Find policy documents

1. Search by key word or decision number:

     Your search options (tick):

2.Jump to policies that begin with a particular letter by making a selection from this A-Z list:



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)