Clinical governance supports aged care organisations to deliver high-quality care so that those receiving care achieve good health and care outcomes.  The Aged Care Quality and Safety Commission (ACQSC) suggests six core, interrelated elements to clinical governance which together promote optimal health and wellbeing outcomes for people receiving aged care services.  Governing bodies need to consider each of these and set up systems to manage, operationalise, and monitor success against them. One of these elements is organisational systems. The other core elements are covered in detail in our clinical governance themes.
Why are organisational systems important for clinical governance?
Organisational systems are imperative in clinical governance to ensure care and services are cohesive and delivered in a consistently safe, effective, and person-centred manner. This will ensure nothing, or no one, is missed or forgotten, but importantly, will also enable effective corporate governance through oversight and decision-making by a board which is ‘in touch’ with the care and services it is ultimately responsible for.
Amongst other things, robust and integrated organisational systems will enhance care, in support of Standard 3(a) of the current Aged Care Quality Standards which requires providers to demonstrate that each care recipient receives ‘safe and effective personal care, clinical care, or both personal care and clinical care’. [3 p54] However, risks to the quality and safety of both forms of care span all levels and operations of an aged care organisation. Clinical governance, therefore, requires a whole-of-organisation ‘systems approach’ to identifying, assessing, reporting, and managing clinical and care risks. This includes a system for responding to and managing incidents (and ‘near misses’) that may occur while delivering care, such as medication errors. 
Organisational systems for clinical governance comprise the integrated set of policies, procedures, and protocols put in place by the governing body to manage care quality and safety across the organisation.  They are the mechanisms by which everyone understands what they are expected to do in providing quality care and managing risks.  These systems underpin and operationalise the clinical governance framework  and help the organisation to meet its legislative and compliance requirements.  These systems therefore are an important part of the organisation’s broader corporate governance arrangements. 
In offering a coordinated and cohesive approach to putting the framework into action, organisational systems can also prevent the organisation from operating in ‘silos’—the ‘enemy of good clinical governance’—in achieving its goals for care.  This includes siloes created by lack of integration and communication between staff with different areas of responsibility, staff working at different worksites, and even different committees within the organisation. An effective organisation-wide system of control over care quality and safety can also strengthen care recipient confidence, providing the service provider has a strategy for communicating and explaining its role and purpose in safeguarding their wellbeing.  Staff expected to work within these systems—who are likely to span the entire operation—need to be clear about their responsibilities and tasks under them. Where they lack the competencies to fulfil the expectations on them, they must receive the appropriate training. 
For operational systems focused on risk and incident management to be effective, they need to be founded on current evidence of best practices and effectiveness, and updated as new evidence and guidelines are produced.  Although they will be unable to eliminate all risks and incidents, these systems will at least provide a structured, proactive approach to addressing them  and serve as a tool for reducing their likelihood and occurrence. 
Moving into the future, organisational systems should be enabled and supported by appropriate technology to maximise their effectiveness, as well as optimise consumer and workforce engagement. Digitisation will also facilitate corporate governance through improved transparency of data, however, the risks of this will also need to be managed (Dr Melanie Tan, personal communication, April 2023).
Organisational systems and Australian aged care regulations
The Quality of Care Principles 2014 that support the Aged Care Act 1997 detail the responsibilities of approved aged care providers in regard to incident management and prevention (Part 4B), which is one important aspect of organisational systems.  This includes the requirement to have an incident management system in place and to establish procedures for its operation. These procedures are to include:
- How incidents are identified, recorded, and reported and to whom
- How support will be provided to the persons affected by the incident
- When remedial action is required and the nature of the action (15MB). 
System procedures are to be documented and made available in an accessible form to everyone within the organisation, including care recipients (15MC). The provider is also responsible for setting out the roles and responsibilities of staff members working within the system to safeguard the health and wellbeing of care recipients or manage and resolve incidents that have taken place (15MD). 
The Aged Care Quality Standards also outline provider responsibilities, including where clinical care is concerned (Standard 3). It requires aged care organisations to have systems in place for effective identification and management of:
- High-impact or high-prevalence risks associated with the care of each consumer (3(b) and 8(3)(d))
- Deterioration or change of a consumer’s mental health, cognitive or physical function, capacity, or condition (3(d))
- Infection-related risks and medication management (3(g)), including antimicrobial stewardship (8(3)(e))
- Incidents (8(3)(d)). 
Standard 3(b) identifies several specific areas of clinical care that pose a high risk to care recipients. These include medication management, the management of pain, preventing and managing pressure injuries, minimising restrictive practices, and managing delirium.  Despite the Aged Care Quality Standards highlighting these issues, the Royal Commission into the Quality and Safety of Aged Care identified them as common areas of clinical care failure.  More recently, ACQSC sector performance reports have indicated that providers still face challenges in the management of high-impact risks and recognising and responding to deterioration. These remain the most frequent areas of non-compliance against the Standards. 
The Revised Aged Care Quality Standards (under public consultation) address the need for organisational systems to identify and manage risks and incidents within Standard 2 (The organisation). Specifically:
- Risks to older people, workers, and the organisation are identified, managed and continually reviewed (Action 2.4.1)
- The provider uses an incident management system to safeguard older people and acknowledge, respond to, effectively manage and learn from incidents (Outcome 2.5). 
Other aged care reforms that also serve to strengthen organisational systems for managing clinical and care risks include:
- The expansion of the National Aged Care Mandatory Quality Indicator Program (QI Program) to include areas such as activities of daily living, incontinence care, hospitalisations, and quality of life.
- Expansion of the QI Program into the home care setting
- Extension of the Serious Incident Response Scheme (SIRS) into home care and flexible care. 
Components of effective organisational systems for clinical governance
There are several components that comprise an effective organisational system for clinical governance. Risk identification and management is another important component of clinical governance.  Organisations therefore need strong risk and incident management systems, as well as processes for their ongoing review and improvement, if they are to successfully deliver care that is both safe and of high quality. While these systems are of prime importance, they need to be supported by other systems within the organisation, in an integrated way. These are equally important and include systems for information management, continuous improvement, feedback and complaints, and regulatory compliance.