Organisaitons providing clinical care to consumers are required to implement a clinical governance framework, the efficetivenss of which is overseen by the Boards who are accountaible for safety and quality across the organisaiton. Fair enough, but where to start and how to manage and maintain the clinical governance system is the hard part.

At OneVault, we help our clients get on top of clinical governance using a number of stategies. One of these is the OneVault recipe for good clinical governance. Here are the main dot points with some key tips:

1. GAP analysis 

Do a gap analysis against each requirement of the Standards. Be brutal. Assume nothing. Assign work to people with the skills and time to complete the task. 

2. RISK analysis

Review your risk register and ensure you look at the clinical and corporate risks. dont forget the risk associated regarding your governance structure.  if the governance and committee structure needs reworking, then do this as a priority. The priority of what work gets done first is based on risk assessment, so start with your high risk areas and work down.

3. POLICY and procedures

Review all policy and procedure against Standards and in according to risk. Yes, policy should be risk rated. This determines how often they need to be reviewed. Ensure your systems of document and version control are robust and that all staff have rapid access to this informaiton. 

4. MONITOR feedback, audits, clinical indicators, incidents and complaints

Review your survey and audit scedule. Make sure you are auditing the 3 core areas. Legislative requirments, Standards requirements and areas of identified high risk. Ensure that exising procedures match your newly reviewed Incident and Feedback policy and if not, update them. Make sure your documentation clearly explains what quality improvements have been linked to audit results, complaints or other feedback. Close the communication loop with staff and share the lessons learnt.

5. QUALITY improvement 

The reason we analyse the incoming information from audit, survey, clincial indicators, incidents, feedback, recommendations and risk analysis is to improve care delivery and reduce risk. Small improvements must be captured and large projects well managed. Track your large QI projects to make sure they actually get completd and deliver improvement, otherwise they will consume time, effort and money for zero benefit. 

6. TRAINING and upskilling

Back to risk...identify the training needs in priority of risk. Like monitoring, there is "must do" training. This includes training to uphold legislative requirements and training to ensure compliance to Standards. It also includes any training needed to address areas of identified high risk. Training for the leadership team is also included in this "must do" space. Do research on what reputable free elearning and information is available online and make the most of it! There aree fantastic resources out there and between the OneVault Learning module and News portal, it takes no time to connect staff to the latest information.

7. COMMUNICATING 

Finally, there is little use doing all this without good communication. This includes providihng meaningful reports to the Board and keeping in touch with the workforce. 

A final word of advice: 

If, as a board member, a director or a manager, you really want to know what is going on....go for a walk, closely observe people,  both those recieveing care and those providing it, talk to these people, look at their living and working environment, imagine yourself as someone being cared for or providng the care and then ask yourself...would it be good enough for me?