Find policy documents
|Aboriginal And Torres Strait Islander Health National Strategic Framework|
The National Strategic Framework for Aboriginal and Torres Strait Islander Health was developed to guide all Australian Governments in a coordinated, collaborative and multi-sectoral approach to improving Aboriginal and Torres Strait Islander health.
|Aboriginal And Torres Strait Islander Health National Strategic Framework (PDF File 350k)|
|Aboriginal And Torres Strait Islander Health Workforce National Strategic Framework|
The Workforce Strategic Framework presents a 5-10 year reform agenda to build a competent health workforce to address the health needs of Aboriginal and Torres Strait Islander peoples.
|National Aboriginal And Torres Strait Islander Health Workforce Strategic Framework 2011-2015 (PDF File 3847k)|
|Aboriginal And Torres Strait Islander Tobacco Control Strategy 2010-2014|
The Strategy aims to improve the health of ACT Aboriginal and Torres Strait Islander communities through improved tobacco control measures.
|Dgd11-084 - Act Aboriginal And Torres Strait Islander Tobacco Control Strategy 2010-2014 (Microsoft Word XML Document 176k)|
|Adult Corrections Health Services Plan 2008-2012|
The Adult Corrections Health Services Plan identifies a framework for the management of the health of remandees and prisoners in detention within the ACT correctional system. The Plan will define the role of ACT Health in providing for the health needs of prisoners.
|Adult Corrections Health Services Plan 2008-2012 (PDF File 279k)|
|Alcohol And Other Drugs (aod) - Act Health Responding To Use Of Non-Prescription Alcohol And Other Drugs (aod)|
The use or supply of Alcohol and/or Other Drugs (AOD), which have not been prescribed as clinical treatment, is not permitted by consumers, visitors or staff within ACT Health facilities. ACT Health takes a harm minimisation approach to AOD use and fully supports consumers who have a history of AOD dependence, through the course of their hospital admission, by establishing an individualised clinical treatment plan appropriate to their specific needs.
|Act Health Responding To Use Of Non-Prescription Alcohol And/Or Other Drugs (aod) Policy (PDF File 174k)|
|Alcohol And Other Drugs (aod) - Act Health Responding To Use Of Non-Prescription Alcohol And Other Drugs (aod) Standard Operating Procedure|
The use or supply of Alcohol and/or Other Drugs (AOD), which have not been prescribed as clinical treatment, is not permitted by consumers, visitors or staff within ACT Health facilities. ACT Health takes a harm minimisation approach to AOD use and fully supports consumers who have a history of AOD dependence, through the course of their hospital admission, by establishing an individualised clinical treatment plan appropriate to their specific needs.
|Responding To Use Of Non-Prescription Alcohol And/Or Other Drugs (aod) Standard Operating Procedure (PDF File 175k)|
|Alcohol, Tobacco And Other Drug Strategy 2010 - 2014|
The ACT Alcohol, Tobacco and Other Drug Strategy 2010-2014 outlines a series of actions aimed at reducing the harms associated with the use of alcohol, tobacco and other drugs in the ACT community. The Strategy reports in detail on the following areas, outlining a current assessment of the situation and challenges, identifying target populations and areas for further intervention, and where appropriate, describing drug availability: tobacco alcohol other drugs comorbidity consumer participation education, and workforce development
| Alcohol, Tobacco And Other Drug Strategy 2010 - 2014 (PDF File 879k)|
Alcohol, Tobacco And Other Drug Strategy - Summary (PDF File 229k)
|Allied Health Professionals Act Standards Of Practice|
The non-clinical Standards of Practice for ACT Allied Health Professionals, which include Continuing Professional Development (CPD) requirements, have been developed to support the operation of the Health Professionals Act 2004. The Standards provide unregistered allied health professionals, the Community and Health Services Complaints Commissioner and Health Profession Boards with a basis for decisions regarding professional misconduct and unprofessional behaviour.
|Allied Health Professionals Act Standards Of Practice (PDF File 1014k)|
|Area Of Need - Vacant Medical Positions - Medical Workforce Application Form||Area Of Need - Vacant Medical Positions - Medical Workforce Application Form (PDF File 82k)|
|Area Of Need - Vacant Medical Positions - Public And Private Sector |
ACT Health is committed to ensure a supply of suitably qualified medical practitioners to meet the requirements of the ACT community. These procedures are in place to ensure that appropriate national recruitment action is taken to attract medical practitioners. This policy applies to all medical positions in the ACT (except general practitioners)including private specialists in District of Workforce Shortage locations as determined by the Australian Government Department of Health and Ageing.
|Area Of Need - Vacant Medical Positions - Public And Private Sector (PDF File 157k)|
|Blood And Fresh Blood Product Administration|
This document provides clear direction for nursing and medical staff in relation to administration of blood and fresh blood products to adult and paediatric patients. The document supports staff meeting the requirements of National Safety and Quality Health Service Standard 7 - Blood and Blood Products and is aligned to the National Guidelines for the Administration of Blood Products - Australian and New Zealand Society of Blood Transfusion Ltd, Royal College of Nursing Australia 2nd Edition, December 2011.
|Blood And Blood Product Administration (PDF File 416k)|
|Blood Borne Virus In Health Care Workers Sop |
The Standing Operating Procedure for Blood Born Virus in Health Care Workers provides detail on the processes for the notification, assessment and identification of the appropriate scope of practice for Health Care Workers infected with a blood born virus who work in Health Directorate facilities.
|Blood Borne Virus In Health Care Workers Sop (PDF File 182k)|
|Blood Borne Virus Strategy For Amc|
The Strategic Framework for the Management of Blood Borne Viruses in the Alexander Maconochie Centre 2012-2014 (the Framework) has been developed to promote transparency and accountability in the management of blood borne virus infections in the Alexander Maconochie Centre (AMC).
| Blood Bourne Virus Strategy For Amc (PDF File 219k)|
Burnet Status Report (PDF File 341k)
Government Response Phaa Report (PDF File 165k)
|Blood Safe E-Learning Tool|
Portfolio Executive have endorsed the implementation of the 'Blood Safe' e-Learning tool as mandatory education for all ACT Health staff involved in the transfusion process. This includes everyone who prescribes; administers; collects pre transfusion specimens; and/or transports blood and blood products. The owner of the e-learning tool has endorsed online access at no cost for ACT Health staff. The Blood Safe e-Learning tool is accessible via Capabiliti.
|Blood Safe E-Learning Booking Instructions (PDF File 63k)|
|Breastfeeding - Act Breastfeeding Strategic Framework 2010-2015|
The overall aim of the framework is to identify strategies to increase the number of infants being exclusively breastfed from birth to six months, and to encourage ongoing breastfeeding with complimentary foods until at least 12 months of age in line with the National Health and Medical Research Council recommendations.
|Act Breastfeeding Strategic Framework (PDF File 483k)|
|Breastfeeding Friendly Workplace Policy|
This policy aims to clearly articulate the roles and responsibilities of the organisation relating to staff who are balancing breastfeeding and work.
|Breastfeeding Friendly Workplace Policy (PDF File 185k)|
|Cancer National Service Improvement Framework|
The National Service Improvement Framework for Cancer is an essential tool for driving improvement in health services for the national health priority area of cancer. The Framework provides a high level guide for service planners, designers, funders and providers in helping to deliver the most appropriate evidenced-based care for cancer.
|Cancer National Service Improvement Framework (PDF File 293k)|
|Caring For Carers Policy|
The Caring for Carers Policy embodies the ACT Governments commitment to better acknowledge carers and address their needs. The Policy outlines 7 core principles that will be actioned through an implementation strategy coordinated by the ACT Department of Disability, Housing and Community Services.
|Caring For Carers Policy (PDF File 334k)|
|Child Protection Policy|
The Children and Young Persons Act 2008 outlines the legislated requirements around child protection in the ACT. The Child Protection Policy establishes guiding principles and the legislative basis for the protection of unborn children and children and young people aged 0 18, by ACT Health employees. The purpose of the Policy is to assist ACT Health employees, including employees working in non-clinical areas, to understand and fulfil their responsibilities in relation to child protection. Staff can access additional support to understand their obligations through the ACT Health Child Protection Advisory Committee Secretariat (6205 8492) or by contacting Isabel Munoz, email: firstname.lastname@example.org
| Child Protection Policy (PDF File 516k)|
Information Sharing Fact Sheet (Word Doc 109k)
Making A Child Protection Report To Care And Protection Services Fact Sheet (Word Doc 102k)
Prenatal Fact Sheet (Word Doc 106k)
Reporting Form For Care And Protection Services (Word Doc 170k)
|Child Protection Policy - Reporting Form|
This policy attachment is for use by ACT Health staff members to report concerns of child abuse to Care and Protection Services as mandated by the ACT Health Child Protection Policy, The Roles and Responsibilities of ACT Health Staff, 2008, Version 5.0.
|Child Protection Policy - Reporting Form (Word Doc 61k)|
|Childrens And Young Peoples Justice Health Services Plan 2008-2012|
The Plan identifies a framework for the management of the health of children and young people in detention within the youth justice system. The Plan defines the role of ACT Health in providing for the health needs of residents; identifies key health needs of the current and expected populations of Bimberi, the services required to appropriately meet these needs, best practice strategies for providing health care to residents, and linkages between government agencies and community services to assist in providing services for residents; and proposes key performance indicators to monitor its implementation.
|Childrens And Young Peoples Justice Health Services Plan 2008-2012 (PDF File 335k)|
|Children's Plan 2010-14|
This ACT plan guides decisions by government and non-government sectors about policies, programs and services for children up to 12 years of age through to 2014.
|Children's Plan 2010-2014 (PDF File 1884k)|
|Chronic Conditions Strategy 2013 - 18|
The ACT Chronic Conditions Strategy 2013 - 18 sets a direction for the care and support of those living with chronic conditions in the ACT over the next 5 years. Although the ACT enjoys good health compared to the rest of Australia, the prevalence of chronic conditions is increasing significantly and currently accounts for nearly 80% of the total burden of disease and injury in the ACT.
|Chronic Conditions Strategy 2013 - 2018 (PDF File 878k)|
|Clients In Community Setting With Deteriorating Health Status Selecting Not To Follow Health Professional Recommendations|
This document provides a standard process for ACT Health clinicians in the community setting to manage clients with a deteriorating health status that choose not to follow health professionals care recommendations.
|Clients In Community Setting With Deteriorating Health Status Selecting Not To Follow Health Professional Recommendations (PDF File 54k)|
|Clinical Repository Implementation Planning Study |
A clinical repository is the first step on the journey to a shared electronic health record and will move the ACT from point to point exchange of clinical information to a shared information model.
|Clinical Repository Implementation Planning Study (PDF File 5951k)|
|Code Of Conduct|
Sets the behaviour that ACT Health expects of its employees.
|Act Health Code Of Conduct (PDF File 19k)|
|Community Sector Funding Policy|
An overarching framework for ACT Health's engagement with the community sector to deliver services in the community.
|Community Sector Funding Policy (PDF File 558k)|
|Conciliation Of Complaints Through The Human Rights Commission|
This policy outlines the agreed process between ACT Health, Calvary Health Care ACT, Human Rights Commission, ACT Government Solicitor and ACT Insurance Authority in dealing with complaints made by members of the public in relation to Health services where the complaint progresses to conciliation. This policy has been developed to inform staff of the appropriate processes and authorisations required for engaging in conciliation with clients through the HRC process. This policy will also ensure that agency representatives are fully prepared when entering conciliation including seeking advice on liability and the appropriateness of financial compensation, if appropriate.
|Conciliation Of Complaints Through The Human Rights Commission Policy (PDF File 89k)|
|Consent And Treatment Policy & Sops|
Health Directorate health professionals must obtain a consumers valid informed consent before beginning any clinical activity, treatment or procedure, except when: The consumer is unable to provide informed consent and then it is sought from an appropriate substitute decision maker, or Urgent medical treatment is required to save a consumers life or prevent serious harm and the consumer is not able to provide consent to the required treatment at the time through a lack of capacity, (e.g. because the consumer is unconscious). An adult consumer is presumed to have the capacity to make decisions about their health care except where it is shown by a clinical assessment that they do not. Written and verbal consent, and the information provided to the consumer must be documented in the clinical record.
| Consent And Treatment Policy (PDF File 148k)|
Consent And Treatment Sop (PDF File 217k)
Consent Capacity And Substitute Decision Maker Sop (PDF File 204k)
Consent For A Child Or Young Person Sop (PDF File 192k)
|Consumer And Carer Participation Framework |
Assist consumers, carers & staff to work in genuine collaboration to increase consumer & carer participation in health care; facilitate joint decision making & improve development, delivery & evaluation of ACTs public health services.
|Consumer And Carer Participation Framework (PDF File 886k)|
|Consumer Feedback Management|
The Consumer Feedback Management Policy and Procedures supports the implementation of the ACT Health Listening and Learning Standards (2004). The policy sets out the systematic process for handling consumer feedback received by ACT Health staff. The Policy and Procedures include the principles guiding consumer feedback management, the muliple methods for consumers to provide feedback, steps in managing consumer feedback, other considerations in feedback management, staff roles and responsibilities and flow charts for each ACT Health Division and Stream.
|Consumer Feedback Management (PDF File 1597k)|
|Consumer Feedback Standards - Listening And Learning|
These standards outline a best practice framework for managing consumer initiated feedback.The Listening & Learning package includes standards, service improvement tool, feedback forms and staff training materials.
|Consumer Feedback Standards - Listening And Learning (PDF File 257k)|
|Consumer Participation And Care Participation Across Mental Health Act - A Framework For Action|
The importance and value of consumer and carer participation in decision-making across all levels of mental health services has been increasingly recognised nationally over the past decade. Participation has been declared a right of consumers and carers in the National Standards for Mental Health Services. There is also evidence that involving consumers and carers in policy development, service planning, implementation and evaluation, leads to improved quality and safety, and greater satisfaction with services. The Framework sets out the principles for participation and the structures required for continuous improvements to the quality of relationships between consumers, carers and staff of Mental Health ACT, and the quality of services. Integral to participation is growth of individuals, groups and organisations. The Framework recognises the varying degrees of readiness for participation and values constant reflection and evaluation to support the growth of all individuals, groups and organisations.
|Consumer Participation And Care Participation Across Mental Health Act - A Framework For Action (PDF File 608k)|
|Consumer, Carer And Community Reimbursement Policy|
Consumer, Carer and Community Representatives provide an important balance to the views of health care professionals, service providers and industry, contributing to a health system that better reflects the needs of all stakeholders. ACT Health Directorate values the contribution that Consumer, Carer and Community Representatives make and is committed to adequately reimbursing Representatives.
| Consumer, Carer And Community Representative Details Form (PDF File 110k)|
Consumer, Carer And Community Representative Reimbursement Policy (PDF File 143k)
Consumer, Carer And Community Representative - Confidentiality Form (PDF File 107k)
|Contractor Safe Work Practice And Compliance Policy|
The purpose of this policy is to set out ACT Health¡¦s expectations of contractors working for ACT Health, particularly in relation to the contractor/s implementing safe systems of work and complying with ACT Health safety practices. Prior to commencement of all minor and major works, Project Managers must: « complete the revised Request to Interfere with Services or Safety Conditions (RISSC Application) form (including variations to contracts) and submit to Property, Management and Maintenance and obtain approval; « all risks must be identified on the RISSC form; « inform staff and affected areas of intended works; « liaise during all stages of intended works with PM&M. Prior to commencement of all minor and major works, contractors and sub-contractors must: « attend induction to ACT Health prior to commencements of works; « provide Material Safety Data Sheets (MSDS) for all products used in the works process; « obtain Validation Cards through the Security Office; « Sign in and out with PM&M.
|Contractor Safe Work Practice And Compliance Policy (PDF File 59k)|
|Coordination Of Inter-Jurisdiction Involvement Review Procedure |
This Memorandum of Understanding between ACT Health and Greater Southern Area Health Service (2005-2008) sets out the procedures for the co-ordination of inter-jurisdictional adverse events that involve ACT Health and the GSAHS. These may occur either in the ACT or in GSAHS-managed South Eastern New South Wales. By agreeing on a joint approach to the co-ordination of inter-jurisdictional adverse events, the ACT Health/GSAHS MoU assures staff and consumers that both ACT Health and the GSAHS are endeavouring to provide optimal outcomes for consumers.
|Coordination Of Inter-Jurisdiction Involvement Review Procedure (PDF File 90k)|
|Coronial Business In Act Health Management - Framework|
The Framework for the Management of Coronial Business in ACT Health outlines a systematic approach to managing the provision of information to the Coroners Office and a process for monitoring the implementation of Coronial Findings and Recommendations. The Framework clearly outlines roles and responsiblities for key stakeholders, and divides the management of Coronial Business into five stages, illustrating how each stage works.
|Framework For The Management Of Coronial Business In Act Health (PDF File 558k)|
|Corporate Governance Statement|
Corporate governance is the way an organisation manages its business, makes its decisions and relates to its stakeholders. It includes the organisation's structures, culture, policies and processes. In the Health Directorate, corporate governance arrangements underpin and are integrated with clinical goveranance and professional governance proceses to ensure that the organisation does what it should.
|Dgd12-002 - Corporate Governance Statement (PDF File 3303k)|
|Corporate Plan 2012-2017 - Act Health|
The ACT Government Health Directorate Corporate Plan (2012-2017) provides direction to the Health Directorate's Business Units to achieve the overarching organisational vision and corporate values. The Plan builds on existing and new plans being developed to provide an organisational framework to prioritise our efforts over the next five years. We aim to deliver better service to our Government to meet the needs of the community and to our community on behalf of our Government.
|Corporate Plan 2012-2017 (PDF File 142k)|
|Data Quality Policy|
The primary purpose of the Data Quality Policy is to ensure that quality data are available to inform and support ACT Health policy and program delivery with the aim to provide highest quality of care and safety of ACT Health clients. This data quality policy derives from the current ACT Health organisational standards and complies with nationally acceptable practices and legislation.
|Data Quality Policy (PDF File 50k)|
|Data Release Policy|
The Data Release Policy provides a framework for ACT Health staff to ensure that all data released is done so with regard to all relevant Government legislation, ACT Health policies and standards, and ensures that the privacy and confidentiality of the individual(s)/organisations(s) is retained.
|Data Release Policy (PDF File 240k)|
|Diabetes Services Strategic Plan 2008-2012|
The Diabetes Services Strategic Plan 2008-2012 sets the strategic direction for the provision of diabetes services in the ACT into the future.
|Diabetes Services Strategic Plan 2008-2012 (PDF File 769k)|
|Digital Health Enterprise Technology Strategy And Implementation Plan|
The Digital Health Enterprise (DHE) technology strategy and implementation plan outlines how technology will support and enable ACT Healths transformation programme (Your health our priority). The transformation programme is developing new service delivery methods and models so that ACT Health can continue providing quality health services in an environment of rapidly rising demand. The transformation programme encompasses new models of care, new and refurbished facilities, workforce planning and enhanced technology capabilities.
|Digital Health Enterprise Technology Strategy And Implementation Plan And Appendices (PDF File 13508k)|
|Discharge Planning Policy|
This policy document provides ACT Health services with a framework for shaping discharge planning practices. It is based on current best practice and articulates the need for streamlined, consistent and recognisable processes, documentation and consumer information across the health portfolio.
|Discharge Planning Policy (PDF File 63k)|
|Early Childhood National Agenda|
This consultation paper proposes a framework for a National Agenda for Early Childhood. It acknowledges that if we truly want to make a difference over the long term, we must have a sustainable approach to improving the health and wellbeing of Australian children, a concerted effort across government, and within the service system based on sound evidence.
|Early Childhood National Agenda (PDF File 951k)|
|Elder Mistreatment - A Resource Guide For Home And Community Care Service Providers |
A resource guide to provide practical guidance to Home & Community Care (HACC) service providers who encounter situations involving the mistreatment or abuse of older people living in the ACT.
|Elder Mistreatment - A Resource Guide For Home And Community Care Service Providers (PDF File 974k)|
|Elective Surgery Access Policy|
The Elective Surgery Access Policy 2011 has been developed to promote clinically appropriate, consistent and equitable management of elective patients and waiting lists in public hospitals in the ACT. Hospitals must actively manage in compliance with the policy.
|Elective Surgery Access Policy 2011 (PDF File 427k)|
|Elective Surgery Access Policy 2011|
The ACT Elective Surgery Access Policy 2011 has been developed to promote clinically appropriate, consistent and equitable management of elective patients and waiting lists in public hospitals in the ACT.
|Act Elective Surgery Access Policy 2011 (PDF File 368k)|
|Electrical Safety Policy|
Health is committed to complying with the Electrical Safety Act 1971 (republication 18 effective 17 December 2009), designed to protect people & property from risk associated with electricity.
| Electrical Safety Policy (Word Doc 716k)|
Att.a Ohsf 012b Safe Work Procedure Inspection Of Electrical Cords To Health Electrical Safety Policy (Word Doc 1077k)
Att.b Workplace Safety Alert 05-2010 To Health Electrical Safety Policy-Pars (Microsoft Word XML Document 2360k)
|Employment Of Overseas Qualified Nurses Policy|
The ACT Government Health Directorate will provide an Overseas Qualified Nurse Program (OQNP) for internationally Registered Nurses who are not eligible for Australian registration under the national registration standards. This policy and SOP provides guidence regarding eligiblty, application processes and successful completion of the Overseas Qualifed Nurse Program offered to nurses who are not eligible for Australian registration.
|Employment Of Overseas Qualified Nurses Policy (PDF File 126k)|
|Endorsed (authorised) Enrolled Nurse Medication Administration Policy|
Medication management is an important part of nursing and midwifery practice that relies on professional and clinical judgement which is underpinned by the appropriate skills, knowledge and competencies, applied in the context of individual, organisational, social, cultural and religious considerations. This policy sits within a professional framework, that facilitates a consistent, safe and effective approach for medication administration by authorised (medication endorsed) enrolled nurses in the ACT. Administration of medications by EENs aligns with relevant legislation, workplace policies, guidelines and procedures.
|Endorsed Authorised Enrolled Nurse Medication Administration Policy - Sop (PDF File 205k)|
|Food And Nutrition Strategic Framework 2012 - 2018|
There is a close relationship between nutrition and health. Optimal nutrition is necessary for healthy growth and development in infants, children and adolescents. Consumption of a varied and nutritious diet is essential for maintaining good physical and mental health throughout the whole of life (WHO 2003). In addition, sharing and enjoying food in a social setting can contribute to social connectedness, mental health and wellbeing.
|Food And Nutrition Strategic Framework 2012 - 2018 (PDF File 1541k)|
|Forfeiture Of Office Policy|
Forfeiture of Office policy was reviewed under the HRMB policy review timeframe and updated into the new format.
|Forfeiture Of Office Policy (PDF File 74k)|
|Fraud Management Framework, Control Plan And Policy|
ACT Health has implemented this Fraud Control Plan and Policy to enhance integrity and to reduce the risk of fraud, as well as assist staff to make decisions in the reporting of fraud, corruption and other criminal offences affecting ACT Health. It is designed to protect public money and property, protect the integrity, security and reputation of ACT Health while maintaining a high level of services to the community consistent with the good government of the ACT.
|Fraud Management Framework, Control Plan And Policy (PDF File 317k)|
|Fundraising By Act Health Staff Guidelines|
In the ACT there is legislation to protect both donors and staff around fundraising activities. This includes the Charitable Collections Act and Lotteries Act 1964. There are also certain taxation implications regarding donation and fundraising monies. These guidelines have been put in place to inform staff of compliance issues and fundraising for ACT Health.
|Fundraising By Act Health Staff Guidelines (PDF File 30k)|
|General Practitioner Reimbursement Policy|
General Practitioners (GPs) are to be remunerated at the hourly rate of $130 plus GST when attending ACT Health non-clinical activities. Some caveats to this policy apply and these are outlined in the scope.
|General Practitioner Reimbursement Policy (PDF File 145k)|
This standard operating procedure will provide ACT Health staff will procedural information relating to Hand Hygiene best practice techniques, related products and skin care. The information provided will ensure that staff can comply with best practice in hand hygiene when caring for patients in order to support the reduction of healthcare associated infections (HAI) caused by the transmission of harmful pathogens.
|Hand Hygiene (PDF File 299k)|
|Hiv Aids, Hepatitis C, Sexually Transmissable Infestions Strategic Framework For The Act 2007-2012|
This Framework has been produced to guide the local response to the issues of HIV/AIDS, Hepatitis C and Sexually Transmissible Infections. The Framework highlights the commonalities between the approaches outlined in the National Strategies on HIV/AIDS, Hepatitis C and Sexually Transmissible Infections, to enable a more coordinated response from ACT Health, policy makers, health care services and the community sector. It also identifies local priorities and actions required, and suggests strategies to achieve change. Improving treatment and care and support outcomes is also an important goal.
|Hiv Aids, Hepatitis C, Sexually Transmissable Infestions Strategic Framework For The Act 2007-2012 (PDF File 284k)|
|Human Immunodeficiency Virus, Hepatitis B Virus And Hepatitis C Virus Infected Health Care Workers Management Policy|
This policy is directed at all health care workers, specifically those involved in exposure prone procedures. It requires that all health care workers in these areas be aware of their status and seek regular serological testing.
|Human Immunodeficiency Virus, Hepatitis B Virus And Hepatitis C Virus Infected Health Care Workers Management Policy (PDF File 152k)|
|Immunisation Strategy 2012-2016|
This ACT Immunisation Strategy is a framework to improve immunisation services and coverage within the ACT. It continues the work achieved in the previous Immunisation Strategy by building on those achievements and outlining focus areas of immunisation.
|Act Immunisation Strategy 2012-2016 (PDF File 464k)|
|Impact Program Guidelines|
The Vulnerable Families Project aimed to improve services for pregnant women - identified as having a significant mental health issue, and/or are receiving opioid replacement therapy - their partners and their families, whose complex issues and intensive support needs require a multi service response. The IMPACT Program is not a standalone service, but a system-wide approach, which facilitates collaborative work within a set of agreed principles, to better meet the needs of vulnerable families. You can locate all forms and related documents online at http://www.health.act.gov.au/IMPACT
|Impact Program Guidelines (PDF File 3080k)|
|Improving Womens Access To Health Care Services And Information|
The Womens Health Framework is a strategic level planning document that provides the vision and principles for planning health services for women of the ACT. A framework is given to ensure that the distinct needs of women are addressed in a planned and coordinated way. Establishing an advisory network; implementing Gender Impact Statements; enhancing and facilitating women centred facility design, developing a workforce strategy and improving data collection are key initiatives to be implemented under the framework.
|Improving Womens Access To Health Care Services And Information: A Strategic Framework 2010-2015 (PDF File 695k)|
|Infection Prevention And Control Policy|
The ACT Health Infection Prevention and Control Policy is designed to minimise the risk of patients within our health care system developing infections. The policy is also designed to minimise the risk of health care workers acquiring infections through occupational injury or exposure.
|Infection Prevention And Control Policy (PDF File 37k)|
|Intellectual Property Policy |
The Intellectual Property policy introduces an asset-management approach to intellectual property, so that items of intellectual property are regarded in the same way as any other asset. The Policy assists in the management of intellectual property as an asset, by focusing on the identification and protection of intellectual property. Identification and protection are crucial steps in managing intellectual property as this ensures that the potential commercial value of the intellectual is not compromised in the event that a decision is made to commercialise the intellectual property.
|Intellectual Property Policy (PDF File 154k)|
|Inter-Hospital Transfer Standard Operating Procedure |
This SOP pertains to all individuals who are involved in patient inter]hospital transfers, including medical, nursing, access unit and administrative staff.
|Inter-Hospital Transfer Sop (PDF File 216k)|
|Internal Audit Policy And Procedures|
The policy facilitates the operation of ACT Healths Internal Audit & Risk Management Branch and the Audit Committee. The internal audit activities and internal reviews provide assurance to the Chief Executive that ACT Healths financial and operational controls designed to manage the organisations risks and achieve the ACT Healths objectives, are operating in an efficient, effective and ethical manner.
|Internal Audit Policy And Procedures (PDF File 242k)|
|Interstate Patient Travel Assistance Scheme (iptas) Policy And Operational Manual|
The updated Policy and Forms commence operation on 2 July 2007. These Guidelines provide information about the criteria and administrative requirements for the ACT Interstate Patient Travel Assistance Scheme (IPTAS). In particular, it provides detailed information on eligibility criteria for ACT IPTAS; the requirement to refer to the nearest treating specialist and the referral process for ACT IPTAS; situations where approval of an escort under ACT IPTAS may be appropriate, including a list of the reasons where provision of an escort may be appropriate; situations where approval of air travel under ACT IPTAS is appropriate, including a list of reasons that may make air travel appropriate and details of the process for obtaining approval for a patient/escort to travel by air.
| Interstate Patient Travel Assistance Scheme (iptas) Policy And Operational Manual (PDF File 424k)|
Iptas Form (Word Doc 722k)
|Intravascular Access Device Selection Policy|
Infusion therapy is commonplace in healthcare however there is potential for infectious and non infectious complications to arise. Thorough patient assessment, appropriate IVAD selection and correct IVAD insertion and removal results in fewer complications and interruptions to therapy, reduced loss of vascular access and the preservation of peripheral veins thus resulting in increased patient satisfaction and decreased healthcare costs.This IVAD selection SOP outlines the decision making process around selecting the right device for the right patient for the right reason.
|Intravascular Access Device Policy (PDF File 93k)|
|Intravenous Immunoglobulin (ivig) Administration Sop|
The purpose of this document is to provide a systematic and consistent approach for the safe and appropriate administration of Intravenous Immunoglobulin IVIg across ACT Health. All staff involved in transfusion of IVIg are responsible for maintaining and updating their knowledge and practices.
| Sop - Ivig - Policy (PDF File 525k)|
Sop - Ivig - Approval (PDF File 564k)
Sop - Ivig - Administration (Microsoft Word XML Document 67k)
|Introduction Of New Health Technology Policy |
All technologies that are new to the public health services in the ACT, or existing technologies that are to be reviewed, will have an electronic application submitted and be assessed by the Health Technology Assessment Committee.
|Introduction Of New Health Technology Policy (PDF File 172k)|
|Learning And Development Framework|
Learning and development aims to enhance clinical care, workplace safety and the overall health and wellbeing of the ACT community through improved practice. The adoption of a Learning and Development Framework by ACT Health demonstrates the value placed on developing the capabilities of staff, individual and team fulfilment and their contribution to the organisation.
|Learning And Development Framework (PDF File 1087k)|
|Living Is For Everyone (life): A Framework For Prevention Of Suicide And Self-Harm In Australia|
The LIFE Framework is a national initiative that can be used by the whole community to plan and conduct suicide prevention programs. The framework consists of three documents, including areas for action, learning about suicide and building partnerships.
|Living Is For Everyone (life): A Framework For Prevention Of Suicide And Self-Harm In Australia (PDF File 2693k)|
|Local Hospital Network Service Level Agreement 2012- 2013 |
The Service Level Agreement between the ACT Health Minister abd the Director-General of the ACT Local Hospital Network Directorate and HD, sets out key accountabilities for the ACT Public hospital services in 2012-2013.
|Act Government Local Hospital Network Service Level Agreement 2012- 2013 (PDF File 4230k)|
|Look Back Policy|
A Look Back is a formal process initiated by the Director-General, following a significant incident, when the Health Directorate becomes aware of a potential risk to a group of consumers.
| Look Back Policy (PDF File 559k)|
Look Back Sop (PDF File 504k)
|Management Of Acute Upper Gastrointestinal Tract Haemorrhage|
This document provides ACT Health staff with territory-wide guidelines for the management of acute upper gastrointestinal tract (UGIT) haemorrhage.
|Management Of Acute Upper Gastrointestinal Tract Haemorrhage Guideline (PDF File 119k)|
|Management Of Patients With Mental Health And Medical/Surgical Co-Morbidities|
The Management of Patients with Mental Health and Medical/Surgical Co-morbidities Policy embodies ACT Healths commitment to providing a collaborative and holistic approach to caring for and improving the management and health outcomes of adult patients with mental health and medical / surgical co-morbidities.
|Management Of Patients With Mental Health And Medical/Surgical Co-Morbidities (PDF File 337k)|
|Maternity - Planned Pre-Labour Caesarean Policy|
This policy states the ACT Health position on the best practice management of planned pre-labour caesarean birth, and supports the organisations commitment to providing the best possible care to women and their babies. It is based on current evidenced best practice in relation to the: risks associated with surgical intervention, and the increased breathing difficulties (neonatal mortality) experienced in babies born by caesarean birth before 29 completed weeks gestation.
|Maternity - Planned Pre-Labour Caesarean Policy (PDF File 48k)|
|Maternity Shared Care Guidelines|
The Maternity Shared Care Guidelines are for use by General Practitioners and staff of the Maternity Units at the Canberra Hospital and Calvary Health Care ACT. The Guidelines are intended to assist with shared maternity care for women who plan to birth within the public system in the ACT and may be used for all women with low risk pregnancies and for selected women with moderate risk pregnancies. Antenatal - maternity - pregnancy - shared care guidelines - general practice
|Maternity Shared Care Guidelines (PDF File 1127k)|
|Maternity Shared Care Guidelines - Checklist For Shared Care Pregnancy|
The Checklist for Shared Care Pregnancy is a checklist for use by General Practitioners and staff of the Maternity Units at the Canberra Hospital and Calvary Health Care ACT. The checklist is to be used in conjunction with the Maternity Shared Care Guidelines. Antenatal - maternity - pregnancy - shared care guidelines - general practice
|Maternity Shared Care Guidelines - Checklist For Shared Care Pregnancy (PDF File 175k)|
|Maternity Shared Care Guidelines - Gp Management Rh Negative Women|
This information sheet is a flow chart for use as a reference by GPs treating RH Negative women during pregnancy who have had a sensitising event. It is to be used in conjunction with the Maternity Shared Care Guidelines 2008. Keywords: Antenatal, pregnancy, general, practice, sensitising event, women
|Maternity Shared Care Guidelines - Gp Management Rh Negative Women (PDF File 74k)|
|Medication Management Policy|
follow the APAC guiding principles to improve health outcomes through the implementation of medication management processes that ensure:Timely, cost effective access to medicinesQuality, safety and efficacy standards, and Quality use of medicines.
|Medication Management Policy (PDF File 272k)|
|Mental Health - Building A Strong Foundation: A Framework For Promoting Mental Health And Wellbeing In The Act 2009-2014|
The purpose of this framework is to guide investment in the development and implementation of activities to promote mental heath and wellbeing in the ACT over the next five years.
| Building A Strong Foundation - Strategic Framework (PDF File 686k)|
Building A Strong Foundation - Fact Sheet (PDF File 108k)
|Mental Health - Fourth National Mental Health Plan 2009-14|
The plan identifies key actions to be led by health ministers, but takes a whole of government approach through involving sectors other than just health. The plan will provide a basis for governments to advance mental health activities within the various portfolio areas in a more integrated way, recognising that many sections can contribute to better outcomes for people living with mental illness.
|Fourth National Mental Health Plan 2009-14 (PDF File 899k)|
|Mental Health Services National Standards|
The National Standards for Mental Health Service are intended to inform consumers and carers about what to expect from mental health services, and embodies the principles contained in the Mental Health Statement of Rights and Responsibilities. There are 11 Standards that address universal issues, organisational structure and delivery of care.
|Mental Health Services National Standards (PDF File 195k)|
|Mental Health Services Plan 2009 - 2014|
The Mental Health Services Plan articulates a clear vision for an integrated mental health sector in the ACT and for establishing a coordinated approach to achieving and maintaining mental health. The Plan outlines the initial steps for achieving a vision for the delivery of mental health services in 2020.
|Mental Health Services Plan 2009 -2014 (PDF File 1078k)|
|Modified Early Warning Scores Policy|
All staff are to apply the Modified Early Warning Scores (MEWS) system when taking patient observations. The purpose of this policy is to improve patient outcomes by detecting and acting upon early signs of deterioration in patients. This will be achieved in part through the implementation of the Modified Early Warning Scores (MEWS) system that identifies trends in patient observations; ensures that timely patient review and appropriate treatment occurs; and improves the documentation of patient observations.
|Modified Early Warning Scores Policy (PDF File 77k)|
|Multicultural Strategy 2006-2009|
The document presents the outcomes of broad consultation with the ACT community. The Strategy sets out the key principles for the whole-of-government approach to fostering, promoting and sustaining cultural diversity in the ACT. Ten key themes form the basis to the Strategy. All areas of ACT Health should be aware of this document and give consideration to the application of its relevant components to ACT Health services and workforce when undertaking policy and planning work.
|Multicultural Strategy 2006-2009 (PDF File 1589k)|
|Multiple Chemical Sensitivities - Care Of Patients|
To minimise discomfort, promote wellbeing and provide a safe environment for patients with Multiple Chemical Sensitivities (MCS). The Health Directorate recognises the significant distress and impairment that is caused by MCS and is committed to providing an environment that reduces exposure to incitants (common triggers that produce clinical symptoms) and improving the health outcomes of people who require hospital based or non hospital based treatment.
|Multiple Chemical Sensitivities - Care Of Patients (PDF File 268k)|
|Nurse Practitioners In The Act The Framework, 2nd Edition July 2008|
The introduction of the nurse practitioner role in the ACT was underpinned by a solid framework to support and integrate necessary policies, practices and documentation for the establishment of new positions. It provided information regarding nurse practitioner authorisation and ongoing support of practicing nurse practitioners. This revised, second edition, includes all the essential information for nurse practioners in the ACT in an easy-to-use and easy-to-access framework document. The second edition utilises up to date information, legislation and policies from within the ACT. It outlines processes required for nurse practitioner authorisation, for the establishment of new nurse practitioner positions and for the ongoing development of practicing nurse practitioners. Thefrequently asked questions section allows for rapid access to the information most often requested. It applies to nurse practitioners working in the public health sector, private sector or in individual practice.
|Nurse Practitioners In The Act The Framework, 2nd Edition July 2008 (PDF File 553k)|
|Nursing And Midwifery Continuing Competence Policy|
This policy brings together a number of local policies and guidelines to support this requirement. It has been compiled with input from various agencies within the ACT including the Australian Nursing Federation (ACT Branch), ACT Nursing and Midwifery Board, Australian Nursing and Midwifery Council, Canberra Hospital, Calvary Health Care (Public) and consumer groups. Implementation of an ACT Health policy framework for nursing and midwifery competence would reduce duplication within each division, therefore leading to clearer governance and direction for all clinicians and administrators in relation to professional competency requirements.
| Nursing And Midwifery Continuing Competence Policy (PDF File 179k)|
Nursing And Midwifery Continuing Competence Policy - Sop (PDF File 178k)
|Nursing And Midwifery Re-Entry Program Policy|
The ACT Government Health Directorate (the Health Directorate) provides nursing and midwifery re-entry programs for Registered Nurses and Midwives of the Australian Capital Territory (ACT) and region to return to nursing or midwifery practice after an absence from practice of up to ten years. These programs are accredited by the Nursing and Midwifery Board of Australia (NMBA) and are designed to facilitate the return to work of suitably qualified nurses and midwives into the workforce of the Health Directorate.
|Nursing And Midwifery Re-Entry Program Policy (PDF File 149k)|
This policy aims to provide direction for the development of organisational systems and processes to support staff, patients and families. Standard Operating Procedures (SOPs) support staff in implementing the policy
|Open Discloure Policy (Word Doc 73k)|
|Opioid Maintenance Treatment Guidelines|
The ACT Opioid Maintenance Treatment Guidelines has been produced by ACT Health to assist ACT Health employees and other practitioners including medical practitioners, pharmacists, alcohol and other drug workers, nurses and health professionals working in community settings, hospitals, mental health services, correctional environments and the police watchhouse. A key focus of the Guidelines is maximising the numbers of practitioners and workers effectively able to treat and support those on opioid maintenance treatment. These Guidelines have been produced by ACT Health in collaboration with the ACT Division of General Practice, the Pharmacy Guild of Australia, ACT Branch and the Canberra Alliance for Harm Minimisation and Advocacy (CAHMA). These partners are integral to the care provided to clients requiring opioid maintenance treatment in the ACT.
|Opioid Maintenance Treatment Guidelines (PDF File 164k)|
|Palliative Care Strategy 2007-2011|
The ACT Palliative Care Strategy 2007-2011 aims to provide overarching direction for the delivery of palliative care services across ACT Health. The aim is to improve community education, awareness and participation; strengthen specialist palliative care services; develop a skilled workforce, and improve information management and data collection.
|Palliative Care Strategy 2007-2011 (PDF File 223k)|
|Patient Controlled Insulin Pumps In Hospital Use Of |
ACT Health endorses and supports patients to continue to use and self-manage their Continuous Subcutaneous Insulin Infusion (CSII) 'insulin pump' as an inpatient.This policy and standard operating procedure (SOP) have been developed to: 1) Establish a common process for all ACT Health staff to follow for patients admitted with an insulin pump in situ, 2) Outline the assessment and decision making process to ascertain competency of the patient to self-manage, 3) Ensure the safety of patients using an insulin pump and 4) Help staff understand and meet their responsibilities in ensuring patients with insulin pumps are managed according to relevant policy, legislation and quality and safety standards.
| Use Of Insulin Pumps Policy (PDF File 85k)|
Use Of Insulin Pumps - Sop (PDF File 104k)
|Patient Identification - Correct Patient, Correct Site, Correct Procedure|
This policy and SOP provide information for use by all ACT Health staff and apply to establishing patient identity prior to all clinical activities (including those performed in settings other than the operating room) that have the potential to cause unintended harm to the patient.SOPs include national standards for Patient Identification Bands and the Surgical Safety Checklist.Patient identification should be confirmed at each point of transfer of responsibility of care and prior to each intervention/treatment. Patient identification checks should be done with the active participation of the patient and patients should be encouraged to ask questions about the correctness of their care in accordance with the Australian Charter of Healthcare Rights (2008).
| Patient Identification - Correct Patient, Correct Site, Correct Procedure - Policy (PDF File 85k)|
Patient Identification - Correct Patient, Correct Site, Correct Procedure - Sop (PDF File 104k)
Patient Identification - Patient Identification Bands Sop (PDF File 85k)
Patient Identification - Surgical Safety Checklist Sop (Microsoft Word XML Document 680k)
Patient Identification - Pathology Specimen Labelling Sop (PDF File 259k)
|Physical Activity Strategic Framework 2012-2015 |
In response to the increased focus on preventive programs, the Health Directorate has developed the ACT Government Health Directorate Physical Activity Strategic Framework 2012-2015 to guide the Health Directorates work in physical activity promotion.
|Physical Activity Strategic Framework 2012-2015 (PDF File 918k)|
|Police Records Check Policy|
This policy has been developed to ensure that ACT Health meets the requirements of the Public Sector Management Act.with respect to Police Checks prior to or during employment. The policy outlines the procedure to ensure that appropriate consideration is given to any convicitons a prospective employee may have.
|Act Health Police Records Check Policy (PDF File 74k)|
|Policy - Act Health Policy Management Framework|
The Framework outlines a single policy management framework for the management of frameworks, policies and standard operating procedures (SOPs) and guidelines (collectively referred to within this document as policy documents). It sets out how policy documents will be initiated, developed, implemented and reviewed.
|Policy - Act Health Policy Management Framework (PDF File 225k)|
|Pressure Injury Prevention And Management Protocol |
This protocol applies to all ACT Health funded acute care services provided at The Canberra Hospital and Calvary Healthcare sites ; and Community Health - Continuing Care Program. It outlines a comprehensive, coordinated and systematic approach, for pressure injury prevention and management across ACT Health, and, the roles and responsibilities of both clinicians and the service areas.
|Pressure Injury Prevention And Management Protocol (PDF File 163k)|
|Primary Health Care Strategy 2011-14|
The ACT Primary Health Care Strategy 20112014 (the Strategy) has been developed to build on the ACT Primary Health Care Strategy 20062009, and to provide a visionary document that reflects the thinking of the ACT community and primary health care sector in relation to primary health care. The Strategy has been developed in the context of the Council of Australian Governments (COAG) health reforms and identifies the core principles and priorities that will provide a roadmap to guide current and future policy, planning and practice in the ACT primary health care sector.
|Primary Health Care Strategy 2011-14 (PDF File 366k)|
|Promotion, Prevention And Early Intervention For Mental Health 2000 National Action Plan|
This action plan contains strategies to address the promotion, prevention and early intervention outcomes identified in the Second National Mental Health Plan. The framework aims to promote mental health; reduce mental health problems through enhancing protective factors and reducing risk factors; and to intervene early to minimise the impact of mental health.
|Promotion, Prevention And Early Intervention For Mental Health 2000 National Action Plan (PDF File 1842k)|
|Providing A Legal Statement Fact Sheet|
Policy, SOP and Factsheet outlining the process when staff are requested to provide a statement in their capaity as an employee of ACT Health by the Coroner or ACT Government Solicitor
|Request For Legal Statement Fact Sheet (PDF File 43k)|
|Providing A Legal Statement Policy|
Policy, SOP and Factsheet outlining the process when staff are requested to provide a statement in their capaity as an employee of ACT Health by the Coroner or ACT Government Solicitor.
|Request For Legal Statement Policy (PDF File 84k)|
|Providing Clinical Health Services In An Off Campus Environment Policy|
Provides a policy and procedural framework that ACT Health employees in all clinical areas can adapt to their everyday work to maximise their safety when providing clinical health services in an off campus environment.
| Providing Clinical Health Services In An Off Campus Environment Policy (PDF File 180k)|
Providing Clinical Health Services In An Off Campus Environment Policy - Sop (PDF File 208k)
Providing Clinical Health Services In An Off Campus Environment - Home Visit Pre-Assessment Form (PDF File 26k)
|Public Health Services To Medicare Ineligible Asylum Seekers|
The policy provides for the non-charging of Medicare ineligible asylum seekers for described public hospital services, and for the same access as Health Care Card holders to public dental and community health services.
|Public Health Services To Medicare Ineligible Asylum Seekers (PDF File 60k)|
|Public Interest Disclosure Policy|
ACT Health's Public Interest Disclosure Policy and Procedures are in place to ensure accountability, ethics, trust and integrity are respected across the service. They provide a mechanism that gives full rise to the Department's obligations under the Public Interest Disclosure Act 1994 (the Act) and facilitate the making of, investigation into, and acting upon, disclosures, as well as the protection of those making them.
|Public Interest Disclosure Policy (Word Doc 91k)|
|Raising The Standard: A Manual To Guide Quality Improvement In Act Community Service Organisations|
This manual is the result of collaborative partnership between the ACT Government and the ACT Community sector to develop a set of generic standards for use in quality improvement of community service organisations in the ACT. The complete package consists of the standards, self-assessment and quality planning guide, tools to support the process, and workbooks.
|Raising The Standard: A Manual To Guide Quality Improvement In Act Community Service Organisations (PDF File 58k)|
|Reconciliation Action Plan 2012-2015|
The Health Directorates vision for Reconciliation is for Aboriginal and Torres Strait Islander peoples living in the ACT and surrounding region to enjoy a quality of life, life expectancy and health status equal to all Canberrans.
|Reconciliation Action Plan 2012-2015 (PDF File 840k)|
|Recruitment Advertising Policy|
ACT Health is committed to the merit selection process and the widest coverage for advertising of vacancies. In order to maximise the return for investment in advertising vacant positions, ACT Health has determined to introduce arrangements to control and standardise the advertising of vacancies outside of the Gazette and website, and to promote ACT Healths corporate image as a single entity organisation through the use of standardised templates.
|Recruitment Advertising Policy (PDF File 92k)|
|Reducing Falls And Falls Injury In Older Adults Across The Act|
This policy document provides ACT Health with a framework for reducing falls and falls injury rates in older adults (i.e. aged 65 years or over, or 55 years or over for ATSI people). It relates to services provided in Acute Care, Residential Aged Care and the Community. Operational procedures and outcomes are included for the development and implementation of division based procedures, capacity building/training, evaluation and resource allocation.
|Reducing Falls And Falls Injury In Older Adults Across The Act (Word Doc 79k)|
|Renal Health Services Plan 2010-2015|
The purpose of this plan is to provide a strategic direction for renal services development to meet increasing demand for the period 2010 to 2015 with a longer term ten year vision. This demand is arising from the increasing number of people who are at risk of developing chronic kidney disease.
|Renal Health Services Plan 2010-15 (PDF File 732k)|
|Request For Legal Advice - Standard Operating Procedure (sop)|
This Standard Operating Procedure (SOP) outlines the procedures to be followed when seeking legal assistance from the ACT Government Solicitor (ACTGS) or from external sources within the private sector with the exception of matters pertaining to ACT Insurance Authority business. It also aims to streamline the management of legal services provided to ACT Health through a centralised and consistent approach to the management of requests for legal advice coordinated through the Insurance and Legal Liaison Unit (ILLU).
| Request For Legal Advice - Sop (PDF File 172k)|
Request For Legal Advice - Form (Word Doc 111k)
|Research Practice Policy|
This document provides a governance structure for research conducted within ACT Health. It covers research definitions, researcher and participant responsibilities, intellectual property and the management of research misconduct.
|Research Practice Policy (PDF File 349k)|
|Restraint Of Patients|
This policy and SOPs provide clear information to staff on the Health Directorate's commitment to, at all times, seeking to prevent the need for restraint of patients and the use of restraint only as a last resort.
| Restraint Of Patients Policy (PDF File 117k)|
Restraint Of Patients Sop (Microsoft Word XML Document 728k)
Code Black And Physical Restraint Of Patients Process At The Canberra Hospital (Microsoft Word XML Document 681k)
|Safety And Quality Framework 2010-2015 - Act Health|
The ACT Health Safety and Quality Framework describes a vision and direction to improve safety and quality in ACT Health and sets out the key activities that will be happening throughout the organisaiton to improve the safety and quality of the service provided to consumers. It includes a summary of safety and quality systems, an outline of the safety and quality governance structure, the education plan to support safety and quality and the Plan outlining specific areas that ACT Health will focus on to improve safety and quality as we move towards 2015.
|Safety And Quality Framework 2010-2015 (PDF File 152k)|
|Senior Medical And Dental Practitioners Appointment And Credentialing Policy|
The ACT Government Health Directorate (HD) is committed to the delivery of safe, appropriate and high quality medical and dental services. This is achieved through best practice recruitment and appointment procedures, robust credentialing and defining of scope of clinical practice, regular performance review and routine re-credentialing. A senior medical or dental practitioner (SMDP) may not provide specialist medical or dental services without a valid appointment and without credentialing and a defined scope of clinical practice.
|Senior Medical And Dental Practitioners Appointment And Credentialing Policy (PDF File 177k)|
|Shared Care Guidelines With General Practice Sop|
The Standard Operating Procedure for the Development or Review of Shared Care Guidelines with General Practice is a guide for clinical areas of ACT Health developing or reviewing Shared Care Guidelines with general practice. It aims to ensure that all Shared Care Guidelines are developed and reviewed in a systematic, consistent and collaborative manner.
|Shared Care Guidelines With General Practice - Sop (PDF File 170k)|
|Significant Incident Reporting Policy|
The Significant Incident Reporting Policy defines the criteria that constitutes a Signinificant Incident. It has now been updated to align with changes to the Australian Institute of Health and Welfare definitions for Sentinel Events. Significant Incidents includes all Catastrophic, Sentinel and Major Incidents under the following categories of People; Clinical; Property & Services; Financial; Information; Business Process and Systems; Reputation; and Environment. It defines the time frames for reporting and the governance arrangements for reporting using the Significant Incidents reporting system on RiskMan. Significant Incident reporting is more commonly known as a SIB which stands for Significant Incident Brief.
|Significant Incident Reporting Policy (PDF File 73k)|
|Smoke-Free Workplace Policy|
This document outlines ACT Health's policy for a smokefree workplace. ACT Health has an obligation to provide a smokefree workplace. The Policy outines where smoking is not permitted, the obligations of staff and visitors and the assistance provided to employees. The Policy has been revised to take account of identified operational issues.
|Smoke-Free Workplace - Revised April (PDF File 35k)|
|Staff Screening And Immunisation Policy|
The purpose of this policy is to minimize transmission of disease between staff and patients. Transmission of disease in health care settings is uncommon. Specifically this policy aims to: advise staff and students of their rights and OHS responsibilities as well as their duty of care to fellow staff, students and users of ACT Health services in relation to diseases outlined in this policy; and assist ACT Health managers to meet their OHS responsibilities and their duty of care to staff, students and other users of ACT Health services in relation to diseases outlined in this policy.
|Staff Screening And Immunisation Policy (PDF File 273k)|
|Strategic Asset Management Policy For Major Equipment|
ACT Health requires assets to be effectively managed in accordance with legislation and related ACT Government policies and is responsible for all financial assets procured regardless of physical location. Asset Management is the process of guiding the acquisition, use and disposal of assets in order to manage the related risks and costs throughout the lifecycle.This policy establishes the framework to support future growth and reduce resource commitment to manage major equipment assets within the organisation
| Strategic Asset Management Policy For Major Equipment (PDF File 157k)|
Strategic Asset Management Policy For Major Equipment - Attachment (PDF File 22k)
|Student And Trainee Clinical Placement Policy|
The ACT Government Health Directorate (Health Directorate) accepts students and trainees undertaking health and health related courses for clinical placement within the Health Directorate facilities. The Health Directorate is committed to providing quality clinical placement, supervision and/or management of student and trainees health professions which does not compromise safe multidisciplinary patient-centred care.
|Student And Trainee Clinical Placement Policy (PDF File 154k)|
|Suicide Prevention: Managing The Risk Of Suicide In The Act 2009-14|
This strategy provides a service development framework to guide an integrated, whole of community approach to suicide prevention across the lifespan in the ACT.
| Managing The Risk Of Suicide - Fact Sheet (PDF File 99k)|
Managing The Risk Of Suicide In The Act 2009-2014 (PDF File 480k)
|Support Of People With Disabilities Requiring Hospital Treatment Guidelines And Procedures Manual |
The Guidelines and Procedures manual has been developed to assist staff with the management and support of people with disabilities requiring hospital treatment. The manual provides advice on planned admissions and emergency admissions. Staff are encouraged to refer to the manual as required.
|Support Of People With Disabilities Requiring Hospital Treatment Guidelines And Procedures Manual (PDF File 367k)|
ACT Health is committed to the principles of ecologically sustainable development by closely monitoring its use of resources, integrating economic, social and environmental considerations into decision making, and implementing measures to minimise the impact of agency activities on the environment.
|Act Health Sustainability Strategy (PDF File 239k)|
|Toys In The Workplace|
This standard operating procedure provides information to staff to enable them to minimize risks associated with the provision, use, cleaning and storage of toys in ACT Health facilities. The information provided ensures that toys provided in the workplace are: 1) of a construction that minimizes the risk of harm, 2) able to be rigorously cleaned, and 3) effectively cleaned frequently and regularly to minimize the development and transmission of infection.
|Toys In The Workplace (PDF File 76k)|
|Training Management System Capabiliti Policy|
The TMS policy ensures that a centralised system is used across ACT Health to manage, record and report on learning and development activities. A global view of all learning and development activities across ACT Health from both internal and external providers (such as InTACT who provide training to ACT Health staff) will provide accurate data for planning of learning/training activities, measuring against key performance indicators of the ACT Health Business Plan, and meeting legislative requirements by reporting on essential education. All training, including eLearning and Self Directed Learning Packages (SDLP), conducted in ACT Health shall be recorded on the Training Management system ACT Health Capabiliti. The Policy contains a hyperlink to a Toolkit to assist ACT Health staff who wish to develop eLearning packages. All training courses, including eLearning, shall be recorded on the ACT Health Education Activity register.
| Toolkit For Development Of Elearning Packages (PDF File 742k)|
Training Mgt System Policy (PDF File 586k)
|Transfusion Guideline - Massive|
These guidelines address the appropriate management of uncontrolled bleeding associated with secondary coagulopathy. Clearly agreed guidelines have the advantage of enabling coordination of care and rapid delivery of appropriate therapy in the emergency circumstance of massive transfusion.
|Transfusion Guideline - Massive (PDF File 115k)|
|Use Of Act Health Facilities For The Purposes Of Fundraising, Sponsorship, Promotional Or Educational Guidelines|
This policy provides guidelines for ACT Health with regard to the use of the ACT Health Facilities and in what circumstances ACT Health Facilities can be used for fundraising, sponsorship, and promotional and educational purposes.
|Use Of Act Health Facilities For The Purposes Of Fundraising, Sponsorship, Promotional Or Educational Guidelines (PDF File 37k)|
|Waste Management Policy|
Health Directorate Divisions, Branches and Units will follow processes outlined in the Health Directorate Waste Management Plan. Compliance requirements include: Provision of waste stream guidelines in all areas; Provision of the appropriate containers, equipment and systems to support the principles of reduce, reuse and recycle; Education and training of waste management staff and contractors, about regulatory responsibilities and waste and environment management principles.
|Waste Management Policy (PDF File 145k)|
Five year plan identifying factors to develop effective and responsive policies, programs and services to meet the needs of women and girls.
|Act Women's Plan 2010-15 (PDF File 484k)|
|Work Health And Safety Policy|
The approach of the Health Directorate to Work Health and Safety (WHS) is one of continuous improvement. This occurs by establishing measurable objectives, targets and consistently reviewing our processes in WHS performance with the aim to eliminate workplace injury/ illness. This is to be achieved through full consultation and by enhancing the skills, knowledge and commitment of Health Directorate workers.
|Work Health And Safety Policy (PDF File 132k)|
|Young People's Plan|
Four year plan designed to provide a flexible and responsive context for government agencies, community organisations, the ACT community and young people to support improved outcomes for young people.
|Young People's Plan (PDF File 1517k)|
|Your Guide To Engaging With The Community|
The Community Engagement Manual is a valuable resource that provides a comprehensive set of tools and techniques to assist agencies when engaging with the community to reach the most desirable outcomes for everyone concerned. The manual promotes a greater sense of collaborative partnership and encourages government agencies to focus on quality and greater participation. Community Engagement
|Your Guide To Engaging With The Community (PDF File 1013k)|