policy development guideline -...

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ACT HealthOperational Guideline Policy Development Contents

Contents...................................................................................................................................1

Introduction............................................................................................................................. 2

Scope........................................................................................................................................3

Section 1 – Getting Started.......................................................................................................3

Section 2 – Approval to go Ahead............................................................................................4

Section 3 – Development.........................................................................................................5

Section 4 – Drafting..................................................................................................................6

Section 5 – Consultation...........................................................................................................8

Section 6 – Submission and Endorsement..............................................................................11

Section 7 – Document Management......................................................................................12

Section 8 – Implementation of your Policy Document and communicating with Staff..........12

Section 9 – Review and Evaluation.........................................................................................13

Related Policies, Procedures, Guidelines and Legislation.......................................................14

Definition of Terms.................................................................................................................14

Search Terms..........................................................................................................................15

Attachments...........................................................................................................................15

Attachment 1: Legislation Guide........................................................................................16

Attachment 2: Style Guide..................................................................................................17

Attachment 3: Tip Sheets...................................................................................................21

Tip Sheet 1: How to use heading/bullet styles...............................................................21

Tip Sheet 2: Updating the Contents Page.......................................................................22

Tip Sheet 3: Do’s and Don’ts for Policy Development....................................................24

Tip Sheet 4: Quick Style Guide........................................................................................25

Tip Sheet 5: Troublesome Words...................................................................................26

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Introduction

This guideline provides ACT Health staff with the necessary information to navigate the Policy Development Cycle and produce well written, effective policy documents.

The underlying purpose of ACT Health policy documents is to ensure that the care provided by ACT Health staff across the range of health services and facilities is evidenced based, culturally appropriate and person centred. The policy development process encourages collaboration and consolidation across disciplines to provide consistency of care to patients across the organisation. Policies ensure we are accountable for the care we provide and the way in which staff engage with each other to deliver services.

Within ACT Health there are two committees responsible for the approval of policy documents and their subsequent upload to the Policy Register:1. Canberra Hospital and Health Services (CHHS) Policy Committee2. ACT Health Policy Advisory Committee

1. CHHS Policy Committee (CHHS-PC)The role of the CHHS-PC is to: Revise and endorse all policy documents developed and reviewed within Canberra

Hospital and Health Services (CHHS). Provide governance, oversight and guidance in the development and management

of policies for all of CHHS. Ensure an effective suite of patient centred, evidenced based documents exist to

support safe, high quality care in CHHS.2. Policy Advisory Committee (PAC)

The role of PAC is to oversee development of and endorse policy documents, which apply to all of ACT Health, including strategic documents such as plans and frameworks that demonstrate ACT Health’s approach to significant health issues.

The Policy Development CycleBoth Committees oversee all elements of the Policy Development Cycle for their respective policy documents. The elements are: Identifying the need for a policy document Initiating approval for proposed policy work Writing your policy, including

Research and analysis to support your policy Drafting Consultation and incorporating feedback

Policy Committee review and endorsement Document management Implementation, and Ongoing Review/Evaluation.


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Back to Table of Contents

Scope

This guideline applies to all staff involved in the development and endorsement of policy documents across ACT Health.

For the purposes of this guideline, policy documents refers to policies, procedures, guidelines, frameworks, plans and placeholders.

The aim of this guideline is to provide the process for all staff to follow to ensure consistency across policy development and to reduce the duplication of documents on the Policy Register.


Section 1 – Getting Started

Assess Divisional/Organisational NeedsBefore developing a policy document there are some key questions that you should ask:1. Why do you need to write a policy document?

For example, will writing a policy document improve patient safety and health outcomes by: Controlling real or perceived risks or hazards? Improving clinical care through the introduction of a new treatment or change in

practice? Improving morbidity/mortality outcomes? Improving use of budget and resources? Ensuring compliance with legislation? Aligning practice with ACT or Federal Government initiatives, or ACT Health

priorities?

Consider whether a new policy document is the best way of addressing the issue or whether it can be addressed by other means, e.g. through development of a unit orientation manual.

2. Are there suitable external (International, National or interstate) policy documents that could be used or adapted for use in ACT Health?If there are external policy documents or professional/best practice standards that address the topic and are endorsed for use in ACT Health by the relevant senior executive or clinical experts/leads, an initiation request for a placeholder on the Policy Register may be submitted to the relevant Committee. A placeholder provides a link to the external document for staff to access it at its home site.


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3. Is there already a similar or related policy document on the Policy Register?If there is already a suitable document addressing the matters of concern, no further work is required other than to ensure your staff are aware of the existing document. To identify if there is an existing policy document that covers the topic, practice, treatment or risk, search the ACT Health Policy Register on SharePoint.

If there is an existing policy document that covers similar/related issues and you believe the existing document should be amended to incorporate additional matters, please contact the relevant Committee Secretariat for advice.

4. If you are sure no other policy documents could cover the issue, consider how your new policy document will align with existing policy documents?For example, if there is an overarching policy document e.g. Consent and Treatment Policy, the information in the new document must not contradict the information in the overarching document. Try to avoid duplicating information. It is better to refer to related documents and inform staff that the documents must be read together.


Section 2 – Approval to go Ahead

1. Initiation Request: Staff wishing to begin work on any policy documents will need to seek agreement from the relevant Policy Committee. Once you have completed the steps in section 1 and are certain a new document is required, you need to complete an Initiation Request form approved by the relevant Divisional Executive Director.

An electronic copy of the Initiation Request can be found on the Health Hub: (http://acthealth/c/HealthIntranet?a=da&did=5004883&pid=1439967004)

2. The Initiation Request is your opportunity to put the case for your policy development work, the more information provided at this stage and the clearer the description of the purpose and impact of the policy position the more likely your initiation request will be considered and approved expeditiously. The initiation request should include information on: What sort of document is required - decide if your document is a policy, procedure,

guideline or placeholder. Please contact the CSQU Policy Team on 6174 7933 and ask for assistance if you are unsure or refer to the definitions at the end of this document.

What the content of your policy will be, including whether it contains information related to medications, clinical forms or consumer handouts.

3. Please consider carefully the scope and nature of your proposed document:


http://acthealth/c/HealthIntranet?a=da&did=5004883&pid=1439967004

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If the document will outline an overarching strategic ACT Health position on a heath matter OR if your document will outline matters affecting ALL ACT Health staff, then it is a Tier One level document and should be considered by the Policy Advisory Committee.

If your document will outline the clinical approach to a health matter OR a matter affecting staff from all of CHHS or particular Division/s, but not ALL ACT Health staff then it is a Tier Two level document and should be considered by the CHHS Policy Committee.

4. Once your initiation request has been approved, you will receive notification and advice on how to progress, including all of the required templates and forms.


Section 3 – Development

1. Assemble a development team (if appropriate/optional). A development team is a group of subject experts and interested staff to provide the author with advice and assistance through the policy development phase. The development team should have members from across the organisation (where appropriate) and be multidisciplinary.

2. Develop a timeline: Factor in reasonable times to undertake research, drafting the policy document, consulting with key users, incorporating feedback and submitting the policy to the Policy Committee. Allow at least one month for Committee approval processes.

3. Research and Analysis: Research must be conducted to ensure your policy document is evidence based and will meet the needs of stakeholders. You may also be able to find a document from another health service that can be adapted for use within ACT Health. Research activities may include: Conducting a literature review (Contact the ACT Health Library for assistance with

this) Searching and reviewing related policy documents – this could include ACT Health

or other health services, state, other jurisdictions, national and/or international, as appropriate, identifying current best available practice

Meeting with stakeholders Consultation with experts Examination of data and statistics.


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4. Legislation: It is important that all policy documents reference relevant state or national legislation. It is only necessary to list legislation that is directly related to the subject of the policy document. Please refer to Tips for Legislation at Attachment 1.

5. Communication and implementation: During this stage of the policy development cycle you will also need to think about how the policy document will be communicated to staff and implemented. Refer to Section 8 Implementation of this document for more information.

6. Review/evaluation: All policies must be regularly reviewed and evaluated to ensure their currency and effectiveness. Refer to section 9 for further information.


Section 4 – Drafting

To start drafting your policy document: Make sure you are using the correct template, which you will be provided upon approval

of the initiation request Read the instructions in the policy, procedure or guideline templates to determine what

you need to include in each section of your document Read the Style Guide at Attachment 2 and the Tip Sheets at Attachment 3 of this

document for tips and hints on format, style and important points for consideration when drafting your policy

Ensure consideration is given to staff and consumers where English is their second language or there may be low levels of literacy

When using time frames in policy documents please use 24 hour time (ie 07:00 – 13:00) Do not use hyperlinks to other policy documents on the Policy Register within the policy

document, as policy review dates rarely coincide and documents you are linking to may be superseded. However, you may hyperlink to sections within your policy document or external website if you are certain these links will not change within the review period of the document.

Naming your policy document: It is very important that the name of the document easily identifies the content Consider how staff might search for the policy document on the Policy Register and use

key search words in the title Keep the title as short as possible Start with words that describe the subject or issue to assist staff who may search for a

policy document alphabetically. For example, ‘Alcohol and Other Drugs: Responding to Use’ or ‘Code Blue: Activation of’

If applicable, the title should specify if the document applies to a particular cohort. For example ‘Adults only’

Use simple language and plain English Do not use acronyms or abbreviations, and Where possible words such as ‘the’ or ‘a’ should not be used at the start of your title.


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Impact on Staff/Patients/Carers:During the drafting and consultation stages of the document you must consider the economic, social and environmental impact of the policy position you are proposing in your policy document.

For Tier 1 documents, please use the whole of government triple bottom line (TBL) assessment form and guideline for this purpose and submit it with your policy document for consideration by the relevant Committee.

For Tier 2 documents, the following must be considered: Aboriginal and Torres Strait Islander Impact:

An Aboriginal and Torres Strait Islander Health Impact Statement may be required. If you are unsure if this is the case please contact the Aboriginal and Torres Strait Islander Health Policy Unit on 6207 9172.

Multicultural/Diversity impact: Consideration should be given to the audience:o How many staff/patients/carers coming from Culturally and Linguistically Diverse

background could be affected by the document. o Will the proposed document impact LGBTI people (lesbian, gay, bisexual,

transgender and intersex) or people with disabilities? o For further information please contact the Multicultural Health Policy Unit on

6205 1011. Domestic/Family Violence and Sexual Assault Impact:

Consider the potential impact on those who have current or past experience of DFV or SA. For further information please contact Policy and Stakeholder Relations on 6207 1783.

Search TermsSearch terms are single words or short phrases that can be used to find your document. Search terms should be limited to 15 or 20 words across the main themes of your document. It is important to consider what words staff using the document would look for.

Attachments:Attachments form part of the policy document and should be included within the document when submitted for endorsement. Attachments should not be submitted as separate documents. Please ensure that all attachments are clearly labeled and included in the table of contents and referred to within the document.

Test your document:When your draft is complete, it is important that your document is tested by both key users and staff with no prior knowledge of the content of the document.

Ask staff members to read the draft, to test it and provide you with some feedback


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about how it reads. For example, after reading the draft once: Did they understand the content? Could they identify the essential messages easily? Did they understand what they needed to do? Did the information provide a logical step by step process to be followed? Were there any words they didn’t understand? Were there any typing mistakes to be corrected?

Prior to sending the document out for consultation, make sure the policy document is plainly marked on each page as a ‘Draft’ so that it cannot be confused with an endorsed document. You will need to have a system for version control as ongoing changes are made to the draft before and after consultation (see Section 5 for more information on the consultation process).


Section 5 – Consultation

Thorough consultation with key stakeholders must be demonstrated for your policy documents to progress through the relevant Committee.

Please note that the Policy Committee secretariats can aid authors in consultation by offering guidance and support but cannot carry out the consultation for you. A broad and detailed consultation process must be completed.

Note:There is a consultation management page on ACT Health’s Policy Register site that the CSQU Policy team can set up for you and assist you in utilising. This allows all those asked to consult to make track changes on the same copy of the document thereby simplifying the process for the author.

Consultation must at a minimum include the following:1. All relevant Executives Directors and their equivalents 2. All relevant executive EOs or business managers3. The Divisional representatives on the relevant Committee4. Health care consumer representatives (phone Health Care Consumer’s Association: 6230

7800)Please note that The ACT Government guide, Engaging Canberrans – A guide to community engagement, 2011 specifies a minimum six week consultation period for external stakeholders.

5. Any external and internal stakeholders who will be affected by the proposed policy document position.

Additional consultation may be required as follows:


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1. The Health Policy Unit and the Aboriginal Torres Strait Islander Health Practice Centre for advice on potential health impacts on vulnerable populations (email: [email protected] )

2. Union/ employee representatives for any draft documents relating to enterprise agreements or other industrial matters.

3. Clinical Ethics Committee for any draft documents relating to: organ donation or tissue/blood issues; reproductive Issues; withdrawal of treatment; consent and/or competence; use of therapeutic products of limited availability. For further information about the Clinical Ethics Committee, see their intranet page on the HealthHub.

4. National Standards Group Committee through the National Standards Team (phone 6205 1506)

5. Medication Management Committee and Drugs & Therapeutic Committee (email [email protected])

6. Clinical Forms Committee (phone 6244 2245 or email [email protected]) if your document contains or references a clinical form

7. Consumer Handouts and Publications Committee (email [email protected]) if your document contains or references a consumer handout

Some excellent resources for staff to use when planning consultation with consumers and other external stakeholders are the: ACT Health Consumer and Carer Participation Framework (available on the Policy

Register) ACT Government Guide Engaging Canberrans – A guide to community engagement

(available on the Policy Advisory Committee webpage in the Policy Writing Resources section)

Engaging and Consulting with Aboriginal and Torres Strait Islander Communities in the ACT (available on the Policy Register and the Policy Advisory Committee webpage in the Policy Writing Resources section). The Aboriginal and Torres Strait Islander Practice Centre is able to provide advice on whether an Aboriginal and Torres Strait Islander Health Impact Statement is required.

The Culturally and Linguistically Diverse (CALD) Backgrounds Framework.

Managing Consultation Feedback:When circulating a document for consultation identify the scope for comment so that stakeholders are clear on what their feedback should cover.

If areas have issues with feedback deadlines, they should be asked to contact the author as soon as possible to seek an extension of the timeframe.


mailto:[email protected]




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Specify a deadline of ideally two to four weeks for providing feedback. Documents relating to high risks or sensitive issues may need a longer consultation period. A shorter consultation period may be appropriate for: Brief documents Minor amendments following review, and Simple processes.

The ACT Government guide, Engaging Canberrans – A guide to community engagement, 2011, specifies a minimum six week consultation period for documents seeking input from external stakeholders.

When circulating documents for comment, clearly state how feedback is to be provided, to whom and by when.

Review of Feedback:The author needs to review and assess feedback received to decide whether to: Accept the feedback and incorporate changes in the draft , or Justify why feedback will not result in changes to the draft.

The consultation feedback summary template forms part of the package of documents required by the Policy Committee. It will be provided to the author upon approval of the initiation request. A summary of all feedback must be recorded on the template to highlight the issues raised, explain how issues have been addressed, and provide evidence of appropriate consultation and consideration of all stakeholder views. The consultation summary sheet should: List each one of the stakeholders by name and position to whom the draft policy

document was given during the consultation phase Summarise the feedback received by each stakeholder Explain either how feedback was incorporated or why it was not incorporated Include a notation that ‘No response was received’ if a stakeholder does not provide

feedback within the set time frame (note: this should not be considered as endorsement or agreement with the policy document and further consultation may still be required).

Minor feedback relating to formatting, spelling, and grammar and typing mistakes etc may be summarised as ‘minor editing amendments’.


Section 6 – Submission and Endorsement

Before a policy document may be considered active, the documents and any supporting material must be endorsed by the appropriate Committee and uploaded onto the Policy Register.


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Note:If your document includes the following: Clinical forms - please ensure these forms are endorsed by the Clinical Forms Committee

prior to submission to the relevant Policy Committee. Consumer Handouts - please ensure these handouts are endorsed by the Clinical

Handouts Committee prior to submission to the relevant Policy Committee. Reference to Medication: please ensure all medications are reviewed/endorsed by the

Medication Management Committee prior to submission to the relevant Policy Committee.

The Policy Team can help facilitate these processes where required.

When your policy document has been drafted and the consultation period is finished and the document finalised, you should submit the following to the appropriate Policy Committee via email to either [email protected] (Tier One ACT Health Wide documents only) or [email protected] (Tier Two CHHS documents only): Completed Submission for Approval request form signed by Divisional Executive

Director Draft policy document/s Consultation feedback summary Archive form outlining any superseded policy documents (where necessary) – note: this

includes a full document revision Proof of endorsement where documents or supporting materials are required to be

endorsed by another governance body before submission.

Please only submit clean copies, ie. no tracked changes or reviewer comments.

When the Committee Secretariat receives your document they will undertake a quality assessment and then list the document for consideration at the next appropriate committee. Two committee reviewers will read your document and provide suggested changes if required. You will receive an outcome report including a decision about endorsement, as well as any required changes that need to be made and resubmitted prior to final endorsement. You will receive confirmation via email when your document has been endorsed and uploaded to the Policy Register for use.

Note:If your document is not to be uploaded immediately following approval, (eg. because it will be launched at an event, or after a communications strategy), you must include the requested date for upload on the submission for approval form.





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Section 7 – Document Management

Document management is about ensuring the validity, quality and transparency of ACT Health policy documents.

All document authors are required to maintain an official file for their document. This file should contain all documentation related to the development of your policy, including: Initiation Request and approval Consultation feedback form Draft version with reviewer comments/tracked changes Submission for approval form Archive form (if required) Any written communication (ie. emails) about the development of the policy Outcome report from Policy Committee Final endorsed version of the policy

The Policy Register Manager is responsible for document management including: Tracking policy documents due for review and advising responsible areas of the

need to review before expiration. Uploading new documentation Removing earlier or superseded versions from the Policy Register Managing the lists of publically available policy documents to ensure only those

that may have particular privacy or security implications are not made publicly available.


Section 8 – Implementation of your policy document and communicating with Staff.

During planning for implementation you will need to consider who will be affected by the new or revised policy position outlined in the document and determine the most appropriate, effective and efficient way of informing them. This information must be included on the Policy Submission for Approval Form.

Consider and identify: Those with responsibility for implementing the policy document. The resources needed to implement the policy document? Policy document

owners may be responsible for the provision of training and this should be factored into the area’s budget.

The need for staff education or training. Any policy documents requiring changes to established practice should be accompanied by an information session, training or workshop.


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How staff are going to know about the new or revised policy document so they can adhere to it?

Any changes to practices needed and how this will be managed?

Communicating the new or revised policy decision to staffEach new or revised policy document must be communicated to staff, particularly those likely to be impacted by its introduction or whose practices will need to change as a result.

The Policy Committee Secretariats arrange monthly all staff emails in the form of a Director-General or Deputy Director-General CHHS Alert outlining recent policy endorsements. These do not necessarily occur immediately after the new policy is activated by upload to the Policy Register. It is therefore important that authors actively manage targeted communications to those staff most likely to be affected by the policy decision which should be communicated through line managers. Policy committee representatives should also notify their Divisions of policy endorsement decisions. This might include: All staff emails at branch/division level Face-to-face meetings/discussions Information sessions Staff forums Team briefings by managers (a team briefing template is available on the Policy

Advisory Committee webpage in the Policy Writing Resources section) Newsletters Communication books used by specific work areas.

Some policy documents will need more comprehensive communication strategies, such as a media release or launch, and advice to stakeholders in the form of brochures, advertising, training sessions and community announcements.


Section 9 – Risk Rating and Review

Policy documents and any supporting material need to be reviewed regularly to ensure they retain their relevance and effectiveness. When the document is endorsed by the relevant Policy Committee a review date between 12 months and five years will be determined based on the risk rating of the document.

The risk rating is determined using the risk rating matrix contained in the ACT Health Risk Management Guideline. This risk is based on the likelihood and expected consequence of an incident that may occur if the policy document was either not in place or was not current. This process takes into account the advice of the document owner. High risk documents or those subject to regular external influence should have an earlier review date while low risk or those not expected to change may be given a full five year endorsement.


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Note: It is not necessary to wait until the allocated review date to revise the document. An earlier review is appropriate, and possibly required if: An incident has occurred resulting in a need for review or change to process or

policy There is a change in infrastructure or procedure, or Legislation, best practice guidelines or ACT Government policy or strategic

direction has changed.

As part of the review process, policy documents require evaluation in accordance with their specific scope and associated risk. Evaluation is critical to measure and assess the impacts and merits of policies and to determine appropriateness, effectiveness and efficiencies related to a particular policy, and to contribute to future improvements.


Related Policies, Procedures, Guidelines and Legislation

PoliciesPolicy Management Policy

GuidelinesRisk Management Guidelines


Definition of Terms

Plan Sets out a direction and goals for the Health Directorate in relation to a particular area of

health concern Has a timeframe and end date Requires a report at the end date including a decision on need for further Plan.

Guideline: Articulates the scope in which clinical/operational decisions are made, and are based on

best available evidence If a Guideline is not followed the rationale needs to be clearly documented.

Placeholder: On the Policy Register with a link to appropriate external document, eg. National/ whole

of government policy document or professional guidelines.

Policy: A systematically developed document based on legislation, Standards, regulations

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Short and to the point statement of an ACT Health policy position on a health issue Compliance with policies is mandatory A policy is often, but not always supported by a procedure or guideline.

Procedure: Describes how staff should operate/ complete required process in ACT Health Based on best available evidence and the considered judgment of staff Describes the step by step process for consistent implementation/performance of a

certain task May relate to corporate/administrative activities, or in the hospital and health services

environment operational or clinical activities If a procedure is not followed, the rationale for this needs to be clearly documented.


Search Terms

Policy Committee, Policy Development, Procedure, Guideline, Plan, Policy Development Cycle, Consultation, Implementation


Attachments

Attachment 1: Legislation GuideAttachment 2: Style GuideAttachment 3: Tip Sheets

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval28/02/2018 Minor review to include

ACT Health specific information

PAC and CHHS-PC Chairs

This document supersedes the following: Document Number Document Name

Attachment 1: Legislation GuideThis Legislation Guide provides information for staff writing policy documents to ensure ACT Health policy and procedure documents reference relevant legislation.

It is only necessary to list legislation that is directly related to the subject of the policy document. The following list provides examples of ACT and Commonwealth legislation that


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may apply (note this is not an exhaustive list – for full list of ACT legislation, visit http://www.legislation.act.gov.au/a/ ):

Financial Management Financial Management Act 1996

Population HealthMedicines, Poisons and Therapeutic Goods Act 2008Transplantation and Anatomy Act and Medical Treatment (Health Directions) Act 2006Human Rights Act 2004

Quality and SafetyWork Health and Safety Act 2011Workers Compensation Act 1951

Business and InfrastructureGovernment Procurement Act 2001Territory Records Act 2002

E-Health and Clinical RecordsFreedom of Information 1989Health Records (Privacy and Access) Act 1997

Human ResourcesPublic Interest Disclosure Act 2012Public Sector Management Act 1994

Canberra Hospital and Health ServicesGuardianship and Management of Property Act 1991Health Records (Privacy and Access) Act 1997

Mental Health, Justice Health and Alcohol and Drug ServicesOperational SupportACT Mental Health Act 2015


http://www.legislation.act.gov.au/a/

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Attachment 2: Style GuideTemplates

Policy, Procedure and Guideline templates are available from the relevant Policy Committee or the Hub Policy Guidance page LINK….. Email: Quality, Governance and Risk, Clinical Safety and Quality Unit (CSQU) Policy Team at [email protected] , Phone: 6174 7933 (ext 47933) or Policy Advisory Committee Secretariat at [email protected], phone: 6207 1783 (ext 71783)

Each section of the template must be completed. Additional headings/sections may be inserted, where necessary. Heading, paragraph and

bullet styles have been set on the templates so it is important that the approved templates be used. Where an extra heading etc needs to be included please see the How to Use Heading Styles guide (Attachment 5, tip sheet 1).

Please ensure that when submitting documents for review and endorsement by the Policy Committee that these documents contain no tracked changes or comments from the consultation phase.

FontUse: Name of Procedure/Policy or Guideline: Calibri 22 bold Document Title: Calibri 18 bold Template headings (in the grey or black box): Heading Style 1 (Calibri 14 bold) Sub headings: Heading Style 2 (Calibri 12 bold)

o Please ensure no space exists between a Heading Style 2 and the underneath Body Text

Body Text: Calibri 12 Bullets: List bullet. Banding (Background Color of Title):

o Guidelines: Light Grey – RGB: 217, 217 and 217 o Procedures: Dark Grey - RGB:166, 166 and 166o Policies: Black - RGB: 0, 0 and 0

Note: Please ensure that appropriate heading styles are used as the contents page is generated from the heading styles applied throughout the document. For help with this see attachment 5 or contact the Policy Team Email: [email protected] Phone: 6174 7933.

Attachments When inserting attachments please refer to them in your document (see Attachment 1

etc) Ensure the title of the attachment is in the following font: Heading Style 2 (Calibri 12

bold)

Simple Language and Plain English





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Use simple language and plain English so that staff can find, read and understand what they need to do relevant to their jobs, as quickly and easily as possible. For example: Use simple words. For example, use the word ‘give’, instead of ‘administer’ Avoid use of jargon. If using medical terminology include in the Definitions section at the

end of the policy document Use short sentences. Try for a maximum of 20 to 25 words per sentence Convey information as briefly and to the point as possible. Avoid use of excess words to

put across an idea. For example ‘The car is red’ is better than ‘the colour of the car is red’ Information that provides background or further reading should not be included in the

body of the document but may be:o Listed in the references sectiono Placed in an attachment at the end of the document, oro Available on relevant Divisional web site for staff to access as a resource. (A clear

description of where staff may find it on the intranet should be included in the policy document).

Use lists of dot points instead of longer sentences and paragraphs Avoid repeating information already stated.

Dot Points If all dot points in a series are sentences, they take full punctuation. If they consist of sentence fragments, then no punctuation is used except for a full stop

after the last point (do not use ‘and’ at the end of the second last dot point). A colon is used after the lead-in sentence to clarify the link with the dot points that

follow.

Numbering of Procedure StepsThe procedure section must be numbered so that it is described and is read, in the order of necessary steps that staff must follow.

AbbreviationsAbbreviations are to be spelt out in full the first time a term is used in the document, followed by the abbreviation e.g. Policy Advisory Committee (PAC).

Only use abbreviations, acronyms and symbols approved by the Canberra Hospital Clinical Records Forms Committee when providing information to guide clinical practice, (Refer to: ACT Health Abbreviations and Symbols policy and the list of approved abbreviations, acronyms and symbols on the Clinical Forms Register on the ACT Health intranet).

It is also useful to include all acronyms in the definitions section.

Highlighting InformationAs much as possible, important information should appear in the front of the document so that it is read first. Use of bold type can be used sparingly to highlight a specific statement.Formatting that should not be used to highlight information includes: Underlining


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Capitals Larger font size or different font style Colored text.

Boxes may be used to highlight Alerts/Notes and should be entered as followed:

Alert/ Note: enter body text

Consistency Choose one descriptive term and use throughout the document. For example, use of the

term ‘consumer’, ‘clients’, or ‘patients’ to describe patients. Use of punctuation should be consistent throughout the document. At the end of every section within your document, ensure there is a link back to the table

of contents.

Search TermsList the search terms to be used to assist in locating this document on the Policy Register.

Referencing ACT Health/CHHS Policy Documents When referencing other relevant ACT Health/CHHS policy documents in the body of the

document use the following style: Refer to Health Directorate Consent to Treatment Policy ensuring the title of the document is italicised.

LegislationLegislation is to be written in italics with date in normal text. E.g. Human Rights Act 2004. It is only necessary to list legislation that is directly related to the subject of the policy document. For example, it is understood that staff must comply with the Public Sector Management Act 1994 and is not necessary to reference this legislation in every ACT Health policy document.

Journal Articles etcVancouver Referencing is the preferred method of referencing. The Vancouver uses sequential numbers in the text, either bracketed or superscript. The numbers refer to either footnotes or endnotes that provide source detail. An example of this is:1. Hoppert M. Microscopic techniques in biotechnology. Weinheim: Wiley-VCH;

2003.2. Drummond PD. Triggers of motion sickness in migraine sufferers. Headache.

2005;45(6):653-6.3. Meltzer PS, Kallioniemi A, Trent JM. Chromosome alterations in human solid

tumors. In: Vogelstein B, Kinzler KW, editors. The genetic basis of human cancer. New York: McGraw-Hill; 2002. p. 93-113.


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HyperlinksHyperlinks to external references can be used but the author or owner of the location of the documents will need to ensure that the links are current. As an alternative to a hyperlink, provide the name of the website where the information can be accessed, if applicable.

As hyperlinks are prone to change, do not link to documents on the Policy Register as it becomes difficult to maintain these links.

Time – how to express Where possible the use of 24 hour time is preferred (i.e. 07:00 – 13:00).

Accessibility RequirementsTo facilitate readability by people with visual acuity issues: Provide a brief written description of pictures or diagrams Avoid the use of the symbol‘/’ where possible Separate paragraphs with sufficient white space. E.g. One line space Adhere to formatting of the policy, procedure and guideline templates.

Culturally and Linguistically Diverse and Low Levels of EducationPlease ensure that consideration is given to both staff and consumers for whom English is a second language and those groups where literacy levels are low.

Impact on vulnerable populations.Policies and procedures may have a direct or indirect impact on vulnerable populations including Aboriginal and Torres Strait Islanders, culturally and linguistically diverse communities, LGBTIQ people, people with a disability and survivors of family violence and sexual assault. Contact the Aboriginal and Torres Strait Islander Practice Centre and the Health Policy Unit at [email protected] for advice about the potential impact arising from your policy documents. Feedback from those units should be included on your consultation feedback form and incorporated as appropriate.

For PAC documents, the Summary Template from the Triple Bottom Line Framework should be submitted with your final documents.



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Attachment 3: Tip SheetsTip Sheet 1: How to use heading/bullet styles

1. Highlight text to be changed to appropriate heading/bullet style.

2. Select desired heading/bullet style to be applied. Appropriate heading styles for use in policy documents can be found at the top of the screen.

3. If you are inserting a numbered list please use the outline numbers option.


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Tip Sheet 2: Updating the Contents Page

Updating an Existing Contents PageWhen a document is completed, the contents page can be updated to ensure it matches with the headings throughout the document.

1. Highlight the contents page

2. Right click over the highlighted section and select Update Field


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3. A dialogue box will appear, select Update Entire Table, then press ok


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Tip Sheet 3: Do’s and Don’ts for Policy Development

Do: Check for similar documents on the

Policy Register Use a new template each time you write

a policy document. This is obtained on approval of an Initiation Request

Consult with key users, other areas eg. Aboriginal and Torres Strait Islander Practice Centre and the Health Policy Unit and consumers where appropriate

Where possible address all points raised during the consultation phase

Consider the audience and use clear, concise, simple language

Provide brief explanations/definitions for unique terms where appropriate

Be consistent with ACT Health and ACT Government policy

Use correct and consistent terminology Spell out all acronyms when first used Check grammar, punctuation and

spelling (do not rely on the computer spell-checker)

Provide links for further information where appropriate

Don’t: Change the template Use an old template Split names and dates over lines. Use the

text wrap functionality Make assumptions Use excessively long sentences, or

provide unnecessary information


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Tip Sheet 4: Quick Style Guide

Abbreviations ie. ‘that is’ or ‘in other words’ eg. ‘for example’ Do not abbreviate ‘Aboriginal and Torres

Strait Islander’ Instead of using ‘etc.’, redraft using ‘such

as’ or ‘including’ Write acronyms and abbreviations in full

the first time you refer to them

Capitalising use capitals when referring to a specific

government, directorate or division use lower case in generic instances Capitalise when referring to a published

document

Grammar A division, or body, is a singular entity

(Examples: Each division is responsible for… or Divisions will be responsible for)

Standardisation Use an ‘s’ not a ‘z’ e.g. Organisation,

apologise, prioritise, analyse, specialise

Published material Always write out legislation titles in full at

the first reference, including the year. Use italics in: titles of Acts, Regulations

and Disallowable Instruments Use normal type in: Bills and abbreviated

titles for Acts, Regulations and Disallowable Instruments

Punctuation Use non-breaking spaces (Ctrl Shift

spacebar) to prevent breaking titles, names and dates across lines

Use a non-breaking hyphen (Ctrl Shift hyphen) in doubled up vowels, except coordinate and cooperate (e.g. co-owner)

Possessions - the apostrophe comes before the‘s’ in the singular, and after the ‘s’ in the plural Examples: The government’s policies don’t… Governments’ budgets aren’t…

Numbers and dates Numbers from one to ten are spelt in full,

e.g. three days not 3 days Use commas as separators in numbers

(e.g. 20,000) Use symbols in tables [%, $m, $b], but

write out in text (e.g. 20 per cent, $8 million/billion)

Use numerals in a series (e.g. she has 17 laptops and 5 manuals)

When two numbers follow each other in a sentence, write the first as a word and the following as a numeral (e.g. there are three, 5-year projects).

The financial year should be written as 2017-18

Use date structure as 1 April 2015, not 1st April 2015

A number at the start of a sentence must be spelt in full.


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Tip Sheet 5: Troublesome Words

Accept and Except‘Accept’ means to receive, admit, regard as true, say yes.‘Except’ means to exclude, other than, to leave out.

Advice and Advise‘Advice’ is a noun. It is a suggestion, opinion or recommendation.‘Advise’ is a verb, meaning ‘to give advice’, to give information, notify and suggest types of action.

Affect and Effect‘Affect’ means to produce a change in or influence something.‘Effect’ means a change that occurred. When an ‘s’ is added, ‘effects’ means personal belongings.

Alternate and Alternative‘Alternate’ means by turns or every other.‘Alternative’ is one of two or more choices/opportunities.

Compliment and Complement‘Compliment’ means praise or admiration.‘Complement’ is to make complete or perfect, goes well together.

Dependent and Dependant‘Dependent’ means relying on something.‘Dependant’ means a person supported by someone else.

Discrete and Discreet‘Discrete’ means separate, distinct, detached.‘Discreet’ means cautious, restrained.

Disinterested and Uninterested‘Disinterested’ means impartial or having no stake.‘Uninterested’ means lacking interest.

It’s and Its‘It’s’ is the abbreviation of it is, e.g.: It’s an excellent written summary.‘Its’ is the possessive form, e.g. Its summary was excellent.

Licence and License‘Licence’ is a noun, e.g. she holds a pilot’s licence.‘License’ is a verb, e.g. they will license her to fly.

Personal and Personnel‘Personal’ means belonging or relating to a particular person.‘Personnel’ refers to the people employed in an organisation, business, or service.

Practice and Practise‘Practice’ is a noun, e.g. he did a lot of practice.‘Practise’ is a verb, e.g. he practised a lot e.g. Doctors and lawyers practise their profession; both have practices.

Principle and Principal‘Principle’ means a rule.‘Principal’ means main, chief, most important e.g. The school principal setvery clear principles.

There and Their‘There’ refers to a place.‘Their’ shows possession, that something belongs to them
