Implementation guidelines for public mental health services and private hospitals

Standard 8: Governance, leadership and management

Page last updated: October 2010

The MHS is governed, led and managed effectively and efficiently to facilitate the delivery of quality and coordinated services.

Suggested evidence


The intent of this Standard is to ensure that structures are in place to facilitate effective governance of the mental health service (MHS).

Integration and coordination (Criterion 8.1)

There should be evidence of integration with both internal and external stakeholders.

Mental health services can be stand-alone psychiatric units, community-based services, or services co-located with psychiatric general hospitals. The MHS organisational structure should identify it as a discrete entity within the larger organisation where this is applicable.

There should be clear links between the MHS and the wider organisation in the organisation's operational and strategic plans. The MHS should be able to identify a single point of accountability for the MHS in all settings and programs.

The MHS should address both corporate and clinical governance responsibilities.

The governing body of the MHS delegates authority to senior executives and managers and defines their responsibility in operating clinical and non-clinical services to achieve the MHS goals and ensure service integration, coordination and effective outcomes for its consumers.

Promotion and prevention (Criterion 8.2)

The MHS should develop a plan for the organisation that identifies the position responsible for developing promotion and prevention strategies for the organisation and individual staff.Top of page

Development and review of strategic plan (Criterion 8.3)

The MHS should have documented evidence of participation of staff, consumers, carers and representatives of key groups in the community, in the developing and reviewing the strategic plan.

The strategic plan includes the following components:
  • a needs analysis of consumers and the community
  • a service evaluation plan, including measuring health outcomes for individual consumers and consumer groups with specific needs
  • a plan for maximising consumer and carer participation in the MHS
  • a plan for promoting mental health and addressing early identification and prevention of mental health problems
  • a staff development plan.
The differences and values of the MHS community should be reflected in the strategic plan. The plan also needs to be consistent with legislative requirements, and national and state or territory mental health policies and related documents.

Compliance with legislation and related Acts (Criterion 8.4)

Commonwealth and state or territory legislation guides the development of policies and procedures. There should be a policy and procedure framework for the MHS.

There should systems for disseminating information when changes are made to mental health legislation and for monitoring and evaluating compliance with the organisations' policies and procedures.

These systems should include:
  • identification and dissemination of new or amended standards
  • codes of practice
  • guidelines and legislation.

Resources (Criterion 8.5)

The MHS should be able to demonstrate sound financial management practices and a clear budget allocation for the delivery of services.

Recruitment, selection and staff development (Criteria 8.6, 8.7)

Policies, procedures and staff records should show evidence of the following:
  • professional development
  • regular performance review
  • supervision and staff support programs
  • statement of roles and responsibilities
  • diversity of backgrounds in staff recruitment
  • completion of an orientation program based on the National Standards.
The MHS should identify the professional development needs of staff and ensure ongoing staff participation in education, performance review and professional development programs.

Top of pageFormal orientation programs for new staff should:
  • incorporate information on the National Standards and their implementation
  • reflect the National Practice Standards for the Mental Health Workforce (2002)
  • are based on the needs of the MHS
  • are based on the needs of the target population
  • include comprehensive competency training.
The MHS should ensure that staff have access to formal supervision. Depending on the setting, supervision of staff can be multidisciplinary, discipline specific, individual or group, through peer and case review.

Formal structures and delegations should be identified and regularly reviewed.

Critical incidents (Criterion 8.8)

The MHS should have a formal process to review critical incidents. The process should support staff and others within the MHS affected by the critical incident. The outcomes of the review of incidents should be used to guide ongoing prevention plans. Further information on critical incidents is available in the guidelines for Standard 2 Safety.

Information management (Criterion 8.9)

Information management includes health records in both individual and aggregated formats that is understandable to those involved in the delivery of care.

The MHS should collect outcomes data as identified in the National Outcomes and Casemix Classifications (for public mental health services) and Centralised Data Management Service Model (for private mental health services).

The MHS should also collect the relevant administrative and statistical data in all settings as appropriate to the service including National Minimum Data Sets (NMDS), Hospital Casemix Protocols (HCP) and nationally agreed Key Performance Indicators (KPIs). The MHS should adopt the Australian Bureau of Statistics' Standards for Statistics on Cultural and Language Diversity, (1999).

Public mental health services are required to collect information as identified in the agreed national key performance indicators for Australian public mental health services and use this for quality improvement.

Data management systems provide evidence of:
  • compliance with legislative requirements
  • achievement of reporting requirements.

Risk management (Criterion 8.10)

Information gathered through feedback, complaints, incidents and adverse reporting should be part of clinical and corporate governance, including risk management processes.

The MHS must have documented systems that are evaluated to ensure corporate and clinical risks are:
  • identified
  • analysed
  • evaluated
  • treated
  • continuously monitored and reviewed
  • communicated.
Further information on risk management is available from the guidelines for Standard 2 Safety and Standard 4 Diversity responsiveness.Top of page

Formal quality improvement program (Criterion 8.11)

The MHS analyses data to promote effective care for consumers and their carers, to assist with evaluating service delivery and developing staff training programs. Data management systems provide evidence of quality improvement activities as a result of data evaluation.

The MHS should have documented systems that are evaluated to ensure complaints, adverse events, critical incidents and near misses reporting are used for quality improvement activities. Information gathered for this reporting should be part of clinical governance, including risk management processes.

The quality improvement program should include evaluation of services and individual health outcomes, using information from staff, consumers, carers, other service providers and the community. This should result in improvements in services.

Staff, consumers, carers, key groups within the community and other service providers, should be involved in service evaluation.

Suggested evidence

Evidence that may be provided for this standard includes:
  • a strategic plan showing:
    • how the MHS is aligned with the wider organisation if this is applicable
    • staff, consumer and carer participation in developing the plan
  • the current operational plan
  • evidence of stakeholder involvement in plans
  • staff records
  • details of data management systems
  • outcomes data and indicators
  • evidence of compliance systems
  • policies and procedures covering:
    • framework for the development of policies
    • schedules for policy review
    • evaluation of compliance to policies and procedures
    • regular review and update of policies
    • human resources.