How to lead positive outcomes for the key areas of focus for Clinical Governance

In 2017 Safer Care Victoria and the Australian Safety and Quality Commission created new Clinical Governance Frameworks. Dr Sue Matthews shares her tips on how to lead positive outcomes for the key areas of focus for Clinical Governance.

“As a leader in an organisation, you have to role model what you expect from others, not just by doing the right thing but by asking the right questions and then feeding back”.

Interview with Sue Matthews – CEO – The Royal Women’s Hospital

By Fi Mercer

I recently had my annual catch up and interview with Dr Sue Matthews, CEO of The Women’s, during which I asked for her tips on how to lead positive outcomes for the key areas of focus for Clinical Governance, for the purpose of sharing with our Governance community. In 2017 Safer Care Victoria and the Australian Safety and Quality Commission created new Clinical Governance Frameworks. These centre around the following six headings, which are also the key headings in the new Governing Clinical Care Module on the Governance Evaluator Platform. They are:

  1. Governing Safety and Quality
  2. Leading a safe and Quality Culture
  3. Genuinely partnering with consumers
  4. Staff who deliver care safely
  5. Safety and Quality Systems
  6. Evaluating Safety and Quality

Sue very generously shared some great tips from her past and present leadership experiences relating to each of the six headings:


Sue felt that key to leading on your vision and strategy for providing safe and quality services is to inspire a shared vision throughout the planning process. To achieve this, everyone has to be aligned to providing safe quality care from the ground up and thereby setting the right culture.

Sue achieves this by regularly running sessions where executives and managers discuss how this vision and strategy works, providing an opportunity to contribute and become involved so they in turn can engage their teams to contribute and be inspired. The outcome of this is achieving strategic alignment from top to bottom, from individuals to departments and subsequently throughout the organisation.

Sue went on to say that “it is therefore important to remember that quality and safety is not a department or a committee” and “not to defer to a single person to be in charge of quality and safety in your department or organisation”. Sue is very clear that the culture has to be that ‘’safety and quality is everyone’s business’’.

Sue believes that “as a leader in an organisation you have to role model what you expect from others, not just by doing the right thing but by asking the right questions and then feeding back”. Sue said one way to drive this is for all leaders to question their staff, for example; Do you have any patient or staff safety concerns? It is such an important question and the answers need to be addressed. There needs to be a feedback loop relating to the answers so you are genuine in your leadership role.


In describing how to lead for a positive safe and quality culture, Sue noted it is important to reflect on the origins of how hospitals run. The origins of hospitals were based on the military. Many processes and cultures (particularly the hierarchies) were originally derived from activities for caring for the wounded from the battle fields of wars. This includes how doctors, nurses and other staff act together. This is sometimes a strongly kept culture by these groups, even today.

Another strong keeper of this culture can be the community, some of which very much like it to be this way, she said “Communities can hold hospitals back or down to stay the same”. Sue believes based on her experience that often, communities like and expect doctors to be in charge and to make decisions about how hospitals function. Communities often hate change, particularly in long-standing institutions like hospitals, which are often iconic in the community.

Therefore, we are tasked with fostering the right culture in a community as well as a hospital. A tip for changing the community’s belief for how the culture should be is to educate them and provide the right information because “if communities don’t have information they fill the vacuum with their own beliefs and the culture won’t change”.

In bringing about this cultural change it is helpful for boards and communities to understand that changing a culture takes time. In particular, big services are more complex and smaller services are more connected to their communities. Both can create issues for changing a culture.

Sue went on to say that there are other factors that impact on why certain cultures exist, which needs to be acknowledged if you are to change and lead a safe and quality culture. In specialty health organisations the culture often relates to why the organisation was started originally. For example; The Women’s started primarily to support the most vulnerable women in our society and likewise the Royal Children’s to support children and their families, but other hospitals may have started to provide a variety of services to support their small rural community.

At the end of the day, the culture we desire is for everyone to play their important role in creating a team approach to leading a safe and quality environment. This team is inclusive of all staff, volunteers, consumers and community.


Sue thought that this is such an important area and one in which there is much opportunity for improvement. She said that at The Women’s their Consumer Advisory Committee is essential.

Sue went on to say that “understanding from consumers what they want” is key and moving from a ‘’teach and tell approach to a listen and explore style is an essential ingredient for getting this right. We genuinely have to shift the way we do things”.

She said that we need to remember that “each one of us has expertise BUT we are not the complete expert”. We need to provide expertise and information to our consumers and communities so they can then decide what they want, they are the experts in their own lives.

To illustrate this point and how we can do this better Sue told a story about her leadership role in another organisation where there was a non-English speaking, elderly inpatient who had diabetes.  She described how he was put into the set regime for care, including diet, medication and so on. He was about to go home and everyone thought he and his now well-educated wife were going very well. Sue, however, thought he was blankly smiling and nodding about all the compliance orders which he probably wouldn’t adhere to once at home. Sue said she took it upon herself to chat to the elderly gentleman’s daughter about this despite the best staff and programs. His daughter said “are you kidding me – an elderly Italian man being expected to not eat pasta, wine, sweets etc etc !!!!!!” Sue said they immediately changed his regime, in partnership with his daughter, to one he could adhere to.

Sue said that if this gentleman had gone home and not adhered to his regime the next step would have been to label him, by the genuinely very caring staff, as ‘non-compliant’.  Sue noted it is “humanness” to label people.  Sue said this is a very good example of ‘we told and not listened’. Due to our military origins, we are trained to solve others’ problems and we listen to work out a solution, not genuinely to hear their story or uniqueness. With military precision on behalf of others, we Assess, Plan, and Implement, for them not with them.

Sue strongly believes that moving forward to be able to genuinely partner with our consumers and to create exceptional experiences for them we need to start by asking our consumers and/or their family/carers/community to gain knowledge, then provide supports they really need and hold everyone accountable to it happening in a positive way. This is the foundations for co-designing and co-producing safe quality health services.

Sue noted Lyn Swinburne, a consumer advocate with Breast Cancer Network Australia   and how she believes that “if a culture says you can co-design and produce with your consumers – then you will”. This then enables us to empower our clients.

What are the structures for empowerment with our consumers/carers/community?

  1. Knowledge – access to information
  2. Support – ask what do you need?
  3. Accountability – hold everyone accountable to the process, but not in a punitive way.

NOTE: Key to success is to learn from a mistake even though it’s the hardest thing to do it has the best outcomes.


Sue discussed at length the importance of staff working in an overall environment that didn’t just support them to be well trained, credentialed and compliant but enabled them to live and breathe the culture. This culture includes a safe and healthy work environment. Staff are there to provide a safe and quality health service for their clients and everyone else, but they can’t do that if they aren’t safe themselves. It also shouldn’t matter who they are on the team or where they work. Everyone must feel this.

Sue tells a wonderful example of their car park attendant whose smiling face and caring helpful attitude is the beginning of everyone’s experience of The Women’s culture. He genuinely is supported to engage with the vision in the same way a nurse, administration staff or board member would. She feels part of achieving this is to make sure that the staff are prepared and supported to provide a safe quality service as well as receive it themselves when required.

Sue said she makes sure the staff have the same caring support available to them as they give to their clients, for example, the introduction of Family Violence Leave for any staff requiring this. They also have staff awards and healthy staff programs.


Sue talked about the importance of safety and quality systems for measuring what we do to build a culture of continuous improvement. She also went onto say that we need to be wary because what we measure drives behaviour and sets cultures. Sue believes we are more and more compliance focused to make sure we have stuck to policies and procedures in our measurements and this often goes against genuinely meeting our clients’ needs and being innovative for that. To be innovative to genuinely meet clients’ needs, staff need to be empowered to make decisions. They need to know what decisions they can make as individuals and as a team.

She told a great story with an example of a culture and quality systems and processes that supported innovative decision making without causing any problems. The example was of the Nordstrom Department Store in America where every staff member is given a copy of the policies and procedures and they must carry on their person at all times whilst at work. There is only one policy in the organisation, which is ‘you will use good judgement at all times’. A particular young team member was asked by a client to return a tyre – she stated that we don’t sell tyres. She, however, noticed that the client was getting very upset and was elderly. She decided to take the tyre and issue a refund. She was not in trouble or breaking the rules as she felt and it was seen to be using ‘good judgement’.  Sue believes a game changer would be for “You will use your good judgment” to come into health wherever it’s appropriate. She said, imagine if staff were not empowered to make good judgements like this and they were afraid, then such good judgement would be measured as being non-compliant with the rules and a poor decision.

Sue believes that many rules /policies are written for the staff and not for the clients/families or community members. In extreme cases, the staff have been sticking to the rules and not helping the client. Sue noted that in healthcare we often design rules in response to mistakes as a way of trying to prevent them occurring again, but this culture facilitates and expects the rules to be adhered to, even if they still don’t help the clients.

At The Women’s they asked managers to share policies that prevent staff from providing exceptional care to patients and that make life difficult for staff.. They are working through these policies to eliminate or change them.  Sue said that in particular, they like to ask new staff to question ‘why do we do this or why do we do it this way?’.


Again, Sue felt it is very important to be skilled in evaluating safe and quality health services and said an important question to understand is “how we measure the organisation as a whole?” Sue believes it is very important to have safety and quality as number one to measure, instead of finance, but it is important not to lose sight of staff, clients and finance in the mix.

She recommended a balanced scorecard approach not only about safety but about the quality of care, staff and consumers as well.

Sue also recommends the importance of the CEOs role for informing and influencing the board about how to measure more than just compliance but to understand the culture as well. Sue suggested activities with the board such as:

  • Stories at the board table by or about clients or different staff members
  • Give context, background and explain what is meant by this story
  • Encourage the board to ask ‘so what ‘about information and reports