Terms Of Reference

Having regard to the findings of the Lourdes Inquiry and to responses to health system failures in other jurisdictions:

The Commission will develop proposals for a health service wide (encompassing both the public and the private sectors) system of governance based on corporate accountability for the quality and safety of health services. These proposals should constitute a framework which includes mechanisms and arrangements that will enable the verifiable implementation of nationally agreed managerial and clinical standards. The framework should include any necessary legal, managerial, administrative, technical, human resource measures.

As a component of any proposed framework, the Commission will inter alia examine and make recommendations in relation to:

• a system of leadership for clinicians and managers which would underpin robust corporate accountability for institutional and clinical performance;
• a statutory system of licensing for public and private health care providers and services;
• the process of quality assurance of clinical services (with an emphasis on clinical outcomes) for public and private health care providers and services;
• procedures for healthcare professionals and managers to anticipate risks and promote good performance through effective risk identification, near-miss and critical incident reporting;
• the participation of patients and carers and support staff in engaging with health care providers on health services planning and the quality of care received;
• the participation by all health care staff in audit programmes which will aim to ensure quality improvement and that trends in adverse clinical events, complaints, adverse drug reactions and adverse events with medical devices are effectively analysed and disseminated;
• the means to ensure that evidence-based practice is supported and applied routinely in everyday practice;
• the governance of regulatory bodies in the health system and ways in which effective integration can be enabled between the various bodies.