Governance

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Clinical governance

Clinical governance is the system through which organisations are accountable for continuously monitoring and seeking to improve the quality of their services and ensuring the safeguarding of these standards. 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. 

The EMHS Clinical Governance Framework (CGF) details how EMHS meets relevant statutory and policy requirements, aligns with WA’s strategic goals for clinical care, and meets the National Safety and Quality Health Service (NSQHS) Standards for the provision of safe patient care. 

Accountability

While all staff contribute to and support the delivery of safe patient care and consumer experience, the following 5 roles, based on the National Model Clinical Governance Framework, have specific responsibilities to ensure effective clinical governance systems: 

• The EMHS Board has ultimate responsibility for the governance of patient safety and quality of care and is legally accountable (under the HSA 2016) for ensuring appropriate governance structures, processes and staff practices are in place.  
• The EMHS Chief Executive is accountable to the Board for the effective management of all services involved in the provision of safe, effective, appropriate, timely and efficient patient care.  
• EMHS Area Executive Group (AEG) and senior managers (corporate and clinical) are accountable for ensuring effective operational management, including implementation of strategic and operational directions set by the Board and Chief Executive.
• Clinical staff are responsible for the provision of safe and high-quality care and must hold the proper qualifications and skills, and work within their scope of practice. 
• Patients and consumers are participating partners in their own care, and in organisational design and planning. (Click here for more information)

Principles

The key principles that underpin the CGF are mandated via the WA Health Clinical Governance Safety and Quality Policy Framework and include: 

• Care is consumer and carer centred – 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 EMHS to guide quality-improvement activities. 
• Organised for safety – minimisation of clinical risks and incidents, with a systems approach to harm minimisation. 
• Led for high performance – executive and clinical staff have the right qualifications and skills to provide safe, high-quality care and to foster a culture of openness, collaboration and continuous improvement.  

Quality dimensions in health care

There are 7 quality dimensions incorporated in the EMHS CGF: 

• Access to services – the degree to which people can access the healthcare they need, irrespective of geography, socio-economic group, ethnicity, age or sex. This includes availability of services such as waiting times for services and processes involved in accessing services. 
• Effectiveness – the extent to which a treatment, intervention or service achieves the desired outcome. (Click here for more information)
• Efficiency – the relationship between the cost of healthcare and its effectiveness and safety. (Click for more information)
• Timeliness – the relationship between the timing of an intervention, whereby people promptly obtain care, and its effectiveness. 
• Acceptability – the extent to which the wishes, desires, expectations, cultural norms and religious beliefs of patients and families are met. 
• Appropriateness of care – ensuring people receive health care relevant to their clinical needs and current best evidence. 
• Safety of care – ensuring people receive health care without experiencing preventable harm. (Click for more information)

Governance and monitoring

The EMHS Clinical Governance Committee Structure governs the implementation of, and performance against, the CGF. Terms of Reference for each committee within the structure articulate accountability, purpose, roles and responsibilities and how patient care will be monitored.  

The EMHS CGF is evaluated for effectiveness, staff awareness, implementation and compliance on a 2-yearly basis. 

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Sustainable Health Review

Since the April 2019 release of the Sustainable Health Review (SHR) report, the WA Department of Health and HSPs have been progressing this ambitious reform agenda to create a modern healthcare system.   

In 2025-26, EMHS continued to support prioritised recommendations, with a focus on outpatient access reform, digital health, management of complex chronic disease, workforce culture and capability, the health of the Aboriginal community, mental health and equitable access to health care. 

• Recommendation 2a – Halt the rise in obesity in WA by July 2024 and have the highest percentage of population with a healthy weight of all states in Australia by July 2029. 
• Recommendation 3a – Reduce inequity in health outcomes and access to care with a focus on Aboriginal people and families in line with the WA Aboriginal Health and Wellbeing Framework 2015-30. 
• Recommendation 5 – Reduce the health system’s environmental footprint and ensure mitigation and adaption strategies are in place to respond to the health impacts and risks of climate change. Set ongoing targets and measures aligned with the established national and international goals. 
• Recommendation 11a – Improve timely access to outpatient services through moving routine, non-urgent and less complex specialist outpatient services out of hospital settings in partnership with primary care. 
• Recommendation 11b – Improve timely access to outpatient services through requiring all metropolitan HSPs to progressively provide telehealth consultations for 65 per cent of outpatient services for country patients by July 2022 (with Telehealth to become the regular mode of outpatient service delivery for most appointments in both country and metropolitan areas across all disciplines by July 2029). 
• Recommendation 13 – Implement models of care in the community for groups of people who are frequent presenters to hospital. 
• Recommendation 14 – Transform the approach to caring for older people by implementing models of care to support independence at home and other appropriate settings, in partnership with consumers, providers, primary care and the Commonwealth. 
• Recommendation 23 – Build a system-wide culture of courage, innovation and accountability that builds on the existing pride, compassion and professionalism of staff to support collaboration for change.