Table 5 Summary of processes related to key healthcare governance tasks

Processes of selecting healthcare quality data:

• Board endorsed definition of healthcare quality exists that identifies measurable categories of quality

• Conceptual categories used to structure quality reporting

• Board and BQC calendar or schedule that identifies main quality reports and activities

• Detailed board and BQC dashboard indicator framework

• Periodic scheduled management and board review of reporting content

Strategic quality priority processes:

• Strategic priorities addressing quality healthcare

• Limited number of specific strategic priorities for improving quality healthcare

Governance processes:

• Orientation and skill development

• Agenda setting

• Reviewing reporting framework

• Reviewing governance effectiveness

Reporting processes:

• Regular reporting at board and BQC

• Dashboard/s indicators reflecting a range of dimensions of quality

• Periodic (e.g. annual) thematic standalone quality reports addressing clinical risks, quality systems and program areas

• Periodic (e.g. annual) thematic operational quality committee reports

Operationalising quality priorities:

• Mechanism for cascading strategic priorities at governance level into subordinate plan

• Subordinate governance plan incorporates quality priorities from all sources (planned and emergent)

Identifying performance variation processes:

• Key quality indicators presented with analysis and action implemented, (including no action)

• Quantitative data presented graphically with trends, agreed targets or acceptable limits or benchmark comparison

• Data disaggregated to reflect program level, where possible

• Internal and external reports provided with summary briefing document with background, analysis of data and issues and action

• Periodic longer term thematic analysis to identify causes of variation (e.g. incidents, patient feedback or experience)

• • Internal methods of performance assessment against evidence-based standards in areas of clinical risk

Monitoring progress processes:

• Measurable quality strategies at a governance level

• Regular reporting on progress with quality strategies at a governance level

Action identification processes:

• Data analysis and system level action in response to all quantitative and qualitative data

• Mechanisms for tracking implementation and effectiveness of action that arise out of data review