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Clinical Governance, Safety and Quality

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Policy framework statement

The Clinical Governance, Safety and Quality Policy Framework specifies the clinical governance, safety and quality requirements that all Health Service Providers (HSPs) must comply with in order to ensure effective and consistent clinical care across the WA health system.

Purpose

The purpose of this policy framework is to ensure:

patients receive care that is safe, effective, appropriate to their needs, timely and efficient
minimum standards and consistency are maintained with continuous improvement across the WA health system
clinical governance structures and processes are maintained across the WA health system.

Applicability

This policy framework is binding on each HSP to which it applies or relates.

Principles

The key principles that underpin this policy framework are:

Care is consumer and carer centred

Consumer partnership is evident at all levels of the organisation.

Care is driven by information

Relevant, accurate information is available and used at all levels of the HSPs organisation to guide quality improvement activities.

Led for high performance

Executive and clinical staff have the right qualifications and skills to provide safe, high quality health care; and to foster a culture of openness, collaboration and continuous improvement.

Organised for safety

Minimisation of clinical risks and incidents and a systems approach to harm minimisation.

Legislative context

This policy framework is made pursuant to ss 26(2)(a)(c)(d)(l) of the Health Services Act 2016.

The Health Services Act 2016 refers to policy frameworks in ss. 26-27 and s. 34(2)(c). Other relevant parts in the Act that relate specifically to this policy framework include ss. 20(1)(l), 34(2)(h), 34(3) and 95(3)(a).

The legislation below, may also apply:

Coroners Act 1996
Guardianship and Administration Act 1990
Health and Disability Services (Complaints) Act 1995
Health and Disability Services (Complaints) Regulations 2010
Health Services (Quality Improvement) Act 1994
Mental Health Act 2014

Mandatory requirements

Under this policy framework HSPs must comply with all mandatory requirements* including:

Policy framework custodian

Assistant Director General
Clinical Excellence Division

Enquiries relating to this Policy Framework may be directed to: PolicyFrameworkSupport@health.wa.gov.au

Review

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This policy framework will be reviewed as required to ensure relevance and recency. At a minimum this policy framework will be reviewed within two years after first issue and at least every three years thereafter.

Version	Effective from	Amendment(s)
70	23 January 2025	Policy review and amendments to MP 0122/19 Clinical Incident Management Policy. Amendments include: Purpose section refined; Applicability section – contracted health entities statement updated; Removal of requirements applicable to HSS; Policy requirement sections strengthened, refined, and updated; Policy requirement timeframes updated to support WA health entities in conducting thorough clinical incident investigations; Compliance monitoring section updated to reflect PSSU as the policy owner and responsibility for policy compliance on behalf of System Manager; Definitions section: Inclusion of ‘Closing the loop’, ‘Comprehensive analysis’, ‘Concise Incident analysis’, ‘Contributing factors’, ‘Consumer’, ‘Data custodian’, ‘Hazard’, ‘Just culture’, ‘Risk and Notifiable’ and ‘Reportable conduct’, ‘Synopsis report’ and ‘WA health entities’ definitions. Removal of ‘Notifier’ definition; Supporting information documents: Clinical Incident Management Guideline and Clinical Incident Management Toolkit refined and updated; Inclusion of Clinical Incident Management Toolkit within the Clinical Incident Management Guideline.
69	22 October 2024	Amendment to MP 0084/18 Credentialing and Defining the Scope of Clinical Practice Policy. Amendments include the update of the related document: 'Credentialing and Defining the Scope of Clinical Practice for Medical Practitioners Standard'.
68	22 October 2024	Amendments to MP 0175/22 Consent to Treatment Policy. Amendments include the following: inclusion of policy requirements Section 3.5.1 Health Practitioner Students to clarify consent to treatment provide by health practitioner students; Policy requirement 3.1 refined; Related document: 'Consent to Treatment Procedure' updated to reflect policy requirement 3.5.1; Supporting information: minor updates to documents; Hospital Consent Forms A, B and C in relation to consent to treatment by health practitioner students.
67	3 September 2024	Policy review and amendments to MP 0130/20 Complaints Management Policy. Amendments include the following: Purpose section refined to include a statement to identify out of scope areas for the policy; Applicability amended to include WA health entities and exclude Health Support Services; Policy requirements refined and updated to include a statement of reporting requirements for contracted health entities; Compliance monitoring refined to reflect updated policy requirements; Supporting information: 'Complaints Management Guidelines' and 'Complaints Management Toolkit' updated; Definitions section refined to reflect updated policy terminologies. Inclusion of 'WA health entity' and 'WA health system' definitions.
66	20 August 2024	Amendment to MP 0104/19 Medication Review Policy. Amendments include the following: Supporting information revised and updated to reflect changes in reporting: 'Best Practice Principles for Medication Review', 'WA Medication History and Management Form', 'Medication Reconciliation Audit Guidelines' and 'WA Medication Reconciliation Audit Tool - Single Patient'. Removal of 'Medication Review Reporting Form'. Policy contact updated.
65	16 August 2024	Policy review and amendment to MP 0076/18 Cardiotocography (CTG) Monitoring Policy. Policy title amended to include the abbreviation CTG. Purpose section refined. The inclusion of Health Service Providers and mandatory policies to be read in conjunction with policy. Applicability section amended for consistency with other CNMO policies. Policy requirements updated and condensed. Inclusion of a new requirement for multidisciplinary meetings. Audit information moved to compliance section 4. Compliance monitoring section updated to align with other CNMO policies and ensure clarification on what/how monitoring will occur. Related document: Cardiotocography (CTG) Monitoring Standard updated to clarify documentation and escalation processes. Definitions section: inclusion of a definition for ‘WA health system.’ Policy contact amended to reflect new policy ownership with the Chief Nursing and Midwifery Office.
64	19 July 2024	New mandatory policy: MP 0186/24 Use of Restrictive Practices in Non-Authorised Healthcare Settings Policy. This policy outlines the minimum requirements for the safe and lawful use of restrictive practices on patients in a non-authorised healthcare setting.
63	10 July 2024	Amendment to MP 0084/18 Credentialing and Defining the Scope of Clinical Practice Policy. Amendments include the following: Health Professional definition updated and related document: Credentialing and Defining the Scope of Clinical Practice for Nursing and Midwifery Standard updated.
62	8 July 2024	Amendment to MP 0093/18 Access to Public Maternity Services for Privately Practising Endorsed Midwives Policy. Amendment to Compliance Monitoring section: the HSP annual report data to be submitted to the Office of the Chief Nursing and Midwifery Officer (OCNMO) on behalf of the System Manager updated to the end of January each year.
61	18 June 2024	Policy review and amendment to MP 0053/17 Patient Alert Policy. Policy title amended from WA Clinical Alert (MedAlert) Policy to Patient Alert Policy. Purpose section amended to clarify the scope of the policy. Applicability section amended to include a statement on contracted health entities. Policy requirements section amended to align with the approach taken in other mandatory policies. Compliance monitoring section amended to reflect policy requirements. A full policy review was undertaken, so a new cycle will commence.
60	9 May 2024	Amendment to MP 0078/18 Medication Chart Policy. Revised and updated related document: WA Anticoagulation Medication Chart Adult Chart.
59	24 April 2024	Policy review and amendments to MP 0093/18 Access to Public Maternity Services for Privately Practising Endorsed Midwives Policy. Amendments include the following: Policy renamed from 'Access for Endorsed Midwives into Public Maternity Units Policy' to 'Access to Public Maternity Services for Privately Practising Endorsed Midwives'; the term 'Endorsed Midwife' replaced with 'Privately Practising Endorsed Midwife' throughout the policy; Purpose section refined for clarity; Applicability amended to Health Services Providers who provide maternity services for consistency with other Chief Nursing and Midwifery Office (CNMO) policies; Policy requirements amended to include credentialing, re-credentialing, training and insurance requirements; Compliance monitoring section updated to align with other CNMO policies; Definitions section refined and updated and policy contact updated to reflect policy ownership.
58	3 April 2024	Policy review and amendments to MP 0077/18 Statewide Medicines Formulary Policy. Amendments include the following: Purpose section refined for clarity and improved readability; Applicability section updated to include contracted health entities; clarified and updated policy requirements on governance arrangement for the Statewide Medicines Formulary; clarified compliance monitoring requirements from Department of Health and Health Service Providers; WA Drug Evaluation Panel (WADEP) renamed to WA Medicines Evaluation Panel (WAMEP); Updated supporting information: included link to the updated WA Statewide Medicines Formulary Guidelines, Individual Patient Approval (IPA) Guideline for the WA Individual Patient Approval System (WAIPAS), updated Antimicrobial Stewardship Guidance Document and CATAG: Guiding Principles for Medicines Stewardship Programs; Definitions and policy contact sections updated.
57	9 February 2024	Amendments to MP 0078/18 Medication Chart Policy. Revised and updated related documents: WA Hospital Medication Chart Short Stay Adult Chart; WA Hospital Medication Chart Long Stay Adult Chart; WA Paediatric Hospital Medication Chart Short Stay; WA Paediatric Hospital Medication Chart Long Stay; WA Anticoagulation Medication Chart Adult Chart; WA Clozapine Initiation and Titration Chart Adult Chart and WA Agitation and Arousal PRN Chart Adult Chart.
56	20 December 2023	Amendment to MP 0076/18 Cardiotocography Monitoring Policy. Policy ownership changed from Executive Director, Patient Safety and Clinical Quality to Principal Midwifery Advisor, Chief Nursing and Midwifery Office. Policy contact section amended to reflect the policy ownership change.
55	12 December 2023	Amendment to MP 0080/18 Assistant in Nursing Policy. Policy requirement in AIN (Student) section refined to streamline AIN (Student) eligibility, whilst still meeting completion and academic good standing requirements with an NMBA approved program of study. Removal of course codes and WA university constraints within this section.
54	29 November 2023	Amendment to MP 0084/18 Credentialing and Defining the Scope of Clinical Practice Policy. Amendments include the following: Policy requirements Section 3.5 title Allied Health Practitioners and Health Science Professionals Change to Allied Health Professionals; Inclusion of policy requirements section 3.6 Aboriginal Health Practitioners; Updated and refined the Compliance Monitoring section; Related Document: 'Allied Health and Health Science Professions Standard' updated an amended; Updated definition of Allied Health Professional, included new definition for Aboriginal Health Practitioners and removed definition for WA health system; Inclusion of the supporting information 'National Association of Aboriginal and Torres Strait Islander Health Workers and Practitioners; Update of the HSUWA PACTS agreement to 2022 and updated email contact at Policy Contact section.
53	4 October 2023	Amendment to MP 0080/18 Assistant in Nursing Policy. Policy requirements section amended to clarify that an AIN (Student) may continue employment as an AIN upon completion of NMBA-approved program.
52	6 September 2023	Policy review and amendment to MP 0095/18 Clinical Handover Policy. Amendments include: Purpose section amended to clarify the need for the policy, applicability section amended to exclude specific HSPs and include a statement on contracted health entities, policy requirements section refined to reflect a contemporary approach to clinical handover and removal of three supporting information.
51	20 July 2023	Amendment to MP 0080/18 Assistant in Nursing Policy to reflect: i. addition of employment pathway for Graduate Entry Master of Nursing (Graduate Entry) and Master of Midwifery (Graduate Entry) students; ii. addition of employment pathway for internationally qualified nurses (IQN) enrolled into an undergraduate IQN accelerated nursing program with Edith Cowan and Curtin University only.
50	19 July 2023	Minor amendment to MP 0122/19 Clinical Incident Management Policy 2019. Broken hyperlinks amended throughout supporting information documents: Clnical Incident Management Guideline 2019 and Clinical Incident Management Toolkit 2019.
49	1 July 2023	Policy review and amendments to MP 0134/20 National Safety and Quality Standards Accreditation Policy. Insertion of information on the updated National and Safety Quality Standards in the Purpose section, updated contracted health entities statement, insertion of updated information on short notice accreditation within the Policy Requirements section, updated and refined the Compliance Monitoring section, Inclusion of related document: National Safety and Quality Standards Accreditation Procedure to capture operational requirements previously in policy requirements, updated related document title and information to 'Timeframes for submission of accreditation information and reporting to LARU', removed related document 'LARU Accreditation Authorisation and or Reporting Schedule' as old version, inclusion of additional supporting information and removal of definitions not required.
48	28 June 2023	Minor amendment to MP 0098/18 Review of Death Policy. The related document: Death in a Hospital Form - Section 5.2 Deaths Reportable to the Chief Psychiatrist amended to 28 days to reflect alignment with the Office of the Chief Psychiatrist's policy for mandatory reporting of notifiable incidents to the Chief Psychiatrist.
47	8 May 2023	Minor amendment to MP 0175/22 Consent to Treatment Policy. Updated MP 0051/17 Language Services Policy link within Policy Requirements 3.4 section. Updated Supporting Information document: Decision making tree for engaging an interpreter.
46	13 December 2022	Publication of new policy MP 0175/22 Consent to Treatment Policy to come into effect on 13 March 2023. This policy supersedes OD 0657/16 WA Health Consent to Treatment Policy.
45	8 November 2022	Policy review and amendments to MP 0078/18 Medication Chart Policy. Amendments include the following: Refined and reworded policy to update and clarify information, inclusion of a medications charts table within the Policy Requirements section, refined the Compliance Monitoring section, updated all related documents charts, included the supporting information document Medication Chart Policy Compliance Assessment and Action Form and transitioned to the current mandatory policy template.
44	2 September 2022	Amendments to MP 0080/18 Assistant in Nursing Policy. AIN (student) to maintain up to 4 months (16 weeks) ongoing employment on completion of their NMBA-approved program, and clarification of WACHS AIN qualification requirements.
43	10 August 2022	Publication of new MP 0171/22 Recognising and Responding to Acute Deterioration Policy to come into effect on 22 January 2023.
42	13 July 2022	Amendments to MP 0080/18 Assistant in Nursing Policy. Addition of employment pathway for undergraduate Diploma of Nursing (enrolled nurse) students; addition of employment pathway for enrolled nurses with current NMBA registration actively enrolled into an NMBA approved Bachelor of Nursing (enrolled nurse) conversion program and specification of Chief Nurse and Midwifery Office as System Manager in the Compliance Monitoring section.
41	22 June 2022	Minor Amendment to MP0098/18 Review of Death Policy Related Document: Death in Hospital Form. Section 3: How to Report a Death to the Coroner updated to reflect availability of Coronial Investigation Squad 24 hours-a-day, 7 days-a-week.
40	3 March 2022	Minor Amendments to MP 0080/18 Assistant in Nursing Policy Related Documents to include COVID-19 related tasks.
39	19 January 2022	Major amendments to MP 0080/18 Assistant in Nursing Policy. Updated information and inclusion of Assistant in Nursing (Maternity setting) Related Document.
38	17 January 2022	Policy Review and minor amendment to MP 0093/18 Access for Endorsed Midwives into Public Maternity Units Policy. Policy transitioned to the current Policy template. Complete policy review was undertaken, a new review cycle will now commence.
37	1 October 2021	Minor Amendment to MP 0076/18 Cardiotocography Monitoring Policy. Update to supporting information and Policy contact email.
36	3 August 2021	Supporting Information for Policy Framework: Clinical Governance, Safety and Quality - WA Pressure Injury Prevention and Management Clinical Guidelines - To be rescinded on 30 September 2021. Internal review determined that the Guidelines are no longer relevant within the current context of NSQHSS v.2. and guidance for clinical staff available in international guidelines, The risks consulting to this level are minimal.
35	30 June 2021	Retitle OD 0657/16 as part of the OD/IC Project while under redevelopment to a Mandatory Policy.
34	16 June 2021	Major Amendment MP 0076/18 Cardiotocography Monitoring Policy. Policy transitioned to the current Policy template. Clarification provided on interpretation practices and audit requirements.
33	22 April 2021	New MP 0154/21 Managing Voluntary Assisted Dying Policy provided in advance of implementation on 1 July 2021.
32	9 February 2021	Major Amendment to MP 0072/17 Health Technology Governance Policy.
31	5 February 2021	Rescindment: OD 0592/15.
30	12 October 2020	Major Amendment to MP 0098/18 Review of Death Policy and Related Document Death in Hospital Form.
29	6 May 2020	New MP 0134/20 National Safety and Quality Health Service Standards Accreditation Policy, superseded OD 0410/12 and the National Safety and Quality Health Service Standards in Western Australia.
28	10 February 2020	New MP 0131/20 High Risk Medication Policy, superseded OD 0561/14, OD 0647/16 and OD 0658/16.
27	3 February 2020	New MP 0130/20 Complaints Management Policy, superseded OD 0589/15.
26	1 November 2019	New MP 0122/19 Clinical Incident Management Policy 2019, superseded OD 0611/15.
25	8 October 2019	Major Amendment to MP 0084/18 Credentialing and Defining the Scope of Clinical Practice Policy and Related Document.
24	16 August 2019	Major Amendment to MP 0080/18 Assistant in Nursing Policy and Related Document.
23	15 August 2019	Rescinded OD 0579/14 from Supporting Information.
22	5 August 2019	Rescinded OD 0004/06 and OD 0486/14 from Supporting Information.
21	11 July 2019	Rescinded IC 0231/15 and Guideline from Supporting Information.
20	29 April 2019	Major amendment to MP 0098/18 Review of Death Policy: Section 5 updated to refer to two versions of Review of Death reporting template. Death in Hospital Form updated to clarify aspects relating to the provision of medical records to the Coroner in the event of a reportable death.
19	26 February 2019	New MP 0104/19 Medication Review Policy, superseded OD 0039/07 from Supporting information.
18	11 February 2019	Major amendment to MP 0095/18 Clinical Handover Policy.
17	1 January 2019	New MP 0098/18 Review of Death Policy, superseded OD 0448/13 from Mandatory requirements.
16	6 June 2018	New MP 0086/18 Recognising and Responding to Acute Deterioration Policy, superseded OD 0501/14 from Supporting Information.
15	10 May 2018	New MP 0084/18 Credentialing and Defining Scope of Clinical Practice Policy, superseded OD177/09 and OD 0505/14 and IC 0181/14 from Supporting Information.
14	4 April 2018	New MP 0080/18 Assistant in Nursing Policy, superseded OD 0419/13.
13	14 March 2018	Rescinded OD 0551/14 from Supporting Information.
12	15 February 2018	Rescinded OD 0667/16 from Supporting Information.
11	17 January 2018	New MP 0078/18 Medication Chart Policy, superseded OP 2080/06, OD 0648/16, OD 0522/14 and OD 0596/15. Please note the original was not published, instead version 1.1.was published after urgent minor amendments. Rescinded OP 2080/06, OD 0648/16 and OD 0522/14 from Mandatory Requirements.
10	10 January 2018	New MP 0076/18 Cardiotocography Monitoring Policy. New MP 0077/18 Statewide Medicines Formulary Policy, superseded OD 0626/15. Rescinded OP 1755/04 and OD 0626/15 from Supporting Information. Major Amendment to OD 0657/16.
9	21 December 2017	Updated Policy Framework Custodian. Changes were not made to Policy Framework landing page until 10 January 2018.
8	8 November 2017	New WA Pressure Injury Prevention and Management Clinical Guideline and You Matter: A Guideline to Support Engagement with Consumers, Carers, Communities and Clinicians in Health to Supporting Information, superseded OD 0477/13 and WA Health Consumer, Carer and Community Engagement Framework. Rescinded OD 0477/13 and WA Health Consumer, Carer and Community Engagement Framework from Supporting Information.
7	4 October 2017	New MP 0072/17 Health Technology Governance Policy, superseded OD 0541/14. Rescinded OD 0541/14 from Mandatory Requirements.
6	28 August 2017	Rescinded OD 0316/11 from Supporting Information.
5	6 July 2017	Rescinded OD 0397/12 and OD 0020/06 from Supporting Information.
4	21 June 2017	Rescinded OD 0376/12 from Supporting Information.
3	14 June 2017	New MP 0053/17 WA Clinical Alert MedAlert Policy, superseded OD 511/14.
2	14 September 2016	Rescinded OD 0316/11 from Supporting Information.
1	1 July 2016	Original version

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Approval

This policy framework has been approved and issued by the Director General of the Department of Health as the System Manager.

Approval by	Dr David Russell-Weisz, Director General, Department of Health
Approval date	01 July 2016
Date published	06 June 2018
File number	F-AA-40142

Compliance

This policy framework is binding on those to whom it applies or relates. Implementation at a local level will be subject to audit.

Glossary of terms

Term	Meaning
Applicability	Under Section 26 of the Health Services Act 2016, policy frameworks may apply to: All Health Service Providers A type of public health service facility A type of public health service A type of staff member of a health service provider.
Clinical audit	A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria. Where indicated, changes are implemented and further monitoring is used to confirm improvement in healthcare delivery.
Clinical care standard	A document comprising of a small number of quality statements that describe the care patients should be offered by health professionals and health services for a specific clinical condition or defined clinical pathway in line with current best evidence.
Clinical incident	An event or circumstance resulting from health care which could have, or did, lead to unintended and/or unnecessary harm to a patient/consumer.
Clinical governance	A system through which organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care. This is achieved by creating an environment in which there is transparent responsibility and accountability for maintaining standards and by allowing excellence in clinical care to flourish.
Clinical governance processes	Policies, procedures and systems, such as a patient identification policy, for maintaining and improving the safety and quality, and the effectiveness and dependability, of services provided by a health service provider.
Clinical governance structures	Organisational structures, such as clinical audit committees, created for maintaining and improving the safety and quality, and the effectiveness and dependability, of services provided by a health service provider.
Clinical management	Positions, and their incumbents, which directly manage one or more clinicians. Clinical management positions may also be clinicians.
Continuous improvement	A systematic, ongoing effort to raise an organisation's performance as measured against a set of standards or indicators.
Health Service Provider	Health Service Provider means a health service provider established under s. 32 of the Health Services Act 2016 and may include North Metropolitan Health Service (NMHS), South Metropolitan Health Service (SMHS), Child and Adolescent Health Service (CAHS), WA Country Health Service (WACHS), East Metropolitan Health Service (EMHS), Quadriplegic Centre and Health Support Services (HSS).
Quality improvement activities	Activities conducted by a Health Service Provider in order to improve the quality and/or safety of the care they provide to patients. Quality improvement activities should use the Health Service Providers own data in combination with current best-evidence.
WA health system	The WA health system is comprised of the Department of Health, Health Service Providers (NMHS, SMHS, CAHS, WACHS, EMHS, Quadriplegic Centre and HSS) and to the extent that contracted health entities provide health services to the State, the contracted health entities.