Roles and responsibilities – checklist
Health care teams
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.
Consumer participation
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 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 providing
feedback
Facilitate access to Respecting Patient
Choices Program as appropriate
Involve patients in patient and procedure
identification processes
Attachment G – Roles and responsibilities
Victorian clinical governance policy framework – a guidebook
Roles and responsibilities – checklist
Health care teams
Clinical effectiveness
Level of involvement
Participate
Leadership
No
Opportunity
Not
Applicable
Review date
Health care teams – required activities
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
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
Attachment G – Roles and responsibilities
Victorian clinical governance policy framework – a guidebook
Roles and responsibilities – checklist
Health care teams
Level of involvement
Participate
Leadership
No
Opportunity
Not
Applicable
Review date
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
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
Attachment G – Roles and responsibilities
Victorian clinical governance policy framework – a guidebook
Roles and responsibilities – checklist
Health care teams
Level of involvement
Participate
Leadership
No
Opportunity
Not
Applicable
Review date
Participate
Leadership
No
Opportunity
Not
Applicable
Review date
Health care teams – development activities
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
Level of involvement
Health care teams – required activities
Work within defined 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
Attachment G – Roles and responsibilities
Victorian clinical governance policy framework – a guidebook
Roles and responsibilities – checklist
Health care teams
Level of involvement
Participate
Leadership
No
Opportunity
Not
Applicable
Review date
Participate
Leadership
No
Opportunity
Not
Applicable
Review date
Supervise junior staff and support their
development of skills, knowledge and
competency to provide safe, high quality care
Health care teams – development activities
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
Level of involvement
Health care teams – required activities
Risk management activities:
 risk identification and assessment
 report significant 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
Attachment G – Roles and responsibilities
Victorian clinical governance policy framework – a guidebook
Roles and responsibilities – checklist
Health care teams
Level of involvement
Participate
Leadership
No
Opportunity
Not
Applicable
Review date
Comply with legislative requirements as
outlined in policies such as notification of
deaths to coroner and relevant special
committees and other notifiable incidents
Health care teams – development activities
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 specific time, location and
standardized format
Attachment G – Roles and responsibilities
Victorian clinical governance policy framework – a guidebook