Implementation guidelines for private office based mental health practices

Standard 8: Governance, leadership and management

Page last updated: October 2010

The MHS is governed, led and managed effectively and efficiently to facilitate the delivery of quality and coordinated services.

Guidelines
Suggested evidence

Guidelines

The intent of this Standard is to ensure that structures are put in place to facilitate effective governance of the mental health services (MHS).

Integration and coordination (Criterion 8.1)

The MHS should address both corporate and clinical governance responsibilities.

The MHS strategic plan needs to accord with legislative requirements and national and state/territory level mental health policies and related documents.

The MHS should ensure that staff have access to formal supervision. Depending on the setting, supervision of staff can be multidisciplinary, discipline specific, under an individual or group, or by peer or case review.

Critical incidents (Criterion 8.8)

The MHS should have a formal process to review critical incidents. The process should support both staff and others within the MHS affected by the critical incident. The outcomes of the review of incidents should be used to inform ongoing prevention plans.

Further information on critical incidents is available in the guidelines for Standard 2 Safety.

Data management systems provide evidence of:
  • compliance with legislative requirements
  • achievement of reporting requirements.
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Risk management (Criterion 8.10)

Information gathered through feedback, complaints, incidents and adverse reporting should be part of clinical and corporate governance, including risk management processes.

The MHS must have documented systems that are evaluated to ensure corporate and clinical risks are:
  • identified
  • analysed
  • evaluated
  • treated
  • continuously monitored and reviewed
  • communicated.
Further information on risk management is available from the guidelines for Standard 2 Safety and Standard 4 Diversity responsiveness.

Formal quality improvement program (Criterion 8.11)

The MHS analyses data to promote effective care for consumers and their carers.

The MHS has documented systems that are evaluated to ensure complaints, adverse events, critical incidents and near misses reporting are used for quality improvement activities. Information gathered through feedback, complaints, incidents and adverse events reporting should be part of clinical governance, including risk management processes.

Suggested evidence

Evidence that may be provided for this standard includes policies and procedures covering:
  • a framework for the development of policies
  • schedules for policy review
  • evaluation of compliance to policies and procedures
  • regular review and update of policies
  • human resources.