Clinical governance and quality improvement systems to support clinical safety

By implementing the Clinical Governance Standard and the Partnering with Consumers Standard, your healthcare service will establish an individualised clinical governance framework. These systems and processes that make up the clinical governance framework can be used to implement the Clinical Safety Standard, which addresses risks to safety and quality commonly encountered.

This action requires healthcare services to apply the systems and processes developed when implementing the Clinical Governance Standard to each criterion described in the Clinical Safety Standard. This will ensure a consistent approach to managing safety and quality risks in the healthcare service.

Policies and procedures written to address safety and quality risks should be developed and implemented in a way that is consistent with Action 1.02 Policies and procedures. That is:

• Policies and procedures aim to reduce or eliminate safety and quality risks in the healthcare service
• The workforce is supported to implement policies, procedures and protocols, including making them easily accessible
• A schedule is implemented to monitor, review and update policies and procedures using a risk management approach 

Policies and procedures must address clinical safety risks relevant to your healthcare service. Key clinical safety risks are described in the Clinical Safety Standard and include preventing and controlling infections, medication safety, comprehensive care, communicating for safety, and recognising and responding to serious deterioration and harm.

Links Action 1.02 Policies and procedures to actions in the Clinical Safety Standard.

Risk management approaches to identify, analyse, evaluate and treat safety and quality risks established should be used to address clinical safety risks relevant to your healthcare service. Key clinical safety risks are described in the Clinical Safety Standard and include preventing and controlling infections, medication safety, comprehensive care, communicating for safety, and recognising and responding to serious deterioration and harm.

Links Action 1.04 Risk management to actions in the Clinical Safety Standard.

All people who form part of your healthcare service’s workforce must understand their safety and quality roles in the context of your healthcare service. Orientation and access to training should occur on commencement to the service, whenever responsibilities change and when new services are introduced. The identification of training requirements should be consistent with Action 1.15 Safety and quality training and address the clinical safety risks relevant to your healthcare service. These include preventing and controlling infections, medication safety, comprehensive care, communicating for safety, and recognising and responding to serious deterioration and harm.

Links actions 1.09 and 1.10 Patient populations and social determinants of health; 1.15 and 1.16 Safety and quality training; 1.17 Safety and quality roles and responsibilities; and 1.18 Evaluating performance to actions in the Clinical Safety Standard.

• Develop and implement policies and procedures for clinical safety
• Use risk-management processes established in Action 1.04 to identify, monitor, manage and review risks associated with clinical safety
• Deliver or provide access to training on relevant clinical safety risks based on the patient population and the specific needs of the workforce

How is your healthcare service’s clinical governance framework used to:

• support implementation of policies and procedures for clinical safety?
• identify and manage risks associated with clinical safety?
• identify training requirements for clinical safety?

• Policies and procedures that provide guidance on relevant clinical safety issues
• Risk register entries relating to clinical safety
• Training documents, for example, orientation training plans and records, for members of the workforce relating to clinical safety 

Resources relating to this Action may be added as they become available. 

By implementing the Clinical Governance Standard and the Partnering with Consumers Standard, your healthcare service will establish an individualised clinical governance framework. These systems and processes that make up the clinical governance framework can be used to implement the Clinical Safety Standard, which addresses commonly encountered risks to safety and quality. These include preventing and controlling infections, medication safety, comprehensive care, communicating for safety, and recognising and responding to serious deterioration and harm.

This action requires healthcare services to use quality improvement systems for each criterion described in the Clinical Safety Standard to:

• Identify and collect data within available within your healthcare service to monitor clinical safety risks
• Act on areas identified for improvement
• Document clinical safety risks and action taken.  

Links actions 1.03 Measurement and quality improvement and 1.07 Feedback and

• Identify and collect data within your healthcare service that can be used to inform improvements to clinical safety
• Take action to address identified areas for improvement in clinical safety
• Document clinical safety risks using established processes from actions 1.03 and 1.05 and action taken

• What data does your healthcare service review to identify clinical safety improvements?
• What clinical safety changes have been made as a result of the review of data?
• How is information about your healthcare service’s clinical safety performance documented and reported?

• Clinical safety data, for example incidents, collected and reviewed to identify safety and quality improvements
• Example of clinical safety changes made within the healthcare service as a result of the review of data and implementations made
• Meetings or communication records where discussion about clinical safety incidents occurred, and the strategies and actions taken to address identified risks
• Reports on clinical safety

Institute for Healthcare Improvement: Plan, Do, Study, Action (PDSA) Worksheet. A useful tool for documenting a test of change.

Implementing the Partnering with Consumers Standard is fundamental to the delivery of safe, high-quality health care. Implemented together with the Clinical Governance Standard, your healthcare service will establish an individualised clinical governance framework.

This action requires healthcare services to apply principles of partnering with consumers, health literacy and shared decision making, developed when implementing the Partnering with Consumers Standard, to each criterion described in the Clinical Safety Standard. These include preventing and controlling infections, medication safety, comprehensive care, communicating for safety, and recognising and responding to serious deterioration and harm.   

Links actions 2.02 and 2.03 Healthcare rights and informed consent; 2.04 and 2.05 Shared decisions and planning care; 2.06 Communication that supports effective partnerships; and 2.07 Accessing healthcare service information to actions in the Clinical Safety Standard.

• Use processes developed when implementing the Partnering with Consumers Standard to inform implementation of relevant actions in the Clinical Safety Standard
• Support the workforce to communicate effectively with patients, carers and families about clinical safety, tailored to their needs and preferences

• What processes from the Partnering with Consumers Standard do healthcare providers use to involve patients in relevant clinical safety areas?
• How does your healthcare service ensure that information provided to patients regarding clinical safety are tailored to their needs and health literacy?

• Examples of information material and resources relating to clinical safety displayed or provided to patients, families and carers in plain language, available in different languages and formats
• Documents outlining processes relating to clinical safety that include how patients are supported to be actively involved in their own health care
• Examples of healthcare records that demonstrate healthcare providers have partnered with patients in shared decision making about clinical safety
• Patient feedback regarding areas of clinical safety

Australian Commission on Safety and Quality in Health Care: Partnering with Consumers. Information and resources to support healthcare services understand the value of partnerships with consumers, how to engage with consumers and integrate person-centred approaches.