About clinical governance

Clinical governance is defined as 'an integrated set of leadership behaviours, policies, procedures, responsibilities, relationships, planning, monitoring and improvement mechanisms that are implemented to support safe, quality clinical care and good clinical outcomes for each consumer.' [1]

A clinical governance framework sets out what an organisation can do to ensure the quality and safety of clinical care for consumers and support good clinical outcomes and quality of life. Identifying, considering and managing risk is at the core of clinical governance.

In aged care, clinical governance applies to the clinical care provided by staff, as well as care provided by external healthcare providers and contracted service providers. Regardless of who directly delivers the care to the consumer, the aged care organisation is accountable for providing safe and quality care and services to consumers. [2] 

Clinical governance supports aged care staff and visiting practitioners to provide safe, quality clinical care for consumers. It means having systems and processes in place to support consistent clinical quality and safety and minimise the risk of poor clinical outcomes.  

Clinical governance also has important benefits for staff working in aged care. Where there are good clinical governance arrangements in place, there are improved working environments, support for professional development, a clear understanding of roles and responsibilities, greater trust, and protections for staff. [3]

The governing body of an aged care organisation (i.e., the board of directors) is accountable for the quality and safety of clinical care in that service and is responsible for making sure that the organisation has:

• a holistic framework and integrated systems to manage safety and quality; and  
• clear roles, responsibilities and accountability for safety and quality. [4] 

But everyone has a role to play in clinical governance. That includes the board, as well as senior executives, operational managers, the workforce (i.e. staff, employees), health practitioners, and consumers and their representatives. [5] Ideally, all staff will be engaged in identifying, managing and if necessary, promptly escalating risks. [4] As one submission to the Royal Commission into Aged Care Quality and Safety put it, ‘clinical governance needs to move beyond the board room and into every resident's room.’ [6]

The Aged Care Quality Standards set out the things that aged care providers need to do to deliver quality care. This includes having clinical governance arrangements in place. The current Aged Care Quality Standards require aged care services that provide clinical care to demonstrate the use of a clinical governance framework (Standard 8, 3(e)). However, in response to the Aged Care Royal Commission, the standards are currently under review. The proposed revised standards also include clinical governance within a specific standard for clinical care. [7] 

Aged Care Quality and Safety Commission (ACQSC) assessors consider aged care organisations’ use of a clinical governance framework to support clinical quality and safety when undertaking accreditation audits (among other things).  

The ACQSC encourages a culture of ‘self- assurance,’ where provider organisations have systems and processes in place to critically examine their own performance and consumer outcomes on an ongoing basis, to identify and manage risks, and continuously improve. 

The most recent ACQSC report on the performance of the aged care sector notes that clinical governance was the eighth most common requirement where non-compliance was found in residential aged care services. [8] This indicates a failure to comply with requirements for clinical governance is a common problem in the aged care sector. 

The Aged Care Royal Commission also explicitly recognised the need to improve clinical governance in the aged care sector:

Providers need to shoulder some of the responsibility for the systemic problems of the aged care system. Specifically, providers have not focused sufficiently on the provision of high-quality and safe care, on older people’s wellbeing, on service innovation and excellence, on listening to older people and hearing their complaints, on effective clinical governance of their services, and on workforce leadership, development, skills and culture. [9 p26]

Governance of clinical services has also been identified as a key area of risk in-home care services that can have significant impacts on consumers, with high rates of complaints and non-compliance. [2]

Here are some examples of what inadequate or ineffective clinical governance looks like:

• Unclear pathways for reporting, escalating and responding to risks and issues that may impact the clinical care of consumers 
• Ineffective systems for ensuring workers have the necessary skills, training and support to provide best practice clinical care 
• Limited mechanisms for monitoring care delivery and consumer clinical outcomes to ensure care continues to meet needs and inform organisational continuous improvement 
• A lack of oversight of, and accountability for, the coordination and delivery of clinical care to consumers 
• Unclear roles and responsibilities, such that there may be gaps in care planning, management/coordination and delivery of care and services (particularly where third parties are involved) 
• Ineffective information management systems, resulting in workers delivering clinical care not having access to the information required to deliver care. [2]

Developing a clinical governance framework often does not mean starting from scratch. Many of the elements of clinical governance may have been in place for some time, but they may not have been brought together into a single framework that has the clear purpose of ensuring safe, quality clinical care and good clinical outcomes for consumers. 

All aged care organisations are different, and so each will need to have a clinical governance framework that is tailored to suit the characteristics of their organisation and the types of clinical services they provide. There are, however, some core elements of clinical governance. A clinical governance framework should set out a systematic approach to action in the following areas: 

• Leadership and culture 
• Consumer partnerships 
• Organisational systems 
• Monitoring and reporting 
• Effective workforce 
• Communication and relationships. [10] 

ARIIA has compiled resources to help an organisation develop and implement a clinical governance framework or improve an existing framework. 

1. Aged Care Quality and Safety Commission. Fact sheet 1: Introduction to clinical governance [Internet]. ACQSC; 2019 [cited 2023 Apr 11]. Available from: https://www.agedcarequality.gov.au/sites/default/files/media/Fact_sheet_1_Introduction_to_clinical_governance.pdf  
2. Aged Care Quality and Safety Commission. Quality and safety in home services – 5 key areas of risk [Internet]. Guidance for governing bodies of home service providers. ACQSC; 2022 [updated 2022 Jun 29; cited 2023 Apr 11]. Available from: https://www.agedcarequality.gov.au/sites/default/files/media/quality-and-safety-in-home-services-5-key-areas_0.pdf   
3. Western Governors University. Importance of clinical governance [Internet]. WGU; 2021 [updated 2021 Nov 1, cited 2023 Apr 11]. Available from: https://www.wgu.edu/blog/importance-clinical-governance2111.html  
4. Australian Institute of Company Directors. Clinical governance for boards in the aged care sector [Internet]. Sydney: AICD; 2020 [updated 2021 Jan 1, cited 2023 Apr 11]. Available from: https://www.aicd.com.au/corporate-governance-sectors/clinical/best-practice/clinical-governance-for-boards-in-the-aged-care-sector.html  
5. Aged Care Quality and Safety Commission. Fact sheet 4: Roles and responsibilities for clinical governance [Internet]. ACQSC; 2019 [cited 2023 Apr 11]. Available from: https://www.agedcarequality.gov.au/sites/default/files/media/Fact_sheet_4_Roles_and_responsibilities_for_clinical_governance.pdf  
6. Royal Commission into Aged Care Quality and Safety. Exhibit 11-66 - wit.0484.0001.0001 - Statement of John Brian Maddison [Internet]. Royal Commission into Aged Care Quality and Safety; 2019 [cited 2023 Apr 11]. Available from: https://agedcare.royalcommission.gov.au/media/21556  
7. Department of Health and Aged Care. Review of the Aged Care Quality Standards [Internet]. Canberra: Australian Government; 2022 [cited 2023 Apr 11]. Available from: https://www.agedcarequality.gov.au/providers/quality-standards/strengthened-quality-standards  
8. Aged Care Quality and Safety Commission. Sector performance report, October - December 2022 [Internet]. Canberra: Australian Government; 2023 [cited 2023 Apr 11]. Available from: https://www.agedcarequality.gov.au/media/94463  
9. Royal Commission into Aged Care Quality and Safety. Final report: Care, dignity and respect. Volume 1: Summary and recommendations [Internet]. Commonwealth of Australia; 2021 [cited 2023 Apr 11]. Available from: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf  
10. Aged Care Quality and Safety Commission. Fact sheet 3: Core elements of clinical governance [Internet]. ACQSC; 2019 [cited 2023 Apr 11]. Available from: https://www.agedcarequality.gov.au/sites/default/files/media/Fact_sheet_3_Core_elements_of_clinical_governance.pdf