{ "entity_id": "S-VIC-028", "folder": "Safer-Care-Victoria", "name": "Safer Care Victoria", "type": "Statutory Authority", "jurisdiction": "VIC", "portfolio": "Health", "website": "https://www.safercare.vic.gov.au/", "data_status": "partial", "completeness": { "has_strategy_brief": true, "has_strategy_structured": true, "has_vision": false, "has_kpi_targets": false, "has_kpi_results": false, "has_strategy_overview": true, "has_legislation_text": true, "has_legislation_structured": false, "has_global_initiatives_text": false, "has_ideas": true, "has_artifacts": true, "n_ideas": 12, "n_legislation": 0, "n_artifacts": 9, "n_kpi_targets": 0, "n_kpi_results": 0, "n_outcomes": 4, "verified_own_data": true }, "strategy_profile": { "status": "needs_review", "confidence": "medium", "summary": "This domain includes what people can do for their own health and wellbeing, as well as what is done with and for people in a healthcare setting. This domain pivots on considering the whole person (or family). This means understanding their physical, cultural and social context, to identify what makes a difference to a person’s health, wellbeing and safety.", "official_site_url": "https://www.safercare.vic.gov.au/", "source_documents": [ { "type": "strategie", "title": "Victorian Clinical Governance Framework – 2024 (PDF, 1.19 MB)", "url": "https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf", "period": "2024", "confidence": "medium" }, { "type": "strategie", "title": "Partnering in healthcare: a framework for better care and outcomes (PDF, 982.75 KB)", "url": "https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf", "period": "2019", "confidence": "medium" }, { "type": "strategie", "title": "Safer Care Victoria Strategic Plan 2023-26 (PDF, 248.62 KB)", "url": "https://www.safercare.vic.gov.au/sites/default/files/2023-10/SCV%20Strategic%20Plan%202023-2026.pdf", "period": "2023", "confidence": "medium" }, { "type": "corporate_plan", "title": "Corporate Plan", "url": "https://www.safercare.vic.gov.au/sites/default/files/2018-03/SCV%20Corporate%20Plan%202017-2018.pdf", "period": "2018", "confidence": "high" } ], "purpose": null, "vision": null, "strategic_priorities": [], "values": [], "outcomes": [ { "name": "Outcome 1: Personalised and holistic", "description": "This domain includes what people can do for their own health and wellbeing, as well as what is done with and for people in a healthcare setting. This domain pivots on considering the whole person (or family). This means understanding their physical, cultural and social context, to identify what makes a difference to a person’s health, wellbeing and safety.", "activities": [ "Actively engage consumers in partnership opportunities across all aspects of the healthcare system.", "Implement a statewide consumer network." ], "source_url": "https://www.safercare.vic.gov.au/sites/default/files/2018-03/SCV%20Corporate%20Plan%202017-2018.pdf", "source_page": 10, "source_deep_url": "https://www.safercare.vic.gov.au/sites/default/files/2018-03/SCV%20Corporate%20Plan%202017-2018.pdf#page=10" }, { "name": "Outcome 2: Working together", "description": "Personalised and holistic care is possible when people work together in strong teams, partnerships and share knowledge. Knowledge transfer is a two-way street.", "activities": [ "Co-develop improvement and innovation activities.", "Collaboration and engagement among consumers, families and health professionals." ], "source_url": "https://www.safercare.vic.gov.au/sites/default/files/2018-03/SCV%20Corporate%20Plan%202017-2018.pdf", "source_page": 14, "source_deep_url": "https://www.safercare.vic.gov.au/sites/default/files/2018-03/SCV%20Corporate%20Plan%202017-2018.pdf#page=14" }, { "name": "Outcome 3: Shared decision-making", "description": "Shared decision-making includes the process by which health decisions are made by consumers and health professionals, using the best available evidence and discussion of consumers’ preferences.", "activities": [ "Involve consumers at the service design, policy and governance levels.", "Use consumers’ expertise in care." ], "source_url": "https://www.safercare.vic.gov.au/sites/default/files/2018-03/SCV%20Corporate%20Plan%202017-2018.pdf", "source_page": 18, "source_deep_url": "https://www.safercare.vic.gov.au/sites/default/files/2018-03/SCV%20Corporate%20Plan%202017-2018.pdf#page=18" }, { "name": "Outcome 4: Equity and inclusion", "description": "Responding to diverse needs is complex. People want to be engaged and empowered in their healthcare experience and journey. Some groups and communities are often under-represented in healthcare participation opportunities and structures and over-represented in clinical risk.", "activities": [ "Responding to diverse needs is complex.", "Informed by a definition of equity provided by the World Health Organization, equity is the absence of avoidable or remediable differences among groups of people." ], "source_url": "https://www.safercare.vic.gov.au/sites/default/files/2018-03/SCV%20Corporate%20Plan%202017-2018.pdf", "source_page": 22, "source_deep_url": "https://www.safercare.vic.gov.au/sites/default/files/2018-03/SCV%20Corporate%20Plan%202017-2018.pdf#page=22" } ], "performance_measures": [], "document_alignment_terms": { "must_support": [], "watch_terms": [], "avoid_claiming_without_evidence": [] }, "review_note": "Structured strategy exists but is incomplete." }, "strategy_brief_md": "# Safer Care Victoria — Strategy Brief\n\n**Reporting period**: 2024-25\n**Corporate plan in force**: 2025-26\n**Corporate Plan**: [2025-26](https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf)\n\n## Outcomes\n\n### Outcome 1: Personalised and holistic\nThis domain includes what people can do for their own health and wellbeing, as well as what is done with and for people in a healthcare setting. This domain pivots on considering the whole person (or family). This means understanding their physical, cultural and social context, to identify what makes a difference to a person’s health, wellbeing and safety. [[CP p.10](https://www.safercare.vic.gov.au/sites/default/files/2018-03/SCV%20Corporate%20Plan%202017-2018.pdf#page=10)(https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf#page=10)]\n\n**Key activities:**\n- Actively engage consumers in partnership opportunities across all aspects of the healthcare system.\n- Implement a statewide consumer network.\n\n### Outcome 2: Working together\nPersonalised and holistic care is possible when people work together in strong teams, partnerships and share knowledge. Knowledge transfer is a two-way street. [[CP p.14](https://www.safercare.vic.gov.au/sites/default/files/2018-03/SCV%20Corporate%20Plan%202017-2018.pdf#page=14)(https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf#page=14)]\n\n**Key activities:**\n- Co-develop improvement and innovation activities.\n- Collaboration and engagement among consumers, families and health professionals.\n\n### Outcome 3: Shared decision-making\nShared decision-making includes the process by which health decisions are made by consumers and health professionals, using the best available evidence and discussion of consumers’ preferences. [[CP p.18](https://www.safercare.vic.gov.au/sites/default/files/2018-03/SCV%20Corporate%20Plan%202017-2018.pdf#page=18)(https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf#page=18)]\n\n**Key activities:**\n- Involve consumers at the service design, policy and governance levels.\n- Use consumers’ expertise in care.\n\n### Outcome 4: Equity and inclusion\nResponding to diverse needs is complex. People want to be engaged and empowered in their healthcare experience and journey. Some groups and communities are often under-represented in healthcare participation opportunities and structures and over-represented in clinical risk. [[CP p.22](https://www.safercare.vic.gov.au/sites/default/files/2018-03/SCV%20Corporate%20Plan%202017-2018.pdf#page=22)(https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf#page=22)]\n\n**Key activities:**\n- Responding to diverse needs is complex.\n- Informed by a definition of equity provided by the World Health Organization, equity is the absence of avoidable or remediable differences among groups of people.", "strategy_overview_evidence_md": null, "internal_strategy_evidence_md": "# Safer Care Victoria - Strategy, Performance, and Operating Profile\n\n**Generated at**: 2026-05-09T22:50:13.623760+00:00\n**Entity ID**: S-VIC-028\n**Entity type**: Statutory Authority\n**Jurisdiction**: VIC\n**Portfolio**: Health\n**Website**: https://www.safercare.vic.gov.au/\n\n> Draft generated from scraped source material. Treat this as an evidence pack for editorial review, not a final judgement.\n\n## Source Coverage\n\n| Source type | Count |\n|---|---:|\n| other-pdfs | 5 |\n| pages | 15 |\n| strategies | 3 |\n\n## Executive Readout\n\n### Purpose\n\n- Consumer involvement is integral to creating a responsive health system.’\nFigure 3: Implementation timeline\nWhat we will deliver in 2019–20\nFEBRUARY JULY\nLaunch of Partnering in healthcare Identify baseline data for Partnering in\nframework document and planning healthcare implementation\nresources\nDevelop evaluation strategy\nMARCH\nDECEMBER\nShared decision-making to feature in\nDevelop resources to support shared\nBetter Care Victoria Innovation Fund\ndecision-making strategies\nLaunch resources to support\nAPRIL equitable and diverse consumer\nengagement\nInaugural Partnering in healthcare\nforum held 29–30 April\n2020\nJUNE\nPartnering in healthcare outcomes\nsummit held\n30 June deadline for health\nShared decision-making projects\nservices to submit at least two\nlaunched in health services\ndomains and priority areas for\naction\n32 Safer Care Victoria Partnering in healthcare\n Source: `strategies/Partnering-20in-20healthcare-20framework-202019_WEB.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf)`\n- [pages 34,35,36]\nFigure 3: Implementation timeline\nWhat we will deliver in 2019–20\nFEBRUARY JULY\nLaunch of Partnering in healthcare Identify baseline data for Partnering in\nframework document and planning healthcare implementation\nresources\nDevelop evaluation strategy\nMARCH\nDECEMBER\nShared decision-making to feature in\nDevelop resources to support shared\nBetter Care Victoria Innovation Fund\ndecision-making strategies\nLaunch resources to support\nAPRIL equitable and diverse consumer\nengagement\nInaugural Partnering in healthcare\nforum held 29–30 April\n2020\nJUNE\nPartnering in healthcare outcomes\nsummit held\n30 June deadline for health\nShared decision-making projects\nservices to submit at least two\nlaunched in health services\ndomains and priority areas for\naction\n32 Safer Care Victoria Partnering in healthcare\n Source: `strategies/Partnering-20in-20healthcare-20framework-202019_WEB.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf)`\n- [pages 1,2,3,4,5]\n[Page 1]\nPartnering in healthcare\nA framework for better care and outcomes\n Source: `strategies/Partnering-20in-20healthcare-20framework-202019_WEB.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf)`\n- This will be achieved\nby delivering work across the scope of our accountabilities:\nThe development and implementation Those supporting the department’s\nof a comprehensive state-wide safety annual service delivery performance\nand quality dashboard measures, as they relate to our work6\nPrograms we have been The delivery of government\ncommissioned to deliver to meet election commitments that SCV is\nspecific outcomes accountable for\nWe will detail our workplan and strategic initiatives in our “Providing a clinician perspective is not just a\nAnnual Plans and report on our key achievements and platform, but a responsibility to advocate for my\nchallenges in our Annual Reports during this strategic cycle - patients and for solutions to challenges in the health\n1 July 2023 to 30 June 2026.\n Source: `strategies/SCV-20Strategic-20Plan-202023-2026.pdf (https://www.safercare.vic.gov.au/sites/default/files/2023-10/SCV%20Strategic%20Plan%202023-2026.pdf)`\n\n### Role and Functions\n\n- [Page 27]\nWorkforce\nSigns of success: Workforce\nWorkforce planning • Every role has a clearly defined position description which outlines responsibilities and functions and is linked to individual\nand resourcing performance monitoring.\nmeets\n• Succession planning is proactive and occurs regularly for all key roles.\norganisational\n• Workforce planning is effective and ensures the organisation is resourced appropriately with the right capability, and high-risk areas\nneeds\nare clearly identified and monitored (e.g. percentage of new employees and agency/locum employees).\n• Employee orientation and induction includes explanation of local clinical governance systems, practices, and culture.\n• There is a system for ensuring critical clinical training requirements have been met.\n• Resource planning and allocation provides for effective and safe employees supervision and mentoring ratios.\n Source: `strategies/Victorian-20Clinical-20Governance-20Framework.pdf (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)`\n- [Page 3]\nContents\nForeword 3\nPart 1: Overview 4\nDefining high-quality care 5\nClinical governance in the Victorian health sector 6\nClinical governance principles 7\nPart 2: The ideal clinical governance mindset 8\nAdaptive leadership 8\nPartnering with consumers 9\nContinuous improvement 9\nPart 3: Your clinical governance role 11\nPart 4: Five clinical governance domains in application 15\nLeadership and culture 16\nPartnering with consumers 19\nWorkforce 25\nRisk management 30\nClinical practice 35\nGlossary 41\nUseful resources 44\nReferences 46\nDelivering high-quality care Safer Care Victoria 1\nOFFICIAL\n Source: `strategies/Victorian-20Clinical-20Governance-20Framework.pdf (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)`\n- This will be achieved\nby delivering work across the scope of our accountabilities:\nThe development and implementation Those supporting the department’s\nof a comprehensive state-wide safety annual service delivery performance\nand quality dashboard measures, as they relate to our work6\nPrograms we have been The delivery of government\ncommissioned to deliver to meet election commitments that SCV is\nspecific outcomes accountable for\nWe will detail our workplan and strategic initiatives in our “Providing a clinician perspective is not just a\nAnnual Plans and report on our key achievements and platform, but a responsibility to advocate for my\nchallenges in our Annual Reports during this strategic cycle - patients and for solutions to challenges in the health\n1 July 2023 to 30 June 2026.\n Source: `strategies/SCV-20Strategic-20Plan-202023-2026.pdf (https://www.safercare.vic.gov.au/sites/default/files/2023-10/SCV%20Strategic%20Plan%202023-2026.pdf)`\n- Effective systems also work to ensure each role’s\ncore functions and responsibilities are universally understood.\n Source: `strategies/Victorian-20Clinical-20Governance-20Framework.pdf (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)`\n- Consumer involvement is integral to creating a responsive health system.’\nFigure 3: Implementation timeline\nWhat we will deliver in 2019–20\nFEBRUARY JULY\nLaunch of Partnering in healthcare Identify baseline data for Partnering in\nframework document and planning healthcare implementation\nresources\nDevelop evaluation strategy\nMARCH\nDECEMBER\nShared decision-making to feature in\nDevelop resources to support shared\nBetter Care Victoria Innovation Fund\ndecision-making strategies\nLaunch resources to support\nAPRIL equitable and diverse consumer\nengagement\nInaugural Partnering in healthcare\nforum held 29–30 April\n2020\nJUNE\nPartnering in healthcare outcomes\nsummit held\n30 June deadline for health\nShared decision-making projects\nservices to submit at least two\nlaunched in health services\ndomains and priority areas for\naction\n32 Safer Care Victoria Partnering in healthcare\n Source: `strategies/Partnering-20in-20healthcare-20framework-202019_WEB.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf)`\n- [pages 34,35,36]\nFigure 3: Implementation timeline\nWhat we will deliver in 2019–20\nFEBRUARY JULY\nLaunch of Partnering in healthcare Identify baseline data for Partnering in\nframework document and planning healthcare implementation\nresources\nDevelop evaluation strategy\nMARCH\nDECEMBER\nShared decision-making to feature in\nDevelop resources to support shared\nBetter Care Victoria Innovation Fund\ndecision-making strategies\nLaunch resources to support\nAPRIL equitable and diverse consumer\nengagement\nInaugural Partnering in healthcare\nforum held 29–30 April\n2020\nJUNE\nPartnering in healthcare outcomes\nsummit held\n30 June deadline for health\nShared decision-making projects\nservices to submit at least two\nlaunched in health services\ndomains and priority areas for\naction\n32 Safer Care Victoria Partnering in healthcare\n Source: `strategies/Partnering-20in-20healthcare-20framework-202019_WEB.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf)`\n\n### Strategic Priorities\n\n- [pages 44,45,46,47,48,49,50]\nStatement of Priorities\nSoPs consist of four parts:\n• Part A provides an overview of the service profile, strategic priorities, and\ndeliverables the health service will achieve in the year ahead.\n• Part B lists the key financial, access and service performance priorities\nand agreed targets.\n• Part C lists funding and associated activity.\n• Part D forms the service agreement between each health service and the\nState of Victoria for the purposes of the National Health Reform\nAgreement.\n Source: `strategies/Victorian-20Clinical-20Governance-20Framework.pdf (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)`\n- Rolling out the framework\nThis framework applies to all Victorian public\nAt a minimum, please identify two domains and health services\nthe priorities you will choose to focus on in the This framework replaces Doing it with us not\nnext 12 months. for us: Strategic Direction 2010–2013 and the\nCultural Responsiveness Framework: guidelines\nBy June 30 2019, you need to:\nfor Victorian health services.\n Source: `strategies/Partnering-20in-20healthcare-20framework-202019_WEB.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf)`\n- Consumer involvement is integral to creating a responsive health system.’\nFigure 3: Implementation timeline\nWhat we will deliver in 2019–20\nFEBRUARY JULY\nLaunch of Partnering in healthcare Identify baseline data for Partnering in\nframework document and planning healthcare implementation\nresources\nDevelop evaluation strategy\nMARCH\nDECEMBER\nShared decision-making to feature in\nDevelop resources to support shared\nBetter Care Victoria Innovation Fund\ndecision-making strategies\nLaunch resources to support\nAPRIL equitable and diverse consumer\nengagement\nInaugural Partnering in healthcare\nforum held 29–30 April\n2020\nJUNE\nPartnering in healthcare outcomes\nsummit held\n30 June deadline for health\nShared decision-making projects\nservices to submit at least two\nlaunched in health services\ndomains and priority areas for\naction\n32 Safer Care Victoria Partnering in healthcare\n Source: `strategies/Partnering-20in-20healthcare-20framework-202019_WEB.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf)`\n- [pages 34,35,36]\nFigure 3: Implementation timeline\nWhat we will deliver in 2019–20\nFEBRUARY JULY\nLaunch of Partnering in healthcare Identify baseline data for Partnering in\nframework document and planning healthcare implementation\nresources\nDevelop evaluation strategy\nMARCH\nDECEMBER\nShared decision-making to feature in\nDevelop resources to support shared\nBetter Care Victoria Innovation Fund\ndecision-making strategies\nLaunch resources to support\nAPRIL equitable and diverse consumer\nengagement\nInaugural Partnering in healthcare\nforum held 29–30 April\n2020\nJUNE\nPartnering in healthcare outcomes\nsummit held\n30 June deadline for health\nShared decision-making projects\nservices to submit at least two\nlaunched in health services\ndomains and priority areas for\naction\n32 Safer Care Victoria Partnering in healthcare\n Source: `strategies/Partnering-20in-20healthcare-20framework-202019_WEB.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf)`\n- [Page 2]\nContents page\n3\nAcknowledgement of Country\n4\nMessage from the Chief Executive Officer\nConsumers are essential to building a 5\nsafer healthcare system\n6\nOur strategy at-a-glance\n7\nAbout us\n8\nWhy safety is our priority\n9\nOur strategic plan\n14\nEnabling principles\n16\nMeasuring our impact\n2 Strategic Plan 2023-2026 Safer Care Victoria\n Source: `strategies/SCV-20Strategic-20Plan-202023-2026.pdf (https://www.safercare.vic.gov.au/sites/default/files/2023-10/SCV%20Strategic%20Plan%202023-2026.pdf)`\n- [Page 6]\nOur strategy at- a- glance\nVision\nA safer healthcare system for all Victorians\nAim July 2023 to June 2026\nTo co-create a consistently safe and continuously improving healthcare system\nOur Strategic Priorities (What we do)\n1.\n Source: `strategies/SCV-20Strategic-20Plan-202023-2026.pdf (https://www.safercare.vic.gov.au/sites/default/files/2023-10/SCV%20Strategic%20Plan%202023-2026.pdf)`\n- [Page 10]\nSTRATEGIC PRIORITY 1:\nSafety through leadership\nand reform\nWe work locally and at every level of the system to influence safety improvement.\n Source: `strategies/SCV-20Strategic-20Plan-202023-2026.pdf (https://www.safercare.vic.gov.au/sites/default/files/2023-10/SCV%20Strategic%20Plan%202023-2026.pdf)`\n- [Page 11]\nSTRATEGIC PRIORITY 2:\nSafety through\nstrengthening governance\nEffective clinical governance is fundamental to ensuring safe and high-quality care.\n Source: `strategies/SCV-20Strategic-20Plan-202023-2026.pdf (https://www.safercare.vic.gov.au/sites/default/files/2023-10/SCV%20Strategic%20Plan%202023-2026.pdf)`\n- [Page 12]\nSTRATEGIC PRIORITY 3:\nSafety through\nproactive monitoring\nWe actively monitor the safety of our healthcare system to improve the quality of care and prevent\npatient harm.\n Source: `strategies/SCV-20Strategic-20Plan-202023-2026.pdf (https://www.safercare.vic.gov.au/sites/default/files/2023-10/SCV%20Strategic%20Plan%202023-2026.pdf)`\n- [Page 13]\nSTRATEGIC PRIORITY 4:\nSafety through\neffective intervention\nWe are creating a continuously improving healthcare system that learns from, and acts to, prevent harm\nby driving system level change.\n Source: `strategies/SCV-20Strategic-20Plan-202023-2026.pdf (https://www.safercare.vic.gov.au/sites/default/files/2023-10/SCV%20Strategic%20Plan%202023-2026.pdf)`\n\n## KPIs, Targets, and Where They Are At\n\n- MEDICATION SAFETY ITEM ACTION\nSTANDARD\nClinical governance and quality Partnering with consumers 4.3, 4.11, 4.12\nimprovement to support medication\nmanagement\nDocumentation of patient Medication reconciliation 4.5, 4.6\ninformation\nContinuity of medication Medication review 4.10*\nmanagement\nInformation for patients 4.11\nProvision of a medicines list 4.12\nExamples of evidence from the NSQHS workbook, aligning each standard to the domain:\n policy documents that describe the processes for gaining patient consent, or consulting with substitute\ndecision-makers, for the administration of medicines\n results of patient experience surveys about medication management\n documented examples of actions taken as a result of medication review.\n Source: `other-pdfs/FACT-20SHEET-20--20Personalised-20and-20holistic.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-08/FACT%20SHEET%20-%20Personalised%20and%20holistic.pdf)`\n- This will be achieved\nby delivering work across the scope of our accountabilities:\nThe development and implementation Those supporting the department’s\nof a comprehensive state-wide safety annual service delivery performance\nand quality dashboard measures, as they relate to our work6\nPrograms we have been The delivery of government\ncommissioned to deliver to meet election commitments that SCV is\nspecific outcomes accountable for\nWe will detail our workplan and strategic initiatives in our “Providing a clinician perspective is not just a\nAnnual Plans and report on our key achievements and platform, but a responsibility to advocate for my\nchallenges in our Annual Reports during this strategic cycle - patients and for solutions to challenges in the health\n1 July 2023 to 30 June 2026.\n Source: `strategies/SCV-20Strategic-20Plan-202023-2026.pdf (https://www.safercare.vic.gov.au/sites/default/files/2023-10/SCV%20Strategic%20Plan%202023-2026.pdf)`\n- [pages 24,25,26,27]\ne as a direct feedback on improving overall response to the feedback.\ncomplaints, to an result of consumer feedback. consumer experience.\nadvisory committee\nwhose members are\ntrained and supported.\n Source: `strategies/Victorian-20Clinical-20Governance-20Framework.pdf (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)`\n- However, we still require you to complete the Statement of Intent for 2025-26 as normal. (Should any changes to the Statement of Intent result from the refresh consultations, this will impact your 2026-27 SOI next year).\n Source: `pages/strategies-index__01.html (https://www.safercare.vic.gov.au/best-practice-improvement/partnering-with-consumers/pih)`\n- We\nl identify the most useful ways to\nknow this because we asked hundreds of people\nmeasure and report on progress with\nwhat was most important to the them, and this\nPartnering in healthcare\nframework is the result.\n Source: `strategies/Partnering-20in-20healthcare-20framework-202019_WEB.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf)`\n- Consumer involvement is integral to creating a responsive health system.’\nFigure 3: Implementation timeline\nWhat we will deliver in 2019–20\nFEBRUARY JULY\nLaunch of Partnering in healthcare Identify baseline data for Partnering in\nframework document and planning healthcare implementation\nresources\nDevelop evaluation strategy\nMARCH\nDECEMBER\nShared decision-making to feature in\nDevelop resources to support shared\nBetter Care Victoria Innovation Fund\ndecision-making strategies\nLaunch resources to support\nAPRIL equitable and diverse consumer\nengagement\nInaugural Partnering in healthcare\nforum held 29–30 April\n2020\nJUNE\nPartnering in healthcare outcomes\nsummit held\n30 June deadline for health\nShared decision-making projects\nservices to submit at least two\nlaunched in health services\ndomains and priority areas for\naction\n32 Safer Care Victoria Partnering in healthcare\n Source: `strategies/Partnering-20in-20healthcare-20framework-202019_WEB.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf)`\n- [pages 34,35,36]\nFigure 3: Implementation timeline\nWhat we will deliver in 2019–20\nFEBRUARY JULY\nLaunch of Partnering in healthcare Identify baseline data for Partnering in\nframework document and planning healthcare implementation\nresources\nDevelop evaluation strategy\nMARCH\nDECEMBER\nShared decision-making to feature in\nDevelop resources to support shared\nBetter Care Victoria Innovation Fund\ndecision-making strategies\nLaunch resources to support\nAPRIL equitable and diverse consumer\nengagement\nInaugural Partnering in healthcare\nforum held 29–30 April\n2020\nJUNE\nPartnering in healthcare outcomes\nsummit held\n30 June deadline for health\nShared decision-making projects\nservices to submit at least two\nlaunched in health services\ndomains and priority areas for\naction\n32 Safer Care Victoria Partnering in healthcare\n Source: `strategies/Partnering-20in-20healthcare-20framework-202019_WEB.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf)`\n- [Page 2]\nContents page\n3\nAcknowledgement of Country\n4\nMessage from the Chief Executive Officer\nConsumers are essential to building a 5\nsafer healthcare system\n6\nOur strategy at-a-glance\n7\nAbout us\n8\nWhy safety is our priority\n9\nOur strategic plan\n14\nEnabling principles\n16\nMeasuring our impact\n2 Strategic Plan 2023-2026 Safer Care Victoria\n Source: `strategies/SCV-20Strategic-20Plan-202023-2026.pdf (https://www.safercare.vic.gov.au/sites/default/files/2023-10/SCV%20Strategic%20Plan%202023-2026.pdf)`\n- I am\nparticularly interested in equity and acting on social\ndeterminants of health to ensure that everyone in\nVictoria can enjoy the best health possible.”\nClinical Lead,\nContinuing Care Learning Health Network\n6 Refer to Budget Paper 3: Service Delivery at: Budget papers | Victorian Budget 23/24 | Victorian Budget\n16 Strategic Plan 2023-2026 Safer Care Victoria\n Source: `strategies/SCV-20Strategic-20Plan-202023-2026.pdf (https://www.safercare.vic.gov.au/sites/default/files/2023-10/SCV%20Strategic%20Plan%202023-2026.pdf)`\n- [Page 3]\nContents\nForeword 3\nPart 1: Overview 4\nDefining high-quality care 5\nClinical governance in the Victorian health sector 6\nClinical governance principles 7\nPart 2: The ideal clinical governance mindset 8\nAdaptive leadership 8\nPartnering with consumers 9\nContinuous improvement 9\nPart 3: Your clinical governance role 11\nPart 4: Five clinical governance domains in application 15\nLeadership and culture 16\nPartnering with consumers 19\nWorkforce 25\nRisk management 30\nClinical practice 35\nGlossary 41\nUseful resources 44\nReferences 46\nDelivering high-quality care Safer Care Victoria 1\nOFFICIAL\n Source: `strategies/Victorian-20Clinical-20Governance-20Framework.pdf (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)`\n- Australian Commission on Safety and Quality in Health Care (2020) Australian Charter of Healthcare\nRights (second edition), ACSQHC \nAustralian Commission on Safety and Quality in Health Care (2021) National Safety and Quality Health\nService Standards (second edition), ASQHC \nAustralian Commission on Safety and Quality in Health Care (2023) Partnering with consumers,\nACSQHC, \nAven T (2022) A risk science perspective on discussion concerning Safety I, Safety II, and Safety III,\n Source: `strategies/Victorian-20Clinical-20Governance-20Framework.pdf (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)`\n- CLINICAL GOVERNANCE ITEM ACTION\nSTANDARD\nGovernance, leadership and culture Governance, leadership and 1.1, 1.2*\nculture\nOrganisational Leadership 1.3, 1.4*, 1.5\nClinical Leadership 1.6\nPatient safety and quality systems Measurement and quality 1.8, 1.9\nimprovement\nRisk Management 1.10\nIncident management 1.11, 1.12\nsystems and open disclosure\nFeedback and complaints 1.13, 1.14\nmanagement\nDiversity and high-risk groups 1.15\nClinical performance and Safety and quality training 1.19, 1.21*\neffectiveness\nSafe environments for the delivery of Safe environment 1.31*, 1.32*,1.33*\ncare\nExamples of evidence from the NSQHS workbook, aligning each standard to the domain:\n communication with the workforce or consumers on the health service organisation’s clinical governance\nframework for safety and quality performance\n Source: `other-pdfs/FACT-20SHEET-20--20Effective-20communication.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-08/FACT%20SHEET%20-%20Effective%20communication.pdf)`\n- COMPREHENSIVE CARE ITEM ACTION\nSTANDARD\nClinical governance and quality Partnering with consumers 5.3\nimprovement to support\nDesigning systems to deliver 5.4*\ncomprehensive care\ncomprehensive care\nItem\nDeveloping the comprehensive care Planning for comprehensive 5.8*, 5.9\nplan care\nScreening of risk 5.10\nDeveloping the 5.13\ncomprehensive care plan\nDelivering comprehensive care Using the comprehensive care 5.14\nplan\nComprehensive care at the 5.17*, 5.20*\nend of life\nMinimising patient harm Nutrition and hydration 5.28*\nPreventing delirium and 5.30*\nmanaging cognitive\nimpairment\nPredicting, preventing and 5.31*, 5.32*\nmanaging self-harm and\nsuicide\nPredicting, preventing and 5.34*\nmanaging aggression and\nviolence\nMinimising restrictive 5.35*\npractices: restraint\nMinimising restrictive 5.36*\npractices: seclusion\n Source: `other-pdfs/FACT-20SHEET-20--20Effective-20communication.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-08/FACT%20SHEET%20-%20Effective%20communication.pdf)`\n- [pages 23,24,25,26,27]\nn Allowing time to ask questions, and have\nstaff answer them in an understandable\nOther suggestions for improvement from way, will support this.’\nour consultation\nProvide information to consumers, and\nensure they have the opportunity to\nask questions about their rights and\ncare options.\n Source: `strategies/Partnering-20in-20healthcare-20framework-202019_WEB.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf)`\n\n## Key Metrics\n\n| Values found | Evidence | Source |\n|---|---|---|\n| $9, 6% | x���{pT�\u0019�/$\u0010 \u00106%P\u000bj���B �8�\u0001\u0013�#EG\u0005�V\u0014�ӎ\u0016-��*jU0��0�\u0014�;>��B\\|�D��\nmQ�F�j�\u0014\u0007\u0004�\u0004�\b�\u0002I\b��dw�����:����>��#{Ϲ��ۻ�y�I+�\u0012C�����~�Gz�\u0013~���k\u001f�=��\u0001\\|�_�!�n���<����gz�_�>��������7��{��x�/������^���=ԯ�\\\u000f�g�x�\u000f�! ���}�\u0003\u001c����\u000b?�#�G��\u0001�x�\u001f�\u0013�'z�^S���\u0005�o��\u001e���\u0007�q�?�G�x���\\|�\u0003�t�?�W�o]֟�U������G�����^���7\u001f���L���>.>7��]\u000f��=~z\u0017_�W\u0005���[�@�����\u0001�?q��\u001f\u0010��\f�uuƜ�l��)S����]��\u0011y��?g��:^����?�j��~�4>�/J�[��0WS�@դd>ϩ��������h�S����++\u0012���\u0018\u0015O����f&���4����$9�\u001c�\u0017&[;)rN\u001a��� | `pages/strategies-index__03.html 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���ޒ�\u000e\u00192$:&�o�}\u001a�(-#c�\\�E�+�I�\fo���\u001ac����\u001c{&(\u0018U\u000b\n\u000b�C(\u0004žs�\u000f�\u0006��2*:u�\b{A\u000b0LL>�b�A�\u0014��#�'`�۸e���\u0004�1�#���wx]���?}\u0006em�UѴsv+\u0014L�9��\u0011{���<\f\n� ���A]\u0004\u0018�'j:��Ϊ���\u001e=bu�o�\u001d��}��\n>\n1\u0006\u0006F�cŊ\u0015��t\u0011p��$��\nX�r%�����\u0002�\u0018p]�l s�������\u0002'��1�\\x���\u000e�\u001422Y�� \u0006\b����\b4��_X��7\u0011J��:E�\u0001��tu:N�6��dSn�]Vv!�\u000b���nV戬ܜ�Ϩ�3��v\u0011\u0004���N�+�E�t9��w�Сo޼!�E�\u0011{�1�\u0006���h�i�l�`�7�����c\u0019�Ï\u001f?&V��]�\u0014\u001e�U\u0013\u0003�\"ē�\u0018\u0018TAJJ������0a�i�\u0004�Ç\u000f���\u001b~>ΠA�����sǛ�yճP���3`��\u000f�+++��ۗN/4:]s�dN�é�φ��)tk[{� �\u001c\u001f��w | `pages/strategies-index__03.html (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)` |\n| $4 | ��c``�)\u001e_����ʙ3g\u0004�~&P�v�0gãp`�9Mܬ��O.\\\u0007n�����\"�.\u00177X�����\b\\��__\u0006�o��>��Y�� %2�\n׿��R�l���D��������ML�niiA�Y;\u001ew���\u001f%Cdbb\"3�\u0003\u0005��\"\u0010\b�Cz3\u001e�^�zx\u000f����ZZZ\u001f,���>#VWI\u00129+�I>Aa�[���\u0014Jx�%��c\u00182��'�h\\|\\\np�\f�����4��'\u001a�%/]r\\\u0012�5���,�?�\b���C\u001e��O� 7���r\u001a��\u0001>�aB\u0013���\u0016TZ#�KEFE������\u0017/^��k\u001c֩�\u001a��\"k��끂R&ijj޿\u001f�gɇ�\u001cEFF\n���Ԅ�dH\u001e?+���=$4� �ׁ�\u000e.�QnC�?�e\u0001w��(�-_��eN�\u0006�s\u000b湉��g\u001c2X�sʷ\u0004���%�\\|+�{fP�8\u0012�g�+�h$bM��\u0011\u001b�=}�\\\f�*��F́�U�Vuuu�;?�0e�\n���\u00071�*PPcM:::���ȭ�˺\u0017����٬Y�\u0004�^ZZ�5\u001a��F* | `pages/strategies-index__03.html (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)` |\n| 12 per cent | While most preventable clinical\nhas been an amazing opportunity to be part of making\nincidents do not result in injury, it has been estimated that\nour health system better for all Victorians.”\naround 12 per cent of avoidable adverse events will result in\nserious physical or psychological harm, permanent disability Clinical Lead,\nor most tragically, death3,4. | `strategies/SCV-20Strategic-20Plan-202023-2026.pdf (https://www.safercare.vic.gov.au/sites/default/files/2023-10/SCV%20Strategic%20Plan%202023-2026.pdf)` |\n\n## Key Achievements\n\n- Learn more\n20 November\nREPORT\nAnnual Report 2024–25\nOur 2024-25 annual report highlights our achievements and the initiatives we‘ve undertaken with our partners to improve the quality and safety of healthcare for Victorians.\n Source: `pages/about.html (https://www.safercare.vic.gov.au/about-us)`\n- This will be achieved\nby delivering work across the scope of our accountabilities:\nThe development and implementation Those supporting the department’s\nof a comprehensive state-wide safety annual service delivery performance\nand quality dashboard measures, as they relate to our work6\nPrograms we have been The delivery of government\ncommissioned to deliver to meet election commitments that SCV is\nspecific outcomes accountable for\nWe will detail our workplan and strategic initiatives in our “Providing a clinician perspective is not just a\nAnnual Plans and report on our key achievements and platform, but a responsibility to advocate for my\nchallenges in our Annual Reports during this strategic cycle - patients and for solutions to challenges in the health\n1 July 2023 to 30 June 2026.\n Source: `strategies/SCV-20Strategic-20Plan-202023-2026.pdf (https://www.safercare.vic.gov.au/sites/default/files/2023-10/SCV%20Strategic%20Plan%202023-2026.pdf)`\n- CRANAplus (2013) Clinical governance guide for remote and isolated services in Australia, CRANAplus\nwebsite \nGandhi T, Kaplan G S, Leape L, Berwick D M, Edgman-Levitan S, Edmondson A, Meyer G S, Michaels D,\nMorath J M, Vincent C, Wachter R (2018) Transforming concepts in patient safety: a progress report, BMJ\nQuality and Safety, 27(12):1019-1026. doi:10.1136/bmjqs-2017-007756.\n Source: `strategies/Victorian-20Clinical-20Governance-20Framework.pdf (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)`\n- PARTNERING WITH ITEM ACTION\nCONSUMERS STANDARD\nClinical governance and quality Integrating clinical governance 2.1*\nimprovement systems to support\nApplying quality improvement 2.2*\npartnering with consumers\nsystems\nPartnering with patients in their Healthcare rights and informed 2.3, 2.4, 2.5*\nown care consent\nSharing decisions and planning 2.6, 2.7\ncare\nHealth literacy Communication that supports 2.8*, 2.9, 2.10,\neffective partnerships\nPartnering with consumers in Partnerships in healthcare 2.11, 2.12, 2.13*, 2.14\norganisational design and governance planning, design,\ngovernance measurement and evaluation\nExamples of evidence from the NSQHS workbook, aligning each standard to the domain:\n policy documents that describe the health service organisation’s processes for partnering with\nconsumers, including the:\n– mechanisms available to engage with consumers\n Source: `other-pdfs/FACT-20SHEET-20--20Personalised-20and-20holistic.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-08/FACT%20SHEET%20-%20Personalised%20and%20holistic.pdf)`\n- Consumer involvement is integral to creating a responsive health system.’\nFigure 3: Implementation timeline\nWhat we will deliver in 2019–20\nFEBRUARY JULY\nLaunch of Partnering in healthcare Identify baseline data for Partnering in\nframework document and planning healthcare implementation\nresources\nDevelop evaluation strategy\nMARCH\nDECEMBER\nShared decision-making to feature in\nDevelop resources to support shared\nBetter Care Victoria Innovation Fund\ndecision-making strategies\nLaunch resources to support\nAPRIL equitable and diverse consumer\nengagement\nInaugural Partnering in healthcare\nforum held 29–30 April\n2020\nJUNE\nPartnering in healthcare outcomes\nsummit held\n30 June deadline for health\nShared decision-making projects\nservices to submit at least two\nlaunched in health services\ndomains and priority areas for\naction\n32 Safer Care Victoria Partnering in healthcare\n Source: `strategies/Partnering-20in-20healthcare-20framework-202019_WEB.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf)`\n- [pages 34,35,36]\nFigure 3: Implementation timeline\nWhat we will deliver in 2019–20\nFEBRUARY JULY\nLaunch of Partnering in healthcare Identify baseline data for Partnering in\nframework document and planning healthcare implementation\nresources\nDevelop evaluation strategy\nMARCH\nDECEMBER\nShared decision-making to feature in\nDevelop resources to support shared\nBetter Care Victoria Innovation Fund\ndecision-making strategies\nLaunch resources to support\nAPRIL equitable and diverse consumer\nengagement\nInaugural Partnering in healthcare\nforum held 29–30 April\n2020\nJUNE\nPartnering in healthcare outcomes\nsummit held\n30 June deadline for health\nShared decision-making projects\nservices to submit at least two\nlaunched in health services\ndomains and priority areas for\naction\n32 Safer Care Victoria Partnering in healthcare\n Source: `strategies/Partnering-20in-20healthcare-20framework-202019_WEB.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf)`\n- [Page 2]\nContents page\n3\nAcknowledgement of Country\n4\nMessage from the Chief Executive Officer\nConsumers are essential to building a 5\nsafer healthcare system\n6\nOur strategy at-a-glance\n7\nAbout us\n8\nWhy safety is our priority\n9\nOur strategic plan\n14\nEnabling principles\n16\nMeasuring our impact\n2 Strategic Plan 2023-2026 Safer Care Victoria\n Source: `strategies/SCV-20Strategic-20Plan-202023-2026.pdf (https://www.safercare.vic.gov.au/sites/default/files/2023-10/SCV%20Strategic%20Plan%202023-2026.pdf)`\n- I am\nparticularly interested in equity and acting on social\ndeterminants of health to ensure that everyone in\nVictoria can enjoy the best health possible.”\nClinical Lead,\nContinuing Care Learning Health Network\n6 Refer to Budget Paper 3: Service Delivery at: Budget papers | Victorian Budget 23/24 | Victorian Budget\n16 Strategic Plan 2023-2026 Safer Care Victoria\n Source: `strategies/SCV-20Strategic-20Plan-202023-2026.pdf (https://www.safercare.vic.gov.au/sites/default/files/2023-10/SCV%20Strategic%20Plan%202023-2026.pdf)`\n- [Page 3]\nContents\nForeword 3\nPart 1: Overview 4\nDefining high-quality care 5\nClinical governance in the Victorian health sector 6\nClinical governance principles 7\nPart 2: The ideal clinical governance mindset 8\nAdaptive leadership 8\nPartnering with consumers 9\nContinuous improvement 9\nPart 3: Your clinical governance role 11\nPart 4: Five clinical governance domains in application 15\nLeadership and culture 16\nPartnering with consumers 19\nWorkforce 25\nRisk management 30\nClinical practice 35\nGlossary 41\nUseful resources 44\nReferences 46\nDelivering high-quality care Safer Care Victoria 1\nOFFICIAL\n Source: `strategies/Victorian-20Clinical-20Governance-20Framework.pdf (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)`\n- [pages 13,14,15]\nensuring high-quality care is the central priority and that the strategy is effectively\nimplemented.\n• Establishing a clear organisational vision that encompasses a strong safety culture to enable the provision of consistently high-\nBoards quality care.\n(or equivalent*) • Overseeing the operationalisation of the Victorian Clinical Governance Framework within the organisation.\n• Assuring that all clinicians employed at their health service, either as staff or as contractors, are credentialled and are working\nwithin their scope of practice.\n• Empowering employees and consumers (at the individual, organisational and system level) to be effective and represented across\nthe organisation and provide authentic opportunities for them to be heard.\n Source: `strategies/Victorian-20Clinical-20Governance-20Framework.pdf (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)`\n- [pages 32,33,34]\nk registries are • Emergency management plans and crisis plans are developed and in place.\nforward looking and\n• Rigorous measurement of performance and progress is benchmarked and used to manage risk and drive improvement in the\npreventative\nquality of care.\n• The board receives regular reports on workforce risks, ensures succession plans are in place and workforce pressures and gaps\nare identified.\n Source: `strategies/Victorian-20Clinical-20Governance-20Framework.pdf (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)`\n- Australian Commission on Safety and Quality in Health Care (2020) Australian Charter of Healthcare\nRights (second edition), ACSQHC \nAustralian Commission on Safety and Quality in Health Care (2021) National Safety and Quality Health\nService Standards (second edition), ASQHC \nAustralian Commission on Safety and Quality in Health Care (2023) Partnering with consumers,\nACSQHC, \nAven T (2022) A risk science perspective on discussion concerning Safety I, Safety II, and Safety III,\n Source: `strategies/Victorian-20Clinical-20Governance-20Framework.pdf (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)`\n\n## Key Issues, Risks, and Recommendations\n\n- COMPREHENSIVE CARE ITEM ACTION\nSTANDARD\nClinical governance and quality Partnering with consumers 5.3\nimprovement to support\nDesigning systems to deliver 5.4*\ncomprehensive care\ncomprehensive care\nItem\nDeveloping the comprehensive care Planning for comprehensive 5.8*, 5.9\nplan care\nScreening of risk 5.10\nDeveloping the 5.13\ncomprehensive care plan\nDelivering comprehensive care Using the comprehensive care 5.14\nplan\nComprehensive care at the 5.17*, 5.20*\nend of life\nMinimising patient harm Nutrition and hydration 5.28*\nPreventing delirium and 5.30*\nmanaging cognitive\nimpairment\nPredicting, preventing and 5.31*, 5.32*\nmanaging self-harm and\nsuicide\nPredicting, preventing and 5.34*\nmanaging aggression and\nviolence\nMinimising restrictive 5.35*\npractices: restraint\nMinimising restrictive 5.36*\npractices: seclusion\n Source: `other-pdfs/FACT-20SHEET-20--20Effective-20communication.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-08/FACT%20SHEET%20-%20Effective%20communication.pdf)`\n- [pages 15,16,17,18]\nsupports and encourages productive partnerships\nand collaboration at the individual and organisational levels.\n• Provide employees with timely performance and improvement data and feedback, actively involving them in identifying and\naddressing issues, and ensuring appropriate action is taken.\n• Actively identify, prioritise, monitor, and manage key risk areas, leading escalation, and response efforts when safety is\ncompromised.\n• Support employees who are impacted when quality and safety processes fail.\n• Assuring that all clinicians employed at their health service, either as staff or as contractors, are working within their scope of\npractice.\n• Work to ensure employees feel they are valuable and critical assets within the organisation.\n Source: `strategies/Victorian-20Clinical-20Governance-20Framework.pdf (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)`\n- [Page 3]\nContents\nForeword 3\nPart 1: Overview 4\nDefining high-quality care 5\nClinical governance in the Victorian health sector 6\nClinical governance principles 7\nPart 2: The ideal clinical governance mindset 8\nAdaptive leadership 8\nPartnering with consumers 9\nContinuous improvement 9\nPart 3: Your clinical governance role 11\nPart 4: Five clinical governance domains in application 15\nLeadership and culture 16\nPartnering with consumers 19\nWorkforce 25\nRisk management 30\nClinical practice 35\nGlossary 41\nUseful resources 44\nReferences 46\nDelivering high-quality care Safer Care Victoria 1\nOFFICIAL\n Source: `strategies/Victorian-20Clinical-20Governance-20Framework.pdf (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)`\n- Australian Commission on Safety and Quality in Health Care (2020) Australian Charter of Healthcare\nRights (second edition), ACSQHC \nAustralian Commission on Safety and Quality in Health Care (2021) National Safety and Quality Health\nService Standards (second edition), ASQHC \nAustralian Commission on Safety and Quality in Health Care (2023) Partnering with consumers,\nACSQHC, \nAven T (2022) A risk science perspective on discussion concerning Safety I, Safety II, and Safety III,\n Source: `strategies/Victorian-20Clinical-20Governance-20Framework.pdf (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)`\n- CLINICAL GOVERNANCE ITEM ACTION\nSTANDARD\nGovernance, leadership and culture Governance, leadership and 1.1, 1.2*\nculture\nOrganisational Leadership 1.3, 1.4*, 1.5\nClinical Leadership 1.6\nPatient safety and quality systems Measurement and quality 1.8, 1.9\nimprovement\nRisk Management 1.10\nIncident management 1.11, 1.12\nsystems and open disclosure\nFeedback and complaints 1.13, 1.14\nmanagement\nDiversity and high-risk groups 1.15\nClinical performance and Safety and quality training 1.19, 1.21*\neffectiveness\nSafe environments for the delivery of Safe environment 1.31*, 1.32*,1.33*\ncare\nExamples of evidence from the NSQHS workbook, aligning each standard to the domain:\n communication with the workforce or consumers on the health service organisation’s clinical governance\nframework for safety and quality performance\n Source: `other-pdfs/FACT-20SHEET-20--20Effective-20communication.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-08/FACT%20SHEET%20-%20Effective%20communication.pdf)`\n- This will be achieved\nby delivering work across the scope of our accountabilities:\nThe development and implementation Those supporting the department’s\nof a comprehensive state-wide safety annual service delivery performance\nand quality dashboard measures, as they relate to our work6\nPrograms we have been The delivery of government\ncommissioned to deliver to meet election commitments that SCV is\nspecific outcomes accountable for\nWe will detail our workplan and strategic initiatives in our “Providing a clinician perspective is not just a\nAnnual Plans and report on our key achievements and platform, but a responsibility to advocate for my\nchallenges in our Annual Reports during this strategic cycle - patients and for solutions to challenges in the health\n1 July 2023 to 30 June 2026.\n Source: `strategies/SCV-20Strategic-20Plan-202023-2026.pdf (https://www.safercare.vic.gov.au/sites/default/files/2023-10/SCV%20Strategic%20Plan%202023-2026.pdf)`\n- [Page 47]\nResource link Leadership and Partnering with Risk\nWorkforce Clinical practice\nculture consumers management\nSCV Credentialing and scope of practice for senior\n•\nmedical practitioners policy\n• • • •\nSCV Just Culture Guide\nSCV Just Culture in adverse event reviews • • • • •\nfactsheet\n• • • •\nSCV Leadership and Safety Culture factsheet\n•\nSCV Partnering in healthcare\nSCV Sentinel events and Statutory Duty of • • • • •\nCandour\nVictorian Agency for Health Information eHealth • •\ndata interpretation videos\nVictorian Department of Health Occupational • • • • •\nviolence and aggression\n• • • • •\nVictorian Public Interest Disclosure Act 2012\n• • • • •\nVictorian Safety Culture Guide\n• • • • •\nVictorian Whistleblowers Protection Act 2001\nDelivering high-quality care Safer Care Victoria 45\n Source: `strategies/Victorian-20Clinical-20Governance-20Framework.pdf (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)`\n- [pages 5,6,7]\n*, 5.20*\nend of life\nMinimising patient harm Nutrition and hydration 5.28*\nPreventing delirium and 5.30*\nmanaging cognitive\nimpairment\nPredicting, preventing and 5.31*, 5.32*\nmanaging self-harm and\nsuicide\nPredicting, preventing and 5.34*\nmanaging aggression and\nviolence\nMinimising restrictive 5.35*\npractices: restraint\nMinimising restrictive 5.36*\npractices: seclusion\nExamples of evidence from the NSQHS workbook, aligning each standard to the domain:\n results of consumer and carer experience surveys, and actions taken to deal with issues identified\n feedback from patients and carers regarding their involvement in care, the extent to which their needs\nwere met and participation in shared decision making\n consumer and carer information packages or resources about advance care planning.\n Source: `other-pdfs/FACT-20SHEET-20--20Effective-20communication.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-08/FACT%20SHEET%20-%20Effective%20communication.pdf)`\n- Consumer involvement is integral to creating a responsive health system.’\nFigure 3: Implementation timeline\nWhat we will deliver in 2019–20\nFEBRUARY JULY\nLaunch of Partnering in healthcare Identify baseline data for Partnering in\nframework document and planning healthcare implementation\nresources\nDevelop evaluation strategy\nMARCH\nDECEMBER\nShared decision-making to feature in\nDevelop resources to support shared\nBetter Care Victoria Innovation Fund\ndecision-making strategies\nLaunch resources to support\nAPRIL equitable and diverse consumer\nengagement\nInaugural Partnering in healthcare\nforum held 29–30 April\n2020\nJUNE\nPartnering in healthcare outcomes\nsummit held\n30 June deadline for health\nShared decision-making projects\nservices to submit at least two\nlaunched in health services\ndomains and priority areas for\naction\n32 Safer Care Victoria Partnering in healthcare\n Source: `strategies/Partnering-20in-20healthcare-20framework-202019_WEB.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf)`\n- [pages 34,35,36]\nFigure 3: Implementation timeline\nWhat we will deliver in 2019–20\nFEBRUARY JULY\nLaunch of Partnering in healthcare Identify baseline data for Partnering in\nframework document and planning healthcare implementation\nresources\nDevelop evaluation strategy\nMARCH\nDECEMBER\nShared decision-making to feature in\nDevelop resources to support shared\nBetter Care Victoria Innovation Fund\ndecision-making strategies\nLaunch resources to support\nAPRIL equitable and diverse consumer\nengagement\nInaugural Partnering in healthcare\nforum held 29–30 April\n2020\nJUNE\nPartnering in healthcare outcomes\nsummit held\n30 June deadline for health\nShared decision-making projects\nservices to submit at least two\nlaunched in health services\ndomains and priority areas for\naction\n32 Safer Care Victoria Partnering in healthcare\n Source: `strategies/Partnering-20in-20healthcare-20framework-202019_WEB.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf)`\n- It was also\nfor consumer participation in healthcare. informed by recommendations in:\nThis built on the previous work undertaken by\nl Consumer participation in the health system\nthe department.\n(Victorian Auditor-General’s Office, 2012)\nThe framework comprised five key areas, drawn\nl KPMG recommendations regarding the\nfrom the best evidence, practice and research,\nsummative evaluation of policy frameworks:\nthrough which work could make a real difference.\n– Doing it with us not for us: Strategic\nTo test this framework, SCV consulted widely\ndirection 2010–2013 (2009)\nabout how best to improve healthcare in Victorian\n– Cultural responsiveness framework (2009)\nhospitals.\n Source: `strategies/Partnering-20in-20healthcare-20framework-202019_WEB.pdf (https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf)`\n- Horvat, L, Horey, D, Romios, P & Kis-Rigo, J\nCoulter, A 2011, Engaging Patients in Healthcare,\n2014, ‘Cultural competence education for\nOpen University Press, United Kingdom.\nhealth professionals’, Cochrane Database\nof Systematic Reviews, Issue 5, viewed 14\nDelbanco, T, Berwick, D, Boufford, J, Edgman-\nNovember 2018, \nAustralian Commission on Safety and Quality in Health Care (2021) National Safety and Quality Health\nService Standards (second edition), ASQHC \nAustralian Commission on Safety and Quality in Health Care (2023) Partnering with consumers,\nACSQHC, \nAven T (2022) A risk science perspective on discussion concerning Safety I, Safety II, and Safety III,\n Source: `strategies/Victorian-20Clinical-20Governance-20Framework.pdf (https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf)`\n\n## Global Ideas and Case Study Inputs\n\n_No global-intelligence source text found yet. Run `CLAUDE/global-ideas-scraper.py ` to populate case-study sources._\n\n## Source Artifacts Used\n\n- `strategies/Partnering-20in-20healthcare-20framework-202019_WEB.pdf` - strategies - https://www.safercare.vic.gov.au/sites/default/files/2019-02/Partnering%20in%20healthcare%20framework%202019_WEB.pdf\n- `strategies/SCV-20Strategic-20Plan-202023-2026.pdf` - strategies - https://www.safercare.vic.gov.au/sites/default/files/2023-10/SCV%20Strategic%20Plan%202023-2026.pdf\n- `strategies/Victorian-20Clinical-20Governance-20Framework.pdf` - strategies - https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf\n- `pages/about.html` - pages - https://www.safercare.vic.gov.au/about-us\n- `pages/contact.html` - pages - https://www.safercare.vic.gov.au/contactus\n- `pages/homepage.html` - pages - https://www.safercare.vic.gov.au/\n- `pages/leadership.html` - pages - https://www.safercare.vic.gov.au/about-us/our-leadership-team/anna-love\n- `pages/news-latest.html` - pages - https://www.safercare.vic.gov.au/news\n- `pages/priorities-index.html` - pages - https://www.safercare.vic.gov.au/about-us\n- `pages/priorities-index__04.html` - pages - https://www.safercare.vic.gov.au/about-us/plans-and-reports/annual-plan-2025-26\n- `pages/priorities-index__05.html` - pages - https://www.safercare.vic.gov.au/about-us/plans-and-reports/strategic-plan-2023-26\n- `pages/publications-index.html` - pages - https://www.safercare.vic.gov.au/publications\n- `pages/recommendations-index.html` - pages - https://www.safercare.vic.gov.au/events/dont-chase-recommendations-fix-the-themes-a-smarter-sapse-approach\n- `pages/strategies-index.html` - pages - https://www.safercare.vic.gov.au/best-practice-improvement/clinical-governance/framework\n- `pages/strategies-index__00.html` - pages - https://www.safercare.vic.gov.au/best-practice-improvement/clinical-governance/framework\n- `pages/strategies-index__01.html` - pages - https://www.safercare.vic.gov.au/best-practice-improvement/partnering-with-consumers/pih\n- `pages/strategies-index__02.html` - pages - https://www.safercare.vic.gov.au/publications/victorian-clinical-governance-framework\n- `pages/strategies-index__03.html` - pages - https://www.safercare.vic.gov.au/sites/default/files/2024-08/Victorian%20Clinical%20Governance%20Framework.pdf\n- `other-pdfs/FACT-20SHEET-20--20Effective-20communication.pdf` - other-pdfs - https://www.safercare.vic.gov.au/sites/default/files/2019-08/FACT%20SHEET%20-%20Effective%20communication.pdf\n- `other-pdfs/FACT-20SHEET-20--20Equity-20and-20inclusion.pdf` - other-pdfs - https://www.safercare.vic.gov.au/sites/default/files/2019-08/FACT%20SHEET%20-%20Equity%20and%20inclusion.pdf\n- `other-pdfs/FACT-20SHEET-20--20Personalised-20and-20holistic.pdf` - other-pdfs - https://www.safercare.vic.gov.au/sites/default/files/2019-08/FACT%20SHEET%20-%20Personalised%20and%20holistic.pdf\n- `other-pdfs/FACT-20SHEET-20--20Shared-20decision-making.pdf` - other-pdfs - https://www.safercare.vic.gov.au/sites/default/files/2019-08/FACT%20SHEET%20-%20Shared%20decision-making.pdf\n- `other-pdfs/Partnering-20in-20healthcare-20statement-20of-20intent-202025-26.pdf` - other-pdfs - https://www.safercare.vic.gov.au/sites/default/files/2025-06/Partnering%20in%20healthcare%20statement%20of%20intent%202025-26.pdf\n\n## Gaps To Fix\n\n- No corporate plan text source found.\n- No annual report text source found.\n- No global comparison/case-study sources found.", "legislation_md": "# Safer Care Victoria - Acts and Legislation Discovery\n\n**Generated at**: 2026-05-09T21:35:51.596885+00:00\n**Entity ID**: S-VIC-028\n**Jurisdiction**: Victoria\n**Portfolio**: Health\n\n> This is an evidence-based discovery list from scraped department material. A mention does not always mean the department administers the legislation; high-confidence and official register links should be reviewed.\n\n## Summary\n\n- Source files scanned: 23\n- Unique legislation references found: 5\n\n| Type | Count |\n|---|---:|\n| Act | 5 |\n\n## Legislation References\n\n### Mental Health and Wellbeing Act 2022\n\n**Type**: Act\n**Confidence**: medium\n**Mentions**: 1\n**Register search**: https://www.legislation.vic.gov.au/search?q=Mental+Health+and+Wellbeing+Act+2022\n\n**Sources**:\n- `pages/leadership.html`\n\n**Evidence contexts**:\n- e groups both within and external to the Department of Health and Human Services, at state and national levels\nsupport the delivery of clinical quality and safety within our funded services\nexecutive sponsor to the\nMental Health Improvement Program\nLearn more\nMental Health and Wellbeing Act 2022\nView more\nView less\nVictoria's\nMental Health and Wellbeing Act 2022\nis a key element to the government's mental health reform agenda, and places individuals and carers at the centre of mental health treatment and care.\nBest practice\nView more\nView less\nMental\n Source: `pages/leadership.html`\n\n### Victoria's Mental Health and Wellbeing Act 2022\n\n**Type**: Act\n**Confidence**: medium\n**Mentions**: 1\n**Register search**: https://www.legislation.vic.gov.au/search?q=Victoria%27s+Mental+Health+and+Wellbeing+Act+2022\n\n**Sources**:\n- `pages/leadership.html`\n\n**Evidence contexts**:\n- alth and Human Services, at state and national levels\nsupport the delivery of clinical quality and safety within our funded services\nexecutive sponsor to the\nMental Health Improvement Program\nLearn more\nMental Health and Wellbeing Act 2022\nView more\nView less\nVictoria's\nMental Health and Wellbeing Act 2022\nis a key element to the government's mental health reform agenda, and places individuals and carers at the centre of mental health treatment and care.\nBest practice\nView more\nView less\nMental Health Intensive Care Framework\nThe Mental Health Intensive Care Fr\n Source: `pages/leadership.html`\n\n### Victorian Public Interest Disclosure Act 2012\n\n**Type**: Act\n**Confidence**: medium\n**Mentions**: 1\n**Register search**: https://www.legislation.vic.gov.au/search?q=Victorian+Public+Interest+Disclosure+Act+2012\n\n**Sources**:\n- `strategies/Victorian-20Clinical-20Governance-20Framework.pages.jsonl`\n\n**Evidence contexts**:\n- t\n•\nSCV Partnering in healthcare\nSCV Sentinel events and Statutory Duty of • • • • •\nCandour\nVictorian Agency for Health Information eHealth • •\ndata interpretation videos\nVictorian Department of Health Occupational • • • • •\nviolence and aggression\n• • • • •\nVictorian Public Interest Disclosure Act 2012\n• • • • •\nVictorian Safety Culture Guide\n• • • • •\nVictorian Whistleblowers Protection Act 2001\nDelivering high-quality care Safer Care Victoria 45\n\n[page 48]\nReferences\nAustralian Commission on Safety and Quality in Health Care (2013) Australian open disclos\n Source: `strategies/Victorian-20Clinical-20Governance-20Framework.pages.jsonl`\n\n### Victorian Whistleblowers Protection Act 2001\n\n**Type**: Act\n**Confidence**: medium\n**Mentions**: 1\n**Register search**: https://www.legislation.vic.gov.au/search?q=Victorian+Whistleblowers+Protection+Act+2001\n\n**Sources**:\n- `strategies/Victorian-20Clinical-20Governance-20Framework.pages.jsonl`\n\n**Evidence contexts**:\n- orian Agency for Health Information eHealth • •\ndata interpretation videos\nVictorian Department of Health Occupational • • • • •\nviolence and aggression\n• • • • •\nVictorian Public Interest Disclosure Act 2012\n• • • • •\nVictorian Safety Culture Guide\n• • • • •\nVictorian Whistleblowers Protection Act 2001\nDelivering high-quality care Safer Care Victoria 45\n\n[page 48]\nReferences\nAustralian Commission on Safety and Quality in Health Care (2013) Australian open disclosure\nframework, ACSQHC,