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Assessment Task 1- Written Activities

Explain how you would define clinical governance.
Clinical governance is a methodical approach to maintaining and improving the quality
of patient care within a health system. It is a term applied to collecting all the activities
that promote, review and monitor the quality of patient care using a systematic and
integrated approach.
Clean governance is the main vehicle by which hospitals are held accountable for
safeguarding high standards of health care (including poor professional performance),
for continuously improving the quality of their services, and for creating and
maintaining an environment in which clinical excellence can flourish.
The activities encompassed by clinical governance are not new. Clinicians have always
been concerned to offer the best standard of care to their patients. Many doctors audit
their personal practice and their patients outcomes and actively pursue their own
professional education and development. As attention to evidence-based medicine is
making relevant information more accessible, clinicians are comparing their customary
practices against effectiveness standards, while medical indemnity organisations and
hospitals work energetically to reduce and manage clinical risk.

Figure 1 Components of clinical governance framework (Courtesy: Victorian clinical governance policy
framework guide)

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Provide a summary of the risk management strategy for NSW Health.

Management of risk in health care should be part of both strategic and operational
planning in clinical and non clinical sector of health care. Risk management should be
considered as an integrated approach when determining clinical practice, equipment
design and procurement, capital development, information technology, contractor
management, workplace health and safety, workforce management, and financial
planning, and all other areas of operation.
To identify the priorities of risk management and quality improvement, the approach to
quality, and the structure of an internal improvement and risk management program,
the organisation should determine:

The priorities of stakeholders

Activities involved in the strategic plan highlighted.
Risk management and improvement activities related to the strategic goals.
Problems identified and/or are reported.
External requirements.
Are there particular clinical areas that need support
Resources available to make improvements and manage risks.
Staff with expertise in quality improvement and risk management.
The greatest risks/Opportunities to the organization and the consequences
associated with them.

Following are few ways in which we can approach risk management and structure to
take:
Who will be responsible for and coordinate the activities and programs?
How will the organisation involve the staff?
How will the organisation communicate its plans for improvement and risk
management to stakeholders?
How will progress be monitored?
How will improvements be monitored?
What body / group / committee will monitor progress and/or improvements?
What tools should be utilised?

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Figure 2 A roadmap for changing culture (Courtesy:The Australian Council on Healthcare Standards (ACHS))

Explain the challenges you currently face with either clinical governance or risk
management within your team.
Risk management, clinical governance and quality improvement are achieved through
team activity. There is no defined way to develop and implement risk management and
clinical governance in your work team.The team should encompass the vision and
goals of the organisation. In a team-oriented environment, everyone contributes to the
overall success of the organisation. Even though individual staff have a specific job
function and belong to a specific department, they are unified with other staff members

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to accomplish the overall objectives. The bigger picture drives their actions and their
function exists to serve the bigger picture.
A team approach can help facilitate:

Achievement of quality improvement targets

Provision of quality service
Organization-wide knowledge
Collaboration in work practices
Transparency in communication
The achievement of desired outcomes and continuous quality improvement within
the organisation.

A team is a group of people working together towards a common goal. Characteristics of

an effective team include:
Members who share a common purpose and goals and are multi-skilled flexible
management
Managers who are facilitators and not just supervisors
The capacity to make decisions which are coordinated and based on expertise and
best practice.
'Team building' is the process of enabling a group of people to reach their goal. Items
that may
Assist organisations during the development and implementation of teams include:
Make time and allow personal space for innovation
Recognise achievements and reward appropriately
Use measurement systems and information management systems that are aligned
with the goals of the team.
Recognise team leaders and encourage constructive interactive behaviour.
Encourage consensus to build ownership of the teams actions and productivity.
One of the most common problem associated with team management is that attempts to
tag on multidisciplinary involvement were often unsuccessful. Today we work in teams
and hence clinical governance and risk management is a multidisciplinary activity. Th
quality of care a patient receives depends on the care of a whole chain of people, and
doctors are just one link in that chain.
Often poor communication skills and considerable variation in hopsitals, nursing staff
who accompany medical staff on their separate ward rounds will testify to the problems
of juggling different decisions made on the same patient. Neglected groups out of hours
staff can result in poor patient care.

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Provide examples of strategies you will put in place to address these challenges,
please identify three strategies
Develop effective leadership
The clinical governance leads for each department or team must be people must be
people who have the confidence of their colleagues and the leadership potential to
provide direction and encourage effective change.
Collaborate
Greater attention must be paid to encouraging closer investment of patients and t
linking primary and secondary care. Quality should be viewed from the patient's
perspective and efforts should be made to incorporate what patient value (for example,
accessibility, information, and communication, interpersonal skills) as well as more
technical professional values of quality of care.
Monitor Progress
The progress should me measured using SMART objectives (Specific, measurable,
achievable, realistic and timely). The more specific the objective, the more likely it is
that improvements will occur.
Explain how you define risk management.
A systems approach to implementing risk management should ensure that risk
management is an integral part of all decision making by providing a framework to
assess and prioritise risks for existing services as well as service planning. A system for
embedding the risk management process is required. Risk Management is the
organisation wide process. It is aligned in their focus on identifying potential problems
and implementing corrective strategies. Intregrating the two program risk management
and quality improvement can increase an organisations ability to minimise errors,
enhance and improve care and services.
The goal of risk management in health care is to:
Minimise the likelihood of possible events that have negative consequences for
consumers / patients, staff and the organisation.
Minimise the risk of death, injury and/or disease for consumers / patients,
employees and others as a result of services provided.
Enhance consumer / patient outcomes.
Manage resources effectively.
Support legislative compliance and to ensure organizational viability and
development.

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Figure 3 Risk Management process overview (Courtesy: www.safetyandquality.gov.au)

Provide examples of forums, processes or tools you use to assist in identifying

risks within your workplace.
The risk management program should be relevant to the clinical services provided to
ensure safe, quality care and services. For example, the risks associated with obstetric
services are different from those in aged care services; hence risk management
strategies would vary accordingly.
Examples of processes and strategies that assist with risk identification and
management include:
Clinical examples
o Collection and effective use of clinical indicators
o Morbidity and mortality reviews
o Clinical audits
o Adverse outcome screening and clinical incident reporting
o Health record audits and clinical content reviews
o Medical emergency reviews
o Medication management strategies
o Consumer / patient risk assessments (e.g. falls, pressure areas, VTE)
o Peer review and peer supervision
o Effective use of complaints and feedback from consumers / patients and
staff
o Evidence, literature, research.
Non-clinical examples
o Collection and effective use of indicators relevant to the organisation
o Audit processes
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o
o
o
o
o
o
o
o
o
o
o
o

Budget variance monitoring

Project activity reports
Purchasing and product evaluation
Fraud minimisation schemes
WHS risk assessments and hazard identification
Lost time injury reports
Political change management strategies
Workplace safety strategies
Financial management strategies
Contingency and disaster planning
Redundancy in systems
Information technology and data entry system infrastructure and
capabilities
o Workforce planning

Figure 4 Risk Within the Work place

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g)Provide examples of legislation, codes of practice and national standards you need to
be aware of to manage risk in your workplace. Describe what relevance they have for
your workplace
The EQUIP program provides a frame work for organisation to evaluate their
performance in risk management and quality management.

As per this program the organisation is expected to identify and implement

effective risk and quality management process.

Standard 1 National Safety and quality health Service (NHQHS) of the specific risk
management and quality improvement actions focus on the framework that promote
integration of risk management with quality improvement strategies and inform
decision making and planning.
Standard (3-10) requires organisation to carryout risk assessment of their system.
Standard (4) require organisation to carryout a complete medical assessment of their
system.
Most of the standards are obvious about the management of risk, such as standard 3
pertaining of health care associated infection risks, and standard 4 pertaining to
medication safety cost.
The core business for all health service providers is delivery of safe and effective
consumer/ patient care. The risk management program should be relevant to the
clinical services provided to ensure safe, quality care and services. For example, the risk
associated with obstetric services are different from those in aged care services, hence
risk management strategies would vary accordingly.
Rsik should be considered using existing process such as audits, data, trends,literature
and risk assessment tools, as well as via planned review of issues with stake holders
through mechanism such as brainstorming sessions.
For example, consumer / patient risk screening and/or assessments such as falls risk or
mobility assessment tools will be different from tools used to assess risks to
achievement of strategic goals, or workplace safety risks. It is important that any tool
used is validated by an expert internal source and/or agreed for use by the governing
body.
For example, a fall can have consequences for a patient that range from no harm to
additional surgical procedures and in a worst case scenario, death.

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Locate the current policy that addresses reasonable adjustment in the workplace
for people with a disability. Discuss your responsibilities in regards to this policy.
Unreasonable relationship is defined by whether or not the adjustment would create an
unjustible hardship to the whole organisation
It is a term applied to the administrative, environmental or procedural alterations
required to enable the person with disability to work effectively and enjoy equal
opportunity with others. By law, employers are required to provide reasonable
adjustments for an employer.

Provision of appropriate equipment or assistance to ensure there is no barrier

in the selection process
Job redesign;
Training or retaining;
Providing essential information in suitable formats.
Modifications to equipment or the supply of specialised equipment, furniture or
work related aids.
Flexible work arrangements.
Alterations to premises or work areas.

Unjustifiable Hardship - employers are obligated to provide reasonable adjustments

unless such an adjustment would result in unjustifiable hardship to the employer. It is
difficult to define unjustifiable hardship because each circumstance and organisation is
unique and is determined on a case-by-case basis. However, unjustifiable hardship is
generally determined by considering.

The cost of the adjustment required in light of the organisation's financial situation, and
The extent to which the adjustment will result in substantial benefits or detriments to
other employees, including those who do not have disability.
Communicating the availability of reasonable adjustments ensures that all applicants
and employees are notified of the availability of reasonable adjustments.

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Assessment Task 2 Case Study

As per the information provided by the IIMS Manager we have plotted an excel table
based on the number of hours an employee works in my department.

Occupational
Physiotherapist
Physiotherapist
Social Worker
Dietician

FTE (Full time

Employees)

Total
hours

Per
Week

0.5

20

p/w

0.5
1
0.25

20
40
10

p/w
p/w
p/w

Table 1: Employees working hours per week

1
3
1
4

Full time Employee Staff

Specialist
Junior Medical Officers
Resident Medical Officer
Visiting Medical Officers
Table 2: Staffing Profile Medicine

Critique the incident data that you have been provided with, and provide
examples of any notable trends that you might be concerned about.

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Since, the incident reporting system should be used to reports incidents that caused the
potential to cause harm or did actually harm the patients the employees should have
been careful in reporting all of the incidents to maintain integrity of the risk
management process. As you can see in the row 2 of table 1 we have only one recorded
incident of wrong medication use which cannot be true. The hospital staff did not
report more than 80% of the events in the medical setting due to misconceptions, staff
misperceptions about what constitutes medication errors.
As clearly stated earlier the ward being an elderly patient ward there is a high chance of
patients suffering with delirium syndrome. In this syndrome the patients witness state
of hyperativeness, hypoactiveness and mixed.New research has established that this
incidence can account for 3-29% of the total incident ratings. A major problem with the
development of delirium during hospitalisation is that the condition is often
misdiagnosed or under-recognised by health professionals.

Draw conclusions about the reporting culture within this team.

As we can clearly see from the IIMS reporting system that there has been a poor
incident management response from the team at the May Fair hospital. Several
examples of the incidents can be which needed to be accurately reported are The wrong
dosage of a medication administered to a patient

Quantity of medication not given when prescribed to be given. (MEDICATION)

Inappropriate treatment given to a patient, e.g. wrong procedure conducted.
(MEDICATION)
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A staff member injured in the course of their duties, e.g. back injury while lifting.
(FALL)
Injury to a visitor e.g. fall on a wet floor in the hallway. (FALL)

If you were the leader of this team what strategies would you put in place to
ensure that there is a positive reporting culture within the team and that all team
members were accountable for reporting incidents?
As a team leader I would make the incident reporting system practical by making it
necessary for the staff members reporting the incident or hazard to draw the attention
of the manager to the incident to ensure accurate recording of the detail.
Further, I would classify the events and investigate them on a 'just culture' basis: the
purpose is to improve safety, not to allocate blame. Based on the ISR, there may be a
local investigation, in-depth case review, RCA or review of aggregate data on a specific
incident types.
In addition, I would collaborate the events to create list of potentially reporting events
and provide technical assistance to employees in using the list and diagnosing the risk
and incidents.
Provide examples of further information you could utilise to assist you in your
analysis of this data.
I follow a risk matrix identification system to categorise, a report incident.
For example, when a clinical incident is identified immediate action is necessary to
reduce risk to the patient. This includes providing immediate care to the patient who is
involved in the incident, making the surrounding safe to prevent immediate recurrence
of the incident and gathering essential information about the chain of events.

Further, I can classify the incident based on the SAC ratings.

For example, follow the chart provided below to understand the importance of SAC
ratings to classify the risk associated and the level of importance ranging from,
SAC 1- Red classification (High importance) caused due to serious harm or death.
SAC 2- Medium Importance caused by health care
SAC-3 Minor or no Harm condition.

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Table: 3 SAC Rating

Assessment Task 3 - Risk Register

The steps of risk management process have been broken down into 5 easy steps. Each of
the five steps is designed as per reference to Australian/ NewZeland AS/NZS 4360:2004
Risk Management, and strategies.

Figure 5: Risk Management Process

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Step 1: Establish the context:

Since my current service has an extensive waiting list. In order to reduce the waiting
time for patients/clients to access the required service our pilot program will Identify
and understand the organizations operating environment and strategic context in order
for Health Services clinical risk management program to be effective.
We have to develop external and internal context, identifying the relevant stakeholders
and their relationship with the organization. The objectives and interest of these
organisation need to be identified as well as any treats they may pose to your
organisation management process.
The following factors should be considered:
The business, environment (Political and financial) such as,

Minimising disruption to services (proper rostering of the employees).

Occupational Health and safety requirements which influence your organization.
(Provide training for external employees-Volunteers from the local community)
Fund Availability. (Since fund is available you should have a proper procedure
claim to claim it; for example, documented evidence of food expense).

External stakeholders and key business drivers,

Providing the patient with adequate refreshment facilities, waiting rooms

and child care areas and additional staff to address patient queries.

Step 2: Identify the Risks:

To identify the risk you should perform a detail brainstorming of what can happen/
when and where can it happen/ how and why can it happen in a clinical setting. The key
here is to identify the source of the clinical risk or hazard that has a potential to cause a
harm; the event or incident that occurs and the impact on the organisation or its
stakeholders. Once we have identified the consequence of the clinical risk we have to
understand the contributing factors for the clinical risk and where and when it has
happened.

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Figure 6 Clinical Risk Management Guidelines for the Western Australian Health System (Possible methods to Identify
risks)

For example, of risk identification is a possibility of patient falling in a hospital scenario.

It can happen due to wet floors, ceasure condition in patient, wrong medication, etc.
This can happen in the bathrooms where floors are wet. As a preventive measure we
have to advise the hospital staff to display a wet floor sign board, mop the floors in
every two hours.
Step 3: Analyse the Risks:
In this step we have to consider the existing controls over the clinical risks, further the
probable severity of the consequences should the risk give rise to the incident and the
degree of likelihood than those the consequence may occur. Different method of
analysis can be implemented, ranging from quantitative methods, for example, defines
quantitative risk levels for a particular medical procedure or define the likelihood of a
communicable disease. A risk in a clinical setting has two distinguished based on the
following parameters, for example, fall occurring due to person slipping or tripping due
to a variety of reasons. The likelihood of a person falling is at level 3 possible and it can
happen at least once in three to five years.

Figure 7 Risk Classification based on the likelihood of occurrence

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Step 4: Evaluate and Prioritise clinical risks:

Risk evaluation and analysis process consist of of comparing the level of risk found
during the analysis process with the previously established risk criteria and further
developing a prioritised list of risks for additional action. When establishing an
evaluation criteria for the clinical risk we should identify the levels of clinical risk the
organization is willing to accept for the external and internal stakeholders. We use the
risk evaluation criteria to run the risk and measure them if they are within the
acceptable limits and at which level of management they should be managed.
Step 5: Treat the clinical Risks:
Risk treatment involves identifying the range of options for treating the risk, accessing
those options, preparing risk treatment plans and implementing them.

Figure 8 Example of risk matrix, showing risk definition and classification based on As/NZS ISO 31000:2009

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Document at least five (5) of the issues identified and completes the Risk Register
below.

Risk
No
1.1

Risk
Description
Clinical care
and patient
safety
(Falls)

1.2

Clinical care
and patient
safety
(Medication
errors)

1.3

Clinical care
and patient
safety
(Correct
patient
identificatio
n
procedure)

Conseque
nce
Falls
(Wet/
Slippery
Floor,
Medication
reaction/
overdose,
Suffocatio
n, Low
Blood
Sugar
Levels,
Ceasure,
etc)
Medication
errors (
Wrong
prescriptio
n,
dispencing
and
administra
tion of
drugs)
which
result in
death,
drug
overdose,
allergies,
etc

Likelihood

Rati
ng
M

Current
Treatment
By early
assessment to
allow timely and
effective
implementation
of falls
prevention
strategies

Planned treatment and

monitoring
IIMS reporting/ Monthly
IIMS reporting of falls/Data
is monitored and reproted
to the cinnical
council/vQuality meetings/
Liability claims.

Responsibil
ity
This
includes
whether the
exisiting
controls
have been
effectively
implemente
d or require
strengthene
n .(quality of
care
committee)

Possible
(Moderate)

Implementation
of National
Medication
Charts (NIDC)/
IIMS
Reporting/Investi
gation of major
incident reports
feedback to the
medication safe
committee

IIMSreports, Monthly IIMS

reports on
medication/fluid
errors,Facility KPI's for
mediaction errors.
Medication errors
monitored by Medication
safety committee.

Possible
(major)

All patient
require to fill out
an form in which
they need to
specify any
injuries,
medication or
any
communicable
illness. Based on
the information
provide they
receive an color
coded arm band
to ensure correct
identification.
Patient
Identification
based on 3 "W"
approach which
involves What is
your name/date
of birth and
medical record
number

IIMS reports, Monthly

identification band audits
(carried by Pathology)

Continue
Monitoring
via
pharmacy.
Implement
improvemen
t based on
IIMS
investigation
recommend
ation.
Impprove
performance
management
and
disciplinary
procedures.
Introduction
of electronic
prescription
system.
IIMS
investigation
. Monthly
Audits on ID
bands.
Implemeting
additional
auditing and
review of
quality of
the current
audits,
changing of
methodolog
y, and
implemeting
of strategies
to address
audit
findings.
Improving
process
around
perrformanc
e
management
and staff
being held
accountable

Correct
patient
Identificati
on
procedure.
(Wrong
Identificati
on can
result in
medication
errors or
in certain
situations
death too

Possible
(Moderate)

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for.

1.4

Clinical care
and patient
safety
(manual
handling)

To
eliminate /
reduce /
minimise
the risk or
injury to
staff /
patients
utilising
correct
manual
handling
procedure
s ( Falls,
back
injury,
trips and
slips, etc)

Possible
(Major)

1.5

Clinical care
and Patient
safety
(Clinical
Documentat
ion and
clinical
information
system)

Inproper
documenta
tion may
result in
medication
errors,
inproper
patient
identificati
on and
affect
bariatric
patient
mangemen
t. To meet
the
required
quality
standards
and
adequately
and

Possible
(moderate)

All staff clinical

and non clinical
receive face to
face manual
handling training
pertinent
to role in
mandatory
training annually
at Balmain.
All staff are
required to
complete the
online manual
handling training
via the CEWD
website prior to
attending the face
to face training
BH_PD2011_0.00
9 risk
management
policy for both
clinical and non
clinical.
BH_PD2011_0.00
1 manual
handling policy.
SLHD demands
checklist is
signed by all new
employees. All
tasks have a risk
assessment, risk
management, risk
elimination or
substitution
control
assessment
carried out.
BH_PD2012_004
clinical
documentation
policy
BH_PD2012_N.01
0 clinical
handover policy
Clinical
information
systems that
allow for
adequate
communication
of risks
Multidisciplinary
handover
Standards of
documentation
monitored by
facility auditing
program
including care

IIMS reports
Nurse Educator CEWD
training
reports on staff trained
WHS committee dashboard
for
monitoring of any manual
handling
related incidents
Investigation of all
incidents

IIIMS
reports
Investigatio
ns of any
adverse
manual
handling
incidents
Review of
current
manual
handling
chart by
physiothera
py
department

IIMS analysis
Bedside Clinical handover
audits
Implementation of the new
electronic
nurse ward handover

Continue
documentati
on audits
Continued
implementat
ion /
assessment
of the
electronic
handover
tools
Audits of the
A-G
assessment
/
documentati
on
standards

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[RISK MANAGEMENT]
identify
patient
care issues
and
associated
risks for
patient
and staff
(eg
infection,
aggression,
bariatric
care)

plans
and discharge
planning
GP networks /
electronic health
records

Table 4: Risk Register (http://www.mapl.com.au/risk/risk3.htm)

Task 4- Workplace Consultation

How well does your team understand risk management?
Risk management is best achieved by teamwork. The team, which I work with, complies with
the goals and objectives of the organization to control a risk. All of my staff members are
actively involved in risk management. General staff is responsible for the following activities,
Reporting the incidents via the NSW incident management system.
Identifying and accessing the risk in accordance with the risk management procedure.
Providing additional information regarding the risk when requested.
Embedding the risk management in day- to day operations within their areas.

Do they have knowledge of the reporting process for incidents?

Yes, our staffs at Balmain Hospital are thorough with the reporting process for incidents. We
have an electronic incident reporting system called Balmain Risk Management system. This is
used to record the incident data. The incident or hazard should be entered into the incident
reporting system immediately to ensure accurate recording of the details. In addition the staff
member should report the incident or hazard to the manager.

Do they see risk management as a positive activity?

Yes, my staff considers risk management as a positive activity. All of my staff members are
involved in the risk management process, including identifying, analysing and reporting on
risks.

Does the team identify they receive adequate feedback following incident report?
Yes, we provide adequate feedback on the incident reporting and encourage the staff members
to participate in the incident reporting process. Once the incident is reported then it will be
forwarded to the nominated manager. If there are any risk control activities that is performed at
a local level after the matter is discussed at the team building meeting.

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Is there anything you need to implement to ensure your team has a positive risk
management culture?
I feel that it is important to ensure that my entire staff understands, in a way appropriate to
their role, what Balmain Hospitals risk strategy is what the risk priorities are and how their
particular responsibilities in the agency fit into the risk management framework. If this is not
achieved, appropriate and consistent embedding of risk management and an organisational risk
culture will not be achieved and risk priorities may not be consistently addressed.

References
http://www.aig.com/Chartis/internet/US/en/Patient%20Safety%20Hospital%
20Risk%20White%20Paper_tcm3171-482027.pdf
http://www.achs.org.au/media/69305/risk_management_and_quality_improve
ment_handbook_july_2013.pdf
http://www.achs.org.au/media/69305/risk_management_and_quality_improve
ment_handbook_july_2013.pdf
http://www.safetyandquality.health.wa.gov.au/docs/clinical_gov/Introduction_to_Clini
cal_Governance.pdf

Risk Management and Quality Improvement Handbook. EQuIPNational. July

2013.
Clinical Risk Management Guidelines for the NSW Australian Health System.

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