8.2 Delivering 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

Patient experience is a good indicator of the quality of health services. Strong evidence shows that patients who have better experiences, report being listened to and treated with respect by their health providers and are more likely to follow advice, get follow-up care, and fill their prescriptions.

Consumer and whānau engagement provides a way for patients to make a complaint or give a compliment, up to being involved in co-designing improvement initiatives, or organisational decision-making.

Some common methods used for patient feedback to health services are:

(adapted from Carman et al, 2013)

  1. complaints and compliments
  2. visual satisfaction (happy /sad face touch screen kiosks)
  3. real time feedback
  4. surveys
  5. focus groups and consumer groups
  6. in-depth interviews and collection of patient stories
  7. experienced based co-design of improvement initiatives.


1.Using patient feedback to identify quality improvement activities.

There are several ways to find a quality improvement opportunity:

  • variation between groups, for example, Māori patients reporting worse access to care compared to non-Māori
  • low-scoring questions for your practice
  • comments (from your survey data), complaints or additional sources of patient feedback (see below for group examples).

2. Co- design

To identify what improvement action is needed you may use one of the following approaches:

  • A patient advisory group who contribute ideas on how patients prefer to receive healthcare. This group may have 6 - 8 patients from a range of diverse groups and may meet every three to six months.
  • A focus group would be a similar group but would meet as a one-off to provide feedback on a specific topic. This might include members from your priority populations, such as Māori, Pacific people or disabled people.

Anonymous comment cards. These could be used to ask for specific feedback, for example, ask how people currently receive their test results and whether there are other methods they would prefer.

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

Patient surveys

The primary care patient experience survey (PES) is a good starting point for engaging with patients and most general practices participate in the PES survey every quarter. For more information on PES please refer to our resources below.

Reviewing your patient experience feedback can:

  • Help practices understand what benefits their patients the most and identify further opportunities for improvement.
  • Help maintain strong patient-practice relationship by listening and responding to patient feedback. This encourages patients to seek care when they need it and to remain with the practice.

To show that practice population experience survey results demonstrate consumer engagement, practices should continuously review patient feedback alongside other feedback such as complaints and compliments. Practices should seek patient experience feedback at least annually.

To explain how feedback from all groups in your patient population is obtained, practices can utilise the PES survey feedback report. If using an alternate survey system, such as one designed by the practice, you will need to provide the survey form, method, and final report.

Depending on your response rates for priority groups, you may need to consider other feedback methods, such as a focus group.

Changes to services resulting from patient feedback; closing the loop

The practice should inform patients and the team about changes to services resulting from patient feedback, this could be done through a practice newsletter, practice website, flyers on the front desk, or notices in the waiting area. Feedback to the practice team could occur at meetings, via notices on the intranet, team noticeboards or the team communication book.

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.