Ensure staff have access to the latest approved versions of corporate policies and procedures

This Register is designed to manage all documents developed to articulate or guide the organisation’s behaviour. For example:

• Organisational policies, procedures, protocols, work instructions, relating to:
  • Governance
  • Corporate
  • Operational
  • Service provision
• Forms, templates, signage check sheets
• External guidelines, training resources, Standards
• Internal signage

This Register is designed to manage any document that has a specified expiry date. For example:

• Funding agreements
• Employment agreements
• Insurance policies
• MOU / partnership agreements
• Service Level Agreements (SLA)
• Warranty agreements

• Employment/locum agencies
• Other health service providers / subcontractors
• Suppliers of medical consumables and equipment
• ICT providers
• Catering services that provide food services for clients
• Suppliers and contractors e.g. cleaning and maintenance

This Module is designed to provide reports on how the organisation meets the requirements of standards, either for internal report or for external auditors. The Accreditation Module can be used for any published health and related standards.

This Module is designed to track the organisation’s exposure to identified risks, real and perceived, that have the potential to impact on the organisation’s objective or standing in the community and has been developed to align with the requirements of ISO 31000 Risk Management – Guidelines. Scope of risk could include:

• Corporate risks – admin, finance, HR, ICT, Quality, IPC
• Reputational risks
• Operational risks
• Service provisions risks
• WHS risks

Monitor and evaluate the performance of critical systems and processes.

This Register is a specialised register for managing compliance and monitoring performance through internal and external audits, reviews, evaluations, and inspections. For example:

• Compliance audits of critical processes, e.g. HR File audit, complaints management audit
• Performance audits, e.g. program evaluations, measurement against Quality Objectives, KPIs
• Critical equipment inspections e.g. Calibration of equipment
• Workplace Health and Safety audits

Ensure critical activities are undertaken to meet compliance obligations.

This Register is a general register for managing compliance tasks which the organisation is required to do. For example:

• Contractual requirements, e.g. Funding reports
• Asset maintenance, e.g. Vehicle servicing
• Actions required by industry Standards
• Actions required by legislation or other regulations
• Licensing requirements for the organisation, e.g. Permits (not the individual)
• Actions required by organisational policies, e.g. annual staff performance reviews

Note: The Compliance Register is not designed to manage audits, staff licensing checks or training. These tasks should be managed through the specialised registers for audits, licensing and training.

Ensure staff, supplier and contractor credentials are checked as required.

This Register is a specialised register designed to manage compliance relating to license checks of staff and other individuals, including external service providers and credentialing checks, for example:

• APHRA / APC / other professional registration checks
• Medical insurance/indemnity relating to an individual
• National Police Check
• Working with Children Check
• Driver license checks

Note: It is recommended that these tasks are assigned to the ‘person’ not the ‘position’, when scheduling the task.

Ensure staff maintain the required competencies to perform their role

This Register is a specialised register designed to manage compliance relating to staff training for example:

• Induction / orientation
• Mandatory training
• Occupational specific training
• Management training e.g. budget management, people management

Note: It is recommended that these tasks are assigned to the ‘person’ not the ‘position’, when scheduling the task.

This Register is designed to support the reporting of issues related to process, including:

• Non-conformances
  • Where the process has not been followed
  • Where equipment does not meet required specifications
  • Where services do not meet expected outcomes
• Recommendations arising from audits, internal or external
• Recommendations for improvement arising from adverse event
• Suggestions for improvement

This Register is designed to support the reporting of adverse events, including identified hazards.

• Service provision incidents, e.g. clinical incidents
• Operational incidents
• Workplace health and safety incidents
• Identified hazards

Note: Essential to establishing a reporting culture is to support a ‘no blame’ culture. It also requires all staff to take responsibility to report adverse events.

Note: The Feedback Register was designed to record feedback from external sources, e.g. clients, other service providers.

Staff feedback can be recorded on the Improvement Register.

This Register is designed to track and monitor what external stakeholders are saying about the organisation.

• All feedback and complaints – non-personnel related
• External feedback from clients, suppliers and other external stakeholders

This Register is designed to manage the repairs of all plant (facilities) and equipment:

• Repairs relating to plant and equipment
• Repairs relating to vehicles
• Repairs relating to other assets

This Register is designed to provide a central location for all records which relate to managing safety, quality and risk, including those that may be required to be provided to an external auditor. For example:

• All records associated with completing tasks scheduled in LOGIQC, where evidence may be required by an external auditor
• All other records that may need to be provided to an auditor

The Contact Register is designed to manage those business contacts that may be necessary to support staff to complete tasks that have been allocated through the QMS.

For example:

• Contacts relating to contracts where acquittal reporting and other reporting requirements have been tasked in the QMS
• Suppliers who will be managed through the Supplier Register
• Suppliers who manage maintenance or repairs to plant and equipment, including fire and safety equipment, those who calibrate equipment
• External auditors
• Corporate officer suppliers
• Suppliers of medical consumables and medical equipment

Note: It is not recommended that the Contact Register replicates other contact data bases the organisation may have in place.