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. 

NEW: Interactive Learning Tool

July 26, 2023: Island Health's Simulation Team has created an interactive learning module called Advancing the Understanding to make it easier to learn about the new clinical governance model. This self-paced, self-guided online resource provides information about clinical governance, our new model, and the various functions, resources and supports that are being developed. We encourage you to explore this resource and share your comments and questions. This module will be updated as we continue to refine the work​.


NEW: Committee Terms of Reference updated and posted

Aug. 1, 2023:  Earlier this year we shared Version 1.0 of the draft terms of reference for the Integrated Clinical Governance Council and C.A.R.E. Network committees (Operations Excellence and Clinical Excellence).  We collected feedback that identified gaps and helped us understand that these documents can be difficult to understand, due to the shift from current state and because people are still learning about the new model overall.​

In Version 2.0 we have addressed gaps, updated changes to membership and meeting management cadence and tried to simplify the language. As the committees begin operations, we will create version 3.0 with more input from committee members, and look to update the ToRs in 2024.

Find Version 2.0 of Terms of Reference documents in our Resource Library.​ ​​


CGII Newsletters

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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.​

cgi frame work.jpg

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.



Future State Model

July 31, 2023In response to requests from staff and medical staff who have been involved in the Clinical Governance Improvement In​itiative, we have developed a new graphic depicting the different components of the new Clinical Governance model. No comp​onents of the model have changed from the previous visual that you may have seen. This depiction is easier to read and visually highlights the importance of local structures and patient, family and community voices. What do you think? Let us know at

Figure 1. 

CG Model 20230721_w_popouts_R2 (004).jpg

 Click here for PDF.

​​Clinical Governance Secretariat Page

Click here to visit the ​​Clinical Governance Secretariat page. Island Health's Clinical Governance Secretariat is a new resource dedicated to the administration and coordination of governance work to ensure the effective coordination and operation of Clinical Governance committees.

Clinical Governance Model: Local Level Design

Click here to access the Clinical Governance Model: Local Level Design page. 

CGII Town Halls

C.A.R.E. Network Committee Membership

Point-of-care staff and patients are in the best position to identify opportunities to improve the quality of our health-care services. Staff and medical staff will soon have a new opportunity to help lead quality improvement at the regional level by participating in new committees with Island-wide impact. 

An expression of interest will open on April 19th to identify members of those new committees. Read more below, and join us at a drop-in virtual town hall to learn more about this opportunity.

​Learn more at a Drop-In Town​ Hall

There are currently no upcoming CGII Townhalls. Please watch this space for future announcements.

Date ​Link
​Thursday April 27th at 4:30pm-5:30pm ​Microsoft teams: Click here to join the meeting

Meeting ID: 255 310 283 914 

Passcode: pb8MvS 

Call-In (audio only): 

+1 778-401-6203,,561905883# 

  Canada, Victoria 

+1 236-800-8270,,561905883# 

  Canada, Duncan 

+1 236-362-5020,,561905883# 

  Canada, Nanaimo 

+1 778-725-4725,,561905883# 

  Canada, Vancouver 

Phone Conference ID: 561 905 883# ​

Wednesday May 3rd at 1:00pm-2:00pm​ ​Microsoft teams: Click here to join the meeting
​Meeting ID: 285 932 883 293 

Passcode: dwbtZ6 

Call-In (audio only): 

+1 778-401-6203,,282836857# 

  Canada, Victoria 

+1 236-800-8270,,282836857# 

  Canada, Duncan 

+1 236-362-5020,,282836857# 

  Canada, Nanaimo 

+1 778-725-4725,,282836857# 

  Canada, Vancouver 

Phone Conference ID: 282 836 857# 

Common Questions

Why are we setting up new regional committees?

The existing committee structure is not integrated making it difficult to navigate and enable accountable decision making. New committees also provide an opportunity to address issues of professional and geographic representation.  Transforming our clinical governance will enable us to meet our goal of delivering consistent, high-quality care to everyone, in every ​community.

What is a C.A.R.E. Network?

C.A.R.E. Networks are regional structures that will complement and support the geographic or community structures responsible for day-to-day service delivery. Thirteen C.A.R.E. Networks will replace Quality Councils and other regional committees.  

What are Operations Excellence Committees and Clinical Excellence Committees? 

Each C.A.R.E. Network is organized into two Committees, Clinical Excellence and Operations Excellence. These committees will collaborate to identify, prioritize and implement regional change initiatives to improve quality for Network services.  They will be responsible for annual Quality Improvement Plans, regional service standards and policies and evaluating clinical innovations. 

The CECs and OECs in each Network will work in close partnership with each other and emerging local Quality and Operations structures in each community. 

What commitee roles are available? 

Chairs for all OECs and CECs are appointed. The Expression of Interest will identify regular members of all Operations Excellence and Clinical Excellence committees. Anyone who would like to join one of these committees, including current Quality Council members, should apply. 

What qualifications do I need to join a C.A.R.E. Network committee? 

The Clinical Excellence Committee members will be people with specialized knowledge related to the definition and assessment of the standards that define “quality” while the Operations Excellence Committee members will be those who have specialized knowledge in how to design and implement change effectively.  Both committees will have:

Representatives from local quality and operations structures reflective of the diversity of Island Health communities Interdisciplinary staff and medical staff that represent the scope of professions in the service Representation from People/Family/Community Advisory Structures

Will there be other opportunities for me to participate in governance in the future? 

Yes! C.A.R.E. Network committees are just one part of the new, consolidated governance structures. Additional opportunities in the future may include supporting quality improvement at the local level, through taskforces or clinical services planning. 

Representatives from resource teams will also be part of these respective committees based on their areas of expertise, and on the stage of committee work.  For example the OECs will have members from finance, enterprise change management, and enterprise project management involved, while the CECs will involve members from decision support, research, professional practice, and quality & safety departments.​

What is the time commitment?

Committee members will be expected to attend two 2-hour meetings each month, for a total monthly commitment of four hours. In addition there will be education and onboarding activities prior to committee activation in September. 

Will this be an add-on to my current workload? How will I be supported to participate? 

Part of the committee selection and onboarding process will include conversations with senior leaders to ensure that new members have the time they need to participate in committees within their existing role. Logistical support, through a new secretariat, will also be provided.  

Why should I consider joining a C.A.R.E. Network committee? 

The new clinical governance model is an investment for point-of-care staff to have more involvement in improving quality and increase their level of engagement at work. This is an exciting opportunity for point-of-care staff to contribute to patient safety, experience, quality of care and health equity across all of Island Health.

I’m interested but I want more information​

Review CGII reference materials like the C.A.R.E. Network Q&A, join us at an upcoming town hall (schedule is on this page) or email us at

About C.A.R.E Networks:

The Expression of Interest (EOI) seeking to identify individuals interested in joining the C.A.R.E. Network committees has now been closed. Individuals will be contacted by the end of June about the status of their application. If you have any questions in the meantime, please don't hesitate to reach out the CGII project team at

Expression of Interest Background 
  • Clinical governance is a systematic approach used by organizations to oversee, shape, manage and continuously improve the quality of care (HSO Standard 1003:2021(E)).
  • In 2022 Island Health adopted a single organizational governance structure for clinical planning, policies and standards, aligned to best practices. This structure is intended to strengthen the foundations of Island Health clinical governance and ensure culturally safe, high-quality care
  • This structure, as one element of a refreshed clinical governance model, reflects the provincial/governmental, organizational, regional and local point of care levels of the system: each with its own responsibilities and accountabilities.
  • At the regional level, 13 C.A.R.E. Networks were established as the core clinical services committees to represent the groupings of common/aligned services provided by interdisciplinary and collaborative teams in alignment with our vision, purpose and values.
  • ​​​​Each C.A.R.E. Network will include an Operations Excellence Committee (OEC) and Clinical Excellence Committee (CEC). The OEC and CEC of each C.A.R.E. Network will work in close partnership with each other as well as the Local Quality and Operations Committees in each community.
    • OEC primary functions are to provide expertise in how to make operational changes to clinical policy, standards and clinical operating models, and sustain performance.
    • CEC primary functions are to provide expertise in the identification of clinical risks and the appropriate response based on leading practice. Other functions include quality standards monitoring clinical safety and quality processes and improving performance in prioritizing safety.

More information on the OEC and CEC can be found on the Terms of Reference

Roles & Responsibilities for Committee Members

Prepare for and attend committee meetings:

  • Attend twice monthly meetings and additional ad-hoc meetings to their best effort
  • Inform the CG secretariat where attendance is not possible
  • Review all relevant material prior to committee meetings
  • Provide input to and approval for the records of decision, ensuring their accuracy


Participate in decision-making and recommendations development:

  • Provide input into discussions and decision-making, raising local and regional considerations, potential impacts, and other relevant considerations
  • Contribute to the development of recommendations and identification of issues that will be brought to the ICGC

Represent the C.A.R.E. Network on working groups, as needed:

  • Use expertise and experience to serve on working groups as determined necessary by the Chair

Facilitate communication, collaboration and information flow with other committees, as required

  • Ensure information flow between the C.A.R.E. Network and Local Quality and Operations structures

Ensure cultural safety and uphold Island Health’s commitment to combatting anti-Indigenous racism and championing equity, diversity and inclusion


Time Commitment
  • 2 monthly 2-hour virtual meetings, not including time for review of pre-read materials
Membership Selection Process Overview
  • All EOI submissions will be anonymized for review by a Selection Committee.
  • Selection Committee membership includes representatives from Quality, Medical Staff Association (MSA), Nursing and Allied Health Advisory Committee (NAHAC), Human Resources, Executive Medical Director, Executive Directors, Patient Partner, Implementation Science and Professional Practice.
  • The Selection Committee will review submissions against pre-defined evaluation criteria focused on skills, experience and competencies.
  • The Selection Committee will prioritize the following representation on all committees:
    • Diversity from all geographies where services are provided, e.g. rural and remote, urban centres and small communities;
    • All staff and disciplines (e.g., including medical staff, nursing, allied health) within the Network, including frontline and leadership perspectives; and
    • Person, Family, and Community voice representatives (to be determined as per the Engagement Strategy).
Questions and Answers for Medical Staff about Committee Membership


A separate process will take place to identify members of Specialty Service Area committees.  Current committees focused on specialty services should continue their work. SSA members do not need to respond to the EOI for their "hosting" Network (e.e. Heart Heath to Medicine). 


The Expression of Interest will identify members of Operations Excellence Committees (OECs) and Clinical Excellence Committees (CECs) that are part of new regional governance bodies called C.A.R.E. Networks. The EOI will be open from April 19 to May 19.


A separate process will take place to identify members of Specialty Service Area committees. Current committees focused on specialty services should continue their work. SSA members do not need to respond to the EOI for their "hosting" Network (e.e. Heart Heath to Medicine).


C.A.R.E. Networks are regional structures within the new clinical governance model that reflect groupings of common / aligned services. There are 13 Networks, including: Critical Care; Diagnostic Imaging; Emergency Medicine; Home and Community Care; Laboratory Medicine; Long-term Care; Medicine; Mental Health & Substance Use; Pediatrics; Perinatal, Newborn and Women’s Health; Primary Care; Rehabilitation / Restorative Health and Surgery.


Operations Excellence and Clinical Excellence committees within each Network will have distinct but complementary functions. They will share responsibility for the development of annual quality improvement plans, identification of clinical innovations and regional service standards and policies.


It is expected that four medical staff will be needed for each Clinical Excellence Committee and two for each Operations Excellence Committee. Each committee will have approximately 20 members, not including chairs and patient partners. Remaining membership will include representatives from local quality and operations committees and professions that represent the scope of practice in the service.


Each OEC and CEC will have different members. This is to align people with the right skills to the right decisions and ensure that people don’t spend time in meetings without a clear role.


In some cases C.A.R.E. Networks also include Specialty Services (ie: Trauma is aligned to Surgery). This is to account for highly specialized services, where only a very limited group of specialists or experts in these services are qualified to participate in decision-making, and where the services are not of sufficient size to warrant a separate C.A.R.E. Network. The plan for committee membership on Speciality Service Areas will be developed in September once the C.A.R.E. Network transition has been completed.


Committee members should expect to dedicate five hours per month to prepare for and attend two virtual meetings.


The rate of pay is being evaluated by physician compensation.


C.A.R.E. Network committees will begin functioning in September.


A new secretariat team will be dedicated to the coordination and administration of governance work, including communication.


Diversity from all regions where services are provided, e.g. rural and remote, urban centres and small communities, is an important principle of C.A.R.E. Network design


Current Quality Council members who would like to join C.A.R.E. Network committees must submit an Expression of Interest to be considered.


An online Expression of Interest will be open from April 19 to May 19, 2023. All interested individuals, including current Quality Council members, should use this process to join a C.A.R.E. Network Clinical Excellence or Operations Excellence Committee. A selection committee will include representation from the Medical Staff Association (MSA), Nursing and Allied Health Advisory Committee (NAHAC), Human Resources, Patient Partners and Clinical Governance leads representing quality, patient safety and clinical services delivery. The Selection Committee will review submissions against pre-defined evaluation criteria focused on skills, experience and competencies.


The Chairs for Operations Excellence and Clinical Excellence Committees are appointed.

Helpful Resources:

Information and Resources:

Questions? Please email