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1. Scope

1.1. This policy outlines the overarching Clinical Governance Framework for the development, delivery, monitoring and evaluation of services provided by Open Arms.

2. Context

2.1. Clinical governance reflects the integrated systems, processes, leadership and culture that are at the core of providing safe, effective, accountable and person-centred care underpinned by continuous quality improvement.

2.2. Clinical governance is a key component by which Open Arms leadership and staff share responsibility and accountability to clients and the veteran community for the delivery of services that are safe, effective, integrated, high quality and continuously improving. A transparent and robust Clinical Governance Framework enhances trust and confidence in Open Arms.

2.3. Open Arms is supported by a strong workplace culture of fairness, respect and transparency, grounded in purposeful action that occurs across all levels of the organisation. Systems to support and protect a skilled, competent and proactive workforce include targeted recruitment, engagement, induction, development and retention of high-performing staff.

2.4. Open Arms recognises that client experience and participation are crucial indicators of quality and safety. Effective partnerships are essential for improving care outcomes and driving continuous quality improvement. Listening and responding to the client voice is at the centre of good clinical governance.

2.5. Open Arms supports good clinical practice through systems that support clinicians and peers to provide safe and appropriate care while working within the scope of the service. Open Arms strives to deliver person-centred, cohesive and integrated care – at all times, along the care continuum – ensuring a shared understanding of the care pathway and goals between workers and clients.

2.6. Minimising and safeguarding against clinical risk requires a structured approach to safety that is both proactive and responsive. Consistent safe practice is built on staff awareness and knowledge. It is supported by robust systems that prioritise safety. Effective systems support staff to identify and respond appropriately when things go wrong.

3. Principles

3.1. Open Arms maintains a commitment to ensuring every client has a positive experience.

3.2. Open Arms puts clients at the centre of care, viewing them as critical partners in the design, delivery and evaluation of services.

3.3. Open Arms delivers high quality care that is:

  • safe: elimination of avoidable harm during delivery of care
  • effective: appropriate and integrated care is delivered in the right way, at the right time, with the right outcomes for each client
  • person centred: an individual’s values, beliefs, specific contexts and situations guide the delivery of care and organisational planning.

3.4. Open Arms maintains strong clinical engagement and leadership, whereby ownership of care processes and outcomes is promoted and practised by all staff, and staff actively participate and contribute their expertise and experience.

3.5. Open Arms empowers staff and clients through organisational culture and systems that are designed to facilitate the pursuit of safe care, and delivery that is centred on clients.

3.6. Open Arms maintains a commitment to continuous quality improvement, whereby rigorous measurement of performance and progress is benchmarked and used to manage risk and drive improvement in the quality of care.

3.7. Open Arms demonstrates clear accountability and takes ownership of actions and decision-making, including maintaining compliance with legal and reporting responsibilities, learning from errors, and accountability for decisions and behaviours.

3.8. Open Arms ensures effective planning and resource allocation so that staff have access to regular training and educational resources to maintain and enhance their required skill set.

4. Clinical Governance Framework

4.1. The Open Arms Clinical Governance Framework is illustrated in Figure 1. It includes a broad range of provisions to ensure that Open Arms delivers on its commitment to provide high-quality services to the veteran community.

Figure 1: Open Arms Clinical Governance Framework (adapted from

4.2. Leadership and culture

4.2.1. The Open Arms leadership maintains a clear vision for the service and for improving the quality of care through commitment to – and active practice of – the Open Arms Leadership Compact.

4.2.2. Leadership teams (national and regional) are visible (see the Open Arms organisational charts) and actively engage with and support clients, clinicians, managers and staff through national and regional meetings, updates, operational supervision and advisory forums.

4.2.3. Open Arms leadership is informed by the Australian Public Service Employee Census, is actively reviewed and responds to rates of satisfaction and staff engagement. 

4.2.4. Appropriate governance structures, including committee and reporting processes, are in place to effectively monitor and improve clinical performance. Information on the Open Arms Continuous Quality Improvement Steering Committee is available in the Continuous Quality Improvement Policy (102). 

4.2.5. Open Arms has active change management strategies to communicate, enable and sustain quality improvement processes through the integration of structured change processes which are focused on people, process and tools. The Open Arms change management strategy aligns with the Department of Veterans’ Affairs (DVA) change management agenda, which focuses on culture, leadership initiatives, change capability transformation and the development of a high-performing workforce.

4.2.6. Open Arms values and actively incorporates lived experience into design, development, implementation and evaluation of policy and programs through operationalising the Open Arms lived experience framework. This includes lived experience representation on committees such as the National Advisory Committee and Regional Advisory Forums.

4.2.7. Systemic integration of lived experience peer workers – in both client facing and national operations roles – enhances organisational military cultural awareness and competence. 

4.2.8. Open Arms maintains open and transparent communication policies and procedures through the use of a single source of truth through the online Communication and Operations Resource Exchange (CORE) platform.

4.3. Client partnerships

4.3.1. The Open Arms Care Policy is client centred and ensures clients are partners in their own recovery, commencing on intake – where they are invited to state preferences for allocation (including worker type, location, timing) – through to collaborative care planning, treatment and discharge from an episode of care.

4.3.2. Client feedback, both positive and negative, is sought and used to review and improve services. This is achieved through both the Client Feedback Management System and Open Arms specific client satisfaction surveys.

4.3.3. Feedback, including complaints, is responded to in consultation with the client to reach suitable resolutions and these outcomes are then used to drive improvement.

4.3.4. Open Arms actively engages in co-design with its clients and lived-experience workforce to ensure needs are recognised and perspectives considered. This includes using surveys, forums and workshops during project design, implementation and evaluation. 

4.3.5. The Open Arms Rights and Responsibilities brochure provides a transparent, easily understood contract of mutual obligations between Open Arms and its clients to ensure accountable partnerships.

4.4. Workforce

4.4.1. Open Arms has a robust staff onboarding process (see the Mental Health Workforce Policy (400)) that includes orientation and induction in safety and quality issues.

4.4.2. Open Arms engages appropriately qualified and skilled mental health workers to deliver its mental health services. 

4.4.3. Training in military culture is provided by Open Arms to its entire workforce, to enhance understanding, engagement and collaboration with our clients in a culturally appropriate way. 

4.4.4. SStaff have the requisite skills, knowledge and experience in working with serving and ex-serving military and their families, including understanding high-prevalence clinical conditions in these populations and evidence-based approaches to supporting clients experiencing them.

4.4.5. Peer workers operate within a clinical framework and their client work is overseen by clinicians.

4.4.6. Clinical support staff are supervised by clinicians and trained in the areas of confidentiality and immediate support, including through attendance at Mental Health First Aid (MHFA), Applied Suicide Intervention Skills Training (ASIST) or safeTALK as applicable.

4.4.7. Performance frameworks provide a mechanism to ensure mental health workers are meeting continuing professional development requirements. For in-centre workers this includes the use of Performance Agreement and Development Plans. For Outreach Program contractors this includes initial statutory registration eligibility checks and annual registration audits.

4.4.8. Quality systems, including workforce skills audit, are in place to ensure critical clinical and peer work training requirements are met.

4.4.9. Open Arms mental health workers receive regular supervision (internal and external) and mentoring and support, including access to the employer assistance program.

4.4.10. Staff have access to grievance and dispute processes or mediation processes, based on principles of transparency and social justice. 

4.5. Clinical Practice

4.5.1.    This section should be read in conjunction with the Open Arms Care Policy (202), Clinical Risk Management Policy (203) and Continuous Quality Improvement Policy (102).

4.5.2.    Open Arms complies with the legal and reporting responsibilities of the DVA and with Commonwealth and state/territory mandatory reporting obligations, as well as requirements of relevant professional registration agencies.

4.5.3.    Clinicians and peers work within their approved credentialing and scope of practice requirements and regularly review their own performance.

4.5.4.    Clinical auditing and clinical incident reviews contribute to continuous quality improvement by identifying opportunities to enhance services to clients and eliminate or mitigate risk. Open Arms has a Clinical Audit Framework to ensure that regular review points are built into the delivery of care and built into policies and procedures supporting the investigation of clinical incidents.

4.5.5.    Samples of care plans are reviewed by senior clinicians, including the use of outcome measures and feedback to evaluate the effectiveness of care. This includes consideration of complex cases at multidisciplinary group clinical review meetings.

4.5.6.    Leadership teams and senior workers provide oversight and supervision to clinical and peer teams, to ensure evidence-based best practice approaches are being applied.  

4.5.7.    The Open Arms Care Coordination Procedure (202-09) is situated in a person-centred model of care. The procedure employs a proactive, integrated and collaborative approach to coordinate care, handover and referral to complimentary or alternate services and supports. 

4.5.8.    Where treatment errors are identified through complaints or systemic review processes, including case reviews and audit, the issue is addressed promptly through the relevant Open Arms procedure(s).

4.6. Risk management

4.6.1.    This section should be read in conjunction with the Open Arms Clinical Risk Management Policy (203).

4.6.2.    Risk identification and treatment strategies are regularly reviewed to ensure early identification of trends in risk across all clinical and peer-based services.

4.6.3.    Where safety is compromised, leadership and risk systems support staff to initiate appropriate and timely escalation, management and corrective action.

4.6.4.    All issues related to risk are subsequently reviewed in order to inform future practice and improve safety.

4.6.5.    Open Arms supports staff to pursue safe practice and speak up when safety issues are identified.

4.6.6.    Clinical processes, equipment and technology are designed to minimise error and support clear, unambiguous communication between staff.

4.6.7.    Risk considerations and data inform goal and priority setting and the development of business and strategic plans.

4.6.8.    Clinical incidents are investigated using a restorative practice approach – to identify underlying systems issues – and this information is used to improve safety.

4.6.9.    Open disclosure processes are in line with the Australian open disclosure framework (ACSQHC 2013). Additional information on open disclosure is included in the Clinical Risk Management Policy (203).

5. Implementation

5.1.    The National Manager:

  • ensures appropriate systems and processes are in place to maintain the quality and safety of services
  • ensures that quality indicators are monitored
  • promotes an organisational culture that values the pursuit of excellence in care, the identification of system issues and collaborative development of strategies to improve care.

5.2.    The Assistant National Manager:

  • ensures that service improvement and clinical incident review recommendations are routine components of performance feedback in Open Arms regions
  • ensures that systems are in place to monitor the delivery of services, including reporting of clinical incidents.

5.3.    The Assistant National Manager National Operations (roles now within the Mental Health and Wellbeing Services Division):

  • ensures that effective clinical governance systems are in place across Open Arms sites and services, including those delivered by contracted providers
  • is responsible for quality improvement activities and monitoring.

5.4.    Open Arms leadership teams:

  • manage clinical operations and service delivery
  • ensure that the quality of care provided to Open Arms clients is consistently high and aligned with current evidence-based best practice
  • ensure that near misses and clinical incidents are reported consistently
  • ensure that workers involved in care where there has been an adverse outcome are actively engaged in review of systems and input into any recommendations for improvement.

5.5.    Open Arms workers:

  • provide mental health services in accordance with Open Arms policy
  • identify and report incidents and opportunities for service improvement.

6. Parent Policy

6.1. 100 Governance Policy

7. Subordinate Policies

7.1. 201 Eligibility Policy

7.2. 202 Open Arms Care Policy

7.3. 203 Clinical Risk Management Policy

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