Policies and procedures

Policies, procedures and protocols are important tools to describe a healthcare service’s agreed ways of working. They form an integral part of its clinical governance framework. They should:

• Address how safety and quality risks are identified, prioritised, minimised or eliminated 
• Support compliance with safety and quality legislation, regulation and jurisdictional requirements
• Be based on evidence and best practice
• Be implemented consistently throughout the healthcare service, with implementation monitored
• Be regularly reviewed to identify whether there are areas for improvements 
• Be updated when improvements are identified and improvements implemented. 

Policies, procedures and protocols relating to safety and quality may also be relevant to your healthcare service’s legal, jurisdictional and business obligations. For certain healthcare services, integrating these systems may be appropriate. At all times, your healthcare service must adhere to regulatory requirements as prescribed in relevant Commonwealth, state and territory legislation, such as work health and safety obligations.

The content and complexity of the policies, procedures and protocols will vary depending on the size of healthcare services. Sole providers may describe their safety and quality policies, procedure and protocols in a simple format whereas large healthcare services may require more comprehensive documentation.

• What policies, procedures and protocols are available in your healthcare service? What safety and quality risks do they seek to reduce or eliminate?
• How does the workforce access and use policies, procedures and protocols?
• How is the implementation of policies, procedures and protocols monitored and reviewed to identify areas of improvement?

• Develop safety and quality policies, procedures and protocols relevant to reducing or eliminating safety and quality risks in the healthcare service. 
• Support the workforce to implement policies, procedures and protocols, including making them easily accessible. 
• Implement a schedule to monitor, review and update policies and procedures using a risk management approach.

• The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:
• Policies, procedures and protocols that aim to reduce or eliminate safety and quality risks 
• Observation that demonstrates policies and procedures are easily accessible by the workforce and used in everyday practice
• Documented changes to policies, procedures and protocols implemented following the monitoring and review of implementation and identification of improvements.

Commission resource

• National Model Clinical Governance Framework – provides guidance on policies, procedures and protocols, based on the NSQHS Standards. The principles and strategies outlined are broadly applicable.