The document below provides a suggested Governance Framework template Hospital Foundations may
wish to adapt for their own use.
Statutory bodies are required to establish a Governance Framework under section 7 of the Financial and
Performance Management Standard 2009
(http://www.legislation.qld.gov.au/LEGISLTN/CURRENT/F/FinAccPManSt09.pdf).
Additional governance resources and templates are available on the OHSA website at:
(http://www.health.qld.gov.au/ohsa/html/resources.asp).
[Insert Foundation Name]
Governance Framework
The Financial and Performance
Management Standard 2009
(FPMS) (s7) prescribes the
requirement for a statutory body,
such as a Hospital Foundation, to
establish a governance
framework.
Overview
Governance is aimed at achieving organisational goals and objectives, and can be described as the set of
responsibilities and practices, polices and procedures used to provide strategic direction, ensure
objectives are achieved, manage risks and use resources responsibly and with accountability 1.
Good governance is fundamental to achieving our mission. The [insert Foundation name] Governance
Framework is designed to assure adequate accountability to our many stakeholders and to encourage
performance improvement while meeting our obligations and legislative requirements. It is intended that the
Framework will assist [insert Foundation Name] staff to understand and apply the principles of good
governance, and to assess the strengths and weaknesses of current governance practice and improve it.
The principles
The framework is based on six (6) good governance principles:
1.
2.
3.
4.
5.
a common sense of purpose and direction
the organisation is functionally and structurally aligned to achieve its objectives
clear understanding of expectation in roles and responsibilities
being clear about the responsibility and authority of individuals and groups
outcomes are expressed in measurable terms and reported upon in an accurate, reliable and
timely manner
6. there are consequences for good and poor performance with emphasis on recognition, learning
and improving.
The mechanisms
The mechanisms are the practices, policies, processes and documents associated with each of the
principles, which are used to drive and support good governance in practice. The mechanisms and their
alignment to the six governance principles are noted in the figure below. Some of these mechanisms are
mandatory for the Foundation, for example, because they are required under legislation, whilst others
represent good practice.
1 Australian
Public Service Commission. 2007. Building Better Governance. Australian Government.
Hospital Foundation Governance Framework Template
Page 1 of 10
- Planning
- Stakeholder
Engagement
- Risk
Management
- Board
- Organisation
Structure
- Committee
Structure
- Role
Descriptions
- Code of
Conduct
- Probity and
Ethics
- Delegations
- Performance
Management
Framework
- Legislation
- Committee
Terms of
Reference
- Performance
- Annual Reports
- Evaluation
- Monitoring and
- Risk
Reporting
- Annual Financial
Statements
- Patient, Family,
Management
- Audit
- Organisational
Development
Volunteer and
Staff Experience
Framework
Governance maturity matrix (appendix 1)
The maturity matrix enables the [insert Foundation Name] (Board and Executive) to assess its governance
standards against best practice. Use of the matrix provides an overview of the strengths and weaknesses
of current governance practice, and assists with prioritising activities that will strengthen governance
standards. The maturity matrix identifies three levels of maturity – developing, established and mature –
and some corresponding indicators that may demonstrate the Foundation is functioning at that level. This is
intended to allow the Foundation to identify strengths and areas that require development, track progress
and identify a pathway towards achieving best practice.
Resources and Tools (appendix 2)
Appendix 2 provides a list of useful resources and tools to assist in operationalising the governance
mechanisms.
ACNC Governance Standards
The [insert Foundation Name] is aware that the Australian Charities and Not-for-profits Commission Act
2012 (ACNC Act) establishes a framework for a set of minimum governance standards applicable to
registered charities from 1 July 2013.
The [insert Foundation Name]’s has reviewed the standards to ensure the Foundation is meeting the
proposed standards and has practices and procedures in place to cover them. [It may be beneficial to list
the standards and expand on how the Foundation meets each standard. Information on the minimum
governance standards is available on the ACNC website at:
(http://www.acnc.gov.au/ACNC/Manage/Ongoing_Obs/Governance/ACNC/Edu/GovStds_overview.aspx).]
Standard 1: Purposes and not-for-profit nature of a registered entity
Standard 2: Accountability to members
Standard 3: Compliance with Australian laws
Standard 4: Suitability of responsible persons
Standard 5: Duties of responsible persons
Hospital Foundation Governance Framework Template
Page 2 of 10
Appendix 1 – Governance Maturity Matrix
Progress Levels 
Governance Principles 
 Developing
 Established
 Mature
Minimum mandated requirements met
Firm progress in development of good systems
/ processes
Comprehensive assurance framework in
place
Results being achieved
Ongoing review and improvement evident
Foundation plans (operational, enabling etc.) are
clearly aligned to the Strategic Plan and support the
Plan’s delivery.
Board schedules annual debate on
organisational purpose, in light of achievement
of purpose during the year, and sets the future
strategic direction of the Foundation.
Principles accepted and commitment to action /
Documented processes in place
1. Common sense of
purpose and direction
Organisational purpose debated and agreed.
Governance Mechanisms:
Strategic Plan developed that complies with
Queensland Government requirements (including
identification of risks) and affirms Foundation
purpose and vision.
 Planning
 Stakeholder Engagement
 Risk Management
Values and priorities identified and agreed with
stakeholders.
Operational Plan(s) in place that document key
delivery areas for each team/service area.
Any non-compliance with strategic plan/priorities is
explained.
Informal/ad hoc processes for engaging
stakeholders are in place.
Stakeholder Engagement Strategy developed.
Enabling plans developed focusing on key activities
that underpin the Foundation’s activities, e.g.
events, relationship management, marketing and
communications, workforce, volunteers, corporate
services.
A Risk Management and Assurance Framework is
in place across the Foundation. Known risks are
identified and treatment plans are in place.
Hospital Foundation Governance Framework Template
Key targets and objectives within Foundation plans
are reflected in Executive staff performance
agreements (or equivalent).
Evidence that targets and priorities are being met.
Regular reporting to Board and Executive in place.
Process for regular review of Foundation strategic
Plan/directions is in place.
Formal links/processes for engaging relevant
stakeholders are in place and documented.
Formal strategies for ensuring appropriate
engagement with the workforce and workforce
stakeholders are in place.
A high degree of understanding and awareness of
risk can be demonstrated across the Foundation.
Operational risks are managed at point of delivery.
Key strategic risks have been identified and
recorded and are reviewed regularly by the Board.
Foundation has an integrated planning process
in place which aligns strategic, operational and
other planning with resource allocation.
Evidence that effective partnership working
and mutually beneficial relationships with
stakeholders have been established. Staff,
supporters and the community trust the
organisation.
The Board is confident that it has intelligent
analysis and assurance regarding the risks
faced by the Foundation. Foundation risk
profile informs the Board’s review of strategy.
The Board is engaged in evaluation of
fundraising/business failures elsewhere and
potential applicability /occurrence within the
Foundation.
The Foundation’s risk appetite (tolerance) has been
discussed and agreed by the Board. This has been
communicated across the Foundation and built into
plans.
Page 3 of 10
Progress Levels 
 Developing
 Established
 Mature
Minimum mandated requirements met
Firm progress in development of good systems
/ processes
Comprehensive assurance framework in
place
Results being achieved
Ongoing review and improvement evident
Governance Principles 
Principles accepted and commitment to action /
Documented processes in place
2. The organisation is
functionally and
structurally aligned to
achieve its objectives
Organisational structure is documented based on
the main functions required to raise funds
(consistent with the Hospital Foundations Act 1982)
and to achieve the strategic direction of the
Foundation.
Organisational structure is established that provides
clear reporting lines and clarity on functional area
responsibilities.
Committee structure and functions are
reviewed. Committees are working effectively.
Board is able to focus on strategic decisions.
All positions report to a higher position.
Governance Mechanisms:
Committee structure in place that is aligned to
organisational structure and functions.
Committee structure in place with clear terms of
reference and scheme of delegation and reporting.
Committees contain work at a devolved level,
except where tolerances are breached requiring
escalation.
Temporary committees/project groups report
on progress and conclude when their
purpose/objectives are delivered.
 Board
 Organisation Structure
 Committee Structure
Annual cycle of Board activity established.
Board and committee support role/s (secretariat)
identified and defined.
Workforce strategy developed and documented.
All committees report to a higher level committee or
position.
The Board is leading, rather than following,
agendas.
Wider community resources are leveraged to
improve organisational capability/performance.
Annual cycle of Board activity is in place, including
reporting processes.
There is an identified position providing
acompliance and tracking role for the Board
and its business.
A dedicated resource(s) is in place to support the
administration and effectiveness of the Board and
its committees.
The Foundation can demonstrate that it is an
employer of choice. Formalised succession
planning is in place.
Workforce strategy is clearly aligned to the Strategic
Plan and supports the Plan’s delivery. Strategies to
develop organisational capability and capacity in
place across the Foundation.
Hospital Foundation Governance Framework Template
Page 4 of 10
Progress Levels 
Governance Principles 
3. Employees and
Officers have a clear
understanding of
expectations in roles
and responsibilities
Governance Mechanisms:
 Role Descriptions
 Code of Conduct
 Probity and Ethics
 Delegations
 Performance Framework
 Developing
 Established
 Mature
Minimum mandated requirements met
Firm progress in development of good systems
/ processes
Comprehensive assurance framework in
place
Results being achieved
Ongoing review and improvement evident
Induction and orientation programs are promoted
and delivered to new staff and Board Members.
Induction programs are in place which convey
expectations specific to teams/service areas.
Role descriptions clearly articulate how an
individual’s role assists in achieving organisational
objectives.
The Foundation has acquired a reputation for
its good governance practice.
Principles accepted and commitment to action /
Documented processes in place
Induction and orientation programs developed to
inform new staff and Board Members of key topics
of culture, values, organisational structure and
mission, as well as Foundation policies, procedures
and contacts.
Every position has a corresponding role description
documented.
Identified conflicts of interest and inappropriate
behaviour are properly considered and the Board is
confident that any appropriate actions are followed
through.
Role descriptions are consistent with
Foundation objectives and operational plans.
Systems and processes are in place to assess the
level of adherence to delegations.
The Board and executive team demonstrate
and uphold the principles and values of the
code of conduct and promote an organisational
culture that values high ethical standards and
behaviour.
The Board has explicit and accepted standards of
conduct in place.
Instruments of delegation and delegation manuals
are kept current.
Effective procedures are in place for review of
delegations.
A conflict of interest register is in place and is
updated by the Board and staff regularly. Identified
conflicts are reviewed and appropriate action taken.
Board members are clear about when to absent
themselves from Board discussions and decisions.
Accountability for delivery of the Foundation’s
strategic objectives is articulated through executive
staff objectives. Operational plans and staff
objectives are informed by executive staff objectives
and accountabilities.
Changes to delegations are communicated
clearly and in a timely manner to affected
employees.
Staff and Board Members are familiar with their
ethical obligations under the Public Sector Ethics
Act 1994 and their responsibility to uphold the
ethics principles and values and the Foundation’s
code of conduct.
Delegations are in place to ensure that
responsibilities are matched with the necessary
authority.
Instruments of delegation are easily accessible and
understandable to those required to perform
delegated functions or those impacted by these
delegated functions.
Performance and development plans align
individual staff objectives with the objectives within
the team/service area’s operational plan. The PDA
process is used to clarify roles and responsibilities,
performance expectations and developmental
requirements/opportunities.
Evidence that the Foundation’s strategic
direction is being achieved through executive
staff objectives. All members of the Board and
Foundation executive team are recognised as
adding value.
Evidence that team/service area operational
plans are being achieved through individual
staff objectives.
A performance management framework for the
Foundation’s staff is in place.
Performance and development agreements (PDAs
are in place for Foundation staff.
Hospital Foundation Governance Framework Template
Page 5 of 10
Progress Levels 
Governance Principles 
4. Individuals and
groups (committees)
are clear about their
respective
responsibility and
authority
Governance Mechanisms:
 Developing
 Established
 Mature
Minimum mandated requirements met
Firm progress in development of good systems
/ processes
Comprehensive assurance framework in
place
Results being achieved
Ongoing review and improvement evident
The Board is familiar with its statutory and other
obligations.
Board competencies agreed. Gaps identified and
training/development in place.
The roles, responsibilities and obligations of Board
members are clear, agreed and specified.
Board self-assessment of performance annually.
Performance of committees and project groups
against terms of reference/objectives reviewed
on regular basis (+/- annually). Business of the
committee reflects the committee’s functions
as per the terms of reference.
Principles accepted and commitment to action /
Documented processes in place
Board induction and development program in place.
Terms of reference in place for all committees and
project groups.
 Performance
Management Framework
Staff are able to access information on the
legislative requirements of their position.
 Legislation
Performance Management Framework for the
Foundation agreed, which includes KPIs/metrics
that allow monitoring against the Foundation’s
strategic objectives and the service standards
specified within the operational plan.
 Committee Terms of
Reference
5. Outcomes are
expressed in
measurable terms and
reported in an accurate,
reliable and timely
manner
Governance Mechanisms:
 Annual Reports
Procedures developed to monitor, measure and
report performance results.
Foundation meets reporting requirements set by
Government.
Information and reporting requirements have been
communicated to the Board and Foundation
Committees.
Board receives regular performance reports and is
notified of variance to performance.
 Monitoring and Reporting
 Annual Financial
Statements
 Patient, Family, Volunteer
and Staff experience
Hospital Foundation Governance Framework Template
Committee terms of reference are reviewed
annually.
Process for tracking compliance in place with
regular reports provided to the Board (including
compliance with legislation).
Non-compliance with statutory and other obligations
is identified and addressed in a timely manner.
Performance Management Framework for the
Foundation implemented and performance
expectations communicated to staff through
performance agreements (or equivalent) and staff
objectives.
Formal and coordinated reporting to monitor
performance against fundraising and donations /&
volunteer services targets is in place with a clearly
defined governance pathway.
Processes in place to ensure data quality and
integrity.
High quality information is routinely generated for
the Board and Board Committees.
The Board takes decisions based on evidence.
Formalised processes in place to seek patient,
family, volunteer, and staff experience and
feedback.
Governance systems and structures are
reviewed to ensure they remain fit for purpose.
A resource is identified to provide expert
advice to the Board and Foundation staff on
compliance.
Changes to statutory and other obligations are
communicated to the Board and staff
proactively and clearly.
Decision taking is improved through high
quality, timely information.
Performance monitoring is aligned to the
planning cycle and debate on organisational
purpose.
Reporting arrangements are reviewed to
ensure effectiveness/usefulness.
Patient, family, volunteer, and staff feedback
and experience is considered as part of
performance monitoring cycle and within the
Foundation’s planning activities.
Page 6 of 10
Progress Levels 
Governance Principles 
6. There are
consequences for good
and poor performance
with emphasis on
recognition, learning
and improvement
Governance Mechanisms:
 Evaluation
 Risk Management
 Audit
 Organisational
Development
 Developing
 Established
 Mature
Minimum mandated requirements met
Firm progress in development of good systems
/ processes
Comprehensive assurance framework in
place
Results being achieved
Ongoing review and improvement evident
There is a process in place to prospectively
evaluate risks.
Continuity plans are regularly tested and there is a
sound understanding of risks and opportunities.
Mechanisms in place to provide Board with
assurance that risks are being effectively managed.
Audit Committee role developed to provide
independent scrutiny of Foundation’s activities.
The Board is confident that it can respond in a
timely fashion to serious crises, should the
need arise.
Audit Committee established. (not mandatory)
Opportunities for staff training and development are
identified, including opportunities for recognition and
success sharing.
Principles accepted and commitment to action /
Documented processes in place
Documented process for dealing with good and
poor organisational performance that is consistent
with the Foundation’s Performance Management
Framework.
Escalation protocol for performance variance
agreed.
Organisational development strategy is in place,
with an emphasis on developing capability and
capacity across the Foundation.
Audit Committee is recognised for playing a
key role in scrutiny of the Foundation’s
activities.
Good performance is acknowledged.
Strategies are in place to support the
recognition and sharing of success, and
promote learning and improvement.
Individual performance is monitored against agreed
performance and development plans.
The Board and Foundation Executive promote
through example an organisational culture that
supports continuous improvement in
outcomes/service delivery.
Commitment to organisational development made
by Board. Strategy under development.
The Board allows others to observe and
challenge its ways of working.
Hospital Foundation Governance Framework Template
Page 7 of 10
Appendix 2 – Resources and Tools
Governance
Principle
Document name
Purpose
Location/Link
Principle 1:
Agency Planning
Requirements
This document provides agencies with information for strategic planning,
operational planning and other specific purpose planning. Compliance with this
document is mandated under the Financial and Performance Management
Standard 2009.
Department of the Premier and Cabinet (Performance
and Delivery Office)
Purpose and
Direction
Email: pm@premiers.qld.gov.au
(http://www.premiers.qld.gov.au/publications/categories/
plans/planning-requirements.aspx)
Strategic Plans –
Minimum Requirements
Checklist
These fact sheets provide a summary of the minimum requirements (taken from
the Agency Planning Requirements) for a statutory body in relation to developing
a strategic and an operational plan.
Operational Plans –
Minimum Requirements
Checklist
The webcast also provides guidance on the strategic planning process and
requirements.
Office of Health Statutory Agencies
http://www.health.qld.gov.au/ohsa/html/resources.asp
Strategic Planning for
Government Bodies Webcast
A Guide to Risk
Management
These guidelines have been prepared as an information reference and contain
the minimum principles and procedures of a basic risk management process.
The guide is not mandatory, however, application of the guide will encourage
better practice.
Principle 3:
Roles and
Responsibilities
‘Governing Queensland’
Handbooks, including
‘Welcome Aboard’
A suite of five handbooks and a guide for members of Queensland government
boards, committees and statutory authorities which explain the process of
government in Queensland and the responsibilities of key participants.
‘Welcome Aboard: A guide for members of government boards, committees and
statutory authorities’ sets out the role of these bodies and the responsibilities of
those serving as government board members, including their fiduciary duties.
Principle 4:
Responsibility
and Authority
Queensland Treasury and Trade
(http://www.treasury.qld.gov.au/office/knowledge/docs/ri
sk-management-guide/index.shtml)
Department of the Premier and Cabinet (State Affairs
Branch)
(http://www.premiers.qld.gov.au/publications/categories/
policies-and-codes/handbooks.aspx)
Public Sector Ethics Fact
Sheet
This fact sheet provides Health statutory agencies with information on the
minimum requirements they are obliged to comply with under the Public Sector
Ethics Act 1994.
Office of Health Statutory Agencies
Statutory Body Guide
The Statutory Body Guide has been designed to assist members of a statutory
body’s board, management and administrative team in assessing their
obligations under the Financial Accountability Act 2009, the Financial and
Performance Management Standard 2009 and the Financial Accountability
Handbook. The guide is not mandatory but is considered to be best practice.
Queensland Treasury and Trade (Financial
Management Branch)
Hospital Foundation Governance Framework Template
http://www.health.qld.gov.au/ohsa/html/resources.asp
Email: fmhelpdesk@treasury.qld.gov.au
(http://www.treasury.qld.gov.au/office/knowledge/docs/s
tatutory-body-guide/index.shtml)
Page 8 of 10
Governance
Principle
Document name
Purpose
Location/Link
Financial Accountability
Handbook
The Financial Accountability Handbook is designed to assist accountable officers
and statutory bodies discharge their responsibilities under the Financial
Accountability Act 2009, the Financial and Performance Management Standard
2009 and the Financial Accountability Regulation. Section 15(2) of the Financial
Accountability Act 2009 requires accountable officers and statutory bodies to
have regard to the Financial Management Handbook published by Queensland
Treasury.
Queensland Treasury and Trade
Financial Reporting
Requirements for
Queensland Government
Agencies
These annual financial statement requirements include the minimum reporting
requirements and assist statutory bodies in the preparation of their financial
statements.
Queensland Treasury and Trade
Financial Management
Tools
The financial management tools contain a number of examples and consideration
points to assist statutory bodies in assessing their obligations under the current
financial legislation in Queensland and the Financial Accountability Handbook.
The tools provided are not mandatory and may be adapted or modified to meet
the needs of individual organisations.
Queensland Treasury and Trade
Financial Management
Practice Manual (FMPM)
Guidance Template for
Hospital Foundations
The Office of Health Statutory Agencies has developed the FMPM Guidance
Template to assist Hospital Foundations in the development of their own FMPM.
Modelled on the financial management methods of a range of public sector
entities, the template provides questions, prompts and directions to guide the
development of a financially sound and robust FMPM.
Office of Health Statutory Agencies
Queensland Procurement
Policy
The Queensland Procurement Policy (QPP) provides an overarching principlesbased framework that seeks to deliver excellence in procurement outcomes for
Queenslanders. All statutory bodies are required to comply with the Queensland
Procurement Policy and Queensland's trade agreement obligations.
Department of Housing and Public Works
(http://www.treasury.qld.gov.au/office/knowledge/docs/fi
nancial-accountability-handbook/index.shtml)
(http://www.treasury.qld.gov.au/office/knowledge/docs/fi
n-reporting-req/index.shtml)
(http://www.treasury.qld.gov.au/office/knowledge/docs/fi
nancial-management-tools/index.shtml)
(http://www.health.qld.gov.au/ohsa/html/hf-fmpmguide.asp)
(http://www.hpw.qld.gov.au/supplydisposal/government
procurement/ProcurementPolicyGuidance/StateProcure
mentPolicy/Pages/Default.aspx)
Office of Health Statutory Agencies –
Procurement/Purchasing Requirements Fact Sheet
(under review to align with the QPP):
http://www.health.qld.gov.au/ohsa/html/resources.asp
Principle 5:
Outcomes
Queensland Government
Performance
Management Framework
and Guide to the
Queensland Government
Performance
Management Framework
plus on-line tools
The Guide to the Queensland Government Performance Management
Framework presents a practical overview of the key concepts within the
Performance Management Framework. It assists government agencies develop
a greater understanding of the Performance Management Framework and
provides assistance in the following areas:

planning

resource management

performance management and monitoring
Hospital Foundation Governance Framework Template
Department of the Premier and Cabinet (Performance &
Delivery Office)
Email: pm@premiers.qld.gov.au
(http://www.premiers.qld.gov.au/publications/categories/
guides/perf-manage-framework.aspx)
Page 9 of 10
Governance
Principle
Document name
Purpose

Principle 6:
Consequences
Location/Link
performance reporting.
Better Practice Guide:
Output Performance
Measurement and
Reporting
This better practice guide provides a checklist to support effective output
performance measurement and reporting, recommendations on what to include
in a performance measures or ‘data’ dictionary and provides signposting to
further reference material and information on the compilation and reporting of
performance information.
Queensland Audit Office
Annual Report
Requirements for
Queensland Government
Agencies
This document provides information about the legislative and reporting
requirements for annual reports for all Queensland Government agencies,
including statutory bodies.
Department of the Premier and Cabinet (Performance
and Delivery Office)
Better Practice Guide:
Performance Reviews
This better practice guide has been developed to assist organisations to adopt a
performance review system that enables analysis and interpretation of
performance information, facilitates discussions on how performance can be
improved and translates these discussions into action. It will help agencies to
satisfy the objectives of the Queensland Government Performance Management
Framework.
Queensland Audit Office
Audit Committee
Guidelines: Improving
Accountability and
Performance
These guidelines have been prepared to assist agencies with the establishment
and maintenance of audit committees.
Queensland Treasury and Trade
Hospital Foundation Governance Framework Template
(http://www.qao.qld.gov.au/downloadables/publications/
best_practice/qao_bpg_output_report.pdf)
(http://www.premiers.qld.gov.au/publications/categories/
guides/annual-report-guidelines.aspx)
(http://www.qao.qld.gov.au/downloadables/publications/
best_practice/qao_bpg_performance%20_reviews.pdf)
(http://www.treasury.qld.gov.au/office/knowledge/docs/i
mproving-performance/index.shtml)
Page 10 of 10