Governance documentation will provide a functional structure to support staff in their various clinical and corporate roles.

Clinical governance documentation will promote best patient care and outcomes and each type of governance documentation will be clearly defined and be developed according to a set process to provide consistency in practice.

Governance Documents will be accessible to all staff to be able to guide them in corporate or clinical practices as required.

This Protocol is designed to provide staff with the following processes in order to complete the following tasks:

• Submit a new Governance Document Proposal,
• Complete a new Governance Document for ratification,
• Review of an existing Governance Document for ratification.

STATEMENT OF PRINCIPLE (SOP'S)

Ballarat Health Services Statements of Principle are organisational policies that clearly outline the objectives of BHS in relation to areas of clinical care, strategic and governance, operational, physical infrastructure, financial, information management and human resource management.

There are six SOP’s:

• Principles Of Clinical Care
• Governance
• People and Culture
• Resources Management
• Information Management
• Redevelopment And Infrastructure

Policy (POL)-Underlying and giving effect to these statements of principle will be a consolidated series of high-level policies. The Policy will provide high level direction and guidance, set priorities and allocate responsibilities in key areas. The Policy sets out the rules for action (ie what should be done).

Other Documents -Supporting both the Statements of Principle and BHS Policy documents are a series of Guidelines and Protocols (clinical and non-clinical). These documents clearly outline the requirements of staff across the health service.

Clinical Practice Guideline (CPG) - CPGs are sets of non-mandatory principles or recommendations for the management of a particular clinical circumstance. CPGs will include particular recommendations for procedures or practices. They are developed to assist practitioners with decisions about appropriate health care practices for specific clinical circumstances, but do not replace their knowledge and skills.

Clinical Practice Protocol (CPP) - CPPs describe the ways in which staff are expected to implement a specific clinical practice (ie how to do it). A CPP will include procedural steps, decisions or algorithms relating to clinical practice, detailing instructions or requirements that are expected to be followed.

Non-clinical Guideline (NCG) – Non-clinical Guidelines are non-mandatory recommendations for management of specific non-clinical issues that can be used to assist staff to make a decision. Guidelines suggest how certain functions can be performed.

Non-clinical Protocol (NCP) - Non-clinical Protocols describe the ways in which staff are expected to implement a policy or guideline (ie how to do it). Protocols should provide a framework of the action required to achieve the goals, by detailing specific procedural steps/actions

Drug Guidelines (DRG's) - Drug Guidelines are described as the way in which staff are expected to administer a particular medication. They are based on Therapeutic guidelines and best practice. A DRG will include Exclusions, Generic and Trade names, Pharmacology and Phamacokinetics, Drug Interactions, Dosage and Administration, Adverse Effects and Presentations.

Manuals And Plans (MAPS) - Manuals and Plans are a comprehensive series of documents which cover a range of scenarios related to a specific topic or event.

Consumer Information Document (CID) - Template on which to store BHS produced consumer information which guides the purpose, use and distribution of those documents.

Governance Documentation Administrator – Person who has an organisational overview for the effective administration of the Governance documentation framework.

Super User – A super user will be allocated from each directorate to coordinate the governance documentation process inclusive of the approval for development of new documents, the review process for existing documents, the development of relevant stakeholder lists and assistance as required to the authors of the documents.

Owner – The person/ position responsible for the governance document.  This is the position that the alert for review of documents will be sent to for actioning.  The owner does not necessarily have to review the documents but has the responsibility to coordinate the review process.

Author – The person that writes/ reviews the document

Stakeholders – Individuals/departments that comment on documents that will either directly or indirectly affect them.

The current Ballarat Health Services Style Guide (2nd Edition 2018), is the recommended format for the development of a Governance Document and a copy of this guide can be sourced in Appendix 6.

The current review time line status of all Governance Documents (GD’s) are visible to all relevant Directors (Responsible Persons), Super Users, Document Owners and Authors.

The GDM system has the following automatic email alert time line system as each GD comes into the window time line for review:

• 6 months from review date of the GD the Author / Owner receives an email advising of the need for review of the GD with a hyperlink inclusion to log in to the GDM system
• 5 months from review date of the GD the Author / Owner receives an email advising of the need for review of the GD with a hyperlink inclusion to log in to the GDM system
• 4 months from review date of the GD the Author / Owner receives an email advising of the need for review of the GD with a hyperlink inclusion to log in to the GDM system
• 3 months from review date of the GD the Author / Owner receives an email advising of the need for review of the GD with a hyperlink inclusion to log in to the GDM system,
• 2 months from review date of the GD the Author / Owner receives an email advising of the need for review of the GD with a hyperlink inclusion to log in to the GDM system,
• 1 month from review date the Owner/Author and Super User receives an email advising of the need for review of the GD with a hyperlink inclusion to log in to the GDM system,
• 2 weeks from review date the Owner/Author and Super User receives an email advising of the need for review of the GD with a hyperlink inclusion to log in to the GDM system,
• 1 week from review date the Owner/Author and Super User receives an email advising of the need for review of the GD with a hyperlink inclusion to log in to the GDM system,
• At the review / expiry date of the GD the Owner/Author, Super User and Director receives an email advising of the need for review of the GD with a hyperlink inclusion to log in to the GDM system and this email reminder repeats every 7 days until the review and ratification of the GD is completed.

Medical Records (MR) Forms are not to be uploaded as an Appendix attachment to a Governance Document and should be referenced by Form Number and Name within the content of the document only.
This is to ensure that only current, updated MR Forms are used for clinical documentation and that static copies, as Appendix items, are not printed and used.
Please see Appendix 8 for a link to the current library of MR forms - both paper based and electronic.

Submitting a new Governance Document Proposal:
To access the information for the GDMS V2 upgraded Governance Document Manager System, see Appendix 1.

Completion of a new Governance Document for ratification:

To view the Governance Documentation Online Ratification Power Point guide, see Appendix 2.

To access the new Governance Document request checklist, see Appendix 3.

Process for review and ratification:

For a Governance Documentation Review Checklist, see Appendix 4.

1.     The document is reviewed and changes made as required by the owner/author

2.     Stakeholders are allocated to review the relevant document

3.     Stakeholders review the document and make appropriate comments

4.     Comments are reviewed by the owner/author and accepted or rejected as appropriate

5.     Document dates are finalised and the document is progressed for ratification to the appropriate regulatory authority

• All Corporate Governance documents finalised for ratification are submitted to the Corporate Online Review Group on the first Monday of each month, for online ratification by the second Friday of that month.

• All clinical documents finalised for ratification are submitted to the Clinical  Online Review Group on the second Monday of each month, for online ratification by the third Friday of that month.

• All drug guidelines ready for ratification are submitted to the medication Safety & Therapeutics Committee (MSTC) monthly.

6.     Once the document is ratified by the appropriate Regulatory Authority the following tasks will be undertaken:

• It will be published on the intranet from 1 to 5 years by a Centre for Safety and Innovation (CSI) Administrator (see Appendix 5),

• The previous document version on the intranet will be retired,

• The document owner will be sent a courtesy email advising of the Ratification of the document, publication to the Intranet and subsequent retirement of the previous version of the document if applicable.

7.     If the reviewed document is not approved by the Relevant Authority, the reasons why will be forwarded to the owner/author for follow up. The document will be returned for further development.

8.     Once the Document Owner / Author has completed the review of these recommended amendments the process is completed and the following will occur:

• If the document was ratified pending changes it will be published to the Intranet with the 3 year review date from time of publication (unless otherwise advised).

• If the document was rejected with no ratification quorum reached it will be resubmitted for ratification at the next scheduled Regulatory Authority meeting or Online Review date.

Printed and Filed Copies of Governance Documents:

The Governance Documentation Search Page on the BHS Intranet/Internet is considered the single point of truth source version of all current documents.
However, there is a need at times to print and store hard copy Versions of high Risk Documents that need to be accessed at short notice as determined per department.
Appendix 7 provides a monthly hard copy checklist for these documents that need to be checked every month and signed off as the current version as per the the Governance Documentation Search Page.
A periodic Audit will be undertaken to ensure the current Version of the printed copies of Governance Documents is maintained at all times.