Pd 2007005

Policy Directive

Legislative Compliance

Organisational, Management and Staff Obligations Document No: SSW_PD2007_ 005 Functional Sub-Group: Corporate Governance

Clinical Governance

Summary: The legislative compliance program should aim to prevent, and where necessary, identify and respond to, non-compliance with laws, regulations and relevant professional codes and Australian Standards. This policy provides guidance for staff about their legislative obligations and how compliance can be assessed.

Approved by: Director of Corporate Services Publication (Issue) Date: July 2007 Next Review Date: July 2010 Replaces Existing Policy: Yes (GB&M: 2.7.1, dated April 2007) Previous Review Dates: April 2007 Note: Sydney South West Area Health Service (SSWAHS) was established on 1 January 2005 with

the amalgamation of the former Central Sydney Area Health Service (CSAHS) and the former South Western Sydney Area Health Service (SWSAHS).

In the interim period between 1 January 2005 and the release of single Area-wide SSWAHS policies (dated after 1 January 2005), the former CSAHS and SWSAHS policies were applicable as follows:- SSWAHS Eastern Zone : CSAHS SSWAHS Western Zone: SWSAHS

Compliance with this policy directive is mandatory Page 1 of 12

Sydney South West Area Health Service Policy No: SSW_PD2007_005 Date Issued: July 2007


LEGISLATIVE COMPLIANCE ORGANISATIONAL, MANAGEMENT AND STAFF OBLIGATIONS Contents 1. Introduction 2. Identification of Compliance Obligations, Promoting Awareness and Facilitating

Compliance

2.1 Statutory Obligations and Regulatory Requirements 2.2 Common Law Obligations 2.3 Relevant Professional Codes and Standards of Practice 2.4 SSWAHS Policies and Procedures 2.5 Facilitating Compliance 2.6 Centralised Systems to Facilitate Compliance

3. Identification and Allocation of Responsibilities

3.1 Key Responsibilities for Staff 3.2 Key Responsibilities for Managers 3.3 Senior Managers and Executive Staff

4. Assessing Compliance 5. Monitoring Compliance 6. Recording Outcomes / Results at Monitoring Compliance 7. Legislation Register 8. Potential Non-compliance / Breach 9. Reference 10. Definitions



LEGISLATIVE COMPLIANCE ORGANISATIONAL, MANAGEMENT AND STAFF OBLIGATIONS 1. Introduction

Sydney South West Area Health Service (SSWAHS) is committed to complying with relevant legislation and obligations and to facilitate this, all facilities / services are required to establish a compliance program, which is consistent with Area Health Service policy and which addresses key risks and meets organisational needs. An effective compliance program is considered an important element in fulfilling the corporate governance responsibilities of the organisation, whether in relation to clinical or non-clinical obligations. The compliance program should aim to prevent, and where necessary, identify and respond to, non-compliance with laws, regulations and relevant professional codes, Australian standards, NSW Health policies and SSWAHS policies / procedures. This is best done by promoting a culture at all levels within the organisation of valuing compliance with both statutory and common law obligations. Compliance is to be achieved through the joint actions of staff and management. The general aim of the compliance program is to prevent non-compliance through a structured and planned program. Such a program includes:

identifying compliance obligations and promoting awareness; allocating responsibility to the relevant officers to facilitate staff and organisational

compliance with obligations; undertaking a risk assessment of obligations to identify actions / strategies to

prevent / minimise risks of non-compliance; assessing how well each facility / service meets its obligations and identifying

where and how it could improve; establishing monitoring mechanisms to provide an information base for

management, including identifying any non-compliance and remedial action taken; establishing reporting mechanisms, including an annual report, to relevant

management and quality committees; promoting to staff and management awareness of the importance of compliance

with specific obligations, as well as commitment to compliance, as an organisational value;

fostering continuous improvement in compliance processes across the service to ensure obligations are met.

The risks addressed by this policy:

Corporate and clinical risks

The aims / expected outcomes of this policy

To facilitate staff awareness of their legislative obligations and to provide guidance to facilities / services to establish compliance programs.



2. Identification of Compliance Obligations, Promoting Awareness and Facilitating Compliance Compliance obligations may be categorised as follows: Statutory obligations and regulatory requirements Common law obligations Relevant professional codes and standards of practice SSWAHS policies and procedures Primary / useful sources of information in relation to these obligations are outlined below (sections 2.1-2.4).

2.1 Statutory Obligations and Regulatory Requirements

Legislation applicable to the NSW Health system, including SSWAHS, is listed on the NSW Health Intranet site at NSW Health Legal Branch Acts & Regulations.

This site lists key legislation, along with information about:

- existing legislation under review - new legislation being drafted

2.2 Common Law Obligations

Useful sources of information about common law obligations may be found at: http://www.austlii.edu.au and http://www.agis.nsw.gov.au Key word searches are required to identify and retrieve information.

Where deemed necessary, professional legal advice may be obtained in accordance with the provisions of the SSWAHS Delegations Manual.

2.3 Relevant Professional Codes and Standards of Practice

Sources of information about professional standards of practice include Professional Associations, such as the Colleges, Guilds and other Associations.

Professional staff are encouraged to join their relevant professional associations to obtain up-to-date information about professional development and advances in their field of practice.

Other Bodies and Agencies with recognised expertise include, for example:

- Professional Registration Boards - Universities and other teaching facilities - Australian Council Healthcare Standards (ACHS) - NSW Ombudsman - Independent Commission Against Corruption (ICAC) - NSW Privacy



- Anti-Discrimination Board - Professional consultants engaged to lead key projects eg project

managers engaged to undertake major capital works - SSWAHS staff with recognised expertise

Australian Standards can be accessed at: http://www.standards.com.au Key word searches are required to identify and retrieve information.

2.4 SSWAHS Policies and Procedures SSWAHS policies are located on the SSWAHS intranet site at:

http://intranet.cs.nsw.gov.au/SSWPolicies/default.htm

SSWAHS ensures that policies and procedures are available to govern the operations of facilities / services. These policies and procedures are in accordance with NSW Health Department and Statutory requirements.

The general manager / service director of each facility / service within SSWAHS is responsible for developing procedures consistent with legislation and with the policies of the NSW Health Department and SSWAHS, where specific procedures are deemed necessary.

Policies / Procedures must be reviewed at least every 3 years.

2.5 Facilitating Compliance

SSWAHS facilitates compliance with its policies, by-laws and regulations and any applicable statutes and regulations through its management structure. To facilitate compliance it is necessary to:

document policies and procedures conduct audits undertake risk assessments provide training sessions develop health and safety plans Each facility / service shall be able to provide evidence that it has undertaken such activities, based on their particular organisational needs.

The general manager / service director of each facility / service is responsible for implementing a system to promote the understanding and awareness of compliance obligations to all staff. Systems / mechanisms that are deemed to be suitable, for example, include:

Stating key compliance obligations in policy documents and position

descriptions Incorporating compliance as a component of the Induction / Orientation

program



Incorporating compliance training in appropriate staff development activities

Providing specific training to staff with specific responsibilities, prior to or when there are legislative changes

Incorporating compliance certification into the performance planning and review processes

Conducting annual checks of professional registrations Conducting pre-employment risk assessments

2.6 Centralised systems to facilitate compliance

The following centralised monitoring systems have been established and general managers / service directors are to submit information to the nominated officers to facilitate maintenance of the systems and monitoring of non-compliance and potential non-compliance:

Environment Protection Authority (EPA) licences Director Corporate

Services Annual Fire Statement (due date) Director Corporate Services WorkCover Prohibition Improvement Notice (PINs) (copy of notice and key

facility contact officer) Director Corporate Services Public Health Director Public Health Proof of Professional staff registration facility general managers (and HR

departments) data is to entered into Workforce Potential non-compliance which poses a significant risk to the organisation

Director Corporate Services 3. Identification and Allocation of Responsibilities Identification and Allocation of

Responsibilities

3.1 Key Responsibilities for Staff gaining a full understanding of their legal obligations complying with their legal obligations, including their SSWAHS policy

obligation undertaking relevant training reporting incidents of non-compliance assisting with investigations

3.2 Key Responsibilities for Managers

operating the facility under the authority of the Health Services Act 1997, as well as other relevant legislations

implementing both NSW Health Department and Area policies and procedures implementing effective controls to achieve compliance, for example

conducting criminal record checks on persons applying to work within SSWAHS; ensuring OHS inspections are undertaken; providing equipment to enable safe work practices

provide access to training for staff to raise their awareness with respect to legislation eg privacy legislation, child protection legislation

recording and reporting non-compliances / breaches monitoring the effectiveness of controls



ensuring equipment that requires certification is certified implementing health and safety plans and any other relevant plans which

facilitate compliance

3.3 Senior Managers and Executive Staff

The responsibilities for senior managers and executive staff include those listed above for managers as well as: undertaking risk assessments and prioritising any strategies to minimise

the risk of non-compliance supporting staff and managers to achieve their obligations reporting and investigating any potential breaches of compliance implementing systems to facilitate compliance, for example:

- the establishment of a register to monitor critical licence expiry dates for ionising equipment

- the establishment of a register to monitor key certification dates for annual fire statements

4. Assessing Compliance

Compliance will be assessed, primarily, by:

Conducting of audits, by the Internal Audit Unit, with the Units audit program having been developed based on greatest risk

Conducting facility based audits both random and scheduled. These are to be determined on a risk assessment needs basis

Assessing staff knowledge Reviewing exceptions / incident reports to identify incidents of potential non-

compliance and then initiate corrective action Issuing of notices of breach by relevant authorities eg EPA, WorkCover, Councils,

NSW Fire, NSW Police Compliance audits will include, but not be limited to:

Audits conducted by the Internal Audit Unit and as approved by the SSWAHS

Audit and Corporate Risk Management Committee Medication / prescribing audits and S8 / S4D drug prescribing / administration /

storage audits Medical Records audits OHS workplace inspections Issue of Annual Fire statements Review of professional registration renewal dates

Assessing staff knowledge will include, but not be limited to, conducting targeted staff

surveys, based on organisational needs, for example: for staff working in food services, assessing their knowledge of food safety

requirements for staff working in medical records, seeking to confirm that they understand

privacy legislation for staff who work at the Department of Forensic Medicine, assessing their

knowledge of the Human Tissue Act



for staff working in HR and payroll services, assessing their knowledge of industrial relations legislation and award interpretation

incorporating specific questions into staff performance reviews incorporating questionnaires / surveys into staff development and training

programs, for example, as a part of the training programs for OHS, fire safety and CPR

conducting online assessments, for example, staff knowledge of the Code of Conduct

Incident / exception reports which might indicate a potential breach of legislative compliance will include, but not be limited to:

IIMS incident reports Allegations of breaches of privacy Allegations of discriminatory behaviour Staff complaints Industrial disputes Breach notices or court appearances, which might indicate a potential breach of legislative compliance, will include, but not be limited to:

Receipt of PINS from WorkCover or prosecutions by WorkCover NSW Privacy Commission investigations NSW Ombudsman investigations ICAC investigations Anti-Discrimination Board appearances EPA notices re: breach of licensing requirements Industrial Relations Commission appearances Liability cases

5. Monitoring Compliance Each facility / service will establish a system to monitor compliance / non-compliance. Such will include a record of actions taken to facilitate future compliance. This system, which should be incorporated into existing structures and systems, will provide for:

monitoring particular incidents, actions taken and outcomes monitoring trends in compliance, over time Undertaking trend analysis and documenting any changes made to improve / enhance existing practices should assist with demonstrating positive outcomes from the implementation of this policy. All incidents of non-compliance and those with a significant potential for non-compliance are to be reported to the SSWAHS Director Corporate Services and other relevant authorised personnel of the SSWAHS organisation such that knowledge can be shared and risks associated with non-compliance minimised.

Each facility / service will record training aimed at facilitating compliance with legislative obligations.



The Audit and Corporate Risk Management Committee reviews the following data to assess risk, including risk of non-compliance with legislative obligations:

Risk/Issue

KPI

Equipment failures Fire incidents and Fire Brigade inspections Utility supply failure Legionella testing results Property Claims (insurance)

Asset Management

Motor Vehicle Claims (insurance) Disaster Management

Activations of disaster plans

Fraud/ corruption Trade creditors overdue

Financial

Tendering complaints

Grievances Staff misconduct (disciplinary action / terminations) Staff terminations

Human Resources

Staff training

Machine downtime clinical systems CCIS, Labs Machine downtime non-clinical systems Workforce, Oracle Application outages PACS web PABX downtime

Information Management

Breach of Privacy

Industrial Relations Commission: court actions Administrative Decisions Tribunal: court actions Anti-Discrimination Board: court actions GREAT: court actions WorkCover: prosecutions / court actions EPA: prosecutions / court actions

Legal / Legislative

FOI: tribunal appeals

SAC 1 Events Patient Incidents / Accidents Service Access Liability Cases Suicides Falls in the elderly Patient Complaints Specific Clinical Indicators

Patient Safety

Breaches of NH&MRC guidelines



Risk/Issue

KPI

Initiatives to improve safety EQuIP Accreditation Serious breaches of SSWAHS policy Critical stock supply

Public Health

Notifiable Diseases

Accidents / Incidents Security Workers Compensation reports Large Workers Compensation Claims Radiation safety exposures

Safety staff and visitors

WorkCover PINS 6. Potential Non-compliance / Breach

The general manager / service director shall either directly or through a delegated officer:

implement a system to ensure they are notified of all non-compliances / breaches

for which they are responsible, immediately they occur notify SSWAHS Executive of significant potential breaches of legislative

compliance in accordance with the SSWAHS incident reporting policy / procedure initiate appropriate and reasonable action with respect to the matter, including the

immediate management of the situation, analysis of the incident, implementation of corrective action and development of preventative strategies which are to be monitored for effectiveness

All staff shall notify their supervisor immediately they become aware that a potential non-compliance / breach has occurred or is likely to occur.

In cases of wilful or intentional breaches of compliance obligations, the SSWAHS Discipline Policy and Procedure may be activated.

Examples of Potential Non-compliance / Breach The following examples illustrate a major non-compliance / breach:

An accident on SSWAHS premises, or whilst involved in a SSWAHS activity, that

results in an injury leading to hospitalisation or death

Example: breach of the Occupational Health and Safety Act 2000; NSW, and the incident may be investigated by WorkCover Authority

A major investigation by a regulatory or statutory body

Example: Legislative breach

A major impact on business continuity



Example: Engineering Services fails to monitor the cooling towers. As a consequence an outbreak of Legionella occurs, which leads to facility closures until the source of the disease can be identified and treated.

7. Legislation Register

Each facility should manage issues that arise through the implementation of this policy in a legislation register.

8. References Staff (as appropriate) should be encouraged to regularly visit the following websites to raise awareness of current legislation Key NSW Legislation: http://www.health.nsw.gov.au/csd/llsb/acts/ (for current legislation and new / amended legislation)

Key Commonwealth Legislation: http://www.com.law.gov.au/

NSW Health Policy Directives and Guidelines: http://www.health.nsw.gov.au/policies/index.html

Relevant Australian Standards includes: http://www.standards.com.au

Australian Council for Safety and Quality in Health Care Standards: http://www.safetyandquality.org/

9. Definitions

All definitions identified below have been sourced from the Australian Standard AS 3806 - 1998 - Compliance Programs:

Codes: are mandatory industry codes, and voluntary industry codes with which SSWAHS chooses to comply.

Compliance: is meeting obligations under laws, regulations, codes or organisational standards.

Compliance program: is the coordinated activity of documenting obligations, ensuring responsibility for meeting obligations is clearly allocated and understood, the monitoring and reporting mechanisms for assessing how well obligations are being met, and the management activity for addressing non-compliance with obligations and improving systems for meeting obligations.

Obligation: is a requirement specified by laws, regulations, codes or organisational standards.

Organisational standards: are any codes of ethics, codes of conduct, good practices and charters that SSWAHS deems to be appropriate standards for its day-to-day



operations. In most cases these are detailed in the Manual of Policies and Procedures, and include the Area Health Services Code of Conduct.

Responsible officer: is the officer allocated responsibility for facilitating compliance with a specific obligation.

Risk assessment: in the context of SSWAHS compliance program, means assessing the level of risk of non-compliance with legislative obligations

2. Identification of Compliance Obligations, Promoting Awareness and Facilitating Compliance 2.1 Statutory Obligations and Regulatory Requirements

2.2 Common Law Obligations2.3 Relevant Professional Codes and Standards of Practice2.4 SSWAHS Policies and Procedures 2.5 Facilitating Compliance2.6 Centralised systems to facilitate compliance

3. Identification and Allocation of Responsibilities Identification and Allocation of Responsibilities3.1 Key Responsibilities for Staff 3.2 Key Responsibilities for Managers3.3 Senior Managers and Executive Staff

4. Assessing Compliance5. Monitoring Compliance6. Potential Non-compliance / BreachExamples of Potential Non-compliance / Breach

8. ReferencesNSW Health Policy Directives and Guidelines: http://www.health.nsw.gov.au/policies/index.html

9. Definitions

Print:

Pd 2007005

Documents

Transcript of Pd 2007005