Top risks identified by Health boards in 2018. Risk 4: Governance of Clinical Care – Part 1

The Governance Evaluator 2018 Governance Capability Benchmark Report analysed board evaluation responses from over 70 boards comprising almost 700 members across multiple industries.

This month we commence our two-part investigation into Governance of Clinical Care; the issues uncovered in our research, as well as tips and resources for ensuring your board is leading a culture that supports the delivery of safe & quality health care.

What is Governance of Clinical Care?

The National Clinical Governance Framework, based on the NSQHS Standards (2nd edition) produced by the Australian Commission on Safety and Quality in Health Care (2017) states that the governance of clinical care involves a complex set of leadership behaviours, policies, procedures, and monitoring and improvement mechanisms that are directed towards ensuring good clinical outcomes.

In addition, as more health care organisations expand to encompass aged care services, effective governance of clinical care must also take into account the imperatives of the Aged Care Quality Standards (2018), including Consumer-Directed Care.

Both Standards are incorporated in the Governance of Clinical Care module themes of the Governance Evaluator Board Evaluation. Due to their complexity and importance, the findings that relate to each theme will be examined in depth across two reports:

Governance of Clinical Care Part 1 will explore:

  • Genuinely partnering with consumers
  • Governing safety and quality
  • Staff who deliver safe care

Governance of Clinical Care Part 2 will explore:

  • Leading a safe and quality culture
  • Safety and quality systems
  • Evaluating safety and quality

Within the Governance Evaluator, each theme is explored via a series of targeted questions, each with four possible responses:

  • No: Represents an early capability assessment of the board in that area. Any responses in this category highlight the need for board capability improvement and education.
  • Yes, but qualified: Indicates that board capability is developing and not yet at a mature governance level. Again, these point to opportunities for focus and education.
  • Yes: Represents a mature governance capability within the board and the criteria wholly satisfied, as judged by the participants.
  • Unsure: Measures a construct other than overall board capability as it reflects individual members of the board or leadership team that are unsure of the board’s level of functioning.

Genuinely Partnering with Consumers

Health care and aged care are undergoing an important revolution with the increasing involvement of patients and recipients of care as consumers.

From a health care perspective, the Medical Journal of Australia (MJA) states that “the role of consumers is now extending beyond being passive health care recipients and even active participants in their own care to involvement in innovation and value co-creation in health care — from being ‘users and choosers’ to becoming ‘makers and shapers’ of services. For active dialogue to occur in co-creation, consumers must become equal partners with health care organisations and providers, with the focus on areas of interest to all parties.” 

Similarly, a report by the Institute for Health and Ageing and the Australian Catholic University, Older and Wiser: Putting the Consumer’s Voice at the Centre of Residential Aged Care states that “the advent of Consumer-Directed Care (CDC) in Australian Residential Aged Care Facilities (RACFs) will require a revolutionary change in the service delivery mindset” (p7:2017). This commences the process leading to a change in status from ‘care recipient’ to ‘consumer’ and to being encouraged and supported to having a consumer voice which is at the centre of service delivery planning, design, delivery and evaluation.

Genuinely engaging with consumers in the planning, design, delivery and evaluation of care can improve the decision-making of organisations, the behaviour of clinicians and care delivery staff, and the experience of consumers, their families and carers, and may lead to more appropriate care.

2018 Benchmark Data key finding:

Q: Does the Board partner with consumers?

Fig 1:  2018 evaluation findings for genuinely partnering with consumers

Only 57% of health boards are satisfied that their directors all understand the increasing shift toward the paradigm of consumers-as-partners being genuinely embedded within the care framework and have actively and successfully embraced the level of engagement needed to bring these changes to fruition.

Top Tips for Genuinely Partnering with Consumers

  • Understand who your consumers are. This will depend on the services your organisation provides.
  • Have a plan for consumer engagement that has more than one strategy for genuine engagement.
  • Lead a culture for continuous review and development – it is not sufficient to just ‘hear the voice’, it is also essential to maintain the connection with consumers and others through the planning, implementation and review stages. Key to true engagement is to always return to acknowledge the input and what has occurred as a result.
  • In the health sector, effective boards have in place a combination of:
    • A consumer engagement plan with clear reporting structures for boards and consumers
    • Consumer and/or community engagement board subcommittees
    • Agendas at board meetings that start with a consumer story
    • Planned walkarounds with directors, CEO and/or executives
    • Satisfaction surveys that produce well-trended and benchmarked reports
    • Director training for consumer engagement

Aged care is more complex due to the agedness, frailty, vulnerability and often cognitive impairment of the consumer and often the consumer’s voice comes from many sources, such as loved ones, family, carers and others. This necessitates a variety of strategies for hearing the consumer voice in relation to consent, choice and dignity of care. Effective aged care boards don’t have the consumer on the board but have many processes, such as:

  • A resident/consumer engagement plan that identifies the consumers and their definition of vulnerability
  • A consumer engagement plan with clear reporting structures for boards, residents/ consumers and identified others
  • Residents committees who report to the quality committee or the board
  • Annual meetings with large groups of consumers and their family/carers to hear and make sense of multiple voices
  • Satisfaction surveys that produce well-trended and benchmarked reports

Links to Resources

Governance Evaluator has sourced some resources which we think you might find useful to build any board’s capabilities in this area:

  • Contact Kellie O’Callaghan (O’Callaghan + Co), an expert in bringing the voice of the consumer to the table
  • On the road to value co-creation in health care: the role of consumers in defining the destination, planning the journey and sharing the drive. Read here
  • Older and Wiser: Putting the Consumer’s Voice at the Centre of Residential Aged Care. Read here.
  • The Victorian Health care Experience
  • People Matters Survey
  • Governance Evaluator customers can access the following, and other useful resources via the platform here.
    • Governance Manual – 8.3 Terms of Reference for a Consumer Advisory Committee
    • Governance TV – Kellie O’Callaghan – Effective Stakeholder Engagement; how to plan, measure and assess

Governing Safety & Quality

Governing safety and quality is about ensuring that the health care organisation delivers safe, high-quality care to its consumers. From an aged care perspective, this safe, high-quality care must be in accordance with the principles of Consumer-Directed Care resulting in an enhanced quality of life as measured by validated instruments.

Safe, quality clinical care is the core business of health and aged care organisations and this is a key focus of the board. The board is accountable for the quality of care delivered in, and by, the organisation and its staff. The board is responsible for ongoing continuous review and development of quality and safety. This requires the board to frequently review, evaluate and amend based on consumer and staff feedback about quality and safety, thereby continually improving all aspects of the business.

2018 Benchmark Data key finding:

Q: Is the Board governing safety and quality?

Fig 2:  2018 evaluation findings for Governing Safety & Quality

73% of health boards are satisfied that their strategic and organisation quality and safety plans reflect the importance of safe, quality health service provision; the leadership of the safety and quality committee is skilled, knowledgeable and committed; and that all directors have an appropriate level of understanding of the safety and quality of services provided to enable them to govern effectively.

Top Tips for Governing Safety & Quality

  • In your strategic planning process, ensure that ‘provision of safe and quality services to your community’ is the vision and mission
  • Demonstrate and develop leadership, experience and skills for relevant board subcommittees such as the quality and/or clinical governance subcommittees, by:
    • Gaining a strong understanding of the corporate and sector skills and experiences of directors, and ensuring directors who have strong or significant health/aged care sector and clinical governance skills and experience are leading the quality/clinical governance committee
    • Ensuring all directors are well inducted into the safety and quality and risks of the organisation
    • Investing in upskilling directors who don’t have strong sector/clinical governance skills

Links to Resources

Governance Evaluator has sourced some resources which we think you might find useful to build any board’s capabilities in this area:

  • Chapter 2 of the DHHS Directors Toolkit, which can be accessed here
  • LASA, the national peak body representing and supporting providers of age services across residential care, home care and retirement living, has a useful range of reports and policy documents on their website:
  • Duckett, Stephen & Cuddihy, Maree & Newnham, Harvey & Victoria, issuing body & Victoria. Department of Health and Human Services, issuing body. (2016). Targeting zero: supporting the Victorian hospital system to eliminate avoidable harm and strengthen the quality of care: report of the review of hospital safety and quality assurance in Victoria. Melbourne: Victorian Government available at
  • Governance Evaluator Development & Skills Matrix for health, aged care and human services boards – click here for a demonstration
  • Governance Evaluator customers can access the following, and other useful resources via the platform here.
    • Governance TV – Dr Liz Mullins – What I learnt at Djerriwarrh Health Services
    • Governance TV – Dr Alison Brown – How to lead culture at a board level for quality and safety

Staff who deliver safe care

A manifestation of the organisation’s commitment to safe, quality care is that staff work, and are enabled to work, in a manner which minimises the risk of harm to consumers and themselves and that maximises the likelihood of safe, quality care outcomes.

The National Safety and Quality Health Service Standards and The Single Aged Care Quality Framework Standards require organisations to monitor the performance of staff with responsibility for patient/consumer care, as underperformance represents a significant risk to consumer care, to the organisation, and undermines community confidence in the sector.

2018 Benchmark Data key finding:

Q: Is the Board sure that staff are appropriate for the delivery of safe care?

Fig 3:  2018 evaluation findings for staff who deliver safe care

76% of health boards are satisfied that there are appropriate and effective controls in place to ensure that all staff understand and are aligned with the principles of Consumer-Directed Care; are supported with professional development and are appropriately skilled, experienced and credentialed to provide quality care whilst working within a defined scope of practice.

Top Tips for boards to ensure staff who deliver safe care

  • Understand your duty of care for staff by ensuring management are held to account for compliance with relevant Occupational Health and Safety Laws and sustaining a workplace culture that values staff, their professionalism and wellbeing
  • Receive high-quality information/reports about clinical and non-clinical staff performance so that you are assured about the safety of the workplace and the ability of staff to perform their duties effectively
  • Emphasise to management the importance of, and hold management accountable for, employing appropriately skilled, credentialed staff
  • Encourage and support continuing professional development, staff education and training as a critical component of ensuring the delivery of safe and quality care

Links to Resources

Governance Evaluator has sourced some resources which we think you might find useful to build any board’s capabilities in this area:

  • Credentialing health practitioners and defining their scope of clinical practice: A guide for managers and practitioners, which can be accessed here
  • Safer Care Victoria leadership & learning program fact sheet can be accessed here
  • Governance Evaluator customers can access the following, and other useful resources via the platform here.
    • Governance Evaluator TV – Managing clinical risk, ensuring quality and safety (Effective Clinical Governance)
    • Resources Manual – 4E Staff engagement and accountability