Royal Commission Series: new governance standard

Over the past few weeks, we have been highlighting a number of the Royal Commission’s recommendations, as well as updating you on resources that can help you implement best practices.

Our focus today is on Recommendation 90: New governance standard.

The Royal Commission’s executive summary of its final report emphasised the need to ensure high standards of governance within aged care providers:

“Provider governance and management directly impact on all aspects of aged care. Deficiencies in the governance and leadership of some approved providers have resulted in shortfalls in the quality and safety of care.

“Governance arrangements provide for the systems by which an organisation is controlled and operates, and the mechanisms by which the organisation and its people are held to account. They are set by the leaders of an organisation, in particular the board or governing body. They are implemented by executive leaders and workers who report to those executive leaders. They involve everyone in an organisation.”

In the Royal Commission’s view, the existing governance requirements under the Aged Care Quality Standards “do not provide a sufficiently strong basis for the governance and leadership of aged care providers.”

The Commission's recommendations

Recommendation 90 sets out a proposal for more robust governance requirements to be introduced, to drive improvements to the aged care system.  Key components of the recommendation include requirements that providers:

  • Have governing body members who possess the appropriate mix of skills, experience and knowledge of governance responsibilities, to ensure the delivery of safe and high-quality care by the provider;
  • Have a care governance committee, to monitor and ensure accountability for the quality of all care provided;
  • Seek and receive regular feedback from consumers, their representatives and staff, on the quality and safety of the services they deliver, and ways in which the services could be improved;
  • Have an integrated complaints management system, including regular reporting to the governing body about complaints, any patterns, and underlying reasons for the complaints;
  • Have effective risk management practices in place covering care risks and also financial and other organisation risks;
  • Give particular consideration to ensuring continuity of care in the event of default by contractors or subcontractors; and
  • Have a governing body representative provide an annual attestation that the governing body has satisfied itself that the provider has structures, systems and processes in place to deliver safe and high-quality care.

How can BNG help?

SPP’s existing self-assessment for the Aged Care Quality Standards is an excellent way for providers to better understand the core components of a comprehensive approach to governance.

The self-assessment goes well beyond just listing the requirements of the standards.  It guides providers through the core approaches and processes they should implement in order to achieve best practice across their organisation, and in the area of governance it includes detailed, educative, best practice modules covering topics such as:

  • Organisational structure and accountabilities; governing body recruitment, induction and training; and reporting;
  • Clinical governance;
  • Risk management systems;
  • Financial controls and management; and
  • Performance monitoring and evaluation, and quality improvement.

It also includes modules on client and community feedback and complaints.

All of the modules include downloadable resources such as policy templates, to help providers develop their own policies and procedures.

Towards Best Practice: Clinical Governance self-assessment

We also have a separate self-assessment for Clinical Governance, which is based on guidance from the Aged Care Quality and Safety Commission. It addresses clinical governance at a more granular level and details the processes that should be in place for a clinical governance framework. The self-assessment outlines the roles and responsibilities of all individuals involved in care including the governing body, senior executive team, operational manager, the workforce, health practitioners and consumers.


We have many resources which will assist providers to implement a comprehensive approach to governance across their organisation, including a whole resource topic on “Governance and Management”.  You can find this section in the Reading Room under the heading “SPP Resources by Topic”.

You can also search for other resources using the search bar in the Reading Room. A number of our resources address Recommendation 90, including information sheets and policies covering:

  • Client Feedback;
  • Quality Management and Continuous Quality Improvement;
  • Complaints Management; and
  • Risk Management.

While the governance requirements are yet to be formally implemented, your organisation can get ahead by working through our self-assessments and implementing best practice policies and procedures across the organisation.  

To access these resources, and hundreds more, log in to SPP.

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You can access these governance resources and many more in the SPP platform. 

Clinical governance in aged care – putting the principles into practice

Clinical governance is essential for delivering safe, quality clinical care and good clinical outcomes for each consumer. It provides the organisation with a framework for continuously improving services. At its core, it is about all members of the organisation, at all levels, asking: ‘What went well? What can I be doing better?’. Implementing a clinical governance framework will assist providers to consistently deliver good clinical outcomes for all patients and meet their requirements under various sets of standards.

The requirement for a clinical governance framework is consistent across the major national standards that apply to providers who may deliver clinical services to consumers, including the RACGP Standards for general practices, the National Safety and Quality Health Services Standards and the Aged Care Quality Standards. Although the three standards have different underlying approaches to clinical governance that are specific to their relevant service providers, there is commonality across all three in their focus on key areas including risk management, continuous quality improvement and consumer-centred care.

The Aged Care Quality Standards require aged care services that provide clinical care to demonstrate the use of a clinical governance framework (Standard 8, 3(e)). Standard 8  – Organisational Governance – of the Aged Care Quality Standards requires a clinical governance framework to be in place, which “includes but is not limited to” processes to address antimicrobial stewardship, minimising the use of restraints and practising open disclosure.

To supplement these high level requirements in the Aged Care Quality Standards, and to provide more practical assistance to providers, the Aged Care Quality and Safety Commission has released a number of resources that address clinical governance at a more granular level, and detail the processes that should be in place for a clinical governance framework. The Commission has worked with a number of stakeholders to develop these resources to help providers enhance patient care and safety, allocate resources effectively and work towards continuous improvement.

Roles and responsibilities

Clinical governance encompasses all of the relationships within the service, and the way they work together to deliver safe and high-quality care. A key element of implementing clinical governance in practice is understanding what everyone’s responsibilities are, what they should be held to account for and how you can support them to fulfil their roles. Implementing a clinical governance framework not only assists all stakeholders to understand their roles and responsibilities, but creates an environment where clinical care can thrive because all team members accept responsibility for ensuring effective care.

All stakeholders must be involved in the implementation of the clinical governance framework, from the governing body, which plays a key role in implementing and reviewing clinical governance processes, right down to the consumers who play a role in working in partnership with the organisation.

     ·      Governing Body

The governing body is accountable for clinical quality and safety and the clinical governance arrangements within your service. Governing body members should set a clear strategic direction and organisational culture that drives safety and quality in care. 

     ·      Senior executives

Senior executives are responsible for visibly supporting and implementing the culture around clinical care set by the governing body, as well as reporting against the framework’s KPIs. They assist with ensuring that information, support and opportunities are provided to the workforce to assist them to understand their roles.

     ·      Operational managers

Operational managers must manage the implementation of clinical governance measures and support the workforce in implementing the framework.

     ·      Staff members

All members of the workforce have a role in providing care to consumers. They must prioritise the provision of safe, quality care and services to consumers in everything that they do. 

     ·      Health practitioners

Health practitioners are accountable for delivering clinical care that meets relevant professional standards. 

     ·      Consumers

Consumers themselves play a crucial role in the implementation of a clinical governance framework. Their communication of their preferences for clinical care, engagement with staff in the planning and delivery of their clinical care, and their feedback about their experiences are important elements of the clinical governance framework.

How can we help?

Our new clinical governance self-assessment is based on the resources developed by the Commission, and will assist providers to put in place and monitor the core elements of their clinical governance framework.  It will also help you to ensure that each stakeholder group understands their roles and responsibilities, and contributes to the process.

The self-assessment addresses the following areas:

  • Leadership and culture
  • Consumer partnerships
  • Organisational systems
  • Monitoring and reporting
  • Effective workforce
  • Communication and relationships

Within these areas, the self-assessment also segments the roles and responsibilities of individuals and assesses whether they are appropriately trained and have the competence to fulfil their roles.

Completing the self-assessment will help you implement best practice by identifying any gaps or opportunities for improvement within your organisation’s clinical governance systems and processes.

You can find the new self-assessment in SPP under the Standards tab > Australian National Standards.

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You can access the new clinical governance self-assessment and much more in the SPP platform. 

Contingency planning: the importance of a “Plan B”

It is important that organisations have risk management plans in place to ensure that they are prepared for changes that may affect the operation of their business. Changes could involve internal factors or issues, or there could be external factors that are outside the control of the organisation. Contingency planning is essential for risk management and business continuity. Lack of contingency planning can mean that your organisation is exposed to unnecessary risks, or that it cannot quickly take steps to mitigate or respond to the impacts of certain risks, if indeed they do eventuate.  

With the spread of COVID-19 (novel coronavirus) currently being monitored around the world, it is a good reminder to businesses to have a risk management plan in place. While Australia is currently at low risk from the coronavirus, it is possible that the number of cases will steadily increase. Organisations should consider and plan for changes to the way they do business, that may come about due to the spread of the virus. For aged care facilities, this is particularly important as the virus appears to have more serious consequences for older people. A contingency plan is important for both aged care organisations, as well as other workplaces who may have to accommodate changes to the operation of their business. The spread of the virus may have impacts such as a rise in absenteeism, or requirements for businesses to arrange for some or all staff to work from home.

It is not possible to anticipate all risks that a business faces, however a risk management plan is essential to identify and prepare for potential risks. Anticipating potential risks, and formulating a plan to respond to and mitigate those risks, can help prevent significant loss to productivity. It is important that businesses regularly evaluate, review and update their business continuity plans.

BNG has a number of resources that can assist organisations to identify risks and impacts to their business, and develop recovery or alternative plans that can be implemented.

Risk register and management plan template:

  • This resource guides organisations in identifying risks, prioritising them according to likelihood that they will happen as well as impact if they do occur, and finally creating a recovery plan or a strategy for continuing operations in alternative ways;
  • It guides the organisation through potential risks to do with:
    • Governance and management
    • Legal/ compliance
    • Financial/ funding
    • Human resources
    • Work health and safety
    • Reputation and relationships
    • Operations and service delivery; and
    • Administration and information technology

Business impact analysis template:

  • This template assists organisations to identify which activities are critical to the operation and continuation of the organisation; and
  • it allows them to identify and assess the potential impact that failure of certain operations will have on the organisation.

Business continuity policy:

  • This policy assists businesses in the process for preparing for potential risks and recovering and returning to their pre-incident condition as quickly and effectively as possible.

These documents are all available in SPP:

  • Policy: Business continuity
  • Template: Business Impact Analysis
  • Template: Risk register and management plan

You can access these resources by searching for “business” or “risk” in the Reading Room. 

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