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    Victorian Clinical Governance Framework

    The Victorian Clinical Governance Framework helps providers to:

    • understand the clinical governance roles and responsibilities within their organisation
    • evaluate their clinical governance systems and processes
    • ensure individual and collective accountability for high quality care.

    View the framework >

    Clinical governance capability building and support

    We regularly run targeted clinical governance capability sessions for Boards and Executives of Victorian health services.

    See below for a full list of clinical governance capability programs. For more information on any of the programs email culture.capability@safercare.vic.gov.au.

    Clinical Governance Health Check  

    The Clinical Governance Health Check supports Boards and Executives of health services to understand and consider their clinical governance capability, maturity, and readiness to consistently deliver high quality healthcare The results of the assessment can be used to guide your improvement journey.

    For more information or to access the Clinical Governance Health Check, email culture.capability@safercare.vic.gov.au.

    Victorian Safety Culture Guide

    The Victorian Safety Culture Guide supports healthcare Boards, CEOs and Executives in assessing and monitoring their organisation’s safety culture using various methods commonly available in most Victorian health services. 

    Safety culture is crucial for improving patient care, staff wellbeing and overall organisation performance. Measuring and monitoring safety culture is vital for preventing harm. Senior health care leaders are key to fostering and maintaining a positive safety culture. 

    View the safety guide >

    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. 

    Morbidity and Mortality Framework

    We developed a framework and toolkit to guide Morbidity and Mortality (M&M) meetings. This will provide health services with a systems-based approach to the M&M case reviews and discussions.

    Using the framework and toolkit in M&M meetings will help health services to:

    • improve the quality and consistency of M&M meetings
    • improve staff psychological safety in meetings
    • develop stronger recommendations to improve quality and safety of care.

    View the framework >

    Credentialing policy obligations 

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

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