Clinical governance framework

Reliable, safe and effective care

Calvary is committed to delivering excellence in care and providing the highest possible levels of patient, resident and client safety. The Calvary clinical governance framework sets out the key structures, systems and processes that enable organisation wide accountability.

The framework and focus of our clinical governance systems is to ensure excellence across the continuum of care for our patients, residents and clients.

The framework

The framework is comprised of five key areas:

1. Leadership and culture

High-quality healthcare requires engaged clinicians and patients. Visible, accountable and purposeful leadership at all levels of a service is required to cultivate an inclusive and just culture that will make engagement a reality.

A strong organisational culture is required to support leaders and staff to create and maintain high-quality care.

2. Consumer partnership

At Calvary, an outstanding patient, resident and client experience is underpinned by a genuine commitment to partner with our consumers to enable us to understand and meet their needs, expectations and wishes. Central to this partnership is involving our consumers in their care decisions and the planning, design and evaluation of our care and services.

We include consumers in key organisational governance committees at both local and national levels to benefit from their input and feedback in areas such as safety, facility design and quality improvement.

3. Workforce

An engaged and appropriately skilled workforce is central to the delivery of safe care and achieving excellent clinical and care outcomes at Calvary. The Calvary workforce is comprised of staff who are employed by the organisation, together with medical practitioners and allied health practitioners, with whom we partner in caring for our patients.

4. Risk management

Minimising and safeguarding against clinical risk requires a structured approach to safety that is both proactive and reactive. Clinical risk management strategies and processes are integrated with broader governance within Calvary to identify, monitor, review and mitigate risk.

5. Clinical practice

All services maintain the appropriate operating licenses against relevant service standards. Calvary uses evidence based guidelines to inform and direct the delivery of care and reduce unwarranted care variation.

Data and analytics are used to develop a comprehensive understanding of our clinical performance and to inform opportunities for continuous system, process and practice improvement.

We transparently monitor performance against meaningful key performance indicators and targets, cascading through all levels of the organisation.

Data sources and definitions

How we measure clinical quality and safety

In July 2014, Calvary undertook a comprehensive update of our clinical incident information systems to ensure that our data complied with the most current incident definitions and standards.

Here are the definitions and sources of data used to calculate our clinical safety and quality indicators:

Term/reference	Definition
Infection rate Staphylococcus aureus Bacteremia (SAB)	Numerator Number of healthcare acquired SAB infections identified in multi and same day patients Denominator 10,000 Occupied Bed Days Benchmark 0.87/10,000 Occupied Bed Days Reference AIHW 2014. SAB in Australian public hospitals 2013–14: Australian hospital statistics. Health services series no. 59. Cat. no. HSE 155. Canberra: AIHW.
Hand Hygiene	Numerator Number of observed (audited) hand hygiene moments that are associated with appropriately performed hand hygiene Denominator Number of hand hygiene moments observed Benchmark 85% Reference Hand Hygiene Australia
Patient falls	Numerator Number of patient/resident falls Denominator 1,000 Occupied Bed Days Benchmark 3.5/1,000 Occupied Bed Days Reference There is no Australian recommended rate for hospital falls. An “industry rate” 3.5/1000 Occupied Bed Days has been used, based on the references below: - Victorian Quality Council (2006). Evaluation of the effectiveness of the “Minimising risk of falls and fall-related injuries guidelines for acute, subacute and residential care settings”. Falls rates vary between 2 and 7 per 1000 Occupied Bed Days in acute settings. - National Database of Nursing Quality Indicators (NDNQI) in the USA. Falls – approx. 3.6 per 1000 bed days - Institute for Clinical Systems Improvement (ICSI). Prevention of falls (acute care). Health care protocol. Bloomington (MN): 2010 Apr. In 2007, Massachusetts publicly reported average rates of 3.57 falls/1,000 Occupied Bed Days in hospitals of 200-299 beds, and 4.76 falls/1,000 Occupied Bed Days in hospitals over 500 beds.
Medication incidents	Numerator All medication errors Denominator 1,000 Occupied Bed Days Benchmark <5 / 1,000 Occupied Bed Days Reference Clinical Excellence Commission NSW (2013) clinical incident management Jul-Dec 2013