Compliance

Other legal disclosures

Compliance with Public Sector Standards and ethical codes

Public Sector Standards 

The Public Sector Standards in Human Resource (HR) 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 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, 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 also manages any claims made against the Public Sector Standards. Advice is also provided where appropriate in order to reach a prompt, satisfactory outcome at the most appropriate level. 

During 2024-25, there were: 

• 6 breach of standard claims lodged against the employment standards 
• 0 were resolved internally and withdrawn 
• 0 are currently being managed by HR 
• 6 were referred to the Public Sector Commission 
• 0 breach of standard claims for grievance resolution, performance management, termination or redeployment standards.

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 2024-25, in addition to mandatory training, EMHS has developed targeted training for specific areas, including:

• Code of Conduct training for the EMHS Board 
• Training on investigations for managers and supervisors 
• E-learning module for Medicine Discrepancies investigations.

EMHS has also updated and published the following key integrity related policies:

• 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 and aimed at reducing EMHS’ exposure to fraud and corruption
• Reporting Inappropriate Behaviours Procedure – 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 EMHS Ethical Conduct Advisory Committee (ECAC) was established in 2023-24, comprising of a group of senior executive stakeholders. The ECAC has met regularly throughout 2024-25, with its main functions being the development and management of strategies to improve integrity awareness, compliance and culture.  

EMHS commenced 56 disciplinary processes in relation to potential breaches of policy and/or the Code of Conduct in 2024-25. All suspected breaches of discipline, including reportable misconduct were managed in accordance with the requirements of the WA Health Discipline Policy and where appropriate reported to external oversight agencies as required by legislation.

Recordkeeping

The State Records Act 2000 (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 (SRC). An amended RKP submitted by EMHS in May 2024 was approved by SRC on 27 August 2024. In accordance with the State Records Act 2000, a review of the plan must be submitted every 5 years. 

EMHS Corporate Recordkeeping section has recently changed Directorates from Office of the Chief Executive (OCE), to the Chief Information Office, reporting to the Chief Information Officer (CIO).   

Corporate records across EMHS are created and maintained in both physical and electronic formats, with electronic records managed via shared network drives or the approved Electronic Document and Records Management System (EDRMS), Hewlett Packard Records Manager 8.3. A system-wide upgrade to a newer EDRMS version is underway across all Health Service Providers, with implementation expected by the end of 2025. Following the upgrade, further rollout to non-participating corporate areas is planned to support consistent records management practices. 

As of 30 June 2025, there were over 600 staff who were active in Records Manager with over 1.215 million documents and emails, created and saved since its inception in 2019. 

An internal audit of EMHS recordkeeping practices was conducted in 2023 to assess compliance with the Act and the effectiveness of electronic records management controls. The audit report, received in January 2024, identified areas for improvement across the 7 Records Management Standards, with a focus on 5 key themes requiring significant improvement to support a successful uplift in records management policy and practices within EMHS. The primary recommendation, Support and Leadership for Records Management Practices, outlined that there must be demonstrated leadership and accountability from EMHS’ Executive and Senior Management teams. To address this recommendation, the Corporate Information and Records Management Policy was significantly updated to provide clarity on requirements for specific positions, in alignment with the responsibilities outlined in section 3.5 of the State Record’s Office Information Management Framework for WA. These changes were endorsed by the Area Executive Group on 11 July 2024. Progress is underway to address the remaining audit recommendations. 

The Recordkeeping Awareness Training forms part of the mandatory e-learning suite and informs staff about good recordkeeping practices, including outlining the roles and responsibilities of EMHS employees in complying with the RKP and relevant policies. This is part of the staff induction process for all health staff.  

The EMHS Corporate Recordkeeping team successfully developed and published a self-directed, online learning course ‘HPE Records Manager E-Learning’, which went live in June 2023 in ‘MyLearning’. This is provided to new staff who require access to Records Manager (RM) and is accessible to all EMHS corporate staff. The course replaces the historical face-to-face method of training and staff are able to re-visit the course at any time. The Corporate Records team ensures staff are supported in their use of the EDRMS by providing one-on-one assistance when required, in addition to the online course.

Expenditure on advertising

In 2024-25, EMHS did not incur any expenditure on advertising in accordance with section 175ZE of the Electoral Act 1907 (WA). 

Act of grace payments

EMHS did not make any act of grace payments in 2024-25 pursuant to Section 80(1) of the Financial Management Act 2006 (WA).

Disability access and inclusion

EMHS is committed to ensuring people with a disability, as well as their families and carers, have the same opportunities as others to access our services, facilities, employment and information, consistent with the EMHS vision and values. EMHS acknowledges people with disability and believes in the social model of disability which highlights that everyone has a responsibility to ensure that the environments, activities, and programs they are developing are created accessibly and inclusively. 

Throughout 2024-25, EMHS hospitals and services have developed, implemented and enhanced a range of initiatives to 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, EMHS.

EMHS has a significant, long-term commitment to improve access to its services and events. In 2024-25:  

• International Day of People with Disability was celebrated across all EMHS sites with events that included staff education and awareness raising, and community engagement activities. EMHS co-hosted with Disability Health Network an event that included an engaging line-up of speakers that presented on the day, including people with disability and community experts sharing their personal stories and advice. This year’s theme – ‘Easy to Read. Easy to Reach’ shone a spotlight on the guiding principles of Easy Read, and how we can develop and share information that is easier to access and understand.
• Commonwealth Games and Paris Paralympian Ben Wright visited Royal Perth Hospital (RPH) where he spoke candidly about his life of growing up with a disability, and the amazing highs and lows of his sporting achievements. At Bentley Health Service (BHS) staff took part in a game of ParaVolley followed by a game of wheelchair basketball that was attended by several star players from the Fremantle Dockers. At Kalamunda Hospital, afternoon tea was coupled with some fun educational activities in a bid to build understanding of the challenges people with disability experience.

Buildings and facilities

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

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 2024-25 by:

• implementation of increased dedicated senior car parking and ACROD bays above minimum requirements across sites 
• ongoing review and improved signage at entry points across sites
• free call phones installed across hospital sites for patients and visitors to use and seek assistance or directions
• establishment of specialised geriatric assessment teams in Emergency Departments to improve safety and quality of care for older adults
• improved access to RPH Milligan’s 150 Club, with ramp installation.

Information and communication

Outcome three: People with disability receive information from EMHS 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 are regularly reviewed to ensure it meets the needs of healthcare users, includes adequate information, is available in different formats and uses appropriate language.  

Across 2024-25 EMHS has:

• continued to monitor publications, ensuring the ability to obtain in different formats for accessibility  
• signage and wayfinding markers reviewed with additional aids provided at key locations including directions to amenities 
• increased access to alternative ‘call buttons’ and communication aids on inpatient wards 
• utilisation of digital solutions (e.g. computer programs activated by eye movement) to assist with communication 
• audit conducted of hearing loop utilisation and accessibility.

Quality of service

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

A range of strategies have been introduced at EMHS to ensure people with disability receive the same high level of care. Key actions in 2024-25 included:

• expansion of volunteer ‘Forget Me Not’ program which enables more time to create meaningful connections supporting people with dementia and cognitive impairment through their hospital journey 
• expansion of telehealth access and training to increase access options for outpatient services 
• study days, including a dementia study day and virtual reality workshop to help staff understand how we can provide better care to patients living with dementia, and a paediatric study day focussed on supporting children with neurodiversity
• following a successful trial in 2024, the use of virtual reality technology has continued at Kalamunda Hospital for palliative care patients to engage in experiences otherwise inaccessible due to loss of physical function.

Complaints and safeguarding

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

EMHS regularly reviews its complaints management policy to maximise the way feedback and complaints are received and to ensure it meets the needs of healthcare users. 

A variety of methods are available for providing feedback and lodging complaints including paper based, EMHS website, e-mail, verbal and via staff/volunteers assisting to compile complaints, and monitoring of patient feedback including quarterly review at Disability Access and Inclusion Committee meetings.  

Visual aids and equipment (e.g. dedicated phones) regarding ‘Aishwarya’s CARE call’ and other consumer-initiated care escalation pathways are installed across EMHS hospitals, especially in emergency departments.

Consultation and engagement

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

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

This includes the use of consumers and staff with lived experience of physical and mental health disability within EMHS hospital Disability Access and Inclusion Committees and Consumer Advisory Committees 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 EMHS.

EMHS is committed to ensuring people with a disability can obtain and maintain employment. During 2024-25:

• EMHS participation in Staff with Disability and Allies Network annual conference continued to grow 
• EMHS became a member of the Australian Disability Network
• new Diversity, Equity and Inclusion role created for EMHS 
• ongoing review of EMHS workforce policies to ensure the inclusion of equity, diversity and inclusion principles.

Workplace diversity and inclusion

EMHS is committed to becoming a leader in the health sector by striving for inclusion targets that reflect the diversity of the communities we serve. We are dedicated to fostering a workplace culture that values diversity and inclusion, recognising that staff who feel safe, supported, and engaged contribute to better health outcomes and stronger organisational performance.

Over the past year, EMHS has progressed several key diversity and inclusion initiatives, including:

• Continuing to host our Aboriginal employee forums, to provide a dedicated space for our Aboriginal employees to connect, share cultural experiences, and focus on wellbeing, peer mentoring, and self-care. Through open discussion and yarning, the forum strengthens support networks and reinforces our commitment to cultural safety and empowering our Aboriginal workforce. 
• Being the only Health Service Provider to host 6 Aboriginal students through the Public Sector Commission/Curtin University Vacation Program pilot, offering hands-on experience and career exposure. The initiative showcased our commitment to fostering Aboriginal talent and workforce diversity, while building meaningful connections with future health professionals. 
• Co-hosted the International Day of People with Disability with the Disability Health Network, featuring speakers, including EMHS staff, with lived experience and community insights. Aligned with the 2024 theme ‘Easy to Read. Easy to Reach’, the event promoted inclusive communication through Easy Read principles. 
• Proudly took part in the 2024 Pride Parade, demonstrating our ongoing commitment to inclusion and support for the LGBTQIA+ community for both staff and consumers. Under the theme ‘Together, Go West’, PrideFEST celebrated authenticity, visibility, and advocacy for inclusive laws and affirming healthcare.

Through continued focus and targeted initiatives, through the implementation of our Multicultural Plan 2024–2027, Aboriginal Health Priority Area and Deliverables 2024-25 and the EMHS Disability Access and Inclusion Plan, we aim to remain a valued employer in the health sector and better reflect the diverse communities we serve. 

EMHS acknowledges there are areas that can be improved, so we are committed to continuing to work towards a culture of inclusion. In June 2025, a staff survey was conducted across EMHS which sought feedback from staff, including on diversity and inclusiveness in the workplace. The results from this survey will assist in identifying areas for improvement and the development of suitable action plans.