Assessing organisational ISG policies and procedures for content and quality
This is the third in a set of documents to assist organisations in implementing the South Australian Government’s Information Sharing Guidelines
for Promoting Safety and Wellbeing (ISG). It follows on from the Information Sharing Guidelines, and the Guide to Writing an ISG Appendix.
Following is a simple but powerful audit tool. It can be used to assist with the drafting of the ISG Appendix document, as a final check when the
Appendix is complete or as an organisation’s preparation for quality auditing processes such as the Service Excellence Program.
It has been developed with extensive practical advice from organisations and experienced quality auditors.
There is no generic template dictating the form of an organisation’s ISG Appendix so you are free to develop your own Appendix as you would any
other organisational procedure. This assessment tool is a solid final check for an organisation that it is fully aligned with the ISG.
It will be useful to all Government agencies that are required to implement the ISG.
It will be of particular assistance to NGOs who are funded by the South Australian Government to provide services to families and are signatories
to the Master Agreement and are required to implement the ISG (Clause 45 Information Sharing).
The Ombudsman SA website has copies of the Information Sharing Guidelines and the Guide to Writing an Appendix for download as well as fact
sheets and other tools and resources.
For advice and assistance contact the SA Principal Advisor, Information Sharing on telephone (08) 8226 8699 or toll free 1800 182 150
(outside metro SA only)email: isg@ombudsman.sa.gov.au
Each of the eight requirements and their sub-sections are listed in the left hand column and next to each sub-section is the evidence that
demonstrates that the requirement has been met. There is a compliance check box for each requirement and the right hand column provides
space for recording the action to be taken is the requirement has not been met.
RATING:
C=Compliant
PC=Partially Compliant
NC= Non-compliant
1. ISG APPENDIX
The ISG Appendix is the procedure each organisation develops to explain to their staff, within the context of their
organisation and services, how to interpret and implement the ISG.
0B
REQUIREMENTS
5B
1.1 An ISG Appendix has
been developed.
EVIDENCE
6B
Organisational policies and procedures (Appendix)
has been completed to guide staff in implementing
the ISG approach to sharing of personal information
(sometimes referred to as ‘disclosure of personal
information’).
The ISG Appendix includes:
•
protocols for gaining consent from clients
and for discussing limited confidentiality
•
following lines of approval/supervision
•
documentation practice
•
examples of case studies
•
cultural guidance.
•
ISG Decision Making Steps and Practice
Guide (see www.ombudsman.sa.gov.au)
RATING
7B
REMEDIAL ACTION REQUIRED
8B
C
PC
NC
Note:
Related policies and procedures that need to be cross referenced and updated to reflect the ISG may include:
Confidentiality and Privacy, Supervision, Client Record Keeping, Staff Induction, Complaints, Supervision Learning and Development for Volunteers, Child
Safe Environments, Client Services Policy, Child Protection Policy, Cultural Competence Policy, Code of Conduct, Collaboration & Strategic Positioning, DV
& Family Violence Policy, Client Safety Policy, Client Induction Checklist, Authority to Share Information form, Management of Personal Information, Student
Placement and Work Experience, Information Sharing for Volunteers and Students.
RATING:
C=Compliant
PC=Partially Compliant
NC= Non-compliant
2. PROTOCOLS FOR GAINING CONSENT AND DISCUSSING LIMITED CONFIDENTIALITY
The ISG Appendix includes guidance to staff and volunteers about gaining informed consent and discussing limited
confidentiality. Relevant policies and procedures are referenced.
9B
REQUIREMENTS
10B
2.1 Guidance is provided
about the general
considerations of
informed consent.
EVIDENCE
11B
RATING
12B
The Appendix describes the general considerations
of obtaining and monitoring informed consent
(reference ISG page 14-15).
C
A statement similar to the following is used on
consent forms :
NC
This agency/organisation follows the SA
Government Information Sharing Guidelines for
Promoting Safety and Wellbeing (ISG). This means
that this organisation will work closely with other
agencies to coordinate the best support for you and
your family. Under the ISG your informed consent
for the sharing of information will be sought and
respected in all situations unless:
•
it is unsafe or impossible to gain consent or
consent has been refused; and
•
without information being shared, it is
anticipated a child, young person or adult
will be at risk of serious harm, abuse or
neglect, or pose a risk to their own or public
safety.
PC
REMEDIAL ACTION REQUIRED
13B
RATING:
C=Compliant
REQUIREMENTS
14B
PC=Partially Compliant
EVIDENCE
15B
NC= Non-compliant
RATING
16B
(2.1 continued) Guidance
is provided about the
general considerations of
informed consent.
Records of seeking consent are kept – this may
include a signed consent form, client file notes or a
written record of verbal consent. There is evidence
staff have discussion with all clients about consent
and their rights to privacy.
C
2.2 Guidance is provided
about Privacy and
Confidentiality
principles and
procedures, and also
about appropriate
information sharing
practice when
interacting with
clients.
The Appendix describes how:
C
•
Clients are to be provided with information
that explains their consent to share
information will be sought unless it is unsafe
or impossible to do so.
•
Clients are to be informed that their
information may be shared without consent
if it is anticipated a child, young person or
adult may be at risk of serious harm, abuse,
or neglect, or there is a risk to public safety.
•
Clients are to be advised with whom their
information may be shared, for what
purpose and what may happen for them (or
their family) as a result of the disclosure.
•
Clients are to be provided with information
about their right to complain and how to do
so if they believe their information has been
inappropriately disclosed.
PC
NC
PC
NC
REMEDIAL ACTION REQUIRED
17B
RATING:
C=Compliant
REQUIREMENTS
18B
2.3 Privacy and
Confidentiality
policies and
procedures are in
place.
PC=Partially Compliant
EVIDENCE
19B
Organisational Privacy and Confidentiality policies
and procedures:
•
pay regard to the preservation of an
individual’s privacy whilst ensuring safety
and wellbeing.
•
outline responsibilities and provide direction
about how to meet requirements for
protecting privacy (as defined by the ISG
approved by Cabinet October 2008, South
Australian Privacy Principles, and
Commonwealth Privacy Act).
•
make reference to personal information
being shared when it is agreed that risk is
serious and anticipated – but not
necessarily imminent. (Note: the SA Privacy
Committee has granted an exemption to the
test of imminence (Privacy Principle 10b) for
agencies implementing the ISG. The
Commonwealth Privacy Commissioner has
made a Public Interest Determination that
allows NGOs to implement the ISG.)
•
provide guidance about seeking informed
consent and explaining to clients the limits
of professional confidentiality.
•
roles, resources and related policies that
support staff and volunteers in making
appropriate information sharing decisions
are noted or cross referenced.
NC= Non-compliant
RATING
20B
C
PC
NC
REMEDIAL ACTION REQUIRED
21B
RATING:
C=Compliant
PC=Partially Compliant
NC= Non-compliant
3. FOLLOWING LINES OF APPROVAL AND SUPERVISION
Decisions to share information without consent or refusal to share information must be approved by an appropriate
line manager. This section of the Appendix should clearly define relevant protocols and explain who can support and
approve information sharing decisions.
22B
REQUIREMENTS
23B
3.1Policies and
procedures detailing
the requirement to
seek authorisation for
the disclosure of
personal information
without client consent
or refusing to share
are in place.
EVIDENCE
24B
The ISG Appendix and related policies and
procedures clearly describe:
•
circumstances when information sharing
without consent or refusing to share would
be justified (see ISG pp 8 and 9)
•
the requirement for seeking support and
approval to share information without
consent and when refusing to disclose
information
•
who to go to and how to seek authorisation
for refusal or sharing without consent
•
what documentation is required
•
specific protocols for volunteers and who
authorises and shares information for them
when they have wellbeing and safety
concerns
RATING
25B
C
PC
NC
REMEDIAL ACTION REQUIRED
26B
RATING:
C=Compliant
REQUIREMENTS
27B
3.2 Staff with
responsibilities for
supporting and
approving information
sharing decisions are
identified and
appropriately
inducted
PC=Partially Compliant
EVIDENCE
28B
Staff responsible for authorising sharing without
consent or refusal to share are aware of their
responsibilities, have received appropriate training,
and provide necessary support to operational staff
and volunteers.
NC= Non-compliant
RATING
29B
C
PC
NC
Job and Person specifications describe
responsibilities for supporting and approving
information sharing decisions.
Information is available that directs staff to the
people in the organisation who can assist them to
make decisions about information sharing.
If a relevant line manager is not available,
information is available to clarify who else in the
organisation can support information sharing
decisions and provide necessary approvals.
There is dispute resolution for when information
sharing decisions cannot be agreed (ISG p 21).
3.3 Records of approval
for sharing without
consent and refusal
to share information
are kept (see
documentation
practice).
Records are kept detailing:
• the purpose (the immediate or anticipated
risk the information was intended to
address)
• why consent was not obtained
• who authorised information sharing without
consent or refusal to share
• why information sharing was refused
• what was shared, when, and by whom
• agencies and contact people involved
• outcomes and/or follow up
C
PC
NC
REMEDIAL ACTION REQUIRED
30B
RATING:
C=Compliant
PC=Partially Compliant
NC= Non-compliant
4. DOCUMENTATION PRACTICE
Step 9 of the ISG Decision Making Steps asks: “Has the information sharing decision been recorded?”
31B
As a minimum, decisions to share without consent and refusal to share must be recorded. It is preferable that other
important steps in information sharing are also recorded. Information sharing and documentation must be secure.
32B
REQUIREMENTS
33B
4.1 Policies and
procedures detailing
secure record
keeping and sharing
of client information
are in place.
EVIDENCE
34B
RATING
35B
R
The ISG Appendix and related organisational
policies and procedures provide clear instruction for
secure record keeping practice (this may include
client files, case notes, electronic data bases and
paper forms).
Staff and volunteers know what to record and where
to record it.
Client records are secure.
Information sharing practice is secure.
C
PC
NC
ATING
REMEDIAL ACTION REQUIRED
36B
REMEDIAL ACTION REQUIRED
38B
RATING:
C=Compliant
REQUIREMENTS
39B
4.2 Protocols and
systems ensure
records of information
sharing are kept. As
an absolute minimum,
records must be kept
when client
information is shared
without consent and
when information
sharing is refused.
4.3 Documentation
provides evidence of
appropriate information
sharing practice.
PC=Partially Compliant
EVIDENCE
40B
NC= Non-compliant
RATING
41B
Case files, client records, or other relevant forms of
documentation used by the organisation record
when client information is shared without consent or
where refusal to share occurs.
The Appendix and related policies and procedures
also state it is preferable to record all significant
information sharing decisions such as:
• if consent was sought
• reasons for overriding the client’s wishes or
for not seeking consent
• advice received or requested from others
(including staff at the Child Abuse Report
Line)
• reasons for not agreeing to an information
sharing request
• what information was shared, when, and by
whom
• the purpose (the immediate or anticipated
risk the request was intended to address)
• why consent was not obtained
• who authorised information sharing without
consent or refusal to share
• why information sharing was refused
• agencies and contact people involved
• outcomes and/or follow up
C
Documentation has evidence that the ISG Decision
Making Steps And Practice Guide is being followed
by staff and volunteers.
C
PC
NC
PC
NC
REMEDIAL ACTION REQUIRED
42B
RATING:
C=Compliant
PC=Partially Compliant
NC= Non-compliant
5. CASE STUDIES
Case studies should describe the practical application of the ISG and illustrate appropriate information sharing
practice.
1B
REQUIREMENTS
43B
5.1 Case studies describe
circumstances where
the ISG is
appropriately
implemented.
EVIDENCE
44B
Case studies explain information sharing practice
according to the ISG.
Case studies provide examples where:
•
informed consent is sought and granted
•
information sharing without consent is
justified
•
information sharing would be refused
•
gaining consent is impossible or dangerous
•
improved service coordination that can
result from improved information sharing
•
consequences for clients of inadequate or
inappropriate information sharing practice.
Case studies follow approved organisational policies
and procedures for sharing information and follow
the ISG STAR principles.
Case studies are de-identified.
RATING
45B
C
PC
NC
REMEDIAL ACTION REQUIRED
46B
RATING:
C=Compliant
REQUIREMENTS
47B
(5.1 continued) Case
studies describe
circumstances where the
ISG is appropriately
implemented
PC=Partially Compliant
EVIDENCE
48B
Case studies reflect information sharing that is
legitimate – for example:
•
to give a more effective service
•
alert a provider to an individual’s need for a
service
•
avoid duplication or compromising of
services
•
divert a child, young person or adult from
offending or harming themselves
•
protect groups of children, young people
and adults from potential harm
•
protect community members from potential
harm
•
protect providers in situations of danger
•
protect a child, young person or adult from
being abused or neglected.
NC= Non-compliant
RATING
49B
REMEDIAL ACTION REQUIRED
50B
RATING:
C=Compliant
PC=Partially Compliant
NC= Non-compliant
6. CULTURAL GUIDANCE
In order to respond appropriately to the needs of people from culturally diverse backgrounds, it is critical that
agencies and organisations respond in a culturally appropriate manner and increase their level of cultural
competence.
2B
REQUIREMENTS
51B
6.1 There are resources
available to support
and guide staff in
responding to the
needs of people from
culturally diverse
backgrounds.
EVIDENCE
52B
RATING
53B
The ISG Appendix provides recommendations
about sources for cultural guidance and promotes
the principles of cultural respect.
C
Relevant organisational policies and procedures are
cited.
NC
Advice is given about available resources for
cultural guidance (see A Guide to Writing an ISG
Appendix p 24)
PC
REMEDIAL ACTION REQUIRED
54B
RATING:
C=Compliant
PC=Partially Compliant
NC= Non-compliant
7. INDUCTING STAFF AND VOLUNTEERS
Training and induction to the ISG and Appendix needs to be provided to all relevant staff and volunteers.
3B
REQUIREMENTS
55B
7.1 Staff and volunteers
are inducted into ISG
policies and
procedures
EVIDENCE
56B
RATING
57B
Induction programs and training about information
sharing are provided to all relevant staff and
volunteers.
C
There is evidence that staff and volunteers have
been inducted and that induction is ongoing.
NC
PC
REMEDIAL ACTION REQUIRED
58B
RATING:
C=Compliant
PC=Partially Compliant
NC= Non-compliant
8. ISG DECISION MAKING STEPS AND PRACTICE GUIDE (available at www.ombudsman.sa.gov.au)
The ISG Decision Making Steps is the process to be followed for appropriate information sharing. The Practice Guide
assists staff in following the ISG step by step approach. Both of these documents should be included in the Appendix.
4B
REQUIREMENTS
59B
8.1 Staff and volunteers
are provided and
follow the ISG
Decision Making
Steps and Practice
Guide
EVIDENCE
60B
The ISG Decision Making Steps and Practice Guide
is included in the organisation ISG Appendix.
There is evidence (see documentation practice) that
Decision Making Steps are followed.
ISG resources including copies of the ISG Decision
Making Steps and Practice Guide are available to
staff and volunteers.
RATING
61B
C
PC
NC
REMEDIAL ACTION REQUIRED
62B