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ACT Health - Corporate Governance Statement
ACT Health - Corporate Governance Statement
ACT Health - Corporate Governance Statement
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
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 agencys 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.
Table of Contents
Foreword
Corporate Governance
Chapter 1
Corporate Governance
Vision, values and key performance areas Health Directorate Code of Conduct
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 Population Health Division Quality and Safety Unit Financial Management Executive Coordination Unit Communications and Marketing Unit Internal Audit & Risk Management
9.09 9.10
Minister and Legislative Assembly Director-General Public sector senior executives Managers and employees Professional positions and roles Committees External agencies
Sustainability
Chapter 17
Sustainability Strategy
Consumer Experience
Patient and family centred care Community engagement Advisory and consultative process Disclosure, transparency & Freedom of Information
Policy management framework (incl. corporate and clinical policy) Strategic and service planning Plans and strategies
Clinical Governance
Chapter 28 Chapter 29
Corporate Governance
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
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.
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 entitys 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.
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 portfolios 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.
The Health Directorate corporate plan is informed by and links to the broader ACT Governments strategic planning framework:
Direction setting
Vision Goals Progress indicators Government priorities Priority indicators Strategic objectives Strategic indicators Service objectives Financial performance Accountability indicators
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 governments 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.
Vision
The Government and the Health Directorate vision is Your health, our priority.
Values
The Health Directorates 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.
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:
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.
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.
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.
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.
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
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.
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.
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
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.
Chapter 7
Resource Management
Legislative framework
ACT public sector accounting and financial responsibilities are set out in the Financial Management Act 1996 .
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.
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.
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.
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.
Organisational Positions
Operational Areas
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
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
Responsibilities
Service delivery through: 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.
Communication and collaboration through: 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.
Research, teaching, training and development through: 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
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.
Communication and collaboration through: 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.
Strategic planning through: 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.
Safety and quality through: 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 DirectorGeneral, 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 Directors Council Management Advisory Council Safety and Quality Committee Work Safety Committee and Accreditation Steering Group
Organisation chart
Responsibilities
Service delivery through: 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.
Strategic planning through: 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.
Research, teaching, training and development through: 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 Directors 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
Responsibilities
Service delivery through: 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.
Communication and collaboration through: 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.
Strategic planning through: 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. Research, teaching, training and development through: 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
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
Responsibilities
Service delivery through: 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.
Communication and collaboration through: 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.
Strategic planning through: 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.
Safety and quality through: 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.
Research, teaching, training and development through: 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 divisions 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
Responsibilities
Service delivery through: 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 Directorates 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.
Research, teaching, training and development through: 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.
Operational management through: 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
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
Responsibilities
Service delivery through: 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.
Communication and collaboration through: Liaising with consumers and other stakeholders to inform day to day operational issues, and longer term planning
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.
Safety and quality through: 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.
Research, teaching, training and development through: 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,
The Executive Director of the Division of Pathology represents the Health Directorate at the National Pathology Accreditation Advisory Council (NPAAC).
Organisation Chart
MEDICINE
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 divisions 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 patients 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
Role
Responsibilities
Service delivery through: 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.
Communication and collaboration through: Promoting effective working relationships with individuals, agencies and networks Establishing clear processes of communication within the division, and Demonstrating the Health Directorates 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.
Safety and quality through: 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.
Research, teaching, training and development through: 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
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
Responsibilities
Service delivery through: 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.
Communication and collaboration through: 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 Promoting and maintaining collegiate relationships with professional groups and stakeholders.
Strategic planning through: Undertaking the responsibility for contributing to and maintaining the organisations 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.
Safety and quality through: 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.
Research, teaching, training and development through: 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 and quality of services.
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
Responsibilities
Service delivery through: 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.
Communication and collaboration through: 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.
Strategic planning through: 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.
Research, teaching, training and development through: 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 and quality of services.
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
Responsibilities
Service delivery through: 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 Governments commitment to provide health system information to the Commonwealth Department of Health and Ageing and other national bodies Managing the directorates 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 directorates 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.
Communication and collaboration through: 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.
Strategic planning through: 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.
Safety and quality through: 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.
Research, teaching, training and development through: 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.
Operational management through: 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
Responsibilities
Service delivery through: 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.
Strategic planning through: 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.
Safety and quality through: 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.
Research, teaching, training and development through: 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..
Operational management through: 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
Responsibilities
Service delivery through: 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 nongovernment 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 Promoting and maintaining collegiate relationships with professional groups and stakeholders.
Strategic planning through: 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.
Safety and quality through: 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.
Operational management through: 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
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-Generals Steering Committee (CADP), and Information and Communication Technology Committee
Organisation Chart
Chapter 9.02.7
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
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 Directorates 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 populationfocused 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 womens 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.
Communication and collaboration through: 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 PHDs 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 Directors 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 Registrations 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
Responsibilities
Service delivery through: 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.
Communication and collaboration through: 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.
Operational management through: 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:
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.
Responsibilities
Service delivery through: Coordinating internal financial reporting within the Health Directorate and meeting the directorates 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 Solicitors 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.
Research, teaching, training and development through: 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 DirectorGeneral. 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.
Responsibilities
Service delivery through: 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 Ministers 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 Directorates 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 Ministers office Managing the Health Directorates relationship with the Cabinet Office, including the preparation of Cabinet and Assembly Business Coordinating the Directorates 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.
Strategic planning through: 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.
Safety and quality through: 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
Responsibilities
Service delivery through: 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.
Communication and collaboration through: Coordinating communication between the media, Health Directorate and Ministers 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.
Safety and quality through: 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.
Research, teaching, training and development through: 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
Responsibilities
Service delivery through: 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.
Communication and collaboration through: Reporting on a regular basis to the Audit and Risk Management Committee and the DirectorGeneral 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 Generals 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-Generals Office and private contractors to develop a schedule of external audit for the Health Directorate.
Safety and quality through: 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.
Research, teaching, training and development through: 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 units 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
Responsibilities
Service delivery through: 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.
Strategic planning through: 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.
Safety and quality through: 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.
Research, teaching, training and development through: 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.
Operational Management through: Effective management of the units 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
Chapter 9.10
Responsibilities
Service delivery through: Effective management of donated funds to support new services, equipment, facilities or research both in the short and longer term.
Communication and collaboration through: 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.
Safety and quality through: 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.
Research, teaching, training and development through: Engaging with relevant professional and not-for-profit organisations to ensure continued development of unit staff, and
Monitoring performance and outcome measures to identify any areas for continuous improvement.
Operational Management through: Effective management of the units 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
Chapter 10
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 fouryear 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.
Ministerial accountability
Ministers are accountable for: The administration of an ACT Public Service Directorate, statutory authority or Governmentowned 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.
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.
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.
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 Governments 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 workers 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 directorates 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 Corporate Governance Statement Issue 5, December 2011 Chapter 11, Page 3
Executive Directors 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)
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 executives 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.
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.
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.
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.
Official comment
The Public Sector Management Act prohibits public employees from making unauthorised public comments.
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. Directors-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.
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.
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.
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.
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
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.
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 Directorates 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 directorates 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 directorates 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 organisations 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.
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.
Consumer Experience
Chapter 18
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
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 ACT 2, 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
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 Institute 3 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
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.
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.
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.
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.
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 committees 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.
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.
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.
Chapter 21
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.
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.
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 Evidencebased: 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 Tier 1 Governance Group Executive Council Scope National Whole of ACT Government Health Sector in the ACT Health Directorate and the non-government and private sectors Examples Commonwealth Agreements Social Compact Childrens Plan ACT Health Child Protection Policy HIV, AIDS, Hepatitis C, Sexually Transmissible Infections Strategic Framework for the ACT 2007-2021 Maternity Shared Care Guidelines
-continued
Health Directorate impact on all divisions, branches and units in the organisation Strategy and Corporate or Canberra Hospital and Health Services
Tier 2
Corporate and Strategy Executive Forum or Canberra Hospital and Health Services Executive Forum Division, branch or unit Executive Fora
Consent to Treatment Policy Procurement Policy Open Disclosure Policy Media Policy Antibiotic Use Standard Operating Procedure (SOP) Electrical Cord Safety SOP
Tier 3
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 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.
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.
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.
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.
Tier 2
Corporate and Strategy Executive Forum or Canberra Hospital and Health Services Executive Forum Division, branch or unit operational team/service
Whole of ACT Government Health Sector in the ACT Health Directorate and the non-government and private sectors Health Directorate impact on all divisions, branches and units in the organisation Strategy and Corporate or Canberra Hospital and Health Services
Corporate Plan Capital Asset Development Plan Critical Care Services Plan Adult Corrections Health Services Plan Population Health Unit Business Plan
Tier 3
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.
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 Childrens Plan.
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.
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
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).
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 Childrens Plan 2010-2014 - Developed under the governance of the Department of Housing and Community Services and ACT Health the first ACT Childrens Plan was launched in 2004. This complemented the Canberra Plan and the Canberra Social Plan. The ACT Childrens 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
detection and early treatment; integration and continuity of prevention and care; and selfmanagement; 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.
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.
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
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:
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.
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.
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
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.
General Canberra Hospital and Health Services Group, and Deputy Director-General Strategy and Corporate.
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.
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 Directorates Integrated Risk Management Policy, procedures and guidelines support the task of establishing the context, identifying, analysing, evaluating, treating, monitoring and communicating risks. The directorates 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.
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 directorates 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 directorates 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.
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 DirectorGeneral 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.
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.
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
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.
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%20Fa mily%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%2020082012.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%20Se rvices%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%2020 10-2014.pdf\> ACT Health, 2010, Digital Health Enterprise Technology Strategy and Implementation Plan, ACT Government, Canberra.
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Accessed May 2011. <http://acthealth/c/healthintranet?a=sendfile&ft=p&fid=703906448&sid=> ACT Health, 2010, Chief Executives 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 Ministers 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 Ministers Department, 2008, The Canberra Plan Towards our second century, ACT Government, Canberra. Accessed May 2011 < http://www.cmd.act.gov.au/policystrategic/canberraplan>
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Chief Ministers 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 Ministers 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 Ministers 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 Ministers 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 Childrens 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/199313/default.asp > Health Practitioner Regulation National Law (ACT) Act 2010, ACT Government 2011, Canberra. Accessed June 2011.
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http://www.legislation.act.gov.au/a/2010-10/default.asp 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/199769/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
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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
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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)
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