Legal and Regulatory Services Branch

ACCOUNTING MANUAL

FOR

MINISTRY OF HEALTH AND AMBULANCE SERVICE

AMENDMENT NO 19 19 (14/7/16)

Where a number appears at the bottom of an amended page [e.g. 17(13/08/15) – amendment number, date] an alteration has been made or new section included. The amendments as indicated reflect the provisions of Policy Directives/Guidelines/Information Bulletins: • PD2016_027 –Chapter 1 and 7 – Public Interest Disclosures

as notified by Strategic Relations and Communications on 14 July 2016 The Manuals and complete amendments are available on the Internet at http://www.health.nsw.gov.au/policies/manuals/index.asp If you choose to print the amendment, make sure you print it double sided. If you are missing any amendments please email cgrm@doh.health.nsw.gov.au They can be emailed to you in an electronic version.

REMOVE PAGE(S) INSERT PAGE(S)

Chapter (1) 1.1 – 1.4, 1.7 – 1.28

Chapter (7) 7.1-2, 7.5-8

Chapter (1) 1.1 – 1.4, 1.7 – 1.28

Chapter (7) 7.1-2, 7.5-8

INTRODUCTION 1.1 GENERAL The following material has been prepared for the purpose of assisting and training officers whose duties involve the various accounting functions operative throughout State Health Central Administration and the Ambulance Service and to satisfy the requirements of Section 11(3), Public Finance and Audit Act 1983 and Treasurer’s Direction 720.03. Officers should be aware, however, that although the material has been presented in the format of a State Health Accounting Manual, many of the procedures etc., contained herein relate to and are governed by legislation, regulations, certain rules etc. that apply throughout the Public Service. An accounting officer is to ensure that in the exercise of accounting duty he/she is aware of and complies with the following statutory requirements, standards, concepts and policy in regard to accounting including accrual accounting. • Public Finance and Audit Act 1983 and Regulations. • Treasurer’s Directions. • Public Sector Management (Goods and Services) Regulation 1995. • Financial Accounting and Reporting Directives issued by the NSW Treasury (for example, the

Financial Reporting Code on Accrual Accounting for Inner Budget Sector Entities, as amended). • Circulars on Accounting and Reporting issued by the NSW Treasury relevant to Inner Budget

Sector Entities. • Statements of Accounting Concepts and Accounting Standards issued by the Australian Accounting

Research Foundation and the Australian Accounting Standards Board, as applicable to Inner Budget Sector Entities.

State Health would welcome any suggestions as to how the Manual could be improved. Any such suggestions should be conveyed to the Audit Branch in the first instance. As with other State Health Manuals it has been issued in loose leaf form to facilitate amendment. Executive clerical officers should ensure junior staff are aware of the existence of the Manual and of the ways it can be utilised.

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INTRODUCTION 1.2 CORRUPT CONDUCT – REPORTING TO INDEPENDENT COMMISSION AGAINST CORRUPTION (ICAC) (PD2011_070) PD2011_070 rescinds PD2009_034. PURPOSE This policy document prescribes policy and procedures that requires all NSW Health Chief Executives to report possible corrupt conduct in accordance with the Independent Commission Against Corruption Act 1988 (the Act). The policy also requires Chief Executives to provide a copy of all such reports to the Ministry of Health. The Act imposes an obligation on Chief Executives of NSW Health Organisations, as “Principal Officers”, to report possible corrupt conduct to the Independent Commission Against Corruption (ICAC). The quality of information reported to ICAC is a significant factor influencing its effectiveness in fighting corruption. MANDATORY REQUIREMENTS Any matter that the Chief Executive suspects on reasonable grounds concerns or may concern corrupt conduct as described in Section 8 of the Act must be reported to ICAC. An effective internal reporting system (refer PD2016_027, Public Interest Disclosures) must be established in each NSW Health organisation to facilitate the flow of corruption reports to the organisation’s Chief Executive. All ICAC notifications made to ICAC should be forwarded at the same time to the Ministry of Health for the attention of the Compliance Unit, Legal and Corporate Governance Branch. IMPLEMENTATION Roles and Responsibilities Chief Executives (however designated) are required: • As “Principal Officers” (see Definitions Section) (under section 11 of the ICAC Act) to report any

matter that he/she suspects on reasonable grounds, concerns or may concern corrupt conduct (see Definitions Section) to ICAC. The words suspects on reasonable grounds mean there is a real possibility that corrupt conduct is or may be involved. Certainly, proof is not necessary. In some cases you may hold the suspicion even though no individual has been identified, such matters should be reported. A report should be made as soon as you have a reasonable suspicion that corrupt conduct may have occurred or may be occurring. The Act contains no provision permitting delay in reporting. The ICAC prefers matters to be reported prior to disciplinary or other action being taken. Matters must be reported to the ICAC regardless of any duty of secrecy or other restriction on disclosure.

• To ensure that an effective internal reporting system is operating and communicated within the organisation.

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INTRODUCTION 1.7 CODE OF CONDUCT (PD2015_035) rescinds PD2012_018.

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INTRODUCTION 1.8 PUBLIC INTEREST DISCLOSURES (PD2016_027) PD2016_027 rescinds PD2015_027. PURPOSE This Policy Directive provides procedures for receiving, assessing and managing public interest disclosures in compliance with the Public Interest Disclosures Act 1994 (NSW).

In accordance with the core values of NSW Health – Collaboration, Openness, Respect and Empowerment – all NSW Health staff who become aware of wrongdoing should report it.

This Policy Directive is intended to clearly state the rights and responsibilities of staff in relation to public interest disclosures. NSW Health staff should have confidence that reports of serious wrongdoing which are reported in accordance with the legislation and this policy will be treated appropriately, including protection from reprisals.

This policy is not intended to be used for staff grievances. If a staff member makes a report under this policy which is substantially a grievance, the matter should be dealt with in accordance with PD2010_007 Grievance – Effective workplace Resolution

MANDATORY REQUIREMENTS

The Public Interest Disclosures Act 1994 (NSW) (the PID Act) requires public authorities to have a policy and procedure for receiving, assessing and dealing with public interest disclosures.

A report in relation to the following categories of wrongdoing may be a public interest disclosure:

• Corrupt conduct • Maladministration • Serious and substantial waste • Government information contravention • Local government pecuniary interest contravention.

NSW Health is committed to being open and accountable by encouraging staff to raise their concerns about serious wrongdoing and by providing protection for those staff who speak out about wrongdoing.

NSW Health will support staff to report instances of wrongdoing.

NSW Health organisations will provide statistical information about public interest disclosures to the NSW Ombudsman for each six month period ending 30 June and 31 December.

As Principal Officers, Chief Executives of NSW Health organisations and the Secretary, NSW Ministry of Health have legislative responsibilities under the PID Act as outlined below.

IMPLEMENTATION Principal Officers are required to:

• Ensure that the contents of this policy directive are effectively communicated to staff within their organisation and that staff are aware of the protections available under the PID Act to a person who makes a public interest disclosure

• Ensure that their organisation complies with the obligations under the PID Act and this policy

• Designate a disclosures co-ordinator as being responsible for receiving and assessing public interest disclosures on behalf of the authority and who will be responsible for the functions outlined within this policy

• Comply with their roles and responsibilities as outlined in the legislation and this policy.

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INTRODUCTION 1.9 All staff are required to:

• Report known or suspected wrongdoing and support those who have made a report of wrongdoing • If requested, assist those dealing with a report including providing information and co-operate with

an investigation • Maintain confidentiality with respect to a report of wrongdoing • Treat any person dealing with a report of wrongdoing with courtesy and respect • Respect the rights of people who are the subject of a report • Not take reprisal action against any individual in relation to a report of wrongdoing. 1. BACKGROUND 1.1 About this document NSW Health is committed to high standards of ethical and accountable conduct. Any staff member who has knowledge of, or who has witnessed serious wrongdoing should make a confidential report about the wrongdoing. A strong culture of reporting wrongdoing promotes integrity, accountability and good management within NSW Health.

These procedures are designed to assist NSW Health to ensure that the workplace is an environment where:

• Employees are encouraged to disclose wrongdoing without fear of reprisal

• Disclosures of wrongdoing are assessed and dealt with in a fair and efficient manner The

Ombudsman’s guidelines and model internal reporting policy have been considered in formulating

these procedures as required by the Public Interest Disclosures Act 1994 (NSW).

1.2 Key definitions

For the purposes of this policy, the following definitions apply:

Corrupt Conduct – ‘Corrupt Conduct’ is broadly defined in Sections 8 and 9 of the ICAC Act 1988. The main element of corruption is the misuse of public office. Commonly, corruption involves the dishonest or partial use of power or position resulting in one person being advantaged over another. Corruption can take many forms including (but not limited to):

• A public official improperly uses the knowledge, power or resources of their position for personal gain

• A public official dishonestly or improperly exercises their functions, breaches public trust or misuses information or resources acquired during the course of their official functions

• A member of the public influences, or tries to influence, a public official to use his or her position in a way that is dishonest biased or breaches public trust.

Disclosures Coordinator – a person or position, appointed by the principal officer and responsible for assessment and management of PIDs, as well as statutory reporting of PID statistics for a public authority. The principal officer may be the disclosures coordinator for the public authority.

Government Information Contravention – a failure to properly fulfill functions under the Government Information (Public Access) Act 2009 (the GIPA Act). For example, this could include:

• Destroying, concealing or altering records to prevent them from being released • Knowingly making decisions contrary to the GIPA Act • Directing another person to make a decision contrary to the GIPA Act.

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INTRODUCTION 1.10 Grievance – A written or oral statement made by a staff member regarding a concern arising in the workplace. Examples may include, but are not limited to, interpersonal conflict, the way work is allocated or managed, interpretation of people management policies, or a perceived unfairness in the workplace. The grievance usually involves some concern or personal distress, and will usually, though not always, involve other people.

Fraud - An intentional, dishonest act or omission done with the purpose of deceiving.

Investigating Authority –

An investigating authority is any of the following:

• The Auditor-General • The Independent Commission Against Corruption (ICAC) • The Ombudsman • The Police Integrity Commission (PIC) • The PIC Inspector • The Office of Local Government, • The ICAC Inspector, and • The Information Commissioner. Local Government Pecuniary Interest Contravention – failure to comply with requirements under the Local Government Act 1993 relating to the management of pecuniary interests.

Maladministration – conduct which involves action or inaction of a serious nature that is:

• Contrary to law or • Unreasonable, unjust, oppressive or improperly discriminatory or • Based wholly or partly on improper motives. NSW Health – refers collectively to NSW health organisations

NSW Health organisation – For the purposes of this policy directive, a public health organisation as defined under the Health Services Act 1997, NSW Ambulance, Health Infrastructure, HealthShare NSW, eHealth NSW, NSW Health Pathology, any other administrative unit of the Health Administration Corporation and all organisations under the control and direction of the Minister for Health or the Minister for Mental Health.

Pecuniary interest – an interest that a person has in a matter because of a reasonable likelihood or expectation of appreciable financial gain or loss.

Principal Officer – the Chief Executive of a health organisation, or the Secretary, NSW Health (in relation to the Ministry of Health).

Public Health Organisation – a health organisation for the purpose of this policy refers to a local health district, a statutory health corporation, or an affiliated health organisation in respect of its recognised establishments and recognised services as listed in the Health Services Act 1997.

Public Interest Disclosure - a disclosure of wrongdoing which meets the requirements for protection under Part 2 of the Public interest Disclosures Act 1994. This type of disclosure was formerly referred to as a protected disclosure.

Public Official - an individual who is an employee of, or otherwise in the service of a public authority. This includes all permanent, temporary and casual staff members of NSW Health, including those engaged under contracts, visiting medical officers, volunteers, and board members.

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INTRODUCTION 1.11 Role Reporter – A NSW Health staff member who, as part of their day-to-day work responsibilities may report serious wrongdoing to the Chief Executive, PID coordinator or disclosures officer. A report made in this way is known as a ‘role report’ and is counted separately in the PID statistical reports to the NSW Ombudsman. Role reporters may not consider they require the same levels of support and protection as other PID reporters, although their report otherwise meets the criteria to be considered a PID. For example, common role reporters would be auditors, investigators, supervisors and managers.

Serious and Substantial Waste - any uneconomical, inefficient or ineffective use of resources, authorised or unauthorised, which results in significant loss/wastage of public funds/resources.

Staff member - any person working in a casual, temporary or permanent capacity in NSW Health, including consultants, contractors, board members and any person performing a public official function whose conduct could be investigated by an investigating authority.

Wrongdoing – any wrongful conduct, including but not limited to serious wrongdoing relating to corrupt conduct, maladministration, serious and substantial waste, failure to deal appropriately with Government Information or local government pecuniary interest contravention. Not all wrongdoing will be capable of being considered a public interest disclosure and attract the protections afforded under the legislation, for example bullying and harassment or practices which may affect the health and safety of staff or patients.

1.3 Legal and legislative framework

The Public Interest Disclosures Act 1994 (NSW) (“the PID Act”) represents the NSW Government’s commitment to maintaining the integrity of the public sector. The PID Act provides legislative protection from reprisals for people who have made a disclosure of serious wrongdoing and specifies penalties for knowingly making false disclosures or taking reprisals against someone substantially for making a public interest disclosure.

Section 6D of the PID Act requires public authorities to have a policy governing the procedures for receiving, assessing and dealing with public interest disclosures.

The Independent Commission Against Corruption Act 1988 governs the reporting of corruption to the ICAC. Principal Officers are required to report any public interest disclosure relating to corruption to ICAC.

The Work Health and Safety Act 2011 relates to workplace health and safety. This legislation imposes a duty on employers to ensure the health and safety of their staff. In certain circumstances, failure to provide protection for a Staff Member who makes a disclosure could constitute a breach of obligations under this legislation.

1.4 Related Policies

The following policies may be of assistance when considering this document: • Code of Conduct PD2015_049 • Corrupt Conduct - Reporting to ICAC PD2016_XX • Managing Misconduct PD2014_042 • Grievance – Effective workplace Resolution PD2010_007 • Bullying – Prevention and Management of Workplace Bullying in NSW Health PD2011_018

2. REPORTING WRONGDOING

2.1 What is a Public interest disclosure? A public interest disclosure (PID) is a report made by a public official that relates to serious wrongdoing which is a matter of public interest – namely corrupt conduct, maladministration, serious and substantial waste of public money, local government pecuniary interest contravention or government information contravention.Disclosures about serious wrongdoing of this nature which meet some other criteria (see 2.3) will be dealt with as public interest disclosures and in accordance with this policy.

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INTRODUCTION 1.12 2.2 What should be reported? NSW Health Staff are encouraged to report any suspected wrongdoing they encounter within NSW Health. In most cases, the wrongdoing should initially be reported to a manager or supervisor. However, reports about five categories of serious misconduct – corrupt conduct, maladministration, serious and substantial waste of public money, breach of the GIPA Act, and local government pecuniary interest contravention – should be made to the Principal Officer, the PID coordinator or a PID officer. Examples of wrongdoing which would be considered a PID are provided below.

All other wrongdoing or suspected wrongdoing should be reported to a supervisor, to be dealt with in line with the relevant policies. This might include:

• Bullying, harassment or unlawful discrimination • A grievance between two staff members • Practices that endanger the health or safety of staff or the public • Minor wrongdoing which can be locally managed. Even if the concerns reported are determined not to be a public interest disclosure, they may raise important issues. Regardless of whether the report is considered a PID, the report will be treated seriously. Reports which are not dealt with as a PID may be dealt with in accordance with other NSW Health policies, such as the grievance or misconduct policies.

2.3 When may a report be considered a PID?

A report about the conduct of a public official or a public authority will be considered a PID if, on assessment, it is found to meet the criteria of a public interest disclosure under the PID Act. These requirements are:

a) The report is one of the five categories of serious wrongdoing outlined below (2.5) b) The person making the report is a public official as defined by the PID Act. c) The report is made to an appropriate person (see 4.2) d) The person making the report honestly believes, on reasonable grounds that the information they

are reporting shows, or tends to show, wrongdoing.

This means that a public interest disclosure cannot be based on a mere allegation that is unsupported by any facts, circumstances or evidence. It is not necessary for the person reporting the wrongdoing to prove that wrongdoing occurred, but there must be some information to support their allegation. A belief is considered to be an “honest belief” unless there is evidence to the contrary.

Information which would show, or tend to show wrongdoing may include:

• Direct observation of wrongdoing • Corroborative observation by others • Evidence such as unbalanced accounts or contradictory records.

2.4 When will a report NOT be considered a PID?

Reports by staff are not PIDs if they: • Do not meet all of the above requirements (including the requirement of seriousness), • Mostly question the merits of government policy, or • Are made with the sole or substantial motive of avoiding dismissal or other disciplinary action.

2.5 What type of wrongdoing may be considered a PID?

Not all reports of wrongdoing will be considered a PID. Reports which are considered grievances, workplace disputes and minor misconduct will be managed under the relevant policy. Under the PID Act, reports in relation to the following categories of serious wrongdoing may, if they otherwise meet the criteria, be considered a public interest disclosure:

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INTRODUCTION 1.13 a. Corrupt conduct Corrupt conduct is the dishonest or partial exercise of official functions by a public official.

For example, this could include: • The improper use of knowledge, power or position for personal gain or the advantage of others • Acting dishonestly or unfairly, or breaching public trust • A member of the public influencing or trying to influence a staff member to use their position in a

way that is dishonest, biased or breaches public trust.

b. Maladministration

Maladministration is conduct that involves action or inaction of a serious nature that is contrary to law, unreasonable, unjust, oppressive or improperly discriminatory or based wholly or partly on improper motives. For example, this could include:

• Making a decision and/or taking action that is unlawful • Refusing an application for reasons that are not related to the merits of the application.

c. Serious and substantial waste of public money

Serious and substantial waste is the uneconomical, inefficient or ineffective use of resources that has resulted in the significant loss or wastage of public resources. For example, this could include:

• Not following a competitive tendering process for a large scale contract • Having severely inadequate processes in place for a system involving large amounts of public

funds.

d. Government Information Contravention

This is a failure to properly fulfill functions under the Government Information (Public Access) Act 2009 (GIPA Act). For example, this could include:

• Destroying, concealing or altering records to prevent them from being released • Knowingly making decisions that are contrary to the legislation • Directing another person to make a decision that is contrary to the legislation.

e. Local Government pecuniary interest contravention

This is a failure to comply with requirements under the Local Government Act 1993 relating to management of pecuniary (financial) interests. For example this could include

• A council staff member recommending a family member for a council contract • A councilor participating in planning permission decisions relating to a development in which they

or their family have some interest.

3. ROLES AND RESPONSIBILITIES

3.1 NSW Health organisations

NSW Health organisations have a responsibility to establish and maintain a work environment which supports staff who report wrongdoing. This includes taking steps to protect reporters from reprisal and managing reports of wrongdoing appropriately. Confidentiality will be maintained where practical and appropriate. Rights and responsibilities for staff making, managing or subject to a PID are set out in section 7 of this policy. Once a staff member reports wrongdoing to a NSW Health organisation, ‘ownership’ of the matter will reside with the organisation. This means it is up to the organisation which received the report to assess the matter and determine whether a report should be investigated and, if so, how it should be investigated and by whom. NSW Health will deal with all reports fairly and reasonably and will respect the rights of any staff members making, or subject of, a report.

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INTRODUCTION 1.14 3.2 Principal Officers

The principal officer has ultimate responsibility for maintaining the internal reporting system and ensuring the organisation complies with the PID Act and this policy directive.

Principal officers can receive reports from staff and have a responsibility to:

• Appoint a disclosures coordinator • Review reports assessed by the disclosures officer, to approve the disclosures officers

recommendation whether or not the report should be treated as a public interest disclosure, and to decide how the report will be dealt with in consultation with the disclosures coordinator

• Ensure there are strategies in place to support reporters, protect reporters from reprisal and manage workplace conflict that may arise in relation to a report

• Make decisions following any investigation or appoint an appropriate decision-maker • Take appropriate remedial/disciplinary action or systemic reform where wrongdoing is

substantiated or systemic problems are identified • Refer actual or suspected corrupt conduct to the Independent Commission Against Corruption

(ICAC) • Refer any evidence of a reprisal offence under section 20 of the PID Act to the Commissioner of

Police or the ICAC.

3.3 Disclosures Coordinator

The disclosures coordinator (PID coordinator) is appointed by the principal officer to receive and assess reports, and is the primary point of contact for the reporter. The disclosures coordinator has a responsibility to monitor compliance with the PID Act and this policy directive. The PID coordinator will also undertake and/or supervise the following:

• A documented assessment of all reports to determine whether or not a report should be treated as a public interest disclosure

• A documented decision about how the report will be dealt with • Coordinate the response to a report • Acknowledge reports as required by the PID Act and provide updates and feedback to the reporter • Assess whether it is possible and appropriate to keep the reporter’s identity confidential • Conduct a documented risk assessment relating to the risk of reprisal and workplace conflict related

to or likely to arise out of a report, and develop strategies to manage any risk identified • Where required, provide or coordinate support to staff involved in the reporting or investigation

process, including protecting the interests of any officer the subject of a report • Monitor and ensure organisational compliance with the PID Act • Provide six-monthly reports to the NSW Ombudsman in accordance with section 6CA of the PID

Act • Provide the Compliance Unit at the Ministry of Health with a copy of their six-monthly report to

the Ombudsman.

3.4 Disclosures Officers

The principal officer may nominate a number of disclosures officers according to organisational requirements. Disclosures officers are additional points of contact within the internal reporting system that can provide advice about the system and the internal reporting policy, receive reports of wrongdoing and assist staff to make reports. NSW Health disclosures officers receive training to enable them to conduct and document PID assessments and risk assessments.

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INTRODUCTION 1.15 Disclosures officers have a responsibility to:

• Document any reports received verbally, and have the document signed and dated by the reporter (if possible)

• Assist staff to make reports privately and discreetly when requested • Discuss with the reporter any concerns they may have about reprisal or workplace conflict • Conduct an assessment and forward reports to the disclosures coordinator or principal officer for

approval and additional assessment where necessary • Assist the disclosures coordinator with risk assessments and PID management • Assist in raising awareness of the Public Interest Disclosures Act and the Public Interest

Disclosures Policy within their organisation. 3.5 Staff involved in investigating a public interest disclosure Staff investigating a disclosure have a responsibility to: • Adhere to principles of procedural fairness. • Be aware of, and minimise reprisal risks and alert the PID coordinator where they arise. • Finalise investigations of public interest disclosures within 6 months from the date of assessment. 3.6 Supervisors and Line Managers Supervisors and line managers should be aware of the internal reporting policy and are responsible for creating a work environment where staff are confident about reporting wrongdoing. They have a responsibility to:

• Encourage staff to report known or suspected wrongdoing within the organisation and support staff when they do

• Identify reports made to them in the course of their work which could be public interest disclosures, and assist the staff member to make the report to a PID officer, disclosures coordinator or to the principal officer

• Implement local management strategies, in consultation with the disclosures coordinator, to minimise the risk of reprisal or workplace conflict in relation to a report

• Notify the disclosures coordinator or principal officer immediately if they believe a staff member is being subjected to reprisal as a result of reporting wrongdoing.

3.7 All Staff

It is important that NSW Health staff contribute to a workplace where known or suspected wrongdoing is reported and dealt with appropriately. All staff are required to: • Report serious wrongdoing within NSW Health and support those who have made reports of

wrongdoing. • If requested, assist those dealing with the report, including supplying information on request,

cooperating with any investigation and maintaining confidentiality. • Respect the rights of officers the subject of reports and treat them fairly. • Treat any staff member or person dealing with a report of wrongdoing with courtesy and respect. Staff must not: • Victimise or harass anyone in connection with a report. • Knowingly make false or misleading reports of wrongdoing all staff are reminded of their

obligation to adhere to the NSW Health Code of Conduct. A breach of the code could result in disciplinary action.

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INTRODUCTION 1.16 4. MAKING A PUBLIC INTEREST DISCLOSURE 4.1 Written, verbal and anonymous PIDs Written reports help to prevent confusion or misinterpretation. NSW Health has a reporting form to simplify this process. A verbal report of wrongdoing (either face-to-face or over the telephone) will also receive the protections under the PID Act if it meets the legislative requirements for a public interest disclosure. A person making a verbal PID may be asked to sign a copy of the written record documenting the PID prepared by the person receiving the report. An anonymous report may still be considered a PID if, the organisation determines that it meets the relevant legislative criteria. However, it is very difficult for the organisation to provide any protection to an anonymous reporter, or provide any support, information or feedback about what action has been taken following the report. Anonymous reporting may not prevent identification of the reporter by the subject of the report or other colleagues, and it is difficult for the organisation to prevent reprisal under these circumstances. 4.2 Who can receive a public interest disclosure? • The Secretary, NSW Health • The Principal Officer of a NSW Health organisation • The disclosures coordinator of a NSW Health organisation • A disclosures officer of a NSW Health organisation.

Outside of NSW Health

Investigating Authorities:

• Auditor-General — for serious and substantial waste • Independent Commission Against Corruption (ICAC) — for corrupt conduct • Ombudsman — for maladministration • Information Commissioner – for a breach of the GIPA Act • Office of Local Government – for disclosures about local councils • Police Integrity Commission (PIC) — for police misconduct • PIC Inspector — for disclosures about the PIC or its staff • ICAC Inspector — for disclosures about the ICAC or its staff. 4.3 Other external reporting – Members of Parliament or journalists In limited circumstances a member of parliament or a journalist can receive a public interest disclosure, but only when the report has previously been made to an appropriate person within NSW Health or an Investigative Authority and a number of other criteria have been met.

Under s19 of the PID Act, reports made to a Member of Parliament (MP) or a journalist will not receive the protections of the PID Act unless

• The same issues have previously been reported to one of the people or agencies referred to in 4.2 and

• That report has either not been investigated, or no action has been recommended following investigation or the reporter has not been informed about the outcome of the matter within six months and

• The reporter can show that they have reasonable grounds for believing that the disclosure is substantially true and that it is in fact substantially true.

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INTRODUCTION 1.17 Reports made to a person within or external to NSW Health not listed in s 4.2 and 4.3 of this policy will not be protected under the PID Act. Such a report may breach legal obligations or the code of conduct, for example if the report discloses confidential information.

4.4 Role reporters and reports which are not initially recognised as possible PIDs

Occasionally reports are made by a person in the course of the performance of their day to day functions, which otherwise meet the requirements to be considered a PID. For example, an internal auditor, investigator, manager or supervisor who encounters serious wrongdoing uncovered during their regular employment responsibilities, and reports it to a disclosures officer, the Chief Executive or disclosures coordinator. The reporter in this instance may not recognise that they are making a PID. These people are known as ‘role reporters’.

Role reporters are entitled to the protections of the PID Act. It is important that these reports are appropriately assessed and managed by the PID coordinator, and included in the statistical data to be reported to the NSW Ombudsman and annual report.

If a staff member receives a report and they are not sure whether the matter is a public interest disclosure, they should refer the person making the report to the disclosures coordinator or a disclosures officer to seek advice about how to manage the report as soon as possible.

The disclosures coordinator is responsible for ensuring that the person making the report is provided with information about the assessment and advised whether or not the matter is determined to be a public interest disclosure. If the matter is not assessed as a Public Interest Disclosure, it should be referred for further management as appropriate, and the person making the report should be notified about the referral.

5. MANAGEMENT OF PUBLIC INTEREST DISCLOSURES WITHIN NSW HEALTH

5.1 Assessment and management of reports

All reports identified as possibly being a PID – even where the reporter has not identified their report as a PID - will be subject to a documented assessment by the disclosures coordinator (or a disclosures officer under the supervision of the disclosures coordinator or principal officer) to determine what action will be taken to deal with the report and whether the report is a public interest disclosure. The assessment process will include:

• Identifying and addressing any immediate risks to staff or patients

• Determining whether the matter should be managed as a PID or whether it is more appropriately managed under another policy (e.g. grievance)

• Identifying whether there is any requirement for immediate internal or external reporting (for example, reporting suspected corruption pursuant to s11 of the ICAC Act)

If further information is required in order to determine whether the report is a public interest disclosure, then appropriate further action may be taken to allow an assessment. In accordance with the provisions of the PID Act and this policy, confidentiality should be preserved during the assessment process.

Following assessment, if the report is determined not to be a public interest disclosure, but raises an issue requiring attention, it will be referred for appropriate management action.

Once the assessment process is complete, the person who made the report will be advised in writing about the outcome of the assessment process and any proposed further action. It is up to the disclosures coordinator to decide whether an investigation should be carried out and how that investigation should be carried out.

In assessing a report, even where the report is determined to be a PID, the disclosures coordinator or principal officer may decide that the report should be referred elsewhere or that no further action should be taken in respect of the report.

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INTRODUCTION 1.18 5.2 Communication following PID Assessment

Acknowledgement

The disclosures coordinator will provide staff whose report is assessed as a PID with the following information (except in the case of anonymous reporters who cannot be contacted):

• A written acknowledgement that the disclosure has been received

• A copy of the Public Interest Disclosures policy (not required for role reporters)

• The name and contact details of a person dealing with the disclosure

This information will be provided as soon as possible, but under the PID Act it must be provided within forty-five (45) days from the date of the report.

Feedback

Within six months of the disclosure being made, the disclosures coordinator will provide the person who made the report with information regarding whether action was taken or is proposed to be taken in response to the disclosure or other information about the outcome of the matter. Privacy requirements may mean that limited information can be provided.

If the subject of the report is aware of the report which has been made, they should also be provided with appropriate information about the outcome of the matter. Where a report is unsubstantiated, it may be appropriate to provide correspondence clearly stating that the PID was unsubstantiated.

5.3 Managing risks and workplace conflict

When assessing a possible PID, the disclosures coordinator will conduct a risk assessment to identify risks of detrimental action in reprisal as well as risks of workplace conflict associated with the report. Assessment of risks of workplace conflict may require liaison between disclosures coordinators and workplace relations managers. This will assist the health organisation to determine strategies to deal with any identified risks (including risks of detrimental action and related risks of workplace conflict or difficulties).

Consultation with PID reporter

Consulting with the PID reporter about the source and level of risk when they first make their report helps to manage their expectations and reduces the potential for conflict – including conflict with management about whether effective support was provided.

The PID Manager or PID coordinator should clearly communicate to the reporter the importance of reporting any suspected reprisal action to them, particularly if they become the subject of any allegation, to enable the organisation to coordinate its response to effectively manage risks and conflict.

Consultation with staff managing other related complaints

PID complaints are often complex, involving multiple workplace issues and more than one related complaint. It is relatively common that a PID reporter may either make, or be subject to, workplace grievance or bullying complaints at the same time as their PID is being managed by the disclosures coordinator. The risk of reprisal or of perceived reprisal increases where these other complaints are running parallel to the PID process.

It is important to note that while any other complaints will be managed separately under the appropriate policy (Grievance – Effective workplace Resolution PD2010_007 or Bullying – Prevention and Management of Workplace Bullying in NSW Health PD2011_018 or Managing Misconduct PD2014_042) they can have an effect on the PID reporter, and require careful consideration by the PID manager.

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INTRODUCTION 1.19 For this reason, it is important that the PID manager communicate with those managing the other complaints. Notwithstanding the importance of maintaining confidentiality, it may become necessary for the PID manager or coordinator to discuss the PID report with the person managing a grievance, bullying or misconduct allegation involving the PID reporter. The PID reporter should be consulted prior to any such discussion.

Strategies should be in place to ensure that the organisation is confident that any allegation, investigation or disciplinary action against a person making a PID does not constitute detrimental action, and that any conduct alleged by a person making a PID does not reflect detrimental action being taken against them. Communication is an essential aspect of development of successful strategies for managing the risk of detrimental action.

There are serious penalties associated with detrimental action (see s6 of this policy). Under the PID Act, once a person has demonstrated that they have made a PID and were subject to detrimental action – it is for the organisation to prove that the action was not as a result the PID. Risk Management Strategies

Strategies for risk management may include: • Relocating the reporter or subject of a report within the workplace • Transfer of the reporter or subject of a report to another position for which they are qualified • Allow the reporter or subject of a report to take a leave of absence while the matter is investigated.

These actions are acceptable risk management strategies and, where reasonable in the circumstances, are not considered to represent any form of punishment or reprisal.

5.4 Investigation process

Once a decision has been made to investigate a matter, the parameters of the investigation should be set by the Principal Officer or disclosures coordinator.

The Principal Officer or disclosures coordinator is responsible for approving

• The decision to investigate • The terms of reference for the investigation • The appointment of an internal or external investigator.

The investigation should be conducted in a timely manner and having regard to the principles of procedural fairness. To prevent any action being taken against a person for reporting wrongdoing, where possible and appropriate, NSW Health will keep the identity of staff who report wrongdoing confidential.

It is important that staff making a report, or involved in managing a report do not disclose information about the process or allegations to any person not involved except where necessary, both before and after making the report. Any staff involved in the investigation or management of a report, including witnesses, are also required to maintain confidentiality and not disclose any information to anyone except for those handling the report.

Examples of situations where the confidentiality requirements may no longer apply include:

• The person reporting wrongdoing consents in writing to the disclosure of the information, or • It is generally known that the person made the disclosure because they voluntarily identified

themselves, or • It is essential, having regard to the principles of natural justice, that information be disclosed to a

person, or • The NSW Health organisation considers that the disclosure of identifying information is necessary

to investigate the matter effectively or it is otherwise in the public interest to do so.

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INTRODUCTION 1.20 5.5 Reporting requirements Under legislation, each Public Authority is responsible for:

• Reporting public interest disclosures data to the Ombudsman for each 6 month period ending on 30 June and 31 December as required by the PID Act and regulations

• Reporting public interest disclosures to Parliament annually as required by the PID Act and regulations.

A report must be submitted by each Public Authority to the Ombudsman for each reporting period, including where the Public Authority has not received any PIDs during the relevant reporting period.

The disclosures coordinator will be responsible for the management of the database and coordinating provision of statistics to the Ombudsman. The disclosures coordinator will also provide a copy of the statistics provided to the Ombudsman to the Compliance Unit, Ministry of Health.

The Compliance Unit, NSW Ministry of Health will compile a consolidated annual statistics report for all NSW Health to be included in the NSW Health annual report in accordance with the annual reporting requirements of the PID Act.

It is important that NSW Health organisations ensure that their PID statistics are accurately recorded and maintained as they will be reported to Parliament and the Ombudsman, and may be subject to audit as part of the Ombudsman’s oversight of PID Management.

6. PROTECTIONS PROVIDED BY THE PID ACT

The PID Act provides protection for people reporting wrongdoing by imposing penalties on persons who take detrimental action against a person substantially in reprisal for making a public interest disclosure. This includes where a person takes reprisal action in the mistaken belief that a person made a public interest disclosure.

The criminal penalties that can be imposed include imprisonment or fines (100 penalty units or imprisonment for 2 years, or both). Detrimental action may also constitute workplace misconduct which would result in disciplinary action. A person who takes detrimental action against someone who has made a disclosure may be required to financially compensate that person for loss suffered.

Under the PID Act, any evidence of reprisal action in relation to a PID must be referred for investigation to the Commissioner of Police or the Independent Commission Against Corruption.

6.1 What is a reprisal?

A reprisal is any detrimental action taken substantially because someone has made, or is suspected to have made, a public interest disclosure in accordance with the PID Act. A reprisal is any detrimental action taken substantially because someone has made, or is suspected to have made, a public interest disclosure in accordance with the PID Act.

Detrimental action is defined in the PID Act to mean action causing, comprising or involving any of the following:

• Injury, damage or loss • Intimidation or harassment • Discrimination, disadvantage or adverse treatment in relation to employment • Dismissal from, or prejudice in, employment • Disciplinary proceedings.

6.2 Managing Reprisal Allegations

If detrimental action is being taken against someone in reprisal for making a report of wrongdoing, this should be reported to the disclosures coordinator or principal officer immediately.

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INTRODUCTION 1.21 The disclosures coordinator will assess the report of reprisal to determine what further action should be taken to resolve the issue including, but not limited to:

• Appointing an appropriate investigator to review the allegation of reprisal • If it is established that reprisal is occurring, take all steps necessary to stop the reprisal action and

protect the reporter • Referring any evidence of reprisal to ICAC or the Police as required by the PID Act • Taking appropriate disciplinary action against anyone proven to have taken or threatened reprisal in

response to a public interest disclosure.

6.3 Protection against legal action

A person making a disclosure which meets the requirements for public interest disclosures under the PID Act, will not be subject to any liability and no action, claim or demand can be taken against them for making the disclosure. A person making a public interest disclosure will not have breached any confidentiality or secrecy obligations and will have the defence of absolute privilege in defamation. 7. RIGHTS AND RESPONSIBILITIES OF INDIVIDUALS INVOLVED IN PIDS All NSW Health staff who have reported wrongdoing, been the subject of a report, been a witness in an investigation or been involved in the management of a report, regardless of whether they have made a public interest disclosure, are able to access an Employee Assistance Program, which provides counseling services to staff. Further information can be provided by the disclosures coordinator or disclosures officer.

The disclosures coordinator may consider appointing an appropriate support person (usually a manager or disclosures officer) to provide assistance and support to a person who has made a report or is the subject of a PID. The disclosures coordinator will consider whether this is necessary and appropriate in the course of managing the PID.

7.1 Staff who are reporting wrongdoing

Rights

• To have your report treated seriously • To communicate valid concerns without fear of reprisal or other unreasonable response • To fair and impartial management of the matter • To have access to support (EAPS) and to have a support person present at interviews. • To be informed, at least in general terms, about the actions taken and the outcome of the matter • To a reasonable explanation of how the matter will be managed, including management of

confidentiality, the likely timeframe for the matter, whether the matter may be reported to an external agency and who is responsible for making decisions about the outcome of the matter.

Responsibilities

• To honestly believe the complaint you make to be true • To maintain confidentiality – this means not discussing this matter with anyone aside from those

involved in managing your complaint • To clearly identify the issues of the complaint and provide all relevant information and supporting

documents as soon as possible. • To comply with reasonable requests to provide information • To co-operate with people managing the matter • To treat those involved in managing the complaint with courtesy and respect.

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INTRODUCTION 1.22 7.2 Staff who are the subject of a Report

Rights • To be informed about the nature of the allegations at an appropriate stage in the investigation • To fair and impartial management of the matter • To have an opportunity to respond to the allegations including to deny the allegations, to call

evidence to rebut the allegations and/or to explain mitigating circumstances • To have access to support (EAPS), and to have a support person present at interviews • To be informed, at least in general terms, about the actions taken and the outcome of the matter • To be provided with the opportunity to respond in the event that any adverse findings or comments

are made in relation to you • To a reasonable explanation of how the matter will be managed, including management of

confidentiality, the likely timeframe for the matter, whether the matter may be reported to an external agency and who is responsible for making decisions about the outcome of the matter.

Responsibilities

• To be honest in your responses • To maintain confidentiality – this means not discussing this matter with anyone aside from those

involved in managing the matter • To co-operate with people managing this matter • To comply with reasonable requests to provide information • Not to take reprisal action against any person in association with this matter • To treat those involved in managing the complaint with courtesy and respect. 7.3 Staff who are involved in management of a Report

Rights

• To determine how to best manage a report • To finalise matters on the basis of outcomes they consider to be satisfactory in the circumstances • To expect honesty, cooperation and reasonable assistance from staff reporting wrongdoing,

providing information or who are the subject of a report of wrongdoing • To be treated with courtesy and respect • To a safe and healthy working environment • To modify, or restrict communication in response to unacceptable behaviour.

Responsibilities

• To deal with all people making or subject to a report of wrongdoing professionally, fairly and impartially

• To provide reasonable assistance to staff members who need help to make a report of wrongdoing and, where appropriate, during the assessment and management of the report

• Where the matter is investigated, to give people the subject of a report of wrongdoing a reasonable opportunity to respond to allegations during the course of any investigation and before any final decision is made

• To inform people who are the subject of investigation, at an appropriate time, about the substance of the allegations made against them and the substance of any proposed adverse comment or decision that they may need to answer or address

• To keep a person who has made a PID informed of the actions taken and the outcome of their report • To take all reasonable and practical steps to ensure that a person who has made a PID is not

subjected to any detrimental action in reprisal for making their report.

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INTRODUCTION 1.23 8. FALSE OR MISLEADING DISCLOSURES

It is a criminal offence to willfully make a false or misleading statement when reporting wrongdoing. NSW Health will not support staff that willfully make false or misleading reports. Such conduct may be a breach of the code of conduct and result in disciplinary action.

The PID Act imposes serious penalties if a person knowingly makes false or misleading disclosures, including possible criminal charges (50 penalty units or imprisonment for 12 months, or both) and disciplinary action for misconduct.

9. MORE INFORMATION

Information around public interest disclosures is available on the intranet for each NSW health organisation. The Compliance Unit, Legal and Regulatory Services, Ministry of Health can provide guidance and information about PIDs to reporters, PID coordinators and staff members who are the subject of a PID on (02) 9391 9582.

Further information including factsheets and guidelines about PIDs can be found on the NSW Ombudsman’s website at www.ombo.nsw.gov.au.

10. APPENDICES This policy directive is supported by a number of Appendices.

Appendix 1.1 Template – Report of serious wrongdoing

Appendix 1.2 Template - .Assessment of internal report

10.1 Template – Report of Serious Wrongdoing

Details of reporter (You can make an anonymous report by leaving this section blank) Name:

Position:

Division/Unit: Preferred method of contact

Telephone: Telephone

Email: Email

Postal address: Post

Details of the wrongdoing being reported

Description:

• What happened?

• Where did this happen?

• When did this happen?

INTRODUCTION 1.24

• Is it still happening?

[Attach an additional page if required]

How did you become aware of this?

Name and position of people involved in the wrongdoing:

Name Position

Attach any additional relevant information or indicate where supporting evidence may be found:

Supporting evidence Attached

Name and position of other people who may have additional information:

Name Position

Statement

I honestly believe that the above information shows or tends to show wrongdoing.

Signature of reporter (Do not sign if you want to make an anonymous report)

Date report submitted (Essential information)

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INTRODUCTION 1.25 10.2 Template – Assessment of internal Report Assessment of an internal report against the criteria in the Public Interest Disclosures Act 1994 For Completion by Disclosures Coordinator

Public Interest Disclosures Act Criteria Comments

1 Is the reporter a public official? Yes

No

Anonymous

If the reporter is not a public official, as defined in the PID Act the report is not a PID.

If the reporter is anonymous, the content of the report may indicate that the reporter is a public official. In such cases it is always best to assume the reporter is a public official unless there is evidence to indicate the reporter is not a public official.

2 Is the report about the conduct of a public official or a public authority?

Yes

No

If the report is not about the conduct of a public official or public authority, as defined in the PID Act, the report is not a PID.

3 Is the report about one of the categories of conduct in the PID Act?

Breach of the GIPA Act

Serious maladministration

LG pecuniary interest contravention

Corrupt conduct

Serious and substantial waste of public money

Yes

No

If the report is not about one of the categories of conduct in the PID Act it is not a PID.

For more information about these categories of conduct see NSW Ombudsman PID Guideline B2.

If you have answered no because you believe the maladministration or waste of public money was not serious or substantial enough, clearly record your reasons over the page.

4 Does the reporter have reasonable grounds to believe that the information they have reported shows or tends to show the alleged wrongdoing?

Yes

No

Assume the reporter has an honest belief unless there is evidence to the contrary.

If another person, given the same conditions, would take the same viewpoint, this is reasonable grounds.

The reporter must be able to show or tend to show evidence of the alleged wrongdoing, i.e. they witnessed it or they have documentary or other evidence. It

INTRODUCTION 1.26

cannot be hearsay.

If you have answered no, clearly record your reasons over the page.

5 Was the report made to the principal officer, or a public official nominated to receive disclosures in the public authority’s Internal Reporting Policy?

Yes

No

If the report was not made to the principal officer or a nominated disclosures officer the report is not a PID.

If the reporter has not made the report to an authorised person they should be redirected to one.

6 Does the report primarily question the merits of government policy?

Yes

No

If the report primarily questions the merits of government policy the report is not a PID.

7 Is there substantial evidence indicating that the report was made solely or substantially with the motive of avoiding dismissal or other disciplinary action?

Yes

No

If the report has been made solely or substantially with the motive of avoiding dismissal or other disciplinary action the report is not a PID.

A high evidential threshold is required to conclude the reporter’s motives were improper.

If you have answered yes, you should have sound reasons and clearly record those reasons over the page.

Further comments

• The PID assessment should be based on the content of the disclosure, not the outcome of any investigation.

• If in doubt, err on the side of caution and interpret the PID Act broadly – i.e. assume that the PID Act applies and proceed accordingly.

• For further advice, please contact the NSW Ministry of Health at compliance@doh.health.nsw.gov.au 02 93919582 or alternatively the NSW Ombudsman PID Unit on pid@ombo.nsw.gov.au or 02 9286 1000.

Assessment

Based on this assessment, should the report be treated as a Public Interest Disclosure?

Yes No

If yes, was the PID made: incidental to the performance of reporter’s day-to-

day functions, under a statutory or other legal obligation on the

reporter, otherwise.

______________________________________ Signature of disclosures coordinator

Date:

If yes, the following steps will be taken:

For example

• No further action; or

• review issues; or

• investigate issues; or

• meet with reporter…

AND

• correspondence to reporter indicating outcome of assessment process and any proposed action.

If no, the following steps will be taken:

For example

• No further action; or

• Referral to appropriate unit for action; or

• Investigation…

AND

• Correspondence to reporter indicating outcome of assessment process and any proposed action.

Reasons for decision

POLICY STATEMENT

Implementation checklist

Assessed by:

Date of Assessment:

IMPLEMENTATION REQUIREMENTS Not

commenced Partial

compliance Full compliance

1. Staff are aware of the policy and the protections

available under the Public Interest Disclosures Act 1994

Notes:

2. Disclosure Coordinator has been nominated and

details published on intranet and provided to Ministry of Health

Notes:

3. Public Interest Disclosures training provided to all

managers and supervisors

Notes:

4. Strategies to prevent corruption, maladministration, serious and substantial waste and government information contravention are included in Health Service Business Plans

Notes:

5. Establish database and procedures for collecting

statistics on Public Interest Disclosure for reporting biannually to NSW Ombudsman and annually to NSW Parliament as required by legislation

Notes:

6. Establish procedures for risk assessment and

management strategies for effectively dealing with disclosures and minimising reprisal risks

Notes:

INTRODUCTION 1.28 NSW HEALTH SPONSORSHIP POLICY (PD2005_415) Sponsorship is a useful and potentially beneficial mechanism that reinforces and enhances NSW Health business activities. Across the health system cash and in-kind sponsorships have been used for some time to support a range of activities that are inline with NSW Health strategic directions. The NSW Health Sponsorship Policy has been developed to ensure that NSW Health organisations respond in a consistent and ethical way to seeking and granting sponsorships. It recommends that each organisation methodically approach sponsorships by identifying potential opportunities, preparing sponsorship plans, seeking approval dependent on level of commitment, formally confirming arrangements and monitoring and evaluating partnerships to maximise benefits and protect public confidence. This policy was developed by the NSW Health Sponsorship Committee, in consultation with all Area Health Services, ICAC and the Audit Office of NSW. 1. CONTEXT Over the past two decades there has been a national and international trend for government agencies to develop community partnerships and to seek sponsorship from the private sector. Through such arrangements and as a result of additional funds, many government agencies have been able to develop new services and receive regular income from sponsorship. The public health system, particularly through individual hospital and community facilities, is often a beneficiary of sponsorship arrangements. As well as the benefits, there are risks associated with sponsorship. Sponsorship agreements require careful review to ensure they fit within an ethical framework that complies with accountability and transparency requirements set out for the public sector and are in the public interest. Additionally, there is a responsibility to ensure that a sponsorship agreement provides good value, that the conditions of agreement are fair and transparent and that the arrangement is appropriately documented and monitored and will not create any conflicts of interest for the sponsorship agency. This policy provides a framework to ensure compliance with basic principles established by the Independent Commission Against Corruption (ICAC) to assess sponsorship proposals. The policy is applicable to all NSW Health public health organisations and contains a process for assessment, approval and implementation of sponsorships, a checklist and a draft contract. 2. WHAT IS SPONSORSHIP? 2.1 Definition of Sponsorship The ICAC defines sponsorship as:

‘a contribution in money or kind, generally by the corporate sector or private individuals, in support of a public sector activity. It does not include the selling of advertising space, joint ventures, consultancies and gifts or donations when the reciprocal benefit provided by the government agency does not extend beyond some modest acknowledgment.’1

This definition is adopted for the purpose of this NSW Health policy.

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1 “And now a word from our Sponsor: Review of the ICAC Sponsorship principles.” NSW 1995

FRAUD CONTROL STRATEGY 7.1 FRAUD CONTROL STRATEGY – DEPARTMENT OF HEALTH, NSW (PD2007_070) PD2007_070 rescinds PD2005_059. 1. Introduction The Department of Health promotes an organisational culture that will not tolerate any act of fraud or corruption. This Fraud Control Strategy aims to foster an environment that actively discourages fraudulent activities in order to protect the Department’s assets, interests and reputation, and to provide a transparent framework for reporting and investigating fraud should it occur. Fraud prevention and control must be the responsibility of all staff and all levels of management, and not just selected people or units within the Department. The Department acknowledges that our staff are the best defense against fraudulent activity and play a critical role in preventing and detecting fraud. Staff are encouraged to familarise themselves with the Department’s fraud control strategy and to be aware of the role they can play. Any instances of fraud detected, as being perpetrated against the Department, will be fully investigated and the perpetrators prosecuted to the maximum extent allowed under the law. A cornerstone of this strategy is the mandatory requirement for Branch Directors or equivalent to undertake a fraud risk analysis on an annual basis in respect of their area of responsibility. The Guide to Fraud Risk Assessment Tool located on the Internal Audit Branch’s intranet site has been introduced to assist Directors to assess the adequacy of existing controls and to determine if additional fraud counter measures are required. 1.1 Overview This Fraud Control Strategy sets out the fraud control and prevention policies and procedures of the Department of Health. It details the Department’s approach to the prevention, detection, reporting and investigation of fraud and corruption. It also identifies current activities that may be susceptible to fraud and corruption, and provides strategies for better management and control of those activities. Effective implementation of this strategy will help ensure that public confidence in the integrity of the Department of Health is maintained and our ability to minimize the loss of resources due to fraud can assist us to achieve our strategic goals. 1.2 Department of Health’s Policy and Attitude to Fraud and Corruption The Department of Health promotes an organisational culture that does not tolerate any act of fraud or corruption. This Fraud Control Strategy is designed to put this principle into practice. Apart from the legal consequences of fraud and corruption, improper acts have the potential to damage the Department’s public image and reputation. Unresolved allegations can also undermine an otherwise credible position and reflect negatively on innocent individuals. All staff must be above fraud and corruption. Sanctions will apply to those who are not. In addition, staff must act so they are not perceived to be involved in such activities. Through transparent and accountable decision-making, together with open discussion by staff and managers about the risks of fraud and corruption, the Department seeks to foster an organisational climate that does not tolerate fraud or corruption.

FRAUD CONTROL STRATEGY 7.2 The Department will deal fairly with all parties in the course of investigating allegations of fraud or corruption. However, if fraud or corruption is proven, appropriate sanctions and/or disciplinary proceedings under the Public Sector Employment and Management Act 2002 will be applied. Matters referred to the Independent Commission Against Corruption (ICAC) or NSW Police may lead to criminal proceedings. Offenders can expect to be required to repay the full cost of any theft, misappropriation or improper benefit, including interest. If the offender has monies owing by the Department, such sums may be offset against any inappropriate benefit obtained. The prevention of fraud and corruption requires that all staff members act ethically and professionally in accordance with the Code of Conduct (PD2015_035). 1.3 Relationship with other Policy Directives In addition to the Code of Conduct, this Strategy has a close relationship with the following: • Public Interest Disclosures PD2016_027 • Corrupt Conduct – reporting to the Independent Commission Against Corruption PD2011_070 • Conflicts of Interest and Gifts and Benefits PD2010_010 • NSW Government Personnel Handbook (Chapter 9 — Discipline). The Department’s approach to fraud and corruption, as set out in this strategy, is designed to include the Auditor-General’s Ten Attributes of Best Practice in Fraud Control http://www.audit.nsw.gov.au/ and is based on the standards, principles and strategies set out in Australian Standard AS 8001 – 2003- Corporate Governance – Fraud and Corruption Control. 2. Definitions of fraud and corruption Fraud and corruption can be distinguished from other forms of unethical behaviour. The following definitions are based on those contained in the Australian Standard for Fraud and Corruption Control (AS 8001-2003). Corruption Dishonest activity in which a director, executive, manager, employee, contractor, volunteer or work experience student acts contrary to the interests of the Department and abuses his/her position of trust in order to achieve some personal gain or advantage for him or herself or for another person or entity. Fraud Dishonest activity, by Department of Health employees, contractors, volunteers, work experience students or external persons, causing actual or potential financial loss to the Department, including the theft of moneys or other property. This includes the deliberate falsification, concealment, destruction or improper use of documentation used for a normal business purpose or the improper use of other information or position. Examples of fraud and corruption are provided in Appendix 1

FRAUD CONTROL STRATEGY 7.5 All Branch Directors are responsible for: • Completing an annual fraud risk assessment utilising the Fraud Risk Assessment tool located on

the Department’s Work Support Centre http://internal.health.nsw.gov.au/employinfo/ ; • Monitoring their workplaces to identify and address situations that are likely to raise ethical

dilemmas; • Ensuring that staff are not placed in potentially difficult or compromising situations; • Being available and supportive to staff who require guidance on conflicts of interest and other

ethical dilemmas; • Fostering a work environment free of harassment, discrimination, victimisation, corruption, mal-

administration and waste • Ensuring that staff are aware of the principles contained in the Code of Conduct and the

established systems and procedures for addressing ethical problems – The Code’s advice on conflict of interest situations should be emphasized to all staff;

• Supporting and protecting staff who report, in good faith, instances of potentially unethical or corrupt practices;

• Ensuring that staff are treated fairly, equitably and in accordance with relevant legislation and policy;

• Ensuring effective and correct use of delegations of authority; • Ensuring that all staff involved in contact with individuals or organisations external to the

Department properly record their actions, comments and undertakings on Departmental files. This is a safeguard against false and malicious allegations against officers;

• Ensuring all staff take at least two weeks continuous leave in any period of 12 months • Ensuring that appropriate structured referee checks and pre employment criminal record checks are

completed for every recruitment action. • Setting a good example in actions and deeds • Supporting and providing assistance through the Employee Assistance Program, to staff identified

as having “personal issues” such as substance abuse, addictions and gambling. 3.6 All Departmental Staff All staff, contractors, consultants and volunteers must act ethically and not engage in, assist or tolerate any fraudulent or corrupt activity. If an employee knows about or has good reason to suspect possible corrupt conduct, including fraudulent activity, within the Department, he/she must report that information to the Director-General or the Director, Corporate Governance and Risk Management or their immediate manager or another manager or to ICAC. The Protected Disclosures Act 1994 offers employees protection from reprisal when reporting fraudulent activity. Further details on reporting and protection from reprisal are described in Corrupt Conduct – reporting to the Independent Commission Against Corruption PD2011_070 and Public Interest Disclosures PD2016_027. 4. Fraud and Corruption Risk Management 4.1 Areas at Risk of Fraud An important part of fraud and corruption prevention is understanding where the areas of risk are in relation to the Department’s responsibilities and functions. Based on studies by ICAC and the Queensland Crime and Misconduct Commission, the following public sector operational areas and functions are perceived to have high fraud and corruption risk ratings: • financial functions — such as the receipt of cash, revenue collection and payment systems,

salaries and allowances, and entertainment expenses

FRAUD CONTROL STRATEGY 7.6 • construction, development and planning functions — ranging from land rezoning or development

applications to construction and building activities • regulatory functions — involving the inspection, regulation or monitoring of facilities and

operational practices, including the issue of fines or other sanctions • licensing functions — such as the issue of qualifications or licences to indicate proficiency or

enable the performance of certain activities • demand driven or allocation-based functions — where demand often exceeds supply, including

the allocation of services or grants of public funds, or the provision of subsidies, financial assistance, concessions or other relief

• procurement and purchasing functions — including e-commerce activities, tendering, contract management and administration

• other functions involving the exercise of discretion, or where there are regular dealings between public sector and private sector personnel (especially operations that are remotely based or have minimal supervision).

Examples of fraud and corruption are provided in Appendix 1 and in the Fraud Assessment Tool available on the Department’s Work Support Centre http://internal.health.nsw.gov.au/employinfo/ 4.2 Regular fraud risk assessment Managers are responsible for annually reviewing their areas of activity to assess potential risks, develop strategies to address those risks and to determine the effectiveness of the control mechanisms they have implemented. These strategies should be integrated into branch work practices and procedures, and also form part of staff discussions and performance reviews. Branch Business Plans should reflect these activities. To assist managers, a Fraud Risk Assessment tool has been installed on the Department’s Work Support Centre. The assessment tool can help managers and staff to assess the adequacy of existing controls and to determine whether additional fraud countermeasures are required. The Manager, Internal Audit Branch is available to provide advice and assistance to managers in completing the assessment tool. Branches that are subject to regular review by Internal Audit Branch eg salaries, should discuss with the Manager, Internal Audit, the need to complete the annual review so that duplication is avoided. Internal Audit Branch will conduct a compliance review of all Departmental business units/branches on a 3 year cycle to ensure that managers have completed their fraud risk assessment to a satisfactory standard. 5. Procedures for Reporting Fraud All Departmental staff has a duty to report suspected fraudulent activity. The Department of Health has developed and published policies and processes to facilitate the reporting of suspicions of fraud or other corrupt conduct. Staff should be aware of the reporting systems described in Public Interest Disclosures PD2016_027 and Corrupt Conduct – reporting to the Independent Commission Against Corruption PD2011_070. Details of making a protected disclosure can be found on Corporate Personnel Service’s website.

FRAUD CONTROL STRATEGY 7.7 The internal reporting system can be summarized as; employees can report to their immediate manager, or another manager, or Director Corporate Governance and Risk Management or the Director-General. The protected disclosure reporting system complements existing communication channels between managers and staff. Staff are encouraged to continue to raise their concerns at any time with their managers, but as an alternative they have the option of making a protected disclosure in the manner outlined in Public Interest Disclosures PD2016_027. The Protected Disclosures Act 1994 offers employees protection from reprisal when reporting fraudulent activity. Members of the public, and other stakeholders such as suppliers or contractors can report suspicions of fraud or corruption by writing to or telephoning the Director Corporate Governance and Risk Management (9391 9000), or by email to nswhealth@doh.health.nsw.gov.au . Anonymous reports from members of the public will be treated in accordance with the merits of the issues raised and the adequacy of the information provided. 6. Procedures for Fraud and Corruption Investigation The decision to investigate a suspected incident of fraud is made by the Director-General based on the advice of the Manager, Internal Audit or Director, Corporate Governance and Risk Management. The Director, Corporate Governance and Risk Management or Manager, Internal Audit will make an assessment of the issues and available information related to the suspected fraud before advising the Director-General. This may include preliminary enquiries that involve a review of relevant documentation and/or an interview with the complainant or persons related to the suspected incident. Before an investigation commences, the Director-General must receive and approve of an investigation plan that describes the terms of reference for the investigation, the resources and methodology to be used and the anticipated timeframe for concluding the investigation. Investigations will be undertaken by: • Internal Audit Branch when the fraud incident is related solely to the Department and does not

involve other public health organisations; • Corporate Governance and Risk Management Branch when the fraud incident relates to

organisations external to the Department; • Contracted external investigators arranged and managed by either Internal Audit Branch or

Corporate Governance and Risk Management Branch. Contracted investigators will be used when departmental investigative resources are not available or when an additional ‘arms length’ level of independence is required. All investigations are conducted in accordance with and to the standards contained in the Department’s “Protocol for Investigations” and “ Investigation Manual”‘. Fraud investigation reports are submitted to the Director-General who then decides what action is necessary to address the investigation findings. The Department will deal fairly with all parties in the course of investigating allegations of fraud or corruption. However, if fraud or corruption is proven, appropriate sanctions and/or disciplinary proceedings under the Public Sector Employment and Management Act 2002 will be applied. Matters referred to the Independent Commission Against Corruption (ICAC) or NSW Police may lead to criminal

FRAUD CONTROL STRATEGY 7.8 proceedings. Offenders can expect to be required to repay the full cost of any theft, misappropriation or improper benefit, including interest. If the offender has monies owing by the Department, such sums may be offset against any inappropriate benefit obtained. 7. Communication of Fraud Control Strategy Even the most clearly written Fraud Control Strategy will have limited effect in influencing the ethical culture of an organisation or reducing the incidence of fraud and corruption if staff are not fully conversant with the document and have an understanding of how the requirements outlined translate into their day to day environment. Communication of the Strategy will specifically be undertaken as hereunder: Recruitment Action: • Include a copy of the Strategy in job information packages; • Refer to the Strategy in job/position descriptions; • Make an awareness of public sector values part of the job selection criteria; • Ask questions in job interviews regarding the Code of Conduct and public sector values, including

what prospective employees understand by acting “honestly”; • Include in Induction processes information and guidance on the Code of Conduct including the

behaviours and standards expected within the Department; Learning and Development: • Ethics education will form part of the Department’s learning and development strategy; • Undertaking, by staff and Directors of corruption resistance training; • Placement of document on the Department’s Work Support Centre and regular e-mail broadcasts

to staff to make them aware of its existence and need to be aware of the provisions of the Strategy and the Code of Conduct;

• Inclusion of references to the Strategy and Code of Conduct in Director-General’s Newsletters on an ad-hoc basis;

• Inclusion of a Fraud Control self assessment tool on the Department’s Work Support Centre for compulsory use by Branch Directors

8. Review of Fraud Control Strategy Corporate Governance and Risk Management Branch has responsibility for ensuring that this Fraud Control Strategy is subject to an on-going process of continuous improvement, monitoring and adjustment to ensure its viability in addressing current fraud control issues.