We have consulted with BHS, DjHS, MH, PH and DH, and we considered their views when reaching our audit conclusions. As required by the Audit Act 1994, we gave a draft copy of this report, or relevant extracts, to those agencies and asked for their submissions and comments. 

Responsibility for the accuracy, fairness and balance of those comments rests solely with the agency head.

Conclusion

While health services act when they identify underperformance or emerging risks, they do not consistently identify and respond to quality and safety risks in a timely way. Significant delays in completing serious incident investigations and resulting actions to address underlying issues mean that patients remain at risk of known avoidable harm for too long. 

Conclusion

MH and PH have made greater improvements to their patient safety cultures since Targeting Zero, than BHS and DjHS. They have done this by embedding their clinical governance frameworks in their organisations and supporting staff to actively uphold patient safety. 

Conclusion

Not all audited health services have embedded their clinical governance frameworks in their organisations. While their frameworks are generally consistent with the VCGF, only MH and PH use their frameworks to identify specific local quality and safety priorities, raise staff awareness and drive changes in organisational practices. 

Health services provide care in complex and high-pressure environments where avoidable harm to patients can occur. Effective clinical governance cultures, systems and processes minimise this risk and reduce the potential for harm.

A health service's clinical governance framework describes the activities it will undertake to minimise harm and maximise the quality of patient care. Health services must meet national and state standards for clinical governance.

Agencies were required to self‐attest to the accuracy and completeness of their survey response. The survey sought information on the status of performance audit recommendations:

• from all VAGO performance audits tabled in Parliament in 2018–19 to 2019–20 and two audits that tabled in early 2020–21
• that were reported to us in our 2020 survey as unresolved from audits tabled in 2015–16 to 2017–18.

In total, the survey included 1 063 recommendations from 76 audits involving 102 agencies. 

Departments reported more timely completion rates for recommendations from 2015–16 to 2020–21. Departments completed recommendations from 2018–19 quicker than previous years, as overall completion rates dropped from a median of 35 months to in 2017–18 to 13 months in 2018–19. 

Figures E1 to E4 show a breakdown of between-year trends of department completion times. Due to the short timeframe between reviewing and publishing, we included only two audits from 2020–21. This is why we have excluded 2020–21 in the figures. 

This review includes 1 063 recommendations in 76 audits. We have listed audited agencies with recommendations in these audits below.

FIGURE D1: 2020–21 audits and agencies