8.2 Clinical governance

8.2 Delivering clinical governance

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

The practice ensures processes are in place to deliver the four core elements of clinical governance:

  • patient engagement and participation
  • clinical effectiveness
  • quality improvement/patient safety
  • an effective and engaged workforce

Documented clinical governance activities:

  • Clinical governance meeting agendas and minutes.
  • Clinical governance quality plan, including goals and quality activities. 
  • Practice population experience survey results demonstrate consumer engagement. 
  • Explain the methods used to obtain feedback from all groups in the patient population (including Māori and under-represented groups).

Clinical governance structures and processes need to always ensure the following core elements are present:

  • Patient engagement and participation
  • Clinical effectiveness; including equitable outcomes
  • Quality improvement/patient safety/ infection control
  • Engaged, effective workforce

Patient engagement and participation

Better understanding and talking with the people that visit your practice will help target the services you provide and improve equitable health outcomes. Collaboration can be directly with patients, whānau or families, or with community organisations that represent, support, or serve practice populations. It is especially important to engage with Māori and other underserved or marginalised groups in your enrolled population.

Examples of consumer engagement and participation includes:

  • Patient feedback (review complaints register, positive feedback, patient experience survey results)
  • Approval and oversight of progress on clinical aspects of the Māori health plan
  • Oversight of any co-design activities being considered/implemented with patients/community
  • Oversight of shared decision-making processes undertaken in collaboration with patients/families (written and verbal consent, shared care plans)

Some ideas for achieving authentic patient feedback may include:

  • Appointing patient representatives from a range of diverse groups to feed back to the practice via an organised bulk email communication. If you don’t have this set up already then Mail Chimp is a good, free service.
  • Practices may invite a few patients from a range of diverse groups to attend a patient advisory group that meets, for example, every three to six months.
  • Patient feedback forums could happen where practices select six patients and their whānau for regular catered meetings.
  • Social media platforms, for example Google review, Facebook, Instagram or other fitting sites allow practices to capture informal feedback.


It’s important to ensure that advice, feedback and information gathered during discussions with collaborators is considered when developing or configuring services, and that feedback on what is being done as a result is shared with collaborators. Some ways of doing this are through newsletters, the practice website, flyers on the front desk, or notices in the waiting area  It's also important to ensure patient experience information such as complaints, compliments and adverse events are collected, analysed and reported by ethnicity.

Dr Liam Watson
Dr Liam Watson loves the challenge and variety of working rurally.

Patient surveys

When choosing a survey, the aim should be to capture feedback from a broad range of people, including Māori and other underserved or marginalised groups in order to get a full representation of the patient population. Practices need to consider the delivery method and also whether the survey will return the information they need.

One survey option is the primary care patient experience survey (PES). The PES is used to understand patients’ engagement in primary and secondary care. Although it is very comprehensive and includes how a patient’s overall care is managed between their general practice, diagnostic services, specialists, and/or hospital staff, the length can discourage patients from completing it.

Some considerations when selecting a survey:

  • Is it online only, if so, how will patients who do not have reliable access to the internet complete the survey?
  • The length and time needed to complete it.
  • The relevancy of the questions.
  • Whether it is available in different languages.

Practices can use a variety of methods to obtain patient feedback, ideally this process is a continuous one and is managed by the clinical governance team member.

However, at a minimum, practices need to distribute a patient experience survey at least annually. Depending on the patient feedback collected, a practice may decide to re-survey again in six months to test any changes made from previous feedback.

Changes to services resulting from patient feedback

The practice needs to inform patients and the general practice team about changes to services resulting from patient feedback.

Results from the survey can be communicated to patients through tools such as a practice newsletter, practice website, flyers on the front desk, or notices in the waiting area.

Major changes to the service such as hours of opening or seasonal additions such as influenza clinics could be advertised in the public notices of the local or community newspapers.

Feedback to the practice team can occur at meetings, and via notices on the intranet, team noticeboards, team communication book, etc.

Clinical effectiveness

  • Oversight and approval of clinical policies.
  • Oversight of infrastructure important to clinical services (for example, existing and new technology, PMS, medical equipment).
  • Take part in the design and implementation of infection prevention and control systems.
  • Reducing variation in clinical practice (equitable approaches including for Māori health and utilising best practices and evidence based care).
  • Ensure classification lists in PMS are reviewed at least annually.
  • Oversight of all clinical audit activities.
  • Oversight of medicines reconciliation including test results.
  • Review of recall activities (immunisation, screening) to identify effectiveness in reaching eligible target populations.

Quality Improvement/patient safety/infection control

  • Learning from adverse events, trends, excellence and risk management (oversight of incident register, monitor actions, approve formal reports from serious event review, oversight of clinical risk register, make recommendations for improvements, share learnings).
  • Oversight of any Continuous Quality Improvement (CQI) activities (includes approval of new projects, review of progress and measures, and supporting processes/decisions).
  • Take part in the design and implementation of infection prevention and control systems within the practice.
  • Approval and oversight of progress and input into the practice’s quality plan.
Dr Vanisi Prescott and her daughter dance for a TikTok
Dr Vanisi Prescott and her daughter dance for a TikTok

Effective engaged workforce

An effective engaged workfoce involves:

  • Employing team members who reflect the practice population.
  • Training needs that are tailored for individual team members in accordance with the overall training goals of the practice.
  • Team members who are encouraged to develop skills to support Māori and under-served groups within the practice population.
  • Processes for the induction of all team members. 
  • Ensuring advice is available to confirm roles and responsibilities meet the clinical needs of the practice. 
  • Guaranteeing safe staffing: for both short term leave and planning for longer term practice needs.