CLINICALGOVERNANCE

YOUR GUIDE TO THESE KEY AREAS:

IN AGED CARE

Governance, leadership and culturePartnering with consumersRoles and responsibilities of theworkforce

Consumer safety and qualityimprovement systemsClinical performance and effectivenessSafe environment for the delivery of care

Clinical governance is the set of relationships and responsibilities between aservice and its stakeholders to guarantee good outcomes and continuously striveto improve clinical care for consumers. Clinical governance is one of the key areas that ACQSC assessors will be lookingat when visiting your service for an assessment contact. Read on to find out what good clinical governance looks like in practice, and howour suite of resources can help your service implement robust clinical governanceprocesses.

WHAT ISCLINICALGOVERNANCE?

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Leaders at all levels inthe service should useclinical governancesystems which improvethe safety and quality

of care for consumers. Leaders should foster aculture of openness, partnership, learning andcontinuous improvement. A strongorganisational culture will support yourworkforce to deliver their best.

Consumers should beinvolved as partners intheir own servicedelivery, and contributeto planning anddecision making

through a co-design approach. Processesshould ensure that the needs of consumerswho do not have family or otherrepresentatives are recognised and served.

All staff membersshould be accountablefor their contribution tothe safety and qualityof care delivered. In

aged care, this means designating roles for thegoverning body, executives and managers, health practitioners, personal care staff, andother staff.

Safety and qualitysystems should beintegrated withgovernance processesso that organisations

can actively manage and improve the safetyand quality of care for consumers. Risksshould be identified and managed proactively,and incidents should be recorded and actedon. 

The workforce shouldhave the rightqualifications, skillsand supervision toprovide safe, highquality care. When

clinical care is delegated to personal carestaff, they should be trained and supervisedby health practitioners, or work under theirdirection. 

The environmentshould promote safeand high-quality care.This includesthoughtful design, and

the maintenance of buildings, equipment, andinfrastructure that are fit for purpose. Theenvironment should be culturally welcoming,and allow for flexible visiting arrangements.

KEY AREAS OF CLINICALGOVERNANCE

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KEY AREAS+RESOURCES

CLINICAL GOVERNANCE INAGED CARE

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Board or management committee meetingtemplate Board or management committee: Goodpractice info sheetLeadership, continuity and accountabilitypolicy

1. Governance, leadershipand culture

Clinical governance systems areincorporated into corporate governancestructures.

Leadership, a culture of continuousimprovement and safety are key prioritiesset by the governing body.

Resources:

Central to organisational priorities;Encouraged to provide feedback ontheir experiences; andWell informed on their care plans.

Client service planning info sheetClient feedback policySupported decision-making and dignity ofrisk policy

2. Partnering with consumers

Effective consumer partnerships are keycomponents of improving healthcareoutcomes and driving continuousimprovement. Consumers are:

Resources:

Governing body roles and responsibilitiespolicyStaff position descriptions policyStaff position description template

3. Roles and responsibilities

For effective governance, services musthave clearly defined roles andresponsibilities for the governing body,senior executives, clinical leaders /management, health service staff andconsumers. This will ensure organisation-wide accountability, consistency andeffective communication.

Resources:

Open disclosure policyKey elements of client safety and wellbeingContinuous quality improvement registerQuality management policy

4. Consumer safety andquality improvement systems

Safety and quality systems supportclinicians to provide the highest level ofsafe and quality care. They areincorporated into governance processes,and are continuously monitored andimproved upon.

Resources:

First, use thesetwo key resources:

Clinical governance policyClinical governance info sheet

And then dive in to our othertemplates, policies and info sheets!

Complaints management info sheetComplaints management policyComplaints information for clients -templateComplaint submission formComplaint acknowledgement letter Complaint process tracking formComplaint registerComplaint response letter

Incident management and procedurespolicyIncident report templateIncident investigation templateIncident register

Risk management info sheetRisk management policyRisk registerRisk management - key steps checklist

Complaints management:

Incident management:

Risk management:

KEY AREAS+RESOURCES

Staff recruitment policyStaff induction policyStaff development and training policyVisiting health practitioners policy

5. Clinical performance andeffectiveness

Effective clinical governance relies on aqualified, skilled and competent workforce.

Procedures on hiring, training and retainingstaff are in place to ensure consumersreceive safe and high quality care.

Resources:

Waste management policy Infection prevention and control policyAntimicrobial stewardship policySafety and security in RACFs policy

6. Safe environment for thedelivery of care

The working environment is both physicallyand mentally safe for consumers andclinicians. Facilities support the delivery ofsafe and high-quality care for consumers.

Resources:

Our suite of resources coversthe full breadth of the

incidents, complaints, and riskmanagement cyles!

You can access all these resources, andhundreds more, in the SPP or ACSA QualityPortal Reading Room.

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Plus!