Clinical Governance Standard

CEC supports implementation of the National Safety and Quality Health Service (NSQHS) Standards Clinical Governance within NSW Health facilities.

Governance, leadership and culture

Action 1.01 - Governance, leadership and culture

Clinical Excellence Commission

  • A guide to Safety Culture Measurement
  • Become a Safety and Quality Partner
  • NSW Safety System Model
  • REACH
  • Serious Incident Reviews
  • System Safety Culture.

NSW Health

  • Clinical Governance in NSW (PD2024_ 010)
  • Generic Service Agreement template
  • Strategic directions NSW Health.

NSW Government

  • PMES Survey.

Action 1.02 - Governance, leadership and culture

The governing body ensures that the organisation’s safety and quality priorities address the specific health needs of Aboriginal and Torres Strait Islander peoples.

NSW Health

  • Aboriginal Health Plan
  • Aboriginal Health.

Action 1.03 - Organisational leadership

  • Clinical Governance in NSW (PD2024_ 010).

Action 1.04 - Organisational leadership

  • Aboriginal Health Impact Statements are completed for all state-wide policies
  • Aboriginal Health Plan
  • Aboriginal workforce in NSW Health.

Action 1.05 - Organisational leadership

  • Aboriginal Health Impact Statements are completed for all state-wide policies
  • Enterprise-wide risk management (PD2022_023).

Action 1.06 - Clinical leadership

  • Clinical Governance in NSW (PD2024_ 010) - Section 3 Key Accountabilities
  • Healthcare Safety and Quality Capabilities
  • Mandatory training - Health Education and Training Institute.

NSW Government

  • NSW Public Service Commission Capability Framework.

Patient safety and quality systems

Action 1.07 - Policies and procedures

  • NSW Health Policies and Other Policy Documents (PD2022_047)
    • For NSW Health Policies workforce feedback (NSW state-wide consultation) is held by the policy author and cannot be published without evidence of the process having being undertaken.

Action 1.08 - Measurement and quality improvement

  • Action plans are developed within QIDS for audit results QIDS and QARS
  • Bureau of Health Information (BHI)
  • HAC data is provided in Health System Performance Reports
  • NSW Health Performance Framework.

Action 1.09 - Measurement and quality improvement

  • Health System Performance Reports
  • Meetings with NSW Health to review Performance
  • Safety and Quality Accounts
    • Annual Reports.

Action 1.10 - Risk management

  • Emergency Management Arrangements for NSW Health (PD2012_067)
  • Enterprise-wide risk management (PD2022_023)
  • Health Incident Coordination Framework (PD2019_ 023)
  • Health System Performance Reports.

Action 1.11 - Incident management systems and open disclosure

  • Incident Management (PD2020_047 )
  • Incident Management Policy Resources
  • Lessons learned are regularly developed and distributed
  • Serious Incident Review Committees.

Action 1.12 - Incident management systems and open disclosure

  • CEC Open Disclosure internet page
  • Open Disclosure Handbook
  • Open Disclosure Policy (PD2023_034)
  • Open disclosure eLearning modules are available at HETI Online. They have been developed by the CEC for clinicians and other health care staff and include:
    • Introduction to Open Disclosure
    • A mandatory short lesson designed for all clinicians and other health care staff
    • Clinician Disclosure Module
    • Six short lessons designed to develop the skills required by clinicians to perform
    • Clinician Disclosure with patients or support people immediately following a patient safety incident
    • Serious incident Reviews.

Action 1.13 - Feedback and complaints management

  • CEC Consumer Feedback internet page
  • Complaints Management (PD2020_013)
  • NSW Health Elevating the Human Experience
  • BHI NSW Patient Survey Program
  • Consumer feedback via ims+
  • NSW Health actively invites feedback compliments, general feedback and complaints
  • PROMS and PREMS.

Action 1.14 - Feedback and complaints management

  • CEC Consumer Feedback internet page
  • Complaints Management (PD2020_013)
  • Consumer feedback via ims+ NSW Health actively invites feedback compliments, general feedback and complaints
  • NSW Health Elevating the Human Experience.

Action 1.15 - Diversity and high-risk groups

Local Health Service

  • Refer to local clinical services plan.

NSW Health

  • NSW Aboriginal Health Partnership Agreement 2015-2025
  • Aboriginal and Torres Strait Islander Origin - Recording of Information of Patients and Clients
  • Aboriginal Cultural Activities Policy
  • Aboriginal Family Health Workers - Operational Guidelines
  • Aboriginal Health Impact Statement
  • ACI Consumer Enablement Guide
  • Communicating Positively: A Guide to Appropriate Aboriginal Terminology​
  • Education Centre Against Violence
  • Good Health - Great Jobs Key Performance Indicator Report, July to December 2011
  • Multicultural Health Policy
  • NSW Aboriginal Health Plan 2013-2023
  • NSW Aboriginal Health Plan 2024-2034
  • NSW Health Good Health - Great Jobs: Aboriginal Workforce Strategic Framework 2016 - 2020
  • NSW Health Services Aboriginal Cultural Engagement Self-Assessment Tool
  • NSW Mental Health Reform 2014 - 2024 '12 Months On'
  • Phase 1 Report - Analysis of Current NSW Health Aboriginal Health Worker Environment - Discussion Paper
  • Respecting the Difference: An Aboriginal Cultural Training Framework for NSW Health
  • Statement of Commitment
  • The NSW Health Aboriginal Family Health Strategy: Responding to Family Violence in Aboriginal Communities.

Action 1.16 - Healthcare records

  • Health Care Record - Documentation and Management (PD2012_013)
  • eHealth electronic medical record resources
  • NSW Health is working towards the development of a Single Digital Patient Record.

Action 1.17 - Healthcare records

  • NSW Health Record Security and Access (PD2019_054).

Action 1.18 - Healthcare records

  • NSW Health Record Security and Access (PD2019_054).

Clinical performance and effectiveness

Action 1.19 - Safety and quality training

  • HETI Training Matrix
  • My Health Learning: By employee and organisational administrators
    • The Safety & Quality Essentials Pathway.

Action 1.20 - Safety and quality training

  • HETI Training Matrix
    • My Health Learning: By employee and organisational administrators.

Action 1.21 - Safety and quality training

  • Mandated respecting the difference training - My Health Learning
  • Aboriginal health Impact Statement
  • Aboriginal Health Impact Statement (PD2017_034)
  • NSW Aboriginal Health Plan 2024-2034
  • NSW Health Guideline: Communicating Positively: A Guide to Appropriate Aboriginal Terminology (GL2019_008).

NSW Government

  • People Matters Employment Survey results.

Action 1.22 – Performance management

  • Leading Performance, Development and Talent Management
  • Performance and Talent System.

Action 1.23 – Credentialing and scope of clinical practice

  • Credentialing & Delineating Clinical Privileges for Senior Medical Practitioners & Senior Dentists (PD2019_056)
  • Credentialing health practitioners and defining their scope of clinical practice:
    • A guide for managers and practitioners.

Action 1.24 – Credentialing and scope of clinical practice

  • Credentialing & Delineating Clinical Privileges for Senior Medical Practitioners & Senior Dentists (PD2019_056)
  • Credentialing health practitioners and defining their scope of clinical practice:
    • A guide for managers and practitioners.

Action 1.25 – Safety and quality roles and responsibilities

  • The Safety & Quality Essentials Pathway.

Action 1.26 – Safety and quality roles and responsibilities

  • The Safety & Quality Essentials Pathway.

Action 1.27 Evidence-based care

  • Statewide policies endorse relevant clinical practice guidelines and mandatory training.

Action 1.28 - Variation in clinical practice and health outcomes

  • HAC Data
  • Bureau of Health Information
  • Health System Performance Reports and NSW Health Performance framework
  • NSW Policy Directive Clinical Governance in NSW (PD 2024_010).

Safe environment for the delivery of care

Action 1.29 - Safe environment

  • Health Infrastructure lead capital development for NSW Health
  • Asset Management (PD2022_044)
  • NSW Health Policy and Standards for Security Risk Management in NSW Health Agencies.

Action 1.30 - Safe environment

  • NSW Health Policy and Standards for Security Risk Management in NSW Health Agencies
  • NSW Health Emergency Preparedness
    • Overarching plans
    • Work Health and Safety: Better Practice Procedures (PD2018_013).

Action 1.31 - Safe environment

Action 1.32 - Safe environment

  • Refer to local guidance.

Action 1.33 - Safe environment

  • Aboriginal Health Impact Statement
  • NSW Health Aboriginal Health Plan 2024-2034.