51639015 Clinical Governance

8/13/2019 51639015 Clinical Governance

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IN FORM AT ION SER I E S NO . 1. 2

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Western Australian

Clinical Governance Guidelines



ACKNOWLEDGEMENTS

The Office of Safety and Quality in Health Care acknowledges and appreciates the input of all individuals and groups

who have contributed to the development of this document. In particular, the Office of Safety and Quality in Health

Care would like to recognise the valuable contribution of members of the Western Australian Council for Safety and

Quality in Health Care for their guidance and support.

The Office of Safety and Quality in Health Care will undertake further consultation with Health Services to ensure

the implementation of this Policy at the local level.

The Western Australian Council for Safety and Quality in Health Care will provide a leadership role in monitoring

and evaluating the implementation of the Policy by hospitals and health services across the Western Australian health

system to ensure the delivery of consumer-focused, safe, quality health care in Western Australia.

This document is protected by copyright. Copyright resides with the State of Western Australia. Apart from any use

permitted by the Copyright Act 1968 (Cth), no part of this document may be published, or reproduced in any material

form whatsoever, without the permission of the Office of Safety and Quality in Health Care, Department of Health (WA).



Foreword

Building a safe, high quality health care system requires all of us who wo

in health care to take responsibility for our own behaviours and the actio

of individuals and teams who work with us.

Clinical Governance is a recently developed concept which brings togethe

all the activities that demonstrate to our patients, the community, govern

and our peers that we hold ourselves responsible for providing safe, high

quality health care. This in turn, demonstrates our accountability for the care that

we all provide to our patients.

The Clinical Governance Series of documents, developed by the Department of Hea

Office of Safety and Quality, sets out the vision, goals, and methods for implement

a standardised clinical governance system in the Western Australian health care syThese documents include the:

• Clinical Governance Framework;

• Western Australian Clinical Governance Guidelines;

• Setting Standards For Making Health Care Better: Implementing Clinical Gover

in Western Australian Health Services; and

• Clinical Governance Standards for Western Australian Health Services.

Many of the components of the WA Clinical Governance Framework are already in p

and clinicians and managers in our hospitals and health services are leading the wor

in their use of clinical information to help them improve the care they provide. How

modern government health policy requires us to bring these clinical governance compo

together within a single integrated system. This enables individual patient care to be prsupported by clinical units, hospitals, health services and departmental divisions.

In this way, Clinical Governance becomes the overarching system in our daily clinic

and management practice.

I t th li i l d t d t k t th



ll

CLINICAL GOVERNANCE

POLICY PRINCIPLES

DEFINITION

THE FOUR PILLARS OF CLINICAL GOVERNANCE

CRITICAL SUCCESS FACTORS

CULTURAL CHANGES IN HEALTH SERVICES

CLINICAL GOVERNANCE IN FOCUS: TEAMWORK, PARTNERSHIP, COMMUNICATION

IMPLEMENTATION OF CLINICAL GOVERNANCE IN THE WA PUBLIC HEALTH SYSTEM

REQUIREMENTS FOR CLINICAL GOVERNANCE ANNUAL REPORTS IN 2004-5

STEP ONE: DIRECTION, ACCOUNTABILITY AND PRACTICAL ARRANGEMENTS

STEP TWO: DEFINE WHERE THE ORGANISATION IS NOW

STEP THREE: DESIGN AND AGREE ON THE DEVELOPMENT PLAN

STEP FOUR: SET IN PLACE INTERNAL AND EXTERNAL REPORTING ARRANGEMENTS

REPORTING REQUIREMENTS FOR 2004/2005 AND 2005/2006

ATTACHMENT A

Table of Contents



CLINICAL GOVERNANCE

The Department of Health’s aim is to deliver awell-managed, high quality health care servicethat responds to the needs of the Western

Australian population and:• is recognised for its high standards and its

commitment to continually reviewingand updating practice in the light of testedand evaluated evidence so patients can beconfident they are getting modern,effective treatment;

• is reliable and consistent in its delivery, sopeople can be sure of high quality serviceswhenever and wherever they use publichealth facilities; and

• learns from experience and shares thatlearning across all health care providersso people know their views and experiencesare valued and useful.

The Western Australian Strategic Quality Plan forSafety and Quality in Health Care 2003 – 2008,sets out the Department of Health’s strategy forensuring quality of care and is the driving forcefor the development of health services in theState. Clinical governance is the anchor of thisstrategy. It applies to all sections of the publichealth service.

Clinical governance1 brings a spotlight onto howclinical services are provided. It means systematicmechanisms must be put in place in all hospitalsto assist staff and to promote and develop qualityactivities.

POLICY PRINCIPLES

The Strategic Quality Plan 20a five-year plan for our publIt will build a health system

continuous improvement in care, protecting established hpromoting a learning environvariability in outcomes is reddecisions are based on curreevidence of effectiveness.

The guiding principles of this

• ready access to services aforward health informati

• efficiency and effectivenprovision to ensure the mobtained for the most peState’s health resources;

• reproducibility of clinicaoutcomes across similar

• safe services, with an empreventing and managin

• appropriate care, applyinprinciples of efficiency ato the individual; and

• participation by all interethe community in decisioorganisation and delivery

Clinical governance is centraIts successful implementatio



DEFINITION

Clinical governance can be defined as;

“A systematic and integrated approach to

assurance and review of clinical responsibility and accountability that improves quality and safety resulting in optimal patient outcomes.” 3

Clinical governance is first and foremost abouthelping clinical services in the mid-range of performance to move closer to the highest qualityservices, as judged both by local recognition andby national benchmarking against similar Health

Sevices. It also involves recognising and learningfrom outstanding services around the State,which in some cases will require setting asideaspects of the competitive spirit that has existedbetween some services.

Clinical governance also requires WesternAustralian Health Sevices to be able to

demonstrate to the public that their servicesare of a high standard and that they are safe.In taking their responsibilities seriously, HealthSevices already look for ways to prevent andreduce clinical error. Health Sevices must nowshow they are becoming learning organisationsin the sense of acknowledging their successesand failures and applying the lessons learned

from failures as widely as appropriate acrossthe organisation.

The challenge put forward byQuality Plan is to move all Hin the state towards providin

quality outcomes for patientthe care provided for West Aa high standard and in someinternational recognition for In others, however, standardsbe less consistent for varioushospital services fall somewhtwo extremes, with much to

also areas where patients, domanagers believe things cou

Some Health Sevices have alrdeveloping and implementingplan for clinical, operational agovernance, applying accountransparency across each aremany of the components in pto draw these together into asystematic program.

Clinical governance cannot binstantly. Important culturalnecessary and these will takeorganisational structures canrelatively quickly, these also

operate smoothly and to beschanges, however, need to hademonstrate clinical governaactively implemented througAustralian health system.

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THE FOUR PILLARSOF CLINICAL GOVERNANCE

In September 2001, the Department of Healthfinalised a new model for Clinical Governancefor development and implementation inhospitals and health services across the WApublic health system. The model, outlinedbelow, is based on four pillars:

PILLAR ONE: CONSUMER VALUE

The first pillar is consumer value, whichencourages health services to involve theircommunities and stakeholders in maintaining

and improving the performance of theirHealth Service and in the planning for theorganisation’s future. There are many differenttypes of consumers in health care, including:the commonwealth, local government, non-government organisations and consumers.

Effective consumer participation requiresleadership to ensure that the involvementis valuable, effective and results in a positiveoutcome for the health of the population.

The key elements of Consumer Value areConsumer Liaison and Consumer Participation:

• Consumer liaison involves ongoingstrategies which promote two waycommunication between consumers andthe Health Services. Some examples includeinformed consent, complaint management,patient satisfaction surveys and providinginformation about services to patients, theirfamilies and carers. The information obtainedfrom these strategies support informed

PILLAR TWO: CLINICAL PERAND EVALUATION

The second pillar aims to guaprogressive introduction, useevaluation of evidence-based

The outcome is a culture wheorganisational and clinical peincluding clinical audit is comexpected in every clinical sertools that will assist Health Sthis outcome are Clinical StaIndicators and Clinical Audit.

• Clinical standards incorguidelines, pathways andprotocols. These standarbodies such as the Cochrthe Royal Colleges or by groups, and are often baevidence criteria, such asthe National Health and Council. 5

• Clinical indicators are mebenchmarks that enable hcompare themselves agaiServices. To facilitate healimprovement clinical indimeaningful and reflect clistandards.

• Clinical audits are a metand improving clinical prdefined as ‘the systematicevaluation of the efficienof organisational systemsClinical audits analyse the



PILLAR THREE: CLINICAL RISK

The third pillar concentrates on minimisingclinical risk and improving overall clinical safety.This is achieved through the identification andreduction of potential risks and examination of

adverse incidents for causative and contributingfactors and trends within and across services.To maximise learning opportunities lessons shouldbe shared at a local, area and statewide level.Some aspects of clinical risk management are:

• Incident and adverse event reporting,monitoring and trend analysis. This

incorporates activities such as learningfrom local incidents or patterns of incidents,including near hits and management of serious adverse events and maintaining a riskregister and monitoring medico-legal cases.

• Sentinel event reporting, monitoringand clinical investigation, which definesthe process for identification, reportingand investigating sentinel events in linewith Department of Health policy.

• Risk profile analysis includes theidentification, investigation, analysis andevaluation of clinical risks and the selectionof the most appropriate method of correcting,eliminating or reducing identifiable risks.

PILLAR FOUR: PROFESSIONALDEVELOPMENT AND MANAGEMENT

The fourth pillar supports the selection andrecruitment of clinical staff, their ongoingprofessional development, the maintenance

professional development andprocesses are aligned with thobodies to minimise extra demKey elements include:

• Competency Standards:Health Service must be chave adequate skills and properly trained within tto undertake the responsposition within the Healtincludes an assessment bService upon appointmen

assessment throughout t• Continuing Professiona

which includes ongoing education and research ato the responsibilities anclinicians employed by th

CRITICAL SUCCESS FAC

For clinical governance to beWestern Australian Health Se

• a supportive, open and inwhere education, professresearch and sharing goo

practice are valued and c

• a commitment where quof the organisation and ostaff, and is explicitly supallocation of resources;

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• regular executive level discussion of all mainquality areas for the Health Sevices and strongsenior clinical and administrative leadership; and

• thoughtful, appropriate and integrated use

of information to plan, review and monitorprogress.

CULTURAL CHANGES IN HOSPITALS

The biggest impact that clinical governancemakes is to change people’s attitudes and

thinking about their own organisation and howit functions. Health Sevices will become learningorganisations, where constructive criticism,cooperative development and inter-professionalrespect allow successes to be celebrated andmistakes are not considered blameworthy butopportunities for improvement.

CLINICAL GOVERNANCEIN FOCUS: TEAMWORK,PARTNERSHIP, COMMUNICATION

The overriding purpose of clinical governanceis delivering quality care to patients across thepublic health service, beginning with tertiaryhospitals. The next section of this guidance setsout what steps Health Sevices can take to

ensure effective clinical governance is in place.

Clinical governance in disciplines that deal withchronic conditions in particular will inevitablyinvolve different agencies. Some services, such asgeriatric and rehabilitation medicine, already have

IMPLEMENTATION OF GOVERNANCE IN THE WHEALTH SYSTEM

Clinical Governance has been

a key recommendation of theCommittee, with recommend

“A statewide Clinical Govewhich involves the followshould be implemented w

• clinical audit;

• clinical risk;

• consumer values; and

• professional developand management.“ 7

To progress this recommendaGovernance Implementation

established under the HealthImplementation Taskforce.

Implementation of clinical gothis framework at the Healthresponsibility of both managTo facilitate the introductionsupport for clinical governanshould establish a Clinical Gowith responsibility for:

• development of a co-orddriven, clinical practice rand methodology, whichthe Health Service;



In addition, depending on the needs of individualHealth Sevices and the availability of resources,consideration may also be given to establishingclinical subcommittees, to facilitateimplementation and reporting to the Clinical

Governance Team. These might include a:

• Clinical Practice Sub-Committee;

• Professional Development Sub-Committee; and

• Clinical Risk Management Sub-Committee.

REQUIREMENTS FORCLINICAL GOVERNANCEANNUAL REPORTS IN 2004-2005

Different Health Sevices will be at differentstages of clinical governance implementationby June 2005. The Department of Health requiresthat all Health Sevices report on the following

areas:

• an account of how clinical governance willbe directed and led within the hospital, howaccountability is being addressed and whatpractical arrangements have been implemented;

• how clinical decision making is beingsupported by appropriate and accessibleevidence, with details on progress on localuse of clinical guidelines;

• progress on integrated planning for quality,including information systems to supportdata collection;

• a description of how lesslearned and applied fromcomplaints and reviews o

To demonstrate progress in t

reports should be prepared usteps outlined below:

• set direction, accountabiarrangements for clinicathe Health Service;

• define where the organis

• decide and agree a develresult of (2); and

• set in place internal and arrangements for clinica

STEP ONE: DIRECTION, AAND PRACTICAL ARRANG

Different patterns of leaders

in clinical governance will suServices. In some, the Chief to nominate a lead clinician cause and to oversee, direct governance matters in the HElsewhere, the Chief Executivwish to take on this role, or tother alternatives that fit bet

culture and practice.

Local details are not importanmatters is that clinical governcharacterised by:

• Inclusiveness: ensuring a

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• Constancy of purpose: keeping theorganisation’s commitment to its ownclinical governance program buoyantand mainstream;

• Accounting for progress: always knowingwhat has been achieved and what is stilloutstanding; and

• Communicating: keeping all staff andpartner external agencies up to date asthe clinical governance program evolves.

STEP TWO: DEFINE WHERE

THE ORGANISATION IS NOWBefore any plans for progress can be drawn up, eachhospital must know where it is starting. Involving allclinical areas, the review should include:

• a comprehensive assessment of theorganisation’s strengths and weaknessesin the areas of clinical governance;

• identifying and prioritising areas for action(using objective information, includingfeedback from patients);

• an assessment of existing informationcollection for monitoring quality;

• checking the extent of any shortfalls

(in risk or information management,clinical audit or patient involvement);

• ensuring the systems that are already inplace fit the quality activities they serve; and

• making sure the organisation’s management

STEP THREE: DESIGN ANON THE DEVELOPMENT P

Building on the assessment aSevices can then decide how

• bring every part of the ha satisfactory level of pe

• develop the necessary into support clinical gover

• find and provide for any training gaps about aspegovernance.

STEP FOUR: SET IN PLACINTERNAL AND EXTERNAREPORTING ARRANGEME

Reports to the Chief Executive the accountability contained inThe nature, range and importagovernance issues that are rep

Executive determine how the cprogram is set up within the Hissues that are discussed by thexecutives and the Director Geimportant message to the whoeventually to the local media, tthose external agencies with wSevice works. The more extens

discussions, the more people whas a clear sense of direction iand is taking it very seriously.

Open debate is important butmeaningful discussion will on



Health Services will be required to provide annualreports on their clinical governance structuresand activities. The style and content is a matter

for individual hospitals to decide but HealthService chief executives must agree with theDirector General what the common core reportingelements will be for clinical performance andevaluation, professional development andmanagement, clinical risk and consumer value.

In general, each annual report should answerthe questions:

• Where did we start?

• What progress have we made and howdo we measure it?

• What are we planning to do next?

Reports should be presented in straightforward

language and in a style that makes them easyto follow by non-specialist readers. As far aspossible, quantitative information should beused to demonstrate progress.

REPORTING REQUIREMENTSFOR 2004/2005 AND 2005/2006

The agreed safety and quality activities tobe implemented by hospitals and health servicesin 2004/2005 and 2005/2006 will be finalisedin consultation with Area Health Services indue course.

ATTACHMENT A

Future papers to be publishecover topics including:

• Clinical risk managemen

• Incident reporting and m

• Informed consent

• Credentialling

• Coronial reviews

• Root cause analysis• Evidence based practice

• The use of audit as a qua

• Complaint management

• Open disclosure in WA: wwhen things go wrong

• Involving and engaging cin health policy and plan

• Statutory obligations for

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Notes



Notes





Western Australian Clinical Governance Guidelines

Information Series No. 1.2 (2nd Edition 2005)

Office of Safety and Quality in Health CareWestern Australian Department of Health189 Royal Street, East Perth Western Australia 6004Tel: (08) 9222 4080 Fax: (08) 9222 4014Email: [email protected]: http://www.health.wa.gov.au/safetyandquality/

H P 2 4 4 5 J B 2 0 0 0 6 M A R 0 5

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51639015 Clinical Governance