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Quality Management Framework

In 2011, the Commission engaged international mental health advisors Gregor Henderson Ltd to provide advice on a quality assurance framework for WA's mental health system. The purpose was to recommend functions and processes that will ensure Western Australians with mental health problems or mental illness (individuals) receive the best available evidence based care. 

Gregor Henderson prepared a report Developing a Quality Assurance Framework for Mental Health in Western Australia: Final Report. One of the main recommendations of the report was the establishment of an independent monitoring and evaluation process for Community Managed Organisations (Organisations) modelled on the one currently used in the disability sector. Organisations are all Commission funded not-for-profit and for-profit non government organisations, including licensed private psychiatric hostels.

In March 2013, the Commission invited Gregor Henderson to review the progress to date in relation to the recommendations made in his initial 2011 report. During his visit, Gregor spoke with a range of key stakeholders to ascertain progress and to identify current issues and further actions for the Commission to consider.

The Gregor Henderson's second report (2013) and the Commission's response can also be downloaded.

The recommendation to establish an independent monitoring and evaluation process has been progressed by the Commission and forms one part of the Quality Management Framework which comprises: 

  • an annual self assessment against the National Standards for Mental Health Services (the Standards) and person centred practices (Outcomes and Indicators and Examples of Evidence), this includes a 12 month continuous improvement plan; 
  • improved reporting, tracking, management and investigation (as required) of Notifiable Incidents; and 
  • Quality Evaluations that will be conducted by a panel of independent evaluators (including carers and people with a lived experience of mental illness).  

Independent Quality Evaluations

The intent of Independent Quality Evaluations is to focus on how an organisation is continuously improving its services, supporting individuals to meet their individual goals (Outcomes) and meeting the National Mental Health Standards 2010. A key component of the Quality Evaluations is identifying the satisfaction people (individuals, families and carers) have experienced accessing the services including their perception and confidence in how the organisation is meeting their needs. Having an independent team of Evaluators look at an organisation’s services and speak to the people accessing them in a confidential manner can provide the opportunity for continuous improvement activities that otherwise may not be identified.

Independent Quality Evaluations will provide the opportunity for Evaluators, external to the service and the Commission to:

  • meet with individuals, family members, carers, advocates and other stakeholders;
  • observe services in operation; 
  • meet with Board members, management and staff; and 
  • review documentation, systems and management processes as required.

All Independent Quality Evaluations will involve a minimum of two Evaluators, of which one will be a Team Leader who will be the primary contact and also responsible for collating the evidence and writing the report. The number of Evaluators in a team undertaking a Quality Evaluation of an organisation will depend on the size (number of people served), spread (locations) and complexity (e.g. clinical services, target groups) of the services being evaluated. The aim is that at least one member in the team will be a person with lived experience of mental illness or a family member / carer for someone who has a mental illness. From commencement of the preliminary meeting it is expected to take up to 12 weeks to collect the evidence and complete the final report. 

All Commission funded Organisations will: 

  • receive training and information on the evaluation process and requirements; 
  • be scheduled for an evaluation once every three years (this will currently be approximately 20 Organisations per annum); 
  • complete annual self assessment that will continue to complement the evaluation process; and 
  • develop a continuous improvement plan that will be updated and revised annually.

Please see the Quality Management Framework booklet and outcomes indicators document for more information.

The following organisations are scheduled for an evaluation during 2018:

Organisation name:

Quality Evaluation commencing:

     Romily House

January 2018

     Mind Australia

February 2018

     Anglicare CYPRESS program

March  2018


March 2018

     Share and Care Northam

March 2018

     Women’s Healthcare Association (Northbridge)

April 2018

     Pathways (Bunbury)

May 2018


May 2018

     St Bartholomew’s House

June 2018


We encourage all consumers, family and carers to provide feedback on the services being evaluated. If you would like to find out how you can be involved in the evaluation process or for more information contact quality@mhc.wa.gov.au or call 655 30224/ 655 30335.

Notifiable Incidents

All Community Managed Organisations (CMOs) funded by the Mental Health Commission (MHC) are also required to report Notifiable Incidents to the MHC within a reasonable timeframe.

Please ensure you use Internet Explorer when filling in the forms below.

For Mental Health Services
Please click to find the Guidelines for Notifiable Incidents and the Notifiable Incident Form. Accommodation services can also use the Office of the Chief Psychiatrist's Notifiable Incident Form - OCP.

The Form is password protected and the password has been communicated to all of the funded organisations. 

For AOD Services
Please click to find the AOD Guidelines for Notifiable Incidents and the AOD Notifiable Incident Form.

The Form is password protected and the password has been communicated to all of the funded organisations. 

If you require any information please email quality@mhc.wa.gov.au

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