Standard 8 - Requirement (3) (c)
Effective organisation wide governance systems relating to the following:
i) information management
ii) continuous improvement
iii) financial governance
iv) workforce governance, including the assignment of clear responsibilities and accountabilities
v) regulatory compliance
vi) feedback and complaints
Intent of this requirement
Organisation wide governance is about how the organisation applies and controls authority below the level of the governing body. Authority flows from the governing body to the Chief Executive Officer (or similar role), then, to the executive or management team and throughout the organisation. This requirement lists the key areas that an organisation needs for effective organisation wide governance systems. These systems should take into account the size and structure of the organisation. They should also help to improve outcomes for consumers.
The key areas for organisation wide governance systems are:
a. Information management
Effective information management systems and process give appropriate members of the workforce access to information that helps them in their roles. It also makes sure consumers can access information about their care and services. These systems cover how an organisation maintains, stores, shares and destroys information and how it controls privacy and confidentiality. Information that supports consumers to make decisions should be relevant and accurate and provided in a timely manner.
b. Continuous improvement
Continuous improvement systems and processes assess, monitor and improve the quality and safety of the care and services provided by the organisation. This includes the experiences of consumers. These systems help the organisation to identify where quality and safety is at risk. They also help an organisation to respond appropriately and promptly to these risks. Organisations must have a plan for continuous improvement and check their progress against this plan to improve the quality and safety of care services.
c. Financial governance
Financial governance systems and processes manage the finances and resources that the organisation needs to deliver safe and quality care and services. Organisations are expected to include the capital and revenue costs of maintaining safety and quality in their financial planning. Effective financial management and reporting systems give the governing body the assurance they require to be satisfied of compliance with this requirement.
d. Workforce governance – including assigning clear responsibilities and accountabilities
Workforce governance systems and process make sure workforce arrangements are consistent with regulatory requirements. They also need to make sure the organisation has enough skilled and qualified members of the workforce. The organisation must support and develop its workforce to deliver safe and quality care and services. Members of the workforce need to have clear responsibility and accountability for managing the safety and quality of care and services, and sufficient authority to do this.
e. Regulatory compliance
Regulatory compliance systems and process make sure the organisation is complying with all relevant legislation, regulatory requirements, professional standards and guidelines. This requirement doesn’t measure how an organisation complies with other legislative frameworks, but provides an understanding of whether the organisation itself undertakes this task.
f. Feedback and complaints
Feedback and complaints systems and processes actively look to improve results for consumers. The system used is relevant and proportionate to the range and complexity of care and services the organisation delivers, as well as its size and scale. The system follows principles of transparency, procedural fairness and natural justice and meets best practice guidelines.
- Does the organisation have a documented whole-of-organisation governance framework, which includes personal and clinical care if delivered?
- Does the governance framework focus on strategic needs?
- Does the organisation have systems to monitor and evaluate how they perform against strategic and other objectives for safe and quality care and services?
- Does the organisation support a culture of evaluation that includes transparency, openness and a two-way sharing of information and advice across the organisation?
- If services are not performing at peak level, does the organisation move resources to ensure appropriate consumer outcomes?
- Does the organisation use regular reviews and evaluation to identify new needs and tackle current continuous improvement priorities?
- How do the organisation’s risk and responsibility systems and processes include ethical decision-making in the organisation?
- Where the organisation uses services from other specialist providers, are the different levels of responsibility for governance and monitoring clear to everyone?
Examples of actions and evidence
- Consumers say the organisation asks for their opinions about the care and services, listens to them and makes improvements as a result.
- Consumers say they are confident their care and services are well managed.
- Consumers say the organisation has made changes when something has gone wrong to prevent it happening again.
- Consumers say they can review information on the safety and quality of care and services the organisation delivers.
Workforce and others
- Management of the organisation can describe their role in developing governance frameworks to support the governing body’s strategies for safe, inclusive and quality care and services.
- The workforce can describe how the organisation supports openness, discussion, engagement, respect, trust and a culture of good governance.
- The workforce can describe how they take part in activities that identify, measure and evaluate problems within the organisation and in the care and services it delivers to consumers. They can also describe how improvements are made.
- Members of the workforce are clear on their authority to make decisions to meet the strategic or planned objectives of the organisation. They say policies that inform decisions are easy to understand and accessible to all members of the workforce.
- Members of the workforce can describe how the organisation makes sure the processes in their particular areas are efficient and effective. They say the organisation prevents, responds to and manages risks appropriately.
- Workforce orientation, training or other records that show how the organisation supports the workforce to meet this requirement.
- Evidence of systems and processes, from the care and service level through to the governing body level, for managing and governing all aspects of care and services.
- Performance monitoring records given to the governing body show whether the organisation is performing at peak level and meeting its policy, planning and operational goals.
- Committee and meeting records show management of the organisation and the governing body have information, data and options to make informed decisions.
- Evidence of policies and instruments of delegation that make it clear to the workforce, and help them to understand, the organisation’s compliance and other obligations.
- Evidence of continuous improvement across the organisation.