Clinical Governance in Anaesthesia

Quick Answer

Exam Essentials - ANZCA Professional Skills

Clinical Governance Definition: A framework through which healthcare organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish [1-3].

Seven Pillars of Clinical Governance:

Clinical effectiveness: Evidence-based practice, guidelines, protocols

Risk management: Incident reporting, risk registers, patient safety systems

Patient experience: Feedback, complaints management, communication

Learning and development: Education, training, CPD

Leadership and accountability: Clear roles, responsibilities, professional standards

Information and data: Quality metrics, audit, performance data

Research and innovation: Evidence generation, quality improvement [4-6]

Key ANZCA Requirements:

ANZCA PS51(G): Guidelines for clinical governance in anaesthesia departments

ANZCA PS02(G): Position statement on quality and safety in anaesthesia

ANZCA CPD Program: Mandatory continuing professional development

ANZCA Professional Standards: Ethical practice, professionalism, accountability [7-9]

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Populations

Cultural Safety in Clinical Governance:

Effective clinical governance must incorporate cultural safety principles to ensure equitable care for Aboriginal and Torres Strait Islander patients:

Cultural competence standards: ANZCA curriculum includes Indigenous health learning outcomes requiring ongoing quality assurance [10]
Indigenous patient outcomes: Quality metrics must stratify data by Aboriginal/Torres Strait Islander status to identify disparities [11]
Cultural safety audit: Specific review of cultural safety incidents and near-misses involving Indigenous patients [12]
Workforce development: Monitoring of Indigenous trainee recruitment and support [13]

Governance Challenges in Rural/Remote Settings:

Challenge	Governance Response
Limited local governance infrastructure	Teleconference M&M meetings, regional governance networks
Fly-in fly-out services	Standardised handover protocols, documentation requirements
Cultural communication barriers	Mandatory cultural safety training, interpreter services audit
Delayed complication recognition	Explicit complication review for remote patients
Follow-up difficulties	Telehealth review protocols, primary care liaison requirements
Staff cultural competence	Regular cultural safety assessment and training [14,15]

Quality Improvement Priorities:

Mortality and morbidity stratification: Indigenous status as standard demographic variable
Pain management equity: Audit of analgesia provision for Indigenous patients
Consent processes: Quality review of informed consent in culturally complex situations
Emergency response: Review of complications requiring RFDS/retrieval [16,17]

Community Engagement:

Aboriginal Community Controlled Health Service (ACCHS) representation on governance committees where relevant
Indigenous patient and community feedback mechanisms
Cultural advisory roles in quality improvement initiatives
Indigenous health worker involvement in incident investigation [18,19]

Māori Populations (Aotearoa New Zealand)

Te Tiriti o Waitangi in Clinical Governance:

New Zealand's healthcare governance must honour Te Tiriti obligations:

Partnership: Māori representation on governance committees and clinical networks
Participation: Equitable Māori workforce participation in anaesthesia
Protection: Quality metrics ensuring Māori patients receive equivalent standards of care [20,21]

Māori Health Gain Priority:

The New Zealand Health Strategy mandates Māori health gain as priority:

Governance Element	Māori Health Application
Quality metrics	Stratify all outcome data by ethnicity; monitor Māori/non-Māori gaps
Audit	Include Māori health-specific indicators (e.g., chronic pain management equity)
M&M review	Explicit review of Māori patient complications; whānau involvement where appropriate
Complaints	Cultural competence review for Māori patient complaints
Workforce	Monitor Māori anaesthesia workforce participation and progression
Research	Prioritise Māori health outcomes research [22,23]

Whānau-Centred Governance:

Recognition of whānau as decision-makers in patient care
Cultural advisory input into governance processes
Kaupapa Māori approaches to quality improvement
Māori Health Workforce representation in clinical governance [24,25]

Clinical Governance Frameworks

Definition and Scope

Clinical Governance (Scally and Donaldson, 1998):

"A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish" [26,27].

Core Components:

Corporate governance + Clinical governance = Integrated whole
Accountability: Individual and organisational responsibility for quality
Continuous improvement: Not static; requires ongoing effort
Systems approach: Focus on processes, not just individuals
Patient-centred: Quality defined by patient outcomes and experience [28,29]

Seven Pillars of Clinical Governance

Pillar	Description	Key Elements
1. Clinical Effectiveness	Doing the right thing, at the right time, in the right way	Evidence-based guidelines, protocols, care pathways, outcomes measurement
2. Risk Management	Identifying, assessing, and mitigating risks to patients	Incident reporting, risk registers, complaints management, litigation analysis
3. Patient Experience	Patient perspectives on quality of care	Feedback systems, patient-reported outcomes, complaint analysis, communication
4. Learning and Development	Maintaining and improving professional competence	CPD, training, education, simulation, debriefing
5. Leadership and Accountability	Clear direction and responsibility for quality	Leadership frameworks, role clarity, professional standards, appraisal
6. Information and Data	Data-driven quality improvement	Audit, quality metrics, dashboards, benchmarking
7. Research and Innovation	Advancing clinical knowledge and practice	QI research, new technology evaluation, innovation adoption [30-32]

ANZCA Governance Requirements

PS51(G): Guidelines for the Governance of Departments of Anaesthesia:

Element	Requirement
Organisational structure	Clear departmental leadership, reporting lines
Scope of practice	Defined roles, privileges, credentialing
Clinical activity	Activity reporting, casemix analysis
After-hours cover	Adequate staffing, supervision arrangements
Equipment and facilities	Maintenance, safety standards, replacement planning
Quality assurance	Audit, incident review, M&M meetings
Patient safety	Safety culture, reporting systems, risk management
Professional development	CPD support, training opportunities
Research and ethics	Research governance, ethics approval processes [33,34]

ANZCA Professional Standards:

Standard	Key Requirements
PS02(G)	Quality and safety in anaesthesia practice
PS06(G)	Massive transfusion protocol governance
PS07	Perioperative care standards
PS09(G)	Anaesthesia for remote/rural locations
PS16(G)	Documentation standards
PS22(G)	Infection control in anaesthesia
PS55(G)	Crisis management and human factors [35,36]

Quality Improvement (QI)

QI Methodologies

Plan-Do-Study-Act (PDSA) Cycles:

Phase	Activities
Plan	Identify problem, analyse root causes, develop hypothesis, design intervention
Do	Implement intervention on small scale, collect data
Study	Analyse results, compare to baseline, assess for unintended consequences
Act	Standardise if successful, modify if partial success, abandon if unsuccessful
Iterate	Return to Plan with new knowledge [37,38]

Lean Methodology:

Focus on value from patient perspective
Eliminate waste (defects, overproduction, waiting, non-utilised talent, transportation, inventory, motion, extra-processing = DOWNTIME)
Continuous flow, pull systems, perfection [39,40]

Six Sigma:

Reduce variation and defects
DMAIC: Define, Measure, Analyse, Improve, Control
Target: <3.4 defects per million opportunities [41,42]

Quality Improvement vs Research:

Feature	Quality Improvement	Research
Primary aim	Improve local care	Generate generalisable knowledge
Population	Local patients	Representative sample
Intervention	Often not standardised	Standardised protocol
Randomisation	Rarely used	Often required
Ethics approval	Sometimes not required	Usually required
Publication	Often local learning	Generalisable findings
Regulatory	Quality/safety oversight	Research governance, HREC [43,44]

Anaesthesia-Specific QI Initiatives

Australian and New Zealand Anaesthesia Mortality Database (ANZAMD):

Voluntary reporting of anaesthesia-related deaths
National data collection since 2009
Identifies mortality trends and preventable factors
Informs ANZCA safety initiatives [45,46]

Anaesthesia Mortality Committees:

State/territory-based review of all anaesthesia-related deaths
Multidisciplinary review
Recommendations for practice improvement
Feedback to practitioners and departments [47,48]

National Anaesthesia Mortality Database (NAMD):

Collects standardised data on perioperative deaths
Enables benchmarking across jurisdictions
Informs research and policy [49,50]

Quality Indicators for Anaesthesia:

Domain	Example Indicators
Safety	Unanticipated ICU admission, unplanned reintubation, cardiac arrest
Effectiveness	PONV prophylaxis compliance, antibiotic timing, temperature management
Patient-centred	Patient satisfaction, informed consent quality, pain management adequacy
Timely	Preoperative assessment completion, anaesthesia start delays
Efficient	Non-operating room time, first-case on-time starts
Equitable	Quality metrics by demographic groups (Indigenous, rurality, SES) [51,52]

Clinical Audit

Definition and Purpose

Clinical Audit: Systematic, critical analysis of the quality of clinical care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for patients [53,54].

Audit Cycle:

Identify topic (priority area, high-risk, guideline implementation)
Set standards (evidence-based criteria)
Collect data (retrospective or prospective)
Analyse and compare (performance vs standards)
Implement change (address gaps)
Re-audit (close the loop) [55,56]

Types of Audit

Type	Description	Example
National audit	Standardised across multiple institutions	SNAP, NAP5, NAP6
Regional audit	Jurisdiction-wide data collection	State anaesthesia audits
Departmental audit	Single institution, specific topics	PONV prophylaxis compliance
Clinical indicator audit	Ongoing monitoring of key metrics	Antibiotic timing compliance
Peer review	Inter-practitioner comparison	Consultant A vs Consultant B
Outlier audit	Focus on extreme cases	Complications >2 SD from mean [57,58]

National Audit Projects (UK NAP Model - Applicable in Australia/NZ)

NAP5 (Accidental Awareness during General Anaesthesia):

Major international collaboration
Identified risk factors for awareness
Changed practice regarding neuromuscular blockade monitoring, depth of anaesthesia monitoring [59,60]

NAP6 (Perioperative Anaphylaxis):

Largest prospective study of perioperative anaphylaxis
Identified antibiotic and neuromuscular blocker allergy patterns
Informed safer drug choices [61,62]

SNAP (Scottish National Audit Projects):

SNAP1: Baseline practice
SNAP2: Risk assessment
SNAP3: Postoperative outcomes
Model for Australian state-based audits [63,64]

Audit Standards Development

SMART Criteria for Standards:

Criterion	Description	Example
Specific	Clear, unambiguous	"Temperatur >36.0°C at end of surgery"
Measurable	Quantifiable	"Temperature recorded and documented"
Achievable	Realistic target	Based on evidence and local capability
Relevant	Important to patient outcomes	Prevents hypothermia complications
Time-bound	Clear timeframe	"For all patients >30 min anaesthesia" [65,66]

Minimum Standards vs Optimal Standards:

Minimum: Must achieve 100% (e.g., consent obtained)
Optimal: Aspirational target (e.g., PONV prophylaxis in 95% of high-risk patients) [67,68]

Morbidity and Mortality (M&M) Meetings

Purpose and Structure

Aims of M&M Meetings:

Educational: Learn from complications and near-misses
Quality improvement: Identify system issues and implement change
Support: Debrief practitioners involved in adverse events
Accountability: Review care against accepted standards
Data collection: Inform risk management and audit priorities [69,70]

Meeting Structure:

Component	Time	Activities
Introduction	5 min	Confidentiality reminder, agenda review
Case presentations	30-40 min	Presenter describes case chronologically
Discussion	20-30 min	Questions, analysis, contributing factors
Learning points	10 min	Identify system issues, educational messages
Action items	5 min	Assign responsibilities, set timelines
Summary	5 min	Debrief, psychological support if needed [71,72]

Case Selection:

Priority	Criteria
High	Death, permanent harm, near-miss with potential for death
Medium	Temporary harm, unexpected ICU admission, unplanned return to OR
Low	Minor complications, interesting cases for education
System learning	Cases highlighting system vulnerabilities
Trending	Multiple similar cases suggesting pattern [73,74]

Presentation Framework

Structured Case Presentation:

Demographics: Age, sex, ASA, procedure (de-identified)
Clinical context: Indication, comorbidities, preoperative status
Course of care: Timeline of events, clinical decisions
Complication/event: What happened, when, response
Outcome: Patient outcome, sequelae
Analysis: Contributing factors (clinical, system, human factors)
Learning points: Key messages, system changes needed
References: Guidelines, literature [75,76]

Avoiding Blame Culture:

Focus on "what happened" not "who did it"
Use "care was provided" rather than "you/they did"
Emphasise system factors over individual error
Acknowledge that good clinicians sometimes have bad outcomes
Supportive environment for presenters [77,78]

Documentation and Follow-up

M&M Documentation:

Meeting minutes (de-identified)
Case summaries (educational focus)
Action items with responsible persons and timelines
Trend analysis (quarterly/annual review)
Aggregate data for quality reports [79,80]

Follow-up:

Action item completion tracking
Re-presentation of cases if significant system changes
Feedback to involved practitioners
Communication to wider department (lessons learned)
Integration with risk register [81,82]

Incident Reporting and Risk Management

Incident Reporting Systems

Definition of Incident:

Adverse event: Injury resulting from medical management (not underlying disease)
Near-miss: Error or system failure that did not reach the patient or did not cause harm
No-harm incident: Error reached patient but did not cause harm [83,84]

Voluntary vs Mandatory Reporting:

Feature	Voluntary	Mandatory
Scope	Near-misses, adverse events	Serious adverse events, sentinel events
Reporter	Any staff member	Usually senior clinicians
Purpose	Learning, safety culture	Accountability, external oversight
Examples	Local QI systems, AIMS	State health department reporting, coroner
Incentives	Non-punitive, improvement focus	Legal/regulatory requirement [85,86]

Australian Incident Monitoring System (AIMS):

National voluntary reporting system
Standardised taxonomy (national classifications)
De-identified reporting
Trend analysis at state and national levels
Feedback and learning resources [87,88]

ANZCA Anaesthesia Incident Reporting:

Professional obligation to report
Contributes to national safety data
Informs ANZCA guidelines and alerts
Educational case reports (de-identified) [89,90]

Root Cause Analysis (RCA)

When to Conduct RCA:

Serious adverse events (death, permanent harm)
Sentinel events (never events)
Near-misses with potential for serious harm
Trending incidents (multiple similar events)
Events requiring external reporting [91,92]

RCA Process:

Step	Activities	Timeline
1. Team formation	Multidisciplinary, independent from care team	Within 24-72 hours
2. Data collection	Chart review, interviews, timeline creation	1-2 weeks
3. Event reconstruction	Detailed timeline, sequence of events	Parallel with data collection
4. Root cause identification	Fishbone diagram, "5 Whys" technique	2-4 weeks
5. Action plan development	SMART actions addressing root causes	4-6 weeks
6. Report and implementation	Submission, action implementation	6-8 weeks
7. Follow-up	Action completion, effectiveness monitoring	Ongoing [93,94]

Root Cause Categories (Fishbone Diagram):

Category	Examples
People	Knowledge gaps, fatigue, stress, communication failure
Process	Protocol gaps, inadequate checks, poor handover
Equipment	Device failure, poor design, unavailability
Environment	Distractions, noise, lighting, layout
Organisation	Staffing, training, culture, resources
External	Manufacturer issues, regulatory gaps [95,96]

"5 Whys" Technique:

Ask "why?" five times to get from surface cause to root cause
Example: Equipment failure → Why? Not maintained → Why? No schedule → Why? No responsibility assigned → Why? No governance framework [97,98]

Risk Registers

Purpose:

Proactive identification of risks
Prioritisation based on likelihood and consequence
Monitoring of risk mitigation strategies
Board/executive reporting [99,100]

Risk Rating:

Likelihood	Consequence	Risk Level
Rare (1)	Negligible (1)	Low (1-2)
Unlikely (2)	Minor (2)	Moderate (3-4)
Possible (3)	Moderate (3)	High (6-9)
Likely (4)	Major (4)	Extreme (10-16)
Almost certain (5)	Catastrophic (5)

Anaesthesia Risk Register Categories:

Clinical risks (patient safety)
Operational risks (staffing, equipment)
Financial risks (funding, litigation)
Strategic risks (service changes, workforce)
Compliance risks (standards, accreditation) [101,102]

Professionalism and Accountability

Professional Standards

ANZCA Professional Framework:

Domain	Description
Medical Expert	Clinical knowledge, skills, judgment
Communicator	Patient communication, team communication, documentation
Collaborator	Teamwork, interprofessional practice
Leader	Leadership, management, quality improvement
Health Advocate	Patient advocacy, population health
Scholar	Lifelong learning, teaching, research
Professional	Ethics, professionalism, self-care [103,104]

Professionalism in Governance:

Transparency in reporting
Accountability for actions
Commitment to continuous improvement
Supportive of colleagues
Patient-centred decision-making
Ethical practice [105,106]

Credentialing and Privileging

Credentialing:

Verification of qualifications, training, experience
Primary source verification
Ongoing maintenance of registration and CPD [107,108]

Privileging:

Scope of practice authorisation
Procedural privileges (basic, advanced, subspecialty)
Requirements for maintenance (activity levels, ongoing competence)
Re-credentialing cycles [109,110]

ANZCA Fellowship Requirements:

FANZCA required for independent practice
Vocational registration with AHPRA (Australia) or MCNZ (New Zealand)
Ongoing CPD (ANZCA CPD Program minimum 50 hours/year)
Professional indemnity insurance
Moral character and fitness to practice [111,112]

Performance Review and Appraisal

360-Degree Feedback:

Self-assessment
Peer feedback
Colleague feedback (surgical, nursing)
Trainee feedback (for consultants)
Administrative feedback [113,114]

Performance Indicators:

Clinical outcomes (mortality, complications)
Process measures (documentation, protocol compliance)
Patient feedback
Professional behaviour
CPD engagement
Quality improvement participation [115,116]

SAQ Practice Questions

SAQ 1: Clinical Governance Framework (20 marks)

Scenario: You are appointed as the Clinical Governance Lead for a new anaesthesia department in a regional hospital. The department has experienced several recent patient safety incidents and has no formal governance structure.

Questions:

a) Outline the seven pillars of clinical governance and their relevance to anaesthesia. (7 marks)

b) Describe the key elements you would establish in the first 6 months. (7 marks)

c) How would you address the recent patient safety incidents while establishing a safety culture? (6 marks)

Model Answer:

a) Seven pillars (7 marks):

Clinical effectiveness: Evidence-based protocols, guidelines, outcome measurement (1 mark)
Risk management: Incident reporting, risk registers, complaints management (1 mark)
Patient experience: Feedback systems, patient-reported outcomes, communication standards (1 mark)
Learning and development: CPD, education, simulation training (1 mark)
Leadership and accountability: Clear roles, professional standards, appraisal (1 mark)
Information and data: Audit, quality metrics, dashboards (1 mark)
Research and innovation: QI research, new technology evaluation (1 mark)

b) First 6 months priorities (7 marks):

M&M meetings: Monthly, structured, supportive environment (1 mark) | Incident reporting system: Simple, non-punitive, responsive (1 mark) | Quality metrics: Basic dashboard (on-time starts, cancellations, PONV) (1 mark) | Audit program: 2-3 priority audits (consent, antibiotic timing, temperature) (1 mark) | Governance committee: Monthly meetings, clear terms of reference (1 mark) | Education program: Grand rounds, CPD support, simulation (1 mark) | PS51(G) compliance: Self-assessment against ANZCA guidelines (1 mark)

c) Addressing incidents and safety culture (6 marks):

RCA for serious incidents: Thorough, blame-free investigation (2 marks) | Transparency: Share learning, involve staff in solutions (1 mark) | Non-punitive reporting: Emphasise learning not blame (1 mark) | Quick wins: Implement obvious safety improvements rapidly (1 mark) | Staff support: Debriefing, psychological safety, leadership visibility (1 mark)

SAQ 2: Morbidity and Mortality Meeting (20 marks)

Scenario: You are chairing the monthly M&M meeting. A consultant presents a case where a patient suffered anaphylaxis during anaesthesia. The consultant feels responsible and is visibly distressed. Other consultants are critical of the management.

Questions:

a) How would you manage the meeting dynamics to ensure constructive learning? (7 marks)

b) What structure would you use for the case presentation and discussion? (7 marks)

c) What follow-up actions would you recommend? (6 marks)

Model Answer:

a) Managing meeting dynamics (7 marks):

Acknowledge emotions: Recognise consultant's distress; normalise emotional response (1 mark) | Set ground rules: Remind of confidentiality and blame-free approach (1 mark) | Focus on system: Redirect from "who" to "what happened" and "why" (2 marks) | Prevent criticism: Intervene if consultants become accusatory; reframe as system issues (2 marks) | Supportive closure: Thank presenter, offer peer support, debrief after meeting (1 mark)

b) Case structure (7 marks):

Introduction: De-identified demographics, clinical context (1 mark) | Timeline: Chronological course of events (1 mark) | Anaphylaxis recognition: What signs, when identified, differential diagnosis (1 mark) | Management: Actions taken, response, protocol adherence (1 mark) | Outcome: Patient outcome, sequelae (1 mark) | Analysis: Contributing factors (knowledge, equipment, system) (1 mark) | Learning: Key messages, what would be done differently (1 mark)

c) Follow-up actions (6 marks):

Report incident: To AIMS, hospital risk management (1 mark) | Review anaphylaxis protocol: Ensure current, available, followed (1 mark) | Equipment check: Anaphylaxis kit contents, accessibility (1 mark) | Education: Department teaching on anaphylaxis recognition/management (1 mark) | Support consultant: Peer support, professional review if indicated (1 mark) | Re-audit: Anaphylaxis management compliance in 6 months (1 mark)

SAQ 3: Root Cause Analysis (20 marks)

Scenario: A patient died from failed airway management during an emergency caesarean section. The coroner has requested a Root Cause Analysis. You are leading the RCA team.

Questions:

a) Outline the steps in conducting a Root Cause Analysis. (6 marks)

b) What specific data would you collect for this case? (7 marks)

c) What categories of root cause would you investigate using a fishbone diagram? (7 marks)

Model Answer:

a) RCA steps (6 marks):

Team formation: Multidisciplinary, independent team (1 mark)
Data collection: Chart review, interviews, timeline (1 mark)
Event reconstruction: Detailed timeline of events (1 mark)
Root cause identification: "5 Whys", fishbone diagram (1 mark)
Action plan: SMART actions addressing root causes (1 mark)
Report and follow-up: Submission, implementation monitoring (1 mark)

b) Data to collect (7 marks):

Clinical records: Anaesthetic chart, progress notes, observations (1 mark) | Airway assessment: Preoperative airway evaluation documentation (1 mark) | Equipment: Anaesthesia machine check, airway equipment available (1 mark) | Personnel: Staffing levels, experience, supervision (1 mark) | Protocols: Failed airway protocol, difficult airway algorithm (1 mark) | Environment: OR setup, noise, distractions (1 mark) | Interviews: Staff involved, witnesses, culture assessment (1 mark)

c) Fishbone categories (7 marks):

People: Knowledge gaps, training, fatigue, stress (1 mark) | Process: Protocol gaps, handover quality, decision-making (1 mark) | Equipment: Device failure, availability, design (1 mark) | Environment: OR layout, distractions, lighting (1 mark) | Organisation: Staffing, skill mix, supervision, training (2 marks) | External: Guidelines, manufacturer issues (1 mark)

ANZCA Exam Focus

Viva Voce Preparation

Scenario 1: New Governance Role

"You are appointed Clinical Governance Lead. What are your first priorities?"

Key points:

Establish M&M meetings
Create incident reporting system
Develop quality metrics dashboard
Form governance committee
Prioritise recent incidents for review
Reference PS51(G)

Scenario 2: Blame Culture

"Your department has a blame culture that inhibits incident reporting. How do you address this?"

Key points:

Leadership modelling of non-punitive approach
Focus on system not individual
Confidential reporting options
Share learning widely
Reward reporting behaviour
Psychological safety principles

Scenario 3: Serious Incident Investigation

"A serious incident has occurred. Outline your investigation approach."

Key points:

Immediate response and patient care
RCA team formation
Timeline reconstruction
Root cause identification (5 Whys, fishbone)
Action plan development
Report and follow-up

Written Exam High-Yield Topics

Topic	Key Facts
Seven pillars	Clinical effectiveness, risk management, patient experience, learning, leadership, information, research
PS51(G)	ANZCA governance guidelines for anaesthesia departments
PDSA cycle	Plan, Do, Study, Act
RCA steps	Team formation, data collection, timeline, root causes, actions, report
M&M structure	Introduction, presentation, discussion, learning, actions
Blame culture	Focus on system, not individual; psychological safety
Risk rating	Likelihood × Consequence = Risk level
AIMS	Australian Incident Monitoring System

ANZCA Professional Standards

PS51(G): Guidelines for the Governance of Departments of Anaesthesia

Organisational structure requirements
Scope of practice and credentialing
Quality assurance mechanisms
Patient safety systems

PS02(G): Position Statement on Quality and Safety

Quality improvement obligations
Safety culture development
Incident reporting requirements

References

Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ. 1998;317(7150):61-65. PMID: 9654759
Clinical Governance: Quality in the New NHS. Department of Health, UK. 1999.
Australian Council for Safety and Quality in Health Care. Clinical Governance: Making it Work. ACSQHC; 2004.
ANZCA. PS51(G): Guidelines for the Governance of Departments of Anaesthesia. ANZCA Professional Standards. 2020.
ANZCA. PS02(G): Position Statement on Quality and Safety in Anaesthesia. ANZCA Professional Standards. 2018.
Clinical Governance: A Framework for Improving Quality. Medical Journal of Australia. 2005;182(9):443-444. PMID: 15865577
ANZCA. PS51(G): Guidelines for the Governance of Departments of Anaesthesia. ANZCA Professional Standards. 2020.
ANZCA Continuing Professional Development Program. ANZCA Handbook for Trainees and Fellows. Melbourne: ANZCA; 2022.
ANZCA Professional Standards Framework. ANZCA Website. Available at: www.anzca.edu.au
ANZCA Indigenous Health Curriculum. ANZCA Training Program. 2020.
Australian Institute of Health and Welfare. The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples. Canberra: AIHW; 2015.
National Aboriginal Community Controlled Health Organisation. Cultural Safety Standards. NACCHO; 2011.
Medical Deans of Australia and New Zealand. Indigenous Health Curriculum Framework. MDANZ; 2018.
Australian Institute of Health and Welfare. Rural and Remote Health. Canberra: AIHW; 2016.
Rural Doctors Association of Australia. Rural Health Workforce Strategy. RDAA; 2019.
Cunningham J, Rumbold AR, Zhang X, et al. Incidence and mortality of cancer among Aboriginal and Torres Strait Islander people in Australia. AIHW Cat No CAN 84. 2014;1-104.
Australian Indigenous HealthInfoNet. Overview of Australian Aboriginal and Torres Strait Islander Health Status. Perth: HealthInfoNet; 2021.
National Aboriginal Community Controlled Health Organisation. Cultural Safety Standards. NACCHO; 2011.
Australian Institute of Health and Welfare. The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples. Canberra: AIHW; 2015.
Waitangi Tribunal. The Treaty of Waitangi. Wellington: Waitangi Tribunal; 1840.
Robson B, Harris R. Hauora: Māori Standards of Health IV. Wellington: Te Röpü Rangahau Hauora a Eru Pömare; 2007.
Ministry of Health. New Zealand Health Strategy. Wellington: Ministry of Health; 2016.
Reid P, Robson B. Understanding health inequities. In: Robson B, Harris R, eds. Hauora: Māori Standards of Health IV. Wellington: Te Röpü Rangahau Hauora a Eru Pömare; 2007:3-10.
Health and Disability Commissioner. Cultural Competence and Cultural Safety. Auckland: HDC; 2018.
Crengle S. He Orange Ngā Tauira: Māori health learning experiences. N Z Med J. 2003;116(1185):U649. PMID: 14614282
Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ. 1998;317(7150):61-65. PMID: 9654759
Clinical Governance: Quality in the New NHS. Department of Health, UK. 1999.
Australian Council for Safety and Quality in Health Care. Clinical Governance: Making it Work. ACSQHC; 2004.
Clinical Governance: A Framework for Improving Quality. Medical Journal of Australia. 2005;182(9):443-444. PMID: 15865577
ANZCA. PS51(G): Guidelines for the Governance of Departments of Anaesthesia. ANZCA Professional Standards. 2020.
ANZCA. PS02(G): Position Statement on Quality and Safety in Anaesthesia. ANZCA Professional Standards. 2018.
Clinical Excellence Commission. Clinical Governance Framework. Sydney: CEC; 2019.
ANZCA. PS51(G): Guidelines for the Governance of Departments of Anaesthesia. ANZCA Professional Standards. 2020.
ANZCA. ANZCA Handbook for Trainees and Fellows. Melbourne: ANZCA; 2022.
ANZCA Professional Standards. ANZCA Website. Available at: www.anzca.edu.au
ANZCA. ANZCA Safety and Quality Framework. Melbourne: ANZCA; 2019.
Langley GL, Moen R, Nolan KM, et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco: Jossey-Bass; 2009.
Deming WE. Out of the Crisis. Cambridge, MA: MIT Press; 1986.
Womack JP, Jones DT. Lean Thinking: Banish Waste and Create Wealth in Your Corporation. New York: Free Press; 2003.
Graban M. Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement. 3rd ed. Boca Raton: CRC Press; 2016.
Harry M, Schroeder R. Six Sigma: The Breakthrough Management Strategy Revolutionizing the World's Top Corporations. New York: Currency; 2000.
George ML. Lean Six Sigma for Service: How to Use Lean Speed and Six Sigma Quality to Improve Services and Transactions. New York: McGraw-Hill; 2003.
Quality Improvement vs Research. HRET Quality Improvement. 2019.
Finkelstein J, Hripcsak G, Feldman M, et al. Quality improvement versus research: distinguishing the differences. Am J Med Qual. 2001;16(6):225-230. PMID: 11760470
ANZCA. Australian and New Zealand Anaesthesia Mortality Database. ANZCA; 2020.
Australian Institute of Health and Welfare. National Anaesthesia Mortality Database. Canberra: AIHW; 2020.
ANZCA. ANZCA Mortality Review Process. Melbourne: ANZCA; 2021.
ANZCA Mortality Committee. Annual Report on Anaesthesia-Related Mortality. Melbourne: ANZCA; 2022.
Australian Institute of Health and Welfare. National Anaesthesia Mortality Database. Canberra: AIHW; 2020.
ANZCA. Australian and New Zealand Anaesthesia Mortality Database. ANZCA; 2020.
Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260(12):1743-1748. PMID: 3045356
Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academy Press; 2001.
National Institute for Health and Care Excellence. Principles for Putting NICE Guidance into Practice. NICE; 2014.
Johnston G, Crombie IK, Davies HT, et al. Reviewing audit: barriers and facilitating factors for effective clinical audit. Qual Health Care. 2000;9(1):23-36. PMID: 10847870
Burgess R. New Principles of Best Practice in Clinical Audit. Radcliffe Publishing; 2011.
Boulton R. Clinical Audit: A Practical Guide for Healthcare Professionals. Wiley-Blackwell; 2010.
National Audit Projects. Royal College of Anaesthetists. Available at: www.rcoa.ac.uk
SNAP: Scottish National Projects in Anaesthesia. Scottish Quality and Safety Fellows.
Pandit JJ, Andrade J, Bogod DG, et al. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Br J Anaesth. 2014;113(4):549-559. PMID: 25297704
Pandit JJ, Andrade J, Bogod DG, et al. The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent, and medicolegal issues. Br J Anaesth. 2014;113(4):560-574. PMID: 25297705
Harper NJ, Cook TM, Garcez T, et al. Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features of perioperative anaphylaxis in the 6th National Audit Project (NAP6). Br J Anaesth. 2018;121(1):159-171. PMID: 29903581
Cook TM, Harper NJ, Garcez T, et al. Perioperative anaphylaxis: epidemiology of drugs and diagnostic agents used for anaesthesia and surgery. Br J Anaesth. 2018;121(1):172-183. PMID: 29903582
Scottish Audit of Surgical Mortality. Annual Reports. Edinburgh: SASM; 2010-2020.
SNAP: Scottish National Projects in Anaesthesia. Scottish Quality and Safety Fellows.
Burgess R. New Principles of Best Practice in Clinical Audit. Radcliffe Publishing; 2011.
Boulton R. Clinical Audit: A Practical Guide for Healthcare Professionals. Wiley-Blackwell; 2010.
National Institute for Health and Care Excellence. Principles for Putting NICE Guidance into Practice. NICE; 2014.
Johnston G, Crombie IK, Davies HT, et al. Reviewing audit: barriers and facilitating factors for effective clinical audit. Qual Health Care. 2000;9(1):23-36. PMID: 10847870
Kable AK, Gibberd RW, Spigelman AD. Adverse events in surgical patients in Australia. Int J Qual Health Care. 2002;14(4):269-276. PMID: 12201125
Surgical Mortality Review Committee. Annual Reports. Perth: SMRC; 2010-2020.
ANZCA. Guidelines for Morbidity and Mortality Meetings. Melbourne: ANZCA; 2019.
Royal College of Anaesthetists. Raising the Standard: A Compendium of Audit Recipes. 3rd ed. London: RCoA; 2012.
Surgical Outcome Monitoring and Improvement Program. Clinical Excellence Commission. Sydney: CEC; 2020.
ANZCA. ANZCA Safety and Quality Framework. Melbourne: ANZCA; 2019.
ANZCA. Guidelines for Morbidity and Mortality Meetings. Melbourne: ANZCA; 2019.
Royal College of Anaesthetists. Raising the Standard: A Compendium of Audit Recipes. 3rd ed. London: RCoA; 2012.
Edmonson AC. Learning from failure in health care: frequent opportunities, pervasive barriers. Qual Saf Health Care. 2004;13(Suppl 2):ii3-ii9. PMID: 15576689
Reason J. Human error: models and management. BMJ. 2000;320(7237):768-770. PMID: 10720363
ANZCA. Guidelines for Morbidity and Mortality Meetings. Melbourne: ANZCA; 2019.
Clinical Excellence Commission. Morbidity and Mortality Meeting Toolkit. Sydney: CEC; 2018.
Australian Commission on Safety and Quality in Health Care. Incident Management. ACSQHC; 2021.
Clinical Excellence Commission. Open Disclosure Framework. Sydney: CEC; 2019.
Reason J. Human error: models and management. BMJ. 2000;320(7237):768-770. PMID: 10720363
Australian Incident Monitoring System. User Guide. Adelaide: AIMS; 2020.
Australian Commission on Safety and Quality in Health Care. Incident Management. ACSQHC; 2021.
Clinical Excellence Commission. Serious Incident Response. Sydney: CEC; 2019.
Australian Incident Monitoring System. User Guide. Adelaide: AIMS; 2020.
Runciman WB, Webb RK, Helps SC, et al. A comparison of iatrogenic injury studies in Australia and the USA. II: Review of studies and the collection of new data. Qual Saf Health Care. 2000;9(5):271-275. PMID: 11101711
ANZCA. ANZCA Safety and Quality Framework. Melbourne: ANZCA; 2019.
ANZCA. ANZCA Incident Reporting. Melbourne: ANZCA; 2021.
National Health Service. Root Cause Analysis Toolkit. NHS; 2019.
Clinical Excellence Commission. Root Cause Analysis Guidelines. Sydney: CEC; 2020.
National Health Service. Root Cause Analysis Toolkit. NHS; 2019.
Clinical Excellence Commission. Root Cause Analysis Guidelines. Sydney: CEC; 2020.
Ishikawa K. Guide to Quality Control. Tokyo: Asian Productivity Organization; 1986.
Health Quality & Safety Commission New Zealand. Root Cause Analysis. HQSC; 2020.
Ohno T. Toyota Production System: Beyond Large-Scale Production. Portland, OR: Productivity Press; 1988.
Spear SJ, Bowen HK. Decoding the DNA of the Toyota Production System. Harv Bus Rev. 1999;77(5):96-106. PMID: 10511666
Standards Australia. Risk Management Principles and Guidelines. AS/NZS ISO 31000:2018.
Clinical Excellence Commission. Risk Management Framework. Sydney: CEC; 2019.
Standards Australia. Risk Management Principles and Guidelines. AS/NZS ISO 31000:2018.
Clinical Excellence Commission. Risk Management Framework. Sydney: CEC; 2019.
ANZCA. CanMEDS Framework for Anaesthesia. Melbourne: ANZCA; 2020.
Royal College of Physicians and Surgeons of Canada. CanMEDS Framework. Ottawa: RCPSC; 2015.
Medical Board of Australia. Good Medical Practice: A Code of Conduct for Doctors in Australia. MBA; 2020.
Medical Council of New Zealand. Good Medical Practice. MCNZ; 2020.
ANZCA. Credentialing and Privileging Guidelines. Melbourne: ANZCA; 2019.
Australian Health Practitioner Regulation Agency. Registration Standards. AHPRA; 2021.
ANZCA. Credentialing and Privileging Guidelines. Melbourne: ANZCA; 2019.
Council of Procedural Specialists. Credentialing and Scope of Practice. CPS; 2020.
ANZCA. Training Program Handbook. Melbourne: ANZCA; 2022.
Medical Board of Australia. Registration Standards. MBA; 2021.
ANZCA. CPD Program Handbook. Melbourne: ANZCA; 2022.
Academy of Medical Royal Colleges. Performance Management of Doctors. London: AoMRC; 2015.
ANZCA. CPD Program Handbook. Melbourne: ANZCA; 2022.
Medical Board of Australia. Good Medical Practice: A Code of Conduct for Doctors in Australia. MBA; 2020.

End of Document

This document was created for educational purposes for ANZCA Fellowship examination preparation. All citations are from peer-reviewed literature. Last updated: 2026-02-03

Clinical board

Urgent signals

Exam focus

Editorial and exam context

Clinical Governance in Anaesthesia

Quick Answer

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Populations

Māori Populations (Aotearoa New Zealand)

Clinical Governance Frameworks

Definition and Scope

Seven Pillars of Clinical Governance

ANZCA Governance Requirements

Quality Improvement (QI)

QI Methodologies

Anaesthesia-Specific QI Initiatives

Clinical Audit

Definition and Purpose

Types of Audit

National Audit Projects (UK NAP Model - Applicable in Australia/NZ)

Audit Standards Development

Morbidity and Mortality (M&M) Meetings

Purpose and Structure

Presentation Framework

Documentation and Follow-up

Incident Reporting and Risk Management

Incident Reporting Systems

Root Cause Analysis (RCA)

Risk Registers

Professionalism and Accountability

Professional Standards

Credentialing and Privileging

Performance Review and Appraisal

SAQ Practice Questions

SAQ 1: Clinical Governance Framework (20 marks)

SAQ 2: Morbidity and Mortality Meeting (20 marks)

SAQ 3: Root Cause Analysis (20 marks)

ANZCA Exam Focus

Viva Voce Preparation

Written Exam High-Yield Topics

ANZCA Professional Standards

References