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.
Clinical Governance Toolkit
The Clinical Governance Toolkit is an essential resource for implementing or refining clinical governance practice. It compiles key resources to help health services implement the Victorian Clinical Governance Framework within their organisation.
Clinical governance self-assessments
Aligned to the Victorian Clinical Governance Framework, our self-assessment tools allow Victorian health services to determine and strengthen their clinical governance. Together, they provide a complete view of organisational clinical governance from top to bottom.
Clinical Governance Maturity Matrix
The Clinical Governance Maturity Matrix supports Victorian health services to evaluate and enhance their clinical governance maturity. It provides guidance on identifying strengths and areas for improvement across the organisation.
This comprehensive self-assessment matrix is supported by practical resources and tools to guide implementation, planning, and continuous improvement.
Learn more about the maturity matrix
Clinical Governance Leadership Health Check
The Clinical Governance Leadership Health Check helps health service boards and executives to:
- undertake a self-assessment of their clinical governance leadership practices
- identify insights and focal areas to improve their clinical governance leadership.
Learn more about the health check
Foundations of Clinical Governance for Boards and Executives
The Foundations of Clinical Governance for Boards and Executives program aims to strengthen the co-leadership of clinical governance which enables boards, CEOs and executives of Victorian health services to support the delivery of high-quality care.
Foundations of Clinical Governance Part 1: Roles and Responsibilities
- Recognise the Victorian Clinical Governance Framework, and the five clinical governance domains
- Be able to clearly articulate the practical relevance of clinical governance in their organisations
- Have explored the differences between roles and responsibilities to effectively co-lead clinical governance in their organisations
Foundations of Clinical Governance Part 2: Quality Committee Simulation
- Recognise Safer Care Victoria’s Safety Culture Conceptual Framework, its importance in healthcare settings and how safety culture influences good clinical governance
- Be confident in identifying gaps in safety and quality data.
- Be able to define their roles and responsibilities in implementing sentinel event recommendations to effectively co-lead clinical governance in their organisations.
For more information 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.
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.