News and updated Group-wide policies

St John of God Health Care governs its operations through the use of policies, procedures and guidelines which must be in keeping with the Vision, Mission and Values of SJGHC, relevant legislation, licensing/accreditation standards, organisational objectives and industry best practice whilst adhering to the SJGHC By-Laws and the Catholic Health Australia Code of Ethical Standards.

The following is a summary of what was new or changed in the Group Policy recently:

GCL 027 Surgical Count
This policy outlines the minimum requirements for the surgical team in performing the surgical count, to ensure that unintended items are not retained within the patient on conclusion of surgery/invasive procedures. Policy has been reviewed and changes made to address fatigue management, clarity around management of counts where two or more procedures are being undertaken on the same patient and other minor additions.

GCLM 011 Rooming In
This policy promotes and give direction to caregivers for the practice of rooming-in and where a Division chooses to provide a “well baby night nursery” provides details in relation to appropriate documentation and identification processes. Policy reviewed to incorporate minor changes and the inclusion of a “well baby night nursery” register.

GCLM 004 Count Process Following Vaginal Birth
To provide instructions to midwives/obstetricians on the correct process for recording instruments and packs which may be used during spontaneous or assisted vaginal birth, in order to minimise the risk of accidental retention of packs or instruments. Key changes made are incorporation of the Vaginal Count Sheet into the Group standardised Partogram and amendments to process for performing a second count when there has been a change in midwifery caregiver.

MAM 001 Management Authority Matrix (MAM)
The document sets out the delegation of powers from the Group Chief Executive Officer to senior executives and the St John of God Hauora Trust Board. Material changes and additions included in the latest version include:

• Alignment with current organisational structure, including a new, separate section covering Social Outreach (§15).
• Amended approval levels covering Contracts with government (other than DVA) (see §3.2), Contracts prepared/managed by divisions or directorates (see §3.4.b) and Contracts for consultancy services, agency or temporary contractors (see §3.4.c). The effect of the change is that the GCEO approves contracts >$5M, EDs and GDF approve contracts <$5M and CEOs and GDs approve <$250k.
• Amended authority covering Operational invoice approval (see §6.4). The effect of the change is that the GCEO approves operational invoices >$2M, EDs and GDF approve contracts <$2M, CEOs approve <$250k and GDs (other than GDF) approve <$125k.
• New authority for approving minor variations to student placement agreements (see §3.6.b).
• Amended authority covering Worker’s compensation settlements (see §17.6). The effect of the change is that the GCEO approves settlements >$50k, EDs and GDs approve settlements <$50k (CEOs recommend to EDs).
• Amended approval levels for Ex gratia settlements/payments to patients (see §8.2.a), Sponsorships (see §9.4), Appointment (and Termination) of Director of Mission Integration (see §10.4.a and §10.4.b, respectively) and Appointment (and Termination) of DMC members (see §17.1.b and §17.4.b, respectively).

The following were reviewed, approved and uploaded with no significant change:

Nil

The following were archived:

• GLD 005 Sisters of St John of God Staff Fellowship.