Other legal disclosures

Unauthorised use of credit cards

WA Government purchasing cards can be issued by EMHS to employees where their functions warrant usage of this facility.

These credit cards are not to be used for personal (unauthorised) purposes (i.e. a purpose that is not directly related to performing functions for the agency).

All credit card purchases are reviewed by someone other than the cardholder to monitor compliance. If during a review it is determined that the credit card was used for unauthorised purchases, written notice must be given to the cardholder and the EMHS Board.

EMHS had 2 instances (total amount of $17) where a purchasing card was used for personal purposes in 2023-24. A review of these transactions confirmed they were immaterial and the result of genuine and honest mistakes.

No further action was deemed necessary as prompt notification and full restitution was made by the individuals concerned. These were not referred for disciplinary action.

Within the period of 1 July 2023 to 30 June 2024:	Total
Instances of use for personal purposes	2
Aggregate amount of personal use expenditure	$17.00
Aggregate amount of personal use expenditure settled by a due date	$17.00
Aggregate amount of personal use expenditure settled after a due date	$0
Aggregate amount of personal use expenditure remaining unpaid at end of financial year	$0
Number of referrals for disciplinary action instigated by the notifiable authority	0

Expenditure on advertising

In 2023-24, EMHS did not incur any expenditure on advertising in accordance with section 175ZE of the Electoral Act 1907 (WA).

Compliance with public sector standards and ethical codes

Public Sector Standards

The Public Sector Standards in Human Resource Management (the standards) set out the minimum standards of merit, equity and probity to be complied with by WA public sector bodies and their employees. The Department of Health and EMHS maintain Human Resources (HR) policies and guidelines that are consistent with the standards.

These are available to all employees on the EMHS intranet and/or the Department of Health policy frameworks internet pages.

Information about the public sector standards is promoted and available to employees via:

notification of the breach claim rights and processes, including relevant deadlines applicable to the standards
information, fact sheets, policies and guidelines on the EMHS intranet
recruitment, selection and appointment training for recruiting managers and panel members
the EMHS peak performance training for line managers.

The HR Directorate provides information, guidance and support to all managers to promote best practice and application of these policies and procedures and manages any claims made against the standards. Advice is also provided where appropriate, in order to reach a prompt, satisfactory outcome at the most appropriate level.

During 2023-24, there were:

Code of Conduct

Integrity and ethical behaviour are integral to EMHS’ core business. EMHS regularly encourages staff to reflect on the EMHS values (including accountability, integrity and respect) and to incorporate these into their work.

To support awareness of their responsibilities, new staff receive and acknowledge the Code of Conduct as a part of their offer of employment to work with EMHS. Responsibility for workplace behaviours and conduct is reinforced at formal induction and through completion of mandatory training.

During 2023-24, EMHS developed an Integrity Strategy, intended to update and embed integrity related policies and procedures and to raise staff awareness of those policies and the pathways by which breaches of those policies can be reported. The Integrity Strategy includes the:

Integrity and Ethical Governance Framework – to describe the principles, organisational structures and mechanisms, along with the cultural factors, that guide how EMHS practices, manages and accounts for integrity.
Fraud and Corruption Control System – developed to address fraud and corruption risks aimed at reducing EMHS’ exposure to fraud and corruption.
Reporting Inappropriate Behaviours Procedure – which describes staff obligations in relation to reporting any instance of inappropriate workplace behaviour or staff conduct, along with the range of pathways by which such conduct can be reported.

The Strategy includes the development of an integrated communications strategy for the promotion of the above policies and available reporting pathways.

EMHS commenced 49 disciplinary processes in relation to potential breaches of policy and/or the Code of Conduct in 2023-24. All suspected breaches of discipline, including reportable misconduct, were managed in accordance with the requirements of the WA Health Discipline Policy and where appropriate, were reported to external oversight agencies as required by legislation.

During 2023-24, EMHS established the Ethical Conduct Advisory Committee (ECAC), the function of which includes development and management of:

strategies to improve integrity awareness, compliance and culture
the EMHS Integrity and Ethical Governance Framework
EMHS integrity related policies and procedures, and related documents for staff awareness, education and EMHS wide improvements
integrity and ethical governance issues, to ensure compliance with relevant policy and statutory obligations.

East Metropolitan Health Services diversity and inclusion

EMHS is committed to becoming a leader in diversity and inclusion, striving for representation targets that reflect the diverse communities we serve.

To attract and keep talented people working in our organisation, we are dedicated to nurturing a culture of inclusion at work. We know staff who are engaged, feel supported and safe, are more productive and can provide EMHS and our community better service, leading to better health outcomes overall.

In the most recent Department of Health survey, EMHS employees highly rated their commitment to organisational goals, their ability to make good use of their skills and abilities, and understanding how their contributions help EMHS achieves its overall objectives. We aim to build on this through our inclusion activities.

As part of our effort this year, EMHS has:

With 83 new champions trained, expanded our Aboriginal Health Champions program – for non-Aboriginal staff to become allies for Aboriginal consumers and staff, contributing to Aboriginal health outcomes.
Engaged in targeted programs to employ students with disability, from Aboriginal and Torres Strait Islander backgrounds, and from culturally and linguistically diverse backgrounds. These programs include the Public Sector Commission’s Solid Futures program, the pilot vacation placement program for university students and the School Based Traineeship program. EMHS also continued engaging interns through the McCusker Centre for Citizenship (UWA).
10 employed Aboriginal young people and graduates.
With 109 Aboriginal staff, work is continuing on increasing opportunities for Aboriginal peoples in our workplace through focused employment initiatives such as using the exception in the Equal Opportunity Act 1984 (WA) and Commissioner’s Instruction 39.

EMHS has exceeded the government’s aspirational target for the representation of women in senior/executive roles (50 per cent) with 56 per cent of these roles filled by women.

In the latest data 19.6 per cent of our staff identify as being from a Culturally and Linguistically diverse (CALD) background, significantly surpassing the government’s aspirational target of 5 per cent.

EMHS was the only HSP to onboard and successfully place 5 Aboriginal and Torres Strait Islander students for a two-week placement during their university study break. The program enables students to earn, gives them a taste of working in the Health environment and gives them the opportunity to learn some of the skills they need to be job ready.

With ongoing focus on inclusion, EMHS continues to be an employer of choice for the best and brightest and evolves to better reflect the communities in our care.

Disability access and inclusion

EMHS is committed to ensuring people with disability, as well as their families and carers, have equitable access to our services, facilities, employment and information, consistent with EMHS’ vision and values and in compliance with the Disability Services Act 1993 (WA) (DSA).

The EMHS Disability Access and Inclusion Plan (DAIP) outlines our strategies and actions for meeting the 7 disability outcome areas identified in the Disability Services Regulations 2004.

Throughout 2023-24, a range of developments helped improve outcomes for consumers and staff with disability.

General services and events

Outcome one: People with disability have the same opportunities as other people to access the services of, and any events organised by, a public authority.

EMHS has a significant, long-term commitment to improve access to its services and events.

In 2023-24, this included:

Launch of the First Steps program, aimed at enhancing care for people on the autism spectrum accessing services across our sites. The program includes guidance to staff in the use of safe, affirmative language and developing effective communication with autistic patients and their families via helpful resources – helping staff understand the impact that care environments, including the emergency department (ED), can have on autistic consumers.
Significant International Day of People with Disability events were held across EMHS, including staff education and awareness raising, and community engagement activities. The highlight was having the Western Australian Institute of Sport (WAIS) and the Fremantle Dockers come together in a wheelchair basketball coaching session and exhibition match at Bentley Health Service (BHS).
Animal therapy across EMHS has continued to expand, including having the Royal Perth Hospital (RPH) and BHS Occupational Therapy (OT) Department staff present on the Dog Therapy Visitation Program at the National OT Exchange Conference.

Bentley Health Service patient Pamela with Delta Therapy Dog ‘Takumi’

Buildings and facilities

Outcome two: People with disability have the same opportunities as other people to access the buildings and other facilities of a public authority.

Regular and ongoing maintenance of EMHS buildings, grounds, car parks and facilities ensure we comply with relevant disability and access requirements.

Further improvements were made in 2023-24 by:

locating a dedicated, permanent wheelchair bay within the Royal Perth Hospital (RPH) Emergency Department (ED) waiting room, improving access to the department
reviewing the RPH Outpatient Department accommodation with the aid of a consumer with disability, to provide better care facilities for people with disability
creating a dementia friendly garden at Armadale Health Service (AHS), designed to incorporate disability access principles and provide a therapeutic space that enhances the wellbeing of consumers
improving disability friendly spaces for staff and consumers, with Bentley Health Service (BHS) developing a quiet space for staff and patients within
Q Block and RPH creating a Staff Wellness Room within A Block
installing a number of wheelchair ramps at BHS M Block, ensuring better access to the basketball courts and external patio area. New wheelchair accessible outdoor tables have also been installed.

Information and communication

Outcome three: People with disability receive information from a public authority in a format that will enable them to access the information as readily as other people are able to access it.

EMHS publications and patient information is regularly reviewed to ensure it meets the needs of healthcare users, includes adequate information, is available in different formats and uses appropriate language.

Initiatives in 2023-24 included:

continued improvement of wayfinding across EMHS, by providing branding and accessibility guidelines for navigational services
introducing Patient Care Boards in BHS Older Adult and Rehabilitation wards as an additional communication strategy with patients, carers and multidisciplinary teams, capturing “what matters to me most” for patients
improved access to information on EMHS intranet pages as part of improvements to EMHS web services.

Quality of service

Outcome four: People with disability receive the same level and quality of service from the staff of a public authority as other people receive from the staff of that public authority.

A range of strategies has been introduced at EMHS to ensure people with disability receive the same high level of care. Key actions in 2023-24 included:

continued adoption of staff equity, diversity and inclusion training for staff, including a module on disability inclusion and awareness
new eLearning provided to staff on National Disability Insurance Scheme (NDIS) basics, helping clinicians gain a greater understanding of the NDIS and how to access the scheme
increased disability resources for staff on the EMHS intranet
a ’grand round’ presentation by 2 EMHS staff members who are working and living with disability
continued implementation of the dementia friendly program, in line with RPH working towards becoming the first health service in Australia to become dementia-friendly.

Complaints and safeguarding

Outcome five: People with disability have the same opportunities as other people to make complaints to a public authority.

EMHS reviewed its complaints management policy again in 2024 to continue to ensure it maximises the way feedback and complaints are received.

Additional strategies to receive feedback include the inclusion of QR codes on posters and brochures to increase the options for providing feedback.

Consultation and engagement

Outcome six: People with disability have the same opportunities as other people to participate in any public consultation by a public authority.

Broad consultation with consumers is regularly undertaken in the delivery and design of EMHS services.

This includes consumers and staff with lived experience of disability sitting on EMHS Disability Access and Inclusion Committees and Consumer Advisory Committees, and being involved in the review of services, policies and programs. EMHS also regularly engages with the community and disability service providers as part of its service planning process.

Employment people and culture

Outcome seven: People with disability have the same opportunities as other people to obtain and maintain employment with a public authority.

EMHS is committed to ensuring people with disability can obtain and maintain employment. During 2023-24:

EMHS staff participated in and promoted the inaugural Staff with Disability and Allies Network annual conference
staff bathroom facilities in administrative areas of the hospital were refurbished
EMHS workforce policies were reviewed to ensure they featured equity, diversity and inclusion principles.

Recordkeeping

The State Records Act 2000 (WA) (the Act) mandates the statutory recordkeeping practices for State Government agencies.

Section 19 of the Act states that every government organisation must have a Recordkeeping Plan (RKP) that has been approved by the State Records Commission. In May 2024, EMHS submitted for approval an amended RKP to the State Records Commission in line with its legislative obligations.

EMHS undertook an internal audit in August 2023 which highlighted areas for development against the mandatory principles across the 7 Records Management Standards. The suite of findings against the audit scope found that there are 5 crucial themes that require significant improvement to support a successful uplift in records management policy and practices. Work is being undertaken to progress the implementation of audit recommendations.

The Recordkeeping Awareness Training program forms part of the mandatory learning program for all staff and is usually completed upon induction. The training outlines the roles and responsibilities of EMHS employees in complying with the RKP and relevant policies. The Corporate Recordkeeping area is also in the process of developing a robust training program for the Electronic Document Records Management System (EDRMS), which will offer face to face as well as online training modules.

EMHS continues to roll out the EDRMS across EMHS corporate areas. Since the implementation in 2019, there have been 963,656 records saved to 30 June 2024, with 507 active users within the system. Compliance audits are conducted, ensuring the EDRMS is being maintained and corporate records are captured appropriately.