ACT Health - Corporate Governance Statement

Corporate Governance Statement

Issue 5, December 2011 ‘World class performance in the provision of public services comes from

getting the right people, the right culture, the right quality of information

and the right systems on which to make decisions and then binding these

together within an effective management structure – Corporate

Governance.’

Paddy Fitzgerald

Corporate Governance in the Public & Voluntary Sectors

Corporate Governance Statement — Issue 5, December 2011

Foreword

‘Corporate governance generally refers to the processes by which organisations are directed, controlled and held to account. It encompasses authority, accountability, stewardship, leadership, direction and control exercised in an organisation’

Corporate Governance in Commonwealth Authorities and Companies Australian National Audit Office (ANAO)

In the public sector, this can mean:

‘…the set of responsibilities and practices, policies and procedures, exercised by an agency’s executive, to provide strategic direction, ensure objectives are achieved, manage risks and use resources responsibly and with accountability.’

ANAO and Department of the Prime Minister and Cabinet, 2006 cited in Building Better Governance, Australian Public Service Commission, 2008

The Health Directorate Corporate Governance Statement (CGS) outlines who we are, what we do and are accountable for, and who we report to. The CGS does not go into a lot of detail. It provides an overview of the organisation and is a starting point for gaining further detailed information on specific information. It is intended for all staff and other interested parties, and covers: • Organisation structures, roles and relationships • Policies and procedures, and • Accountability mechanisms. Some of the issues addressed in the Health Directorate CGS are: • Our vision and values • Our code of conduct • Legislation governing the Health Directorate as a public sector agency • Our organisation structure • Accountability of all staff, and • The inter-relationship of corporate, clinical and professional governance processes and activities

The Health Directorate is a learning organisation that continues to evolve to meet future challenges of the health sector and improve upon existing achievements. Research and best practice evidence has driven changes in how we undertake our work and relate to our consumers and the broader community both on a day-to-day basis, and in longer term planning.

The Health Directorate Corporate Governance Statement hopes to reflect this.

Dr Peggy Brown Director-General October 2011

http://www.anao.gov.au/uploads/documents/Corporate_Governance_in_Commonwealth_Authorities_and_Companies.pdf

http://www.apsc.gov.au/publications07/bettergovernance.htm

Corporate Governance Statement — Issue 5, December 2011 – Page iii

Table of Contents

Foreword

Corporate Governance Chapter 1 Corporate Governance

Values and Code of Conduct Chapter 2 Vision, values and key performance areas Chapter 3 Health Directorate Code of Conduct

Compliance and Controls Chapter 4 Legislation Chapter 5 Delegations Chapter 6 Financial delegations – Director-General Instructions Chapter 7 Resource management

Organisational Structure and Roles Chapter 8 Health Directorate organisation structure Operational Areas 9.01 Canberra Hospital & Health Services Group

9.01.1 Operational Support 9.01.2 Division of Surgery & Oral Health 9.01.3 Division of Women, Youth & Children 9.01.4 Division of Critical Care & Imaging 9.01.5 Division of Capital Region Cancer Service 9.01.6 Division of Rehabilitation, Aged & Community Care 9.01.7 Division of Mental Health, Justice Health, Alcohol & Drug Services 9.01.8 Division of Pathology 9.01.9 Division of Medicine

9.02 Strategy and Corporate Group

9.02.1 E-health & Clinical Records 9.02.2 Professional Leadership, Research & Education 9.02.3 Performance & Innovation 9.02.4 Business & Infrastructure 9.02.5 Policy & Government Relations 9.02.6 Service & Capital Planning 9.02.7 Human Resource Management

9.03 Population Health Division 9.04 Quality and Safety Unit 9.05 Financial Management 9.06 Executive Coordination Unit 9.07 Communications and Marketing Unit 9.08 Internal Audit & Risk Management

Corporate Governance Statement — Issue 5, December 2011 – Page iii

9.09 Donate Life ACT 9.10 Canberra Hospital Foundation

Roles and Accountability Chapter 10 Minister and Legislative Assembly Chapter 11 Director-General Chapter 12 Public sector senior executives Chapter 13 Managers and employees Chapter 14 Professional positions and roles Chapter 15 Committees Chapter 16 External agencies Sustainability Chapter 17 Sustainability Strategy

Consumer Experience Chapter 18 Patient and family centred care Chapter 19 Community engagement Chapter 20 Advisory and consultative process Chapter 21 Disclosure, transparency & Freedom of Information

Policy Management Framework and Strategic Planning Chapter 22 Policy management framework (incl. corporate and clinical policy) Chapter 23 Strategic and service planning Chapter 24 Plans and strategies Clinical Governance Chapter 25 Quality & safety Chapter 26 Performance management Chapter 27 Research

Risk Management & Audit Chapter 28 Risk management and internal audit Chapter 29 Workplace safety Bibliography and References

Corporate Governance

Corporate Governance Statement — Issue 5, December 2011 – Chapter 1, Page 2

Chapter 1 – Corporate Governance

“Improving organisational performance and accountability to deliver more appropriate, efficient and effective public services is the hallmark of good governance.”

Strengthening Performance and Accountability – A Framework for the ACT Government, Chief Minister and Cabinet Directorate 2011

What is corporate governance? Corporate governance is the way an organisation manages its business, makes its decisions and relates to its stakeholders. It includes the organisation’s structures, culture, policies and processes. In the Health Directorate, corporate governance arrangements underpin and are integrated with clinical governance and professional governance processes to ensure that, the “organisation does what it should and avoids what is unacceptable”

Carver J, 1990, Boards That Make a Difference cited in Introduction to Clinical Governance, Western Australia Department of Health

Legislative framework In the Australian Public Service legislative structures regulate the role of public sector agencies, their Chief Executives and their employees. In the Australian Capital Territory (ACT) the primary source of this information is the Public Sector Management Act 1994. Legislation that is specific to the Health Directorate is the Health Act 1993, which outlines the primary objectives for health service provision in the Territory, and the Public Health Act 1997 which seeks to protect the public from public health risks.

Principles of effective corporate governance There are a number of key principles that underpin good governance in public sector entities, which fall into personal and managerial qualities:

Australian National Audit Office

http://www.cmd.act.gov.au/policystrategic/accountability


http://www.safetyandquality.health.wa.gov.au/docs/clinical_gov/Introduction_to_Clinical_Governance.pdf

http://www.legislation.act.gov.au/a/1994-37/default.asp




Leadership Leadership is required from the Director-General and Executive in terms of: • Clearly identifying and articulating responsibilities • Understanding and facilitating relationships with stakeholders • Communicating unambiguously to the Minister • Clearly stating government priorities, and • Coherently setting organisational values.

Commitment Corporate governance is both process and people oriented and requires a commitment to implement the elements of this at all levels of the agency, including: • Open communication • An emphasis on corporate values and ethical conduct • A systematic, risk management approach • Quality in service delivery, and • A responsible relationship to and with stakeholders.

Integrity The integrity of an organisation is based on the honesty, objectivity and propriety of those who work within it. Integrity is also dependent on the effectiveness of the entity’s probity structures, including: • Personal standards • Professionalism • Decision-making practices • Procedures • Control frameworks, and • The quality of performance management and reporting.

Accountability Sound accountability in the public sector requires the clear articulation of the roles, responsibilities and powers of the Minister and the Director-General as well as all other relevant stakeholders.

Transparency Transparency means an ongoing commitment to openness regarding decision-making processes and the actions of the agency, and an understanding that the public has the right to clear information about these processes.

Integration Integration within an agency refers to the ability of the various organisational elements to work together to achieve a common goal, while adhering to shared principles, values and ethics.

Elements of good corporate governance There is no single model of corporate governance, however good corporate governance in public entities includes at least the following common elements: • Public governance; • Management structures; • Strategic and business planning; • Performance management; • Risk management;


• Compliance and controls; • Audit; and • Values and code of ethics. Elements of the governance of public sector entities

Australian National Audit Office

Public governance ACT public sector agencies are accountable to the relevant Minister for the delivery of government commitments, and Ministers in turn are accountable for their portfolio’s performance to the Chief Minister, the ACT Legislative Assembly and to the community.

Management structure In the public sector, legislative responsibility rests with the Director-General of the agency for the efficient, effective and ethical use of public resources. ‘Whoever governs exercises ultimate authority within organisations and is finally held accountable for overall organisational performance by stakeholders. In essence, those who govern authorise what organisations do. Executives manage organisations by virtue of the authority delegated to them by those who govern.’

Good Governance: A Philosophical Discussion of the Responsibilities and Practices of Organizational Governors. Bird, F.

Canadian Journal of Administrative Sciences, Dec2001, Vol. 18 Issue 4.

Strategic and business planning An organisation’s corporate plan sets the direction of the whole entity for the future. Corporate plans articulate an agency’s vision, objectives and values, as well as provide the framework for achieving these. Organisational priorities are established within this framework and performance indicators and reporting requirements are set.

http://web.ebscohost.com/ehost/viewarticle?data=dGJyMPPp44rp2%2fdV0%2bnjisfk5Ie46a9JtayvT7Ck63nn5Kx95uXxjL6srU6tqK5Jr5a1Uq6puEmyls5lpOrweezp33vy3%2b2G59q7SbKur0yvprZJtJzqeezdu33snOJ6u97jgKTq33%2b7t8w%2b3%2bS7TrCutU23qKR%2b7ejrefKz5I3q4vJ99uoA&hid=21


The Health Directorate corporate plan is informed by and links to the broader ACT Government’s strategic planning framework:

The Canberra Plan

Annual Statement of Intent

Corporate PlansStrategic Service and Asset

Plans

Annual Budget Papers

Government strategic planning

Direction setting

Agency strategic planning

Operational planning

and resource

allocation

• Vision• Goals• Progress indicators

• Government priorities• Priority indicators

• Strategic objectives• Strategic indicators

• Service objectives• Financial performance •Accountability indicators

ACT Planning Framework, in Strengthening Performance and Accountability, 2011

The Health Directorate Corporate plan can be viewed via the intranet or internet.

Performance management In public sector agencies performance is measured against the achievement of the government’s stated goals and objectives. To achieve this, a framework to evaluate and report against outcomes, outputs and resource requirements is established for key performance areas of importance. These are referred to as key performance areas (KPAs). In this context, results or outcomes refer to the actual achievements of the organisation, which in the case of a public sector agency means the positive or negative effect of their service on the community. Outputs measure the process through which the agency delivers its services or goods to the public. Cost refers to the financial and other resources that are necessary to deliver these services or goods. Benchmarking between similar entities can be a useful tool in establishing, comparing and evaluating agency performance. Triple Bottom Line reporting refers to the broader responsibility of organisations for the economic, environmental and social impact of their activities. Reporting by public sector agencies against the Triple Bottom Line is now a requirement of annual reports.

Risk management Risk is an occurrence that may prevent an organisation from achieving its business objectives. Risk management is not a separate process but part of good management and is comprised of three principal steps: risk identification, risk analysis and risk mitigation. Good risk management in the public sector means making decisions in accordance with statutory requirements, consistent with public sector values and ethics, and considering their social, environmental and economic implications. In short, it is more important to make the right decision, rather than the quick decision.


http://inhealth/PPR/Policy%20and%20Plans%20Register/Corporate%20Plan%202010-2012%20-%20ACT%20Health.pdf

http://www.health.act.gov.au/publications/reports/annual-reports/

Vision and Values


Chapter 2 – Vision, values and key performance areas

Vision The Government and the Health Directorate vision is “Your health, our priority”.

Values The Health Directorate’s values are articulated in the Corporate Plan 2010-2012. Our values are: • Care • Excellence • Collaboration and • Integrity. Developed by staff of the directorate, our values represent what we believe is important and worthwhile. They underpin the way we work and how we treat each other. We often see people in our community at their most vulnerable. The way we interact with them is extremely important and directly influences their experience of care. Both compliments and complaints from our consumers are largely to do with our commitment to our values, as evidenced by our behaviour. Further information on our values is available on the directorate intranet. Key Performance Areas The key performance areas for the Health Directorate are: • Consumer Experience • Sustainability • Hospital and Related Care • Prevention • Social Inclusion and Indigenous Health • Community Based Health • Aged Care. These seven performance areas build upon the seven overarching objectives of the National Health Care Agreement. Emphasis is placed within the plan on Consumer Experience and Sustainability. These core objectives support the achievement of our vision, by embedding our values in the strategic planning and delivery of services, to meet the needs of the community now and into the future. These can be viewed within the Corporate Plan 2010-2012


http://acthealth/c/HealthIntranet?a=da&did=5284609&pid=0



Chapter 3 - Code of Conduct

Regardless of who we are within the organisation, we are public sector employees of the ACT Public Service, working within the ACT Government Health Directorate. CODE OF CONDUCT

The behaviour expected of public sector employees is established by Public Sector Management Act 1994. The Health Directorate Code of Conduct sets out what behaviour is expected of staff. Any breaches of the Code of Conduct are managed in accordance with the procedures outlined in relevant certified agreements. Our Code of Conduct directs that:

We act honestly and with integrity The Health Directorate is judged on the actions of its’ employees. Acting with honesty and integrity will maintain the respect and confidence that we desire from the community.

We value and maintain our professionalism Professionalism is conduct that fosters and preserves our reputation as individuals, builds the reputation of the Health Directorate and supports our duty of care. Professional and ethical conduct by employees is integral to the organisation. If we compromise this principle, we will lose the respect and confidence of our colleagues and clients.

We know and respect the law and act accordingly Compliance with all the laws and statutes that govern us is an essential part of our operations. Violations of laws and regulations can have serious consequences for the Health Directorate and the individual concerned.

We avoid conflict of interest A conflict of interest occurs where an employee has a personal or professional interest sufficient to influence, or appear to influence, the objective performance of their duties. A real or apparent conflict of interest can jeopardise confidence in the Health Directorate. Therefore, we do not participate in activities that could put us in such a position.

We respect privacy and do not misuse information Respect for client privacy and business confidentiality is central to the Health Directorate’s credibility. At all times, we comply with the laws governing disclosure of information and we treat the privacy of our clients, colleagues and business affairs as a high priority.




We strive to be good citizens and achieve community respect The Health Directorate is committed to service excellence and aims to maintain public confidence and respect. This can only be achieved if we are aware of our responsibilities and are accountable for our actions. The full Code of Conduct, incorporating statements of how we demonstrate these key behaviours can be found within the Central Policy and Publication Register, under a key word search of ‘conduct’.

http://inhealth/PPR/default.aspx

Compliance and Controls


Chapter 4 – Legislation

Governing and law-making often overlap, but in theory, government powers are divided between three institutions:

• parliament, which makes laws (legislative power);

• executive government which implements, administers and enforces laws (executive power); and

• courts which interpret and apply laws (judicial power).

In addition to setting the strategic direction and vision for the ACT community, a core function of the Australian Capital Territory Government is to make new laws or change existing laws. The Health Directorates’ governance is, at the highest level, directed by relevant Commonwealth and ACT legislation. The enacting of this legislation on a day to day basis occurs through the interpretation of the law into Directorate specific policies and procedures.

Administrative Arrangements Under the Australian Capital Territory (Self-Government) Act 1988 and the Public Sector Management Act 1994, the Chief Minister allocates powers and responsibilities for government business to Ministers and their portfolios. These determinations are referred to as Administrative Arrangements and can be found on the ACT Government Legislation Register.

Legislative responsibilities - Minister for Health Under the Administrative Arrangements the Minister for Health and the Health Directorate are allocated responsibility for the following matters; • Health policy and infrastructure • Acute health services • Community health services • Cancer services • Aged care and rehabilitation services • Mental health services • Population health services • Local hospital network

In addition to the above, the ACT Government may allocate other responsibilities to the Minister for Health and to the Health Directorate at any time.

Public Sector Management Act 1994 The Public Sector Management Act 1994 (the Act) provides the legislative framework for employment in the ACT Public Service. The Act sets out general provisions (i.e. values and principles) and deals with primary employment issues including categories of employment, promotion, transfer, appeal and review mechanisms and discipline. The Act is supported by the Public Sector Management Standards.

http://www.austlii.edu.au/au/legis/cth/consol_act/acta1988482/

http://www.legislation.act.gov.au/a/1994-37/current/pdf/1994-37.pdf


http://www.legislation.act.gov.au/ni/2011-351/default.asp






Public Sector Management Standards The Public Sector Management Standards (the Standards) operate under the Act and provide specific information on a range of employment-related conditions of service and entitlements, and instruction on the application of the Act in defined circumstances. The Standards have been written to expand on and provide detailed direction on the practical application of the broader principle-based statements made in the Act. The Standards apply to all persons employed in the Australian Capital Territory Public Service.

Awards and Industrial Agreements Awards and Industrial Agreements approved under the terms of the Fair Work Act 2009 either add to conditions of service provided under the Act and Standards, or where an inconsistency exists between these documents, amend conditions of service provided under the Act and Standards.

Health Act 1993 The Health Act 1993 governs the provision of health services in the ACT. The Act is supported by the Health Regulation 2004. The Health Act 1993 outlines the principles for the provision of services and commitments in the delivery of public hospital services to eligible persons in the ACT, and directly influences how services are provided by the Health Directorate. Public Health Act 1997 The Public Health Act 1997 seeks to protect the community from health risks, provide information about the health of the community to inform appropriate policy development and implementation and respond to health risks. The Public Health Act 1997 is supported by the Public Health Regulation 2000. Health Practitioner Regulation National Law (ACT) As at 1 July 2011, the ACT became a participating jurisdiction in the National Regulation and Accreditation Scheme. The regulation of the ten major registered health professions is now governed by the Health Practitioner Regulation National Law (ACT) Act 2010. As a consequence, the existing legislation (Health Professionals Act 2004) is being phased out. The Act supports National Boards involvement in both the assessment of a health practitioners initial suitability for registration and the monitoring of a registrant’s ongoing standards of practice. The Act provides that the National Boards may establish panels to assess and take action in relation to registered health practitioners’ standards of practice. The Act also provides for the ACT Civil & Administrative Tribunal (ACAT) to adjudicate serious reports about a health practitioner’s standard of practice. The Act requires that the Human Rights Commission and the National Boards jointly participate in the management of all reports about registered health practitioners. The Act aims to enhance public protection through a pro-active and contemporary scheme of health professional registration. Increased transparency, accountability and community participation are features of the Act.

http://www.legislation.act.gov.au/di/2006-187/default.asp

http://www.comlaw.gov.au/Details/C2010C00741


http://www.legislation.act.gov.au/sl/2004-14/default.asp







http://www.ahpra.gov.au/


Health Professionals Act 2004 The Health Professionals Act 2004 continues to apply to a residual group of health professions who are not participants of the National Regulation and Accreditation Scheme. The Act is supported by the Health Professionals Regulation 2004.

Medicines, Poisons and Therapeutic Goods Act 2008 The Medicines, Poisons and Therapeutic Goods Act 2008 aims to promote and protect public health and safety by minimising misadventure with medicines and regulated substances, ensuring that consumers of medicines have enough information to allow them to use them safely and effectively, developing a framework for authorising and licensing both medicines and poisons and controlling the way in which medicines and poisons are managed. The Act is supported by the Medicines, Poisons and Therapeutic Goods Regulation 2008.

Human Rights Commission Act 2005 The Human Rights Commission is established by legislation and includes the Health Services Commissioner. The Health Service Commissioner is responsible for complaints handling and investigation procedures relating to health professionals and health practitioners. This role, as set out in the Human Rights Commission Act 2005, intersects with the Health Practitioner Regulation National Law (ACT) Act 2010 and the Health Professionals Act 2004.

Health Records (Privacy and Access) Act 1997 The Health Records (Privacy and Access) Act 1997 provides guidance on how clinical health records will be managed and maintained within the ACT. This Act directly influences clinical records policy and procedures within the Health Directorate.

Privacy ACT 1988 (Cwlth) The Privacy Act 1988 (Cwlth) requires Commonwealth and ACT Government agencies to comply with Information Privacy Principles (IPP), which are detailed in the legislation. Broadly speaking, the IPPs regulate how personal information may be collected, used, accessed, disclosed and secured by agencies. Freedom of Information Act 1989 The Freedom Of Information Act 1989 allows individuals access to government information within specified boundaries and in some instances allows individuals to correct information about themselves which they consider is not accurate. For further information regarding the FOI Act please contact the Freedom of Information Coordinator on 6205 1340.

Legislative responsibilities – Health Directorate In addition to complying with Legislation, the Health Directorate is responsible for supporting the Minister in ensuring new and existing legislation specific to health issues remains current. This work is specific to: • Blood Donation (Transmittable Diseases) Act 1985 • Drugs of Dependence Act 1989, • Epidemiological Studies (Confidentiality) Act 1992 • Food Act 2001 • Gene Technology Act 2003 • Gene Technology (GM Crop Moratorium) Act 2004



http://www.legislation.act.gov.au/a/2008-26/








http://www.austlii.edu.au/au/legis/cth/consol_act/pa1988108/

http://www.legislation.act.gov.au/a/alt_a1989-46co/default.asp

http://acthealth/c/HealthIntranet?a=da&did=5223830




http://www.legislation.act.gov.au/isysquery/search.asp

http://www.legislation.act.gov.au/a/2003



• Health Act 1993 • Health Practitioner Regulation National Law (ACT) Act 2010 • Health Professionals Act 2004 • Health Professionals (Special Events Exemptions) Act 2000 • Health Records (Privacy and Access) Act 1997 • Human Cloning and Embryo Research Act 2004 • Intoxicated People (Care and Protection) Act 1994 • Medicines, Poisons and Therapeutic Goods Act 2008 • Mental Health (Treatment and Care) Act 1994, except part 8, part 9, section 141, section 142

and section 143 • Public Health Act 1997 • Radiation Protection Act 2006 • Smoke-Free Public Places Act 2003 • Supervised Injecting Place Trial Act 1999, except sections 7, 8 and 13 • Tobacco Act 1927 • Transplantation and Anatomy Act 1978

Legislative responsibilities - Health Directorate officers Some officers of the Health Directorate have special responsibilities and powers allocated to them through legislation. One example of such powers is the authority allocated to the Chief Health Officer to declare a disease or medical condition to be a notifiable condition under Section 101 of the Public Health Act 1997. For further examples of special powers allocated to Health Directorate officers please refer to the relevant legislation.

http://www.legislation.act.gov.au/a/1993-13/default.asp%20%3e


















Chapter 5 – Delegations

Definitions

Head of Power - is the officer authorised under legislation to perform particular functions or to exercise particular powers, for example the Director-General. Delegate - is a person authorised by instrument or in writing to exercise certain powers under legislation.

Delegation of government functions Powers to carry out specific government functions, such as the delivery of health services, are delegated through Acts of the Assembly. For example the Minister for Health and theHealth Directorate are allocated responsibility for health policy, health infrastructure, acute health services, community health services, cancer services, aged care and rehabilitation services, mental health services, population health services and the local hospital network (See Chapter 6).

Delegation of human resource functions Decisions relating to general public sector administration and human resource management are delegated under Enterprise Bargaining Agreements made under the Workplace Relations Act 1996, Public Sector Management Act 1994 (PSM Act), and the Public Sector Management Standards . These delegations are referred to as HR delegations. HR delegations can be categorised into seven broad segments: • Recruitment • Establishment • Salary and allowances • Study-bank • Discipline, grievances, inefficiency • Leave, and • Permanent part time work. Most powers relating to officers of the public service are vested in the Director-General under the PSM Act. Section 36 of the Act provides that the Director-General can in turn further delegate these powers to others. Information and best practice guidelines for authorising, making, reviewing and managing delegations are available at Delegations under the ACT Legislative Employment Framework: Information Note 2007

Delegation of financial functions Decisions relating to the allocation and management of financial resources are delegated under the Financial Management Act 1996. These delegations are also referred to as Financial Delegations. The Director-Generals’ Financial Instructions provide detailed guidance on what financial delegations exist and how they are best managed. This is available online at: Finance Matters Online - Director General's Financial Instructions.

http://www.comlaw.gov.au/Details/C2004A05064



http://www.cmd.act.gov.au/__data/assets/pdf_file/0019/117028/in092007.pdf






The Director-General has signed instruments that delegate various financial powers to officials holding the positions listed on the following schedules: • Expenditure and Payment Authorisations • Write-off and Disposal of Assets • Write-off and Deferral of Debts • Finance Leases • Investment of Surplus Monies, and • Cash Advances (i.e. Petty Cash/register float holders).

Other delegations In addition to the above types of delegations, an officer at a higher level can authorise an officer at a lower level to carry out a particular task. This type of authorisation can be given expressly or can be implied. As this type of authorisation is without a legal reference, it should only be used as a last resort.

The reason for delegations Delegations are designed to give managers flexibility in managing their operational areas. In exercising delegations, managers should ensure they are applied in a fair and equitable manner.

Rules for issuing delegations There are certain rules relating to the issue of delegations. These include: • All decisions should be traceable to a ‘head of power’ (see definition at beginning of this section) • Delegations should be issued to a position number, not a person • Delegations must be issued to specific positions, and not as a blanket provision for a range of

positions (eg not ‘for all ASO 6s’) except in relation to HR delegations where the latter can apply • New delegations do not have to be issued when the occupant of the office issuing the delegation

(the ‘delegator’) changes • The delegate makes the decision in his or her own right, not on behalf of the delegator, and

hence they should put their name to any decision made pursuant to the delegation • The person delegating the power cannot delegate the ‘power to delegate’ unless specifically

authorised by legislation • An officer cannot exercise powers if they have not been delegated • If new powers are put into the Act, an instrument of delegation is required before the powers

can be exercised, and • Each Director-General should keep the originals of all schedules of delegations of his or her

powers to satisfy legal evidential requirements, and provide up to date copies to each delegate.

Good practice in delegating authority The following good practices should be considered when delegating authority: • Delegations should be exercised by a person holding a position at least one level above the

position to which the decision relates • Some powers should be retained at the Executive level or even by the Director-General • Supervisor’s delegations will normally include all of the delegations of the staff working for them • It is generally preferable if delegations are issued to the lowest classification level possible, while

maintaining efficient operations within the organisation, and • Only in exceptional situations should delegations be issued to classifications below

Administrative Services Officer 5 (ASO 5 – or their equivalent).

http://cid/c/healthintranet?a=glob&object=1121737682







Good practice when exercising delegated authority When exercising delegated authority, delegates should keep in mind the following good practices: • Regularly check that you have the power to make the decision under consideration, preferably by

sighting (and retaining) the relevant instrument of delegation • Consult your supervisor if you have any doubts about your role in decision making • Ensure that your decision complies with current relevant legislation, regulations and instructions; • If necessary, seek advice from the Financial Management Unit • Do not approve expenditure for yourself or in other situations where there could be a conflict of

interest • Declare any potential conflict of interest to your supervisor, especially if the decision involves a

relative or friend, and • If the decision under consideration has budgetary implications, consult your finance officer to

check that money is available.


Chapter 6 – Director-General Instructions

FINANCIAL MANAGEMENT ACT

In accordance with the Financial Management Act 1996, all authority and accountability for the Health Directorate rests with the Director-General. DIRECTOR-GENERAL INSTRUCTIONS

The Director-General Instructions provide an overall framework for financial operations within the Health Directorate without going into procedural detail. They are designed to empower managers to manage their own areas of responsibility. The Director-General Instructions include guidelines and direction on the following topics:

• 1.1 Delegation of Authority

• 1.2 Risk Management

• 1.3 Budget Management & Control

• 1.4 Budget Process (Under development)

• 1.5 Reporting Responsibility

• 1.6 Accounts and Records

• 1.7 Audit Committee

• 1.8 Integrity & Fraud Management

• 1.9 Insurance and Indemnities

• 2.1 Spending Authority

• 2.2 Procurement of Goods and Services

• 2.3 Payment of Accounts

• 2.4 Travel and Cabcharge

• 2.5 Official Hospitality

• 2.6 Grant Administration

• 2.7 Act of Grace Payments

• 2.8.1 Engagement of Consultants

• 2.8.2 Use of Contractors

• 2.9 Credit Cards









http://cid/c/healthintranet?a=glob&object=-2027845478




http://acthealth/c/healthintranet?a=glob&object=1122963285










• 3.1 Cash Management

• 3.2 Trust and Other Third Party Monies and Property

• 4.1 Debt Management and Invoicing

• 5.1 Accountable Forms

• 6.1 Asset Management

• 7.1 Revised Goods and Services Tax

• 7.2 Fringe Benefits Tax

• 8.1 Deductible Gift Recipients (Donations) Policy

• 9.1 Salary Packaging

The Instructions outline what staff are authorised to do, how to do it and who to seek further advice from if required. The Instructions are regularly reviewed and updated by the Financial Management Unit to ensure information is current. Executive and senior managers are responsible for ensuring staff are aware of and follow the Director-General Instructions. This and other finance policies can be accessed at Finance Matters Online on the Health Directorate intranet.


http://acthealth/c/healthintranet?a=glob&object=1283139719











Chapter 7 – Resource Management

Legislative framework ACT public sector accounting and financial responsibilities are set out in the Financial Management Act 1996 .

ACT Government revenue ACT Government income is derived from land sales, stamp duty, fines and other fees from taxpayers. In addition to this the ACT also receives Commonwealth funding in the form of Commonwealth Government Grants.

ACT Government budget ACT Government expenditure for the coming financial year is outlined in the Budget. It is through the Budget process that decisions regarding what should be funded, how and why are made. The Budget process also involves the setting of priorities and the establishment of performance indicators and time frames. The scope of Budgets can vary from the formal, legislatively backed whole-of-government Budget process, to the administrative arrangements of individual sections where a manager is accountable for the use of resources and collection of revenue. Performance against the Budget is one of the main mechanisms for public sector accountability. The Budget is also the focus of scrutiny by the Legislative Assembly, the media, other agencies, the community and credit rating organisations. Information on current and prior ACT Government Budgets can be found on the ACT Treasury website.

Budget cycle The overall Budget cycle is made up of the following stages: • Preparation – the formulation of budget proposals by Directorates, their prioritisation by

Ministers and decisions regarding overall Budget priorities by the Government; • Authorisation – Legislative Assembly approval of the Budget followed by Ministerial and

administrative (directorate) allocations authorised by the Assembly; • Implementation – planning, using, monitoring, reporting and reviewing finances over the year; • Reporting – annual reporting to the public as well as internal reporting on a more frequent basis; • Performance review – reporting on overall performance against objectives.

Public sector accountability for resource management All staff of the ACT Public Service (ACT PS) are accountable for the responsible management of government resources. All staff have a responsibility to use resources, purchased to assist the Directorate in the delivery of services, in the most efficient manner possible.



http://www.treasury.act.gov.au/budget/index.shtml



Health Directorate staff involved in the management of resources should refer to Finance Matters Online - Director General's Financial Instructions for guidance on what they are authorised to do, the scope of this authorisation and the manner in which they carry out these responsibilities.

Fraud and corruption prevention Fraud refers to the taking or obtaining of money or other benefit by deception from the government when not entitled to it, or attempting to do so. Fraud against the ACT Public Service reduces the quality and quantity of goods and services available to the ACT community. Corruption –refers to an officer if he or she seeks, obtains or receives any benefit, other than lawful salary and allowances, on the understanding that the officer will do or refrain from doing anything in the course of his or her duties, or will attempt to influence any other officer on behalf of any person. Fraud and corruption prevention within the Health Directorate is managed in accordance with the Public Sector Management Standards and according to the ACT Public Service Integrity Policy 2010. Directors-General have primary responsibility and accountability for the implementation of fraud and corruption control strategies appropriate to their particular agency. As custodians of the public trust and public resources, Health Directorate staffhave a responsibility to report evidence of suspected maladministration, corruption or fraud.



http://www.cmd.act.gov.au/__data/assets/pdf_file/0006/187179/integritypolicy2010.pdf

Organisational Structure


Chapter 8 - Organisational Structure

The Health Directorate was restructured in March 2011to best meet the challenges of:

• An increasing demand for services and the need to respond to this;

• The large, and increasing size of the organisation ;

• The implementation of the Capital Asset Development Program;

• Delivering service excellence; and

• Preparing and implementing changes arising under the National Health Care Reform program Restructure 2011

Operational Areas At the highest level, the Health Directorate is structured into two Groups: • Canberra Hospital & Health Services • Strategy & Corporate and operational areas that report directly to the Director-General: • Population Health Division • Quality and Safety Unit • Financial Management • Executive Coordination Unit • Communications and Marketing Unit • Internal Audit &Risk • Donate Life ACT • Canberra Hospital Foundation The two groups are led by Deputy Directors-General. They are structured into direct clinical service provision divisions and strategic and corporate support branches. Canberra Hospital & Health Services Group employs the majority of staff working within the directorate. The relationship of these entities are provided in the attached organisation chart. The role, responsibilities and accountabilities of these operational areas are outlined within the ‘Operational Areas’ section of this document. Organisational Positions As identified in earlier chapters, specific roles, responsibilities and delegations are allocated to identified positions and functions in the organisation. Individuals within these positions may progress the objectives of the agency through specific operational areas that they have direct delegation over, or by leading specific activity across the organisation. The structure of the organisation and participation in key committees and meetings assists this process. The specific roles, responsibilities and accountabilities of identified positions and the scope of identified position levels across the organisation are described within the ‘Roles and Accountability’ section later in this document.


http://www.health.act.gov.au/c/health?a=sendfile&ft=p&fid=1314583829&sid=


Relationship with other government and community agencies The ACT Public Service is comprised of nine Directorates, with key leadership from the Head of Service, who also serves as Director-General of the Chief Minister and Cabinet Directorate. The Directorate structure and functional directory is available at the Public Sector Review internet site. The Health Directorate forms one of these entities. The aim of this structure is to present the community with one public service and one public service face, so that we can serve our customers - our citizens, in the best possible way and meet their demands. The ACT Public Service Strategic Board provides whole of government leadership and direction to the ACT Public Service. The Health Directorate is represented on this board by the Director-General. This board provides the peak body for identifying and providing direction on issues that cut across the directorates of the public service. The Health Directorate liaises closely with many other agencies in government, particularly the Community Services Directorate and its agency - the Office for Children, Youth and Family Support. The Health Directorate also engages with an extensive range of non-government health and community service providers. Building and sustaining good relationships with these providers is an important aspect of the organisations’ business. Organisational Chart – next page

http://www.cmd.act.gov.au/

http://www.actpsreview.act.gov.au/home

http://www.dhcs.act.gov.au/

Corporate Governance Statement — Issue 5, October 2011 – Chapter 8

Operational Areas

Corporate Governance Statement — Issue 5, December 2011 – Chapter 9.01, Page 2

Chapter 9.01 – Canberra Hospital & Health Services

CANBERRA HOSPITAL & HEALTH SERVICES

Role Canberra Hospital & Health Services is led by the Deputy Director-General and provides acute, sub-acute, primary and community based health services to the ACT and surrounding region. A comprehensive range of services are delivered from the Canberra Hospital campus including acute inpatient care, overnight and day services and outpatient treatment. Canberra Hospital is the largest public hospital in the region, supporting a population in excess of 500,000. The hospital delivers a full range of medical, surgical and obstetric services, including complex procedures in areas such as cardiac surgery, neurosurgery and neonatal intensive care. Strong links exist between hospital and community-based services, as many of the operational divisions deliver services across the continuum of care to ensure continuity of care for patients. The community based services of the Health Directorate include early childhood, youth and women’s health; dental services, rehabilitation and community care; mental health and alcohol and drug services. In addition, justice health services are provided within the Territory’s’ detention facilities. The nine divisions of the group are: • Division of Surgery & Oral Health; • Division of Women, Youth & Children; • Division of Critical Care & Diagnostics; • Division of Capital Region Cancer Service; • Division of Rehabilitation, Aged & Community Care; • Division of Mental Health, Justice Health, Alcohol & Drug Services; • Division of Pathology; • Division of Medicine; and • Division of Operational Support The Health Directorate is a partner in teaching with the Australian National University and the University of Canberra. Detailed information on each of these Divisions are contained in the following section. The Canberra Hospital and Health Services Group liaises closely with Calvary Public Hospital (managed by the Little Company of Mary) to ensure effective coordination of services across the territory. A number of Divisions provide services within Calvary Public Hospital facilities and many of the community based services liaise closely to ensure a seamless service is provided. As two members of the ACT’s Local Hospital Network, Calvary Hospital and the Canberra Hospital also provide advice to the Director-General on the clinical and corporate governance framework needed to maintain and improve patient care and services, and provide advice on methods to


http://www.calvary-act.com.au/about/


improve efficiency across the public hospitals. In addition, the Local Hospital Network provides an annual report to the Minister for Health.

Reporting structure • The Deputy Director-General reports directly to the Director-General, Health Directorate. • The Deputy Director-General leads the Canberra Hospital & Health Services through the

Executive Director of each of the divisions.

Committee representation The Deputy Director-General, Canberra Hospital & Services is represented on the following Tier One committees: • Executive Council • Executive Directors’ Council • Management Advisory Council • Clinical Senate • Safety and Quality Committee • Workplace Safety Committee • Audit and Risk Management Committee • Workforce Strategy Committee • Redevelopment Committee • Information and Communication Technology Committee


Organisation chart

Corporate Governance Statement — Issue 5, December 2011 – Chapter 9.01.1, Page 1

Chapter 9.1.01 – Division of Operational Support

OPERATIONAL SUPPORT

Role The Division of Operational Support is responsible for the clinical leadership of allied health, medical and nursing, and midwifery professions and the provision of a range of therapeutic allied health services and operational support for the Canberra Hospital and Health Services Group. The Operational Support Division is comprised of: • Medical Services Executive Director • Nursing & Midwifery Executive Director • Acute Support Services, and • Senior Business Advisor.

Responsibilities Service delivery through:

• Improving access to, and the experience of interacting with, health services through liaison, ward services, pastoral care, and interpreter support services

• Providing therapeutic professional health services to patients of Canberra Hospital and Health Services

• Supporting professional groups through active representation and coordination, and • Advising the Deputy Director-General and relevant senior management on implementing and

reporting of operational matters including rostering and financial matters.

Communication and collaboration through:

• Providing representation of, and high level advice to, the Deputy Director-General and Executive Directors of the group on professional issues relating to the medical, nursing and therapeutic allied health professions

• Forming and fostering effective working relationships and networks within the Directorate and with relevant external bodies

• Demonstrating the values of the Health Directorate within day to day interactions, and • Contributing to service discussions and debates critically and constructively.

Safety and quality through

• Using the Riskman incident management system to identify, analyse and report on clinical and workplace safety issues

• Ensuring appropriate governance processes are in place to support the delivery of best practice services

• Providing clinical after-hours support, and • Promoting positive performance management to enhance the capacity of staff.


Research, teaching, training and development through:

• Working closely with tertiary education partners to co-ordinate and enhance teaching, learning and research activities

• Actively contributing to accreditation processes • Facilitating access to research, teaching and training opportunities for staff , and • Promoting mutually beneficial participation in external professional organisations and peak

bodies. Operational management through:

• Advising the Deputy Director-General on financial matters • Rostering coordination and management for nursing, medical, ward services and acute support

services staff • Providing after-hours operational and rostering support, and • Implementing Directorate policies.

Reporting structure • The Director and Executive Directors within the Operational Support Division report to the

Deputy Director-General, Canberra Hospital and Health Services Group.

Committee Representation The Operational Support Division is represented on the following Tier One committees: • Executive Directors’ Council • Management Advisory Council • Accreditation Steering Committee • Safety and Quality Committee • Work Safety Committee, and • Workforce Strategy Committee.


Organisation chart


Chapter 9.01.2 – Division of Surgery & Oral Health

SURGERY & ORAL HEALTH

Role The Division of Surgery & Oral Health is responsible for the delivery of inpatient and outpatient surgical services at the Canberra Hospital, and prevention and treatment dental health programs for children, targeted youth, and adults of the ACT community. Services are provided at the Canberra Hospital, community health centres and within other agency facilities. The Surgery & Oral Health Division is comprised of: • Community Dental Health Program • Ophthalmology • Surgical Inpatient Wards at the Canberra Hospital:

• 11B • 10A • 9A • 9B • 6B

• Peri operative and Pain Management Services • Anaesthetics • Operating Theatres • Post-Operative Recovery Suite • Acute Pain Management Unit • Surgical Outpatient Services • Surgical Bookings • Pre-Admission Clinic • Registrar Review Clinic


• delivering high quality surgical care, along the care continuum, in inpatient and outpatient settings

• providing dental services for pre-school and primary aged children, adults who are the primary holder of a current Centrelink card, and for youth and adults in an ACT detention facility, and

• achieving goals for health service provision and clinical issues identified within the Corporate and Group business planning process.


• Developing a broad range of strategic partnerships, networks and working relationships with key stakeholders, groups and organisations both within and external to the division, and

• Promoting and maintaining collegiate relationships with professional groups and stakeholders.


Strategic planning through:

• Actively contributing to planning sessions to enhance clinical services and provide direction for future service delivery

• Developing and implementing a division business plan which incorporates goals and targets developed by the Health Directorate in consultation with other service providers and consumers, and

• Developing organisation-wide strategies in consultation with individual service units, facilities and consumer representatives, for efficient service delivery.

Safety and quality through:

• Fostering a culture of best practice and learning within the Division • Actively using Riskman to identify, track and report on adverse clinical and workplace safety

issues • Valuing feedback from all stakeholders to assist in identifying new and emerging issues; • Identifying, reviewing, implementing and sustaining improvements in practice in collaboration

with consumers and staff, and • Collaborating within and beyond the organisation to benchmark services for quality and

efficiency.


• Promoting a skilled and motivated workforce within a culture of the learning organisation through effective performance management, and

• Demonstrating and actively supporting working relationships with tertiary education partners through partnerships and collaboration.

Operational management through: • Managing financial resources and targets within budget for the Surgery & Oral Health Division • Comparing case-mix and service costs with benchmarks to inform efficiency improvements, and • Building a culture of continuous review and improvement to support improvements in efficiency

and quality of services.

Reporting structure • The Executive Director, Surgery & Oral Health Division reports to the Deputy Director-General,

Canberra Hospital and Health Services Group • The Executive Director leads the Division through the monthly Division of Surgery & Oral Health

Executive meeting.

Committee Representation The Executive Director, Surgery & Oral Health Division is represented on the following Tier One committees: • Executive Directors’ Council • Management Advisory Council • Accreditation Steering Committee • Work Safety Committee, and • Safety and Quality Committee.


Organisation chart


Chapter 9.01.3 – Division of Women, Youth and Children

WOMEN, YOUTH & CHILDREN

Role The Women, Youth & Children Division (WYC) provides a broad range of primary, secondary and tertiary health care services. The provision of services is based on a family centred, multidisciplinary approach to care in partnership with the consumer and other service providers. Services are provided at the Canberra Hospital, community health centres and in community based settings including client’s homes, schools and child and family centres. Some services are provided within other agency facilities. Women, Youth and Children Division services comprise: • Maternity including Midcall and Canberra Midwifery Program • Womens’ Health including screening, gynaecology and violence against

women programs • Neonatology including Neonatal Intensive Care Unit, Special Care Nursery, specialist

clinics, newborn hearing screening and ACT Newborn Retrieval Service • Paediatrics including inpatient care, specialist clinics, community paediatricians and

genetics • Maternal and Child Health including a universal home visit following birth, support for

breast feeding and parenting, immunisation and referral • Services that support children and their families with complex care needs.

- the Community Asthma Support Service - Caring for Kids Program (care in the home for children with complex needs.) - Child at Risk Health Unit. (care for children affected by violence and abuse). - IMPACT coordinates care for woman with complex care needs who are pregnant

and/or have young children - child protection training for clinicians.

• School based nursing services including immunisation, kindergarten health checks, school youth health checks and special school nurses, and

• Nurse audiometry providing hearing assessments to children and adults. The division is led by the Executive Director who provides strategic leadership for the delivery of health services.

Responsibilities

Clinical leadership through:

• Liaising with other jurisdictions and agencies, and researching national and international practice to ensure currency of practice and models of care

• Initiating change in service units within the division to maximise quality of care and produce optimum efficiency,and


• Promoting and maintaining a professional collegiate approach to relationships with professional groups, consumers and other stakeholders in relation to the leadership and operational management of WYC clinical services.


• Disseminating the WYC Business plan, to inform staff and key stakeholders of objectives that reflect components of the Corporate Plan

• Developing a broad range of strategic partnerships, networks and working relationships with key stakeholders, groups and organisations both within and external to the division

• Promoting and maintaining collegiate relationships with professional groups and stakeholders, and

• Representation on key committees within the Health Directorate as well as cross-jurisdictional meetings.


• Actively contributing to service and infrastructure planning to meet current and projected or emerging demands

• Participating in whole of government planning, implementing and reporting to address issues impacting on women, youth and children, and

• Listening to consumers and key stakeholders to inform the division of current and emerging issues.


• Working collaboratively with clinicians, planners, administrators and the community in the ongoing definition of improved models of integrated service delivery

• Promoting performance management to build capacity of staff • Using information from clinical and workplace safety incident monitoring and clinical review

processes to inform areas for improvement, and • Supporting areas in working to meet accreditation standards through benchmarking and quality

improvement. Research, teaching, training and development through:

• Promoting active participation in accreditation, teaching and training activities • Supporting a culture of continuing professional development for all staff, including development

of professional and operational management skills, and • Fostering clinical and basic research and academic excellence. Operational management through:

• Ensuring appropriate governance of work units and teams for operational and clinical issues • Managing the allocation of resources and monitoring of this against service delivery targets, and • Implementing relevant organisational and divisional policies and procedures.

Reporting structure • The Executive Director, Women, Youth and Children Division reports to the Deputy Director-

General, Canberra Hospital and Health Services Group;


Committee Representation The Executive Director of Women, Youth and Children Division is represented on the following Tier One committees: • Executive Director’s Council • Management Advisory Council • Safety and Quality Committee • Work Safety Committee and • Accreditation Steering Group

Organisation chart


Chapter 9.01.4 – Division of Critical Care & Imaging

CRITICAL CARE & IMAGING

Role The Division of Critical Care & Imaging is responsible for the delivery of acute critical care, retrieval and imaging services. These are provided as inpatient and outpatient services at the Canberra Hospital. A strong emphasis is placed across all sections on accessible and timely care, delivered to a high standard of safety and quality. This is underpinned by the Division’s commitment to research and training. The Division of Critical Care & Imaging is comprised of: • Intensive Care Unit

• Medical Emergency Team • ICU outreach

• Emergency Department • Medical Imaging • Retrieval Services • Patient Flow Management

• Medical Assessment and Planning Unit/Surgical Short Stay Unit • Surgical Assessment and Planning Unit • Demand Management Unit


• Delivering coordinated services along the care continuum from retrieval to provision of critical care assessment and treatment

• Accessibility to adult and paediatric medical assessment and treatment in a timely manner according to clinical need through the emergency department

• Appropriate care provision to complex patients through effective clinical assessment and planning

• Providing diagnostic imaging, interventional radiology and nuclear medicine services; • Achieving goals for health service provision, and • Providing clinical leadership and support to staff and patients across the agency from specialty

units. Communication and collaboration through:

• Promoting and maintaining a professional collegiate approach to relationships with professional groups, consumers, and other stakeholders in relation to the leadership and operational management of critical care services

• Fostering performance management across all sections of the division, and • Developing a broad range of strategic partnerships, networks and working relationships with key

stakeholders, groups and organisations both within and external to the division.



• Developing and implementing a Critical Care & Imaging business plan which reflects goals of the Corporate Plan in consultation with other service providers and consumers

• Liaising with other service areas and agencies to identify current and future service issues and strategies to address these, and

• Using relevant clinical and operational information analysis to inform future planning needs. Patient safety and quality through:

• Engaging with consumers, staff and other stakeholders to improve services and models of care, and

• Contributing to, and using information from risk management reporting and review processes to inform areas for improvement.


• Partnering with tertiary education facilities to support nursing, medical and allied health training and research, and

• Supporting learning opportunities for staff. Operational management through: • Managing financial resources of the division to ensure appropriate allocation of budget and

monitoring of this against targets, • Implementing relevant directorate policies including Infection Control, Workplace Safety and

Human Resource Management; and • Effective dissemination of information regarding operational management issues within teams of

the division.

Reporting structure • The Executive Director, Critical Care & Imaging reports to the Deputy Director-General, Canberra

Hospital and Health Services Group • The Directors of Intensive Care Unit, Emergency Department, Retrieval Services, Medical

Assessment and Planning Unit, Surgical Assessment and Pplanning Unit, Diagnostic Imaging, and the Director of Nursing report to the Executive Director, and form the executive of the Division.

Committee Representation The Executive Director of Critical Care & Imaging Division is represented on the following Tier One committees: • Executive Director’s Council • Management Advisory Council • Accreditation Steering Committee • Work Safety Committee, and • Safety and Quality Committee.

The Intensive Care Unit Director represents the Health Directorate on the Australian Commission on Safety and Quality in HealthCare, national steering committee for Recognising and Responding to Clinical Deterioration.


Organisation chart


Chapter 9.01.5 – Division of Capital Region Cancer Service

CAPITAL REGION CANCER SERVICE (CRCS)

Role The Capital Region Cancer Service (CRCS) Division is responsible for the provision of Medical Oncology, Clinical Haematology, Radiation Oncology, BreastScreen and Immunology services for the ACT and surrounding region, offered as screening, inpatient and outpatient services. The division also manages and coordinates health intake and client support services.. The clinical services of CRCS integrates existing cancer services in the ACT and South Eastern NSW, to ensure a continuum of care to consumers ranging from, screening, diagnosis, treatment, and palliative care. Services are provided on an area-wide basis and delivered at a number of locations ranging from hospital and community settings to the patient’s home. The Capital Region Cancer Service is comprised of: Inpatient and Outpatient services for • Breast Screen ACT • Clinical Immunology • Clinical Haematology • Medical Oncology • Radiation Oncology Health Directorate Intake Service & Client Support including: • Health Centre administration • Central Outpatient administration (Canberra Hospital) • Community Health Intake • National Health Call Centre Network (ACT) • Transcription Services


• Delivering coordinated services along the cancer care continuum, including screening, diagnosis, treatment and palliative care in a range of settings, including public, private and community venues, such as hospitals, community health centres and the home environment

• Providing breast cancer screening, medical oncology, radiation oncology, clinical haematology, chemotherapy, immunology services, cancer counselling support, rehabilitation and palliative care, and

• Supporting positive engagement between the community and the Health Directorate through the provision of timely and appropriate clinical administrative support services including intake, reception, and administrative support to clinical areas to ensure effective communication.




• Demonstrating the values of the Health Directorate through day-to-day interactions with consumers, colleagues and other stakeholders

• Developing a broad range of strategic partnerships, networks and working relationships with key stakeholders, groups and organisations both within and external to CRCS, and

• Implementing strategies, based on feedback, within the division to improve communication internally.


• Contributing actively to business, service and infrastructure planning to meet current and emerging service demands and to reflect the objectives of the Health Directorate, and

• Listening to, consulting and using feedback from consumers, staff and other stakeholders to inform planning relating to CRCS

Safety and quality through: • Working with consumers, other service areas and facilities and staff to develop organisation wide

strategies to improve the quality and efficiency of services • Building capacity within the CRCS workforce to provide best practice services through

performance development and related professional development, and • Using information from clinical, work safety, workforce and operational management processes

to identify issues impacting on the safety and quality of services and the workplace and to inform strategies to address these.


• Building a culture of continuous learning and innovation, underpinned by a commitment to performance management;

• Supporting strong partnerships with tertiary education facilities to provide teaching and training opportunities, and

• Ensuring accreditation and professional standards are identified and integrated in daily practice.

Operational management and coordination through:

• Managing the day-to-day performance of all CRCS services, with the exception of those provided by Calvary Health Care

• Ensuring appropriate governance processes of clinical, corporate and professional issues are established and used, and

• Ensuring effective management of resources, including allocation, monitoring and reporting of these against service targets.

Reporting structure • The Executive Director, Capital Region Cancer Service reports to the Deputy Director-General,

Canberra Hospital and Health Services Group; • The Directors of Breast Screen ACT, Information and Analysis, Operations, Medicine, Nursing and

Allied Health report to the Executive Director and form the executive of the division.


Committee Representation The Executive Director of Capital Region Cancer Service Division is represented on the following Tier One committees: • Executive Directors’ Council • Management Advisory Council • Accreditation Steering Committee • Work Safety Committee, and • Safety and Quality Committee

Organisation Chart


Chapter 9.01.6 – Division of Rehabilitation, Aged & Community Care

REHABILITATION, AGED & COMMUNITY CARE (RACC)

Role The Rehabilitation, Aged & Community Care (RACC) Division integrates the public health system rehabilitation, aged and community care services across the ACT. The division aims to improve the quality and accessibility of services for individuals. RACC promotes a continuum of care which includes prevention, assessment, diagnosis, treatment, support, rehabilitation and maintenance. RACC adopts an area-wide approach to patient-centred care. To this end RACC works closely with others to improve the communication between primary, acute, sub-acute and community healthcare, as well as fostering professional development and promoting best practice in rehabilitation, aged and community care. RACC services are delivered at a number of locations and in varied environments, ranging from hospital settings to the patient’s home. RACC services include: Community Care Services • Community Nursing • Community Allied Health • Workforce Office of Rostering Management (WORM) Geriatric Medicine • Ward 11A Canberra Hospital • Ortho-geriatric medicine Canberra Hospital • GEM Unit at Calvary Hospital • Research Rehabilitation Medicine • Ward 12B Canberra Hospital • Rehabilitation Independent Living Unit (RILU) • Aged Care Rehabilitation Unit (ACRU) at Calvary Hospital Client Support Services • Clinical Technology • Prosthetics and Orthotics • Independent Living Centre • Equipment Loan Scheme • ACT Equipment Scheme • Domiciliary Oxygen and Respiratory Support Scheme (DORSS) • Falls Assessment and Prevention Service



Nursing • Aged Care Assessment Team • Rapid Assessment of the Deteriorating Patient at risk (RADAR) • Day Care Programs • Nurse Practitioners • Walk-in Centre • Veterans’ Support Service Allied Health Service • Physiotherapy • Occupational Therapy • Prosthetics and Orthotics • Psychology • Social Work • Speech Pathology • Community Rehabilitation Team including: Driver Assessment Rehabilitation Service &

Vocational Assessment Rehabilitation Service • Transitional Therapy & Care Program Operational Support • Administration • Information Management • Manager of CADP & Related Projects


• Delivering coordinated services along the rehabilitation, aged and community care continuums in a range of settings such as hospitals, clinics, community health centres and the home environment, and

• Promoting the goals of RACC through provision of clinical expertise, knowledge and skills with other clinical areas and organisations, as required.


• Developing and sustaining a range of strategic partnerships, networks and working relationships with key stakeholders, groups and organisations both locally and nationally, and

• Working with key stakeholders, including service providers, community representatives, and carers, in relation to improving services.


• Undertaking community service planning and implementation of planning decisions jointly with various stakeholders

• Articulating the vision, goals and objectives of RACC through annual business plans • Contributing to division, directorate and area-wide planning to meet existing and emerging

service demands, and • Reflecting current research and best practice in rehabilitation, aged and community care within

strategic planning documents.



• Ensuring effective establishment and implementation of clinical, corporate and professional governance processes

• Using information obtained from governance processes to inform quality improvement strategies, and

• Ensuring practices reflect current research and evidence-based practice in care standards and service models.


• Capacity building within the division for research and teaching • Supporting teaching and training schedules of tertiary education partners, and • Promoting a culture of continuous learning within the Division.

Operational management through:

• Ensuring managers and supervisors are appropriately trained and supported to implement and monitor management processes, and

• Effective monitoring and reporting of services and resource management through the division’s executive meetings.

Reporting structure • The Executive Director of Rehabilitation, Aged and Community Care reports to the Deputy

Director-General, Canberra Hospital & Health Services Group. • The Directors of Community Care Services, Geriatric Medicine, Rehabilitation Medicine, Client

Support Services, Nursing, and Allied Health services report to the Executive Director and form the executive of the division.

Committee Representation The Executive Director of Rehabilitation, Aged & Community Care is represented on the following Tier One committees: • Executive Directors’ Council • Management Advisory Council, • Accreditation Steering Committee, • Work Safety Committee and • Safety and Quality Committee


Organisation chart


Chapter 9.01.7 - Division of Mental Health, Justice Health, Alcohol & Drug Services

MENTAL HEALTH, JUSTICE HEALTH, ALCOHOL & DRUG SERVICE

Role The Mental Health, Justice Health and Alcohol & Drug Services Division provides health services through hospitals and community based facilities, as well as through partnerships with community organisations. The services provided range from prevention and treatment to recovery and maintenance. Consumer and carer participation is encouraged in all aspects of service planning and delivery. The division works in partnership with consumers, carers and a range of government and non-government service providers to ensure the best possible outcomes for clients. The services of Mental Health, Justice Health and Alcohol & Drug Services Division are delivered at a number of locations and in varied environments, ranging from hospital inpatient and outpatient settings, community health centres, detention centres, other community settings and the consumer’s home, and include: Mental Health • Child & Adolescent Mental Health Services • Mental Health Rehabilitation & Speciality Services • Access and Acute Mental Health • Mental Health & Sector Development • Academic Unit of Psychological Medicine Justice Health • Alexander Maconochie Centre • Bimberi Youth Justice Centre • Symonston Periodic Detention Centre • ACT Court Cells Alcohol & Drug Services • Medical Services • Consultation, Liaison, Co-Morbidity & Impact Team • Opioid Treatment Service • Withdrawal Service • Counselling Treatment Service • Diversion Service




• Delivering coordinated services along the mental health, justice health and alcohol and drug care continuums in a range of settings such as hospitals, clinics, community health centres and the home environment

• Reflecting best practice and current research within service delivery standards and models of care

• Devising strategies, in consultation with other facilities, for efficient service delivery that optimises quality and access to care, and

• Working within consumers and carers in service planning, delivery and evaluation. Communication and collaboration through:

• Developing continuum of care processes through collaboration with other internal and external stakeholders

• Using feedback from stakeholders to identify and improve upon communication strategies of the division

• Promoting, through active demonstration of the Health Directorate’s values, a collegiate approach to every day interactions, and

• Disseminating the vision, goals and objectives of the division through the annual business plan. Strategic planning through:

• Actively participating in strategic planning processes for the division, group and directorate • Contributing, and at times leading planning processes for the mental health, justice health and

alcohol & drug sectors at both a Territory and National level, and • Using information from clinical and operational processes, in addition to current research and

best practice to inform contributions to planning processes. Safety and quality through:

• Ensuring staff, through effective performance management, have the capacity to provide best practice services

• Promoting the use of clinical and work place safety incident management and reporting processes to identify issues and inform strategies to address these, and

• Ensuring established clinical, professional and corporate governance processes are used and reviewed within the division.


• Actively working with tertiary education partners in the provision of teaching and training • Promoting a culture of learning, through effective performance management and opportunities

for development, and • Supporting and seeking out opportunities for research.


• Ensuring effective communication about, and monitoring of, resources within and across the Division against service targets,

• Benchmarking and comparison of case-mix costs to inform improvements in quality and efficiency of areas, and

• Supporting managers in resolving complex operational issues.


Reporting structure • The Executive Director of Mental Health, Justice Health and the Alcohol & Drug Services Division

reports to the Deputy Director-General, Canberra Hospital & Health Services Group. • The Directors of Mental Health, Justice Health and Alcohol & Drug Services report to the

Executive Director, and form the executive of the division.

Committee representation The Mental Health, Justice Health and Alcohol & Drug Services Division Executive Director is represented on the following Tier One committees: • Executive Directors’ Council • Management Advisory Council • Work Safety Committee, and • Safety and Quality Committee

The division represents the Health Directorate on a number of national, ongoing committees: • National Prisoner Census (Australian Institute of Health and Welfare) • National Child and Adolescent Disaster Response Working Group • National Child and Adolescent Mental Health Services Outcome Measurement Expert Group • Activity Based Funding – Mental Health Advisory Working Group • Safety and Quality Partnership Subcommittee • Quality Use of Medicines Group • State and Territory Mental Health Disasters Group, and • Reducing Adverse Medication Events Working Group


Organisation Chart

Corporate Governance Statement — Issue5, December 2011 – Chapter 9.01.8, Page 1

Chapter 9.01.8 - Division of Pathology

PATHOLOGY

Role

The Division of Pathology provides specialist pathology services to the general community, and pathology testing while patients are in hospital and when they return to their homes.

Pathology is a medical specialty looking at disease processes and their cause. Body tissue, blood and other bodily fluids are analysed to assist medical practitioners in identifying the cause and severity of disease, and to monitor treatment. The Division of Pathology is made up of a range of clinical specialities – Anatomical Pathology; Chemical Pathology; Haematology; Cytogenetics; Immunology; Microbiology and Molecular Pathology.

Services are provided at eight collection centres across the ACT and also through a home collection service for when patients are too frail or unwell to attend a community centre. Analysis of collected samples occurs at the two laboratories within the ACT, located at the Canberra Hospital and Calvary Hospital. The Division of Pathology is comprised of: • Anatomical Pathology • Chemical Pathology • Diagnostic Haematology • Diagnostic Immunology • Microbiology • Cytogenetics • Molecular Pathology • Specimen Collection • IT & Laboratory Information Systems • Business Support • Customer Services


• Delivering coordinated services across the clinical specialties and business services sections in a range of settings such as hospitals, clinics, community health centres and the home environment, and

• Facilitating effective internal stakeholder and consumer feedback and representation in service planning, delivery and evaluation.


• Liaising with consumers and other stakeholders to inform day to day operational issues, and longer term planning

http://health.act.gov.au/health-services/canberra-hospital/our-services/act-pathology/


• Supporting mutually beneficial relationships with local, national and international professional bodies and accreditation agencies, and

• Ensuring effective internal communication processed within the Division of Pathology. Strategic planning through:

• Actively participating in the longer-term strategic direction of the Health Directorate and the role of the division within it

• Undertaking annual business planning, reflecting goals of the Health Directorate Corporate Plan, and

• Consulting with consumers, staff and other stakeholders to inform planning and implementation of planning decisions.


• Ensuring adherence to professional accreditation and practice standards within day to day work and policies and procedures of the division

• Using information from clinical review processes and clinical and workplace safety incident management systems to reflect upon processes and practice and identify areas for improvement, and

• Promoting appropriate and targeted professional development through effective performance management.


• Mentoring and providing opportunities for teaching, training and research within the division • Promoting a culture of continuous learning through active demonstration of best practice and

integration of current research into Divisional policies and procedures, and • Working in partnership with tertiary education facilities to provide teaching and training places. Operational management through:

• Accountability of the divisional executive team for allocating, monitoring and reporting on resource use against service targets

• Benchmarking services in terms of quality and efficiency to identify areas for improved performance and

• Ensuring staff of the division are aware of, and adhere to, relevant organisation and divisional policies and procedures.

Reporting structure • The Executive Director of the Pathology Division reports to the Deputy Director-General,

Canberra Hospital & Health Services; • The Directors of Anatomical Pathology, Haematology/Cytogenetics, Chemical Pathology,

Immunology, Microbiology/Molecular Pathology, the Principal Scientist and Director of Operations report to the Executive Director, and form the executive of the division.

Committee representation The Pathology Division Executive Director is represented on the following Tier One committees: • Executive Directors’ Council • Management Advisory Council, • Accreditation Steering Committee,


• Safety and Quality Committee, and • Work Safety Committee The Executive Director of the Division of Pathology represents the Health Directorate at the National Pathology Accreditation Advisory Council (NPAAC).

Organisation Chart


Chapter 9.01.9 - Division of Medicine

MEDICINE

Role The Division of Medicine provides a range of medical specialties and pharmaceutical services. A strong emphasis is placed across all sections on accessible and timely care, delivered to a high standard of safety and quality. This is underpinned by the division’s commitment to research and training. The division works in partnership with professional colleagues, consumers, and a range of government and non-government service providers to ensure the best possible outcomes for clients. Services are predominantly provided at the Canberra Hospital, but may also be provided in community settings or the patient’s home. The Division of Medicine is comprised of: • Renal Services

• Respiratory and Sleep Service • Gastroenterology & Hepatology • Cardiology • Pharmacy • Neurology • Rheumatology • Dermatology • Infectious Disease Prevention and Control • Hospital in the Home • Medical Inpatient Services

• 7A • 8B • 6A

• Endocrinology • Diabetes Services • Chronic Disease Management

• Chronic Care Program • Medical Day Unit • Medical Outpatients


• Delivering coordinated services across the medical specialties in a range of settings such as hospitals, clinics, community health centres and the home environment

• Providing Pharmacy services to all units within Canberra Hospital and Health Services, and • Facilitating effective internal stakeholder and consumer representation in service planning,

delivery and evaluation.



• Promoting effective working relationships with individuals, agencies and networks • Establishing clear processes of communication within the division, and • Demonstrating the Health Directorate’s values in our everyday interactions. Strategic planning through:

• Developing and disseminating an annual business plan for the division that reflects objectives articulated in the Corporate Plan;

• Contributing to the longer-term strategic direction of the Health Directorate and the role of the division within it, and

• Using feedback from consumers and other stakeholders to inform strategic planning.


• Devising strategies in consultation with others stakeholders and facilities for efficient service delivery that optimises quality and access to care,

• Using and participating in clinical review processes and clinical and workplace safety incident management processes, and

• Supporting accreditation processes across the division.


• Providing a range of training places in partnership with tertiary education providers • Mentoring new researchers and seeking opportunities for research within the division, and • Ensuring effective performance management is undertaken to support staff to build their skills

and knowledge to provide best practice services. Operational management through:

• Managing and monitoring resources across the division against service targets • Comparing service delivery costs and standards with benchmarks to initiate and sustain

improvements in quality and efficiency, and • Ensuring appropriate governance mechanisms exist within the division to allow accountability of

team and unit management to the Executive Director.

Reporting structure • The Executive Director of the Division of Medicine reports to the Deputy Director-General,

Canberra Hospital & Health Services • The Director of Pharmacy, Director of Chronic Disease, the Clinical Director of Medicine and the

Director of Nursing report to the Executive Director and form the executive of the division.

Committee representation The Division of Medicine Executive Director is represented on the following Tier One committees: • Executive Directors’ Council; • Management Advisory Council; • Safety and Quality Committee; • Accreditation Steering Committee; and • Work Safety Committee.


Organisation Chart


Chapter 9.02 - Strategy & Corporate

STRATEGY & CORPORATE

Role The Strategy & Corporate Group is led by the Deputy Director-General Strategy & Corporate. The role of the Strategy & Corporate Group is to provide corporate and strategic support to clinical service areas. The group supports the delivery of acute, primary and community healthcare services to the ACT and surrounding region, and plans for workforce and health services needs into the future. Strategy & Corporate provides infrastructure, policy, funding and strategic planning support to the organisation to ensure that clinical services can meet current and future demands. Strategy & Corporate is also responsible for managing government relations, including legislative requirements and management of intradepartmental relationships and for management of Non Government Organisation funding and agreements. The Branches within the Group liaise closely with operational areas and divisions in undertaking their function. All branches work across the Health Directorate. The seven branches of the group are: • E-health & Clinical Records • Professional Leadership, Education & Research • Performance & Innovation • Business & Infrastructure • Policy & Government Relations • Service & Capital Planning, and • Human Resource Management. Detailed information on each of these branches is contained in the following section. Strategy & Corporate negotiates and manages the contractual arrangements between the Health Directorate and the Little Company of Mary for the provision of public hospital services at Calvary Hospital, Bruce. Calvary Public Hospital is required, under the agreement, to meet set performance based objectives and targets as well as quality and safety targets. Calvary Public Hospital reports against this Service Level Agreement to both the Director-General and Minister for Health. While Strategy & Corporate maintains a corporate relationship with Calvary Public Hospital, the Canberra Hospital and Health Services group also maintains a strong operational relationship to ensure effective delivery of clinical services.

Reporting structure • The Deputy Director-General reports directly to the Director-General. • The Deputy Director-General leads the Strategy & Corporate Group through the Strategy &

Corporate Executive.



Committee representation The Deputy Director-General, Strategy & Corporate is represented on the following Tier One committees: • Executive Council • Executive Directors’ Council • Management Advisory Council • Clinical Senate • Safety and Quality Committee • Work Safety Committee • Audit and Risk Management Committee • Workforce Strategy Committee • Redevelopment Committee, and • Information and Communication Technology Committee


Organisation chart


Chapter 9.02.1 – E-health & Clinical Records

E-HEALTH & CLINICAL RECORDS

Role The E-health & Clinical Records Branch is led by the Chief Information Officer (CIO) who provides high-level leadership and advice on policies, planning, and implementation of strategies in relation to health information, Information Communication and Technology (ICT) projects and clinical records management. The E-health & Clinical Records Branch is responsible for: • Implementation and support of the Health Directorate Information Technology (IT) Strategic Plan • Management and support of Health Directorate clinical records across acute, primary and

community based services • Coordination of ICT projects • Management of the relationship with Health Directorate ICT vendors • Financial reporting on Health Directorate use of ICT • Development, implementation and maintenance of ICT policies and procedures, and • Ensuring Health Directorate information security; The Branch is comprised of: • Clinical Records • E-health Strategic Planning • NEHTA & National E-health Initiatives and E-health Projects

• Clinical Systems • Support Systems • Digital Health Infrastructure • ACTHEIM


• Identifying the need for, and undertaking the development of, proposals and business cases for ICT projects

• Co-ordinating ICT projects across the Health Directorate • Managing ICT security within the Health Directorate, and • Coordinating and managing clinical record services across all Divisions of the Health Directorate.


• Providing advice and assistance to all areas of the organisation in relation to clinical records management and ICT projects and issues

• Developing a broad range of strategic partnerships, networks and working relationships with key stakeholders, groups and organisations both within and external to the branch, and





• Undertaking the responsibility for contributing to and maintaining the organisation’s ICT Strategic Plan, and

• Contributing to the planning and implementation of e-Health strategies to support major infrastructure redevelopment under the Capital Asset Development Plan.


• Fostering a culture of best practice and learning within the Branch • Ensuring requirements for ICT projects are developed using sound business analytical processes

and methodologies and are in line with ACT Government policies • Identifying, reviewing, implementing and sustaining improvements in work practices, in

collaboration with consumers and staff • Collaborating within and beyond the organisation to benchmark services for quality and

efficiency, and • Using the Riskman system to report workplace safety and clinical incidents to monitor and flag

issues for improvement.


• Promoting a skilled and motivated workforce within a culture of the learning organisation through effective performance management, and

• Demonstrating and actively supporting working relationships with tertiary education partners through partnerships and collaboration.

Operational management through: • Managing financial resources and targets within budget for the E-Health and Clinical Records

Branch • Comparing project costs and benchmarking services to inform efficiency improvements, and • Building a culture of continuous review and improvement to support improvements in efficiency


Reporting structure • The E-health & Clinical Records Branch is led by the Chief Information Officer (CIO) who reports

to the Deputy Director-General, Strategy & Corporate • The Directors of Clinical Records and Program Directors (Digital Infrastructure, Clinical and

Support) report to the Chief Information Officer and form the executive of the branch. • The Portfolio Information and Communication Technology Committee (ICT governs all ICT policy,

project and strategic decisions, and maintains a watching brief over all ICT projects.

Committee representation The Chief Information Officer is represented on the following Tier One committees: • Executive Directors’ Council • Management Advisory Council • Safety and Quality Committee • Redevelopment Committee, • Work Safety Committee, and • Information and Communication Technology Committee


and represents the Health Directorate on the :

• National Health Electronic Transition Authority (NEHTA) Stakeholder Reference Group; • National E-Health Information Principal Committee (NEHIPC); and • National Chief Information Officer Forum.

Organisation chart


Chapter 9.02.2 – Professional Leadership, Education & Research

PROFESSIONAL LEADERSHIP, EDUCATION & RESEARCH

Role The Professional Leadership, Education & Research Branch provides strategic leadership and high level advice on professional, research and education matters to the Minister, ACT Government, the Health Directorate and other government and non-government agencies as relevant. The branch develops, implements and evaluates key initiatives, policies and frameworks relating to the clinical professions, research, and education; and facilitates effective relationships with key stakeholders to achieve evidence based practice professional standards, models of collaboration and workplace reform. The branch is comprised of the following sections: • Chief Nurse (Nursing & Midwifery Office) • Allied Health Advisor (Allied Health Advisors’ Office) • Principal Medical Advisor • Student Placement Unit • Medical & Dental Professional Standards Unit • GP Advisor • Research Office • Clinical Trials • Academic Unit of General Practice • School of General Practice, Rural & Indigenous Health • School of Clinical Medicine (incl. Health Directorate Library) Strong partnerships exist with a range of vocational and tertiary institutions within the territory to support the work undertaken by the branch. This includes the ANU Medical School (ANUMS), University of Canberra, Canberra Institute of Technology and Charles Sturt University.


• Providing high level strategic advice on professional issues to the ACT Government and the Health Directorate

• Contributing to, developing, and implementing policy relating to clinical professionals, their practice and workforce issues

• Supporting research and clinical trial functions across the organisation, and • Providing clinical teaching and coordination clinical placements across the branch.



• Actively demonstrating an inter-professional approach to professional leadership, research and innovation through tri-partisan accountability and communication within and across the branch

• Building and maintaining key relationships with educational institutions, registration authorities, health professional and peers at the local and national level

• Providing a focal point for communication and professional leadership in relation to contemporary workforce innovation and best practice, and

• Establishing and maintaining a forum of senior health professionals to ensure appropriate linkages with related disciplines across the Territory.


• Establishing and communicating strategic direction on professional issues to the workforce and other stakeholders

• Identifying and building the professional workforce capacity to achieve organisational goals, and • Contributing to the planning and implementation of Health Directorate planning processes,

representing the role of professional groups within it. Safety and quality through:

• Fostering a culture of learning and innovation within the professional workforce • Demonstrating the application of evidence based practice in the delivery of services • Using feedback from staff, consumers and other stakeholders to improve upon the services

offered by the branch • Promoting a skilled and motivated workforce through effective performance management, and • Co-ordinating internal reporting of registration and credentialing processes within the

organisation.


• Supporting the research functions across the Health Directorate • Promoting opportunities for staff to gain experience and expertise in research, teaching and

training, and • Demonstrating and actively supporting working relationships with education partners through

partnerships and collaboration.

Operational management through: • Managing financial resources and targets within budget for the Professional Leadership,

Research and Innovation Branch • Comparing project costs and benchmarking services to inform efficiency improvements, and • Building a culture of continuous review and improvement to support improvements in efficiency


Reporting structure • The Chief Nurse, Allied Health Advisor, Principal Medical Advisor (PMA) as the three

professional leads within the Professional Leadership, Education and Research Branch (PLERB) share operational accountabilities for the Branch and report to the Deputy Director-General Strategy & Corporate.

• The ACT Health Directorate GP Advisor sits within PLERB under the PMA professional reporting arm.


Committee representation The Professional Leadership, Research and Innovation Branch, through the Allied Health Advisor, Chief Nurse and Principal Medical Advisor are represented on the following Tier One committees: • Executive Directors’ Council • Management Advisory Council • Clinical Senate • Safety and Quality Committee • Workforce Strategy Committee, • Work Safety Committee, and • Information and Communication Technology Committee And represent the Health Directorate on the following national committees: • NAHAC (National Allied Health Advisory Committee – Allied Health Advisor) • NAHCC (National Allied Health Classification Committee – Allied Health Advisor) • ANZCCN (Australian & New Zealand Council of Chief Nurses – ACT Chief Nurse)


Organisation chart


Chapter 9.02.3 – Performance & Innovation

PERFORMANCE & INNOVATION

Role The Performance & Innovation Branch is responsible for providing high level, timely and accurate advice to the Minister, Director-General and directorate staff on matters relating to health performance, information management, development of clinical networks and business process redesign. It is also responsible for delivering on the Health Directorate’s national commitments in relation to the provision of information and data. The following sections report directly to the Executive Director of the Branch: • Innovation and re-design • Health Performance • Analysis of Health Finance • Information Management Services, and • Clinical Services Improvement.


• The provision of timely, accurate and relevant health system performance information for the Minister, the public, health service executives, managers, and staff, to ensure accountability and to assist in the identification of areas for system improvement

• Provision of analysis to the Minister and senior officers in relation to health system performance; • Meeting the Government’s commitment to provide health system information to the

Commonwealth Department of Health and Ageing and other national bodies • Managing the directorate’s performance data holdings in line with national and ACT standards,

including the collection, collation, storage and development of data sets • Promoting skills and experience in system improvement and redesign by supporting redesign

efforts undertaken within the organisation • Assisting the directorate to develop models of care within the Capital Asset and Development

Program • Managing the directorate’s Project Management Office, including expert advice on the

development, management, and implementation of projects and providing a central location for the reporting of projects, and

• Managing the elective surgery waiting list and providing policy advice in relation to access to elective surgery in the ACT.


• Promoting and maintaining collegiate relationships with professional groups and stakeholders • Working collaboratively with clinical areas in relation to re-design processes • Working with senior management to develop system performance measures and reports • Establishing partnerships across the organisation to improve the way data is collected and used

to reflect on services and drive system improvement, and


• Providing advice and support to staff across the organisation in relation to the data collection and analysis.


• Contributing to the longer-term strategic direction of the Health Directorate through planning processes

• Ensuring that Government commitments in relation to Performance & Innovation are implemented, and

• Developing and implementing a Performance & Innovation business plan which supports the goals and targets developed by the Health Directorate, in consultation with other service providers and consumers.


• Building capacity within the organisation for process evaluation and re-design • Developing new data systems and processes, in conjunction with other areas of the organisation,

to further improve the type of information available to inform the Minister and senior management, and

• Utilising accurate performance data to inform decisions regarding areas for clinical service improvement.


• Assisting with the development of models of care within a structured change management framework

• Implementing effective performance management to inform professional development and training requirements,

• Working with colleagues across Australia to review, develop and implement new data, information and reporting standards, and

• Working closely with colleague organisations and professional organisations to enhance learning, research activities and the provision of evidence-based practice solutions.


• Ensuring resources within the branch are effectively managed and monitored on a day-to-day basis and in the longer term, and

• Implementation and monitoring of relevant directorate policies and procedures.

Reporting structure • The Executive Director heads up the Performance & Innovation Branch and reports to the

Deputy Director-General, Strategy & Corporate; • The Directors of Innovation and Re-design; Health Performance; Health Financing and Analysis;

Information Management Services and Clinical Services Improvement form the executive of the branch.


Committee representation The Performance & Innovation Branch Executive Director is represented on the following Tier One committees: • Executive Directors’ Council • Management Advisory Council • Safety and Quality Committee • Work Safety Committee • Workforce Strategy Committee; and • Redevelopment Committee.

Organisation Chart


Chapter 9.02.4 - Business and Infrastructure

BUSINESS AND INFRASTRUCTURE

Role The Business and Infrastructure (B&I) Branch is led by the Executive Director who is responsible for providing a range of operational and support services across all areas of the Health Directorate. Services are provided from in-house resources, through managed contracts or through other ACT Government agencies and include: Infrastructure Support • Engineering Services (CADP) • Food Services • Property Management & Maintenance • Domestic & Environmental Services Client Services, Security & Emergency • Security Services • Fire & Emergency • Transport • Communications • Residential Accommodation • Volunteer Services Business Support • Biomedical Engineering • Medical Physics • Medical Technology Systems • Sterilising Systems Strategic Support • Strategic Asset Management • Strategic Procurement • Strategic Supply Management • Tenancy & Asset Management Systems & Reporting • Accreditation Support • Branch Culture & Change Support • Branch Support • Records Management • Business Continuity Planning and Sustainability • Mailroom Services




• Delivering coordinated business and infrastructure services across the Health Directorate, and • Seeking to continuously improve and rationalise services and costs for business and

infrastructure services within the Health Directorate. Communication and collaboration through:

• Developing a broad range of strategic partnerships, networks and working relationships with key stakeholders, groups and organisations within the Health Directorate, with suppliers and with the broader community

• Promoting and maintaining collegiate relationships with professional groups and stakeholders, and

• Working with key stakeholders in relation to improving services, including service providers, community representatives and colleague organisations.


• Participating in the establishment of the longer-term strategic direction of the Health Directorate and the role Business & Infrastructure within it

• Developing portfolio-wide strategies in consultation with individual service units, facilities and consumer representatives for efficient service delivery

• Developing and implementing a Business & Infrastructure business plan which supports the goals and targets developed by the Health Directorate, in consultation with other service providers and consumers

• Improving business support and infrastructure services through technical and process reviews, risk management, monitoring and best practice initiatives, and participating in a continuous quality improvement process and

• Undertaking service planning and implementation of planning decisions jointly with stakeholders.


• Identifying, establishing and maintaining systems and services, which support clinical areas in the provision of effective quality of service and patient safety management systems

• Identifying and implementing systems and services to provide the Health Directorate staff a safe working environment and one which supports the effective provision of clinical and non-clinical services

• Providing business and infrastructure services in a timely manner, with monitoring of service delivery to allow service review and improvements to occur on a ongoing basis, and

• Initiating and participating in activities aimed at improving resource management and service outcomes.


• Building a culture of continuous learning and innovation within the branch • Implementing effective performance management to inform professional development and

training requirements • Working closely with colleague organisations and professional organisations to enhance learning,

research activities and the provision of best practice solutions, and • Achieving and maintaining accreditation..



• Providing leadership and promoting a commitment to high quality customer service principles, practices and attributes, as well as OH&S principles

• Allocating and monitoring resources to ensure the delivery of required services, and • Encouraging and supporting the professional and management development of all staff; and • Implementing directorate policies.

Reporting structure • The Executive Director reports to the Deputy Director-General, Strategy & Corporate Group. • The Directors of Infrastructure Support; Strategic Support; Client Services, Security & Emergency;

Business Support and Systems & Reporting (the management team) report to the Executive Director, Business and Infrastructure.

• The day-to-day management of the Branch is the responsibility of the Executive Director and the management team.

Committee Representation The Executive Director, Business and Infrastructure is represented on the following Tier One committees: • Executive Directors’ Council • Management Advisory Council • Safety and Quality Committee • Workforce Strategy Committee • Work Safety Committee • Redevelopment Committee, and • Information and Communication Technology Committee


Organisation chart


Chapter 9.02.5 – Policy & Government Relations

POLICY & GOVERNMENT RELATIONS

Role The Policy & Government Relations Branch is responsible for providing advice to the Health Directorate and the ACT Government on strategic health policy issues of national, territory-wide and health-sector-wide importance and inter-governmental issues, particularly the National Health Care Agreement, National Partnership Agreements and cross-border agreements. Policy & Government Relations negotiates with funding bodies and service providers and manages service agreements with the non-government and government sectors, including aged care, chronic disease, primary care, community based services, drug and alcohol, home and community care, mental health and Aboriginal and Torres Strait Islander health. In addition, the branch liaises and works closely with commonwealth, other state and territory jurisdictions and other areas of the Health Directorate on strategic health policy, funding agreements, costing issues and other relevant matters. Policy & Government Relations Branch assists other areas of the Health Directorate with the policy development process and with liaison and negotiations with the government, non-government and private sectors as required.


• Providing high level strategic advice on intergovernmental relations, funding arrangements and hospital costs

• Advising on the appropriateness and implications of funding offers from the Commonwealth and other state jurisdictions

• Leading the development and implementation of intergovernmental agreements involving the Health Directorate, including the National Health Care Agreement, and National Partnership Agreements, cross border agreements and Department of Veterans’ Affairs agreements

• Overseeing the process of negotiation of intergovernmental agreements involving the Health Directorate, and

• Leading many Tier 1 policy development processes (see the Policy Management Framework) through effective negotiation and liaison.


• Managing policy areas relating to aged care, chronic disease, primary care, community health, drug and alcohol, home and community care, mental health and Aboriginal and Torres Strait Islander health

• Providing advice and assistance to other areas of the directorate, as required, on the policy development framework and process

• Negotiating and managing funding agreements with relevant non-government and government service providers and assisting other areas of the directorate in negotiations with the non-government and private sectors


• Developing whole-of-directorate policies, which do not fit logically into the responsibility of other areas

• Delivering advice to Government on health matters raised by the ACT Legislative Assembly or other forms of public inquiry on policy, funding arrangements, intergovernmental relations and hospital costs

• Developing a broad range of strategic partnerships, networks and working relationships with key stakeholders within the Health Directorate and across ACT Government Directorates, and



• Working closely with the Australian Government on relevant national policy, funding and costing matters

• Maintaining close working relationships with other directorates on whole-of ACT Government policy issues

• Maintaining formal communication and liaison with other ACT Government bodies on relevant policy, funding and costing issues

• Maintaining communication with non-government organisations, peak bodies and the community on relevant health policy issues, and

• Working with stakeholders to undertake strategic service and implementation planning.


• Reviewing proposed policies to ensure consistency with other existing or proposed policies and adherence to the Policy Management Framework

• Ensuring Directorate compliance with intergovernmental agreements, including regular reporting, data requirements and milestone achievements

• Working with service delivery units to improve standardisation of costs data • Reviewing plans and policies from a client perspective to ensure ongoing quality improvement to

these , and • Participating in activities to improve efficiency of resource management and use by the branch. Research, teaching, training and development through:

• Building a culture of continuous learning and innovation within the branch • Working closely with colleague organisations and professional organisations to enhance learning,

research activities and the provision of best practice solutions, and • Demonstrating work practices that achieve, contribute to and maintain accreditation standards.


• Allocating and monitoring the use of resources to deliver the required work of the branch • Ensuring effective performance management and professional development of staff within the

branch, and • Implementing directorate policies.

Reporting structure • The Executive Director leads the Policy & Government Relations Branch and reports to the

Deputy Director-General, Strategy & Corporate. • Unit managers report to the Executive Director, and form the executive of the branch.


Committee representation The Executive Director of the Policy & Government Relations Branch is represented on the following Tier One committees: • Executive Directors’ Council • Management Advisory Council • Safety and Quality Committee • Information and Communication Technology Committee, and

Work Safety Committee The Executive Director represents the Health Directorate on the National Health Policy Priorities Principal Committee (HPPPC). Organisation chart


Chapter 9.02.6 – Service & Capital Planning

SERVICE & CAPITAL PLANNING

Role The Service & Capital Planning Branch is responsible for: • Leading and facilitating the process of whole-of-government plans (as they relate to the Health

Directorate and health services), the Health Directorate Corporate Plan, Territory-wide strategic plans and clinical service plans that have a Territory-wide impact; and

• The planning, co-ordination and implementation of the Health Directorate Capital Asset Development Program (CADP).

Responsibilities Service delivery through: • Leading the process of planning within the directorate • Overseeing the planning and implementation processes for the Health Directorate infrastructure

program, including development and management of program timeframes and financial control of internal project activities, and

• Linking key contractors involved in the Capital Asset Development Plan with Health Directorate stakeholders.

Communication and collaboration through: • Overseeing the process of stakeholder consultation so that an appropriate range of views can be

incorporated into plans, and that their input is managed in accordance with the project program and report requirements throughout the program

• Providing responses to requests for information to Government, the directorate and the community, and

• Regularly updating executive and staff on progress of major programs, and the implications of this on practice, through a range of communication strategies.

Strategic planning through: • Contributing the expertise of the branch to directorate planning processes, for immediate and

longer term planning, and • Providing high level support and facilitation to the change management process within the

Health Directorate. Safety and quality through: • Ensuring planning is informed by current information relating to policy and evidence-based

practice, and • Ensuring planning is undertaken on the basis of appropriate data collection and analysis.

Operational management through: • Preparing and implementing a business plan for the Branch which reflects the objectives of the

Directorate Corporate Plan, and delivers services required of the branch;



• Effective management of the team, and individuals within it, to deliver a high standard of service in a cohesive, collaborative working environment, and

• Monitoring and effective management of resources to support the work of the branch.

Reporting structure • The Executive Director Service & Capital Planning heads the branch and reports to the Deputy

Director-General, Strategy & Corporate.

Committee representation The Executive Director Service & Capital Planning is represented on the following Tier One Committees:

• Executive Directors’ Council • Management Advisory Council • Safety and Quality Committee • Redevelopment Committee • Work Safety Committee • Director-General’s Steering Committee (CADP), and • Information and Communication Technology Committee

Organisation Chart

Corporate Governance Statement — Issue 5, December 2011– Chapter 9.02.7, Page 1

Chapter 9.02.7 – Human Resource Management

HUMAN RESOURCE MANAGEMENT

Role The Human Resource Management Branch (HRMB) is responsible for a wide range of human resource management services. HRMB provides high-level strategic advice and direction setting on workforce policy, planning and management issues including, people management policy and practice, return to work, workplace relations, leadership development, orientation and staff development. The Branch is organised into seven discrete but inter-related sections: • Human Resources Operations • Workforce Policy and Planning • Workplace Relations • Organisational Development • Case Management, and • Staff Development Unit.

The Executive Director of the Human Resource Branch is also nominated as the Senior Executive Responsible for Business Integrity Risk (SERBIR).

Responsibilities Service delivery through: • Promoting best practice in workforce management through provision of industrial relations

policy development, consultancy, monitoring, advice and advocacy services • Providing advice on complex conditions of employment and advising on workplace disputes,

discipline, grievance and redundancy matters • Developing human resource management capability by coordinating specific human resource

initiatives; frameworks and strategic policy development, and • Providing assistance on employment and recruitment strategies, including overseas recruitment.

Communication and collaboration through: • Developing and maintaining effective local and national networks to assist in delivery of best

practice human resource management services • Working collaboratively with stakeholders, including professional and industrial bodies to

promote a more flexible, responsive and sustainable health workforce, and • Contracting external expertise, as required, to support staff support programs and specific

projects. Strategic planning through: • Ensuring a sustainable, contemporary workforce that is able to provide a quality service through

the use of data to inform planning and the development of competency based workforce to ensure the right person for the job

• Leading workforce planning and policy development across the directorate and within specific operational areas

• Contributing the expertise of the branch to broader directorate planning processes, and


• Managing workforce information to assist the directorate in workforce management and planning.

Safety and quality through: • Facilitating the development of evidence-based policies and protocols to guide human resource

management initiatives, policies and practice • Benchmarking with other organisations and jurisdictions to monitor the services provided to the

directorate in terms of quality and performance, and • Listening to internal consumer feedback to inform continuous improvement of services. Research, teaching, training and development through: • Undertaking research on workforce redesign which includes extended job roles and flexible

practice scopes • Developing and managing the learning and development framework and programs • Coordinating Health Directorate involvement in the Australian Public Service and ACT Public

Service training programs and executive and corporate training schemes, and • Coordinating Health Directorate participation in the Graduate Administrative Assistant Program

(GAA), Study Bank and other organisation wide programs.

Operational Management through • Ensuring a cohesive, collaborative working environment through effective performance

management of HRMB teams, and individuals within these • Allocating, managing and monitoring the resources of the branch to support the work required,

and • Developing a business plan that reflects the objectives of the Directorate Corporate Plan and

identifies the services required of the branch and the strategies that will be implemented to achieve this.

As the Senior Executive Responsible for Business Integrity Risk (SERBIR), the Executive Director of HRMB is responsible for: • Responding to queries and matters of concern raised by staff relating to business integrity • Informing the Audit and Risk Management Committee and the Director-General about matters

relating to business integrity risk, and • Contributing as an active member to the Audit and Risk Management Committee. Reporting structure • Human Resource Management Branch is led by the Executive Director, Human Resource

Management who reports to the Deputy Director-General, Strategy & Corporate Group.

Committee representation The Executive Director, Human Resource Management Branch is represented on the following Tier One committees: • Executive Directors’ Council • Management Advisory Council • Safety and Quality Committee • Audit and Risk Management Committee • Workforce Strategy Committee • Work Safety Committee • Redevelopment Committee, and • Information and Communication Technology Committee


Organisation Chart


Chapter 9.03 – Population Health Division

POPULATION HEALTH DIVISION

Role Population Health Division (PHD) is led by the Chief Health Officer and is responsible for the management of public health issues within the ACT. PHD is comprised of five sections, each with discrete but complementary functions: • Executive Support Office • Policy Support Office • Health Promotion Branch • Epidemiology Branch, and • Health Protection Service.

Responsibilities PHD fulfils a range of statutory responsibilities and delegations under various public health legislation, including Public Health Act 1997, Blood Donation (Transmittable Diseases Act) 1985, Drugs of Dependence Act 1989, Epidemiological Studies (Confidentiality) Act 1992, Food Act 2001, Gene Technology Act 2003, Gene Technology (GM Crop Moratorium) Act 2004, Health Act 1993, Human Cloning and Embryo Research Act 2004, Medicines, Poisons and Therapeutic Goods Act 2008, Radiation Protection Act 2006, Smoke-free Public Places Act 2003, Tobacco Act 1927, Transplantation and Anatomy Act 1978.

The Chief Health Officer is supported by the Population Health Executive Team (PHET) in providing leadership, governance and direction in the development, management and evaluation of service delivery across PHD. Service delivery through multi-disciplinary branches which provide discrete, but complementary functions to achieve agreed outcomes:

• The Policy Support Office (formerly Population Health Executive Office), is responsible for the development and implementation of policy on a range of public health issues, including sexual and reproductive health, blood and blood products, organ and tissue donation, healthcare facility licensing and gene technology.

• The Health Promotion Branch is responsible for policy and program delivery in the areas of health promotion and disease prevention. Health promotion activities aim to strengthen the skills and capabilities of individuals, as well as influence the social, environmental and economic conditions that impact on the health of individuals and the population of the ACT.

• The Epidemiology Branch collects, analyses and disseminates information on the health status and health-related behaviours of the ACT population. This information is used to monitor, evaluate and guide health planning and policy. It provides advice and assistance for research and

















evaluation activities across the health portfolio and broader research community. The cervical cytology register is a unit of the Directorate’s Epidemiology Branch.

• The Health Protection Service manages risks and implements strategies for the prevention of, and timely response to public health events. This is achieved through a range of regulatory and policy activities relating to areas such as food safety, communicable disease control, environmental health, emergency management, pharmaceutical products, tobacco control, and analytical services.

The Chief Health Officer, with support from PHET, holds the following responsibilities: • Contributing a population health perspective to the Health Directorate and government activities,

including planning and implementation • Providing leadership in the development of population health policy in the ACT • Working as a member of the Health Directorate executive to coordinate and deliver population-

focused campaigns • Developing and implementing a business plan for PHD incorporating goals and targets established

by the Directorate and reflecting the overarching priorities established by “Towards A Healthier Australian Capital Territory – A Strategic Framework for Population Health 2010-2015”

• Developing strategies in consultation with other Health Directorate Divisions, ACT Government Directorates, and non-Government agencies for efficient service delivery that optimise quality and equitable access to services

• Regulating and monitoring public health matters such as food safety, communicable disease control and notifiable disease surveillance, environmental health, pharmaceutical products, forensic laboratory testing and tobacco control

• Oversight of health emergency management and response, in collaboration with other Health Directorate Divisions and ACT Government Directorates

• Effectively administering the Health Promotion Grants Program to deliver community development activities for specific populations and settings

• Providing timely and accurate epidemiological information on the health status of the ACT population including production of the biennial report of the Chief Health Officer, and

• Overseeing the cervical cytology register which is a central and confidential list of ACT women’s pap test results. The register, through the cervical screening program, seeks to reduce morbidity and mortality from cervical cancer.

Operational management and coordination through:

• Managing resources effectively across PHD through effective financial, asset, and workforce management

• Accountability for the overall performance of all PHD services • Establishing processes that require a consultative approach to planning and management across

all disciplines and across all work units of the division • Promoting cohesiveness of purpose within PHD and maintaining positive relationships with

other Health Directorate Divisions, ACT Government Directorates, and non-Government agencies

• Supporting Branch managers by identifying solutions to complex operational, process and policy issues

• Facilitating liaison and communication between Divisions of the Directorate, external service providers and other stakeholders, and

• Undertaking scientific analyses in the areas of air quality monitoring, microbiology, illicit drugs, toxicology and forensic chemistry to provide scientific data to support the activities of the Health Protection Service and other ACT government agencies.



• Developing and implementing key public health related legislation • Coordinating policy on a range of population health matters including sexually transmissible and

blood borne infections, blood supply and use, organ and tissue transplantation, and biotechnology, health

• Providing health promotion policy advice at national and local level • Building capacity for health promotion within the organisation, in external agencies and the

broader ACT community through provision of targeted resources and opportunities • Sustaining effective partnerships with key stakeholders in the ACT to develop public health

policy and health promotion in the Canberra community • Developing policy and providing information, monitoring and enforcement in relation to a wide

range of public health activities, including food safety, tobacco control, cooling towers, the safety of recreational and potable waters, medicines and poisons, Radiation Safety and infection control

• Developing a broad range of strategic partnerships, networks and working relationships with key stakeholders, groups and organisations both within and external to the organisation

• Promoting and maintaining a professional collegiate approach to relationships with professional groups, consumers and other stakeholders in relation to the leadership and operational management of population health services, and

• Representing PHD on a variety of forums and present information relevant to a range of audiences and purposes.

Quality and Safety:

• Building capacity for change within PHD to ensure continuous improvement to maximise quality of services and produce optimum efficiency

• Coordinating emergency preparedness across the Health Directorate, including planning for business continuity and liaising on preparedness matters with other agencies

• Undertaking surveillance, investigation and public health management of notifiable diseases; • Promoting and coordinating the ACT component of the national immunisation program, and • Achieving and maintaining accreditation of work practices within PHD, including those promoted

by the Australian Council on Health Care Standards, Australian Commission on Safety and Quality in Healthcare , professional colleges and other relevant accreditation programs.

Research, teaching, training and development by:

• Conducting and commissioning surveys to monitor the status of population health activities and behaviours of the ACT community

• Maintaining registers of specific health population groups such as the ACT Cancer Registry and the ACT Maternal and Perinatal Data Collection, and

• Working closely with tertiary education partners to enhance regional teaching, learning and research activities.

Operational management by:

• Providing leadership and promoting a commitment to high quality customer service principles, practices and attributes

• Establishing safe working practices and a safe working environment • Ensuring effective learning and achievement planning for all staff with linked professional

development, and • Allocating, managing and monitoring PHD’s resources to ensure efficient and effective delivery

of services.


Reporting structure • PHD is led by the Chief Health Officer who reports to the Director-General. • The division is comprised of five branches: Policy Support Office, Executive Support Office, Health

Promotion Branch, Epidemiology Branch and the Health Protection Service. The Directors of each branch, along with the PHD senior staff specialists report to the Chief Health Officer and form the Population Health Executive Team (PHET), which has operational control over the day-to-day activities of Population Health.

Committee representation The Chief Health Officer is represented on the following Tier One committees: Executive Council Executive Director’s Council Management Advisory Council Work Safety Committee Information and Communication Technology Committee Accreditation Steering Committee, and Safety and Quality Committee PHD represents the Health Directorate on the following national committees: Standing Council on Health Sub-committees: • National Health and Medical Research Council • National Commission for Safety and Quality in Healthcare –Accreditation Standards Regulators

Implementation Working Group • Working Group of the Breastfeeding Jurisdictional Senior Officials Group (BJOG) • Inter-jurisdictional Committee on Drugs: Tobacco Standing Committee • Data Linkage working Group (through the Health Policy Priorities Principal Committee (HPPPC) • Jurisdictional Blood Committee

- Jurisdictional Working Group on Cord Blood Banking • Cognate Committee on Organ and Tissue Donation • Australian Population Health Development Principal Committee (APHDPC)

APHDPC subcommittees - The Screening Subcommittee - Gene Technology Standing Committee - Blood Borne Viruses and Sexually Transmissible Infections Subcommittee (BBVSS) - Interim Food and Nutrition Subcommittee - Australian Health Protection Committee (AHPC)

• AHPC sub-committees - Environmental Health Committee (enHealth) - Health All Hazards subcommittee - Communicable Disease Network of Australia (CDNA) CDNA subcommittees: - National Surveillance Committee (NSC), - Seasonal Influenza Surveillance Systems Working Group (SISSWG), - Enhanced Invasive Pneumococcal Disease Surveillance Working Group (EIPSWG), - Case Definitions Working Group (CDWG) - National Immunisation Committee (NIC) - OzFoodNet Working Group


• National Partnership Agreement on Preventive Health sub-committees: - Implementation Working Group (IWG) - Healthies Steering Committee - Campaign Reference Group – National Tobacco Social Marketing Campaign - Campaign Reference Group – Measure up Social Marketing Campaign - Industry Partnership Consultative Forum - Go for 2&5 National Coordination group

Other Ministerial Council Sub-committees: • Environmental Protection and Heritage Council Peer Review Committee • Food Regulation Standing Committee (through the Australia and New Zealand Food Regulation

Ministerial Council) - Implementation Sub-Committee of Food Regulation Standing Committee - Standards Australia FT24 Food Microbiology Committee - Standards Australia FT20 Food Microbiology Committee

• Radiation Health Committee - Radiation Regulators Forum

Australian Institute of Health and Welfare sub-committees • National Perinatal Data Development Committee • Australasian Association of Cancer Registries • Population Health Information Development Group • Public Health Expenditure Technical Advisory Group • Australian Association of Cancer Registration’s Data and Coding Committee Other National Committee representation • Senior Managers of Australian and New Zealand Forensic Laboratories

- Australian and New Zealand Forensic Laboratories - Toxicology Senior Advisory Group - Australian and New Zealand Forensic Laboratories - Illicit Drug Specialist Senior Advisory

Group • National Food Surveillance Network • Senior Officers Working Group for the Labelling Logic Review. • National on-site regulators forum (septic tanks) • National re-use Water regulators forum • Population Health Research Network (PHRN) management group • National Cervical Program Managers meeting

- National Cervical Data managers meetings - National Cervical Data Dictionary and data set Committee - National Cervical Data linkage planning and scoping Committee - National Cervical coding Committee

• National Burden of Disease reference group • Jurisdictional Immunisation Coordinators • National Cancer Data and Coding Committee • Centre for Health record Linkage Advisory Group (CHeRL)


Organisation Chart


Chapter 9.04 - Quality and Safety Unit

QUALITY AND SAFETY UNIT

Role The Quality and Safety Unit is led by the Executive Director and is responsible for a systematic approach to maintaining and improving the quality of patient care and workplace staff safety across the Health Directorate. The Quality and Safety Unit is comprised of three sections, with responsibility for:

• Policy and Projects; • Operational Support; and • Workplace Safety


• leading a multi-disciplinary team of discrete, but complementary functions to achieve agreed outcomes

• contributing high level advice and reporting to the Director-General, senior managers and staff on matters concerning safety and quality of patient care and workplace safety

• working as a member of the Health Directorate executive and fostering a spirit of team cooperation

• building capacity for change within the unit and relevant work teams to ensure continuous improvement to maximise quality of services and produce optimum efficiency

• developing strategies in consultation with other areas and agencies for efficient service delivery that optimises quality and access to services

• monitoring patient safety and quality initiatives to meet legislation requirements • facilitating liaison and communication between teams of the unit, other areas of the Directorate,

external service providers and other stakeholders, and • implementing agreed services for the unit specified by the Health Directorate.


• identifying the potential effect of national health agendas and policy priorities on the Health Directorate and disseminating this to the organisation

• developing, coordinating and implementing key patient care and workplace safety related legislation and policies

• developing a broad range of strategic partnerships, networks and working relationships with key stakeholders, groups and organisations both within and external to the organisation

• promoting and maintaining a professional collegiate approach to relationships with professional groups, consumers and other stakeholders in relation to the leadership and operational management of population health services, and

• representing the unit on a variety of forums and providing feedback on these to relevant staff.


Quality and Safety:

• coordinating accreditation programs • providing continuous improvement in the management of workplace health and safety • delivering a range of staff screening and immunisation programs through the Occupational

Medicine Unit • coordinating engagement of consumers in relation to the delivery of health care services • building capacity for effective consumer engagement within the organisation and the broader

ACT community through provision of targeted resources and opportunities • sustaining effective partnerships with key stakeholders in the ACT, and • coordinating and delivery of targeted patient care and workplace safety programs.

Research, teaching, training and development by:

• monitoring significant inter-divisional and intra-divisional sources of clinical risks and actions to mitigate those risks

• leading the development, management, reporting and evaluation of patient safety functions, activities and outcomes against targets and governance requirements

• ensuring effective investigation, monitoring, analysis and reporting of workplace health and safety issues to drive continuous improvement

• participating in research and evaluation activities • building a culture of continuous learning and innovation • working closely with tertiary education partners to enhance regional teaching, learning and

research activities, and • achieving and maintaining accreditation within the unit, including those promoted by the

Australian Council on Health Care Standards, Quality Improvement Council, Professional Colleges and other relevant accreditation programs.


• accounting for the day-to-day performance of all unit services • developing and implementing a business plan for the Quality and Safety Unit incorporating

goals and targets established by the Directorate • managing technology and physical resources effectively across the unit by effectively managing

current assets and anticipating and responding to emerging technologies • supporting unit managers by identifying solutions to complex operational, process and policy

issues, and • implementing infection control, occupational health & safety and human resource policies and

procedures.

Reporting Structure • The Executive Director Quality and Safety reports to the Director-General. • The Directors of Workplace Safety Section, Operational Support and Policies and Projects report

to the Executive Director and form the executive of the Quality and Safety Unit.


Committee Representation

The Executive Director of the Quality and Safety Unit is represented on the following committees: Internal • Executive Council • Executive Directors’ Council • Management Advisory Council • Clinical Senate • Safety and Quality Committee • Work Safety Committee • Workforce Strategy Committee, and • Information and Communication Technology Committee The Executive Director represents the Health Directorate on the following national committees: • Australian Commission on Safety and Quality in Health care Inter-jurisdictional Committee • ACHS State Advisory Committee

Organisation Chart:


Chapter 9.05 – Financial Management

FINANCIAL MANAGEMENT

Role Financial Management is led by the Chief Finance Officer and is responsible for managing the directorate's budget, financial reporting, general financial support services, patients’ accounts, insurance and co-ordination of legal advice. Financial Management is made up of four teams: • Financial Management Unit ; • Insurance and Legal Liaison ; • Revenue and Financial Services; and • Financial Operations Support.


• Coordinating internal financial reporting within the Health Directorate and meeting the directorate’s external financial reporting responsibility to Treasury

• Providing insurance liaison and advice on behalf of the Health Directorate • Ensuring that the cash flow of the Health Directorate is managed appropriately • Managing a range of specific account and payments processing, including patient admissions and

discharges and Visiting Medical Officer Payments, and • Coordinating centralised debt recovery. Communication and collaboration through:

• Leading and managing the Health Directorate Budget process • Ensuring staff are aware of, and comply with the Financial Management Act, through education

and knowledge of the Director-General Financial Instructions • Coordinating requests for legal advice from the Government Solicitor’s Office • Providing a link between the Health Directorate and Shared Services who are responsible for the

management of the Financial Management Information System, accounts payable, external reporting, general ledger, asset management and banking, and

• Providing support and advice on specialist financial support functions, such as quantative risk analysis, trends and variance.

Strategic planning through: • Ensuring that appropriate insurance cover is maintained for foreseeable organisational risks, and • Actively contributing to the Health Directorate planning processes to address both current and

emerging issues, and plan for future services. Safety and quality through:

• Continually improving insurance and indemnity reporting systems • Reviewing and maintaining the Director-General Financial Instructions • Using feedback from consumers to review and improve upon service delivery, and



• Promoting a culture of best practice across Financial Management, through active performance management and development.


• Providing relevant information to national data collections, and • Creating opportunities for training and development of staff. Operational management through: • Providing corporate financial accounting services, • Implementing relevant policies and procedures • Managing the resources of Financial Management to deliver required services, and • Ensuring managers and supervisors are appropriately trained and supported to implement and

monitor management processes.

Reporting structure • Financial Management is headed by the Chief Finance Officer (CFO) who reports to the Director-

General. • The managers of the Financial Management Unit, Insurance and Legal Liaison, Revenue and

Financial Services and Financial Operations teams report to the Executive Director and form the executive of Financial Management

• External reporting to Treasury is coordinated by Financial Management

Committee representation The Executive Director, Financial Management is represented on the following Tier One committees: • Executive Council • Executive Directors’ Council • Management Advisory Council • Workplace Safety Committee • Work Safety Committee, and • Redevelopment Committee Organisation Chart


Chapter 9.06 – Executive Coordination

EXECUTIVE COORDINATION

Role The Executive Coordination Unit is responsible for providing high level, timely and accurate advice to the Minister, Director-General, and the Health Directorate on administrative, coordination and legislative matters. The Unit also coordinates Health Directorate advice to other Government Directorates as required. The Executive Coordination team delivers support and secretariat services to Ministerial and Health Directorate committees and administers Freedom of Information requests.


• Providing high-level strategic advice to the Minister, Director-General and senior management on administrative, coordination and legislative matters in the form of briefs, ministerial replies, Cabinet documents and Assembly business documents

• Coordinating liaison between the Health Directorate, the Legislative Assembly, Cabinet and the Minister’s Office

• Providing timely and accurate secretariat support to identified Health Directorate committees;, and

• Administering Freedom of Information requests. Communication and collaboration through:

• Coordinating Assembly business and administering the Cabinet and legislation program for the Minister for Health

• Managing the Directorate’s relationship with the Minister through timely provision of briefings and responses to correspondence and through the provision of the Directorate Liaison Officer who works in the Minister’s office

• Managing the Health Directorate’s relationship with the Cabinet Office, including the preparation of Cabinet and Assembly Business

• Coordinating the Directorate’s response to draft legislation, codes of practice, regulations, standards and guidelines

• Managing the relationship with the Ombudsman and preparing documentation for the Ombudsman on request, and

• Developing a broad range of strategic partnerships, networks and working relationships with key stakeholders within the Health Directorate and across ACT Government Directorates.


• Developing directorate-wide strategies in consultation with individual service units, for efficient provision of ministerial and Cabinet services

• Developing and implementing an Executive Coordination Unit business plan which supports the goals and targets developed by the Health Directorate, in consultation with other service providers and consumers, and



• Undertaking service planning and implementation of planning decisions jointly with stakeholders.


• Providing education and advice to Directorate staff as required on issues relating to executive coordination, including ministerial briefings, correspondence and Cabinet documents

• Identifying, establishing and maintaining systems to support the provision of high quality and timely executive coordination services

• Reviewing submitted documents for consistency and adherence to quality standards, and • Using feedback from consumers to ensure ongoing quality improvement to services. Research, teaching, training and development through:

• Building a culture of continuous learning and innovation, underpinned by a commitment to performance management and professional development

• Working closely with colleague units within other agencies and jurisdictions to enhance learning and the implementation of evidence based practices within the unit

• Conducting training and workshops relating to best practice standards for government business, and

• Ensuring accreditation and professional standards are identified and integrated in daily practice. Operational management through:

• Allocating, managing and monitoring the units resources to deliver the required services; • Establishing safe working practices and a safe working environment; • Developing a culture of inclusiveness through collaborative decision making and consultation;

and • Ensuring effective performance management and professional training aligned to meet service

needs.

Reporting structure • The Director, Executive Coordination leads the Executive Coordination Unit and reports to the

Director-General.

Committee representation The Director of the Executive Coordination Unit is represented on the following Tier One committees: • Executive Directors’ Council • Management Advisory Council, • Accreditation Steering Committee, • Work Safety Committee, and • Workforce Strategy Committee Organisation Chart – next page


Organisation chart


Chapter 9.07 – Communications & Marketing Unit

COMMUNICATIONS & MARKETING UNIT

Role The Communications & Marketing Unit is led by the Manager who is responsible for providing high level, strategic and timely advice to the Minister, Director-General and Executive Directors on media, marketing and communications issues. The Communications & Marketing Unit is the point of contact for all media inquiries and responses for the directorate, and liaises and coordinates media activity with the Minister’s Office. The team also leads the development and implementation of communication and marketing strategies, as well as overseeing the design and production of publications and marketing tools. The unit is responsible for organising events that promote health and community care services strategically and creatively to influence the perceptions and support of consumers, the community and staff.


• Advising and liaising with the Minister, the Director-General and Executive Directors on media matters and communications activities

• Leading the development and implementation of Health Directorate communications and marketing strategies

• Marketing health and community care services to create positive perceptions of the organisation, and

• Coordinating and supervising the design and production of publications and promotional material relating to directorate activities, including the Health Directorate Annual Report.


• Coordinating communication between the media, Health Directorate and Minister’s Office • Preparing written responses, media releases and other media-related material • Acting as media spokesperson for the Health Directorate as required • Developing policies and guidelines relating to communication, marketing and media issues • Developing a broad range of strategic partnerships, networks and working relationships with key

stakeholders within the Directorate, across ACT Government directorates and in the broader community

• Promoting the work, vision and values of the Health Directorate through organising media opportunities and events, exhibitions, display activities, public functions and developing and maintaining the Directorate website, and

• Providing a media monitoring service to the portfolio. Strategic planning through: • Advising on, developing and implementing media and communication strategies in relation to

sensitive government matters • Developing directorate-wide strategies in consultation with individual service units, for efficient

service delivery, and



• Developing and implementing a Marketing and Communications business plan which supports the goals and targets developed by the Health Directorate, in consultation with other service providers and consumers.


• Identifying, establishing and maintaining systems and services, which support all areas of the Health Directorate in the provision of effective and high quality marketing and communications strategies

• Reviewing provision of media, marketing and communications services from a consumer perspective and seeking feedback on service provision to ensure ongoing quality improvement, and

• Initiating and participating in activities aimed at improving resource management within the team.


• Building a culture of continuous learning and innovation within the unit • Implementing effective performance management to inform training requirements, and • Working closely with other directorates and professional organisations to enhance learning

opportunities, and the provision of evidence based work practices. Operational management through:

• Developing a business plan for the unit that aligns with the strategic direction of the directorate • Ensuring directorate policies are implemented, to provide an inclusive and safe working

environment, and • Effectively managing the resources of the unit to deliver the required media, marketing and

communication services for the directorate.

Reporting structure • The Manager Communications & Marketing leads the Communications & Marketing Unit and

reports to the Director-General. • The Executive Council governs all strategic decisions regarding communication, marketing and

media matters.

Committee representation The Manager of Communications and Marketing is represented on the following Tier One Committees: • Executive Directors’ Council • Management Advisory Council, and • Work Safety Committee.


Organisation chart


Chapter 9.08 – Internal Audit & Risk Management

INTERNAL AUDIT & RISK MANAGEMENT

Role Internal Audit & Risk Management (IARM) is led by the Manager who is responsible for providing high level, timely and accurate advice to the Director-General, Executive Directors and the Health Directorate Audit and Risk Management Committee on audit and risk management matters. Under the leadership of the Manger, Internal Audit & Risk Management, IARM undertakes internal audit activities including special investigations and manages the Health Directorate audit process. The unit is also responsible for facilitating integrated risk management activities across the organisation and providing secretariat support to the Health Directorate Audit and Risk Management Committee.


• Developing and managing the Health Directorate audit program • Providing high level advice to the Director-General and the Audit and Risk Management

Committee on the level and effectiveness of controls on high risk areas, and • Providing secretariat support to the Health Directorate Audit and Risk Management Committee.


• Reporting on a regular basis to the Audit and Risk Management Committee and the Director-General on the implementation of the audit program and risk related matters

• Managing the development and documentation of policies, practices and procedures for audit and risk management

• Providing advice and assistance to Health Directorate business units regarding audit and risk management issues, and

• Liaising with the ACT Auditor General’s Office concerning Health Directorate audits. Strategic planning through:

• Planning risk based internal audit reviews within the directorate • Representing and contributing the expertise of the Internal Audit and Risk Unit to Health

Directorate planning processes, and • Working collaboratively with external agencies, such as the ACT Auditor-General’s Office and

private contractors to develop a schedule of external audit for the Health Directorate.


• Developing and implementing a system of qualitative and quantitative performance indicators to measure the internal audit and risk management unit performance

• Developing, implementing and maintaining risk management policy and processes within the organisation, and

• Ensuring compliance with legislative requirements and risk management policies.



• Educating Health Directorate managers and staff on risk management • Benchmarking with other jurisdictions and similar organisations to monitor best practice

standards and performance, and • Engaging with relevant professional organisation to ensure continued development of unit staff. Operational Management through: • Effective management of the unit’s resources to ensure service standards are met • Implementing all relevant Health Directorate policies and procedures, and • Ensuring effective performance management of staff within IARM.

Reporting structure • The Manager, Internal Audit & Risk Management reports to the Director-General.

Committee representation The Manager, Internal Audit and Risk Management provides secretariat services to the Audit and Risk Management Committee, and is represented on the following Tier One Committees:

• Executive Directors’ Council, • Management Advisory Council, • Accreditation Steering Committee, and • Safety and Quality Committee.

Organisation structure


Chapter 9.09 – DonateLife ACT

DONATE LIFE ACT

Role Donate Life ACT, formally the ACT Organ and Tissue Donation Service, is part of the national DonateLife Network. Coordinated by the Australian Organ and Tissue Authority, the network aims to achieve a significant and sustained increased in the number of organ and tissue donation and transplantation. The Unit is led by the Medical Director and is responsible for the delivery of the national reform program relating to organ and tissue donation and transplantation in the ACT. The ACT Bone Bank is also integrated with DonateLife ACT.


• Advocating for potential donors and their families • Coordination of the consenting, donation and retrieval process • Providing bereavement support and follow-up, and • Providing health and community education on the organ and tissue donation process. Communication and collaboration through:

• Providing high level advice and expertise to staff of the Health Directorate • Liaising with other jurisdictions and organisations to facilitate organ and tissue donation, and • Promoting the objectives of organ and tissue donation to the broader community.


• Contributing the expertise of Donate Life ACT to both the Health Directorate planning processes, and those of the National Donate Life Network, and

• Representing Donate Life ACT within relevant committees and planning sessions.


• Monitoring performance against both the Health Directorate, and National Donate Life Network standards for service delivery

• Benchmarking with other jurisdictions to ensure best practice standards are maintained, and • Listening to consumer feedback to identify areas for future improvement.


• Engaging with relevant professional and not-for-profit organisations to ensure continued development of unit staff

• Facilitating training placements within the unit, and • Monitoring performance and outcome measures to identify any areas for continuous

improvement.

http://www.donatelife.gov.au/The-Network/ACT.html

http://www.donatelife.gov.au/

http://www.donatelife.gov.au/The-Authority/About-us.html


Operational Management through: • Effective management of the unit’s resources to ensure service standards are met • Implementing all relevant Health Directorate and National DonateLife policies and procedures,

and • Ensuring effective performance management of staff within the unit.

Further information on the work of the unit is available on the Health Directorate Intranet

Reporting structure • The Medical Director, Donate Life ACT reports directly to the Director-General. • The Medical Director leads Donate Life ACT Unit with the support to the Donate Life ACT

Manager who is responsible for the day to day management of the agency. Committee representation Donate Life ACT is represented on the following Donate Life national committees: • State Medical Directors and Jurisdictional Representatives Working Group • State Managers Meeting • Death Audit Working Group • Eye and Tissue Working Group • Communications Reference Group • Donor Family Support Implementation Group, and • Gift of Life National Board Organisation Chart


Corporate Governance Statement — Issue 5,December 2011 – Chapter 9.10, Page 1

Chapter 9.10 – Canberra Hospital Foundation

CANBERRA HOSPITAL FOUNDATION

Role The Canberra Hospital Foundation is a public charitable foundation to raise funds for services and research promoting the health and wellbeing of residents of the Australian Capital Territory and the surrounding region. While acknowledging the role of government in the provision of universal health care, the Canberra Hospital Foundation seeks to engage the community to support and enhance the ACT health care system. Reporting directly to the Director-General, the Foundation utilises direct donation, endowments and bequeaths and fundraising events to assist financial support of new and emerging services, equipment, facilities and research.


• Effective management of donated funds to support new services, equipment, facilities or research both in the short and longer term.


• Promoting the role of a public charitable foundation within the ACT health system • Liaising with relevant areas of the Health Directorate in relation to fundraising opportunities and

support of their work by the foundation, and • Transparent processes for both donation, and grant allocation. Strategic planning through:

• Contributing the expertise of the Canberra Hospital Foundation, and that of its Board to planning processes for the Health Directorate, and

• Ensuring a business plan is in place for the Foundation, and implementing and monitoring this.


• Ensuring the integrity of the foundation is promoted through clear and transparent governance processes, and

• Benchmarking with other jurisdictions and similar organisations to ensure best practice standards are met and maintained.


• Engaging with relevant professional and not-for-profit organisations to ensure continued development of unit staff, and

http://canberrahospitalfoundation.org.au/home/

Corporate Governance Statement — Issue 5,December 2011 – Chapter 9.10, Page 2

• Monitoring performance and outcome measures to identify any areas for continuous improvement.

Operational Management through: • Effective management of the unit’s resources to ensure service standards are met, and • Ensuring effective performance management of staff within the unit.

Reporting structure • The Manager of the Canberra Hospital Foundation reports to the Director-General. • The Board of the Canberra Hospital Foundation provides annual reports to the Director-General.

Organisation chart

Roles and Accountability

Corporate Governance Statement — Issue 5, December 2011– Chapter 10, Page 2

Chapter 10 – The Minister and ACT Legislative Assembly

THE ACT CONSTITUTIONAL FRAMEWORK

The ACT Government was created through Commonwealth laws made under the Australian Constitution in 1988. It is comprised of three elements: The Executive serves the Community, in accordance with the laws of the Territory, through the ACT Public Service. The ACT Executive consists of the Chief Minister and up to 4 other Ministers chosen by the Chief Minister from the Members of the Assembly. The Executive is responsible for the day-to-day government of the ACT. The Executive implements legislation and develops and maintains the ACT budget through the ACT Public Service. The ACT Public Service serves the Executive under the various heads of ACT Directorates. The Legislature or ACT Legislative Assembly consists of 17 full-time members who serve a fixed four-year term. Members are elected by the people of the Territory. The Assembly is responsible for making laws for the peace, order and good government of the Territory, scrutinising the Executive, electing the Chief Minister and debating issues of importance to the people of the Territory.

ACT laws passed by the Legislative Assembly are called Acts and those made by the Federal Parliament in relation to the ACT are called Ordinances.

The Judiciary consists of the judges of the Supreme Court and the magistrates of the Magistrate Court. The judges and magistrates are appointed in accordance with law and can only be removed in exceptional circumstances.

The Judiciary is responsible for dispensing justice in the Territory and ensuring the rule of law.

Public Sector accountability – the Role of the Minister In the ACT Public Sector directorates are accountable to the relevant Ministers for the delivery of Government commitments. Ministers in turn are accountable for their portfolio’s performance to the ACT Legislative Assembly.

Ministerial accountability Ministers are accountable for: • The administration of an ACT Public Service Directorate, statutory authority or Government-

owned corporation • Responding to questions about their administration of a Directorate, and • Introducing Government Bills and guiding their passage through the Legislative Assembly.

Allocation of workloads to Ministers is articulated within the Administrative Arrangements, 2011 (No. 11), outlined more fully in Chapter 4 – Legislation.




Non-executive members’ accountability Those members of the ACT Legislative Assembly, who are not Ministers, are called non - executive members. They may participate in all aspects of proceedings including voting, moving motions, introducing Bills (called Private Members’ Bills), asking questions, raising matters of public importance and lodging petitions. Committees of the Legislative Assembly are made up of non-executive members.

Legislative Assembly Committees Legislative Assembly Committees are responsible for: • Participating in the examination of policy options • Making recommendations to Government about policy directions • Providing input into the legislative process • Facilitating community input into Government decisions • Scrutinising the activities of Government, particularly through the budget estimates process. The Assembly can refer matters to committees or committees can choose their own subjects for inquiry. Standing Committees are usually formed at the beginning of an Assembly’s term. They exist until the next election and generally retain the same members during that term. Each of the standing committees have been given the responsibility for examining and inquiring into particular matters that are associated with the various activities undertaken by Government. Standing committees established under the 7th Assembly (December 2008), which are ongoing are: • The Standing Committee on Health, Community and Social Services • The Standing Committee on Education, Training and Youth Affairs • The Standing Committee on Justice and Community Safety • The Standing Committee on Justice and Community Safety (performing the duties of a Scrutiny of

Bills and Subordinate Legislation Committee), also known as the Scrutiny Committee • The Standing Committee on Planning, Public Works and Territory and Municipal Services • The Standing Committee on Public Accounts • The Standing Committee on Climate Change, Environment and Water, and • The Standing Committee on Administration and Procedure. Select Committees are formed to look at one specific issue. Once they report on that one issue they are dissolved and cease to operate. Their work is done through Committee Inquiries. More information on the Legislative Assembly for the ACT can be found on the internet.

http://www.parliament.act.gov.au/index.asp


Chapter 11 – Director - General

DIRECTOR- GENERAL

Role The Public Sector Management Act provides for the constitution of the ACT Public Service and the establishment of Administrative Units, including the Health Directorate. Through the Administrative Arrangements 2011 (No.1) the Director-General of the Health Directorate has been allocated responsibility for the following matters: • Health policy and infrastructure • Acute health services • Community health services • Cancer services • Aged care and rehabilitation services • Mental health services • Population health services • Local hospital network In addition to the above, the ACT Government may allocate other related responsibilities to the portfolio at any time. The Director-General of the Health Directorate has responsibility for establishing working arrangements within the Directorate to ensure that directorate responsibilities are met in the most effective manner.

Responsibilities

Manage the following strategic issues: • Improve the health of the residents of the ACT though improved access to and safety and

quality of care • Achieve sustainable and strategic growth in the directorate, articulated in and implemented in

alignment with strategic plans Your health-our priority, Health e-Future and Health Directorate Corporate Plan and with national priorities and reforms for health

• Build a culture of learning, innovation and equity through enhanced teaching and research • Implement effective clinical, corporate and professional governance • Establish regular written and face-to-face communication with staff of the Health Directorate

and • Ensure effective and meaningful stakeholder inter-relationships, including the ACT community,

consumers, professional organisations & bodies and other government and non-government agencies.


http://www.legislation.act.gov.au/ni/2011-244/current/pdf/2011-244.pdf

http://health.act.gov.au/c/health?a=sp&did=10241971



Provide effective and ethical leadership: • Drive performance management process for the executive management team • Recruitment of skilled executive managers to the directorate, and • Effectively delegate the implementation of the ACT Government’s priorities in health to

members of the directorate executive and monitor outcomes on a regular basis.

Build effective clinical, corporate and professional governance processes: • Implement an effective clinical, corporate and professional governance framework • Maintain effective credentialing and appointment systems • Maintain and enhance contemporary clinical risk management practices • Provide effective information management to support patient safety, and • Ensure the Quality and Safety Unit operates to enhance patient safety and quality improvement.

Best practice in people management: • Implement electronic performance management agreements and report regularly to executive

on progress • Maintain a rigorous Safety Management System that assures appropriate Occupational Health

and Safety mechanisms are in place across the organisation • Continue efforts in management of active worker’s compensation cases, rehabilitation and

return to work of injured workers as well as effective preventative measures • Promote Equal Employment Opportunity • Enhance organisation wide approaches to reducing staff bullying and harassment • Continue to offer and promote staff training and development opportunities • Implement an effective leadership and development program for senior, middle and aspiring

managers, and • Actively support industrial democracy.

Ensure effective stewardship of financial resources and directorate assets: • Meet agreed budget • Maintain adequate cash reserves • Effective implementation of directorate’s capital asset development and works program,

information management plan and information technology systems • Formulate a directorate-wide asset strategic plan • Achievement of a program of asset maintenance, and • Development of a renewed cross-border agreement in line with the National Healthcare

Agreement.

Lead the effective delivery of Health Services • Development and implementation of a Preventative Health Strategic Framework • Achievement of national screening targets for breast and cervical screening • Implementation of the Youth Smoking Prevention strategy • Maintenance of childhood immunisation • Maintenance of a smoke-free workplace • Effective influenza pandemic plan in place • Effective infectious disease control


• Maintain clinical streaming across the Health Directorate and develop a new clinical stream for women and children

• Implementation of strategies to improve hospital access for booked surgery and emergency patients

• Reduction in bed occupancy rates towards 85% • Achievement of inpatient admission targets and non-admitted patient occasions of service

targets • Reduction in readmission rates • Achievement of mental health inpatient admission targets and non-admitted patient occasions

of service targets, and • Formulation and implementation of a government Drug Action Plan.

Ensure appropriate stakeholder engagement and effectively manage key interrelationships. • Provision of comprehensive and effective advice to the Minister • Effective communication with Medical Staff • Effective cooperation with the Southern NSW and Murrumbidgee Local Health Districts of NSW • Effective liaison with the Division of General Practice, academic institutions and private

hospitals, and • Actively support a Clinical Training Network to pursue new and innovative regional training

opportunities. Continue to promote research and development within the Health Directorate and associated academic institutions • Maintain the Health and Community Care Research Council • Provide support to the ANU Medical School, the Research Office and a research support

program, and • Liaise effectively with all tertiary education partners. Meet all legislative and statutory compliance requirements • Effective progression of Government Health Legislation Program • Compliance with Coronial Recommendations and • Compliance with Relevant Health Legislation. Enhance the Safety and Quality of Health Services • Effective coordination of quality improvement systems and • Update and implement the framework to prevent aggression and bullying in the workplace.

Promote sustainability of health services • Implement a Health Directorate Sustainability Strategy, and • Maintain effective business continuity plans.

Reporting structure • The Director-General of the Health Directorate reports to the Minister for Health • Members of the Executive Council and identified units report to the Director-General.

Committee representation The Director-General is represented on the following Tier One Committees: • Executive Council


• Executive Director’s Council • Management Advisory Council • Safety and Quality Committee • Workplace Safety Committee • Workforce Strategy Committee • Audit and Risk Management Committee (as observer) • Redevelopment Committee, and • Information and Communication Technology Committee

The Director-General is represented on the following national committees: • Australian Health Ministers Advisory Council (AHMAC) • National E-Health Transition Authority Board(NEHTA) • Australian Ministerial Advisory Council on Ageing (MACA) • Council of Australian Governments Health and Ageing Working Group (COAG) • Health Workforce Australia Board (HWA)


Chapter 12 – Public Sector Executives

EMPLOYMENT OF EXECUTIVES

Directors-General and executives in the ACT Public Service (ACTPS) are engaged under contract for periods not exceeding five years. These arrangements are outlined within the Public Sector Management Act 1994, and in detail within the ACTPS Executive Handbook, 2010. Executive contracts focus on performance and accountability, as evidenced by the performance agreement, which forms an integral part of an executive’s contract. The terms and conditions of executive employment are regulated by the: • Contract • Public Sector Management Act 1994 (the PSM Act) • Management Standards or other instruments made under the PSM Act • Determinations made by the Remuneration Tribunal under the Remuneration Tribunal Act 1995,

and • Other ACT Acts as applicable (eg: Health Act). Executive employment is not regulated by any Awards or Certified Agreements made by Fair Work Australia. ROLE OF EXECUTIVES

Executive Capabilities are a way of classifying and describing the behaviours that characterise successful ACT Public Service executives and, by implication, the values and personal attributes that lie behind them. The five key areas are: • Leadership and integrity • Strategic vision • Management acumen • Community and service focus, and • Environment and organisational astuteness. Further information about Executive capabilities can be found on the Public Sector Management and Labour Policy Group website at www.psm.act.gov.au.



http://www.cmd.act.gov.au/__data/assets/pdf_file/0011/116768/exechb.pdf


http://www.cmd.act.gov.au/__data/assets/pdf_file/0003/116769/execcapabil.pdf


KEY ACCOUNTABILITIES OF EXECUTIVES

Within one month of commencement of an executive contract, a performance agreement must be negotiated with the Director-General (or in the case of a Director-General, with the Director-General of the Chief Minister and Cabinet Directorate). It is essential that the performance agreement contains meaningful performance indicators and timeframes against key accountabilities. Performance agreements are required to be reviewed regularly. Key accountabilities underpinning Executive Performance Agreements are: • The Government’s Annual Plan • The Directorate’s Corporate Plan • Strategic Plans in the area of the executive’s responsibility • Corporate behaviour, training and development requirements • Leadership skills • Operational management issues, including:

- Implementation of performance management plans - OH&S performance - Effective application of human resource policies - Financial management and performance - Output and outcomes performance

GENERAL OBLIGATIONS OF EXECUTIVES

As with all staff, executives participate in a performance management process. Within one month of commencement of an executive contract, a performance agreement must be negotiated with their direct supervisor. In addition, as public sector employees, all executives must comply with the general obligations, or code of ethics set out in the Public Sector Management Act 1994. In some instances, the manner in which executives meet these obligations may vary from general staff, with detail on the requirements on this available in the ACTPS Executive Handbook, 2010.




Chapter 13 – Managers and Officers

DEFINITIONS

Manager means a person who has responsibility for planning, organising and leading a work team or activity. Officer includes all employees. Resources mean people, equipment, information, knowledge and funds.

LEGISLATIVE FRAMEWORK

The Public Sector Management Act (the Act) provides the legislative framework for the employment of the majority of staff in the ACT Public Service. The Act sets out general provisions (i.e. values and principles) and primary employment issues including categories of employment, promotion, transfer, appeal and review mechanisms and discipline. The Act is supported by the Public Sector Management Standards. The following sections provide a brief summary of the Public Sector Management Act and the Public Sector Management Standards, as they relate to ACT PS employees:

Code of ethics It is not enough that administrative decisions achieve the right result. The way things are done, and in particular the way public employees behave, is also crucial. Public employees are expected to behave in accordance with the highest ethical standards. Ethical behaviour involves making decisions in a world of competing loyalties, priorities and responsibilities, where it is often not possible to lay down hard and fast rules.

Reasonable care and skill Employees should perform their duties with reasonable care and skill. Public confidence in decision-making and the image of the ACT PS as a whole is directly affected by the actions of individual employees.

Impartiality Staff are obliged to act impartially. Whatever their personal beliefs and preferences, employees must serve the government of the day. Members of the public and other employees must also be treated impartially and fairly.

Probity Employees must act with probity. Probity, or honesty and integrity, is a core public service value. Many other ethical requirements elaborate what it means to act with probity in different situations.







Courtesy and sensitivity Employees are expected to deal with colleagues and clients courteously and sensitively. Excellent client service should be provided for both internal and external clients.

Service to the public Staff should make every effort to understand the intent of the laws and procedures their work involves. While always working within the limits of any discretionary powers they may have, employees should avoid a narrow approach to the needs of the clients they serve.

Anti-harassment or unlawful coercion The Public Sector Management Act prohibits harassment or unlawful coercion of colleagues or members of the public. It is a serious infringement of their rights and will be dealt with accordingly.

Compliance with legal provisions Employees are obliged to comply with the Public Sector Management Act, Public Sector Management Standards and other laws of the Territory. Employees must be familiar with all legislation specific to their work area.

Compliance with lawful directions Staff must comply with any lawful and reasonable direction given by a person having authority to give the direction.

Conflicts of interest Employees should declare and take reasonable actions to avoid conflicts of interest. This includes interests that could conflict, or appear to conflict, with the proper performance of their official duties.

Taking improper advantage of a position or information Employees must not take, or seek to take, improper advantage of their position or official information for personal gain.

Unauthorised disclosure of official information Unauthorised disclosure or leaking of official information is a breach of the Code of Ethics section of the Public Sector Management Act.

Official comment The Public Sector Management Act prohibits public employees from making unauthorised public comments.

Improper use of territory property Official resources are financed by taxpayers’ money. Public employees will be held to account for the use of these resources. In general, official resources should be used only for official purposes.








Reporting fraud, corruption and maladministration As custodians of the public trust and public resources, public employees have a responsibility to report evidence of suspected maladministration, corruption or fraud.

Fairness and equity Equal Employment Opportunity is a key organisational principle of the ACT Public Service. Under the Access and Equity Program, no client or potential client should be disadvantaged in accessing a service or receiving an equitable program outcome by virtue of their background.

Fraud prevention Fraud – the taking or obtaining by deception of money or any other benefit from the government when not entitled to that money or benefit, or attempting to do so – this includes evading a liability to government. Corruption – an officer is corrupt if he or she seeks, obtains or receives any benefit, other than lawful salary and allowances, on the understanding that the officer will do or refrain from doing anything in the course of his or her duties or will attempt to influence any other officer on behalf of any person. Director’s-General have primary responsibility and accountability for the implementation of fraud and corruption control strategies appropriate to their particular directorate. EMPLOYMENT CONDITIONS

The Public Sector Management Act sets out the way in which people (other than Directors-General) can be employed in the ACTPS, including their salaries, career moves, handling of grievances, managing performance, dealing with criminal matters, absences from work and leave conditions. RESPONSIBILITIES & ACCOUNTABILITIES

ALL STAFF

Public Sector employees are accountable to Government for the way in which public service functions are discharged. Public Sector values and principles stipulate that there be a clear delineation between responsibilities and functions. For accountability purposes, performance indicators must be developed and reported against regularly. Within the Health Directorate, a performance management framework and policy exists to support all staff to: • Work towards common outcomes through agreed roles and responsibilities • Improve communication and feedback between staff and management, and • Build an environment of improvement and accountability.

The underlying assumption of performance management in the Health Directorate is that everybody wants to do the best job they can.


http://health.act.gov.au/c/health?a=dlpol&policy=1902516743


As officers of the Health Directorate, all staff are responsible for: • Understanding their role in the team and how it inter-relates with those of colleagues, other

areas and the goals of the organisation • Actively contributing to their team and the broader organisation through planning, evaluation,

review and re-design of systems and practices as required • Understanding their employment conditions, and how these translate to day-to-day activities

and relationships • Being aware of the values of the organisation and how these are demonstrated in their day to

day actions and interactions • Positively engaging in performance management processes to ensure development needs are

identified and supported, and • Reporting and working with their manager in a professional and productive manner.

MANAGERS

Managers are accountable for monitoring and improving the performance of those who report to them. Managers also need to consider the impact of the decisions they make and their interactions with members of staff. Strategic management, through planning, budgeting, implementing and monitoring and reporting and evaluation should be integrated into daily work practices. Managers are responsible for the overall performance of a work team or section, including: • Understanding how the team functions and its’ role within the organisation and conveying this

information to staff and stakeholders • Effectively managing resources to deliver the services required • Demonstrating how corporate goals and objectives translate into day-to-day activities such as

key performance areas, quality and safety strategies and work relationships • Providing leadership through practices such as open and professional communication,

responding to issues in a positive manner and working collaboratively with the team to create a safe and supportive environment that offers opportunities and challenges to staff;

• Ensuring that occupational health and safety principles and practices are observed, and that workplace illness and injury prevention strategies and staff returning to work are supported

• Ensuring that their staff: - Know what their priorities and targets are and how this contributes to the organisation - Are appropriately trained and supported to perform to the required standard - Have access to relevant information, and - Are encouraged and motivated and get recognition for their work.

• Working with staff to develop a work culture recognised for its collaborative problem solving and decision-making through honest communication.


Chapter 14 – Professional Positions and Roles

The inter-relationship between corporate, clinical and professional governance is central to the Health Directorate meeting its key priorities and ensuring the delivery of accessible, high quality and safe health care. To support clinical staff in providing quality and safe services, a range of strategic and operational professional positions and roles exist. These are briefly outlined in this chapter. More detailed information on specific positions is found through relevant duty statements and job descriptions. STRATEGIC PROFESSIONAL POSITIONS Professional Advisors The Health Directorate employs an Allied Health Advisor, Chief Nurse, and Principal Medical Advisor to provide strategic advice and leadership on a broad range of issues impacting upon the relevant workforce, including: • Workforce planning and reform • Workforce recruitment and retention • Professional practice and regulations • Evidence-based practice models, and • Education, research and policy. The advisors develop and maintain Territory wide perspectives relating to their relevant professions. They are supported by clinical professionals and project staff to progress major projects in collaboration with other agencies and institutions as well as from within the directorate. Within the Health Directorate these roles provide relevant professional representation on key committees, and complement line management communication to staff within the professions. The professional advisors liaise closely with clinical leaders within operational areas across the directorate to ensure effective communication and coordination of professional activities across the organisation. General Practice Advisor The General Practice Advisor aims to enhance communication and partnerships between the Health Directorate, the ACT Division of General Practice and General Practitioners (GPs) to facilitate a seamless health service and better patient outcomes. OPERATIONAL PROFESSIONAL ROLES The following descriptions are intended to provide individuals unfamiliar with the Health Directorate with an awareness of the main professional groups working within the directorate. This description is not detailed and does not reflect every position or classification within the organisation. The terms used may vary from those in formal employment agreements.


Operational Support - Allied Health Director, Nursing & Midwifery Executive Director and Medical Services Executive Director These roles provide leadership for professional issues across the operational areas of the organisation. Located in the Operational Support Division of the Canberra Hospital and Health Services , the positions represent the professions on key operational committees and are responsible for driving clinical leadership, strategic planning in relation to operational services and liaising with the relevant professional advisors to implement strategic initiatives. Senior Allied Health Practitioner A Senior Allied Health Practitioner encompasses the Health Professional Classifications 4-6. These roles include the fields of senior/specialist practitioner, tutor/educator/preceptor and manager. These roles demonstrate expertise and specialisation in their field of practice with a high level of accountability and responsibility. They often lead teams of clinicians or student and manage the delivery of services across a range of clinical teams. Allied Health Practitioner An Allied Health Practitioner encompasses the Health Professional Classifications 1 – 3. These positions are typically direct patient care roles, ranging from new graduates to those with at least 3 years experience (or equivalent competency). Staff may have worked for one to many years within these roles.

Summarised from: Allied Health Professional Classifications and Career Structure

Allied Health Assistant (AHA) An Allied Health Assistant is a vocationally trained staff member who supports the delivery of allied health services under the direction of a Health Professional or Senior Health Professional.

Source: Evaluation of the impact of upskilling ACT Health Technical Officers working in Speech Pathology, Physiotherapy and Occupational Therapy

Executive Director Nursing and Midwifery (EDNM) The Executive Director Nursing and Midwifery is responsible for providing high level advice on operational matters and performance related nursing issues to relevant Executive Directors (at their request) and the DDG Canberra Hospital and Health Services. The EDNM has a role in developing and maintaining consistent nursing practice across the Canberra Hospital and Health Services. Director of Nursing (DON) A Director of Nursing provides strong leadership for all professional issues across a specific nursing division. The Director of Nursing is responsible for the operational management, standards of practice and support services within the relevant division of the hospital/health service. Assistant Director of Nursing (ADON) An Assistant Director of Nursing functions either within a Clinical, Management, Research or Educational stream. They demonstrate a strong leadership role and have the ability to apply strategic direction to operational planning and management of staff within a specific nursing division. Nurse Practitioner Educated and endorsed to function autonomously and collaboratively in an advanced and extended clinical nursing role, Nurse Practitioners collaborate with medical officers and other health professionals. They perform advanced assessment, order diagnostic tests and interpret the results, initiate referrals to relevant healthcare providers, and prescribe appropriate medications and other therapies as needed. This role is only available to those employees who are registered as a Nurse



http://www.health.act.gov.au/c/health?a=sendfile&ft=p&fid=-1309203606&sid=

http://www.health.act.gov.au/c/health?a=sendfile&ft=p&fid=-1309203606&sid=


Practitioner with the Nursing and Midwifery Board of Australia in their specific scope of practice, and appointed to a designated Nurse Practitioner position. Clinical Nurse Consultant/Clinical Midwife Consultant A Clinical Nurse Consultant/Clinical Midwife Consultant can provide direct clinical care at an advanced practice level. They are responsible for implementing changes to clinical care based on evidence based practice. The Clinical Nurse Consultant/Clinical Midwife consultant also initiates and leads research and quality improvement activities within their area of expertise. Nurse Manager Nurse Managers are accountable for the management of human and material resources either supporting a division or a specific patient/client area. The Nurse Manager develops policies and standards to provide sound human resource management practices within a defined area. Registered Nurse/Registered Midwife A Registered Nurse and a Registered Midwife (Levels 1 – 2) delivers direct nursing and/or midwifery care. Individuals in these roles range from working under supervision to demonstrating competence in advanced care. Registered Nurses and Midwives may support Enrolled Nurses and supervise clinical students. Enrolled Nurse An Enrolled Nurse (Level 1-2) delivers nursing care to patients/clients in any practice setting under the supervision of a Registered Nurse/Registered Midwife. The role ranges from newly graduate, to those demonstrating competency in an area of extended practice. Enrolled Nurses provide support to student and new graduate Enrolled Nurses. Medical Staff Specialist Employed directly by the Health Directorate, a Medical Staff Specialist is fully registered and meets the requirements of the relevant professional college for the field in which they are working (eg: The Royal Australasian College of Physicians). Visiting Medical Officer Engaged by the Health Directorate on a contractual basis, a Visiting Medical Officer is fully registered and meets the requirements of the relevant professional college for the field in which they are working. Vocational Medical Officer A Vocational Medical Officer is qualified and registered to practice, but is undertaking supervised training to meet the membership requirements of the relevant professional college of the field in which they wish to specialise and work. Pre-vocational Medical Officer A Pre-Vocational Medical Officer is qualified, with conditional registration. They are undertaking mandatory supervised training to gain ongoing registration and have not yet nominated their chosen area of specialty or practice.

http://www.cpmc.edu.au/?page=contents&subpage=our-members




Chapter 15 – Committees

Committees within the Health Directorate are established against the following levels: Tier One – Directorate level Tier Two – Division/branch level and Tier One Sub-Committees Tier Three – Program/team level Information within the organisation is cascaded down from Tier One Committees, and similarly information and issues can be raised at the Tier Three level and reported and managed up through the higher committee tiers. The overarching governance committee for the Health Directorate is the Executive Council.


Executive Council The role of this peak council is to: • support the Director-General to meet responsibilities outlined in the Health Act and other

relevant legislation • make recommendations on the strategic direction, priorities and objectives of the organisation

and endorse plans and actions to achieve the objectives, and • set an example for the corporate culture throughout the organisation. Membership is limited to nine members, comprising: • Director-General (Chair) • Deputy Director-General, Canberra Hospital & Health Services • Deputy Director-General, Strategy & Corporate • Chief Finance Officer • Chief Health Officer • Executive Director, Quality & Safety • Consumer Representative • Academic Representative, and • Chair, Clinical Senate

Sub-Committees Executive Directors’ Council This council provides an opportunity for all Executive members to collaboratively work in partnership with other areas of the Health Directorate to influence policy direction, manage risk and maximise operational effectiveness and to inform Executive Council on strategic operational matters and risk management. There are twenty-six members of the council, including professional advisors and executive directors of the organisation.

Management Advisory Council The membership of the Executive Directors’ Council, key professional positions within divisions and representatives of stakeholder groups including consumers and professional staff across the organisation comprise the Management Advisory Council. The broad membership reflects the role of the council, which is to promote engagement with staff across the organisation, facilitate information sharing and discussion on government priorities and key strategic and operational issues, and to provide advice to the Executive Council.

Clinical Senate The Clinical Senate provides a means for medical practitioners, nurses, allied health professionals, therapeutic, scientific and diagnostic representatives, as well as consumers and carers to assume a leadership role in advising and leading clinical and system wide reform. The group provides a forum for advising the Director-General on matters relating to: • the coordination and development of clinical planning • clinical and resource decision making • other clinical issues of relevance to health service delivery in the ACT, and • issues of key concern to the Director-General.



Safety and Quality Committee Comprising executive and professional advisor positions and academic and consumer representatives, the role of this committee is to: • set strategic directions, priorities and objectives in quality and safety • oversee clinical practice improvement, quality improvement, accreditation, clinical governance

matters (including sentinel events), consumer engagement and clinical policy, and • monitor research activity across the Health Directorate. Work Safety Committee This committee provides a strategic overview of the Directorate’s approach to workplace safety; provides advice and makes recommendations to the Director-General about policies, strategies, allocation of resources and legislative arrangements for workplace health and safety; and addresses whole of agency workplace safety issues that are unable to be resolved at Division or Branch Level. Audit and Risk Management Committee This committee is established to provide assurance and assistance to the Director-General on the directorate’s risk, control and compliance frameworks, and external accountability responsibilities, as prescribed in the Financial Management Act . The committee contributes to management and delivery of health services through oversight of financial statements, internal control, internal audit, external audit and compliance. The membership provides strategic advice to the Director-General on organisation-wide risk management and facilitates the prevention of fraud risk. The Committee is chaired by an independent Chairperson, who is external to the directorate. The Director-General attends meetings as an observer. Workforce Strategy Committee This committee is to: • give strategic context and direction for development of the Health Directorate workforce,

including a focus on workforce planning; recruitment and retention strategies; organisational development, workplace culture and leadership; human resource management, including employee relations and industrial matters; training and education, including essential education and academic linkages and research

• ensure all associated strategies are coordinated, integrated and aligned to the broader Health Directorate strategic objectives, and

• strategically oversee the impact of organisational re-design on the workforce profile and on workplace health and safety.

The membership is comprised of members of the executive, strategic and operational professional advisors, and directors of Human Resource Management Branch sections.

Redevelopment Committee The Redevelopment Committee provides the oversight of the implementation of the ACT Government Health Capital Asset Development Program (CADP) and provides strategic advice and recommendations to ensure that the capital works and infrastructure align with the strategic and endorsed service planning directions of the Health Directorate. The committee includes membership external to the Directorate, including the Minister for Health and representatives from Chief Minister and Cabinet Directorate, Government Solicitor, Treasury, Procurement Solutions and Shared Services ICT. Representatives of THINC Health Australia, the contractor providing project management services, also attend.



Information and Communication Technology Committee This committee provides a forum for: • setting strategic Information and Communication Technology (ICT) direction, priorities and

objectives; and • endorsing plans and actions to achieve the directorate’s objectives, optimise returns on ICT

investment, and ensure continual alignment of ICT strategic planning with the strategic goals of the Health Directorate.

Membership is comprised of members of the executive, professional advisors, representatives of Shared Services ICT, health care consumers, Calvary Public Hospital, and ACT Division of General Practice. Accreditation Steering Committee This committee provides a forum for: • strategic advice on accreditation activities in the Health Directorate; • monitor progress reports from Accreditation Portfolio Leaders; • monitor QSU Accreditation and Evaluation Team progress against accreditation milestones • endorse annual self assessment report prior to its presentation to Executive Council, and • Provide regular reports to Executive Council on the organisation’s progress towards

accreditation.


Chapter 16 – External Agencies

EXTERNAL AGENCIES

On a day -to-day basis, the Health Directorate is accountable for its services and actions to the ACT community. This occurs through everyday interactions to more formal consultative and reporting processes. Identified as a core objective of the Corporate Plan 2010-2012, the experience of patients and their carers of the ACT health system is more fully outlined within the Consumer Experience section of this document. In addition to direct accountability to the community, the Health Directorate demonstrates accountability and transparency through a number of formal external scrutiny processes:

Accreditation The Australian Council of Healthcare Standards (ACHS) is a national accreditation body that provides external review and rating of health services against established best practice standards including mandatory criterion. Corporate and operational areas of the Health Directorate participate in the ACHS accreditation cycle to review, monitor and improve upon their services. In addition, some clinical areas and services participate in additional specialty accreditation systems that are relevant to their particular specialty.

The Human Rights Commission The Human Rights Commission manages claims of unlawful discrimination and complaints regarding health services, services for older people, disability services and services for children and young people. The Health Services Commissioner of the Human Rights Commission is mandated to deal with complaints about the provision of health services and services for older people, and complaints about contraventions of the privacy principles or of a consumer's right of access to his or her health records under the Health Records (Privacy and Access) Act 1997.

Judicial and administrative reviews External scrutiny of the health portfolio may include judicial and administrative tribunals, as well as review by the Office of the Auditor-General or the ACT Ombudsman.

Government inquiries and reports As outlined in Chapter 10, there are ACT Legislative Assembly Committee Inquiries with a particular focus on health and community services. In terms of the Health portfolio, the most important committee is the Standing Committee on Health, Community and Social Services.

Disclosure, transparency and Freedom of Information (FOI) This issue is discussed in detail in the Disclosure, Transparency and Freedom of Information chapter within the Consumer Experience section.


http://www.achs.org.au/


http://www.audit.act.gov.au/

http://ombudsman/

http://ombudsman/

http://www.legassembly.act.gov.au/

Sustainability


Chapter 17 - Sustainability

The Health Directorate seeks to work towards collaborative leadership, healthy ecosystems, wellness, resilience and environmental security for staff, clients and the broader community. This vision and supporting objectives are articulated within the Sustainability Strategy. The strategy was developed to ensure alignment with the ACT Canberra Plan and the ACT Climate Change strategy “Weathering the change”. However, the scope of the document is not restricted solely to environmental sustainability issues. Identified as one of two overarching objectives of the 2010-2012 Corporate Plan, sustainability is seen as driving change and influencing the manner in which all activity is undertaken within the Directorate. To reflect this, the Health Directorate is aiming to embed sustainability within all areas of work with the purpose of: • Minimising risk and cost from reactionary, fragmented decisions • Future proofing for success in this dynamically changing environment, and • Developing actions directed at ensuring sustainable provisions of services for the future. The sustainability vision aligns with focus areas of activity: • Models of Care • Buildings and Infrastructure • The Digital Health Environment • Transport • Regulatory Environment • Workforce, and • Partnerships and External Service Delivery Embedding sustainability into the culture of the Health Directorate will be achieved by alignment of all business and clinical areas within the Directorate with the outcomes stipulated in the vision, supported by effective communication and innovation.

http://inhealth/PPR/Policy%20and%20Plans%20Register/Sustainability%20Strategy.pdf

http://www.cmd.act.gov.au/policystrategic/canberraplan

http://www.environment.act.gov.au/climate_change/weathering_the_change/Climate_Change_Strategy.pdf


Consumer Experience


COMMITMENT TO CONSUMER AND CARER INVOLVEMENT

Within health systems internationally and nationally, a range of terms are used to describe consumers of health care. Traditionally, the term patient has been used in acute care settings and to describe the role relationship of ‘doctor and patient’. The term client or consumer has been used more frequently in community based settings. Within Australia, many health agencies use both ‘patient’ and ‘consumer ’, to reflect the different context in which individuals may interact with an organisation (eg: Department of Health and Ageing). With increased information resources available to them, the community can be considered as pro-active consumers of health care, who actively seek specific services, query treatment approaches or conduct their own research into a diagnosis (Calabretta, N, Consumer-driven, patient centred health care in the age of electronic information, J Med Libr Assoc. 2002 January; 90(1): 32–37. Accessed June 2011). This is also reflected in the terminology used by agencies established to represent users of health care services, such as the Consumers Health Care Forum of Australia and Health Care Consumers Association of the ACT. For the purposes of this document, the terms ‘patient’ and ‘consumer’ are used. The Health Directorate is committed to consumer and carer participation for the purposes of: • recognising the consumer as the primary member of the health care team • improving the safety and quality of services • improving health outcomes for consumers through their active involvement in their own health

care • providing equitable care and access to services, and • ensuring consumer satisfaction with our services. Consumers and their carers participate in decision making though a range of opportunities, including: • actively participating in their own health care, through consumer and family-centred care service

models • community engagement • consumer representation • advisory bodies • consumer feedback, and • external scrutiny through external agencies and disclosure, transparency and Freedom of

Information. Information is provided in more detail on these processes, excluding external scrutiny, within the following section. Information on consumer involvement, through external agencies is contained within Chapter 16 of this document.

http://www.health.gov.au/internet/main/publishing.nsf/Content/Home

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC64755/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC64755/

https://www.chf.org.au/

http://www.hcca.org.au/cms/index.php?page=about_hcca

http://www.hcca.org.au/cms/index.php?page=about_hcca


Chapter 18 – Patient and Family Centred Care

PATIENT AND FAMILY CENTRED CARE

‘Patient-centred care is health care that is respectful of, and responsive to, the preferences, needs and values of patients and consumers. The widely accepted dimensions of patient-centred care are respect, emotional support, physical comfort, information and communication, continuity and transition, care coordination, involvement of family and carers and access to care.

Research demonstrates that patient centred care improves the experience of health care and creates public value for services. When health professionals, managers, patients, families and carers work in partnership, the quality and safety of health care rise, costs decrease, provider satisfaction increases and patient care experience improves.’

Patient Centred Care: Improving quality and safety through partnerships with patients and consumers

Australian Commission on Safety and Quality in Health Care - Patient and Consumer Centred Care(2011)

As identified in the following extract, a focus is on the collaborative approach:

‘Patient and family-centered care .... is characterized by a collaborative approach to caregiving and decision-making. Each party respects the knowledge, skills, and experience that the other brings to health care encounters. The patient, family and health care team collaboratively assess the needs and development of the treatment plan.1

Institute of Patient- and Family- Centered Care Context In recent years a number of activities across the Health Directorate have converged toward the need for a more structured and systematic approach to improving our delivery of patient and family centred care. Increased international and national discussion and consumer advocacy on these issues have also been key drivers of change.

Since 2007 the Innovation and Re-design Unit has conducted formal interviews with consumers and families as part of their innovation and redesign methodology. More recently, this has been extended to interviewing staff to better understand the gap between staff, patient and family expectations of a health care experience.

Similarly, while developing new Models of Care as part of the Capital Asset Development Program, staff identified patient and/or family centred care as their primary guiding principle, but experienced some difficulty articulating exactly what is meant by this term.

In addition, a recurrent theme in consumer and patient feedback to the Health Directorate is about the need to improve communication with consumers and families and involve them more in decision making.

Most recently, the discussion paper ‘Towards a Patient and Family Centred Model in the ACT2, released in January 2011, discusses the definition of patient and family centred care (PFCC), the

1 Institute of Patient- and Family- Centered Care viewed on 15th July 2010 at http://www.ipfcc.org/faq.html 2 ACT Health, Towards a Patient and Family Centred Model in the ACT, January 2010

http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PCCC

http://www.ipfcc.org/faq.html

http://acthealth/c/healthintranet?a=sendfile&ft=p&fid=1300315053&sid=


results of international work and makes recommendations for how to move forward in the ACT with this work.

The Innovation and Re-design Unit are now piloting a process with the Division of Women, Youth and Children for introducing the patient and family centred care model across the Health Directorate.

Listening to the consumer experience The methodology of interview and ‘shadowing’ patients, their families and staff that has been used since 2007 has provided the Health Directorate with considerable insight into how we provide services and how these are experienced. Analysis of this data shows that there continues to be room for improvement in the way we partner with consumers and families to achieve the best possible outcomes. Areas consistently requiring improvement include: • information • communication and education • coordination and integration of care • emotional support, and • transition and continuity.

The collection methods of consumer and staff experiences across the Health Directorate have expanded over the years. However, the Picker principles continue to be used as the analysis tool. These principles were established by the Picker Institute3 following 8000 interviews with consumers and families to ascertain what people expect from their health care experience: Respect for patients’ values, preferences and expressed needs Coordination and integration of care Information, communication and education Physical comfort Emotional support and alleviation of fear and anxiety Involvement of family and friends Transition and continuity; and Access to care

Picker Institute, 2011

Alignment Consumer and family centred care is aligned with, and informs a number of key documents and areas of work across the organisation, including:

• ACT Health Corporate Plan 2010 – 2012 • Redesign/improvement projects • the Capital Asset Development Program • National Access Program; • Models of Care development.

3 Picker Institute viewed 25th May 2011 at http://pickerinstitute.org/

http://pickerinstitute.org/


http://acthealth/c/HealthIntranet?a=da&did=5307903


http://acthealth/c/HealthIntranet?a=da&did=5309656&pid=1287710871&sid=

http://acthealth/c/HealthIntranet?a=da&did=5309656&pid=1287707608&sid=


Chapter 19 – Community Engagement

COMMUNITY ENGAGEMENT

The ACT Government is committed to engaging the Canberra community in the development and delivery of government policies, programs, public works and services. Engagement with the community is an everyday feature of government business. It can range from responding to a telephone query from a member of the public to a complex service planning issue requiring community input.

Community engagement is any activity that enables the government to: • respond to issues raised by the community • inform the community about proposed government policies and actions • provide the opportunity for the community to voice an opinion on proposed government

policies and proposals • invite the community to submit proposals for government consideration, or • work more closely with the community to shape policy options and priorities.

The ACT Government has established an online Community Engagement site to support this process. The site provides an overview of the community engagement process, the benefits this can achieve for both the community and government and provides a succinct listing of current public engagement processes. Engaging Canberrans - a guide to community engagement available on this site, is a manual to provide government directorates with guidance to planning, conducting and evaluating a community engagement activity and suggests a range of tools and techniques that government agencies can use.

The Health Directorate and Community Engagement A consumer or carer perspective brings different and important dimensions to what constitutes safe and quality health care. It is only by working in partnership with consumers, carers and community members and listening to and learning from their participation, that it is possible for health services to truly appreciate what constitutes quality, safe health care The Health Directorate has prioritised the consumer experience within the Corporate Plan 2010-2012, with this influencing all aspects of the directorate’s activity. Prior corporate and annual business plans also demonstrate an emphasis on effectively partnering with consumers and the broader community to inform decision making relating to our health services. Overall, there is evidence that consumer participation frequently adds different information from that provided by government, researchers and health service providers. Engagement is enhanced when there is clarity and understanding between government and community about the level of participation being offered. The right level of engagement is critical to the value of the exercise and can help manage expectations.

http://www.communityengagement.act.gov.au/engagement_process

http://www.communityengagement.act.gov.au/__data/assets/pdf_file/0005/240890/Community_engagement_July2011_FA_screen.pdff




Levels of community engagement There are four levels of community engagement: Information – provides the public with information on government decisions and activities. Mechanisms include fact sheets, web sites, advertisements, information kits and 1800 phone numbers. Consultation – used when community input is required to influence the government’s decision on a preferred option on a particular matter when the issues existing and options available are well developed and articulated. Mechanisms include public comment and submission, focus groups, surveys and interviews with stakeholders. Involvement – working with the community to develop policy options. Community involvement is also referred to as multilateral communication. Community involvement is used when issues are more complex and the community’s ideas are sought to help shape policy options as well as analyse pros and cons. Mechanisms include working groups, public workshops and consultative committees. Collaboration – partnering with the public in the consideration of issues and preferred solutions. Collaboration is used when there is an opportunity for shared agenda setting and substantial timeframes for deliberation on an issue. Mechanisms include: strategic advisory boards, committees, consensus building forums and round table discussions. A community engagement or consultation activity may include: • the general community • peak bodies • community organisations • diverse groups, and • consumers.

CONSUMER ENGAGEMENT

To ensure effective engagement with and consultation of health care consumers, the Health Directorate provides funding and support to the Health Care Consumers Association of the ACT to co-ordinate and provide consumer involvement in a range of activities for collecting, monitoring and facilitating a consumer perspective to improve ACT public health services. Responsibilities of the Health Care Consumers Association of the ACT include: The provision of a Consumer Representatives Program • a comprehensive program to resource, support and facilitate effective participation by

consumer representatives in activities and mechanisms related to safety and quality, planning, development, delivery monitoring and evaluation of public health services and broader health policies in the ACT, and

• provision of advice on and the development of alternative methods/mechanisms for consumer involvement in these activities.

The provision of a consumer perspective in other projects including: • development of strategic health policies • involvement in Health Directorate quality and safety activities, and • liaison with the Territory, health care providers and other local or national government,

consumer and community organisations, groups and agencies regarding consumer participation in providing advice.

http://www.hcca.org.au/


CONSUMER AND CARER FEEDBACK

Consumer feedback is any information that a consumer provides about their experiences while using your service. Consumer feedback can be a compliment, a comment or a complaint.

The Health Directorate consumer feedback program is called Listening & Learning. By listening to and learning from consumer feedback, it is possible for Health Directorate staff to truly appreciate what constitutes quality and safe health care from the perspective of our consumers. The ACT Health Consumer Feedback Standards have been developed to improve the quality and safety of health care in the ACT. Implementation of the standards will ensure that quality improvements are made to the way services are delivered as a result of Consumer Feedback.

Important principles underlie the handling of consumer feedback within the directorate. The Consumer Feedback Management policy and procedures outline the principles, and roles & responsibilities for staff who receive consumer feedback and instruction on how to progress the feedback to resolution. The Consumer Engagement Team works within the Quality and Safety Unit. The team provides advice and liaison for consumers, carers and Directorate staff in matters relating to consumer feedback and consumer engagement more broadly. EXTERNAL SCRUTINY

The Health Directorate demonstrates accountability and transparency through a number of external scrutiny processes. These are outlined within Chapter 16 – External Agencies and Chapter 21 Disclosure, Transparency & Freedom of Information.

http://inhealth/PPR/Policy%20and%20Plans%20Register/Consumer%20Feedback%20Standards%20-%20Listening%20and%20Learning.pdf

http://inhealth/PPR/Policy%20and%20Plans%20Register/Consumer%20Feedback%20Standards%20-%20Listening%20and%20Learning.pdf

http://inhealth/PPR/Policy%20and%20Plans%20Register/Consumer%20Feedback%20Management.pdf


Chapter 20 – Advisory and Consultative Process

The Health Directorate values the perspective that patients, health care consumers and the broader community, including individuals with specific expertise can bring to key advisory committees. Membership of committees may be appointed at the Ministerial level, by the Director-General or by relevant Executive Directors. Detail of committee’s appointed by either the Minister or Director-General are outlined below: ADVISORY COMMITTEES APPOINTED BY MINISTER FOR HEALTH ACT LOCAL HOSPITAL NETWORK (LHN) COUNCIL

Membership The LHN Council has a minimum membership of six and a maximum of ten members.

Role and Function Arising from the National Health and Hospitals Network Agreement in 2010, the ACT Local Hospital Network (LHN) is comprised of the Canberra Hospital, Calvary Public Hospital, Clare Holland House and the Queen Elizabeth II Family Centre, with the Health Directorate managing service contracts. The ACT LHN Council (the Council) provides key strategic advice to the ACT Local Hospital Network, the Director-General of Health and the ACT Minister for Health on operational matters critical to the ACT LHN’s success. The membership and key functions of the Council are identified within the Health Act. Commencing in 2011, the ACT Government intends to review the ACT LHN arrangements after 12 months of operation. ACT MINISTERIAL ADVISORY COUNCIL ON MENTAL HEALTH Membership The Ministerial Advisory Council on Mental Health (MACMH) consists of six members. Members are individuals with particular mental health expertise, appointed by the Minister, 3 ex-officio members and 2 secretariat positions from the Health Directorate. The Minister of Health chairs the Council.

Role and Function Established in 2009 under legislation, the Ministerial Advisory Council on Mental Health ensures that consumers of mental health services, carers and the non-government sector are able to provide advice to Government on mental health policy and services. The council meets four times a year. The objective of the council is to provide advice to the ACT Minister of Health on mental health consumer and carer interests, policy and services where they: • represent an emerging, important and urgent matter for the mental health services system • were not foreseen when the Mental Health Services Plan 2009-2014 (MHSP 09-14) was drafted • were included in the MHSP 09-14 but are at risk of not being implemented without special

attention, and • provide an opportunity for collaboration between the Council and the Mental Health SOG (a

strategic oversight group, co-chaired between the Health Directorate and the ACT Mental Health Consumers Network that provides oversight of the implementation of the Mental Health Services Plan).


HEALTH DIRECTORATE HEALTH & MEDICAL RESEARCH COUNCIL

Membership The Health Directorate Health & Medical Research Council has no less than ten and no more than twelve members appointed by the Minister for Health.

Role and Function The council provides advice to the Minister for Health and the Health Directorate on the: • Coherent development of the health research sector in the ACT, including communication

networks, training in research and major research collaborations • Disbursement of funds from the Health Research Support Program, including assessment of

grants submissions • Health research policy and programs, including conducting reviews of specific research activities

as requested, and • Planning for the strategic development of research facilities and infrastructure in the ACT. The Health Directorate Health & Medical Research Council reports annually to the Minister for Health. The council maintains linkages with the Health Directorate Human Research Ethics Committee, the Clinical Senate, the ACT Knowledge Based Economy Board and groups responsible for health and medical research policy nationally and in other jurisdictions. DRUGS ADVISORY COMMITTEE

Membership The Drugs Advisory Committee is appointed by the Minister for Health in accordance with Section 66 of the Drugs of Dependence Act 1989. Members are appointed for a period of three years. There are currently three members, including the chair. The committee meets approximately three times a year.

Role and Function The aim of the Drugs Advisory Committee is to: • Advise the Chief Health Officer on the prescription of drugs of dependence and to ensure that

such prescription is consistent with high standards of ethical practice • Progress referrals from the Chief Health Officer • Determine appeals against the Chief Health Officer’s decisions in regard to the prescription of

drugs of dependence • Direct the Chief Health Officer to grant, vary or refuse an application to prescribe a drug of

dependence, and • Provide policy advice, which reflects current best practice on guidelines for the prescribing of

drugs of dependence. SEXUAL HEALTH, HIV/AIDS, HEPATITIS C AND RELATED DISEASES - MINISTERIAL ADVISORY COUNCIL (SHARHD)

Membership SHARHD has nine members including the chairperson, appointed by the Minister for Health.



Role and Function The council provides advice to the Health Directorate and to the Minister for Health on a range of matters relating to the prevention and management of sexually transmissible infections and blood-borne viruses in the ACT, with a particular emphasis on HIV/AIDS and Hepatitis C. Meetings are held every three months. ADVISORY COMMITTEES ESTABLISHED BY THE DIRECTOR-GENERAL HEALTH DIRECTORATE - PRIVATE HOSPITAL LIAISON COMMITTEE

Membership The Health Directorate- Private Hospital Liaison Committee is made up of the heads of all ACT public and private hospitals. The Director-General chairs the committee.

Role and Function The Health Directorate - Private Hospital Liaison Committee was established to provide a regular forum for private hospitals and the Health Directorate to exchange information. The role of the committee is to: • provide a forum for exchange of information between private hospitals and the Health

Directorate • provide a forum for coordination of joint initiatives, and • coordinate common policy interests between private hospitals and the Health Directorate. HEALTH DIRECTORATE - TERTIARY EDUCATION LIAISON COMMITTEE

Membership The Health Directorate - Tertiary Education Liaison Committee is made up of representatives of ACT tertiary education institutions, representatives of the Health Directorate and representatives of the Community Services Directorate. The Director-General chairs the committee.

Role and Function The purpose of this committee is to improve communication and interaction between the Health Directorate and tertiary education organisations within the ACT. The committee was established to: • provide a forum for tertiary education institutions to raise issues within the directorate • provide a forum for the joint planning of the interaction between the Health Directorate and

tertiary education institutions • provide a formal framework for workforce development issues to be shared between tertiary

education institutions and the Health Directorate • explore undergraduate training opportunities and resolve issues arising from undergraduate

training programs, and • provide a forum for the development of postgraduate training programs, including PhD studies.


HEALTH DIRECTORATE HUMAN RESEARCH ETHICS COMMITTEE

Membership The Health Directorate Human Research Ethics Committee has ten members appointed by the Director-General of Health.

Role and function: The Human Research Ethics Committee is responsible for: • considering ethical implications of all proposed research that involves patients or staff of the

Health Directorate and to determine whether or not they are acceptable on ethical grounds • providing the surveillance and monitoring of research projects until completion, so that the

Committee may be satisfied that they continue to conform with approved ethical standards • approving the use of investigational drugs as appropriate • maintaining a record of all proposed research projects • establishing and maintaining communication with the National Health & Medical Research

Council’s (NH&MRC) Australian Health Ethics Committee and provide access to information on request, and

• considering and providing advice on ethical considerations associated with issues referred to it by the Minister for Health or the community.


Chapter 21 – Disclosure, Transparency and Freedom of Information

Access to health information is a sensitive matter. It is often necessary to balance the right to privacy with the right to know. The Health Directorate operates within a strict legislative framework but as far as possible attempts to be open and accountable in arranging the provision of access to information about health and the services we provide.

FREEDOM OF INFORMATION (FOI)

ACT Freedom of Information Act 1989 - gives citizens a legally enforceable right of access to official information in documentary form held by Ministers and directorates, except where exception in accordance with the legislation are applied or an essential public interest requires confidentiality to be maintained. The legislation also provides the right to require information about the operations of ACT directorates to be made publicly available, particularly rules and practices affecting citizens in their dealings with those directorates. Directorates are required to report on Freedom of Information (FOI) matters in the form of annual FOI Statements. The Health Directorate’s Freedom of Information (FOI) Officer coordinates requests on behalf of the agency. The Officer maintains the agency’s FOI Statement Register, including its index of documents used by officers of the Directorate to make decisions or recommendations affecting members of the public. Documents that may be considered under FOI include: • Copies of Health Directorate contracts with medical officers, specialists and private medical

practitioners with visiting rights to hospitals; • Copies of briefing notes, submissions, minutes and reports relating to directorate functions,

prepared for the Ministers and for advisory bodies and working parties; • Databases relating to personnel administration, assets registers, inpatient morbidity statistics

and accounting systems; • Files on general policy and procedural matters; • Legislative Assembly questions, ministerial briefings, financial management, public health and

health inspections, general correspondence and files on establishments and secretarial matters; • Publications, manuals and guidance for agency; and • Maps and plans of Health Directorate facilities, such as hospitals and health centres, working

plans and drawings for proposed buildings or facilities under alteration or construction, and maps of the ACT and surrounding region used for the planning and delivery of services.

ACCESS TO CLINICAL RECORDS

The Health Directorate holds medical and client records at many of its functional units. These include clinical records relating to inpatient and non-admitted patient activity occurring at hospital, health centres, other facilities and the patients home. Members of the public can have access to these records under the Health Records (Privacy and Access) Act 1997. Access to the clinical record is managed under the auspices of the Health Directorate Clinical Records Department.





PUBLIC INTEREST DISCLOSURE

Disclosures under the Public Interest Disclosure Act 1994 are received and dealt with by the Director-General of the Health Directorate or their delegate. The Health Directorate is committed to ensuring that integrity, trust, accountability and ethics are respected across the service. The Health Directorate respects all disclosures and takes all necessary steps to ensure the protection of a person making a disclosure, including maintaining confidentiality and privacy. All investigations are conducted in line with the principles of natural justice and procedural fairness. The Health Directorate will take any reasonable and necessary action to prevent alleged misconduct from continuing or reprisals from occurring and to institute appropriate and timely action, including possible criminal charges, when warranted. The contact person within the Directorate is the Senior Executive Responsible for Business Integrity Risk, who can be contacted on 6205 1083. TERRITORY RECORDS

The introduction of the Territory Records Act 2002 aims to: • Encourage open and accountable government by ensuring that territory records are made,

managed and, if appropriate, preserved in an accessible format; • Preserve territory records for the benefit of present and future generations; and • Ensure that public access to records is consistent with the principles of the Freedom of

Information Act 1989. To support the objectives of this Act, the Records Management Centre has primary responsibility for developing and implementing the Records Management Program and providing advice to staff on legislation, departmental policy and procedures affecting administrative records management.




Policy Management Framework


Chapter 22 – Policy Management Framework

POLICY MANGEMENT FRAMEWORK All policy development occurs under the auspices of the Policy Management Framework and with support of the Policy Advisory Group. Reflecting the inter-relationship between clinical and corporate governance, the framework was developed in recognition that while the content of policy documents differ, the processes for development, dissemination, implementation, evaluation and review can be the same. The following principles underpin the framework:

• Standardisation: all documents in a standard format and location to make it easier for staff to access them

• Simplification: the use of plain English and limited jargon • Evidence-based: the use of best available evidence to support good practice • Quality consultation: stakeholders effectively contributing throughout the policy

management cycle • Robust governance and endorsement: staff can be certain they are operating under

appropriate documents • Communication: staff and stakeholders are informed of new documents • Education and training: staff are instructed about new documents • Compliance: systems exist to monitor compliance with documents, and • Review & evaluation: consideration of review and evaluation processes and measures in the

policy development process. The framework provides definition of the Health Directorate wide policy documents, an overview of policy governance and the policy management cycle and outlines document management. While the Policy Management Framework applies to policy documents which involve more than one Division, Branch or Unit, the same processes are used for policies developed by a single division, stream, branch or team. Tiers of Policy Guidance is provided within the framework document on the hierarchy of policy within the directorate.

Level Governance Group Scope Examples Tier 1 Executive Council National • Commonwealth Agreements Whole of ACT Government • Social Compact

• Children’s Plan Health Sector in the ACT -

Health Directorate and the non-government and private sectors

• ACT Health Child Protection Policy

• HIV, AIDS, Hepatitis C, Sexually Transmissible Infections Strategic Framework for the ACT 2007-2021

• Maternity Shared Care Guidelines

http://health.act.gov.au/c/health?a=dldivpoldoc&document=2220



-continued Health Directorate – impact on all divisions, branches and units in the organisation

• Consent to Treatment Policy • Procurement Policy • Open Disclosure Policy • Media Policy

Tier 2 Corporate and Strategy Executive Forum or Canberra Hospital and Health Services Executive Forum

Strategy and Corporate or Canberra Hospital and Health Services

• Antibiotic Use Standard Operating Procedure (SOP)

• Electrical Cord Safety SOP

Tier 3 Division, branch or unit Executive Fora

Individual division, branch or unit

• Flash Sterilisation in Perioperative Area

• Seclusion of Mental Health Consumers

National Policies (Tier 1) National policies outline a national position on a health issue. These policies are usually developed in consultation between the Australian Government and State/Territory Governments. These policies are normally endorsed by a national body like the Australian Health Ministers’ Conference (AHMC) or the Australian Health Ministers’ Advisory Council (AHMAC), or are governed by a Commonwealth - State/Territory Agreement. ACT contribution to national policies requires the approval of the Health Directorate Executive Council and often the Minister for Health. The Minister will need to be involved if the policy is being developed for endorsement at Ministerial Council level, like AHMC.

Whole of ACT Government Policies (Tier 1) Whole of ACT Government policies outline the ACT Government’s position on territory-wide issues. These policies are usually developed in consultation between the Chief Minister & Cabinet Directorate and other ACT Government Directorates. Health Directorate contributions to these policies require the approval of the Director-General, Executive Council and sometimes the Minister for Health.

Health-Sector in the ACT Policies (Tier 1) Health-sector policies within the ACT outline the Health Directorate position on health sector wide issues. These policies are usually developed in consultation between the Health Directorate, non-government organisations, peer groups and consumers. An example of a sector-wide policy is the Child Protection Policy. Sector-wide policies require the approval of the Executive Council and sometimes the Minister for Health. Health Directorate Policies (Tier 1) Policy documents are Tier 1 documents when they:

i. Have relevance across the directorate ii. Address an issue of high risk for the organisation

Tier 1 documents are usually policies, however Standard Operating Procedures will be considered at this level when they are meet the above criteria or need to be considered in conjunction with a Tier 1 policy.



These policies are developed by areas with specific expertise or responsibility for the topic area, such as: • Human Resource Management Branch (eg: Leave Without Pay Policy, Study Leave Policy) • Finance Division (eg: Director-General Financial Instructions), and • Quality & Safety and Unit (eg Patient Identification Policy and SOPs)

These policy documents require sign off by the Director General through the Executive Council. Policy documents addressing divisions, branches or units (Tier 2) Policy documents in this tier apply to all areas of the organisation. They are usually Standard Operating Procedures (SOPs) that relate to a Tier 1 policy. Tier 2 documents are usually developed by operational areas that have specialist knowledge, for example Pharmacy develops Medication SOPs, Infection Control develops hand hygiene SOPs. Tier 2 documents require the approval of the relevant Deputy Director-General through the relevant governance committee. Branch/Division or Unit policy documents (Tier 3) Policy documents at this level are those that apply only to a division, branch or unit in the operation of their work. They are usually SOPs and are developed by the operational area for approval by the relevant executive director.

Local Policy documents (Tier 4) Local policies are often operational and frequently procedural in nature. These policy documents are best developed and managed by areas with relevant expertise or topic responsibility, such as local leave management SOPs. They require endorsement by the relevant executive director, director or manager.

Policy Advisory Group (PAG) The Policy Advisory Group (PAG) reports to Executive Council and provides a quality check for Tier 1 documents prior to their submission for approval. PAG has senior manager/director level representatives from each operational area of the directorate and its role is to: • provide a quality check against the principles and processes outlined in the Policy

Management Framework, and • coordinate policy development and review activities to reduce duplication.

All Tier 1 documents are reviewed by PAG prior to submission to Executive Council. PAG has a fast track secretariat review process for urgent and lower risk documents, and a standard review process by the full group for all other documents. PAG is chaired by the Director of the Policy and Project Section of the Quality and Safety Unit. DIRECTOR-GENERAL DECISIONS To ensure the timely notification of important governance/guidance documents to all staff within the Health Directorate, a protocol for the registration and notification of policies, plans and guidelines and strategies that have been endorsed by the Director-General and considered as highly relevant across the organisation exists. These are known as the Director-General Decisions.



Following the endorsement of governance/guidance documents, a unique identifier number (DGD No.) is allocated, the document is uploaded on the Intranet/Internet and a DGD Alert is disseminated to staff through electronic mail to advise them of these important documents. Not all policy or governance documents are notified as a DGD. CENTRAL POLICY AND PLAN REGISTER A Central Policy and Plan Register on the Health Directorate intranet administers policies in tiers 1-3. The purpose of the Policy Register is to maximise awareness of policies across the Directorate and minimise the risk of duplication or inconsistency. Approval to upload documents to the Policy and Plan register is governed by the relevant executive that endorses the document. The area responsible for developing the policy is usually allocated responsibility for reviewing the document when required.



Chapter 23 – Strategic and Service Planning

STRATEGIC AND SERVICE PLANNING

There are three tiers of strategic and service development planning undertaken by the Health Directorate. The levels are the same as those established under the policy framework.

Level Governance Group Scope Examples Tier 1 Executive Council National • Council of Australian Governments

National Action Plan on Mental Health 2006-2011

• National Oral Health Plan 2004-2013 Whole of ACT Government • Children’s Plan

Health Sector in the ACT - Health Directorate and the non-government and private sectors

• ACT Chronic Disease Strategy • ACT Primary Health Care Strategy

Health Directorate – impact on all divisions, branches and units in the organisation

• Corporate Plan • Capital Asset Development Plan

Tier 2 Corporate and Strategy Executive Forum or Canberra Hospital and Health Services Executive Forum

Strategy and Corporate or Canberra Hospital and Health Services

• Critical Care Services Plan • Adult Corrections Health Services Plan • Population Health Unit Business Plan

Tier 3 Division, branch or unit – operational team/service

Individual division, branch or unit

• Individual Learning and Achievement Plan

• Project Plan

The Policy and Government Relations Branch, Service and Capital Planning Branch and Population Health frequently lead the negotiation and development around strategic plans at the Tier 1 level, with input from areas with specific expertise.

National Planning (Tier 1) National plans outline a national direction on a health issue and often inform more detailed jurisdiction level plans being developed. These plans are normally endorsed by a national body like the Australian Health Ministers’ Conference (AHMC) or the Australian Health Ministers’ Advisory Council, or are governed by a Commonwealth - State/Territory Agreement. Health Directorate contributions to national planning require the approval of the Executive Council, the Director-General and frequently the Minister.

Whole-of-ACT-Government Planning (Tier 1) Whole-of-ACT-Government plans outline the ACT Government’s position on a territory-wide issue. These plans usually cover a 3-5 year period.


Whole-of-ACT-Government plans require the approval of the Executive Council, the Director-General and the Minister for Health. One example is the ACT Children’s Plan.

Health Sector in the ACT Planning (Tier 1) Health- sector plans within the ACT support the future development of operational and clinical services by identifying how the Health Directorate, non-government and private sectors will implement future directions in key clinical and operational policy areas. Based on agreed policy and strategies, service plans usually articulate future models of care and service delivery; contain projections of service demand and identify associated infrastructure, workforce and information technology and governance requirements. The plans also identify responsibility for implementing each task and reporting progress against performance indicators. Health-sector plans require the endorsement of Executive Council, the Director-General, and at times, the Minister for Health. Health Directorate Planning (Tier 1) Directorate wide plans support the organisation to meet its vision, key priorities and objectives. These plans usually have a timeframe of 2 to 5 years. An example of this is the Corporate Plan. These plans require the approval of the Executive Council and the Director-General.

Planning at the division, branch or unit level (Tier 2 ) Planning conducted at the group, division, branch or unit level is informed by Health Directorate plans, and ‘cascades’ down to more specific objectives of each area. These plans identify the strategies that will be used to meet objectives, and the resources required to do so. The negotiation and development of these plans is usually the responsibility of the relevant business area and these plans require the approval of the Director-General, Deputy-Director or executive director, depending on the operational area level. Local - Operational Planning (Tier 3) Tier 3 plans are highly specific and concrete in nature. They frequently reflect a specific project, or relate to an individual. The negotiation and development of these plans is the responsibility of the relevant individual and these plans require the approval of the local manager. CENTRAL POLICY AND PLAN REGISTER A Central Policy and Plan Register includes plans in tiers 1-5, maximising accessibility, and through this minimising the risk of duplication or inconsistency. The Central Policy and Plan Register is available in electronic format to all Health Directorate staff on the Intranet and to the public via the Internet. Approval to upload documents to the register is governed by the relevant committee responsible for approval of the documents (e.g.: Executive Council). The area responsible for developing the plan is responsible for initiating the review and update of the plan as required.




Chapter 24 – Plans & Strategies

ACT Government vision for Canberra The ACT Government’s vision for Canberra as articulated in The Canberra Plan: Towards our Second Century is that Canberra will be recognised as: • A truly sustainable and creative city • An inclusive community that supports its vulnerable and enables them to reach their potential • A centre of economic growth and innovation • The proud capital of the nation and home of its pre-eminent cultural institutions, and • A place of natural beauty.

Health Directorate Plans and Strategies To contribute to the broader ACT Government vision, the Health Directorate’s vision is “Your health-our priority”. This vision is supported by a range of strategic plans that identify objectives for the organisation. There is recognition that the demand for health services is increasing every year. Expanding health technologies, consumer expectation and an increasing and ageing population all contribute to this demand. For the ACT community to be assured of receiving sustainable, safe and quality health services now and into the future the ACT Government has committed over $1billion dollars for redevelopment across hospital and community based health settings. This redevelopment is underpinned by extensive health services planning, and is influenced by, and influences, all aspects of Health Directorate services. Key changes and priorities of the ‘Your health- our priority’ programme includes: • Promotion of prevention and early intervention • Expanding the availability of services to meet growing demand • Providing care as close to the community as possible • Improving ease of access for patients to services • Providing integrated care via multidisciplinary and collaborative clinical teams, and • Enabling patients and carers to be more involved in their health care. To enable this new service delivery model, the programme is investing in: • New models of care • Improvements to the physical infrastructure of the Health Directorate • Workforce planning and change management, and • Technology to support the transformation programme (referred to as the Digital Health

Enterprise or DHE).

http://www.cmd.act.gov.au/__data/assets/pdf_file/0013/120217/canberra_plan_text_V5.pdf

http://www.cmd.act.gov.au/__data/assets/pdf_file/0013/120217/canberra_plan_text_V5.pdf

http://health.act.gov.au/about-us/your-health-our-priority/


The following plans are instrumental in guiding the strategic direction of the Health Directorate: Corporate Plan 2010-2012 – identifies the seven overarching focus areas of the National Health Care Agreement and under these, specific objectives, and performance indicators for the Health Directorate. The plan identifies how this work cascades down to the Group, Division, Branch and Unit business plans. Capital Asset Development Plan – identifies the infrastructure and capital asset requirements to deliver improved models of care to meet future demand and for the provision of health services to 2022. Information on the background, stages and the progress of the plan are available at ‘Your health- our priority’ on the Health Directorate intranet. Clinical Services Plan 2005-2011 - provides the strategic framework for the delivery of public hospital and community services up to 2011. As a broad planning document, the plan identifies the challenges in the health system, the number and types of services to be delivered in the future, and the infrastructure requirements. Specific clinical service plans, developed as related documents to the Clinical Services Plan 2005-2011 and to assist the Capital Asset Development Plan include: • Adult Corrections Health Services Plan 2008-2012 • Children and Young Peoples Justice Health Services Plan 2008-2012 • Critical Care Services Plan 2007-2011 • Diabetes Service Strategic Plan 2008-2012 • Mental Health Services Plan 2009-2014, and • Renal Health Services Plan 2010-2015.

E-Health – The ACT Government has committed $90 million investment in e-health capacity and information and communication technology (ICT) infrastructure. Known as Health e-Future, this forms a key part of the $1 billion Your health – our priority Plan and supports the National E-Health Strategy announced by the Commonwealth Government in 2008. The Health e-Future work program is supported by the Digital Health Enterprise (DHE) technology strategy and implementation plan, which provides an ICT strategy to support the Health Directorate into the future. This change programme encompasses new models of care, new and refurbished facilities, workforce planning and enhanced technology capabilities. Health Workforce Plan 2005-2010 – this plan was developed to manage, within the ACT, the workforce implications of service growth and the ageing Australian population. Aboriginal and Torres Strait Islander Health and Family Well-Being Plan 2005-2011 - articulates the way in which the relevant aspects of the National Social and Emotional Wellbeing Strategy, the National Health Workforce Strategy, the ACT Health Action Plan and the Canberra Plan will be implemented in the ACT. Its focus is on building strong communities through family resilience, through health in the context of overall wellbeing, and collaborative action. ACT Children’s Plan 2010-2014 - Developed under the governance of the Department of Housing and Community Services and ACT Health the first ACT Children’s Plan was launched in 2004. This complemented the Canberra Plan and the Canberra Social Plan. The ACT Children’s Plan 2010-2014, aims to create a shared vision of a child friendly city, explain why this is important for all and outline how we will get there. Chronic Disease Strategy 2008-2011 - aligning with the National Chronic Disease Strategy, it incorporates the four action areas from the National Strategy: prevention and risk reduction; early





http://inhealth/PPR/Policy%20and%20Plans%20Register/Clinical%20Services%20Plan%202005-2011.pdf

http://inhealth/PPR/Policy%20and%20Plans%20Register/Adult%20Corrections%20Health%20Services%20Plan%202008-2012.pdf

http://inhealth/PPR/Policy%20and%20Plans%20Register/Childrens%20and%20Young%20Peoples%20Justice%20Health%20Services%20Plan%202008-2012.pdf

http://inhealth/PPR/Policy%20and%20Plans%20Register/Critical%20Care%20Services%20Plan%202007-2011.pdf

http://inhealth/PPR/Policy%20and%20Plans%20Register/Diabetes%20Services%20Strategic%20Plan%202008-2012.pdf

http://inhealth/PPR/Policy%20and%20Plans%20Register/Mental%20Health%20Services%20Plan%202009-2014.pdf

http://inhealth/PPR/Policy%20and%20Plans%20Register/Renal%20Health%20Services%20Plan%202010-15.pdf

http://health.act.gov.au/about-us/e-health/



http://acthealth/c/healthintranet?a=sendfile&ft=p&fid=703906448&sid=%3e

http://inhealth/PPR/Policy%20and%20Plans%20Register/Workforce%20Plan%202005-2010.pdf

http://inhealth/PPR/Policy%20and%20Plans%20Register/Aboriginal%20and%20Torres%20Strait%20Islander%20Health%20Family%20Well%20being%20Plan%202006-2011.pdf

http://inhealth/PPR/Policy%20and%20Plans%20Register/Childrens%20Plan%202010-2014.pdf


http://inhealth/PPR/Policy%20and%20Plans%20Register/Chronic%20Disease%20Strategy%202008-2011.pdf


detection and early treatment; integration and continuity of prevention and care; and self-management; as well as an additional action area focused on research and surveillance. Alcohol, Tobacco and Other Drug Strategy 2010-2014 – aims to improve the health and social well of the ACT community through harm minimisation, developing evidence based policies to support effective management and ensuring the implementation of these occur in a respectful way. ACT Palliative Care Strategy 2007-2011: The ACT Palliative Care Strategy aims to provide overarching direction for the delivery of palliative care services across Health Directorate. The vision for palliative care service provision articulated in the Strategy is that Health Directorate will deliver palliative care as appropriate to people of all ages, respecting their choices and needs; ensuring care is provided in accordance with the standards developed by Palliative Care Australia. ACT Primary Health Care Strategy: The ACT Primary Health Care Strategy is a visionary document that builds on the work of the ACT Primary Health Care Strategy 2006-2009 and aims to reflect the thinking of the ACT community and primary care sector in relation to primary health care. The Strategy has been developed in the context of the Council of Australian Governments (COAG) health reforms and identifies the core principles and priorities that will provide a roadmap to guide current and future policy, planning and practice in the ACT primary health care sector. In the ACT, a number of health related plans already exist. The intention of this strategy is not to duplicate priorities identified in these other plans but to acknowledge, complement and collaborate as required in order to achieve the stated objectives. Similarly, there are a number of national health related strategies and plans which will provide overarching guidance for this Strategy. These plans and their relationship to areas of the Strategy are indicated throughout this document. It is acknowledged that no one organisation can implement this strategy on its own. With a coordinated and integrated primary health care sector as a goal, the ACT Government Health Directorate will work in partnership with the ACT Medicare Local, the primary care sector and the community to implement the actions and strategies identified within the Strategy. Access to all current Health Directorate Plans and Strategies can occur through the ‘Policy and Plan Register’ on the intranet, or internet via a key word search.

http://inhealth/PPR/Policy%20and%20Plans%20Register/Alcohol,%20Tobacco%20and%20Other%20Drug%20Strategy%202010-2014.pdf

http://inhealth/PPR/Policy%20and%20Plans%20Register/Palliative%20Care%20Strategy%202007-2011.pdf



Clinical Governance


CLINICAL GOVERNANCE Clinical Governance is the term used to describe a systematic approach to maintaining and improving the quality of patient care within a health system. It is about the ability to produce effective change so that high quality care is achieved. It requires clinicians and administrators to take joint responsibility for making sure this occurs.

When Clinical Governance is effective, it has the potential to: • Make positive changes you want to see happen • Improve the quality of care for patients, and • Provide a better experience for staff.

New South Wales Health Within the Health Directorate, “this is our system of reporting and accountability to check that we are continuously working towards improving safety and quality. All health professionals, support staff and managers have a role in safeguarding high standards of care by creating an environment in which excellent clinical care can be delivered”.

ACT Health Safety and Quality Framework 2010-2015 Elements of Clinical Governance Clinical Governance is underpinned by effective corporate governance and is closely related to professional governance. As such, elements of three governance approaches form a part of each system. Clinical governance is comprised of quality and safety strategies including clinical policy development, audit, risk and incident management, clinical review and consumer engagement. Elements of corporate and professional governance, such as effective performance management and training and development also contribute. Some of the elements of clinical governance are outlined within the following section. These are not stand-alone strategies, but are inter-related with corporate and professional governance processes in their application.

http://www.health.nsw.gov.au/mhdao/clinical_governance.asp

http://inhealth/PPR/Policy%20and%20Plans%20Register/Safety%20And%20Quality%20Framework%202010-2015%20-%20ACT%20Health.pdf


Chapter 25 - Safety & Quality

SAFETY AND QUALITY Safety: Our goal is to prevent harm to consumers. This is partially achieved through addressing workload stress, however, we also learn from specific mistakes. We encourage incident reporting to determine how and why processes have gone wrong. We can then build systems around the reality of human error to prevent errors before they cause harm. Quality: Our goal is to provide our consumers with the best known care, using standardised processes, at all times and in all places. To do this we must keep abreast of the latest research and developments in patient care from around the world and ensure that all relevant staff are appropriately trained, skilled and resourced to deliver the best care possible.

ACT Health Safety and Quality Framework 2010-2015 Within the 2010-2012 Corporate Plan, the Health Directorate identifies its objective to provide a health system that is informed by high quality information in which consumers experience seamless and safe care when transferring between settings. It is recognised worldwide that there are inherent risks associated with being a patient or consumer in the health system. Minimising unintentional harm associated with healthcare delivery is a priority for the Directorate. Quality and safety initiatives and processes, implemented across the organisation, contribute to the clinical governance of the organisation, and in turn, assist the delivery of excellent clinical care. Detail on the work of the Quality and Safety Unit can be found at Chapter 9.06. Integrating quality and safety into everyday work practices is the responsibility of all staff involved in the planning, development, support of and delivery of health services. It is not restricted to clinicians, but applies to all staff of the Health Directorate. This chapter provides some detail on specific quality and safety strategies that are currently used to support this effort. Frameworks and Planning: In 2010, Australian Health Ministers endorsed the Australian Safety and Quality Framework for Health Care. The framework describes a vision for safe and high-quality care for all Australians and sets out the actions needed to achieve this vision. The Framework specifies three core principles for safe and high-quality care. These are that care is consumer centred, driven by information, and organised for safety. The framework identifies twenty-one areas for action to improve the safety and quality of care in all healthcare settings over the next decade. The Health Directorate released the Safety and Quality Framework in October 2010. It describes the vision and direction to improve safety and quality that the Health Directorate will work towards until 2015. The four parts of the framework are:



http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/C774AE55079AFD23CA2577370000783C/$File/32296-Australian-SandQ-Framework.PDF




• Safety and Quality Systems in the Health Directorate • Safety and Quality Governance • Safety and Quality Education, and • Safety and Quality Plan. This plan aligns the themes with those outlined by the Australian Commission on Safety and Quality in Health Care Framework document. Safety and Quality Activities: Within the Health Directorate, activities that support safety and quality include: Clinical Review Clinical Review committees provide a multidisciplinary and systematic mechanism for identifying, evaluating and reporting clinical system issues to facilitate continuous improvement of health services leading to improved patient/client/consumer outcomes. Clinical Audit

Clinical Audit aims to enable health professionals to evaluate and measure practice through clinical audit activities to ensure the delivery of effective health care. It is comprised of:

• Clinical Indicators: Measuring clinical management / outcomes of care and used to flag clinical issues

• Procedural Audit: the process of collecting information on clinical procedures, analysing and reporting these to track and review the performance of a specific clinical unit, and

• Compliance Audit: Determining compliance with policy, procedure, codes of practice and industry standards.

Clinical Policy Clinical policy development occurs under the auspices of the Policy Management Framework, outlined in Chapter 22 of this document. The Quality and Safety Unit assists the development of policies within and across the Health Directorate by participating in, and providing secretariat support to, the Policy Advisory Group, which is tasked with implementing the framework. Incident Management RiskMan is an incident reporting system for the immediate notification and management of adverse clinical and workplace incidents or near misses within the Health Directorate. Incidents are initially outcome rated, requiring the actual impact of the incident to be assessed against a standard system of outcomes. Following investigation of the incident, the outcome rating may be amended to more accurately reflect the actual impact of the incident. Ongoing management of the incident report is transparent to the initial reporter. Staff have the ability to monitor the progress of their report by following an audit trail. Trends of incidents across the organisation can be identified from this system, with these being reported to the relevant committee for consideration and action. Medico-legal and Claims Coronial Coordination All incidents that occur within the Health Directorate are assessed from a medico-legal perspective. Support is provided by the Quality and Safety Unit in the identification and coordination of clinical







matters requiring notification to ACT Insurance Authority (ACTIA) and the coordination of Coronial and other legal matters involving clinicians.

Accreditation and Evaluation The Health Directorate recognises that it is our collective responsibility to assure the general community that our health services are of the highest standard. Quality monitoring and reporting systems have been put in place to review, evaluate and measure the extent to which these standards have been achieved.

Information on the Quality Information Framework and how this functions in the workplace is available on the Safety and Quality pages of the Health Directorate intranet.

The Directorate is accredited by the Australian Council on Healthcare Standards (ACHS) until February 2013. Some services have implemented additional, specialty accreditation systems that are relevant to their particular specialty.

Clinical Risk Management Risk Management is defined as: the culture, processes, and structures that are directed towards the effective management of potential opportunities and adverse effects (AS/NZS 4360:2004). Clinical Risk Management concentrates on minimising clinical risk and improving overall clinical safety for patients and staff. This is achieved through the identification and reduction of potential risks and examination of adverse events for factors and trends. This information informs quality improvement activities across the Health Directorate. Further detail is available on these activities via the Health Directorate intranet. Committees supporting safety and quality Information that relates to, or impacts upon safety and quality is provided from a broad range of reporting systems and processes. Once identified, this information is reviewed, and if action is required, addressed through the Health Directorate committee structure. Tier One Committees that consider safety and quality information include: • Executive Council • Executive Directors’ Council • Management Advisory Council • Clinical Senate; • Safety and Quality Committee • Work Safety Committee; • Audit and Risk Management Committee • Workforce Strategy Committee • Redevelopment Committee, and • Information and Communication Technology Committee.







A number of subcommittees provide significant information sources to inform the work of the organisation. These include:, Clinical Audit Committee (CAC): This committee oversees territory-wide clinical audit, clinical review and incident management processes conducted throughout the Health Directorate. CAC augments existing divisional and stream committee structures and processes across the territory. It reports to the Safety and Quality Committee. CAC is established as an approved quality assurance committee under the Health Act 1993 (ACT). Medical and Dental Appointment Advisory Committee The role of the Medical and Dental Appointment Advisory Committee (MDAAC) is to oversee the medical specialist and dental specialist appointment and re-appointment process and provide recommendations to clinical divisions. The committee is established as an approved public sector clinical privileges committees under the Health Act (1993) ACT. Secretariat support for the MDAAC is provided by the Medical & Dental Professional Standards Unit. Health Technology Assessment Committee (HTAC) This committee provides advice to the Health Directorate on the role, safety, efficacy and resource implications of proposed new health technologies that have been supported for use within Australia by a recognised authority, such as the Australian Government Medical Services Advisory Committee. New drugs are not evaluated by the HTAC as effective systems are currently in place to assess applications for the use of new medications within the Directorate. The policy entitled “Introduction of New Technology” sets out the common and comprehensive approach to the adoption of new technologies in the ACT. Ethics Committee

The ACT Health Human Research Ethics Committee (ACTH-HREC) is the official Human Research Ethics Committee for the Health Directorate. The ACTH-HREC is constituted according to National Health and Medical Research Council (NHMRC) guidelines.

The aim of the ACTH-HREC is to ensure that high ethical standards are maintained in research projects to protect the interests of research subjects, investigators and the institution. In carrying out these functions, the ACTH-HREC takes into consideration guidelines issued by the NHMRC together with local cultural and social attitudes. Secretariat support is provided by the Health Directorate Research Office.





Performance Management


Chapter 26 – Performance Management

This section deals with four tiers of performance management: • organisational performance management • executive performance management • operational area performance management, and • team and individual performance management. DIRECTORATE PERFORMANCE MANAGEMENT

In addition to the accountabilities of the Director-General and all staff of the Health Directorate, the organisation can be measured against the government’s priorities for health through the Corporate Plan. The Health Directorate is also responsible for the preparation of an Annual Report under the Annual Reports (Government Agencies) Act 2004. Annual Reports are public documents that must be presented to the Legislative Assembly within three months of the end of each financial year. Annual Reports must provide an honest and accurate account of all material information about the operations of the department, including: • Directorate role and overall performance • Organisational governance arrangements • Financial performance • Human resource performance • Information and access (including Freedom of Information Statement), and • Community and environmental performance. Health Directorate Annual Reports can be found on the Health Directorate internet. Scrutiny of the directorate’s performance by Legislative Assembly committees and other external agencies is outlined within Chapter 10. EXECUTIVE PERFORMANCE MANAGEMENT

Accountability and the performance management of the senior executive service is outlined in Chapter 12 of this document. OPERATIONAL AREA PERFORMANCE MANAGEMENT

All divisions, branches and units provide formal monitoring and reporting against their finance and performance at relevant executive meetings on a monthly basis. This, in turn is monitored and reported to Executive Council as the overarching governance meeting for the organisation. In addition, the relevant executive responsible for operational areas meet, and regularly report on performance and discuss resolution of issues with either the Director-General, Deputy Director-





http://www.health.act.gov.au/publications/reports/annual-reports/


General Canberra Hospital and Health Services Group, and Deputy Director-General Strategy and Corporate. TEAM PERFORMANCE MANAGEMENT

Managers are responsible for the overall performance of their team. Managers also play a key role in performance through: • Monitoring and managing service outcomes, quality, quantity and cost • Maximising benefits from the use of resources • Improving employee skills and knowledge through education, training and supervision; • Providing clarity around work priorities • Identifying training and development needs of staff and ensuring they are linked to business

objectives, and • Maintaining a team culture and environment which is positive and constructive, enabling

employees to do their best. Managers regularly meet and report on performance and discuss resolution of issues with the relevant executive director. STAFF PERFORMANCE MANAGEMENT

The Health Directorate has a performance management framework called Working Together To Enhance our Performance, which is designed to maintain or improve the performance of individual staff and through them, workgroups and the organisation. Components of the directorate’s performance management framework are; • Core organisational objectives set by the Director-General • Divisional / professional objectives and expected level of performance • Job specific objectives, and • Training and development needs. The Health Directorate has an electronic performance management system (ELAP – Electronic Learning and Achievement Planning) which enables the recording and tracking of individual performance agreements and 6/12 month review discussions. The underlying assumption in performance management is that everybody wants to do the best job they can. It is the role of the performance management process to positively harness this goodwill and nurture the skills and talent of staff to assist them to carry out their role. The electronic system is a useful tool; however the emphasis is on having the ongoing, regular performance discussions and two-way feedback between individuals and their managers. This is known to increase staff member engagement and work satisfaction while ensuring that the directorate has a skilled workforce that has the capacity to deliver high quality services.




Chapter 27 – Research

RESEARCH

The Health Directorate is involved in a variety of research projects in the ACT and surrounding region, nationally and internationally. While research activity occurs across all sections of the Directorate and in partnership with a range of tertiary education partners, a significant proportion of activity is based at the Canberra Hospital and through the Australian National University Medical School (ANUMS). The Health Directorate has developed a Research Practice Policy and Guidelines for Research Practice to provide a framework of standards to guide researchers, and the institutions in which they work, in acceptable research practices. The Research Office was established to support researchers across the directorate to ensure quality and competitiveness of new submissions for national and international research funding applications.

The Research Office identifies over 39 research units that it supports and assists. This is inclusive of allied health, nursing & midwifery and medical staff. Further information is available on the projects, collaborative associates and associated research institutions are available under the ‘Our Research’ page on the website

Some key committees that support research activity across the Directorate include: • Health Directorate Human Research Ethics Committee, and • Health Directorate Research Strategy Committee The functions and membership of these committees are available on the website.

http://health.act.gov.au/health-services/canberra-hospital/about-us/anu-medical-school

http://inhealth/PPR/Policy%20and%20Plans%20Register/Research%20Practice%20Policy.pdf

http://inhealth/PPR/Policy%20and%20Plans%20Register/Research%20Practice%20Guidelines.pdf

http://healthresearch.anu.edu.au/index.php/divisions-departments/research-office/about-us



http://healthresearch.anu.edu.au/index.php/human-research-ethics-committee

http://healthresearch.anu.edu.au/index.php/rsc

Risk Management and Internal Audit

Corporate Governance Statement — Issue 5, December 2011, Chapter 28 Page 2

Chapter 28 – Risk Management and Internal Audit

RISK

Risk is the possibility that an event or activity will have a negative impact on the objectives of the directorate. The Health Directorate is committed to providing a high quality service to our community, and safe effective care to our consumers. To achieve this we must manage any risk that either impacts or has the potential to impact on organisational goals.

Risk management requires that the Health Directorate continually improves the culture that supports processes, structures and accountabilities for effectively managing risk. All staff are responsible for the identification and management of risk in their work area. The Health Directorate’s Integrated Risk Management Policy, procedures and guidelines support the task of establishing the context, identifying, analysing, evaluating, treating, monitoring and communicating risks. The directorate’s risk management protocols comply with the Risk Management Standard, AS/NZS ISO 31000. Risk management is not a separate process but part of corporate governance. RESPONSIBILITY FOR RISK MANAGEMENT

The Director-General is required to promote the efficient, effective and ethical use of government resources. The Director-General will promote and assure risk management strategies are in place to minimise risks and to improve overall directorate performance. Group, Branch, Division and Unit Heads are responsible for ensuring they, and their staff, apply the principles of risk management and integrate them with their planning and administration of functions, processes or activities. All staff must identify and report risks, and carry out risk treatment strategies as directed by managers, and in compliance with Health Directorate protocols. AUDIT - LEGISLATIVE BACKGROUND

The Financial Management Act 1996, Part 4, Section 36, requires that the Director-General maintains adequate internal controls, including the safeguarding of assets of the directorate, compliance with applicable legislation and the proper reporting of the financial results of the directorate. RESPONSIBILITY FOR INTERNAL AUDIT

The Director-General is responsible for ensuring that appropriate levels of control exist within the Health Directorate to minimise risk. To achieve this, the Director-General may request internal audits

http://inhealth/PPR/Policy%20and%20Plans%20Register/Risk%20Management%20Integrated%20Policy%20and%20Procedures.pdf



that may assist managers to meet their responsibilities and initiate special investigations when indicated. Group, Branch, Division and Unit Heads are responsible for financial and other reporting, internal control and compliance with laws, regulations and ethics within the directorate and implementing a process of review within their area. Managers may be requested at least annually to provide the Audit Committee with suitable topics for audit, which they consider would assist their own process of review. Internal Audit & Risk Manager is responsible for: • Managing the Internal Audit and Risk Management team and its functions • Providing reasonable assurance to management about the adequacy and effectiveness of the risk

management and control framework in operation • Providing a value added service to improve the integrated risk management framework through

advising on and implementing a best practice approach • Preparation of reports and recommendations to the Director-General on audit policies,

procedures, guidelines and plans • Implementation and coordination of the Internal Audit Program in accordance with Health

Directorate policy • Submission of reports, briefs, minutes and other correspondence as required to Senior

management, Directorate Committees including the Audit and Risk Management Committee on the directorate’s audit and risk management activities, policies, guidelines, procedures, and plans

• Planning internal audits within the Health Directorate, conducting audit reviews and providing audit certificates as required

• Developing audit programs for consideration by the Audit Committee • Providing reports to the Audit Committee on the progress of the directorate’s audit program • Advising directorate managers and staff on internal audit and risk management matters, and • Liaising with the Treasury Directorate on the ACT Government Risk Management Framework. Senior Executive Responsible for Business Integrity Risk (SERBIR) is responsible for: • Promoting integrity in the directorate and raising awareness and acceptance of the ACT Integrity

Policy and the Health Directorate Fraud Management Framework, Control Plan and Policy (which integrates components of the ACT Integrity Policy) at every opportunity;

• Implementing integrity strategies and processes for the detection and investigation of fraud and corruption

• Establishing and maintaining the management information system that records all instances of fraud and corruption

• Reporting regularly to the Audit Committee on the cases that are being dealt with by the directorate, and

• Reporting to the Director-General and the Audit and Risk Management Committee on overall compliance with the ACT Integrity Policy.

AUDIT AND RISK MANAGEMENT COMMITTEE

This committee is established to provide assurance and assistance to the Director-General on the directorate’s risk, governance and compliance frameworks, and external accountability responsibilities, as prescribed in the Financial Management Act . The committee contributes to management and delivery of health services through oversight of financial statements, internal control, internal audit, external audit and compliance. The membership provides strategic advice to

http://www.cmd.act.gov.au/__data/assets/pdf_file/0007/116764/integritypolicy.pdf


http://inhealth/PPR/Policy%20and%20Plans%20Register/Fraud%20Management%20Framework%20Control%20Plan%20and%20Policy.pdf




the Director-General on organisation-wide risk management and facilitates the prevention of fraud risk. The Committee is chaired by an independent chairperson, who is external to the Health Directorate. The Director-General attends meetings as an observer. INTERNAL AUDIT

The primary role of internal audit is to provide reasonable assurance to management about the adequacy and effectiveness of the integrated risk management framework in operation. Internal Audit provides management with analysis, appraisals, and recommendations on the operations reviewed. Internal audit is supported through: • Access to documents, records, premises and electronic systems • Independence, represented through direct reporting to the Director-General and to the Internal

Audit and Risk Management Committee • The Integrated Risk Management Policy, and related guidelines • An annual audit program • A quality assurance program • Liaison and coordination with the ACT Government Audit Office, as external auditors • Liaison and contracting of contracted external auditors as required to report to the Director-

General or Audit and Risk Management Committee • Staff meeting audit practice standards, as prescribed by professional bodies, and • Continuing education and performance management of internal auditors. Further information can be obtained on the Health Directorate Intranet site under Business Support/Risk Management.

http://inhealth/PPR/Policy%20and%20Plans%20Register/Risk%20Management%20Integrated%20Policy%20and%20Procedures.pdf



Chapter 29 – Workplace Safety

LEGISLATIVE BACKGROUND

Occupational health and safety (OHS) responsibilities in the Territory are outlined in the Work Safety Act 2008 and related legislation, regulations and approved codes of practice and guidance material published by WorkSafe ACT. The aims of the Work Safety Act are to: • Secure and promote work safety of people at work • Eliminate, at their source, risks to workplace safety • Implement a risk management approach to workplace safety • Protect people from the risks to work safety as a result of the activities of people at work • Foster cooperation and consultation between employers and employees • Protect workers from injury and illness • Provide strategies to protect workers physical and psychological needs, and • Provide a framework for continuous improvement. The Work Safety Act 2008 intends to: • Enable employers and employees to identify safety risks and to develop measures to control and

eliminate them • Encourage everyone with workplace safety responsibilities to comply with their obligations • Empower regulators to assist more directly with addressing risks at a workplace before accidents

and injuries occur, and • Provide high penalties (both personal and organisational) when contraventions of the legislation

expose people to risk of serious harm, or cause serious harm. WORKPLACE SAFETY POLICY

The Health Directorate is committed to the provision of a safe and healthy working environment for all employees, where employee contribution drives a culture of continuous improvement in injury prevention. This commitment is outlined in the Workplace Safety Policy for the directorate. Responsibilities of both the organisation and staff are outlined within the policy. The policy outlines the proactive approach to managing workplace safety and ensuring the effective management of injury prevention strategies. The Workplace Safety Policy underpins the directorates’ programs, training and reporting related to occupational health and safety. Outlined in detail on the Workplace Safety intranet site, this work contributes to the ACT Public Sector Workplace Health Strategic Plan for 2008-2012 which is focused on "Continuous improvement in the management of workplace health and safety through Leadership, Injury Prevention".

Support to staff, managers and the executive of the directorate in implementing this policy, and the related strategies are provided by Workplace Safety section of the Quality and






http://www.cmd.act.gov.au/__data/assets/pdf_file/0014/117014/whsstratplan.pdf


Safety Unit The Health Directorate has developed the Safety Management System (SMS) to address local occupational health and safety (OHS) policy and procedural requirements relevant to Health operations. The Health SMS provides processes necessary to comply with our OHS responsibilities and has been developed with the purpose of providing "hands-on" guidelines for all line managers, employees and relevant support staff.

Corporate Governance Statement — Issue 5, December 2011 – Bibliography and References, Page 1

Bibliography and References

ACT Community Engagement Online. ACT Government, 2011, Canberra. Accessed May 2011 <http://www.communityengagement.act.gov.au/index>

ACT Health, 2005, ACT Health Workforce Plan 2005- 2010, ACT Government, Canberra Accessed May 2011 < http://inhealth/PPR/Policy%20and%20Plans%20Register/Workforce%20Plan%202005-2010.pdf> ACT Health, 2005, Clinical Services Plan 2005-2011, ACT Government, Canberra. Accessed May 2011. <http://inhealth/PPR/Policy%20and%20Plans%20Register/Clinical%20Services%20Plan%202005-2011.pdf> ACT Health 2006, A New Way – Aboriginal and Torres Strait Islander Health and Family Wellbeing Plan 2006-2011, ACT Government, Canberra. Accessed May 2011 http://inhealth/PPR/Policy%20and%20Plans%20Register/Aboriginal%20and%20Torres%20Strait%20Islander%20Health%20Family%20Well%20being%20Plan%202006-2011.pdf ACT Health, 2007, Critical Care Services Plan 2007-2011, ACT Government, Canberra. Accessed May 2011. <http://inhealth/PPR/Policy%20and%20Plans%20Register/Critical%20Care%20Services%20Plan%202007-2011.pdf> ACT Health, 2008, ACT Chronic Disease Strategy 2008-2011, ACT Government, Canberra. Accessed May 2011. <http://inhealth/PPR/Policy%20and%20Plans%20Register/Chronic%20Disease%20Strategy%202008-2011.pdf> ACT Health, 2008, Adult Corrections Health Services Plan 2008-2012, ACT Government, Canberra. Accessed May 2011. <http://inhealth/PPR/Policy%20and%20Plans%20Register/Adult%20Corrections%20Health%20Services%20Plan%202008-2012.pdf> ACT Health, 2008, Children and Young Peoples Justice Health Services Plan 2008-2012, ACT Government, Canberra. Accessed May 2011. http://inhealth/PPR/Policy%20and%20Plans%20Register/Childrens%20and%20Young%20Peoples%20Justice%20Health%20Services%20Plan%202008-2012.pdf ACT Health, 2008, Diabetes Service Strategic Plan 2008-2012, ACT Government, Canberra. Accessed May 2011. <http://inhealth/PPR/Policy%20and%20Plans%20Register/Diabetes%20Services%20Strategic%20Plan%202008-2012.pdf> ACT Health, 2009, Mental Health Services Plan 2009- 2014, ACT Government, Canberra Accessed May 2011 http://inhealth/PPR/Policy%20and%20Plans%20Register/Mental%20Health%20Services%20Plan%202009-2014.pdf ACT Health, 2009, Mental Health Services Plan 2009-2014, ACT Government, Canberra. Accessed May 2011 <http://inhealth/PPR/Policy%20and%20Plans%20Register/Mental%20Health%20Services%20Plan%202009-2014.pdf> ACT Health 2010, Work Safety Policy, ACT Government, Canberra. Accessed May 2011 http://acthealth/c/healthintranet?a=sendfile&ft=p&fid=-697648572&sid= ACT Health, 2010, ACT Health Sustainability Strategy July 2010, ACT Government, Canberra. Accessed May 2011 < <http://inhealth/PPR/Policy%20and%20Plans%20Register/Sustainability%20Strategy.pdf> ACT Health, 2010, Alcohol, Tobacco and Other Drug Strategy, 2010-2014. ACT Government, Canberra. Accessed May 2011 <http://inhealth/PPR/Policy%20and%20Plans%20Register/Alcohol,%20Tobacco%20and%20Other%20Drug%20Strategy%202010-2014.pdf\> ACT Health, 2010, Digital Health Enterprise Technology Strategy and Implementation Plan, ACT Government, Canberra.

http://www.communityengagement.act.gov.au/index

http://inhealth/PPR/Policy%20and%20Plans%20Register/Workforce%20Plan%202005-2010.pdf

http://inhealth/PPR/Policy%20and%20Plans%20Register/Clinical%20Services%20Plan%202005-2011.pdf



http://inhealth/PPR/Policy%20and%20Plans%20Register/Critical%20Care%20Services%20Plan%202007-2011.pdf

http://inhealth/PPR/Policy%20and%20Plans%20Register/Chronic%20Disease%20Strategy%202008-2011.pdf





http://inhealth/PPR/Policy%20and%20Plans%20Register/Diabetes%20Services%20Strategic%20Plan%202008-2012.pdf



http://acthealth/c/healthintranet?a=sendfile&ft=p&fid=-697648572&sid

http://inhealth/PPR/Policy%20and%20Plans%20Register/Sustainability%20Strategy.pdf

http://inhealth/PPR/Policy%20and%20Plans%20Register/Alcohol,%20Tobacco%20and%20Other%20Drug%20Strategy%202010-2014.pdf/

http://inhealth/PPR/Policy%20and%20Plans%20Register/Alcohol,%20Tobacco%20and%20Other%20Drug%20Strategy%202010-2014.pdf/


Accessed May 2011. <http://acthealth/c/healthintranet?a=sendfile&ft=p&fid=703906448&sid=> ACT Health, 2010, Chief Executive’s Financial Instructions – Finance Online, ACT Government, Canberra. Accessed May 2011 <http://inhealth/PPR/Policy%20and%20Plans%20Register/Chief%20Executives%20Financial%20Instructions%20(CEFI).pdf>

ACT Health, 2010, Policy Management Framework, ACT Government, Canberra. Accessed May 2011. < http://health.act.gov.au/c/health?a=dldivpoldoc&document=2220> ACT Health, 2010, Renal Health Services Plan 2010-15, ACT Government, Canberra. Accessed May 2011. <http://inhealth/PPR/Policy%20and%20Plans%20Register/Renal%20Health%20Services%20Plan%202010-15.pdf> ACT Health, 2010, Safety and Quality Framework 2010-2015, ACT Government, Canberra. Accessed May 2011 <http://inhealth/PPR/Policy%20and%20Plans%20Register/Safety%20And%20Quality%20Framework%202010-2015%20-%20ACT%20Health.pdf> ACT Health, 2005. Working Together to Enhance Our Performance, ACT Government, Canberra. Accessed May 2011 < http://health.act.gov.au/c/health?a=dlpol&policy=1902516743> ACT Treasury, 2011, ACT Budget Papers, Canberra. Accessed May 2011 < http://www.treasury.act.gov.au/budget/index.shtml> Administrative Arrangements, 2011 (No. 11), ACT Government 2011, Canberra. Accessed May 2011 http://www.legislation.act.gov.au/ni/2011-244/current/pdf/2011-244.pdf

Annual Reports (Government Agencies) Act 2004, ACT Government 2011, Canberra. Accessed May 2011. http://www.legislation.act.gov.au/a/2004-8/default.asp

Australian Commission on Quality and Safety In Health Care, 2010, Australian Safety and Quality Framework for Health Care. Commonwealth of Australia, Canberra. Accessed May 2011. <http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/C774AE55079AFD23CA2577370000783C/$File/32296-Australian-SandQ-Framework.PDF>

Australian National Audit Office, 2003, Public Sector Governance Volume 1 Better Practice Guide – Framework, Processes and Practices, Commonwealth of Australia, Canberra

Australian National Audit Office, 2003, Public Sector Governance Volume 2 Better Practice Guide – Guidance Papers, Commonwealth of Australia, Canberra

Australian National Audit Office, 2005, Better Practice Guide – Public Sector Audit Committees, Commonwealth of Australia, Canberra.

Australian Public Service Commission, 2007, Building Better Governance, Commonwealth of Australia, Canberra. Accessed May 2011 <http://www.apsc.gov.au/publications07/bettergovernance.pdf > Blood Donation (Transmittable Diseases Act) 1985, ACT Government 2007, Canberra. Accessed May 2011. http://www.legislation.act.gov.au/a/1985-27/default.asp Calvary Hospital Home Page, Canberra 2011. Accessed May 2011-05-25 http://www.calvary-act.com.au/about/ Chief Minister’s Department, 2007 Information Note: Delegations Under the ACT Legislative Employment Framework, ACT Government, Canberra. Accessed May 2011. <http://www.cmd.act.gov.au/__data/assets/pdf_file/0019/117028/in092007.pdf > Chief Minister’s Department, 2008, The Canberra Plan – Towards our second century, ACT Government, Canberra. Accessed May 2011 < http://www.cmd.act.gov.au/policystrategic/canberraplan>

http://acthealth/c/healthintranet?a=sendfile&ft=p&fid=703906448&sid

http://inhealth/PPR/Policy%20and%20Plans%20Register/Chief%20Executives%20Financial%20Instructions%20(CEFI).pdf


http://inhealth/PPR/Policy%20and%20Plans%20Register/Renal%20Health%20Services%20Plan%202010-15.pdf





http://www.legislation.act.gov.au/ni/2011-244/current/pdf/2011-244.pdf





http://www.apsc.gov.au/publications07/bettergovernance.pdf


http://www.calvary-act.com.au/about/


http://www.cmd.act.gov.au/policystrategic/canberraplan


Chief Minister’s Department, 2010, ACTPS Executive Handbook – January 2010, ACT Government, Canberra. Accessed May 2011. <http://www.cmd.act.gov.au/__data/assets/pdf_file/0011/116768/exechb.pdf Chief Ministers Department, 2010, ACT Public Service Integrity Policy 2010, ACT Government, Canberra. Accessed May 2011 <http://www.cmd.act.gov.au/__data/assets/pdf_file/0006/187179/integritypolicy2010.pdf> Chief Minister’s Department, 2010, New Selection Criteria for Executive & Chief Executive Positions, ACT Government, Canberra. Accessed May 2011 http://www.cmd.act.gov.au/__data/assets/pdf_file/0014/116411/1002execcap2.pdf Chief Minister’s Department, 2011, ACT Public Sector Review: One Government, One ACT Public Service¸ ACT Government, Canberra. Accessed May 2011 <http://www.actpsreview.act.gov.au/home> Chief Minister’s Department, 2011, Strengthening Performance and Accountability –A Framework for the ACT Government, ACT Government, Canberra, Accessed May 2011 <http://www.cmd.act.gov.au/__data/assets/pdf_file/0020/184601/Strengthening_Prefromance_and_Accountability_-_A_Framework_for_the_ACT_Government.pdf > Department of Housing and Community Services, 2010, ACT Children’s Plan 2010-2014. ACT Government, Canberra. Accessed May 2011. <http://inhealth/PPR/Policy%20and%20Plans%20Register/Childrens%20Plan%202010-2014.pdf>

Drugs of Dependence Act 1989, ACT Government 2010, Canberra. Accessed May 2011. http://www.legislation.act.gov.au/a/alt_a1989-11co/default.asp

Epidemiological Studies (Confidentiality) Act 1992, ACT Government 2007, Canberra. Accessed May 2011 http://www.legislation.act.gov.au/a/1992-26/default.asp

Fair Work Act 2009, Commonwealth of Australia 2010, Canberra. Accessed May 2011 http://www.comlaw.gov.au/Details/C2010C00741

Fitzgerald, P. 2002 Corporate governance in the public and voluntary sectors. Royal Society of Arts, London

Freedom of Information Act, 1989, ACT Government, 2009, Canberra. Accessed May 2011. http://www.legislation.act.gov.au/a/alt_a1989-46co/default.asp

Food Act 2001, ACT Government 2009, Canberra. Accessed May 2011. http://www.legislation.act.gov.au/isysquery/search.asp Gallagher, Katy MLA, Local Hospital Network Established, Media Release 2011, Canberra. Accessed May 2011. http://www.chiefminister.act.gov.au/media.php?v=10588 Gene Technology Act 2003, ACT Government 2009, Canberra. Accessed May 2011. http://www.legislation.act.gov.au/a/2003 Gene Technology (GM Crop Moratorium) Act 2004, ACT Government, 2004, Canberra. Accessed May 2011. http://www.legislation.act.gov.au/a/2004 Government Procurement Act 2001, ACT Government 2011, Canberra. Accessed May 2011 http://www.legislation.act.gov.au/a/2001-28/default.asp Government Procurement Regulation 2007, ACT Government 2009, Canberra. Accessed May 2011 http://www.legislation.act.gov.au/sl/2007 Health Act 1993, ACT Government 2011, Canberra. Accessed May 2011 <http://www.legislation.act.gov.au/a/1993-13/default.asp >

Health Practitioner Regulation National Law (ACT) Act 2010, ACT Government 2011, Canberra. Accessed June 2011.


http://www.cmd.act.gov.au/__data/assets/pdf_file/0006/187179/integritypolicy2010.pdf

http://www.cmd.act.gov.au/__data/assets/pdf_file/0014/116411/1002execcap2.pdf

http://www.actpsreview.act.gov.au/home

http://www.cmd.act.gov.au/__data/assets/pdf_file/0020/184601/Strengthening_Prefromance_and_Accountability_-_A_Framework_for_the_ACT_Government.pdf

http://www.cmd.act.gov.au/__data/assets/pdf_file/0020/184601/Strengthening_Prefromance_and_Accountability_-_A_Framework_for_the_ACT_Government.pdf




http://www.comlaw.gov.au/Details/C2010C00741


http://www.legislation.act.gov.au/isysquery/search.asp

http://www.chiefminister.act.gov.au/media.php?v=10588




http://www.legislation.act.gov.au/sl/2007





Health Professionals Act 2004, ACT Government 2010, Canberra. Accessed May 2011. <http://www.legislation.act.gov.au/a/1993-13/default.asp >

Health Professionals Regulation 2004, ACT Government 2010, Canberra. Accessed May 2011 < http://www.legislation.act.gov.au/sl/2004-41/default.asp >

Health Professionals (Special Events Exemptions) Act 2000,ACT Government, 2010. Accessed June 2011 http://www.legislation.act.gov.au/a/2000-25/default.asp

Health Records (Privacy and Access) Act 1997, ACT Government, 2011, Canberra. Accessed May 2011. http://www.legislation.act.gov.au/a/1997-125/default.asp

Human Cloning and Embryo Research Act 2004, ACT Government 2009, Canberra. Accessed May 2011. http://www.legislation.act.gov.au/a/2004-22/default.asp

Human Rights Commission Act 2005, ACT Government 2010, Canberra. Accessed May 2011 <http://www.legislation.act.gov.au/a/2005-40/default.asp>

Intoxicated People (Care and Protection) Act 1994, ACT Government 2009, Canberra. Accessed June 2011. http://www.legislation.act.gov.au/a/1994-85/default.asp Institute of Patient- and Family- Centred Care, Frequently Asked Questions, 2010. Accessed May 2011 http://www.ipfcc.org/faq.html Medicines, Poisons and Therapeutic Goods Act 2008, ACT Government 2011, Canberra. Accessed May 2011. http://www.legislation.act.gov.au/a/2008-26/

Mental Health (Treatment and Care) Act, 1994, ACT Government 2011, Canberra. Accessed May 2011. http://www.legislation.act.gov.au/a/1994-44/default.asp

New South Wales Health, Systems and Initiatives – Clinical Governance, NSW Government, Sydney. Accessed May 2011 < http://www.health.nsw.gov.au/mhdao/clinical_governance.asp>

Office of Quality and Safety in Health Care, 2003, Introduction to Clinical Governance – A Background Paper Information Series No. 1.1, Department of Health, Government of Western Australia. Accessed May 2011 <http://www.safetyandquality.health.wa.gov.au/docs/clinical_gov/Introduction_to_Clinical_Governance.pdf Work Safety Act 2008, ACT Government 2011, Canberra. Accessed May 2011 Performance Agreements of ACT Health Executive Staff 2011(Confidential, Unpublished)

Public Health Act 1997, ACT Government 2011, Canberra. Accessed May 2011 http://www.legislation.act.gov.au/a/1997-69/default.asp

Public Interest Disclosure Act 1994, ACT Government 2004, Canberra. Accessed May 2011. < http://www.legislation.act.gov.au/a/1994-108/default.asp>

Public Sector Management Act1994, ACT Government 2011, Canberra. Accessed May 2011 <http://www.legislation.act.gov.au/a/1994-37/default.asp >

Public Sector Management Standards 2006, ACT Government 2011, Canberra. Accessed May 2011. < http://www.legislation.act.gov.au/di/2006-187/default.asp>

Radiation Protection Act 2006, ACT Government 2010, Canberra. Accessed May 2011. http://www.legislation.act.gov.au/a/2006 Smoke-free Public Places Act 2003, ACT Government 2010, Canberra. Accessed May 2011. http://www.legislation.act.gov.au/a/2003









http://www.ipfcc.org/faq.html



http://www.health.nsw.gov.au/mhdao/clinical_governance.asp

http://www.safetyandquality.health.wa.gov.au/docs/clinical_gov/Introduction_to_Clinical_Governance.pdf









Territory Records Act 2002,ACT Government 2011, Canberra. Accessed May 2011 <http://www.legislation.act.gov.au/a/2002-18/default.asp> Tobacco Act 1927, ACT Government 2011, Canberra. Accessed May 2011 http://www.legislation.act.gov.au/a/1927-14/default.asp Transplantation and Anatomy Act 1978, ACT Government 2011, Canberra. Accessed May 2011. http://www.legislation.act.gov.au/a/1978-44/default.asp Victorian Law Foundation, 2011, Rural law online – How Government Works, Victoria. Accessed May 2011 http://www.rurallaw.org.au/handbook/xml/ch10s03.php Work Safety Regulations 2009, ACT Government 2011, Canberra. Accessed May 2011 http://www.legislation.act.gov.au/sl/2009-45/default.asp




http://www.rurallaw.org.au/handbook/xml/ch10s03.php



Riding the Technology Wave (Presentation by Associate Professor Steven Boyages, CEO Western Sydney Area Health Service, Undated)

Selection Criteria for Chief Executives and Executives (ACT Government, April 2005)

Simply the Best - Workplaces in Australia (Working Paper 88 by Dr Daryll Hull and

Vivienne Read, University of Sydney, December 2003)

Strategic Directions for Health 2000 - 2005 - Better Health, Good Health Care (NSW Health, October 2000)

The Canberra Hospital Home Page (The Canberra Hospital TCH - Intranet and Internet, April 2005)

Universal Health Services Inc - Corporate Governance (Universal Health Services Inc, 2004)

Working Together – Shaping our Future with our People – A Strategic Plan for Building a Sustainable ACT Health Workforce (ACT Health, December 2004)