Organisational policies, procedures understand the clinical performance of its and protocols organisation, among other things. (Standard 1, Item 1.1: Implementing a Good clinical governance requires strong strategic governance system that sets out policies, and cultural leadership of clinical services. The procedures and/or protocols) board should focus on: The board, through the senior executive, is reviewing plans providing cultural leadership; • responsible for ensuring the organisation maintains ensuring the appropriate allocation • a comprehensive set of organisational policies and of resources; associated procedures and protocols, and reviews these regularly. These need to: ensuring there is appropriate delegation; • provide direction for the operation of maximising staff engagement; • • the organisation; using data and information effectively to • address clinical safety and quality; and monitor and report on performance across the • health service organisation, to the governing be consistent with the regulatory obligations • body; and of the organisation, board and executive. ensuring well-designed and integrated • The board should delegate responsibility to systems are in place for identifying and management for the development and maintenance managing clinical risk.2 of the policies and associated procedures and protocols. The board may seek confirmation of the The board should comprise people with an use and effectiveness of these policies, procedures appropriate mix of skills to fulfil its governance roles, and protocols through reports and require responsibilities and accountabilities. The board may management to take timely action where there are also seek input from appropriately skilled breaches in compliance. individuals. Board roles Board roles Endorse the system for policy Define the vision, mission and values of • • development and review. the organisation, with particular emphasis on patient-centred care Ensure a comprehensive set of • principles and practices. policies and associated procedures and protocols are developed Prioritise and allocate time at board • and implemented. meetings to review clinical governance and to ensure the effectiveness of the Ensure a system exists to • systems that are in place. review compliance with the policies. Ensure board and senior organisation’s • members’ of clinical executives’ knowledge governance is current through access to training and education opportunities. Clinical governance (Standard 1, Item 1.1: Establishing and maintaining a clinical governance framework) The Australian Securities and Investment Commission (ASIC) identified a key duty of boards what your company is For health as ‘know doing’.1 service organisations this requires the board to
Organisational policies, procedures and protocols (Standard 1, Item 1.1: Implementing a governance system that sets out policies, procedures and/or protocols) The board, through the senior executive, is responsible for ensuring the organisation maintains a comprehensive set of organisational policies and associated procedures and protocols, and reviews these regularly. These need to: • provide direction for the operation of the organisation; • address clinical safety and quality; and • be consistent with the regulatory obligations of the organisation, board and executive. The board should delegate responsibility to management for the development and maintenance of the policies and associated procedures and protocols. The board may seek confirmation of the use and effectiveness of these policies, procedures and protocols through reports and require management to take timely action where there are breaches in compliance. Board roles • Endorse the system for policy development and review. • Ensure a comprehensive set of policies and associated procedures and protocols are developed and implemented. • Ensure a system exists to review compliance with the organisation’s policies. Clinical governance (Standard 1, Item 1.1: Establishing and maintaining a clinical governance framework) The Australian Securities and Investment Commission (ASIC) identified a key duty of boards as ‘know what your company is doing’.1 For health service organisations this requires the board to understand the clinical performance of its organisation, among other things. Good clinical governance requires strong strategic and cultural leadership of clinical services. The board should focus on: • reviewing plans providing cultural leadership; • ensuring the appropriate allocation of resources; • ensuring there is appropriate delegation; • maximising staff engagement; • using data and information effectively to monitor and report on performance across the health service organisation, to the governing body; and • ensuring well-designed and integrated systems are in place for identifying and managing clinical risk.2 The board should comprise people with an appropriate mix of skills to fulfil its governance roles, responsibilities and accountabilities. The board may also seek input from appropriately skilled individuals. Board roles • Define the vision, mission and values of the organisation, with particular emphasis on patient-centred care principles and practices. • Prioritise and allocate time at board meetings to review clinical governance and to ensure the effectiveness of the systems that are in place. • Ensure board members’ and senior executives’ knowledge of clinical governance is current through access to training and education opportunities.
Guide-to-the-National-Safety-and-Quality-Health-Service-Standards-for-health-service-organisation-boards.docx