Clinical Governance Framework: Governance, leadership and culture

The roles and responsibilities for this component of the Clinical Governance Framework relate to the establishment of, and participation in, corporate and clinical governance systems.

Patients and consumers

  • Use organisational systems and processes to contribute to the planning, design and operation of the health service organisation
  • Identify opportunities for improvement of the health service organisation and communicate these to relevant individuals or bodies
  • Consider taking an active role in the governance of the health service organisation, when opportunities exist

Clinicians

  • Actively take part in the development of an organisational culture that enables, and gives priority to, patient safety and quality
  • Actively communicate their profession’s commitment to the delivery of safe, high-quality health care
  • Model professional conduct that is consistent with a commitment to safety and quality at all times
  • Embrace opportunities to learn about safety and quality theory and systems
  • Embrace opportunities to take part in the management of clinical services
  • Encourage, mentor and guide colleagues in the delivery of safe, high-quality care
  • Take part in all aspects of the development, implementation, evaluation and monitoring of governance processes

Managers (including clinical managers)

  • Actively communicate the commitment of the health service organisation to the delivery of safe, high-quality care
  • Create opportunities for the workforce to receive education in safety and quality theory and systems
  • Model the safety and quality values of the health service organisation in all aspects of management
  • Support clinicians who embrace clinical leadership roles
  • Lead the development of business plans, strategic plans, and organisational policies and procedures relevant to safety and quality
  • Integrate safety and quality into organisational plans, policies and procedures
  • Set up effective relationships with relevant health services to support good clinical outcomes

Governing bodies

  • Lead development of a common organisational language in safety, quality and clinical governance
  • Actively communicate the commitment of the governing body to the delivery of safe, high-quality care
  • Are satisfied that an effective culture of safety and quality exists within the health service organisation
  • Lead the organisation towards achieving a ‘blame-free’, accountable and learning culture
  • Are aware of how the health service organisation sits within a wider network of local and other health services and providers
  • Set up an effective relationship with the chief executive officer, founded on a mutual commitment to safety and quality of care
  • Ensure that the organisation has a comprehensive suite of plans, strategies and policies that support safety and quality of care
  • Ensure that organisational resources are allocated to support safety and quality of care
  • Create relevant education and training opportunities for managers and executives
  • Allocate enough board time and attention to safety and quality of care
  • Monitor organisational culture, and identify and capture improvement opportunities and ensure that they are acted on