An Introduction to Organisational Policies

Policies are general guidelines or statements about how the organisation will function, including how it will meet legal obligations and sustain itself as a business, while procedures “create a roadmap showing how a policy can be implemented or how a service can be delivered. Procedures refer to the various types of tasks performed by employees, resources that are necessary, boundaries of the service, and contingency plans for executing an alternative if the policy cannot be implemented (plan B)” (O’Donnell & Vogenberg, 2012, p. 341). Specific areas of policy are designed in particular ways. For example, take this description of a human resource policy from the New South Wales (NSW) Government: the policy is “a statement which underpins how human resource management issues will be dealt with in an organisation. It communicates an organisation’s values and the organisation’s expectations of employee behaviours and performance.”

It is important to note that, when we talk about policies, we are actually referring to both the policy (also known as the policy statement) and an attached set of procedures that support the policy’s enactment. When we talk about acting “in accordance with policy” or “following policy”, for example, we actually mean following the procedures attached to a given policy. So, when we refer to ‘policies’ in this unit, we generally mean policies and their procedures or other associated guiding documents.

Why Do Policies Matter?

Workplace policies and procedures guide the behaviour of staff and managers in areas that are critical to the legal, ethical, and professional responsibilities they hold and to the purpose of the organisation.

(Just note that the NSW Government has overstated the power of policies in this extract: even the best-written policies can’t ‘ensure’ uniformity or anything else, but they promote appropriate behaviour by clearly communicating and guiding actions. As you become familiar with policy examples, you will find that the word ‘ensure’ is inappropriately used quite often! Similarly, while policies should guide staff behaviour in ways that is compliant with legislation, if the policies are not followed or enforced, the organisation is non-compliant.)

What Policies and Procedures Does My Practice Need?

Policies need to cover all key areas of organisational practice, with associated procedures to guide staff in carrying them out. These include staff and management responsibilities in relation to their work roles, clients, and each other; how information is collected, stored, and used; human resources – recruitment, professional development, supervision, and processes when worker behaviour is unacceptable; how the organisation upholds human rights, including anti-discrimination policies, as well as the rights of members of particular groups; work health and safety; management of complaints/grievances; financial management and processes within the organisation; and use of communications and other technologies.

Consider the guidance of the Australian Commission on Safety and Quality (ACSQHC) on Action 1.07: Policies and Procedures, one of their standards for allied health services:

Watch

The policy development process is more of a cycle than a single process. This is because, for the most part, there will already be policies in place when we go to develop a policy initiative, so we won’t be developing a set of policies from scratch but will be addressing issues in the current set of organisational policies and procedures; these issues are often a lack of currency (i.e., aspects of existing policies are out-of-date) or gaps in the existing set of policy documents. So, the cycle often starts when notice that a policy or procedure is no longer relevant or is lacking in important ways.

Our first step is to evaluate the current policy documents and undertake research on what the current standards are. Relevant areas for consideration include legislation and regulation changes, updated codes of ethics or practice for allied health professions, community standards and expectations, and changing social or political conditions. We often need to consult others to evaluate where the policies, as they currently stand, are not meeting client or organisational needs, and to help identify the full range of potential options for rectifying this.

The second step is to draft a new potential policy or related document. Employing organisations generally use a specific format for policies, which we need to follow as we do this, so through this unit we will look at what policies must include and a several policy format examples. As we do our drafting, we need to address community and professional expectations, as well as the rights and responsibilities that we will shortly discuss. For example, we need to ensure that the rights of all key stakeholders are addressed and that the policy we draft is backed-up by good practice guidelines, legislation, or evidence-based guidance relevant to the area of policy development. We may also need to create links to other sources of information that support policy implementation, such as specific laws or professional requirements, or other policies that the new initiative will relate to. Finally, we need to consider how the policy will be implemented and develop a plan for sharing and testing the appropriateness of the policy before it is finalised and rolled out.

This brings us to step three: testing the draft policy. This isn’t just about sharing information with staff, but a comprehensive process whereby we can get the input of key stakeholders regarding the implementation of the policy and, in particular, what aspects of the policy can (or must) be improved.

In step four, we finalise our draft policy and put together whatever additional information, guidance, or plans the organisation and its stakeholders require in order to implement it, and present these to the decision-making body for the organisation (e.g., board, directors, a relevant committee). In the usual course of events, these decision-makers will be familiar with the draft policy because and will have been actively involved in (and may even have instructed us to start) the policy review process. Some, however, will not be familiar with the area or with the development process, so you need to be prepared to present and advocate for your policy initiative, because these decision-makers are the ones who will determine whether the draft initiative is ratified (that is, given formal approval and rolled out, either replacing an old policy or as a brand-new policy addressing an area that previously was not covered).

Finally, we roll out our policy implementation plan. In doing this, we need to make sure that sufficient time and resources are provided to everyone who will be involved in implementing the new policy such that they can do this effectively. We also need to keep channels of communication open, so that we are made aware of any issues with its implementation. This is where we start to see that the policy development process really is a cycle, because as feedback comes in that the new policy needs to be changed in some way – say, to better support implementation or to meet a responsibility we missed have not addressed – we go back to step one and start the process again.

At this point in your course, it won’t surprise you to learn that organisational policy and law, as well as key ethical considerations in the healthcare professions, are inter-related. So, let’s look at some core legal and ethical considerations that you will need to either explicit the address and your policies or ensure your policies are consistent with. Having already completed units in managing legal and ethical responsibilities, work health and safety, and risk management, you will probably find these familiar, but reviewing them here will help you ‘connect the dots’ between these considerations and the policies you develop.

Duty of Care Versus Negligence

Duty of care doesn’t just apply to professionals. In fact, duty of care is their responsibility held by every adult in the community in some manner. But we are not concerned with this broad definition of duty of care here. Rather, we are concerned about the duty of care that healthcare professionals or the general staff of healthcare practices owe, primarily to their clients, but also to one another, to site visitors, and to members of the general public. In the allied health setting, our major duty of care is our responsibility that each professional in the practice has to provide (or support provision of) services that are appropriate to clients and to avoid actions that could be harmful to clients or relevant others.

The first responsibility – to do things that are in the interests of or promote the safety of another person - is what we might call a positive responsibility because it relates to what we do. The second – the responsibility to avoid acts that could cause harm to others – is what we might call a negative responsibility, in that it relates to what we do not do. The importance of both types of duty of care can be clarified with examples. We can enact the positive responsibility when we make sure that our premises are safe to access, for example, while we meet the negative responsibility by not undertaking risky tasks that are beyond our work-role boundaries or professional competencies. Similarly, the healthcare professional might meet their positive responsibility by contacting another service provider when a client needs additional interventions that the practitioner doesn’t provide, and meets their negative responsibility by refusing to provide interventions that could harm the client.

Where duty of care responsibilities are not met, this is known as negligence. And, just as there are two types of responsibility in duty of care, there are two ways that we can be negligent. We can either be negligent through what we do (that is by placing a client or other relevant person at risk through some action we’ve taken) or place the person at risk or cause them harm by failing to do something that it is with in our responsibility to do. Again, we can clarify these with examples. Passing on inaccurate information about a client to their health care provider and thereby negatively impacting their treatment would be negligence through something we do, while failing to undertake appropriate risk management processes in setting up or maintaining the practice setting could lead to harm, in which case we would have been negligent through our failure to meet our responsibilities.

Policy Development and Duty of Care

Duty of care is absolutely essential to many of the policies you will develop. Many policies, and their associated protocols, are directly aimed at supporting workers and the organisation to meet their duty of care responsibilities and avoiding negligence. For example, policies and procedures relating to direct client service include responsibilities and processes that are essential to protecting clients and avoiding harm; work health and safety (WHS) policies and procedures aim to reduce physical and psychology risks to workers, clients, and site visitors; child protection policies and procedures aim to uphold our duty of care to children; and so on. This means that you need to be familiar with duty of care and able to integrate up-to-date standards and practices for meeting duty of care responsibilities within the policy initiatives you undertake. So, where will you find this information?

There are two primary ways that we can find information about what is considered appropriate in terms of enacting our duty of care (also known as discharging our duty of care) and avoiding negligent action. The first is through engaging with relevant publications, such as many of the readings and resources referred to in this Study Guide. For example, child protection legislation, work health and safety (WHS) regulations, and codes of practice for organisations and particular professionals all provide guidance on what is expected of people in particular roles. By being familiar with the legislation in your state or territory, particularly regarding healthcare provision, WHS, and similar industry-related laws and regulations will help you develop your sense of what the community and legal standards are in the role of practice manager.

For example WHS laws, regulations, and codes of practice will be discussed shortly. Through exploring them, you will enhance your sense of what a practice manager needs to do in order to meet their responsibilities to their staff and clients. There are many resources that can be accessed in flashing out this information, such as the WHS guides that each state or territory government produces for work in different industries. A practice manager who insures that their practice operates in accordance with these guidelines would generally be considered to have met their duty of care in relation to the safety of staff, clients, and other visitors to the worksite. In contrast, a practice manager who fails to implement policies and processes in accordance with the WHS guidelines of their state or territory and relevant to their particular practice setting could be negligent.

The other source of information that can be used to guide determinations about what does or doesn’t meet duty of care responsibilities is a little more vague. It relates to industry standards and community expectations. For example, one factor courts use in determining whether a professional has been negligent or not is whether their behaviour accords with what is generally considered appropriate by professionals in the same industry. These can be clearly set out, such as in the codes of practice of a particular industry, but they are not necessarily as clear or detailed as the guidelines produced by regulatory bodies, such as the WHS guidelines we have already mentioned. These standards can often change – there are plenty of actions in response to child abuse or domestic and family violence (DFV), for example, that were common in the health services in previous decades but would be considered negligent today. As such, it will be important to regularly refresh your knowledge in this area regularly.

Work Health and Safety

Strongly related to duty of care is WHS. As you know WHS is a significant part of a practice manager’s responsibility. As such, while we address key points here, we know you are already very familiar with WHS from HLTWHS004 Manage Work Health and Safety, as well as other legal-, ethical-, and compliance-related units, and we will be moving relatively quickly through these concepts, knowing that you have those materials to refer back to if needed.

Originally, WHS regulations focused on physical safety – that is, identifying and managing risks to physical health – with organisations responsible for introducing and ensuring the application of practices to reduce injury risks associated with hazards such as lifting, carrying, and pushing objects; walking or climbing in potentially dangerous conditions; infection control; exposure to hazardous substances; and other hazards to physical health and functioning. (Remember, a hazard is something that could cause harm, while a risk is an assessment of the nature, potential severity, and likelihood of that harm.) All of these physical hazards remain critical concerns, of course, but we it is not recognised that we also face psychosocial risks at work, and that these are core concerns for WHS, too.

Psychosocial risks are things that could do psychological harm – such as leading to anxiety, burnout, or mental health disorders – or physical harm, such as raising the risk of cardiovascular or musculoskeletal disorders. Comcare (n.d.), Australia’s national WHS authority, identifies key psychosocial hazards including job demands, poor management, harassment, and exposure to traumatic experiences. This is a particular focus in the healthcare sector:

WHS legislation (which refers to both WHS acts and associated regulations) are set out by each state or territory government, but most are largely similar, in accordance with SafeWork Australia’s model WHS laws. The acts are the overarching legislation that sets our legal responsibilities, which the regulations provide more information about how those with WHS responsibilities can go about meeting them. Perhaps the most user-friendly resources, however, are WHS codes of practice. If you don’t already have a copy, you should download How to Manage Work Health and Safety Risks: Code of Practice (SafeWork Australia, 2018) for a very practical guide to risk management in WHS. You should also search online for codes of practice or other guidelines published by your state or territory government. For example, a practice manager in Queensland should be guided by:

• Meeting your responsibilities under the state’s/territory’s WHS legislation.
• Information about managing WHS risks in relation to particular types of service delivery. For example, if the practice has practitioners who do or may undertake work in client homes, the practice manager must ensure there are policies, procedures, and resources in place to meet the responsibilities set out in Workplace Health and Safety Queensland’s A Guide to Working Safely in People’s Homes (WHSQ, 2018).
• Information addressing particular types of risk. For example, the more recent recognition of psychosocial risks has lead the Queensland Government to produce Managing the Risk of Psychosocial Hazards at Work: Code of Practice (WHSQ, 2022) to help address these risks. To support managers in facilitating the changes needed to accord with this code, they have also produced a Communications Kit.

Remember that codes of practice and other guidelines are regularly updated, so you need to access the most up-to-date version of any code you are using.

WHS and Policy Development

One of the reasons that WHS is so important to policy development in allied health practice is that health and social care services are among the leading contributors to the serious claims of work-related injury in Australia (SafeWork Australia, 2023, p. 12; see the image on the previous page). In addition to harm to staff, of course, there are many people who attend allied health practices, including clients and their family members, many of whom are particularly vulnerable. So, creating practice spaces and processes that meet safety standards is one essential priority for policy development.

• The ways hazards can be identified, including regular methods that managers undertake as well as other methods that may be required in particular circumstances and how hazards identified in an ad hoc manner (e.g., as staff go about their work) are reported.
• Risk assessment and control processes associated with all identified hazards.
• Establishment and maintenance of safe work processes, including education of staff as to appropriate and inappropriate actions in their specific area of work. For example, staff undertaking client care tasks face many similar but also some different risks to those undertaking administrative tasks, so the WHS guidance to each group must be appropriately tailored.

In creating policies to address WHS risks, the ideal is to remove the risk entirely, but this often isn’t possible. For example, there is no policy that can stop a worker being abused by a client or that can make effectively remove everything that could cause a physical injury in a workplace. What we need to do, however, is to adequately identify hazards and assess risk levels in relation to each identified hazard, then institute policies, procedures, and work practices that minimise risks to staff, clients, and other relevant people. That is, we need to apply the risk management process you are already familiar with to both physical and psychosocial risks (Work Health and Safety Queensland, 2022, p. 14; see image right).

WHS policies and procedures also need to consider:

• Who all the stakeholders are and how they will be consulted and involved in the review and development of policies, procedures, and work practices.
• How barriers to reporting hazards will be encouraged, who has responsibility for communicating identified hazards to management, and how management must respond to identified hazards.
• Processes for documentation of all WHS-related matters, including the risk management processed outlined above, as well as WHS incidents and follow-up actions, and consequences for staff (including managers) who do not meet their WHS responsibilities.

Rights and Responsibilities in Allied Health

Human Rights and Healthcare Rights

As you know, human rights are those things we are all entitled to as human beings, including the right to health and to receive health services that meet our needs.

Healthcare Rights

Let’s look in a little more detail at healthcare-related rights. There is a set of rights agreed by state and territory governments across the country and which apply to every person receiving healthcare, stating that each of us has the right (see next page).

Access

• Healthcare services and treatment that meets my needs

Safety

• Receive safe and high quality health care that meets national standards
• Be cared for in an environment that is safe and makes me feel safe

Respect

• Be treated as an individual, and with dignity and respect
• Have my culture, identity, beliefs and choices recognised and respected

Partnership

• Ask questions and be involved in open and honest communication 
• Make decisions with my healthcare provider, to the extent that I choose and am able to
• Include the people that I want in planning and decision-making

Information

• Clear information about my condition, the possible benefits and risks of different tests and treatments, so I can give my informed consent
• Receive information about services, waiting times and costs
• Be given assistance, when I need it, to help me to understand and use health information
• Be told if something has gone wrong during my health care, how it happened, how it may affect me and what is being done to make care safe

Privacy

• Have my personal privacy respected
• Have information about me and my health kept secure and confidential

Give feedback

• Provide feedback or make a complaint without it affecting the way that I am treated
• Have my concerns addressed in a transparent and timely way
• Share my experience and participate to improve the quality of care and health services

^{(ACSQHC, n.d.)}

Other Rights and Responsibilities

We have already covered several key responsibilities of workers within healthcare settings in general, and of practice managers in particular, through our discussions of WHS, confidentiality, and human and healthcare rights. But what other responsibilities do you and other workers have? And what rights do you and other staff have?

As a practice manager, you will have many responsibilities relating to administration; oversight, supervision, and governance; financial management; communications; and more. Many of those responsibilities will be mentioned in the examples in case studies and policy templates we explore throughout this unit. The clinicians and administration work workers within your practice will also have responsibilities that are specific to their roles. Allied health practitioners, of course, have many responsibilities relating to the provision of ethical and effective healthcare services and these clinical responsibilities are very different from those of other workers within the organisation. However, there are client rights and worker responsibilities that apply across the board.

For example, as you already know, clients of allied health services have rights to privacy and confidentiality. This means that they should be provided with treatment in private settings, unless there are group programs or spaces to which they have consented; it also means that information about the client which includes everything from their name, phone number, and date of birth to the details of the issues they are experiencing and the treatments they are receiving is considered private, and that it is the clients right to decide who has this information. As such, excepting in very specific circumstances, it is not allowed for any worker to share this information without the client’s consent, whatever the worker’s role. However, if the client or another relevant person is in a situation of significant risk if emergency services need to be called or if the clients records are subpoenaed for legal processes, the client may not have the right to determine whether information is shared for this specific purpose.

You may have noticed that the client right to privacy and confidentiality goes together with the workers’ responsibility to protect privacy and confidentiality. Similarly, the client or site visitor right to enter a safe treatment space goes hand-in-hand with every workers; responsibility to operate in accordance with WHS requirements. Similarly, practice management hold all the same responsibilities in this area as other workers, but also has the responsibility to ensure policies and work processes are in place – and are followed! – such that the workplace is a safe space for themselves, other workers, clients, and site visitors to enter and either conduct or receive services within.

In the healthcare industry, we most often focus on the rights of clients or patients and the responsibilities of healthcare providers or other workers within a practice setting. However, there are situations in which the rights of clients/patients and of workers are the same. For example, everyone has the right to be treated with respect and to be free from abuse within the healthcare setting. This right applies equally to every person involved with the service regardless of their role within the environment.

There are also some rights of workers that it is the responsibility of management to uphold. These include setting up structures for safe and effective work provision reducing risks associated with physical and psychological injury, providing the resources required to do the work and maintaining employment provisions, such as pay that accord with industrial relations law within Australia. Similarly, employing organisations need to work in accordance with anti-discrimination law (you can find a quick guide to that here) and avoid discrimination in their hiring and treatment of staff, as well as in their behaviour towards clients/patients.

Another useful source of information on the legal and ethical considerations we need to take into account when developing and implementing policies are the codes of practice of the various health professions. We have already introduced codes of practice for WHS, but the particular allied health professions within your practice will all have their own codes of practice, too. Many of these are similar because they tend to relate to core underlying principles. For example, health professions have core values and rights they recognise, which we have already discussed, while the helping professions (some of which are also allied health professions) have core values, which overlap with healthcare values:

This means that any good code of practice for an allied health professional, regardless of their specific profession, will require that they uphold key client rights in relation to these principles. These codes of practice are not legally binding, but a good code of practice or code of ethics will be developed in consultation with legal and professional standards and breaching them can result in professional sanctions. However, codes of practice do not cover all the ethical or professional issues that can arise in allied health practice, and they tend not to provide practical steps to take in order to meet all their standards; rather, their guidance is more general and focused at setting out standards that promote ethical practice. As such, they need to be read and applied in concert with legal, ethical, and professional knowledge and standards of good practice. Organisations can support their staff in meeting the standards set out in codes of practice by ensuring that their policies and, in particular, the procedures set out to guide staff action are consistent with the relevant codes of practice: Because procedures outline practical steps to achieve policy aims, where policies are aligned with codes of practice, following the associated procedures should mean that staff act in accordance with these codes.

Rights and Policy Development

The rights and associated responsibilities we have been discussing are core concerns for us in this unit because they are some of the most important areas to address in policy development. We need to make sure that our policies:

• Make clear statements about these rights and responsibilities.
• Provide clear guidance (through procedures and other resources) for staff and managers in upholding these rights and meeting other responsibilities.
• Are enforced, with failure to act in accordance with policies identified and addressed with reasonable grievance or performance management and professional discipline processes.

In this section, we have developed a basis of legal, ethical, and other professional considerations for the development of workplace policies, as well as getting a sense of the overall development process. Before we go on, it will be useful to consider some recent and ongoing changes in the area of policy development; these will no doubt influence the policies of your practice and will be interesting areas for you to keep an eye on.

We have already noted several trends in workplace policy development in general and in the health sector in particular. For example, we have discussed the integration of psychosocial risk management into WHS policies. We have also seen the codification of healthcare rights. An area related to this, and one we will look at later in this unit, is the increasing recognition of the need to make healthcare services more inclusive and accessible, particularly for marginalised groups. Many resources to support work in these areas are provided by state and territory governments, so it is worth searching for them with key terms (e.g., “cultural safety”) and your state or territory – you will probably find plenty of quality resources to support your policy development initiatives.

In fact, the very fact of the importance of allied health and associated increase in government focus on it is relevant to policy development.

Now that there is a greater government focus, for example, there is increased government funding and guidance for allied health provision, as well as potentially increased oversight by governments through regulation and accreditation processes. Becoming familiar with these processes and requirements, then developing policy initiatives consistent with them, will be essential in your role as practice manager.

Particular principles and practices, as well as techniques and formats for policies and related processes, will be covered as we discuss the stages of policy development that they are particularly relevant to. So, as you progress through the unit, you will notice that there are many more key terms and concepts that arise. But we have enough of an introduction now to the core responsibilities and considerations for policy development that we can get into the process itself, which is where we turn our attention next.

In this section of the study guide, you learned about organisational policies and procedures, including policy development and implementation, as well as organisational, professional, legal and ethical considerations that need to be considered when planning, developing, and implementing policy.

• Allied Health Support. (2023). The how-to of policies and procedures. https://www.alliedhealthsupport.com/the-how-to-of-policies-procedures/
• Australian Commission on Safety and Quality in Health Care. (2023). Action 1.07: Policies and procedures. https://www.safetyandquality.gov.au/standards/nsqhs-standards/clinical-governance-standard/patient-safety-and-quality-systems/action-107
• Australian Commission on Safety and Quality in Health Care. (n.d.). Australian charter of healthcare rights. https://www.safetyandquality.gov.au/sites/default/files/2019-06/Charter%20of%20Healthcare%20Rights%20A4%20poster%20ACCESSIBLE%20pdf.pdf
• Australian Human Rights Commission. (n.d.). What are human rights? https://humanrights.gov.au/about/what-are-human-rights
• Cohen, C., Pignata, S., Bezak, E., Tie, M. & Childs, J. (2023). Workplace interventions to improve well-being and reduce burnout for nurses, physicians and allied healthcare professionals: A systematic review. BMJ Open, 13, e071203. https://doi.org/10.1136/bmjopen-2022-071203
• Comcare. (n.d.). Psychosocial hazards. https://www.comcare.gov.au/safe-healthy-work/prevent-harm/psychosocial-hazards
• Corey, G., Corey, M. S., & Corey, C. (2023). Issues and ethics in the helping professions (11th ed.). Cengage.
• Indigenous Allied Health Australia. (n.d.). Policy position statement: A rights approach to allied health. https://iaha.com.au/wp-content/uploads/2020/02/A-Rights-Approach-to-Allied-Health-Position-Statement.pdf
• NSW Government. (n.d.) Workplace policies and procedures checklist. https://www.industrialrelations.nsw.gov.au/employers/nsw-employer-best-practice/workplace-policies-and-procedures-checklist/
• O’Donnell, J., & Vogenberg, F. R. (2012). Policies and procedures: Enhancing pharmacy practice and limiting risk. Health Care and Law, 37(6), 341-344.
• SafeWork Australia. (2018). How to manage work health and safety risks: Code of practice. https://www.safeworkaustralia.gov.au/system/files/documents/1901/code_of_practice_-_how_to_manage_work_health_and_safety_risks_1.pdf
• SafeWork Australia. (2023). Key findings. https://www.safeworkaustralia.gov.au/sites/default/files/2023-01/key_whs_stats_2022_17jan2023.pdf
• Tarode, S., & Shrivastava, S. (2022). A framework for stakeholder management ecosystem. American Journal of Business, 37(2), 76-88. https://doi.org/10.1108/AJB-01-2020-0003
• Work Health and Safety Queensland. (2022). Managing the risk of psychosocial hazards at work: Code of practice. https://www.worksafe.qld.gov.au/__data/assets/pdf_file/0025/104857/managing-the-risk-of-psychosocial-hazards-at-work-code-of-practice.pdf