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.

The Clinical Governance Assessment Tool for Boards 

The Clinical Governance Assessment Tool for Boards (the tool) has been developed to assist Board members and Executives to assess their level of functioning in relation to key clinical governance concepts. 

If you would like more information about the tool, see our Clinical Governance Assessment Tool for Boards fact sheet or contact systemsafety@safercare.vic.gov.au.

Clinical governance training and support

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

View our events calendar to find the full list of training programs offered by SCV and register for a session. 

Performance reports and data

Health data is an important part of a clinical governance toolkit which informs the Board, CEO and Executives about health services performance and steers clinical governance activities. The Victorian Agency for Health Information (VAHI) have 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

If your health service has been impacted by an adverse event, review the Victorian sentinel events guide and the adverse event review and response process. 

SCV also facilitates training on the Fundamentals of adverse patient safety event reviews.

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.

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.