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 Clavary Clinical Governance Framework (the Framework) sets out the key structures, systems and processes that enable organisation-wide accountability for the delivery of high quality, safe care.


Calvary – Clinical Governance Framework 2017


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

Calvary has in place a robust Clinical Governance Framework made up of the following elements:

Local and national processes that manage clinical risk, quality and safety

  • Incident management policies and procedures for the identification, notification and investigation of clinical incidents, risks and near misses
  • Policies and procedures based on best available evidence
  • Regular review and update of policies and procedures as part of a robust document management system
  • Policy and processes for whistle-blowers – “Speak-out”

Systems to support ongoing improvement of clinical effectiveness

  • Clinical quality & safety indicators are used to routinely monitor clinical quality and effectiveness at local and national level
  • Clinical quality and safety indicators are benchmarked nationally and externally
  • All incidents are investigated for opportunities for improvement
  • All serious clinical incidents are fully investigated and recommendations reported to the Board
  • Quality and performance indicators are reported to the Calvary Board
  • All services are fully accredited

Ensuring workforce capability to support clinical quality

  • All staff undergo comprehensive induction including the Calvary Code of Conduct (729 kB)
  • Implementing robust processes for credentialing, including registration checks and scope of practice review
  • Providing competency based education and training for all staff

Partnership with consumers and the community

  • All Calvary services have been assessed against ACSQHC Health Service Standard 2: Working with Consumers
  • Consumer complaints and feedback are welcomed and management targets are established for response and review
  • Open disclosure policies and procedures exist

Calvary supports a culture of open and transparent partnership with consumers and the community

The information provided on this site is to ensure that the communities Calvary serves have access to information about the quality of services provided.