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Policy framework statement

The Performance Policy Framework specifies the system performance management requirements that all Health Service Providers (HSPs) must comply with in order to ensure effective and consistent minimum standards of performance 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:

  • clear accountabilities, interventions and escalation processes including mechanisms for remediation when performance does not meet expected standards 
  • the roles, functions and powers legislated in the Health Services Act 2016 are understood 
  • the WA health system has a common set of performance objectives and targets for each HSP 
  • alignment of the Performance Management Policy (PMP) with the Service Agreements, Performance Agreements and the Operational Plan performance reporting is available to support effective performance management 
  • toolsets and business rules are in place to support consistent results in performance monitoring and evaluation 
  • a clear understanding of performance levels and performance improvement opportunities. 


This policy framework is binding on each HSP to which it applies or relates. Specifically, HSP Boards and HSP Chief Executives.


The key principles that underpin this policy framework are: 


Clearly defined roles and responsibilities to deliver health services at agreed standards and volumes. 

Consistency with National and State health service delivery objectives, priorities and outcomes. 

Escalation processes 
Well-defined escalation processes and recovery pathways for performance concerns. 

A balanced approach that has clear linkages to clinical planning, budget, activity, and safety and quality priorities. 

Recognition and reward for performance that is sustained and outstanding. 

Service improvements focus 
A strong focus on mechanisms to enhance service delivery and health care outcomes. 

Clear and agreed performance targets and thresholds and well-defined intervention processes to address poor performance

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 s. 20(1)(m) which refers to the function of the DG to monitor the performance of HSPs and to take remedial action when performance does not meet the expected standard. Other relevant provisions include s. 34(2)(l) and (m), which refer to the requirements of the HSP to manage its performance against the performance measures and operational targets stated in the Service Agreements and to provide performance data to the DG. Further ss. 94-102 refers to the appointment of advisers and administrators to the Board and the dismissal of the Board.

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

There is no supporting information for this policy framework.

Policy framework custodian

Assistant Director General
Purchasing and System Performance 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 8 November 2016 Original version
2 8 November 2016 12 December 2016 Major Amendment to MP 0037/16
3 12 December 2016 13 February 2017 Major Amendment to MP 0037/16
4 13 February 2017 1 July 2017 Major Amendment to MP 0037/16
5 1 July 2017 6 December 2017 New MP 0055/17 superseding MP 0037/16
6 6 December 2017 15 March 2018 Major Amendment to MP 0055/17
7 15 March 2018 6 June 2018 Major Amendment to MP 0055/17 v.2.0
8 6 June 2018 27 June 2018 Major Amendment to MP 0055/17 v.3.0
9 27 June 2018 3 July 2018 New MP 0089/18
10 3 July 2018 26 September 2018 MP 0055/17 rescinded
11 26 September 2018 8 February 2019 Major Amendment to MP 0089/18 v.2.0
12 8 February 2019 10 July 2019 Major Amendment to MP 0089/18 v.3.0
13 10 July 2019 11 July 2019 New MP 0111/19 Performance Management Policy 2019-20 published (supersedes MP 0089/18 Performance Management Policy 2018-19)
14 11 July 2019 14 October 2019 Supporting Information removed as included within MP 0111/19 Performance Management Policy 2019-20
15 14 October 2019 20 December 2019 Major Amendment to MP 0111/19 v.1.0 
16 20 December 2019 15 April 2020 Major Amendment to MP 0111/19 v.2.0 
17  15 April 2020  18 December 2020 Major Amendment to MP 0111/19 v.3.0 
 18 18 December 2020 1 July 2021 Major Amendment to MP 0111/19 v.4.0
 19  1 July 2021  Current Major Amendment to MP 0111/19 v.5.0



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 published10 July 2019
File numberF-AA-40153


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.
Performance indicator Provides an ‘indication’ of progress towards achieving the organisation’s objectives or outputs.
Performance management The management and governance system that regulates and addresses performance concerns.
Performance standards The establishment of relevant targets and thresholds to monitor performance.
Performance thresholds The clearly defined limits at which a performance indicator measurement will trigger an action, response or intervention.
Service Agreement The annual Agreement between the Director General of the Department of Health and the Health Service Providers. The agreement will include a Statement of Priorities directing policy, service targets, budgets and performance measures as performance indicators.
Targets For performance indicators are generally established and agreed as part of the Executive’s annual PA. Targets are based on current government priorities and commitments, historical performance and trends, agency capability and consumer demand. Targets maybe expressed as absolute numbers, ratios, and percentages; or as a range (such as 75% to 85%, rather than just a single figure of 80%). Targets should be challenging but achievable.
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.