In this section you will learn to:
- Clearly articulate and document policies and procedures to support legal and ethical practice in readily accessible formats.
- Integrate documentation and record keeping requirements into policies and procedures.
- Ensure systems protect client information.
- Nominate the roles and responsibilities of different people in meeting requirements where multiple people are involved.
- Distribute policies, procedures and legal information to colleagues and peers in a timely fashion.
Supplementary materials relevant to this section:
- Reading F: Effective Handling of Complaints Made to Your Organisation
- Reading G: HSQF Quality Pathways for service providers – Information Sheet 4
So far, you have learned about the key legal and ethical considerations of practice management practice. While it is important for practice managers to possess an understanding of legal and ethical frameworks, in practice, practice managers can also rely upon their organisation’s policies and procedures to assist them in their decision-making. Every organisation will have their own policies and procedures that practice managers will be expected to comply with. In this section of the module, we will outline a number of key policies and procedures that you are likely to work with in any practice management role.
Whilst monitoring policies and procedures are more often associated with managerial positions, it is increasingly common that staff of all levels are involved in developing and reviewing policies and procedures. Particularly, staff can provide valuable feedback on practicalities of organisational policies and procedures and make sure they are offering useful guidance. As such, it is beneficial for practice managers to develop knowledge and skills in relation to developing policies and procedures.
So, what exactly are policies and procedures?
Policies are “statements of principles that guide decision-making and service delivery. In the allied health and community sector, policies are often based on legislation (Community Door, 2018). Whereas procedures are “more detailed instructions about how policies should be carried out by employees” (Community Door, 2018). These documents also outline an organisation’s position and value on a subject, such as work ethics and good practice standards, so that workers are guided to work in an ethical manner. Because a single piece of legislation applies to a range of organisations providing different services, individual organisations must develop relevant policies and procedures to outline principles that will guide implementation within its specific context.
| Policies | Procedures |
|---|---|
| Statements of principles that guide decision-making and service delivery | Detailed instructions about how policies should be carried out by employees |
For example, the Privacy Act 1988 is applicable to a wide range of organisations. Therefore, an allied health organisation may develop relevant policies (e.g., client information policy) to outline principles that will guide information handling within its specific context. In addition, the organisation may develop record keeping procedures and referral procedures to complement client information policy to ensure client information is collected, stored, and shared in accordance with these requirements. Essentially, organisational policies, procedures, and protocols can provide practice managers with a set of clear guidelines for how the organisation operates (internal work practice) and how client work (external service delivery) should be completed so that it is lawful and complies with all organisational values and practices.
Policies and procedures are developed to help organisations and its workers adhere to the values of the organisation as well as any relevant legislation. They are also important sources of guidance whenever an ethical dilemma arises, assisting workers to incorporate all relevant considerations and follow appropriate structure to consult and make the most appropriate decisions. This will help to ensure that:
- A practice manager’s actions and decisions comply with current good practice principles, relevant codes of ethics, and all legislation.
- Both individual practice managers and their organisations are protected from legal action.
- Practice managers can be confident in their decision making.
- There is consistency in the way individuals within the organisation operate so the organisation works efficiently and effectively.
Now that you are aware of the importance of having clear, well-written policies and procedures, we will now look at some common policies and procedures relevant to practice management. Remember that each organisation will have different range of documents – it is impossible to provide a comprehensive overview in this module – hence you must take time to learn about those in relation to your work context.
Every organisation typically has a wide range of policies and procedures covering every facet of work. Some are specifically relevant to external service delivery and client-relevant processes (e.g., client intake procedures); some are developed to guide internal management practices (e.g., equal employment opportunity); and some would cover both internal management and external service delivery practices (e.g., WHS). The extract below provides you with an idea of the wide range of topics that organisational policies and procedures can cover.
Among many other things, policies and procedures address:
- standards of workplace behaviour
- code of conduct
- codes of practice
- workplace health and safety
- workplace harassment
- equal employment opportunity
- first aid
- infection control
- grievance procedure
- emergency procedures
- client service delivery
- eligibility criteria
- privacy and confidentiality
- children in the workplace
(Adapted from Community Door, 2018)
Reflect
As you go through the list above, consider how some of these might be used to address legal and ethical considerations you have learned in the previous section. For instance, which of these policies and procedures may be relevant to promoting compliance with:
- Protecting human rights of clients/ workers?
- WHS legislation?
- Anti-discrimination legislation?
- Industrial practice standards?
- Duty of care?
Records Management
Records management is an important aspect of practice management practice, practice managers must ensure adequate and accurate records management. Each organisation will have their own specific policies and procedures to ensure ethical and legal practice and to protect their client’s rights to privacy and confidentiality. As you should recall from the first section of this Study Guide, privacy and consent are important in all areas of practice management. Clients need to feel confident that the organisation they are working with is keeping their information safe and confidential.
Generally, records are kept either in a paper file, on the computer, or both. Only the people who need access to these files should be able to access them. Organisations must make sure clients’ information is stored securely, and practice managers need to ensure they are keeping their records up-to-date. Policies and procedures exist for an important reason, and when they are not followed correctly it can place clients, workers, and organisations at risk, as outlined in the case study below.
Case Study
Freddy is an experienced practice manager and is generally well-liked by everyone. However, Freddy hates all the legality surrounding practice management and feels that it “gets in the way of the job”. Freddy often says it’s better to be with the client rather than doing paperwork. While Freddy is enthusiastic about his job, his carelessness about paperwork has the potential to cause major problems for him and his organisation and could put a client in danger.
One day, Freddy is talking with a client at reception when the client discloses that they feel unsafe at home, that they feel like they can’t manage anymore, and that they need help. Freddy talks with the client about their issues; however, he doesn’t report it to anyone, and he doesn’t file any paperwork.
Overnight the client is put in a dangerous situation in which they hurt themselves and others trying to get out of the situation. The client ends up in hospital and has to speak to the police. The organisation is shocked when they are contacted, as they have nothing on file to say this client was at risk. The organisation speaks with all of their staff to ascertain whether there was any way this situation could have been averted. Freddy discloses that the client told him that they felt unsafe at home on numerous occasions, but that he had talked with the client on each occasion. When asked how many occasions and how frequently he has talked with this client, Freddy admits that he is unsure.
Maintaining efficient and appropriate records will protect a practice manager and their organisation from ethical or legal issues. For this reason, it is important that appropriate records management and documentation principles are integrated into an organisation’s policies and procedures.
Client Protection
It is important for allied health organisations to have clear policies and procedures in place to ensure their compliance with client protection legislation (e.g., child, disabled, or elder person protection) and relevant standards. Below are some critical considerations when designing such policies and procedures.
There are many different ways to set out a [client] protection policy, but most have a clear statement about the organisation’s commitment to safeguarding [clients] and then a procedure that outlines how this is implemented in practice.
The document should contain:
- Details of how staff/volunteers are recruited and selected, including checks that are done to verify their suitability to work with [clients]. This could also be a separate policy.
- Details of relevant staff/volunteer support and supervision (e.g. client protection training, regular meetings)
- Guidelines that help staff/volunteers deal with a disclosure of abuse by a [client]
- Guidelines for procedures to follow if an accusation is made against a member of staff/volunteer
- The designated roles in dealing with any incidents – for 'workers' this should be to record information and pass it on to the 'appropriate person' in the organisation (i.e. a supervisor, manager, designated person in the organisation), who should then report it to the relevant agency. A secondary contact should also be detailed in case an allegation is made against the 'appropriate person'. The confidentiality of the information must be safeguarded at all times.
- How and when information should be recorded – this should be as soon as possible, using a standard form to ensure all necessary information is recorded. Reports should also be made regarding subsequent action taken. All reports should be clearly signed and dated by the individual recording the information and kept in a secure place.
- What your organisation recognises as abuse and indicators that might suggest a client is experiencing abuse.
- Reassurance that workers are protected from legal action if reporting a genuine, client protection concern. Even if the report turns out to be wrong, if it is made in good faith (i.e. it is not malicious) the person providing it is protected.
- When and how an organisation will make a referral.
(Adapted from Youth Scotland, 2017)
By having clear, unambiguous policies and procedures in place, practice management organisations can help ensure that their staff are well-equipped to handle issues of client safety.
Workplace health and safety (WHS) is important in all Australian workplaces, and allied health organisations are no exception. As previously mentioned, workplace health and safety was covered in much greater detail in a previous unit (HLTWHS004 Manage work health and safety); however, at this stage it is important for you to understand that all workplaces hold potential risks to an individual’s physical and emotional health and safety and that organisations must have specific policies and procedures in place to minimise these risks. Practice managers need to comply with these policies and procedures to help ensure that their workplace is safe and does not jeopardize the health of workers or clients.
As a practice manager you will need to be familiar with your own responsibilities in relation to WHS practices in your workplace. Additionally, as you progress within your career and take on supervisory or management responsibilities, you will be responsible for making sure that you, the organisation, and other workers comply with their responsibilities. You may also be involved in audit or periodic inspections in order to maintain WHS compliance.
Specific WHS-related policies and procedures relate to the presence of children in the workplace. Children might come into the workplace as clients, the children of clients, or even the children of employees. From a legal perspective, the organisation has a responsibility for the safety of every person attending the service venue. Practice managers and organisations also have a duty of care to the wellbeing of clients and their children. As such, WHS risk assessment and management procedures should account for the possible presence of children in the workplace, even when the service is intended for adult clients. Ultimately, the service environment should be scanned for potential hazards to children, and these should be eliminated, or appropriate controls put in place.
An additional consideration relates to the supervision of children. Children should not be left unsupervised. This can become problematic if a client presents for service with their children with the intention of leaving their children in the waiting room during the session. In such cases, workers should discuss the potential safety issues with the client and reschedule the appointment for a time when the client can obtain supervision for their children.
Complaints Management
All service users (clients and their families or carers) have the right to make a complaint. A client who is dissatisfied with the service they have received, whether by the practice manager or by another service, may choose to make a complaint. Whilst complaint often has a negative connotation, it is indeed one useful way for organisations to identify issues in operations or service delivery in order to address them. As such, it is important for organisations to have a complaints management policy and procedure in place, which sets out the requirements and responsibilities of an organisation in relation to handling complaints made by either a client, a guardian/carer, or a concerned member of the public.
Complaints management is about dealing with and resolving individual complaints. It is also about using information to identify potential improvements to decision-making, practices and service delivery.
Benefits of complaints management include:
- increased customer satisfaction
- improved organisation reputation
- reduced costs by resolving complaints internally and efficiently
Complaints are an essential part of the accountability process. Every person or organisation has a right to complain and seek a remedy (a resolution) for decisions, actions or services by [organisations] adversely affecting them.
(Queensland Ombudsman, 2021, p.1)
Most organisations will have their own policies and procedures in place to provide guidance on how to handle client complaints. In many cases, organisations will require the client to put their complaint in writing, although some services do accept verbal complaints. Often organisations will have a complaints form which can be used to record complaints. However, with the advancement in technology, online forms, emails and contact via social media are becoming far more common methods of submitting complaints. As a practice manager, it is a part of your role to assist a client if they wish to make a complaint and to follow organisationals procedures to do this.
Complaints procedures will often set out:
- The types of complaints that can be received.
- The methods through which complaints can be made.
- How to handle the complaint(s) as well as communication and timeframe requirements, including the roles and responsibilities of different persons.
- How people can make appeals and seek outside assistance if necessary.
It is important for staff to be aware of their organisation’s requirements in regard to handling, recording and responding to complaints. It is also important for managers to ensure that they are being appropriately implemented.
Reading
Reading F: Effective Handling of Complaints Made to Your Organisation
Reading F provides an overview on complaint handling (management) as well as ten principles of effective complaints management system. Consider how you may use this to support development of complaint management policy and procedures.
An example of a grievance procedure is also provided below.
Grievance Procedure
I. Definition
A grievance is a complaint or expression of dissatisfaction regarding service delivery.
II. Procedures
- Client expresses dissatisfaction verbally or in writing.
- The worker will attempt to resolve situation with the client.
- If this is not possible, then the worker will notify their Manager who will document the complaint and investigate the issue. Information collected will include:
- Identification of those involved
- Nature of complaint
- Date complaint received and by whom
- Summary of follow-up activities
- The Manager will be responsible for collecting relevant information about the grievance, for taking action to resolve the grievance and for documenting all progress.
- The Manager will attempt to resolve the complaint between the parties involved. If no satisfaction results, then each party has the right to appeal. Appeals are presented to the General Manager. If no agreement can be reached then the matter will be resolved by the Community Service Ombudsman.
- Thirty days after expressing grievance, clients or service providers will receive in writing all grievance facts and decisions.
In addition, complaints management should cover complaints relating to internal work practices and operations, such as the relations between workers and practices that impact on workers’ wellbeing. Practice managers have the right to make complaints about their own role and treatment. All employees in Australia are protected by the relevant industrial relations legislation and if any practice managers believe that their rights are being breached then they have the option to make a complaint either through internal organisational channels (e.g., their managers and/or the human resources department) or external channels, such as the Fair Work Ombudsman. It is important for the organisations to uphold workers’ right and make sure that those in a managerial position are prepared to support staff carrying out actions to their rights.
Included in the AAPM Code of Ethical Conduct (Reading D) is the Rules and Procedures for managing complaints through AAPM (Appendix A). Through these procedures, AAPM aims to:
- deliver an effective complaint handling system founded on the principles of fairness, accessibility, responsiveness, and efficiency.
- ensure individuals who make a complaint are respected and aware of the process of consideration of their complaint and the outcome.
- provide transparency around AAPM’s process for receiving, handling, and investigating complaints.
- enable AAPM to apply lessons learnt from complaints received for continuous improvement.
(AAPM, 2023, p. 14)
This document includes the procedure for investigating complaints, responding to complaints, and time frames of the complaint process. Anyone who has concerns about health administrators should be directed to this code and be encouraged to read through the relevant information before contacting AAPM.
There should also be a policy and procedure in place detailing how to develop, implement and review policies and procedures. The Queensland Government (2020) has outlined a number of steps for implementing policies and procedures.
- Identify Need: This includes identifying whether new policies and procedures are needed, considering the effects of changes, assigning responsibilities to relevant team members, and considering required time, knowledge and skills needed.
- Research: This involved analysing potential scope of the policy and its interconnectedness with other policies and procedures and researching the policy topic.
- Draft and Consult: Draft improvement/amendment/new policy using templates, consult with relevant staff, governing bodies, customers, and stakeholders.
- Finalise and Implement: Incorporate final changes, perform a second round of consultations, if required, and develop supporting resources; apply version control to documents, inform staff of new or updated policies, procedures and other documentation, advise customers of any changes, make new files accessible to staff, check immediate impact and effectiveness.
- Monitor, review and improve: In this stage, it’s important to monitor new or updated policies and document any issues that arise, and review all relevant documents cyclically.
Reading
Reading G: HSQF Quality Pathway for service providers – Information Sheet 4
Reading G provides a more detailed description of each of the above stages for creating new or improved policies and procedures.
When developing policies and procedures, organisational managers should ensure that they follow a standard format, that they are clearly articulated, easily understandable, and are readily accessible. Typically, a well-written policy will include the following elements:
- Title and description: Title must clearly convey the purpose of the policy. Provide a brief description of what the policy entails.
- Definitions: Any important words need to be clearly defined so that the content of the policy is easily understood.
- Procedures: Provides the information/steps needed to implement the policy.
- Record keeping: Requirements on documentation and recording, including how confidentiality of people involved (e.g., workers, clients) are to be protected.
- Roles and responsibilities: Outline the tasks and responsibilities of different people involved in implementing and monitoring this policy to promote accountability.
An example policy and procedure for critical incident reporting is included below (Community Door, n.d.). This template is one of the many policy and procedures templates that are free to download from the Community Door’s website (a Queensland government funded effort to support health and community organisations). Of course, individual organisations will need to make sure they adapt this template to meet their organisational context and needs. For now, take note of how the above elements can be combined into a useful, clear, and easy to understand and apply policy and procedure.
Critical Incident Report
Policy: Critical incidents involving services, employees or clients will be reported in accordance with procedures to ensure they are efficiently and effectively managed.
This policy recognises the importance of the health, safety and well-being of clients, staff, volunteers and the public. A standard system of reporting critical incidents will enhance quality service provision and minimise the risk of harm to clients, staff, volunteers and the public.
Definitions: A critical incident is a traumatic event or situation, either accidental or deliberate, where there is risk of or actual serious harm, injury or death.
Procedure: All critical incidents must be recorded on the organisation’s Critical Incident Report and include the following actions:
At the time of the incident:
- Contact emergency services as soon as it is safe to do so. Ensure injured and/or traumatised employees, clients or members of the public are provided with an appropriate emergency response.
- Inform the Manager or most relevant staff member, immediately. It is the Manager’s responsibility to inform the Chairperson of the Management Committee.
- Where the critical incident involves suspected criminal activity, the matter must be reported to the Queensland Police Service, regardless of any issues of consent or confidentiality.
- Inform government agencies, such as funding agencies and the Department of Industrial Relations, in accordance with legislative requirements. More detailed reporting may be required in some circumstances, e.g. where the incident involves a child or an adult with impaired capacity. Your local Community Support Officer or equivalent in Communities and Disability Services Queensland will provide advice on these matters.
Immediately after the incident:
- Assist those involved in the incident to contact family or support persons to advise them of the situation.
- Provide people who have been exposed to the critical incident with emotional support and practical assistance.
- Assist in providing transport if required.
- If the critical incident is of a Police nature or a workplace health and safety issue, ensure the area or site is not disturbed.
Following the incident:
- Encourage employees or clients to seek further assistance if necessary.
- Defuse any issues for employees involved in the critical incident.
- Provide a professional post-trauma counselling service if required.
- Return the worksite to normal operation as soon as practicable.
- Follow up with employee’s status at a later date as required.
- For further information regarding workplace health and safety issues contact the Department of Industrial Relations, Workplace Health and Safety Infoline on 1300 369 915.
As you can see in the extract above, the policy and procedure document clearly outlines the goals and actions to be taken in the event of a critical incident. Having clear and well-developed policies and procedures is crucial for ensuring that organisations deliver consistent and quality service.
Self Reflection
Take a few moments to reflect upon the policies and procedures that you need to follow in your current work role (or in a role you have had in the past).
Does following policies and procedures make it easier to perform your role competently?
Have you ever worked for an organisation that did not have clear, well-written policies and procedures? How did this impact your ability to perform your role effectively?
If you become a manager, what steps will you take to ensure that your staff have access to clear, well-written policies and procedures?
Remember that policies and procedures are not documents set in stone. Changes may need to be made as new services are introduced, as legislation changes, or as best-practice standards are amended. It is the organisation’s responsibility to make sure that there are regular review mechanisms in place and that policies and procedures are updated in a timely manner.
Once policies are written or updated then they need to be distributed to all staff in a timely fashion. This may be done via the organisation’s intranet, a staff meeting, through email, through training sessions, or even by posting updates and changes to policies/procedures on a staff notice board. The type of methods used will largely depend upon the level of changes being made and the size and nature of organisation. For example, if the change consists of a simple update to minor details within a section of an existing procedure, then management might choose to update the procedure on the organisation’s intranet, email all staff, and put an update on a staff notice board. Alternatively, if a whole new policy or procedure was being introduced or amended then it would be important to ensure that staff were informed of these changes in more detail (e.g., through discussion in a team meeting) and provided with the necessary training so that they are capable of properly implementing the new policy or procedure.
Whenever policies and procedures are changed or updated, organisational management must ensure that all staff understand how to apply the information and what the changes to policy and procedure means for them and their role, as well as other workers. In an allied health organisation, different staff may have different and varied roles and responsibilities that are outlined in the organisation’s policies and procedures. For example, specific staff members may be nominated as specialist personnel for the reporting of situations of risk, mandatory reporting, or WHS issues. Additionally, supervisors and managers are typically responsible for monitoring staff compliance with policies and procedures and dealing directly with any breaches, whereas lower-level staff might only be responsible for ensuring their own compliance.
In this section of the module, you learned about the importance of policies and procedures for ensuring legal and ethical compliance in practice management. You learned about how organisations and managers develop policies and procedures, as well as what these policies and procedures typically include. You also learned about some of the common policies and procedures that relate to practice management, including those relating to records management, client protection, children in the workplace, workplace health and safety, and complaints management. It is important for organisations to make sure all staff are kept informed and updated on organisational policies and procedures, as well as how to refer legal and ethical issues and breaches and access specialist legal advice when required.
- Community Door. (n.d.). Policies, procedures & templates. https://communitydoor.org.au/resources/administration/policies-procedures-templates
- Community Door. (2018c). Defining policy and procedures. In Section 3: Following policy and procedures. Queensland Council of Social Service. https://etraining.communitydoor.org.au/resources/etraining/units/chccs301a/section3/section3topic01.html
- Legal Aid. (2021). Policies and Procedures. https://www.legalaid.qld.gov.au/About-us/Policies-and-procedures
- Queensland Government. (2020). HSQF Quality Pathway for Service Providers – Information Sheet 4. https://www.dsdsatsip.qld.gov.au/resources/dsdsatsip/work/hsqf/info-sheet-4.pdf
- Queensland Ombudsman. (2021). Complaints management. https://www.ombudsman.qld.gov.au/ArticleDocuments/206/QO%20CMT%20Resource%20-%20April%202021%205th%20edition%20%20-%20SECURE%20-%20PUBLIC.PDF.aspx
- Youth Scotland. (2021). Child Protection. http://www.youthworkessentials.org/safe-sound/policies-procedures/child-protection.aspx
