NSQHS Standard 1: Governance for Safety and Quality in Health Service Organisations Governance and quality improvement systems Governance and leadership (Standard 1, Item 1.1: Implementing a governance system) A health service organisation’s governance system is an important element in safeguarding and improving the safety and quality of care. Evidence links high performance of health service organisations to effective governance systems.1 The board of a health service organisation is responsible for: • governing all domains of organisational activity in that health service, including business performance, human resources management, information technology, work health and safety, and the safety and quality of the services the organisation delivers; and • setting the organisation’s quality improvement and risk management culture. The ultimate responsibility for ensuring the integrity and effectiveness of the governance system rests with the governing body.2 A board’s role is to oversee management, not to manage.3 The board may require the organisation to establish committees or groups to support its work. These groups may address issues within the organisation such as: • audit and risk processes • the safety and quality framework • consumer advisory processes • clinical governance responsibilities. The board will need to ensure these processes are integrated and collaborative. One way of achieving this may be through board representation on these groups. Board roles • Design and endorse a governance system that will enable the board to monitor, review and evaluate all aspects of organisational performance and direct the senior executive on systems to be implemented when changes are required. • Take the lead on setting the organisation’s safety and quality culture. • Take ultimate responsibility for the safety and quality performance of the health service organisation.
Organisational policies, procedures and protocols (Standard 1, Item 1.1: Implementing a governance system that sets out policies, procedures and/or protocols) The board, through the senior executive, is responsible for ensuring the organisation maintains a comprehensive set of organisational policies and associated procedures and protocols, and reviews these regularly. These need to: • provide direction for the operation of the organisation; • address clinical safety and quality; and • be consistent with the regulatory obligations of the organisation, board and executive. The board should delegate responsibility to management for the development and maintenance of the policies and associated procedures and protocols. The board may seek confirmation of the use and effectiveness of these policies, procedures and protocols through reports and require management to take timely action where there are breaches in compliance. Board roles • Endorse the system for policy development and review. • Ensure a comprehensive set of policies and associated procedures and protocols are developed and implemented. • Ensure a system exists to review compliance with the organisation’s policies. Clinical governance (Standard 1, Item 1.1: Establishing and maintaining a clinical governance framework) The Australian Securities and Investment Commission (ASIC) identified a key duty of boards as ‘know what your company is doing’.1 For health service organisations this requires the board to understand the clinical performance of its organisation, among other things. Good clinical governance requires strong strategic and cultural leadership of clinical services. The board should focus on: • reviewing plans providing cultural leadership; • ensuring the appropriate allocation of resources; • ensuring there is appropriate delegation; • maximising staff engagement; • using data and information effectively to monitor and report on performance across the health service organisation, to the governing body; and • ensuring well-designed and integrated systems are in place for identifying and managing clinical risk.2 The board should comprise people with an appropriate mix of skills to fulfil its governance roles, responsibilities and accountabilities. The board may also seek input from appropriately skilled individuals. Board roles • Define the vision, mission and values of the organisation, with particular emphasis on patient-centred care principles and practices. • Prioritise and allocate time at board meetings to review clinical governance and to ensure the effectiveness of the systems that are in place. • Ensure board members’ and senior executives’ knowledge of clinical governance is current through access to training and education opportunities.
Roles of the board and executive (Standard 1, Item 1.2: The board, chief executive officer and/or other higher level of governance within a health service organisation taking responsibility for patient safety and quality of care) While the board and senior executives together play a role in planning and reviewing integrated governance systems that promote patient safety and quality, their roles differ. The board provide oversight by setting the direction for the organisation, ensuring accountability and shaping culture. Senior executives are responsible for implementing the strategic direction set by the board and senior executive, and for reporting on the performance of the organisation to the board. The board is responsible for providing leadership and direction to the health service organisation it governs, and is legally responsible for the overall performance of its health service organisation. The board provides leadership for the organisation by: • setting goals; • setting the organisation’s safety culture; • ensuring adequate resources are available for the implementation of safety and quality systems and initiatives by the organisation; and • allocating time at its meetings to discuss safety and quality issues. The board’s governance functions are fulfilled by: • ensuring accountability; • monitoring safety and quality performance; • overseeing compliance with the organisation’s statutory and regulatory obligations; and • ensuring that structures and systems are in place to deliver health services. The board delegates the development and monitoring of safety and quality plans. The overarching framework should align with the strategic direction and support the development of plans that incorporate achievable and measurable goals, with accountability for actions clearly explained. Figure1: Complementary safety and quality roles of the board and senior executives
A schedule of data collection, reviews and audits should be developed by management to assist the board in monitoring the quality and adequacy of clinical and organisational systems. Review mechanisms should reflect the organisation’s inputs, outputs and outcomes. Assessment of these systems should be based on their effectiveness in supporting safe and high-quality care for each patient and be informed by incident reports, near misses and hazards. The board may also consider receiving regular safety and quality presentations, reports and patient stories from senior managers and clinicians. These could be scheduled in accordance with agreed criteria (for example, areas of significant risk or the highest frequency errors or incidents). Examples of safety and quality reports can be found in Section 3 of this guide. Board roles • Participate in defining safe and high-quality care. • Review a dashboard of key quality outputs related to quality goals and other reporting requirements. Clinical practice To maximise the effectiveness of care, members of the workforce need to provide care that is current, best practice and evidence-based. Management needs to establish and facilitate systems to enable safe and high-quality patient care. The board needs to ensure there are systems in place to monitor the use and effectiveness of clinical guidelines and pathways. Application of clinical guidelines (Standard 1, Item 1.7: Developing and/or applying clinical guidelines or pathways that are supported by the best available evidence) Evidence-based clinical guidelines or clinical pathways are designed to improve the quality of health care and decrease unwarranted variation in the provision of health care, or the use of ineffective or harmful interventions. Where variation in the provision or use of health care is not as a result of patient preference or clinical need, it is unwarranted. Clinical guidelines are critical links between the best available evidence and good clinical practice, and are key tools in an effective quality and safety system. The board should ensure systems are in place to: • make available current clinical guidelines or pathways, where they exist; and • assist in the provision of care that is evidence-based and ensures unwarranted variations in care are minimised. Board roles • Ensure the organisation adopts and routinely reviews its clinical practices to ensure they are current, evidence-based and effective. • Ensure systems are in place for the regular review of reports on participation and performance in clinical registries or audits established by professional groups and organisations. • Review reports on audits of unwarranted clinical variation.
The board should be assured that ongoing education and training programs support, among other things, the competency of staff to provide safe care in their clinical roles and to meet the quality objectives of the organisation, as well as ensuring members of the workforce understand their safety and quality roles. The board should ensure resources are available for training and continuing professional development and a process exists for monitoring staff participation. Additionally, the board should ensure that board members are provided with training to promote their own understanding of how to partner with consumers in their governance and leadership roles and interpret safety and quality reports and evaluations. Board roles • Adopt an organisational orientation, education and training system that defines the organisation’s commitment to education and training in safety and quality. • Ensure the education and training system is adequately resourced and training attendance records are maintained. • Ensure mandatory orientation, education, maintenance and renewal of clinical competency and training requirements are in place. • Ensure the system includes clinician training on partnering with consumers relevant to their role. • Receive regular reports on the implementation and outcomes of the system. Workforce feedback (Standard 1, Item 1.13: Seeking regular feedback from the workforce to assess their level of engagement with, and understanding of, the safety and quality system of the organisation) Gaining an understanding of the workforce’s attitude, perception, knowledge and use of safety and quality systems can provide information on the areas where additional education, change management resources or improvement of the safety and quality system should be targeted. Feedback from members of the workforce may include informal feedback through usual collegiate and management communication processes, or formal feedback through: • structured analysis of de-identified information gained from performance reviews • audits and surveys targeting specific elements of the safety and quality system • organisational climate and cultural surveys • clinicians’ engagement in governance processes • communication with the board • reports on de-identified staff complaints that includes analysis of the potential risks to the organisation’s quality-management capacity. The board may also wish to consider using standardised staff surveys to measure the workforce’s attitude towards safety and quality. The US Department of Health and Human Service’s Agency for Healthcare Research and Quality has a series of surveys on patient safety culture.5 These surveys include simple questions for hospital staff, and allow health service organisations to compare their results with other international health service organisations through a comparative database. Board role • Review reports of feedback from the workforce and recommendations from management.
Open disclosure (Standard 1, Item 1.16: Implementing an open disclosure process based on the national open disclosure standard) ‘Open disclosure’ is the open discussion with patients and/or their carers of incidents that result in harm to a patient receiving health care.2 The Australian Open Disclosure Framework6 has been endorsed by all Health Ministers for implementation in all health service organisations, and the board should ensure that its health service organisation’s open disclosure processes comply with this framework. The board should provide leadership for the implementation of effective open disclosure systems by: • fostering an organisational culture characterised by openness and constructively learning from mistakes; • ensuring the Australian Open Disclosure Framework is in place; • ensuring adequate resources are allocated to support implementation of the Australian Open Disclosure Framework; • ensuring responsibility for implementing the Australian Open Disclosure Framework is allocated to a senior manager; • ensuring compliance with the Australian Open Disclosure Framework is monitored and any incidents of non-compliance are investigated; and • regularly reviewing summary reports on performance in open disclosure. Board roles • Ensure the Australian Open Disclosure Framework is implemented. • Ensure adequate resources are allocated to implement open disclosure systems. • Ensure the organisation’s education, training and orientation adequately address open disclosure. • Review reports on performance in open disclosure.
Patient rights and engagement The Australian Charter of Healthcare Rights (the Charter) was developed by the Commission and adopted by all Health Ministers in 2008. The Charter defines a patient’s right to access, safety, respect, communication, participation, privacy and comment. These rights should translate for patients into safe, high-quality health care and the provision of information to allow participation in decisions about their care.7 Patients’ rights (Standard 1, Item 1.17: Implementing through organisational policies and practices a patient charter of rights that is consistent with the current national charter of healthcare rights) Local charters of healthcare rights should be consistent with the Charter. Some jurisdictions have developed supporting information that expands on the Charter. The board should formally adopt the Charter or its jurisdictional equivalent and delegate its implementation throughout the organisation to an individual or committee. Board roles • Ensure the Australian Charter of Healthcare Rights or its jurisdictional equivalent is adopted. • Ensure systems exist for the effective implementation of the Charter. Planning for care and informed consent (Standard 1, Item 1.18: Implementing processes to enable partnership with patients in decisions about their care, including informed consent to treatment) Consumers and carers have the right to receive easily understood information and to make informed decisions about their health care in a timely and culturally appropriate manner. The health service organisation’s focus should be patient-centred care. Open communication between consumers, carers and clinicians underpins the prevailing ethical framework for contemporary health care. The board needs to be confident that information provided to patients is accurate, relevant and meaningful to patients and addresses health literacy issues and related implications faced by the organisation. Effective systems should be in place for informing patients and their carers about their treatment, determining their treatment preferences, and for gaining and documenting their consent to treatment. Patients should be partners in making decisions about their care. ‘Advance care planning’ is the process of preparing for likely scenarios near the end of life. The process usually includes: assessment of, discussion about and documentation of a patient or their carer’s understanding of the consumer’s medical history and condition, values, preferences, and personal and family resources. The board should periodically receive summary reports on the processes, implementation and effectiveness of advanced care planning in its organisation. Board role • Ensure an effective system is in place that accommodates the use of advance care planning.
Consumer and community feedback and partnerships (Standard 2, Item 2.2: Implementing policies, procedures and/or protocols for partnering with patients, cares and consumers) Evidence is building that there is a link between effective partnerships with consumers, good consumer experience and high-quality care.9 Using consumer feedback and involving consumers in the governance of health service organisations is an important part of the process of establishing effective partnerships and driving quality improvement. Partnering with consumers in governance is about listening to and using consumer knowledge, skills and experience in a systematic way to deliver better health care. Seeking and using consumer and carer feedback through surveys, focus groups, patient stories, committees, compliments and complaints processes and incident management systems is increasingly being seen as a useful mechanism for establishing partnerships, informing quality improvements and improving consumers’ experiences. The board should ensure that its health service organisation’s community is engaged in the decision-making process and is given opportunities to outline its expectations for the health service organisation. Feedback from communities can assist the board in planning strategic direction for future undertakings. Board roles • Review reports on consumer involvement in service delivery planning. • Ensure systems are in place to promote consumer feedback and community engagement. Training for consumers (Standard 2, Item 2.3: Facilitating access to relevant orientation and training for consumers and/or carers partnering with the organisation) The board should ensure that orientation is provided to consumers, to assist them to be effective partners. Training may also be required for consumers who regularly participate in partnership opportunities. Where a board requires a formal consumer committee to be established, systems should be put in place to ensure that the selection of members is appropriate and that members are given training in their roles and responsibilities, and are oriented to their role and the organisation’s governance framework to enable them to function effectively. Board role • Ensure resources are allocated for consumer and carer orientation and training.
Sample report from a large health service organisation The example below from a large health service organisation demonstrates a divisional approach to reporting and covers both the regular data reporting and the higher-level overview by service. Presentation Governance Data March Medical Services annual safety and quality report (including clinical registry performance results) • Safety and quality governance committee report • Accreditation status report • Internal audit report • Root cause analysis (RCA) report • Strategic audit plan • Safety and quality indicators • Clinical risk register report • Significant event status report • Safety and quality governance minutes June Mental Health Drug and Alcohol annual safety and quality report (including clinical registry performance results) • Safety and quality governance committee report • Accreditation status report • Internal audit report • RCA report • Annual quality plan • Consent audit report • Review risk ratings matrix • Safety and quality governance framework • Safety and quality indicators • Clinical risk register report • Significant event status report • Safety and quality governance minutes September Surgical Services annual safety and quality report (including clinical registry performance results) • Safety and quality governance committee report • Accreditation status report • Internal audit report • RCA report • Quality plan progress report • Quality of care report • Safety and quality indicators • Clinical risk register report • Significant event status report • Safety and quality governance minutes December Community health and rehabilitation services annual safety and quality report (including Australasian Rehabilitation Outcomes Centre results) • Safety and quality governance committee report • Accreditation status report • Internal audit report • RCA report • Quality plan progress report • Medical indemnity claims report • Safety and quality Indicators • Clinical risk register report • Significant event status report • Safety and quality governance minutes Presentation Governance