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.