Clinical Governance Framework Policy Template for Aged Care
Clinical governance is the system by which aged care providers are accountable for continuously improving the quality and safety of care. It is a board-level obligation under the Strengthened Aged Care Quality Standards — and providers without a documented clinical governance framework are exposed to significant regulatory risk.
This free Clinical Governance Framework Policy template gives boards, CEOs, and clinical leaders a structured document that defines their clinical accountability structures, quality oversight mechanisms, and continuous improvement commitments.
What Is Clinical Governance in Aged Care?
Clinical governance encompasses all the activities by which an organisation ensures that care is safe, effective, person-centred, timely, efficient, and equitable. In aged care it includes:
- Board and executive accountability for clinical outcomes
- Clinical performance monitoring and reporting
- Credentialing and scope of practice management for clinical staff
- Incident and adverse event management
- Clinical audit and peer review
- Evidence-based practice and clinical guideline adoption
- Consumer and family engagement in care quality
Strengthened ACQS Requirements for Clinical Governance
Standard 8 (Organisational Governance) of the Strengthened Aged Care Quality Standards requires providers to demonstrate that governance systems — including clinical governance — are effective, accountable, and continuously improving. Boards and governing bodies are specifically held accountable for clinical safety outcomes.
What This Template Includes
- Clinical governance policy statement
- Clinical governance structure (committee and reporting lines)
- Board and executive clinical accountability obligations
- Clinical performance indicators and monitoring framework
- Credentialing and scope of practice procedures
- Clinical audit program requirements
- Incident and adverse event learning system
- Consumer engagement in clinical quality
- Roles and responsibilities matrix
- Legislation and standards references
Download the Free Clinical Governance Framework Policy Template
Instant access. Editable Word document. No credit card required.
Frequently Asked Questions
Do small aged care facilities need a clinical governance framework?
Yes. The obligations under the Strengthened ACQS apply to all approved providers regardless of facility size. The governance structures may be simpler in a smaller organisation, but the accountability obligations are the same.
Who is responsible for clinical governance in an aged care facility?
Ultimately, the Board or governing body. The Strengthened ACQS make this explicit — directors are personally accountable for the quality and safety of care delivered by the organisation.
