Our clinical governance framework
The Notting Hill Day Hospital has developed a comprehensive clinical governance framework based on an integrated approach to clinical risk management and continuous quality improvement. This framework measures four major areas of organisational performance including:
Clinical risk management:
- Our culture promotes and encourages staff to report incidents, risks and near misses.
- Our incident management policy outlines the process for assessing and investigating incidents.
- Clinical policies are developed in accordance with evidence-based best practice.
- Clinical, risk and safety policies are reviewed on a regular basis and updated as required.
Clinical effectiveness:
- Quality and safety indicators are used to measure and monitor performance.
- Quality plans are initiated when significant issues are flagged.
- Quality and safety indicators are benchmarked nationally.
- Serious clinical incidents are reported to VIC Health.
- Medical practitioners are represented on the Medical Advisory Committee, Clinical Practices Committee and Senior Medical Group.
- High-risk areas are audited on a regular basis.
- Quality performance and safety issues are reported to the Audit & Risk Committee.
- All facilities meet the standards for accreditation.
Competent workforce includes:
- A comprehensive recruitment program.
- A strict process for checking credentials, registration and scope of practice for all clinical disciplines.
- Having a comprehensive orientation for new staff and medical practitioners that includes quality and risk systems.
- Having targeted education and competency requirements in all clinical areas.
Consumer participation includes:
- Involving consumers to evaluate marketing material, forms, patient flow, procedures and clinical processes.
- Consumers participating in our risk management and quality improvement activities.
- The review of the complaints and feedback processes, including patient satisfaction surveys, to ensure they are managed in a timely way and that results are fed back to senior management.
- Open disclosure between medical practitioners and consumers is actively promoted.
