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CHS20/081
Canberra Health ServicesGuideline Policy and Guidance Documents – Review and Development Contents
Contents...................................................................................................................................1
Introduction............................................................................................................................. 2
Scope........................................................................................................................................4
Section 1 – Getting started.......................................................................................................4
Section 2 – Approval to go ahead.............................................................................................6
Section 3 – Development.........................................................................................................7
Section 4 – Drafting..................................................................................................................8
Section 5 – Consultation.........................................................................................................10
Section 6 – Submission and endorsement..............................................................................13
Section 7 – Document management......................................................................................15
Section 8 – Implementation of your policy or guidance document and communicating with staff........................................................................................................................................ 16
Section 9 – Risk rating and Evaluation....................................................................................17
Related Policies, Procedures, Guidelines and Legislation.......................................................19
Search Terms..........................................................................................................................19
Attachments...........................................................................................................................19
Attachment 1: CHS Policy and Guidance Documents Development Flowchart..................21
Attachment 2: Legislation Guide........................................................................................22
Attachment 3: Style Guide..................................................................................................23
Attachment 4: Tip Sheets...................................................................................................27
Tip Sheet A: How to use headings and bullet styles.......................................................27
Tip Sheet B: Updating the contents page.......................................................................28
Tip Sheet C: Do’s and Don’ts for Policy or Guidance document Review or Development....................................................................................................................................... 30
Tip Sheet D: Quick style guide........................................................................................31
Tip Sheet E: Troublesome Words...................................................................................32
Attachment 5: Risk Rating Policy or guidance documents..................................................33
Attachment 6: Evaluation of Policies..................................................................................34
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Introduction
For the purposes of this guideline, the term policy and guidance documents refers to policies, procedures, guidelines, manuals, and placeholders.
This guideline provides Canberra Health Services (CHS) staff with information to navigate the review and development cycle and produce well written, effective policy and guidance documents (see Attachment 1 CHS Policy and Guidance Documents Development Flowchart).
The purpose of CHS policy and guidance documents is to provide a consistent approach for work undertaken by CHS staff, contractors and volunteers that align the with CHS vision, role and values.
CHS policy and guidance documents ensure that the care and services provided across the organisation is safe for both patients and staff, evidenced based, consistent, culturally appropriate and person centred.
The review and development process encourages collaboration and consolidation across disciplines and divisions, to provide consistency of care to consumers and consistency of service across the organisation. This ensures we are accountable for the care we provide and the way in which staff engage with each other to deliver services.
Policy and guidance documents ensure CHS complies with legislation, statutory requirements, National Standards and Whole of Government policies.
Policy and Guidance Document typesPolicy – is an overarching, organisational wide directive about how staff are to act in defined circumstances or regarding a particular situation. Policies are documents based on legislation, Standards, regulations and/or ACT Government requirements and compliance is mandatory. A policy is often, but not always, supported by a procedure or guideline.
Procedure – details specific methods or actions staff must undertake to complete required processes within CHS. Procedures inform staff about how to complete clinical or administrative actions consistently across the organisation. The actions are evidence based and informed by staff who are subject matter experts. Non-compliance with a clinical procedure must be clearly documented in the patient’s clinical record.
Guidelines – detail the recommended practice to be followed by staff but allow some discretion or autonomy in its implementation or use. Guidelines are written when more than one option is available under a given set of circumstances, and the appropriate action requires a judgement decision. Guidelines may also be used when the supporting evidence for one or other course of action is ambiguous.
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Placeholder – a short document that states CHS endorsement of, and where applicable, compliance with an international, national or state guidelines or standards and provides a weblink to the external document for staff to refer to. The placeholder identifies any exceptions to the use of the external document or includes further information on CHS process if required. Placeholders can also be used where internal documents have been developed but are held on other platforms e.g. SharePoint, HealthHub, ACT Health Directorate Policy Register.
Manual – These documents collate a range of clinical and operational policies, procedures, guidelines for a specific, contained geographical or functional unit. The purpose of a manual is to enable ease of use/location/compliance of key information for a specific team.
GovernanceThe CHS Policy Committee (CHS PC) is responsible for the oversight and approval of all policy and guidance documents within the organisation. The Committee has representation from each Division within CHS along with a Consumer representative. Administrative support for the Committee is provided by Quality, Safety, Innovation and Improvement (QSII).
The role of the CHS PC is to: provide governance, oversight and guidance in the development, review and monitoring
of policy and guidance documents developed or revised for CHS facilitate an effective suite of evidence based, legislatively compliant documents to
support safe, person centred, high quality care in CHS review and endorse all policy and guidance documents developed and revised within
CHS provide oversight during the review period of policy and guidance documents to ensure
they are effective, fit for purpose and patient centred.
The Review and Development CycleThe elements of the Review and Development Cycle are: identifying the need for a policy or guidance document, including determining which
type of document is needed seeking approval, both Divisional and CHS PC, for the proposed document developing the document, including:
o undertaking research and analysis to support the proposed documento drafting the documento consulting with relevant parties and incorporating their feedback, where relevant
CHS PC review, resubmission (as applicable) and endorsement document management i.e. official filing implementation once endorsed ongoing review and evaluation.
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Strategies, Frameworks and PlansStrategy – method or plan chosen to bring about a desired future, such as achievements of a goal or solution to a problem. Strategies are written with a high level (strategic) focus and does not generally include specific details.
Framework – overview or outline of interlinked items which supports an approach to a specific objective. A Framework serves as a guide to reaching the objective. A framework will usually sit underneath a strategy and provides the structure within which the organisation operates.
Plan – written account of an intended future course of action aimed at achieving specific goals or objectives within a specified time frame. It gives details of what needs to be done, when, how, and by whom. A plan will usually sit under a framework or strategy and provides operationalised instruction to staff about how to meet required objectives and goals.
Canberra Health Services Governance Committee (CHSGC) is responsible for the oversight and endorsement of organisation wide Strategies, Frameworks and Plan. The Office of the Chief Executive is the Secretariat for this Committee.
Note:Templates for Strategies, Frameworks and Plans can be obtained from the Communications and Government Relations Unit, and are available on the ACT Public Service intranet page
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Scope
This guideline applies to all staff involved in the development, review, endorsement, implementation and evaluation of policy and guidance documents across CHS.
The aim of this guideline is to clearly outline the process all staff should follow to ensure review and development (including review and evaluation) of guidance documents is consistent across CHS and to reduce the duplication of documents on the CHS Policy and Guidance Register.
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Section 1 – Getting started
Assess Divisional and Organisational needsBefore developing a policy or guidance document contact the QSII Policy Team ([email protected]), and consider the following:
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1. Do you need to write a policy or guidance document? For example, will writing a policy or guidance document improve patient/staff safety and health outcomes or improve service provision by: controlling real or perceived risks or hazards? improving clinical care through the introduction of a new treatment or change in
practice? improving morbidity and mortality outcomes? improving use of budget and resources? ensuring compliance with legislation, statutory requirements and National
Standards? aligning CHS practice with ACT Health Directorate, ACT (whole of government) or
Federal Government policies or initiatives? supporting staff to meet CHS priorities, vision, role and values?
Consider whether a new policy or guidance document is the best way of addressing the issue or whether it can be addressed by other means, e.g. through development of a unit orientation manual.
2. Are there suitable external (international, national or interstate) guidance documents that could be used or adapted for use in CHS?Do external guidance documents or professional/best practice standards exist that address the topic? If so, an initiation request for a placeholder on the Policy and Guidance Documents Register may be submitted to the CHS PC. A placeholder provides a link to the external document for staff to access at its home site. Ensure that the proposed use of external documents have been confirmed as appropriate for use in CHS by the relevant senior executive and/or clinical experts and leads.
3. Is there already a similar or related policy or guidance document on the Policy and Guidance Documents Register?When commencing development of any policy or guidance document staff must check the CHS Policy and Guidance Documents Register: (https://actgovernment.sharepoint.com/sites/intranet-health/PPR/default.aspx) to identify if there is an existing policy or guidance document that covers the topic, practice, treatment or risk. If there is already a suitable document addressing the matter of concern, no further work is needed. You will need to make sure your staff are aware of the existing document.
If there is an existing policy or guidance document that covers similar or related issues and you believe the existing document could be amended to include additional matters rather than creating a new document, please contact the Policy Team for advice: email [email protected], ph: 512 47933.
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4. If you are sure no other policy or guidance documents exist that could cover the issue, consider how your new policy or guidance document will align with existing policy or guidance documents.For example, if there is an overarching policy or guidance document e.g. Consent and Treatment Policy, the information in the new document must not contradict the information in the overarching document. Try to avoid duplicating information. It is better to refer to related documents and inform staff that the documents must be read together.
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Section 2 – Approval to go ahead
Initiation Request: Before beginning development or a review of any policy or guidance document, you will need to seek agreement from the CHS PC. Once you have completed the steps in Section 1 and are certain a new document is needed or a document requires review, you must complete an Initiation Request form, and have it approved by the relevant Divisional Executive Director/Executive Group Manager, Director of Nursing, Clinical Lead or Senior Manager.
An electronic copy of the Initiation Request can be found on the Health Hub: https://healthhub.act.gov.au/governance/policy-and-clinical-guidance
The Initiation Request is your opportunity to state, in 1-2 paragraphs, your case for your policy or guidance document review or development work. The more information you provide at this stage and the clearer your description of the purpose and impact of the policy or guidance document, the more likely your initiation request will be approved. The initiation request should include information about: the type of document needed, if you are unsure or for assistance please contact the
Policy Team on 512 47933 or email [email protected]. the content of your document, including whether it contains information related to
medications, clinical forms or consumer handouts.o For more information about developing consumer handouts, see the Health Hub:
https://healthhub.act.gov.au/patient-care/patient-experience/consumer-handouts-publications
o For more information about developing a clinical form, see the Health Hub: https://healthhub.act.gov.au/workplace-support/clinical-records-forms
o Policy or guidance documents containing references to specific medications, need to be endorsed by the Medication Safety Standard Committee. The Policy Team will arrange this once the document has been endorsed by the CHS PC.
Once your Initiation Request has been approved, you will receive an email outlining you Initiation Request approval and how to progress your documents development (including all the necessary templates and forms).
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Section 3 – Development
1. Assemble a working group (if appropriate): A working group is a group of subject matter experts and interested staff to provide you with advice and assistance through the policy and guidance document review/development phase. The working group should be multidisciplinary and have members from areas across the organisation where the document will apply.
2. Develop a timeline: Factor in reasonable times to undertake research, drafting the policy or guidance document, consulting with key users, incorporating feedback and CHS PC endorsement processes. Allow at least one month for committee approval processes.
Please note: CHS recommends, where possible, a minimum six-week consultation period for
external stakeholders if your document contains specific references to medications, it will also need to be
endorsed by the National Standards Medication Safety Committee. Please allow extra time for this. The Policy Team will facilitate this process.
3. Research and analysis: Research must be conducted to ensure your policy or guidance document is evidence based and will meet the needs of stakeholders. You may also be able to find a document from another health service that can be adapted for use within CHS. You will need to seek permission from the document owner to use the resource within CHS, if permitted this resource can then be adapted as a procedure or a placeholder can be used to link to this information. Some documents may indicate that use by other services is allowed with appropriate acknowledgement. Research activities may include: a literature review – contact the CHS Library for help with this process finding and reviewing related policy and guidance documents – this could include
CHS or other health services, including national and international. This information will help you identify current, best practice
meeting with stakeholders consulting with experts examining data and statistics.
4. Legislation: It is important that all policy and guidance documents refer to relevant state or national legislation. It is only necessary to list legislation that is directly related to the subject of the policy or guidance document. See Tips for Legislation at Attachment 2 .
5. Communication and implementation: During this stage of the Review or Development Cycle you will need to plan for implementation of the policy or guidance document and
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how it will be communicated to staff and implemented. Refer to Section 8 - Implementation of this document for more information.
6. Review and evaluation: All policies must be regularly reviewed and evaluated to ensure they remain current and effective. Refer to Section 9 - Risk Rating and Review for further information.
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Section 4 – Drafting
To start drafting your policy or guidance document: make sure you are using the correct template. This will be sent to you when your
Initiation Request is approved. read the instructions in the template to learn what you need to include in each section
of your document read the Style Guide at Attachment 3 and the Tip Sheets at Attachment 4 of this
document. These attachments include tips and hints on format and style, and important points to consider when drafting your policy or guidance document
ensure you consider staff where English is their second language or who may have low levels of literacy
when referring to time please use 24-hour time (i.e. 07:00 – 13:00) do not use hyperlinks to other policy or guidance documents on the Policy and Guidance
Documents Register within the document. Policy or guidance review dates rarely coincide and documents you link to may be superseded. You may hyperlink to sections within your document or external websites if you are certain these links will not change within the review period of the document.
Naming your policy or guidance document: It is very important that the name of the document makes it easy for staff to identify the
content Consider how staff might search for the policy or guidance document on the Policy and
Guidance Documents Register. Use key search words in the title Keep the title as short as possible Start with words that describe the subject or issue to assist staff who may search for a
policy or guidance document alphabetically. For example, ‘Alcohol and Other Drugs: Responding to Use’ or ‘Code Blue: Activation of’
If applicable, the title should specify if the document applies only to a specific group. For example, ‘Adults only’
Use simple language and plain English Do not use acronyms or abbreviations Where possible words such as ‘the’ or ‘a’ should not be used at the start of your title.
Impact on staff, patients and carers:
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When drafting and seeking consultation on your document, you must consider the economic, social and environmental impact of the position you are proposing in your policy or guidance document.
Consider: Aboriginal and Torres Strait Islander Impact:
Consideration of cultural impacts on Aboriginal and Torres Strait Islander Health should be considered. If you require assistance please contact the CHS Aboriginal and Torres Strait Islander Liaison Service by emailing [email protected]. You can also refer to the Aboriginal and Torres Strait Islander Elected Body protocol for working with Aboriginal and Torres Strait Islander peoples
Multicultural impact: How many staff, patients and carers from culturally and linguistically diverse backgrounds could be affected by the document? For further information please contact the Multicultural Health Unit on 6205 1011 or at [email protected]
LGBTQI+ impact:Will the proposed document impact LGBTI people (lesbian, gay, bisexual, transgender and intersex)? For further information please refer to Capital of Equality: An ACT Government strategy or contact Office for LGBTIQ+ Affairs at [email protected]
Disability impact:Is the content or implementation of the document likely to impact on a person with a disability? Is the document about care and services delivered to people with a disability?
When considering the impact of the document on staff (including staff who identify as Aboriginal and Torres Strait Islander, are LGBTQI+, come from a multicultural background, or have a disability) please contact CHS Manager for workforce inclusion on 5124 9900 to discuss the document.
During planning for implementation, you will need to consider who will be affected by the new or revised policy or guidance document and determine the most appropriate, effective and efficient way of informing them.
Identify and consider: those with responsibility for implementing the policy or guidance document the resources needed to implement the policy or guidance document. Policy or guidance
document owners may be responsible for the provision of training. This should be factored into the area’s budget
the need for staff education or training. Any policy or guidance documents requiring changes to established practice may need to be supported by information sessions, training or workshops. In addition, the change may need to be communicated through executive structure, leadership groups and existing committees for managers to inform down to local staff and ensure the change is adopted.
how staff are going to know about the new or revised policy or guidance document, so they can follow it
any changes to practices needed and how this will be managed.
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Search Terms:Search terms are single words or short phrases that can be used to find your document on the CHS Policy and Guidance Documents Register. Search terms should be limited to a total of 20 words across the main themes of your document. It is important to consider what words that staff using the document may use when looking for your document.
Attachments:Attachments form part of the policy or guidance document and should be included within the document. They should not be included as separate documents. Please ensure that all attachments are clearly labeled, included in the table of contents and referred to within the body of the document. If the attachments are Clinical Forms or Consumer Handouts that have yet to be endorsed please contact the Policy Team ([email protected]) for more information.
Test your document:When your draft is complete, it is important that your document is tested by both key users and staff with no prior knowledge of the content of the document.
Ask staff members to read the draft, to test it and provide you with some feedback about it. For example, after reading the draft once: did they understand the content? could they identify the essential messages easily? did they understand what they needed to do? did the information provide a logical step by step process to be followed? were there any words they didn’t understand? were there any typing mistakes to be corrected?
Before sending the document out for consultation, make sure the policy or guidance document is plainly marked on each page as a ‘Draft’ so that it cannot be confused with an endorsed document. You can use the watermark feature in Word to do this. You will need to have a system for version control, as ongoing changes are made to the draft before and after consultation (see Section 5 - Consultation for more information on the consultation process).
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Section 5 – Consultation
Thorough consultation with key stakeholders must be demonstrated for your policy or guidance document to be endorsed by the CHS PC.
Please note that the Policy Team can help you seek consultation by offering guidance and support but cannot carry out the consultation for you. A broad and detailed consultation process must be completed.
Note:The Policy Team can upload your document to a central Consultation page on SharePoint. This allows key stakeholders, within CHS, to provide feedback via tracked changes on a single version of your document. This can make the consolidation of feedback easier. If you’d like to set up a consultation page please contact the team via email [email protected].
Consultation must, at a minimum, include the following:1. All relevant Executives Directors/Executive Group Managers and their equivalents.2. All relevant Executive Officers or Business Managers.3. Divisional representatives on the CHS PC.4. Consumer representatives. This can include consulting with the consumers who access
the service being documented in the policy or guidance document. If the document requires consultation with consumers or a group of consumers as it affects them directly, for example Consent to Treatment policy, you will need to send the document to all or the most suitable consumer group below. Please note, a minimum six-week consultation period for external stakeholders is recommended.
To find a consumer representative, contact: Health Care Consumers Association (HCCA): Ph 6230 7800 ACT Mental Health Consumer Network: Ph 6230 5796 Carer’s ACT: 6296 9900
5. Any external and internal stakeholders who will be affected by the proposed document.
Additional consultation may be needed. Contact the:1. CHS Aboriginal and Torres Strait Islander Liaison Service ([email protected] ) and
the Aboriginal and Torres Strait Islander Health Practice Centre for advice on potential health impacts on vulnerable populations (email: [email protected] )
2. Relevant unions and employee representatives, for any draft documents relating to enterprise agreements or other industrial matters
3. Clinical Ethics Committee, for any draft documents relating to: organ donation or tissue and blood issues; reproductive issues; withdrawal of treatment; consent and competence; use of therapeutic products of limited availability. For further information
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about the Clinical Ethics Committee, see their intranet page on the HealthHub: https://healthhub.act.gov.au/about-us/canberra-health-services/clinical-ethics-committee
4. Appropriate/relevant National Standards Committee: a. Partnering with Consumers (email: [email protected])b. Preventing and Controlling Healthcare Associated Infections (email:
[email protected])c. Medication Safety (email: [email protected])d. Comprehensive Care (email: [email protected])e. Communicating for Safety (email: [email protected])f. Blood Management (email: [email protected])g. Recognising and Responding to Acute Deterioration (email:
[email protected])5. Drugs and Therapeutic Committee, if your document relates to medications that require
formulary changes (email: [email protected]) 6. Clinical Forms Committee, if your document contains or references a clinical form (ph:
5124 2245 or email: [email protected]) 7. Consumer Handouts Committee, if your document contains or references a consumer
handout (email: [email protected]).
Resources for staff to use when planning consultation with consumers and other external stakeholders include: ACT Health Consumer and Carer Participation Policy (available on the Policy and
Guidance Documents Register) ACT Government Strong Families website: https://www.strongfamilies.act.gov.au/ Protocols for working with Aboriginal and or Torres Strait Islander peoples (available on
the Policy and Guidance Documents Register) ACT Multicultural Framework 2015 - 2020 ACT Community Group Directory
https://www.communityservices.act.gov.au/multicultural/services/act-community-group-directory/search
Managing consultation feedback:When circulating a document for consultation, identify the scope for comment so that stakeholders clearly know what their feedback should cover.
If areas can’t meet feedback deadlines, they should be asked to contact the author as soon as possible to seek an extension of the timeframe.
Specify a deadline to internal stakeholders of ideally two to four weeks to provide feedback. Documents relating to high risks or sensitive issues may need a longer consultation period. A shorter consultation period may be appropriate for: Short/Summary documents (i.e. placeholders) minor amendments following review simple processes.
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When circulating documents for comment, clearly state how feedback is to be provided, to whom and by when.
Review of feedback:You need to review and assess the feedback you receive to decide whether to: accept the feedback and incorporate changes in the draft, or justify why feedback will not result in changes to the draft.
The consultation feedback summary template, forms part of the package of documents the CHS PC will need to review and endorse your policy or guidance document. You will be sent the template for this when your initiation request is approved. A summary of all feedback must be recorded on the template to highlight the issues raised, explain how issues have been addressed, and provide evidence of appropriate consultation with consideration of all stakeholder views. The consultation summary sheet should: List each stakeholder by name, position and area/unit/division Summarise the feedback received by each stakeholder Explain either how feedback was incorporated or why it was not incorporated Include a notation of ‘Nil Comment/No Changes Required’ if you receive a response
that a stakeholder has reviewed the document but does not recommend any changes Include a notation that ‘No response received’ if a stakeholder does not provide
feedback within the set time frame (note: this should not be considered as endorsement or agreement with the policy or guidance document and further consultation may still be needed).
Minor feedback relating to formatting, spelling, grammar and typing mistakes may be summarised as ‘minor editing amendments’.
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Section 6 – Submission and endorsement
Before a policy or guidance document may be disseminated for use, the documents and any supporting material must be endorsed by CHS PC and uploaded to the Policy and Guidance Documents Register by the Policy Team.
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Note:If your document includes the following: Clinical forms - please ensure these forms are endorsed by the Clinical Forms Committee
prior to submission to the CHS PC or are in the process of being endorsed Consumer handouts - please ensure these handouts are endorsed by the Consumer
Handouts Committee prior to submission to the CHS PC or are in the process of being endorsed
Reference to specific medication: please ensure all references to medications have been consulted with a pharmacist before submitting to the CHS PC. When the document is submitted to the Committee, the Policy Team will submit it to the Medication Safety Committee for endorsement. Only once the document has been endorsed by CHS PC and Medication Safety Committee will it be uploaded to the Policy and Guidance Documents Register.
The Policy Team can help facilitate these processes where required.
When your policy or guidance document has been drafted, the consultation period has ended and the document has been finalised (i.e. feedback incorporated), the next step is to submit the following to the CHS PC via email to [email protected]: Completed Submission for Approval request form, signed by your Divisional Executive
Director or Executive Group Manager. Please note, if you don’t have this level of approval to proceed your document will not go to the CHS PC. Submission forms now include a space for you to list any archiving that may be required, please list here any policy or guidance documents your new document will replace (where necessary) – note: if your submission is a revision of an existing document, include the existing document here
Draft of the finalised policy or guidance document Consultation feedback summary Proof of endorsement, where documents or supporting materials require endorsement
by another governance body before being submitted to the CHS PC. The proof can be an email stating endorsement.
AlertWhen sending through your submission, please make sure your policy or guidance document and consultation feedback form is: in Word format (please do not send a scanned or PDF versions) without tracked changes or reviewer comments.
When the CHS PC Secretariat receives your document, a quality assessment will be undertaken by a case manager and the document will be listed for consideration at the next committee meeting. Depending on the level of feedback from the case manager you may be asked to make amendments prior to papers being disseminated to the CHS PC for consideration.
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When the CHS PC meets, two members of the committee will review your document and provide suggested changes if needed. After the Committee meeting, you will receive an Outcome Report including a decision about endorsement, as well as any required changes that need to be made prior to upload to the Policy and Guidance Documents Register.
Please note, the outcome report will outline what changes are required and comments for authors consideration. Required changes must be incorporated by the author and changes that are for consideration must be looked at but not necessarily incorporated.
You will receive confirmation via email when your document has been endorsed and uploaded the CHS Policy and Guidance Documents Register for use.
Note:If your document is not to be uploaded immediately following approval, (e.g. because it will be launched at an event, or after a communications strategy), you must include the requested date for upload on the submission for approval form.
Note:Under the Freedom of Information Act 2016, all CHS policy and guidance documents are made publicly available via the internet unless to do so would pose a risk to security or safety of patients or the public. If you believe your document should not be available on the internet, discuss this with your Executive Director/Executive Group Manager when they sign the submission form. They will need to appropriately complete the FOI Open Access Scheme section of the form.
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Section 7 – Document management
All document authors should maintain an official (paper) file for their policy or guidance document review/development. This file should contain all documentation related to the development of your policy or guidance document, including: Initiation Request and approval Consultation feedback form Draft version with reviewer comments/tracked changes Submission for approval form Archive form (if required) Any written communication (i.e. emails) about the development of policy or guidance
document Outcome report from the CHS PC Final endorsed version of the policy or guidance document.
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The Policy and Guidance Documents Register Manager (located in QSII Policy Team) is responsible for document management including: Tracking policy and guidance documents on the Policy and Guidance Documents
Register due for review and advising responsible areas of the need to review before expiration.
Uploading new documents to the Policy and Guidance Documents Register Removing earlier or superseded versions from the Policy and Guidance Documents
Register Managing the lists of publicly available policy and guidance documents, to ensure only
those that may have particular privacy or security implications are not made publicly available.
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Section 8 – Implementation of your policy or guidance document and communicating with staff
During planning for implementation, you will need to consider who will be affected by the new or revised position outlined in the policy or guidance document and determine the most appropriate, effective and efficient way of informing them. This information must be included on the Policy Submission for Approval Form.
Consider and identify: Those with responsibility for implementing the policy or guidance document The resources needed to implement the policy or guidance document. Document
owners may be responsible for the provision of training and this should be factored into the area’s budget
The need for staff education or training. Any documents requiring changes to established practice should be accompanied by an information session, training or workshop
How staff are going to know about the new or revised policy or guidance document, so they can adhere to it
Any changes to practices needed and how this will be managed.
Communicating the new or revised decision to staffEach new or revised policy or guidance document must be communicated to staff, particularly those likely to be impacted by its introduction or whose practices will need to change as a result.
The CHS PC Secretariat arranges a monthly all CHS Staff Email: CHS PC in the form of a Chief Executive Officer Alert, outlining recent policy or guidance document endorsements. These do not necessarily occur immediately after the new policy or guidance document is activated by upload to the CHS Policy and Guidance Documents Register. Therefore, it is important that authors actively manage targeted communications to those staff most likely to be affected by the decision, which should be communicated through line managers. CHS PC representatives should also notify their Divisions of policy or guidance document
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endorsement decisions.
Communication activities might include: All staff emails at CHS/branch/division level Face-to-face meetings/discussions Information sessions Staff forums Team briefings by managers Staff Bulletins or Newsletters Communication books used by specific work areas.
Some policy or guidance documents will need more comprehensive communication strategies, such as a media release or launch, and advice to stakeholders in the form of brochures, advertising, training sessions and community announcements. The CHS Communications and Government Relations Unit can be contacted for advice and assistance by email: [email protected]
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Section 9 – Risk rating and Evaluation
Risk RatingPolicy or guidance documents and any supporting material need to be reviewed regularly to ensure they retain their relevance and effectiveness. When the document is endorsed by the CHS PC, a review date between 12 months and five years will be determined, based on the risk rating of the document.
The risk rating is determined using the risk rating matrix contained in the ACT Health Risk Management Guideline. This risk is based on the likelihood and expected consequence of an incident that may occur, if the policy or guidance document was either not in place or was not current. High risk documents or those subject to regular external influence should have an earlier review date, while low risk or those not expected to change may be given a full five-year endorsement.
As part of the submission process, document authors are required to risk rate their documents using the Risk rating matrix. For more information about risk rating policy or guidance documents, refer to Attachment 5.
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Note: It is not necessary to wait until the allocated review date to revise the document. An earlier review is appropriate, and possibly required if: An incident has occurred resulting in a need for review or change to process There is a change in infrastructure or procedure, or Legislation, best practice guidelines or ACT Government policy or strategic
direction has changed.
EvaluationAs part of the review process (of an existing policy or guidance document), all documents need to be evaluated in accordance with the specific scope and associated risk. Evaluation is to be completed by the local divisional owner and should measure and assess the impacts and merits of policy or guidance documents. Evaluation should determine appropriateness, effectiveness and efficiencies related to a particular policy or guidance document to contribute to future improvements.
A useful evaluation tool is the ACT Government Evaluation Policy and Guidelines (2010) (which can be found on the Chief Minister, Treasury and Economic Development Directorate website: https://www.cmtedd.act.gov.au/policystrategic/accountability/report). This report advises that the scaling of an evaluation should be dependent on the characteristics of the policy or guidance document, in particular, relating to its risk, resource requirements, strategic priority and public profile. For example, a low risk policy or guidance document with minimal resource requirements which is similar to previous successful policies would require only informal evaluation with limited data and resource allocation, while a more high risk policy or guidance document which is resource intensive, controversial or politically significant would require a formal, detailed evaluation with comprehensive reporting and wider release of results.
At a minimum, all CHS policy or guidance documents need to undergo informal evaluation, as part of their review process. This evaluation must ask several base level questions as to the success and usefulness of the current document. This should involve: Assessing the impacts and achievements of the document to date Determining ways to improve Scope and application:
o Efficiency – is the document easily accessible and simple to administer? Are costs and benefits appropriately addressed and distributed?
o Effectiveness – Is the program meeting its objectives and producing worthwhile outputs?
o Appropriateness – does the document align with health service and/or government priorities and meet community needs? Is it producing valuable outcomes?
Findings to be documented in local areas and in changes to the document, not in a formal report.
Higher risk policy or guidance documents require more formal evaluation, involving the steps outlined above, and must also include the following:
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More formal and objective data collection (for example, the number of incidents reported on RiskMan)
Evaluation may include objective, external stakeholders, or a panel of evaluators – for example the CHS PC, in addition to local area and as part of existing document consultation process
Findings to be documented more thoroughly – for example in a formal report, and should be reflected in improvements to guidance documents
Findings to be disseminated more widely in line with organisational objectives and priorities (e.g. budget related, accreditation may be escalated to broader executive level).
The results of this evaluation should be communicated to the key stakeholders identified in the evaluation/planning process and should lead to further developments and improvement in the existing policy or guidance document.
For examples of the level of evaluation required for two types of policy or guidance documents, refer to Attachment 6.
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Related Policies, Procedures, Guidelines and Legislation
GuidelinesRisk Management Guidelines
LegislationFreedom of Information Act 2016Human Rights Act 2004Work Health and Safety Act 2011
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Search Terms
Policy Committee, Policy Development, Procedure, Guideline, Plan, Policy Development Cycle, Consultation, Implementation, Endorsement, Review, Guidance
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Attachments
Attachment 1: CHS Policy and Guidance Documents Development FlowchartAttachment 2: Legislation GuideAttachment 3: Style GuideAttachment 4: Tip SheetsAttachment 5: Risk Rating Tip SheetAttachment 6: Evaluation of Policy or guidance documents
Disclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.
Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 18/03/2020 Complete Revision Denise Lamb, ED QSII CHS Policy Committee
This document supersedes the following: Document Number Document NameCHHS16/055 Policy Development Guideline
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Attachment 1: CHS Policy and Guidance Documents Development Flowchart
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Attachment 2: Legislation GuideThis Legislation Guide provides information to ensure Canberra Health Services policy or guidance documents reference relevant legislation.
It is only necessary to list legislation that is directly related to the subject of the policy or guidance document. The following list provides examples of ACT and Commonwealth legislation that may apply (note this is not an exhaustive list – for full list of ACT legislation, visit http://www.legislation.act.gov.au/a/):
Financial Management Financial Management Act 1996
Population HealthMedicines, Poisons and Therapeutic Goods Act 2008Transplantation and Anatomy Act and Medical Treatment (Health Directions) Act 2006Human Rights Act 2004
Quality and SafetyWork Health and Safety Act 2011Workers Compensation Act 1951
Business and InfrastructureGovernment Procurement Act 2001Territory Records Act 2002
E-Health and Clinical RecordsFreedom of Information 1989Health Records (Privacy and Access) Act 1997
Human ResourcesPublic Interest Disclosure Act 2012Public Sector Management Act 1994
Canberra Hospital and Health ServicesGuardianship and Management of Property Act 1991Health Records (Privacy and Access) Act 1997
Mental Health, Justice Health and Alcohol and Drug ServicesOperational SupportACT Mental Health Act 2015
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Attachment 3: Style GuideTemplatesDocument templates are available from the: Policy and Guidance Documents Register: Policy Development Resources HealthHub: https://healthhub.act.gov.au/governance/policy-and-clinical-guidance/chhs-
policy-development Policy Team at [email protected] Each section of the template must be completed. Additional headings and sections may be inserted where necessary. Heading, paragraph
and bullet styles have been set on the templates. It is important that the approved templates be used. Where an extra heading needs to be included, please see Attachment 3: Tip Sheet 1 - How to Use Heading Styles guide.
When submitting documents for endorsement by the CHS PC, make sure they contain no tracked changes or comments from the consultation phase.
FontUse: Name of policy or guidance document: Calibri 22 bold Document Title: Calibri 18 bold Template headings (in the grey or black box): Heading Style 1 (Calibri 14 bold) Sub-headings: Heading Style 2 (Calibri 12 bold)
o Please ensure no space exists between a Heading Style 2 and the underneath Body Text
Body Text: Calibri 12 Bullets: List bullet Banding (Background Color of Title):
o Guidelines: Light Grey – RGB: 217, 217 and 217 o Procedures: Dark Grey - RGB:166, 166 and 166o Policies: Black - RGB: 0, 0 and 0.
Note: It is important you use appropriate heading styles in your document. The contents page is generated from the heading styles applied throughout the document. For help with this see Attachment 3: Tip sheet 2 - Updating the contents page or contact the Policy Team Email: [email protected] Phone: 6174 7933.
Attachments When inserting attachments please refer to them in your document (for example, see
Attachment 1). Ensure the font for the title of the attachment is Heading Style 2 (Calibri 12 bold).
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Simple language and plain EnglishUse simple language and plain English so that staff can find, read and understand what they need to do quickly and easily. For example: use simple words. For example, use the word ‘give’, instead of ‘administer’ avoid use of jargon. If using medical terminology include it in the Definitions section at
the end of the policy or guidance document use short sentences. Aim for a maximum of 20 to 25 words per sentence make information as brief and to the point as possible. Avoid use of excess words to put
across an idea. For example, ‘The car is red’ is better than ‘the colour of the car is red’ information that provides background or further reading should not be included in the
body of the document. It may be:o listed in the references sectiono placed in an attachment at the end of the documento available on the relevant Divisional network folder or intranet site for staff to access
as a resource. (A clear description of where staff may find it on the intranet should be included in the policy or guidance document)
use lists of dot points instead of longer sentences and paragraphs avoid repeating information that has already been stated.
Dot points If all dot points in a series are sentences, they take full punctuation, including starting
with a capital letter. If they consist of sentence fragments, then no punctuation is used except for a full stop
after the last point (do not use ‘and’ at the end of the second last dot point). These dot points start with a lower-case letter.
A colon is used after the lead-in sentence to clarify the link with the dot points that follow.
Numbering of procedure stepsThe procedure section must be numbered so that it is described and is read in the order of necessary steps that staff must follow.
AbbreviationsAbbreviations are to be spelt out in full the first time a term is used in the document, followed by the abbreviation e.g. Canberra Health Services Policy Committee (CHS PC).
Only use approved abbreviations, acronyms and symbols. Refer to: Approved Abbreviations, Acronyms and Symbols on the Policy and Guidance Documents Register.
It is also useful to include all acronyms in the definitions section.
Highlighting informationImportant information should appear in the front of the document so that it is read first. Use of bold type can be used sparingly to highlight a specific statement.
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Formatting that should not be used to highlight information includes: underlining capitals larger font size or different font style coloured text.
Boxes may be used to highlight alerts or notes and should be entered as followed:
Alert/Note: enter body text
Consistency Choose one descriptive term to use throughout the document. For example, use either
‘consumer’, ‘client’, or ‘patient’. Use of punctuation should be consistent throughout the document. At the end of every section within your document, ensure there is a link back to the table
of contents.
Search termsList the search terms that will be used to help staff locate this document on the Policy and Guidance Documents Register.
Referencing CHS Policy or guidance documentsWhen referencing other relevant CHS policy or guidance documents in the body of the document, use the following style: Refer to Consent to Treatment Policy ensuring the title of the document is italicised.
LegislationLegislation is to be written in italics with date in normal text. E.g. Human Rights Act 2004. It is only necessary to list legislation that is directly related to the subject of the policy or guidance document. For example, it is understood that staff must comply with the Public Sector Management Act 1994 and is not necessary to reference this legislation in every CHS policy or guidance document.
Journal Articles etcVancouver Referencing is the preferred method of referencing. This system uses sequential numbers in the text, either bracketed or superscript. The numbers refer to either footnotes or endnotes that provide source detail. An example of this is:1. Hoppert M. Microscopic techniques in biotechnology. Weinheim: Wiley-VCH;
2003.2. Drummond PD. Triggers of motion sickness in migraine sufferers. Headache.
2005;45(6):653-6.
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3. Meltzer PS, Kallioniemi A, Trent JM. Chromosome alterations in human solid tumors. In: Vogelstein B, Kinzler KW, editors. The genetic basis of human cancer. New York: McGraw-Hill; 2002. p. 93-113.
HyperlinksHyperlinks to external references can be used but you or the owner of the location of the documents will need to ensure that the links are current. As an alternative to a hyperlink, provide the name of the website where the information can be accessed, if applicable.
As hyperlinks are prone to change, do not link to documents on the CHS Policy and Guidance Documents Register.
Writing time Where possible the use of 24-hour time is preferred (i.e. 07:00 – 13:00).
Accessibility requirementsTo help people with visual acuity issues access the information in the document: provide a brief written description of pictures or diagrams avoid the use of the symbol / where possible separate paragraphs with one line of white space follow the formatting of the policy or guidance documents templates.
Culturally and Linguistically Diverse and Low Levels of EducationPlease ensure that consideration is given to both staff and consumers for whom English is a second language and those groups where literacy levels are low.
Impact on vulnerable populationsPolicies and procedures may have a direct or indirect impact on vulnerable populations including Aboriginal and Torres Strait Islanders, culturally and linguistically diverse communities, LGBTQI+ people, people with a disability and survivors of family violence and sexual assault.
The potential impact arising from your policy or guidance documents should be considered and stakeholders who can provide appropriate review and advice. Feedback should be incorporated in your document and included on your consultation feedback form.
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Attachment 4: Tip SheetsTip Sheet A: How to use headings and bullet styles
1. Highlight the text to be changed to heading or bullet style.
2. Select the heading or bullet style to be applied. Appropriate heading styles for use in policy or guidance documents can be found at the top of the screen.
3. If you are inserting a numbered list, please use the outline numbers option.
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Tip Sheet B: Updating the contents page
Updating an existing contents pageWhen a document is completed, the contents page can be updated so that it matches with the headings throughout the document.
1. Highlight the contents page
2. Right click over the highlighted section and select Update Field
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3. A dialogue box will appear, select Update Entire Table, then press ok
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Tip Sheet C: Do’s and Don’ts for Policy or Guidance document Review or Development
Do: Check for similar documents on the
Policy and Guidance Documents Register.
Use a new template each time you write a policy or guidance document. This will be sent to you when your Initiation Request is approved.
Consult with key users, other areas eg. CHS Aboriginal and Torres Strait Islander Liaison Service and consumers where appropriate.
Where possible, address all points raised during the consultation phase.
Consider the audience and use clear, concise, simple language.
Provide brief explanations and definitions for unique terms where appropriate.
Be consistent with CHS and ACT Government policy.
Use correct and consistent terminology. Spell out all acronyms when first used. Check grammar, punctuation and
spelling (do not rely on the computer spell-checker).
Provide links for further information where appropriate.
Don’t: Change the template. Use an old template. Split names and dates over lines. Use the text wrap functionality. Make assumptions. Use excessively long sentences or
provide unnecessary information.
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Tip Sheet D: Quick style guide
Abbreviations i.e. ‘that is’ or ‘in other words’ e.g. ‘for example’ Do not abbreviate ‘Aboriginal and Torres
Strait Islander’ Instead of using ‘etc.’, redraft using ‘such
as’ or ‘including’ Write acronyms and abbreviations in full
the first time you refer to them
Capitalising use capitals when referring to a specific
government, directorate or division use lower case in generic instances capitalise when referring to a published
document
Grammar A division or body is a singular entity
(Examples: Each division is responsible for… or divisions will be responsible for)
Standardisation Use an ‘s’ not a ‘z’ e.g. organisation,
apologise, prioritise, analyse, specialise
Published material Always write out legislation titles in full at
the first reference, including the year. Use italics in: titles of Acts, Regulations
and Disallowable Instruments Use normal type in: Bills and abbreviated
titles for Acts, Regulations and Disallowable Instruments
Punctuation Use non-breaking spaces (Ctrl Shift
spacebar) to prevent breaking titles, names and dates across lines
Use a non-breaking hyphen (Ctrl Shift hyphen) in doubled up vowels, except coordinate and cooperate (e.g. co-owner)
Possessions - the apostrophe comes before the s in the singular and after the s in the plural. Examples: The government’s policies don’t… Governments’ budgets aren’t…
Numbers and dates Numbers from one to ten are spelt in full,
e.g. three days not 3 days Use commas as separators in numbers
(e.g. 20,000) Use symbols in tables [%, $m, $b], but
write out in text (e.g. 20 per cent, $8 million/billion)
Use numerals in a series (e.g. she has 17 laptops and 5 manuals)
When two numbers follow each other in a sentence, write the first as a word and the following as a numeral (e.g. there are three 5-year projects).
The financial year should be written as 2017-18
Use date structure as 1 April 2015, not 1st April 2015
A number at the start of a sentence must be spelt in full.
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Tip Sheet E: Troublesome Words
Accept and Except‘Accept’ means to receive, admit, regard as true, say yes.‘Except’ means to exclude, other than, to leave out.
Advice and Advise ‘Advice’ is a noun. It is a suggestion, opinion or recommendation.‘Advise’ is a verb, meaning ‘to give advice’, to give information, notify and suggest types of action.
Affect and Effect‘Affect’ means to produce a change in or influence something; or; the emotion a person is presenting‘Effect’ means a change that occurred. When an ‘s’ is added, ‘effects’ means personal belongings.
Alternate and Alternative‘Alternate’ means by turns or every other.‘Alternative’ is one of two or more choices.
Compliment and Complement‘Compliment’ means praise or admiration.‘Complement’ is to make complete or perfect, goes well together.
Dependent and Dependant‘Dependent’ means relying on something.‘Dependant’ means a person supported by someone else.
Discrete and Discreet‘Discrete’ means separate, distinct, detached.‘Discreet’ means cautious, restrained.
Disinterested and Uninterested‘Disinterested’ means impartial or having no stake.‘Uninterested’ means lacking interest.
It’s and Its‘It’s’ is the abbreviation of it is, e.g.: It’s an excellent written summary.‘Its’ is the possessive form, e.g. Its summary was excellent.
Licence and License‘Licence’ is a noun, e.g. she holds a pilot’s licence.‘License’ is a verb, e.g. they will license her to fly.
Personal and Personnel‘Personal’ means belonging or relating to a person.‘Personnel’ refers to the people employed in an organisation, business, or service.
Practice and Practise‘Practice’ is a noun, e.g. he did a lot of practice.‘Practise’ is a verb, e.g. he practised a lot e.g. Doctors and lawyers practise their profession; both have practices.
Principle and Principal‘Principle’ means a rule.‘Principal’ means main, chief, most important e.g. The school principal setvery clear principles.
There, Their and They’re‘There’ refers to a place.‘Their’ shows possession, that something belongs to them‘They’re’ is the abbreviation of ‘they are’.
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Attachment 5: Risk Rating Policy or guidance documents
Tips to risk rate your policy or guidance document:All policy or guidance documents are required to be risk rated. These easy steps will guide you to risk rate your policy or guidance document.1. Use the Risk Rating Matrix to determine risk, see the appendix to the Risk Management
Framework, which can be found on the Policy and Guidance Documents Register2. Use the equation to find out the right risk rating
Likelihood x Consequence = Risk Rating
3. Use the definitions and the tables below to work at the likelihood and consequence for the risk rating
Definitions: Consequence – What is the outcome to the patient/organisation if the policy or guidance
document did not exist, was not current or was not followed. For example, if the organisation did not have a policy or guidance document for how to safely prescribe and administer medication (Medication Handling Policy)
Likelihood – How likely is the consequence to occur if the document did not exist, was not current or was not followed.
Example – BHRC Clinical Risk Assessment1. Consequence - Outcome to the patient/organisation if the clinical risk assessment is
incomplete. Answer: Major
2. Likelihood – How often would a major consequence occur if the procedure was not followed? Answer: Possible.
3. Risk Rate = High4. Review Period – 3 years
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Attachment 6: Evaluation of Policies
The following are examples of assessing the required level of evaluation for a policy or guidance document.
Medication Handling Policy: Scope of document: In line with NSQHSS Standard 4 – Medication Safety. Applies to all
CHS staff to improve patient safety and bring medication handling in line with relevant legislation
What sort of evaluation is required to answer agreed evaluation questions – quantitative data on number of medication related incidents over the time the document has been in use (compared to prior to implementation). Qualitative data from several wards and/or pharmacy as to local use and awareness of document.
Document performance to date including problems and/or opportunities for improvement: Review of data (qualitative and quantitative) relating to the use and appropriateness of the document and whether it responds to key issues and outcomes for which it was developed
Identifying key stakeholders of the document, and who would benefit from outcomes of an evaluation: Medication Safety Standards Group, Drug and Therapeutics Committee, Pharmacy, all of CHS relating to medications.
Who should evaluate: Should be evaluated by all key stakeholders above, including the CHS PC.Outcome: High risk, formal report evaluation to be included with policy update.
ACT Equipment Loan Service Policy: Scope of document: governance of ACT equipment loan service What sort of evaluation is required to answer agreed evaluation questions: discussions
with areas using document Document performance to date including problems and/or opportunities for
improvement: review of data relating to issues accessing and implementing the ELS policy
Identifying key stakeholders of the document, and who would benefit from outcomes of an evaluation: RACS, Equipment Loan Service
Who should evaluate: local area.Outcome: Low risk, internal evaluation as part of document update.
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