Each week in the lead up to Accreditation, Northern Health will focus on a different Standard. You will hear from the Chair of each of the Standard Committees about the key points you need to know.

This week, we speak with Dr Bill Shearer, Executive Director Quality, Safety and Transformation about Standard 1: Clinical Governance.

What is this Standard about?

Standard 1: Clinical Governance is the way we ensure safe, quality care for our patients. Put simply, it’s about the processes we undertake to assure ourselves, our patients and the community that we are delivering on our vision of “A healthier community, making a difference for every person, every day”.

We tend to see the Accreditation standards as an external check on what we are doing, but realistically it’s just a statement of the things we are doing and a reminder of the things we can improve on.

At Northern Health, this Standard involves a Quality and Safety Performance Management system that is built around two systems, for collection of information about clinical performance:

• A continuous system where we collect information about clinical performance (sometimes people use the term clinical indicators). This is also the system that allows us to compare our performance with others, or with established standards of care such as Commission clinical guidelines.
• A reactive system where we collect information about times when care hasn’t gone as we would wish, such as deaths, adverse events, and complaints.

We have very specific rules about both systems to help us decide where we should concentrate our efforts at improvement. We use a risk/opportunity lens to help with that decision.

Our focus is very much on reducing unwarranted clinical variation, that is, care that is appropriate for our patients’ needs, and informed by the best evidence available.

We have designed specific tools to investigate variance in performance or incidents, and a structured way of designing improvements in the quality and safety of care.

What are the top five ways staff can be prepared for Accreditation against this Standard?

1. Read the simple procedures to the quality and safety performance management system and clinical governance and patient experience – trusted care.
2. Understand how the area you are working in actively manages clinical performance – particularly local area audits, incidents, and deaths.
3. Know what the most important quality and safety issues are in your area and what is being done to improve them.
4. Know how to report any quality and safety concerns you have and how those concerns are handled.
5. Know what the health service is focusing on improving and how you contribute to that?

What are the top five questions staff need to be able to answer about this Standard?

1. What is your role in clinical governance?
2. What are the steps in managing an adverse event?
3. What happens when a patient dies in your area?
4. What are the things that are improving in your area?
5. What does your team need to do better?

Is there anything else you would like staff to know about this Standard? 

This is just how we do our jobs properly!

Click here to lean more about Standard 1: Clinical Governance.