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Aboriginal And Torres Strait Islander Cultural Protocols For Events Policy

The Aboriginal and Torres Strait Islander Cultural Protocols Policy and related Standard Operating Procedures provide ACT Health staff with the appropriate Aboriginal and Torres Strait Islander protocols to be used when preparing and organising for ‘A Welcome to Country and/or Acknowledgement of Country and/or an Aboriginal Smoking Ceremony’.
pdf icon Aboriginal And Torres Strait Islander Cultural Protocols For Events Policy  (PDF File 157k)
pdf icon Aboriginal And Torres Strait Islander Cultural Protocols For Events Sop (PDF File 153k)
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.
pdf icon Aboriginal And Torres Strait Islander Health National Strategic Framework (PDF File 350k)
Aboriginal And Torres Strait Islander Health Workforce Action Plan 2013-2018

The Aboriginal and Torres Strait Islander Health Workforce Action Plan 2013-2018 seeks to increase the number of Aboriginal and Torres Strait Islander peoples employed in ACT Health.
pdf icon Aboriginal And Torres Strait Islander Health Workforce Action Plan 2013-2018  (PDF File 2253k)
Aboriginal And Torres Strait Islander Health Workforce National Strategic Framework 2012 -2015

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.
pdf icon 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)
Administration Of Hospital Admissions And Discharges Policy

As part of the implementation of Activity Based Funding under the National Health Reform Agreement, ACT Health has developed an Administration of Hospital Admissions and Discharges policy and an associated Admitted Patient Activity Data Standards document. The policy and the attached data standards provide a set of detailed clear rules and criteria to count, record and classify public hospital activity in a timely manner.
pdf icon Admitted Patient Activity Data Standards (PDF File 833k)
pdf icon Administration Of Hospital Admissions And Discharges Policy (PDF File 546k)
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.
pdf icon 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.
pdf icon 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
pdf icon Alcohol, Tobacco And Other Drug Strategy 2010 - 2014 (PDF File 879k)
pdf icon 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.
pdf icon Allied Health Professionals Act Standards Of Practice (PDF File 1014k)
Area Of Need For Vacant Medical Practitioner Positions In The Public And Private Sector Policy And Sop

The purpose of this policy is to inform public and private sector employers of the requirements to seek Area of Need status when recruiting International Medical Graduates to medical practitioner vacancies.
pdf icon Area Of Need For Vacant Medical Practitioner Positions In The Public And Private Sector Policy (PDF File 158k)
pdf icon Area Of Need For Vacant Medical Practitioner Positions In The Public And Private Sector Sop (PDF File 240k)
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.
pdf icon 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.
pdf icon Blood Borne Virus In Health Care Workers Sop  (PDF File 182k)
Blood Borne Virus Strategy For Amc

The Framework is intended to guide policies and procedures relating to the prevention and management of blood-borne virus (BBV) infection in the Alexander Maconochie Centre (AMC) with a view to reducing the morbidity and mortality associated with BBV infection for both detainees and the broader community
pdf icon Blood Bourne Virus Strategy For Amc (PDF File 1080k)
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.
pdf icon 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.
pdf icon 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.
pdf icon Cancer National Service Improvement Framework (PDF File 293k)
Caring For Carers Policy

The Caring for Carers Policy embodies the ACT Government’s 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.
pdf icon Caring For Carers Policy (PDF File 334k)
Child Protection Policy

• The ACT Health Child Protection Policy establishes the guiding principles, responsibilities and legislative basis for ACT Health staff to protect unborn children, children and young people aged 0 and up to 18 years. • The ACT Health Child Protection SOP aims to improve the protection of children by assisting both clinical and non-clinical ACT Health staff to understand and fulfil their responsibilities in relation to child protection, including how to make a child protection report. • The ACT Health Child Protection Practice Paper provides additional information on child abuse, neglect and child protection issues to assist ACT Health staff, students and volunteers fulfil their role in protecting children and young people, to be child-centred in their practice, and to protect and promote the best interests of the child.
pdf icon Child Protection Policy (PDF File 247k)
pdf icon Child Protection Practice Paper (PDF File 737k)
pdf icon Information Sharing Fact Sheet (PDF File 127k)
pdf icon Making A Child Protection Report To Care And Protection Services Fact Sheet (PDF File 274k)
pdf icon Prenatal Fact Sheet (PDF File 122k)
pdf icon Reporting Form For Care And Protection Services (PDF File 108k)
Children’s And Young People’s 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.
pdf icon Children’s And Young People’s 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.
pdf icon 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.
pdf icon 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.
pdf icon 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.
pdf icon Clinical Repository Implementation Planning Study (PDF File 5951k)
Code Of Conduct

Sets the behaviour that ACT Health expects of its employees.
pdf icon 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.
pdf icon 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.
pdf icon Conciliation Of Complaints Through The Human Rights Commission Policy (PDF File 89k)
Conflict Of Interest Policy

The purpose of this policy is to inform ACT Health staff and volunteers of their responsibilities in relation to the declaration of any conflict of interest, whether perceived, potential or actual.
pdf icon Conflict Of Interest Policy (PDF File 155k)
pdf icon Conflict Of Interest Sop (PDF File 180k)
Consent And Treatment Policy & Sops

Health Directorate health professionals must obtain a consumer’s 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 consumer’s 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.
pdf icon Consent And Treatment Policy (PDF File 148k)
pdf icon Consent And Treatment Sop (PDF File 217k)
pdf icon Consent Capacity And Substitute Decision Maker Sop (PDF File 204k)
pdf icon 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 ACT’s public health services.
pdf icon Consumer And Carer Participation Framework (PDF File 886k)
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.
pdf icon 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.
pdf icon 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.
pdf icon Consumer, Carer And Community Representative - Confidentiality Form (PDF File 107k)
pdf icon Consumer, Carer And Community Representative Details Form (PDF File 110k)
pdf icon Consumer, Carer And Community Representative Reimbursement Policy (PDF File 142k)
Consumer, Carer And Community Representative Reimbursement Sop (Microsoft Word XML Document 682k)
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.
pdf icon 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.
pdf icon 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.
pdf icon 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.
pdf icon 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.
pdf icon Corporate Plan 2012-2017 (PDF File 142k)
Data Quality Policy

To further improve the quality of data used for clinical and business decisions the exisitng Data Quality Policy has been reviewed and a new Data Quality Framework has been developed.The Data Quality Policy and Framework provides an objective approach to assessing and improving the quality of data created and managed by ACT Health. The framework encompasses four main components: •The Data Integrity Strategy •Data Quality Policy •The Data Quality Improvement Cycle •Data Quality Assessment tool The framework can be applied to all data collections within ACT Health including databases, systems, registries and reports. The framework applies to all staff members that create, modify, use and interpret data including executive, management, data management, clinical and administration staff.
pdf icon Data Quality Policy (PDF File 156k)
pdf icon Data Quality Framework (PDF File 1181k)
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.
pdf icon 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.
pdf icon 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 Health’s 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.
pdf icon 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.
pdf icon Discharge Planning Policy (PDF File 63k)
Drug Policies And Services Framework For The Amc 2013-2015

The purpose of the Framework is to give coherence and transparency to the delivery of drug policies and services in the Alexander Maconochie Centre. The Framework outlines how performance against the Framework will be measured along with the governance arrangements which will ensure the operationalisation of the framework.
pdf icon Drug Policies And Services Framework For The Amc 2013-2015  (PDF File 324k)
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.
pdf icon 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.
pdf icon Elder Mistreatment - A Resource Guide For Home And Community Care Service Providers (PDF File 974k)
Electrical Safety Policy

This Policy provides guidance to all staff in ACT Health workplace sites, other related entities performing construction work onsite and any other visitors to workplaces, about compliance responsibilities with relevant legislation and regulatory requirements to reduce the risk of electric shock occurring to staff and patients.This includes: •Business units’ compliance with the Safety Management System (SMS) and related Standard Operating Procedures (SOP) regarding electrical safety; Making sure all electrical equipment is safe, in good working use and has a current tag attached; •Provision of SOP’s regarding use and activities likely to involve the use of electricity and any disruption to services as a result of programmed works; •Provision of arrangements for the safety of all people and property likely to be affected while electrical work is carried out.
pdf icon Electrical Safety Policy (PDF File 170k)
Employee Assistance Program Policy

ACT Health, through Enterprise Agreements (EA), supports employees and their immediate family by providing access to an independent, confidential and professional counselling service at no cost to the employee.
pdf icon Employee Assistance Program Policy  (PDF File 148k)
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.
pdf icon 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.
pdf icon 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.
pdf icon 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.
pdf icon 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.
pdf icon 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.
pdf icon Fundraising By Act Health Staff Guidelines (PDF File 30k)
General Practitioner Reimbursement Policy

The Executive Council considered the revised General Practitioner Reimbursement Policy, and endorsed the policy with a rate of $150 per hour plus GST, increased from the 2009 rate of $130 per hour plus GST. The Policy provides for the remuneration of General Practitioners for their time when participating in ACT Health non-clinical activities where direct GP input is sought. The Policy will be due for further review in 2015.
pdf icon Gp Reimbursement Policy (PDF File 141k)
Hand Hygiene

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.
pdf icon Hand Hygiene (PDF File 299k)
Healthy Food And Drink Choices Policy

Healthy food and drink choices must be provided and promoted to staff, volunteers and visitors at: • ACT Health facilities • ACT Health activities including meetings, functions, events, education sessions and fundraising activities. Nutrition Standards have been developed by ACT Health to specify the types of food and drinks to be provided and promoted in the following food and drink supply situations: • food outlets including cafeterias, cafes, shops • vending machines • catering, fundraising, rewards, incentives, gifts, prizes and give-aways • advertising, promotion and placement • alcohol • water provision • sponsorships. The Director-General ACT Health or delegate is able to authorise an exemption for occasional social events or fundraising benefits.
pdf icon Healthy Food And Drink Choices Policy (PDF File 232k)
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.
pdf icon 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.
pdf icon 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.
pdf icon 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
pdf icon Impact Program Guidelines (PDF File 3080k)
Improving Womens Access To Health Care Services And Information

The Women’s 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.
pdf icon Improving Women’s Access To Health Care Services And Information: A Strategic Framework 2010-2015 (PDF File 695k)
Incident Management Policy And Sops

Effective incident management requires an organisation wide approach with clear points of accountability for reporting and feedback at all levels in the organisation. The principles of transparency, accountability, obligation to act, no blame culture and collaboration should be applied at each step of the incident management process. The steps include identification, notification, classification, investigation, action and evaluation. Open communication and documentation should occur throughout the entire process. Incident management should occur in accordance with relevant legislation, standards and policies. This policy and associated Standard Operating Procedures (SOPs) aim to uphold the Australian Charter of Health Care Rights and the Human Rights Act.
pdf icon Incident Management Policy (PDF File 238k)
pdf icon Incident Management Sop (PDF File 294k)
pdf icon Look Back Sop (PDF File 182k)
pdf icon Open Disclosure Sop (PDF File 242k)
pdf icon Release Of Riskman Incident Notifications Sop (PDF File 146k)
pdf icon Significant Incident Sop (PDF File 222k)
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.
pdf icon 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.
pdf icon Intellectual Property Policy  (PDF File 154k)
Intensive Care In The Act During An Influenza Pandemic Guidelines

The Guidelines offer guidance for providing surge capacity and maintaining services during a pandemic period. The Guidelines have been revised to include updated ACT and New South Wales Health policies and procedures relevant to influenza pandemic.
pdf icon Guidelines For Intensive Care In The Act During An Influenza Pandemic (PDF File 783k)
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.
pdf icon Inter-Hospital Transfer Sop (PDF File 721k)
Internal Audit Policy And Procedures

The policy facilitates the operation of ACT Health’s Internal Audit & Risk Management Branch and the Audit Committee. The internal audit activities and internal reviews provide assurance to the Chief Executive that ACT Health’s financial and operational controls designed to manage the organisation’s risks and achieve the ACT Health’s objectives, are operating in an efficient, effective and ethical manner.
pdf icon Internal Audit Policy And Procedures (PDF File 242k)
Interprofessional Learning, Education And Practice Policy

This policy applies to all health professionals working in direct and indirect patient/client care in ACT Health. It defines interprofessional collaborative practice and learning and assigns accountability and responsibilities for interprofessional learning implementation.
pdf icon Interprofessional Learning, Education And Practice Policy (PDF File 160k)
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.
pdf icon Interstate Patient Travel Assistance Scheme (iptas) Policy And Operational Manual (PDF File 424k)
doc icon 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.
pdf icon 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.
pdf icon Sop - Ivig - Policy (PDF File 525k)
pdf icon 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.
pdf icon 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.
pdf icon Learning And Development Framework (PDF File 907k)
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.
pdf icon 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 2013- 2014

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.
pdf icon Act Government Local Hospital Network Service Level Agreement 2013- 2014 (PDF File 4589k)
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.
pdf icon Look Back Policy (PDF File 559k)
pdf icon 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.
pdf icon 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 Health’s 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.
pdf icon Management Of Patients With Mental Health And Medical/Surgical Co-Morbidities (PDF File 337k)
Massive Transfusion Sop

The purpose of this document is to give clear direction to staff to appropriately manage uncontrolled bleeding associated with secondary Coagulopathy. In patients with critical bleeding requiring massive transfusion, the use of a Massive Transfusion Protocol (MTP) to facilitate timely and appropriate use of Red Blood Cells (RBC) and other blood components may reduce the risk of mortality and Acute Respiratory Distress Syndrome (ARDS).
pdf icon Massive Transfusion Sop (PDF File 178k)
pdf icon Massive Transfusion Flow Chart (PDF File 47k)
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.
pdf icon 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
pdf icon 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
pdf icon 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
pdf icon 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.
pdf icon 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.
pdf icon Building A Strong Foundation - Strategic Framework (PDF File 686k)
pdf icon 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.
pdf icon 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.
pdf icon 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.
pdf icon 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.
pdf icon Modified Early Warning Scores Policy (PDF File 77k)
Multicultural Co-Ordinating Framework - Towards Culturally Appropriate And Inclusive Services 2014-2018

This document expresses the commitment of ACT Health to providing services and information to people from culturally and linguistically diverse (CALD) backgrounds. It is the expectation that all Divisions/Branches/Work Units will work with and be supported by the Multicultural Health Policy Unit to: improve CALD data collection; deliver culturally safe and appropriate services and information; engage CALD consumers in providing feedback and participating in service planning and review; and develop the cultural competence of all staff. The document outlines a number of key focus areas for action across the organisation, including actions linked to compliance with the Australian National Safety and Quality Health Service Standards. Progress in implementing the Co-ordinating Framework will be monitored and reported on.
pdf icon Multicultural Framework (PDF File 6297k)
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.
pdf icon 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. The‘frequently 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.
pdf icon 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.
pdf icon Nursing And Midwifery Continuing Competence Policy (PDF File 179k)
pdf icon 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.
pdf icon Nursing And Midwifery Re-Entry Program Policy (PDF File 149k)
Open Disclosure

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
doc icon 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.
pdf icon Opioid Maintenance Treatment Guidelines (PDF File 164k)
Palliative Care Services Plan 2013-2017

The ACT Palliative Care Services Plan 2013-2017 (the Plan) provides strategic direction for the development of palliative care in the ACT to best meet current and projected population needs.
pdf icon Palliative Care Services Plan 2013-2017  (PDF File 436k)
pdf icon Palliative Care Services Plan 2013-2017 - Technical Paper (PDF File 2389k)
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.
pdf icon Use Of Insulin Pumps Policy (PDF File 85k)
pdf icon 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).
pdf icon Patient Identification - Correct Patient, Correct Site, Correct Procedure - Policy (PDF File 85k)
pdf icon Patient Identification - Correct Patient, Correct Site, Correct Procedure - Sop (PDF File 104k)
pdf icon Patient Identification - Patient Identification Bands Sop (PDF File 85k)
Patient Identification - Surgical Safety Checklist Sop (Microsoft Word XML Document 680k)
pdf icon 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 Directorate’s work in physical activity promotion.
pdf icon 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.
pdf icon Act Health Police Records Check Policy (PDF File 74k)
Policy Management Policy

The following Standardisation, simplification, evidence-based, quality consultation, robust governance and endorsement processes, communication, education and training, implementation, compliance and review and evaluation.
pdf icon Policy Management Policy (PDF File 618k)
Policy Management Tier 1 Sop

Robust policy development and management supports health services to meet community needs, can result in better health outcomes and improve consumer satisfaction.
pdf icon Policy Management Tier 1 Sop (PDF File 694k)
Pressure Injury Prevention And Management

This policy provides for a comprehensive, coordinated and systematic approach, for pressure injury prevention and management across the Health Directorate that includes systems, staff and patients.
pdf icon Pressure Injury Prevention And Management (PDF File 602k)
Primary Health Care Strategy 2011-14

The ACT Primary Health Care Strategy 2011–2014 (the Strategy) has been developed to build on the ACT Primary Health Care Strategy 2006–2009, 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.
pdf icon 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.
pdf icon 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
pdf icon 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.
pdf icon 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.
pdf icon Providing Clinical Health Services In An Off Campus Environment Policy (PDF File 180k)
pdf icon Providing Clinical Health Services In An Off Campus Environment Policy - Sop (PDF File 208k)
pdf icon 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.
pdf icon 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.
doc icon 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.
pdf icon Raising The Standard: A Manual To Guide Quality Improvement In Act Community Service Organisations (PDF File 58k)
Reconciliation Action Plan 2012-2015

The Health Directorate’s 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.
pdf icon 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 Health’s corporate image as a single entity organisation through the use of standardised templates.
pdf icon 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.
doc icon 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.
pdf icon 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).
pdf icon Request For Legal Advice - Sop (PDF File 172k)
doc icon 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.
pdf icon 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.
pdf icon 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.
pdf icon 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.
pdf icon 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.
pdf icon Shared Care Guidelines With General Practice - Sop (PDF File 170k)
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.
pdf icon 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.
pdf icon 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
pdf icon Strategic Asset Management Policy For Major Equipment  (PDF File 157k)
pdf icon 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.
pdf icon 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.
pdf icon Managing The Risk Of Suicide - Fact Sheet (PDF File 99k)
pdf icon 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.
pdf icon Support Of People With Disabilities Requiring Hospital Treatment Guidelines And Procedures Manual  (PDF File 367k)
Sustainability Strategy 2010 - 2015

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.
pdf icon Sustainability Strategy 2010 - 2015 (PDF File 201k)
Towards Zero Growth Healthy Weight Action Plan

The Towards Zero Growth Healthy Weight Action Plan sets the ambitious goal of zero growth in rates of obesity in the ACT.
pdf icon Towards Zero Growth Healthy Weight Action Plan (PDF File 2296k)
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.
pdf icon Toys In The Workplace (PDF File 76k)
Training Education Study Assistance Sop

The Training, Education and Study Assistance Standard Operating Procedure applies to all staff. It provides comprehensive information on responsibilities and management of learning and development activities in ACT Health. This SOP replaces several previous policies and guidelines: • Training Management System Capabiliti policy • Charges for non-attendance at SDU programs policy • Study Assistance guidelines • Positive Professional Development Pathway guidelines (ACT Health loans scheme)
pdf icon Training Education Study Assistance Sop (PDF File 406k)
Triple Bottom Line Assessment Sop

Since 1 March 2013, policy submissions requiring a decision by Cabinet have required a Triple Bottom Line Assessment (TBL) to have been conducted, and a TBL summary attached to the relevant Cabinet Submission. A TBL assessment is used to identify and address social, environmental and economic factors into policy development; hence the term “triple bottom line”. The framework encompasses standard good policy development principles, such as identification of the problem to be addressed, the identified desired outcomes, impact assessment and analysis of risks associated with implementation of the policy proposal. Therefore ACT Health is required, where necessary, to complete a TBL Assessment when developing policy or making changes to policy for decision by Government. The standard operating procedure applies to all staff involved in the preparation of policy or legislation that goes to Cabinet in the form of a Cabinet Submission.
pdf icon Triple Bottom Line Assessment Sop (PDF File 142k)
pdf icon Triple Bottom Line Assessment Sop- Attachment A (PDF File 158k)
Underperformance Policy

ACT Health is committed to ensuring that the underperformance process is managed in accordance with the relevant section from the relevant Health Directorate Enterprise Agreement. This policy aims to provide a fair, prompt and transparent framework for action to be taken where an employee continues to perform below the expected standard to: • Create an environment of high work standard; • Ensure a high level of positive public opinion towards ACT Health and the ACT Public Service as a whole; • Treat seriously, promptly and fairly all cases of underperformance with due regard to procedural fairness, natural justice, confidentiality and privacy; • Create an awareness and understanding of these objectives.
pdf icon Underperformance Policy (PDF File 151k)
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.
pdf icon Use Of Act Health Facilities For The Purposes Of Fundraising, Sponsorship, Promotional Or Educational Guidelines (PDF File 37k)
Waiting Time And 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.
pdf icon Act Waiting Time And Elective Surgery Access Policy (november 2013) (PDF File 1287k)
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.
pdf icon Waste Management Policy (PDF File 145k)
Women's Plan

Five year plan identifying factors to develop effective and responsive policies, programs and services to meet the needs of women and girls.
pdf icon 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.
pdf icon Work Health And Safety Policy (PDF File 132k)
Workforce Plan 2013-2018

This Plan progresses the national health workforce agenda by using the domains identified in Health Workforce Australia's National Health Workforce Innovation and Reform Strategic Framework for Action 2011-2015 as a framework. Local linkages have been achieved through the inclusion of strategies to address local workforce issues identified by stakeholder. The Plan is divided in to five key focus areas: Health Workforce Reform Health Workforce Development Health Workforce Leadership Health Workforce Planning Health Workforce Policy Each Focus area includes targeted strategies and actions required to progress the strategies. Executives and managers need to identify and implement all strategies relevant to their service.
pdf icon Workforce Plan 2013-2018 (PDF File 1080k)
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.
pdf icon 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
pdf icon Your Guide To Engaging With The Community (PDF File 1013k)

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