National Model Clinical Governance Framework
National ModelClinical GovernanceFramework
Published by the Australian Commission on Safety and Quality in Health CareLevel 5, 255 Elizabeth Street, Sydney NSW 2000Phone: (02) 9126 3600Fax: (02) 9126 3613Email: mail@safetyandquality.gov.auWebsite: www.safetyandquality.gov.auISBN: 978-1-925665-18-5 Australian Commission on Safety and Quality in Health Care 2017All material and work produced by the Australian Commission on Safety and Quality in Health Care is protectedby copyright. The Commission reserves the right to set out the terms and conditions for the use of such material.As far as practicable, material for which the copyright is owned by a third party will be clearly labelled. TheCommission has made all reasonable efforts to ensure that this material has been reproduced in this publicationwith the full consent of the copyright owners.With the exception of any material protected by a trademark, any content provided by third parties, and whereotherwise noted, all material presented in this publication is licensed under a Creative Commons AttributionNonCommercial-NoDerivatives 4.0 International licence.Enquiries about the licence and any use of this publication are welcome and can be sent tocommunications@safetyandquality.gov.au.The Commission’s preference is that you attribute this publication (and any material sourced from it) using thefollowing citation:Australian Commission on Safety and Quality in Health Care. National Model Clinical Governance Framework.Sydney: ACSQHC; 2017.DisclaimerThe content of this document is published in good faith by the Australian Commission on Safety and Qualityin Health Care for information purposes. The document is not intended to provide guidance on particularhealthcare choices. You should contact your healthcare provider on particular healthcare choices.This document includes the views or recommendations of its authors and third parties. Publication ofthis document by the Commission does not necessarily reflect the views of the Commission, or indicate acommitment to a particular course of action. The Commission does not accept any legal liability for any injury,loss or damage incurred by the use of, or reliance on, this document.AcknowledgementThe Commission would like to thank all of our partners for their contributions to the development of the NSQHSStandards and their continuing commitment to improving safety and quality across the Australian healthcaresystem.This document was released in November 2017.
ContentsForeword iiSummary iiiIntroduction 1Corporate (organisational) governance of health service organisations 3Key concepts 3Responsibilities of governing bodies for corporate governance 3Clinical governance and the National Model Clinical Governance Framework 5Clinical governance as an integrated component of organisational governance 5Components of the Clinical Governance Framework 6Importance of culture in clinical governance 8Roles and responsibilities for clinical governance 9Governance, leadership and culture 11Patient safety and quality improvement systems 12Clinical performance and effectiveness 14Safe environment for the delivery of care 16Partnering with consumers 17Appendix: NSQHS Standards 19Acknowledgements 30Glossary 31References 35National Model Clinical Governance Frameworki
ForewordAustralians enjoy good health outcomes, andgenerally trust health service organisations andclinicians to provide safe and high-quality healthcare. However, safety and quality lapses continue tooccur that can have a major affect on people’s livesand on the broader health system.Since 2015, a number of state and territorygovernments have engaged the AustralianCommission on Safety and Quality in HealthCare to review identified patient safety problems.These reviews have shown that some health serviceorganisations have problems implementing keyclinical governance processes. Issues that have beenidentified include problems with: Implementing an open disclosure responseconsistent with national and local standards Ensuring that incident management andinvestigation systems can provide adequatesurveillance to recognise major safety failures orrisks Implementing corrective action in response toidentified patient safety risks and failures Establishing complaint management systemsthat include a partnership with patients andcarers Ensuring a robust and positive safety culture Clearly understanding the roles andresponsibilities of boards, the executive, clinicalteams and clinicians in clinical governance.iiThe National Model Clinical GovernanceFramework has been developed to improvethese issues. It provides a consistent nationalframework for clinical governance that is basedon the National Safety and Quality Health ServiceStandards. It supports a shared understanding ofclinical governance among everyone working inhealth service organisations, including clinicians,managers and members of the governing body.This will ensure that clinical governance systemsare implemented effectively, and support safer andbetter care for patients and consumers.We take this opportunity to thank members ofthe Advisory Panel who provided expert advice inthe development of the National Model ClinicalGovernance Framework for their time and expertise.Ms Wendy Harris QCChairNational Model Clinical Governance FrameworkAdvisory PanelProfessor Villis Marshall ACChairAustralian Commission on Safety and Quality inHealth CareNational Model Clinical Governance Framework
SummaryPatients, consumers and the community trustclinicians and health service organisations toprovide safe, high-quality health care.Clinical governance is the set of relationshipsand responsibilities established by a healthservice organisation between its state or territorydepartment of health, governing body, executive,workforce, patients, consumers and otherstakeholders to ensure good clinical outcomes.It ensures that the community and health serviceorganisations can be confident that systems are inplace to deliver safe and high-quality health care,and continuously improve services.Clinical governance is an integrated componentof corporate governance of health serviceorganisations. It ensures that everyone – fromfrontline clinicians to managers and members ofgoverning bodies, such as boards – is accountableto patients and the community for assuring thedelivery of health services that are safe, effective,integrated, high quality and continuouslyimproving.The elements in the Clinical GovernanceFramework are also mandatory for health serviceorganisations that need to meet the requirementsof the NSQHS Standards when they are accredited.As with the NSQHS Standards, however, theClinical Governance Framework does not specifyhow a health service organisation should developor implement its clinical governance systems. Eachhealth service organisation needs to put in placestrategies to meet the requirements of the NSQHSStandards for clinical governance that considerits local circumstances. The Clinical GovernanceFramework builds on the NSQHS Standards,providing more information about corporate andclinical governance, and roles and responsibilitiesfor people within a health service organisation.Further resources will also be available to supportthe Clinical Governance Framework for specifictarget audiences and settings.To support the delivery of safe and high-qualitycare for patients and consumers, the AustralianCommission on Safety and Quality in HealthCare has developed the National Model ClinicalGovernance Framework (the Clinical GovernanceFramework). The Clinical Governance Frameworkis based on the National Safety and Quality HealthService (NSQHS) Standards – in particular, theClinical Governance Standard and the Partneringwith Consumers Standard. The Clinical GovernanceFramework has five components: Governance, leadership and culture Patient safety and quality improvement systems Clinical performance and effectiveness Safe environment for the delivery of care Partnering with consumers.National Model Clinical Governance Frameworkiii
IntroductionHealth care in Australia is provided by teams ofclinicians working in partnership with patients,families and carers. It is delivered in a wide varietyof public and private organisations, ranging fromsole proprietorships to large statutory corporationsand public companies.Patients, consumers and the community trustclinicians and health service organisationsto provide safe, high-quality health care, andmost Australians have access to such care.Australia’s clinicians are highly regarded as skilledprofessionals who are committed to meeting thehealthcare needs of their patients. Key safety andquality risks have been identified, and strategiesexist to improve the safety and quality of healthcare. Although there is a strong system-widecommitment to continuous improvement, delaysand problems with implementation mean thatfailures in safety and quality continue to occur.Australia generally performs well in internationalcomparisons about health.1 However, althoughmost health care in Australia leads to goodoutcomes, patients do not always receive the carethat is most appropriate for them, and preventableadverse events occur across the Australianhealthcare system.2 Lapses in safety and quality,and unwarranted variation in health care providedto different populations within Australia havesubstantial costs, in terms of both the effect onpeople’s lives and financially.2,3The delivery of health care is a complex endeavour.Contemporary models of care are sophisticated andrapidly changing, as are the expectations of patientsand consumers. Health service organisations suchas hospitals sit within intricate webs of differenttypes of services across tertiary, secondary andprimary sectors. Patients and consumers movebetween these services and sectors, and safety andquality risks exist at all points on these journeys.4-6Traditionally, ensuring an acceptable standard ofsafety and quality was viewed as predominantlythe responsibility of individual clinicians. Now, theimportance of the individual and collective roles andresponsibilities of patients, consumers, clinicians,healthcare teams, managers, directors, governingbodies and departments of health is well recognised.National Model Clinical Governance FrameworkAlthough the safety and quality of health careprovided to each patient are highly dependent onthe skills and performance of individual clinicians,safety and quality are also a professional andorganisational responsibility. They rely on effectivegovernance and management processes, and theestablishment of systems involving a large numberof contributors in health service organisations andacross the health system.To support the delivery of safe and high-qualityhealth care, and the best possible outcomesfor patients in this complex environment, theAustralian Commission on Safety and Quality inHealth Care (the Commission) has developed thisNational Model Clinical Governance Framework(Clinical Governance Framework) for public andprivate healthcare organisations in the acute sector.The Clinical Governance Framework is based onthe National Safety and Quality Health Service(NSQHS) Standards (second edition), particularlythe Clinical Governance Standard and thePartnering with Consumers Standard.7 As part ofthe complete set of NSQHS Standards, these twostandards constitute a complete and robust clinicalgovernance framework.Purpose of the ClinicalGovernance FrameworkThe purpose of the Clinical Governance Frameworkis to ensure that patients and consumers receivesafe and high-quality health care by describing theelements that are essential for acute health serviceorganisations to achieve integrated corporate andclinical governance systems. Through these systems,organisations and individuals are accountableto patients and the community for continuouslyimproving the safety and quality of their services.The Clinical Governance Framework: Defines clinical governance Provides the context for clinical governancebeing an integrated component of corporategovernance1
Describes the key components of a clinicalgovernance framework, based on the NSQHSStandards Discusses the role of culture in supporting goodclinical governance Outlines the roles and responsibilities of, andessential partnership between, patients andconsumers, clinicians, managers, and governingbodies (such as boards) in implementing effectiveclinical governance systems in health serviceorganisations.Application and use ofthe Clinical GovernanceFrameworkIt is mandatory for all Australian hospitals andday procedure services to be assessed through anindependent accreditation process to determinewhether they have implemented the NSQHSStandards. Therefore, the elements in the ClinicalGovernance Framework are also mandatory forthese health service organisations.As with the NSQHS Standards, the ClinicalGovernance Framework does not specify howa health service organisation should develop orimplement its clinical governance systems. Rather,it outlines the components of a clinical governanceframework to enable health service organisationsto develop and implement their own governancesystems, considering local needs, values and thecontext in which services are provided.The Clinical Governance Framework builds on theNSQHS Standards, providing more informationabout corporate and clinical governance, and rolesand responsibilities relating to clinical governancefor people within a health service organisation.Detailed guidance about strategies to meet therequirements of the NSQHS Standards is includedin the guides for hospitals and other types ofhealth service organisations that are currentlybeing developed by the Commission. The ClinicalGovernance Framework should be used with thesedocuments.The Clinical Governance Framework can be used byclinicians, managers, executives, governing bodies,and state and territory departments of health to2support effective clinical governance and improvethe safety and quality of care.The Clinical Governance Framework willbe supported by resources developed by theCommission for specific target audiences, includingmembers of governing bodies (such as boards),clinicians and consumers. Resources will also bedeveloped to support application of the ClinicalGovernance Framework in specific settings, such asprivate hospitals and day procedure services.The Clinical Governance Framework applies topublic and private health services in the acute sector.As noted earlier, however, the delivery of healthcare in Australia is complex, and patients movebetween different types of services across acuteand primary sectors. Because of this complexity,and the safety and quality risks that exist at thesetransition points4-6, there is a need to work towardsan integrated system of clinical governance forthe whole health system. The Clinical GovernanceFramework is a starting point for future work thatwill explore clinical governance in primary care.8Definition of clinicalgovernanceThe definition of clinical governance that underpinsthe Clinical Governance Framework is as follows:Clinical governance is the set of relationshipsand responsibilities established by a healthservice organisation between its state orterritory department of health (for the publicsector), governing body, executive, clinicians,patients, consumers and other stakeholdersto ensure good clinical outcomes.9 It ensuresthat the community and health serviceorganisations can be confident that systemsare in place to deliver safe and high-qualityhealth care, and continuously improve services.Clinical governance is an integrated componentof corporate governance of health serviceorganisations. It ensures that everyone– from frontline clinicians to managersand members of governing bodies, such asboards – is accountable to patients and thecommunity for assuring the delivery of healthservices that are safe, effective, integrated,high quality and continuously improving.National Model Clinical Governance Framework
Corporate (organisational) governanceof health service organisationsClinical governance is an integrated componentof corporate governance. This section providesan overview of key concepts and elements ofcorporate governance, particularly regarding theresponsibilities of governing bodies such as boards.Key conceptsA large proportion of Australian health careis delivered in public sector and private sectororganisations governed by bodies such as boardsof directors. Boards are generally well versed in theconcepts and practices of corporate governance,which is recognised as a responsibility of governingbodies, and is distinguished from responsibility formanagement and service delivery.The concept of clinical governance is bestunderstood as founded in, and consistent with,broader concepts of corporate or organisationalgovernance.*Robert Tricker is credited with creating the term‘corporate governance’. According to Tricker10:The governance role is not concerned withthe running of the company, per se, but withgiving overall direction to the enterprise, withoverseeing and controlling the executive actionsof management and with satisfying legitimateexpectations of accountability and regulationby interests beyond the corporate boundaries.Corporate governance encompasses theestablishment of systems and processes that shape,enable and oversee management of an organisation.It is the activity, undertaken by governing bodiessuch as boards, of formulating strategy, settingpolicy, delegating responsibility, overseeingmanagement, and ensuring that appropriaterisk management and accountability arrangementsare in place throughout the organisation.Management, on the other hand, is concernedwith doing – with coordinating and managing theday-to-day operations of the business.11Responsibilities ofgoverning bodies forcorporate governanceGood governance is clearly recognised as aresponsibility of governing bodies such as boards:It is the board’s responsibility to ensure goodgovernance and to account to [shareholders]for their record in this regard.12Management has an operational focus, whereasgovernance has a strategic focus. Managers runorganisations, whereas their boards ensure thatorganisations are run well and in the right direction.The governing body derives its authority to conductthe business of the organisation from the enablinglegislation and the organisation’s constitutionaldocuments, where applicable. The board ‘governs’the organisation by establishing a ‘governancesystem’, elements of which are implemented by theboard itself, leaders and the workforce at all levels ofthe organisation. As part of its governance system,the governing body: Establishes a strategic and policy framework Delegates responsibility for operating theorganisation to the chief executive officer, who,in turn, delegates specific responsibilities tomembers of the workforce Supervises the performance of the chief executiveofficer Monitors the performance of the organisationand ensures that there is a focus on continuousquality improvement.* In the public sector, since not all health service organisationsare corporations with a governing board, the term‘organisational governance’ can be used, rather than ‘corporategovernance’.National Model Clinical Governance Framework3
The model described by Tricker for the role andfunctions of governance highlights both theforward-looking (leadership and performance)and retrospective (accountability and conformance)elements of good governance (Figure 1).10The generally accepted governance duties andresponsibilities of a governing body such as a boardinclude: Appointing a chief executive officer, supportingthem to lead the organisation and evaluatingtheir performance In consultation with management, setting andreviewing organisational plans and strategies Endorsing and approving budgets, and majorfinancial and organisational decisions Ensuring that the organisation is be
National Model Clinical Governance Framework i Contents Foreword ii Summary iii Introduction 1 Corporate (organisational) governance of health service organisations 3 Key concepts 3 Responsibilities of governing bodies for corporate governance 3 Clinical governance and the National
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1 Definition of clinical governance used in this review Clinical governance is a systematic and integrated approach to ensuring services are accountable for delivering quality health care. Clinical governance is delivered through a combination of strategies including: ensuring clinical competence,
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