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Clinical governance can be supported through effective regulatory design - and setting minimum standards. However, clinical governance is not just about compliance.

It has been acknowledged in the context of aged care reforms that an ‘improved approach to regulating aged care will go beyond compliance to foster a culture and practice of continuous improvement to deliver higher quality care that better supports the wellbeing of senior Australians.’ Indeed, clinical governance is aspirational, and a culture of continuous improvement should be embedded in any care organisation - not only at the point of care through to management, but also within the governing body.

The Royal Commission into Aged Care Quality and Safety (Royal Commission) recommended that every approved provider of aged care should ‘have members of the governing body who possess between them the mix of skills, experience and knowledge of governance responsibilities, including care governance, required to provide governance over the structures, systems and processes for ensuring the safety and high quality of the care delivered by the provider.’

More broadly, the Australian Institute of Company Directors has stated, in relation to board recruitment:

‘Having the appropriate mix of competencies for a board to undertake its role is seen as the most important requirement of a modern of board. In short, a board without the mix of competencies required to fulfil its task is a board which is bound to fail.’

The proposed amendments to the Commonwealth Aged Care Act 1997, through the Aged Care and Other Legislation Amendment (Royal Commission Response No. 2) Bill 2021 (Bill), if passed, will require (amongst other things) approved providers of aged care to ensure at least one member of their governing body has ‘experience in the provision of clinical care’. The (Revised) Explanatory Memorandum to the Bill (EM) confirms alignment of the proposed changes to these requirements and further states:

‘Clinical skills and expertise are critical, given a provider’s core business is providing services to older Australians who have been assessed as requiring additional care and or support to ensure their safety, health, wellbeing and quality of life. The amendments do not specify the clinical experience required to qualify as a member of approved provider’s governing body - each approved provider should consider the clinical experience and qualifications that will best support their decision making in view of the types of care and services that are provided.’

As explained by the EM, relevant clinical experience and expertise (as determined by the provider) should enable information reported about care delivery to be interpreted, and potential problems identified.

It is important to note that while some smaller organisations may be excluded from this requirement (provided they meet certain conditions), this by no means abrogates their responsibility for clinical governance. The EM suggests that in these circumstances, other methods should be adopted to support effective governance, such as ‘by seeking external advice or opinions on particular matters from a person with experience in the provision of clinical care when executive decision-making impacts or interacts with the delivery of care by aged care providers.’ The Bill does not set this out as a specific requirement - however clinical governance is not just a regulatory obligation; it is about striving towards optimal outcomes, in any event.

The proposed reforms are a positive step towards embedding clinical governance in aged care, starting with governing bodies. In addition, the Bills proposes the establishment of a ‘quality care advisory body’ (to report on the quality of care delivered, which must be considered by the governing body), and a ‘consumer advisory body’ (to give feedback on the quality of care and services, which must be considered by the governing body). However, at this stage, we do not know when the legislation will be passed, or whether further amendments will be made.

Nevertheless, if we adopt an authentic clinical governance approach, we should be taking these steps regardless (at a minimum).

The Royal Commission informed us that governing bodies of approved providers did not always give adequate attention to the quality of care delivered - despite this being part of their core business. Providers of any care, whether aged care or otherwise, not only owe a duty of care to their clients/patients, but should aspire to provide the best possible consumer-centred care they can. Clinical governance is about achieving optimal outcomes, not just delivering the bare minimum. If we practice robust clinical governance, compliance will follow.

If a board’s oversight of clinical governance is to have any real effect, common sense dictates that there must be a clinical presence - someone who understands clinical care. We do not need Parliament to tell us this - what we need is a true understanding of what clinical governance really means, and the right skill set to support it. We start by acknowledging that clinicians are well equipped with the skills and insights required to affect positive change in the broader health system.

Let us not wait to see what Parliament ultimately decides - let’s decide for ourselves now. A clinician should always be on the board of any organisation that delivers care (noting that even ‘non-clinical’ care has the potential to impact clinical outcomes in a vulnerable cohort of people). Ultimately, it is the governing body that oversees outcomes, and is accountable for them.