A Tool for Quality and Risk Management
Policies and procedures are critical in underpinning quality systems and risk management frameworks within healthcare and aged care organisations. These documents are the foundation for organisational governance, guiding safe and effective care delivery while ensuring compliance with regulatory requirements.
Read our comprehensive Guide to Policy Management for an update on creating and managing policies and details about what policies are required.
Using this Training Requirement
This Training Requirement provides guidance on understanding and implementing the specific actions related to Policies and Procedures within the National Safety and Quality Health Service (NSQHS) Standards and Strengthened Aged Care Quality Standards.
Rather than focusing solely on education or training, this Training Requirement emphasises the systems, processes, and records needed to demonstrate compliance and effectiveness in managing policies and procedures.
Understanding the Relevant Actions in the Standards
Action 1.07: Policies and Procedures
The health service organisation uses a risk management approach to:
- Set out, review, and maintain the currency and effectiveness of policies, procedures and protocols.
- Monitor and take action to improve adherence to policies, procedures and protocols.
- Review compliance with legislation, regulation and jurisdictional requirements.
National Safety and Quality Health Service (NSQHS) Standards
Action 2.3.6: Accountability and quality system
The provider maintains and implements policies and procedures that are current, regularly reviewed, informed by contemporary, evidence-based practice, and are understood and accessible by workers and relevant parties.
Accountability for Quality Systems
The effective development, implementation, and maintenance of policies and procedures require clear accountability at multiple organisational levels.
Governing Body Accountability
The governing body is accountable for ensuring a robust policy and procedure management system.
Operational Accountability
- An organisation’s Quality team or department is responsible for operationalising the policy management system.
- Responsibilities include:
- Drafting, implementing, and maintaining policies relevant to their specific area of operation.
- Conducting regular audits to ensure adherence to policies.
- Facilitating communication and training for staff to understand and apply policies effectively.
Workforce Roles and Responsibilities
All staff members are responsible for:
- Complying with policies and procedures relevant to their roles.
- Providing feedback on the effectiveness and practicality of policies.
- Reporting any issues or incidents related to policy adherence.
Meeting Policy and Procedure Requirements
Organisations need to establish robust policy and procedure management systems to meet these standards. Consider focusing on these key components:
TR-image_Policy-Procedure-Requirements.png)
1. Clear Process for Policy Development
2. Strict Approval and Review
- Feedback from audits.
- Updates to regulatory or best practice guidelines.
- Input from staff and consumers.
3. Effective Distribution of Policies
- Easy to organise, locate and navigate.
- Available in plain language.
4. Monitor Implementation and Record-Keeping
- Audit trails.
- Incident reports.
- Feedback mechanisms.
- Policy creation and approval dates.
- Review schedules and outcomes.
- Evidence of policy acknowledgement.
5. Training and Education (If Required)
While education is not the primary focus of compliance, provide targeted training if identified for:
- Staff groups implementing high-risk or complex policies (e.g., infection control).
- Novice Quality or L&D staff who are new to their roles and responsible for policy writing or review.
Evidence of Compliance
Organisations can demonstrate a robust and effective approach to policy and procedure management by referring to detailed lists of evidence that may be audited:
The following high-priority items are identified as items auditors will request to assess the effectiveness of policies and procedures within their overall review of your quality system:
1. Current, Comprehensive Policy Documentation
- Version-controlled policies and procedures, with regular review schedules documented.
- Policies aligned with contemporary, evidence-based practices and regulatory requirements.
2. Monitoring and Review Mechanisms
- Audit reports showing adherence to policies.
- Records of periodic reviews and updates.
- Feedback mechanisms for staff and stakeholders to assess policy relevance and effectiveness.
3. Implementation and Accessibility
- Evidence that policies are communicated to staff and easily accessible (e.g., intranet, printed manuals).
- Records of staff acknowledgment of policy updates or changes.
4. Governance and Continuous Improvement
- Meeting minutes demonstrating governance oversight and decision-making based on policy performance.
- Action plans or reports detailing improvements based on audits, feedback, and incidents.
The Importance of Policies and Procedures in Quality Standards
The regulatory requirements for policies and procedures are embedded within broader quality management and risk system requirements outlined in the Strengthened Aged Care Quality Standards and NSQHS Standards. Both sets of quality standards highlight that:
- Policies and procedures are integral to establishing accountability and fostering a culture of continuous improvement.
- They provide a structured approach to managing safety and quality risks, aligning with evidence-based practices and contemporary guidelines.
- Compliance with policies and procedures ensures consistent care delivery and mitigates consumer and staff risks.
Related Resources
References
- Australian Commission on Safety and Quality in Health Care, 2023. 'NSQHS Standards'
- Aged Care Quality and Safety Commission, 2023. 'Strengthened Aged Care Quality Standards'
Author
Zoe Youl
Zoe Youl is a Critical Care Registered Nurse with over ten years of experience at Ausmed, currently as Head of Community. With expertise in critical care nursing, clinical governance, education and nursing professional development, she has built an in-depth understanding of the educational and regulatory needs of the Australian healthcare sector.
As the Accredited Provider Program Director (AP-PD) of the Ausmed Education Learning Centre, she maintains and applies accreditation frameworks in software and education. In 2024, Zoe lead the Ausmed Education Learning Centre to achieve Accreditation with Distinction for the fourth consecutive cycle with the American Nurses Credentialing Center’s (ANCC) Commission on Accreditation. The AELC is the only Australian provider of nursing continuing professional development to receive this prestigious recognition.
Zoe holds a Master's in Nursing Management and Leadership, and her professional interests focus on evaluating the translation of continuing professional development into practice to improve learner and healthcare consumer outcomes. From 2019-2022, Zoe provided an international perspective to the workgroup established to publish the fourth edition of Nursing Professional Development Scope & Standards of Practice. Zoe was invited to be a peer reviewer for the 6th edition of the Core Curriculum for Nursing Professional Development.
