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DGD15/017

ACT Health Policy Policy ManagementPolicy Statement

All policy, procedure and guideline document development is undertaken according to standardised principles and processes as outlined in this policy and its suite of process documents.

The ACT Health Policy Management Policy and the associated Policy Development Guideline is a system that guides the provision of evidence based safe care and services. It informs the governance and structure of policy development and implementation across ACT Health. It allows the organisation to meet its legal and other obligations.

Purpose

The following principles underpin ACT Health policy management. Documents are to be: Consistent in format. All documents are developed according to a standardised process

and in agreed formats. Written in clear, concise and simple language. Evidence-based and professionally informed. All documents are evidence based and

identify the relevant, most up to date references. Assessed for their impact on vulnerable populations based on advice from relevant

stakeholders within ACT Health and externally. . Subject to detailed and broad consultation, including consumers where relevant.

Consultation feedback is recorded and, where appropriate, incorporated. Regularly reviewed and updated. All documents are scrutunised for possible duplication

with existing policies and any opportunities to adopt national or international guidelines/standards or whole of ACT government documents, where appropriate, in preference to developing an ACT Health policy.

Archived if not relevant. All documents have a limited lifespan and a formal review/ update must be commenced within 3-6 months prior to expiry date.

Easily accessible. Held in a central location accessible to all staff at all times. Documents relevant to informing the general public on key processes and procedures will be made available on the public ACT Health website.

Doc Number Version Issued Review Date Area Responsible PageDGD15-017 1.1 April 2015 April 2019 DDG – Strategy

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Scope

The Policy Management Policy applies to the management of all ACT Health policy documents as described below. Staff in all Divisions, Branches and Units must comply with this policy and its suite of process documents when managing ACT Health policy documents.

Types of DocumentsThe following types of policy documents are used in ACT Health.

Policy:A policy is a systematically developed document based on legislation, standards, regulations and/or ACT Health requirements. Policies provide staff with information on their legislative responsibilities or actions required by the organisation.

A policy is a statement that regulates organisational action and governs the conduct of people and the activities of the system. A policy states what staff must do and is used where organisational compliance or instruction is required. Compliance with policies is mandatory. A policy is usually, but need not always be, supported by a procedure or guideline.

The relevant ACT Health policy template must be used for all ACT Health policies.

Procedure – Clinical or Operational:A procedure states how staff should do things in ACT Health.

Procedures are based on best available evidence and the considered judgement of staff. A procedure document describes the step by step process for the consistent implementation or performance of a certain process or task. Procedures may relate to corporate/administrative activities, or in the hospital and health services environment, to operational or clinical activities. They may be stand-alone documents.

If a procedure is not followed, the reasons for this need to be clearly documented in either the clinical record or other relevant documentation.

The relevant ACT Health procedure template must be used for all ACT Health procedure documents.

Guideline:Guidelines articulate the scope within which clinical / operational decisions are made, based on best available evidence. If a guideline is not followed, the rationale needs to be clearly documented in either the clinical record or other relevant documentation.


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Guidelines are written when more than one option is available in a given set of circumstances and a judgement decision is required if evidence for one or other course of action is ambiguous. Guidelines establish the scope of such decisions.

The relevant ACT Health guideline template must be used for all ACT Health guideline documents.

Framework:Framework documents provide agreed direction for the organisation and describe the components of a safe and efficient system of care or service delivery that will be mobilised to implement this direction. They are often aimed at a broad audience of stakeholders. Frameworks may have a high level strategic focus or provide operational information about how a system works to address policy goals.

There is no prescribed template for ACT Health Frameworks. For an example of a framework see the Food and Nutrition Strategic Framework 2012 — 2018 or the Aboriginal and Torres Strait Islander Health Workforce Action Plan 2013-2018.

Clinical Pathway:A clinical form outlining a standardised, evidence-based multidisciplinary management plan, which identifies the appropriate sequence of clinical interventions, timeframes, milestones and expected outcomes across the care continuum. Clinical pathways differ from policies, procedures and guidelines as they are utilised by the multidisciplinary team to guide and document and have a focus on the quality and co-ordination of care.

Clinical pathways are evidence based and promote an interdisciplinary approach. Clinical pathways must be supported by an endorsed policy document. They are intended to improve clinical processes through consistent management of risk, reducing duplication and documentation requirements through use of a standardised, evidence-based tool and reducing variation in health service process delivery.

The Division with ownership of the Clinical Pathway is responsible for developing and carrying out an ongoing monitoring and evalutation plan to ensure adherence to pathways is monitored and variation is acted on accordingly. Clinical Pathways are endorsed through CHHS Policy Committee and are escalated to Clinical Governance Executive Committee for oversight of their ongoing monitoring and evaluation.

There is no prescribed template for ACT Health Clinical Pathway. See the Clinical Records Forms Register on Sharepoint for further information.

Classification of documentsPolicy documents are classified as Tier 1 or Tier 2 documents as follows:


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Tier 1:Policy documents that require endorsement at Tier 1 level are those that: have relevance across the organisation and/or; address an issue meeting criteria of major or catastrophic risk across more than 2

parameters of the Consequence Definition Table of the ACT Health Risk Management Guidelines.

Tier 1 policies apply to all ACT Health staff members and are subject to ACT Health wide consultation.

Procedures are considered at this level when they meet the above criteria or need to be considered in conjunction with a Tier 1 policy.

Tier 1 policies are developed by areas with specific expertise or responsibility for the topic area, such as: People, Strategy and Services (eg. Leave Without Pay Policy, Study Leave Policy). Financial Management Unit (eg. Director-General Financial Instructions). CHHS (eg. Radiation Management policy and Radiation Management Plans)

Tier 1 policies include those that involve data capture or performance information and reporting that pertains to governance across ACT Health or has inter-governmental significance.

Tier 2:Policy documents require endorsement at Tier 2 level when they: are operational in nature and/or; may relate to the work of more than one branch, in this case only one policy should exist

that covers all relevant branches.

Tier 2 documents are usually developed by operational areas that have specialist knowledge, for example Pharmacy develops medication procedures, Infection Prevention and Control develops hand hygiene procedures, and are subject to consultation with areas responsible for implementing the procedures.

Tier 2 documents may include clinical and operational policies that do not involve data capture or performance information and reporting that pertains to governance across ACT Health or has inter-governmental significance.

Future management of expired documentsTo assist with efficient and timely processing of expired documents, the following process will be implemented:1. Six months prior to expiry an automated alert will notify the Policy Team of the policy

document’s upcoming expiry. 2. The policy team will notify the relevant owner of the need to update or archive the

expiring document or to consolidate it with other documents. Doc Number Version Issued Review Date Area Responsible PageDGD15-017 1.1 April 2015 April 2019 DDG – Strategy

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3. At expiry the author and the relevant ED will be notified of the expiry of the document and the requirement to address.

Roles & Responsibilities

GovernanceThe following groups are responsible for endorsing the following policy documents in line with the Corporate Governance Statement. See diagram at Attachment 1.

Tier Endorsement Type of Policy Documents

1 Policy Advisory Committee (PAC)

Strategic documents (ie frameworks, strategies and plans), policies and procedures relevant across the whole organisation

2 Canberra Hospital and Health Services (CHHS) Policy Committee

Clinical and operational policies and procedures and guidelines relating to the work of branches

Within this endorsement structure, the following governance committees and line areas have roles and responsibilities in ensuring compliance with the policy management system:

Executive Directors’ Council (EDC): Noting of PAC endorsed Tier 1 policies and procedures; Chaired by Director-General; Secretariat: Ministerial and Government Services.

CHHS Clinical Governance Committee Executive Noting of CHHS Policy Committee Tier 2 policies, procedures and guidelines.

Strategy and Corporate / Population Health / Health Infrastructure and Planning Division Executive Committees Consideration and endorsement of Tier 2 policy documents.

Policy Advisory Committee (PAC) (Tier 1)1. Consider and approve as appropriate:

a) requests to develop new policy documentation, including guidelines and strategic plans.

b) requests to revise or replace existing policy documents.2. Assess reviews undertaken by line areas.3. Undertake a quality check against the principles and processes outlined in the Policy

Management Policy and its suite of process documents. This includes: a) checking that robust consultation has been undertaken, and that consumer input

has been sought, recorded and incorporated as appropriate;


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b) checking that proposed policy documents do not duplicate existing ACT Health, ACT Government or national guidance materials.

Endorse policy documents as appropriate. Chaired by Executive Director, Policy and Stakeholder Relations; Secretariat: Policy and Stakeholder Relations.

CHHS Policy Committee (Tier 2) Reviews and, where appropriate, endorses Tier 2 Clinical and Operational policies and

procedures and guidelines; Provides information to CHHS Clinical Governance Committtee on policies and

procedures endorsed by the CHHS Policy Committee; Provides a quality check against the principles and processes outlined in the Policy

Management Policy and its suite of process documents. Where used, customised CHHS templates are consistent with this policy and suite of process documents. This includes checking that robust consultation has been undertaken, and that consumer input has been sought, recorded and incorporated as appropriate;

Coordinates policy development and reviews policy activities to reduce duplication. This includes an initiation process to approve all new policy development and revisions of existing policies;

Membership from all Clinical and operational branches at decision-maker level. Equitable distribution across medical, nursing and allied health staff. Includes Calvary HealthCare representatives to ensure alignment of processes and procedures;

Chaired by Senior Staff Specialist; Secretariat: Quality, Governance and Risk, Clinical Effectiveness Policy Team.

Policy Register Manager, Quality, Governance and Risk Manages the policy register Allocates Director-General Decision numbers to Tier 1 policy documents and uploads

these to the policy register and Allocation of CHHS Decision numbers for Tier 2 policy documents and uploads these to

the policy register.


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Evaluation

Outcome Measures Improved standardisation and reduction of total number of policy documents for each Tier, and Target of 90% of policy documents to be reviewed within the review period allocated on

endorsement.

Related Policies, Procedures, Guidelines and Legislation

LegislationHuman Rights Act 2004Territory Records Act 2002

PoliciesACT Health Corporate Governance Statement ACT Health Risk Management Guidelines ACT Health Policy Management: suite of process documents will be available on the policy register.ACT Health Consumer and Carer Participation PolicyACT Government Triple Bottom Line Framework and AssessmentEngaging and Consulting with the Aboriginal and Torres Strait Islander Communities in the ACT

GuidelinesACT Health Policy Development Guideline

StandardsAustralian Commission on Safety and Quality in Health Care (2008) Australian Charter of Healthcare RightsAustralian Commission on Safety and Quality in Health Care (2010) Australian Safety and Quality Framework for Health CareAustralian Commission on Safety and Quality in Health Care (2012) National Safety and Quality Health Service Standards.

References

1. Queensland Department of Health (2016) Clinical Pathways Frequently Asked Questions Available at: https://www.health.qld.gov.au/__data/assets/pdf_file/0017/432215/pathway-faq.pdf Retrieved on 2 February 2018

Search Terms


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https://www.health.qld.gov.au/__data/assets/pdf_file/0017/432215/pathway-faq.pdf

https://www.health.qld.gov.au/__data/assets/pdf_file/0017/432215/pathway-faq.pdf

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Policy, procedure, guideline, strategy, framework, plan, pathway, management, Tier 1, Tier 2

Attachments

Attachment 1: Hierarchy of policy in ACT Health

Disclaimer: This document has been developed by ACT Health specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval28/02/2018 Minor review to include

information pertaining to Clinical Pathways added

Matt Richter, ED Policy and Stakeholder Relations

PAC and CHHS-PC Chairs

19/06/2018 Updates to clinical pathways governance and amended exsiting committee structure

ED Policy and Stakeholder Relations

PAC and CHHS-PC Chairs

This document supersedes the following: Document Number Document Name


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Attachment 1. Hierarchy of Policy in the ACT Health

Scope Directorate Endorsement Tier

ACT Health Sign Off Document Numbering Examples

National Policies on ACT – Commonwealth Agreements

Whole of ACT Government Social Compact: Policy for the Partnership between the ACT Government and the Community Sector

Whole of ACT Health Sector(ACT Health and the non-government and private

sectors)

Tier 1 Policy Advisory Committee N/A Aboriginal and Torres Strait Islander Health Workforce Action Plan 2013-2018

ACT Health Tier 1Policy Advisory Committee

Director-General Decision (DGD) Number

ACT Health Child Protection Policy Intellectual Property Respect at Work Research Practice Policy Electrical Safety Policy

CHHS Tier 2 CHHS Policy Committee CHHS Number Clinical Audit Activities Policy Extubation Policy


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