8.1: Clinical governance and leadership

8.1: Clinical governance and leadership

Clinical governance is a combination of activities and relationships that connect governance with management.

Standard - what we'll be assessing on Evidence to provide for assessment

The practice ensures there are clear clinical governance, leadership and equity responsibilities, and processes, reflective of disciplines within the practice team.

  • Clinical governance roles and responsibilities written into job descriptions. 
  • A designated champion for equity with role description. 
  • Clinical governance policy and procedure.

What's clinical governance?

Clinical governance is a combination of activities and relationships that connect governance with management in the four core health areas. It includes much of the positive quality and safety work already underway in general practice, and its flexible framework allows for the adaptation of clinical governance systems within practices of all shapes and sizes.

New Zealand’s Health Quality and Safety Commission (HQSC) have published a guidance document for all health and disability providers in this country which summarises clinical governance as, “An organisation-wide approach to the continuous quality improvement of clinical services. It is larger in scope than any single quality improvement initiative, committee or service. It involves the systematic joining-up of all patient safety and quality improvement initiatives within a health organisation.”

Governance systems have long been established in commercial businesses, but clinical governance in health takes it a step further by adding the four core elements of healthcare.

Practices can adapt the framework to suit the character and construct of their business, for example, large or corporate style practices will have a different way of practising clinical governance to small or solo GP practices.

Roles and responsibilities for the clinical governance member, along with a policy and procedure will assist with defining a practice’s clinical governance system and help their team to achieve the practice’s mission, goals, and values.

GP takes the blood pressure of patient
Dr Ros Wall takes a patient's blood pressure

Clinical governance roles and responsibilities

The four core elements of clinical governance described in indicator 8.2 should give you an idea of which team members would be best suited to which responsibilities. Depending on the size of the practice, there may be one or more people in each role or one person adopting multiple roles.

Signed role descriptions could be included in the HR files of the individual team members or added as an appendix to their original role description.

Equity champion

While equity is a practice-wide responsibility, it's important to designate one practice member or a team of people to drive equity and Māori health initiatives, and consistently provide an equity perspective. An equity champion could be in a leadership role or could be a clinician with a specific passion for equitable health outcomes for all patients. An equity champion is knowledgeable on and advocates for equity in health care.

The equity champion’s signed role description needs to be included in their HR file or added as an appendix to their original role description.

Clinical governance policy

A clinical governance policy and procedure must include:

  • a policy statement
  • identification of a Chairperson
  • Representation on the clinical governance team from the practice team and the inclusion of the equity champion
  • roles and responsibilities of the clinical governance team members
  • description of the frequency of meetings
  • the process for team members to add items to the agenda
  • inclusion of a standing agenda covering core elements of clinical governance (including Māori health, patient safety and quality and effectiveness of care)
  • responsibilities and timeframes for documentation of meeting minutes/summary, including the process for sharing with wider practice team
  • description of the management of the quality plan
  • an actions register, with assigned responsibilities and timeframes.