Clinical Governance, Safety and Quality Policy Framework
View the PDF document of the Clinical Governance, Safety and Quality Policy Framework.
1. 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.
The Director General (DG) of the Department of Health is the System Manager responsible for the overall management, strategic direction and stewardship of the WA health system. The DG will use policy frameworks to ensure a consistent approach to a range of matters undertaken by HSPs. Policy frameworks must be complied with and implemented as a part of ongoing operations.
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.
This policy framework is binding on each HSP to which it applies or relates.
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.
5. Legislative context
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
6. Mandatory requirements
Under this policy framework HSPs must comply with all mandatory requirements* including:
- Access for Eligible Midwives into Public Maternity Units - OD 0570/14
- Clinical Incident Management Policy (2015) - OD 0611/15
- Credentialing and Defining Scope of Clinical Practice for Health Professionals (Nursing and Midwifery) in WA Health Services – A Policy Handbook - OD 0505/14
- Health Technology Governance Policy - MP 0072/17
- Implementation of the Australian Health Service Safety and Quality Accreditation Scheme and the National Safety and Quality Health Service Standards in Western Australia - OD 0410/12
- Implementation of the National Inpatient Medication Chart - OP 2080/06
- National Standard for User-Applied Labelling of Injectable Medicines, Fluids and Lines - OD 0647/16
- Revision of the Adult WA Anticoagulation Medication Chart (WA AMC) - OD 0522/14
- The Policy for Credentialling and Scope of Clinical Practice for Medical Practitioners (2nd Edition) - OD 0177/09
- WA Clinical Alert (MedAlert) Policy - MP 0053/17
- WA Health Complaint Management Policy - OD 0589/15
- WA Health Consent to Treatment Policy - OD 0657/16
- WA Open Disclosure Policy - OD 0592/15
- WA Paediatric National Inpatient Medication Chart - OD 0648/16
- Western Australian Review of Death Policy - OD 0448/13
*Any mandatory requirement document that references the Hospitals and Health Act 1927 must be interpreted as a requirement under the Health Services Act 2016.
7. Supporting information
The following documents support and inform the implementation of the mandatory requirements:
- Administration of Fluoride Varnish by Non-Dental Practitioners - OD 0667/16
- Antimicrobial Stewardship Policy - OD 0626/15
- Assistants in Nursing – Duties and Competencies - OD 0419/13
- Baby Friendly Health Initiative – Hospital breastfeeding policy 2014 - OD 0551/14
- Clinical Handover Policy - OD 0484/14
- Falls Risk Assessment and Management Plan (FRAMP) - OD 0579/14
- Pharmaceutical Review Policy - OD 0039/07
- Prescription and Management of Patient Controlled Intravenous Analgesia - OD 0658/16
- Rationalisation of Warfarin Brands - OP 1755/04
- Resources to support Health Services facilitate Access and Credentialing for Eligible Midwives - IC 0181/14
- The Correct Patient, Correct Site and Correct Procedure Policy and Guidelines for WA Health Services (2nd Edition) - OD 0004/06
- WA Health Allied Health Clinical Handover Form and Guideline - IC 0231/15
- WA Health Clinical Deterioration Policy - OD 0501/14
- WA Health Patient Identification Policy 2014 - OD 0486/14
- WA High Risk Medication Policy - OD 0561/14
- Clinical Risk Management Guidelines for the Western Australian Health System
- WA Pressure Injury Prevention and Management Clinical Guideline
- You Matter: A guideline to support engagement with consumers, carers, and communities in health
8. Policy framework custodian
Assistant Director General
Clinical Services and Research Division
Enquiries relating to this policy framework may be directed to:
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||Effective to||Amendment(s)|
|PF2016_01||1 July 2016||Current||Original version|
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||1 July 2016|
|Date published||1 July 2016|
|Dept. File No||F-AA-40142|
This policy framework is binding on those to whom it applies or relates. Implementation at a local level will be subject to audit.
12. Glossary of terms
|Applicability||Under Section 26 of the Health Services Act 2016, policy frameworks may apply to:
|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.|