Action 1.07

The governing body should ensure the development, review and maintenance of a comprehensive set of organisational policies, procedures and protocols. These documents should cover clinical safety and quality risks, and be consistent with the organisation’s regulatory obligations.

Develop policies, procedures and protocols

The governing body must clearly delegate responsibility for developing and maintaining policies, procedures and protocols. This includes identifying a custodian to ensure that the processes for developing, reviewing and monitoring compliance with policies, procedures and protocols are documented. Roles and responsibilities of individuals and committees with the authority to amend or endorse each policy, procedure or protocol should be documented.

Clinical policies may be developed or adapted at different levels within the organisation. However, all policy, procedure and protocol documents should be incorporated into a single coherent suite to maximise the effectiveness of the policy development process.

Support effective implementation of a policy system by ensuring that the workforce has:

• Ready access to relevant policies, procedures and protocols
• Position descriptions, contracts, by-laws or other mechanisms that require the workforce to comply with their roles, responsibilities and accountabilities, and with organisational policies, procedures and protocols.

Monitor compliance with legislation, regulation and state or territory requirements

Keep information about instances of noncompliance with the organisation’s policies, procedures and protocols. Where appropriate, incorporate the information into the organisation’s risk register and quality improvement planning processes.

Maintain well-designed legislative compliance processes. Incorporate a compliance register to ensure that the organisation’s policies are regularly updated, enabling the organisation to respond to regulatory changes, compliance issues and case law.

Identify relevant industry standards, and develop processes to implement and monitor compliance with these standards, which may include:

• Service-specific standards such as for mental health, pathology or medical imaging, where these services are applied
• Standards Australia standards
• The Building Code of Australia
• Guidance developed by peak bodies, such as the Australian Medicines Handbook.

Examples of evidence

Select only examples currently in use:

• Documented processes for developing, authorising, and monitoring the implementation of, the health service organisation’s policy documents
• Register of policy document reviews, including the date of effect, dates that policy documents were amended and a prioritised schedule for review
• Examples of policy documents that have been reviewed in response to identified risks, or changes in legislation, regulation or best practice
• Committee and meeting records that describe the governance structure, delegations, roles and responsibilities for overseeing the development of policy documents
• Audit results of healthcare records and clinical practice for compliance with policy documents
• Results from workforce surveys and feedback on policy documents
• Data and feedback from the risk management, incident management and complaints management systems that are used to update policy documents
• Communication with the workforce on new or updated policy documents
• Training documents on new or amended policy documents, or use of policy documents
• Schedule and timelines for statutory reporting.

The governing body should ensure the development, review and maintenance of a comprehensive set of organisational policies, procedures and protocols. These documents should cover clinical safety and quality risks, and be consistent with the organisation’s regulatory obligations.

Develop policies, procedures and protocols

The governing body must clearly delegate responsibility for developing and maintaining policies, procedures and protocols. This includes identifying a custodian to ensure that the processes for developing, reviewing and monitoring compliance with policies, procedures and protocols are documented. Roles and responsibilities of individuals and committees with the authority to amend or endorse each policy, procedure or protocol should be documented.

All policy, procedure and protocol documents should be incorporated into a single, coherent system to maximise the effectiveness of the policy development process.

Support effective implementation of a policy system by ensuring that the workforce has:

• Ready access to relevant policies, procedures and protocols
• Position descriptions, contracts, by-laws or other mechanisms that require the workforce to comply with their roles, responsibilities and accountabilities, and with organisational policies, procedures and protocols.

Monitor compliance with legislation, regulation and state or territory requirements

Keep information about instances of noncompliance with the organisation’s policies, procedures and protocols. Where appropriate, incorporate the information into the organisation’s risk register and quality improvement planning processes.

Maintain well-designed legislative compliance processes. Incorporate a compliance register to ensure that the organisation’s policies are regularly updated, enabling the organisation to respond to regulatory changes, compliance issues and case law.

Identify relevant industry standards, and develop processes to implement and monitor compliance with these standards, which may include:

• Service-specific standards such as for mental health, pathology or medical imaging, where these services are applied
• Standards Australia standards
• The Building Code of Australia
• Guidance developed by peak bodies, such as the Australian Medicines Handbook.

Examples of evidence

Select only examples currently in use:

• Documented processes for developing, authorising, and monitoring the implementation of, the health service organisation’s policy documents
• Register of policy document reviews, including the date of effect, dates that policy documents were amended and a prioritised schedule for review
• Examples of policy documents that have been reviewed in response to identified risks, or changes in legislation, regulation or best practice
• Committee and meeting records that describe the governance structure, delegations, roles and responsibilities for overseeing the development of policy documents
• Audit results of healthcare records and clinical practice for compliance with policy documents
• Results from workforce surveys and feedback on policy documents
• Data and feedback from the risk management, incident management and complaints management systems that are used to update policy documents
• Communication with the workforce on new or updated policy documents
• Training documents on new or amended policy documents, or use of policy documents
• Schedule and time lines for statutory reporting.

MPSs or small hospitals that are part of a local health network or private hospital group should ensure that local procedures or work instructions are consistent with established policies, procedures and protocols, and are relevant to their patients and the services they provide. This will only be relevant if there is a process at the network or group level to develop, implement and regularly review policies, procedures and protocols.

Small hospitals that are not part of a local health network or private hospital group should develop, review and maintain policies, procedures and protocols. These documents should cover clinical safety and quality risks, and be consistent with the organisation’s regulatory obligations.

All policy documents should be incorporated into a single coherent system to maximise the effectiveness of the policy development process.

The workforce should have:

• Ready access to relevant policies, procedures and protocols
• Position descriptions, contracts, by-laws or other mechanisms that require the workforce to comply with their roles, responsibilities and accountabilities, and with organisational policies, procedures and protocols.

Monitor compliance with the organisation’s policies, procedures and protocols. If appropriate, incorporate the information into the organisation’s risk register and quality improvement plan.

Examples of evidence

Select only examples currently in use:

• Documented processes for developing, authorising, and monitoring the implementation of, the health service organisation’s policy documents
• Register of policy document reviews, including the date of effect, dates that policy documents were amended and a prioritised schedule for review
• Examples of policy documents that have been reviewed in response to identified risks, or changes in legislation, regulation or best practice
• Committee and meeting records that describe the governance structure, delegations, roles and responsibilities for overseeing the development of policy documents
• Audit results of healthcare records and clinical practice for compliance with policy documents
• Results from workforce surveys and feedback on policy documents
• Data and feedback from the risk management, incident management and complaints management systems that are used to update policy documents
• Communication with the workforce on new or updated policy documents
• Training documents on new or amended policy documents, or use of policy documents
• Schedule and timelines for statutory reporting.