Clinical Governance within a Community Child

and Youth Health Nursing Context

Presentation by Sonya Preston

on Wednesday 24 October 2012

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).

Clinical Safety and Quality Governance Framework

in Hospital and Health Services

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).

Planning for

Safety and Quality

Planning for Safety & QualityClinical 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

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.

Planning for Safety & QualityAll 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)

Planning for Safety & Quality

Identified the key service challenges within strategic plan by monitoring trends through safety & quality reporting systems.

Action for

Safety and Quality

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.

Action for Safety & QualityImplementation of a clinical incident management process.

Application of the clinical service capability framework

Consumer feedback & complaints management process

Implementation of clinical audit & review process

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

Action for Safety & QualityService 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.

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

Balanced Monitoring for

Safety & Quality

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

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.

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.

Balanced Monitoring for Safety & Quality

Targeted clinical audits that are meaningful to the clinical service provision

Ensure appropriate sampling and data measurements.

Appraisal, Learning and Action

for Safety & Quality

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

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

QUESTIONS