Clinical Governance Standard

Leaders of a health service organisation have a responsibility to the community for continuous improvement of the safety and quality of their services, and ensuring that they are patient centred, safe and effective.

Intention of this standard

The Clinical Governance Standard aims to ensure that a clinical governance framework is implemented to ensure that patients and consumers receive safe and high-quality health care.

This standard aims to ensure that there are systems in place within health service organisations to maintain and improve the reliability, safety and quality of health care. This standard, together with the Partnering with Consumers Standard, set the overarching requirements for the effective implementation of all other standards. The Clinical Governance Standard recognises the importance of governance, leadership, culture, patient safety systems, clinical performance and the patient care environment in delivering high quality care.


Leaders at all levels in the organisation set up and use clinical governance systems to improve the safety and quality of health care for patients.

Action groups

Governance, leadership and culture

Organisational leadership

Clinical leadership

Safety and quality systems are integrated with governance processes to enable organisations to actively manage and improve the safety and quality of health care for patients.

Action groups

Policies and procedures

Measurement and quality improvement

Risk management

Incident management systems and open disclosure

Feedback and complaints management

Diversity and high-risk groups

Healthcare records

The workforce has the right qualifications, skills and supervision to provide safe, high-quality health care to patients.

Action groups

Safety and quality training

Performance management

Credentialing and scope of clinical practice

Safety and quality roles and responsibilities

Evidence-based care

Variation in clinical practice and health outcomes

The environment promotes safe and high-quality health care for patients.

Action groups

Background to this standard

Patients and the community trust clinicians and health service organisations to provide safe, high-quality health care.

Clinical governance is the set of relationships and responsibilities established by a health service organisation between its department of health (for the public sector), governing body, executive, workforce, patients and consumers, and other stakeholders to deliver safe and high-quality health care. It ensures that the community and health service organisations can be confident that systems are in place to deliver safe and high-quality health care, and continuously improve services.

Clinical governance is an integrated component of corporate governance of health service organisations. It ensures that everyone – from frontline clinicians to managers and members of governing bodies, such as boards – is accountable to patients and the community for assuring the delivery of health services that are safe, effective, high quality and continuously improving.

Each health service organisation needs to put in place strategies for clinical governance that consider its local circumstances.

To support the delivery of safe and high-quality care for patients and consumers, the Australian Commission on Safety and Quality in Health Care (the Commission) has developed the National Model Clinical Governance Framework. The framework has five components based on the criteria in the Clinical Governance Standard and the Partnering with Consumers Standard. Health service organisations should refer to the framework for more details on clinical governance, and the associated roles and responsibilities.

Publication, report or update
Guide, user guide or guidelines