In healthcare, accountability without capability is an uncomfortable and unjustifiable gap. It’s a gap that modern health systems can no longer continue to ignore.
Healthcare boards carry one of the most important responsibilities in our society. Ensuring that organisations caring for vulnerable people are safe, effective, sustainable and worthy of public trust.
Why then, does this one important question still remain largely unaddressed:
Is it reasonable for us to expect that those responsible for overseeing clinical risk, have demonstrated at least a minimum level of healthcare-specific governance capability, before they assume that responsibility?
Unfortunately, the answer to this question, in almost all Australian healthcare settings, is … No.
This is not a criticism of individual directors. Healthcare boards are often populated by highly accomplished people who bring deep expertise from business, finance, law, government, community leadership and clinical practice. These perspectives are essential. Good governance requires diversity of thinking.
So, the issue is not whether directors are intelligent, experienced or committed. The issue is whether the complexity of healthcare now requires a different type of governance capability.
Healthcare is obviously unlike most other sectors. A failure in a financial services organisation may first appear through financial indicators. A failure in manufacturing may be picked up through quality defects or production metrics.
In healthcare though, deterioration is often more subtle and more gradual.
It can appear through changes in workforce culture, declining psychological safety, increasing near misses, delayed escalation, variations in clinical outcomes, deteriorating patient experience, or patterns hidden within routine performance reports.
The challenge is that these signals rarely announce themselves as a crisis. Because they are often much more nuanced and emerge gradually. They require people who understand not only what the data says, but what the data might mean.
This is the difference between receiving information and governing effectively.
Over recent decades, healthcare has developed increasingly sophisticated systems of professional accountability.
Clinicians are registered through the Australian Health Practitioner Regulation Agency (AHPRA), with defined scopes of practice, professional standards and continuing professional development requirements.
Healthcare executives increasingly pursue formal leadership development and recognised qualifications. Specialist disciplines such as health informatics, quality improvement and clinical risk management also have established competency pathways.
Healthcare boards, however, remain different.
A person can be appointed to a hospital board, health service board or healthcare organisation and immediately assume responsibility for oversight of patient safety, clinical quality and organisational risk without any consistent requirement to demonstrate healthcare governance capability.
To be clear, this does not mean directors need to become clinicians. And it does not mean every board member needs decades of healthcare experience.
But it does raise an important governance question:
Shouldn’t those with ultimate accountability for healthcare outcomes be expected to understand the systems through which those outcomes are created?
The evidence, and common sense, both increasingly suggests that the answer should be yes.
Research examining healthcare organisations internationally has consistently demonstrated that effective boards are not passive recipients of quality information. They actively engage with clinical performance, challenge assumptions, understand risk indicators and create environments where concerns can be identified early.
The important lesson from this research is not that boards need to be filled exclusively with clinicians. Rather, it is the notion that healthcare boards require collective literacy in the systems they govern.
Healthcare boards don’t need to know every clinical detail. But they should be able to know which questions to ask, when to challenge reassurance, and how to recognise when apparently acceptable information may be representing emerging risk.
Many of healthcare’s most significant failures have demonstrated this principle.
Related
The Francis Inquiry into Mid Staffordshire NHS Foundation Trust in the UK revealed devastating failures in care, culture and leadership.
One of the most confronting lessons was that warning signs existed before the crisis became undeniable. Data existed. Concerns existed. The challenge was that the organisation’s governance systems did not effectively interpret and respond to those signals.
Similarly, the investigation into the Bacchus Marsh and Djerriwarrh Health Service perinatal deaths in Victoria highlighted that accountability for patient safety extends beyond individual clinical decisions. It concluded that governance systems must be capable of identifying patterns, questioning assumptions and ensuring that concerns are escalated appropriately.
In both cases, the issue was not a lack of information, it was a failure to translate information into actual action. This distinction matters.
Healthcare governance is not about having access to more reports. Modern boards already receive extensive reporting. The problem starts when we pay close consideration to whether those reports are actually being understood within the context of clinical reality.
Australia has already begun recognising that governance capability matters in other parts of the care system.
Following the Royal Commission into Aged Care Quality and Safety, reforms have introduced stronger governance expectations, including requirements relating to board composition, independence and capability. This reflects an important principle: organisations responsible for vulnerable populations require the type of governance structure that understands the specific risks of that context.
And yet an interesting inconsistency remains.
Aged care governance now has explicit capability expectations, while many hospital and health service boards – that are overseeing some of the most clinically complex environments in the country – often continue to operate without a recognised healthcare governance competency framework.
Emergency departments, intensive care units, maternity services, mental health services and surgical systems all involve significant clinical complexity and risk. The question is not whether these environments require strong governance.
Because they clearly and obviously do.
The question is whether that governance capability should be assumed, or actually demonstrated.
Some may argue that existing approaches, such as fit and proper person requirements, good reputations, and powerful professional relationships are sufficient. And these frameworks can be valuable because integrity, character and suitability matter.
But suitability is not the same as competence, is it?
A person can be highly ethical, experienced and capable, while still lacking the specific knowledge required to effectively oversee clinical governance.
Which is why contemporary healthcare governance requires moving beyond just asking whether someone is appropriate to serve on a board. It requires asking whether they have demonstrated the capability that is practically needed to govern safely.
Nevertheless, a recognised healthcare governance credential should not create unnecessary barriers or replace the judgement of boards.
Instead, it should provide a common foundation. It should complement traditional director education with the ability to understand clinical governance systems, patient safety principles, healthcare regulation, quality improvement and the practical realities of healthcare delivery. It should recognise that healthcare governance sits at the intersection of strategy, finance, risk and clinical outcomes.
This evolution has just now started unfolding.
The AICD–AIHE Foundations of Directorship™ for Healthcare and the AICD-AIHE Company Directors Course™ for Healthcare Leaders, are two of the first programs in Australia that represent one example of a model that combines established director education with healthcare-specific clinical governance capability.
These programs bring together traditional governance foundations with a dedicated health-focused component delivered by experienced healthcare leaders.
The intention here is not to create a separate class of healthcare directors. It is to support directors who are better equipped to govern healthcare organisations in an increasingly complex environment.
Because boards should now be asking themselves different questions. Not simply: “Do we have experienced directors?”, but:
- “Do we have directors who understand the risks unique to healthcare?”
- “Can we confidently interpret the signals of clinical deterioration?”
- “Is healthcare governance capability deliberately considered in our board appointments, renewal and succession planning?”
The new era of healthcare governance does not need to be defined by more oversight. Healthcare already has extensive oversight. Rather, it needs to be defined by better-informed oversight.
Having said this, it is true that a recognised governance credential can’t just guarantee good governance on its own. Because no qualification can replace judgement, courage, culture or leadership.
But it can establish the foundational premise that healthcare has long valued in almost every other critical area: a shared baseline of demonstrated capability.
This is because healthcare carries a unique responsibility. When governance fails, the consequences are not simply financial, reputational or operational. They can result in catastrophic and irreversible harm experienced by patients, families and communities.
The future of healthcare governance should therefore not depend on whether boards happen to possess the knowledge required to understand clinical risk. It should depend on whether that capability has been intentionally developed, recognised and maintained.
Because in healthcare, accountability without capability is an uncomfortable and unjustifiable gap.
And it’s a gap that modern health systems can no longer continue to ignore.
Dr Sidney Chandrasiri is the CEO of the Australian Institute of Health Executives.
This article was first published by the AIHE. Read the original article here.