Document facilitator: Chief Legal Officer
Senior document owner: HHS Committee
Document number: ID 1.8357
Issue Date: 29 June 2020
Review Date: 29 June 2023
Type:
Policy
Name:
Legislative compliance
Policy
Capital and Coast District Health Board (CCDHB) is committed to complying with all
relevant legislation and applicable laws. In addition, all employees have a
responsibility to ensure their activities on behalf of CCDHB comply with legislation
and applicable laws.
The aim of the Legislative Compliance policy and programme is to:
Facilitate legislative compliance and provide employees with access to the
information they need to ensure that they are acting within the law in their
day-to-day work activities, including CCDHB’s relevant policies, procedures
and processes.
Provide for timely monitoring and reporting on CCDHB’s compliance with key
legislation within CCDHB’s risk management reporting system.
Ensure measures are taken to mitigate and identify risks associated with
non-compliance with legislative obligations and ensure ongoing compliance.
Ensure that CCDHB policies and procedures comply with relevant legislation.
Enable CCDHB to demonstrate it is taking reasonable steps to monitor and
ensure compliance with all relevant legislation and other laws. Provide the
Chief Executive (CE), Board members and other stakeholders with
reasonable assurance that CCDHB is complying with all relevant legislation
and other legal obligations.
Scope
This policy applies to all Board members, employees and all persons working within
or for CCDHB. This includes but is not limited to:
Volunteers
Contractors
Access holders
Temporary agency employees
Students
Visiting health professionals
status holders
Legislative compliance policy
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Document facilitator: Chief Legal Officer
Senior document owner: HHS Committee
Document number: ID 1.8357
Issue Date: 29 June 2020
Review Date: 29 June 2023
Definitions
Relevant legislation
Includes Acts, subordinate Regulations, Standards and Codes.
Employee
For the purpose of this Policy the term “employee” is used to include all persons who
work within CCDHB and/or who are identified in the scope above.
Principles
There is a substantial number of Acts and Regulations that apply to CCDHB
representing differing levels of risk to the organisation and individual employees.
The legislative compliance programme establishes a framework which identifies the
key legislative and other legal requirements with which CCDHB and individual
employees must comply. The programme is an integral component of CCDHB’s risk
management strategy and processes and quality and governance systems, and is
based on the following principles:
Accountability – All employees are accountable for understanding and
complying with the legal and regulatory framework applicable to CCDHB and
their own actions and work activities.
Risk identification and management – Each employee is responsible for
identifying and reporting legal compliance risks in their workplace and
ensuring appropriate measures are taken (within their sphere of responsibility)
to mitigate identified compliance issues. The legislative compliance
programme will facilitate identification of non-compliance with legislation and
provide employees with access to the information they need to ensure that
they are acting within the law.
Monitoring – The legislative compliance manual, policies and procedures will
be monitored on an on-going basis to ensure compliance with relevant
legislation.
Reporting - CCDHB’s compliance with key legislation will be monitored and
reported on within CCDHB’s risk management reporting system and the
annual legislative compliance reports to be provided by Executive Leadership
Team members who are allocated owners of the legislative compliance
obligations in their areas of responsibility.
The risks to CCDHB and individual employees from non compliance with legislation
include:
Patient Safety
Risks to employees and visitors
Reputational risk
Political risk
Financial penalties
Legal action
Personal liability of employees and Board members
Legislative compliance policy
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CapitalDoc ID 1.8357
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Chief Legal Officer
Senior document owner: HHS Committee
Document number: ID 1.8357
Issue Date: 29 June 2020
Review Date: 29 June 2023
Roles and responsibilities
The responsibilities of employees are reinforced by specific mention in job
descriptions and service orientation. This is
not a complete list but an indicative
aide.
CCDHB Board
Is ultimately accountable and responsible for risk management and ensuring
there are adequate systems in place to identify, monitor, and report on risks
including legislative compliance and statutory obligations.
Financial, Risk and Audit Committee of the Board
The Financial, Risk and Audit Committee is a committee of the Board and on its
behalf ensures that CCDHB has risk management policies and processes,
including legislative compliance in place, and that CCDHB’s risks are effectively
managed.
Chief Executive (CE)
Responsible to the CCDHB Board for legislative compliance and ensuring
CCDHB maintains a legislative compliance programme.
Delegate responsibility for overseeing legislative compliance management for the
hospitals and health services to the Executive Leadership Team (ELT).
Notify the Board of any significant non-compliance issues and provides “sign-off”
to the Board on the status of legislative compliance at CCDHB.
Professional Heads
The Chief Medical Officer, Chief Nursing Officer, Chief Allied Health Officer will
ensure compliance with professional body requirements.
ELT (including Executive Directors, Professional Heads and GM MHAIDS)
Ensure the Legislative Compliance Policy and programme is operational at all
levels of the organisation, but in particular in those compliance areas for which
they have been allocated individual responsibility.
Delegate responsibility for overseeing legislative compliance management to
Clinical leaders, business managers and Quality Leaders within their directorates
Provide “sign-off” to the CE in an annual report on the existence of adequate
policies, procedures and practices to ensure legislative compliance (see the
annual report form in Appendix 1).
Ensure non-compliance with legal obligations is identified, reported on and
managed in accordance with this Policy and the Risk Management Policy.
Notify the CE of any significant non-compliance issues.
Identify legislative compliance training and educational needs within the individual
ELT Member’s services and ensure that Team Leaders and employees are
appropriately orientated, trained and resourced to meet their legislative
compliance obligations and responsibilities.
Legislative compliance policy
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CapitalDoc ID 1.8357
Regard printed versions of this document as out of date – The CapitalDoc
document is the most current version
Document facilitator: Chief Legal Officer
Senior document owner: HHS Committee
Document number: ID 1.8357
Issue Date: 29 June 2020
Review Date: 29 June 2023
Quality Improvement and Patient Safety
Support the introduction and ongoing implementation of the Legislative
Compliance Policy and programme at all levels of the organisation.
Coordinate the reporting of significant legal risks identified in the risk register
reports to the Chief Legal Officer
Chief Legal Officer
Responsible for maintaining the Legislative Compliance Policy and ensuring
annual updates of the Legislative Compliance Manual
Legislation Compliance
Manual Capital and Coast District Health Board
Monitor and advise on relevant legislative changes as they occur.
Advise on legal issues in relation to legislative compliance.
Provide information and support on legal compliance matters to all Directorates
and services of the DHB.
Responsible for ensuring new legislation, or relevant changes to current
legislation and other legal obligations, is promulgated through the organisation in
a timely fashion.
Review CCDHB policies for compliance with legislation as part of the policy
review process
Collating of annual legislative compliance reports from the ELT and monitoring
and reporting on legislative compliance to the CE.
Policy Facilitators
Notify CCDHB Legal Services as part of a policy review process to ensure that
the policy complies with all relevant legislation.
All employees
Participate in any legislative compliance training and maintain an awareness of
their legislative compliance obligations.
Demonstrate awareness and understanding of the Legislative Compliance Policy
and programme.
Responsible for ensuring they provide services that comply with all their legal
obligations when undertaking work activities for CCDHB.
Take prompt action to minimise or prevent non-compliance with legislative
obligations within their areas of responsibility and authority.
Notify the Team Leader/Business Manager/Clinical Director immediately of non-
compliance issues in accordance with the reporting requirements in this Policy
and the Risk Management Policy.
Legislative compliance process
The legislative compliance process includes:
Maintaining an up-to-date Legislative Compliance Manual of applicable
legislation .
Legislation Compliance Manual Capital and Coast District Health Board
Legislative compliance policy
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CapitalDoc ID 1.8357
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document is the most current version
Document facilitator: Chief Legal Officer
Senior document owner: HHS Committee
Document number: ID 1.8357
Issue Date: 29 June 2020
Review Date: 29 June 2023
Monitoring of legal requirements and changes to relevant legislation to ensure
that any relevant changes are reflected in CCDHB policies and procedures
and are disseminated to persons who need to know.
Reporting of non-compliance through CCDHB’s risk management reporting
system.
ELT members reporting on legislative compliance in those areas for which
they have been allocated individual responsibility. (The form of the annual
reports for ELT members is set out in Appendix 1).
Training for employees on key legislation and their responsibilities.
Reporting
The legislative compliance programme is an integral component of the risk
management system. Reporting of legislative compliance risks occurs through the
risk reporting system – (refer to CCDHB’s Risk Management Policy for the timing of
risk reporting).
In addition, assurance of the existence and adherence to CCDHB policies,
procedures and processes and reporting of any non-compliances is made through
the annual reports by the ELT to the CE. ELT members are expected to make
reasonable inquiries in the areas for which they are responsible. ELT members may
however rely on assurances and information from ELT colleagues and other CCDHB
managers when they provide their annual reports.
The annual reports are collated by the Chief Legal Officer and form part of the Chief
Legal Officer’s reporting on legislative compliance to the CE. The annual reports
should be provided ahead of the final audit each year.
The form of the annual reports can be found at Appendix 1.
Related documents
CCDHB documents:
Risk Management Policy
Other documents:
Legislation Compliance Manual Capital and Coast District Health Board
Table allocating legislative compliance responsibilities of ELT members
References:
Standards Australia and Standards New Zealand Legal Risk Management Handbook
HB 296:2007
Standards Australia and Standards New Zealand Australian/New Zealand
Handbook. Risk Management Guidelines Companion to AS/NZ 4360:2004
Disclaimer: This document has been developed by Capital & Coast District Health
Board (CCDHB) specifically for its own use. Use of this document and any reliance
on the information contained therein by any third party is at their own risk and
CCDHB assumes no responsibility whatsoever.
Legislative compliance policy
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Document facilitator: Chief Legal Officer
Senior document owner: HHS Committee
Document number: ID 1.8357
Issue Date: 29 June 2020
Review Date: 29 June 2023
ANNUAL LEGISLATIVE COMPLIANCE REPORT
I have read the sections of the Legislative Compliance Manual where primary
responsibility for reporting on compliance with the legislative obligations has been
allocated to me.
CCDHB meets its legislative obligations through the development, maintenance and
compliance with policies, procedures and other processes. These policies and
processes may be very specific to particular areas or activities, or they may apply
generally across large parts of CCDHB, or to the whole organisation.
I have made due inquiry with the service leaders and managers in my Directorate,
and with relevant ELT colleagues, about the policies, procedures and processes
necessary to ensure compliance with the sections of the Legislative Compliance
Manual where I have been allocated responsibility for reporting on compliance.
I confirm:
(1) CCDHB has policies, procedures and processes in place to ensure
compliance with the legislative obligations where the primary responsibility for
reporting on compliance has been allocated to me; and
(2) I have not been made aware of any material or systemic failures in the
implementation of the policies, procudures and process that CCDHB is relying
on to ensure compliance with these legislative obligations.
The exceptions (apart from those already listed in the risk register) are (if any):
ELT Member
Date
Material or systemic non-compliance issues of concern for the Directorate
Please list here if any:
Legislative compliance policy
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