Clinical Governance Unit

Clinical Governance Unit - Peter Mac Cancer Centre

Clinical governance involves ensuring quality assurance; quality improvement and patient safety are part of everyday routines and practices, as well as being characteristics of every team that provides care.


Clinical governance is at the heart of all health services. In recent years, it has become embedded throughout hospitals, including Peter Mac. Board members, the hospital executive and all clinical staff are all responsible for overseeing the clinical governance of the hospital.

To put clinical governance into action, there are specific areas of work that hospitals do, which are depicted in the figure below. By successfully implementing each component, we know we are delivering a high quality service for our patients. The design shows how the four different components are linked around a central focus on patient care.


Clinical Governance supports high quality, effective clinical practice and minimises risks to patients. It involves:
  • Regularly reflecting on practice
  • Using up to date evidence to improve what you do
  • Continually developing skills and knowledge
  • Working together as a team to ensure improvements are made
  • Learning from errors and putting systems and processes in place to avoid them happening again
  • Including patients in decisions about their care and in improving services
  • Taking an active role in improvement activities

Clinical Governance involves ensuring quality and patient safety is part of the everyday practice at Peter Mac. The Clinical Governance Unit provides a structure to support these organisational activities:

Meet the team
Fiona Watson
Director of Quality & Organisational Development
Reporting to the CEO, the Director of Quality & Organisational Development is responsible for the design and implementation of initiatives that influence organisational effectiveness and the delivery of high quality, safe patient care. Fiona provides leadership for the Clinical Governance Unit and the Redesigning Care Program at Peter Mac. Fiona also has responsibility for Organisational Development and is working closely with HR to establish and implement a framework for organisational development, change and improvement. For more information contact Fiona Watson

Meet the members of the Clinical Governance Unit
Dr Bernard Street
Director of Medical Services
The Director of Medical Services, Dr Bernard Street, together with the Chief Medical Officer and Divisional Directors, provides professional leadership to medical staff across Peter Mac sites and expert medical administrative advice to the Peter Mac Executive. This is to ensure that Peter Mac provides the safest and highest quality clinical services within its capability.

Dr Street is responsible for:
  • Clinical governance processes;
  • Medical appointments and credentialling processes;
  • Introduction of new medical technologies and clinical practice;
  • Medical education, training and staff development;
  • Medical workforce planning;
  • Medico-legal matters;
  • Clinical Ethics.

Linda Nolte
Quality Improvement Manager
At Peter Mac, we aim for continuous improvement in the safety and quality of care provided to our patients. Clinical effectiveness activities focus on reviewing, measuring, monitoring and improving health care for our consumers. These activities include clinical audit, monitoring performance indicators, quality reporting, implementing evidence based standards, benchmarking our data, and ensuring clinical staff are supported throughout the organisation to achieve safe, efficient and effective patient outcomes.

Our Quality Improvement Manager, Linda Nolte leads this work across the organisation.

Amrit Dhillon
Consumer Engagement Coordinator
Peter Mac values its patients and their families and works to provide the best possible health care and access to services. Amrit Dhillon was appointed in 2009 to work with the Community Advisory Committee and the Cultural Diversity Committee to provide consumers with a voice in Peter Mac and ensure that all aspects of our services reflect the needs of consumers.

Peter Mac values patient feedback, as it provides great insight into the concerns, suggestions and complements of consumers on the services we provide.

Danielle Murray
Manager of Redesigning Care
In November of 2008 Danielle Murray was appointed as Manager of Redesigning Care to establish a new organisation-wide improvement program for the hospital. Our Redesigning Care program is being supported by a 4-year Statewide DHS initiative called the ‘Redesigning Hospital Care Program’. This program is assisting with the establishment of local redesign teams and supporting them with skills development, expert mentorship and project funding. The aim of the overall program is to assist Victorian public hospitals to build internal capability to improve their own performance. This will be done implementing clinical process redesign projects, targeted at areas identified as being of strategic priority for their organisation.

For more information on Peter Mac's Redesigning Care program click here >>

Executive Assistant/Document Controller for Policy and Procedures
The Executive Assistant provides support for the Clinical Governance Team and for the Director of Quality & Organisational Development. This includes supporting various Committees including the Consumer Advisory Committee (CAC) and the Clinical Governance Committee (CGC). The Executive Assistant is the point of contact for the Peter Mac Consumer Advisory Committee and Consumer Register Members and is also the document controller for all Peter Mac policies and procedures.

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