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Standards for general practices (4th edition)

including Interpretive guide for Aboriginal and Torres Strait Islander health services

Standard 3.1 Safety and quality

Our practice is committed to quality improvement.

Criterion 3.1.3

Clinical governance

Our practice has clear lines of accountability and responsibility for encouraging improvement in safety and quality of clinical care.

Indicators

► A. Our practice has leaders who have designated areas of responsibility for safety and quality improvement systems.

► B. Our practice shares information about quality improvement and patient safety within the practice team.

Explanation

Key points

  • Good clinical governance ensures the accountability of individuals for the delivery of safe and effective quality care
  • It takes leadership to build an empowered and participative team that delivers high quality and safe care to patients.

Clinical governance

Clinical governance is a ‘system through which organisations are responsible for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish’.4

The elements of clinical governance commonly include:

  • education – basic and ongoing
  • clinical audit
  • clinical effectiveness – evidence based practice
  • risk management – clinical and general
  • research and development
  • openness.

The Australian Commission on Safety and Quality in Health Care proposes a similar model5 and argues that effective clinical governance includes:

  • recognisably high standards of care
  • transparent responsibility and accountability for maintaining those standards
  • a constant dynamic of quality improvement.

In a recent study, Phillips et al6 explored the link between quality and clinical governance in primary healthcare and found seven key areas to support clinical governance: ensuring clinical competence, clinical audit, patient involvement, education and training, risk management, use of information and staff management.

Clinical leaders

The appointment of a clinical leader is designed to ensure:

  • the ongoing development of an organisational culture wherein participation and leadership in safety and quality improvement are resourced, supported, recognised and rewarded
  • the ability to hold accountable all staff involved in monitoring and improving care and services
  • a multidisciplinary team approach developed to endorse and promote a climate of safety and quality that does not blame, but rather seeks to solve problems.

In small practices one person may fulfil the role of clinical leader, while in larger practices several team members may become designated clinical leaders.

Although a clinical leader will have primary responsibility for a particular area of activity (such as infection control), other members of the practice team may have delegated responsibility for specific activities (such as environmental cleaning or sterilisation within the area of infection control). Whatever the allocation of leadership responsibilities within a practice, it is vital that all members of the practice team take individual responsibility for a multidisciplinary culture of safety, quality and open communication.

Role of clinical leaders

Through the clinical leader a general practice can develop a systematic approach to monitoring, managing and improving safety. This will include clear delineation of, and support for, corresponding staff accountability and responsibility. This approach should ensure practices have:

  • a team based approach to care, in which each team member will be aware of their role and responsibilities for improving the patient’s clinical outcomes
  • an accurate record of each patient’s health history
  • supports to assist members of the clinical team in providing evidence based care
  • mechanisms to identify and mitigate clinical risk for the practice, the staff and the patients
  • systems and procedures to learn and share safety lessons and to implement solutions to prevent harm through changes to practice processes
  • strategies to decrease variability in care delivery and outcomes for patients
  • procedures to provide timely and equitable access to care
  • accurate registers of patients with specified chronic conditions
  • systems to manage patients with chronic conditions systematically and to proactively identify those at special risk or those who would benefit from special intervention
  • the capacity to extract specified clinical data and to collate that data to guide improvement in the practice.

Sharing information about quality improvement and patient safety

Good clinical leadership is required to engage the entire practice team in a commitment to excellence. Quality improvement can relate to many areas of a practice and achieving improvements will require the collaborative effort of the practice team as a whole. The clinical leader will need to nurture a culture of openness and mutual respect that allows just and open discussions about areas for improvement.

Resources

A useful article on the role of clinical governance in improving quality has been published by Phillips et al and is available at www.anu.edu.au/aphcri/Spokes_Research_Program/Stream_Thirteen.php.

References

  1. Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998;317:61–5.
  2. Australian Commission on Safety and Quality in Health Care. Draft National Safety and Quality Healthcare Standards. Sydney: ACSQHC, 2009.
  3. Phillips C, Hall S, Pearce C, et al. Improving quality through clinical governance in primary healthcare. Canberra: Australian Primary Healthcare Research Institute, 2010
Standard 3.1 Safety and quality

Our practice is committed to quality improvement.

Criterion 3.1.3

Clinical governance

Our practice has clear lines of accountability and responsibility for encouraging improvement in safety and quality of clinical care.

In a nutshell

Your health service has in place a system of accountability that enables clinicians and other staff to maintain and improve high-quality healthcare to patients. This means that at least one person should have the role of clinical leader with accountability for developing and overseeing the clinical governance framework, and other staff may take on other important roles. See Criterion 3.1.3 Clinical governance of the Standards for general practices for more information about these roles.

The focus should be on achieving:

  • a high standard of safe, quality healthcare
  • a culture of accountability and openness through an effective and well-communicated risk-management system (for clinical and general staff)
  • continued improvement to health service delivery through review, education and training, and staff management (such as clinical audits, basic and ongoing education).
  • In an ACCHS context, the focus on teamwork – in particular multidisciplinary teams – and tailoring service delivery to meet localised needs should also be recognised when considering clinical governance models. Good communication and information-sharing skills and processes are also required. Effective clinical governance for your health service may also include identifying and documenting accountability for systems such as:
  • patient travel
  • sharing patient information with other health services in your region
  • population-based health checks (for example, school-wide health checks or STD checks)
  • community-based palliative care
  • cultural safety and competence induction and training of non-Indigenous staff
  • integration of multidisciplinary services within your health service (for example, physio, nutrition or using a maternal/child health community health service model rather than GP-focused model).

Key team members

  • Director of clinical services/clinical team leader
  • CEO/director
  • Health service manager
  • Board
  • Clinical leaders
  • Administrative and clinical staff

Key organisational functions

  • Clinical governance framework
  • Human resources (documenting accountability and responsibilities in position descriptions)
  • Performance management process
  • Continuing education and training of all staff (including internal communications and training policies)
  • Clinical audit reports
  • Risk management (clinical and general risk management and controls)
  • Clinical health management practices and protocols
  • Research and development activities and reports
  • Clinical safety (clinical staff safety policy, patient informed consent policy, culturally safe and competent clinical practice)
  • Quality improvement reports
  • Staff communication (including internal communications polices, staff meetings, clinical staff meetings)

Indicators and what they mean

Table 3.3 explains each of the indicators for this criterion. Refer to Criterion 3.1.3 Clinical governance of the Standards for general practices for more information and explanations of some of the concepts referred to in this criterion. 

Table 3.3 Criterion 3.1.3 Clinical governance
IndicatorWhat this means and handy hints
▶ A. Our practice has leaders who have designated areas of responsibility for safety and quality improvement systems. Your health service ensures good clinical governance by appointing clinical leaders (such as a medical director or public health officer) with designated accountability and responsibility for specified areas of clinical care. In a small service, this could mean one clinical leader. In a larger, multidisciplinary team, this could mean several clinical leaders who are responsible for different areas of clinical governance. These areas could include infection control, ongoing education and training, clinical audits, risk management, quality improvement, complaints management or patient feedback.

The allocation of clinical leaders means that your health service could ensure that:
  • an organisational culture of participation and leadership in safety and quality improvement is resourced, supported, recognised and rewarded
  • you hold all staff accountable and involved in monitoring and improving care and services
  • a culture of safety and quality is promoted that solves problems rather than allocates blame.
The clinical leadership role is also to develop a systematic approach to monitoring, managing and improving safety, and to ensure that staff are clear about their responsibilities and accountabilities when it comes to clinical safety and quality patient care. A clinical leader could ensure that your health service has:
  • a team-based approach to care, where members have clear roles and responsibilities for improving patients’ clinical outcomes
  • accurate records of each patient’s health history
  • support structures to assist members of the clinical team in providing evidence-based care
  • mechanisms to identify and prevent clinical risk for your health service, the staff and patients
  • systems and procedures to share information and learn from each other about clinically safe practices, and implementing solutions to prevent future harm to patients
  • strategies to maintain consistency in care delivery and outcomes for patients
  • procedures to ensure timely and equitable access to care
  • accurate registers of patients with chronic conditions
  • systems to manage chronic disease patients, and to proactively identify those at risk or those who could benefit from early intervention
  • the capacity to extract clinical data and collate them to guide improvements to your health service.
▶ B. Our practice shares information about quality improvement and patient safety within the practice team. Good clinical leadership engages all clinical staff members in a commitment to excellence. This is best achieved when a culture of openness and mutual respect is promoted to allow for open discussions about problem areas, and can usually be done at clinic team meetings. It is therefore recommended that a regular agenda item for team meetings would be to discuss quality improvement and patient safety issues in your health service.

Case study

Below is a description of the ways in which an Aboriginal community controlled health service can participate in clinical governance. Not all of these good practices are required by the Standards, but they illustrate the many practical and creative things that ACCHSs can do to ensure they deliver services of high safety and quality to their community.

The service has formed a clinical governance committee whose terms of reference include:

  • 
designated accountability and responsibility for key areas of patient safety and quality improvement
  • 
open communication and reporting of safety and quality issues and events, and active participation in the development, implementation and monitoring of solutions
  • 
development of an organisational culture that does not blame but instead looks for solutions to problems and learns from mistakes
  • 
staff involvement at all levels to monitor and improve healthcare systems
  • 
active support of management.

The health service manages its staff to ensure best practice and clinical competence. All staff have responsibilities for relevant aspects of clinical governance clearly written into their position descriptions and the service’s performance management system addresses these through induction and ongoing training, performance planning and performance review.

Clinical staff’s continuing professional development (CPD) activities are recorded and kept up to date in accordance with the requirements of their profession. Clinical staff are rostered to deliver in-services on clinical topics. Sometimes external presenters are invited to present at these regular in-services. Staff attendance at these in-services and education events is recorded.

Internal communication about clinical governance issues, activities and outcomes is extensive and takes place verbally at meetings and presentations and through documented reports and updates.

The board takes an active leadership role with respect to clinical governance matters, and staff are regularly invited to make presentations at board meetings about significant clinical governance issues and achievements. 

Showing how you meet Criterion 3.1.3

Below are some of the ways in which an Aboriginal community controlled health service might choose to demonstrate how it meets the requirements of this criterion for accreditation against the Standards. Please use the following as examples only, because your service may choose other, better-suited, forms of evidence to show how it meets the criterion.

  • Ensure the clinical leader’s role and position description includes designated accountability and responsibilities for defined areas of clinical care.
  • Ensure position descriptions for other clinical staff include any specific roles and responsibilities for aspects of clinical governance.
  • Keep clinical governance committee agendas and minutes.
  • Keep clinical staff meeting agendas and minutes.
  • Keep board meeting agendas and minutes.
  • Keep clinical governance reports.
  • Ensure that team and annual planning meeting documents show that staff discuss quality improvement and patient safety issues, confirm who is responsible for key areas of safety and quality improvement activity, and confirm who has overall accountability for the safety and quality of clinical care (clinical governance).
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