Monitoring and reporting

Clinical governance supports aged care organisations to deliver high-quality care and services to achieve good health and wellbeing outcomes through positive care experiences. [1] Although there is no ‘one-size fits all’ approach to clinical governance, [1] 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. [2] Governing bodies should consider each of these and set up systems to manage, operationalise, and monitor success against them. One of these elements is monitoring and reporting. The other core elements are covered in detail in our clinical governance themes.

Why are monitoring and reporting important for clinical governance?   

Aged care governing bodies and providers need a clear understanding of how the organisation is performing in delivering consistently safe and effective care. [3] They are therefore responsible for implementing systems for collecting, analysing, and reporting on a range of data sources including (but not limited to):   

  • Feedback from care recipients and their families on their experiences of care 

  • Data on care recipient outcomes measured against a mandated set of care and clinical indicators 

  • Identified risks, incidents (both serious, non-reportable, and near misses) and how they were managed and resolved. [2]  

Access to reliable data of this kind supports organisational clinical governance in several ways. It provides evidence that the provider is fulfilling its obligation to report on compliance with and performance against regulatory requirements. [4] Data from monitoring activities are also key for identifying risks in a timely way and mitigating them before they lead to incidents. [2] Most importantly, performance monitoring data supplies the means for continuous quality improvement, supporting organisations to understand where changes are needed and where they might be underperforming against national benchmarks. [2, 5] Tracking performance trends over time can also reveal areas of incremental, sustained improvement. This information should be passed on to the workforce as an acknowledgement of their hard work, as well as to care recipients and the governing body. [2] Providing staff with visible evidence of how their work has positively impacted care quality may also contribute to building a strong workplace culture of quality, safety, and ongoing self-evaluation. [6]  

The plan for implementing, reviewing, and improving monitoring and reporting activities across the organisation, along with details of roles and responsibilities, might form part of the clinical governance framework. [7] 

Monitoring, reporting, and Australian aged care regulations 

Under the Aged Care Quality Standards (2019), aged care governing bodies are required to provide evidence of how the organisation monitors, reports, and improves its performance against the requirements of each Standard, including those addressing areas of personal care and clinical care (Standard 3) and organisational governance (Standard 8). [8] This evidence demonstrates the organisation’s commitment to and drive towards quality improvement across all areas of its operation. [8] However, the Quality Standards also specify areas where governance systems are required for more systematic monitoring and reporting purposes. These areas include:  

  • Regularly reviewing the effectiveness of care and services (2(3)(e)) 
  • Feedback and complaints (6(3)(d); 8(3)(c)(vi)) 
  • Performance of each member of the workforce (7(3)(e)) 
  • Continuous improvement (8(3)(c)(ii)) 
  • Regulatory compliance (8(3)(c)(v)) 
  • Managing high-impact or high-prevalence risks associated with care (3(3)(b); 8(3)(d)(i)) 
  • Identifying and responding to abuse and neglect (8(3)(d)(ii)) 
  • Managing and preventing incidents (8(3)(d)(iv)). [8] 

Together, monitoring and reporting across these areas contribute to the organisation meeting the overarching requirement that each care recipient receives ‘safe and effective personal care, clinical care, or both personal care and clinical care...’ (Standard 3(a)). [8 p59]  

Consistent with the recommendations of the Royal Commission into Aged Care Quality and Safety, the government has implemented several reform initiatives that strengthen the monitoring and reporting requirements of aged care providers. In the Revised Aged Care Quality Standards, monitoring and reporting requirements are now largely contained within Standard 2: The organisation. This Standard holds the governing body responsible for ‘monitoring improvement to care and services, informed by engagement with older people, their carers and families, workers, and data on care quality.’ [9 p11] More specifically, the provider is expected to:  

  • Implement a quality system for monitoring organisational performance, including safety and quality of services (Action 2.3.1(d)) 
  • Monitor that investments in priority areas deliver outcomes for older people (Action 2.3.2) 
  • Regularly report on its quality systems and performance to older people and their families and carers (Action 2.3.4) 
  • Collect and analyse data and engage with older people and workers to inform risk assessment and management (Action 2.4.3) 
  • Collect and analyse incident data and report outcomes to older people and workers (Action 2.5.5) 
  • Collect and analyse feedback and complaints data and report outcomes to the governing body, older people, and workers (Action 2.6.5). [9]  

Under the National Aged Care Mandatory Quality Indicator Program, residential aged care providers are also charged with collecting data across eleven quality indicators and providing these data to the Department of Health and Aged Care. [10] These indicators cover pressure injuries, physical restraint, unplanned weight loss, falls and major injuries, medication management, activities of daily living, incontinence care, hospitalisation, workforce, consumer experience, and quality of life. [10]

The Serious Incident Reporting Scheme (SIRS) has also been extended to include home care services as well as residential aged care. [11, 12] This means home care providers must now have an incident management system in place alongside practices to manage risks to home care recipients. SIRS details aged care providers’ responsibilities in ensuring ‘reportable’ incidents negatively impacting the health and wellbeing of care recipients (or which might be reasonably expected to do so) are reported to the Aged Care Quality and Safety Commission. [12] 

Components of effective monitoring and reporting for clinical governance 

Effective monitoring of care quality and safety starts with understanding the aspects of performance aged care providers must measure and report on under their regulatory requirements. It includes details of serious incidents, as well as quantitative quality indicator data often in the form of frequencies of an occurrence or the proportion of care recipients achieving a specific, measurable target outcome. There should also be effective mechanisms in place for rapid monitoring of areas of high clinical or care risk (e.g., infectious outbreaks) and for getting this information to the leadership in a timely and efficient manner. [4]   

Monitoring should also extend to other aspects of care that provide evidence of quality assessment of the organisation’s performance against the Quality Standards. These data can be used for internal auditing purposes and make it possible to demonstrate quality improvement across specific areas of care. [2] Data might be in the form of feedback or complaints from care recipients, or documentation of identified risks, incidents, or near misses and how they were managed or resolved. [8] As aged care organisations vary in the types of services they provide and to whom, each organisation should determine for itself what constitutes a recordable ‘incident’ for monitoring purposes. [11] 

Once the ‘what should be monitored’ is understood, the ‘how’ can be determined. As part of its clinical governance responsibilities, the leadership will need to implement a range of robust and appropriate methods for collecting the necessary data, underpinning them with policies and procedures that are regularly reviewed. These methods and processes form part of the organisation’s ‘quality system’ and may include validated tools, surveys, use of a real-time risk or incident management system, or the routinised staff entry of specific metrics (e.g., weight) into a computerised software program at the point of care. 

Once collected and collated, data from monitoring activities should be analysed and interpreted to identify trends or patterns indicating ongoing or emerging care quality and safety issues, opportunities for improvement, as well as areas of achievement. [2] The organisation’s clinical governance framework should specify the process and schedule for reporting clinical and care quality and safety performance outcomes to the governing body, the workforce, and care recipients. [13]  

Further information on systems for managing risks, incidents, feedback, and complaints are provided in other themes within this series. 

What might effective monitoring and reporting for clinical governance look like?

People working in an aged care organisation with effective monitoring and reporting processes in place may be more likely to agree with the following statements: 

  • The organisation has implemented effective systems and measures for monitoring performance and care outcomes against quality and safety objectives. [8] 
  • Measures of clinical care quality and safety performance are as rigorous as those for measuring financial performance. [3]  
  • Data are collected for analysis of performance using a variety of sources including risk and incident data, feedback from care recipients and their families, and documented concerns of staff (who are protected under a whistleblowing policy). [4]    
  • The organisation regularly analyses clinical quality and safety data to identify trends, emerging issues or risks, and opportunities for improvement. [4] 
  • Clinical quality and safety data are routinely reported to the governing body, consumers and workforce. [6] 
  • Staff feel ‘psychologically safe’ when raising concerns as part of monitoring and reporting requirements under the Quality Standards. [14]
  1. Tan M. Aged care regulation through the looking glass of clinical governance: A framework for aged care providers. Australian Health Law Bulletin. 2022;30(5/6):116-126.  
  2. Aged Care Quality and Safety Commission. Fact sheet 3: Core elements of clinical governance [Internet]. Canberra, ACT: ACQSC; 2019 [cited 2023 Apr 14]. Available from:
  3. Australian Institute of Company Directors. Board governance in the aged care sector [Internet]. Australia: AICD; 2020 [cited 2023 Apr 20]. Available from:
  4. Australian Institute of Company Directors. Clinical governance for boards in the aged care sector [Internet]. Australia: AICD; 2021 [cited 2023 Apr 20]. Available from:
  5. Aged Care Quality and Safety Commission. Sector performance report: October-December 2022 [Internet]. Canberra, ACT: ACQSC; 2022 [cited 2023 Apr 21]. Available from:
  6. Aged Care Quality and Safety Commission. Fact sheet 1: Introduction to clinical governance. Canberra, ACT: ACQSC; 2019 [cited 2023 Apr 14]. Available from:
  7. Riverview Lutheran Rest Home Inc. Clinical governance framework. Loxton, SA: Riverview Lutheran Rest Home; 2020 [cited 2023 Apr 20]. Available from:
  8. Aged Care Quality and Safety Commission. Guidance and resources for providers to support the Aged Care Quality Standards [Internet]. Canberra, ACT: ACQSC; 2022 [cited 2023 Apr 20]. Available from:
  9. Department of Health and Aged Care (Australia). Revised Aged Care Quality Standards: Draft for Pilot [Internet]. Canberra, ACT: Department of Health and Aged Care; 2023 [cited 2023 Jun 6]. Available from:
  10. Department of Health and Aged Care (Australia). National Aged Care Mandatory Quality Indicator Program (QI program). Manual Part A – Version 3 [Internet]. Canberra, ACT: Department of Health and Aged Care; 2023 [cited 2023 Jul 6]. Available from:
  11. Tan M. Clinical governance and the Serious Incident Response Scheme in home and community aged care. Australian Health Law Bulletin. 2023;31(1):10-15.  
  12. Aged Care Quality and Safety Commission. Serious Incident Response Scheme [Internet]. Canberra, ACT: ACQSC; n.d. [updated 2023 Apr 24; cited 2023 Apr 28]. Available from: 
  13. Aged Care Quality and Safety Commission. Toolkit: Developing and implementing a clinical governance framework. Canberra, ACT: ACQSC; 2019 [Available from:
  14. McKellar D, Hanson J. Codesigned framework for organisational culture reform in South Australian older persons' mental health services after the Oakden Report. Aust Health Rev. 2020 Dec;44(6):862-866.
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Selected resources

Organisational self assessment tool 1: Aged care service and consumers

This Aged Care Quality and Safety Commission tool can be used by people responsible for developing a clinical governance framework for an aged care service to support an understanding of the characteristics of the aged care service and consumers, and to inform clinical governance arrangements. (Clicking on the link will download an MS Word doc.)

Updated 06 Jun 2023
Information Sheet
Fact sheet 2: Clinical governance and the Aged Care Quality Standards

The second in a series of Aged Care Quality and Safety Commission information sheets that describes the links between clinical governance and the Aged Care Quality Standards. This fact sheet discusses the quality assessment and compliance monitoring processes as they relate to clinical governance and clinical quality and safety.

Updated 11 Apr 2023
Toolkit: Developing and implementing a clinical governance framework

This Aged Care Quality and Safety Commission information sheet describes the steps that should be taken when developing and implementing a clinical governance framework, or reviewing and identifying areas for improvement where a clinical governance framework is already in place.

Updated 12 Apr 2023