SPJ Kerja Bakti

ABCD
Department of Human Services,

Victoria
Review of the current state of

clinical governance in Victoria
Final project report
Government
May 2008
This report contains 53 pages
Review of the current state of clinical governance in
VictoriaFINAL.doc
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ABCD
Department of Human Services, Victoria
Review of clinical governance in Victoria- Final Report
Government
May 2008
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This report provides a summary of KPMG’s findings during the course of the work undertaken
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Final Report - clinical governance in VictoriaFINAL - 21 May 2008 i

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Contents
1 Executive summary 1
2 Background 5
3 Review of the current state of clinical governance in Victoria 11
4 Framework development and issues for implementation 16
5 Overview of the clinical governance framework 23
6 Conclusions and recommendations 29
7 Glossary 33
Appendix A Key informants interviewed 35
Appendix B Consultation focus group participation 36
Appendix C Consultation on Draft Clinical Governance Framework 39
Appendix D Example - Strategies relevant to identified roles and

responsibilities 41
Appendix E Attachment – Quality and safety measurement framework 43
Final Report - clinical governance in VictoriaFINAL - 21 May 2008 ii

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1 Executive summary
The Quality and Safety Branch of the Victorian Department of Human Services (DHS) has
engaged external consultants KPMG to undertake a statewide review of clinical governance and
assist in determining future directions in relation to governance of patient safety and quality of
care.
The project included:
• a review of current clinical governance practice in Victoria
• development of a proposed strategic framework, Enhancing clinical care- A framework for

improving the governance of health care quality and safety in Victoria (clinical governance
framework).
1.1 Project approach

In evaluating current clinical governance strategies and developing a clinical governance
framework and recommendations on future directions the following approach was taken:
• a detailed review of the literature to examine existing clinical governance frameworks,

current national and international directions
• a review of existing policies, outcomes of previous relevant reviews and current strategies
• a review of the current state of clinical governance in Victoria with particular reference to
the systems and processes in place for governance of quality and safety
• consultations with a range of individuals from the health sector, DHS, representatives of
Boards of Directors and content experts in quality and safety or governance
• an Industry Round Table with representatives of key stakeholder groups to agree a vision
and forward direction for clinical governance in Victoria, identify key issues, underpinning
principles and potential strategies to move forward
• distribution of a draft outline of the clinical governance framework for comment
• consultations including workshops, written feedback and interviews with key informants to
test a draft outline of the proposed framework.
1.2 Current state assessment of strengths and opportunities

There are a number of examples of excellence and innovation in governance of quality and
safety. Strategies to foster an open and just culture and embed open disclosure are implemented
in many health services. However there is significant variation between services and it was
Final Report - clinical governance in VictoriaFINAL - 21 May 2008 1

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acknowledged that there were a number of areas for improvement in the quality and safety of
clinical service delivery.
There is limited access to robust quality and safety performance measures with a need for better
coordination and access to reports that provide meaningful information at all levels of the
system. There is variability in the capacity of boards to effectively govern quality and safety
systems. There is a need for increased focus on quality and safety in the annual Statement of
Priorities and in longer-term strategy both at state and health service level and a more balanced
approach that reflects all dimensions of quality.
1.2.1 Purpose of the clinical governance framework

The clinical governance framework describes an approach to improving the governance and
performance of the health care system and assure optimal health care outcomes for Victorians.
This approach aims to enhance and support provision of quality care and minimise harm to
patients through:
• providing direction on the establishment of rigorous, integrated systems that support

delivery of safe, efficient and effective health care and expectations on implementation of
these systems
• clarifying roles and responsibilities at each level of the health system and the shared
responsibility and accountability for quality and safety of care between consumers,
clinicians, managers, boards and government
• promoting a balanced approach that acknowledges the importance of all dimensions of

quality including safety, effectiveness, appropriateness, acceptability, access and efficiency
• fostering excellence and innovation in the improvement of quality and safety
• providing a mechanism for coordinating and integrating state-wide priorities and strategic
direction for quality and safety activities with mainstream policy and direction setting
• outlining requirements for education, training and development of workforce capacity in

leadership and management of health care quality and safety
• recognising and building on significant achievements in quality improvement and risk

management systems.
The clinical governance framework provides a coordinated plan of action for DHS, key
stakeholders and Victorian health services to develop the capacity of the health system to
deliver sustainable, patient focussed, high quality care.

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1.3 Implementation
A number of issues should be considered in implementation of the framework. These include:
• the need for a set of core set of quality and safety performance measures and the significant
challenges in developing these
• the impact of other concurrent reviews and projects on the outcomes of this project and the
clinical governance framework
• the need to develop strategies to support innovation while ensuring that benefits are
incorporated across the system
• coordinating existing reports to minimise burden and maximise value to the system and
developing a consensus view on the way forward on public reporting
• giving effect to levers for implementing quality and safety strategies at all levels of the
system
• consideration of financial implications for implementation of the clinical governance

framework.
1.3.1 Recommendations
The following recommendations summarise the key requirements for effective implementation
of the clinical governance framework. A detailed implementation plan should be developed and
will need to consider timing, resourcing and support structure requirements. These include that;
• the outcomes of concurrent related projects and reviews are considered and adjustments
made to the clinical governance framework to accommodate the findings of the reviews
• DHS in collaboration with key stakeholders communicate the clinical governance

framework and the implications for the health system to health services and other
stakeholder groups
• DHS in consultation with key stakeholders reviews the priority scheme for the clinical
governance framework and develops a detailed long term implementation plan
• DHS in consultation with relevant stakeholders develop a set of core quality and safety
indicators and explore opportunities to increase use of state and national registry data in
governance processes
• DHS make the clinical governance framework available to private health providers and
relevant stakeholders in the private health sector

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• the financial implications of implementing the clinical governance framework for health
services are considered and if necessary funding made available or the prioritisation scheme
adjusted to ensure requirements are achievable within the available resources.

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2 Background
The Quality and Safety Branch of the Department of Human Services (DHS) engaged external
consultants KPMG to undertake a statewide review of clinical governance in Victoria and assist
in determining future directions in relation to governance of patient safety and quality of care.
2.1 Objectives of the project

The objectives of the project are to:
• evaluate the implementation and effectiveness of the current Clinical Governance strategy
• advise DHS on options for clinical governance in Victoria, based on the review findings and
a review of national and international clinical governance practice
• develop a clinical governance framework for Victoria.
The project addresses one of the recommendations of the Paterson review of future governance
arrangements for safety and quality in health care. There is a clear expectation that jurisdictions
will review their existing safety and quality systems and ensure there are appropriate
governance structures in place with clear lines of responsibility and accountability at each
organisational level. 1
2.2 Project deliverables

This report is the final deliverable for the project and summarises findings of earlier stages of
the project and provides recommendations regarding the implementation of the proposed
strategic framework, Enhancing Clinical Care: A framework for improving the governance of
quality and safety of health care in Victoria (the clinical governance framework). Deliverables
for the project are:
• a desktop review of national and international literature and key DHS policies in relation to
clinical governance
• a review of the current state of clinical governance in Victoria, a report of findings of the
consultation process
• a proposed strategic framework
• final project report.
1
Paterson R National Arrangements for Safety and Quality in Health Care in Australia - Review of future governance
arrangements for safety and quality in health care AHMC 2005
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2.2.1 Structure of this report

This second chapter provides a context for the report including an outline of the project, our
approach, the policy context for clinical governance in Victoria and other initiatives that impact
on the project. The third chapter provides an overview the assessment of the current state of
clinical governance including identified strengths as well as opportunities for improvement. The
fourth chapter provides a commentary on development of the clinical governance framework,
rationale for inclusions and exclusions and issues to consider in implementation of the clinical
governance framework. The fifth chapter provides an overview of the clinical governance
framework. The final chapter outlines recommendations and suggested next steps for moving
the clinical governance framework forward.
2.3 Our approach

In evaluating current clinical governance strategies and developing a clinical governance
framework and recommendations on future directions, the following approach was taken:
• a detailed review of the literature to examine:
- elements of clinical governance and existing clinical governance frameworks
- current international directions particularly in the UK, New Zealand, Canada and the
United states
- implementing clinical governance
- the Victorian context including existing policies, outcomes of previous relevant reviews
and current strategies
• review of the current state of clinical governance in Victoria with particular reference to the
systems and processes in place for governance of quality and safety
• consultations with a range of individuals from the health sector, DHS, representatives of
Boards of Directors and content experts in quality and safety or governance
• an Industry Round Table with representatives of key stakeholder groups to agree a vision
and forward direction for clinical governance in Victoria identify key issues, underpinning
principles and potential strategies to move forward
• distribution of a draft outline of the clinical governance framework for comment
• consultation workshops to test a draft outline of the proposed framework.

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2.4 Context
Victoria has a strong history of leadership and improvement in the safety and quality of health
care. Key stakeholder groups and those with interest in clinical governance in Victoria are:
• DHS and specifically the Quality Branch
• the Victorian Quality Council
• health service boards and CEOs
• consumers of health services
• Victorian communities
• clinicians and health service managers
• various state-wide special committees such as the:
- Clinical Risk Management Committee
- Consultative Councils (Surgical, Anaesthetic, Obstetric and Paediatric Mortality and

Morbidity.
Other groups that may have an interest in clinical governance include the Office of the Health
Services Commissioner, public and private indemnity insurers, professional colleges and
accreditation agencies.
Over the last four years, there has been a focus on addressing issues identified by the Victorian
Public Hospital Governance Reform Panel, namely: 2
• clarification of roles and accountabilities in the governance of health services
• development of an annual Statement of Priorities establishing key deliverables, performance

priorities and associated measurable Key Performance Indicators
• increasing the focus on benchmarking activities, together with the supporting data systems
and standard data definitions
• establishment of regular forums to improve relationships and interaction between CEOs and
boards of health services, the Department of Human Services and the Minister
• expansion of existing mechanisms to allow for intervention in instances where health

services do not meet performance targets
• enhancement of the effectiveness of health service boards through induction and training
processes, and by ensuring an appropriate mix of skills and experience on boards
2
Victorian Department of Human Services. Victorian Public Hospital Governance report Panel report. August 2003
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• moving to a three-year allocation of funding to maximise accountability of boards through

transparent and definite funding.
2.4.1 Policy directions

A number of strategies and initiatives have shaped the development of existing structures and
programs within health services. The major policy documents and frameworks that guide health
service risk management and governance activities are listed below:
• The Clinical Risk Management Strategy 3
• Victorian Quality Council (VQC) Safety and Quality Framework 4
• Leading clinical governance in health services - A supplementary paper to the VQC Safety
and Quality Framework 5
• Clinical governance in community health – Reporting Guidelines 6
• Doing it with us not for us - Participation in your health service system 2006–09
• Credentialling and defining the scope of clinical practice in Victorian health services – a
policy handbook. 7
While the review focused on policies and guidelines that specifically relate to quality of care or
patient safety, it is important to acknowledge that these sit within a broader suite of policies that
provide direction for health services and their boards include:
• Directions for your health system- Metropolitan Health Strategy 8
• Rural directions for a better state of health 9
• Community Health Services – creating a healthier Victoria 10
• Care in your community: A planning framework for integrated ambulatory health care 11
3
Victorian Department of Human Services. Clinical Risk Management Strategy. July 2001.
4
Victorian Department of Human Services. Victorian Quality Council. A safety and quality improvement
framework for Victorian Health Services. July 2005.
5
Leading clinical governance in health services – The Chief Executive Officer and Senior Manager roles. A
supplementary paper to the VQC Safety and Quality Framework. 2005.
6
Clinical Governance in Community Health – Board of management Clinical Governance Reporting Guidelines
7
Credentialling and defining the scope of clinical practice for medical practitioners in Victorian health services –
policy handbook. 2007. Department of human services
8
Metropolitan Health and Aged Care Services Division, Victorian Government, Department of Human Services,
2003
9
Rural and Regional Health Services Branch, Rural and Regional Health and Aged Care Services, Victorian
Government Department of Human Services, 2005.
10
Primary and Community Health Branch Victorian Government Department of Human Services, 2004
11
Victorian Government Department of Human Services, 2007.
http://www.health.vic.gov.au/ambulatorycare/downloads/care_in_your_community.pdf
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12
• New directions for Victoria's mental health services – the next five years
• Growing Victoria Together 13
• A Fairer Victoria 14
These broader policies have implications for clinical governance processes, strategies and
activities as they shape organisational priorities and service delivery.
2.4.2 Other projects to be considered

There are a number of other related projects that will impact on the outcomes of this review,
may require amendments to the proposed Framework or should be taken into consideration in
implementing the clinical governance framework. They are:
• Review of the role of DHS and the Quality Branch.
• Review of the Victorian Quality Council.
• Evaluation of consumer advisory committees and consultative councils.
• Review by the Auditor General of clinical risk management and particularly on the
management of clinical incidents in public hospitals. This follows the 2003 review that put
forward a number of recommendations in relation to clinical risk management and
governance.
• Rural Health Service Benchmarking Project (funded by DHS Rural and Regional Health
Services Branch) to establish agreed financial and performance indicators for boards that
can be used to measure and compare performance with other health services. The Rural
Health Service Benchmarking Project was drawn on to develop a list of measures to test in
the draft clinical governance framework.
• Development of a Comprehensive Comparative Data Set for Victorian Health Services – the
Victorian Health Service Management Innovation Council is partnering with DHS as part of
the Victorian Health Reform Program. It aims to minimise variation in public health service
performance through the development of an appropriate set of performance measures.
• Consumer leadership development program aims to harness existing leadership capacity and
further develop it to promote the consumer perspective and effectively influence the health
system to bring about change.
12
Metropolitan Health and Aged Care Services Division, Victorian Government Department of Human Services
2002.
13
2001 Growing Victoria Together, Department of Premier and Cabinet http://www.dpc.vic.gov.au
14
2008 A Fairer Victoria, Department of Planning and Community Development
http://www.dvc.vic.gov.au/web14/dvc/dvcmain.nsf
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• Development of national patient charter of rights – The Australian Commission on Safety

and Quality in Health Care (the Commission) is developing a national patient charter of
rights that sets out the key rights of patients when receiving health care. On finalisation of
the national charter DHS and Victorian health services should review their patient charters
for consistency with the national charter.

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3 Review of the current state of clinical governance in Victoria

The review of current clinical governance practices was conducted between January 21 and
February 14, 2008. The complete findings of the review are contained in the second project
report, Review of the current state of clinical governance in Victoria – report of findings of the
consultation process.
3.1 Review methodology

The assessment of current clinical governance practices focused on the systems and processes
that are in place within Victoria’s public health services. While it is acknowledged that ideally a
review of clinical governance would include a measure of effectiveness in improving patient
outcomes, the existence and accessibility of outcomes data is limited and variable. Thus the
review methodology was based on assessing the state of existing systems and processes through
consultations, using surveys, interviews and focus groups.
3.2 Consultation activities

Consultation activities focused not only on current arrangements, but also canvassed
stakeholders’ views on opportunities for improvement and priorities for the future. Consultation
activities included:
• Interviews – telephone and face-to-face interviews were conducted with a number of key
informants. Key informants are listed in Attachment A.
• Site visits – six site visits were undertaken between January 21 and February 6, 2008. At
each of the site visits a range of meetings were organised with health service executive,
hospital managers, senior clinicians and clinical unit managers. In addition face-to-face
surveys of clinical staff and a focus group was undertaken at each of the six sites listed
below. Focus group participants are listed in Attachment B.
- St Vincent’s Hospital
- The Geelong Hospital
- Monash Medical Centre
- Warragul Health Service
- Peter McCallum Cancer Centre
- The Austin Hospital
• CEO and board of directors focus group – a focus group was held with a number of
CEOs and board directors from rural, regional and metropolitan health services. Participants
of the focus group are listed in Attachment B.
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• Surveys – two survey instruments were used to elicit the views of senior clinicians and
health service managers experience of clinical governance. In addition a survey instrument
was used to conduct short face-to-face interviews of clinicians at the coalface of clinical
care delivery.
• Desktop review – a review of existing policies, frameworks, committee structure

documents or board reporting schedules that were forwarded by health services to the
project team for consideration.
3.2.1 Limitations of the review

The findings were based primarily on information provided during consultation activities at six
sites, and through voluntary surveys and interviews with key informants. While information was
sought from 92 Victorian health services or agencies, slightly less than one third of all health
services have contributed to the review in the time available. Therefore the findings may not
have fully represented the diversity of practices in place across Victoria. The project team has
sought to minimise the effect of these issues, their potential limitations on the findings should
be considered when considering the assessment of current practice.
3.3 Findings of the review

The review of clinical governance identified a number of strengths within clinical governance
systems in Victoria as well as opportunities for improvement. A summary of the key findings of
the review are outlined in the following sections.
3.3.1 Elements of clinical governance

There were many similarities in the functional elements that make up the system of clinical
governance within health services. During the course of the seven focus groups these elements
were identified. Although there was some minor variation, these elements generally included:
• governance structures and reporting lines
• strategic and business planning
• policies, frameworks and guidelines
• consumer participation:
- involvement in governance and management
- complaints and compliments management and learning
- patient and carer partnership in care processes such as self management and open
disclosure
• risk management systems

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• improvement programs and initiatives
• evidence based guidelines
• accreditation
• performance monitoring and reporting systems.
Culture, leadership, education and training were identified as critical determinants in the
effectiveness of safety and quality governance systems. Human resource management activities
including credentialling, definition of scope of practice, performance management were also
identified as key elements of the system.
While the grouping above implies that these are discreet, unrelated activities the reality is that
there is considerable overlap and co-dependency between each of the elements.
3.3.2 Strengths of the current system

In some health services governance structures are reported to be working well and individual
health services are able to set these up to suit the size of the service, the setting and the type of
services provided. Significant progress has been made in defining roles and responsibilities at
various organisational levels.
Risk management systems are becoming more established, particularly those activities related to
incident management. Substantial progress has been made in fostering a culture of safety and
quality with good incident reporting and a shift from blame of individuals to a focus on systems
and process improvement, although there is room for further improvement, particularly among
medical clinicians.
DHS and the VQC play an important enabling role, fostering innovation and excellence in a
number of safety and quality programs such as Risk Management and the RCA program. DHS
fosters networking through training programs and establishment of working groups and
committees, and provides an avenue for funding the spread of innovation. The less directive
approach adopted by DHS appears to have resulted in ownership and leadership of safety and
quality within health services.
There are a number of examples of innovation and excellence in safety and quality systems
within Victorian health services. There also appears to be strong informal networking and
sharing of information and tools between health services.
3.3.3 Opportunities for improvement

A number of opportunities for improvement were highlighted during the review of current
practice.

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3.3.3.1 Strategy and relationships

• There is a lack of clarity regarding the different roles of the Statewide Quality Branch,
VQC, and other strategic external organisations and their relationship with health services.
• Increased transparency of priority setting and greater focus on quality and safety in balance
with finance and access at state level is required.
• There is a need to strengthen the coordination and facilitation role of DHS and maximise
opportunities to convert local innovation and excellence to benefits across the Victorian
system. There was a strong message that health services wanted greater direction on the
safety and quality systems that should be in place although this needs a balanced approach
to ensure ownership, responsibility and accountability for quality and safety is retained
within health services.
3.3.3.2 Health service boards

There is an opportunity to strengthen the system of clinical governance through building the
capacity of boards to govern safety and quality. There is significant variation in board reporting
practices with different information provided in a variety of formats that are not always tailored
to the level required. There is strong consensus that there would be significant benefits from
DHS providing specific direction on information that should be provided to boards and board
committees as well as strategies for flagging outlier performance and for engaging boards in
robust discussion of the issues. There was also strong support for central development of
reporting templates and checklists to strengthen the execution of the board’s role.
Stakeholders were looking to the clinical governance framework to provide boards with
guidance on the safety and quality systems and processes that need to be place, as well as assist
in setting strategic directions for further development. There is an opportunity at State level, to
coordinate the development of tools and templates to facilitate stronger governance of safety
and quality through training at induction of new board directors and ongoing development of
existing directors. There is an opportunity to build on the work already undertaken in
development of rural health service boards.
3.3.3.3 Measurement of quality and safety

Measurement of safety and quality performance is a major area of concern for many with
current performance measures lacking a true balanced score card approach and little uniformity
in approach to measurement between health services. High level rewards to improve safety and
quality performance, including funding incentives, are missing. A standard suite of quality KPIs
would allow more robust measurement of performance and enhance benchmarking
opportunities at local, state and national levels. There is also an opportunity locally to better
utilise existing data in clinical registries to provide assurance on the safety and quality of care.

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3.3.3.4 Consumer and community participation

There is variable success in engagement of consumers and communities in governance of
clinical care, risk management, improvement activities and Evaluating Effectiveness of
Participation (EEP) projects. Guidance on strategies for consumer involvement, case studies or
information from exemplar sites may assist efforts.
3.3.3.5 Safety and quality improvement activities

Currently improvement activities are project based without strong integration into longer term
strategic plans with the result that benefits may not be sustained. There is some indication that
the improvement in risk management systems may have come at the expense of improvement
activities in some health services and that this was exacerbated by the project based approach to
improvement initiatives. The importance of Clinical Practice Improvement and collaborative
projects in effecting improvement across the system should continue to be recognised and
funded accordingly. The use of clinical audit to assist in managing performance and providing
assurance on the quality of clinical care is patchy. There is opportunity to facilitate the spread of
existing good work in implementation of evidence based guidelines and clinical audit across the
state. There is also a need to further develop understanding of effective change management
methods and strategies including those that promote innovation and modify behaviour.
Any clarification and articulation of the differing roles of the Statewide Quality Branch and the
VQC should acknowledge that there needs to be a single point of accountability for health
services have access to the support and tools they need to effectively and efficiently delivery the
mandatory elements of the clinical governance framework.

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4 Framework development and issues for implementation

The development of the clinical governance framework was informed by the activities outlined
in Section 2.3 of this report. Stakeholders who participated in these development activities and
in providing feedback on the draft clinical governance framework are listed in Attachment C.
The framework spans across the various levels of the system and takes into account the key
stakeholders in patient safety and clinical quality (Figure 4.1).
Figure 4.1 Positioning of the framework within the levels of the health system and key
stakeholders
Community & consumer Victorian Quality Council
Department of
Minister Health and Aging
Enhancing clinical care
Australian Commission
Department of Human Services for Safety and
Quality in Health Care
VQC, Clinical Consultative Councils
Professional colleges
Statewide clinical networks
Registration boards
Health service boards
Peak professional groups
CEO and executive Peak consumer groups
Office of the Health Services

Clinical teams and managers Commissioner
The clinical governance framework outlines responsibilities for implementation and identifies
those key stakeholder groups that should be either consulted or included implementation. At
each level there is the expectation that one of these groups will take responsibility for
oversighting, coordinating or actioning the proposed strategies.
4.1 Rationale for the structure and focus of the clinical governance
framework
While the purpose and focus of the clinical governance framework was to improve governance
of clinical care the following requirements for the clinical governance framework were

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identified throughout the review process. It was identified that the clinical governance
framework should:
• focus at the interface between consumers and clinical teams where quality and safety is
determined, and outline the systems, structure and supports that need to be in place to
continuously improve safety and quality of care
• outline requirements at all levels of the health system for governance of clinical care
(Figure 4.1)
• outline the scope of quality and safety activities that should be governed by health service
boards
• provide levers that may be used at multiple levels of the system for implementation of
mandated systems and processes
• clarify roles and responsibilities in relation to governance of clinical care at all levels of the
system.
The governance process outlined in the clinical governance framework describes a continuous
cycle of oversight and direction of the clinical operations of health services that is linked into
processes to ensure integration and coordination of quality and safety activities to improve
sustainability.
4.2 A developmental framework

The clinical governance framework is designed to acknowledge the different stages of
development of safety and quality systems in each health service and offers a developmental
approach. It provides direction on required strategies to assist health services in prioritising
development and implementation of systems and processes. It also provides stretch goals and
strategies for pursuing excellence although it does not aim to provide a comprehensive list of
quality and safety strategies. It is designed to allow regular updates to strategies to cater for
advancements in safety and quality systems. The clinical governance framework is flexible to
account for differences between health services in their size, geographical setting, resourcing,
infrastructure, service delivery models and workforce.
4.3 Scope
The clinical governance framework has been developed specifically to be applicable to all
public sector health services including acute, community, sub-acute and aged care services. The
ambulance services were considered out of scope due to the difference in arrangements for
clinical service delivery. The project team noted that the Rural Ambulance Service is currently
developing a strategy for governance of quality and safety
While private providers were out of scope for the purposes of this project the applicability of the
clinical governance framework to the private setting should be explored with private health
providers and relevant stakeholders.

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4.4 Roles and responsibilities

The clear delineation of roles and responsibilities with respect to clinical governance was seen
to be critical by all stakeholders. There was broad consensus on the need to update the roles and
responsibilities outlined in the document The Healthcare Board’s role in clinical governance
although these were seen to be generally relevant and appropriate to use as the basis for the
clinical governance framework. 15
There were a mix of opinions on the level of detail required in the delineation of roles however
CEOs thought that as much detail as possible should be provided. There was strong support for
an interpretation of roles and responsibilities in line with the clinical governance framework
strategies. An example of this is set out in Attachment D.
The outcomes of the review of the VQC and the Quality branch will impact the roles and
responsibilities defined in the clinical governance framework and will need to be considered in
finalising the clinical governance framework in subsequent revisions and updates of the
document.
4.5 Improvement and innovation

There was concern that the current project based approach and seed funding for specific one off
projects did not support a sustainable coordinated approach to improvement of safety and
quality. However the value of seed grants in fostering innovation was acknowledged. It was felt
that there would be benefit in establishing alternate processes where seed funding was tied into
more strategic long term programs to deliver sustainable change that focussed on identified
priority areas. This would also provide a setting in which funding mechanisms ensure that
priority programs are incorporated in “business as usual”. The following cycle is suggested for
implementing innovation into statewide practices.
Identified Innovation Where ideas Roll out tool

priority area grants are supported kit, spread
performance to address by evidence experience
gaps performance develop tool through
gaps kit networks
The clinical governance framework describes a mechanism whereby performance gaps are
identified through collaboration between VQC, DHS State Quality Branch, national clinical and
safety and quality bodies. These gaps should be prioritised and areas of focus for safety and
quality improvement identified.
15
Leading clinical governance in health services – The Chief Executive Officer and Senior Manager roles. A
supplementary paper to the VQC Safety and Quality Framework. 2005
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4.6 Performance measurement

Reporting organisational performance is a critical activity in the governance of clinical care.
Safety and quality performance measures are used to monitor organisational performance,
identify trends including improving or deteriorating performance, compare performance with
like organisations, and identify risk and opportunities for improvement.
There was strong consensus among most stakeholders that a core set of quality and safety
measures be established, including data definitions, collection processes and centralised
mechanisms of collating data and reporting back to health services. This is a critical activity and
will have a significant impact on the degree to which the clinical governance framework is able
to be implemented. Central coordination of data collection and reporting was supported by
stakeholders. The VICNISS data set was seen as an excellent example of this and provided
health services with the ability to drill down and investigate potential outlier performance.
4.6.1 Developing quality and safety measures

Two approaches to development of a core set of safety and quality measures were identified:
• a centrally driven approach, led by DHS that focussed primarily on the use of administrative
data though included other measures that are included in the state databases
or
• a clinician driven approach through the emerging clinical networks or through specialty
groups convened specifically for the purpose to develop consensus on the measures which is
then implemented by DHS. Specially convened groups will need to be convened
periodically to review and update the measures.
There was concern that measures developed without clinician input would have limited
evidence base to support it. A combination of both approaches would have the advantage of
access to at least some measures in the short term while a longer term strategic approach which
had strong clinician engagement and buy-in the longer term.
There were differing views on the advantages of using outcome measures over processes
measures with smaller services arguing strongly that outcome measures had little value where
there were small activity volumes. Outcome measures were also seen as less responsive with
significant delays between care provision, care outcomes and the outcome being known and
reported. Also, for episodic care, many adverse outcomes were undetected as the patient was
transferred or discharged from the service prior to the outcome being known. The clinical
governance framework proposes a mix of both structure, outcome and process measures that
have evidence based links to health outcomes. It also takes an approach to measuring
implementation of key strategies from the clinical governance framework however this should
be in line with priority areas and at least in the initial stages be confined to required strategies to
minimise the burden on health services.

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4.6.2 Related projects

There are a number of projects and initiatives underway that will impact and inform a list of
quality and safety measures for Victorian health services. These are:
• Victorian Health Service Management Innovation Council is developing a comprehensive

comparative data set which includes an appropriate set of performance measures that aims
to decrease variation in public health service performance
• Australian Commission for Safety and Quality in Health Care will recommend national data
sets for safety and quality, working within current multi-lateral governmental arrangements
for data development, standards, collection and reporting; and work towards reporting
publicly on the state of safety and quality 16
• COAG performance indicators that are part of State Commonwealth agreements
• Rural Health Service Benchmarking Project (funded by DHS Rural and Regional Health
Services Branch) is working to establish agreed financial and performance indicators for
boards that can be used to measure and compare performance with other health services. It
will also design and implement centralised data capture and reporting. DHS have identified
three groups of indicators for benchmarking: financial and workforce; service delivery
processes, patient safety and satisfaction; and service improvement and sustainability.
4.6.3 Testing acceptability of measures

A potential list of quality and safety measures identified through the Rural Health Service
Benchmarking Project was reviewed. A small subset of these measures that represented service
level safety and quality measures was included in the Draft outline of the clinical governance
framework document and was tested with stakeholders. There was little support for the list of
proposed measures. Stakeholder feedback was that the measures did not include a good balance
of process and outcome measures and did not reflect the range of services provided.
A larger set of measures plus some broadly accepted process measures (Attachment E) was
tested with a group of key informants. Significant concerns were raised regarding their
reliability and use unless robust processes were put in place to investigate and verify results.
The project team concluded:
• progress in the projects listed in the section above should be monitored and where relevant,
learnings should be incorporated into the clinical governance framework measures
• indicators based on administrative datasets should be used with caution and only where
there is a process for data integrity checks and analysis of underlying factors causing
variation prior to their use as indicators of performance
16
Australian Commission fro Safety and Quality in Health Care 2007 Information strategy
http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/703C98BF37524DFDCA25729600128BD
2/$File/Information%20Strategy%20September%202007.pdf
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• it is essential to develop clinician ownership of measures. Clinicians are more likely to

support and use of measures that:
- are developed in collaboration with clinical groups
- have strong evidence base
- have processes in place to ensure they are updated and are in line with current evidence
- are used primarily to inform improvements to clinical care.
4.7 Performance reporting

The clinical governance framework specifies that health services should report to the board,
community and DHS on defined elements of performance that reflect the functioning of quality
and safety systems within the organisation. It further specifies that reporting requirements
should be integrated and aligned to ensure that reporting is not duplicated or creates a burden on
the system.
To ensure this DHS should consider current reporting requirements including Quality of Care
Report and harmonise items reported and formatting requirements to enable health services to
develop aligned reporting and prevent duplication.
There was varying support for a move to public reporting of quality and safety measures with
stakeholders identifying examples of misinformation and inaccurate interpretation of reported
performance by the media. There was strong consensus that if quality and safety measures were
to be reported to the public they needed to be able to factor in issues such as variation in risk
factors and nature of services provided by different organisations. It was also recognised that
there was limited understanding of what consumers and community want reported and the
format which would be best able to provide them with the information they need.
4.8 Levers for implementing quality and safety strategies

The clinical governance framework identifies a number of levers which should be used to move
the safety and quality agenda forward. These include:
• involvement of key stakeholders including professional colleges, registration boards and

insurers in shaping of State and health service priorities for quality and safety improvement
• the incorporation meaningful safety and quality targets into the annual Statement of
priorities
• funding specific priority safety and quality initiatives
• developing meaningful ways of rewarding safety and quality including financial incentives
to supplement current quality awards program.

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4.9 Financial implications

It is important to consider the boundaries in which the clinical governance framework will be
implemented. From a financial perspective matters of relevance include:
• funding and service agreements dictate the purpose for which funding is provided. Funding
to health services is on the assumption that certain quality activities are carried out as
outlined in policy directives and listed in the statement of priorities
• the current funding provided assumes organisations can provide and manage their current
governance system as part of day to day operation
• the challenge for health services with tight budget to implement additional programs and
activities that are not already in place without external support
• implementation of resource intensive programs such as clinical audit and the use and
analysis of administrative data to flag potential outlier performance will have significant
resource implications for health services
• central development of implementation support materials and education programs will

maximise the efficiency of implementation activities.

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5 Overview of the clinical governance framework

The complete clinical governance framework is provided as a stand-alone document however
the following section provides a brief overview of the key elements.
Consumers have a right to safe, high quality evidence based health care, openness and honesty
of communication and to be cared for in an environment that fosters shared decision making and
trust between providers and consumers. Clinicians and clinical teams play a pivotal role in
providing safe, high quality care in partnership with consumers and require robust systems and
processes to support them in providing that care. Enhancing clinical care – A framework for
improving the governance of the quality and safety of healthcare describes an approach to
improving the governance and performance of the health care system.
5.1 Framework principles

The following principles provide a basis for supporting excellence and good governance of
clinical care delivery:
• focusing on consumer/patient/client/resident outcomes and their experiences of care
• building a culture of trust, honesty and respect among all participants within the system
(consumers, clinicians, ancillary staff, management, board and government)
• fostering organisational commitment to continuous improvement and enhancing clinical

care
• establishing rigorous monitoring, reporting, response and evaluation systems for

organisational performance
• building clinical leadership and ownership
• supporting governance of health service performance with robust information and reporting
systems
• rewarding good performance in quality and safety.
The consumer, their needs and their experience of the care provided, is the focus of health
service provision. Clinicians and clinical teams are responsible and accountable for the safety
quality of care they provide. The health service board CEOs and management are responsible
and accountable for ensuring the systems and processes are in place to support clinicians in
providing safe, high quality care and engage clinicians to participate in governance activities.
Governance of the health system occurs at all levels and requires performance review and
improvement at every level from the Minister, DHS, health service boards, CEOs, managers,
clinicians and non-clinical staff. The health service board is accountable for the quality and
safety of clinical services to the Minister of Health, and through the Minister who is acting on
their behalf, to the local community.
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5.2 Health service governance

Any system of governance of clinical care must operate within the health service’s overall
system of governance which includes financial and corporate functions. The governance of
clinical care occurs within the context of the broader governance role of boards that includes
setting strategic direction, managing risk, improving performance and ensuring compliance with
statutory requirements (Figure 5.1). 17
Figure 5.1 Representation of health service governance context
ce
l ian
Ri
p
sk
om
lc Health Service Board
as
ga
se
Le
ss
m
en
t
Financial &
Clinical care
assets
Other
Pe
Corporate
rfo
functions
rm
an
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ce
ate
en
s tr
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Governance of an organisation occurs at all levels and requires a program of review and
improvement of internal processes and outcomes at every level from the board, the CEO, the
manager team, clinicians and non-clinical staff.
The required elements of clinical governance are:
• Priorities and strategic direction are set and communicated clearly
• Planning and resource allocation supports achievement of goals
• Culture is positive and supports patient safety and quality improvement initiatives
• Legislative requirements are complied with
17
Achieving best practice corporate governance in the Public Sector. Chartered Secretaries Australia’s Public Sector
Governance Forum 2003
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• Organisational and committee structures, systems and processes are in place
• Measure performance and progress of quality and safety systems
• Report, review and respond to performance to support continuous improvement of

quality and safety
• Roles and responsibilities are clearly defined and understood by all participants in the
system
• Continuity of care processes ensures that there is continuity across service boundaries.
Figure 5.2: Representation of components of the clinical governance framework
Governance of
clinical care
Measure Priorities and
performance strategy
Planning and
Report review
resource
and respond to
allocation
performance
Consumer Experience Clinical

Patient & quality
of care Teams
Resident
Roles and Culture

responsibilities
Continuity of Legislative
care compliance
Organisation &
committee
structures, systems
and processes

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5.3 Domains of quality and safety

Consumer participation, clinical effectiveness, effective workforce and risk management – these
four domains of quality and safety provide a conceptual framework for the strategies to enhance
the delivery of clinical care. Within each domain there are a number of quality and safety
management functions in place that require direction and oversight by governing bodies.
5.3.1 Consumer participation

Consumer participation should occur at multiple levels of the organisation through activities
such as community consultation and consumer partnership on governance and management
committees, and within improvement initiatives or clinical risk management activities.
Consumer participation is sought in planning, policy development, health service management,
clinical research, training programs and guidelines development. The organisation uses
consumer complaints, compliments, surveys and Freedom of Information (FOI) requests to
inform improvements. Consumer input is used in the development of information resources and
communication strategies for patients, residents and carers.
Strategies should be in place to ensure:
• consumers are empowered to participate in their care
• consumers participate in organisational processes including planning, improvement and

monitoring
• there is clear, open and respectful communication between consumers at all levels of the
health system
• services respond to the diverse needs of consumers and the community with humanity
• consumers provide feedback on clinical care and service delivery and services learn from it
• rights and responsibilities of ‘patients’ are promoted to community, consumers, carers,

clinicians and other health service staff. 18
5.3.2 Clinical effectiveness

Clinical effectiveness is ensuring the right care is provided to the right patient who is informed
and involved in their care at the right time by the right clinician with the right skills in the right
way.
• clinicians are empowered to improve clinical care delivery
• clinicians actively involve consumers as partners in their care
18
Doing it with us not for us - Participation in your health service system 2006–09 (as above)
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• clinical innovation is fostered and supported
• clinical service delivery processes are streamlined and efficient
• clinicians participate in designing systems and processes
• quality improvement activities are planned, prioritised and have sustainability strategies in
place
• clinical care delivery is evidence based
• standards of clinical care are clearly articulated and communicated
• performance of clinical care processes and clinical outcomes are measured
• clinical performance measures are used to evaluate and improve performance
• quality improvement activities are reviewed externally
• new procedures and therapies are introduced in manner that assures quality and safety issues
have been considered and acted on.
5.3.3 Effective workforce

All staff employed within health services must have the appropriate skills and knowledge
required to fulfil their role and responsibilities within the organisation. Support is required to
ensure clinicians and managers have the skills, knowledge and training to perform the tasks that
are required of them and that they understand the concept of governance. Processes should be in
place to support the appropriate selection and recruitment of staff, maintenance of professional
standards and control the safe introduction of new therapies or procedures.
• workforce development is planned and ensures a health workforce with appropriate skill and
professional group mix is available
• the health workforce has the appropriate qualifications and experience to provide safe high
quality care
• workforce development activities to improve quality and safety is coordinated and efficient
• expectations and standards of performance are clearly communicated
• workforce is supported in their roles through training, development and mentoring
• the health workforce is fulfilling its roles and responsibilities competently

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• workforce competence is sustained, innovation is fostered and corporate knowledge is

passed on
• multidisciplinary teamwork is fostered and supported.
5.3.4 Clinical risk management

Clinical risk management is part of the broader organisational risk management system which
integrates the management of organisational, financial, occupational health and safety, plant,
equipment and patient safety risk. Minimising clinical risk and improving safety of care requires
a systems approach. This is achieved through development of systems level response to issues
that sustain an environment that allow adverse events to occur. This occurs within the frame of a
just culture rather than focussing on and blaming individuals. Clinical risk management and
improvement strategies are integrated within improvement and performance monitoring
functions.
Clinical risk management strategies should be in place to ensure:
• clinical incidents are identified and reported
• clinical incidents are investigated and underlying systems issues and root causes are
identified
• risks are proactively identified, assessed and reported
• organisational culture supports open communication and systems approach to learning from
incidents
• clinical processes and technology supports are designed to minimise error and ensure clear,
unambiguous communication
• known clinical risks are responded to proactively
• risk information is considered in settings goals, priorities and developing business and
strategic plans
• legislation is complied with
• policies and protocols are reviewed and managed
• risk management activities are reviewed externally
• methods to improve patient safety is researched and innovative interventions developed.

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6 Conclusions and recommendations

There needs to be an integrated and coordinated approach to ensure that implementation of the
clinical governance framework aligns with State priorities and national directions. The
following section outlines a way forward which will centre on development of a detailed
implementation plan for the clinical governance framework.
6.1 Going forward

Full implementation of the clinical governance framework needs to be staged to ensure that the
goals and strategies can be factored into planning cycles. A detailed implementation plan is
required to support implementation at all levels of the Victorian health system. As a starting
point it is important for DHS that all relevant stakeholders have an understanding of the clinical
governance framework and their roles and responsibilities in implementation.
There are six key areas of focus in moving forward. These are:
• considering the outcomes of concurrent related projects and reviews and their impact on the
clinical governance framework
• modifying the clinical governance framework to accommodate findings of concurrent

projects
• communicating the clinical governance framework to stakeholders
• agreeing priorities for implementation and developing a detailed implementation plan
• developing or identifying existing tools and education programs to support implementation

of the clinical governance framework
• developing an agreed core set of safety and quality measures for reporting performance.
6.1.1 Consider the implications of other projects

As outcomes and findings of other projects identified in Section 2.4.2 of this report come to
hand the implications of these need to be considered and their impact on the clinical governance
framework identified.
6.1.2 Modify the clinical governance framework

Where appropriate the clinical governance framework should be modified to accommodate
recommendations and directions from the projects and reviews. In particular they should be
used to:
• provide clarification of roles and responsibilities of DHS, VQC and the clinical networks

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• inform development of the core set of quality and safety measures
• identify areas for prioritisation of focus in development of clinical risk management systems
• identify further strategies to promote consumer leadership and participation in quality and
safety activities.
6.1.3 Communicating the clinical governance framework to stakeholders

Communication of the clinical governance framework is critical to ensure that there is a
common understanding of its purpose and use among key stakeholders. DHS should do this in a
collaborative way with the sector. A communication strategy needs to include:
• communication materials that include the nature shape, purpose and benefits of the clinical
governance framework
• building on existing engagement and ownership of stakeholders
• a focus on engaging with clinicians and developing a clinician friendly “strategy on a page”
document to facilitate dissemination.
6.1.4 Agreeing priorities for implementation

The clinical governance framework provides the basis for a prioritisation scheme for
implementation. The following issues should be taken into consideration when prioritising
strategies for implementation:
• good clinical governance systems rely on strong leadership on quality and safety from
board, CEOs, executive and senior clinicians however this is an area that needs
improvement at all levels of the system
• there is variability in the safety and quality systems and processes that are in place across
Victorian health services. Some health services, particularly those in rural centres that do
not have strategies in place that the clinical governance framework defines as required.
Health services often struggle to access expertise or materials, tools and templates to support
implementation of these systems
• budgetary constraints will effect the capacity of some health services to implement elements
of the clinical governance framework where they are not resource neutral
• there is significant variability in the health service board governance of safety and quality.
There is limited capacity of some boards to direct and oversight clinical service delivery
with many focussing on financial and throughput issues.

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6.1.5 Developing implementation supports

The clinical governance framework identifies the need for training and implementation toolkits
(inclusive of literature review, education kit, risk assessment tools, audit tools, case studies etc)
to support health services implementing systems and processes. It proposes a central model to
decrease the requirement for each health service to develop their own and maximise
efficiencies. There is a need to:
• identify existing training programs (such as the Root Cause Analysis and clinical incident
investigation training), tools and other resources that facilitate implementation of the clinical
governance framework
• develop and deliver a program to promulgate effective governance practices among boards
and to increase their understanding and capacity to govern quality and safety of clinical care
is required
• coordinate existing tools and resources so that they are accessible and can be related to
framework strategies. Identify gaps in implementation supports for required strategies and
develop resources to address these.
6.1.6 Developing measures to report quality and safety performance

Developing a core set of quality and safety performance measures requires:
• engagement with relevant stakeholders including clinicians, clinical networks, health

services, health service boards and consumers
• consideration of outputs of other related projects and programs that will inform or impact
the dataset
• central co-ordination of data collection and reporting structures including coordination of

existing statewide data base reports
• development of statistically and logically robust reports that are appropriate for public
reporting.
6.2 Recommendations
The following recommendation summarise the key requirements for effective implementation of
the clinical governance framework. The detailed implementation plan will need to consider
timing, resourcing and support structures required:
• That the outcomes of concurrent related projects and reviews be considered and adjustments
made to the clinical governance framework to accommodate the findings of the reviews
• That DHS in collaboration with key stakeholders communicate the clinical governance
framework and the implications for the health system to health services and other
stakeholder groups
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• That DHS in consultation with key stakeholders reviews the priority scheme for the clinical
governance framework and develops a detailed long term implementation plan
• That DHS in consultation with relevant stakeholders develop a set of core quality and safety
indicators and explore opportunities to increase use of state and national registry data in
governance processes
• That DHS make the clinical governance framework available to private health providers and
relevant stakeholders to allow them to test applicability of to the private health sector
• That the financial implications of implementing the clinical governance framework for
health services be considered and if necessary funding made available or the prioritisation
scheme adjusted to ensure requirements are achievable within the available resources.

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7 Glossary
Accreditation an evaluation by an independent body of the degree of
compliance by an organisation with previously determined
standards and, if adequate, the award of a certificate.
Adverse event an incident in which harm resulted to a person receiving

health care.
Benchmarking a continuous process of measuring quality or performance

specifically in relation to efficiency and effectiveness.
Clinical audit a quality improvement process that seeks to improve patient

care and outcomes through systematic review of care against
explicit criteria and the implementation of change. Aspects of
the structures, processes and outcomes of care are selected and
systematically evaluated against explicit criteria. Where
indicated, changes are implemented at an individual team, or
service level and further monitoring is used to confirm
improvement in health care delivery.
Clinician health care staff involved in clinical aspects of patient care,

mainly, but not restricted to, allied health, nurses and doctors.
Clinical governance the system by which the governing body, managers, clinicians
and staff share responsibility and accountability for the quality
of care, continuously improving, minimizing risks, and
fostering an environment of excellence in care for consumers/
patients/residents 19 .
Consumer people who are current or potential users of health services.

This includes children, women and men, people living with a
disability, people from diverse cultural and religious
experiences, socioeconomic status and social circumstances,
sexual orientations, health and illness conditions.
Credentialling the formal process used to verify the qualifications,

experience, professional standing and other relevant
professional attributes of medical practitioners for the purpose
of forming a view about their competence, performance and
professional suitability to provide safe, high quality health
care services within specific organisational environments.
Framework a set of principles and long-term goals that form the basis of
making rules and guidelines, and to give overall direction to
planning and development.
19
This definition is based on Australian Council on Healthcare Standards (2004) ACHS News, Vol 12 1-2, ACHS
Sydney.
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Incident an event or circumstance which could have, or did lead to,

unintended and/or unnecessary harm to a person and/or a
complaint, loss or damage.
Open Disclosure the open discussion with a patient or their carer when things
go wrong with their health care.
Performance measures measures of structures, processes and outcomes of quality and

safety of care. Includes clinical indicators as a subset which
are measures of the effectiveness and efficiency of health
providers in providing health care.
Quality doing the right things, for the right people, at the right time
and doing them right the first time.
Safety a state in which risk has been reduced to an acceptable level.
Strategy a range of actions, programs, activities, and policies that

provide a guide for implementation to achieve a goal.

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May 2008
Appendix A Key informants interviewed

Elaine Bennett - Peninsula Health Care Network
Jo Bourke - Barwon Health
Alison Brown – Victorian healthcare Association Ltd
Mary Draper - The Royal Women's Hospital
Cindy Hawkins - Melbourne Health
Jigi Lucas - Eastern Health
Annie Moulden -Royal Children's Hospital
Anna Macleod - Austin Hospital
Anne Maddock - Vincents Hospital
Joanne Moorfoot - Southern Health
Allison McMillan - DHS
Liza Newby – Consumer and Board member VQC
Jenny Peterson - Northern Health
Grant Phelps – DHS and Ballarat Health Service
Bill Shearer – Southern Health
Tony Triado - DHS
Tony Walker - Ambulance
Margaret Way - Bayside Health
John Zelcer - Eastern Health Board
Alan Wolff – Wimmera Health Service
Graeme Houghton - Eye & Ear Hospital

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Appendix B Consultation focus group participation

Table B1 - Attendance at health service focus groups
Name Health Service Position
Sue Brereton Barwon DND Surgical
Ann Hague Barwon DND Rehab & Aged Care
Karen Ray Barwon Quality and Clinical Safety Coordinator, Aged Care
Greg Weeks Barwon Director of Pharmacy
David Pluecblah Barwon Clinical Safety Manager
Jack Beever Barwon Quality Control Manager
Rod Fawcett Barwon Director of Medical Education and Training
Mary Hyland Barwon Mental Health
Robyn Blackman Barwon DND
Fiona McKime Barwon Director Sub-acute services
Mark Lee Barwon Director Community Health
Therese Cotter Barwon DND Women and Children's
Jo Burke Barwon Quality and Clinical Safety Manager
Jan Bennett West Gippsland ADON - Aged Care
Anne Curtin West Gippsland DON
Diane More West Gippsland ADON - Project Nurse
Wendy Tilling West Gippsland Locum Customer Service and Quality Manager
Kathy Bailey West Gippsland DDON/PSM
Simon Fraser West Gippsland Director of Medical Services
Susan McLeod West Gippsland Risk Cons, Latrobe Regional Hospital
Kerrie Missen West Gippsland Manager, Latrobe Regional Hospital
Michael McStephen West Gippsland Quality Manager, Bairnsdale Regional Health
Service
Ormond Pearson West Gippsland CEO
John Anderson West Gippsland Director of Corporate Services
Bernie McKenna West Gippsland CNM, Medical
Allison Merrigan West Gippsland ADON Clinical Initiatives
Daniel Scholtes West Gippsland NUM Theatre
Grant Phelps Southern Gastroenterologist, Ballarat Health Services
Bill Shearer Southern Strategy, Performance and Planning
Wayne Reevney Southern Executive Director, Medical Services
Kylie Ward Southern Executive Director, Nursing and Midwifery
Shelly Park Southern CEO, Southern Health
Fiona Webster Southern Executive Director, Strategy, Performance and
Planning
Siua Siuarajati Southern Executive Director, Acute Services
Filomena Gavarella Southern Clinical Risk Manager, Strategy, Performance and
Planning
Kato Gray Southern Director, Aged Services
Prof Julian Smith Southern Medical Director, Specialty Program
Jo-Anne Moorfoot Southern Quality Director, Strategy, Performance and Planning

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Name Health Service Position

Kathy Simons Austin Quality Manager, NEMICS
Shane Crowe Austin Deputy Director, Ambulatory and Nursing Services
Rhyl Gould Austin Director Cancer, Spinal and Outpatients CSU
Lyn Roberton Austin Patient Representative
Jen Hancick Austin ADON
Cathy Nall Austin Director of Physiotherapy
Hayley Hellinger Austin project officer
Jane Evans Austin Manager, Quality and Planning
Leanne Turner Austin Director, Specialty Services CSU
Anne McGrath Austin Medication Safety Pharmacist
Leanne Tolby Austin Risk Manager
Carole Smith Austin Medical Director, Pathology
Anna McLeod Austin Manager, Clinical Governance Unit
Delia Comodo Peter Mac NUM, Ward 2
Michael Cooney Peter Mac NUM, Chemo Day ward
Eileen Thompson Peter Mac Patient Advocate
Erwin Loh Peter Mac Deputy CMO
Aldo Rolfo Peter Mac Director of Radiotherapy
Linda Nolte Peter Mac Manager, Quality Improvement
Elizabeth Ballinger Peter Mac Manager of Social Work
Justine Mizen Peter Mac Clinical Risk Manager
Mei Krishnasamy Peter Mac Research Fellow
Wal Crellin Peter Mac Consumer
Tracey Pearce Peter Mac Director Operations - Nursing
Dr Monica Slavin Peter Mac Consultant, Infection Control
Dan Mellor Peter Mac Deputy Director, Pharmacy
Stephen Thomas Peter Mac Director of Ambulatory Care
Tessa Jones Peter Mac Head of Psychology
Alan Balloch Peter Mac Quality Manager Pathology
Naida Hutton Peter Mac NUM, Theatre
Stuart Sandon Peter Mac Privacy Officer, Health Information Services
Louise Vecchi Peter Mac HR Consultant Recruitment
Patricia O’Rourke St Vincent's Chief Nursing Officer and Chief of Clinical
Operations
Peter Choong St Vincent's Chief Medical Officer
Evange Romas St Vincent's Physician and chair of the Quality Council
Kathryn Bailey St Vincent's Chief Physio
Jill Dickinson St Vincent's NUM 5W
Katie Cunnington St Vincent's Clinical Practice Improvement Nurse
Michael Enright St Vincent's A/NUM ED
Christine Holland St Vincent's Clinical Risk Manager
Jigi Lucas St Vincent's Quality Manager
Harshal Nandurkar St Vincent's Director of Haematology
Jill Dunn St Vincent's NUM, Ellenlie

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Table B2 - Attendance at CEO and Board of Director focus group

Name Service Position
Metropolitan
Professor Alan Fels Bayside Health BOD
Dr John Zelcer Eastern Health BOD
Dr George Morstyn Royal Women's Hospital BOD
Prof John McNeil MAS BOD
Dr Sandra Hacker Northern Health BOD
Catherin Brown RVEEH BOD
Dr Brian Stagoll DHSV BOD
Kathryn Cook Western Health CEO
Linda Sorrell Melbourne Health CEO
Dr Tracey Batten Eastern Health CEO
Stephen Cornelissen Mercy Health and Aged Care CEO
Felix Pintado DHSV CEO
Dr Tony Cull RCH CEO
A/Prof Les Reti Royal Women's Hospital For CEO
Dr Humsha Naidoo Northern Health For CEO
Rural/Regional
Margaret Rae Alexandra District Hospital President
Mr Ross Walker Echuca Regional Health BOD
Suzanne McKenzie Ballarat Health Service BOD
Jean Anderson Maryborough District Health BOD
Judy Lasarus Beechworth Health Service BOD
Lea Pope Bass Coast Regional Hospital CEO
Heather Byrne Alexandra District Hospital CEO
Wayne Sullivan Bairnsdale Regional Health CEO
Gary Templeton Gippsland Southern Health CEO
Dan Weeks Numurkah District Health CEO
Michael Delahunty Echuca Regional Health CEO
Geoff Iles Colac Area Health CEO
Mr John Davies East Grampians Health CEO
Linda West Otway Health CEO
John O Neill Portland District Health CEO
Andrew Rowe Ballarat Health Service CEO
Bart Ruyter The Kilmore & District Hospital CEO
David Lee Moyne Health Services CEO
Stephen Owens Casterton Memorial Hospital CEO
Jan Webb Beechworth Health Service CEO
Dr John Best AO Cobram District Hospital DMS
Jacqui Smith Kyneton District Health Service DMS
Bronwyn Beadle Maryborough District Health Acting CEO

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Appendix C Consultation on Draft Clinical Governance

Framework
Workshop –Friday 14 March – 9.00-10.00
Metropolitan CEOs in attendance at planning meeting
Meeting Friday 14 March 10.30 – 13.00
Alan Wolff – Wimmera Health

Jo Burke – Barwon Health
Workshop –Friday 14 March 14.00-16.00
Anna Macleod – the Austin Hospital

Anne Maddock – St Vincent’s Hospital
Marg Way – Bayside Health
Mary Draper – Royal Womens Hospital
Jack Beever – Barwon
Rebecca Smith – Barwon
Jill Jukes – Peninsula Health
Rodney Fawcett – Barwon Health
Leanne Toby – The Austin Hospital
Humsha Naidoo – Northern Health
Fiona Webster – Southern Health
Jan Webb – Beechworth Health Service
John Herbst Beechworth Health Service BOD
Ian Pollerd – Eye and Ear Hospital BOD
Nick Radford – Eye and Ear Hospital
Filomena Ciaravella - DHS
Tony Triado - DHS
Other consultations
John Zelcer – Eastern Health BOD

John Zalcberg – Peter MacCallum Cancer Center
Erwin Loh– Peter MacCallum Cancer Center

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Linda Nolte– Peter MacCallum Cancer Center

Michael McStephen – Bairnsdale Regional Health Service
Tony McBride – Health Issues Centre
Written feedback received
Tracie Andrews – Oral Health Services Division, Dental Health Services Victoria
Cathy Balding – La Trobe University
Alison Brown – Victorian healthcare Association Ltd
Mary Draper- Royal Women’s Hospital
Simon Fraser – Board Member VQC and West Gippsland Healthcare Group
John Herbst and Judy Lazarus - Beechworth Health Service
Anna MacLeod – Austin Health
Liza Newby – Consumer and Board Member VQC
Lind Nolte – Peter MacCallum Cancer Centre
Lea Pope – Bass Coast Health Service
Katherine Simons – Austin Health
Jacqueline Smith
Linda Sorrell – Melbourne Health
Margaret Way – Bayside Health

ABCD
Government
May 2008
Appendix D Example - Strategies relevant to identified roles

and responsibilities
Table D1 – Strategies relevant to roles and responsibilities - DHS
Department of Human Services

Role Strategies
Emphasising and enacting the equal importance Quality and safety strategies are key parts of annual
of both clinical and corporate governance statement of priorities
Key quality and safety indicators that reflect the breadth
of dimensions of quality are part of statement of
priorities KPIs
Working in partnership with key stakeholder DHS coordinates an annual roundtable to develop
groups to develop and prioritise strategies and priority areas for investment in improvement of quality
mechanisms for improving safety and quality and safety
within Victoria
Coordinate and support implementation of Coordinate development of literature review, model
agreed national standards and prioritised policies, toolkits, and education resources to support
strategies implementation.
Developing and supporting policy, legislation Review reporting performance on key quality and safety
and regulation which promote clinical indicators
governance as a key tenet of health service
Review compliance with baseline policy requirements
governance
Where performance issues identified support and review
health service plans to improve performance
Where underlying causes of poor performance are
sustained initiate sanctions
Ensuring appropriate governance and Communicate expectations, policies and requirements of
accountability arrangements to provide public their position to board directors
assurance of safety and quality through
Coordinate board training and orientation programs
allocating responsibility for clinical governance
specifically targeted at quality and safety
to Boards of Directors and clearly
communicating the responsibilities and
expectations involved
Implementing accountability and reporting Monitor performance reporting and review of health
mechanisms to ensure clinical governance services demonstrating performance issues. Implement a
responsibilities are met. program of escalated response where there is sustained
non-compliance with policy directives
Ensure reporting requirements are integrated
with key indicator and comparative performance Develop tools and templates to support robust reporting
data of quality and safety activities and issues to boards and
board quality committees that are based on best practice
models

ABCD
Government
May 2008
Department of Human Services

Role Strategies
Funding prioritised strategies to ensure ongoing Long, medium and short term planning of improvement
sustainability of improvement initiatives initiatives to provide sustainable building of baseline
levels of systems and processes
Fostering innovation through demonstration or Long, medium and short term planning of improvement
collaborative care projects, integrating findings initiatives for innovation projects
into policy and facilitating the spread of
findings across the health system
Supporting health services in managing and Establish statewide incident database
reporting quality and safety issues
Coordination of risk information from incident reporting,
Coroners reports, Office of the Health Services
Commissioner, TGA and other relevant sources
Coordinating statewide data collection of key Specify key clinical and other performance indicator
indicator data, providing health services with collection requirements, data definitions and reporting
comparative performance data and participation requirements
in national data collections
Align data collection and reporting requirements for
health services so that reporting can be used to fulfil
multiple purposes and prevent duplication of
requirements
Coordinating and driving quality systems Incorporate improved delivery of information technology
development, information technology and data to support clinical care delivery such as online results
collection to support the delivery of high quality reporting, medication management systems and other
clinical care through funding incentives. clinical decision support tools into capital planning and
implementation strategies
Providing information and education about Coordinating delivery of core set of education programs
improvement tools, techniques and innovation that require specialist input:
from both health care and other industries.
• incident investigation and management
• open disclosure

ABCD
Government
May 2008
Appendix E Attachment – Quality and safety measurement

framework
The clinical governance framework measurement strategy outlines a range of measures that
should be considered for inclusion to support governance of quality and safety. It is not
designed to be a comprehensive list and many specialist or tertiary referral services will have a
significantly larger set of measures in use. It is rather a point from which to develop a more
formal list of measures for use across the state. Many of the indicators are part of existing
indicator lists in use within DHS and/or Victorian health services:
• structure and strategy measures
• process indicators
• outcome indicators
The list is a work in progress and it is anticipated that, as measures are used and refined,
information systems improve and priority areas are developed the list will change.
E.1 Structure and strategy

Structure and strategy measures will require development and testing. A starting point for this is
reporting against required strategies listed in Section 4. Health should review each of the
strategies outlined in this Framework determine application, measure progress in
implementation.
Not appropriate – the strategies are not relevant to this health service either because of the scope
or types of services provided.
No action – the strategies are relevant but the strategies have not been implemented as yet. This
may be for a range of reasons such as it is a lower priority than others or implementation of the
strategy is reliant on other strategies, action at state level or development of materials to support
implementation.
Planned – a plan to implement strategies has been outlined in the health service strategic,
business and quality plans. The plans include a timeframe for implementation, risks and barriers
to implementation and strategies to overcome them articulated in the plan.
Partially implemented – the strategy has been implemented either in part across the whole
service or in parts of the health services.
Fully implemented - the strategy has been implemented in full across all areas of the health
service.
Evaluated – the effectiveness of implementation has been evaluated either through review of
performance or audit of processes and activities.

ABCD
Government
May 2008
Table E1 – Example format for structure and strategy measures
Functions Strategy Not No action Planned Partially Fully Evaluated

appropriate implemented implemented
Consumers are involved in • Consumers participate in

care processes developing information resources
for clinical purposes and self
management materials
• Consumers are involved in patient
identification protocols (Right side
right patient right procedure)
• Clinical teams involve consumers
in care and increase awareness of
communication styles, use of plain
English and respecting consumer
choice.
• Expert patients deliver self
management programs
Clinicians participate in • Senior clinicians provide

designing systems and leadership for process redesign
processes activities
• Clinicians and clinical teams
engage in process redesign within
their workplace

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Government
May 2008
Functions Strategy Not No action Planned Partially Fully Evaluated

appropriate implemented implemented
Process redesign activities are

sponsored and supported by
management
The health workforce has the • Health services implement the

appropriate qualifications and Credentialling and defining the
experience to provide safe, scope of clinical practice in
high quality care Victorian health services – a policy
handbook
• There are robust processes for
checking and maintaining current
information on registration and
special conditions of registration
for nursing and allied health staff
• Nurses, allied health or others who
are working in advanced clinical
roles have clearly defined scope of
practice and guidelines for delivery
of treatments outside their usual
scope of practice

ABCD
Government
May 2008
E.2 Process measures

There are a number of process measures that have strong evidence links to clinical outcomes.
The following list offers a short list of basic process measures as a starting point. Health
services should review each to determine applicability within their service setting. The
following have been developed base on findings of consultation
Table E2 – Proposed list of process measures 20
Area Process measures Dataset

Clinical Appropriate Venous Thromboembolism prophylaxis
Infection control Surgical antibiotic prophylaxis guideline - Victorian DHS
compliance with antibiotic timing
Clinical % with assessment complete for relevant known
clinical risks. (Focus on known clinical risks.
Determined at local level and may rotate through a
defined list)
Clinical (subset of the % risk rated patients/residents with appropriate use
above) of pressure relieving materials to prevent pressure
ulcers
Clinical Time to thrombolysis for AMI (emergency) AHRQ
Clinical • Medications at discharge for AMI and ACS –
Aspirin, B Blockers and ACE inhibitors
Consumer response % Complaints responded to within 30 days
Consumer participation Consumer participation in health service quality
committee
Consumer experience VPSM overall core index ≥ state mean for hospital
category
Workforce Sick leave utilisation
Intensive care Proportion of after hours discharge Victorian DHS
Clinical Care planning in community health (under
development)
Cleaning Performance against cleaning standards during audit Victorian DHS
(target 85%)
20
The Agency for Healthcare Research and Quality (AHRQ) Safety Indicators
http://www.qualityindicators.ahrq.gov/psi_overview.htm

ABCD
Government
May 2008
E.3 Outcome indicators

Table E3 – Proposed list of clinical outcome indicators
Clinical area Existing indicators Dataset

Aged care Prevalence of pressure ulcers Victorian DHS
Prevalence of falls and fall-related fractures Victorian DHS
Incidence of use of physical restraint Victorian DHS
Incidence of residents using nine or more different Victorian DHS
medicines
Prevalence of unplanned weight loss Victorian DHS
Mental Health Single seclusion episodes (% of all separations from Victorian DHS
adult acute inpatient)
Multiple seclusion episodes (% of all separations Victorian DHS
from adult acute inpatient ward)
Procedural safety Foreign body left in during procedure Victorian DHS
Complications of anaesthesia Victorian DHS
Postoperative hip fracture Victorian DHS
Postoperative haemorrhage or haematoma Victorian DHS
Postoperative respiratory failure Victorian DHS
Postoperative pulmonary embolism or deep vein Victorian DHS
thrombosis
Postoperative sepsis Victorian DHS
Postoperative wound dehiscence in abdomino-pelvic Victorian DHS
surgical patients
Accidental puncture and laceration Victorian DHS
Targeted areas of risk – Serious medication related clinical incidents Victorian DHS
medication safety
(Others to be developed based on NSW Therapeutic
Advisory Group indicator set-see below)
Targeted areas of risk – The number of patients who develop one or more Victorian DHS
pressure ulcers Stage 1 pressure ulcer/s, during their admission,
during the reporting quarter.
The number of patients who develop one or more Victorian DHS
Stage 2 pressure ulcer/s, during their admission,

ABCD
Government
May 2008

pressure ulcer/s, during their admission, during the
reporting quarter.
The number of patients with a documented pressure Victorian DHS
ulcer risk assessment.
Safety Death in low mortality DRGs Victorian DHS
Failure to rescue Victorian DHS
Iatrogenic pneumothorax Victorian DHS
Infection control - Large Central line associated bloodstream infections in Victorian DHS
hospitals Adult Intensive Care Units
Central line associated bloodstream infections in Victorian DHS
Neonatal Intensive Care Units
Peripheral line associated bloodstream infections in Victorian DHS
Neonatal Intensive Care Units
Surgical site infection rates Victorian DHS
i) coronary artery bypass grafts Victorian DHS
ii) cholecystectomy Victorian DHS
iii) colon surgery Victorian DHS
iv) Caesarean section Victorian DHS
v) hip arthroplasty Victorian DHS
vi) knee arthroplasty Victorian DHS
Other selected infections due to medical care Victorian DHS
Infection control - Small Multi-resistant organism infection rate Victorian DHS
hospitals
Laboratory-confirmed bloodstream infections Victorian DHS
Deep and organ space infection rate Victorian DHS
Outpatient haemodialysis event rate Victorian DHS
Compliance with measles vaccination guidelines Victorian DHS
Compliance with hepatitis B vaccination guidelines Victorian DHS
Peripheral venous catheter compliance with Victorian DHS
guidelines
Rate of influenza vaccination (staff) Victorian DHS
Occupational exposures Victorian DHS
Intensive care Standardised mortality ratio Victorian DHS
Crude mortality Victorian DHS
Readmission rate Victorian DHS
Trauma Number of hospitalised major trauma patients Victorian DHS
Death rates (Overall and in-hospital) Victorian DHS

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Government
May 2008

Time and day of injury Victorian DHS
Overall injury severity Victorian DHS
Head injury severity Victorian DHS
Proportion of patients receiving definitive care at an Victorian DHS
appropriate trauma service
Transfers across the system Victorian DHS
Discharge status Victorian DHS
Observed versus unexpected deaths Victorian DHS
Maternity Outcomes for standard primiparae Victorian DHS
Term infants transferred or admitted to SCN or Victorian DHS
NICU for reasons other than birth defect
The rate of administration of antenatal Victorian DHS
corticosteroids to women delivered or transferred
before 34 weeks gestation
Vaginal births after a primary caesarean section Victorian DHS
Five-year gestation standardised perinatal mortality Victorian DHS
ratio
The rate of women referred to postnatal domiciliary Victorian DHS
care
The rate of women offered appropriate interventions Victorian DHS
in relation to smoking
The provision of appropriate breastfeeding support Victorian DHS
and advice
The rate of women receiving timely hospital Victorian DHS
antenatal clinic services
The rate of women of non-English speaking Victorian DHS
background (NESB), without proficiency in English,
who receive appropriate interpreter services
Birth trauma -- injury to neonate AHRQ Patient
safety indicators
Obstetric trauma -- vaginal delivery with instrument AHRQ Patient
safety indicators
Obstetric trauma -- vaginal delivery without AHRQ Patient
instrument safety indicators
Obstetric trauma -- caesarean delivery AHRQ Patient
safety indicators
Cardiac surgery 30 day all-cause risk-adjusted mortality (CABG) Victorian DHS
post-operative deep sternal infections (CABG) Victorian DHS
post-operative haemorrhage requiring return to Victorian DHS
theatre (CABG)

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Government
May 2008

Vascular surgery Stroke after carotid endarterectomy Victorian DHS
Mortality following abdominal aortic aneurysm Victorian DHS
repair elective and ruptured.
Graft complications after infra-inguinal bypass Victorian DHS
surgery
Mortality after endo-luminal stents performed for Victorian DHS
aortic aneurysmal disease
Dental Restorative retreatment within 6 months Victorian DHS
Unplanned returns within 28 days following Victorian DHS
emergency care
Unplanned returns within 7 days following Victorian DHS
extraction
Endodontic retreatment in permanent teeth within 6 - Victorian DHS
12 months
Denture remakes within 12 months Victorian DHS
Radiographs (Number of OPG/Intraoral Radiographs Victorian DHS
taken for new patients in the relevant age group)
Dental Health Services Victoria (DHSV) provided Victorian DHS
regional and statewide reports to agencies to enable
them to benchmark themselves and undertake
professional development etc with the results. The
reports are not published.

ABCD
Government
May 2008
Table E4 – Proposed list of indicators for development
Clinical area Developmental indicators Dataset
Primary Health In March 2007 the Australian Institute for Primary
Care (AIPC) completed a Discussion Paper for the
Victorian Department of Human Services: Clinical
Governance in Community Health Services:
Development of a Clinical Indicator Framework. As
a follow-up action a working group has been
established to develop indicators for the sector.
Blood Serious transfusion clinical incidents.
The Better Safer Transfusion Program rolling
schedule of audits
Surgical Outcomes Participation in process Victorian Surgical
Consultative
Council
Medication safety Victorian DHS is exploring the use of a Performance
Indicators in Medication Safety (PIMS) toolkit. This
incorporates a set of thirty indicators, from which
healthcare services select indicators that address
their local medication safety priorities, identified
through self-assessment. The indicators are based on
those developed by the New South Wales
Therapeutic Advisory Group.
Victorian Audit of Surgical Participation in audit process Royal
Mortality Australasian
College of
Surgeons and
DHS


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ABCD

Department of Human Services,

Review of the current state of

Final Report - clinical governance in VictoriaFINAL - 21 May 2008 i

3 Review of the current state of clinical governance in Victoria 11

4 Framework development and issues for implementation 16

5 Overview of the clinical governance framework 23

6 Conclusions and recommendations 29

Appendix A Key informants interviewed 35

Appendix B Consultation focus group participation 36

Appendix C Consultation on Draft Clinical Governance Framework 39

Appendix D Example - Strategies relevant to identified roles and

Appendix E Attachment – Quality and safety measurement framework 43

Final Report - clinical governance in VictoriaFINAL - 21 May 2008 ii

The project included:

• a review of current clinical governance practice in Victoria

• development of a proposed strategic framework, Enhancing clinical care- A framework for

1.1 Project approach

• a detailed review of the literature to examine existing clinical governance frameworks,

• distribution of a draft outline of the clinical governance framework for comment

1.2 Current state assessment of strengths and opportunities

Final Report - clinical governance in VictoriaFINAL - 21 May 2008 1

1.2.1 Purpose of the clinical governance framework

• providing direction on the establishment of rigorous, integrated systems that support

• promoting a balanced approach that acknowledges the importance of all dimensions of

• fostering excellence and innovation in the improvement of quality and safety

• outlining requirements for education, training and development of workforce capacity in

• recognising and building on significant achievements in quality improvement and risk

Final Report - clinical governance in VictoriaFINAL - 21 May 2008 2

• consideration of financial implications for implementation of the clinical governance

• DHS in collaboration with key stakeholders communicate the clinical governance

Final Report - clinical governance in VictoriaFINAL - 21 May 2008 3

Final Report - clinical governance in VictoriaFINAL - 21 May 2008 4

2.1 Objectives of the project

• develop a clinical governance framework for Victoria.

2.2 Project deliverables

• a proposed strategic framework

• final project report.

2.2.1 Structure of this report

2.3 Our approach

• a detailed review of the literature to examine:

- elements of clinical governance and existing clinical governance frameworks

- implementing clinical governance

• distribution of a draft outline of the clinical governance framework for comment

• consultation workshops to test a draft outline of the proposed framework.

Final Report - clinical governance in VictoriaFINAL - 21 May 2008 6

• DHS and specifically the Quality Branch

• the Victorian Quality Council

• health service boards and CEOs

• consumers of health services

• clinicians and health service managers

• various state-wide special committees such as the:

- Clinical Risk Management Committee

- Consultative Councils (Surgical, Anaesthetic, Obstetric and Paediatric Mortality and

• clarification of roles and accountabilities in the governance of health services

• development of an annual Statement of Priorities establishing key deliverables, performance

• expansion of existing mechanisms to allow for intervention in instances where health

• moving to a three-year allocation of funding to maximise accountability of boards through

2.4.1 Policy directions

• The Clinical Risk Management Strategy 3

• Victorian Quality Council (VQC) Safety and Quality Framework 4

• Clinical governance in community health – Reporting Guidelines 6

• Directions for your health system- Metropolitan Health Strategy 8