Delivering a Healthy WA
North Metropolitan Health Service, Mental Health

Safety, Quality and Performance

What is Clinical Governance? | Governance Frameworks | Embedding Safety and Quality Systems in Mental Health | Clinical Risk Management Systems | Incident Investigation and Reporting | Performance and Benchmarking | Area Quality Improvement | Contact details

What is Clinical Governance?

Clinical Governance is defined as:

"A systematic and integrated approach to assurance and review of clinical responsibility and accountability that improves quality and safety resulting in optimal patient outcomes."

The primary goal of the Safety, Quality and Performance (SQ&P) Unit is to work with North Metropolitan Health Service (NMHS) Mental Health services to embed safe quality practices across all areas of mental health service delivery. Our vision is to ensure that no matter where you receive mental health care in NMHS Mental Health, it is safe and governed by best practice principles. The SQ&P Unit also support Public Health and Dental Health Services.

Governance Frameworks

The SQ&P Unit aligns with the NMHS Strategic Plan 2017- 2021.

SQ&P Unit adheres to the WA Clinical Governance Framework, which promotes a complete, integrated approach to clinical responsibility.

NMHS Mental Health is accredited against the National Safety and Quality Health Service Standards. We are routinely inspected by an independent body, the Australian Council on Healthcare Standards (ACHS) to assess how well we meet these standards.

NMHS Mental Health is also assessed against the National Standards for Mental Health Services. We have achieved a certificate of recognition against these standards.

NMHS Mental Health participates in the Clinical Monitoring Program whereby the Chief Psychiatrist monitors the treatment and care of mental health patients within Western Australia, including our services, as required by the WA Mental Health Act 2014 (s.515).

NMHS Mental Health are actively involved in implementing the recommendations for improvement in mental health services identified in the Stokes Review of the admission or referral to and the discharge and transfer practices of public mental health facilities/ services in Western Australia.

Establishing safe and quality systems supports the NMHS Vision, Purpose and Values.

Embedding Safety and Quality Systems in Mental Health

Safety Quality and Risk Management Committees

NMHS Mental Health has established the Safety Quality and Risk Management Committees (SQRM Committees) at local, program and service-wide levels.

The SQRM Committees are responsible for monitoring performance data, overseeing risk management, implementing quality improvement initiatives and facilitating communication about safety, quality and risk management across the organisation.

All SQRM Committees include consumer and carer representation. If you would like to be involved as a consumer or carer consultant, or know of someone who may be interested, have a look at our consumer, family, carer and community participation page.

Mental Health Governance Policy

The NMHS Mental Health area governance policies are subject to a standardised process to ensure consistency in policy management, development, implementation, evaluation and compliance.

Clinical Risk Management Systems

Clinical Risk Management is the third pillar of the WA Clinical Governance Framework and concentrates on minimising clinical risk and improving overall clinical safety. WA Health Clinical Risk Management Guidelines.

Incident Investigation and Reporting

A clinical incident is an event or circumstance resulting from health care which could have, or did lead to unintended and/or unnecessary harm to a patient/consumer.

Since February 2014, clinical incidents have been captured on the electronic online Clinical Incident Management System (Datix CIMS).

Severity Assessment Code is the assessment of actual or potential consequences associated with a clinical incident. The SAC rating (1, 2 or 3) is used to determine the appropriate level of analysis, action and escalation.

  • SAC 1 includes all clinical incidents/near misses where serious harm or death is/could be specifically caused by health care rather than the patient’s underlying condition or illness.
  • SAC 2 includes all clinical incidents/near misses where moderate harm is/could be specifically caused by health care rather than the patient’s underlying condition or illness.
  • SAC 3 includes all clinical incidents/near misses where minimal or no harm is/could be specifically caused by health care rather than the patient’s underlying condition or illness.

If you believe a clinical incident may have occurred during your care, you are encouraged to discuss it with the staff involved in providing your care, or ask to speak to a senior staff member. Alternatively, please refer to our Consumer Feedback page.

Open Disclosure

Open Disclosure is the open discussion of adverse events that results in harm (or might result in harm) to a consumer while receiving healthcare with the consumer, their family and carers.

NMHS Mental Health is committed to ensuring open and timely communication with consumers and their relatives/nominated person following an adverse event, clinical incident or sentinel event that has occurred within the service.

Performance and Benchmarking

The SQ&P Unit are responsible for coordinating the collection of a suite of performance indicators across NMHS Mental Health sites. Relevant data is reported to SQRM Committees, the Mental Health Executive Group, the NMHS Clinical Incident Review Committee and the NMHS Board. Performance data is used to monitor safety and quality and to plan quality improvement initiatives.

NMHS Mental Health contributes data to the ACHS Clinical Indicator Program, a national performance data and benchmarking initiative.

Quality Improvement

NMHS Mental Health maintains a central Quality Improvement register, enabling projects to be planned, approved and shared between our services. The approval process ensures that projects adhere to the National Health and Medical Research Council (NHMRC)'s Guidelines for Ethical Considerations in Quality Assurance and Evaluation Activities.

Contact details

Karen Elliott
Safety, Quality and Performance Unit
Fairfield House
83 Fairfield St
Mt Hawthorn WA 6016
Phone: 08 9242 9639
Fax: 08 9242 9644

Our service hours are from 8:30am to 4:30pm Monday to Friday.

If you are feeling unwell and need to talk to someone now, please call the Mental Health Response Line on 1300 555 788

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