Appendix 6
LOGO
Model Community Health Service
CLINICAL GOVERNANCE POLICY AND
PROCEDURES
Approval Date:
Review Date:
Page x of xx
Authorised by: DRAFT
1.
POLICY
Model Community Health Service is committed to ensuring that clients receive high quality
services. The Board of Management is responsible for ensuring good clinical governance,
and the CEO, Managers, Staff, Department of Human Services, and Community all have a
role to play in the process.
2.
PURPOSE AND SCOPE
The purpose of the clinical governance policy is to provide a framework to ensure that all
practitioners employed at Model Community Health Service provide a high quality service. It
will ensure that systems are in place to support, evaluate, and report on safety and quality
across the organisation. The policy defines levels of responsibility across the whole
organisation.
3.
REFERENCES
 Better Quality, Better Health Care - A Safety and Quality Improvement Framework for
Victorian Health Services. The Victorian Quality Council DHS 2003.
 Enabling the Consumer role in clinical governance. The Victorian Quality Council
DHS, 2004.
 The Healthcare Board’s role in clinical governance- The Victorian Quality Council
DHS, 2004
 Leading clinical governance in health services: The Chief Executive Officer and
Senior Manager roles. The Victorian Quality Council DHS, 2005
 Developing the clinical leadership role in clinical governance: A guide for clinicians
and health services. The Victorian Quality Council DHS, 2005
 Health and Community Services Core Module. Quality Improvement Council (QIC) 2004
 Occupational Health and Safety Act 2004
 Model CHS Board of Management Clinical Governance Policy
 Other relevant CHS Policies eg.
Client Access Policy
Assessment and Care Policy
Client Record Policy
Recruitment Policy
Performance Appraisal Policy
Staff Development Policy
Occupational Health and Safety Policy
Service Review Policy
Client and Community Engagement Policy etc…
4.
DEFINITIONS
Clinical Governance
A “framework through which health organisations are accountable for
continuously improving the quality of their services and safeguarding
high standards of care by creating an environment in which
excellence in clinical care will flourish”
Sir Liam Donaldson, NHS Chief Medical Officer
“The responsibility of governing bodies to demonstrate sound
strategic and policy leadership in clinical safety and quality, to ensure
appropriate safety and quality systems are in place, and to ensure
organisational accountability for safety and quality.”
Dr Heather Wellington
Appendix 6
Features of a quality
organisation
A quality organisation is Efficient, Legal, Accountable, Sustainable,
Participatory, Reflexive, Integrated, and its services and programs
are Effective, Competent, Safe, Accessible, Fair, Responsive,
Inclusive and culturally sensitive, Coordinated and has a culture of
continuous quality improvement.
Quality Improvement Council 2004
5.
CLINICAL GOVERNANCE FRAMEWORK
Model Community Health Service is a complex organisation with staff from a range of health
and community service professional backgrounds. To ensure a system of safety and quality
across the service, a clinical governance framework has been developed that each discipline
will use to develop, implement, monitor, improve and report quality and safety activities.
This framework is based on the Victorian Quality Council and QIC guidelines. It outlines four
key organisational elements and six quality dimensions to be considered.
The framework takes a systems approach, ensures a systematic and comprehensive
reporting process, and will ensure that action will be taken on issues identified in a timely
manner. Some aspects of the framework involve organisation wide structures and processes
whilst others are more relevant at the discipline level.
ORGANISATIONAL ELEMENTS
Governance, Leadership & Culture
This includes the structures and processes put in place by the board to meet its governance
obligations and can include:
 Governance Policies
 Organisational Structure
 Strategic & Operational Planning
 Planning & Evaluation Cycle
 Board Reporting requirements
 Delegation of Authority – Financial, Staffing, General
Consumer and Community Involvement
This includes consumers of the service, their families, carers, members and the community
generally. Processes to achieve include:
 Elected Board Members
 Client satisfaction surveys and focus groups
 Client involvement in service reviews
 Client complaints processes
Competence of and education to support service providers
This includes competencies of the organisation as a whole, as well as specific teams, and
individuals who deliver services. Processes in place to achieve this include:
 Recruitment of qualified, experienced professionals
 Annual performance appraisals for all staff
 Professional development
 Staff supervision
 Credentialing
Information Management & Reporting
This includes collection of data, technology necessary for data collection, the reliability and
validity of the data and how it is reported and used. To support the processes, data should be
available, accurate, timely and relevant. Processes include:
 Complaints reporting
 Incident reporting
 Activity reporting
Appendix 6
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
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Wait List reporting
Strategic & Operational Plan reporting
Client Records Audits
DIMENSIONS OF QUALITY
Safety
Clients should be safe both in the environment and with the treatment they receive. All
potential safety risks need to be identified and processes developed to eliminate or minimise
the risks. This is achieved through:
 Accreditation audits (QICSA / HACC / GP)
 Audits – eg. Infection control / Food Safety / Drug Storage
 Incident review
 Complaints review
Effectiveness
Clients expect to benefit from any treatment they receive. To evaluate this, outcome
measures need to be used. A range of measures appropriate for the service provided should
be considered. Measures include:
 Clinical Indicators
 Client satisfaction surveys
 Client complaint processes
Appropriateness
Practitioners need to provide services based on evidence so that the right intervention occurs
for the clients at the appropriate time. Processes to ensure this include use of:
 Clinical pathways
 Standardised assessment tools
 Client care plans
 Client record audits
Acceptability
Acceptability describes whether or not the service meets the needs and expectations of the
range of informed consumers. Processes in place for achieving this dimension include:
 Strategic Planning (includes community and consumer consultation)
 Complaints monitoring
 Client satisfaction surveys and focus groups
 Staff professional development
Access
Access to services should be equitable across the catchment area and for different
community groups. Processes in place to support access include:
 Standardised intake systems
 Service information
 Interpreter systems
 Outreach services
 Demand management systems
 Fee Policy
 Accessible buildings
Efficiency
Efficient use of resources includes examining both cost of services and benefits to
consumers. Current processes addressing efficiency at DCH include:
 Service planning, reporting and evaluation frameworks
 Financial monitoring
Appendix 6
For all of the quality dimensions listed above, each discipline will identify relevant issues, and
develop systems to support monitoring, identifying continuous improvement opportunities,
and mechanisms for reporting on the area.
6.
LEVELS OF RESPONSIBILITY
Board of Management
 have overall responsibility to ensure that the organisation has a quality and safety
management system in place, and to receive regular reports against this system
CEO & Management Team
 have responsibility for development, implementation and review of the system
Practitioners
 have responsibility to be involved in the development, implementation, review and
reporting of the system related to their work
Consumers, the community and other stakeholders
 should be involved in the process as appropriate
Different CHSs will choose the appropriate methodology through which the responsibilities for
clinical governance are enacted. This may be achieved through a Quality Committee or the
existing management meeting structures.
7.
PLANNING AND REVIEW
Model Community Health Service undertakes a comprehensive planning and review process
based on a three yearly cycle. This is monitored annually via a Planning, Reporting &
Evaluation Schedule. The Strategic Plan is reviewed annually leading to the development of
annual Operational Plans which are monitored quarterly.
8
INDIVIDUAL SERVICES
Each service undergoes a full review every three years. This review will focus on all the
dimensions of quality. A summary of this review plus any resulting recommendations are
forwarded via the management group to the Board of Management.
In addition to the above review, each service will develop a report for the Board of
Management annually that outlines current safety & quality processes and intended quality &
safety improvement initiatives.
9
EXTERNAL QUALITY ASSURANCE PROGRAMS
Model Community Health Service undergoes a number of external formal accreditation
programs. These occur in three year cycles commonly with mid-cycle review processes.
They include Quality Improvement Council Service Accreditation (QICSA), Home and
Community Care (HACC) National Standards Accreditation, General Practice (GP)
accreditation, other systems.
10
BOARD REPORTING
A variety of reports are forwarded to the Board for consideration. These include:
Strategic plan review
Annual operational plan
Operational plan progress reports
Service quality & safety system processes
Service review reports
Audit of client complaints
Quality improvement reports
Adverse event reports
Activity reports
Annually
Annually
Quarterly
All services once per year
All services once every three years
Six monthly
As developed
As occur
Quarterly
Appendix 6
Wait list reports
11

Quarterly
DOCUMENTS
Board Reporting Proforma.
12
Date
HISTORY
Initial Issue
Appendix 6
Name and logo of
community health
service
Approval date:
Clinical Risk
Management Policy
and Procedure
Authorised by:
1.
Review Date
Page x of xx
DRAFT Jan-06
POLICY
The Community Health Service is committed to providing clients with high quality
clinical services. This is achieved by ensuring that clinical governance systems are in
place including a Clinical Risk Management Framework. The responsibility for clinical
governance lies with the Board of Management, through the CEO, with input from
management, staff, the Department of Human Services (DHS) and the community.
2.
PURPOSE AND SCOPE
The purpose of this policy is to provide a structured approach to clinical risk
management within a clinical governance framework that ensures that all
practitioners employed at the Community Health Service provide a high quality
clinical service. Systems have been developed that will ensure that potential clinical
risks are identified, analysed, evaluated and subsequently eliminated, reduced or
controlled. Both managers and clinical staff are involved in this annual process.
3.
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
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4.
REFERENCES
Clinical Risk Management Guidelines for the Western Australian Health
System Information Series No. 8, Department of Health, Government of WA
2005
Australia/New Zealand Standard on Risk Management AS/NZS 4360:2004
Community Health Service Policies
o Risk Management Policy
o Clinical Governance Policy
o OHS Policy
o Other relevant policies
DEFINITIONS
RISK
The exposure to the possibility of such things as economic or
financial loss or gain, physical damage, injury or delay, as a
consequence of pursuing a particular course of action. The
concept of risk has two elements: the likelihood of something
happening and the consequences of it.
RISK ANALYSIS
The systematic use of available information to determine how
often specified events may occur and their likely consequences.
The purpose of risk analysis is to identify the causes, effects
and magnitude of risk and provide a basis for risk assessment
and risk treatment.
RISK
ASSESSMENT
The processes used to determine risk management priorities by
evaluating and comparing the level of risk against
organisational standards, predetermined target risk levels or
other criteria.
RISK
The process of determining what can happen, why and how.
Appendix 6
IDENTIFICATION
RISK
MANAGEMENT
The systematic application of management policies, procedures
and practices to the task of identifying, analysing, assessing,
treating, monitoring and communicating risk.
RISK
TREATMENT
The selection and implementation of appropriate management
options for dealing with identified risk.
5.
PROCEDURE
To ensure a system of safety and quality across the service, a clinical risk
management framework has been developed that each discipline will use to develop,
implement, monitor, improve and report quality and safety activities.
The five-step Clinical Risk Management process is based on the risk management
process outlined in the Australian and New Zealand Standard (AS/NZS) 4360:2004.
These are:
1.
2.
3.
4.
5.
Establishing the Context
Clinical Risk Identification
Clinical Risk Analysis
Clinical Risk Evaluation
Clinical Risk Treatment
The framework takes a systems approach, ensures a systematic and comprehensive
reporting process, and will ensure that action will be taken on issues identified in a
timely manner. Each discipline will be responsible for developing its own clinical risk
framework, which will then feed into an organisational risk register.
In addition, monitoring and review are essential components of the risk management
process. It is essential that clinical risks and risk treatment plans, strategies and
management systems are continually monitored to ensure that the organisation is
able to control the implementation of risk treatments.
5.1
Establishing the context
The goals, objectives, strategies, scope and parameters of the activity, or part of the
organisation to which the clinical risk management (CRM) process is being applied,
should be established. To assist in this process, each discipline or program area
should engage in an annual planning process or service plan. This will identify clinical
processes that take place within the service and assist in identification of actual or
potential risks.
5.2
Clinical risk identification
Risk identification seeks to identify the clinical risks that need to be managed. A
comprehensive identification system using a well-structured systematic process is
critical, because a potential risk not identified at this stage will be excluded from
further analysis and treatment.
There are a number of methods for identifying clinical risks. These include: sentinel
event reporting; incidents reporting; complaints data; flow charting/systems design
review; audits or physical inspections; SWOT analysis; networking with peers,
professional groups and industry bodies; FOI requests or medico-legal data.
Appendix 6
Key questions to be asked include:
o What, when, where, why and how are the risks likely to occur and who might
be involved?
o What is the source of each risk?
o What are the consequences of the risk?
o What are the health service’s external and internal obligations?
o Is any further research needed into specific risks?
o How reliable is the information?
o Have the right people been involved in the risk identification process?
o Can it be benchmarked with peer organisations?
5.3
Clinical risk analysis
Analysis of identified risks is a systematic process that seeks to understand the
nature of the clinical risk. During this process, the likelihood and consequence of
each clinical risk are then examined in detail and a risk rating is given according to a
Risk Assessment Matrix. Risks may be rated as low, moderate, high and extreme
and prioritised accordingly.
Steps in this process are:
1.
2.
3.
4.
Determine the adequacy of existing controls
Determine the likelihood of the clinical risk
Determine the potential consequences of the clinical risk
Calculate the level of clinical risk according the following formula
Risk level = Consequence x likelihood
5.4
Clinical Risk Evaluation
Clinical risk evaluation involves comparing the level of risk found during the analysis
process with previously established risk criteria. The output of a clinical risk
evaluation is a prioritised list of risks for further action.
Once the risks are ranked and measured, it should be determined which of the risks
the organisation is prepared to accept and at which level of the organisation they
should be managed. Other options for risk treatment include referral of the risk to a
higher authority for acceptance, amending the activity or task so that the level of risk
is reduced, or lastly, to cancel the activity or task.
5.5
Clinical Risk Treatment
Clinical risk treatment involves identifying the range of options for treating clinical
risk, assessing those options, preparing risk treatment plans and implementing them.
Where risks cannot be eliminated, a combination of treatment options should be
applied to control or treat the risks to the maximum extent possible. Each treatment
option should be evaluated for effectiveness.
Alternative treatment options may include
1. Avoiding the clinical risk
o not proceeding with the activity where the risk is occurring
2. Reducing the level of clinical risk
Appendix 6
o
reducing either the consequences or the likelihood of the risk through
enhancement of existing controls or additional controls
o it is essential that the organisation provide the resources for risk reduction
as required
3. Transferring the clinical risk
o the risk may be shared with another party (transferred by contract,
administrative processes etc)
4. Retaining the clinical risk
o in instances where it is too costly or impossible to avoid, reduce, transfer
or eliminate the risk, the decision to retain the risk should be documented
and listed on a centralised risk register
o periodic monitoring is essential
o contingency plans may be required
Documentation
It is essential for an appropriate level and standard of documentation to be
maintained. This will ensure correct clinical risk management process; enable
decisions, action plans and processes to be communicated internally and externally
as required; demonstrate an appropriate audit trail and provide all staff with accurate
information regarding the organisation’s risk management processes.
Monitoring and review
Monitoring and review of the organisation’s clinical risk management framework is an
essential part of the process. New clinical risks need to be identified and old clinical
risks should be treated and then removed form the register as required. Monitoring
may include internal or external audits, performance reviews, reviews of incident and
investigation reports, review of organisational strategies and policies and program
evaluation. It is recommended that a formal internal review take place annually.
6.
DOCUMENTS
o
7.
DATE
Clinical Risk Management Framework for Community Health Services in
Victoria
HISTORY
Initial Issue