Clinical governance

Clinical governance describes the systems, processes, leadership and culture that helps us to deliver safe healthcare.

This page contains resources to help health services achieve good clinical governance and meet their legislative requirements. 

The Victorian clinical governance framework

The Delivering high-quality healthcare: Victorian clinical governance framework helps health services to:

• understand the clinical governance roles and responsibilities within the health service
• evaluate their clinical governance systems, processes, and reporting mechanisms 
• ensure individual and collective accountability for high quality and safe care.

Clinical governance training and support

Safer Care Victoria regularly runs targeted training sessions for Board members on clinical governance. Register your interest in attending the program.

See below for a full list of current clinical governance training programs and to register for a session check the events calendar or email culture.capability@safercare.vic.gov.au.   

The Clinical Governance Assessment Tool for Boards  

To ensure its use in assisting Boards and Executives to assess their level of functioning and maturity in relation to key clinical governance concepts, the Clinical Governance Self-Assessment Tool for Boards and Executives (the tool) is currently under review. 

For more information about other clinical governance improvement opportunities at your health service, please contact culture.capability@safercare.vic.gov.au.

Performance reports and data

Health data is an important part of a clinical governance toolkit that informs the Board, CEO and executives about health service performance and steers clinical governance activities. The Victorian Agency for Health Information (VAHI) has developed a series of short videos on data interpretation. 

VAHI release a variety of health service performance reports (guide here) including the Board Quality and Safety Report and the Monitor. 

Adverse events

For support in managing the impact of an adverse event in your review, refer to the following resources: Victorian sentinel events guide and the adverse event review and response process. 

SCV also facilitates interactive training sessions on adverse patient safety event reviews, which includes the Fundamentals of adverse patient safety event reviews and Just Culture. See below for the full suite of available and upcoming adverse  training or email culture.capability@safercare.vic.gov.au for more information. 

Credentialing policy obligations 

Our Credentialing and scope of clinical practice for senior medical practitioners policy helps you ensure medical and dental practitioners are qualified, competent, and operating within their scope of practice.

Senior medical practitioners and dentists

Practitioners must maintain professional standards in their area of practice and disclose any personal, legal or professional conditions or restrictions.

Public hospitals

Public hospitals must ensure all medical and dental practitioners they appoint, and retain, are qualified, competent, fit and operating within their scope of practice.

Private hospitals

Safer Care Victoria encourages private hospitals to make all new appointments in accordance with this policy.

Department of Health

The Department of Health website covers a broad range of information for health service Boards and Executives to undertake their broader governance responsibilities including governance resources and regular governance education events. Contact the Health Service Governance Unit at the Department of Health for current resources and opportunities at healthservicegovernance@health.vic.gov.au. 

The Institute of Healthcare Improvement

The Institute of Healthcare Improvement (IHI) resources, including the White Paper: Framework for Effective Board Governance of Health, outline practical clinical governance activities for Boards. 

Reporting your quality and safety activities

Safer Care Victoria provides guidance to health services on transparent reporting of performance and improvement work. 

All public health services and registered community health services submit an annual quality account. Reporting requirements have resumed following a pause in 2019-20 to support health services to respond the pandemic.  

Read the latest guidance.