Continuous improvement in clinical governance
There is a lot more to clinical governance than meets the eye. It’s not just about having frameworks, but ‘living’ them, and continuously improving how we design and implement them.
A recent review of four Victorian health services by the Victorian Auditor-General Office (VAGO) revealed inconsistencies in the extent to which effective clinical governance is practised - with patient safety and high-quality care being the ultimate goal. The review itself was an exercise in clinical governance, by identifying areas for improvement.
The backbone to clinical governance systems and processes in Victorian public health services is the Victoria Clinical Governance Framework (VCGF). In addition, all health services in Australia are accredited against the National Safety and Quality Health Service Standards (NSQHS Standards), which all relate to clinical governance. However, it is also incumbent on individual health services to also have their own specific frameworks – for as we know, one size does not fit all. Clinical governance must be flexible and adaptive, whilst aligning with fundamental principles such as those set out in the VCGF and NSQHS Standards.
What makes clinical governance work – and what can we do to improve it? Clinical governance is futile unless it is translated and embedded into practice, culture and leadership. As identified in the VAGO review, this requires promoting a ‘positive patient safety culture’ where staff feel at liberty to speak up; early identification of, and effective response to, clinical incidents and risk (including sub-optimal performance); effective monitoring and oversight by boards; and continuous improvement through analysis of meaningful indicators and themes. Staff engagement is also crucial; as identified in the VAGO review, the extent to which the importance of clinical governance is understood by staff is a significant factor, as well as their roles and responsibilities within it.
As a nation, we’re not doing too badly. In a survey conducted by the Commonwealth Fund, Australia currently ranks third out of eleven countries in relation its healthcare system overall - measured by access to care, care process, administrative efficiency, equity, and healthcare outcomes. Further, it ranked first under the categories of equity and healthcare outcomes. However, in the spirit of continuous improvement, we must focus not on our success, but our shortfalls – and in relation to care processes and access to care, Australia fell short (ranking 6th and 8th respectively).
In the Commonwealth Fund survey, ‘access to care’ was measured by indicators such as affordability and timeliness - whereas ‘care processes’ related more to the patient experience, including parameters around ‘preventative care, safe care coordinated care, and engagement and patient preferences.’ While the weakness in ‘access to care’ may be due to an insurmountable mismatch between healthcare funding and demand, the ranking of ‘care processes’ broadly correlates with the gaps identified in VAGO’s review, which largely considered factors relevant to this domain.
The VAGO review and Commonwealth Fund survey both suggest that on the whole, we are not doing too badly. However clinical governance includes continuous improvement, and continuous improvement in clinical governance is an embodiment of this principle. We can be proud of winning bronze, however as prudently asserted by Stephen Duckett, it also means we must improve. Clinical governance is a living process that should be lived, continuously.
Links reviewed on 15/02/2024
‘Clinical Governance: Health Services: Independent assurance report to Parliament.’ Victorian Auditor-General’s Office, 24 June 2021.
Delivering high-quality healthcare: Victorian clinical governance framework.’ Safer Care Victoria, June 2017. Accessed on 15/8/2021 at: https://www.bettersafercare.vic.gov.au/publications/clinical-governance-framework
NSQHS Standards, Australian Commission on Safety and Quality in Health Care, accessed on 15/8/2021 at: https://www.safetyandquality.gov.au/standards/nsqhs-standards
‘Mirror, Mirror 2021: Reflecting Poorly. Health Care in the U.S. Compared to other High-Income Countries.’ Fund Reports, August 4, 2021. Accessed on 15/8/2021 at: Mirror, Mirror 2021: Reflecting Poorly | Commonwealth Fund
S Duckett. ‘How does Australia’s health system rate internationally? This year it wins bronze.’ The Conversation, 12 August 2021, accessed on 15/8/2021 at: How does Australia's health system rate internationally? This year it wins bronze (theconversation.com)