A presentation given by Sonya Preston at The Journey, CHA Conference 2012, in the 'Delivering Safety & Quality: Innovations in Clinical Governance' stream.

1. Clinical Governance
within a Community Child
and Youth Health
Nursing Context
Presentation by Sonya Preston
on Wednesday 24 October 2012

2. Clinical Safety and Quality
Governance Framework
in Hospital and Health Services
 Sets out the fundamentals of a
framework
 Provides guidance on establishing the
systems, processes and behaviours
Reference: Queensland Health. 2012. Clinical Safety and Quality Governance
Framework in Hospital and Health Services. State of Queensland (Queensland Health).

3. Four High Level Elements
 Planning for Safety and Quality
 Action for Safety and Quality
 Balanced Monitoring for Safety and Quality
 Appraisal, Learning and Action for Safety
and Quality
Reference: Queensland Health. 2012. Clinical Safety and Quality Governance Framework in
Hospital and Health Services. State of Queensland (Queensland Health).

4. Planning
for
Safety and Quality

5. Planning for Safety & Quality
Clinical Governance Plan developed, implemented
& monitored
Operational plan reflects safety & quality objectives
90 Day action plans include quality initiatives and
risk mitigation strategies
KPI’s measure quality & safety processes and
outcomes

6. Planning for Safety & Quality
PAD processes monitor implementation of safety
and quality objectives.
Service agreements are inclusive of safety &
quality processes
Clinicians engaged in determining the safety &
quality priorities for the service through monthly
processes that identify local risk priorities.

7. Planning for Safety & Quality
All services are supported by IHW to ensure culturally safe
services & facilitate consumer engagement leading to future
planning processes.
Clinical governance implementation progress is tabled
quarterly utilising traffic light system.
Investment in safety culture through implementation of
quality & safety training initiatives such as Caps,
(Communication and Patient Safety) PRIME CI & CF (Patient
Risk Information Management and Evaluation Clinical Incident
& Consumer Feedback), TMS (Team Management Systems)

8. Planning for Safety & Quality
Identified the key service challenges within
strategic plan by monitoring trends through safety &
quality reporting systems.

9. Action
for
Safety and Quality

10. Action for Safety & Quality
Each role description includes duties,
responsibilities & accountabilities that reflect a safety
culture.
Organisational structure supports delegation of
accountabilities associated with quality & safety.
Safety & Quality Committee established with a
comprehensive committee structure.

11. Action for Safety & Quality
Implementation of a clinical incident management
process.
Application of the clinical service capability
framework
Consumer feedback & complaints management
process
Implementation of clinical audit & review process

12. Action for Safety & Quality
Registration, Credentialing & Scope of Practice
processes for regulation compliance.
Mortality & morbidity review
Critical incident review committee
Clearly defined delegations regarding safety &
quality decision making within service

13. Action for Safety & Quality
Service agreement clearly identified responsibilities
for safety & quality.
Safety & Quality Committee effectiveness is
reviewed annually
Key performance indicators are reported monthly
utilising traffic light process
Key performance indicators are identified through
service re-design processes.

14. Action for Safety & Quality
Identified integrated risk management procedure
All project plans, business cases and issues
papers include a risk management plan.
All staff have access to training on risk
management

15. Balanced Monitoring
for
Safety & Quality

16. Balanced Monitoring for Safety & Quality
Actively monitor key performance indicators and
compare against other like service benchmarks.
Measurement of clinical quality is achieved through
the implementation of clinical performance
assessment tool
Formalised case conferencing and peer group
supervision is undertaken within each service

17. Balanced Monitoring for Safety & Quality
Ensure compliance with accreditation bodies and
National Standards.
Internal clinical auditing including scheduled and
spot audits.
Clinical practice reviews undertaken and service
intervention based on scientific knowledge.
Waiting timeframes monitored and minimisation
strategies implemented.

18. Balanced Monitoring for Safety & Quality
LEAN thinking strategies implemented at all service
levels
Both lead and lag indicators are identified to
determine risk management processes
Review of data collection and auditing processes to
ensure usefulness of data.

19. Balanced Monitoring for Safety & Quality
Targeted clinical audits that are meaningful to the
clinical service provision
Ensure appropriate sampling and data
measurements.

20. Appraisal, Learning
and Action
for
Safety & Quality

21. Appraisal, Learning and Action for Safety & Quality
Monitor compliance against the Hospital & Health
Service readiness report in 12 months.
Thoroughly investigate potential areas of concern
such as issues identified in practice reviews,
complaints and risks.
Implementation of education and training

22. Appraisal, Learning and Action for Safety & Quality
Cultural practice training by Aboriginal & Torres
Strait Islander consumer
Escalation for reporting outcomes and risks
Implemented plan do check act cycle to ensure
actions & priorities are incorporated into planning
cycle

23. QUESTIONS