Information sheet
Hospital and Health Service legislated powers and compliance
(Working document provided for illustrative purposes only)
Purpose
This document has been prepared to help identify some of the key legislative powers and compliance requirements for a Hospital and Health Service (HHS/Service). There
are three tables, which include:
Table 1 (pp 2-6):
the key legislated functions and powers of HHSs and who is accountable
Table 2 (pp 7-32):
the legal and administrative framework within which HHSs (as statutory bodies) operate, describing key compliance requirements
Table 3 (pp 33-35):
useful reference documents to assist HHSs to identify and meet their legislated and broader compliance requirements.
It is a working document provided for illustrative purposes to assist HHSs in their development of a compliance register. It is not comprehensive and should not be relied on as
a source document in its own right – original documentation should be consulted and legal advice obtained if required.
Note: hyperlinks are provided in this document to legislation and reference documents – hyperlinks are indicated by blue text with underlining. Press the ‘Ctrl’ key and then
click on the blue text with your mouse to open the document in a new page.
Revision history
Version
Date
Nature of amendments
v.0.6
30/03/12
Initial working draft published on EPM. Outstanding matters highlighted in yellow.
v.0.8
20/04/12
This version provides additional information, including regarding the Integrity Act 2009 and Public Interests Disclosure Act 2010 and
clarifies the matters highlighted in yellow in the previous version, etc.
v.0.9
10/05/12
Updated Table 2 to include obligations under the Worker’s Compensation and Rehabilitation Act, Fire and Rescue Services Act,
Electrical Safety Act, Building Act, etc, and application of Whole of Government Public Works policies.
v.0.10
20/11/12
Updated naming conventions, inclusion of new provisions of amended legislation (e.g. employment arrangements, ownership of land and
buildings) and new regulation, etc.
v.0.11
28/04/14
Updated to reflect amended/new whole-of-government policies and resources. Noting rescinded policies and amended applicability to
HHSs e.g. due to rescinded health service directives. Updated links to current Queensland legislation. Amendments marked in tracked
changes and/or highlighted in yellow.
TABLE 1: HHS functions, powers and accountability
Table 1 provides an illustrative list of the key functions and powers of HHSs as articulated in the Hospital and Health Boards Act 2011 (HHB Act) and other Acts and who is
accountable for the authority, function or power. Where provided for under the HHB Act, certain authority, functions and powers can be delegated by that entity or person to
another entity or person. Refer to local instruments of delegation and delegation manuals or for general information, refer to information sheet 8.3 ‘Hospital and Health Service
delegations’ (http://www.health.qld.gov.au/ohsa/html/8-3-delegations.asp). Note: a key difference between a statutory body and a department is that a statutory body does not
have an accountable officer who parallels the role of the CEO or DG of a department unless the Treasurer appoints one. The entity itself (represented by the Board) is
accountable to the Minister and Parliament for the performance and actions of the entity.
Table 1: HHS functions, powers and accountability
Reference
Power
Accountability
Hospital and Health Boards Act 2011
(Enabling legislation for HHSs which sets out the purpose and specific powers of Services and management of the public sector health system. The Act implements the Queensland Government’s legislative
commitments that stem from the COAG Inter-Governmental National Health Reform Agreement, as agreed in August 2011.)
Section 18 ‘Legal status’
A Service is a body corporate representing the State with the privileges and immunities of the State. A Service may sue and be sued in its own name.
Section 19 ‘Functions of
Services’
States the functions of a HHS. The main function is to deliver the hospital services, other health services, teaching, research and other services stated in
the service agreement for the Service. Other key Service functions include:
- ensure the operations of the Service are carried out efficiently, effectively and economically
- enter into a service agreement with the Chief Executive
- comply with the health service directives that apply to the Service
- contribute to, and implement, State-wide service plans that apply to the Service and undertake further service planning that aligns with the State-wide
plans
- to monitor and improve the quality of health services delivered by the Service, including, for example, by implementing national clinical standards for
the Service
- develop local clinical governance arrangements for the Service
- undertake minor capital works, and major capital works approved by the Chief Executive, in the health service area
- maintain land, buildings and other assets owned by the Service
- for a prescribed Service, employ staff under this Act
- cooperate with other providers of health services, including other Services, the department and providers of primary healthcare, in planning for, and
delivering, health services
- cooperate with local primary healthcare organisations
- to arrange for the provision of health services to public patients in private health facilities
- manage the performance of the Service against the performance measures stated in the service agreement
- provide performance data and other data to the Chief Executive
- consult with health professionals working in the Service, health consumers and members of the community about the provision of health services
- other functions approved by the Minister
- other functions necessary or incidental to the above functions.
Board
Section 20 ‘Powers of
Services’
Provides for the power of Services. Generally, Services have the power of an individual and may, for example, enter into contracts and agreements, and
acquire and dispose of property. Services may also employ health executives, and where prescribed by regulation, other health service employees.
Services may not own assets prescribed by regulation.
Note: section 20A places limitations on dealings with land and buildings.
Board
Section 22 ‘Role of exercising
control over Service’
A Board controls the Service for which it is established.
Board
Section 30 ‘Delegation by
Boards’
A Board may delegate the Service’s functions under this Act and the Financial Accountability Act 2009 to either a committee of the Board (if all of the
members of the committee are Board members); to the Executive Committee established by the Board; or to the Health Service Chief Executive. The
Board
Hospital and Health Service legislated powers and compliance
working document – not government policy – refer source documentation
-
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Table 1: HHS functions, powers and accountability
Reference
Power
Health Service Chief Executive, with the approval of the Board, may sub-delegate these functions to an appropriately qualified employee of the HHS; or to
a health service employee employed in the department and working for the Service.
Note: as the Board controls the Service for which it is established, the Board has the powers specified in the Act for its Service. Note: powers of delegation
of statutory bodies are not included in the Financial Accountability Act itself.
Accountability
Section 32A ‘Hospital and
Health Board must establish
executive committee for the
Hospital and Health Service’
A Board must establish, as a committee of the Board, an executive committee for the Service controlled by the Board.
Note: the executive committee’s functions are specified in section 32B ‘Function of executive committee’.
Board
Section 33 ‘Appointment of
Health Service Chief Executive’
A Board is to appoint a Health Service Chief Executive to manage the Service. The appointment is not effective until it is approved by the Minister. The
person appointed as the Health Service Chief Executive must also be appointed as a health executive. In managing the Service, the Health Service Chief
Executive is subject to direction by the Service’s Board.
Board
Section 34 ‘Delegation by
Health Service Chief Executive’
A Health Service Chief Executive may delegate the Health Service Chief Executive’s functions under this Act to an appropriately qualified employee of the
HHS; or health service employee employed in the department and working for the service (except for authorisation to disclose confidential information in
the public interest under section 160, which cannot be delegated).
Health Service
Chief Executive
Section 43A ‘Minister may
establish ancillary board’
This section gives the Minister power to establish a Hospital and Health Ancillary Board to give advice to a Hospital and Health Board in relation to: a public
sector hospital; or a public sector health facility; or a public sector health service; or a part of the State.
A regulation may prescribe matters relating to the establishment and operation of an ancillary board.
Minister
Section 44 ‘Minister may give
directions to Service’
The Minister may issue a direction to a Service about a matter relevant to the performance of its functions under this Act if it is in the public interest to do
so. The Minister may not give a direction about a health service provided to or the employment of an individual.
Minister
Section 44A ‘Minister may
appoint advisers to boards’
The Minister may appoint a person to be adviser to a Board if the Minister considers that the adviser may assist the Board to improve the performance of
the Board; or the Service controlled by the Board. Sections 44B – 44E deal with matters regarding the appointment of advisers, their functions, duty of
disclosure, and obligations of the Board in relation to advisers.
Minister
Section 46 ‘Delegation by Chief
Executive’
The departmental Chief Executive may delegate any of his/her functions (with the exception of three specified) to a Health Service Chief Executive. The
Health Service Chief Executive, with the written approval of the Chief Executive, may sub-delegate to an appropriately qualified Service health executive or
Service employee.
Departmental Chief
Executive
Section 56 ‘Appointment of
health service auditors’
A health service auditor may be appointed by a Health Service Chief Executive to undertake an audit in the Service.
Health Service
Chief Executive
Section 60 ‘Powers of health
service auditors’
A health service auditor may require an employee of the Service to give the auditor a document, including a document that contains confidential
information.
Health Service
Auditor
Section 64 ‘Reports by health
service auditors’
The Service must comply with any direction issued by the departmental Chief Executive after consideration of a report on a Service by a health service
auditor.
After considering the report of a health service auditor, the departmental Chief Executive or Health Service Chief Executive may take the action he or she
considers appropriate in relation to the matters identified in the report.
Board & Health
Service Chief
Executive
Section 65 ‘Chief Executive
may request report from Health
Service Chief Executive
A Health Service Chief Executive must give the departmental Chief Executive a copy of a health service audit report if requested to do so by the Chief
Executive.
Health Service
Chief Executive
Section 67 ‘Appointment of
health service employees’
A Service may appoint health executives in the Service. A prescribed Service may also appoint a person as a health service employee in the Service.
Division 2 ‘Health executive service’ outlines the purpose of the health executive service, principles of employment, basis of employment, and fixing of
remuneration packages and classification levels for health executives. The departmental Chief Executive sets the remuneration packages, classification
levels and terms and conditions of contracts of health executives. Section 75 ‘Exclusion of certain matters from review under other Acts’ provides that
appointment decisions regarding health executives, their contract of employment or the application of Part 5 of this Act to a health executive are not
industrial matters for the purposes of the Industrial Relations Act 1999. As ‘excluded matters’ they cannot be challenged, appealed, reviewed or called in
question under the Judicial Review Act 1991.
Board
Hospital and Health Service legislated powers and compliance
working document – not government policy – refer source documentation
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Table 1: HHS functions, powers and accountability
Reference
Power
Section 74 ‘Basis of
Each person appointed as a health executive employed by a Service (under section 67) (other than the Health Service Chief Executive) must enter into a
employment for health
written contract of employment with the Health Service Chief Executive.
executives’
Accountability
Health Service
Chief Executive &
Service Health
Executive
The Health Service Chief Executive must enter into a written contract of employment with the chair of the board for the Service. This section also sets out
what the contract of employment must state, and requirements for resignation or termination of a health executive’s appointment.
Board Chair &
Health Service
Chief Executive
Section 82 ‘Establishment of
quality assurance committee’
A Service may, for a matter relating to its functions, establish a quality assurance committee. This section outlines the criteria for establishing a committee
and requirement to notify the departmental Chief Executive in the approved form of the establishment of the committee under this section.
Note: section 83 outlines the restrictions on committees.
Note: Provision for procedures of committees, privacy principles, and review and reporting obligations are included in Part 5 of the Hospital and Health
Boards Regulation 2011.
Board
Section 84 ‘Disclosure of
information’
A committee member or a relevant person for a committee has a duty of confidentiality.
Sections 85 – 92 further outline restrictions around reports, documents and information provided to committees.
Quality Assurance
Committee
Members
Section 98 ‘Appointment of
RCA team’
The Health Service Chief Executive may appoint persons to be members of a Root Cause Analysis (RCA) team to conduct an RCA of a reportable event if
the event happens while a public sector health service is being provided by a Service.
Section 99 states the requirements that must be met in appointing an RCA team.
Sections 100-123 further outline conduct, requirements and reporting of an RCA and duties regarding disclosure or release of information, etc.
Health Service
Chief Executive
Section 125 ‘Appointment of
clinical reviewers’
A clinical reviewer may be appointed by the departmental Chief Executive or Health Service Chief Executive to undertake a clinical review in the Service.
Sections 125 – 138 set out the functions, powers, and duty of confidentiality of clinical reviewers; conduct and reporting of clinical reviews, etc.
Departmental Chief
Executive
Health Service
Chief Executive
Section 129 ‘Powers of clinical
reviews’
A clinical review may require an employee of the department or a Service to give the reviewer a document, including a document that contains confidential
information.
Clinical Reviewer
Section 160 ‘Disclosure of
confidential information in the
public interest’
A Health Service Chief Executive may authorise, in writing, the disclosure of confidential information in the public interest. This authority cannot be
delegated. The annual report of the Service must include a statement about the nature and purpose of any confidential information disclosed during the
financial year.
Health Service
Chief Executive
Sections 163 ‘Appointment of
authorised persons’
A Health Service Chief Executive may, in writing, appoint a person with the necessary expertise or experience to be an authorised person under this Act for
health services land under the control of the Service.
Health Service
Chief Executive
Section 164 ‘Appointment of
security officers’
A Health Service Chief Executive may, in writing, appoint a person with the necessary expertise or experience to be a security officer under this Act for
health services land under the control of the Service.
Sections 162 – 188 outline the conditions of appointment, powers, etc of authorised persons and security officers on health services land.
Health Service
Chief Executive
Section 169 ‘Identity cards’
An authorised person and a security officer must be issued an identity card by the appointer (Health Service Chief Executive), in the form specified in this
section.
Health Service
Chief Executive
Section 175 ‘Regulatory notice’
A Health Service Chief Executive may erect regulatory notices regulating the driving, parking or standing of vehicles on health services land. (A person on
health services land must comply with a regulatory notice unless the person has a reasonable excuse.)
Health Service
Chief Executive
Section 177 ‘Removal and
detention of illegally parked or
abandoned vehicles’
An authorised person may seize and remove an illegally parked or abandoned vehicle on health services land. As soon as is practicable and no later than
14 days after the vehicle is seized, a Health Service Chief Executive must give to the owner of the vehicle a written notice stating how the owner may
recover the vehicle. If the owner cannot be ascertained or located within this period, the notice may be given by publishing it in a newspaper.
Health Service
Chief Executive (or
authorised person
depending on
action taken)
Hospital and Health Service legislated powers and compliance
working document – not government policy – refer source documentation
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Table 1: HHS functions, powers and accountability
Reference
Power
Section 178 ‘Disposal of
If the owner of a seized vehicle does not recover the vehicle within 2 months after notice is given to the owner under section 177(4) and (5), a Health
unclaimed vehicles’
Service Chief Executive may sell the vehicle by public auction. Proceeds of sale must be applied as specified in section 179.
Accountability
Health Service
Chief Executive
Section 184 ‘Prohibition of
smoking’
A Health Service Chief Executive must not nominate a prohibited place as a smoking place.
Health Service
Chief Executive
Section 190 ‘Appointment of
health service investigators’
A health service investigator may be appointed by the departmental Chief Executive or by a Health Service Chief Executive to undertake an investigation in
the Service.
Part 9 ‘Health service investigators’ outlines the functions, powers, reporting requirements, etc. for health service investigators.
Departmental Chief
Executive or Health
Service Chief
Executive
Section 199 ‘Reports by health
service investigators’
After considering a report provided by a health service investigator, the Chief Executive or the Health Service Chief Executive may take the action he or
she considers appropriate in relation to the matters identified in the report.
Note: where the departmental Chief Executive has appointed an investigator to undertake an investigation in a Service, the Chief Executive may
subsequently issue directions to the Service as result of the investigation – the Service must comply with the direction.
Health Service
Chief Executive
Section 200 ‘Chief Executive
may request report from Health
Service Chief Executives’
A Health Service Chief Executive is required to give the departmental Chief Executive a copy of a health service investigation report if requested to do so
by the departmental Chief Executive.
Health Service
Chief Executive
Part 12, Division 1 ‘Transfer
notice’
This Division provides for the transfer of land and buildings between the Department of Health and HHSs.
Minister
Section 274 ‘Disclosure of
personal information of health
service employees and health
professionals’
A Service may disclose personal information held about a person who is, or was, a health service employee or health professional engaged in delivering a
public sector health service to another health agency (the department or a Service) if the information is relevant to the person’s suitability for employment
or engagement, with the other health agency.
Note: this section has the effect of being a disclosure permitted under an Act for the purposes of the Information Privacy Act 2009.
Board
Section 306 ‘Assistance must
be provided’
A Service must assist with the applications made under the Information Privacy Act 2009 and the Right to Information Act 2009 mentioned in sections 300
– 305 (i.e. that were in train immediately prior to commencement on 1 July 2012, including by providing documents relevant to the applications).
Board
Financial Accountability Act 2009
(A Service is a statutory body under this Act. The Act and its subordinate legislation establish the high level financial management and accountability obligations for all statutory bodies.)
Part 4 ‘Provisions applying to
departments and statutory
bodies’
Under section 61 ‘Functions of accountable officers and statutory bodies’ Hospital and Health Services (as statutory bodies) have the following functions:
- to achieve reasonable value for money by ensuring the operations of the statutory body are carried out efficiently, effectively and economically;
- to establish and maintain appropriate systems of internal control and risk management;
- to establish and keep funds and accounts in compliance with the prescribed requirements;
- to ensure annual financial statements are prepared, certified and tabled in Parliament in accordance with the prescribed requirements;
- to undertake planning and budgeting for the statutory body that is appropriate to the size of the statutory body;
- to perform other functions conferred on statutory bodies under this or another Act or a financial and performance management standard.
Board
Hospital Foundations Act 1982
(An Act to provide for the establishment and incorporation of bodies to hold property for and apply property to a continuing object within or associated with hospitals, to make provision with respect to the
administration of those bodies and for related purposes.)
Section 18 ‘Members of body
corporate’
This section specifies how the membership of a hospital foundation will be constituted. The Chair of the Hospital and Health Board for the Service (or their
nominee), for the hospital that is associated with the foundation, is a member of the hospital foundation.
Board Chair
Section 37 ‘Employees’
The secretary of a hospital foundation is to be a suitably senior officer of an associated hospital who is nominated by the Health Service Chief Executive of
the associated Hospital and Health Service.
Health Service
Chief Executive
Section 38 ‘Use of certain
officers and premises’
A hospital foundation may make use of employees, land, premises, office furniture and equipment occupied/owned/used in the associated Hospital and
Health Service on the terms and conditions agreed upon by the foundation and the Health Service Chief Executive.
Foundation &
Health Service
Chief Executive
Hospital and Health Service legislated powers and compliance
working document – not government policy – refer source documentation
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Table 1: HHS functions, powers and accountability
Reference
Power
Accountability
Information Privacy Act 2009
(The Act provides for the fair collection and handling in the public sector environment of personal information, and gives the public a right to apply to access and amend their own personal information.)
Section 31 ‘Health agency to
comply with NPPs’
A Service (as a health agency defined in Schedule 5) must comply with the National Privacy Principles (NPPs) in relation to the collection, storage, use and
disclosure of an individual’s personal information.
(NPPs: http://www.privacy.gov.au/materials/types/infosheets/view/6583)
Board
Note: according to section 32 ‘Noncompliance with particular NPPs’, HHSs will not have to comply with certain NPPs if the individual’s personal information
has previously been published or given for the purpose of publication by the individual.
Integrity Act 2009
(The Act covers the role and functions of the Integrity Commissioner, advice on ethics or integrity issues as well as advice for designated persons on integrity issues; and regulation of contact between lobbyists and
State or local government representatives.)
Section 15 ‘Request for advice’
A designated person may, by written request to the Integrity Commissioner, ask for the commissioner’s advice on an ethics or integrity issue, including
conflicts of interest.
Meaning of ‘designated person’ is defined in section 12 – Ministers, Parliamentary Secretaries, all MPs, statutory officers, Chief Executives, senior
executives, senior officers in government entities, other officers who have been nominated.
Note: Advice from the Integrity Commissioner suggests that Boards and Health Service Chief Executives are statutory office holders for the purpose of
section 12 and hence designated persons able to seek advice under section 15.
Note: Compliance requirements under this Act in relation to lobbying are referred to in Table 2 (page 19) below.
(Queensland Integrity Commissioner Website http://www.integrity.qld.gov.au/page/about-us/index.shtml)
Board /Health
Service Chief
Executive
Disaster Management Act 2003
(An Act to provide for matters relating to disaster management in the State, and for other purposes.)
Section 24 ‘Membership’
Amendments to this section, allow for persons who represent a Service to be represented on a District Disaster Management Group, having regard to
effective disaster management for the disaster district. Members are appointed by the Health Service Chief Executive of the Service the member
ecutive of the department,
and the chair of the district group, of the appo
28B).
Health Service
Chief Executive
Personal Injuries Proceedings Act 2002
(An Act to regulate particular claims for and awards of damages based on a liability for personal injuries, and for other purposes.)
Section 9A ‘Particular provision
for notice of a claim procedure
for medical negligence case’
This section relates to a claim based on a medical incident that is alleged to have given rise to personal injury. The claimant must give written notice (initial
notice) of the claim to the person against whom a proceeding based on the claim proposed to be started. If the place at which the medical incident
happened is the place under the control of a Service – the initial notice must be given to the Health Service Chief Executive of the Service.
Hospital and Health Service legislated powers and compliance
working document – not government policy – refer source documentation
Claimant and
Health Service
Chief Executive
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TABLE 2: Legal and administrative framework for HHS operation – key compliance requirements
Each statutory body is governed by its own enabling legislation, the Statutory Bodies Financial Arrangements Act 1982 (SBFA Act) as well as other legislative requirements
that are common to all statutory bodies. HHSs will also have additional obligations placed upon them (as depicted in the diagram below), for example, by the HHS service
agreement, common industrial framework, regulations made under the Hospital and Health Boards Act 2011 (HHB Act), and Health Service Directives issued by the Minister
or Departmental Chief Executive. Table 2 lists some of these key legislative and other compliance requirements that a Hospital and Health Service (as a statutory body) must
comply with – it is not a comprehensive list of obligations and therefore illustrative only.
Hospital and Health Service legislated powers and compliance
working document – not government policy – refer source documentation
-7-

Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
Accountability
Supporting documents / guidelines
STATE LEGISLATION
Hospital and Health Boards Act 2011
(Enabling legislation for HHSs which sets out the purpose and specific powers of Services and management of the public sector health system. The Act implements the Queensland Government’s legislative
commitments that stem from the COAG Inter-Governmental National Health Reform Agreement, as agreed in August 2011.)
Section 9 ‘Management of
health system
performance’
Services are individually accountable for their performance and are required to report on
their performance to the departmental Chief Executive (who is required by section 8 to
monitor Service performance).
Board
Section 13 ‘Guiding
principles of Act’
Describes the principles (replicated from the Health Services Act 1991) intended to guide the
achievement of the Act’s object. A person must have regard to the guiding principles when
performing a function or exercising a power under the Act.
All persons
performing a
function or
exercising a
power under the
Act
Section 20 ‘Powers of
Services’
A Service may not own assets prescribed by regulation.
A regulation may provide for, restrict, limit or impose conditions on the Service’s power to
employ health service employees.
Board
Section 20A ‘Limitation on
Service’s dealing with land
and buildings’
This section requires the approval of the Minister and the Treasurer for a Service to buy or
sell land or buildings. In addition, the prior written approval of the Minister and the Treasurer
is required to lease land and buildings from another person, or to lease land and buildings
owned by the Service, unless the lease is of a type prescribed under regulation.
Board
Section 31 ‘Members to
act in public interest’
Requires that a member of a Board must act impartially and in the public interest in
performing the member’s duties.
Board Members
Section 32 ‘Conduct of
business by Boards’
A Board is required to conduct its business in the way stated in Schedule 1 - which outlines
requirements for times and places of meetings, conduct of meetings, keeping of minutes of
meetings, establishment of committees, disclosure of interests, etc.
Board
Division 2A ‘Executive
committees’
A Board must establish, as a committee of the Board, an executive committee for the Service
controlled by the Board. This division sets out the functions of the executive committee, its
membership and how it is to conduct its business.
Note: Part 7 of the Hospital and Health Boards Regulation 2012 specifies other prescribed
committees of the board (see page 12 below).
Board
Section 35 ‘Chief
Executive and Service
must enter into service
agreements’
Requires that the departmental Chief Executive and each Service enter into a service
agreement for the Service, which must be signed on behalf of the Service by the Chair of the
Board. The service agreement must be for a term of not longer than three years (Section 36).
(The service agreement must outline the KPIs and measurements that HHSs are to achieve
and funding to be provided to the Service for the provision of services, etc. – refer section 16
‘Meaning of service agreement’.)
Note: the departmental Chief Executive and the Service must commence negotiations at
least six months before the expiry of the existing service agreement, to allow adequate time
Chair, Board (on
behalf of the
Service)
Hospital and Health Service legislated powers and compliance
The service agreement outlines the performance data and other data
to be provided by a Service to the departmental Chief Executive,
including how, and how often, the data is to be provided (refer to
section 16 ‘Meaning of Service Agreement’). The departmental Chief
Executive, in turn, is responsible for collating and validating the data
provided by Services, and for providing the data to the
Commonwealth and relevant Commonwealth entities, such as the
National Health Performance Authority.
Board System-Wide Induction Information Sheet 9.4 ‘Conflicts of
Interest’, including ‘Attachment 1 – Conflict of Interest Guideline’ and
template statement of board member interest forms.
Service Agreements are published on the Queensland Health
internet site at:
http://www.health.qld.gov.au/hhsserviceagreement/default.asp
working document – not government policy – refer source documentation
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Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
Accountability
Supporting documents / guidelines
for the terms of the agreement to be negotiated (refer section 37).
Note: the HSCE must take the Queensland Mental Health Commission’s whole-ofgovernment strategic plan into account when negotiating the service agreement to the extent
the agreements relate to the delivery of mental health and substance misuse services (refer
page 27 below).
Section 38 ‘Minister may
decide on terms of service
agreement’
The departmental Chief Executive and the Service are to immediately advise the Minister if
they can not agree on the terms of the agreement and which terms they can not agree on.
The Minister must then decide the terms and advise the Chief Executive and the Service.
Board
Section 39 ‘Procedure to
amend service agreement’
If the departmental Chief Executive or the HHS wants to amend the terms of the service
agreement, the party that wants the amendment must give written notice of the proposed
amendment to the other party. If they can not agree on the terms of the amendment, the
party wanting the amendment must immediately advise the Minister – who will make the final
decision – any terms decided by the Minister must be included in the agreement.
Board
Section 19 ‘Functions of
the Services’ and Section
40 ‘Engagement
strategies’ & Section 41
‘Review of strategies’
A Service must develop and publish two strategies, namely, a clinical engagement strategy,
and a consumer and community engagement strategy. These strategies must be developed
in consultation with health professionals, and health consumers and members of the
community, respectively. The strategies must meet the requirements prescribed under a
regulation (refer pp 11-12 below).
The Service must give effect to the strategies in performing its functions under the Act.
Services are also required to review each strategy at least once every three years (section
41), in consultation with the groups consulted for development purposes, as above.
The transitional provision in section 313 requires a Service to develop and publish each of
the strategies within 6 months after commencement of this section on 1 July 2012, i.e. by 31
December 2012.
Board
Requires a Service to use its best endeavours to agree on a protocol with local primary
healthcare organisations to promote cooperation in the planning and delivery of health
services. The protocol must satisfy any requirements prescribed by regulation for the
protocol and be published.
The Service must give effect to the protocol in performing its functions under the Act. The
protocol must be reviewed at least once every 3 years (section 43).
The transitional provision in section 314 requires a Service to use its best endeavours to
agree on and publish a protocol within 6 months after the commencement of this section.
Board
Section 44 ‘Minister may
give directions to Service’
The Minister may issue a direction to a Service about a matter relevant to the performance of
its functions under this Act if it is in the public interest to do so. The chief executive of the
service must publish the direction. The Minister may not give a direction about a health
service provided to or the employment of an individual.
A Service must comply with a direction given by the Minister and include a statement about
any such direction in its annual report.
Board and
Health Service
Chief Executive
Section 44E ‘Obligations
of board in relation to
adviser’
Section 44A provides that the Minister may appoint a person to be an adviser to a Board if
the Minister considers that the adviser may assist the Board to improve the performance of
the Board; or the Service controlled by the Board. Section 44E provides that while an
adviser’s appointment is in force, the Board must provide the adviser with all notices of board
meetings, and all documents and other information provided to Board members. Further, the
Board must permit the adviser to attend all meetings of the Board, and to provide information
Board
Section 313 ‘Requirement
for Service to develop
engagement strategies’
Section 42 ‘Protocol with
primary healthcare
organisations’ and Section
43 ‘Review of protocol’
Section 314 ‘Requirement
for Service to develop
protocol’
Hospital and Health Service legislated powers and compliance
Consumer and Community Engagement Framework
working document – not government policy – refer source documentation
-9-
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
Accountability
Supporting documents / guidelines
A Service must comply with any health service directive issued by the departmental Chief
Executive and which applies to that Service. Directives may apply to all Services, to some
Services or to a stated type of facility or service.
Health service directives may be issued for matters such as (refer section 47):
- standards and policies for the healthcare rights of users of public sector health services;
- standards and policies for improving the quality of health services;
- the use by Services of support services provided by the department, other departments
or other Services;
- the purchasing of goods and services under contracts and agreements entered into by
the department, other departments or other Services;
- the provision of information to the departmental Chief Executive and other entities;
- responding to public health emergencies;
- the setting of fees and charges, including for the provision of services to private patients,
for residential care, and for the supply of pharmaceuticals; and
- other matters prescribed under a regulation.
Board
Health Service Directives are publicly available on the Queensland
Health internet site at:
http://www.health.qld.gov.au/directives/default.asp
Section 51E ‘Health
employment directives
binding’
A Service and an employee of a Service or the department must comply with any health
employment directive issued by the departmental Chief Executive and which applies to that
Service/or type of health service employee. Directives may apply to the department, a
Service or all Services, or to a stated type of health service employee.
Note, section 51C ‘Relationship between health employment directives and other
instruments’ prevents health employment directives or regulations issued under the HHB Act
or the Industrial Relations Act 1999 from changing doctors’ contracts unless the change
provides increased remuneration or other benefit – for example passing on an annual wage
increase.
Board,
Employees
Section 112 ‘Giving of
copy of RCA report or
chain of events documents
– patient safety entities’
If a Health Service Chief Executive commissions an RCA, he/she must give a copy of each
RCA report or chain of events document to a prescribed patient safety entity for an
authorised purpose for the entity.
Note: prescribed safety entities are identified in section 30 of the Hospital and Health Boards
Regulation 2012 (HHBR 2012) and authorised purposes under Schedule 2 Part 2 of the
HHBR 2012.
Health Service
Chief Executive
Section 142 ‘Confidential
information must not be
disclosed’
A designated person (defined in section 139, e.g. health service employee, health
professional, member of a Board of a Service, contractor, volunteer, etc.) has a duty of
confidentiality – i.e. he/she must not disclose, indirectly or directly, confidential information to
another person unless the disclosure is required or permitted under this Act.
Sections 143 to 161 provide the exceptions to this duty of confidentiality.
Board Member,
Health Service
Employee
Section 160 ‘Disclosure of
confidential information in
the public interest’
A Health Service Chief Executive may authorise, in writing, the disclosure of confidential
information in the public interest. This authority cannot be delegated.
The annual report of the Service must include a statement about the nature and purpose of
any confidential information disclosed during the financial year.
Health Service
Chief Executive
Section 316 ‘Reporting
obligations for prescribed
public hospitals to
continue’
Provides that the public hospital reporting required under the Health Services Act 1991 is to
continue, notwithstanding the repeal of that Act. These arrangements will continue until such
time as a regulation is prescribed under this clause. The purpose of this provision is to
transition from State-based hospital reporting to the new national hospital reporting
arrangements.
Board
and advice to the Board during the meeting.
Section 50 ‘Health service
directives binding’
Hospital and Health Service legislated powers and compliance
There is also a Health Service Directives Register accessible to staff
via QHEPS that includes information about Directives under
development or review, as well as rescinded Directives:
http://qheps.health.qld.gov.au/policy/html/directives.htm
Health employment directives may be issued under section 51A,
about the conditions of employment for health service employees.
working document – not government policy – refer source documentation
- 10 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
Schedule 1 ‘Conduct of
business by boards’
Outlines the way in which Boards are to conduct their business
Accountability
Supporting documents / guidelines
Board
Hospital and Health Boards Regulation 2012
(Regulation in support of HHB Act.)
Part 3 ‘Employment
matters’
Provisions relating to staff movements between health system employers.
Departmental
Chief Executive,
Health Service
Chief
Executives,
Board Chairs
Part 4 ‘Engagement
strategies and protocols’
Prescribed requirements for clinician engagement strategies, consumer and community
engagement strategies, and protocol with local primary healthcare organisations.
This Part also specifies that HHSs are required to make available a summary of the key
issues discussed and decisions made in each Board meeting to health professionals working
in the Service, to consumers and the community, and to the Service’s local primary
healthcare organisations (subject to the Board’s obligations relating to confidentiality and
privacy).
Board
Part 5 ‘Quality assurance
committees’
Specifies procedures, privacy principles, information, review and reporting requirements, etc
that apply to quality assurance committees.
Quality
Assurance
Committees
Part 6 ‘Root cause
analysis’
Prescribes events that constitute a reportable event for section 94 of the Act, and what
entities are prescribed patient safety entities for section 112(6) of the Act.
Health Service
Chief Executive
Part 7 ‘Committees of
boards’
Boards must establish the committees of the Board prescribed in section 31, including: a
safety and quality committee, finance committee, and audit committee) to have the functions
specified in sections 32-34.
Note: These are in addition to an Executive Committee which must be established as a
committee of the Board under section 32A of the HHB Act.
Board
Financial Accountability Act 2009
(A Service is a statutory body under this Act. The Act and its subordinate legislation establish the high level financial management and accountability obligations for all statutory bodies.)
Part 4 ‘Provisions applying
to departments and
statutory bodies’
Under section 61 ‘Functions of accountable officers and statutory bodies’ Services (as
statutory bodies) have the following functions:
- to ensure the operations of the statutory body are carried out efficiently, effectively and
economically;
- to establish and maintain appropriate systems of internal control and risk management;
- to establish and keep funds and accounts in compliance with the prescribed
requirements;
- to ensure annual financial statements are prepared, certified and tabled in Parliament in
accordance with the prescribed requirements;
- to undertake planning and budgeting for the statutory body that is appropriate to the size
of the statutory body;
- to perform other functions conferred on statutory bodies under this or another Act or a
financial and performance management standard.
Hospital and Health Service legislated powers and compliance
Board
Financial Accountability Handbook
The Financial Accountability Handbook (FAH) has been designed to
assist accountable officers and statutory bodies discharge their
obligations under the Financial Accountability Act 2009 (the Act), the
Financial and Performance Management Standard 2009 (the
Standard), and the Financial Accountability Regulation 2009 (the
Regulation). It also provides information for agencies on better
practice management and internal control structures. All agencies
(including statutory bodies) must have regard to the Handbook,
which means that agencies must comply with the contents of the
Handbook where they apply to agency circumstances.
Financial Management Tools (provide guidance only, i.e. not
mandatory)
Note, Queensland Treasury and Trade conducted a high-level
review of the Handbook and Financial Management Tools in October
working document – not government policy – refer source documentation
- 11 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
Accountability
Supporting documents / guidelines
2013. The majority of the changes to the Handbook are updates to
related resources and minor wording changes. The most significant
change to the Tools is the addition of information designed to assist
in evaluating and reviewing significant assets. Summary of Changes
information sheets are available on the websites.
Queensland Treasury and Trade Financial Circulars
Information for Statutory Bodies – Legislation, Policies and Guidance
– Appendix 1 Compliance checklists
Australian Accounting Standards Board - Accounting Standards
Section 62 ‘Annual financial statements’ and section 63 ‘Annual reports’ specify
requirements for statutory bodies to prepare financial statements and annual reports.
Board
Section 64 ‘Investments Gifted or Bequeathed to Statutory Body’ describes the requirements
where a statutory body elects to divest itself of an investment that has been either gifted or
bequeathed to it.
Board
Section 77(2) ‘Chief
finance officer’
Each departmental CFO must produce to the accountable officer, being the DirectorGeneral, for each financial year, a statement about whether the financial internal controls are
operating efficiently, effectively and economically.
This requirement does not apply to HHSs as statutory bodies. However, HHSs should have a
process in place to check and test financial internal controls.
[Board]
Online training – Financial Internal Control Awareness Course –
CFO Assurance Statement (available on QHEPS for all System
Manager and HHS staff)
Section 77 ‘Chief finance
officer’ and Section 78
‘Head of internal audit’
Statutory Body Adoption of Chief Finance Officer (CFO) and Head of Internal Audit (HIA)
Roles
Sections 77 and 78 of the FA Act require the accountable officer of a department to delegate
certain responsibilities to a CFO and a HIA.
The legislative arrangements and requirements for statutory bodies are different – there is no
requirement in the legislation for a statutory body to implement the roles of CFO and HIA.
Ultimately this decision rests with the statutory body.
Due to the size and complexity of the statutory body and where its enabling legislation allows
for the delegation of functions, the statutory body may elect to nominate officers to be
responsible for the finance and internal audit functions. Where these roles are introduced, an
agency may elect to follow the minimum responsibilities as set out in the Act, or other
responsibilities specifically developed for the agency.
[Board]
Financial Accountability Handbook – Information Sheet 2.5 ‘CFO’ &
Information Sheet 2.6 ‘HIA’ should be considered as ‘best practice’,
and will assist the agency with developing the roles to be undertaken
by the officers responsible for finance and internal audit.
Financial Accountability Regulation 2009
Statutory bodies may consider the voluntary adoption of the
minimum qualifications set out in the regulation as ‘best practice’.
See tools listed under the Standard below.
Financial and Performance Management Standard 2009 (FPMS)
(The Financial Accountability Act 2009 and this standard establish the high level financial management and accountability obligations for all statutory bodies.)
Section 6 ‘Relationship
with Other Documents’
Statutory bodies have an obligation to consider the application of the requirements of various
documents referred to in the FPMS, e.g. when preparing annual financial statements, a
Service must have regard to Australian Accounting Standards and Interpretations,
Queensland Treasury and Trade issued Minimum Reporting Requirements, Accounting
Policy Guidelines and Non-Current Asset Policy. .
Board
Queensland Treasury Financial Reporting Requirements (FRRs) for
Queensland Government Agencies (including Accounting Policy
Guidelines)
Non-Current Asset Policies for the Queensland Public Sector
Relevant documents as they relate to different sections of the FPMS
are listed in this column below.
Section 7 ‘Governance’
As a statutory body, each Service is required to ensure that a governance framework
appropriate for the Service is established. Governance includes establishing a performance
management system, a risk management system and an internal control structure.
Board
OHSA Information sheet: Hospital and Health Service Delegations
(including template delegation instruments)
Section 8 ‘Internal control
structure’
Each statutory body must establish a cost-effective internal control structure which must
include, for example, an organisational structure and delegations, supportive of the
Board
Financial Accountability Handbook
Hospital and Health Service legislated powers and compliance
working document – not government policy – refer source documentation
- 12 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
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Accountability
objectives and operations of the Service.
Furthermore, the internal control structure must be included in the Financial Management
Practice Manual (FMPM) of the statutory body.
Section 9 ‘Responsibility
for strategic and
operational plans’
Requires each statutory body to develop a strategic plan for the organisation and an
operational plan for the whole of the organisation or the levels of the organisation that are
considered to be appropriate.
Financial Management Tools (provide guidance only, i.e. not
mandatory)
Information for Statutory Bodies – Legislation, Policies and Guidance
– Appendix 1 Compliance checklists
Australian Accounting Standards Board – Accounting Standards
Australian Accounting Standards Board – Interpretations
Board
Department of the Premier and Cabinet (DPC) - Agency Planning
Requirements
OHSA Information sheet: Strategic Plans–Minimum Requirements
Checklist
OHSA Webcast: Strategic Planning for Government Bodies
OHSA Information sheet: Operational Plans–Minimum Requirements
Checklist
Model Strategic Plan Template
Model Operational Plan Template
Board
Queensland Government Performance Management Framework
Queensland Audit Office: Better Practice Guide - Performance
Reviews
Requires that statutory bodies comply with ‘Agency Planning Requirements’ in developing
the plans.
Sections 11 to 14 –
Performance Management
Section 11 ‘Responsibility for performance’ requires all Queensland public sector agencies to
comply with the Queensland Government Performance Management Framework when
managing the performance of their agency.
Supporting documents / guidelines
Section 12 ‘Systems for obtaining information about performance’ requires each statutory
body to have systems in place for obtaining information to enable the statutory body to
decide whether the statutory body is:
(a) achieving the objectives stated in its strategic plan efficiently, effectively and
economically; and
(b) delivering the services stated in its operational plan to the standard stated in the
plan.
Performance Reporting to Boards: A Guide to Good Practice
(Chartered Institute of Management Accountants)
Thirteen Ways to Improve Your Monthly Board Reports (ExcelUser)
NHS sample Board papers
Section 13 ‘Reporting about performance’ specifies that systems must allow reporting about
performance to be provided to the agency at least every 3 months, and to the Minister at
least annually or when the Minister requests the information.
Section 14 ‘Systems for evaluating achievement of objectives’ requires that the performance
management system must allow the body to assess:
(a) the appropriateness of its objectives, and the services that it delivers to achieve its
objectives
(b) whether the performance information is suitable to assess the extent to which the
objectives have been achieved
(c) options to improve the efficiency, effectiveness and economy of the operations of
the agency.
Sections 15 to 28 –
General Resource
Management
These sections deal with the agency’s obligations to establish internal financial systems and
processes that will allow for the efficient, effective and economic management of the
agency’s financial resources.
Board
Section 15 ‘Systems for
managing resources’
Each statutory body must establish the following for efficiently, effectively and economically
managing the financial resources of the statutory body—
(a) a revenue management system;
Board
Hospital and Health Service legislated powers and compliance
Financial Accountability Handbook
Financial management tools
The Financial Accountability Handbook and Financial Management
working document – not government policy – refer source documentation
- 13 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
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Accountability
(b) an expense management system;
(c) an asset management system;
(d) a cash management system;
(e) a liability management system;
(f) a contingency management system;
(g) a financial information management system;
(h) a risk management system.
In establishing the systems, the statutory body must have regard to the Financial
Accountability Handbook published by the Treasury department. Statutory bodies must
regularly review the systems to ensure the systems remain appropriate for managing the
financial resources of the statutory body.
Section 16 ‘Financial
management practice
manuals’
Each statutory body must prepare and maintain an FMPM that complies with related
legislation, regulation and policies for use by staff in the performance of their financial
management roles.
Section 16 (4) of the FPMS requires each person involved in the financial management of a
statutory body to comply with this FMPM.
Supporting documents / guidelines
Tools published by Queensland Treasury and Trade provide
guidance in applying the legislation.
Model HHS Financial Management Practice Manual (FMPM)
(available on request from Department of Health Finance Branch)
The FMPM is the internal instructional manual for the HHS to ensure
compliance with the mandated requirements. The Department’s
Financial Policy Team provides an annual update/review of the
model FMPM for HHSs.
Board
See tools for section 8 above.
Model HHS Financial Management Practice Manual (FMPM)
(available on request)
The HHS FMPM underpins the legislative framework and is the initial
point of reference for HHS employees in relation to HHS financial
The FMPM is the internal instructional manual for the HHS to ensure
compliance with the mandated requirements.
The accounting practices presented in this manual are in compliance
with the principles of Australian Accounting Standards,
Interpretations and Queensland Treasury and Trade’s Financial
Reporting Requirements (FRRs), Accounting Policy Guidelines and
Non-Current Asset Policies for the Queensland Public Sector which
mandate that agencies must comply with the latest accounting
standards and interpretations issued by the Australian Accounting
Standards Board (AASB).
Section 17 ‘Revenue
Management’ & Section
18 ‘ User Charging’
Requirements in relation to establishing a revenue management and user charging system
to ensure all revenue is promptly managed and customers are charged an appropriate
amount for goods and services provided by the statutory body.
Section 18 provides that each accountable officer or each statutory body, in identifying the
goods or services provided by the statutory body for which users are to be charged, must
consider whether—
(a) the users have the capacity to pay for the goods or services; and
(b) the users have a choice whether to accept the goods or services; and
(c) the goods or services are available from a supplier other than a department or
statutory body; and
(d) supplying the goods or services is required or permitted by legislation; and
(e) the goods or services are supplied for the benefit of the general public or for the
benefit only of users who do not have the capacity to pay; and
(f) the administrative costs of charging and collecting the charges are more than, or may
be more than, the revenue collected; and an agreement exists between the department
or statutory body and users about charging for the goods or services; and
(h) charging for the goods or services improves, or may improve, resource allocation
through more economical use of the goods or services; and
(i) other factors exist that the accountable officer or statutory body considers relevant.
Hospital and Health Service legislated powers and compliance
Board
Financial Accountability Handbook
Note: The Health Services Regulation 2002 has been superseded by
the Hospital and Health Boards Regulation 2012 from 1 July 2012.
The fees and charges section in the Health Services Regulation is
not replicated in the new regulation. Fees and charges for services
are applied by Health Service Directive as provided under section
47(2)(h) of the HHB Act. Refer to the Health Service Directive at:
http://www.health.qld.gov.au/directives/default.asp
#QH-HSD-008:2012 ‘Own Source Revenue – Central
coordination of Fees and Charges Increases and Category
“C” Negotiation and Acquisition’
working document – not government policy – refer source documentation
- 14 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
Accountability
Supporting documents / guidelines
Section 19 ‘Expense
Management’
Requires each statutory body to manage expenses in accordance with an expense
management system which provides for promptly identifying, approving, managing and
recording expenses and the timely paying of expenses.
To the extent they apply to a statutory body, the statutory body must comply with the
following documents in developing the expense management system, including: the State
Procurement Policy published by the Department of Housing and Public Works, the
Queensland Ministerial Handbook published by DPC and General Guidelines for Personal
Expenses and the Use of Credit Cards by Public Service Employees issued by the Office of
the Public Service Commissioner.
Board
Queensland Procurement Policy (QPP)
The State Procurement Policy has been superseded by the
Queensland Procurement Policy, which took effect on 1 July 2013.
The QPP provides the framework for all Queensland Government
procurement. All statutory bodies are required to comply with the
QPP and Queensland’s trade agreement obligations. (See page 30
below).
Queensland Ministerial Handbook
Section 20 ‘Record of
special payments’
Each statutory body must have an expense management system that keeps a record of
special payments over $5,000.
Board
Section 21 ‘Loss from
offence or misconduct’
and Section 22 ‘Other
losses’
These sections set out the requirements in relation to keeping written records and
notifications where applicable to loss of the statutory body’s property as a result of an
offence or misconduct or other reason.
Board
Section 23 ‘Asset
Management’
Requirement to manage the assets of the statutory body in accordance with an asset
management system that ensures evaluations (similar to business cases) are prepared
before acquiring, maintaining or improving a significant physical asset, with completion
reviews undertaken to ensure that objectives contained in the evaluations were met.
An asset management system must ensure that assets are regularly maintained and must
comply with or have regard to numerous policy and guidelines (examples listed in supporting
documents column).
Board
Hospital and Health Service legislated powers and compliance
Financial Management Tools
Non-Current Asset Policies for the Queensland Public Sector
(NCAPS) – includes guidance/policy on the new valuation
requirements arising from adopting AASB 13 effective 2013/14
(Note: as of February 2014, these policies are being reviewed and
revised – refer to status advice on the Queensland Treasury
website.)
Transaction Policy
Queensland’s Project Assurance Framework
Public Private Partnerships and Value for Money Framework
Department of Health Finance Branch – Guidance documents
(available on request):
- Financial Arrangement Types
- Approval process for Financial Arrangements
- Project Assurance Framework
- Asset Disposal Process for Service Assets and No Service
Assets.
Health Service Directive – Procurement and Logistics
Project assurance framework: Policy for alliance contracting
Project assurance framework: Alliance establishment and
management
Public Interest Map policy
Queensland Procurement Policy
QGCPO – Supply Arrangements
Financial Management Framework
Leasing in Queensland Public Sector Policy Guidelines (refer also
page 18)
SBFA Act Operational Guidelines
working document – not government policy – refer source documentation
- 15 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
Accountability
Supporting documents / guidelines
Investment Policy Guidelines for Statutory Bodies
Guidelines for the Formation and Post Approval Monitoring of
Companies
Section 20A of the HHB Act – Limitations on Service’s dealing with
land or buildings
Statutory Bodies Financial Arrangements Act 1982 – details financial
powers of HHSs and approval requirements to enter into financial
arrangements (refer also pages 19-20).
Section 24 ‘Cash
management’
Statutory bodies must manage the body’s cash in accordance with a cash management
system which provides for control and recording of cash transactions.
Board
Financial Accountability Handbook
Section 25 ‘Liability
management’
Statutory bodies must manage their liabilities in accordance with a liability management
system, which promptly and accurately records liabilities, e.g. for operational costs and
capital expenditure, and complies with ‘Leasing in the Queensland Public Sector – Policy
Guidelines’.
Board
Financial Management Framework
Overdraft Facilities Operational Guidelines for the Public Sector
Leasing in Queensland Public Sector Policy Guidelines
The Leasing Guidelines are mandatory guidelines that apply to the
leasing of all assets, but exclude tenancy leases of real property and
leases of passenger or commercial motor vehicles obtained from QFleet by a tied client.
Statutory Bodies Financial Arrangements Act 1982 – details financial
powers of HHSs and approval requirements to enter into financial
arrangements, such as borrowings, providing Guarantee, etc. (refer
also pages 19-20).
Section 26 ‘Contingency
Management’
A statutory body must manage its contingent assets and contingent liabilities in accordance
with a contingency management system, which promptly identifies, records and reports on
contingencies.
Board
A contingent asset or liability crystallises as the result of a future
event that is outside the control of the agency.
Financial Accountability Handbook
Section 27 ‘Financial
information management’
Requires a statutory body to comply with the mandatory principles stated in the Information
Standards and ensure that its financial information management system aligns with the
targets stated in the QGEA and complies with the Public Records Act 2002.
Board
Queensland Government Enterprise Architecture (QGEA)
QGEA Documents, including current Information Standards
Public Records Act 2002
Section 28 ‘Risk
Management’
Requires management of strategic and operational risks in accordance with a risk
management system.
Board
Queensland Treasury Audit Committee Guidelines – Improving
Accountability and Performance
AS/NZS ISO 31000:2009 Risk Management Principles and
Guidelines
HHS risk management frameworks and/or policies should be
compatible with this international standard. For further information,
contact the Risk and Governance Unit, Governance Branch email:
QHIRM@health.qld.gov.au
Queensland Treasury – A Guide to Risk Management
Department of Health Risk Management Policy and Standards
Part 2 Division 5 ‘Internal
audit and audit committee’
(Sections 29 to 35)
Requirement for a statutory body to establish an internal audit function (section 29(2)) if
directed by the Minister or if the Service considers it appropriate. Systems for ensuring the
internal audit function operates efficiently, effectively and economically must be developed
and implemented (section 29(3)).
The internal audit function must function under an internal audit charter (section 30) and
Board
The internal audit function should conform to the:
International Professional Practices Framework (IPPF) (developed
by the International Institute of Internal Auditors)
Hospital and Health Service legislated powers and compliance
working document – not government policy – refer source documentation
- 16 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
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Accountability
Supporting documents / guidelines
Under section 35 ‘Audit committees’ statutory bodies may establish an Audit Committee. If
they do, they must have regard to the Queensland Treasury document ‘Audit committee
guidelines – improving accountability and performance’, develop Terms of Reference,
include members of the governing body, etc.
Note: HHSs are required to form an audit committee under the Hospital and Health Boards
Regulation 2012 (Part 7).
[Board]
Queensland Treasury and Trade Audit Committee Guidelines –
Improving Accountability and Performance
Sections 36 – 41 –
Contract Performance
Guarantees
These sections detail the obligations and responsibilities attaching to contract performance
guarantees. Contract performance guarantees are securities provided by a contractor, or on
a contractor’s behalf, to ensure a contractor completes all obligations under a contract
negotiated between an agency and a contractor.
Board
Section 43 ‘Preparation of
annual financial
statements of statutory
bodies’
Requirement to prepare certified annual financial statements for submission to the AuditorGeneral on the date agreed to allow the financial statements to be certified by not later than
2 months from the end of the financial year to which the statements relate, and to include
these statements within the HHS’s annual report.
Requires that statements must be prepared having regard to the minimum reporting
requirements mentioned in Treasury’s ‘Financial reporting requirements for Queensland
Government agencies’.
Board
Section 44 ‘Financial
statements of newly
formed departments and
statutory bodies’
A newly formed statutory body must, under section 43, prepare the body’s first annual
financial statement for the period from the statutory body’s formation day until the end of the
financial year in which the statutory body was established.
Board
Section 45 ‘Timing for
giving annual financial
statements to auditorgeneral’
Statutory bodies must give financial statements to the Auditor-General on the date agreed
between the agency and the Auditor-General, to allow the financial statements to be certified
by the external auditor not later than 2 months from the end of the financial year, or a later
date approved in exceptional circumstances by the Treasurer.
Board
Section 46 ‘Consideration
of Auditor General’s
Report’
Obligation to consider the Auditor-General’s report on audited financial statements, and any
matters arising from the Auditor-General’s report.
Board
Division 3 ‘Annual reports
and final reports’ Sections
49 – 53
Requirement to produce an annual report covering each financial year to the Minister. The
report must be tabled in the Legislative Assembly within 3 months of the end of the financial
year to which the report relates. Requirement that the annual report must comply with the
DPC document ‘Annual report requirements for Queensland Government agencies’.
Board
undertake planning including the preparation of a strategic audit plan and audit plan (section
31, section 34). The internal audit function must also prepare reports to the audit committee
(section 32), which must be considered by the statutory body (section 33).
Queensland Treasury and Trade Financial Reporting Requirements
(FRRs) for Queensland Government Agencies (including Accounting
Policy Guidelines)
Non-Current Asset Policies for the Queensland Public Sector
Australian Accounting Standards and Interpretations
Auditor-General Act 2009 and Auditor-General Regulation 2009
(refer also page 22)
Auditor-General Act 2009 and Auditor-General Regulation 2009
(refer also page 22)
Annual report requirements for Queensland Government agencies
OHSA Information sheet: Annual reports– Online publication
checklist for health statutory bodies Note: The annual report of the
Service must include a statement about the nature and purpose of
any confidential information disclosed during the financial year (refer
HHB Act section 160).
Statutory Bodies Financial Arrangements Act 1982 & Statutory Bodies Financial Arrangements Regulation 2007
(A Service is a statutory body under this Act. The primary purpose of the Act and regulation is to establish the borrowing and investment powers of statutory bodies. Provisions also address the role of the Treasurer
in providing guarantees . Under this Act, the Treasurer may guarantee the performance of obligations of a statutory body under a financial arrangement entered into by the body (sections 16 and 76). The Treasurer
can charge a fee for this guarantee. The Treasurer can delegate functions under this Act to another Minister.)
Section 7 ‘Exercise of
powers under this Act’
A statutory body may exercise a power under this Act only if the body is satisfied, on
reasonable grounds, that exercising the power is necessary or convenient for performing its
Hospital and Health Service legislated powers and compliance
Board
Department of Health Finance Branch - Guidance documents
(available on request):
working document – not government policy – refer source documentation
- 17 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
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Accountability
functions under its authorising Act or another Act.
Supporting documents / guidelines
- Financial Arrangements Types
- Approval Process for Financial Arrangements
- Project Assurance Framework
The above guidelines detail approval requirements for the different
financial arrangements that a HHS may wish to enter into.
Section 31 ‘General
banking powers for day-today operations’
A statutory body may only operate an account with an overdraft facility with the Treasurer’s
approval. The account must be operated in Australian money.
Board
The Under Treasurer has granted each HHS an approval to operate
a specific CBA bank account in overdraft up to a HHS specific limit.
Part 5 ‘Borrowing Powers’
Statutory bodies in the Health portfolio are to comply with Part 5 of the Statutory Bodies
Financial Arrangements Act 1982. Statutory bodies must be stated in a regulation to have
borrowing powers under the Act.
Board
HHS have not been assigned borrowing powers under the SBFA
Regulation or HHB Act. HHS require the Treasurer’s approval to
borrow an amount (refer part 7A).
Leasing in Queensland Public Sector Policy Guidelines
Part 6 ‘Investment powers’
Section 42 ‘Investment
power depends on
allocation under
regulation’
A statutory body may invest under this part depending on whether a regulation allocates a
statutory body one of the three categories of investment powers. Where investments are not
permitted under Part 6 of the Act, a statutory body may seek approval from the Treasurer
under Part 7A of the Act. Requests are considered on a case-by-case basis.
HHSs have been allocated Category 2 investment powers by amending Schedule 4 of the
Statutory Bodies Financial Arrangements Regulation to include HHSs.
Board
Queensland Treasury Investment Policy Guidelines for Statutory
Bodies
The guidelines provide a general outline of the impact of the SBFA
Act on the operations of statutory bodies and aims to assist statutory
bodies in understanding their obligations under the Act and provide
information to assist in developing better-practice policy frameworks
for the investment of funds.
Queensland’s Project Assurance Framework
Project assurance framework: Policy for alliance contracting
Project assurance framework: Alliance establishment and
management
Public Interest Map policy
Public Private Partnerships and Value for Money Framework
QGCPO – Supply Arrangements
Financial Management Framework
Leasing in Queensland Public Sector Policy Guidelines
SBFA Act Operational Guidelines
Investment Policy Guidelines for Statutory Bodies
Guidelines for the Formation and Post Approval Monitoring of
Companies
Part 7, Division 3 , Section
60A ‘Statutory body may
enter into a type 1
financial arrangement’
A statutory body may, with the Treasurer’s approval, enter into a type 1 financial
arrangement.
Board
Note, the Treasurer’s general approval has been sought under this
section for HHSs to enter into Deeds of Indemnity, Insurance and
Access for HHS Board members and senior executive officer as
defined in section 33 or section 67(2) of the HHB Act. Refer to Board
system-wide induction information sheet 10.6 ‘Indemnity and
insurance arrangements for Directors and Officers’ available at:
http://www.health.qld.gov.au/ohsa/html/module10.asp
Type 1 financial arrangement means an arrangement that provides for, relates to, is directed
towards or includes 1 or more of the following—
(a) entering into or performing a deferred payment arrangement if the payment period is
more than 3 years;
(b) entering into a joint venture, partnership or trust;
(c) forming, or participating in forming, a corporation;
(d) acquiring, consolidating, dealing with, disposing of, holding or issuing bonds,
debentures, inscribed stock, shares, stock or other securities of any statutory body or
Hospital and Health Service legislated powers and compliance
working document – not government policy – refer source documentation
- 18 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
Accountability
Supporting documents / guidelines
Board
The Treasurer has delegated authority for these approvals to the
Under Treasurer. The Minister for Health’s endorsement would be
required prior to seeking the Under Treasurer’s approval.
Financial Management Framework
Overdraft Facilities: Operational Guidelines for the Public Sector
SBFA Act Operational Guidelines
Leasing in Queensland Public Sector Policy Guidelines
corporation;
(e) entering into an arrangement, covenant, guarantee, promise or undertaking to meet
liabilities or obligations incurred by or to a person, whether or not the person is a party
to the arrangement, covenant, guarantee, promise or undertaking;
(f) underwriting an issue of debentures, shares or other securities;
(g) entering into another arrangement prescribed under a regulation as a type 1
financial arrangement.
Part 7A ‘Power for type 2
financial arrangements’
Section 61A ‘Statutory
body may enter into a type
2 financial arrangement
with Treasurer’s approval’
This part applies to a statutory body if the statutory body does not have power to enter into a
particular type 2 financial arrangement (e.g. borrow an amount) under another part of this
Act, its authorising Act or another Act. Type 2 financial arrangements for which a HHS
requires approval are:
(a) borrowing an amount
(b) lending an amount
(c) investing an amount
(d) taking land or an interest in land (section 20A of HHB Act has precedence over this)
(e) acquiring, consolidating, dealing with, disposing of or holding buildings or other
structures, for providing infrastructure other facilities for the public or part of the public
(refer s.20A HHB Act)
(f) granting or taking a lease
(g) granting financial accommodation
(h) accepting, discounting, drawing, endorsing or issuing a bill of exchange, promissory
note, payment order or other negotiable instrument
(i) holding property as a trustee or agent
(j) acquiring, consolidating, dealing with, disposing of, holding or reissuing foreign
currency
(k) entering into another arrangement prescribed under a regulation.
The Under Treasurer has granted the HHSs an approval to hold and
expend General Trust Fund monies. Associated documents are:
- Trust and Fiduciary Fund – Administration of Patient Fiduciary
and General Trust monies
- Protocol for Managing the General Trust Fund
- General Trust Guide.
For example, under section 61A, a statutory body may, with the Treasurer’s approval, borrow
an amount.
Acts Interpretation Act 1954
(The meaning of Queensland State legislation is governed by the provisions in the Interpretation Act. The Act prescribes the meanings of common terms and provides courts with clear directions to resolve a range of
potential inconsistencies.)
Part 7 ‘Functions and
powers conferred by Acts’
Outlines the operation of conferral, performance, delegation of statutory functions and
powers; making of appointments, acting appointments, etc. e.g. section 27A ‘Delegation of
functions or powers’ outlines how delegation of functions and powers works.
-
Information Privacy Act 2009
(The Act provides for the fair collection and handling in the public sector environment of personal information, and gives the public a right to apply to access and amend their own personal information.)
Section 31 ‘Health agency
to comply with NPPs’
As amended by the HHB ACT, a Service (as a health agency defined in Schedule 5) must
comply with the National Privacy Principles (NPPs) in relation to the collection, storage, use
and disclosure of an individual’s personal information.
Note: According to section 32 ‘Noncompliance with particular NPPs’ HHSs do not have to
comply with certain NPPs if the individual’s personal information has previously been
published or given for the purpose of publication by the individual.
Hospital and Health Service legislated powers and compliance
Board
NPPs:
http://www.privacy.gov.au/materials/types/infosheets/view/6583
Office of the Information Commissioner (Queensland)
OHSA Information sheet: Recordkeeping–General, Digital, Cloud
Computing
working document – not government policy – refer source documentation
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Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
Section 33 ‘Transfer of
personal information
outside Australia’
A health agency may transfer an individual’s personal information to an entity outside of
Australia only in certain circumstances specified in this section.
Accountability
Supporting documents / guidelines
Board
Right to Information Act 2009
(The Act gives the public a right of access to information held by government unless, on balance, providing access would be contrary to the public interest. A Service is an agency under this Act.)
Part 3 ‘Dealing with
applications’
The Act sets out the way an agency must deal with applications for information.
Note: an ‘agency’ is defined in section 14 – a department, a local government, a public
authority, a government owned corporation, or a subsidiary of a government corporation.
Section 16 defines a ‘public authority’ as an entity established for a public purpose by an Act,
an entity created by the Governor in Council or a Minister, etc.
Board
www.qld.gov.au/right-to-information/
Ministerial Guidelines and Links to Departmental Publication
Schemes
Chapter 2 ‘Disclosure
other than by application
under this Act’
Under section 20 ‘Requirement for policy documents to be publicly available’, Services are
required to have copies of their policy documents available for inspection and purchase by
the public.
Under section 21 ‘Requirement for publication scheme’ Services must publish a publication
scheme setting out the classes of information that the agency has available and the terms on
which it will make the information available, including any charges. This may include a
disclosure log of documents that have been released in response to RTI applications.
Board
The Act does not apply to certain documents (e.g. a document
created for a root cause analysis of a reportable event under the
HHB ACT) and entities (e.g. a quality assurance committee
established under the HHB ACT).
Public Interest Disclosure Act 2010 (PIDA)
(A Service is a ‘public sector entity’ under this Act and the Health Service Chief Executive is the ‘Chief Executive officer’ for this entity.)
Chapter 3 ‘Obligations of
entities to whom
disclosure may be made’
Section 28 ‘Reasonable
procedures to deal with
public interest disclosures’
The PIDA applies to Health Service Chief Executives, including obligations in regard to, for
example, establishing procedures to deal with public interest disclosures (PIDs), keeping
records of PIDs, and ensuring protections are in place for disclosers.
Section 28 provides for the establishment of reasonable procedures by the Chief Executive
of a public sector entity.
Section 29 provides that the Chief Executive officer of a public sector entity must keep a
proper record of disclosures.
Health Service
Chief Executive
Section 29 ‘Record of
disclosure’
The Queensland Ombudsman administers the PIDA. Under section
60, the Ombudsman has issued a Standard about the way in which
agencies must deal with PIDs, including a requirement to provide
information to the Ombudsman regarding PIDs received. The
Standard is binding on all entities within the jurisdiction of the PIDA
as well as on Government Owned Corporations.
Public Interest Disclosure Standard No. 1
For further information:
(http://www.ombudsman.qld.gov.au/PublicationsandReports/PublicIn
terestDisclosures/tabid/339/Default.aspx)
Note: Given the HHB ACT (section 21) establishes each HHS as a
separate unit of public administration, the accountability to report
complaints of suspected official misconduct and to assess and report
on PIDs rests with each Service.
Auditor-General Act 2009
(Establishes the position of the Queensland Auditor-General and the Queensland Audit Office (QAO). The Act also confers on the Auditor-General and the QAO the functions and powers necessary to carry out
independent audits of all Queensland public sector agencies.)
Section 46 ‘Access to
documents and property’
Section 47 ‘Obtaining
Information’
External Audit – The Auditor-General of Queensland is required by the Auditor-General Act
2009 to audit each year the financial accounts of all public sector entities and to provide
independent reports to the Queensland Parliament. The Queensland Audit Office (QAO)
assists the Auditor-General in discharging the legislated responsibilities.
All accounting and associated records of HHSs will therefore be audited by the QAO. The
audit will be conducted in a manner as considered appropriate, having regard to
parliamentary and associated timeframes. Each HHS must grant the audit team access to all
Hospital and Health Service legislated powers and compliance
Board
Queensland Audit Office
working document – not government policy – refer source documentation
- 20 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
Accountability
Supporting documents / guidelines
records, and stated information as and when requested as required by sections 46 and 47 of
the Act. In addition, each HHS will be responsible for liaising directly with the Audit Manager
and providing solutions to the audit issues that are raised.
Statutory bodies also have an obligation under the FPMS to consider the Auditor-General’s
report on their audited financial statements, and any matters arising from the AuditorGeneral’s report.
Integrity Act 2009
(The Act covers the role and functions of the Integrity Commissioner, advice on ethics or integrity issues as well as advice for designated persons on integrity issues; and regulation of contact between lobbyists and
State or local government reps.)
The Act places certain
requirements on
government
representatives in relation
to lobbying activity.
For example:
Section 70 ‘Related
lobbying by former senior
government representative
prohibited’
Section 71 ‘Lobbying by
unregistered entity
prohibited’
The definition of government representative in section 44 includes ‘a public sector officer’.
Section 47 defines public sector officers as: “the Chief Executive of, or a person employed
by, 1 of the following entities— (a) a department; (b) a public service office (as defined in
Schedule 1); (c) a registry or other administrative office of a court or tribunal; (d) a local
government; (e) a corporate entity under the Local Government Act 2009; (f) the
parliamentary service; (g) a government owned corporation; (h) an entity, prescribed by
regulation, that is assisted by public funds.
A government representative must not knowingly permit a former senior government
representative of less than 2 years standing to carry out with the government representative
a related lobbying activity for a third party client.
A government representative must not knowingly permit an entity that is not a registered
lobbyist to carry out a lobbying activity for a third party client with the government
representative.
Health Service
Chief Executive,
Health Service
Employees
Queensland Integrity Commissioner
http://www.integrity.qld.gov.au/index.shtml
Integrity Regulation 2011
The Integrity Regulation 2011 has been amended to include HHSs
as entities prescribed for the meaning of ‘public sector office’ under
section 47(h) of the Act.
Hence provisions concerning regulation of lobbying activity apply to
Services. For example, Services are required to ensure that
lobbyists who approach them are registered on the Integrity
Commission’s Register of Lobbyists. If a lobbyist is not registered,
the Service must discontinue discussions with the lobbyist and
inform the Integrity Commissioner. Services also need to be aware
of restrictions on related lobbying by former senior government
representatives and inform the Commission of any such attempt.
Advice is pending from DPC regarding whether HHSs will also be
required to keep a record of lobbying activity – this is currently an
administrative requirement for departments that may be extended to
HHSs.
Public Sector Ethics Act 1994 (PSEA)
(Declares the ethical principles that are fundamental to good public administration and covers requirements for codes of conduct for public officials.)
Part 3 ‘Ethics values’
Part 4 ‘Codes of conduct
for public officials’
The PSEA outlines the ethical obligations of employees within the Queensland Public
Sector. The PSEA provides four (4) ethics principles for the public sector:
(a) Integrity and impartiality
(b) Promoting the public good
(c) Commitment to the system of government and
(d) Accountability and transparency.
The PSEA also incorporates a range of “ethical values” associated with each of the ethics
principles. The values provide guidance on the interpretation and application of the ethics
principles. These principles and values form the basis of the codes of conduct required to be
developed by each statutory body.
Board, Health
Service Chief
Executive,
Health
Executive
Service, Health
Service
Employees
The PSEA ethics principles and values apply to all public service
agencies and public sector entities, including statutory bodies, and
include the application of the Code of Conduct for the Queensland
Public Service.
Queensland Government Ethics Website
Code of Conduct for the Queensland Public Service
OHSA Information sheet: Public Sector Ethics
On-line Ethics, Integrity and Accountability training available on
QHEPS at: http://qheps.health.qld.gov.au/safety/elearning.htm
Public Service Act 2008
(The Act fixes principles to guide public service management, public service employment and the work performance and personal conduct of public service employees.)
Part 3 ‘General Public
Service Principles’ is
extended through Public
Section 25 ‘The Management and Employment Principles’
(1) Public service management is to be directed towards—
(a) providing responsive, effective and efficient services to the community
Hospital and Health Service legislated powers and compliance
Board, Health
Service Chief
Executive,
Queensland Public Service Commission (PSC)
The Commission is established under the PSA and provides advice
to the Premier, the Minister Assisting the Premier, and government
working document – not government policy – refer source documentation
- 21 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
Accountability
Supporting documents / guidelines
Service Regulation 2008
and the Government; and
(b) maintaining impartiality and integrity in informing, advising and assisting
the Government; and
(c) promoting collaboration between Government and non-government
sectors in providing services to the community; and
(d) continuously improving public service administration, performance
management and service delivery; and
(e) managing public resources efficiently, responsibly and in a fully
accountable way; and
(f) promoting the Government as an employer of choice; and
(g) promoting equality of employment opportunity.
(2) Public service employment is to be directed towards promoting—
(a) best practice human resource management; and
(b) equitable and flexible working environments in which all public service
employees are—
(i) treated fairly and reasonably; and
(ii) remunerated at rates appropriate to their responsibilities; and
(c) a diverse and highly skilled workforce drawing from Government and
non-government sectors.
(3) Subsections (1) and (2) are the management and employment principles.
Section 26 ‘Work performance and personal conduct principles’
In recognition that public service employment involves a public trust, a public service
employee’s work performance and personal conduct must be directed towards—
(a) achieving excellence in service delivery; and
(b) ensuring the effective, efficient and appropriate use of public resources;
and
(c) giving effect to Government policies and priorities; and
(d) collaborating with other departments with a focus on public service-wide
priorities as well as department-specific priorities; and
(e) providing sound and impartial advice to the Government; and
(f) improving all aspects of the employee’s work performance; and
(g) carrying out duties impartially and with integrity; and
(h) acting honestly, fairly and in the public interest; and
(i) interacting with staff members under the Ministerial and Other Office
Holder Staff Act 2010 respectfully, collaboratively and with integrity; and
(j) observing all laws relevant to the employment; and
(k) ensuring the employee’s personal conduct does not reflect adversely on
the reputation of the public service; and
(l) observing the ethics principles under the Public Sector Ethics Act 1994,
section 4; and
(m) complying with an approved code of conduct and any approved standard
of practice as required under the Public Sector Ethics Act 1994, section
12H or 18.
Health
Executive
Service, Health
Service
Employees
on the administration of the Queensland Public Service and the
management and employment of public service employees.
Chapter 2 ‘Equality of
employment opportunity’
All government entities must act to promote equality of employment opportunity (s30) and
provide a report (s31) to the Public Service Commission for each financial year about the
outcome of actions required with s30 during the financial year. If the commission chief
executive is dissatisfied with any matter relating to the report, he/she may recommend to the
HSCE
PSC Policy – Annual Equality of Employment Opportunity Reporting
to the Commission Chief Executive Policy (this policy specifies the
data requirements for reporting).
QH HR policy G2 (QH-POL-132) ‘Equity and Diversity’ applies to
Hospital and Health Service legislated powers and compliance
working document – not government policy – refer source documentation
- 22 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
Accountability
agency’s chief executive the taking of action to overcome that dissatisfaction – the agency’s
chief executive must ensure the action recommended is taken or give the Minister and
commission chief executive a notice stating the reasons why the action cannot be taken.
Supporting documents / guidelines
HHSs until such time as they become prescribed employees.
Note: this report is currently provided via data file from the
Department on behalf of HHS direct to PSC. If PSC request
qualitative information (e.g. activities or initiatives undertaken) the
HHSs could report this directly.
Public Service Regulation 2008
Schedule 2 ‘Applied
provisions and rulings for
health service employees’
Schedule 2 of the Public Service Regulation 2008 specifies the applied provisions of the
Public Service Act and rulings extended to health service employees.
Health Service
Employees,
Health Service
Chief Executive
The intent is to extend the provisions to apply to HHSs based on
current human resources policy. The scope of application is primarily
the same as what is currently extended to health service employees,
with the addition of a few provisions, which are currently applied
through policy or directive rather than the PSR 2008 (e.g. section 24
– Part 2, Items 12 and 13; Part 3, Items 1, 10, and 19). It reflects the
new system (HHSs and the department) and employment
arrangements (a Service prescribed by regulation may also employ
health service employees under the HHB Act) - the Health Service
Chief Executive will be responsible for the employment and
management of health service employees employed by the HHS.
Public Records Act 2002
(Provides for the management of public records in Queensland.)
Section 7 ‘Making and
keeping of public records’
Requires public authorities to make and keep full and accurate records of their activities.
Board, Health
Service Chief
Executive,
Health
Executive
Service, Health
Service
Employees
Clinical Records Retention and Disposal Schedules
General Retention and Disposal Schedule (GRDS) for Administrative
Records
OHSA information sheet: Recordkeeping-General, Digital, Cloud
Computing
Queensland State Archives
Section 15 ‘Meaning of
responsible public
authority’
Section 15 provides that when records relating to a particular function are transferred to
another public authority, responsibility for the records is also transferred.
Board
The first stage of the Records Transfer process for administrative
and functional records has been completed, and endorsement has
been received from each Health Service Chief Executive. Further
transfer processes will need to be progressed in the future for
Personnel, Workplace Health and Safety, and Capital Works and
Infrastructure records, which currently remain the property of the
Department of Health.
Section 62C ‘Responsible
public authority for public
record’
Provides that the health department will remain the responsible public authority for public
records given to the State archives prior to the commencement of the HHB ACT.
Department
Crime and Misconduct Act 2001
(A Service is a unit of public administration under this Act.)
Section 38 ‘Duty to notify
commission of official
misconduct’
If a public official (CEO of a unit of public administration) suspects that a complaint, or
information or matter involves, or may involve, official misconduct, they must notify the Crime
and Misconduct Commission of the complaint.
Health Service
Chief Executive
Section 43 ‘Responsibility
of public officials, other
The CEO of a unit of public administration has a responsibility to deal with a complaint about,
or information or matter involving, official misconduct that is referred to it by the commission.
Health Service
Chief Executive
Hospital and Health Service legislated powers and compliance
Crime and Misconduct Commission Queensland
http://www.cmc.qld.gov.au/
Note: Given the HHB Act establishes each HHS as a separate unit
of public administration, the accountability to report complaints of
suspected official misconduct and to assess and report on PIDs
working document – not government policy – refer source documentation
- 23 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
than the commissioner of
police’
Accountability
Section 44 outlines how complaints must be dealt with.
Supporting documents / guidelines
rests with each Service.
Health Ombudsman Act 2013
(An Act to establish a health ombudsman and to provide for a system for dealing with complaints and other matters relating to the health, conduct or performance of health practitioners and the services provided by
health service organisations. Most provisions will commence on 1 July 2014.)
Section 8 ‘Meaning of
health service provider’
A Hospital and Health Service is included in the definition of a health service provider.
Section 48 ‘Power to
require information’
A health service provide may be required to give particular information to the health
ombudsman within a stated period and the provider must do so unless they have a
reasonable excuse.
Health Service
Chief Executive
54 ‘Power to require
information’
For the purpose of facilitating resolution of a complaint, the health ombudsman may require a
provider to provide particular information within a stated period.
Health Service
Chief Executive
Section 89
‘Implementation of
recommendations and
supplementary report’
Under this section, when, or after, giving a copy of an investigation report to the health
service provider, the health ombudsman may ask the health service provider to provide a
report about any implementation of the recommendations of the investigation report. The
provider must comply with the request unless the provider has a reasonable excuse.
Health Service
Chief Executive
139 ‘Requirement to
negotiate in good faith’
During conciliation of a health service complaint, the complainant and relevant health service
provider must negotiate in good faith.
Health Service
Chief Executive
Health Quality and Complaints Commission Act 2006
(The Act provides for oversight and review of, and improvement in, the quality of health services, and independent review and management of health complaints.)
Section 20 ‘Duty of
provider’
All Queensland healthcare providers (both organisations and individuals) have a legal duty to
establish, maintain and implement reasonable processes to improve the quality of their
health services. The commission may set standards about the processes a provider may
adopt to comply with this (section 22).
Section 23 ‘Consideration
of provider’s compliance
with s 20(1)’
For deciding whether a provider is meeting its obligations under section 20, the commission
may have regard to a commission standard or to whether the provider has been accredited
by a competent entity.
Board
Heath Quality and Complaints Commission
http://www.hqcc.qld.gov.au/Pages/Home.aspx
When established, the Health Ombudsman will replace the HQCC
and the HQCC Act will be repealed.
Model Governance Framework for Clinical Safety and Quality in
HHSs (May 2012)
-
Heath Quality and Complaints Commission Standards
Three HQCC standards continue to apply to all Queensland public
and licensed private acute and day hospitals and to individuals
working in and/or for hospitals. HQCC has stated that these health
care standards will be retired in 2014.
Since January 2013, all Queensland health service organisations
have been required to be accredited against the 10 National Safety
and Quality Health Service Standards at any accreditation renewal
after this date.
Australian Commission on Safety and Quality in Health Care
(ACSQHC) – National Safety and Quality Health Service Standards
Public Health Act 2005
(An Act to protect and promote the health of the Queensland public, and for other purposes.)
Chapter 4 ‘Infection
control for health care
facilities’
Part 3 ‘Infection control
All public healthcare facilities must have an Infection Control Management Plan (ICMP)
(section 152). The owner/operator of a healthcare facility must develop and implement an
ICMP (section 154).
‘Operator’ is defined as the person who has the day to day operation and control of the
Hospital and Health Service legislated powers and compliance
Board
Queensland Health Internet Site - ICMP
working document – not government policy – refer source documentation
- 24 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
management plans’
Accountability
Supporting documents / guidelines
facility.
Note: Responsibility for the operation and control of facilities is conferred on the Board via
the concurrent lease.
Queensland Mental Health Commission Act 2013
(An Act to establish the Queensland Mental Health Commission and for related purposes.)
Section 35 ‘Regard to be
had to whole-ofgovernment strategic plan
when negotiating service
agreements’
The health service chief executive must take the Queensland Mental Health Commission’s
whole-of-government strategic plan into account when negotiating service agreements under
that Act to the extent the agreements relate to the delivery of mental health and substance
misuse services.
Health Service
Chief Executive
Worker’s Compensation and Rehabilitation Act 2003
(An Act to establish a workers’ compensation scheme for Queensland, and for other purposes.)
Section 46 ‘Employer’s
legal liability’
An employer is legally liable for compensation for injury sustained by a worker employed by
the employer.
Board
Section 48 ‘Employer’s
obligation to insure’
This section provides that every employer must for each worker employed by the employer
insure and remain insured against injury sustained by the worker for compensation and
damages.
Currently WorkCover insurance wage declarations and processing of premium payments are
provided by Corporate Finance.
Board
Under the Service Agreement, HHSs must continue to work within the Safety Management
System (SMS), of which the Workplace Rehabilitation System (WRS) forms a part. By
working within the WRS, HHS's fulfil their obligations under the Worker's Compensation and
Rehabilitation Act 2003 as follows:
- Section 46: Employer's legal liability
- Section 48: Employer's obligation to insure
- Section 226: Employer's obligation to appoint rehabilitation and return to work
coordinator
- Section 227: Employer's obligation to have workplace rehabilitation policy and
Board
Section 226 ‘Employer’s
obligation to appoint
rehabilitation and return to
work coordinator’
Section 227 ‘Employer’s
obligation to have
workplace rehabilitation
policy and procedures’
Hospital and Health Service legislated powers and compliance
A ‘worker’ is defined as a person who works under a contract of
service – this includes a majority of persons within a HHS. With the
transition to HHSs these persons will continue to be covered under
local policy arrangements with WorkCover Queensland, the
Queensland worker’s compensation insurer. Local policies were
recently amended to reflect the new HHS names and ABNs.
Persons who do not meet the definition of ‘worker’ – e.g. Hospital
and Health Board Chair, Deputy Chair, Board Members and Hospital
Volunteers, may be covered separately under a Contract of
Insurance (COI), with WorkCover Queensland or other commercial
insurer, or under existing arrangements with the Queensland
Government Insurance Fund (QGIF) Insurance Policy, section 6:
Personal Accident and Illness (Volunteers, Board Members and
Committee Members).
Whilst insurance coverage for persons who do not meet the
definition of ‘worker’ is not mandatory under the presiding legislation,
it should be considered by each HHS through a risk assessment
approach, in order to meet local requirements.
Workplace rehabilitation and return to work policy
Workers’ compensation insurance and employee entitlements
procedure
Board system-wide induction information sheet 6.7 ‘WorkCover’
(OHSA)
Workplace Accreditation Certificate
Workplace Rehabilitation System
Service Agreements
Q-COMP (http://www.qcomp.com.au/ the Worker’s Compensation
Regulatory Authority)
working document – not government policy – refer source documentation
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Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
Accountability
Supporting documents / guidelines
procedures
The system has been re-accredited by the Regulator for a further 3 years until 19 July 2015.
Should a HHS become a prescribed employer these arrangements will need to be reviewed.
Work Health and Safety Act 2011 & Work Health and Safety Regulation 2011 & Work Health and Safety (Codes of Practice) Notice 2011
(The WHS Act provides a framework to protect the health, safety and welfare of all workers at work and of all other people who might be affected by the work. Nationally uniform laws ensure all workers in Australia
have the same standard of health and safety protection, regardless of the work they do or where they work.)
Section 27 ‘Duty of
Officers’
The Health Service Chief Executive, as an ‘officer’ as defined in this Act will have certain
work health and safety obligations under this Act, including due diligence, which is defined as
taking reasonable steps:
(a) to acquire and keep up-to-date knowledge of work health and safety matters; and
(b) to gain an understanding of the nature of the operations of the business or
undertaking of the person conducting the business or undertaking and generally of
the hazards and risks associated with those operations; and
(c) to ensure that the person conducting the business or undertaking has available for
use, and uses, appropriate resources and processes to eliminate or minimise risks
to health and safety from work carried out as part of the conduct of the business
or undertaking; and
(d) to ensure that the person conducting the business or undertaking has appropriate
processes for receiving and considering information regarding incidents, hazards
and risks and responding in a timely way to that information; and
(e) to ensure that the person conducting the business or undertaking has, and
implements, processes for complying with any duty or obligation of the person
conducting the business or undertaking under this Act; and
(f) to verify the provision and use of the resources and processes mentioned in
paragraphs (c) to (e).
For section 27:
The Director
General, Board,
Health Service
Chief Executive,
Health
Executive
Service, other
officers and
senior
departmental
officers where
they have
decision making
powers that
substantially
affect the HHS
or Department’s
business.
The HHB Act outlines that (until such time as a Service is
prescribed) the Director-General (DG) is the employer of staff within
HHS, with the exception of the Health Service Chief Executives
(HSCEs) and health executives who are employees of the Service.
The Director-General and the HSCEs are ‘officers’ (section 252)
under the WHS Act 2011 and therefore hold a responsibility of due
diligence that cannot be delegated.
The QH Occupational Health and Safety Management System sets
out OHS policies, Implementation Standards and associated
guidance material which supports compliance with legislative
obligations and consistency of practice statewide.
Service Agreements between the HHS and the System Manager
stipulate compliance with the relevant safety legislation and the
Safety Management System. However this does not preclude
Services from developing Service specific procedures to meet local
requirements. Once prescribed as employers, HHSs will have their
own occupational health and safety policies and the Service
Agreements will be amended accordingly.
Occupational health and safety legislative compliance evidence
guide and checklist for relevant occupational health and safety
legislative requirements available at:
http://qheps.health.qld.gov.au/safety/assurance/home.htm
Workplace Health and Safety Queensland
Schedule 1
HHSs have asbestos management responsibilities under this legislation. Schedule 1
provides that a reference in the Act to carrying out work includes reference to the storage or
handling of dangerous goods such as asbestos.
Hospital and Health Service legislated powers and compliance
The Asset Management and Maintenance Health Service Directive
specified compliance with the asbestos management and control
sections of the work health and safety legislation. As this directive
has been rescinded as of 1 January 2014, it is important HHSs are
aware of their asbestos management responsibilities under the
legislation.
Note: this aspect of work health and safety legislation is not covered
under the QH occupational health and safety management system
which sets out OHS policies, implementation standards and
associated guidance material as asbestos management was
considered an asset management issue.
working document – not government policy – refer source documentation
- 26 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
Accountability
Supporting documents / guidelines
Fire and Rescue Service Act 1990 & Fire and Rescue Service Regulation 2011 & Building Fire Safety Regulation 2008
(The Act establishes the Queensland Fire and Rescue Service and provides for the prevention of and response to fires and certain other incidents endangering persons, property or the environment and related
purposes.)
Part 9A ‘Building fire
safety’ Division 2
‘Obligations of persons for
fire safety’
Details obligations on the occupier of a building – maintain means of escape from the
building, maintain prescribed fire safety installations, fire and evacuation plan, provide
instruction to persons in the building concerning the action to be taken by them in the event
of a fire threatening the building, etc.
Board
The Building Fire Safety Regulation includes provisions relating to keeping evacuation routes
free from obstacles, occupancy limits for buildings, meaning of specific terms (e.g.
evacuation route, common area), etc.
Board
Further requirements for fire safety are detailed in the QH
occupational health and safety legislative compliance evidence
guide and checklist. Once prescribed as employers, HHSs will
have their own occupational health and safety policies and the
Service Agreements will be amended accordingly.
Queensland Fire and Rescue Service
Electrical Safety Act 2002 & Electrical Safety Regulation 2013 & Electrical Safety (Codes of Practice) Notice 2002
(An Act about electrical safety, and for other purposes.)
Section 30 ’Primary duty of
care’
Part 2 ‘Electrical safety
duties’ Division 3
‘Regulations, ministerial
notices and codes of
practice relating to
electrical safety
obligations’
The obligation includes –
(a) ensuring that all electrical equipment used in the conduct of the person’s business
or undertaking is electrically safe; and
(b) if the person’s business or undertaking includes the performance of electrical work,
ensuring the electrical safety of all persons and property likely to be affected by the
electrical work; and
(c) if the person’s business or undertaking includes the performance of work, whether
or not electrical work, involving contact with, or being near to, exposed parts,
ensuring persons performing the work are electrically safe.
Board
Regulations, ministerial notices and codes of practice may prescribe the way to discharge a
person’s electrical safety obligations.
Board
Further requirements for electrical safety are detailed in the QH
occupational health and safety legislative compliance evidence
guide and checklist.
Queensland Government Electrical Safety Office
Note: the Electrical Safety Regulation 2013 commenced on 1
January 2014 and replaces the 2002 Regulation.
Building Act 1975 & Building Regulation 2006
(The Building Act governs all building work in Queensland and empowers the regulation of certain aspects of buildings and structures.)
The Building Act requires that buildings be constructed in accordance with the Building Code
of Australia and, where Queensland-specific provisions are necessary, the Queensland
Development Code.
The Act also contains specific compliance requirements, for example, in relation to fire safety
for residential care buildings built, approved or applied for before 1 June 2007 (Chapter 7A),
and swimming pool safety (Chapter 8).
Board
Queensland Development Code
Australian Building Codes Board – About the national Construction
Code
Child Protection Act 1999
(This Act provides for the protection of children.)
Section 159H ‘Chief
Executive may ask
particular prescribed
Under this Act, a Health Service Chief Executive is a prescribed entity. The Chief Executive
responsible for the Child Protection Act 1999 may ask a prescribed entity to provide a
service, e.g. to a child in need of protection, that is consistent with the entity’s functions. The
Hospital and Health Service legislated powers and compliance
Health Service
Chief Executive
working document – not government policy – refer source documentation
- 27 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
Accountability
entities to provide a
service’
prescribed entity must be given the information it needs to comply with the request.
Section 159M ‘Particular
prescribed entities giving
and receiving relevant
information’
Allows for relevant information to be provided between a prescribed entity and a service
provider.
Health Service
Chief Executive
Section 159O ‘Release of
information by a health
services designated
person’
A health services designated person may, for this Act, give a relevant person or the
Children’s Court specific confidential information.
‘Designated person’ is defined in section 139 of the HHB ACT and includes a member of a
Board of a Service, health service employee, health professional, etc.
Board Member,
Health Service
Employee
Supporting documents / guidelines
Disability Services Act 2006
(The Act provides for the protection and promotion of the rights of people with a disability.)
Section 123ZZH ‘Relevant
service provider may
request confidential
information from health
professional, the Chief
Executive (health), or a
Health Service Chief
Executive’
This part applies to a funded service provider who provides disability services to an adult
with an intellectual or cognitive disability (a relevant service provider).
The relevant service provider may ask a health professional, the Chief Executive (health), or
a Health Service Chief Executive for confidential information about an adult with an
intellectual or cognitive disability that is relevant to the assessment, or development of a
positive behaviour support plan, short term plan or respite/community access plan for the
Health Service
Chief Executive
Personal Injuries Proceedings Act 2002
(An Act to regulate particular claims for and awards of damages based on a liability for personal injuries, and for other purposes.)
Section 9A ‘Particular
provision for notice of a
claim procedure for
medical negligence case’
This section relates to a claim based on a medical incident that is alleged to have given rise
to personal injury. The claimant must give written notice (initial notice) of the claim to the
person against whom a proceeding based on the claim is proposed to be started. If the
place at which the medical incident happened is the place under the control of a Service –
the initial notice must be given to the Health Service Chief Executive of the Service.
Claimant and
Health Service
Chief Executive
Public Trustee Act 1978
(This Act establishes the Office of the Public Trustee who may be appointed by the Tribunal as administrator for an adult's financial matters.)
Section 105 ‘Unclaimed
property held by hospitals’
Under section 105, a governing body of a hospital is required to take certain steps when it
has in its possession or under its control any property (including money and securities for
money) to which some person is entitled and which property has remained unclaimed for a
period of 3 months or longer, including taking all reasonable steps to ascertain the identity
and whereabouts of the owner of such property and to deliver it to such owner.
The Health Service Chief Executive of the Service in which the hospital is located is a
‘governing body’ under this Act (as amended by the HHB ACT).
Hospital and Health Service legislated powers and compliance
Health Service
Chief Executive
The HHSs have been granted a delegation authority from the Public
Trustee to hold and expend patients monies in terms of the Patient
Fiduciary Fund. Associated documents are:
- Health Service Directive: Trust and Fiduciary Fund –
Administration of Patient Fiduciary and General Trust monies
- Protocol for Managing the Patient Fiduciary Fund
- Patient Fiduciary Guide.
working document – not government policy – refer source documentation
- 28 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
Accountability
Supporting documents / guidelines
OTHER LEGISLATION
Services may have additional responsibilities and obligations placed upon them by a number of pieces of other State legislation (https://www.legislation.qld.gov.au/OQPChome.htm) and Commonwealth legislation
(http://www.comlaw.gov.au/), for example:
Health Portfolio Acts and Subordinate Legislation
(http://www.health.qld.gov.au/legislation/health_portfolio.asp)
Food Act 2006
Food Regulation 2006
Health Act 1937
Health Regulation 1996
Health (Drugs and Poisons) Regulation 1996
Health Ombudsman Act 2013
Health Practitioner Regulation National Law Act 2009
Health Practitioner Regulation National Law Regulation
Health Practitioner Regulation National Law Amendment (Midwife Insurance Exemption) Regulation 2013
Health Practitioners (Disciplinary Proceedings) Act 1999 (previously Health Practitioners (Professional
Standard)s Regulation 2010) (to be repealed)
HEALTH PRACTITIONERS (Professional Standards) Regulation 2010 (to be repealed)
Health Practitioners (Special Events Exemption) Act 1998
Health Practitioners (Special Events Exemption) Regulation 2009
Health Quality And Complaints Commission Act 2006
Hospitals Foundations Act 1982
Hospitals Foundations Regulation 2005
Mater Public Health Services Act 2008
Mental Health Act 2000
Mental Health Regulation 2002
Mental Health Review Tribunal Rule 2009
Pest Management Act 2001
Pest Management Regulation 2003
Pharmacy Business Ownership Act 2001
Private Health Facilities Act 1999
Private Health Facilities Regulation 2000
Private Health Facilities (Standards) Notice 2000
Public Health Act 2005
Public Health Regulation 2005
Public Health (Infection Control For Personal Appearance Services) Act 2003
Public Health (Infection Control for Personal Appearance Services) (Infection Control Guideline) Notice
2013
Public Health Infection Control for Personal Appearance Services Regulation 2003
Queensland Mental Health Commission Act 2013
Public Health (Infection Control for Personal Appearance Services) Act 2003 - A Guide for Local
Government
Public Health (Infection Control for Personal Appearance Services) Act 2003 - What business needs to
know
Public Health - Infection Control Guidelines for Personal Appearance Services 2004
Queensland Institute Of Medical Research Act 1945
Radiation Safety Act 1999
Radiation Safety Regulation 2010
Hospital and Health Service legislated powers and compliance
Health Portfolio Acts and Subordinate Legislation (continued)
Radiation Safety (Radiation Safety Standards) Notice 2010
(The Radiation Safety Act 1999 provides that this Notice is subordinate legislation)
Research Involving Human Embryos And Prohibition Of Human Cloning For Reproduction Act 2003
Research Involving Human Embryos and Prohibition of Human Cloning Regulation 2003
Tobacco And Other Smoking Products Act 1998
Tobacco and Other Smoking Products Regulation 2010
Transplantation And Anatomy Act 1979
Transplantation and Anatomy Regulation 2004
Water Fluoridation Act 2008
Water Fluoridation Regulation 2008
Other State and Commonwealth Legislation
Affirmative Action (Equal Employment Opportunity for Women) Act 1986 (Cth)
Aged Care Act 1997 (Cth) (HHSs delivering aged care services as defined under this Act should refer to
their requirements under this act)
Anti-Discrimination Act 1991
Commission for Children and Young People and Child Guardian Act 2000
Copyright Act 1968 (Cth)
Coroners Act 2003
Criminal Code Act 1899
Disability Discrimination Act 1992 (Cth)
Disability Services Act 1986 (Cth)
Disaster Management Act 2003
Environmental Protection Act 1994
Environmental Protection Regulation 2008
Environmental Protection (Waste Management) Regulation 2000
Human Rights and Equal Opportunity Commission Act 1986 (Cth)
Income Tax Assessment Act 1936 (Cth)
Industrial Relations Act 1999
Industrial Relations Regulation 2011
Industrial Relations (Tribunal) Rules 2000
Judicial Review Act 1991
Ombudsman Act 2001
Police Powers and Responsibilities Act 2000
Privacy Act 1988 (Cth)
Sex Discrimination Act 1984 (Cth)
State Penalties Enforcement Act 1999
State Penalties Enforcement Regulation 2000
Statutory Authorities (Superannuation Arrangements) Act 1994
Superannuation Guarantee (Administration) Act 1992 (Cth)
Waste Reduction and Recycling Act 2011
Waste Reduction and Recycling Regulation 2011
Water Supply (Safety and Reliability) Act 2008
working document – not government policy – refer source documentation
- 29 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
Accountability
Supporting documents / guidelines
COMMON INDUSTRIAL FRAMEWORK
The HHB Act provides for a Service to employ Health Executives, including the Health Service Chief Executive (with the approval of the Minister). All other staff are currently employed by the Director-General,
Department of Health (until such time as a Service becomes a prescribed employer) and therefore current HR policies apply to these staff. Health Employment Directives will apply to prescribed employer HHSs. The
current HR policies are available on QHEPS at: http://www.health.qld.gov.au/hrpolicies/default.asp
The HHB Act also allows HHSs to directly employ staff, once the service is prescribed as an employer under regulation. This will not be automatic; Hospital and Health Services will need to satisfy the Minister that
they have both the capability and the capacity to take on this additional responsibility. This process is underway with HHSs to be prescribed as employer on either 1 July 2014 or 1 July 2015.
The HHB Act provides for state-wide employment and industrial relations arrangements, including the negotiation of certified agreements (consequential amendments have been made in Schedule 4A of the Industrial
Relations Act 1999 to enable this). Staff employed by HHSs are therefore subject to statewide enterprise bargaining agreements and awards, and other statewide employment terms and conditions as determined by
the Director-General, Department of Health.
Schedule 4A of the Industrial Relations Act 1999 modifies the application of this Act to prescribed Hospital and Health Services and their employees.
WHOLE OF GOVERNMENT POLICY
Note: the application of whole of government policies is specific to particular entities as defined in the underpinning legislation or under a regulation.
Queensland Government
Chief Information Office
Queensland Government
Enterprise Architecture 2.0
(QGEA)
QGEA is the collection of ICT policies and associated documents that guide agency ICT
initiatives and investments to improve the compatibility and cost-effectiveness of ICT across
government. The framework unites ICT strategy, ICT policy, Information Standards and
enterprise architecture across the Queensland Government.
Board
Note: in order to determine the applicability of QGEA policies to
HHSs specifically, it needs to be determined whether or not Services
are captured or exempted under the particular legislation
underpinning QGEA policies. For example, Information Standard 18
– Information Security supports the FPMS 2009 and as such applies
to all accountable officers and statutory bodies as defined in the FAA
2009.
Note: There may be specific reporting requirements associated with
individual standards, e.g. IS18.
QGEA Framework 2.0
Queensland Government Chief Information Office – QGEA Website
Current Information Standards (IS31, IS40, IS18, IS26)
Guideline to the Authority and Applicability of the QGEA
OHSA Information sheet: Recordkeeping-General, Digital, Cloud
Computing
[Board/HSCE]
Maintenance Management Framework: Policy for the maintenance
of Queensland Government buildings
Implementation of the mandatory principles of the Information Standards is mandated as key
whole-of-Government ICT planning requirements. Specific Acts and regulations are
provided within each Information Standard. For more information please see the QGEA
guideline on the authority and applicability of the QGEA.
Agency compliance with the QGEA is demonstrated by meeting criteria relating to the
implementation of the Information Standards, policies, requirements and targets. Evidence
of compliance is presented through reporting processes (e.g. annual reports). The QGEA 2.0
compliance and reporting requirements spread sheet provides full details of the policy
requirements, targets and information standard mandatory principles of all issued QGEA
documents, and allows agencies to create specialised views of compliance requirements
(e.g. by compliance target date, artefact or domain).
Department of Housing
and Public Works
Maintenance Management
Framework (MMF)
The Maintenance Management Framework (MMF) is the policy for the maintenance of
Queensland Government buildings.
The MMF applies to all departments (as defined in section 8 of the Financial Accountability
Act 2009) that control or administer buildings and have responsibility for maintenance as part
of the overall asset management of their portfolio. This Policy does not currently apply to
statutory bodies but its use is specified by the Health Service Agreement.
The MMF is a key state government building policy framework which facilitates risk
management in the planning, procurement and delivery of government building projects and
the maintenance of buildings and infrastructure. Its use provides confidence to both
government and industry that there are formalised standards and a consistent approach
across government, particularly in regard to open and transparent business dealings.
Hospital and Health Service legislated powers and compliance
With regards to the MMF, the Health Service Agreement states that
buildings and infrastructure are maintained in accordance with the
specifications of the Transfer Notice as mandated by the HHB Act
(section 307). The transfer notice calls up the MMF specifying that
buildings and infrastructure are to be maintained to the ‘S3’
Condition Standard Rating specified in the MMF. A copy of the HHS
Transfer Notices was provided to each HHS Executive.
working document – not government policy – refer source documentation
- 30 -
Table 2: Legal and administrative framework for HHS operation – key compliance requirements
Reference
Requirement
Department of Housing
and Public Works
Queensland Procurement
Policy
The QPP provides an overarching principles-based framework that seeks to deliver
excellence in procurement outcomes for Queenslanders. Cabinet has mandated this Policy
for application to Departments, statutory bodies and Special Purpose Vehicles. These
entities are collectively referred to as ‘agencies’ within this Policy.
The chief executive officer of a statutory body is the accountable officer responsible for
ensuring the QPP is followed within their agency. They are also responsible for
procurements delivered on their behalf by a provider external to their agency including, for
example, those delivered by shared services providers or under corporate partnership
agreements.
All agency employees are required to be aware of, and comply with, the policy. It is therefore
imperative that all employees receive relevant training. Managers and supervisors are
responsible for ensuring that employees are aware of, and comply with, the policy.
Accountability
Supporting documents / guidelines
Health Service
Chief Executive,
all employees
Queensland Procurement Policy
OHSA Information sheet: Procurement/purchasing requirements
HHSs must also comply with Health Service Directive QH-HSD009:2012 ‘Procurement and Logistics—Use of Contract and Supply
Arrangements’, which directs them to use current (as in place at 1
July 2012) whole-of-government and Queensland Health contract
and supply arrangements.
(www.qcd.qgcpo.qld.gov.au)
SERVICE AGREEMENT
The Service Agreement agrees the hospital services, other health services, teaching, research and other services the Service must deliver. The Service Agreement is binding on the Chief Executive of the
Department of Health and the Service. Refer to comments regarding sections 19, 35, 38 and 39 of the HHB ACT above.
Hospital and Health Service Service Agreements and the Hospital and Health Services Performance Framework are available on the Queensland Health website at:
http://www.health.qld.gov.au/hhsserviceagreement/default.asp
MINISTERIAL AND HEALTH SERVICE DIRECTIVES
HHSs are legally bound by Ministerial directives and by health service directives and health employment directives issued by the Chief Executive of the Department of Health. Refer to comments regarding section
44, section 50 and section 51A of the HHB ACT above.
Health Service Directives are published on the Queensland Health website at: http://www.health.qld.gov.au/directives/default.asp
Ministerial Directives and health employment directives must also be published in a way that is accessible to the public, including for example, on the internet.
QUEENSLAND HEALTH HUMAN RESOURCE (HR) AND OCCUPATIONAL HEALTH AND SAFETY POLICIES AND HEALTH EMPLOYMENT DIRECTIVES
HR Policies applying to Hospital and Health Services
The Queensland Health Human Resource (HR) Policy site contains an alphabetical listing of all Queensland Health HR policy and supporting documents: http://www.health.qld.gov.au/qhpolicy/default.asp
HR Policies are issued to reflect content of the Queensland Health employment framework source documents or terms and conditions that may not be contained in an industrial instrument. Some HR Policies may
apply to non-prescribed Hospital and Health Services, unless specifically identified in the application section of the policy.
Occupational Health and Safety Policies applying to Hospital and Health Services
Occupational Health and Safety Policies apply to the Department of Health and may be adopted or adapted by Hospital and Health Services as required.
Health Employment Directives
Mandatory application of employment conditions will be addressed through Health Employment Directives issued by the Chief Executive of the Department of Health, and as amended from time to time. Health
Employment Directives are published on the Queensland Health website at: http://www.health.qld.gov.au/hrpolicies/
Health Employment Directives must also be published in a way that is accessible to the public, including for example, on the internet.
Non Mandatory Policies, Implementation Standards, Procedures and Guidelines for Hospital and Health Services
Department of Health policies describe the department's "position" or "stance" on a particular issue and are often developed to support a consistent or shared "way of doing business". Department of Health policies
are formal documents representing the department's statement of intent to achieve a particular outcome. All non-mandatory HR/Occupational Health and Safety policy documents may be adopted or adapted for use
by HHSs to support best practice and business continuity.
Hospital and Health Service legislated powers and compliance
working document – not government policy – refer source documentation
- 31 -
TABLE 3: Useful reference documents
Document name
Purpose
Link / Location
Best practice guidance:
Queensland Treasury
Project Assurance Framework
The Project Assurance Framework (PAF) is the foundation framework for ensuring that project management is undertaken
effectively across the Queensland public sector, and delivers value for money to the Government from its significant investment
in project activity.
PAF is a whole-of-government project assessment process that establishes a common approach to assessing projects at critical
stages in their lifecycle. Its aim is to maximise the benefits returned to government from project investments.
The essence of the PAF is that it represents a minimum standard for project investment and management. Other whole-of
government and/or departmental project management arrangements will have slightly different structures and steps to the PAF
to reflect local needs. In this context, the broad outcome being sought is that the PAF’s minimum standards can be
demonstrated in these other project management arrangements. Where agencies choose to depart from any of the PAF’s preproject and project stages, the reasons for this departure should be clearly articulated and approved by the relevant governance
body.
Project Assurance Framework
Project assurance framework: Policy for
alliance contracting
Project assurance framework: Alliance
establishment and management
Public Private Partnerships and Value for
Money Framework
Department of Housing and
Public Works
Government Employee
Housing Management
Framework (GEHMF)
The Government Employee Housing Management Framework (GEHMF) is the whole-of-Government
policy for managing government employee housing.
The GEHMF applies to all departments (as defined in section 8 of the Financial Accountability Act 2009) that control or
administer government employee housing.
Although the framework is not applicable to HHSs, the policy represents good practice in managing asset ownership and
management related risks. HHSs are therefore encouraged to apply this policy in their business operations.
Note, as from 1 January 2014, the Department of Housing and Public Works (DHPW) has taken over the management
responsibilities for all QH staff residences and from 1 July 2014, DHPW anticipates that it will have ownership of these
residences.
Government Employee Housing Management
Framework
Department of Housing and
Public Works
Asbestos Management and
Control Policy for Government
Buildings
The objective of the policy is to provide a framework for the management, control and safe removal of asbestos containing
material. This will assist in ensuring a consistent approach across departments and enable initiatives and available funding to be
directed towards the achievement of the policy objective.
The policy applies to all Queensland Government departments that have obligations to manage and control asbestos containing
material in government controlled buildings that are workplaces and staff residential accommodation. The policy assists all
“persons controlling a business or undertaking” (PCBU) to fulfil responsibilities under the Work Health and Safety Act 2011 and
Regulation. PCBU are expected to implement asbestos management and control policies and strategies to fulfil their legislative
and broader community obligations. The Policy does not apply to statutory bodies and Government Owned Corporations.
Although the policy is not applicable to HHSs, the policy represents good practice in managing asset ownership and
management related risks. HHSs are therefore encouraged to apply this policy in their business operations.
Asbestos Management and Control Policy for
Government Buildings
Department of Housing and
Public Works
Capital Works Management
Framework (CWMF)
The Capital Works Management Framework is the policy for managing risks in the planning and delivery of government building
projects. It applies to all Queensland Government departments (as the term is defined in the Financial Accountability Act 2009)
that control or administer government buildings.
Although the policy is not applicable to HHSs, the policy represents good practice in managing asset ownership and
management related risks. HHSs are therefore encouraged to apply this policy in their business operations.
Capital Works Management Framework
Department of Housing and
Public Works
Strategic Asset Management
Framework
The Strategic Asset Management Framework (SAMF) provides best practice guidelines for the management of Queensland
Government buildings to ensure a systematic approach to effective government building management. It emphasises efficient
building use, integrated planning, whole-of-life costing and environmental sustainability.
The SAMF complements other whole-of-Government policies, including the Capital Works Management Framework, the
Maintenance Management Framework, the Government Employee Housing Management Framework and the Building Asset
Performance Framework.
Strategic Asset Management Framework
Hospital and Health Service legislated powers and compliance
working document – not government policy – refer source documentation
- 32 -
Document name
Purpose
Link / Location
Although the policy is not applicable to HHSs, the policy represents good practice in managing asset ownership and
management related risks. HHSs are therefore encouraged to apply this policy in their business operations.
Department of Housing and
Public Works
Building Asset Performance
Framework
The Building Asset Performance Framework provides best practice guidelines to ensure a systematic, effective approach to
management of government buildings.
It shows how to establish building performance indicators and measures to assist in making better building management
decisions that ensure buildings will effectively meet current and future needs.
Although the policy is not applicable to HHSs, the policy represents good practice in managing asset ownership and
management related risks. HHSs are therefore encouraged to apply this policy in their business operations.
Building Asset Performance Framework
Resources to assist identify statutory body requirements:
Information for statutory bodies
Three documents have been prepared to assist officers with different aspects of a statutory body’s life:
Establishment of Statutory Bodies – Considerations and contacts
Information for Statutory Bodies – Overview of applicable legislation, policies and guidance documents (this includes
compliance checklists at Appendix 1)
Information for Statutory Bodies – Solvency.
(http://www.treasury.qld.gov.au/office/knowledg
e/docs/information-for-statutorybodies/index.shtml)
Office of Health Statutory
Agencies (OHSA)
Fact Sheet: Statutory Bodies
Guidelines and Resources
Provides a list of government resources applicable/useful for Queensland Government statutory bodies.
(http://www.health.qld.gov.au/ohsa/docs/statbodies-guide.pdf)
HHS Model Governance
Framework and Toolkit
The framework focuses on outlining the mandatory governance requirements that Services are required to meet in order to fulfil
the requirements placed on them under legislation and by government as statutory bodies. It also presents a set of good
governance principles, and provides examples of how these might work in the HHS context.
The document has not been updated since prior to 1 July 2012 but may be useful as a guide.
Available on request
Department of Health –
Finance Branch
Draft Financial Management
Framework (FMF)
This document was designed to provide HHSs with information and guidance that may be helpful when first implementing their
own FMF and establishing the systems and processes that enable them to fulfil their role as independent statutory bodies. It
focuses on outlining the financial management requirements that Services are required to meet in order to fulfil the obligations
placed on them under legislation and by government.
The document has not been updated since prior to 1 July 2012 but may be useful as an overview of requirements.
Available on request
Department of Health –
Finance Branch
Financial Arrangement
Guidelines
These documents were designed to help HHSs in determining the approval requirement as per the Statutory Bodies Financial
Arrangement Act 1982 to enter into financial arrangements. The documents also detail applicable policies that need to be
considered in entering into these arrangements. Relevant documents are:
Financial Arrangements Types
Approval Process for Financial Arrangements
Project Assurance Framework.
Available on request
Department of Health –
Finance Branch
Draft Internal Control
Framework
Department of Health –
Finance Branch
Internal Audit Framework
(HHS) (February 2012)
Available on request
This framework outlines the audit committee and internal audit requirements that HHSs should aim to meet in order to fulfil the
responsibilities placed on them by government as statutory bodies.
The document has not been updated since prior to 1 July 2012 but may be useful as an overview of requirements.
Hospital and Health Service legislated powers and compliance
Available on request
working document – not government policy – refer source documentation
- 33 -
Document name
Purpose
Department of Health –
Finance Branch
Draft Audit Committee Charter
as at Appendix A to the Draft
Internal Audit Charter
Department of Health –
Finance Branch
Model HHS Delegation
Framework Model Version 4,
and Policy
Link / Location
Available on request
The document provides a model financial delegations framework model that ensures a structure for maintaining internal control
over expense management.
The document has not been updated since prior to 1 July 2012 but may be useful as a guide.
Hospital and Health Service legislated powers and compliance
Available on request
working document – not government policy – refer source documentation
- 34 -