Information for governing bodies*

This guidance should be read in conjunction with Quality Standard 2 which relates directly to the governing body*.

The governing body* plays an important role in aged care and services. They’re responsible for an organisation delivering quality care* and services (Outcomes 2.2 and 2.3).

The governing body* needs to:  

• supervise provider activities
• lead a culture of safety, inclusion and quality
• help identify and address issues.

It is important the governing body* puts in place processes* to check the organisation’s strategies for delivering tailored care and services meet each older person’s needs, goals and preferences*.  This includes monitoring the organisation’s performance, such as by reviewing reports on:

• how they’re delivering clinical care and services
• how they’re managing complaints*, feedback* and incidents* (Outcomes 2.5 and 2.6)
• the quality of care and services workers* are delivering. For example, through quality assurance or system* reviews (Outcome 2.8).

Make sure the organisation has a culture of safety, inclusion and quality by monitoring and investigating areas you find in the organisation’s reports you can improve. Identify opportunities and make recommendations to your organisation to improve its culture of safety, including quality care*. Provide feedback* and support to the provider.  

You also need to monitor the performance of any associated providers*.

If you find any issues or ways you can improve, you need to address them.  If things go wrong, you need to:

• practise open disclosure*. This means being open about what has gone wrong. Share this information with older people, their supporters and others they may want to involve, such as family and carers*
• have strategies to reduce the risk of things going wrong again.

The provider guidance for Outcome 2.3 has more information on open disclosure*.

Effectiveness of this Standard is reliant on the systems and processes from Standards 1-7.

Standard 2 provides detailed information for governing bodies*.  

Key tasks: 

Outcome 5.1 is closely linked with Standard 2. The governing body* sets and leads the governance* structure and processes*, culture and direction of the organisation. It communicates the organisation’s priorities for improving the quality of clinical care* services to workers* and older people. Good clinical governance* also links to all other outcomes in Standard 5.  

The governing body* should put in place and maintain systems* to communicate the organisation’s priorities and strategic directions for safe and quality clinical care* services to older people and workers*.    

As a governing body*, you need to (Outcome 5.1):  

• approve a clinical governance* framework. Publish it and include it in strategic plans and the overall governance* systems* of the organisation.
• manage the clinical governance* framework. Include systems* that reflect the size and how complex the organisation is to:  
  • set priorities for achieving person-centred*, safe, coordinated and effective clinical care* services  
  • define roles and responsibilities* for delivering and coordinating clinical care* services  
  • work with older people, their supporters, family, carers* and workers* to design care and services
  • keep records, analyse and report on internal and external clinical safety and quality data. This should include feedback* from older people and others involved in their care*
  • make sure the organisation uses contemporary, evidence-based practice*
  • identify and manage clinical risk
  • assess and keep improving clinical care* service quality by collecting data on key focus areas for the provider. This could include older people’s level of satisfaction in how the provider supports their care goals.  
• monitor, review and improve clinical care safety and quality.  

Governing bodies* must monitor how effective the organisation’s clinical governance* systems* are. You need to oversee the provider’s service by assessing regular reporting on care and services from provider management, such as:  

• reviewing services’ clinical performance and outcomes and using these to check how they’re performing, and find ways to improve the quality of care*
• monitoring how providers respond to complaints*, feedback* and incidents*, including if people receiving care and their supporters are happy with the open disclosure* processes*
• reviewing organisational self-assessment tools to collect information on clinical governance* arrangements and find any gaps in the clinical governance* framework that you need to address
• using data and reporting to identify what the organisation’s key priorities are to improve the clinical care* services they’re providing
• making sure the governing body* includes members that have the skills and knowledge to manage, monitor and improve the safety and quality of clinical care* services  
• making sure governing body* members understand what their role and responsibilities* are for monitoring, reviewing and improving person-centred*, safe, coordinated and effective clinical care* services  
• reviewing the governance* structure, role descriptions and contracts for:  
  • the board and associated committees  
  • management  
  • health professionals*
  • other workers*.  

This is important as it makes sure that each person’s responsibility for safe and quality care* is clear for workers* at all levels.

Governing body* members need to be trained in clinical governance* so that you can carry out your role and supervise management’s role. Organisations may choose to develop a skills matrix or framework. This should list the ‘must have’ skills, knowledge and behaviours governing body* members, and the governing body* as a whole, need to have.  

Standard 2 provides detailed information for governing bodies*.   

You can find more resources about the role of the governing body* and governance* in the Quality Standards Resource Centre.

The Commission developed the Governing for Reform in Aged Care Program to support the key recommendations of the Royal Commission into Aged Care Quality and Safety. The Program supports governing body* members, leaders and emerging leaders to strengthen corporate and clinical governance* capabilities and enact critical reform.