Clinical Governance Improvement Initiative

CGII Overview:

The Clinical Governance Improvement Initiative (CGII) was launched in the fall of 2021. Improving clinical governance improves clinical outcomes for patients, families and care teams. We have been listening to our care teams, and we are proud to be taking meaningful steps towards clear, simple, and transparent clinical governance and accountability. According to the Health Standards Organization, clinical governance is the framework by which the governing body, leaders, and health care providers have responsibility and accountability for the quality of care. The CGII is a critical next step in strengthening our​ organizational foundation for culturally-safe high-quality care, and for helping us achieve our strategic framework goals​ by 2025. 


Provide feedback on terms of reference for governance committees

Island Health has been engaged in a Clinical Governance Improvement Initiative (CGII) to improve our decision-making structures and processes to better support point-of-care teams to deliver high quality service. The first recommendation of the CGII was to develop a new, simpler and more responsive clinical governance structure. After engagement with staff and medical staff, a new structure has been approved, and we are now seeking your input on draft terms of reference for organizational and regional Clinical Governance structures.

Terms of Reference should provide clear, well-defined descriptions of each group’s membership criteria, roles, responsibilities and decision-making rights.  We are interested in hearing from medical staff about the clarity, accuracy, and completeness of the Terms of References for:

  • The Integrated Clinical Governance Council: This senior organizational-level committee is accountable to the Executive Leadership Team (ELT) to direct and evaluate defined clinical governance functions and cross-continuum quality improvement activities. CLICK HERE FOR DETAILS AND FEEDBACK FORM.
  • C.A.R.E. Network Clinical Excellence Committees: The C.A.R.E. Networks are clinical services committees at the regional level, reporting to the Integrated Clinical Governance Council (ICGC). The C.A.R.E. Network is the organizing structure for shared decision-making that defines, monitors and enables quality of care for services within the specific Network. The Networks, which will replace the current quality structure, are further organized into two primary Committees: Clinical Excellence and Operations Excellence. The primary function of Clinical Excellence Committees is to provide expertise in the identification of clinical risks and the appropriate response based on leading practice. CLICK HERE FOR DETAILS AND FEEDBACK FORM.
  • C.A.R.E. Network Operations Excellence Committees: The Operations Excellence Committee (OEC) work in close partnership with the Clinical Excellence Committee (CEC) of the same Network, and the Local Quality and Operations Committees in each community. Its primary functions are to provide expertise in how to make operational changes to clinical policy, standards and clinical operating models, and sustain performance. CLICK HERE FOR DETAILS AND FEEDBACK FORM.

The online feedback forms includes embedded information resources, PDFs of the complete Terms of Reference documents and excerpts with specific questions. The forms will be open until March 24, followed by a review and update process. We will report back in April about the results.


QUESTIONS? Please email

Objectives & Principles

The CGII is about improving clinical policy, program planning, and practice standards development and implementation by clarifying accountability and decision processes.  

The initiative includes all the clinical service settings and populations of focus such as acute, long-term care, public health, primary care, home care services, mental health, and indigenous health services.

We will be aligning our clinical governance with the recently developed draft standard for Clinical Governance established by the Health Standards Organization (HSO).  Through our Strategic Framework 2020-2025 we are committed to meeting or exceeding the highest standards of clinical governance, and to addressing clinical governance issues at Island Health that preven​t the prioritization of care to patients and families. ​

Through the Clinical Governance Improvement Initiative (CGII) a framework has emerged that explores 4 major lenses: leadership & culture; continuous improvement; people-centred; and shared decision-making & accountability. This conceptual framework has helped guide our project. Elements of cultural safety and diversity, inclusion, and equity will be considered across all four areas. The CGII framework is adapted from, and reflect common themes across detailed criteria within the HSO Standard for Clinical Governance, Australian National Clinical Governance Frameworks, Island Health Executive Sponsors and input from Deloitte Advisors.​

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Clinical Governance Conceptual Framework

Definitions and Guiding Principles 

In order to create a mutual understanding of clinical governance, we are using the following Health Standards Organization (HSO) 2021 definition:

Clinical Governance (CG)

Systematic processes to oversee, shape, manage, and continuously improve clinical services to ensure safe and quality care. Effective clinical governance is evidence-informed, based on ownership and accountability, shared decision-making, reflective learning and knowledge sharing, and has a culture of safety and trust throughout the organization. Clinical Governance includes the formation and capacity of, interprofessional, collaborative partnerships that include clients, families, partner organizations, and the community, and effectively contribute to the clinical governance of the organization (from Clinical Governance, HSO 2021).

Shared Decision Making – between administrators, clinical service providers, clients, families, partner organizations, and the community, all of whom have an important role in making, informing, and being accountable for clinical decisions that impact the client journey.

Policy – A policy sets out realistic, clear, concise, and non-negotiable requirements (except as specifically provided for in the relevant document) that are fundamental to the mandate, core values, and overall clinical and corporate strategies and goals for the delivery of health care and services.

Clinical Governance Guiding Principles

Alignment – decision processes are aligned across portfolios and at all levels of decision-making.

Accountability – responsibility for, and being able to answer to, a person or group regarding assigned obligations and outcomes of a decision.

Transparency – openness around decision-making processes and outcomes.

Efficiency – decision-making is timely with efficient use of resources.

Effectiveness – decision processes achieve the intended outcome.

Inclusivity – engaging with people who are affected by decisions, in an inclusive, balanced, and equitable manner. They do so by creating a physically, psychologically​, and culturally safe environment for participation that addresses power imbalances between stakeholders.


Oct. 26, 2022 - Island Health launched the Clinical Governance Improvement Initiative in December, 2021 with a commitment to create an effective Clinical Governance (CG) model that is person-centred and driven by population health. Fifteen actions, summarized below, have been identified to achieve this goal. These recommendations were informed and shaped by expert input from Island Health staff and medical staff, examples of best practice from jurisdictions around the world and Island Health's strategic priorities. The recommendations will be carefully  sequenced, implemented and evaluated over an approximate 3-year period. 


Future State Model

The new clinical governance model approved in December 2022 is a single organizational structure for clinical committees to enable shared decision within defined clinical governance processes. This structure has no impact on day to day reporting relationships for individuals; nor does it interfere with day-to-day clinical decisions by teams. The processes in scope include clinical policy and s​tandards, clinical risk and patient safety, performance and quality, clinical innovation, clinical audit and clinical services planning. The model is depicted in a standard hierarchical picture below (Figure 1).  Future iterations of this illustration will focus more on how the decision making flows both up from the people receiving services and down from the Ministry of Health and the inter-relationships between groups. 

The focus of work to date has been to redesign the regional level of the model. One of the next step is to establish a “common” structure for local quality and operations committees to further build out the escalation pathways and information flows. This work will be initiated in the spring 2023.​

Figure 1. 

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Care Network Q&A