Policy and funding guidelines 2015
Volume 2: Health operations 2015–16
Chapter 3: Conditions of funding
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© State of Victoria, Department of Health & Human Services July 2015.
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Contents
Chapter 3: Conditions of funding
Introduction to Chapter 3
3.1Standards
3.1.1Public sector values and principles
3.1.2Safety
3.2Expectations, policies and performance
3.2.1Acute and subacute
3.2.2Mental health services
3.2.3Alcohol and drug services
3.2.4Ageing, aged and home care services
3.2.5Primary, community and dental health
3.2.6Identification and management of vulnerable children
3.3Accreditation
3.3.1Australian Health Service Safety and Quality Accreditation Scheme
3.3.2Pathology services
3.3.3Ambulance Victoria
3.3.4Mental health clinical and community support services
3.3.5Alcohol and drug treatment services
3.3.6Aged care
3.4Clinical governance
3.4.1Health service clinical governance
3.4.2Community health clinical governance
3.5Consumer rights and community participation
3.5.1Australian Charter of Healthcare Rights in Victoria
3.5.2Consumer, carer and community participation
3.5.3Victoria’s health experience
3.5.4Health service community advisory committees
3.5.5Reporting on quality of care
3.5.6Partnerships
3.5.7Service coordination
3.5.8Informed consent for receipt of services
3.5.9Complaint management
3.5.10Health service cultural and linguistic diversity requirements
3.6Financial requirements
3.6.1Health service procurement and purchasing requirements
3.6.2Compliance with financial requirements
3.6.3Goods and services tax
3.6.4Strategic procurement
3.7Asset and environmental management
3.7.1Asset management planning
3.7.2Property portfolio management
3.7.3Asset maintenance
3.7.4Health service environmental management planning and reporting
3.8Information and communication technology standards
3.9Risk management
3.9.1Risk management and assurance
3.9.2Emergency management
3.9.3Fire risk management
3.10Legal obligations
3.10.1Privacy
3.10.2Intellectual property
3.11Payments and cash flow
3.11.1Payments to funded organisations
3.11.2Enterprise bargaining
3.11.3Interim payments for long-stay, high-cost patients
3.11.4Use of contract WIES
3.11.5Health service fees and charges
3.11.6Private patient accommodation charges
3.11.7Redirection of funds
3.11.8Doctors in training secondment arrangements
3.11.9Accountability for visiting medical officer payments
3.11.10Long service leave
3.11.11Medical indemnity insurance
3.12Data collection requirements
3.12.1Data integrity
3.12.2Key systems
3.12.3Acute data reporting requirements
3.12.4Subacute data reporting requirements
3.12.5Ambulance Victoria data reporting requirements
3.12.6Mental health services data reporting requirements
3.12.7Alcohol and drug services data reporting requirements
3.12.8Aged care data reporting requirements
3.12.9Primary, community and dental health data reporting requirements
3.12.10Public health data reporting requirements
3.12.11Workforce data reporting requirements
3.12.12Commonwealth–state reporting requirements
Appendix 3.1: Performance targets and monitoring
Appendix 3.2: Service standards and guidelines
List of tables
Acronyms and abbreviations
1
Conditions of funding
Chapter 3:Conditions of funding
Introduction to Chapter 3
Chapter 3 of these guidelines detail the conditions and expectations of funding that apply to funded agencies, including relevant standards and policies.
These guidelines are a functional document that articulates the performance and financial framework within which state government-funded health sector entities operate. They are a reference for funded organisations regarding the parameters that they are expected to work to and within, as well as the funding linked to various services, in order to achieve the expected outcomes of the Victorian Government.
Chapter 1 of the guidelines sets out new funding and initiatives in 2014–15. Chapter 2 focuses on the financial framework for providing funding. The focus of this part, Chapter 3, is on funding conditions. Chapter 4 of these guidelines includes the modelled budgets for organisations that receive more than $1million in health funding.
Items may be updated throughout the year. Funded organisations should always refer to the policy and funding guidelines website for the most recent version of documents and guidelines.
Where these guidelines refer to a statute, regulation or contract, the reference and information provided in these guidelines is descriptive only. In the case of any inconsistencies or ambiguities between these guidelines and any legislation, regulations and contractual obligations with the State of Victoria acting through the Department of Health & Human Services or the Secretary to the department, the legislative, regulatory and contractual obligations will take precedence.
A note on terminology
The term ‘funded organisations’ relates to all entities that receive departmental funding to deliver services. Aspects of these guidelines referring to funded organisations are applicable to all department-funded entities.
For the purposes of these guidelines, the term ‘health services’ relates to public health services, denominational hospitals, public hospitals and multipurpose services, as defined by the Health Services Act 1988, in regard to services provided within a hospital or a hospital-equivalent setting. Aspects of these guidelines that refer specifically to ‘health services’ are only applicable to these entities.
The term ‘community service organisations’ (CSOs) refers to registered community health centres, local government authorities and non-government organisations that are not health services.
These guidelines are also relevant for Ambulance Victoria, Health Purchasing Victoria, Ramsay Health Care and the Victorian Institute of Forensic Mental Health. The guidelines specify where aspects of the guidelines are relevant for these organisations.
3.1Standards
3.1.1Public sector values and principles
Responsiveness
•Providing frank, impartial and timely advice to the government
•Providing high-quality services to the Victorian community
•Identifying and promoting best practice
Integrity
•Being honest, open and transparent in their dealings
•Using powers responsibly
•Reporting improper conduct
•Avoiding real or apparent conflicts of interest
•Striving to earn and sustain public trust at the highest level
Impartiality
•Making decisions and providing advice on merit without bias, caprice, favouritism or self-interest
•Acting fairly by objectively considering all relevant facts and applying fair criteria
•Implementing government policies and programs equitably
Accountability
•Working to clear objectives in a transparent manner
•Accepting responsibility for their decisions and actions
•Seeking to achieve best use of resources
•Submitting themselves to appropriate scrutiny
Respect
•Treating others fairly and objectively
•Ensuring freedom from discrimination, harassment and bullying
•Using their views to improve outcomes on an ongoing basis
Leadership
•Actively implementing, promoting and supporting these values
Human rights
•Making decisions and providing advice consistent with the human rights set out in the Charter of Human Rights and Responsibilities Act 2006
•Actively implementing, promoting and supporting human rights
Section 8 of the Public Administration Act 2004outlines the principles and what employers must do with them. Employers must establish employment processes to ensure:
•employment decisions are based on merit
•employees are treated fairly and reasonably
•equal employment opportunity is provided
•human rights, as set out in the Charter of Human Rights and Responsibilities Act, are upheld
•public sector employees have a reasonable avenue of redress against unfair or unreasonable treatment
•a career in the public service is fostered (in the case of public service bodies).
The Public Sector Standards Commissioner issues codes of conduct to reinforce the public sector values, and standards on how to apply the employment principles. The codes and standards are binding but not detailed. They enable employers to introduce policies and practices that suit their organisation while also complying with the codes and standards. Employees should consider the codes, standards and any organisational policies when deciding what action to take.
Further information is available on the Victorian Public Sector Commission’s website at
3.1.2Safety
3.1.2.1Pre-employment screening
The department and all funded organisations must undertake relevant pre-employment/pre-placement police record checks on all employees to minimise the risk of employing unsuitable people. Safety screening may also include a Working with Children Check, which is a mandatory screening process for people who volunteer or work with children.
3.1.2.2Staff safety in Victorian health services
All funded organisations are responsible for the safety of their staff, patients and visitors. Fundedorganisations must have systems and processes in place to enable them to identify, assess and control occupational health and safety risks in accordance with their obligations under the Occupational Health and Safety Act 2004.
The Victorian Government has committed to establish a $20 million fund (over four years) to improve facilities in public health services, including mental health services, making them safer for staff, patients and visitors.
In 2015–16 the department will continue to work with health services to implement the government's commitment to establish a simplified mechanism for hospital staff to report violence.A separate module will be developed in the Victorian Health Incident Management System for reporting occupational health and safety incidents.
In 2015–16 the department will continue to work with health services to support improved implementation of Code Grey responses and evaluation of Code Grey responses, in accordance with the Standards for Code Grey Responses (2014). The standards are available at docs.health.vic.gov.au/docs/doc/Code-Grey-Standards>.
3.1.2.3Safe environment for transgender or intersex individuals
Funded organisations have a responsibility to provide a safe environment for women, men, transgender people or people with intersex variations. Services should develop local policies and procedures to facilitate gender-sensitive and safe practice, to promote sexual safety andtoguide staff in preventing sexual activity and responding appropriately to allegations of sexual assault or harassment.
The department has developed the following documents to provide guidance to services:
•Service guideline for gender sensitivity and safety, available at docs.health.vic.gov.au/docs/doc/Service-Guideline-for-Gender-Sensitivity-and-Safety
–the Chief Psychiatrist’s guideline: Promoting sexual safety, responding to sexual activity and managing allegations of sexual assault in adult acute inpatient units, available at docs.health.vic.gov.au/docs/doc/Promoting-sexual-safety-responding-to-sexual-activity-and-managing-allegations-of-sexual-assault-in-adult-acute-inpatient-units--June-2012>.
3.1.2.4Patient and client safety
All funded organisations are responsible for the safety of their patients or clients. Funded organisations should have systems and processes in place to enable them to identify, manage and respond to adverse incidents, reducing the risk of such incidents recurring in future.
Health services and community service organisations (CSOs) that provide services on behalf of the department and report patient or client safety incidents through the Victorian Health Incident Management System (VHIMS) are subject to the Victorian health incident management policy, available at <
CSOs that provide services on behalf of the department and do not report incidents through VHIMS are subject to the (former)Department of Health’s Incident reporting instruction 2013 . The Incident reporting instruction 2013 and accompanying incident report form are available at: Funded Agency Channel
The Incident reporting instruction 2013 provides guidance for reporting incidents or alleged incidents that involved or impacted patients or clients during service delivery. It does not replace an organisations own incident management systems and processes. Organisations’ incident management policies and processes may be reviewed as part of the departments’ routine contract and performance management arrangements.
Supported Residential Services (SRSs)
- SRS are privately operated services, and not funded by the department.
- SRS are registered with the department, which has responsibility for administration of the legislation governing SRS under the Supported Residential Services (Private Proprietors) Act 2010 and a regulatory responsibility under the Supported Residential Services (Private Proprietors) Regulations 2012.
•Effective from 10 April 2014, the incident reporting process for SRS is as follows:
–SRS prescribed reportable incidents are notified to Authorised Officers located in regional offices. Authorised Officer details are available at
–Prescribed reportable incidents in SRS are detailed in the SRS Act and Regulations: Authorised Officers are responsible for recording prescribed reportable incidents through a separate and independent database, the Compliance Reporting and Monitoring System (CRAMS).
–SRS Authorised officers are no longer required to report SRS incidents via the Category One reporting process.
Mental health – reportable deaths
From 1 July 2014, the Mental Health Act 2014 requiresall mental health service providers to inform the Chief Psychiatrist of all reportable deaths within the meaning of the Coroners Act 2008. Mental health service providers include all designated mental health services and all publicly funded mental health community support services (MHCSS).
MHCSS are required to submit the following reports within the relevant timeframes:
- VHIMS reporting CSOs providing MHCSS are required to report the incident in accordance with the Victorian health incident management policy;
- Non-VHIMS reporting CSOs providing MHCSS are required report the incident in accordance with the Incident reporting Instruction 2014; and
- complete a MHA 125 ‘Notice of Death’ form to the office of the Chief Psychiatrist.
More information on what is meant by a ‘reportable death’ and the procedures for reporting them can be found in the Chief Psychiatrist’s guideline on reportable deaths, available at health.vic.gov.au/chiefpsychiatrist>.
3.2Expectations, policies and performance
The following sections outline non-financial performance and behavioural expectations for funded agencies. These expectations are consistent with the Victorian health service performance monitoring framework business rules 2015–16. The framework is discussed in Chapter 1, section 1.3 ‘Accountability framework’ and is available at
3.2.1Acute and subacute
3.2.1.1Integrated cancer services
All health services that treat cancer patients are expected to be active members of the Integrated Cancer Service (ICS) for their region and:
•implement best practice models of care
•improve the integration of care through system coordination and integration
•systematically monitor processes and outcomes of care
•participate in statewide initiatives to support improvement in cancer outcomes.
A continuing focus for the ICS in 2015–16 is to work in collaboration with relevant cancer centres to streamline service improvement priorities within and across the ICS regions.
Host organisations are required to hold funds on behalf of the ICS and act as employers for ICS staff. Host organisations need to ensure that appropriate human resource management, fiscal management processes and accounting procedures are in place. A senior executive should be nominated as the key management contact regarding these matters.
The ICS governance groups, with clinician input, are responsible for:
•decision making about using funds in accordance with both local and statewide priorities for cancer reform
•accountability for the ICS funding
•ensuring value for money
•ensuring sound project management and evaluation processes are employed.
Host organisations and the ICS governance groups must agree to any charges levied by the host for infrastructure support. These charges must be reflective of actual costs incurred and should be reported in the ICS budget. A detailed reporting schedule for integrated cancer services, which identifies requirements and dates/timelines, will be provided in September 2015.
Accountability requirements of the ICS governance groups are to:
•provide an annual review and report of progress against the current strategic plan
•provide half-yearly financial statements (for periods ending 31 December and 30 June)
•participate in the department’s cancer reform meetings and workshops
•provide an annual report (for 2014–15) for public dissemination
•participate in processes to evaluate the impact of cancer reform activities, including reporting outcomes against targets and milestones.
The department reserves the right to conduct an ICS directorate performance and financial audit.
Further information about Victoria’s ICS is available at
3.2.1.2Maternity and neonatal services
The department publishes an annual report of Victorian maternity services performance indicators that contains public-hospital-identified and statewide (public and private) data. The report enables health services to:
•track their own performance trends
•compare results with services of similar profile
•identify priority areas for future focus
•regularly review and plan for performance improvement within a continuous quality framework
•evaluate improvement programs and provide feedback to relevant stakeholders.
Consumer-appropriate information is also included in the report. Future reports will look to include indicators relating to neonatal services (special care nurseries and neonatal intensive care units).
Further information about the maternity and newborn program can be found at
3.2.1.3Blood Matters Program
As part of the ongoing commitment to safe transfusion practice, the Blood Matters Program assists health services to monitor transfusion practices against guidelines and provide recommendations for best practice.
Performance reporting through participating in audits and surveys on clinical practice and governance is required. Health services will be advised of the audits to be conducted in 2015–16.
Serious transfusion incident reporting is voluntary – for serious adverse events with transfusion of blood or blood components, including near-miss incidents. Participation in the program is strongly encouraged and supports national healthcare standards.
Blood and blood products are provided to health services, with the expectation that product use will align with the Australian health ministers’ endorsed National stewardship expectations for the supply of blood and blood products and associated strategies including theNational blood and blood product wastage reduction strategyand Strategic framework for the National Haemovigilance Program (see
The department has helped established the transfusion nurse/trainer/safety officer role across Victoria and continues to support through acute admitted funding.
Activities to support compliance with national guidelines and the National Safety and Quality Health Service (NSQHS) Standards include:
•employment of an appropriately trained nurse/scientist, such as one who holds a Graduate Certificate of Transfusion Practice
•ensuring the role operates within an effective health service transfusion/quality governance structure