has been established to develop indicators for the sector

Blood Serious transfusion clinical incidents

The Better Safer Transfusion Program (BeST) rolling schedule of audits

Surgical outcomes Participation in process Victorian

Surgical

Consultative

Council

Medication safety Victorian DHS is exploring the use of a Performance Indicators

in Medication Safety (PIMS) toolkit. This incorporates a set

of 30 indicators, from which health care services select indicators

that address their local medication safety priorities, identifi ed through

self-assessment. The indicators are based on those developed by the

NSW Therapeutic Advisory Group

Victorian Audit

of Surgical Mortality

(VASM)

Participation in audit process Royal

Australasian

College

of Surgeons

and DHS


The following is a proposed list of standing items for reporting on the quality and safety of clinical

care to board or through board quality committees. The reporting lines will vary between health

services with some reports progressing through alternate sub committees such as workforce.

Report

Suggested frequency

of reporting

Key quality and safety strategic priority areas progress and KPI performance

• Statement of priorities

• Local priorities

Monthly

Clinical risk management report including response to known risks and

incorporating incident trends and proactively identifi ed risks through

coroner's reports and major hospital or patient safety reviews

6 monthly

Serious preventable adverse events Monthly

Summary report of incident fi ndings including systems issues identifi ed,

recommendations and improvement plan

6 monthly

Legislative compliance report Annually

Accreditation reports As required

Credentialling and scope of practice Annually

Outlier performance reporting on performance indicators, issues identifi ed,


Outliers may be identifi ed through a range of techniques including Statistical

Process Control (SPC) charts or comparison to benchmark

3-6 monthly

Consumer participation report Annually

Complaints and compliments report including issues identifi ed,


6 monthly

Victorian Patient Satisfaction Monitor (VPSM) report Annually

Clinical audit report – evaluation of practice against clinical

guidelines/pathways

6 monthly

Quality and safety improvement report includes reports on quality

improvement initiatives, improvement response to identifi ed issues through

risk management activities and performance reports. This should address

progress against the quality business plan or improvement plan

3-6 monthly

Report on quality and safety workforce development including leadership,

succession planning, education and training

Annually

Leadership and culture – boards or committees may choose to have a quality

and safety improvement initiative presented to them by a senior clinician

and/or clinical team or undertake and organisational climate survey

3 monthly

Attachment F: Example report to board


The performance monitoring cycle

The board should monitor the performance within the four domains of clinical governance.

The following provides a model for monitoring performance on an annual cycle.


The clear delineation of roles and responsibilities with respect to clinical governance was seen

to be critical by all stakeholders.

The activity checklists following provide examples of how the roles and responsibilities

may be used to effectively implement the policy framework, in line with the relevant clinical

governance strategies and domains of quality and safety.

There are clearly defined roles and responsibilities for each level in the health service including:

• The department

• Board members

• The chief executive officer and senior executive

• The health care team

• The consumer

The checklists are a tool to assist the stakeholder group review their safety and quality program/

involvement against the elements of the policy.

They provide both required and potential developmental activities for each group and outline the

level of involvement expected.

Attachment G: Roles and responsibilities


This checklist is a tool to assist the department to review its roles and responsibilities

in facilitating effective implementation of the policy.


Level of involvement Planned

Partly

implemented Established

Review

date

The department — required activities

Facilitate development and disseminate resources,

guidelines, training packages and other tools to support

health services including

• culturally-sensitive consumer resources and

translations of key patient education materials

• relevant patient satisfaction tools (e.g. Victorian

Patient Satisfaction Monitor) in acute, community

and aged care settings

• statewide patient charter

• Clinical governance policy framework and tools

to support implementation

The department — development activities


guidelines and tools and use exemplar sites to inform

implementation strategies in the following areas

• facilitate consumer involvement in their care

• gather patient experience information



Partly


Review

date


Actively manage spread of priority areas for improvement

across dimensions of quality through

• balanced funding of initiatives

• ensuring all quality dimensions are represented

in statement of priorities KPIs

Develop core safety and quality indicators in clinical

governance processes

• including data defi nitions and collection methods

Activity checklist — the department



Partly


Review

date

• align with Clinical Registries, accreditation bodies and

ACSQHC measures and other national initiatives

• align public reporting and DHS report requirements

• prioritise funding of new data collections according

to identifi ed priority areas

• facilitate analysis of performance and identifi cation

of systems issues

Foster an environment that allows innovation


Progress information and communication technology (ICT)

strategy to provide information management and technology

solutions that makes the information needed for better

health care available whenever and wherever required.

Coordinate or facilitate collaboration between health

services through mechanisms such as communities

of practice, innovation projects and multicentre

collaborative initiatives to address gaps between

evidence-based care and current practice



health services including

• a directory of evidence-based websites that

provide relevant guidelines and standards to improve

clinical practice

• quality improvement and process redesign

Effective workforce


Partly


Review

date


Facilitate development of networking opportunities and

training programs in leadership and change management




implementation strategies in the following areas

• develop standards for health professionals

• redesign of clinical roles


Risk management


Partly


Review

date


Develop policy and frameworks as required to assist in

implementing clinical governance systems including:

• credentialling and privileging

• incident management and investigation



health services including:

• clinical incident investigation and management

• tools to support implementation of the Clinical

governance policy framework

Monitor and analyse work by peak bodies (eg ACSQHC)

that will have implications for Victorian health services and

communicate implications to health services




implementation strategies in the following areas:

• medical record and multidisciplinary review programs

• evidence-based approaches to management of known

clinical risks

• clinical handover

Develop, implement and maintain a statewide health

incident management system, and ensure periodic review

and analysis of data


This checklist is a tool to assist health service boards of directors to review their safety and

quality program against the elements of the policy. It may be used as a guide to the roles and

responsibilities that boards and management have in facilitating effective implementation

of the policy.

Roles and responsibilities of the board

The board has ultimate responsibility for the governance of clinical care within a health service.

The board appoints the CEO, provides oversight of management, assists in developing strategy

and ensures the achievement of strategic objectives. The board is assisted in its governance

role by the board quality committee, the audit committee and various management risk and

quality committees.


Planned

Partly


Review

date

Board — required activities

Ensure the community advisory committee operates within

the health service and includes consumer members

Ensure the health service has a consumer participation

plan in place

Ensure consumer participation in:

• planning and development

• quality and safety committees

Ensure feedback from consumers including complaints

and satisfaction measures are used to inform planning and

improvement activities

Ensure cultural diversity plan is in place and monitored

Board — development activities

In formulating health service strategic plan consider

strategies from the Offi ce of the Health Services

Commissioner and others involved in health reform

Monitor organisational culture and commitment

to consumer participation and open disclosure

Activity checklist — board



Planned

Partly


Review

date


Consult clinical groups on key safety and quality issues,

risks and opportunities for improvement

Ensure clinician representation on key safety and quality

committees and activities

Ensure a processes for setting health service statement

of priorities, quality plan, strategic and business planning

includes consideration of:

• government priorities

• balance across all dimensions of quality

• management perspective

• clinicians perspective

• consumer perspective

Monitor performance of strategies to address statement

of priorities and oversight resourcing

Monitor safety and quality indicators

Ensure mechanisms are in place for recognising and

rewarding contribution to safety and quality improvement

Ensure health service meets accreditation standards,

responds to accreditation fi ndings, and proactively

implements improvements to address recommendations


Oversight clinical audit and monitor signifi cant gaps

between evidence-based best practice and current practice

Understand high level drivers and barriers

to clinical effectiveness

Ensure strategic plan addresses information strategy

to support safe and high quality care


Effective workforce

Planned

Partly


Review

date


Ensure a staff development and performance management

system is in place


Ensure that workforce planning considers strategies

to achieve appropriate skill mix

Ensure leadership capability development and succession

planning strategies are in place

Risk management

Planned

Partly


Review

date


Ensure an integrated risk management framework is in place

Incorporate information about clinical risks into strategic

and business planning

Oversight the risk management system and review reports

on signifi cant clinical risks and action plans to mitigate risk

Oversight risk and quality committees for the

functions outlined in the Victorian clinical governance

policy framework

Ensure that the quality committee has procedures in place for:

• Credentialling and establishing scope of practice

• Ensuring management of risk associated with

introduction of new procedures and therapies

Oversight processes to ensure legislative compliance

is current

Ensure “whistleblower” process is in place and accessible

to staff

Oversight prioritisation and implementation

of recommendations of sentinel and major adverse

incident investigations

Ensure system risks are identifi ed, reported (through

organisation risk register) and mitigated


Oversight systems to communicate and act on system

risk alerts


Chief executive officer (CEO)/senior management/senior clinicians

This checklist is a tool to assist health service CEOs, senior managers and senior clinicians

to review their safety and quality program against the elements of the policy. It may be used

as a guide to the roles and responsibilities that CEOs, senior management and senior clinicians

have in facilitating effective implementation of the policy.

The CEO and senior management’s role is to implement or oversight implementation of quality

systems within the organisation. Where the implementation is delegated a system of monitoring

should be in place that provides a mechanism to confirm that these systems and processes are

functioning effectively.


Consumer participation Planned Partly

implemented

Established Not

applicable

Review

date

CEO/senior management/senior clinicians — required activities

Involve consumers in developing

resources:

• for clinical and self

management purposes

• that are accessible to diverse

members of the community

• that include translations of key

patient education materials

Develop and report on health service

community participation and cultural

diversity plans

Facilitate consumer participation

on management committees, risk

management activities and quality

improvement programs

Use patient satisfaction measures

and consumer feedback to inform

strategic and business planning, and

improvement activities

Implement best practice processes

to respond to consumer complaints

Implement and communicate

patient charter

CEO/senior management — development activities

Use consumer experience to inform

service delivery models

Include open disclosure as a core

component of leadership development

programs for clinicians and managers

Roles and responsibilities — checklist




Partly


Not

applicable

Review

date


Measure quality and safety

of clinical services and have

mechanisms in place to:

• Monitor performance and trends

over time

• Measure quality across the range

of dimensions- safety, effectiveness,

appropriateness, acceptability,

access and effi ciency

• Analyse measures, fl ag signifi cant

issues for attention and investigate

underlying causes

Support health care teams to investigate

safety and quality issues and implement

improvement strategies

Continuously monitor clinical

activity to determine the effectiveness

of improvement strategies

Develop and communicate quality plan

and priority areas for quality improvement

(statement of priorities) within the

organisation. In developing the statement

of priorities consider:

• Safety and quality performance

measures

• Statewide quality and safety priorities

Report to board areas of sustained

poor safety and quality performance

or signifi cant gaps between best

practice and current practice

Ensure clinician representation on board

and organisational quality committees

Involve clinicians in strategic, business

and quality planning activities and

operational committees



Partly


Not

applicable

Review

date

Sponsor, lead and actively support

organisational improvement initiatives

including quality improvement, clinical

and business process redesign through:

• Active engagement in activities and

acting as a role model

• Advocating for the initiative and

infl uencing other leaders to take

ownership of issues and outcomes

• Removing barriers and facilitating

access to resources

• Assisting initiatives to work across

health service’s divisional and

departmental boundaries

Build a core team with quality

improvement, risk management, process

redesign and change management skills

Support health care teams to access

innovation grants

Report lessons learned and successful

interventions to the wider health system

through DHS and publication in the

academic literature

Ensure the organisation complies with

accreditation standards, responds to

accreditation fi ndings and proactively

implements improvements

Actively support participation

in collaborative projects and statewide

improvement initiatives where there

is alignment with health service priority

areas for improvement

CEO/senior management/senior clinicians — development activities

Benchmark core organisational safety and

quality indicators

Where core indicators are not relevant

to the service (as in the case of specialty

hospitals), develop a relevant set

of indicators

Implement a clinical audit program across

all clinical specialties

Facilitate use of evidence-based

guidelines and tools



Partly


Not

applicable

Review

date

Provide information technology supports

to facilitate access to guidelines,

standards and implementation tools

Implement clinical IT systems with

a robust process that includes testing,

training, process defi nition and support

Include participation in quality and

performance improvement initiatives as

part of employment contracts

Instigate strategies to improve health care

team communication with consumers,

involvement in management and

decisions regarding their care through

training, coaching or academic detailing

Effective workforce

Effective workforce Planned

Partly


Not

applicable

Review

date


Enact a just culture:

• Focus on systems issues and

improvement rather than blaming

individuals

• Support multidisciplinary teamwork

and value the perspectives of all

team members

Communicate quality and safety issues

to all levels of the health service

Ensure members of the health care team

working in clinical roles have clearly

defi ned scope of practice and guidelines

for delivery of treatments

Support redesign of health care roles

ensuring robust processes are in place

to implement changes safely and

appropriately

Implement a system of supervision and

performance management of all staff

• evaluate safety and quality

performance and governance

of clinical care

• communicate supervision

expectations to senior staff


Effective workforce Planned

Partly


Not

applicable

Review

date

Ensure processes are in place to provide

information on safety and quality

programs at orientation and as part

of ongoing workforce development

Ensure resourcing is adequate to allow

release of staff to participate in training

and skills development programs

Implement robust systems to monitor

current registration and special

conditions of registration for medical,

nursing and allied health staff


Defi ne competency standards for

clinical staff working in all areas and

update regularly

Provide resources to develop high

functioning clinical teams, improving

coordination, communication and

escalation procedures through training

and coaching programs

Develop, communicate and enact a code

of conduct relevant for all staff

Undertake succession planning for key

safety and quality positions

Implement strategies to develop clinical

leaders leadership capability

Periodically evaluate the adequacy

of supervision arrangements

Risk management


Partly


Not

applicable

Review

date


Implement an integrated risk

management system including:

• risk reporting by staff

• mechanisms to integrate clinical risk

information in developing strategic

and business plans



Partly


Not

applicable

Review

date

Implement incident assessment,

reporting and management system

that includes:

• fl exible reporting options for staff

• mechanism for management

of “whistleblowers”

• an assessment of the severity

of incidents and their risk of recurrence

• investigation of critical incidents

using established root cause

analysis (RCA) methods and tools

• investigation of serious incidents

and trended minor incidents

of concern using established methods

• prioritisation of recommendations

arising from incident investigations

• continuous monitoring

of performance to assess the

effectiveness of implementation

of recommendations

Establish systems to respond to known

clinical risks (eg medication error, wrong

surgery, falls) that includes:

• assessment of level of risk

• initiation of evidence-based

interventions appropriate to the level

of risk identifi ed

• continuous monitoring

of performance to assess the

effectiveness of implementation

of interventions

Ensure systems are in place for

credentialling of clinical staff and

establishing scope of practice including

mechanisms for action where clinicians

are practising outside that scope or

inappropriately to the role delineation

of the hospital or service

Implement periodic legislative

compliance review



Partly


Not

applicable

Review

date


Establish an organisational risk register

that incorporates corporate and clinical

risk and allows reporting of signifi cant

systems risks through the organisation

Establish a medical records review

program eg limited adverse occurrence

screening (LAOS)

Implement regular safety walk arounds

involving CEO, board, consumers, senior

managers and clinicians

Ensure guidelines for multidisciplinary

team review of incidents, risks, morbidity

and mortality are available and

implemented effectively. Where review

mechanisms are unproductive, implement

strategies such as training and peer

support to improve effectiveness

Foster a culture of excellence and

innovation in improving quality and

managing risks

Implement clinical handover guidelines

that include specifi c handover time,

location, format, structure and

communication sheet. Ensure rostering

facilitates safe clinical handover


This checklist is a tool to assist health care teams to review their safety and quality program

against the elements of the policy. It may be used as a guide to the roles and responsibilities that

health care teams have in facilitating effective implementation of the policy.


Level of involvement Participate Leadership

No

opportunity

Not

applicable

Review

date

Health care teams — required activities

Involve consumers in their care through

• awareness of communication style used

• use of plain English

• respect and encourage

consumer choice and participation

in decision making

• use culturally appropriate style and

interpreters where required

Contribute safety and quality

information to the health service’s

Quality of Care report

Respond to complaints and requests for

further information openly and promptly

Health care teams — development activities

Develop and update resources catering

for the diverse needs of community

members

Provide information to consumers

on systems feedback

Facilitate access to Respecting Patient

Choices Program as appropriate

Involve patients in patient and procedure

identifi cation processes

Activity checklist — health care teams




No

opportunity

Not

applicable

Review

date


Contribute to developing priority areas

for improvement through:

• consultative forums

• board and operational committees

• feedback to clinical representative

on committees/advisory group

Communicate gaps between evidence

and current practice through:

• usual management reporting channels

• clinical groups

• incident reporting

Participate in local quality

improvement activities:

• Clinical audit

• Focused improvement projects such

as improving medication safety,

uptake of evidence-based clinical

management etc

• Process redesign (clinical and

business processes)

Respond to poor process or outcomes

performance through changing and

improving processes or clinical practice

Communicate with consumers (and

update as required) planned care

pathways, treatment guidelines and self

management plans

Involve consumers in care decisions



No

opportunity

Not

applicable

Review

date

Contribute to clinical audit activities:

• establish audit program

• develop audit tools

• undertake audit of performance

against a standard of evidence-

based best practice

• review performance

• implement improvements

• monitor performance after

improvements made (i.e. close the

quality improvement loop)

Collect and report data on safety

and quality performance both up the

organisation to the board and down the

organisation to the staff/patient coalface

Regularly review safety and quality data

including performance over time and

benchmarking results

Use clinical guidelines and tools that have

been implemented within the clinical area

Comply with relevant professional and

accreditation standards and participate

in accreditation activities as required

Ongoing professional development

including training required:

• to deliver new procedures

• in quality improvement and process

redesign

• to provide safe, evidence-based care

• to use information technology

supports effectively



No

opportunity

Not

applicable

Review

date

Participate and lead activities

to set priority areas for quality

improvement through:

• consultative forums

• health service committees

• statewide groups

• feedback to representatives

of above groups

Provide input into development of quality

and business plans. Use local quality

performance data to inform input

Participate and lead quality improvement

and process redesign activities:

• role model for junior staff

• drive improved care and performance

• active participation in local initiatives


Gather consumer experience information

through a variety of methods such as

interviews, focus groups or patient

tracking and use to inform improvement

activities

Provide feedback to clinical teams on

comparative performance measured

through benchmarking and clinical audit

Provide information on accessing and

using guidelines and expectations

regarding compliance and variation

to standards:

• at orientation

• as part of regular performance review

Present and report successful local

innovations to management and peers


Effective workforce


No

opportunity

Not

applicable

Review

date


Work within defi ned roles and

responsibilities/scope of practice

Performance is reviewed annually

with respect to:

• roles and responsibilities

• meeting standards of care

• skills and behaviours that support

safe, high quality care

• multidisciplinary teamwork

• participation in quality and

safety activities

Develop and maintain skills and

competencies and participate

in appropriate professional

development activities

Communicate required standards of care

and existing evidence-based guidelines

to new members of the health care team

Acknowledge individual contributions

to safety and quality improvement and

celebrate success within the team

Provide information on registration and

professional development as required

Practice responsibly with consideration

of fatigue, other human factors and their

effect on performance

Supervise junior staff and support their

development of skills, knowledge and

competency to provide safe, high

quality care


Comply with the spirit and intent of the

health service code of conduct

Participate in training to improve

supervision skills if indicated

during feedback from juniors

or performance review


Risk management


No

opportunity

Not

applicable

Review

date


Risk management activities

• risk identifi cation and assessment

• report signifi cant risks to management

• initiate interventions to minimise harm

• continuous monitoring to measure

effect of intervention

Clinical incident management

• report clinical incidents

• investigate causes of incidents

• implement recommended changes

to prevent recurrence

• continuous monitoring to measure

effect of intervention

• support colleagues involved

in clinical incidents

Multidisciplinary team review

of complications, deaths, near misses

and quality of care

Assess and respond to known clinical

risks such as infections, medication

errors, falls, thromboembolism, pressure

ulcers or other risks relevant to the health

care team

Redesign processes to improve safety

and make it easier to provide the right

care to the right patient in the right place

at the right time

Report all incidents and issues related to

new procedures and therapies

Ensure appropriate training, competency

checks and supervision for staff carrying

out new procedures and therapies

Comply with legislative requirements as

outlined in policies such as notifi cation

of deaths to coroner and relevant special

committees and other notifi able incidents



No

opportunity

Not

applicable

Review

date


Continuous medical record review

program to detect quality of care and

safety issues

Training and skills development

• Multidisciplinary team training

• Risk assessment and interventions

Research into and development

of innovative approaches to minimising

and managing clinical risk

Work in partnership with consumers

to develop interventions to decrease risk

Undertake clinical handover as outlined

in guidelines including specifi c time,

location and standardized format


This checklist is a tool to assist consumers to understand how they can participate in safety

and quality activities as outlined in the policy. It may be used as a guide to the roles and

responsibilities that consumers have in facilitating effective implementation of the policy.

Participation occurs when consumers, carers and community members are meaningfully involved

in decision making about health policy and planning, care and treatment, and the wellbeing

of themselves and the community. It is about having your say, thinking about why you believe

in your views, and listening to the views and ideas of others. In working together, decisions may

include a range of perspectives.12

More detailed information on consumer participation may

be found in the policy Doing it with us not for us participation policy.13

*Where the term consumer is used this includes people who are current or potential users

of health services, carers and the community.


Level of involvement Participate

No

opportunity

Not

applicable

Review

date

Consumers — required activities

Use available information and support to stay informed

and make decisions about their care and treatment

Participate in the development of consumer

information resources

Participate in governance, planning, and safety

and quality improvement activities through structures

such as community advisory committees (CAC) and

quality committees

Participate in the development and evaluation of programs,

system redesign and health promotion strategies

Provide feedback to health services on quality of care

received, including experience, satisfaction, compliments

and complaints

Utilise the Offi ce of the Health Services Commissioner

(OHSC) when the health service response to a complaint

has been inadequate

Consumers — development activities

Skilled consumers and consumer groups provide support

to other consumers

Participate in health care delivery and inform development

of consumer friendly processes, policy and structures

12 Department of Human Services 2005, Consultation paper -participation in your health service system:

Victorian consumers, carers, and the community working together with their health service and the

Department of Human Services, Metropolitan Health and Aged CareService Division, Victorian Government,

Department of Human Services, Melbourne.

13 Department of Human Services 2006, Doing it with us not for us participation policy

Activity checklist — consumer*



No

opportunity

Not

applicable

Review

date

Trained consumers participate in root cause analysis (RCA)

processes where appropriate

Participate in patient and operation site

identifi cation protocols



No

opportunity

Not

applicable

Review

date


Contribute to determining priorities for improving quality

and safety by providing feedback

• through consumer consultative forums

• to health care teams and where appropriate, individuals

Effective workforce


No

opportunity

Not

applicable

Review

date


Contribute to training programs aimed at improving

capability of the health care workforce to effectively involve

consumers in their care

Risk management


No

opportunity

Not

applicable

Review

date


Report suspected incidents to the health care team

Participate in incident management processes

• provide information to incident investigation teams

Provide feedback to health care teams on new therapies

and procedures


Participate in safety walk arounds

Participate in processes targeted at improving the

management of risks to patient safety


This checklist is a tool to assist organisations to review their operational capacity against the

generic structural and process elements essential to achieving effective clinical governance.

Please tick appropriate box and add comments as appropriate.

Senior management commitment

Yes No Notes

Review

date

Senior management is committed

to clinical governance.

Senior management has approved the

organisation’s clinical governance policy

and procedures.

Appropriate resources are allocated to support

clinical governance.

Senior management has established

a governance reporting and monitoring

requirement on the application

of clinical governance.

The organisation provides advice to consumers/

carers about the clinical governance policy.

Training requirements are determined

and scheduled.

Clinical governance policy

A clinical governance policy has been developed

by management and staff and signed by the chief

executive offi cer, in line with the Victorian clinical

governance policy framework.

The policy aligns and directs other

operational policies and the organisation’s

strategic objectives.

The policy has been communicated to all staff.

The policy is reviewed periodically.

Clinical governance — operational management

Responsibility for clinical governance has

been assigned.

The roles and responsibilities of staff involved

in clinical governance are clearly documented

and communicated within the organisation.

The organisation has developed a performance

monitoring tool to assess its requirements against

the policy.

Clinical governance organisational readiness checklist


Safety and quality committee

Yes No Notes

Review

date

A safety and quality committee has been

established or, for small rural health services,

included as a standing agenda item for an

existing committee.

The terms of reference and membership of the

safety and quality committee are clearly defi ned

and communicated.

Staff and management understand the function

of the safety and quality committee.

The safety and quality committee includes

senior clinical representation from across

the organisation.

Minutes of the safety and quality committee

meetings are made available to the chief

executive offi cer, the board of directors or board

of management and the health service staff.

Clinical governance issues are discussed at the

safety and quality committee.

Clinical governance monitoring

There are appropriate audit and monitoring

systems in place to measure and evaluate clinical

governance within the organisation.

Legal considerations

A process is in place to guide decision

making about what and how information

is communicated as part of the clinical

governance framework.

Signed:_________________________

Date:

Chief Executive Officer