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.


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.

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

Mandatory requirements

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

*Any mandatory requirement document that references the Hospitals and Health Act 1927 must be interpreted as a requirement under the Health Services Act 2016.

Supporting information

The following documents support and inform the implementation of the mandatory requirements:

Policy framework custodian

Assistant Director General
Clinical Excellence Division


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)
1 1 July 2016 14 September 2016 Original version
2 14 September 2016 14 June 2017 Rescinded OD 0316/11 from Supporting Information.
3 14 June 2017 21 June 2017 New MP 0053/17, superseded OD 511/14.
4 21 June 2017 6 July 2017 Rescinded OD 0376/12 from Supporting Information.
5 6 July 2017 28 August 2017 Rescinded OD 0397/12 and OD 0020/06 from Supporting Information.
6 28 August 2017 4 October 2017 Rescinded OD 0316/11 from Supporting Information.
7 4 October 2017 8 November 2017 New MP 0072/17, superseded OD 0541/14. Rescinded OD 0541/14 from Mandatory Requirements.
8 8 November 2017 21 December 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.
9 21 December 2017 10 January 2018 Updated Policy Framework Custodian. Changes were not made to Policy Framework landing page until 10 January 2018.
10 10 January 2018 17 January 2018 New MP 0076/18. New MP 0077/18, superseded OD 0626/15. Rescinded OP 1755/04 and OD 0626/15 from Supporting Information. Major Amendment to OD 0657/16.
11 17 January 2018 15 February 2018 New MP 0078/18, 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.
12 15 February 2018 14 March 2018 Rescinded OD 0667/16 from Supporting Information
13 14 March 2018 4 April 2018 Rescinded OD 0551/14 from Supporting Information
14 4 April 2018 10 May 2018 New MP 0080/18, superseded OD 0419/13.
15 10 May 2018 06 June 2018 New MP 0084/18, superseded OD177/09 and OD 0505/14 from Mandatory requirements and 0181/14 from Supporting Information.
16 06 June 2018 1 January 2019 New MP 0086/18, superseded WA Health Clinical Deterioration Policy - OD 0501/14 from Supporting Information. 
17 1 January 2019 11 February 2019 New MP 0098/18, superseded WA Review of Death - OD 0448/13 from Mandatory requirements. 
18 11 February 2019 26 February 2019 Major amendment to MP 0095/18. 
19  26 February 2019  23 April 2019 New MP 0104/19, superseded OD 0039/07 from Supporting information. 
20 29 April 2019 11 July 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.
21 11 July 2019  5 August 2019 Rescinded IC 0231/15 WA Health Allied Health Clinical Handover Form and Guideline from Supporting Information.
22 5 August 2019 15 August 2019 Rescinded OD 0004/06 The Correct Patient, Correct Site and Correct Procedure Policy and Guidelines for WA Health Services (2nd Edition) and OD 0486/14 WA Patient Identification Policy (2014) from Supporting Information.
23  15 August 2019 16 August 2019 Rescinded OD 0579/14 Falls Risk Assessment and Management Plan (FRAMP) from Supporting Information.
24 16 August 2019  8 October 2019 Major Amendment to MP 0080/18 Assisant in Nursing Policy and Related Document. 
25 8 October 2019 1 November 2019 Major Amendment to MP 0084/18 Credentialing and Defining the Scope of Clinical Practice Policy and Related Document.
26 1 November 2019 3 February 2020 New MP 0122/19, superseded OD 0611/15 Clinical Incident Management Policy.
27 3 February 2020 10 February 2020 New MP 0130/20, superseded OD 0589/15 WA Health Complaint Management Policy (2015).
28 10 February 2020 6 May 2020 New MP 0131/20, superseded OD 0561/14 WA High Risk Medication Policy, OD 0647/16 National Standard for User Applied Labelling of Injectable Medicines, Fluids and Lines and OD 0658/16 Prescription and Management of Intravenous Patient Controlled Analgesia.
29 6 May 2020 12 October 2020 New MP 0134/20, superseded OD 0410/12 Implementation of the Australian Health Service Safety and Quality Accreditation Scheme and the National Safety and Quality Health Service Standards in Western Australia
30 12 October 2020 05 February 2021 Major Amendment to MP 0098/18 Review of Death Policy and Related Document Death in Hospital Form. 
31 05 February 2021   09 February 2021  Rescindment: OD 0592/15 WA Open Disclosure Policy.


09 February 2021 22 April 2021 Major Amendment to MP 0072/17 Health Technology Governance Policy
33 22 April 2021 16 June 2021 New MP 0154/21 Managing Voluntary Assisted Dying Policy provided in advance of implementation on 1 July 2021.
 34 16 June 2021 30 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.
35 30 June 2021  3 August 2021 Retitle OD 0657/16 WA Health Consent to Treatment Policy to WA Health Consent to Treatment Policy as part of the OD/IC Project while under redevelopment to a Mandatory Policy.
36 3 August 2021 1 October 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. 
37 1 October 2021 17 January 2022 Minor Amendment to MP 0076/18 Cardiotocography Monitoring Policy. Update to supporting information and Policy contact email.
38 17 January 2022  19 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. 
 39 19 January 2022 Current

Major amendments to MP 0088/18 Assistant in Nursing Policy. Updated information and inclusion of Assistant in Nursing (Maternity setting) Related Document.


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

Approval byDr David Russell-Weisz, Director General, Department of Health
Approval date01 July 2016
Date published06 June 2018
File numberF-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.

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.