ACT Health
Quality and Clinical Governance Framework
2015 - 2018
March 2015
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TABLE OF CONTENTS
1. Quality
3
Definition of Quality Care
Patient-Centredness (or Experience)
Patient Safety
Clinical Effectiveness
Culture of Quality
Continuous Improvement
3
4
5
7
8
8
2. Clinical Governance
10
Definition of Governance
National Safety & Quality in Health Service Standards
Roles and Responsibilities
10
12
12
Appendices
Appendix 1 Other Documents and References
Appendix 2 Clinical Governance Framework Structure
Appendix 3 Clinical Governance Systems
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17
18
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1. Quality
Definition of Quality
Public health care is a complex and diverse industry that, in the ACT, includes preventative services, such as
population health; primary care services, community and home based care; and acute services, such as emergency
and hospital based care. Whilst diverse in nature, at their core is the belief that a person’s health and wellbeing can
affect their ability to lead a full and rewarding life. When people come into contact with our services, the quality of
our care directly reflects this belief.
To maximise the health and wellbeing of our community, ACT Health has a system through which the organisation is
accountable for continually improving the quality of services and safeguarding high standards of care. (Figure 1)
Lord Darzi in his sentinel NHS white paper (1) describes quality health care as
“a triad of patient safety; clinical effectiveness and patient centred care”
Figure 1
Patient
Centredness
Safety
Effectiveness
Being patient centred, safe and effective enables us to become:
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Safe: avoiding injuries to patients from the care that is intended to help them.
Effective: providing services based on scientific knowledge to all who could benefit, and refraining from
providing services to those not likely to benefit.
Patient-centered: providing care that is respectful of and responsive to individual patient preferences,
needs, and values, and ensuring that patient values guide all clinical decisions.
Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care.
Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy.
Equitable: providing care that does not vary in quality because of personal characteristics such as gender,
ethnicity, geographic location, and socioeconomic status. (2) American Institute of Medicine
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Patient-Centredness (or Experience)
“Patient experience is the sum of all interactions, shaped by an organisation’s culture, that influence patient
perceptions across the continuum of care” (3). Driven by the patient’s interaction with our people, processes and the
physical environment (places), the patient experience domain asks the question ”What does our care feel like to our
patients?”.
A positive patient experience begins with understanding that patients have a right to safe, high quality health care.
This means:
 open and honest communication
 receiving information they need to participate in decisions about their care
 being cared for in an environment that fosters trust in those providing care
 receiving care based on clinical need, not personal characteristics such as gender, disability, ethnicity,
geographic location and socio-economic status.
Figure 2 provides an overview of the various aspects of health service delivery that influence the patient experience.
Figure 2
Patient Experience
People
Processes
Places
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Attitudes
Communication
Education
Training
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Consumer Engagement and
Participation
Advance Care Planning
Access to Services/Care
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Building
Accessibility
Environmental Comfort, e.g.
temperature
Patient centred care is healthcare that is respectful of, and responsive to, the preferences, needs and values of
patients and consumers. The dimensions include:
 respect
 emotional support
 physical comfort
 information and communication
 continuity and transition
 care coordination
 involvement of family and carers
 access to care
ACT Health’s patient experience aim for 2015-2018 is to embed patient and family centred care within the service
culture and to partner with patients in all that we do.
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To bring about a positive patient experience:
 we involve our patients and consumers in the development of information, resources and communication
strategies for consumers, patients, and carers;
 we use consumer complaints, compliments, experience surveys and data from patient experience trackers as
well as information from consumer representatives and community organisations to inform improvements
and have established strategies to involve consumers in improvement activities.
Clinical and non-clinical staff put patients and their families at the heart of everything they do because “going the
extra mile” is important to every patient, every time. Front line staff act on local feedback to improve the patient
experience every day and will engage with consumers when redesigning and improving services. Line managers have
an important role to play in developing a positive culture regarding feedback.
Staff follow the ACT Health Consumer Feedback Management Policy which recognises the importance of seeking and
collecting feedback from our consumers, and supporting them to become more involved in their health and
healthcare. Patients and families are advised of how their feedback has been addressed.
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Patient Safety
We know we are keeping our patients safe through:
 the early identification and prevention of patients at risk of harm through accurate timely clinical
documentation by all members of the multidisciplinary team
 providing leadership that is committed to managing clinical risks and preventing clinical incidents including
reporting of clinical incidents in a timely manner in the Riskman system as and when they occur
 active communication of patient safety issues eg Patient Safety Conversations, Mortality and Morbidity
feedback
 a culture that does not accept behaviours or actions that put patients at risk and acknowledges the place of
the patient and staff experience in their significant contribution to quality safe care.
Figure 3. Keeping our patients safe
How do we know?
Monitoring of
Mortality and
Morbidity
Patient Safety
How do we know?
Risk and
Incident
Management
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Global Trigger Tool Screening
Death Screening
Coronial Data Review
Consumer Feedback Data
Clinical Indicator Data
Clinical Audit
Health Round Table Data
Improving Patient Care Tool Data
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Clinical Review and QA Committees
Open Disclosure
Insurance Claims
Complaints Management Process
Incident Management Process
Reliability Tools
How can we improve?
QI Education
Program
 Ward/Unit Level Program – ‘What Matters to
Us?”
 Divisional Quality and Safety Meetings
 Divisional Level Program – “What Matters to
You?”
How can we improve?  Leadership
 Effective Communication
 Strategic Vision and Alignment from ‘Ward to
Board’ and ‘Board to Ward’
Workforce
 Focus on Staff Experience
 Focus on Patient/Consumer Experience
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Sources of data and information we use to monitor patient safety include:
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Mortality Rates
Mortality in low death DRGs
Sentinel Events
Staff Experience survey
Patient Safety Conversations
Clinical Governance Forums
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Improvement Library Data
Serious Adverse Events
Complication Rates
Re-admission Rates
Consumer feedback
Clinical Indicators
How do we achieve this?
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Local teams are responsible for identifying and managing their own risks and recording incidents and near
misses.
Risks that cannot be immediately dealt with must be recorded in the Risk Register with an action plan
developed. The local safety and quality meetings or National Standard Governance Committees across the CHHS
take responsibility for these and escalate to the next level.
Significant incidents are escalated immediately to the Executive Level.
Participation at Patient Safety Conversations and engagement with the Improving Care Tools Program through
robust data collection are key unit based initiatives within the health services that help improve safe quality
patient care.
Clinical Effectiveness
“Clinical effectiveness is ensuring that the most appropriate treatments, interventions, support and services will be
provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.” NHS
Scotland (4)
Clinical effectiveness is characterised fundamentally by:
 the alignment of evidenced based medicine to evidenced based delivery
 a culture where evaluation of improvement and performance including participation in clinical audit and the
Improving Care Tools Program is commonplace and expected in every clinical service
Clinical effectiveness can be achieved through the:
 development of clinical reliability tools (e.g. guidelines for particular diseases and clinical interventions)
 progressive introduction, use, monitoring and evaluation of evidence based clinical pathways
 monitoring of practice variance using tools such as clinical audit, continuous data measurement, and clinical
indicators
 peer review processes.
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Figure 4: Clinical Effectiveness
How do we know?
Measurement
Clinical Effectiveness
How do we know?
Standards and
Policies
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Patient Feedback and Staff Feedback
Activity Data
Audits
Incident and Risk Information
Clinical Indicator Data
Health Roundtable Data
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Compliance with National Standards
Best Practice and Evidence Based Information
Processes that reflect delivery of Evidence
Based Medicine
Compliance with Clinical Pathways/Guidelines
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How can we improve?
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Quality
Improvement
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How can we improve?
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Workforce
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Application of Improvement Tools (Improving
Care Tools Program) in Everyday Patient Care
Education, e.g. What Matters to You Program
Quality Activities and Projects
Workforce Planning
Scope of Practice
Workforce Skills, Credentialing and Up-skilling
Skill Maintenance
Conduct
Performance Management
ACT Health’s clinical effectiveness aim for 2014-2018 is to redesign services for equity, effectiveness and efficiency.
ACT Health is establishing a multi-faceted redesign strategy to support staff in redesigning clinical services for
improved equity, effectiveness and efficiency. ACT Health is involved in numerous clinical networks within the
Territory and across the ACT/NSW border. Collaboration with neighbouring hospitals and health services ensures
consistency of clinical effectiveness and patient outcomes.
Measures we use to monitor clinical effectiveness are aligned to the clinical indicators portfolio .These are used at
multiple levels within the operational and governance domains to deliver clinical outcomes and assure good
governance as well as operational requirements
ACT Health staff at the front line work to ensure that the standards of care in their local areas are appropriate and
deliver the right treatments and interventions at the right time. Local teams are responsible for delivering evidence
based medicine through alignment with the evidence based medicine integral to the policy, guideline and procedure
register available to all clinical and non clinical staff through the electronic platform of Sharepoint. This platform also
affords easy access to the Improvement Register and Improvement Library which facilitates an understanding of
ongoing work in the patient safety and quality work. This allows all members of staff to be responsible for helping to
“close the loop” and improve patient care.
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Culture of Quality
Achieving quality requires an organisation to create a cultural environment which allows quality to flourish. ACT
Health is committed to a fair, open and just culture, where respect and fairness come first for everyone. Creating the
right conditions for staff is vital to the success of this strategy, and vital to achieving our vision, ‘Your Health, Our
Priority’.
The vision of our culture is aligned to the Berwick Report 2013 (5)
“Place the quality of patient care, especially patient safety, above all other aims. Engage, empower and hear patients
and carers at all times. Foster wholeheartedly the growth and development of all staff including their ability and
support to improve the processes in which they work. Embrace unequivocally and everywhere in the service of
accountability, trust and the growth of knowledge”.
Continuous Improvement
The Service Innovation and Redesign Framework provides ACT Health with a shared commitment to change and
improvement that is consistently patient-centred, clinically effective and safe for all.
Supported at an operational level by the HCIDs Quality Improvement Program, ACT Health is establishing the
environment for improvement to become embedded and sustain positive changes in the quality of our care. This
includes supporting teams to learn about what works and what doesn't, and assisting change to occur at the front
line. This empowering strategy will develop the skills and confidence of our workforce to enable them to take the
initiative, be innovative and focus on quality improvement (see Figure 5).
Continuous Measurement is the hallmark of Continuous Improvement. It means data is continually collected and
reviewed with other indicators to provide an overall picture of how care is delivered. This information assists us to
build a timely and balanced picture of the quality of care being delivered to our patients.
ACT Health will incorporate the lessons learned from Professor Sir Bruce Keogh’s Report (6) to provide assurance
across the organisation from the patient to the Executive. It will measure and monitor a wide range of indicators that
will support the organisation to:
 make better sense of the information obtained
 support the early identification of issues
 validate decisions to improve
 recognise and spread the good practice already evident in wards and departments.
(Appendix 3)
A culture of continuous measurement means we can assure patients, families, carers, the general public, the
government and regulatory bodies that we provide high quality care that includes good experience for every patient,
every time, from a professional workforce that is engaged and supported by the organisation. (Appendix 3)
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Improvement Capability Framework
Figure 5. Quality Improvement Program at Canberra Hospital and Health Services (CHHS)
Level description
Whole of Hospital level“What Matters to You?” Program
Divisional levelQuality and Safety Meetings
Ward/Unit level“What Matters to Us?” Program
Culture and Leadership Roles
The following roles create a culture of continuous improvement.
Front Line Level
Continuous improvement is the focus for all frontline teams and is supported with effective education and training
programs coordinated by the HCID. Local teams participate in monthly patient care or “What matters to us?”
meetings to review all patient care information. The meetings focus on what the data has revealed about the quality
of care including trends, issues and risks. Action plans are developed for areas of priority and are guided by standard
improvement science methodology, which emphasises clinical engagement and communication, measurement of
outcomes and small scale testing.
Divisional Level
Continuous updates on patient care information and improvement activities are prepared by the HCID for each
clinical Division. Divisional quality and safety meetings use this information to monitor quality and safety trends,
inform patient care and drive improvement activities. Meetings are designed to improve collaboration between
disciplines at a senior level and engage with senior clinical staff about local improvement activities. Divisions
nominate issues and activities that are likely to have a Division wide impact, for inclusion in the “What Matters to
You” program. Clinical Governance forums at all levels support quality improvement and provide the platform for
assurance and closing the loop for quality of care.
Executive Director Level
Continuous quality improvement is supported at the Executive level by ensuring the focus of improvement is an
organisation wide agenda and is integrated with corporate governance activities such as how we best use our
financial and human resources.
ACT Health is committed to an overarching quality improvement program under the banner of ‘What Matters to
You’. Ultimately this provides a gateway for quality improvement to be embedded within the organisation. The
‘What Matters to You’ program requires each Division through its Executive Director to nominate a multidisciplinary
team to progress improvement work on a clinical problem which matters to them, in providing care to their patients
or consumers.
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Teams supported by their Executive and Professional Leads, and led by senior medical staff attend a series of
workshops conducted bi-monthly to develop skills in improvement science, planning, measuring and data analysis
techniques to realise their intended improvement. Teams are provided with regular coaching sessions from HCID
staff to support and provide feedback on their progress.
Director-General / Deputy Director-General Level
Monthly information regarding patient safety is reviewed by the CHHS and ACT Health senior executive where
consideration and endorsement of recommendations for improvement is required. Depending on the scope of
improvement the Deputy Director-General CHHS or the Director- General of ACT Health assigns responsibility and
monitors the implementation of the actions arising from the recommendations. Decisions relating to the financial
support for improvement activities are made at this level. An annual improvement showcase recognises innovation
and excellence sharing ideas and learnings between teams and Divisions. Such events are supported and attended
by every level of the organisation.
2. Clinical Governance
Definition of Clinical Governance
“Clinical Governance is a system through which organisations are accountable to the community for continually
improving the quality of their services and safe guarding high standards of care, ensuring they are patient-centred,
safe and effective.“ National Safety & Quality Health Service Standards(7)
Quality care cannot be assured unless there is a system of robust corporate and clinical governance to enable
complete oversight of the complex health system our patients, carers and consumers find themselves in ACT.
The ACT Framework for Quality and Governance is the shared vision for clinical governance, including the
organisational structure and lines of accountability that assures the quality of our services, from the individual
patient to all levels of staff.
According to the National Standards of the Australian Commission on Safety and Quality in Health Care (the
Commission), good clinical governance takes into account local needs and values and exhibits eight major
characteristics (see Figure 6). Good clinical governance is:
 participatory
 consensus orientated
 accountable
 transparent
 responsive
 effective and efficient
 equitable and inclusive
 follows the rule of law.
The Commission advises that good clinical governance requires a culture that has:
 strong strategic and cultural leadership that is focused on:
 Effective planning that enables development and improvement contributions to be captured.
 Cultural leadership that prioritises quality and safety, and supports continuous improvements.
 Allocation of resources appropriately to support delivery of quality care
 clarity of safety and quality management responsibilities and delegation so that the workforce is fully
engaged in the design, monitoring and development of service delivery systems
 reliable processes that ensure systems for delivery are well designed and performing
 effective use of data to monitor and report on performance
 Well-designed systems of identifying and managing risk.
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In practice, good clinical governance focuses on creating an environment in which there is transparent responsibility
and accountability for maintaining standards, allowing excellence in clinical care to flourish.
Figure 6: Clinical Governance
Strong Strategic and
Cultural Leadership
Focusing on effective planning,
cultural leadership and
appropriate resource allocation
Well-designed
systems for
Identifying and
Managing Risks
Clarity of Responsibility
and Delegation of
Responsibility
Effective use of Data
and Information
To monitor performance
and help inform the
governance board
and patient care
Reliable Processes
For ensuring systems for health
care delivery are well designed
and performing AND
Clinicians who are fully engaged in
the design, monitoring and
development of
service delivery
systems
Figure 6 depicts the components and characteristics of the governance system. Eight characteristics support the five
integrated components of governance.
The Quality and Clinical Governance Framework recognises that effective business systems are essential to the
delivery of clinical quality. To that end it is noted that the clinical governance structures described in this document
are built on sound corporate governance and organisational structures. This is represented through:
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comprehensive strategic planning
annual business plans
robust financial management systems and delegations
well articulated management and supervision structures
defined human resource management policies including a sound staff performance management framework
comprehensive staff education programs that address clinical and non clinical issues
risk management systems that identify both clinical and non clinical risk
comprehensive infrastructure and equipment maintenance and replacement programs
key operational metrics that assess both operational effectiveness and clinical quality; and
broad consumer engagement on a wide range of service delivery issues.
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These fundamental organisational platforms must be robust and underpin clinical service delivery and a clinical
governance framework that drives toward continual service improvement.
National Safety and Quality in Health Service Standards
The Commission’s National Safety and Quality Health Service (NSQHS) Standards are a set of minimum requirements
that facilitate national consistency in delivering quality healthcare. The Standards along with the Commission’s
Framework and Goals for Safety and Quality are the skeletal framework on which ACT Health governs the delivery of
safe quality care to our patients, consumers and carers. The Clinical Governance Framework (Appendix 2) outlines
the key relationship between the structures of governance committees and the processes that exist for monitoring
and escalating issues to the highest level of governance. Delivery of the ten National Safety and Quality Health
Service Standards are an implicit part of delivering quality patient care and are integral to our core business as a
health system.
Roles and Responsibilities for Clinical Governance
“Assurance is being confident we are doing the right things, the right way. It is never an accident; it is always the
result of high intention, sincere effort, intelligent direction and skilful execution; it represents the wise choice of many
alternatives" William Foster (8)
All staff have a responsibility and are accountable for the quality of our service. and are therefore responsible and
accountable for good clinical governance. All staff have an obligation to govern safe quality care for every patient
every time.
The model of governance in ACT health is a matrix model. This describes an integrated and collaborative approach
whereby the Executive Directors of each the operational areas govern both the non-clinical and clinical staff within
their respective divisions.
Director-General has overall accountability for both clinical and corporate governance and is responsible for
overseeing progress against strategic objectives.
Deputy Directors-General
Deputy Director-General Canberra Hospital and Health Services
Responsible for overseeing the appropriate implementation and response to clinical governance within
Canberra Hospital and Health Services Divisions.
Business Management & Efficiency – aligned to the Canberra Hospital and Health Service (CHHS)
reviews quality, finance, work force and access information to provide advice regarding business
decisions and priorities. The team supports staff and local teams to use appropriate data and
information across a range of key measures to inform financial decision-making. The team works
closely with the HCID to promote redesign and sustainable service improvement that is both
effective and efficient.
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Deputy Director-General Strategy and Corporate
Responsible for overseeing the appropriate implementation and response to clinical governance within the
following areas:
People Strategy & Services (PSS) supports clinical governance in the provision of recruitment,
workforce planning, organisational and staff development services across all areas of ACT Health.
These services orientate staff to the principles of safety and quality as new, continuing or returning
staff members, and coordinate strategies to ensure the ongoing effectiveness of the workforce.
Staff Development Unit (part of PSS) support clinical teams to deliver education that supports safer
clinical practice and innovative ways of working.
Business Intelligence Unit (part of Performance Information) supports the organisation in patient
indicator measurement, performance monitoring and reporting through the provision of highquality, timely and accessible information to clinicians and managers.
Business & Infrastructure works collaboratively across corporate and clinical arenas to provide
operational infrastructure that meets the clinical governance principles. Identifies establishes and
maintains systems and services which support clinical areas in the provision of effective quality of
service and patient safety management systems aligned with accreditation. This includes, but is not
limited to, sterilising, food, cleaning and business continuity services.
E-Health and Clinical Records provides technical solutions for the management of patient based
information to ensure patient records are available for staff, and contribute to audit and
improvement activities. Ensures requirements for ICT projects are developed using sound business
analytical processes and methodologies and are in line with ACT Government policies. Identifies,
reviews implements and sustains improvements in work practices in collaboration with consumers
and staff.
Workplace Safety coordinates our Work Health and Safety Management System to ensure, so far as
reasonably practicable, the physical and psychological health and safety of workers and other
relevant parties. The ethos of ACT Health is that a safe workforce that supports excellent staff
experiences will provide quality healthcare to every patient every time.
Policy and Government Relations develops and reviews proposed policies to ensure consistency with
other existing or proposed policies and adherence to the Policy Management Framework. Ensures
Directorate compliance with intergovernmental agreements including regular reporting data
requirements and milestone achievements.
Deputy Director General – Health Infrastructure and Planning
Responsible for overseeing the appropriate implementation and response to clinical governance by
incorporating the principles of patient-centeredness, safety and effectiveness into design and construction in
the built environment and planning for future service delivery. Ensures planning is informed by current
information relating to policy and evidence based practice.
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Deputy Director-General - Population Health
Responsible for overseeing the appropriate implementation and response to clinical governance within the
division’s multidisciplinary branches. Co-ordinates emergency preparedness across ACT Health including
planning for business continuity and liaison on preparedness matters with other agencies. Updates
surveillance, investigation and public health management of notifiable diseases. Promotes and co-ordinates
the ACT component of the national immunisation program. Reducing the likelihood or frequency of a
person using the healthcare system is the most effective method to mitigate clinical risk.
Consumer Representatives in partnership with health service organisations, support decision makers to keep the
patient at the forefront when planning services, developing models of care, or measuring, evaluating and improving
systems of care. They have a pivotal partnership role in decision making at all levels of governance in ACT Health.
Executive Director HealthCARE Improvement Division
The role of the HealthCARE Improvement Division is to promote and facilitate a culture of excellence, innovation,
education and research in healthcare improvement through a framework designed for the delivery of a safe and
reliable healthcare system. HCID contributes to the governance of ACT Health through monitoring, facilitating and
supporting appropriate areas and providing guidance to the office of the Deputy Director General for CHHS.
HealthCARE Improvement supports staff in divisions and across divisions to develop improvements utilising
Improvement Science methodology through the Quality Improvement Platform. This is achieved through active
teaching and coaching, facilitation of improvement programs and the provision of information and continuous data
analysis for service improvement.
Chief Medical Administrator provides leadership and support to develop and implement clinical governance across
the organisation. The Office is responsible, through working collaboratively with all Executive Directors and Clinical
Directors, for promoting quality leadership and clinical engagement. The Office sets and assures high standards of
professional and clinical practice through the coordination of medical research and clinical trials; local General
Practitioner liaison; the Junior Medical Officer workforce and credentialing; and scope of practice processes for
medical and dental appointments.
The CMA has specific governance of a cohort of junior medical officers i.e. PGY1 and PGY2. This is coordinated by
the Medical Officer Support Credentialing Education and Training Unit (MOSCETU)
All other medical staff including Registrars are governed by the Executive Director of the respective clinical divisions.
Chief Nurse provides leadership to the nursing and midwifery workforce to develop, implement and support
continuous quality improvement in the delivery of safe, effective and patient-centred care and services. Sets and
assures high standards of professional and clinical practice through supportive systems and processes of clinical
governance, including practice development, role development, education and continuing professional
development, workforce planning, and participating in research, audit and evaluation processes. Responsible for
promoting quality leadership and clinical engagement by working collaboratively with all Executive Directors and
Directors of Nursing and Midwifery.
Chief Allied Health Officer (CAHO) provides professional and strategic leadership and high level advice on a broad
range of allied health issues including clinical governance and professional practice, regulation of practice, policy,
workforce reform and innovation, continuous quality improvement and research and education. Advice is provided
at multiple levels including locally to ACT Health and the broader ACT Government as well as to other government
and non-government agencies as relevant. In addition, CAHO liaises and works closely with other state and territory
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jurisdictional Chief Allied Health Offices and colleagues on strategic issues affecting the health care workforce and
allied health professionals in Australia.
CAHO has strong partnerships with a range of vocational and tertiary institutions, regulating authorities, professional
associations, other government agencies and key stakeholders to support the work undertaken by the Office.
Executive Directors are responsible and accountable for ensuring appropriate and effective clinical governance
arrangements are in place, and that activities to improve quality outcomes are occurring within their Divisions.
Executive Directors who are also aligned to the National Standard as Executive Sponsors are responsible for the
delivery of specific governance priorities within their respective Standards .They are required to work collaboratively
with all members of the CHHS Executive Committee and the ACT Health Executive Directors Council Quality and
Safety Committee to deliver a robust, transparent and accountable operational framework for their respective
Standard.
Professional Directors (Clinical Directors (CDs), Directors of Nursing/Midwifery (DONs/DOMs), Directors of Allied
Health (DAHs) are responsible and accountable for ensuring appropriate and effective clinical governance
arrangements are in place, and that activities to improve quality outcomes are occurring within their Divisions.
Directors who are also National Standard Leads or manage Clinical Governance Sub Groups, such as the Drugs and
Therapeutic Committee, are responsible for the delivery of specific priorities within clinical governance.
ADON/Ms, Service, Unit and Team Leaders are responsible for effective clinical governance, risk management and
the implementation of continuous improvement. Managers should take action, both proactively and reactively, in
relation to workforce development, risk management and dealing with patient feedback. In addition they ensure a
high quality service to patients by the continual development of practice according to research evidence and
national standards.
Staff who come into contact with patients or work within the clinical setting take responsibility for promoting the
health, safety and security of patients and carers, the public, colleagues and themselves and to contribute to a
positive patient experience. They are encouraged to suggest and implement improvements in their communities,
wards, areas and departments. All staff are expected to work within their scope of practice.
Patients and carers in partnership with their healthcare providers, are responsible for participating in shared
decision making about their treatment and can promote quality by raising concerns about the safety or effectiveness
of the care they are receiving. Patients and carers are encouraged to tell us about their experience and suggest
improvements to our services.
The assurance of clinical governance in ACT Health is illustrated in Appendix 2. It details the forums used at the
different levels of the organisation where information, data and clinical risks are reported to, and used to inform the
provision of high quality patient care and treatment.
“We can achieve this by acting together across the traditional boundaries of our different roles and responsibilities;
concentrating our will to care, the skills we have acquired, and the resources at our disposal – in order to give our
patients – all of them, whatever their means, wherever they are – the best and safest care that a good health service
can deliver”. Scally and Donaldson(9)
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Appendix 1: Other Documents
Documents relating to the National strategic direction:
National Safety and Quality Health Service Standards
Australian Safety and Quality Framework
Australian Safety and Quality Goals for Health Care
ACT Health Policies:
Consumer Feedback Management
Consumer and Carer Participation Policy
Risk Management
Significant Incident Policy
Incident Management
Corporate Governance Statement
Safety Management System
Towards Culturally Appropriate and Inclusive Services, A Co-ordinating Framework for ACT Health 2014-2018
Other source documents include:
Clinical Governance Standards for Western Australian Health 2005
Standard 1 Governance National Safety and Quality in Healthcare Standards Improvement Guide 2012
Standard 2 Partnering with Consumers National Safety and Quality in Healthcare Standards
Improvement Guide 2012
Beryl Institute 2014
NHS High Quality Care for All 2008
ACT Health Corporate Governance Statement (Revised January 2015)
ACT Health Business Plan 2014-2015
References
1. Darzi, Lord Ara, June 2008 High Quality Care For All NHS - Next State Review Final Report
2. American Institute of Medicine, 2002, Crossing the Quality Chasm A New Health System for the 21st
Century
3. The Beryl Institute 2014
4. NHS Scotland Healthcare Quality Strategy, 2010
5. Berwick, Don, August 2013 National Advisory Board on the Safety of Patients in England A Promise to
Learn a Commitment to Act - Improving the Safety of Patients in England.
6. Keogh, Professor Sir Bruce KBE A Review into the Quality of Care and Treatment provided by 14 Hospital
Trusts in England NHS, July 2013
7. Australian Commission on Safety & Quality in Healthcare National Safety & Quality Health Service
Standards
8. Foster, William A, New York Times, 1939
9. Scally, Gabriel and Donaldson, Liam J Clinical Governance and the Drive for Quality Improvement in the
New NHS in England BMJ 1998; 317:61
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Appendix 2: Clinical Governance Framework Structure
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National Standard Governance
1. Governance Standard Governance
2. Partnering with Consumers Standard Governance
Partnering with Consumers
National Standard Group 2
Sub-Committees / Reports


Consumer Handout Committee
HIP Service Planning User Groups (Health Infrastructure & Planning)
Branch/Divisional/Unit/Service Clinical Governance or Safety & Quality Meetings
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3. Healthcare Associated Infection Standard Governance
4. Medication Safety Standard Governance
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5. Patient Identification Standard Governance
Patient Identification
National Standard Group 5
Sub-Committees / Reports

Branch/Divisional/Unit/Service Clinical Governance or Safety & Quality Meetings
6. Clinical Handover Standard Governance
Clinical Handover
National Standard Group 6
Sub-Committees / Reports

7. Blood and
Blood Products Standard
Governance
Branch/Divisional/Unit/Service
Clinical
Governance or Safety & Quality Meetings
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7. Blood and Blood Products Standard Governance
8. Pressure Injury Standard Governance
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9. Clinical Deterioration Standard Governance
10. Falls and Falls Injury Management Standard Governance
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Appendix 3: Quality and Clinical Governance Systems
Quality and Clinical Governance Systems used throughout ACT Health include but are not limited to the following
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