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Legislative Compliance
Organisational, Management and Staff Obligations
Document No:
SSW_PD2007_ 005
Functional Sub-Group:
Corporate Governance
Clinical Governance
Summary:
Approved by:
July 2007
July 2010
April 2007
Note:
Sydney South West Area Health Service (SSWAHS) was established on 1 January 2005 with
the amalgamation of the former Central Sydney Area Health Service (CSAHS) and the former
South Western Sydney Area Health Service (SWSAHS).
In the interim period between 1 January 2005 and the release of single Area-wide SSWAHS
policies (dated after 1 January 2005), the former CSAHS and SWSAHS policies were
applicable as follows:
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Introduction
2.
3.
4.
Assessing Compliance
5.
Monitoring Compliance
6.
7.
Legislation Register
8.
9.
Reference
10.
Definitions
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Introduction
Sydney South West Area Health Service (SSWAHS) is committed to complying with
relevant legislation and obligations and to facilitate this, all facilities / services are
required to establish a compliance program, which is consistent with Area Health
Service policy and which addresses key risks and meets organisational needs.
An effective compliance program is considered an important element in fulfilling the
corporate governance responsibilities of the organisation, whether in relation to clinical
or non-clinical obligations. The compliance program should aim to prevent, and where
necessary, identify and respond to, non-compliance with laws, regulations and
relevant professional codes, Australian standards, NSW Health policies and SSWAHS
policies / procedures. This is best done by promoting a culture at all levels within the
organisation of valuing compliance with both statutory and common law obligations.
Compliance is to be achieved through the joint actions of staff and management.
The general aim of the compliance program is to prevent non-compliance through a
structured and planned program. Such a program includes:
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2.
2.2
2.3
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Anti-Discrimination Board
Professional consultants engaged to lead key projects eg project
managers engaged to undertake major capital works
SSWAHS staff with recognised expertise
2.5
Facilitating Compliance
SSWAHS facilitates compliance with its policies, by-laws and regulations and
any applicable statutes and regulations through its management structure. To
facilitate compliance it is necessary to:
Each facility / service shall be able to provide evidence that it has undertaken
such activities, based on their particular organisational needs.
The general manager / service director of each facility / service is responsible
for implementing a system to promote the understanding and awareness of
compliance obligations to all staff. Systems / mechanisms that are deemed to
be suitable, for example, include:
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2.6
3.
3.2
operating the facility under the authority of the Health Services Act 1997,
as well as other relevant legislations
implementing both NSW Health Department and Area policies and procedures
implementing effective controls to achieve compliance, for example
conducting criminal record checks on persons applying to work within
SSWAHS; ensuring OHS inspections are undertaken; providing equipment
to enable safe work practices
provide access to training for staff to raise their awareness with respect to
legislation eg privacy legislation, child protection legislation
recording and reporting non-compliances / breaches
monitoring the effectiveness of controls
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3.3
4.
Assessing Compliance
Compliance will be assessed, primarily, by:
Conducting of audits, by the Internal Audit Unit, with the Units audit program
having been developed based on greatest risk
Conducting facility based audits both random and scheduled. These are to be
determined on a risk assessment needs basis
Assessing staff knowledge
Reviewing exceptions / incident reports to identify incidents of potential noncompliance and then initiate corrective action
Issuing of notices of breach by relevant authorities eg EPA, WorkCover, Councils,
NSW Fire, NSW Police
Audits conducted by the Internal Audit Unit and as approved by the SSWAHS
Audit and Corporate Risk Management Committee
Medication / prescribing audits and S8 / S4D drug prescribing / administration /
storage audits
Medical Records audits
OHS workplace inspections
Issue of Annual Fire statements
Review of professional registration renewal dates
Assessing staff knowledge will include, but not be limited to, conducting targeted staff
surveys, based on organisational needs, for example:
for staff working in food services, assessing their knowledge of food safety
requirements
for staff working in medical records, seeking to confirm that they understand
privacy legislation
for staff who work at the Department of Forensic Medicine, assessing their
knowledge of the Human Tissue Act
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for staff working in HR and payroll services, assessing their knowledge of industrial
relations legislation and award interpretation
incorporating specific questions into staff performance reviews
incorporating questionnaires / surveys into staff development and training
programs, for example, as a part of the training programs for OHS, fire safety and
CPR
conducting online assessments, for example, staff knowledge of the Code of
Conduct
5.
Monitoring Compliance
Each facility / service will establish a system to monitor compliance / non-compliance.
Such will include a record of actions taken to facilitate future compliance. This system,
which should be incorporated into existing structures and systems, will provide for:
Undertaking trend analysis and documenting any changes made to improve / enhance
existing practices should assist with demonstrating positive outcomes from the
implementation of this policy.
All incidents of non-compliance and those with a significant potential for noncompliance are to be reported to the SSWAHS Director Corporate Services and other
relevant authorised personnel of the SSWAHS organisation such that knowledge can
be shared and risks associated with non-compliance minimised.
Each facility / service will record training aimed at facilitating compliance with
legislative obligations.
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The Audit and Corporate Risk Management Committee reviews the following data to
assess risk, including risk of non-compliance with legislative obligations:
Risk/Issue
KPI
Asset Management
Equipment failures
Fire incidents and Fire Brigade inspections
Utility supply failure
Legionella testing results
Property Claims (insurance)
Motor Vehicle Claims (insurance)
Disaster Management
Financial
Fraud/ corruption
Trade creditors overdue
Tendering complaints
Human Resources
Grievances
Staff misconduct (disciplinary action / terminations)
Staff terminations
Staff training
Information Management
Legal / Legislative
Patient Safety
SAC 1 Events
Patient Incidents / Accidents
Service Access
Liability Cases
Suicides
Falls in the elderly
Patient Complaints
Specific Clinical Indicators
Breaches of NH&MRC guidelines
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Risk/Issue
KPI
Initiatives to improve safety
EQuIP Accreditation
Serious breaches of SSWAHS policy
Critical stock supply
6.
Public Health
Notifiable Diseases
Accidents / Incidents
Security
Workers Compensation reports
Large Workers Compensation Claims
Radiation safety exposures
WorkCover PINS
All staff shall notify their supervisor immediately they become aware that a potential
non-compliance / breach has occurred or is likely to occur.
In cases of wilful or intentional breaches of compliance obligations, the SSWAHS
Discipline Policy and Procedure may be activated.
Examples of Potential Non-compliance / Breach
The following examples illustrate a major non-compliance / breach:
An accident on SSWAHS premises, or whilst involved in a SSWAHS activity, that
results in an injury leading to hospitalisation or death
Example: breach of the Occupational Health and Safety Act 2000; NSW, and the
incident may be investigated by WorkCover Authority
A major investigation by a regulatory or statutory body
Example: Legislative breach
A major impact on business continuity
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Legislation Register
Each facility should manage issues that arise through the implementation of this policy
in a legislation register.
8.
References
Staff (as appropriate) should be encouraged to regularly visit the following websites to
raise awareness of current legislation
Key NSW Legislation: http://www.health.nsw.gov.au/csd/llsb/acts/ (for current
legislation and new / amended legislation)
Definitions
All definitions identified below have been sourced from the Australian Standard
3806 - 1998 - Compliance Programs:
AS
Codes: are mandatory industry codes, and voluntary industry codes with which
SSWAHS chooses to comply.
Compliance: is meeting obligations under laws, regulations, codes or organisational
standards.
Compliance program: is the coordinated activity of documenting obligations,
ensuring responsibility for meeting obligations is clearly allocated and understood, the
monitoring and reporting mechanisms for assessing how well obligations are being
met, and the management activity for addressing non-compliance with obligations and
improving systems for meeting obligations.
Obligation: is a requirement specified by laws, regulations, codes or organisational
standards.
Organisational standards: are any codes of ethics, codes of conduct, good practices
and charters that SSWAHS deems to be appropriate standards for its day-to-day
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operations. In most cases these are detailed in the Manual of Policies and
Procedures, and include the Area Health Services Code of Conduct.
Responsible officer: is the officer allocated responsibility for facilitating compliance
with a specific obligation.
Risk assessment: in the context of SSWAHS compliance program, means assessing
the level of risk of non-compliance with legislative obligations
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