Mater Health Services Corporate

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1 DEFINITIONS: A Policy is a written set of rules that detail Mater s official position on a given subject. A Procedure is a set of written instructions conveying the approved and recommended steps for a particular act or sequence of acts. Procedures you how. tell Guidelines refer to a best practice process which can be related to clinical, management, operational and technical activities. PRINCIPLE: 1. Having internal policies and procedures in place provides clear direction and support for Mater to achieve its goals and objectives, as well as communicating management s expectations. Internal policies and procedures describe the directions, rules and procedures that relate directly to that area. 2. Any internal polices and procedures established must contain a statement describing how the policy or procedure reflects the mission and values of the Mater. Depending on the type of policy or procedure it may also be appropriate to include the Mater Mission Statement and Values. 3. This policy has been develo ped to establish the framework for policy development and management across the Mater. POLICY: 1. General Framework i. Docucube is the approved corporate system to support the development and management of policies. All policy development and management is to be undertaken utilising the prescribed workflow contained within Docucube. The Senior Policy Officer, Information Management is responsible for the management and maintenance of Docucube. The Docucube Co- ordinator is responsible for assisting policymakers with the development, implementation and management of policy. 2. Development i. Policies shall not be developed in isolation and should be appropriately communicated to ensure there is no duplication. Page 1 of 5

2 ii. Local policies/procedures are not to be adopted w hich conflict with established Mater-wide policies and procedures. iii. The policies and procedures are to be written clearly and concisely, avoiding the use of jargon, abbreviations and acronyms to ensure they are documented and effectively communicated to all staff, thereby encouraging consistency of action and uniformity throughout Mater. 3. Mission Alignment i. Our mission finds its expression in our everyday work. The mercy, dignity, quality, commitment and care we offer to our patients and the way we work with our colleagues is the lived reality of our mission. Policy development serves as a method of communication to promote high standards and achieve a shared and common understanding in an holistic approach to health care. The Guidelines below provide some assistance in how to incorporate our Mission into policy development. 4. Authority / Responsibility i. Ultimate responsibility for all policy, procedures and guidelines lies with the Executive Director of the portfolio proposing the policy. ii. The Executive Director may delegate the authority to approve policy, procedures and guidelines to such persons as he or she may see fit. Upon the exercise of such delegation, the Executive Director shall notify the Docucube Co-ordinator. iii. To minimise the duplication of effort and to ensure that conflicting policies are not promulgated, all proposed clinical policies, procedures and guidelines are to be referred to the Clinical Policy Committee. iv. The Clinical Policy Committee shall operate pursuant to Terms of Reference approved by Mater Executive. 5. Policy Management i. All policies, guidelines and procedures are to be made available via Docucube. Page 2 of 5

3 ii. As a risk management strategy, one hard copy of all clinical policies shall be stored in each Mater hospital. The hard copy s hall be stored in a place to be determined by the Nursing Director (or iii. equivalent) for that facility. The responsibility for ensuring that the hard copy is kept current shall rest with the Docucube Co -ordinator and the Nursing Director. GUIDELINES: MHS Policy Guidelines: inclusion of reference to mission and values in all policies Each MHS Policy must be developed with some discussion about and reference to MHS mission and values, and in accordance with the Policy Template. MHS mission and values are supported and nurtured by embedding them into the strategic and operational dimensions of the business. They are articulated in everyday behaviours. The reference is to be included in the Policy Principle as described at 2. iv. The reference may be expressed in a number of different ways. The following words for inclusion in policies are offered as examples and as a guide only, rather than being prescriptive. They should be adapted appropriately to reflect and articulate the specific policy that is being developed. They are merely a menu of examples and will not fit every situation. Usually a one-sentence overarching statement will be sufficient and will set the tone of the policy. The fact that you develop each policy thinking about its full impact on people and the environment will further articulate MHS values of mercy, dignity, care, commitment and quality in the language that you use. Because you develop policy in this way, you may consider the one-sentence overarching statement superfluous; it may be, but it is a useful reminder to us of what should underpin our policy making and decision making nevertheless. If you require additional advice to help shape a statement that demonstrates your consideration of this issue as part of policy development, please contact the Executive Director Mission Leadership Madonna xxxxxx on x0000 or Page 3 of 5

4 Consistent with and as an expression of its Mercy mission and values, MHS is committed to providing exceptional health care in a safe, high quality, compassionate work environment. within a quality improvement framework. that respects the privacy and dignity of each individual. by responding to the spiritual and emotional needs of patients, families and staff. by implementing x (name the procedure) aimed at improving x (name the outcome). in its provision of high quality professional and reliable telecommunications. through x (name the service). that puts the patient first. by supporting / ensuring the safety of / its staff and volunteers. that is consistent with Catholic moral and ethical teachings. that considers / takes into account / minimises / reduces / the impact on the environment. that is underpinned by responsible governance in relation to the acquisition of x (name the new service). that is underpinned by responsible governance in relation to clinical ethics and the conduct of research ethics. Page 4 of 5

5 that outreaches to the most disadvantaged in the community. CONTACTS: Page 5 of 5

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