HNE Health Principles, Framework and Committees

Clinical Governance is based on the principle that all health professionals, clinicians and managers alike, as well as those in corporate governance, are jointly accountable for quality of patient care and standards of care delivery. Clinical Governance is the framework by which this accountability is ensured and demonstrated.

The Australian Council on Healthcare Standards (ACHS) defines Clinical Governance as the “…system by which the governing body, managers and clinicians share responsibility and are held accountable for patient care, minimising risks to consumers and for continuously monitoring and improving the quality of clinical care…”.

The Antecedents of Clinical Governance
Recognition of the importance of clinical governance in clinical care and health service delivery is relatively recent. The understanding that clinical incidents are usually related to systems rather than individuals is now more widely recognised.

Initially, this understanding was informed through parallels drawn with the non-health total quality management approach of leaders such as W. Edwards Deming. In the early 1990s, the increasingly vocal voices of clinical leaders such as Professor Donald Berwick, formerly the Chief Executive of the Institute for Health Care Improvement and Dr Brent James of Intermountain Healthcare in the United States of America drove knowledge development and innovation, and encouraged data-driven clinical quality improvement and organisational-wide perspectives on key quality and patient safety objectives.

In recent years, parallels have also been drawn between health and other sectors where teamwork is a core part of service delivery.  A common parallel has been with aviation, where the team dynamics of the team of people who fly and staff passenger aircraft have been compared with the dynamics of a multidisciplinary clinical team. There is considerable interest in this area of Human Factors, recognising that teamwork and communication play important roles in the system of care delivery, particularly in complex systems such as health care.  Educational developments such as simulation and clinical communication training are current initiatives that focus on theory and practice in error and incident management in the professional environments of teams.

Principles of Clinical Governance
The NSW Health Patient Safety and Clinical Quality Framework (2005) has identified the following central principles in quality and patient safety:

• Openness about failures
• Emphasis on learning
• Obligation to act
• Accountability
• A just culture
• Appropriate prioritisation of action
• Teamwork
  

In Hunter New England Health, the features of Clinical Governance are described as: 

• Recognition and acceptance by health professionals, clinical staff, managers, executives and Board members that they share accountability for quality and standards of care within the health service
• An environment that promotes and fosters quality of care and safe practice
• Patient care and clinical priorities at the centre of all endeavours
• Partnership between patients, clinicians and management in clinical services review and development
• Systems that monitor, identify, report and evaluate quality of care
• Effective mechanisms that minimise harm and/or risk and address any deficiencies
• Active pursuit of external examples of excellence and related partnerships
• Encouragement of innovation and best evidence practice
• Celebration of success and learnings from past experiences
  

These principles and features are described in the Hunter New England Health Clinical Quality and Safety Framework, which was endorsed by the HNE Health Care Quality Committee and approved by the Chief Executive initially in 2007. This Framework was reviewed using an extensive organisational consultation process in 2009/2010.

Australian Perspectives on Clinical Governance
The Australian Commission on Safety and Quality in Health Care (ACSQHC) commenced on 1 January 2006. Building on the work of its predecessor the Australian Council on Quality and Safety in Health Care, the ACSQHC aims to:

• lead and coordinate improvements in safety and quality in health care in Australia by identifying issues and policy directions, and recommending priorities for action
• disseminate knowledge and advocate for safety and quality
• report publicly on the state of safety and quality including performance against national standards
• recommend national data sets for safety and quality, working within current multilateral governmental arrangements for data development, standards, collection and reporting
• provide strategic advice to Health Ministers on best practice thinking to drive quality improvement, including implementation of strategies and
• recommend nationally agreed standards for safety and quality improvement.
  

More recently, the importance of research into quality improvement has been highlighted and priority for high level funding of research into clinical quality and safety has been recognised. A National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Patient Safety was been established to design, conduct, promote and promulgate high quality multi-centre research to improve quality, safety, efficiency and effectiveness of health care for Australians, and funding for this National Centre was provided by the Australian Council for Safety and Quality in Health Care (now the Australian Commission on Safety and Quality in Health Care) and was awarded through the NMHRC. The consortium was based in the Department of Epidemiology and Preventive Medicine at Monash University, and included a team of experts in health care risk management and patient safety specialists from across Australia.

State Perspectives on Clinical Governance
There have been a number of key developments and initiatives in quality, safety and clinical governance in New South Wales.

In 1999, NSW Health published the well-regarded A Framework for Managing the Quality of Health Services in New South Wales which provided a foundation for the implementation of effective quality improvement programs in NSW Health, and which described six dimensions and the principles underpinning quality improvement. This document was a major milestone that provided a meaningful framework in both the clinical and administrative contexts of health service delivery.

The Clinician’s Toolkit was published in 2001.  This useful and practical document provides information about the tools available to review and improve quality in clinical practice. It is an educational resource, and was produced in collaboration between NSW Health and the NSW Medical Colleges. It remains one of the most useful summary documents of its kind.

The Easy Guide to Clinical Practice Improvement  is a companion document to the Clinician’s Toolkit, and was published in 2002. Its purpose was to provide practical advice on the use of health care data to improve quality and safety, and on concepts of human performance, systems of care and dealing with error.

The NSW Health Patient Safety and Clinical Quality Framework (2005) outlines how Clinical Governance is conducted in the then Area Health Services (now Local Health Districts). The framework is designed to support clinicians and managers in improving quality and safety in clinical care, and identified active involvement of doctors, nurses, allied health professionals, health service managers and the community as a key success factor.

The NSW Health Patient Safety and Clinical Quality Program published in August 2005 provides the framework for structures, priorities and implementation of a quality and safety program for NSW Health public health organisations.

The key components of the program are:  

• Systematic management of incidents and risks
• A new Incident information Management System
• Establishment of a Clinical Governance Unit in each Area Health Service
• A Quality Assessment Program for all public health organisations, and
• The establishment of the Clinical Excellence Commission
  

The NSW Health Patient Safety and Clinical Quality Program describes the following roles and responsibilities for the different organisations involved in quality and safety.

(i)  NSW Health
The NSW Health Clinical Safety, Quality and Governance Branch is part of the Health System Quality, Performance and Innovation Division, and is responsible for the development of the essential components of the NSW Patient Safety and Clinical Quality Program, with lead responsibility for areas such as:  

• setting of standards for Area Health Service quality systems
• development of policies on quality and safety for state-wide implementation
• development and reporting of system-wide quality indicators
• overseeing state-wide governance issues, and
• overseeing consistent implementation of the NSW Patient Safety and Clinical Quality Program
  

(ii)  Clinical Excellence Commission
The Clinical Excellence Commission (CEC) is a statutory health corporation established under the Health Services Act by the NSW Minister for Health as part of the NSW Patient Safety and Clinical Quality Program and builds on the foundation work carried out by the Institute of Clinical Excellence established in 2001. The core mission of the CEC is to identify issues of a systemic nature that affect quality and safety and to develop and advise on implementation strategies to address these issues. It also has a state-wide research oversight, monitoring, education and advisory role.

(iii)  Local Health Districts (formerly Area Health Services)
The then Area Health Services (now restructured as Local Health Districts) are responsible for the quality and safety of their services. As part of the health reforms at the time, clinical governance was embedded in the then new Area Health Services through the mandatory requirement to establish a Clinical Governance unit, which holds responsibility for the rollout of the NSW Patient Safety and Clinical Quality Program. As part of this framework, the Director Clinical Governance reports directly to the Chief Executive.

(iv) Clinical Governance in Local Health Districts/Area Health Services
The NSW Patient Safety and Clinical Quality Program describes a number of functions that guide the role of Clinical Governance in 2004-2005, including the structural establishment of the Health Service’s Clinical Governance unit and the rollout of incident management and complaints management with internal and external reporting functions.  Hunter New England Health had already introduced a Clinical Governance unit in the then Hunter Area Health Service, reported to be the first of its kind in Australia when it was established in 1999. The role of Clinical Governance as outlined in the NSW Patient Safety and Clinical Quality Program also covers continuous quality improvement support, communication training, policy development, mortally review and clinical audit, clinician performance review and integrated risk management.

The Hunter New England Health Context
The initial focus of HNE Health Clinical Governance was around the establishment of the new Area-wide structure, implementation of reporting, monitoring and evaluation systems and the implementation of key policies around complaints management and incident reporting. In Hunter New England Health, this has resulted in a robust reporting culture and acceptance of the use of systems such as Incident Information Management System (IIMS) as part of routine management of quality and safety in patient care.

Building on this early phase, the HNE Health Clinical Governance focus in recent times  has been on the development of a sustainable organisational framework, with the implementation of HNE Health-wide committee and organisational structures and development of organisational capacity and culture through initiatives in areas such as the Hunter New England Health Policy Development and Management Framework, clinical practice improvement and clinician engagement.  External benchmarking and partnerships with other organisations to enhance learning and experience are actively pursued, and more recently, the profile of important clinical practice areas such as clinical ethics has been incorporated into the Hunter New England Health Clinical Governance agenda.

The core components of Hunter New England Health Clinical Governance are:  

• Quality and Patient Safety Governance Framework including Committees
• Clinical Communication
• Clinical Ethics
• Clinical Practice Improvement
• Clinical Risk Management
• Engaging Patients, Consumers and the Community
• Executive Support Service including Complaints Management
• Morbidity, Mortality and Clinical Audit
• New Interventional Procedures and Clinical Practice Innovation
• Patient Safety, Incident Management and Open Disclosure
• Policy and Clinical Practice Guidelines Development and Management
• Professional Practice
• Quality Improvement and Continuous Practice Improvement
• Safety Alerts
• Training, Education and Knowledge Management
  

Hunter New England Health Quality and Patient Safety Governance Framework including Committees

In 2006-2007, Hunter New England Health completed a review of its framework for ensuring quality and patient safety is monitored, managed, reported, evaluated and benchmarked, with particular focus on governance and linkages. The overarching principle for this review was based on the basic concept of Clinical Governance, that is, that clinicians and managers are jointly accountable for quality of patient care and standards of care delivery. In other words, quality and safety is the role of everyone involved in health service delivery and Clinical Governance is the framework by which this accountability is ensured and demonstrated.

To ensure that Hunter New England Health addresses its clinical governance functions, a Governance Structure for Quality is in place.  The peak governance committee is the Health Care Quality Committee, which as of 2011, is a governance committee of the HNE Health Board, and chaired by a Board member. It is the peak governance committee for clinical and corporate quality and safety in Hunter New England Health. The purpose of the committee is to provide leadership in quality in healthcare through a forum that involves clinician leaders, consumer representatives, the Executive of Hunter New England Health and designated members of the Board. The committee will advise the Board and Chief Executive on issues affecting the quality of health care services and has a strategic responsibility and focus.

The Clinical Quality and Patient Care Committee reports to the Health Care Quality Committee and is chaired by the Director Clinical Governance. This committee has a predominantly clinical membership and has an operational focus, including such roles as coordination, monitoring and evaluation of the Hunter New England Health Patient Safety and Clinical Quality initiatives. This committee has consumer representation.

The Clinical Quality and Patient Care Committee provides organisational oversight to expert purpose-specific committees that address major quality and safety areas. These include:

Facility and Service Based Quality and Patient Care Committees 
Quality and Patient Care Committees are established for each operational level commencing at each facility, cluster or service within HNE Health. They are established under the authority of the relevant General Manager and/or Executive Director and report to the relevant General Manager or Executive Director. There should also be Quality and Patient Care Committees (or equivalent) in HNE Health-wide operational units, including corporate services, appropriate to their quality review and improvement activities

The facility/service based Quality and Patient Care Committee provides oversight to monitoring, reporting, evaluation and benchmarking of quality and patient safety within the hospital/service, to ensure continuous improvement and best evidence practice occurs in all aspects of quality of care and service.

It has a direct reporting line to the senior manager of the service/facility and its focus is local leadership and operational oversight. Each committee will have multidisciplinary participation, with formal processes established to communicate with, and receive input from staff and other relevant stakeholders who are not members. Each committee will meet as frequently as needed to provide effective oversight and management, which in the majority of cases will be monthly. In smaller facilities/services the functions of the Quality and Patient Care Committee may be included as a part of the Executive Management Committee or local operational meeting, with standard agenda items incorporated.

The facility/service based Quality and Patient Care Committee will provide oversight of monitoring, reporting, evaluation and benchmarking in relation to:

• Patient outcomes, including clinical indicators
• Quality programs (infection control, quality use of medicines, deteriorating patient, clinical communication, falls injury prevention and as designated annually).
• Incident management, including Root Cause Analyses
• Clinical audit (including death audits)
• Patient Experience (including patient surveys, patient interviews and complaints)
• Clinical Risk Management
• Evidence based practice (including management of policy and guidelines and compliance)
• Education in quality and safety
• Accreditation (including Australian Council on Healthcare Standards, Quality Systems Assessment (QSA), and various Clinical Training Programs)
  

A template Committee Charter for facility/service based Quality and Patient Care Committees is available HERE.

An annual report of the activities of each facility/service based Quality and Patient Care Committee will be submitted to the HNE Health Clinical Quality and Patient Care Committee. The HNE Health Clinical Quality and Patient Care Committee will develop annual summary information about overall HNE Health level activities, and make this available to facility/service based committees, as well as to the Board’s Health Care Quality Committee. The HNE Health Clinical Quality and Patient Care Committee will also provide guidance each year on developments in priority areas for focus and monitoring as established in the annual Patient Safety and Quality Performance Agreement with NSW Health or as directed by the HNE Health Board’s Health Care Quality Committee.