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Clinical governance is the term used to describe a systematic approach to maintaining and improving the quality of patient care within a health system. It is about the ability to produce effective change so that high quality care is achieved. It requires clinicians and administrators to take joint responsibility for making sure this occurs.

When clinical governance is effective, it has the potential to:

  • make positive changes you want to see happen
  • improve the quality of care for patients
  • provide a better experience for staff.

Clinical governance programs and services

The Mental Health Branch (MHB) has a number of clinical governance programs, services and initiatives that address quality and safety issues, risk management, continuous improvement, workforce development and work with key stakeholders at committee level.

Liaison with Official Visitors Program

The MHB provides liaison with the Official Visitors Program including development and implementation of policy resulting from the programs activity as it relates to quality and safety within the mental health service system.

Official Visitors are appointed by the NSW Minister for Health to visit people in mental health inpatient facilities in NSW and are available to assist consumers on community treatment orders.

They aim to safeguard standards of treatment and care, and advocate for the rights and dignity of people being treated under the NSW Mental Health Act 2007. They make regular visits to all inpatient psychiatric facilities across NSW, talk to patients, inspect records and registers, and report on the standard of facilities and services.

Clinical risk management

Clinical risk management is an ongoing and core component of work undertaken within MHB. It involves ongoing monitoring of clinical risk through review and assessment of clinical incidents and 'root cause analysis' reports submitted by local health districts about these incidents.

A clinical incident is any unplanned event resulting in, or having the potential to harm a patient. A root cause analysis is a process used to review and analyse an incident seeking to identify as far as possible all contributing factors leading to the incident and to identify corrective actions to minimise risk of recurrence.

In healthcare, as in any industry, sometimes things go wrong. Equipment can fail, systems can prove inadequate and errors of judgment are made. In relatively very few cases, serious incidents occur that might have been prevented and some of these result in harm to patients.

The majority of these incidents are not the result of a single action by an individual. More commonly, they are generated by a chain of events. Preventing error depends on identifying the deficiencies in the sequence of events and fixing any identified problems.

It is crucial to capture all the relevant information about an incident, investigate all of its causes and to take decisive action to protect patients from a recurrence of that kind of event.

Clinical risk management within MHB supports:

  • improvements in the safety and quality of the healthcare experience for consumers of mental health services in NSW
  • the systematic management of mental health related clinical incidents and risks at the state-wide level, including identifying issues and policy directions, and recommending priorities for action
  • the work of major committees and inquiries which seek to improve the quality of mental health care in NSW Health, including but not limited to the Clinical Advisory Council, the Reportable Incident Review Committee and the Mental Health Priority Task Force.

Clinical Incident Review Committee

The Clinical Incident Review Committee is a local functional component of the MHB and supports the work of this committee.

The Clinical Incident Review Committee is responsible for reviewing clinical incidents that occur within the mental health setting. The committee provides a collaborative and structured approach at a state-wide level to the analysis of clinical incident reports.

The role of committee members is to provide clinical expertise and advice in relation to analysing root cause analysis reports which have a mental health and/or drug and alcohol focus, and to assist in the identification and resolution of associated issues.

Current as at: Tuesday 6 July 2021
Contact page owner: Mental Health Branch