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Clinical Services Planning and Programs

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Policy framework statement

The Clinical Services Planning and Programs Policy Framework specifies the mandatory policy requirements that all Health Service Providers (HSPs) must comply with in order to ensure effective and consistent clinical service planning and program activity across the WA health system.

This policy framework has been developed within the context of the WA Health Clinical Services Framework 2014-2024; and the Clinical Services Framework 2020 Addendums; the Government's blueprint to guide the provision and delivery of safe, high quality public health care in Western Australia.

Purpose

The purpose of this policy framework is to ensure:

consistency of priorities and strategic directions for clinical service planning across the WA health system
coordination and integration of clinical services
clinical service programs are person-centred, based on evidence and within a culture of continuous improvement
efficiency and effectiveness in the provision of clinical services.

For this policy framework:

Clinical Health Service is defined as: a single, diagnostic, therapeutic, rehabilitative, preventative or palliative procedure or a series of such procedures that may be separately identified for billing and accounting purposes/service. It can also refer to a clinical or support service provided under the auspices of an organisation or facility.
Clinical Service Planning is defined as: identifies the priorities and strategic directions for clinical services or plans to guide delivery of services.
Clinical Service Programs is defined as: an organised aggregate of activities directed towards the attainment of defined objectives and targets. A health program is an organised series of activities directed towards the attainment of defined health objectives and targets with a health service defined as a service performed by health professionals or by others under their direction, for the purpose of promoting, maintaining or restoring health.

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:

Compliance and Alignment

Uphold compliance with relevant legislation and maintain alignment to the WA health system’s overarching statewide plans.

Consistency

Ensure consistency with Commonwealth and State Government policies and agreements.

Evidence-based and Accessible

Development and review utilises robust research and evidence. Ensure effective consultation and communication with all relevant stakeholders. Information is accessible to all stakeholders and intended audiences.

WA Health Strategic Intent 2015-2020

Support for the WA community to become healthier with a focus on prevention and support for healthier lifestyle choices; and work with primary health providers and carers to provide integrated and more accessible services.

Increased Health Service efficiency and effectiveness in hospital service delivery; and reduced demands on traditional hospital services.

Increased awareness and improved early detection and intervention of chronic diseases; and reduced numbers of people living with chronic disease through the provision of support for healthier lifestyles.

Continuous commitment to strengthened and embedded approaches to Aboriginal health and wellbeing; increased Aboriginal consumer, carer and community involvement to achieve culturally appropriate health services; and implemented strategic partnerships to improve health services for Aboriginal people.

Legislative context

This policy framework is made pursuant to ss 26(2)(a)(b)(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).

The legislation below, may also apply:

Mental Health Act 2014
Health and Disability Services (Complaints) Act 1995
Health Insurance Act 1973
The Disability Services Act 1993

Mandatory requirements

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

Aboriginal Health

Aged Care

Child Health

Mandatory Reporting of Child Sexual Abuse Training Policy - MP 0166/21

Elective Services

Elective Services Access and Management Policy - MP 0169/21

Emergency Care

Hospital Discharge

Provision of Assistive Technology and Home Modifications Policy - MP 0168/21

Maternity

Newborns and Infants

Safe Infant Sleeping Policy - MP 0106/19

Outpatient Services

Supporting information

The following documents support and inform the implementation of this policy framework:

Statewide Emergency Department WA Police Handover

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)
57	13 May 2025	Amendment to MP 0049/17 Water Immersion During Labour and Birth Policy. Amendments include: Purpose section refined; Policy requirements: bullet points one, four and five refined and updated. Inclusion for HSPs to record SAC 1 and SAC 2 incidents during water immersion births; Related document: Water Immersion During Labour and Birth State-wide Standard-removal of Compliance Audit tool from Appendix. Section 6 updated to reflect compliance monitoring and reference to the Audit Tool; Related document: ‘Water immersion During Labour and Birth Compliance Audit Tool’ a stand-alone mandatory document and updated; Compliance monitoring section updated to reflect the reporting requirements and use of the Water Immersion During Labour and Birth Compliance Monitoring Tool and definition of WA health system included.
56	25 February 2025	Amendment to MP 0106/19 Safe Infant Sleeping Policy. Amendments include: Purpose section updated for clarity and improved readability; Policy requirements wording amended to align with language used throughout the guideline and audit tool; Health professional changed to healthcare worker to be more inclusive; Definition section: inclusion of ‘healthcare worker’; Audit tool updated to allow ease of auditing requirements.
55	30 September 2024	New policy in effect: MP 0187/24 Nurse/Midwife to Patient Ratios Policy. The purpose of this policy is to outline the approach to implementing Nurse/Midwife to Patient Ratios across Health Service Providers that provide inpatient clinical care services. This includes prescribing the mandatory minimum requirements for staffing levels specific to the care delivered. Nurse/Midwife to Patient Ratios will be implemented in a phased approach across the WA health system inpatient services. Phase one of the transition is applicable to clinical care areas (medical and surgical wards) at North Metropolitan Health Service. This policy is applicable only to all North Metropolitan Health Service wards/units classified as metropolitan adult inpatient medical/surgical.
54	5 September 2024	Policy review and amendments to MP 0169/21 Elective Services Access and Management Policy. Amendments include the following: Policy requirements section amended to clarify clinical governance requirements relating to Children in Care, transfer and transition of patients, valued based care and the responsible officer; Compliance monitoring section amended to align with mandatory policy governance requirements; Related documents: 'Elective Services Access Handbook' updated and renamed to 'Elective Services Access Standard' and 'Excluded Procedures Manual' updated; Definitions section amended to include 'Children in care'.
53	1 July 2024	New mandatory policy: MP 0185/24 Health Equity Impact Statement and Declaration Policy. This policy mandates the requirement to report on how the needs of consumers and carers in priority group/s have been considered and incorporated during the development, implementation, review and changes made to significant WA health system initiatives.
52	2 May 2024	Policy review and amendments to MP 0166/21 Mandatory Reporting of Child Sexual Abuse Training Policy. Amendments include the following: Policy requirements section updated to reflect amended legislation: Child and Community Services Amendment Act 2021; Compliance Monitoring section updated to reflect current practice and monitoring requirements by the System Manager (policy owner); Related Documents section updated to include the Mandatory Training eLearning module and the Mandatory Reporting of the Child Sexual Abuse Web eLearning Course; Inclusion of supporting information documents: 'Mandatory Reporting Guide WA-May 2024' and 'Royal Commission into Institutional Responses to Child Sexual Abuse: Final Report Recommendations'; Definitions section: inclusion of Psychologist definition and updated 'Midwife', 'Nurse' and 'Mandatory reporter' definitions; policy contact amended to reflect updated policy owner contact.
51	12 April 2024	Policy review and amendments to MP 0141/20 Public Home Birth Policy. Amendments include the title renamed from Public Home Birth Program Policy to Public Home Birth Policy; ‘Program’ removed throughout the policy; applicability amended for consistency with other CNMO policies; policy requirements amended to establish minimum training requirements for relevant staff and clarify Health Service Provider compliance monitoring requirements; compliance monitoring section updated to align with other CNMO policies; related document: Public Home Birth Program Standard renamed to Public Home Birth Standard, revised, and updated; new related document: Public Home Birth Compliance Audit Tool developed; policy contact amended to reflect new policy ownership with Chief Nursing and Midwifery Office.
50	14 February 2024	Amendment to MP 0049/17 Water Immersion During Labour and Birth Policy. Related document: 'Water Immersion During Labour and Birth: Statewide Standard' updated - the 'Water birth Patient Information' brochure revised and updated to 2024 publication - NMHS Women and Newborn Health Service.
49	20 November 2023	Policy review and amendments to MP 0106/19 Safe Infant Sleeping Policy. Amendments include the purpose section amended to align with policy requirements; applicability section amended to include a statement on contracted health entities; policy requirements amended to clarify training requirements for both health professionals and volunteers; compliance monitoring section amended to standardise reporting requirements; related documents 'Safe Infant Sleeping eLearning Package' and Safe Infant Sleeping Compliance Tool moved from supporting information to related documents and supporting information document 'Safe Infant Sleeping Standard' renamed to 'Safe Infant Sleeping Guideline."
48	16 November 2023	Policy review and amendments to MP 0049/17 Water Immersion During Labour and Birth Policy. Amendments include: Policy title amended form "Women requesting immersion in water for pain management during labour and/or birth" to "Water Immersion During Labour and Birth"; inclusion of preamble (after title and before Purpose section); purpose section updated to align with the policy requirements; policy requirements updated to require HSPs to develop procedures in line with the 'Water Immersion During Labour and Birth: Statewide Standard'; Compliance monitoring updated to reflect policy requirements; Related document 'Statewide clinical guidelines for women requesting immersion in water for pain management during labour and/or birth' renamed "Water Immersion During Labour and Birth: Statewide Standard and updated to reflect current practices; policy contact changed from Women's and Newborns Heath Networks Development Officer to Principal Midwifery Officer, Office of the Chief Nursing and Midwifery Officer.
47	27 October 2023	Minor amendment to MP 0160/21 Aboriginal Health Impact Statement and Declaration Policy. Supporting Information 'Closing the Gap- WA's Implementation Plan' removed and replaced with 'Closing the Gap Implementation Plan 2023-2025 Western Australia'.
46	19 October 2023	Amendments to MP 0166/21 Mandatory Reporting of Child Sexual Abuse Training Policy: • Removed online training module link and inserted wording regarding access to the module on HSPs LMS platforms. • Removal of outdated Supporting Information – State-wide Protection of Children Coordination Unit (SPOCC) Training Calendar.
45	9 October 2023	Amendments to MP 0160/21 Aboriginal Health Impact and Declaration Policy. Amendments include the following: minor amendment to the purpose section referring to Strategic Direction 3, removed the contracted health entities statements from the Applicability section, updated policy requirements to develop local procedures instead of guidelines and include reporting requirements, updated compliance monitoring section to reference the 'Aboriginal Health and Wellbeing Action Template' and 'Aboriginal Health and Wellbeing Annual Report Template', Removal of four supporting information, inclusion of two supporting information: 'Aboriginal Empowerment Strategy-Western Australia 2021-2029 and 'Closing the Gap - WA's Implementation Plan', included definition for Aboriginal Health and Wellbeing Action Plan, Aboriginal Health and Wellbeing Annual Report and WA health entities and removed definition for AHISD form.
44	9 October 2023	Amendments to MP 0071/17 Aboriginal Health and Wellbeing Policy. Amendments include the following: Purpose section amended to clarify the instruments that must be used by Health Service Providers to demonstrate compliance, applicability section amended to exclude QuadCentre, Policy Requirements section amended to clarify requirements on the development of an Action Plan, along with he endorsement and submission of Annual Reports using the Annual Report Template, the endorsee for the Action Plan has changed from the Board Chair to the Chief Executive Officer, Compliance Monitoring section reviewed and refined to reflect policy requirements, inclusion of the Annual Report Template in the Related Documents section and minor formatting amendments to the policy.
43	28 September 2023	Amendment to MP 0169/21 Elective Services Access and Management Policy - Amendment to Related Document - Excluded Procedures Manual updated following the release of the ICD-10-AM/ACHI/ACS 12^th edition.
42	6 September 2023	Minor amendment to MP 0173/22 Patients Awaiting Aged Care Services including Transition Care Program Policy. Updated Policy requirements sections 3.1 Referral to Transition Care Program and 3.4 Reporting on Patients Awaiting Aged Care Services to include 'respite care' as an approved Commonwealth subsidised aged care service.
41	30 November 2022	Amendments to MP 0121/19 Responding to the Abuse of Older People (Elder Abuse) Policy:Policy ownership change and inclusion of contracted health entities within the applicability statement.
40	27 September 2022	Amendment to MP 0169/21 Elective Services Access and Management Policy - Minor amendments to related document: Elective Services Access Handbook.
39	9 September 2022	New MP 0173/22 Patients Awaiting Aged Care Services Including Transition Care Program Policy superseded OD 0290/10.
38	14 March 2022	Guidelines for Protecting Children 2015 rescinded 14 March 2022. Superseded by MP 0166/21 Mandatory Reporting of Child Sexual Abuse Training Policy.
37	17 February 2022	Policy Review and amendments to MP 0071/17 Aboriginal Health and Wellbeing Policy as per below: Complete policy review was undertaken, a new review cycle will now commence. Deleted reference Health Service Performance report. Updated Aboriginal Health and Wellbeing Action Plan and Annual Report due dates. Action Plan Template (Related Document) updated to provide examples. Obsolete Supporting information documents removed and additional current Supporting information documents included.
36	13 December 2021	Reinstatement of OD 0290/10 as Transition Care for the Older Person Guidelines. This is to be a mandatory requirement to ensure continued access of information to health service providers whilst the new mandatory policy is under development.
35	23 November 2021	Supporting Information - Statewide Emergency Department WA Police Handover document added to Clinical Services Planning and Programs Policy Framework.
34	30 September 2021	New MP 0169/21 Elective Services Access and Management Policy supersedes MP 0050/17 Elective Surgery Access and Waiting List Management Policy and MP 0045/17 Urgency Categorisation and Access Policy for Public Direct Access Adult Gastrointestinal Endoscopy Services.
33	12 August 2021	New MP 0168/21 Provision of Assistive Technology and Home Modifications Policy superseded OD 0353/11.
32	29 July 2021	New MP 0167/21 Newborn Hearing Screening Program Policy superseded OD 0239/09.
31	22 July 2021	New MP 0166/21 Mandatory Reporting of Child Sexual Abuse Training Policy.
30	5 July 2021	Major Amendment to the Related Document for MP 0141/20 Public Home Birth Program Policy. The amendment is for a current condition listed in s.2.5 of the Standard (Conditions Requiring antenatal consultation as to eligibility) is moved to s2.4 (Exclusion Criteria).
29	30 June 2021	Rescindment of OD 0518/14, OD 0214/09, OD 0290/10 and OD 0524/14. Retitle OD 0613/15, OP 1928/05, OD 0351/11, OD 0503/14, OD 0530/14 and OD 0606/15 as part of the OD/IC Project while under redevelopment to a Mandatory Policy. Retitle OD 0239/09 and relocate from Mandatory requirements to Supporting information as part of the OD/IC Project while under redevelopment to a Mandatory Policy. Relocate OD 0353/11 content from Mandatory requirements to a redirect link to the Chief Allied Health Office webpage located under Supporting information as part of the OD/IC Project while under redevelopment to a Mandatory Policy.
28	21 May 2021	Minor Amendment to Clinical Services Planning and Programs Policy Framework to create a new heading - Aboriginal Health.
27	11 May 2021	New MP 0160/21 Aboriginal Health Impact Statement and Declaration Policy.
26	28 April 2021	Minor amendment to MP 0121/19 Responding to the Abuse of Older People (Elder Abuse) Policy and Supporting information Guideline: Responding to the Abuse of Older People (Elder Abuse).
25	18 February 2021	Rescinded OP 1816/04 and OP 1503/01 for Eligible Patients.
24	16 February 2021	Rescinded IC 0174/14.
23	22 October 2020	Rescinded OD 0590/15.
22	28 August 2020	Major amendment to Clinical Services Planning and Programs Policy Framework to remove all Supporting Information from the framework.
21	10 August 2020	Rescinded OD 0636/15. New MP 0141/20 Public Home Birth Program Policy, superseded OD 0482/13.
20	4 November 2019	Rescinded OD 0617/15 from Supporting Information.
19	5 September 2019	New MP 0121/19 Responding to the Abuse of Older People (Elder Abuse) Policy.
18	4 September 2019	Rescinded OD 0582/14 from Supporting Information.
17	15 August 2019	Rescinded OP 0176/04.
16	18 April 2019	New MP 0106/19 Safe Infant Sleeping Policy; superseded OD 0474/13 and Framework 2013.
15	28 February 2019	Rescinded BB 45/1 and IC 0065/12 from Mandatory requirements.
14	24 December 2018	Rescinded OD 0608/15 from Mandatory requirements.
13	17 October 2018	Rescinded OD 0442/13 from Supporting Information.
12	10 January 2018	Removed WA Adult Gastrointestinal Endoscopy Services Strategy 2015-2020 from Supporting Information.
11	21 December 2017	Updated Policy Framework Custodian.
10	4 October 2017	New MP 0071/17 Aboriginal Health and Wellbeing Policy to Mandatory Requirements.
9	29 September 2017	Rescinded MP 0016/16 WA Health Statewide Discharge Summary Policy from Mandatory Requirements.
8	10 August 2017	Rescinded OD 0502/14 from Supporting Information.
7	2 August 2017	Removed Publicly Funded Home Births from the Women’s and Newborns Health Network from Supporting Information.
6	11 May 2017	Rescinded OD 0333/11 from Mandatory Requirements.
5	10 April 2017	OD 0608/15 re-added to Mandatory Requirements, removed OD 0618/15 from Mandatory Requirements (already rescinded).
4	4 April 2017	New MP 0050/17 Elective Surgery Access Waiting List Management Policy superseded OD 0402/12, OD 0472/13, OD 0375/12 and OD 0618/15. Incorrectly removed OD 0608/15 from Mandatory Requirements in place of OD 0618/15.
3	3 April 2017	New MP 0049/17 Women requesting immersion in water for pain management during labour and/or birth policy superseded OD 0417/13 as Mandatory Requirement, rescindment of OD 0417/13.
2	17 January 2017	New MP 0045/17 Urgency Categorisation and Access Policy for Public Direct Access Adult Gastrointestinal Endoscopy Services, superseded OD 0409/12 as Mandatory Requirement.
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	17 October 2018
File number	F-AA-40143

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.
Health Service Provider	Means a Health Service Provider established by an order made under section 32(1)(b) of the Health Services Act 2016.
Clinical Protocols	Clinical Protocols can be seen as more specific than guidelines and provide a comprehensive set of rigid criteria outlining the management steps for single clinical condition or aspects of organisation.
WA health system	Pursuant to section 19(1) of the Health Services Act 2016, means the Department of Health, Health Service Providers and to the extent that Contracted Health Entities provide health services to the State, the Contracted Health Entities.