An Introduction to the Clinical Care Standards

What are the Clinical Care Standards?

The Clinical Care Standards are a group of 17 evidence-based quality statements that address the expected level of care and outcomes when managing specific health conditions.

They include guidance for both clinicians and health service organisations, and also include expectations for consumers receiving the relevant type of care. Each Standard includes a set of indicators that can be used by health service organisations to support implementation, monitoring and identify areas for improvement.

The aim of the Standards is to set out a baseline standard of care for the delivery of clinical care wherever this care is being provided, and to reduce variation in care outcomes. Broad implementation of the Standards should ensure that:

  • Patients understand the care they’ll be receiving in order for them to make informed decisions;
  • Clinicians and healthcare professionals understand current best practice, and use this to inform their care delivery; and
  • Health service organisations understand how to best support their clinicians and monitor the level of care their patients are receiving.

The National Safety and Quality Health Service (NSQHS) Standards, which must be followed by all public and private hospitals, day procedure services and public dental practices, include actions that support or require the implementation of the Clinical Care Standards.

Who should follow the Standards?

Two of the Clinical Care Standards, Antimicrobial Stewardship and Delirium, are explicitly referenced under Action 3.18 and Action 5.29 respectively of the NSQHS Standards. Compliance with the requirements of these Standards therefore forms a part of mandatory NQSHS compliance for health service organisations.

Advisory AS18/12 also mandates the Colonoscopy Clinical Care Standard for any health service organisation that provides colonoscopy services under Actions 1.23, 1.24, 1.27b, and 1.28a of the NSQHS Standards.

Following the Clinical Care Standards that are relevant to your service is strongly encouraged as best practice, as it supports improved outcomes for patients.  An evaluation report of the impact of the Clinical Care Standards on patient outcomes revealed that 92% of health organisations surveyed who had implemented one of the Standards reported that it improved the quality of care delivered to patients in that care area. Secondary health data sources relating to the Antimicrobial Stewardship, Delirium and Hip Fracture Standards demonstrate a correlation between the release of each Standard and improved outcomes in the respective areas.

Implementation of relevant Clinical Care Standards can help organisations meet their obligations under the NSQHS Standards, in particular Actions 1.01c, 1.27b, and 1.28.

Which clinical care areas are covered?

The following areas have a specific clinical care standard:

  • Acute Anaphylaxis;
  • Acute Coronary Syndromes;
  • Acute Stroke;
  • Antimicrobial Stewardship;
  • Cataract;
  • Colonoscopy;
  • Delirium;
  • Heavy Menstrual Bleeding;
  • Hip Fracture Care;
  • Low Back Pain;
  • Management of Peripheral Intravenous Catheters;
  • Opioid Analgesic Stewardship in acute pain;
  • Osteoarthritis of the Knee;
  • Sepsis;
  • Stillbirth;
  • Third and Fourth Degree Perineal Tears; and
  • Venous Thromboembolism Prevention.

In addition, the Australian Commission on Safety and Quality in Health Care is developing two new Clinical Care Standards, covering Chronic Obstructive Pulmonary Disease and Psychotropic Medicines in Cognitive Disability or Impairment. The Acute Stroke, Heavy Menstrual Bleeding, Osteoarthritis of the Knee, and Colonoscopy Standards are under review.

The Clinical Care Standards in SPP

A number of our health service clients asked us to look at developing self-assessments to implement some of the Clinical Care Standards. So we’ve worked with them to build one for the Antimicrobial Stewardship Clinical Care Standard, which is now available in SPP.

A self-assessment for the Delirium Clinical Care Standard is on the way next, so make sure to keep an eye out for it!

Organisations can use the results from completing each Clinical Care Standard as evidence to support their compliance against their NSQHS requirements.

If there’s a particular Clinical Care Standard you’d be interested in accessing as a self-assessment, we’d be keen to hear from you – just let us know!

Are you up to date with your NSQHS compliance?

Sign up to SPP to check how your organisation performs against the NSQHS Framework.

Victorian social services framework- what’s changing? 

Currently, Victorian social service providers are required to comply with multiple different sets of regulations depending on the services they offer. Ensuring compliance with overlapping registration, reporting and regulatory requirements overburdens these organisations, in some cases requiring duplicate reporting or conflicting requirements between different frameworks.

In order to streamline the various social services frameworks, the Victorian Department of Families, Fairness and Housing recently released a Consultation Draft of the Social Services Regulations 2023. They are designed to provide a single cohesive regulatory framework for all registered social service providers in Victoria. The new framework aims to both increase efficiency of the social service system by simplifying registration and reporting requirements for providers, and improve the safety of Victorian consumers who engage with the social service system. 

When is the new Victorian social services framework coming into effect?

Following the conclusion of the consultation period on July 16 2023, the final version of the regulations is expected to be published in late 2023, with the scheme commencing on July 1 2024.

Who will it apply to?

There are approximately 700 providers operating in Victoria that will be covered by the scheme, including providers of: 

  • child protection services and secure welfare services delivered by the department; 
  • community-based child and family services,  
  • out of-home care services for children and young people;  
  • disability support services; 
  • family violence services, including services for perpetrators;  
  • sexual assault services; 
  • homelessness services; and 
  • supported residential services. 

What are the main features of the new framework?

As a comprehensive scheme, the framework will encompass multiple stages of regulatory compliance, from establishing the requirements for providers, to monitoring compliance. Some of the key features of the framework include: 

  • The Victorian Social Services Standards; 
  • The establishment and appointment of a new, independent Social Services Regulator; 
  • A Worker and Carer Exclusion Scheme; and 
  • Mandatory registration requirements for organisations providing services within the scope of the scheme.

A brief explanation of each of these features is below, however more in-depth information is also available on the Department’s website.

The Standards

The new Victorian Social Services Standards are the core requirements that registered service providers will need to comply with. The six Standards are: 

  1. Safe service delivery  
  2. Service user agency and dignity  
  3. Safe service environment 
  4. Feedback and complaints  
  5. Accountable organisational governance 
  6. Safe workforce 

The Standards are available to view on Page 56 of the Draft Social Services Regulations, for providers looking for more specific details on each requirement.  We’ve also summarised them in a document that you can access after you log in to SPP.  

The Regulator

The new Social Services Regulator replaces the existing Human Services Regulator and will be appointed in the second half of 2023. They will be granted monitoring and enforcement powers to aid their response to any risks of harm in service provision and will be actively involved in checking workers and carers’ suitability against the Exclusion Scheme. 

The Worker and Carer Exclusion Scheme

The Worker and Carer Exclusion Scheme will replace the Victorian Carer Register and act as a safeguard against risks of harm for service users.  Providers wishing to employ workers or carers will need to request the regulator to check each individual against the database to ensure that they do not pose a risk of harm before they are employed.  


Service organisations within the scope of the framework must be registered to confirm the suitability of the organisation itself and its key personnel to provide services to its users. Suitability matters include: 

  • Criminal history;  
  • A history of fraud;  
  • Findings of misconduct; 
  • Whether registration to provide a social service has been revoked, or has had any conditions/sanctions/restrictions placed on it; and  
  • Whether the person/business has been insolvent. 

Registration will also assess a provider’s arrangements, such as their governance structures, insurance and financial capacity, and determine whether the provider and its key personnel have sufficient qualifications, skills and experience to deliver safe and quality services to its users. 

SPP and the new Victorian Social Services Standards

To help you understand all of the requirements and intended outcomes of the new draft Social Services Standards, we’ve built a new self-assessment module in SPP. Of course, if there are any changes made to the final form of the Standards later this year, we will update our module for those changes. 

And for providers who have been using our existing self-assessment module to follow the current Human Services Standards, we have a mapped self-assessment in the new Standards, so that you can quickly compare the two sets of standards and identify any additional areas of work required.

Are you ready for the new Victorian Social Services Framework?

Sign up to SPP to ensure your organisation is prepared to comply with the changes to social service delivery.

NSQHS Accreditation Assessments for HSOs: What’s Changing? 

From July 2023, the National Safety and Quality Health Service (NSQHS) Standards assessment procedure for accreditation of hospitals or day procedure services (Health Service Organisations, or HSOs) will be changing, with mandatory short notice accreditation assessments replacing the existing announced and voluntary assessments.  

Why the change?

The move to short notice assessments is intended by the Australian Commission on Safety and Quality in Health Care (the Commission) to support the continuous implementation of the NSQHS Standards and reduce the administrative burden of preparing for accreditation assessment”.

The new process is designed to move the focus of assessments from preparation for assessment, to assessment of day-to-day practice. It is intended to support and emphasise continuous self-assessment by HSOs of their compliance with the NSQHS Standards, as well as their implementation of continuous quality improvement strategies.

The Commission requires that HSOs have systems and processes in place to keep their self-assessment documentation up to date, and conduct reviews of their self-assessment and their compliance status at least every three months.  

When will we be assessed?

Short notice accreditation assessments will occur: 

  • at least once within each three-year accreditation cycle;  
  • at least 4 months before the HSO’s accreditation expires;   
  • no sooner than 6 months after the previous assessment; and 
  • within 4 years of the previous assessment. 

HSOs therefore need to be ready for an accreditation assessment at any time. HSOs may request up to 20 business days per accreditation cycle to be excluded from assessment. These are days where a short notice assessment would either directly impact the provision of the service to consumers or the consumers of the service would be unavailable.

When will we be given notice of an upcoming assessment?

The notice period for an upcoming assessment will differ depending on the HSO’s location and/or the specific services provided. 

  • If you are an HSO in a metropolitan, rural or regional area with public transport options, you will be given 24 hours’ notice of assessment. 
  • If you are an HSO in a rural or remote area with either no or restricted public transport options, you will be given 48 hours’ notice of assessment.  

For some HSOs where special permissions must be sought to conduct assessment, such as services in some Aboriginal communities, fly-in fly-out services or services operating in prisons, your assessment notice may be up to 4 weeks to accommodate these requirements. 

For more information, see the Commission’s fact sheet, or feel free to contact us if you have any questions about the new assessment changes.

The importance of active, continuous self-assessment

Regular self-assessment of your compliance with the NSQHS Standards will maintain a focus on identifying opportunities to improve your service delivery. It forms an important step in the cycle of active, continuous quality improvement. As well as tracking compliance with each standard, your self-assessment process should also incorporate improvement opportunities that you identify through consumers’ feedback and complaints, and also from any incidents or near misses that occur. 

Ideally, your streamlined self-assessment system should include: 

  • A chronological record of all the compliance gaps and improvement opportunities you identify, and when you’ve addressed them; 
  • The ability to collaborate on and track improvements, including by assigning responsibility for certain tasks to team members;  
  • A compliance status report that you can generate at any point in time; and 
  • The ability to store and link documentary evidence of your compliance with each standard (for example, relevant policies and procedures that are implemented across your organisation).

How SPP can help

Our NSQHS self-assessment modules allow providers to understand the requirements of the Standards in detail, collate all identified improvement opportunities through an individually curated action plan, and review and report on their compliance status at any time.   

They also provide a helpful way to link relevant evidence against each standard, streamlining the self-assessment process and ensuring that your evidence of compliance is kept up to date. 

SPP also has self-assessments for other standards within the National Safety and Quality family, including for: 

  • Digital Mental Health,  
  • Mental Health for Community Managed Organisations, and  
  • Primary and Community Healthcare. 

In addition, SPP provides a deep pool of resources in our Reading Room (such as policy templates and info sheets) covering all aspects of organisational good governance to help HSOs work towards best practice.  

You can find our NSQHS Standards self-assessments in SPP by searching for ‘NSQHS’ in the Standards tab or under the ‘Australian National Standards’ subheading in that same tab. 

Looking for NSQHS resources?

Sign up for a free trial of SPP.

Lessons from the pandemic: how Standards have evolved

We’re now two years into the pandemic, and the care and support sector has had to make some major adjustments to their service delivery in response to the COVID-19 crisis.

A number of standards have been amended or updated with significant new changes, to provide guidance on improving and standardising infection control processes, as well as ensuring that there are processes to manage workforce capacity and disaster readiness.

We’ve updated our self-assessments in SPP to reflect these changes, and thought it would be helpful to summarise the core themes that have emerged across the different major standards.  

Core infection control and disaster response themes

The core themes that have appeared consistently in standards updates include:

  • ensuring the workforce has the capacity, skills, training and equipment to implement infection prevention and control systems,
  • planning for and sourcing an alternative workforce in the event of disruptions,
  • developing, testing and reviewing an emergency and disaster management plan,
  • reporting to the governing body on infection control processes and implementation/testing of the emergency and disaster management plan,
  • testing, fitting and training in the use of PPE,
  • training in hand hygiene, respiratory hygiene and cough etiquette,
  • implementing stringent processes for communicating relevant information to family, patients and carers,
  • undertaking routine environmental cleaning,
  • ensuring workplace policies and procedures are in line with the relevant state or territory public health requirements,
  • managing movement of staff between areas and supporting staff required to isolate, and
  • procedures for waste management including safe storage and disposal of clinical waste.

These are some key areas that service providers should be addressing to ensure they are on top of their compliance requirements. Providers should check that they are familiar with any updates to standards that apply to their organisation. SPP can assist you with this, as we always update the modules on our platform in response to changes to standards.

Here are the main standards that have been updated to incorporate infection control requirements so far:

The updated Standards

National Safety and Quality Health Service Standards (NSQHS)

Changes to the NSQHS were introduced in May 2021 and include requirements to:

  • plan for public health and pandemic risks,
  • ensure the workforce has the capacity, skills, training and equipment to implement infection prevention and control systems,
  • test, fit, train workers and use PPE, and
  • ensure policies and procedures are in line with the relevant state or territory public health requirements.

NDIS Practice Standards

In November 2021 the NDIS Commission released a number of changes to these standards, to address:

  • planning for alternative workforce arrangements in the event of disruptions,
  • developing, testing, and reviewing emergency and disaster management plans,
  • implementing infection prevention and control precautions throughout all settings,
  • ongoing training on and supplies of PPE for workers, and
  • waste management including safe disposal of clinical waste.

QIC Health and Community Service Standards

In February this year, an updated version of the QIC Standards was released, with updates addressing infection control requirements including:

  • staff training in hand hygiene,
  • infection prevention management program aligning with state and territory guidelines,
  • regular cleaning of the environment, and
  • waste management.

Australian Community Industry Standard

The Australian Community Industry Standard was also updated towards the end of last year to include the following infection prevention and control requirements:

  • workplace preparation for pandemic,
  • workforce response to pandemic consistent with advice from health authorities, and
  • implementing and documenting an outbreak management plan.

RACGP Standards for General Practitioners

The RACGP Standards have seen a number of updates throughout 2021 and more recently in 2022, with the most recent update being in February 2022. The updated requirements address:

  • increased requirements around telehealth consultations (e.g. ensuring privacy etc.),
  • managing the risk of cross infection during a home visit,
  • updated processes for isolating patients and traceability processes for identifying patients who have used instruments,
  • establishing protocols for managing outbreaks of infectious disease in line with local, state and national guidance, and
  • environmental cleaning.

Aged Care Quality Standards

While the Aged Care Quality Standards haven’t been updated with new infection control requirements, the Aged Care Quality and Safety Commission has released a number of resources to guide providers in their implementation of infection control requirements. 

Resources to help you

We’ve developed and updated a number of resources in our platform to assist providers to manage infection control requirements under the standards that apply to them, as well as implement best practice processes. Here are some examples of how we can help:

  • a module for the “First 24 hours – managing COVID-19 in a residential aged care facility”,
  • a module to guide organisations to implement COVID-safe operations based on recommendations from Safe Work Australia,
  • a module to guide organisations through the components they should address in developing infection control / respiratory outbreak plan based on recommendations from various sources including the Department of Health, the Aged Care Quality and Safety Commission, and the NDIS Quality and Safeguards Commission,
  • resource templates including:
    • an outbreak management plan checklist,
    • an information sheet for employers on staff vaccination against COVID-19,
    • first 24 hours – managing COVID-19 in a Residential Aged Care facility checklist,
    • an emergency and disaster management plan,
    • emergency and disaster management procedures,
    • working from home policy,
    • working from home agreement,
    • client risk assessment.

Want to take a closer look at our Covid-19 resources?

2021 – that’s a wrap!

It has certainly been a busy year for service providers and compliance professionals in our sector. Providers have been truly tested by the challenges of the pandemic and a changing regulatory landscape. We invite you to reflect with us on the key developments of this past year.

Child safety

In the child safety space, progress has been underway over the last couple of years to implement the recommendations of the Royal Commission into Institutional Responses to Child Sexual Abuse. We published a blog post on this topic in March of this year.

On 1 July 2021, the new Victorian Child Safe Standards were released, bringing these standards into alignment with the National Principles for Child Safe Organisations. Our mapped self-assessment for the Victorian Child Safe Standards is available on SPP.

NSW followed in a similar vein and in November 2021, legislation passed in NSW Parliament mandating compliance with the NSW Child Safe Standards by certain ‘child safe organisations’. The NSW Child Safe Standards, which also map to the National Principles, can be accessed in SPP.

At present, Australian Catholic Safeguarding Ltd is finalising the Second Edition of the National Catholic Safeguarding Standards, and we expect to be providing assessment modules of these standards early in the New Year.

Aged care

The Royal Commission into Aged Care Quality and Safety was the focal point for aged care this year, with some regulatory changes already implemented and others underway.

The Serious Incident Response Scheme (SIRS) brought in new compliance requirements for residential aged care providers in April. Our Incident Management Procedures (Aged Care SIRS) Policy can help get you up to speed on this. In correlation with SIRS, the Aged Care Quality Standards were updated to include a requirement on incident management, and our ACQS self-assessments have been updated accordingly.

Rules around use of restrictive practices changed, with shift in terminology from ‘restraints’ to ‘restrictive practices’, bringing aged care into alignment with disability regulation. Our updated Use of Restrictive Practices (Aged Care) Policy reflects this.

This year we released an educative version of the Aged Care Quality Standards on SPP, based on the Commission’s Guidance and Resources for Providers document, and which walks providers through their requirements in greater depth. We have also released the Board Governance Toolkit, a comprehensive suite of resources designed specifically to support board members to fulfil their responsibilities under the Aged Care Quality Standards.


In late 2021, the NDIS Practice Standards saw their biggest overhaul since their inception. The NDIS Quality and Safeguards Commission identified emergency and disaster management and mealtime management/swallowing problems as key focal areas for additional guidance and regulation, and brought in three new Practice Standards to reflect this. In addition, a number of Quality Indicators were added and amended, reflecting a focus on infection control, staff training, individualised risk assessments and insurance requirements. Our blog post will flesh this out for you.

All changes to the NDIS Practice Standards are available for completion in SPP, and you can choose from mapped or stand-alone modules, depending on your organisation’s needs.

Health care

The National Safety and Quality Healthcare Service Standards (Second edition) were updated in 2021, to include new requirements around infection control. We added two new modules to our NSQHS self-assessment on SPP to address the new Standard 3 – Preventing and Controlling Infections.

The Australian Commission on Safety and Quality in Health Care has also begun releasing a number of new standards, aiming to ensure a consistent approach to safe and high-quality health care across different service environments. In 2021, we added self-assessment modules for the National Safety and Quality Digital Mental Health Standards and the National Safety and Quality Primary and Community Healthcare Standards to SPP, and we will be closely tracking the development of the National Safety and Quality Mental Health Standards for Community Managed Organisations.

During 2021 we also released three new modules for the RACGP Standards for general practices (5th edition). We worked closely together with the RACGP to ensure that all of the standards, criteria and indicators in each module are reflected in detail in SPP’s self-assessments.


ISO standards are popular accreditations amongst our users, and this year we were pleased to add ISO 27001 Information Security Management Systems to SPP. ISO 27001 is an internationally recognised standard that requires organisations to implement an Information Security Management System (ISMS). The Australian federal government requires ISO 27001 certification for all providers of employment skills training and disability employment services, and a number of health and community service providers also choose to follow this standard.

All the best for the holiday period!

The past 12 months have definitely been jam-packed, and we expect 2022 will be just as busy.

We thank you all for your continued collaboration, and from everyone in the BNG team, we wish you a safe and happy holiday season.

See you next year!

Need to get on top of your compliance work?

Access a broad selection of Standards in SPP.

Update on self-assessments for Victorian providers

Along with all of the national standards that are relevant to Victorian community and health services providers, our SPP platform contains a number of Victorian-specific self-assessments, including for the:

  • Human Services Standards,
  • Victorian Child Safe Standards, and
  • VRQA guidelines for VET providers. 

All of our self-assessments are designed to help organisations to:

  • understand their obligations as simply as possible,
  • monitor their compliance status, and automatically generate gap analysis and improvement plans, as well as
  • create compliance reports and evidence packs for reviewers.

In recent months, we’ve added a number of new Victorian self-assessments into SPP across a range of service areas. This blog post features several key Victorian standards which are new to SPP, and outlines some other Victorian standards that we plan to incorporate over the coming weeks.

Family Violence Multi-Agency Risk Assessment and Management (MARAM) Framework

The MARAM framework assists services to ensure that they are effectively identifying, assessing and managing family violence risk. The framework sets out key principles and elements that should be embedded into policies, procedures, service delivery and practice, and identifies the responsibilities of various organisational areas and staff across the system.

The MARAM framework is supported by a number of resources and tools to guide organisations through their relevant responsibilities under the Framework.

Our self-assessment contains links to the relevant guides, templates and tools, to assist your organisation with implementation of the framework.

Victorian Complaint Handling Standards

These standards are intended to strengthen and improve complaint handling across the health sector, as well as provide consistency for consumers, complainants, health service providers and other stakeholders.

Applies to all Victorian health services

All health services in Victoria are required to meet the complaint handling standards, which came into effect in June 2020.

Self-assessing in SPP

We have incorporated these standards into SPP to assist providers with understanding and meeting their requirements. Self-assessing against the standards will guide organisations through the steps to ensure an effective complaints management system is in place. 

Healthcare that counts framework

The Healthcare that counts framework articulates the role of health services in the early identification of, and effective response to, vulnerable children at risk of child abuse and neglect. 

It promotes collaborative partnerships across all sectors working with vulnerable children and families, to ensure that responsibility for ensuring children’s safety and wellbeing is shared.

Who does it apply to?

All Victorian health services are expected to embed the action areas and performance indicators outlined in the framework into their organisational governance and continuous quality improvement processes, and undertake an annual self-assessment to measure their progress against the framework.

How can SPP help?

We’ve add into SPP a self-assessment for the Healthcare that counts framework, which will enable providers to measure their implementation of, and progress against, the standards.

The self-assessment includes the five action areas to guide improvement, as well as indicators of best practice. Completing the self-assessment will assist health services to improve, sustain and monitor their responses to vulnerable children.

Domestic Violence Victoria Code of Practice

The DV Victoria Code of Practice is designed to enhance the safety of women and children in Victoria, with a model of best practice for services that provide a specialist response to women and children experiencing family violence. 

We are hoping to progress a self-assessment for the Domestic Violence Victoria Code of Practice shortly, so that this can be available in the coming weeks. 

Community Services Quality Governance Framework

The Community Services Quality Governance Framework outlines the principles, domains, roles and responsibilities of quality governance and includes measures of success, and indicators of poor performance.

It is designed for use across a wide range of community services.

We will be adding a self-assessment for these standards into SPP within the next couple of months.   

Need help in other areas?

Our sole focus is to continue to build self-assessments and resources that will simplify and streamline the standards compliance and quality improvement processes of community and health service providers.

Please get in touch if you have suggestions for other resources and self-assessments that could make your life easier!

Sign up for a free trial

You can access these self-assessments and many more in the SPP platform.

Streamlining the general practice accreditation process

We are excited to have released new self-assessments in SPP for all three modules of the RACGP Standards for general practices (5th edition).

Quality and safety for health services

The RACGP Standards were developed by the Royal Australian College of General Practitioners (RACGP) “with the purpose of protecting patients from harm by improving the quality and safety of health services.  The Standards also support general practices in identifying and addressing any gaps in their systems and processes.

What is involved?

There are three modules that make up the RACGP Standards for general practice:

  • the Core module;
  • the Quality Improvement module; and
  • the General Practice module.

We’ve worked together with the RACGP to ensure that all of the standards, criteria and indicators (both mandatory and aspirational) in each module are presented in SPP’s self-assessments.

How do our self-assessments help?

Our three new self-assessments reflect all of the detailed requirements of the RACGP Standards for general practices, as do SPP’s Standards Reports of compliance status with each module. 

Health services can use the self-assessments to:

  • ensure that team members understand all of the requirements of the RACGP Standards;
  • monitor their current compliance status;
  • maintain an up-to-date gap analysis, that identifies areas of non-compliance; and
  • automatically generate a continuous quality improvement plan for the standards, at any time.

They can also assign specific responsibilities to certain team members, and prepare for general practice accreditation by linking evidence of compliance throughout the self-assessments.

Who can use the self-assessments?

Many regional and community health providers deliver a broad range of services to their community – including GP clinics, disability and aged care services, family support, and alcohol and other drug support services, to name just a few.

As a result, they may need to comply with a variety of service delivery standards.  These providers can save lots of time and effort by streamlining all of their compliance work in our platform. 

Already, a number of regional health services and Aboriginal health services have chosen to integrate the new RACGP self-assessments into their other standards compliance and quality improvement work in our SPP platform.

However, our self-assessments are equally helpful to any general practice, or other health service following the RACGP Standards, who wishes to access an online self-assessment platform where they can streamline their general practice accreditation compliance, quality improvement and evidence collation processes!

Want to know more?

Please contact us at, or phone 02 9569 1704, for any queries relating to these new self-assessments, or to enquire about accessing them.

Sign up for a free trial

You can access these new self-assessments 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. 

You have policies and procedures – but are they being implemented?

A common theme across just about all standards that apply to community and health service providers is a requirement to have appropriate policies and procedures in place in order to:

  • ensure the delivery of safe and high-quality services to clients, and
  • meet the governance and quality management requirements of the standards and legislation that applies to them.

But having policies and procedures in place is only the first step.  Even more important is that the policies and procedures are specific to the services and operations of each individual provider, and that they are understood and followed by all workers.

We’ve reviewed a number of recently published audit reports, and we’ve also had some discussions with auditors, and it is clear that some providers fall short along the way to actually implementing their policies and procedures across their organisation.  The consequences of this can be very serious, ranging from unprepared or ill-informed workers, through to the delivery of services that have an increased risk profile, or that are unsafe.

For example, in one recent audit it was found that while the provider had an open disclosure policy and risk framework policy, workers were not consistently following procedures in relation to risk management and incident and feedback identification, and so these were not effective.

In another audit, a provider was found to be non-compliant in their medication management.  Despite the provider having a policy for medication management, workers demonstrated poor practices, including leaving medication out and not keeping them secured. Additionally, despite the service having an incident reporting system, many workers appeared to not use or be aware of the system.

In a number of cases, auditors have reviewed providers’ policies to find that they didn’t even refer to the correct organisation, or the specific services delivered by that provider.  A very early indicator to an auditor of a shortfall between documentation and implementation!

So, how can providers improve the consistent implementation of relevant and appropriate policies and procedures across their organisation?

We’ve set out below some key principles that should be followed.  As well as a couple of key actions.

The policies and procedures must reflect how your particular organisation operates, the services you deliver, and the types of clients to whom you provide services 

  • Auditors report that policies often fail to reflect the practices of the organisation and the skill base of the staff.  Your policies need to be relevant to your organisation and the needs of your consumers.  When tailoring policies to your organisation, consult with consumers, other relevant stakeholders and your workers, to ensure that they reflect the needs and rights of consumers as well as the capabilities and expected practices of workers.

    Policies and procedures also need to address and meet the specific requirements of the legislation and service standards that apply to your organisation, so ensure you refer to and understand the relevant legislation and service standards that apply.  Ensuring that policies and procedures reflect how your organisation operates means that they will underpin consistent practices and service delivery across the whole organisation.

Ensure that staff have read, and understand, your organisation's core policies and procedures 

  • Auditors have provided feedback that organisations often fail to adequately communicate policies and procedures to staff.  You should ensure that each worker reviews, considers and acknowledges their understanding of policies.  To ensure that staff have read and understood them, you can distribute a core pack to each worker containing the relevant policies and procedures, and then structure discussion sessions so that they understand what these mean in practice.  You could maintain a record that each worker has acknowledged receipt of, and read and understood the core pack, for example:

     “I, [insert name here], confirm that I have read and understand the organisation’s policies and procedures relating to (e.g. Client rights, medication management, complaints management, Code of Conduct, incident reporting etc).

    Policies and procedures should be easily available to staff on an ongoing basis, so that they can re-familiarise themselves with them as needed.

Boards play an important role in implementation 

  • Board members play a critical leadership role in setting expectations for behaviour and organisational culture.  They have a responsibility to ensure that policies and procedures are in place, so that all aspects of the business are functioning in line with their purpose and objectives.  Board members should create a culture of review and understanding of policies and procedures.  They need to periodically evaluate the policies that are in place, and be alert to the need for new or updated policies.

Policies and procedures must grow with the organisation 

  • The organisation’s policies and procedures should reflect its sense of identity, its approach to service delivery and the standards it expects of all workers – and these policies and procedures must also be living documents.

    They must be reviewed and updated regularly, to take into account changes to or expansion in services provided, experience from incidents and near misses, as well as feedback and complaints.  Auditors often find that as organisations grow, sometimes their policies and procedures do not adapt to reflect these changes and growth.  Organisations can then find themselves providing certain supports that their policies and procedures don’t address.  It is important for senior management and the governing body to review and update policies regularly throughout the year, so that they reflect any changes.  A good way to implement this is to incorporate a review of policies into regularly scheduled meetings.  

Reinforce policies and procedures through training 

  • Auditors have also found that staff are often not provided with regular refreshers of policies and procedures, some of which may have been amended or updated.  In addition to new staff receiving training on policies and procedures, six monthly refreshers could be scheduled (and records of attendance kept), to ensure that all staff remain familiar with current policies and procedures and are trained on any new requirements, for example for any new or specialised service delivery.

The delivery of consistent, safe and high-quality services does not just depend on having policies and procedures in place for your organisation.  You must ensure that they reflect the services that you currently provide, how you provide those services, and that they are understood and followed by all workers.

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