Clinical Governance

A safety system is determined by the Health Services' maturity and capacity to be reliable and resilient when working under typical conditions, as well as when confronted with unanticipated events.

When Health Services ensure that features of safety resilience are present and effective in services, an environment that manages unpredictability while maintaining reliability is created. A resilient and reliable healthcare safety culture is one where safety is everyone’s responsibility, and compassionate behaviours are evident at all levels of the system.

Embedding safety strategically take time. Readiness for improvement in terms of a psychologically safe culture, capability development infrastructure, safety governance, and accountable leadership behaviours needs to be considered.

The CEC's Healthcare safety culture framework provides a shared model of the interconnected components of healthcare safety culture and highlights the importance of compassionate leadership as an enabler.

The boards of local health districts and special health networks also play a key role in ensuring care is safe and harm is reduced. The CEC's quality improvement for boards resource includes key questions that board members and executives can use to identify gaps in their safety culture and work to improve it.

In a mature safety system, accountability is taken and held by its people, rather than its people waiting to be held accountable by others. It is a culture where safety is everyone’s responsibility, and everyone understands what it means for them.

Accountable leadership and a strong safety culture are crucial for improving the safety and quality of health care. Accountable leaders show commitment to patient safety improvement by supporting a safety culture that encourages and facilitates incident reporting and consumer feedback for learning.

It is essential that leaders ensure all staff are informed and aware of the importance of safety and quality, as well as their individual roles and responsibilities in safety improvement. Accountable leadership helps build a culture across the organisation where there is high-trust, psychological safety, and a shared sense of purpose for staff.

Inclusion of a restorative, compassionate culture for clinicians and consumers fosters the human experience and repairs trust and relationships that may be impacted due to an adverse event.

A systemic safety culture and accountable leadership is dependent on all clinicians sharing a vision, purpose and strategy emphasising mutual respect, trust, collaboration and open, two-way communication to ensure advocacy and psychological safety.

In consultation with NSW Health staff, the CEC has developed the Healthcare Safety and Quality Capabilities to create a shared language to describe the safety and quality capabilities and associated behaviours. These behaviours are expected of all NSW Health employees, leaders and board members.

2025 Patient Safety Week - case study

Our Patient Safety Improvement Program promotes a culture of safety, ongoing learning, and improvement in healthcare. It does this by coordinating NSW Leaders Safety and Quality Forums, where leaders in maternity, neonatal, paediatric, and older persons care work together to cultivate and enhance safety and quality leadership across NSW Health services.

This Patient Safety Awareness Week, we're spotlighting how focusing on accountable leadership and culture ensures that people leaders across the NSW Health hospitals and health centres are well-equipped to guide their teams toward safer practices and better patient outcomes.

Overall, the program’s approach of fostering collaboration, enhancing leadership, and promoting continuous learning plays a crucial role in advancing patient safety and quality across NSW’s healthcare services.

A participant at one of the forums reflected that "Being able to meet other leaders from across the state. It can feel isolating working in a regional/rural setting, so it's nice to know that we have other leaders we can reach out too."

The forums have been evaluated positively over time. Leaders find them relevant, engaging, and a valuable use of their time. They believe the forums help strengthen their roles in safety and quality by applying what they learn to their services.

Examples of this include using co-leadership models, implementing safety activities, building resilience, and reviewing safety systems and clinical data.

Leaders say the most valuable aspect is networking and sharing knowledge with others.

A key part of effective safety governance is the capacity of the health service to provide integrated care. Effective incident and risk management is dependent on the capacity of the health service to identify and analyse contributory, human or system factors, and any root causes.

In effective safety governance, oversight and shared learning must span the entire care continuum to ensure collaborative risk mitigation strategies can be developed for matters that affect multiple aspects of the system.

2025 Patient Safety Week - case study

This Patient Safety Awareness Week we're highlighting how we support NSW Health's commitment to learning and improving when serious clinical incidents occur. The CEC has developed an educational program to build capability within NSW Health services when completing Serious Adverse Event Reviews (SAER).

The program's learning pathway features both eLearning and virtual workshop options. This includes a Fundamentals workshop outlining key concepts to consider for all serious incident reviews along with methodology specific workshops and one targeted for those leading SAER teams.

The program, available for public health services in NSW, enforces the importance of supporting not only the patient and their families when serious incidents occur but supporting all those who are affected. It draws from the Healthcare Safety Culture Framework, emphasising a restorative approach aimed at repairing trust and building relationships that may have been damaged when serious incidents occur. It enforces the need to treat individuals fairly and not blame individuals for failures of the system.

"I found this workshop to be so restorative.…Thank you for providing this workshop in such a kind and compassionate way," a recent workshop participant reflected. "I found this very valuable and great to collaborate with like minds in other settings."

In 2024, the CEC delivered 11 half day Fundamentals workshops, 9 half day methodology workshops and 3 full day team leader workshops. Over 380 participants attended these workshops.

Participants were invited to complete pre and post workshop questionnaires with the majority indicating an increased knowledge in the key learning objectives. Overall, 97% of participants who completed the post knowledge questionnaire indicated they were likely or extremely likely to recommend the workshops to others.

Safety intelligence is the use of data, connected technology and insights to enable a predictive and proactive approach to patient safety. It focuses on data and information, allowing Health Services to monitor incident trends and clinical outcomes over time. These trends are utilised to inform safety and quality decisions. The use of near real-time, meaningful and triangulated data (multiple datasets, methods, and investigations) is vital for system-wide learning and improvement.

The following resources are available to support a safety and quality data surveillance strategy.

• NSW Health's Incident Management System is used to report incidents, hazards or near misses, as well as consumer feedback.
• The CEC's Quality Improvement Data System (QIDS) provides users at all levels of an organisation with a single point of access to information and tools for the purpose of improving the quality and safety of health service delivery.
• The CEC's Quality Audit Reporting System (QARS) is an electronic tool to help improve the quality and safety of health care provided by local health districts, speciality health networks, pillars and NSW Health service providers.
• The Australian Institute of Health and Welfare (AIHW) Health Indictors provide data and information at the national, state and local levels.
• The Agency for Clinical Innovation's (ACI) Patient Reported Measures Program gives patients the opportunity to provide direct, timely feedback about their health-related experiences and outcomes at the point of care. This feedback can help drive improvements in care.
• The Bureau of Health Information (BHI) reports independently on the performance of the NSW healthcare system to inform improvements.

2025 Patient Safety Week - case study

This Patient Safety Awareness Week, we’re sharing a pilot project we've been working on with the NSW Ministry of Health to develop and implement a near real-time capture and reporting of patient experience feedback.

After discharge, patients automatically receive a text message with a survey. When patients complete the survey via mobile phone, patient survey responses are available to staff within 24 to 72 hours.

Early insights suggest patient experience may be influenced by whether the hospital stay is planned or unplanned and by how long the patient stays in the hospital. Survey response rates and results differ depending on the patient’s age and preferred language.

"As health care providers, the most important thing we can do is to listen to those we care for," said Professor Jonathan Morris AM, CEC Associate Director Medical Patient Safety.

"RPES empowers patients and families to share timely feedback about their hospital stay including care, treatment, communication and overall experience. This, in turn, allows hospital staff to act to respond to feedback and make any improvements."

The ongoing pilot project commenced in July 2024 and has been rolled out in 23 wards across Central Coast Local Health District, Hunter New England Local Health District, Murrumbidgee Local Health District and Southern NSW Local Health District.

Patients and their families have submitted more than 2,500 survey responses since the pilot project rollout, allowing clinicians, managers and executives to hear feedback about how the communicate with and provide care to patients.

Safety systems strategically enhance the application of safety and improvement capability in daily conversations and practice by all people, at all levels, across the organisation.

To become a safety system, capability and capacity building is to be embedded within the duties of all staff and leaders. Clear executive sponsorship and collective commitment across the organisation for safety and quality capability development is required. Safety and quality development should be strategically integrated into the organisation’s priorities and planning.

The CEC's Safety & Quality Essentials Pathway is designed to meet the current safety and quality capability needs of everyone at NSW Health. Starting with the essentials, it also provides a path for ongoing training and career development.

2025 Patient Safety Week - case study

We've partnered with Murrumbidgee Local Health District to co-design the next iteration of our reflective practice workshop to include unconscious bias training, which has been instrumental in building a deeper understanding of our bias and how it impacts patient safety.

This Patient Safety Awareness Week, we're highlighting how reflective practice contributes to safer healthcare for patients across NSW, and the work we’re doing to share this practice with colleagues across the state's public health system.

Murrumbidgee's First Nations Mental Health and Patient Safety Workforce teams consulted on local needs when developing the reflective practice resources and workshops. This includes the integration of unconscious bias, its relevance to patient safety work and the use of reflective practice to mitigate biases.

"My highlight was adding unconscious bias – really deepens assumption-making. It has a core place in the content," said a workshop participant.

"The workshop was highly beneficial, and I appreciate the thoughtful design and facilitation that made it such a rewarding experience."

Over 125 NSW Health staff across local health districts, pillar agencies and speciality health networks have attended workshops. They’ve reported a heightened state of self-awareness, making the unconscious conscious through reflective practices that actively question assumptions, scrutinises interpretations we make in healthcare, and seek alternative perspectives that mitigate our biases and enhance patient safety.

This is essential for healthcare professionals as it fosters a reflective practice that transcends the limitations of unconscious biases.

Patient safety and quality improvement is a continuous process of monitoring and improving the safety and quality of care.

This requires health services to use safety intelligence to:

• identify their key safety priorities
• identify areas for improving safety
• implement safety and quality improvement initiatives
• monitor and review safety priorities and initiatives.

A whole-of-organisation approach is required to develop and maintain safety programs. This approach includes:

• ensuring staff have the resources, tools, expertise and skills
• ensuring safety intelligence is available
• setting time for safety improvement
• engaging teams in improvement conversations
• supporting psychological safety and capability development
• ensuring the support and commitment of board and executive members.

The CEC has resources for keeping patients safe and improving quality. The CEC Academy also has a range of programs, tools and resources.

2025 Patient Safety Week - case study

Aboriginal people are distinct and diverse groups with unique cultural practices.

This Patient Safety Awareness Week, we’re sharing how a culturally sensitive approach to open disclosure improves patient, staff and community confidence in how the system responds to real patient safety incidents.

The following case study is based on a fictitious experience of an Aboriginal patient during the open disclosure process.

An Aboriginal man underwent a major surgery at an NSW hospital. Following the surgery, unfortunately an unexpected complication resulted in the man's deterioration, and he required additional support and care following discharge.

The healthcare team followed the open disclosure process, ensuring transparency and honesty in their communication. However, the family had recently lost an Elder in their community and were engaged in Sorry Business at the time.

Due to Sorry Business, the family could not attend the open disclosure meeting at the scheduled time. Acknowledging the cultural significance of Sorry Business, the healthcare team, guided by NSW Health guidelines, took a flexible approach by rescheduling the discussion to accommodate the family’s mourning period.

The dedicated family contact facilitated the meeting in partnership with an Aboriginal Health Worker in a culturally respectful manner. Together, they used Clinical Yarning to ensure that the patient and his family had the time and space to ask questions, express concerns, and fully understand the details of the complication.

As a result, the patient and his family felt heard, respected, and supported throughout the open disclosure process. The healthcare team’s understanding of cultural obligations and the flexibility in accommodating Sorry Business helped build trust and rapport.

This approach improved the patient’s family’s engagement in his care and helped address the historical mistrust that may have been present due to past experiences of discrimination. The culturally sensitive and adaptive approach strengthened the relationship between the family and healthcare providers, fostering a deeper sense of partnership and understanding moving forward.

Read more about Aboriginal cultural engagement during the open disclosure process.

ACI resources

• Finding Your Way shared decision-making model
• Gadji Gadji rehabilitation toolkit