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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

© 2008 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International, a Swiss cooperative. All rights reserved. The KPMG logo and name are trademarks of KPMG. Liability limited by a scheme approved under Professional Standards Legislation.

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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

This report is delivered subject to the agreed written terms of KPMG’s engagement.

This report provides a summary of KPMG’s findings during the course of the work undertaken for Department of Human Services under the terms of the contract dated 29 November 2007.

This report is provided solely for the benefit of the parties identified in the contract and is not to be copied, quoted or referred to in whole or in part without KPMG’s prior written consent. KPMG accepts no responsibility to anyone other than the Department of Human Services for the information contained in this report.

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Contents

Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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

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Final Report - clinical governance in VictoriaFINAL - 21 May 2008

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1 Executive summary

Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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

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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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.

Final Report - clinical governance in VictoriaFINAL - 21 May 2008

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1.3

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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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

Final Report - clinical governance in VictoriaFINAL - 21 May 2008

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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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.

Final Report - clinical governance in VictoriaFINAL - 21 May 2008

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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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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:

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

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 Final Report - clinical governance in VictoriaFINAL - 21 May 2008

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2.2.1 Structure of this report

Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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.

Final Report - clinical governance in VictoriaFINAL - 21 May 2008

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2.4

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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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 Final Report - clinical governance in VictoriaFINAL - 21 May 2008

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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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 Final Report - clinical governance in VictoriaFINAL - 21 May 2008

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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

New directions for Victoria's mental health services – the next five years 12

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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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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.

Final Report - clinical governance in VictoriaFINAL - 21 May 2008

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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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

CommunityCommunity && consumerconsumer

MinisterMinister

DepartmentDepartment ofof HumanHuman ServicesServices

VQC,VQC, ClinicalClinical ConsultativeConsultative CouncilsCouncils StatewideStatewide clinicalclinical networksnetworks

HealthHealth serviceservice boardsboards

CEOCEO andand executiveexecutive

ClinicalClinical teamsteams andand managersmanagers

Enhancing clinical

clinical careEnhancing care

VictorianVictorian QualityQuality CouncilCouncil

DepartmentDepartment ofof HealthHealth andand AgingAging

AustralianAustralian CommissionCommission forfor SafetySafety andand QualityQuality inin HealthHealth CareCare

ProfessionalProfessional collegescolleges

RegistrationRegistration boardsboards

PeakPeak professionalprofessional groupsgroups

PeakPeak consumerconsumer groupsgroups

OfficeOffice ofof thethe HealthHealth ServicesServices CommissionerCommissioner

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. framework should:

Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

It was identified that the clinical governance

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

Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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.

IdentifiedIdentified InnovationInnovation WhereWhere ideasideas prioritypriority areaarea grantsgrants areare
IdentifiedIdentified
InnovationInnovation
WhereWhere ideasideas
prioritypriority areaarea
grantsgrants
areare supportedsupported
performanceperformance
toto addressaddress
byby evidenceevidence
gapsgaps
performanceperformance
developdevelop tooltool
gapsgaps
kitkit
RollRoll outout tooltool
kit,kit, spreadspread
experienceexperience
throughthrough
networksnetworks

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 Final Report - clinical governance in VictoriaFINAL - 21 May 2008

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4.6 Performance measurement

Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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

Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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

Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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,

organisational performance

reporting,

response

building clinical leadership and ownership

and

evaluation

systems

for

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

Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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

Risk assessment Health Service Board Financial & Clinical care assets Other Corporate functions Performance
Risk assessment
Health Service Board
Financial &
Clinical care
assets
Other
Corporate
functions
Performance enhancement
Legal compliance
Planning & strategy

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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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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 and respond
Governance of
clinical care
Measure
Priorities and
performance
strategy
Planning and
Report review
and respond to
performance
resource
allocation
Consumer
Experience
Clinical
Patient
& quality
Teams
Resident
of care
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

Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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.

Strategies should be in place to ensure:

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

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clinical innovation is fostered and supported

Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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.

Strategies should be in place to ensure:

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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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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

Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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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Glossary

Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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

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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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.

Final Report - clinical governance in VictoriaFINAL - 21 May 2008

34

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ABCD

Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government 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

Final Report - clinical governance in VictoriaFINAL - 21 May 2008

35

© 2008 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International, a Swiss cooperative. All rights reserved. The KPMG logo and name are trademarks of KPMG. Liability limited by a scheme approved under Professional Standards Legislation.

ABCD

Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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

Final Report - clinical governance in VictoriaFINAL - 21 May 2008

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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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

Final Report - clinical governance in VictoriaFINAL - 21 May 2008

37

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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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

Final Report - clinical governance in VictoriaFINAL - 21 May 2008

38

© 2008 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International, a Swiss cooperative. All rights reserved. The KPMG logo and name are trademarks of KPMG. Liability limited by a scheme approved under Professional Standards Legislation.

ABCD

Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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 Grant Phelps – DHS and Ballarat Health Service

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

Final Report - clinical governance in VictoriaFINAL - 21 May 2008

39

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Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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 Grant Phelps – DHS and Ballarat Health Service Lea Pope – Bass Coast Health Service Katherine Simons – Austin Health Jacqueline Smith Linda Sorrell – Melbourne Health Margaret Way – Bayside Health

Final Report - clinical governance in VictoriaFINAL - 21 May 2008

40

© 2008 KPMG, an Australian partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International, a Swiss cooperative. All rights reserved. The KPMG logo and name are trademarks of KPMG. Liability limited by a scheme approved under Professional Standards Legislation.

ABCD

Appendix D

Department of Human Services, Victoria Review of clinical governance in Victoria- Final Report Government May 2008

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 of both clinical and corporate governance

Quality and safety strategies are key parts of annual 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 groups to develop and prioritise strategies and mechanisms for improving safety and quality within Victoria

DHS coordinates an annual roundtable to develop priority areas for investment in improvement of quality and safety

Coordinate and support implementation of agreed national standards and prioritised strategies

Coordinate development of literature review, model policies, toolkits, and education resources to support implementation.

Developing and supporting policy, legislation and regulation which promote clinical governance as a key tenet of health service governance

Review reporting performance on key quality and safety indicators

Review compliance with baseline policy requirements

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 accountability arrangements to provide public assurance of safety and quality through allocating responsibility for clinical governance to Boards of Directors and clearly communicating the responsibilities and expectations involved

Communicate expectations, policies and requirements of their position to board directors

Coordinate board training and orientation programs specifically targeted at quality and safety

Implementing accountability and reporting

Monitor performance reporting and review of health services demonstrating performance issues. Implement a

mechanisms to ensure clinical governance responsibilities are met.

Ensure reporting requirements are integrated with key indicator and comparative performance data

program of escalated response where there is sustained non-compliance with policy directives

Develop tools and templates to support robust reporting of quality and safety activities and issues to boards and board quality committees that are based on best practice models