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2026 National Model for Clinical Governance: Practical guide to implementation

This guide is designed to support health services to apply the new 2026 National Model for Clinical Governance (the national model) as an enabler of consistently high-quality care.

It proposes five high-level steps to guide planning for effective implementation of the national model. Health services can use the national model to strengthen current clinical governance arrangements.

The guide supports integrating the national model into governance structures and processes.

It is based on extensive feedback gathered during development and refinement of the national model, as well as implementation evidence and consultation with a broad range of health services on what works well when implementing new guidance on clinical governance.

We thank Dr Cathy Balding for her leadership and expertise in developing this guide. 

 

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Dr Balding specialises in designing and implementing quality and clinical governance systems for impact at the point of care. The guide and practical tools draw on her research and decades of experience working with boards and health system leaders in these areas.

Download the National Model for Clinical Governance

Download the National Model for Clinical Governance
Download the practical guide to implementation

Download the practical guide to implementation

How to use this guide

Everyone begins implementation in a different place. The guide should be used with your existing systems, implementation processes and state, territory and corporate requirements. You may choose to follow the steps in order, or use some of the steps as building blocks to help align your clinical governance system with the national model.

If your clinical governance system is well evolved, you might use the guide as a high-level status check of your own framework and approach. Alternatively, you may decide to use the national model as an opportunity to perform a large-scale review and evolution of your clinical governance system.

Wherever you’re starting, a key to productive implementation of the national model is to agree on a definition of success that can guide planning and assessment of progress and results. Without this, implementation can become an end in itself, rather than a means to achieving the quality of care your organisation wants to be known for. 

Effective implementation that makes a real difference to care requires leadership, planning and sustained focus. Board and executive ownership is a cornerstone of success. Allocate sufficient time and resources to get it right. 

Clinical governance success can be defined as the extent to which it achieves the central aim stated in the national model: ‘delivering care to patients that is consistently high quality and improving’. 

What are the implementation steps?

Compare the national model with your clinical governance system:

  • identify what to introduce and what to adapt.

Develop and approve an implementation plan: 

  • engage consumers and the workforce (including staff and contractors)
  • prioritise changes
  • assign leaders and timelines
  • align with strategic and operational plans.

Introduce the national model and implementation plan: 

  • discuss your approach with the board, executive, senior leaders, managers, consumers and the workforce.

Roll out the implementation plan: 

  • update roles, routines and committee terms of reference and agendas to integrate changes into governance and systems that support everyday work.

Monitor and report on progress: 

  • track measures of progress and output
  • periodically review clinical governance maturity.

What is included in each step?

Suggested activities

To be applied as relevant alongside local, state, territory or corporate clinical governance and implementation processes.

Outputs

Desired results and deliverables for the step.

Questions for reflection on implementation

Prompts for boards and executives to review their role and progress in each step.

Tools

Companion tools to support the steps (recognising that organisations will also use local, state, territory and corporate implementation tools):

The tools are examples only and should be adapted for local needs.

Step 1: Compare the national model with your clinical governance system

The first step for many organisations will be to identify the key gaps between the national model and their internal clinical governance system. 

The gap analysis should be done using your usual processes for assessing any external framework or policy to be implemented. For example, in some organisations, the clinical governance manager or team will produce an initial gap analysis before planning starts. For others, the executive, a committee or a working group may identify key changes required and will plan the organisational approach. Multi-site health services may rely on a corporate office assessment and local reviews. The foundations of clinical governance in the national model may be allocated to subject matter experts.

Whatever approach is taken, the analysis will only be useful if it is based on the reality of how well your current clinical governance system supports consistently high-quality care.

Use the assessment to reflect on opportunities as well as gaps, asking these questions:

  • What do you do well?
  • What could you stop doing?
  • Could you fix some clinical governance pain points for your clinicians and managers?
  • How could implementing the national model make it easier and more beneficial for the workforce to engage with the clinical governance system?

Use evidence to assess the status of your clinical governance system against the national model and seek feedback from patients, carers, consumers and clinicians where required to confirm gaps and strengths.

Top Tips

DO: focus on clarity: describe the changes in concrete and measurable terms.

DON’T: change or replace things you already do well.

Suggested activities

  • Use the snapshot of key changes to compare the intent and content of the national model with your current internal clinical governance system. This will give you a big-picture view of any significant changes required to align your system with the national model and help you assess your implementation scope.
  • Conduct a more detailed comparison of your clinical governance system to compare it to content in the national model, such as roles in high-quality care, examples of good practice and warning signs.
  • Identify changes required to align with the national model. Consider classifying these, for example:
    • What will you introduce (requires development and implementation)?
    • What will you adapt (update or improve the current system)?
    • Which of these changes are major (e.g. significant gap, policy and practice change, poses a key risk) and which are minor (e.g. document changes)?
    • What will you stop doing (e.g. activities not aligned with the national model and not adding value)?
  • Use the implementation maturity scale to establish your baseline status and to track and report progress.

Outputs

  • Organisational gaps are identified and classified as ‘introduce’ or ‘adapt’ activities with major or minor implementation impact.
  • The maturity status of your clinical governance model implementation is rated.

Tools

Implementing the national model is not only about enhancing your current processes; it is also an opportunity to streamline and simplify your clinical governance system.

Reflective questions

Board

  • Do we have evidence that supports the gaps and risks identified in the plan – and what risks should be included in the risk register?
  • Are we satisfied that the plan reflects the intention to better support high-quality care in our organisation?
  • Is there clear integration with existing processes, such as plans for workforce wellbeing, care quality, and diversity, equity and inclusion?
  • Have we identified how we will track and oversee progress?

Executive

  • What are our collective and individual implementation roles?
  • What do our leadership and management teams need from us to support effective implementation?
  • How can we guide implementation to have a positive impact for patients and the workforce at the point of care?

Step 2: Develop and approve an implementation plan

The gap analysis and planning process provide an opportunity to clarify the right big-picture aim for implementation in your organisation. Will you use the national model to enhance an already mature and well-functioning clinical governance system, or seize the opportunity for a major review and evolution of your clinical governance effectiveness? Clarity of purpose will support effective implementation.

The implementation plan should support your aim in a way that is useful for the workforce and achieves high-quality care with patients, as described in the national model (or as described in your organisation’s definition of high-quality care, aligned to the national model).

Use your usual processes to develop the plan. It may be drafted by the clinical governance manager or team, an executive or a working group; or may be developed or led by a corporate or regional office. Similarly, each organisation will have its own process for approving and monitoring the plan.

At a minimum, the plan will describe:

  • gaps
  • risks and priorities
  • key implementation actions
  • timelines and responsible leads.

The implementation plan may also identify oversight committees, measures of progress and outputs, and how these will be reported. For some services, the organisational business or quality plan (or equivalent) may be the implementation vehicle. Some organisations will include a communication plan while others will develop this separately.

Top Tips

DO: build implementation into existing roles and structures, shared across the executive team.

DON’T: present implementation of the national model as a set of tasks with no benefit. 

Suggested activities

Plan development

  • Involve those responsible for implementing the plan. Obtain input from consumer representatives and the workforce to reflect their perspectives on implementation. Clinical leaders and managers, in particular, should be consulted on practical implications of proposed changes.
  • Prioritise implementation activities to focus first on major gaps, particularly those that pose a risk to patients and/or the workforce. Add identified risks posed by gaps to your organisation’s risk register, where appropriate.
  • Set current and desired implementation maturity.
  • Note key changes to be made to your clinical governance framework.
  • Show where implementation links with existing processes such as quality and equity plans.
  • Incorporate measures of progress and how, when and where these will be reported.

Plan approval

Seek implementation plan approval using your usual governance channels. This may require:

  • developing shared executive and board understanding of the intent of the national model, how it supports strategic aspirations for high-quality care, and implications for your organisation’s clinical governance system (are you adjusting or renewing it?)
  • showing how the implementation plan will address gaps and associated risks and support high-quality care
  • clarifying board and executive roles in overseeing and operationalising implementation, and how reporting on the plan will integrate with existing processes for reporting care quality
  • appointing an executive implementation leader, operational steering group (existing or new) and board oversight committee.

Cultivate board support by linking model implementation with strategic and operational priorities. How can the national model drive your organisation’s aspiration for high-quality care and support your clinical governance system to be more purposeful?

Outputs

  • Shared board and executive understanding of intent, content and benefits of the national model is achieved.
  • Current and desired national model implementation maturity is identified.
  • Required changes to the internal clinical governance framework are documented.
  • The prioritised implementation plan is approved and executive leader is appointed.
  • The structure and process for governance and operational oversight of progress and reporting are established.

Tools

Reflective questions

Board

  • Do we have evidence that supports the gaps and risks identified in the plan – and what risks should be included in the risk register?
  • Are we satisfied that the plan reflects the intention to better support high-quality care in our organisation?
  • Is there clear integration with existing processes, such as plans for workforce wellbeing, care quality, and diversity, equity and inclusion?
  • Have we identified how we will track and oversee progress?

Executive

  • What are our collective and individual implementation roles?
  • What do our leadership and management teams need from us to support effective implementation?
  • How can we guide implementation to have a positive impact for patients and the workforce at the point of care?

Step 3: Introduce the national model and implementation plan

Introducing the national model and implementation plan should enable the workforce to understand and relate to their clinical governance role as described in the national model. Large organisations may use a communications team to do this, while others will develop their messaging through the executive lead and/or implementation steering group.

Use the example key messages to develop messaging on a mix of general information about the national model, targeted guidance on implementation in your organisation, and enacting clinical governance roles.

Focus on supplying workforce groups with the information they need to engage with clinical governance changes. Most people will not need to know all the details to enact their role.

Apart from the board, executive, clinical governance manager/team and senior clinical leaders who require detail on implementation intent and process, most of the workforce will want answers to questions such as:

  • Why is there a new national model?
  • Does this mean we have to change everything?
  • How will this help patients?
  • What will this mean for me in my everyday work?
  • What do I need to do now?

The purpose of sharing the national model and implementation plan goes beyond raising awareness; it is about achieving clarity on the required changes and building commitment to the changes.

Top Tips

DO: emphasise the benefits of the changes to patients, carers, consumers and the workforce.

DON’T: overwhelm people with information they don’t need. Focus on people’s roles and how they will use the national model, and provide them with information that helps them enact their responsibilities.

Suggested activities

  • Prepare and approve key messages:
    • how the national model is different: what is changing and why, and how it can improve the quality of care
    • what it means for patients, leaders, managers and the workforce: key changes, how they’ll be implemented and how roles will be supported
    • implementation steps and where to get help or further information.
  • Identify and equip a network of subject matter experts in your organisation to introduce the national model, deliver and reinforce key messages and answer questions. These may be people who are already involved in clinical governance, clinical leaders, consumer representatives and other influential people.
  • Determine channels for distributing the information. These may include:
    • messages from the CEO
    • online and in-person meetings and forums such as grand rounds, team meetings and huddles
    • information sessions
    • existing education and onboarding sessions, information hubs and portals, reward and recognition processes and informal channels such as newsletters, competitions, quizzes and posters.
  • Gather feedback on messaging from consumer groups and the workforce.
    • Are the messages landing well?
    • Is the purpose of the national model clear?
    • Do people understand the national model and the key changes that relate to their roles?
    • Are clinical governance roles clear?

Outputs

  • Key messages and the distribution plan are developed and implemented.
  • A network of subject matter experts promotes the national model and internal implementation steps and roles.
  • Consumer committees and groups, senior leaders and managers provide feedback on their understanding of the intent of the national model and key changes.

Use messaging to position the national model as a positive and practical enabler of high-quality care.

Tools

Reflective questions

Board

  • Do we have a shared understanding of key messages about implementing the national model?
  • How will communication effectiveness be reported to us?

Executive

  • What is our process to make sure that different workforce groups receive the information they need?
  • How will we know how well the national model and the implementation plan are understood?
  • How will we align our implementation actions and key messages for consistency?

Step 4: Roll out the implementation plan

Your clinical governance framework will require modifications, either major or minor, to align with the national model. You are not expected to redevelop your framework to replicate the national model. The important thing is that the intent and content of the national model are clearly reflected in your clinical governance framework and are therefore integral to your clinical governance system.

Incorporate the national model content as required into your clinical governance system and processes, such as board, executive and consumer group agendas, executive business and quality plans, role descriptions, policies and procedures.

Operationalising the national model cannot happen without executive leadership and management. The executive team has both individual and collective implementation roles. Individually, executives are responsible for enabling and equipping their divisional leaders and managers to understand their clinical governance roles, including responsibilities for enacting any changes.

Collectively, the executive team models leadership that supports effective implementation and ensures that new and adapted clinical governance activities are integrated into organisational systems that support patient care.

If the workforce doesn’t perceive the changes as helping them to deliver high-quality care, they will view the changes as just more work. Implementation should aim to embed the content of the national model as business as usual, with the primary intention of supporting the workforce to deliver consistently high-quality care. Prioritise both systems improvement and areas of risk for patients and the workforce.

Top Tips

DO: emphasise with consumers and the workforce what you are doing well. Effective implementation of the national model doesn’t reinvent the wheel but builds on and enhances your clinical governance system.

DON’T: create new clinical governance structures and committees if implementation of the national model can be integrated into existing mechanisms that support high-quality care.

Suggested activities

  • Develop an implementation support structure, led by the appointed executive lead, e.g. tap into existing working groups or committees, or convene a steering group to drive and monitor actions in the implementation plan.
  • Modify your internal clinical governance framework as required to encompass new content in the national model.
  • Allocate implementation actions to relevant executive, divisional and service improvement leaders and embed in their business and operations plans.
  • Update committee charters, terms of reference, standing agendas and reporting to reflect the intent of the national model. Clinical governance and quality-related committees, including consumer committees, should discuss the national model content for which they are responsible, and make changes to agendas and reporting required to fulfil this responsibility.
  • Adjust position descriptions where required to reflect roles as described in the national model for implementing and working with clinical governance systems to support high-quality care, and provide professional development where required.
  • Set up a process to recognise and reinforce individuals and teams who have made changes relating to the national model and have achieved improved clinical governance practice.
  • Collect and spread good news stories showing the benefits of clinical governance.

An overly ambitious program of change may result in implementation without impact, a disengaged workforce and wasted time and resources. Sustained improvement is likely to result from a well-paced process using a proven change-management approach that considers both people and processes.

Outputs

  • A manageable and sustainable implementation process is established.
  • Implementation actions are allocated to relevant leaders and managers with appropriate support.
  • Boards, executives, consumers and the workforce understand their clinical governance and implementation roles.
  • The internal clinical governance framework, systems and committees reflect the intent and content of the national model.

Tools

Reflective questions

Board

  • Do we understand and enact the implementation actions related to our governance role?
  • Are we monitoring unnecessary creation or duplication of clinical governance bureaucracy?

Executive

  • Are we clear on and enacting individual and collective roles in leading and supporting progress?
  • Do our behaviours show that implementing the national model is an organisational priority?
  • Are we providing the right support for clinical leaders and managers to put changes into practice, so they are as simple and practical as possible?

Step 5: Monitor and report on progress

Your implementation plan should describe a monitoring and reporting process that may include:

  • a limited set of measures on progress (are we doing what we said we would do, on time?)
  • implementation outputs (did the change produce concrete results? Are there any unforeseen negatives resulting from removing clinical governance components that are no longer relevant?)
  • feedback from consumers and the workforce (are the changes supporting high-quality care?)
  • progress with evolving clinical governance implementation maturity.

Reporting should allow the executive and relevant operational and governing body committees to track and guide implementation. Where possible, integrate regular implementation monitoring into existing clinical governance reporting to the board and executive. The information should support timely decisions to unblock barriers and accelerate progress.

Your organisation should decide the level of reporting required to drive progress. Boards will require less detail than executives and may decide to receive reports only on high-risk and major gaps, and feedback on the changes from consumers and the workforce. Executive information will include progress on closing all gaps. Depending on the size of the organisation, executives may choose to receive less frequent reporting on minor and low-risk gaps as these may be overseen by an implementation working group or equivalent.

In the short-term implementation window, suggested outputs described in the steps may be used as markers of progress and impact, and/or you may choose to develop progress measures specific to your organisation.

Use existing quality measures to track patient experience and care outcomes over the longer term, adding to these as required to reflect the definition of high-quality care in the national model. Your organisation may wish to set numerical targets for care quality improvement resulting from implementing the national model. Collaborate with clinicians and consumers to make these aspirational timelines and desired results realistic and useful.

Effective implementation of the national model aims to achieve consistently high-quality care. Improvements in clinical governance processes are likely to be seen first, with sustained improvements in care quality over the longer term.

The progress report may include:

  • summary of implementation progress and next steps
  • progress against timelines for high-risk and major gaps and barriers
  • management of clinical risks associated with clinical governance gaps
  • requests for implementation support
  • implementation outputs and impacts, including feedback from consumers and the workforce
  • periodic assessment of clinical governance maturity for each foundation in the national model and for roles and governance.
Top Tips

DO: make reporting brief and to the point: What’s on track? What’s stuck? What needs a decision?

DON’T: let the implementation reality get lost in the data – tell a clear progress story first, then add detail if required to make a case for support or resources to drive progress.

Suggested activities

  • Identify and collect data on measures of implementation:
    • progress (actions taken, progress against timelines)
    • outputs (impact of changes based on data and feedback from consumers and the workforce; evidence of outputs achieved within each implementation step)
    • outcomes (risk reduction and changes in care quality using subjective and objective data – likely to be seen over the longer term).
  • Set up regular progress reporting to the executive and governing body oversight committee, integrated into existing committee reporting and workplans where possible.
  • Provide timely feedback on progress to the workforce and consumer groups.

Outputs

  • Regular progress reports to the executive and relevant governing body committees, aligned with the implementation plan, are established.
  • Committees make timely decisions to support or accelerate progress (e.g. to reduce implementation or clinical risk, remove barriers, redirect effort and resources, increase implementation maturity).
  • Feedback from consumers and the workforce on the usefulness of changes in supporting high-quality care is reported and responded to.
  • Reporting provides evidence of active oversight of implementation progress and outcomes for accreditation.

Tools

Reflective questions

Board

  • Is the relevant board committee receiving regular implementation updates – and do these support board understanding and decision-making?
  • Are we making progress? Where we are not, do we ask the executive to act? Ź What evidence do we have that implementation is improving the patient and workforce experience?
  • Is implementation maturity evolving within each foundation in the national model, and for the board and executive roles?

Executive

  • Are we regularly reviewing progress and making decisions to drive effective implementation within realistic timeframes?
  • Where progress and outcome targets are set, are we providing the support required to achieve them?
  • How are we keeping the workforce and consumer groups engaged in, and informed of, progress?

Don’t measure implementation progress solely on task completion. Balance this with consumer and workforce satisfaction with the implementation process and outcomes to support sustainable change.

Implementation tools

Companion tools to support the steps (recognising that organisations will also use local, state, territory and corporate implementation tools):

Last updated: 04 June 2026