Resources

Leadership and culture are pillars of any clinical governance framework and often cited as the key framework components.   But Dr. Kedar Mate and Josh Clark from IHI challenge us to understand the role that systems play in good care.  They argue that many improvement initiatives fail due to systemic issues rather than a lack of vision or communication from leaders, and advocate for a focus on ‘operating systems’ that support good care.

This IHI blog reinforces the importance of SPC charts and provides links to tools and guides for their use. 

Building a clinical governance framework is challenging, especially for health services that are used or provided across more than one state or territory. This webinar discussed some key components for building a practical clinical governance framework to enhance uptake amongst users of the system. 

Is there a recipe for creating a high-performing health service? Of course there is! We don’t have to look too far into the literature to find multiple sources of evidence on high performance. This study, from the 2015 ‘vault,’ is particularly useful as it identifies seven clear themes from a systematic review of the qualitative literature on high-performing hospitals.

In today’s rapidly evolving healthcare landscape, technology is both an enabler and a challenge, reshaping how we deliver, manage, and access healthcare services. Liz will discuss the critical role of clinical governance and safety in digital health. As we explore frameworks that underpin sound governance, including some takeaways from the Health Innovation Community (HIC) conference, we’ll consider what it means to 'think differently' about health technology - why the integration of clinical governance isn't just about compliance but about achieving better, safer patient outcomes. 

In Australian health services, roles that support consumer safety are a mix of trained specialists, people who evolve on the job and those who struggle through the basics with little opportunity for development. In the UK,  the NHS has created a new role of ‘patient safety specialist’, introduced to bring a more structured, professional approach to patient safety. This evaluation article seeks to understand the professionalisation of patient safety, with implications for the further development of patient safety specialists in the UK and other countries. 

Over the past three decades, many health systems have sought to enhance care delivery. Despite various approaches such as quality improvement and lean management these efforts can fall short. Failures are often attributed to leaders and workers not doing the right things. This article argues that the real quality problems lie in the underlying systems staff work with. It says that human service organisations will be more successful if they focus on designing systems that support the delivery of high-quality care, rather than trying to fix the people working within them.

Spreading, scaling up, and sustaining improvements in human services is a complex challenge that many countries, including the UK, USA, and Australia, have been tackling. Despite significant efforts, the sustainability of scaling up local improvements remains low. One reason for this is the traditional, linear approach to spreading improvements, which often overlooks the complexity and evolving nature of healthcare systems.

We spend a lot of time on root cause analysis (RCA) – and have done it for 20 years or so. But key clinical risks remain stubbornly consistent.

SystemsThinking - A New Direction in Healthcare Incident Investigation.