Clinical Governance Framework

Clinical Safety and Quality

Click here to download a pdf copy the MHPH Clinical Governance Framework.


Policy Statement

Monash House Private Hospital is committed to delivering excellence in quality care and providing the highest possible levels of patient clinical safety. We understand that working in partnership with our patients, consumers and stakeholders will ensure a positive experience for all people in our care. Our commitment to clinical safety and quality is based on a robust foundation of systems and process that:

  • Ensure that open and transparent processes are in place to support the identification and reporting of clinical safety risks and opportunities for improvement
  • Foster an organisational culture that seeks to learn from error and continuously improve the quality and safety of our care
  • Support our staff to consistently deliver high quality reliable care
  • Incorporate processes for working in partnership with our clinicians, consumers and the wider communities we serve.

The Clinical Governance Framework sets out the key policies, systems and process that enables organisational wide accountability for the delivery of quality care. All Monash House Private Hospital services are externally audited by appropriate agencies.

The Monash House Private Hospital Clinical Governance Framework is made up of the following elements:

  • Robust processes that manage clinical risk, safety and quality
  • Systems that support the identification, notification and investigation of all clinical incidents, risks and near misses
  • Policies and procedures that support a culture of open disclosure
  • Committees and processes to drive quality improvement and improve clinical effectiveness
  • Workforce capability building strategies that support quality care, including competency-based education and training for all staff
  • Credentialing processes that incorporate registration checks and scope of practice review
  • Routine measurement and review of clinical safety and quality indicators and transparency of information for consumers
  • Consumer complaints and feedback management that ensures transparency and respect.

Monash House Private Hospital has built a culture of clinical safety and quality that is based on an open and transparent partnership with consumers and the key stakeholders. It is through these partnerships, supported by strong leadership, clinical engagement and appropriate use of technology that Monash House Private Hospital will continue to deliver highly reliable quality care and clinical safety.

Monash House Private Hospital is committed to delivering excellence in care and providing the highest possible levels of patient safety. The Clinical Governance Framework sets out the key structures, systems and processes that enable organisation-wide accountability for the delivery of high quality, safe care.

An effective system of clinical governance that operates at all levels of the organisation is essential to ensure continuous improvement in the safety and quality of care. Good clinical governance makes certain that there is accountability and creates a ‘just’ culture that is able to embrace reporting and support improvement.
Working in partnership with our patients and their families and carers is central to identifying safety and quality issues and the solutions that must be implemented.

The goal of Monash House Private Hospital Clinical Governance Framework is to drive behaviours, both individual and organisational, that lead to better patient care and outcomes.

The National Model Clinical Governance Framework (ACSQHC) defines Clinical governance as:

Clinical governance is the set of relationships and responsibilities established by a health service organisation between its state or territory department of health (for the public sector), governing body, executive, clinicians, patients, consumers and other stakeholders to ensure good clinical outcomes. It ensures that the community and health service organisations can be confident that systems are in place to deliver safe and high-quality health care, and continuously improve services.

Clinical governance is an integrated component of corporate governance of health service organisations. It ensures that everyone – from frontline clinicians to managers and members of governing bodies, such as boards – is accountable to patients and the community for assuring the delivery of health services that are safe, effective, integrated, high quality and continuously improving.

As a component of broader systems for corporate governance, clinical governance involves a complex set of leadership behaviours, policies, procedures, and monitoring and improvement mechanisms that are directed towards ensuring good clinical outcomes. The clinical governance system of a health service organisation therefore needs to be conceptualised as a system within a system – a clinical governance system within a corporate governance system.

Under this model, it is important to recognise the following:

  • Clinical governance is of equivalent importance to financial, risk and other business governance
  • Decisions about other aspects of corporate governance can have a direct effect on the safety and quality of care, and decisions about clinical care can have a direct effect on other aspects of corporate governance, such as financial performance and risk management
  • Governing bodies are ultimately responsible for good corporate (including clinical) governance
  • Governing bodies cannot govern clinical services well without the deep engagement of skilled clinicians working at all levels of the organization.

Corporate governance responsibilities:

Components of the Clinical Governance Framework

The Clinical Governance Framework is based on the NSQHS Standards (2nd ed.) – in particular, the Clinical Governance Standard and the Partnering with Consumers Standard. The Clinical Governance Framework has five components. The central component relates to patients and consumers, who are at the centre of the Clinical Governance Framework.

The five components are as follows:

  1. Governance, leadership and culture – integrated corporate and clinical governance systems are established, and used to improve the safety and quality of health care for patients
  2. Patient safety and quality improvement systems – safety and quality systems are integrated with governance processes to actively manage and improve the safety and quality of health care for patients
  3. Clinical performance and effectiveness – the workforce has the right qualifications, skills and supervision to provide safe, high-quality health care to patients
  4. Safe environment for the delivery of care – the environment promotes safe and high-quality health care for patients
  5. Partnering with consumers – systems are designed and used to support patients, carers, families and consumers to be partners in healthcare planning, design, measurement and evaluation; elements of this component include – clinical governance and quality improvement systems to support partnering with consumers – partnering with patients in their own care – health literacy – partnering with consumers in organisational design and governance.

 National Model Clinical Governance Framework

Clinical governance roles

Good clinical governance provides confidence to the community and everyone who works in a health service organisation that systems are in place to support the delivery of safe, high-quality health care. Within a well-governed healthcare organisation, everyone, including frontline clinicians, managers and the governing body, is accountable for their contribution to the safety and quality of care delivered to patients. These roles are as follows:

  1. Patients and consumers participate as partners to the extent that they choose. These partnerships can be in their own care, and in organisational design and governance.
  2. Clinicians work within, and are supported by, well-designed clinical systems to deliver safe, high-quality clinical care. Clinicians are responsible for the safety and quality of their own professional practice, and professional codes of conduct include requirements that align with the Clinical Governance Framework.
  3. Managers (including clinical managers) advise and inform the governing body, and operate the organisation within the strategic and policy parameters endorsed by the governing body. They are primarily responsible for ensuring that the systems that support the delivery of care are well designed and perform well.
  4. The governing body is ultimately responsible for ensuring that the organisation is run well and delivers safe, high-quality care. It does this by establishing a strong safety culture through an effective clinical governance system, satisfying itself that this system operates effectively, and ensuring that there is an ongoing focus on quality improvement.




In addition to these roles, state and territory departments of health provide centralised and coordinated oversight of the performance of health service organisations and create a common set of safety metrics that report meaningful safety and quality outcomes. Implementation of an organisation’s clinical governance system involves contributions by individuals and teams at all levels of the organisation.


Governance, leadership and culture

The roles and responsibilities for this component of the Clinical Governance Framework relate to the establishment of, and participation in, corporate and clinical governance systems.

Role Responsibilities

Patients and consumers:

  • Use organisational systems and processes to contribute to the planning, design and operation of the health service organisation
  • Identify opportunities for improvement of the health service organisation and communicate these to relevant individuals or bodies
  • Consider taking an active role in the governance of the health service organisation, when opportunities exist.


  • Actively take part in the development of an organisational culture that enables, and gives priority to, patient safety and quality
  • Actively communicate their profession’s commitment to the delivery of safe, high-quality health care
  • Model professional conduct that is consistent with a commitment to safety and quality at all times
  • Embrace opportunities to learn about safety and quality theory and systems
  • Embrace opportunities to take part in the management of clinical services
  • Encourage, mentor and guide colleagues in the delivery of safe, high-quality care
  • Take part in all aspects of the development, implementation, evaluation and monitoring of governance processes.

Managers (including clinical managers):

  • Actively communicate the commitment of the health service organisation to the delivery of safe, high-quality care
  • Create opportunities for the workforce to receive education in safety and quality theory and systems
  • Model the safety and quality values of the health service organisation in all aspects of management
  • Support clinicians who embrace clinical leadership roles
  • Lead the development of business plans, strategic plans, and organisational policies and procedures relevant to safety and quality
  • Integrate safety and quality into organisational plans, policies and procedures
  • Set up effective relationships with relevant health services to support good clinical outcome.


  • Staff at Monash House Private Hospital take responsibility for promoting the health, safety and security of patients and carers, the public, colleagues and themselves and to contribute to a positive patient experience.
  • Are encouraged to suggest and implement improvements in their wards, areas and departments.
  • All staff are expected to work within their scope of practice.

Patients and carers:

  • Patients and carers in partnership with their healthcare providers, are responsible for participating in shared decision making about their treatment and can promote quality by raising concerns about the safety or effectiveness of the care they are receiving.
  • Patients and carers are encouraged to tell us about their experience and suggest improvements to our services.


Australian Commission on Safety and Quality in Health Care. National Model Clinical Governance Framework. Sydney: ACSQHC; 2019.