Governance & Performance
What is Clinical Governance? | Governance Frameworks | Embedding Safety and Quality Systems in Mental Health | Clinical Risk Management Systems | Incident Investigation and Reporting | Performance & Benchmarking | Area Quality Improvement | Contact Details
What is Clinical Governance?
Clinical Governance is defined as:
"A systematic and integrated approach to assurance and review of clinical responsibility and accountability that improves quality and safety resulting in optimal patient outcomes."
The primary goal of Governance & Performance (GaP) is to work with Area Mental Health services to embed safe quality practices across all areas of mental health service and care delivery. Our vision is to ensure that no matter where you work in mental health, governance policies and practices are standardised.
Governance Frameworks
Key Frameworks include the WA Clinical Governance Framework [PDF], which promotes a complete, integrated approach to clinical responsibility concentrating on the 4 Pillars of Clinical Governance [PDF / 1.37MB]. Since 2002 the Office of the Chief Psychiatrist clinical review process, which is designed to monitor the standards of psychiatric care, was modified and set within a Clinical Governance Framework. This process includes the four-pillar model developed by the Office of Safety and Quality, and the Department of Health (DoH), Office of the Chief Psychiatrist CG Review Framework [PDF / 111KB].
The WA Strategic Plan for Safety and Quality in Health Care (2003-2008) [PDF] provides an overview of the strategic framework for promoting the delivery of safe, consumer focused, quality health care in Western Australia.
The Evaluation and Quality Improvement Program (EQuIP) initiatives are important tools for providing high quality and safe health care. The ACHS EQuIP Cycle has recently been updated and the EQUIP 4th Edition includes associated linkages to the National Standards for Mental Health Services (1996).
Establishing safe and quality systems supports the North Metropolitan Area Health Service’s Vision, Purpose and Values.
Embedding Safety and Quality Systems in Mental Health
Key Achievements achieved in implementing and establishing clinical governance systems within mental health include:
Safety Quality & Risk Management Committees
Area Mental Health has established the Safety Quality & Risk Management Committees (SQRM committee) at local & program levels to assist with implementing clinical governance systems. Guidelines [PDF / 92KB] and Terms of Reference [Word / 456KB] have been developed and standardised across the area to support these processes.
Mental Health Area Governance Policy
The North Metropolitan Area Health Service Mental Health area governance policies are subject to a standardised process to ensure consistency in policy management, development, implementation, evaluation and compliance. For further information about Mental Health please read Guidelines for Management of Area Governance Policy and Procedure [PDF / 516KB]. The development of these Area Mental Health guidelines further supports North Metropolitan Area Health Service Governance Policies.
- Guidelines for the Development of NMAHS Governance Policies [PDF]
- Whole of Health Policies (Requires Access to DoH Intranet Website)
Clinical Risk Management Systems
Clinical Risk Management is the third pillar of the WA Clinical Governance Framework and concentrates on minimizing clinical risk and improving overall clinical safety. Clinical Risk Management Guidelines for the Western Australian Health System [PDF].
Incident Investigation and Reporting
AIMS is the system used to report incidents in healthcare. It was implemented state-wide in July of 2001. Reporting within the AIMS reporting process is protected by qualified privilege. (What does this mean? Does it mean that the identities of people who report incidents are protected?) For further information about recent changes to AIMS, see AIMS - Incident Reporting [PDF].
Sentinel Events may signal serious breakdowns in health care systems and require immediate investigation and response. Notification should be made via the Sentinel Event Notification Form (Word [71KB] and PDF [63KB] versions of Notification Form) and RCA Management Flowchart [PDF / 26KB].
The GaP team supports Area Mental Health services by helping to carry out Root Cause Analysis [PDF] of sentinel event investigations. Clinical Investigation Standards [PDF] that have been designed to identify the gaps in hospital systems and the processes of health care.
Performance & Benchmarking
Reporting of Key Performance Indicators to NMAHS Safety Improvement & Risk committee (SIR) [PDF]; Mental Health Executive Group, ACHS [PDF / 118KB].
Area Quality Improvement
Rationale
The formation of the Area Mental Health Service presents an exciting challenge.
The area mental health service governs 41 sites that provide health care. Due to the expansion of the area mental health service, it will be impossible to report meaningfully to ACHS and achieve accreditation if we take the “traditional” site-based approach. An area-wide, evaluation and quality improvement program will strengthen the reliability and validity of evaluations, facilitate data-oriented benchmarking and partnerships, and support our claims to best practice or evidence-based practice. If we conduct area-wide evaluations against the EQuIP criteria, this will support our area-wide commitment to meeting the ACHS standards and criteria.
The establishment of the Safety Quality & Risk Management Committees presents an opportunity to re-engineer our approach to Evaluation and Quality Improvement and demonstrate effective, transparent Governance.
Contact Details
The Manager
Governance and Performance
C/o Shaw House
Private Bag No 1
Claremont Western Australia 6010
Phone: (08) 9347 6911
Email: NMAHS, MH Governance & Performance
File Formats
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