Part 3: Clinical Governance | Insights into the RACGP Standards 6th edition

Building Better Practices: Insights into the RACGP Standards 6th edition
PART 3: Clinical Governance

Following the release of the draft the Royal Australian College of General Practitioners (RACGP) Standards for general practices 6th edition, industry consultation period and the commencement of the pilot program, our team is excited to provide you with a five-part content series exploring key themes within the proposed new edition of the RACGP Standards titled ‘Building Better Practices: Insights into the RACGP Standards 6th edition’.

Through this series, we aim to provide you with a greater understanding of some of the essential elements shaping the RACGP Standards 6th edition.

PART 1 looked into the Quintuple Aim of healthcare improvement and its role in Australian general practice, with our second instalment, PART 2, unpacking Standard 1 of the RACGP Standards 6th edition – ‘Foundations of general practice’.

In PART 3 we explore Standard 2 of the draft RACGP Standards 6th edition which revolves around ‘Clinical Governance’. 

 

DISCLAIMER
The information contained within this content-series is general in nature and has not been provided or reviewed by the RACGP. The RACGP Standards 6th edition are still in draft format and will be undergoing further review and updates as part of the pilot program and consultation period. The details of the 6th edition are subject to change and therefore this information has been collated based on the information provided to us at the time of publishing. Information regarding each proposed new Standard also discusses general themes associated with each particular topic.

 

Clinical Governance within general practice  

Clinical governance is a renowned framework supporting practices to be accountable for the delivery of safe, high-quality and effective healthcare. It supports practice teams to manage risk and works to protect the safety of patients and staff. By embedding a strong clinical governance framework within your practice, you’re enhancing your ability to deliver consistent and quality-focused healthcare for your local community.

While clinical governance may seem complex due to its broad scope and interconnected components, it’s inherently embedded in the day-to-day operations of a practice.

Each member of your practice team can play a pivotal role in operationalising clinical governance principles by implementing policies, fostering a culture of quality improvement, and ensuring compliance with the legislation and the accreditation requirements of the RACGP Standards.

While the framework itself may appear theoretical or intricate, its principles are inherently part of tasks like managing infection control processes, refining workflows, overseeing incident reporting, and ensuring effective staff communication.

Key components of effective clinical governance revolve around the following five areas:

1. Quality Assurance and Improvement: Enables you to ensure systems are in place to monitor, evaluate, and enhance care quality.
2. Risk Management: Supports in identifying, assessing, and mitigating risks to patients, staff, and the practice.
3. Education and Training: Promotes continuous professional development for clinical and non-clinical staff.
4. Performance and Accountability: Assists in setting benchmarks and holding the team accountable for maintaining high standards.
5. Engaging with Patients and Stakeholders: Encourages feedback and fostering a culture of transparency and partnership.

By simplifying the various components associated with an effective clinical governance framework and connecting it to your daily activities, your team will be provided with a strengthened appreciation for its value. This increased understanding will enable your team to further harness this effective tool to drive sustainable improvements in safety, quality, and patient outcomes.

RACGP Standards 6th edition inclusions – current draft

Within the current draft of the RACGP Standards for general practices 6th edition, Standard 2: Clinical Governance, supports your practice to review current systems associated with patient health records, the use of guidelines, transitions of care, infection prevention and control, practice environment and equipment, and research. This Standard aims to foster an open and transparent general practice culture and to promote the digitisation of patient health records.

There are thirteen proposed Criterion within Standard 2 of the 6th edition, which cover the following aspects of clinical governance:

CG1: Clinical Information Systems

CG1: Clinical Information Systems requires your practice to you use digital systems to manage and maintain patient health information, ensuring accuracy and accessibility. This supports effective communication, decision-making, and quality improvement.

Quick tips:

• This Criterion asks your practice to use a digital clinical information system to manage patient health information. Paper-based systems are no longer acceptable. Criterion CG1 acknowledges that hybrid systems may still be needed (e.g. if your practice has patients at residential aged care facilities), however all systems need to be digital
• Use a single digital clinical information system where possible.
• If using multiple systems, ensure summaries and notes are synchronised across platforms.
• Train all practitioners on accessing and recording information consistently.
• New addition: your practice must monitor and report on your environmental performance to track progress toward sustainability goals and compliance with your documented strategies. This continuous quality improvement criterion also asks your practice to measure environmental-impact metrics to assess and manage your overall environmental footprint.

• To promote continuous quality improvement, your practice must conduct at least one clinical improvement activity every 12 months.

CG2: Patient Identification

Summary: Patients must be accurately identified and matched to their health record to avoid errors in care delivery, maintain safety and protect patient confidentiality.

Quick tips:

• Requirements on meeting this Criterion are not prescriptive (unlike in the 5th edition Standards) however demonstrated compliance must ensure that your team is correctly able to identify and match patients to their health records.
• Train staff to confirm identity without compromising confidentiality.
• Avoid relying on shared identifiers like Medicare numbers.

CG3: Facilitating Complete Patient Health Records

Summary: Maintain accurate, up-to-date health records for all active patients, including demographic and medical details.

Quick tips:

• Ensure your practice’s patient health record systems allows:

• Clinicians to record all consultations and clinical-related communications in the patient’s health record
• The practice team to record all communications with patients

• Use coding systems for structured data entry.
• Regularly update patient health summaries and allergy information.
• Educate staff on maintaining comprehensive records.
• CG3 broadly aligns with the RACGP Standards 5th edition requirements regarding the content of health records however proposed new requirements ask for:

• Demographic and identification details for each active patient to include assigned sex at birth, variations of sex characteristics (intersex), gender and pronouns (in addition to identification details, contact details, next of kin and emergency contact information)
• Active patient health records to use nationally recognised medical vocabulary for coding (previously an aspirational indicator in the fifth edition Standards) and contain each patient’s current health summary
• All (100%) of your active patient health records to include known allergies or indicate that the patient has no known allergies.

CG4: Provision of Clinical and Medicines Guidelines

Summary: Provide clinical teams with current, evidence-based guidelines for diagnosis, treatment, and emergency care.

Quick tips:

• Ensure access to Australian-approved guidelines, including emergency protocols.
• Promote sustainable clinical practices by offering resources and strategies.
• Provide your clinical team with current information relating to medicines, including information about the purpose, importance, benefits and risks of medicines
• Have current, best evidence-based and accurate clinical and other emergency care guidelines available.

CG5: Transitions of Care

Summary: Facilitate seamless communication and transfer of patient information during care transitions to minimise risk and support continuity of care.

Quick tips:

• Develop a clinical handover policy for internal and external transitions.
• Use secure systems for transferring patient records.
• Obtain patient consent for record transfers.
• Refer to the RACGP’s ‘Secure use of email in general practice’ fact sheet to support clinical handover via email.
• Refer to the RACGP’s ‘Managing external requests for patient information’ to support transfer of patient information upon patient request.

CG6: Follow-Up Systems

Summary: Ensure timely review and communication of test results, follow-ups and required actions, especially for high-risk outcomes.

Quick tips:

• Although not mandatory it can be helpful to document your recall process for ease of access.
• Maintain a recall and reminder system for patients.
• Document all follow-up attempts in health records.
• Have policies to manage after-hours critical results.

CG7: Managing Clinical Risks and Incidents

Summary: Identify, monitor, and mitigate clinical risks, and learn from incidents to improve safety. Implement improvements based on learnings, events and/or near misses or to further mitigate clinical risks and incidents.

Quick tips:

• Have your process for managing clinical risk documented. You may also like to include your procedures for mitigating clinical risk.
• Maintain a risk register and update it regularly.
• Encourage staff to report incidents without fear of blame and provide support should staff be involved in clinical incidents.
• Analyse incidents to identify root causes and implement solutions.

CG8: Immunisations

Summary: Ensure all practice team members are appropriately immunised based on their roles to protect patients and staff, ensuring immunisation status is recorded in each team member’s personnel file.

Quick tips:

• Document immunisation records and immunity status for staff.
• Offer vaccinations as per state or territory guidelines and refer to the ‘Australian Immunisation Handbook’ to identify recommendation vaccinations for healthcare workers.
• Develop alternative duties for non-immunised team members during outbreaks.

CG9: Infection Prevention and Control, including reprocessing

Summary: Implement evidence-based systems to prevent and control infections within the practice.

Quick tips:

• Assign an Infection Control Coordinator.
• Regularly review and update your documented infection control policy in line with relevant industry and evidence-based guidelines.
• Train all staff on infection prevention protocols. Communicate updates to staff and patients.
• Maintain a clean practice environment and proper sterilisation processes, ensure staff have access to and use appropriate Personal Protective Equipment (PPE).

CG10: Practice Environment

Summary: Provide a clean, safe, and private environment for delivering care.

Quick tips:

• Ensure consultation rooms maintain auditory and visual privacy.
• Provide accessible and hygienic facilities for patients and staff.
• Address cultural and physical accessibility needs.

CG11: Practice Equipment

Summary: Maintain all equipment and medicines to ensure safe and quality care. Ensure staff are appropriately trained to use the equipment safely and correctly.

Quick tips:

• Create a checklist of ‘Required Practice Equipment’ to cross-check you have everything needed to provide comprehensive primary and emergency care, and resuscitation.
• Include essential items in doctors’ bags, such as emergency medicines.
• Keep a maintenance log for equipment servicing.
• Conduct regular training on equipment use.
• Ensure you have a spirometer that is easy to access.
• Keep up-to-date with all manufacturers directions and relevant laws in regards to medicines, samples and medical consumables.

CG12: Maintaining Vaccine Potency

Summary: Follow strict cold chain management processes to preserve vaccine efficacy and ensure safe and effective vaccine delivery.

Quick tips:

• Document your cold chain management processes.
• Assign a cold chain coordinator and train them thoroughly.
• Ensure your cold chain management process complies with the current National vaccine storage guidelines: Strive for 5.
• Monitor refrigerator temperatures at least twice daily.
• Use purpose-built vaccine refrigerators.

CG13: Research

Summary: Ensure ethical standards, approvals, and patient consent are in place when participating in research.

Quick tips:

• Obtain approval from a Human Research Ethics Committee before commencing any research and ensure compliance with any relevant legislation.
• Document patient consent and allow opt-outs for data use.
• Ensure appropriate indemnity insurance for research activities.

Clinical governance is a vital framework in general practice, ensuring the delivery of safe, high-quality, and patient-centred care. By embedding its principles into daily operations, your practice can enhance your risk management systems, accountability, and continuous quality improvement activities to support quality care and business operations.

The draft RACGP Standards 6th edition underscores the importance of clinical governance by detailing criteria such as maintaining complete patient records, infection control, effective care transitions, and sustainable practices.

Implementing robust clinical governance systems fosters transparency, builds patient trust, and empowers practice teams to deliver consistent, evidence-based care while meeting accreditation requirements. Strengthening these systems ultimately drives sustainable improvements in safety, quality, and patient outcomes.

Transition information

The RACGP has stipulated that practices can choose to be accredited under either the 5th or 6th edition Standards for the first 12 months following the publication of the 6th edition – which is currently planned for early 2026. After this transition period, all practices seeking accreditation must meet the requirements of the 6th edition Standards.

Our team will continue to provide you with updates as we work with the RACGP as they refine and test the RACGP Standards 6th edition.

We appreciate your patience as we wait for further information regarding timelines and program readiness. We’re committed to providing you with timely updates to ensure you and your team are informed and prepared for this transition when the time comes.

For current accreditation support with the RACGP Standards 5th edition, contact the AGPAL Team:

P: 1300 362 111
E: info@agpal.com.au