Understanding Clinical Governance: A crucial standard within the Primary and Community Healthcare Standards

The Primary and Community Healthcare Standards focus on people and describe the processes and structures required to provide safe and high-quality healthcare for primary and community healthcare services. The three Primary and Community Healthcare Standards are:

• Clinical Governance;
• Partnering with Consumers; and
• Clinical Safety.

Together, the Clinical Governance and Partnering with Consumers standards form the overarching requirements for Clinical Safety.

This article focuses on the Clinical Governance Standard and its role within the Primary and Community Healthcare Standards. This standard highlights the responsibility of healthcare organisations for continuously improving the quality of their services and safeguarding high quality care.

What is clinical governance in healthcare?

Clinical governance involves the connections and responsibilities among various healthcare groups such as regulators, funders, healthcare workers and patients. Combining safety and quality systems with governance processes is a highly effective method for actively managing and enhancing the safety and quality of healthcare or community service providers.

This integration provides a robust framework for strategic alignment, comprehensive oversight, risk management, continuous improvement, regulatory compliance, and stakeholder engagement, ultimately leading to better outcomes for patients and service users.

The Clinical Governance Standard criteria

The Clinical Governance Standard is made up of four criteria that describe the following key areas covered by this standard:

• • Governance, leadership, and culture
  • Patient safety and quality systems
  • Clinical performance and effectiveness
  • Safe environment for the delivery of care

 

Governance, leadership, and culture

Action 1.01

The governance, leadership, and culture criteria aims to ensure that the healthcare service  implements clinical governance systems to enhance the safety and quality of healthcare for patients.

Some examples of these actions include:

• Establishing and maintaining a clinical governance framework
• Consideration is taken for a consumer’s care when making business decisions
• Ongoing monitoring and regular reviews of the organisation’s service, and
• An organisation practices a culture of safety and quality improvement.

Nurturing a culture of safety and quality requires a well structure plan, implementation and input from the organisation as a whole. This commitment recognises a continuous drive for improvement, the ability to learn from mistakes, and a willingness to implement any required changes.

 

Patient safety and quality systems

Actions 1.02 – 1.14

Combining safety and quality systems with governance processes is an effective method for actively managing and enhancing the safety and quality of healthcare or community service provider. The patient safety and quality systems criteria cover a breadth of items to aid an organisation to excel in this area. These include:

• Establishing and maintaining policies and procedures
• Measuring quality improvement initiatives
• Managing and mitigating risk
• Implementing incident management protocols
• Using an open disclosure framework
• Utilising feedback and complaint mechanisms
• Identifies patient populations, and
• Document consumers healthcare records.

These items and actions listed in the patient safety and quality systems criteria are extensive but they don’t have to be complicated. As long as they provide clear actions to follow in specific situations and are used regularly, they will be suitable for accreditation.

Maintaining policies and procedures, undertaking a risk management assessment, gathering patient feedback, and completing the Australian Open Disclosure Framework are all examples of how an organisation would work toward achieving the actions outlined in this criteria.

 

Clinical performance and effectiveness

Actions  1.15 – 1.21

It is important the workforce has the right qualifications, knowledge, and skills to provide safe and high-quality healthcare. The clinical performance and effectiveness criteria have been included to ensure that, is in fact, the case. The criteria includes but is not limited to the review of staff performance evaluation, role and responsibilities, and safety and quality training.

This means staff in an organisation undergoing accreditation against the Primary and Community Healthcare Standards, not only have the right training to be able to give care, but also making sure the care follows the best evidence and guidelines available. Any deviations from these guidelines should be well-founded, and driven by patient preferences or clinical reasons. Reducing variations helps lower the risk of harm, instilling confidence in patients that qualified and trained professionals deliver healthcare services.

 

Safe environment for the delivery of care

Actions 1.22 – 1.25

The safe environment for the delivery or care criteria outlines that a healthcare setting needs to support safe and high-quality care. Patients should experience a sense of safety and comfort when accessing healthcare services. Organisations should ensure the healthcare location and facility provide a safe, private, and infection-free environment for care. In an accreditation setting, this is assessed against actions like:

• An organisation maximises safety and quality through design of the environment and management of the location where health care is provided,
• Ensuring patients’ privacy, and
• The healthcare service supports a diverse range of patients to access health care.

For a complete list of all criteria, items, and actions assessed in the Primary and Community Healthcare Standards, visit the Australian Commission on Safety and Quality in Health Care website.

Clinical Governance Framework

Implementing the Clinical Governance and Partnering with Consumers standards creates a strong clinical governance framework. A solid clinical governance framework helps healthcare services meet rules and build patient and community trust while improving healthcare delivery over time.

Combining safety and quality systems with governance processes is a highly effective method for actively managing and enhancing the safety and quality of healthcare or community service providers. This integration provides a robust framework for strategic alignment, comprehensive oversight, risk management, continuous improvement, regulatory compliance, and stakeholder engagement, ultimately leading to better outcomes for patients and service users.

Support and Resources

The Clinical Governance Standard ensures that healthcare providers deliver healthcare safely and to the highest standards. Healthcare providers, patients, and the healthcare system should work together to protect patient rights, build trust, improve healthcare experiences, and enhance service delivery.

Undertaking accreditation for the first time can seem challenging, but comprehensive support is available. To find out more information on accreditation to the Primary and Community Standards, view our standards page or contact our team.