Policies and procedures

Our policies and procedures support the delivery of care that is safe, respectful, inclusive and responsive to the needs of our community. They provide a framework for decision-making, guide the way services are delivered and help ensure we meet our obligations under relevant legislation, regulatory requirements, professional standards and accreditation frameworks.

These policies support the rights, safety and wellbeing of consumers, families, carers, visitors, staff, volunteers and the broader community.

At TDHS, we are committed to ensuring every person receives care that is safe, respectful and responsive to their individual needs.

The Australian Charter of Healthcare Rights protects consumers of healthcare services. This Charter describes the rights of people using healthcare services in Australia and recognises the important role consumers play as partners in their own care.

These rights include:

• Access to healthcare and services
• Safe and high-quality care
• Respect, dignity and consideration
• Partnership in decisions about care and treatment
• Information that is clear and easy to understand
• Privacy and confidentiality
• The ability to provide feedback or make a complaint

Consumers receiving aged care services are also protected by the Statement of Rights, which supports autonomy and freedom of choice, equitable access, privacy and confidentiality, communication and complaints, support and connections and safe quality care.

TDHS is committed to partnering with consumers, families and carers in care planning, service delivery and continuous improvement activities.

Feedback helps us understand what we are doing well and where we can improve.

Consumers, carers and visitors are encouraged to share compliments, suggestions, concerns and complaints about any aspect of our services.

TDHS is committed to:

• Listening respectfully to feedback
• Managing concerns fairly and confidentially
• Responding in a timely manner
• Learning from feedback to improve services
• Ensuring consumers can raise concerns without fear that it will affect their care

Where concerns cannot be resolved directly with TDHS, consumers may seek support from external agencies such as the Health Complaints Commissioner, Aged Care Quality and Safety Commission, NDIS Quality and Safeguards Commission or other relevant bodies.

Feedback is an important part of our quality improvement program and helps shape the future development of our services.

Protecting personal and health information is an important part of providing safe and effective care.

TDHS collects and manages personal and health information in accordance with:

• Privacy and Data Protection Act 2014 (Vic)
• Health Records Act 2001 (Vic)
• Freedom of Information Act 1982 (Vic)
• My Health Records Act 2012 (Cth)
• Other relevant legislation and regulatory requirements

Information is collected to support healthcare delivery, aged care services, community programs, quality improvement activities and legal obligations.

Consumers can expect that information will be:

• Collected lawfully and fairly
• Kept secure and confidential
• Accessed only by authorised personnel
• Used only for legitimate purposes
• Protected from unauthorised disclosure

Consumers have the right to access their information and request corrections where information is inaccurate, incomplete or out of date.

TDHS participates in Australia’s national digital health record system, My Health Record.

My Health Record provides a secure online summary of important health information and supports safer, more coordinated care by enabling authorised healthcare providers to access relevant clinical information when required.

Information that may be available through My Health Record includes:

• Shared Health Summaries
• Discharge Summaries
• Pathology reports
• Diagnostic imaging reports
• Prescription and dispensing information
• Advance care planning information

Consumers can choose how their My Health Record is managed, including setting access controls and monitoring who has viewed their information.

Participation in My Health Record is governed by strict privacy and security requirements under Commonwealth legislation.

Consumers have the right to access information relating to their care and health records.

TDHS supports access to information through privacy legislation and Freedom of Information processes where appropriate.

Applications may relate to:

• Personal health records
• Historical records
• Administrative information
• Documents held by the organisation

Requests are managed in accordance with legislative requirements while balancing privacy, confidentiality and the rights of other individuals.

Consumers have the right to make informed decisions about their healthcare.

Before treatment, procedures or interventions occur, healthcare professionals will provide information regarding:

• The nature of the proposed treatment
• Expected benefits
• Potential risks and complications
• Alternative treatment options
• Possible outcomes if treatment is not undertaken

Consumers are encouraged to ask questions, discuss concerns and actively participate in decisions about their care.

Where a person is unable to make decisions independently, healthcare decisions may be made by an authorised substitute decision-maker in accordance with Victorian legislation.

Advance Care Planning allows people to think about, discuss and document what matters most to them in relation to future healthcare.

Advance Care Planning helps ensure that healthcare decisions reflect an individual’s values, preferences and wishes if they become unable to communicate or make decisions in the future.

Planning may include:

• Appointing a Medical Treatment Decision Maker
• Completing an Advance Care Directive
• Discussing future healthcare preferences with family members and healthcare professionals
• Identifying cultural, spiritual or personal wishes that are important to future care

TDHS supports consumers and families to participate in Advance Care Planning conversations and decision-making.

Open disclosure is an open and transparent process used when something unexpected occurs during care.

TDHS is committed to ensuring consumers and families are:

• • Informed about what happened
  • Treated with honesty and respect
  • Given the opportunity to ask questions
  • Supported throughout the process
  • Involved in discussions about ongoing care
  • Kept informed of investigations and improvement actions

Open disclosure supports trust, accountability, learning and continuous improvement.

TDHS is committed to the safety, wellbeing and empowerment of all children and young people.

We have zero tolerance for child abuse and are committed to protecting children and young people from harm. Child safety is embedded throughout our organisation and forms part of our culture, governance, systems and everyday practice.

Children and young people have the right to:

• Feel safe and be safe
• Be treated with dignity, respect and compassion
• Have their voices heard
• Participate in decisions that affect them
• Be protected from abuse, neglect and exploitation
• Feel included, valued and supported

TDHS is committed to:

• Promoting the safety, wellbeing and empowerment of children and young people
• Creating environments where children feel safe and respected
• Encouraging children and young people to communicate openly about concerns
• Taking all concerns regarding child safety seriously
• Responding promptly and appropriately to concerns and allegations
• Supporting families and carers to participate in decisions affecting children
• Maintaining robust child-safe systems and practices
• Meeting the requirements of the Victorian Child Safe Standards

We are committed to the cultural safety, participation and empowerment of Aboriginal and Torres Strait Islander children and young people and to providing inclusive environments for children from culturally and linguistically diverse backgrounds, children with disability and all children and young people accessing our services.

Child safety is a shared responsibility. All Board Directors, employees, volunteers, contractors, students and visitors are expected to contribute to a culture that prioritises the safety and wellbeing of children and young people.

TDHS welcomes and respects people of all cultures, backgrounds, faiths, identities, abilities and life experiences.

We are committed to:

• Providing inclusive and accessible services
• Promoting equity and fairness
• Eliminating discrimination, bullying and harassment
• Supporting diversity in all forms
• Creating culturally safe environments
• Improving access to services for vulnerable and disadvantaged groups

We recognise the importance of Aboriginal cultural safety and are committed to providing care that acknowledges and respects culture, identity, family, community and connection to Country.

The Safe Patient Care (Nurse to Patient and Midwife to Patient Ratios) Act 2015 supports the delivery of safe, high-quality care across Victorian public health services.

The Act establishes minimum nurse-to-patient and midwife-to-patient staffing requirements in specified clinical settings. These staffing requirements support patient safety, improve care outcomes and help ensure consumers receive timely and appropriate care.

TDHS complies with the requirements of the Act and publicly reports staffing information in accordance with Victorian Government requirements.

Safe Patient Care Act – Timboon and District Healthcare Service

As a publicly funded health service, TDHS is committed to maintaining public trust, transparency and accountability.

Requirements relating to gifts, benefits and hospitality help ensure decisions are made fairly, ethically and in the best interests of consumers and the community.

These requirements support:

• Ethical decision-making
• Appropriate management of conflicts of interest
• Responsible use of public resources
• Transparency and accountability
• Public confidence in healthcare services

TDHS manages gifts, benefits and hospitality in accordance with Victorian public sector requirements and governance standards.

Continuous improvement is central to the delivery of safe and high-quality care.

Policies, procedures and service practices are regularly reviewed to ensure they remain current, evidence-based and aligned with legislative, regulatory and accreditation requirements.

This review process is informed by:

• Consumer feedback
• Clinical evidence and best practice
• Quality and safety outcomes
• Accreditation reviews
• Staff feedback
• Legislative and regulatory changes
• Community expectations

Through ongoing review and improvement, TDHS continues to strengthen the quality, safety and effectiveness of the services we provide to our community.