When the clinical detail and the governance failure have to be understood together and understood by someone who can read both. Most governance consultants can review a committee structure. Very few can sit with a mortality and morbidity dataset, a credentialing file, a set of incident reports and eighteen months of board papers, and tell a board what actually went wrong and where the system failed to see it.
That is the work we do.
EKology conducts independent clinical governance reviews for boards and executives facing the situations that cannot be delegated downwards: a sentinel event, a cluster of poor outcomes, a scope-of-practice failure, clinicians who say they raised concerns and were not heard, or a growing sense that the board's assurance about clinical quality is not matched by what is happening in the service.
These reviews are led personally by Dr Emily Kirkpatrick, a practising clinician, Fellow of the Royal Australasian College of Medical Administrators, former Deputy Chief Medical Officer for South Australia, and a serving non-executive director on more than a handful of boards. One reviewer, holding the clinical, managerial and governance lenses at the same time.
- A sentinel event or serious adverse outcome has occurred, and the board needs an independent account of the system failures, not only the clinical ones.
- A cluster of poor outcomes has appeared in one unit, service or specialty, and routine review has not explained it.
- A credentialing, scope-of-practice or supervision failure has come to light, and the board or execs needs to understand how it was possible
- Clinicians have raised concerns either formally or through the grapevine about safety, behaviour or speaking-up culture, and the board is not confident it has the full picture
- The relationship between the board and clinical leadership has broken down, or clinical voice is not reaching the board intact.
- A regulator, coroner, department, minister or accreditation body has asked questions the organisation cannot answer from its existing reporting.
- An inquiry or external review has already reported, and the board needs independent assurance that the recommendations were genuinely implemented rather than merely closed out.
- The board suspects its clinical governance system looks compliant on paper but is not functioning in practice.
Serious incident and adverse outcome reviews
Independent review following a sentinel event, unexpected death, or serious harm. We go beyond the clinical root cause analysis to the governance question the board actually needs answered: what in the system allowed this, what should have detected it earlier, what was known and by whom, and what would have to change for the board or executive to be confident it will not recur.
Service, unit and specialty reviews
Where concerns attach to a particular unit, service line or specialty. We examine clinical outcomes and variation, workload and staffing models, supervision and training, escalation and handover, team functioning and behaviour, and the quality of oversight from the executive and the board.
Credentialing, scope of practice and clinical privileging
Review of how the organisation defines, grants, monitors and withdraws scope of practice. We assess the credentialing committee's operation, the evidence base for decisions, the handling of performance concerns, the interface with professional regulation, and whether the board has any real line of sight over who is permitted to do what.
Clinical culture, speaking up and psychological safety
Where the concern is behavioural rather than technical. We assess whether people raise concerns, what happens when they do, how bullying and unprofessional behaviour are handled, whether consequences are applied consistently regardless of seniority, and whether the board is being told what staff actually experience.
Clinical governance system and framework review
Review of the clinical governance architecture itself: committee structure and terms of reference, the escalation pathway from bedside to board, quality and safety reporting and dashboards, risk registers, consumer partnership, and the interface between clinical and corporate governance. Assessed against the National Model for Clinical Governance and, for aged care providers, the obligations the strengthened Quality Standards place directly on the governing body.
Implementation assurance after an inquiry or review
Independent verification that recommendations from a prior review, coronial finding, accreditation outcome or regulatory action have been implemented in substance, not just marked complete in a tracking spreadsheet or a risk table.
Board-level review of digital health and AI clinical safety
Where clinical risk now arrives through technology. We review what digital systems and AI tools are in clinical use, who approved them, how clinical safety was assessed before deployment, how performance is monitored after go-live, and where accountability sits when a system contributes to harm. This includes the emerging area of machine unlearning.
Complex clinical governance reviews go wrong in predictable ways. They stay too clinical and never reach the governance failure. They stay too governance-focused and never engage with the clinical substance, so clinicians dismiss the findings. They handle individuals carelessly and become a legal problem. Or they produce a report the board cannot act on.
We work to avoid each of those.
Clinical fluency. The reviewer reads the clinical record, the outcome data and the professional standards directly. Clinicians are interviewed by someone who understands the work, which changes both what they say and how much weight they give the findings.
Governance discipline. Every finding is traced to the system that should have prevented, detected or escalated it, and to the level of the organisation accountable for that system, including the board.
Procedural fairness. Documented terms of reference before we begin. Confidentiality that is explained and honoured. Where findings concern named individuals, natural justice, where the substance put to the person and their response genuinely considered before the report is finalised.
Legal awareness. We work alongside your legal advisers where privilege, mandatory notification, coronial process or employment consequences are in play, and we structure the review so it does not create a problem the board did not have.
Findings a board can use. A report written for directors or executives, with clear, evidenced, prioritised, and free of the hedging that makes a review safe to write and useless to act on.
1. Scoping and terms of reference. We agree with the chair, and where appropriate the CEO, company secretary and legal counsel, exactly what is in scope, what is excluded, how individuals will be treated, who receives the report, and how it will be handled. Nothing begins before this is documented.
2. Evidence gathering. Clinical records and outcome data, incident and complaints data, mortality and morbidity review, credentialing and performance files, policies and procedures, committee minutes, board and executive reporting, and prior reviews.
3. Confidential engagement. Structured interviews with clinicians, managers, executives, directors and, where relevant, consumers and families. Confidential channels for those who will not speak on the record.
4. Analysis. Findings tested against national standards and frameworks, professional requirements and comparable practice. The focus is on separating what went wrong clinically from what failed systemically.
5. Natural justice. Where findings concern identifiable individuals, adverse material is put to them and their response is considered before the report is settled.
6. Report and board conversation. A written report to the chair, followed by a facilitated session with the board. In this work, the conversation matters at least as much as the document.
7. Implementation and assurance. A prioritised roadmap with owners and timeframes, and an optional return engagement to test whether the changes actually held.
- An independent review report with findings, evidence, causal analysis and prioritised recommendations, written for directors.
- A system failure analysis connecting each clinical finding to the governance layer that should have caught it.
- An assessment against national standards, including the National Model for Clinical Governance and, where applicable, the Aged Care Quality Standards' obligations on the governing body.
- A high-level remediation roadmap with sequencing, ownership and timeframes.
- A facilitated board session, and where useful a separate executive session or clinical leadership session.
- Where required, a version suitable for regulators, funders or public release, prepared with appropriate care, working with your PR / comms team.
Independence is what makes an external review worth commissioning, so we protect it deliberately. Any actual or perceived conflict, including any relationship with an organisation on whose board Dr Kirkpatrick serves, is disclosed before terms of reference are signed, and we decline engagements where a connection would undermine the standing of the findings.
Reviews are conducted confidentially. Participants are told at the outset how their information will be used, what will be attributed and what will not, and how the report will be distributed.
- Health services and hospitals including local health networks, private hospital groups, day facilities, primary health networks and community health services.
- Aged care providers or entities in the care sector, where the strengthened Quality Standards place direct, documented clinical governance obligations on the governing body.
- Not-for-profit, member and association boards including colleges, peak bodies and member organisations with clinical or professional standards responsibilities.
Complex clinical governance reviews require clear consultation and judgement. Dr Emily Kirkpatrick leads every review personally, where she does not delegate the analysis or the findings.
She is a clinician. A general practitioner and Fellow of the Royal Australian College of General Practitioners, with a Master of Medicine in Skin Cancer. She reads clinical records, outcome data and professional standards directly, and interviews clinicians as a peer.
She is a medical administrator. A Fellow of the Royal Australasian College of Medical Administrators and a Fellow of the Australasian College of Health Service Management, with an MBA in Health Management and a Master of Health Administration. She has run clinical services and knows the difference between a policy that exists and a policy that operates.
She has led at system level, under scrutiny. Deputy Chief Public Health Officer for South Australia, Deputy Chief Medical Officer for South Australia, COVID Community Commander, and Executive Director of Community and Primary Care Partnerships. Roles held in public, under pressure, with decisions examined afterwards. The exact conditions a board finds itself in when something has gone seriously wrong.
She is a quality and safety specialist. A Fellow of the International Society for Quality in Health Care and a Fellow of the Royal Society for Public Health, with a Master of Public Health and graduate qualifications from the Australian Institute of Clinical Governance. Clinical governance is her discipline, not an adjacent interest.
She is a serving director. Non-executive director on several boards in health and education in SA and NSW, and a Graduate of the Australian Institute of Company Directors. She sits on the receiving end of the board papers she reviews, and knows what a director can reasonably be expected to see and what should have been escalated but was not.
She understands where clinical risk is heading. A Certified Health Informatician Australasia and Senior Clinical Lecturer with the Australian Institute for Machine Learning with an Assoicate Professor role at Adelaide University. As digital systems and AI become clinical infrastructure, the clinical safety questions and the governance questions are increasingly the same questions.
That combination is the point. In most reviews these perspectives are split across a panel and reconciled by committee. Here they sit with one reviewer, which is why the findings tend to be sharper and the recommendations more usable.