Figure E1 shows a selection of measures out of a sample of 16 serious incident action plans we reviewed across the four audited health services compared to better practice examples. The selection captures a spread of incident and measure types from the sampled action plans. There were two incidents where health services used relevant measures to assess the impact of implemented actions. We denote these measures with a ‘^’. 

Click the link below to open a PDF copy of Figure E1: Reported and proposed outcome measures for selected serious incidents.

We briefly discuss the audited health services' initiatives to promote a positive patient safety culture below. PH's placemats and MH's improvement huddles and improvement noticeboards are excluded here as these are covered in Section 2.2.

We have consulted with BHS, DjHS, MH, PH and DH, and we considered their views when reaching our audit conclusions. As required by the Audit Act 1994, we gave a draft copy of this report, or relevant extracts, to those agencies and asked for their submissions and comments. 

Responsibility for the accuracy, fairness and balance of those comments rests solely with the agency head.

Conclusion

While health services act when they identify underperformance or emerging risks, they do not consistently identify and respond to quality and safety risks in a timely way. Significant delays in completing serious incident investigations and resulting actions to address underlying issues mean that patients remain at risk of known avoidable harm for too long. 

Conclusion

MH and PH have made greater improvements to their patient safety cultures since Targeting Zero, than BHS and DjHS. They have done this by embedding their clinical governance frameworks in their organisations and supporting staff to actively uphold patient safety. 

Conclusion

Not all audited health services have embedded their clinical governance frameworks in their organisations. While their frameworks are generally consistent with the VCGF, only MH and PH use their frameworks to identify specific local quality and safety priorities, raise staff awareness and drive changes in organisational practices. 

Health services provide care in complex and high-pressure environments where avoidable harm to patients can occur. Effective clinical governance cultures, systems and processes minimise this risk and reduce the potential for harm.

A health service's clinical governance framework describes the activities it will undertake to minimise harm and maximise the quality of patient care. Health services must meet national and state standards for clinical governance.

Agencies were required to self‐attest to the accuracy and completeness of their survey response. The survey sought information on the status of performance audit recommendations:

• from all VAGO performance audits tabled in Parliament in 2018–19 to 2019–20 and two audits that tabled in early 2020–21
• that were reported to us in our 2020 survey as unresolved from audits tabled in 2015–16 to 2017–18.

In total, the survey included 1 063 recommendations from 76 audits involving 102 agencies.