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


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:

  • 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.


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


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.


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

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:

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

Policy framework custodian

Assistant Director General
Clinical Excellence 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)
1 1 July 2016 17 January 2017 Original version
2 17 January 2017 3 April 2017 New MP 0045/17, superseded OD 0409/12 as Mandatory Requirement
3 3 April 2017 4 April 2017 New MP 0049/17 superseded OD 0417/13 as Mandatory Requirement, rescindment of OD 0417/13
4 4 April 2017 10 April 2017

New MP 0050/17 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.

5 10 April 2017 11 May 2017 OD 0608/15 re-added to Mandatory Requirements, removed OD 0618/15 from Mandatory Requirements (already rescinded)
6 11 May 2017 2 August 2017 Rescinded OD 0333/11 from Mandatory Requirements
7 2 August 2017 10 August 2017 Removed Publicly Funded Home Births from the Women’s and Newborns Health Network from Supporting Information
8 10 August 2017 29 September 2017 Rescinded OD 0502/14 from Supporting Information
9 29 September 2017 4 October 2017 Rescinded MP 0016/16 from Mandatory Requirements
10 4 October 2017 21 December 2017 New MP 0071/17 to Mandatory Requirements
11 21 December 2017 10 January 2018 Updated Policy Framework Custodian
12 10 January 2018 17 October 2018 Removed WA Adult Gastrointestinal Endoscopy Services Strategy 2015-2020 from Supporting Information
13 17 October 2018 24 December 2018 Rescinded OD 0442/13 from Supporting Information
14 24 December 2018 28 February 2019 Rescinded OD 0608/15 from Mandatory requirements
15 28 February 2019 18 April 2019 Rescinded BB 45/1 and IC 0065/12 from Mandatory requirements
16 18 April 2019 15 August 2019 New MP 0106/19 Safe Infant Sleeping Policy; superseded OD 0474/13 WA Health Safe Infant Sleeping Policy and Framework 2013
17 15 August 2019 4 September 2019 Rescinded OP 0176/04 National Standards for Public Hospital Admitted Patient Election Processes
18 4 September 2019 5 September 2019 Rescinded OD 0582/14 School Health Services in Western Australia from Supporting Information
19 5 September 2019 4 November 2019 New MP 0121/19 Responding to the Abuse of Older People (Elder Abuse) Policy
20 4 November 2019 10 August 2020 Rescinded OD 0617/15 Special Referral to Child Health Services from Supporting Information
21 10 August 2020 28 August 2020

Rescinded OD 0636/15 Nutrition Standards for Adult Inpatients in WA Hospitals

New MP 0141/20 Public Home Birth Program Policy, superseded OD 0482/13 WA Health Policy for publicly funded Home Births including guidance for consumers, health professionals and health services (Revised October 2013)

22 28 August 2020 22 October 2020 Major amendment to Clinical Services Planning and Programs Policy Framework to remove all Supporting Information from the framework
23 22 October 2020 16 February 2021 Rescinded OD 0590/15 Recording and Reporting of Clinical Care Commencement Date and Time in the Emergency Department
24 16 February 2021 18 February 2021  Rescinded IC 0174/14 Requirements for Aged Care Assessment in Multipurpose Services.
25 18 February 2021  28 April 2021 Rescinded OP 1816/04 Administrative Procedures – Ambulatory Surgery Initiative and OP 1503/01 Access to Public Hospital Services (Including Emergency Services) for Eligible Patients.
26 28 April 2021 11 May 2021 Minor amendment to MP 0121/19 Supporting information Guideline: Responding to the Abuse of Older People (Elder Abuse).
27 11 May 2021  21 May 2021  New MP 0160/21 Aboriginal Health Impact Statement and Declaration Policy.
28 21 May 2021 30 June 2021  Minor Amendment to Clinical Services Planning and Programs Policy Framework to create a new heading - Aboriginal Health.
29 30 June 2021 5 July 2021

Rescindment of OD 0518/14 Bilateral Schedule: Interagency Collaborative Processes When an Unborn or Newborn Baby Is Identified as at Risk of Abuse and/or Neglect, OD 0214/09 Security of Tenure for Residents of Aged Care Facilities, OD 0290/10 Transition Care for the Older Person, OD 0524/14 WA Health Day Therapy Unit Service Delivery Guidelines.  

Retitle OD 0613/15 OP1928/05, 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.

30  5 July 2021 22 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 eligibiity) is moved to s2.4 (Exclusion Criteria).
31  22 July 2021 29 July 2021 New MP 0166/21 Mandatory Reporting of Child Sexual Abuse Training Policy
31 29 July 2021 12 August 2021 New MP 0167/21 Newborn Hearing Screening Program Policy - Superseded OD 0239/09 Newborn Hearing Screening.
32 12 August 2021 30 September 2021 New MP 0168/21 Provision of Assistive Technology and Home Modifications Policy supersedes by OD 0353/11 - Provision of Aids, Equipment and Home Modifications Policy.
 33 30 September 2021 23 November 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.
 34 23 November 2021 13 December  Supporting Information - Statewide Emergency Department WA Police Handover document added to Clinical Services Planning and Programs Policy Framework. 
 35 13 December  Current 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. 


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 published17 October 2018
File numberF-AA-40143


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.