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In September 2022, Safer Care Victoria completed a clinical governance review across Albury Wodonga Health. This review was commissioned by the Chief Executive Officer of Safer Care Victoria (SCV) and completed in late 2022, with the final report released on 12 January 2023. The review used the London Protocol to analyse clinical governance systems at AWH within the Victorian Clinical Governance Framework domains. The review drew on evidence from a wide variety of documents, a site visit, and input from more than 200 relevant stakeholders, including staff and consumers. 

The review identified strengths and opportunities for improvement in AWH’s clinical governance, resulting in 15 findings for the health service, one dual finding for the Department of Health (DoH) and AWH, and 54 recommendations.  AWH developed the 2023 & 2024 AWH Patient Safety and Quality Action Plan to implement these recommendations. This action plan described the specific actions to be completed, the timeline, and the expected outcomes or measures to be achieved.  The action plan was monitored bi-monthly by the Board Patient Safety, Quality, and Service Review Committee.  To support the implementation of the action plan, AWH provided a six-monthly update on the progression of the recommendations to SCV.

In November 2025, Safer Care Victoria informed AWH that they were satisfied that the actions required to address the recommendations from the Review were completed.  The 6-monthly recommendations monitoring process has now ceased. In summary,

• 54 recommendations were made, resulting in 70 separate actions.
• All 54 recommendations have been addressed.
• 69 of the 70 actions, or 98% of the actions, were completed or implemented by early 2025.

AWH is proud of its achievements in implementing the recommendations in the action plan over the past two and half years. This has strengthened our clinical governance systems and processes, increased engagement from consumers and staff, and significantly increased patient and staff safety through awareness, participation, consultation, and change in practices.  AWH will continue to embed, innovate, and improve systems and processes as we strive to deliver safe, high-quality, evidence-based, and person-centered care to everyone, every time.