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The ACHSM Health Management and Leadership Competency Framework identifies Risk Management and Clinical Governance as an action competency relevant to the direct work of health managers and leaders.
On 3 Apr 2024 at the offices of Deloitte Sydney, the ACHSM NSW Branch along with speakers, Dr Cathy Balding, FCHSM GAICD, Director of Qualityworks and Dr Karen Luxford, FCHSM CHE, Group CEO, Australian Council on Healthcare Standards (ACHS) & ACHS International took the opportunity to celebrate 23 health managers and leaders across NSW who every day play important roles in shaping the risk and safety culture of their team and/or organisation.
Congratulations to all the award recipients listed below.
Sydney Local Health District has many residential aged care facilities (RACF). Many residents are unable to access timely dental care due to their complex medical conditions, experiencing rapid deterioration in their oral and general health. Existing outreach models are limited due to workforce shortages. In 2023, Professor Shilpi Ajwani established a novel student-led outreach service in partnership with Sydney University. Her key achievements were the development and implementation of clinical governance protocols and risk mitigation strategies specific to the student workforce in RACF setting. Training resources and clear systems were put in place to support students which are now embedded in practice. Her collaboration with district partners, RACF and the University resulted in the successful piloting of student placement in 2023, expanding to regular placement in 2024.
As part of value-based care initiative, she established a new dental pathway for drug health clients in 2023. Due to the complexity and high-risk nature of this service, under her leadership, the team developed a new model of care defining the clinical governance framework and the identification and management of incidents. In 2023, the pilot won the SLHD Innovation and Excellence award and has now been expanded to other sites.
As the Research Ethics Manager and Executive Officer within the Cancer Institute of NSW, Chehani helps to steer and facilitate the governance of interventional and observational research and evaluation proposals referred to NSW Health.
In her role, she routinely provides specialised advice and direction to Committees and researchers across NSW and Australia, on protecting the rights, mental & physical well-being, dignity & safety of research participants.
A particular emphasis in her work is the protection of the privacy and confidentiality of participants and/or their personal health information held in large, routinely collected databases.
As evidenced by her effective and efficient mitigation of the competing risks of conducting and avoiding research, in accordance with the values and principles of the NHMRC National Statement, Chehani has shown outstanding management and leadership in risk management and clinical governance.
As Deputy General Manager at Nepean Hospital, Michelle models a positive risk culture that encourages staff at all levels to manage risk as a part of their day-to-day work. Staff are encouraged to express their concerns and to elevate concerns to appropriate levels.
Some of the ways in Michelle has built a positive risk culture is through open discussions with staff during executive rounding. A key point of discussion involves the identification of risks and whether staff and local managers are able to put in place appropriate controls and treatment plans. If not, staff are encouraged to escalate their concerns to their senior managers to table at the senior leaders meeting with Hospital Executive to allow the identification, assessment, management and monitoring of risks so that these can be reported to the senior executive team, Chief Executive and Board.
Risk is discussed at Hospital peak committees including the Executive Leadership Team and Clinical Council. Michelle has established a Risk Committee to provide a forum for escalation of risks in a structured way to ensure risks are assessed using the NSW Health Risk Matrix. Michelle has introduced the bowtie methodology to assist in evaluating the extent of the risk, document risk causes, quantify potential risk impacts, assign and monitor controls to mitigate the risk. Michelle has demonstrated leadership in developing a positive risk culture that provides greater oversight of risks and learning opportunities for staff involved.
Rural Doctors Network recommends Sharif Bagnulo – Health Systems Manager, for the ACHSM (NSW Branch) Leadership Recognition Awards. The submission has RDN Board and Executive endorsement.
RDN has responsibility for significant public, corporate and philanthropic funds. The charity’s mission is to enable access to health and social care for remote, rural and disadvantaged communities. Evidence-based practice and implementation science underpins RDN’s way of working as health system transformation and social change is complex. Organisation, program, clinical and relationship governance is fundamental to impact success, reputation and sustainability.
Over 15+ years with RDN, Sharif has committed to professional development and extending his scope of responsibilities. He was recently successful in attaining ACHSM Fellowship.
In 2022-24 Sharif has taken his contribution to the sector to new levels. Within RDN’s post-COVID ‘shift the needle’ strategy, he has taken responsibility for three of our most ambitious projects. He led the creation of RDN’s Knowledge Mobilisation directorate, which is now embedded in organisational construct. The Diabetes Collaborative Commissioning project is a multi-government-tiered, multi-regional and multi-stakeholder innovation aiming to improve health outcomes for 11,500 people living with type 2 diabetes in Western NSW. He has led conceptualisation and implementation of the Rural NSW Nurse Student Placement Program, which in its first 18-months, resulted in 80 nurses in-training securing rural career pathways.
These projects required high-level governance, risk management, continuous improvement performance. Sharif is expert in RDN’s, and our stakeholder’s eyes. This includes Indigenous organisation leaders, who have reported to RDN their trust in Sharif.
Justice Health and Forensic Mental Health Network (Justice Health NSW) provides health care to people in contact with the criminal justice and forensic mental health systems.
As the Director, Office of the Chief Executive – Donna Blomgren’s portfolio includes leading the organisation’s risk management function and advocating for a risk culture at all levels of Justice Health NSW.
Since being appointed to the role in early 2023, Donna has been responsible for leading the organisation’s approach to risk management. In that time, she has:
Donna illustrates a commitment to building a risk culture that will undoubtedly result in safer patient care for people in custody and secure settings in NSW.
She is a Health Manager focused on continual quality improvement and is highly deserving of this recognition.
Steve is an outstanding leader in the Patient Safety Directorate and the Clinical Excellence Commission more broadly. He is an excellent communicator and has real strengths in how he engages with others.
In his current role, Steve has fostered many strong and positive internal and external relationships and effectively collaborates with many others for the purpose of improving patient safety and clinical governance. He is at the forefront on safety intelligence and using data to drive safer clinical services and uses a humorous and engaging approach to do this.
Steve shows vision and purpose and is an inspiration to his team and to many others who work with him. Under Steve’s direction, his team has continued to develop to become more strategic and future focussed in relation to clinical governance and patient safety. While Steve is able to make difficult decisions under pressure, he demonstrates strong awareness of the needs of his team and others.
Steve plays a statewide leadership role that is influencing how we drive safer care and more effective clinical governance in NSW. We are fortunate to have such an excellent leader at the CEC and NSW Health.
Over the past 7 year in this role Karen has had continued success with implementation of extensive and complex programs of work. Recently Karen has led the implementation of Hospital HealthPathways (HHPs) within HNE LHD as the first HHP site outside of Canterbury New Zealand to implement the program.
HHPs aim to provide quick, easy access to best practice clinical guidance and support for HNELHD clinicians. They include referral information, discharge criteria and patient support services. The original target audience included junior medical officer (JMOs) as well as our transient workforce (e.g. locums), however they are now used by all clinicians.
HHP implementation within HNE LHD has been highly successful with:
Surveys carried out in 2018, 2021 and 2023 for our JMOS has shown an increase in the likelihood (very-extremely likely) they would use HHPs every day (13% in 2018 compared to 60% in 2023) with an average of 15,000 HHP page views monthly.
Dr Desai manages multiple community dental clinics that see approximately 500 child and adult patients a week. The public dental clinics provide a range of dental treatments that include preventive care to high-risk complex dental procedures. There is higher representation of vulnerable patients like young children, women experiencing domestic violence, refugees/asylum-seekers, elderly and those with complex health needs compared to private dental practice.
High demand for public dental services along with the complexity of the patient cohort requires strong governance systems and risk mitigation strategies. In 2023-24, Dr Desai has worked on improving governance systems around timely access to care, improving patient experience, and delivering patient-centred care whilst providing safe and high-quality care through her clinical redesign project. The initiatives have improved efficiency and streamlined patient journey.
She has enabled the implementation of various integrated-care pathways with other services to ensure holistic care to more vulnerable pocket of patients. Her work around setting up strong referral and governance systems has ensured more patients from the pathways receive safe and timely care. Some of the collaborations include Drug Health services, mental health services, organisations caring for homeless people, child and family nurses. Many of these initiatives have received state-wide recognition.
Michelle has been working in clinical governance for many years as a Quality Data Systems Support Manager and a Clinical Programs manager and had made a remarkable contribution. Michelle excels in identifying issues and resolving problems by drawing on her diverse range of skills, knowledge and expertise and always in a highly collaborative and engaging way.
Michelle’s colleagues hold her in very high regard. Michelle always supports her team with information for their projects and has made a valued contribution to quality improvement across our organisation.
Michelle has also influenced decision making and improvements at a State level. For example, she has developed numerous audit tools, guidelines, and resources that are now used by the Clinical Excellence Commission (CEC) in the Quality Audit Reporting System (QARS) and the CEC Health Literacy Program.
Michelle has successfully collaborated and negotiated with The Australian Commission in the revision of the Hospital acquired complications specifications that are now used across Australia and she has collaborated with over 300 staff to publish 386 consumer reviewed health information resources in plain English on the Patient Information Portal (PiP), in her commitment to improving health literacy and patient information.
I am not new to NSW Health, but I am new to the CEC, this month being my sixth month as a member of the Maria’s team. Whilst other people may need years to know their managers well, it only took me a few months to know Maria as a manager.
As with any other team, our team has had our challenges during my first few months in the team. It was during those challenging moments that we saw Maria’s continuous quality improvement focused leadership style. She is always focused on user-centred designs in helping our team build safety processes and risk management pathways.
She cultivates a culture where her staff always feel safe and motivated to improve.
An excellent manager is a listener, a change catalyst, a coach and an inspiration. They are compassionate, inclusive and they demonstrate vision. They are not just a manager, but a leader; and that leader is exactly who Maria is everyday.”
Dr Harvey Lander leads a range of Patient Safety (including Mental Health Patient Safety), and Medication Safety Programs. He has provided executive sponsorship to these programs which has involved extensive attention to risk management and clinical governance. Each program area focuses on improving the reliability and resilience of safety systems to prevent major harms across NSW Health. He has been instrumental in establishing robust governance structures for each of these programs ensuring there is key clinical representation on each of the multi-disciplinary advisory committees to guide the direction of the programs and develop the policies, tools and guidance that are adaptable to the clinical needs across the state. During 2023-24 some examples of deliverables in his portfolio included the development of a Falls White Paper (endorsed by the Health Minister), new Sepsis Pathways, establishment of an NSW Medicines Formulary and numerous medication safety guidance documents.
Over the past 12 months (and for many years prior), Dr Lander has exhibited an exceptional dedication to risk management and clinical governance through a series of strategic initiatives and proactive measures aimed at ensuring patient safety and quality care delivery.
Firstly, he spearheaded the implementation of rigorous protocols and procedures designed to identify, assess, and mitigate potential risks across the health system including, but not limited to Sepsis, perinatal safety and medication safety. By fostering a culture of accountability and transparency, he consistently encourages staff members to actively participate in risk identification and reporting processes, facilitating early intervention and prevention of adverse events.
Moreover, Dr Lander has prioritized continuous quality improvement by fostering interdisciplinary collaboration and leveraging data-driven insights to drive informed decision-making. Through regular audits, reviews, and performance evaluations, he facilitated the identification of areas for enhancement while promoting adherence to best practices and regulatory standards – this has been demonstrated clearly in his work with the Mental Health team.
Overall, Dr Lander’s unwavering dedication to risk management and clinical governance in 2023-24 not only enhanced organizational resilience but also underscored his unwavering commitment to delivering high-quality, patient-cantered care in a complex healthcare landscape.
In 2023/24, Prof Danforn Lim AFCHSM emerged as a visionary health leader at SMSG, excelling in risk management and clinical governance by focusing on cultural safety and sensitivity towards culturally and linguistically diverse (CALD) communities. His leadership was pivotal in implementing initiatives that ensured both patients and staff from diverse backgrounds felt safe, respected, and understood within the healthcare setting. Prof Lim championed extensive training on cultural competence for all management and executive staff, enriching their understanding and responsiveness to patients with First Nations or CALD backgrounds’ unique needs. This approach significantly enhanced patient care quality and fostered a more inclusive environment.
Under his guidance, SMSG prioritised creating a workplace where diversity was not just acknowledged but celebrated, leading to a profound sense of belonging among team members. This commitment to inclusivity and safety in the workplace was recognised as SMSG was certified as a Great Place to Work (GPTW) once again in 2023-24. Remarkably, 100% of the team members reported feeling welcome from the outset and safe in their work environment. Furthermore, one of the Centres within the Group was awarded a Certificate of Excellence in General Practice from the CESPHN in August 2023. Prof Lim’s leadership in integrating cultural safety and sensitivity into the fabric of SMSG’s operations has set a benchmark in healthcare, highlighting the profound impact of inclusive practices on clinical excellence and workplace culture.
Katrina has been instrumental in managing 3 small hospitals and more recently 2 large procedural sites over the past year as well as role modelling skills and accountability for many other HSMs in the LHD.
Katrina demonstrates teamwork, transparency attention to detail and overall accountability for patients and staff.
Katrina strives to ensure patient safety while ensuring all staff are competent, well supported and the facilities meet all standards.
It is not before time that Katrina should be recognised for the dedication to managing patient care and staff wellbeing within her roles in WNSWLHD.
Bee’s leadership has resulted in a highly efficient recruitment process at Justice Health NSW. The development and implementation of a centralised recruitment model has significantly reduced wait times for both candidates and hiring managers.
Bee’s efforts have also led to the growth of the recruitment team and the establishment of a talent function within the last 6-9 months. Her contributions have been instrumental in increasing staffing numbers in critical areas and improving application, interview, reference checking, offer management, and candidate onboarding services.
Bee whole-heartedly deserves the recognition for her outstanding leadership!
Padmini has 27 years’ experience as a Health Service Manager and Program Lead for many district wide initiatives and she holds many publications in Positive Strength-based ways of working and for her amazing work in supporting Workplace wellbeing and more recently how this translates to safety, quality and clinical governance. Her work after the 2019 Australian bushfires in Milton Hospital used a Participatory Action Methodology and co-designed a wellness and wellbeing program called ‘SEED’, encompassing five staff led initiatives that promoted healing, wellness, belonging and connection. She uses a Post Traumatic Growth model and creates a non-hierarchical, highly participatory and emotionally safe environment for staff to grow through their vulnerabilities. These initiatives are now embedded into clinical governance processes and initiatives across our district.
Padmini has led the development of a framework for supporting staff across our district in times of crisis and change and the key lessons learnt from the Milton Hospital experience is used to improve workplace culture, better equip staff to care for themselves, develop meaningful connections, strengthen workplace bonds and ultimately to provide safer, high-quality, person-centred care.
Donna is an advocate for the safe, effective, and appropriate use of virtual care across NSW. Her involvement and leadership of several statewide governance committees as both chair and subject matter expert means she can provide a strong voice for the development and innovation of new models of care that provide services to communities across the state. Her expertise and leadership in this area is also valued by her colleagues as she supports new and emerging leaders in how services are delivered in a safe and clinically appropriate way. Donna’s ability to identity risk and develop mitigation strategies is highly valued by her peers. It’s her willingness to support the growth and understanding of risk management and sound governance principles with new and emerging managers and leaders that sets her apart from others. She has also supported the development of auditing tools focused on service readiness for virtual care and digital health initiatives, along with laying the foundations of the Informed Decision Making I virtual care guidance document. Donna would be a worthy recipient of this award as she continues to provide her expertise and support the development of others with the safe use of virtual care and digital health.
Anna has contributed over 10 years of her career towards strengthening clinical governance, patient safety and clinical risk in her very challenging role as Senior Patient Safety and Clinical Risk Manager.
Anna empowers, motivates, leads and mentors others to improve patient safety. She leads, coordinates, and provides intense support and guidance to Patient safety Managers, Executive teams and clinical leads in the incident management processes and human factors and has been instrumental in building incident review capacity to many clinical teams across the local health district.
Anna also has very positive impacts on families who have been affected by a serious incident as she navigates them through the incident management review processes.
Anna has made enormous contribution towards training and mentoring new patient safety managers nursing unit managers and department leads in incident management processes. Anna is contacted from other patient safety managers across the state for advice and has shared her expertise across numerous state forums.
Anna is knowledgeable leader who guides a high performing team of patient safety managers, a consumer’s feedback manager, and policy governance managers to achieve excellence in clinical governance.
Susan Sims leads the Safety Culture Portfolio, in this role she has been exemplary in her leadership in engaging others with, and promoting a culture of, safety, quality and continuous improvement as an enabler for safety systems across NSW Health.
Sue has demonstrated her professionalism as a health manager and leader across the enabling and action domains of the ACHSM competency framework.
A strength of Sue’s is her commitment to modelling compassionate leadership, in particular her ability to listen with empathy and build shared meaning. She is respectful of the diverse biography, voices and experiences that contribute to the safety and quality of healthcare everyday.
Sue encourages others to appreciate and recognise what is working well and sees the leadership potential in every person.
I appreciate this opportunity to recognise Sue’s leadership.
Ms Fiona Strang has led the HealthWISE team as Chief Executive Officer since commencing operations in 2015. With over 30 years’ experience in primary health care, Fiona has an unwavering commitment to the industry and leads the organisation with integrity and excellence, resulting in improved health outcomes for rural and regional communities.
Fiona empowers teams to explore new approaches to health challenges, evident in programs co-designed with key stakeholders and sensitive to community need, e.g. Ezidkhan – supporting Ezidi refugees in Armidale, NSW. Strong external partnerships and consistent program funding validate the reliability of HealthWISE as a service provider of choice. Under Fiona’s leadership, HealthWISE has successfully partnered with multiple Aboriginal Community Controlled Health Organisations to deliver services.
Working on the Corporate Governance Sub-Committee, Fiona exhibits strong ethics in decision making, acting in the best interests of staff, funders, and stakeholders. Fiona has been instrumental in establishing risk management practices across the organisation and is an active member of the Finance, Audit and Risk Sub-Committee.
HealthWISE is unique in the sector as a mainstream organisation with many First Nations services and staff (24%). Fiona has led a pioneering approach to reconciliation action, embedding a Cultural Inclusion Framework since 2021.
Gaye has contributed over 20 years of her career towards strengthening clinical governance, quality improvement and accreditation processes in her role as Senior Manager, Quality Systems and Improvement and Applied Safety and Quality Program Lead.
Gaye empowers, motivates and leads others to improve service delivery continuously. She leads, coordinates, and provides intense support and guidance with teams in the Improvement Science and Effective Leadership in Health Programs, and has been instrumental in building quality improvement capacity to hundreds of staff across the workforce.
In 2022/2023 Gaye led our local health district through the state’s first short notice accreditation assessment with positive results. Gaye is contacted from leaders from hospitals across Australia for advice and has shared her expertise across numerous national forums.
Gaye is an exceptional leader who has guided a high performing team of quality, partnering with consumer, patient reported measures, and clinical program managers to achieve excellence in clinical governance.
Jimmy has been an influential leader across our organization, taking a lead role in improving the quality and safety of care provided here at Sydney Dental Hospital. Jimmy is committed and motivated to improving access to vulnerable populations and has elected to play a lead role on an initiative to improve service provision. Jimmy is well liked by peers and has built a reputation as a friendly, approachable and supportive manager and leader. Jimmy is readily available to collaborate and is often found working with others to support and problem-solve. Jimmy role models patient centred care and helps to motivate and inspire others.
Sharon has made an exceptional contribution to Clinical Governance through her years working in patient safety and quality and more recently in her Consumer Feedback Manager role. She provides excellence in service to support staff, patients, carers and families when responding to their concerns raised in health care related complaints. Sharon actively role models and promotes positive cultural change and by doing so she inspires others within NSW Health. She uses new and innovative ways to collaborate with staff, patients, carers or families to understand solutions to problems and seeks a genuine and authentic approach when communicating and listening to people. Sharon supports effective teamwork to improve patient care by role modelling this behaviour and she applies strong corporate and clinical governance standards that underpin her demonstration of CORE values in all health service interactions. Sharon is passionate about her Consumer Feedback work and making a difference. She advocates for the consumer and is passionate about improving the future for all stakeholders and enjoys seeing the benefits flowing through to improved patient experience. Sharon’s quality standards to her work and commitment to improved outcomes has led to long-term sustainability of full compliance with complaint acknowledgement and completion rates.
In the time I knew Amanda, she was incredibly proficient with leading the team, and facilitating new initiatives and strategies for Clinical Governance. She is incredibly knowledgeable and committed, and her work ethic is commendable and inspirational. Most days, she was at work from 6am – 8pm, sometimes even until 10pm. She abides by the CORE values and has proven that she is what a leader/manager is all about! She’s phenomenal!
Amanda was the Director of Clinical Governance for Concord Hospital in 2023. During this time, I have had the privilege of working with her. Amanda was extremely committed to the organisation and poured herself into ensuring that her team is well looked after. Amanda created strategic initiatives and proactive measures to identify and assess risks within the healthcare setting. Amanda also fostered a culture of continuous improvement and actively engage with healthcare professionals, promoting a learning environment that embraces innovation.
She has demonstrated a diversity and adaptability in her management and leadership style throughout COVID, transition into clinical governance and now as the Director of Nursing for the clinical services integration and population health directorate of SLHD.
Amanda is an excellent clinical and governance leader for SLHD.
She has demonstrated a diversity and adaptability in her management and leadership style throughout COVID, transition into clinical governance and now as the Director of Nursing for the clinical services integration and population health directorate of SLHD.