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Clinical Governance - CAN/HSO 1003:2023 (E)

Clinical Governance - CAN/HSO 1003:2023 (E)

$119.00 CAD

About HSO's Standards

HSO’s standards are the foundation on which leading-edge accreditation programs and evidence-informed public policy are built. Standards create a strong people-centred health care system that stakeholders can rely on to enable people around the world to continuously improve quality of care.

HSO’s standards are formatted using the following structure:

  • Section title. A section of the standard that relates to a specific topic.
  • Clause. A thematic statement that introduces a set of criteria.
  • Criteria. Requirements based on evidence that describe what is needed by people to achieve a particular activity. Each criterion outlines the intent, action, and accountability.
  • Guidelines. Additional information and evidence to support the implementation of each criterion. 

About This Standard

CAN/HSO 1003:2023 (E) Clinical Governance draws on findings from literature reviews, clinical expertise, evidence-informed practices, and those with lived experience.

This standard guides health and social services organizations as they define and develop their clinical governance structures and practices. This is accomplished in part through organizational clinical decision-making teams that are focused on improving care delivery models and, ultimately, health outcomes, across the continuum of care. Effective clinical governance at the organizational level contributes to the delivery of safe, reliable, and high-quality care during clinical encounters at the individual level. By building effective clinical governance structures and practices across the continuum of care, organizations enable sustainable, integrated, and people-centred care for clients and the community, helping to advance safer care and create a healthier world for all.

The content of the standard is structured into the following sections:

  1. Designing people-centred clinical programs and services to meet client and community needs.
  2. Engaging stakeholders in organizational clinical governance practices.
  3. Continuously improving clinical quality and safety.

This standard integrates the principles of equity, diversity, and inclusion outlined in Annex A.

The published evidence used to inform this standard can be found in the bibliography.

This standard is intended to be used as part of a conformity assessment. This standard will undergo periodic maintenance. HSO will review and publish this standard on a schedule not to exceed five years from the date of publication.



This standard enables health and social services organization leaders and organizational clinical decision-making teams to develop or improve the clinical governance structure and implement clinical governance practices to improve the delivery of clinical programs and services, care experiences, and care outcomes across the continuum of care.


      This standard applies to health and social services organizations that provide clinical programs and services across the continuum of care.

      This standard is aimed at the following key audiences:

      • Organizational leaders and workforce members. The standard provides these audiences with information to enable the delivery of sustainable, safe, reliable, integrated, and people-centred care for clients and the community.
      • Clients, designated support persons, and communities. The standard provides these audiences with information that enables them to actively participate as equal members of the care team.
      • Policy makers and health care stakeholders. The standard provides these audiences with information to guide the development of policies that support a healthy and competent workforce and sustainable, safe, reliable, integrated, and people-centred care for clients and the community.

      HSO is an independent, not‑for‑profit corporation and is registered in Canada as a charity, in accordance with Canada Revenue Agency rules, with a mandate to enable and empower people around the world to continuously improve quality of care.

      While designated as a Standards Development Organization by the Standards Council of Canada (SCC), HSO operates independently from SCC. HSO does not receive ongoing funding from SCC, other crown corporations of Canada, or federal or provincial entities.

      HSO charges a nominal fee to help offset the associated costs of development and maintenance of HSO standards, as most HSO standards are self-funded.

      If cost is a barrier to accessing an HSO standard, please email and a team member will assist you.

      Standards available for purchase through this E-Store are considered HSO standards and must only be used in accordance with applicable HSO Terms of Use or client agreement and are not applicable for assessment purposes. If you are part of an assessment program such as the Qmentum accreditation program, with one of our partners including Accreditation Canada, Qualicor Europe, IQG, or IQMH, your assessment body will provide you with the assessment standard prior to the standard being incorporated into your program and used for surveys or assessment purposes. For information on assessment standards, or to obtain the version specific to your program, please contact your assessment provider.

      Standards purchased online are delivered as printable PDF downloads. If you would like a copy printed and shipped to you, please email

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