{"id":"qld:sl-2023-0100","name":"Hospital and Health Boards Regulation 2023","slug":"hospital-and-health-boards-regulation-2023","collection":"regulation","jurisdiction":"qld","status":"in_force","isInForce":true,"actNumber":"100 of 2023","makingDate":null,"administeringDepartment":null,"currentVersion":{"id":173767,"registerId":"qld-sl-2023-0100-current","compilationNumber":null,"startDate":"2026-04-05","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"pt.1","sectionType":"part","heading":"Preliminary","content":"# Preliminary","sortOrder":0},{"sectionNumber":"sec.1","sectionType":"section","heading":"Short title","content":"### sec.1 Short title\n\nThis regulation may be cited as the Hospital and Health Boards Regulation 2023 .","sortOrder":1},{"sectionNumber":"sec.2","sectionType":"section","heading":"Commencement","content":"### sec.2 Commencement\n\nThis regulation commences on 1 September 2023.","sortOrder":2},{"sectionNumber":"sec.3","sectionType":"section","heading":"Definitions","content":"### sec.3 Definitions\n\nThe dictionary in schedule 9 defines particular words used in this regulation.","sortOrder":3},{"sectionNumber":"pt.2","sectionType":"part","heading":"Hospital and Health Services","content":"# Hospital and Health Services","sortOrder":4},{"sectionNumber":"sec.4","sectionType":"section","heading":"Continuation of Hospital and Health Services— Act , s 17","content":"### sec.4 Continuation of Hospital and Health Services— Act , s 17\n\nA place mentioned in schedule 1 , column 2 that, for section 17 (a) of the Act , was declared to be a health service area for a Hospital and Health Service under the expired regulation continues to be a health service area for the Service.\nA Hospital and Health Service mentioned in schedule 1 , column 1 opposite a health service area that, for section 17 (b) of the Act , was established under the expired regulation continues as the Service for the health service area.\nThe name mentioned in schedule 1 , column 1 opposite the health service area that, for section 17 (c) of the Act , was assigned to a Service under the expired regulation continues as the name assigned to the Service.\nIn this section—\nexpired regulation means the expired Hospital and Health Boards Regulation 2012 .\n(sec.4-ssec.1) A place mentioned in schedule 1 , column 2 that, for section 17 (a) of the Act , was declared to be a health service area for a Hospital and Health Service under the expired regulation continues to be a health service area for the Service.\n(sec.4-ssec.2) A Hospital and Health Service mentioned in schedule 1 , column 1 opposite a health service area that, for section 17 (b) of the Act , was established under the expired regulation continues as the Service for the health service area.\n(sec.4-ssec.3) The name mentioned in schedule 1 , column 1 opposite the health service area that, for section 17 (c) of the Act , was assigned to a Service under the expired regulation continues as the name assigned to the Service.\n(sec.4-ssec.4) In this section— expired regulation means the expired Hospital and Health Boards Regulation 2012 .","sortOrder":5},{"sectionNumber":"sec.5","sectionType":"section","heading":"Power to grant or take lease without Minister’s and Treasurer’s approval— Act , s 20A","content":"### sec.5 Power to grant or take lease without Minister’s and Treasurer’s approval— Act , s 20A\n\nFor section 20A (2) of the Act , a lease of a type mentioned in schedule 2 is prescribed.\nFor schedule 2 —\na Service mentioned in part 1 , column 2 of the schedule is a Service that may grant a lease mentioned in column 1 opposite the lease, if the granting of the lease has been approved by the Minister; and\na Service mentioned in part 2 , column 2 of the schedule is a Service that may take a lease mentioned in column 1 opposite the lease.\n(sec.5-ssec.1) For section 20A (2) of the Act , a lease of a type mentioned in schedule 2 is prescribed.\n(sec.5-ssec.2) For schedule 2 — a Service mentioned in part 1 , column 2 of the schedule is a Service that may grant a lease mentioned in column 1 opposite the lease, if the granting of the lease has been approved by the Minister; and a Service mentioned in part 2 , column 2 of the schedule is a Service that may take a lease mentioned in column 1 opposite the lease.\n- (a) a Service mentioned in part 1 , column 2 of the schedule is a Service that may grant a lease mentioned in column 1 opposite the lease, if the granting of the lease has been approved by the Minister; and\n- (b) a Service mentioned in part 2 , column 2 of the schedule is a Service that may take a lease mentioned in column 1 opposite the lease.","sortOrder":6},{"sectionNumber":"pt.3","sectionType":"part","heading":"Employment matters","content":"# Employment matters","sortOrder":7},{"sectionNumber":"sec.6","sectionType":"section","heading":"Definitions for part","content":"### sec.6 Definitions for part\n\nIn this part—\nhealth system employer means a Hospital and Health Service or the department.\nrelevant chief executive , of a health system employer, means—\nif the employer is a Hospital and Health Service—the Service’s health service chief executive; or\nif the employer is the department—the chief executive of the department.\n- (a) if the employer is a Hospital and Health Service—the Service’s health service chief executive; or\n- (b) if the employer is the department—the chief executive of the department.","sortOrder":8},{"sectionNumber":"sec.7","sectionType":"section","heading":"Movement of health service employees, other than health service chief executives, between health system employers","content":"### sec.7 Movement of health service employees, other than health service chief executives, between health system employers\n\nThis section applies to a health service employee other than a health service chief executive.\nA health service employee may be moved from a health system employer to another health system employer—\nby agreement between the relevant chief executives of the employers; or\nby written direction given by the chief executive of the department to the employee and—\nif the movement is between the department and a Hospital and Health Service—the health service chief executive of the Service; or\nif the movement is between Hospital and Health Services—the health service chief executives of each Service.\nHowever, the chief executive may give a written direction under subsection (2) (b) only if the chief executive considers the movement necessary to mitigate a significant risk to the public sector health system.\nBefore giving the written direction, the chief executive must consult with the health service chief executive of any Service in which the employee is and will be employed.\nA health service employee moved from a health system employer to another health system employer under this section is employed by the other health system employer from the date, and for the period (if any), stated—\nfor a movement under subsection (2) (a) —in the agreement mentioned in that subsection; or\nfor a movement under subsection (2) (b) —in the written direction given under that subsection.\n(sec.7-ssec.1) This section applies to a health service employee other than a health service chief executive.\n(sec.7-ssec.2) A health service employee may be moved from a health system employer to another health system employer— by agreement between the relevant chief executives of the employers; or by written direction given by the chief executive of the department to the employee and— if the movement is between the department and a Hospital and Health Service—the health service chief executive of the Service; or if the movement is between Hospital and Health Services—the health service chief executives of each Service.\n(sec.7-ssec.3) However, the chief executive may give a written direction under subsection (2) (b) only if the chief executive considers the movement necessary to mitigate a significant risk to the public sector health system.\n(sec.7-ssec.4) Before giving the written direction, the chief executive must consult with the health service chief executive of any Service in which the employee is and will be employed.\n(sec.7-ssec.5) A health service employee moved from a health system employer to another health system employer under this section is employed by the other health system employer from the date, and for the period (if any), stated— for a movement under subsection (2) (a) —in the agreement mentioned in that subsection; or for a movement under subsection (2) (b) —in the written direction given under that subsection.\n- (a) by agreement between the relevant chief executives of the employers; or\n- (b) by written direction given by the chief executive of the department to the employee and— (i) if the movement is between the department and a Hospital and Health Service—the health service chief executive of the Service; or (ii) if the movement is between Hospital and Health Services—the health service chief executives of each Service.\n- (i) if the movement is between the department and a Hospital and Health Service—the health service chief executive of the Service; or\n- (ii) if the movement is between Hospital and Health Services—the health service chief executives of each Service.\n- (i) if the movement is between the department and a Hospital and Health Service—the health service chief executive of the Service; or\n- (ii) if the movement is between Hospital and Health Services—the health service chief executives of each Service.\n- (a) for a movement under subsection (2) (a) —in the agreement mentioned in that subsection; or\n- (b) for a movement under subsection (2) (b) —in the written direction given under that subsection.","sortOrder":9},{"sectionNumber":"sec.8","sectionType":"section","heading":"Movement of health service chief executives between health system employers","content":"### sec.8 Movement of health service chief executives between health system employers\n\nThis section applies to a health service chief executive.\nA health service chief executive may, with the approval of the Minister, be moved—\nfrom a Hospital and Health Service to the department by agreement between the chair of the Service’s board and the chief executive of the department; or\nbetween Hospital and Health Services by agreement between the chairs of the boards of the Services.\nA health service chief executive may also be moved by the Minister on the recommendation of the chief executive of the department, by written direction given by the Minister to—\nthe health service chief executive; and\neither—\nif the movement is from a Hospital and Health Service to the department—the chair of the board of the Service; or\nif the movement is between Hospital and Health Services—each chair of the boards of the Services.\nThe recommendation of the chief executive of the department mentioned in subsection (3) may be given only if the chief executive considers the movement is necessary to mitigate a significant risk to the public sector health system.\nBefore giving the written direction, the Minister must consult with the chair of the board of any Services in which the health service chief executive is and will be employed.\nA health service chief executive moved from a health system employer to another health system employer under this section is employed by the other health system employer from the date, and for the period (if any), stated—\nfor a movement under subsection (2) —in the agreement mentioned in that subsection; or\nfor a movement under subsection (3) —in the written direction mentioned in that subsection.\nA health service chief executive moved under this section may, as a result of the movement, be employed in a position other than health service chief executive.\n(sec.8-ssec.1) This section applies to a health service chief executive.\n(sec.8-ssec.2) A health service chief executive may, with the approval of the Minister, be moved— from a Hospital and Health Service to the department by agreement between the chair of the Service’s board and the chief executive of the department; or between Hospital and Health Services by agreement between the chairs of the boards of the Services.\n(sec.8-ssec.3) A health service chief executive may also be moved by the Minister on the recommendation of the chief executive of the department, by written direction given by the Minister to— the health service chief executive; and either— if the movement is from a Hospital and Health Service to the department—the chair of the board of the Service; or if the movement is between Hospital and Health Services—each chair of the boards of the Services.\n(sec.8-ssec.4) The recommendation of the chief executive of the department mentioned in subsection (3) may be given only if the chief executive considers the movement is necessary to mitigate a significant risk to the public sector health system.\n(sec.8-ssec.5) Before giving the written direction, the Minister must consult with the chair of the board of any Services in which the health service chief executive is and will be employed.\n(sec.8-ssec.6) A health service chief executive moved from a health system employer to another health system employer under this section is employed by the other health system employer from the date, and for the period (if any), stated— for a movement under subsection (2) —in the agreement mentioned in that subsection; or for a movement under subsection (3) —in the written direction mentioned in that subsection.\n(sec.8-ssec.7) A health service chief executive moved under this section may, as a result of the movement, be employed in a position other than health service chief executive.\n- (a) from a Hospital and Health Service to the department by agreement between the chair of the Service’s board and the chief executive of the department; or\n- (b) between Hospital and Health Services by agreement between the chairs of the boards of the Services.\n- (a) the health service chief executive; and\n- (b) either— (i) if the movement is from a Hospital and Health Service to the department—the chair of the board of the Service; or (ii) if the movement is between Hospital and Health Services—each chair of the boards of the Services.\n- (i) if the movement is from a Hospital and Health Service to the department—the chair of the board of the Service; or\n- (ii) if the movement is between Hospital and Health Services—each chair of the boards of the Services.\n- (i) if the movement is from a Hospital and Health Service to the department—the chair of the board of the Service; or\n- (ii) if the movement is between Hospital and Health Services—each chair of the boards of the Services.\n- (a) for a movement under subsection (2) —in the agreement mentioned in that subsection; or\n- (b) for a movement under subsection (3) —in the written direction mentioned in that subsection.","sortOrder":10},{"sectionNumber":"sec.9","sectionType":"section","heading":"Movement of health service employees employed on a contract","content":"### sec.9 Movement of health service employees employed on a contract\n\nThis section applies to the movement of a health service employee to another health system employer—\nunder section 7 if, immediately before the movement, the employee was appointed on a contract; or\nunder section 8 .\nThe employee is taken to be employed by the health system employer under the contract under which the employee was employed before the movement.\nIf a provision in the employee’s contract is inconsistent with a movement under this part, the movement takes effect despite the inconsistency.\nIf, immediately before the movement, the employee was appointed on a contract for a fixed term, the employee is appointed for the following period from the movement—\nif a period is stated in the agreement or written direction given under section 7 or 8 for the movement—the period stated;\nif no period is stated in the agreement or written direction—the period remaining on the term of the employee’s contract.\nThe period stated in the agreement or written direction mentioned in subsection (4) (a) may not be more than the period remaining on the term of the employee’s contract.\n(sec.9-ssec.1) This section applies to the movement of a health service employee to another health system employer— under section 7 if, immediately before the movement, the employee was appointed on a contract; or under section 8 .\n(sec.9-ssec.2) The employee is taken to be employed by the health system employer under the contract under which the employee was employed before the movement.\n(sec.9-ssec.3) If a provision in the employee’s contract is inconsistent with a movement under this part, the movement takes effect despite the inconsistency.\n(sec.9-ssec.4) If, immediately before the movement, the employee was appointed on a contract for a fixed term, the employee is appointed for the following period from the movement— if a period is stated in the agreement or written direction given under section 7 or 8 for the movement—the period stated; if no period is stated in the agreement or written direction—the period remaining on the term of the employee’s contract.\n(sec.9-ssec.5) The period stated in the agreement or written direction mentioned in subsection (4) (a) may not be more than the period remaining on the term of the employee’s contract.\n- (a) under section 7 if, immediately before the movement, the employee was appointed on a contract; or\n- (b) under section 8 .\n- (a) if a period is stated in the agreement or written direction given under section 7 or 8 for the movement—the period stated;\n- (b) if no period is stated in the agreement or written direction—the period remaining on the term of the employee’s contract.","sortOrder":11},{"sectionNumber":"sec.10","sectionType":"section","heading":"Movement between classification levels","content":"### sec.10 Movement between classification levels\n\nSubject to subsection (2) , the movement of a health service employee under this part may include employing the employee at the same or a different classification level.\nThe employee may be moved to another health system employer at a lower classification level only if the employee consents to the movement.\nHowever, subsection (2) does not prevent movement to a lower classification level as a result of disciplinary action against the employee.\n(sec.10-ssec.1) Subject to subsection (2) , the movement of a health service employee under this part may include employing the employee at the same or a different classification level.\n(sec.10-ssec.2) The employee may be moved to another health system employer at a lower classification level only if the employee consents to the movement.\n(sec.10-ssec.3) However, subsection (2) does not prevent movement to a lower classification level as a result of disciplinary action against the employee.","sortOrder":12},{"sectionNumber":"sec.11","sectionType":"section","heading":"Effect of movement of health service employees other than health service chief executives","content":"### sec.11 Effect of movement of health service employees other than health service chief executives\n\nIf a health service employee is moved under section 7 , the movement has effect unless the employee establishes reasonable grounds for refusing the movement to the satisfaction of—\nif the movement is by agreement under section 7 (2) (a) —the chief executive of the health system employer from which the employee is moved; or\nif the movement is by written direction under section 7 (2) (b) —the chief executive of the department.\nThe health service employee must be given a reasonable time to establish reasonable grounds for refusing the movement.\nSubsection (4) applies if the health service employee refuses the movement after failing to establish reasonable grounds for refusing the movement.\nThe relevant chief executive of the health system employer from which the employee is moved—\nif the movement is by agreement under section 7 (2) (a) —may end the employee’s employment by signed notice given to the employee; or\nif the movement is by written direction under section 7 (2) (b) —must end the employee’s employment by signed notice given to the employee.\nIf the employee establishes reasonable grounds for refusing the movement—\nthe movement is cancelled; and\nthe refusal must not be used to prejudice the employee’s prospects for future promotion or advancement.\n(sec.11-ssec.1) If a health service employee is moved under section 7 , the movement has effect unless the employee establishes reasonable grounds for refusing the movement to the satisfaction of— if the movement is by agreement under section 7 (2) (a) —the chief executive of the health system employer from which the employee is moved; or if the movement is by written direction under section 7 (2) (b) —the chief executive of the department.\n(sec.11-ssec.2) The health service employee must be given a reasonable time to establish reasonable grounds for refusing the movement.\n(sec.11-ssec.3) Subsection (4) applies if the health service employee refuses the movement after failing to establish reasonable grounds for refusing the movement.\n(sec.11-ssec.4) The relevant chief executive of the health system employer from which the employee is moved— if the movement is by agreement under section 7 (2) (a) —may end the employee’s employment by signed notice given to the employee; or if the movement is by written direction under section 7 (2) (b) —must end the employee’s employment by signed notice given to the employee.\n(sec.11-ssec.5) If the employee establishes reasonable grounds for refusing the movement— the movement is cancelled; and the refusal must not be used to prejudice the employee’s prospects for future promotion or advancement.\n- (a) if the movement is by agreement under section 7 (2) (a) —the chief executive of the health system employer from which the employee is moved; or\n- (b) if the movement is by written direction under section 7 (2) (b) —the chief executive of the department.\n- (a) if the movement is by agreement under section 7 (2) (a) —may end the employee’s employment by signed notice given to the employee; or\n- (b) if the movement is by written direction under section 7 (2) (b) —must end the employee’s employment by signed notice given to the employee.\n- (a) the movement is cancelled; and\n- (b) the refusal must not be used to prejudice the employee’s prospects for future promotion or advancement.","sortOrder":13},{"sectionNumber":"sec.12","sectionType":"section","heading":"Effect of movement of health service chief executives","content":"### sec.12 Effect of movement of health service chief executives\n\nIf a health service chief executive is moved under section 8 , the movement has effect unless the health service chief executive establishes reasonable grounds for refusing the movement to the satisfaction of the following—\nif the movement is by agreement under section 8 (2) —the chair of the board of the Service from which the health service chief executive is moved;\nif the movement is by written direction under section 8 (3) —the Minister.\nA health service chief executive must be given a reasonable time to establish reasonable grounds for refusing the movement.\nSubsection (4) applies if the health service chief executive refuses the movement after failing to establish reasonable grounds for refusing the movement.\nThe chair of the board for the Service from which the health service chief executive is moved—\nif the movement is by agreement under section 8 (2) —may end the health service chief executive’s employment by signed notice given to the health service chief executive; or\nif the movement is by written direction under section 8 (3) —must end the health service chief executive’s employment by signed notice given to the health service chief executive.\nIf the health service chief executive establishes reasonable grounds for refusing the movement—\nthe movement is cancelled; and\nthe refusal must not be used to prejudice the health service chief executive’s prospects for future promotion or advancement.\n(sec.12-ssec.1) If a health service chief executive is moved under section 8 , the movement has effect unless the health service chief executive establishes reasonable grounds for refusing the movement to the satisfaction of the following— if the movement is by agreement under section 8 (2) —the chair of the board of the Service from which the health service chief executive is moved; if the movement is by written direction under section 8 (3) —the Minister.\n(sec.12-ssec.2) A health service chief executive must be given a reasonable time to establish reasonable grounds for refusing the movement.\n(sec.12-ssec.3) Subsection (4) applies if the health service chief executive refuses the movement after failing to establish reasonable grounds for refusing the movement.\n(sec.12-ssec.4) The chair of the board for the Service from which the health service chief executive is moved— if the movement is by agreement under section 8 (2) —may end the health service chief executive’s employment by signed notice given to the health service chief executive; or if the movement is by written direction under section 8 (3) —must end the health service chief executive’s employment by signed notice given to the health service chief executive.\n(sec.12-ssec.5) If the health service chief executive establishes reasonable grounds for refusing the movement— the movement is cancelled; and the refusal must not be used to prejudice the health service chief executive’s prospects for future promotion or advancement.\n- (a) if the movement is by agreement under section 8 (2) —the chair of the board of the Service from which the health service chief executive is moved;\n- (b) if the movement is by written direction under section 8 (3) —the Minister.\n- (a) if the movement is by agreement under section 8 (2) —may end the health service chief executive’s employment by signed notice given to the health service chief executive; or\n- (b) if the movement is by written direction under section 8 (3) —must end the health service chief executive’s employment by signed notice given to the health service chief executive.\n- (a) the movement is cancelled; and\n- (b) the refusal must not be used to prejudice the health service chief executive’s prospects for future promotion or advancement.","sortOrder":14},{"sectionNumber":"sec.13","sectionType":"section","heading":"Continuation of entitlements of health service employees","content":"### sec.13 Continuation of entitlements of health service employees\n\nThis section applies to a health service employee of a health system employer (the first employer ) if the employee is appointed to another health system employer without break of service, including as a result of a movement under this part.\nThe following apply for the employee—\nthe employee is entitled to all leave entitlements and superannuation that have accrued to the employee because of the employee’s employment with the first employer;\naccrued recreation leave or accrued sick leave\nthe employee’s continuity of service is not interrupted, including for the purposes of accruing leave entitlements and superannuation, except that the employee is not entitled to claim the benefit of a right or entitlement more than once in relation to the same period of service;\nthe employee’s appointment does not constitute a termination of employment or a retrenchment or redundancy;\nthe employee is not entitled to a payment or other benefit because the employee is no longer employed by the first employer.\nThis section applies to rights accrued and service undertaken before or after the commencement.\n(sec.13-ssec.1) This section applies to a health service employee of a health system employer (the first employer ) if the employee is appointed to another health system employer without break of service, including as a result of a movement under this part.\n(sec.13-ssec.2) The following apply for the employee— the employee is entitled to all leave entitlements and superannuation that have accrued to the employee because of the employee’s employment with the first employer; accrued recreation leave or accrued sick leave the employee’s continuity of service is not interrupted, including for the purposes of accruing leave entitlements and superannuation, except that the employee is not entitled to claim the benefit of a right or entitlement more than once in relation to the same period of service; the employee’s appointment does not constitute a termination of employment or a retrenchment or redundancy; the employee is not entitled to a payment or other benefit because the employee is no longer employed by the first employer.\n(sec.13-ssec.3) This section applies to rights accrued and service undertaken before or after the commencement.\n- (a) the employee is entitled to all leave entitlements and superannuation that have accrued to the employee because of the employee’s employment with the first employer; Examples of leave entitlements that have accrued to the employee— accrued recreation leave or accrued sick leave\n- (b) the employee’s continuity of service is not interrupted, including for the purposes of accruing leave entitlements and superannuation, except that the employee is not entitled to claim the benefit of a right or entitlement more than once in relation to the same period of service;\n- (c) the employee’s appointment does not constitute a termination of employment or a retrenchment or redundancy;\n- (d) the employee is not entitled to a payment or other benefit because the employee is no longer employed by the first employer.","sortOrder":15},{"sectionNumber":"sec.14","sectionType":"section","heading":"Senior health service employees— Act , s 74A","content":"### sec.14 Senior health service employees— Act , s 74A\n\nFor section 74A (1) of the Act , each of the following positions is prescribed as a senior health service employee position—\na position at a classification level mentioned in schedule 3 , part 1 ;\na position mentioned in schedule 3 , part 2 .\n- (a) a position at a classification level mentioned in schedule 3 , part 1 ;\n- (b) a position mentioned in schedule 3 , part 2 .","sortOrder":16},{"sectionNumber":"sec.15","sectionType":"section","heading":"Disclosure of personal information of health service employees and departmental public service employees in particular circumstances","content":"### sec.15 Disclosure of personal information of health service employees and departmental public service employees in particular circumstances\n\nThis section applies to a person’s personal information held by a health system employer if the person—\nis or was a health service employee; or\nis or was a public service employee employed in the department (a departmental public service employee ); or\nis being, or was, considered for appointment as a health service employee or departmental public service employee.\nThe health system employer (the first health system employer ) may transfer or otherwise disclose the person’s personal information to another health system employer (the second health system employer ) if—\nthe information was collected or held by the first health system employer in relation to the person’s employment or appointment with the employer; and\neither—\nfor a person mentioned in subsection (1) (c) whose suitability for employment has not been finally assessed by the first health system employer—the person is being considered for appointment, or is appointed, by the second health system employer; or\nin any other case—the person transfers or moves to, or is appointed by, the second health system employer.\nThis section applies—\nto personal information held by a health system employer before or after the commencement; and\nto matters not dealt with in section 274 of the Act .\nFor this section, a person is considered for appointment as a health service employee or departmental public service employee if—\nthe person applied or otherwise expressed an interest in being appointed; and\nthe person’s suitability for employment has not been finally assessed.\nIn this section—\npersonal information see the Information Privacy Act 2009 , section 12 .\n(sec.15-ssec.1) This section applies to a person’s personal information held by a health system employer if the person— is or was a health service employee; or is or was a public service employee employed in the department (a departmental public service employee ); or is being, or was, considered for appointment as a health service employee or departmental public service employee.\n(sec.15-ssec.2) The health system employer (the first health system employer ) may transfer or otherwise disclose the person’s personal information to another health system employer (the second health system employer ) if— the information was collected or held by the first health system employer in relation to the person’s employment or appointment with the employer; and either— for a person mentioned in subsection (1) (c) whose suitability for employment has not been finally assessed by the first health system employer—the person is being considered for appointment, or is appointed, by the second health system employer; or in any other case—the person transfers or moves to, or is appointed by, the second health system employer.\n(sec.15-ssec.3) This section applies— to personal information held by a health system employer before or after the commencement; and to matters not dealt with in section 274 of the Act .\n(sec.15-ssec.4) For this section, a person is considered for appointment as a health service employee or departmental public service employee if— the person applied or otherwise expressed an interest in being appointed; and the person’s suitability for employment has not been finally assessed.\n(sec.15-ssec.5) In this section— personal information see the Information Privacy Act 2009 , section 12 .\n- (a) is or was a health service employee; or\n- (b) is or was a public service employee employed in the department (a departmental public service employee ); or\n- (c) is being, or was, considered for appointment as a health service employee or departmental public service employee.\n- (a) the information was collected or held by the first health system employer in relation to the person’s employment or appointment with the employer; and\n- (b) either— (i) for a person mentioned in subsection (1) (c) whose suitability for employment has not been finally assessed by the first health system employer—the person is being considered for appointment, or is appointed, by the second health system employer; or (ii) in any other case—the person transfers or moves to, or is appointed by, the second health system employer.\n- (i) for a person mentioned in subsection (1) (c) whose suitability for employment has not been finally assessed by the first health system employer—the person is being considered for appointment, or is appointed, by the second health system employer; or\n- (ii) in any other case—the person transfers or moves to, or is appointed by, the second health system employer.\n- (i) for a person mentioned in subsection (1) (c) whose suitability for employment has not been finally assessed by the first health system employer—the person is being considered for appointment, or is appointed, by the second health system employer; or\n- (ii) in any other case—the person transfers or moves to, or is appointed by, the second health system employer.\n- (a) to personal information held by a health system employer before or after the commencement; and\n- (b) to matters not dealt with in section 274 of the Act .\n- (a) the person applied or otherwise expressed an interest in being appointed; and\n- (b) the person’s suitability for employment has not been finally assessed.","sortOrder":17},{"sectionNumber":"pt.4","sectionType":"part","heading":"Engagement strategies and protocols","content":"# Engagement strategies and protocols","sortOrder":18},{"sectionNumber":"sec.16","sectionType":"section","heading":"Definitions for part","content":"### sec.16 Definitions for part\n\nIn this part—\nAboriginal and Torres Strait Islander community-controlled health organisation means a body corporate that—\nhas a governing body whose members are Aboriginal people or Torres Strait Islander people elected by a local Aboriginal or Torres Strait Islander community; and\nhas rules preventing the distribution of the body corporate’s property to its members; and\ndelivers health services to the local Aboriginal or Torres Strait Islander community.\nchief First Nations health officer means the public service officer employed in the department who is appointed as the chief First Nations health officer.\ncommunity includes a group or organisation consisting of individuals with a common interest.\nan interest in delivery of health services in a particular geographic location\nan interest in particular health issues\na common cultural background, religion or language\nconsumer includes the following entities—\nan individual who uses or may use a health service;\nthe family members, carers and representatives of an individual mentioned in paragraph (a) ;\na group of, or organisation for, individuals mentioned in paragraph (a) or (b) ;\na representative of the group or organisation mentioned in paragraph (c) .\nimplementation stakeholders , for a Service’s health equity strategy, see section 21 .\nservice-delivery stakeholders , for a Service’s health equity strategy, means the following organisations—\nAboriginal and Torres Strait Islander community-controlled health organisations in the Service’s health service area;\nlocal primary healthcare organisations for the Service.\n- (a) has a governing body whose members are Aboriginal people or Torres Strait Islander people elected by a local Aboriginal or Torres Strait Islander community; and\n- (b) has rules preventing the distribution of the body corporate’s property to its members; and\n- (c) delivers health services to the local Aboriginal or Torres Strait Islander community.\n- • an interest in delivery of health services in a particular geographic location\n- • an interest in particular health issues\n- • a common cultural background, religion or language\n- (a) an individual who uses or may use a health service;\n- (b) the family members, carers and representatives of an individual mentioned in paragraph (a) ;\n- (c) a group of, or organisation for, individuals mentioned in paragraph (a) or (b) ;\n- (d) a representative of the group or organisation mentioned in paragraph (c) .\n- (a) Aboriginal and Torres Strait Islander community-controlled health organisations in the Service’s health service area;\n- (b) local primary healthcare organisations for the Service.","sortOrder":19},{"sectionNumber":"sec.17","sectionType":"section","heading":"Prescribed persons—developing health equity strategies","content":"### sec.17 Prescribed persons—developing health equity strategies\n\nFor section 40 (2) (c) of the Act , the following persons are prescribed for the health equity strategy—\nAboriginal and Torres Strait Islander members of the Service’s staff;\nAboriginal and Torres Strait Islander consumers of health services delivered by the Service;\nAboriginal and Torres Strait Islander members of the community within the Service’s health service area;\ntraditional custodians and native title holders of land and waters in the Service’s health service area;\nthe implementation stakeholders for the strategy.\n- (a) Aboriginal and Torres Strait Islander members of the Service’s staff;\n- (b) Aboriginal and Torres Strait Islander consumers of health services delivered by the Service;\n- (c) Aboriginal and Torres Strait Islander members of the community within the Service’s health service area;\n- (d) traditional custodians and native title holders of land and waters in the Service’s health service area;\n- (e) the implementation stakeholders for the strategy.","sortOrder":20},{"sectionNumber":"sec.18","sectionType":"section","heading":"Prescribed requirements for clinician engagement strategies","content":"### sec.18 Prescribed requirements for clinician engagement strategies\n\nFor section 40 (3) (a) of the Act , a clinician engagement strategy of a Service must—\ninclude the following—\nthe objectives of the strategy;\nhow the strategy will contribute to the achievement of the organisational objectives of the Service;\nthe methods to be used for carrying out consultation with health professionals working in the Service, including how the consultation will involve health professionals with a diverse range of skills and experience;\nholding quarterly meetings of a council consisting of senior health professionals to discuss key clinical issues\nappointing health professionals to committees established by the Service\nengaging with the groups of health professionals known as the Queensland Clinical Networks and the body known as the Queensland Clinical Senate\nthe key issues on which consultation with health professionals working in the Service will be carried out;\nsafety and quality of health services\nclinical standards, local clinical governance arrangements, clinical workforce education and training\nservice planning and design for the Service\nservice delivery by the Service\nmonitoring and evaluation of service delivery by the Service\nhow the Service will use information obtained from implementing the strategy to continuously improve consultation with health professionals under the strategy;\nhow the effectiveness of consultation with health professionals under the strategy will be measured and publicly reported; and\nhave regard to national and State strategies, policies, agreements and standards relevant to promoting consultation with health professionals working in the Service; and\nthe National Safety and Quality Health Service Standards, 2nd edition, formulated by the Australian Commission on Safety and Quality in Health Care\noutline the relationship between the Service’s clinician engagement strategy and its consumer and community engagement strategy, health equity strategy and protocol with local primary healthcare organisations; and\nrequire a summary of the key issues discussed and decisions made in each of the Service’s board meetings to be made available to health professionals working in the Service, subject to the board’s obligations relating to confidentiality and privacy.\n- (a) include the following— (i) the objectives of the strategy; (ii) how the strategy will contribute to the achievement of the organisational objectives of the Service; (iii) the methods to be used for carrying out consultation with health professionals working in the Service, including how the consultation will involve health professionals with a diverse range of skills and experience; Examples for subparagraph (iii) — • holding quarterly meetings of a council consisting of senior health professionals to discuss key clinical issues • appointing health professionals to committees established by the Service • engaging with the groups of health professionals known as the Queensland Clinical Networks and the body known as the Queensland Clinical Senate (iv) the key issues on which consultation with health professionals working in the Service will be carried out; Examples of key issues for subparagraph (iv) — • safety and quality of health services • clinical standards, local clinical governance arrangements, clinical workforce education and training • service planning and design for the Service • service delivery by the Service • monitoring and evaluation of service delivery by the Service (v) how the Service will use information obtained from implementing the strategy to continuously improve consultation with health professionals under the strategy; (vi) how the effectiveness of consultation with health professionals under the strategy will be measured and publicly reported; and\n- (i) the objectives of the strategy;\n- (ii) how the strategy will contribute to the achievement of the organisational objectives of the Service;\n- (iii) the methods to be used for carrying out consultation with health professionals working in the Service, including how the consultation will involve health professionals with a diverse range of skills and experience; Examples for subparagraph (iii) — • holding quarterly meetings of a council consisting of senior health professionals to discuss key clinical issues • appointing health professionals to committees established by the Service • engaging with the groups of health professionals known as the Queensland Clinical Networks and the body known as the Queensland Clinical Senate\n- • holding quarterly meetings of a council consisting of senior health professionals to discuss key clinical issues\n- • appointing health professionals to committees established by the Service\n- • engaging with the groups of health professionals known as the Queensland Clinical Networks and the body known as the Queensland Clinical Senate\n- (iv) the key issues on which consultation with health professionals working in the Service will be carried out; Examples of key issues for subparagraph (iv) — • safety and quality of health services • clinical standards, local clinical governance arrangements, clinical workforce education and training • service planning and design for the Service • service delivery by the Service • monitoring and evaluation of service delivery by the Service\n- • safety and quality of health services\n- • clinical standards, local clinical governance arrangements, clinical workforce education and training\n- • service planning and design for the Service\n- • service delivery by the Service\n- • monitoring and evaluation of service delivery by the Service\n- (v) how the Service will use information obtained from implementing the strategy to continuously improve consultation with health professionals under the strategy;\n- (vi) how the effectiveness of consultation with health professionals under the strategy will be measured and publicly reported; and\n- (b) have regard to national and State strategies, policies, agreements and standards relevant to promoting consultation with health professionals working in the Service; and Example of standards— the National Safety and Quality Health Service Standards, 2nd edition, formulated by the Australian Commission on Safety and Quality in Health Care\n- (c) outline the relationship between the Service’s clinician engagement strategy and its consumer and community engagement strategy, health equity strategy and protocol with local primary healthcare organisations; and\n- (d) require a summary of the key issues discussed and decisions made in each of the Service’s board meetings to be made available to health professionals working in the Service, subject to the board’s obligations relating to confidentiality and privacy.\n- (i) the objectives of the strategy;\n- (ii) how the strategy will contribute to the achievement of the organisational objectives of the Service;\n- (iii) the methods to be used for carrying out consultation with health professionals working in the Service, including how the consultation will involve health professionals with a diverse range of skills and experience; Examples for subparagraph (iii) — • holding quarterly meetings of a council consisting of senior health professionals to discuss key clinical issues • appointing health professionals to committees established by the Service • engaging with the groups of health professionals known as the Queensland Clinical Networks and the body known as the Queensland Clinical Senate\n- • holding quarterly meetings of a council consisting of senior health professionals to discuss key clinical issues\n- • appointing health professionals to committees established by the Service\n- • engaging with the groups of health professionals known as the Queensland Clinical Networks and the body known as the Queensland Clinical Senate\n- (iv) the key issues on which consultation with health professionals working in the Service will be carried out; Examples of key issues for subparagraph (iv) — • safety and quality of health services • clinical standards, local clinical governance arrangements, clinical workforce education and training • service planning and design for the Service • service delivery by the Service • monitoring and evaluation of service delivery by the Service\n- • safety and quality of health services\n- • clinical standards, local clinical governance arrangements, clinical workforce education and training\n- • service planning and design for the Service\n- • service delivery by the Service\n- • monitoring and evaluation of service delivery by the Service\n- (v) how the Service will use information obtained from implementing the strategy to continuously improve consultation with health professionals under the strategy;\n- (vi) how the effectiveness of consultation with health professionals under the strategy will be measured and publicly reported; and\n- • holding quarterly meetings of a council consisting of senior health professionals to discuss key clinical issues\n- • appointing health professionals to committees established by the Service\n- • engaging with the groups of health professionals known as the Queensland Clinical Networks and the body known as the Queensland Clinical Senate\n- • safety and quality of health services\n- • clinical standards, local clinical governance arrangements, clinical workforce education and training\n- • service planning and design for the Service\n- • service delivery by the Service\n- • monitoring and evaluation of service delivery by the Service","sortOrder":21},{"sectionNumber":"sec.19","sectionType":"section","heading":"Prescribed requirements for consumer and community engagement strategies","content":"### sec.19 Prescribed requirements for consumer and community engagement strategies\n\nFor section 40 (3) (a) of the Act , a consumer and community engagement strategy of a Service must—\ninclude the following—\nthe objectives of the strategy;\nhow the strategy will contribute to the achievement of the organisational objectives of the Service;\nthe methods to be used for carrying out consultation with consumers and members of the community, including at individual, service and Hospital and Health Service level, and with any ancillary board established for the Service’s board;\nthe key issues on which consultation with consumers, members of the community and any ancillary board established for the Service’s board will be carried out;\nservice planning and design for the Service\nservice delivery by the Service\nmonitoring and evaluation of service delivery by the Service\nhow the Service will actively identify and consult with particular consumers and members of the community who are at risk of experiencing poor health outcomes or who may have difficulty accessing health services;\nThe Service may involve providers of community services as part of the consultation arrangements stated in the strategy.\nhow the Service will use information obtained from implementing the strategy to continuously improve consultation with consumers and the community under the strategy;\nhow the effectiveness of the consumer and communities engagement strategy will be measured and publicly reported; and\nhave regard to national and State strategies, policies, agreements and standards relevant to promoting consultation with health consumers and members of the community about the provision of health services by the Service; and\nthe document called ‘Australian Charter of Healthcare Rights’ published by the Australian Commission on Safety and Quality in Health Care\nthe National Safety and Quality Health Service Standards, 2nd edition, formulated by the Australian Commission on Safety and Quality in Health Care\noutline the relationship between the Service’s consumer and community engagement strategy and its clinician engagement strategy, health equity strategy and protocol with local primary healthcare organisations; and\nrequire a summary of the key issues discussed and decisions made in each of the Service’s board meetings to be made available to consumers and the community, subject to the board’s obligations relating to confidentiality and privacy.\n- (a) include the following— (i) the objectives of the strategy; (ii) how the strategy will contribute to the achievement of the organisational objectives of the Service; (iii) the methods to be used for carrying out consultation with consumers and members of the community, including at individual, service and Hospital and Health Service level, and with any ancillary board established for the Service’s board; (iv) the key issues on which consultation with consumers, members of the community and any ancillary board established for the Service’s board will be carried out; Examples of key issues for subparagraph (iv) — • service planning and design for the Service • service delivery by the Service • monitoring and evaluation of service delivery by the Service (v) how the Service will actively identify and consult with particular consumers and members of the community who are at risk of experiencing poor health outcomes or who may have difficulty accessing health services; Example for subparagraph (v) — The Service may involve providers of community services as part of the consultation arrangements stated in the strategy. (vi) how the Service will use information obtained from implementing the strategy to continuously improve consultation with consumers and the community under the strategy; (vii) how the effectiveness of the consumer and communities engagement strategy will be measured and publicly reported; and\n- (i) the objectives of the strategy;\n- (ii) how the strategy will contribute to the achievement of the organisational objectives of the Service;\n- (iii) the methods to be used for carrying out consultation with consumers and members of the community, including at individual, service and Hospital and Health Service level, and with any ancillary board established for the Service’s board;\n- (iv) the key issues on which consultation with consumers, members of the community and any ancillary board established for the Service’s board will be carried out; Examples of key issues for subparagraph (iv) — • service planning and design for the Service • service delivery by the Service • monitoring and evaluation of service delivery by the Service\n- • service planning and design for the Service\n- • service delivery by the Service\n- • monitoring and evaluation of service delivery by the Service\n- (v) how the Service will actively identify and consult with particular consumers and members of the community who are at risk of experiencing poor health outcomes or who may have difficulty accessing health services; Example for subparagraph (v) — The Service may involve providers of community services as part of the consultation arrangements stated in the strategy.\n- (vi) how the Service will use information obtained from implementing the strategy to continuously improve consultation with consumers and the community under the strategy;\n- (vii) how the effectiveness of the consumer and communities engagement strategy will be measured and publicly reported; and\n- (b) have regard to national and State strategies, policies, agreements and standards relevant to promoting consultation with health consumers and members of the community about the provision of health services by the Service; and Examples of policies and standards— • the document called ‘Australian Charter of Healthcare Rights’ published by the Australian Commission on Safety and Quality in Health Care • the National Safety and Quality Health Service Standards, 2nd edition, formulated by the Australian Commission on Safety and Quality in Health Care\n- • the document called ‘Australian Charter of Healthcare Rights’ published by the Australian Commission on Safety and Quality in Health Care\n- • the National Safety and Quality Health Service Standards, 2nd edition, formulated by the Australian Commission on Safety and Quality in Health Care\n- (c) outline the relationship between the Service’s consumer and community engagement strategy and its clinician engagement strategy, health equity strategy and protocol with local primary healthcare organisations; and\n- (d) require a summary of the key issues discussed and decisions made in each of the Service’s board meetings to be made available to consumers and the community, subject to the board’s obligations relating to confidentiality and privacy.\n- (i) the objectives of the strategy;\n- (ii) how the strategy will contribute to the achievement of the organisational objectives of the Service;\n- (iii) the methods to be used for carrying out consultation with consumers and members of the community, including at individual, service and Hospital and Health Service level, and with any ancillary board established for the Service’s board;\n- (iv) the key issues on which consultation with consumers, members of the community and any ancillary board established for the Service’s board will be carried out; Examples of key issues for subparagraph (iv) — • service planning and design for the Service • service delivery by the Service • monitoring and evaluation of service delivery by the Service\n- • service planning and design for the Service\n- • service delivery by the Service\n- • monitoring and evaluation of service delivery by the Service\n- (v) how the Service will actively identify and consult with particular consumers and members of the community who are at risk of experiencing poor health outcomes or who may have difficulty accessing health services; Example for subparagraph (v) — The Service may involve providers of community services as part of the consultation arrangements stated in the strategy.\n- (vi) how the Service will use information obtained from implementing the strategy to continuously improve consultation with consumers and the community under the strategy;\n- (vii) how the effectiveness of the consumer and communities engagement strategy will be measured and publicly reported; and\n- • service planning and design for the Service\n- • service delivery by the Service\n- • monitoring and evaluation of service delivery by the Service\n- • the document called ‘Australian Charter of Healthcare Rights’ published by the Australian Commission on Safety and Quality in Health Care\n- • the National Safety and Quality Health Service Standards, 2nd edition, formulated by the Australian Commission on Safety and Quality in Health Care","sortOrder":22},{"sectionNumber":"sec.20","sectionType":"section","heading":"Prescribed requirements for health equity strategies","content":"### sec.20 Prescribed requirements for health equity strategies\n\nFor section 40 (3) (a) of the Act , a health equity strategy of a Service must—\nstate the Service’s key performance measures, as agreed by the Service and the chief First Nations health officer, that relate to improving health and wellbeing outcomes for Aboriginal people and Torres Strait Islander people, including—\nactively eliminating racial discrimination and institutional racism within the Service; and\nincreasing access to healthcare services; and\ninfluencing the social, cultural and economic determinants of health; and\ndelivering sustainable, culturally safe and responsive healthcare services; and\nworking with Aboriginal people, Torres Strait Islander people and Aboriginal and Torres Strait Islander communities and organisations to design, deliver, monitor and review health services; and\nset out the actions the Service will take to—\nachieve the key performance measures mentioned in paragraph (a) , including through entering into partnership agreements or other arrangements with the service-delivery stakeholders for the health equity strategy; and\nwork with the implementation stakeholders for the health equity strategy to ensure greater collaboration, shared ownership and decision-making and the implementation of the strategy; and\nimprove the integration of health service delivery between the Service and the service-delivery stakeholders; and\nprovide inclusive mechanisms to support Aboriginal people and Torres Strait Islander people of all needs and abilities to give feedback to the Service; and\nalternative mechanisms for Aboriginal people and Torres Strait Islander people experiencing vulnerabilities to give advice and feedback other than the use of an online or written form\nincrease workforce representation of Aboriginal people and Torres Strait Islander people across all levels of health professions and employment streams to levels at least commensurate with the health service area’s Aboriginal and Torres Strait Islander population; and\nstate how the strategy aligns with—\nthe strategic and operational objectives of the Service; and\nother strategies, policies, guidelines or directives made by, or applying to, the Service under the Act or another Act; and\nthe Service’s consumer and community engagement strategy\npolicies relating to the Human Rights Act 2019\nhealth equity strategies of other Services; and\nother national, state and local government strategies, policies, agreements and standards relevant to promoting shared decision-making, shared ownership and working in partnership with Aboriginal people and Torres Strait Islander people.\nthe National Agreement on Closing the Gap (2020)\nthe Queensland Government Statement of Commitment to reframe the relationship between Aboriginal and Torres Strait Islander Peoples and the Queensland Government\nthe Queensland Health Aboriginal and Torres Strait Islander Cultural Capability Framework 2010-2033 (2015)\n- (a) state the Service’s key performance measures, as agreed by the Service and the chief First Nations health officer, that relate to improving health and wellbeing outcomes for Aboriginal people and Torres Strait Islander people, including— (i) actively eliminating racial discrimination and institutional racism within the Service; and (ii) increasing access to healthcare services; and (iii) influencing the social, cultural and economic determinants of health; and (iv) delivering sustainable, culturally safe and responsive healthcare services; and (v) working with Aboriginal people, Torres Strait Islander people and Aboriginal and Torres Strait Islander communities and organisations to design, deliver, monitor and review health services; and\n- (i) actively eliminating racial discrimination and institutional racism within the Service; and\n- (ii) increasing access to healthcare services; and\n- (iii) influencing the social, cultural and economic determinants of health; and\n- (iv) delivering sustainable, culturally safe and responsive healthcare services; and\n- (v) working with Aboriginal people, Torres Strait Islander people and Aboriginal and Torres Strait Islander communities and organisations to design, deliver, monitor and review health services; and\n- (b) set out the actions the Service will take to— (i) achieve the key performance measures mentioned in paragraph (a) , including through entering into partnership agreements or other arrangements with the service-delivery stakeholders for the health equity strategy; and (ii) work with the implementation stakeholders for the health equity strategy to ensure greater collaboration, shared ownership and decision-making and the implementation of the strategy; and (iii) improve the integration of health service delivery between the Service and the service-delivery stakeholders; and (iv) provide inclusive mechanisms to support Aboriginal people and Torres Strait Islander people of all needs and abilities to give feedback to the Service; and Example— alternative mechanisms for Aboriginal people and Torres Strait Islander people experiencing vulnerabilities to give advice and feedback other than the use of an online or written form (v) increase workforce representation of Aboriginal people and Torres Strait Islander people across all levels of health professions and employment streams to levels at least commensurate with the health service area’s Aboriginal and Torres Strait Islander population; and\n- (i) achieve the key performance measures mentioned in paragraph (a) , including through entering into partnership agreements or other arrangements with the service-delivery stakeholders for the health equity strategy; and\n- (ii) work with the implementation stakeholders for the health equity strategy to ensure greater collaboration, shared ownership and decision-making and the implementation of the strategy; and\n- (iii) improve the integration of health service delivery between the Service and the service-delivery stakeholders; and\n- (iv) provide inclusive mechanisms to support Aboriginal people and Torres Strait Islander people of all needs and abilities to give feedback to the Service; and Example— alternative mechanisms for Aboriginal people and Torres Strait Islander people experiencing vulnerabilities to give advice and feedback other than the use of an online or written form\n- (v) increase workforce representation of Aboriginal people and Torres Strait Islander people across all levels of health professions and employment streams to levels at least commensurate with the health service area’s Aboriginal and Torres Strait Islander population; and\n- (c) state how the strategy aligns with— (i) the strategic and operational objectives of the Service; and (ii) other strategies, policies, guidelines or directives made by, or applying to, the Service under the Act or another Act; and Examples— • the Service’s consumer and community engagement strategy • policies relating to the Human Rights Act 2019 (iii) health equity strategies of other Services; and (iv) other national, state and local government strategies, policies, agreements and standards relevant to promoting shared decision-making, shared ownership and working in partnership with Aboriginal people and Torres Strait Islander people. Examples— • the National Agreement on Closing the Gap (2020) • the Queensland Government Statement of Commitment to reframe the relationship between Aboriginal and Torres Strait Islander Peoples and the Queensland Government • the Queensland Health Aboriginal and Torres Strait Islander Cultural Capability Framework 2010-2033 (2015)\n- (i) the strategic and operational objectives of the Service; and\n- (ii) other strategies, policies, guidelines or directives made by, or applying to, the Service under the Act or another Act; and Examples— • the Service’s consumer and community engagement strategy • policies relating to the Human Rights Act 2019\n- • the Service’s consumer and community engagement strategy\n- • policies relating to the Human Rights Act 2019\n- (iii) health equity strategies of other Services; and\n- (iv) other national, state and local government strategies, policies, agreements and standards relevant to promoting shared decision-making, shared ownership and working in partnership with Aboriginal people and Torres Strait Islander people. Examples— • the National Agreement on Closing the Gap (2020) • the Queensland Government Statement of Commitment to reframe the relationship between Aboriginal and Torres Strait Islander Peoples and the Queensland Government • the Queensland Health Aboriginal and Torres Strait Islander Cultural Capability Framework 2010-2033 (2015)\n- • the National Agreement on Closing the Gap (2020)\n- • the Queensland Government Statement of Commitment to reframe the relationship between Aboriginal and Torres Strait Islander Peoples and the Queensland Government\n- • the Queensland Health Aboriginal and Torres Strait Islander Cultural Capability Framework 2010-2033 (2015)\n- (i) actively eliminating racial discrimination and institutional racism within the Service; and\n- (ii) increasing access to healthcare services; and\n- (iii) influencing the social, cultural and economic determinants of health; and\n- (iv) delivering sustainable, culturally safe and responsive healthcare services; and\n- (v) working with Aboriginal people, Torres Strait Islander people and Aboriginal and Torres Strait Islander communities and organisations to design, deliver, monitor and review health services; and\n- (i) achieve the key performance measures mentioned in paragraph (a) , including through entering into partnership agreements or other arrangements with the service-delivery stakeholders for the health equity strategy; and\n- (ii) work with the implementation stakeholders for the health equity strategy to ensure greater collaboration, shared ownership and decision-making and the implementation of the strategy; and\n- (iii) improve the integration of health service delivery between the Service and the service-delivery stakeholders; and\n- (iv) provide inclusive mechanisms to support Aboriginal people and Torres Strait Islander people of all needs and abilities to give feedback to the Service; and Example— alternative mechanisms for Aboriginal people and Torres Strait Islander people experiencing vulnerabilities to give advice and feedback other than the use of an online or written form\n- (v) increase workforce representation of Aboriginal people and Torres Strait Islander people across all levels of health professions and employment streams to levels at least commensurate with the health service area’s Aboriginal and Torres Strait Islander population; and\n- (i) the strategic and operational objectives of the Service; and\n- (ii) other strategies, policies, guidelines or directives made by, or applying to, the Service under the Act or another Act; and Examples— • the Service’s consumer and community engagement strategy • policies relating to the Human Rights Act 2019\n- • the Service’s consumer and community engagement strategy\n- • policies relating to the Human Rights Act 2019\n- (iii) health equity strategies of other Services; and\n- (iv) other national, state and local government strategies, policies, agreements and standards relevant to promoting shared decision-making, shared ownership and working in partnership with Aboriginal people and Torres Strait Islander people. Examples— • the National Agreement on Closing the Gap (2020) • the Queensland Government Statement of Commitment to reframe the relationship between Aboriginal and Torres Strait Islander Peoples and the Queensland Government • the Queensland Health Aboriginal and Torres Strait Islander Cultural Capability Framework 2010-2033 (2015)\n- • the National Agreement on Closing the Gap (2020)\n- • the Queensland Government Statement of Commitment to reframe the relationship between Aboriginal and Torres Strait Islander Peoples and the Queensland Government\n- • the Queensland Health Aboriginal and Torres Strait Islander Cultural Capability Framework 2010-2033 (2015)\n- • the Service’s consumer and community engagement strategy\n- • policies relating to the Human Rights Act 2019\n- • the National Agreement on Closing the Gap (2020)\n- • the Queensland Government Statement of Commitment to reframe the relationship between Aboriginal and Torres Strait Islander Peoples and the Queensland Government\n- • the Queensland Health Aboriginal and Torres Strait Islander Cultural Capability Framework 2010-2033 (2015)","sortOrder":23},{"sectionNumber":"sec.21","sectionType":"section","heading":"Prescribed persons—giving effect to health equity strategies","content":"### sec.21 Prescribed persons—giving effect to health equity strategies\n\nFor section 40 (5) of the Act , the following persons (the implementation stakeholders ) are prescribed—\nthe service-delivery stakeholders for the health equity strategy;\nthe chief First Nations health officer;\nQueensland Aboriginal and Islander Health Council ABN 97 111 116 762;\nHealth and Wellbeing Queensland established under the Health and Wellbeing Queensland Act 2019 .\n- (a) the service-delivery stakeholders for the health equity strategy;\n- (b) the chief First Nations health officer;\n- (c) Queensland Aboriginal and Islander Health Council ABN 97 111 116 762;\n- (d) Health and Wellbeing Queensland established under the Health and Wellbeing Queensland Act 2019 .","sortOrder":24},{"sectionNumber":"sec.22","sectionType":"section","heading":"Prescribed requirements for protocol with local primary healthcare organisations","content":"### sec.22 Prescribed requirements for protocol with local primary healthcare organisations\n\nFor section 42 (2) (a) of the Act , a protocol of a Service agreed with local primary healthcare organisations must—\ninclude the following—\nthe objectives of the protocol;\nhow the protocol will contribute to the achievement of the organisational objectives of the Service;\nthe key issues on which the Service and the local primary healthcare organisations are to cooperate;\nhealth service integration\nthe protection and promotion of public health\nservice planning and design for the Service\nlocal clinical governance arrangements\nhow the Service and local primary healthcare organisations will support the implementation of the protocol, including arrangements for sharing staff and allowing access to facilities and information management systems;\narrangements for sharing information between the Service and local primary healthcare organisations to improve service delivery and health outcomes;\nhow the protocol aligns with the Service’s cooperative arrangements with other entities delivering services in the health, aged care and disability sectors to improve service delivery and health outcomes;\nhow the Service will use information obtained from implementing the protocol to continuously improve cooperation with local primary healthcare organisations under the protocol;\nhow the effectiveness of the protocol will be measured and publicly reported; and\nhave regard to national and State strategies, policies, agreements and standards; and\noutline the relationship between the Service’s protocol and its consumer and community engagement strategy, clinician engagement strategy and health equity strategy; and\nrequire a summary of the key issues discussed and decisions made in each of the Service’s board meetings to be made available to the Service’s local primary healthcare organisations, subject to the board’s obligations relating to confidentiality and privacy.\n- (a) include the following— (i) the objectives of the protocol; (ii) how the protocol will contribute to the achievement of the organisational objectives of the Service; (iii) the key issues on which the Service and the local primary healthcare organisations are to cooperate; Examples of key issues for subparagraph (iii) — • health service integration • the protection and promotion of public health • service planning and design for the Service • local clinical governance arrangements (iv) how the Service and local primary healthcare organisations will support the implementation of the protocol, including arrangements for sharing staff and allowing access to facilities and information management systems; (v) arrangements for sharing information between the Service and local primary healthcare organisations to improve service delivery and health outcomes; (vi) how the protocol aligns with the Service’s cooperative arrangements with other entities delivering services in the health, aged care and disability sectors to improve service delivery and health outcomes; (vii) how the Service will use information obtained from implementing the protocol to continuously improve cooperation with local primary healthcare organisations under the protocol; (viii) how the effectiveness of the protocol will be measured and publicly reported; and\n- (i) the objectives of the protocol;\n- (ii) how the protocol will contribute to the achievement of the organisational objectives of the Service;\n- (iii) the key issues on which the Service and the local primary healthcare organisations are to cooperate; Examples of key issues for subparagraph (iii) — • health service integration • the protection and promotion of public health • service planning and design for the Service • local clinical governance arrangements\n- • health service integration\n- • the protection and promotion of public health\n- • service planning and design for the Service\n- • local clinical governance arrangements\n- (iv) how the Service and local primary healthcare organisations will support the implementation of the protocol, including arrangements for sharing staff and allowing access to facilities and information management systems;\n- (v) arrangements for sharing information between the Service and local primary healthcare organisations to improve service delivery and health outcomes;\n- (vi) how the protocol aligns with the Service’s cooperative arrangements with other entities delivering services in the health, aged care and disability sectors to improve service delivery and health outcomes;\n- (vii) how the Service will use information obtained from implementing the protocol to continuously improve cooperation with local primary healthcare organisations under the protocol;\n- (viii) how the effectiveness of the protocol will be measured and publicly reported; and\n- (b) have regard to national and State strategies, policies, agreements and standards; and\n- (c) outline the relationship between the Service’s protocol and its consumer and community engagement strategy, clinician engagement strategy and health equity strategy; and\n- (d) require a summary of the key issues discussed and decisions made in each of the Service’s board meetings to be made available to the Service’s local primary healthcare organisations, subject to the board’s obligations relating to confidentiality and privacy.\n- (i) the objectives of the protocol;\n- (ii) how the protocol will contribute to the achievement of the organisational objectives of the Service;\n- (iii) the key issues on which the Service and the local primary healthcare organisations are to cooperate; Examples of key issues for subparagraph (iii) — • health service integration • the protection and promotion of public health • service planning and design for the Service • local clinical governance arrangements\n- • health service integration\n- • the protection and promotion of public health\n- • service planning and design for the Service\n- • local clinical governance arrangements\n- (iv) how the Service and local primary healthcare organisations will support the implementation of the protocol, including arrangements for sharing staff and allowing access to facilities and information management systems;\n- (v) arrangements for sharing information between the Service and local primary healthcare organisations to improve service delivery and health outcomes;\n- (vi) how the protocol aligns with the Service’s cooperative arrangements with other entities delivering services in the health, aged care and disability sectors to improve service delivery and health outcomes;\n- (vii) how the Service will use information obtained from implementing the protocol to continuously improve cooperation with local primary healthcare organisations under the protocol;\n- (viii) how the effectiveness of the protocol will be measured and publicly reported; and\n- • health service integration\n- • the protection and promotion of public health\n- • service planning and design for the Service\n- • local clinical governance arrangements","sortOrder":25},{"sectionNumber":"pt.5","sectionType":"part","heading":"Quality assurance committees","content":"# Quality assurance committees","sortOrder":26},{"sectionNumber":"pt.5-div.1","sectionType":"division","heading":"Preliminary","content":"## Preliminary","sortOrder":27},{"sectionNumber":"sec.23","sectionType":"section","heading":"Definitions for part","content":"### sec.23 Definitions for part\n\nIn this part—\ncommittee means a quality assurance committee established under section 82 of the Act .\nmember means a member of a committee.\nprivacy policy see section 31 .\nspecified information see section 33 .","sortOrder":28},{"sectionNumber":"pt.5-div.2","sectionType":"division","heading":"Procedures of committees","content":"## Procedures of committees","sortOrder":29},{"sectionNumber":"sec.24","sectionType":"section","heading":"Chairperson","content":"### sec.24 Chairperson\n\nIf the entity that established a committee does not appoint a member to be chairperson of the committee, the committee must elect a member to be the chairperson.\nAlso, a committee may elect a member to be chairperson of the committee at any time.\nThe member elected under subsection (1) or (2) is appointed as chairperson when the entity establishing the committee approves the appointment.\nIf a committee was established by an entity other than the chief executive, as soon as practicable after the chairperson is appointed the committee must give the chief executive a written notice containing the following information—\nthe member’s full name;\nthe date the member was appointed as chairperson.\n(sec.24-ssec.1) If the entity that established a committee does not appoint a member to be chairperson of the committee, the committee must elect a member to be the chairperson.\n(sec.24-ssec.2) Also, a committee may elect a member to be chairperson of the committee at any time.\n(sec.24-ssec.3) The member elected under subsection (1) or (2) is appointed as chairperson when the entity establishing the committee approves the appointment.\n(sec.24-ssec.4) If a committee was established by an entity other than the chief executive, as soon as practicable after the chairperson is appointed the committee must give the chief executive a written notice containing the following information— the member’s full name; the date the member was appointed as chairperson.\n- (a) the member’s full name;\n- (b) the date the member was appointed as chairperson.","sortOrder":30},{"sectionNumber":"sec.25","sectionType":"section","heading":"Times and places of meetings","content":"### sec.25 Times and places of meetings\n\nCommittee meetings are to be held at the times and places the chairperson decides.\nHowever, the chairperson must call a meeting if asked in writing to do so by at least the number of members forming a quorum for the committee.\nAlso, a committee must hold its first meeting within 3 months after its establishment.\n(sec.25-ssec.1) Committee meetings are to be held at the times and places the chairperson decides.\n(sec.25-ssec.2) However, the chairperson must call a meeting if asked in writing to do so by at least the number of members forming a quorum for the committee.\n(sec.25-ssec.3) Also, a committee must hold its first meeting within 3 months after its establishment.","sortOrder":31},{"sectionNumber":"sec.26","sectionType":"section","heading":"Quorum","content":"### sec.26 Quorum\n\nA quorum for a committee is the number equal to one-half of the number of its members or, if one-half is not a whole number, the next highest whole number.","sortOrder":32},{"sectionNumber":"sec.27","sectionType":"section","heading":"Presiding at meetings","content":"### sec.27 Presiding at meetings\n\nThe chairperson is to preside at all meetings of a committee at which the chairperson is present.\nIf the chairperson is absent from a meeting or the office of chairperson is vacant, a member chosen by the members present is to preside.\n(sec.27-ssec.1) The chairperson is to preside at all meetings of a committee at which the chairperson is present.\n(sec.27-ssec.2) If the chairperson is absent from a meeting or the office of chairperson is vacant, a member chosen by the members present is to preside.","sortOrder":33},{"sectionNumber":"sec.28","sectionType":"section","heading":"Conduct of meetings","content":"### sec.28 Conduct of meetings\n\nA question at a committee meeting is decided by a majority of the votes of the members present.\nEach member present at the meeting has a vote on each question to be decided and, if the votes are equal, the member presiding also has a casting vote.\n(sec.28-ssec.1) A question at a committee meeting is decided by a majority of the votes of the members present.\n(sec.28-ssec.2) Each member present at the meeting has a vote on each question to be decided and, if the votes are equal, the member presiding also has a casting vote.","sortOrder":34},{"sectionNumber":"sec.29","sectionType":"section","heading":"Minutes","content":"### sec.29 Minutes\n\nA committee must keep the minutes of a meeting of the committee for 10 years after the meeting.\nSubsection (1) does not apply to the extent that the minutes are a public record under the Public Records Act 2002 .\n(sec.29-ssec.1) A committee must keep the minutes of a meeting of the committee for 10 years after the meeting.\n(sec.29-ssec.2) Subsection (1) does not apply to the extent that the minutes are a public record under the Public Records Act 2002 .","sortOrder":35},{"sectionNumber":"sec.30","sectionType":"section","heading":"Other procedures","content":"### sec.30 Other procedures\n\nSubject to this division—\na committee must conduct its business, including its meetings, under the procedures, if any, decided for the committee by the entity that established the committee; or\notherwise, the committee may conduct its business, including its meetings, under procedures decided by the committee.\n- (a) a committee must conduct its business, including its meetings, under the procedures, if any, decided for the committee by the entity that established the committee; or\n- (b) otherwise, the committee may conduct its business, including its meetings, under procedures decided by the committee.","sortOrder":36},{"sectionNumber":"pt.5-div.3","sectionType":"division","heading":"Privacy policies","content":"## Privacy policies","sortOrder":37},{"sectionNumber":"sec.31","sectionType":"section","heading":"A committee must adopt a privacy policy","content":"### sec.31 A committee must adopt a privacy policy\n\nA committee must adopt, by resolution, a written privacy policy (a privacy policy ).","sortOrder":38},{"sectionNumber":"sec.32","sectionType":"section","heading":"Content of privacy policy","content":"### sec.32 Content of privacy policy\n\nA committee’s privacy policy must state the ways the committee, or a member of the committee, may do any of the following—\nacquire and compile relevant information;\nsecurely store relevant information;\ndisclose relevant information;\nask an individual for consent to disclose the individual’s identity under section 83 (2) of the Act .\nThe privacy policy also must state the circumstances under which a record containing relevant information may be copied or destroyed.\nNothing in this section affects the operation of the Information Privacy Act 2009 or the Privacy Act 1988 (Cwlth) .\nIn this section—\nrelevant information means information acquired or compiled by the committee in the performance of its functions.\n(sec.32-ssec.1) A committee’s privacy policy must state the ways the committee, or a member of the committee, may do any of the following— acquire and compile relevant information; securely store relevant information; disclose relevant information; ask an individual for consent to disclose the individual’s identity under section 83 (2) of the Act .\n(sec.32-ssec.2) The privacy policy also must state the circumstances under which a record containing relevant information may be copied or destroyed.\n(sec.32-ssec.3) Nothing in this section affects the operation of the Information Privacy Act 2009 or the Privacy Act 1988 (Cwlth) .\n(sec.32-ssec.4) In this section— relevant information means information acquired or compiled by the committee in the performance of its functions.\n- (a) acquire and compile relevant information;\n- (b) securely store relevant information;\n- (c) disclose relevant information;\n- (d) ask an individual for consent to disclose the individual’s identity under section 83 (2) of the Act .","sortOrder":39},{"sectionNumber":"pt.5-div.4","sectionType":"division","heading":"Information to be made available by committees","content":"## Information to be made available by committees","sortOrder":40},{"sectionNumber":"sec.33","sectionType":"section","heading":"Specified information to be made available to the public","content":"### sec.33 Specified information to be made available to the public\n\nA committee must make available to the public the information stated in subsection (3) (the specified information ).\nThe specified information must—\nfor the first time a committee makes the specified information available to the public—be made available within 3 years after, and relate to the period since, the committee was established; or\notherwise—be made available within 3 years after, and relate to the period since, the committee last made the specified information available.\nFor subsection (1) , the information is—\na statement of the committee’s functions; and\nfor each current committee member—\nthe member’s full name and qualifications; and\nthe member’s office or position; and\na summary of the member’s experience that is relevant to the committee’s functions; and\na summary of the activities undertaken in, and any outcomes of, the performance of the committee’s functions; and\na summary of the committee’s privacy policy.\nThe committee must give the specified information to the entity that established the committee before the committee makes it available to the public.\nA committee may make the specified information available in a form the committee considers appropriate.\nThe specified information may be included in the annual report of the entity that established the committee.\n(sec.33-ssec.1) A committee must make available to the public the information stated in subsection (3) (the specified information ).\n(sec.33-ssec.2) The specified information must— for the first time a committee makes the specified information available to the public—be made available within 3 years after, and relate to the period since, the committee was established; or otherwise—be made available within 3 years after, and relate to the period since, the committee last made the specified information available.\n(sec.33-ssec.3) For subsection (1) , the information is— a statement of the committee’s functions; and for each current committee member— the member’s full name and qualifications; and the member’s office or position; and a summary of the member’s experience that is relevant to the committee’s functions; and a summary of the activities undertaken in, and any outcomes of, the performance of the committee’s functions; and a summary of the committee’s privacy policy.\n(sec.33-ssec.4) The committee must give the specified information to the entity that established the committee before the committee makes it available to the public.\n(sec.33-ssec.5) A committee may make the specified information available in a form the committee considers appropriate. The specified information may be included in the annual report of the entity that established the committee.\n- (a) for the first time a committee makes the specified information available to the public—be made available within 3 years after, and relate to the period since, the committee was established; or\n- (b) otherwise—be made available within 3 years after, and relate to the period since, the committee last made the specified information available.\n- (a) a statement of the committee’s functions; and\n- (b) for each current committee member— (i) the member’s full name and qualifications; and (ii) the member’s office or position; and (iii) a summary of the member’s experience that is relevant to the committee’s functions; and\n- (i) the member’s full name and qualifications; and\n- (ii) the member’s office or position; and\n- (iii) a summary of the member’s experience that is relevant to the committee’s functions; and\n- (c) a summary of the activities undertaken in, and any outcomes of, the performance of the committee’s functions; and\n- (d) a summary of the committee’s privacy policy.\n- (i) the member’s full name and qualifications; and\n- (ii) the member’s office or position; and\n- (iii) a summary of the member’s experience that is relevant to the committee’s functions; and","sortOrder":41},{"sectionNumber":"pt.5-div.5","sectionType":"division","heading":"Review and reporting obligations","content":"## Review and reporting obligations","sortOrder":42},{"sectionNumber":"sec.34","sectionType":"section","heading":"Review of functions","content":"### sec.34 Review of functions\n\nA committee must carry out a review of its functions—\nwithin 3 years after the committee is established; and\nafterwards—within 3 years after the previous review.\nAs soon as practicable after each review is carried out, the committee must give a report about the review to—\nthe entity that established the committee; and\nif the committee was established by an entity other than the chief executive—the chief executive.\n(sec.34-ssec.1) A committee must carry out a review of its functions— within 3 years after the committee is established; and afterwards—within 3 years after the previous review.\n(sec.34-ssec.2) As soon as practicable after each review is carried out, the committee must give a report about the review to— the entity that established the committee; and if the committee was established by an entity other than the chief executive—the chief executive.\n- (a) within 3 years after the committee is established; and\n- (b) afterwards—within 3 years after the previous review.\n- (a) the entity that established the committee; and\n- (b) if the committee was established by an entity other than the chief executive—the chief executive.","sortOrder":43},{"sectionNumber":"sec.35","sectionType":"section","heading":"Annual activity statement","content":"### sec.35 Annual activity statement\n\nA committee must prepare an annual activity statement.\nThe statement must include all of the following for the committee—\nthe chairperson’s full name;\neach member’s full name;\nfor any person appointed as a member during the reporting period—\nthe person’s full name and qualifications; and\nthe person’s office or position; and\na summary of the person’s experience that is relevant to the committee’s functions; and\nthe date the person became a member;\nif a person stopped being a member during the reporting period—the date the individual stopped being a member;\nthe dates of each meeting held by the committee during the reporting period.\nThe annual activity statement must, on or before each anniversary of the day the committee was established, be given to—\nthe entity that established the committee; and\nif the committee was established by an entity other than the chief executive—the chief executive.\n(sec.35-ssec.1) A committee must prepare an annual activity statement.\n(sec.35-ssec.2) The statement must include all of the following for the committee— the chairperson’s full name; each member’s full name; for any person appointed as a member during the reporting period— the person’s full name and qualifications; and the person’s office or position; and a summary of the person’s experience that is relevant to the committee’s functions; and the date the person became a member; if a person stopped being a member during the reporting period—the date the individual stopped being a member; the dates of each meeting held by the committee during the reporting period.\n(sec.35-ssec.3) The annual activity statement must, on or before each anniversary of the day the committee was established, be given to— the entity that established the committee; and if the committee was established by an entity other than the chief executive—the chief executive.\n- (a) the chairperson’s full name;\n- (b) each member’s full name;\n- (c) for any person appointed as a member during the reporting period— (i) the person’s full name and qualifications; and (ii) the person’s office or position; and (iii) a summary of the person’s experience that is relevant to the committee’s functions; and (iv) the date the person became a member;\n- (i) the person’s full name and qualifications; and\n- (ii) the person’s office or position; and\n- (iii) a summary of the person’s experience that is relevant to the committee’s functions; and\n- (iv) the date the person became a member;\n- (d) if a person stopped being a member during the reporting period—the date the individual stopped being a member;\n- (e) the dates of each meeting held by the committee during the reporting period.\n- (i) the person’s full name and qualifications; and\n- (ii) the person’s office or position; and\n- (iii) a summary of the person’s experience that is relevant to the committee’s functions; and\n- (iv) the date the person became a member;\n- (a) the entity that established the committee; and\n- (b) if the committee was established by an entity other than the chief executive—the chief executive.","sortOrder":44},{"sectionNumber":"pt.5-div.6","sectionType":"division","heading":"Miscellaneous","content":"## Miscellaneous","sortOrder":45},{"sectionNumber":"sec.36","sectionType":"section","heading":"Prescribed patient safety entities and authorised purposes","content":"### sec.36 Prescribed patient safety entities and authorised purposes\n\nEach of the following is a patient safety entity for section 85 (3) of the Act , definition prescribed patient safety entity —\nthe administrative unit of the department responsible for coordinating improvements in the safety and quality of health services;\nthe administrative unit of the department responsible for coordinating programs and activities for health service delivery in rural and remote areas;\nan executive committee established by the chief executive to oversee improvements in the safety and quality of health services;\neach safety and quality committee established by a board.\nFor section 85 (3) of the Act , definition authorised purpose , the purposes stated in schedule 4 , part 1 for a prescribed patient safety entity are the purposes prescribed for the entity.\n(sec.36-ssec.1) Each of the following is a patient safety entity for section 85 (3) of the Act , definition prescribed patient safety entity — the administrative unit of the department responsible for coordinating improvements in the safety and quality of health services; the administrative unit of the department responsible for coordinating programs and activities for health service delivery in rural and remote areas; an executive committee established by the chief executive to oversee improvements in the safety and quality of health services; each safety and quality committee established by a board.\n(sec.36-ssec.2) For section 85 (3) of the Act , definition authorised purpose , the purposes stated in schedule 4 , part 1 for a prescribed patient safety entity are the purposes prescribed for the entity.\n- (a) the administrative unit of the department responsible for coordinating improvements in the safety and quality of health services;\n- (b) the administrative unit of the department responsible for coordinating programs and activities for health service delivery in rural and remote areas;\n- (c) an executive committee established by the chief executive to oversee improvements in the safety and quality of health services;\n- (d) each safety and quality committee established by a board.","sortOrder":46},{"sectionNumber":"pt.6","sectionType":"part","heading":"Root cause analyses","content":"# Root cause analyses","sortOrder":47},{"sectionNumber":"sec.37","sectionType":"section","heading":"Reportable events","content":"### sec.37 Reportable events\n\nFor section 94 of the Act , definition reportable event , each of the following events is prescribed—\nsurgery or another invasive procedure being performed on the wrong site of a patient’s body resulting in serious harm to the patient or the death of the patient;\nsurgery or another invasive procedure being performed on the wrong patient resulting in serious harm to the patient or the death of the patient;\nthe wrong surgical or other invasive procedure being performed on a patient resulting in serious harm to the patient or the death of the patient;\nthe unintended retention of a foreign object in a patient after surgery or another invasive procedure resulting in serious harm to the patient or the death of the patient;\na haemolytic blood transfusion reaction caused by ABO incompatibility resulting in serious harm to or the death of the patient receiving the blood transfusion;\nthe suspected suicide of a patient within an acute psychiatric unit or ward;\nan error relating to a patient’s medication resulting in serious harm to the patient or the death of the patient;\nthe use of physical or mechanical restraint resulting in serious harm to a patient or the death of a patient;\nthe use of an incorrectly positioned orogastric or nasogastric tube resulting in serious harm to a patient or the death of a patient;\nthe discharge or release of a patient who is a child under the age of 15 years to an unauthorised person;\na stillbirth;\nany death of a patient, or serious harm or other harm to a patient that is likely to be permanent, that—\nis not mentioned in paragraphs (a) to (i) ; and\nwas not reasonably expected to be an outcome of the health service provided to the patient.\nFor subsection (1) (f) , an acute psychiatric unit or ward is a specialised unit or ward, including a unit or ward within an emergency department, for the treatment and care of admitted patients with a mental illness if the unit or ward—\nis specifically designed with fixtures and fittings that minimise the opportunity for patient suicide; and\nis specifically designed to prevent any unauthorised ingress or egress; and\nis subject to protocols for the observation of patients within the unit or ward.\nIn this section—\nABO incompatibility , in relation to a blood transfusion received by a patient, means the use of an incompatible blood group for the patient in the transfusion.\ninvasive procedure means a medical procedure that enters a person’s body including, for example, by cutting or puncturing the skin or by inserting a needle, tube, device or scope into the body.\nmechanical restraint means a device that controls a person’s freedom of movement.\nmental illness see the Mental Health Act 2016 , section 10 .\nserious harm , for a patient, means harm to the patient—\nthat requires life-saving surgical or medical intervention; or\nshortens the patient’s life expectancy; or\nthat is permanent or long-term physical harm; or\nthat is a permanent or long-term loss of a physical function.\nstillbirth means the birth of a child—\nwho shows no sign of respiration or heartbeat, or other sign of life, after completely leaving the child’s mother’s body; and\nwho—\nhas been gestated for 20 weeks or more; or\nweighs 400g or more.\nunauthorised person , in relation to a child, means a person who—\nis not a parent or legal guardian of the child; or\nis not acting under the express or implied authority of a parent or legal guardian of the child for the purpose of subsection (1) (j) ; or\nis prevented from having access to the child by an order of a court or tribunal.\n(sec.37-ssec.1) For section 94 of the Act , definition reportable event , each of the following events is prescribed— surgery or another invasive procedure being performed on the wrong site of a patient’s body resulting in serious harm to the patient or the death of the patient; surgery or another invasive procedure being performed on the wrong patient resulting in serious harm to the patient or the death of the patient; the wrong surgical or other invasive procedure being performed on a patient resulting in serious harm to the patient or the death of the patient; the unintended retention of a foreign object in a patient after surgery or another invasive procedure resulting in serious harm to the patient or the death of the patient; a haemolytic blood transfusion reaction caused by ABO incompatibility resulting in serious harm to or the death of the patient receiving the blood transfusion; the suspected suicide of a patient within an acute psychiatric unit or ward; an error relating to a patient’s medication resulting in serious harm to the patient or the death of the patient; the use of physical or mechanical restraint resulting in serious harm to a patient or the death of a patient; the use of an incorrectly positioned orogastric or nasogastric tube resulting in serious harm to a patient or the death of a patient; the discharge or release of a patient who is a child under the age of 15 years to an unauthorised person; a stillbirth; any death of a patient, or serious harm or other harm to a patient that is likely to be permanent, that— is not mentioned in paragraphs (a) to (i) ; and was not reasonably expected to be an outcome of the health service provided to the patient.\n(sec.37-ssec.2) For subsection (1) (f) , an acute psychiatric unit or ward is a specialised unit or ward, including a unit or ward within an emergency department, for the treatment and care of admitted patients with a mental illness if the unit or ward— is specifically designed with fixtures and fittings that minimise the opportunity for patient suicide; and is specifically designed to prevent any unauthorised ingress or egress; and is subject to protocols for the observation of patients within the unit or ward.\n(sec.37-ssec.3) In this section— ABO incompatibility , in relation to a blood transfusion received by a patient, means the use of an incompatible blood group for the patient in the transfusion. invasive procedure means a medical procedure that enters a person’s body including, for example, by cutting or puncturing the skin or by inserting a needle, tube, device or scope into the body. mechanical restraint means a device that controls a person’s freedom of movement. mental illness see the Mental Health Act 2016 , section 10 . serious harm , for a patient, means harm to the patient— that requires life-saving surgical or medical intervention; or shortens the patient’s life expectancy; or that is permanent or long-term physical harm; or that is a permanent or long-term loss of a physical function. stillbirth means the birth of a child— who shows no sign of respiration or heartbeat, or other sign of life, after completely leaving the child’s mother’s body; and who— has been gestated for 20 weeks or more; or weighs 400g or more. unauthorised person , in relation to a child, means a person who— is not a parent or legal guardian of the child; or is not acting under the express or implied authority of a parent or legal guardian of the child for the purpose of subsection (1) (j) ; or is prevented from having access to the child by an order of a court or tribunal.\n- (a) surgery or another invasive procedure being performed on the wrong site of a patient’s body resulting in serious harm to the patient or the death of the patient;\n- (b) surgery or another invasive procedure being performed on the wrong patient resulting in serious harm to the patient or the death of the patient;\n- (c) the wrong surgical or other invasive procedure being performed on a patient resulting in serious harm to the patient or the death of the patient;\n- (d) the unintended retention of a foreign object in a patient after surgery or another invasive procedure resulting in serious harm to the patient or the death of the patient;\n- (e) a haemolytic blood transfusion reaction caused by ABO incompatibility resulting in serious harm to or the death of the patient receiving the blood transfusion;\n- (f) the suspected suicide of a patient within an acute psychiatric unit or ward;\n- (g) an error relating to a patient’s medication resulting in serious harm to the patient or the death of the patient;\n- (h) the use of physical or mechanical restraint resulting in serious harm to a patient or the death of a patient;\n- (i) the use of an incorrectly positioned orogastric or nasogastric tube resulting in serious harm to a patient or the death of a patient;\n- (j) the discharge or release of a patient who is a child under the age of 15 years to an unauthorised person;\n- (k) a stillbirth;\n- (l) any death of a patient, or serious harm or other harm to a patient that is likely to be permanent, that— (i) is not mentioned in paragraphs (a) to (i) ; and (ii) was not reasonably expected to be an outcome of the health service provided to the patient.\n- (i) is not mentioned in paragraphs (a) to (i) ; and\n- (ii) was not reasonably expected to be an outcome of the health service provided to the patient.\n- (i) is not mentioned in paragraphs (a) to (i) ; and\n- (ii) was not reasonably expected to be an outcome of the health service provided to the patient.\n- (a) is specifically designed with fixtures and fittings that minimise the opportunity for patient suicide; and\n- (b) is specifically designed to prevent any unauthorised ingress or egress; and\n- (c) is subject to protocols for the observation of patients within the unit or ward.\n- (a) that requires life-saving surgical or medical intervention; or\n- (b) shortens the patient’s life expectancy; or\n- (c) that is permanent or long-term physical harm; or\n- (d) that is a permanent or long-term loss of a physical function.\n- (a) who shows no sign of respiration or heartbeat, or other sign of life, after completely leaving the child’s mother’s body; and\n- (b) who— (i) has been gestated for 20 weeks or more; or (ii) weighs 400g or more.\n- (i) has been gestated for 20 weeks or more; or\n- (ii) weighs 400g or more.\n- (i) has been gestated for 20 weeks or more; or\n- (ii) weighs 400g or more.\n- (a) is not a parent or legal guardian of the child; or\n- (b) is not acting under the express or implied authority of a parent or legal guardian of the child for the purpose of subsection (1) (j) ; or\n- (c) is prevented from having access to the child by an order of a court or tribunal.","sortOrder":48},{"sectionNumber":"sec.38","sectionType":"section","heading":"Prescribed patient safety entities and authorised purposes","content":"### sec.38 Prescribed patient safety entities and authorised purposes\n\nEach of the following is a patient safety entity for section 112 (7) of the Act , definition prescribed patient safety entity —\nthe administrative unit of the department responsible for coordinating improvements in the safety and quality of health services;\nthe administrative unit of the department responsible for coordinating programs and activities for health service delivery in rural and remote areas;\nan executive committee established by the chief executive to oversee improvements in the safety and quality of health services;\neach safety and quality committee established by a board;\neach quality assurance committee.\nFor section 112 (7) of the Act , definition authorised purpose , the purposes stated in schedule 4 , part 2 for a prescribed patient safety entity are the purposes prescribed for the entity.\n(sec.38-ssec.1) Each of the following is a patient safety entity for section 112 (7) of the Act , definition prescribed patient safety entity — the administrative unit of the department responsible for coordinating improvements in the safety and quality of health services; the administrative unit of the department responsible for coordinating programs and activities for health service delivery in rural and remote areas; an executive committee established by the chief executive to oversee improvements in the safety and quality of health services; each safety and quality committee established by a board; each quality assurance committee.\n(sec.38-ssec.2) For section 112 (7) of the Act , definition authorised purpose , the purposes stated in schedule 4 , part 2 for a prescribed patient safety entity are the purposes prescribed for the entity.\n- (a) the administrative unit of the department responsible for coordinating improvements in the safety and quality of health services;\n- (b) the administrative unit of the department responsible for coordinating programs and activities for health service delivery in rural and remote areas;\n- (c) an executive committee established by the chief executive to oversee improvements in the safety and quality of health services;\n- (d) each safety and quality committee established by a board;\n- (e) each quality assurance committee.","sortOrder":49},{"sectionNumber":"pt.7","sectionType":"part","heading":"Nurse-to-patient and midwife-to-patient ratios","content":"# Nurse-to-patient and midwife-to-patient ratios","sortOrder":50},{"sectionNumber":"sec.39","sectionType":"section","heading":"References to shifts","content":"### sec.39 References to shifts\n\nIn this part—\nthe morning shift for a ward is the shift ordinarily worked by nurses or midwives in the ward that mostly falls between 7a.m. and 3p.m.; and\nthe afternoon shift for a ward is the shift ordinarily worked by nurses or midwives in the ward that mostly falls between 3p.m. and 11p.m.; and\nthe night shift for a ward is the shift ordinarily worked by nurses or midwives in the ward that mostly falls between 11p.m. and 7a.m.\nHowever—\nif a shift falls equally across the periods mentioned in subsection (1) (a) and (b) , it is taken to be an afternoon shift; and\nA shift from 11a.m. to 7p.m. is an afternoon shift.\nif a shift falls equally across the periods mentioned in subsection (1) (b) and (c) , it is taken to be a night shift; and\nif a shift falls equally across the periods mentioned in subsection (1) (a) and (c) , it is taken to be a morning shift.\n(sec.39-ssec.1) In this part— the morning shift for a ward is the shift ordinarily worked by nurses or midwives in the ward that mostly falls between 7a.m. and 3p.m.; and the afternoon shift for a ward is the shift ordinarily worked by nurses or midwives in the ward that mostly falls between 3p.m. and 11p.m.; and the night shift for a ward is the shift ordinarily worked by nurses or midwives in the ward that mostly falls between 11p.m. and 7a.m.\n(sec.39-ssec.2) However— if a shift falls equally across the periods mentioned in subsection (1) (a) and (b) , it is taken to be an afternoon shift; and A shift from 11a.m. to 7p.m. is an afternoon shift. if a shift falls equally across the periods mentioned in subsection (1) (b) and (c) , it is taken to be a night shift; and if a shift falls equally across the periods mentioned in subsection (1) (a) and (c) , it is taken to be a morning shift.\n- (a) the morning shift for a ward is the shift ordinarily worked by nurses or midwives in the ward that mostly falls between 7a.m. and 3p.m.; and\n- (b) the afternoon shift for a ward is the shift ordinarily worked by nurses or midwives in the ward that mostly falls between 3p.m. and 11p.m.; and\n- (c) the night shift for a ward is the shift ordinarily worked by nurses or midwives in the ward that mostly falls between 11p.m. and 7a.m.\n- (a) if a shift falls equally across the periods mentioned in subsection (1) (a) and (b) , it is taken to be an afternoon shift; and Example— A shift from 11a.m. to 7p.m. is an afternoon shift.\n- (b) if a shift falls equally across the periods mentioned in subsection (1) (b) and (c) , it is taken to be a night shift; and\n- (c) if a shift falls equally across the periods mentioned in subsection (1) (a) and (c) , it is taken to be a morning shift.","sortOrder":51},{"sectionNumber":"sec.40","sectionType":"section","heading":"Nurse-to-patient and midwife-to-patient ratios applying to particular acute adult wards— Act , s 138B","content":"### sec.40 Nurse-to-patient and midwife-to-patient ratios applying to particular acute adult wards— Act , s 138B\n\nThis section applies in relation to an acute adult ward in a public sector health service facility if, in the table in schedule 5 , part 1 —\nthe facility is listed in the first column; and\na dot point appears opposite the facility in the column for the type of ward.\nThe minimum number of nurses or midwives who must be engaged in delivering health services to patients in the ward is—\nfor the morning shift—the number of patients divided by 4; or\nfor the afternoon shift—the number of patients divided by 4; or\nfor the night shift—the number of patients divided by 7.\nIn this section—\nacute adult ward means an acute ward in which health services are provided to adult patients.\ns 40 amd 2024 SL No. 142 s 4\n(sec.40-ssec.1) This section applies in relation to an acute adult ward in a public sector health service facility if, in the table in schedule 5 , part 1 — the facility is listed in the first column; and a dot point appears opposite the facility in the column for the type of ward.\n(sec.40-ssec.2) The minimum number of nurses or midwives who must be engaged in delivering health services to patients in the ward is— for the morning shift—the number of patients divided by 4; or for the afternoon shift—the number of patients divided by 4; or for the night shift—the number of patients divided by 7.\n(sec.40-ssec.3) In this section— acute adult ward means an acute ward in which health services are provided to adult patients.\n- (a) the facility is listed in the first column; and\n- (b) a dot point appears opposite the facility in the column for the type of ward.\n- (a) for the morning shift—the number of patients divided by 4; or\n- (b) for the afternoon shift—the number of patients divided by 4; or\n- (c) for the night shift—the number of patients divided by 7.","sortOrder":52},{"sectionNumber":"sec.40A","sectionType":"section","heading":"Midwife-to-patient ratios applying to postnatal maternity wards— Act , s 138B","content":"### sec.40A Midwife-to-patient ratios applying to postnatal maternity wards— Act , s 138B\n\nThis section applies in relation to a postnatal maternity ward in a public sector health service facility stated in column 1 of the table in schedule 5 , part 2 .\nFrom the date stated in column 2 of the table opposite the facility, the minimum number of midwives who must be engaged in delivering health services to postnatal patients in the ward is the number of postnatal patients divided by 6.\nIn this section—\npostnatal maternity ward means a maternity ward in which health services are provided to postnatal patients.\npostnatal patient means each of the following persons—\na person receiving care after giving birth;\na newborn baby of a person mentioned in paragraph (a) .\ns 40A ins 2024 SL No. 142 s 5\n(sec.40A-ssec.1) This section applies in relation to a postnatal maternity ward in a public sector health service facility stated in column 1 of the table in schedule 5 , part 2 .\n(sec.40A-ssec.2) From the date stated in column 2 of the table opposite the facility, the minimum number of midwives who must be engaged in delivering health services to postnatal patients in the ward is the number of postnatal patients divided by 6.\n(sec.40A-ssec.3) In this section— postnatal maternity ward means a maternity ward in which health services are provided to postnatal patients. postnatal patient means each of the following persons— a person receiving care after giving birth; a newborn baby of a person mentioned in paragraph (a) .\n- (a) a person receiving care after giving birth;\n- (b) a newborn baby of a person mentioned in paragraph (a) .","sortOrder":53},{"sectionNumber":"sec.40B","sectionType":"section","heading":"Rounding of minimum number of nurses or midwives","content":"### sec.40B Rounding of minimum number of nurses or midwives\n\nIf a minimum number of nurses or midwives worked out under this part is less than 1, the number is taken to be 1.\nOtherwise, if a minimum number of nurses or midwives worked out under this part is not a whole number, the number must be rounded to the nearest whole number (rounding one-half downwards).\nFor the morning shift in an acute adult ward with 7 patients, the number worked out under section 40 (2) (a) is 1.75, so the minimum number of nurses or midwives required is 2.\ns 40B ins 2024 SL No. 142 s 5\n(sec.40B-ssec.1) If a minimum number of nurses or midwives worked out under this part is less than 1, the number is taken to be 1.\n(sec.40B-ssec.2) Otherwise, if a minimum number of nurses or midwives worked out under this part is not a whole number, the number must be rounded to the nearest whole number (rounding one-half downwards). For the morning shift in an acute adult ward with 7 patients, the number worked out under section 40 (2) (a) is 1.75, so the minimum number of nurses or midwives required is 2.","sortOrder":54},{"sectionNumber":"pt.8","sectionType":"part","heading":"State aged care facilities","content":"# State aged care facilities","sortOrder":55},{"sectionNumber":"sec.41","sectionType":"section","heading":"State aged care facilities— Act , ss 138H and 138I","content":"### sec.41 State aged care facilities— Act , ss 138H and 138I\n\nFor sections 138H and 138I of the Act , the State aged care facilities mentioned in schedule 6 are prescribed.","sortOrder":56},{"sectionNumber":"sec.42","sectionType":"section","heading":"Minimum nurse and registered nurse percentages— Act , s 138H","content":"### sec.42 Minimum nurse and registered nurse percentages— Act , s 138H\n\nThis section prescribes the minimum percentage of nurses or registered nurses providing residential care at a State aged care facility prescribed under section 41 during each 24-hour period to the total number of nurses and support workers (the care staff ) providing residential care at the facility during the period.\nAt least 50% of the care staff must be nurses.\nAt least 30% of the care staff must be registered nurses.\n(sec.42-ssec.1) This section prescribes the minimum percentage of nurses or registered nurses providing residential care at a State aged care facility prescribed under section 41 during each 24-hour period to the total number of nurses and support workers (the care staff ) providing residential care at the facility during the period.\n(sec.42-ssec.2) At least 50% of the care staff must be nurses.\n(sec.42-ssec.3) At least 30% of the care staff must be registered nurses.","sortOrder":57},{"sectionNumber":"sec.43","sectionType":"section","heading":"Minimum average daily resident care hours— Act , s 138I","content":"### sec.43 Minimum average daily resident care hours— Act , s 138I\n\nThe minimum average daily resident care hours at a State aged care facility prescribed under section 41 is 3.65 hours.","sortOrder":58},{"sectionNumber":"pt.9","sectionType":"part","heading":"Committees of boards","content":"# Committees of boards","sortOrder":59},{"sectionNumber":"sec.44","sectionType":"section","heading":"Prescribed committees","content":"### sec.44 Prescribed committees\n\nFor schedule 1 , section 8 (1) (b) of the Act , each of the following committees is prescribed—\na safety and quality committee;\na finance committee;\nan audit committee under the Financial and Performance Management Standard 2019 , section 30 .\nA Service must comply with requirements under the Financial and Performance Management Standard 2019 , section 30 in establishing an audit committee.\nThe board establishing the committee may assign a different name to a committee mentioned in subsection (1) , if the name is appropriate having regard to the committee’s functions.\n(sec.44-ssec.1) For schedule 1 , section 8 (1) (b) of the Act , each of the following committees is prescribed— a safety and quality committee; a finance committee; an audit committee under the Financial and Performance Management Standard 2019 , section 30 . A Service must comply with requirements under the Financial and Performance Management Standard 2019 , section 30 in establishing an audit committee.\n(sec.44-ssec.2) The board establishing the committee may assign a different name to a committee mentioned in subsection (1) , if the name is appropriate having regard to the committee’s functions.\n- (a) a safety and quality committee;\n- (b) a finance committee;\n- (c) an audit committee under the Financial and Performance Management Standard 2019 , section 30 . Note— A Service must comply with requirements under the Financial and Performance Management Standard 2019 , section 30 in establishing an audit committee.","sortOrder":60},{"sectionNumber":"sec.45","sectionType":"section","heading":"Functions of a safety and quality committee","content":"### sec.45 Functions of a safety and quality committee\n\nA safety and quality committee established by a Service’s board has the following functions—\nadvising the board on matters relating to the safety and quality of health services provided by the Service, including the Service’s strategies for the following—\nminimising preventable patient harm;\nreducing unjustified variation in clinical care;\nimproving the experience of patients and carers of the Service in receiving health services;\ncomplying with national and State strategies, policies, agreements and standards relevant to promoting consultation with health consumers and members of the community about the provision of health services by the Service;\nthe document called ‘Australian Charter of Healthcare Rights’ published by the Australian Commission on Safety and Quality in Health Care\nthe National Safety and Quality Health Service Standards, 2nd edition, formulated by the Australian Commission on Safety and Quality in Health Care\nmonitoring the Service’s governance arrangements relating to the safety and quality of health services, including by monitoring compliance with the Service’s policies and plans about safety and quality;\npromoting improvements in the safety and quality of health services provided by the Service;\nmonitoring the safety and quality of health services being provided by the Service using appropriate indicators developed by the Service;\nmonitoring the workplace culture of the Service in relation to the safety and quality of health services provided by the Service;\ncollaborating with other safety and quality committees, the department and State-wide quality assurance committees in relation to the safety and quality of health services;\nany other function given to the committee by the Service’s board, if the function is not inconsistent with a function mentioned in paragraph (a) to (f) .\noverseeing workplace health and safety practices in the Service\n- (a) advising the board on matters relating to the safety and quality of health services provided by the Service, including the Service’s strategies for the following— (i) minimising preventable patient harm; (ii) reducing unjustified variation in clinical care; (iii) improving the experience of patients and carers of the Service in receiving health services; (iv) complying with national and State strategies, policies, agreements and standards relevant to promoting consultation with health consumers and members of the community about the provision of health services by the Service; Examples of policies and standards— • the document called ‘Australian Charter of Healthcare Rights’ published by the Australian Commission on Safety and Quality in Health Care • the National Safety and Quality Health Service Standards, 2nd edition, formulated by the Australian Commission on Safety and Quality in Health Care\n- (i) minimising preventable patient harm;\n- (ii) reducing unjustified variation in clinical care;\n- (iii) improving the experience of patients and carers of the Service in receiving health services;\n- (iv) complying with national and State strategies, policies, agreements and standards relevant to promoting consultation with health consumers and members of the community about the provision of health services by the Service; Examples of policies and standards— • the document called ‘Australian Charter of Healthcare Rights’ published by the Australian Commission on Safety and Quality in Health Care • the National Safety and Quality Health Service Standards, 2nd edition, formulated by the Australian Commission on Safety and Quality in Health Care\n- • the document called ‘Australian Charter of Healthcare Rights’ published by the Australian Commission on Safety and Quality in Health Care\n- • the National Safety and Quality Health Service Standards, 2nd edition, formulated by the Australian Commission on Safety and Quality in Health Care\n- (b) monitoring the Service’s governance arrangements relating to the safety and quality of health services, including by monitoring compliance with the Service’s policies and plans about safety and quality;\n- (c) promoting improvements in the safety and quality of health services provided by the Service;\n- (d) monitoring the safety and quality of health services being provided by the Service using appropriate indicators developed by the Service;\n- (e) monitoring the workplace culture of the Service in relation to the safety and quality of health services provided by the Service;\n- (f) collaborating with other safety and quality committees, the department and State-wide quality assurance committees in relation to the safety and quality of health services;\n- (g) any other function given to the committee by the Service’s board, if the function is not inconsistent with a function mentioned in paragraph (a) to (f) . Example of a function for paragraph (g) — overseeing workplace health and safety practices in the Service\n- (i) minimising preventable patient harm;\n- (ii) reducing unjustified variation in clinical care;\n- (iii) improving the experience of patients and carers of the Service in receiving health services;\n- (iv) complying with national and State strategies, policies, agreements and standards relevant to promoting consultation with health consumers and members of the community about the provision of health services by the Service; Examples of policies and standards— • the document called ‘Australian Charter of Healthcare Rights’ published by the Australian Commission on Safety and Quality in Health Care • the National Safety and Quality Health Service Standards, 2nd edition, formulated by the Australian Commission on Safety and Quality in Health Care\n- • the document called ‘Australian Charter of Healthcare Rights’ published by the Australian Commission on Safety and Quality in Health Care\n- • the National Safety and Quality Health Service Standards, 2nd edition, formulated by the Australian Commission on Safety and Quality in Health Care\n- • the document called ‘Australian Charter of Healthcare Rights’ published by the Australian Commission on Safety and Quality in Health Care\n- • the National Safety and Quality Health Service Standards, 2nd edition, formulated by the Australian Commission on Safety and Quality in Health Care","sortOrder":61},{"sectionNumber":"sec.46","sectionType":"section","heading":"Functions of a finance committee","content":"### sec.46 Functions of a finance committee\n\nA finance committee established by a Service’s board has the following functions—\nadvising the board about the matters stated in paragraphs (b) to (g) ;\nassessing the Service’s budgets and ensuring the budgets are—\nconsistent with the organisational objectives of the Service; and\nappropriate having regard to the Service’s funding;\nmonitoring the Service’s cash flow, having regard to the revenue and expenditure of the Service;\nmonitoring the financial and operating performance of the Service;\nmonitoring the adequacy of the Service’s financial systems, having regard to its operational requirements and obligations under the Financial Accountability Act 2009 ;\nassessing financial risks or concerns that impact, or may impact, on the financial performance and reporting obligations of the Service, and how the Service is managing the risks or concerns;\nthe accuracy of the valuation of fixed assets\nthe adequacy of financial reserves\nassessing the Service’s complex or unusual financial transactions;\nany other function given to the committee by the Service’s board, if the function is not inconsistent with a function mentioned in paragraph (a) to (g) .\nperformance and resource management functions\n- (a) advising the board about the matters stated in paragraphs (b) to (g) ;\n- (b) assessing the Service’s budgets and ensuring the budgets are— (i) consistent with the organisational objectives of the Service; and (ii) appropriate having regard to the Service’s funding;\n- (i) consistent with the organisational objectives of the Service; and\n- (ii) appropriate having regard to the Service’s funding;\n- (c) monitoring the Service’s cash flow, having regard to the revenue and expenditure of the Service;\n- (d) monitoring the financial and operating performance of the Service;\n- (e) monitoring the adequacy of the Service’s financial systems, having regard to its operational requirements and obligations under the Financial Accountability Act 2009 ;\n- (f) assessing financial risks or concerns that impact, or may impact, on the financial performance and reporting obligations of the Service, and how the Service is managing the risks or concerns; Examples of financial risks or concerns for paragraph (f) — • the accuracy of the valuation of fixed assets • the adequacy of financial reserves\n- • the accuracy of the valuation of fixed assets\n- • the adequacy of financial reserves\n- (g) assessing the Service’s complex or unusual financial transactions;\n- (h) any other function given to the committee by the Service’s board, if the function is not inconsistent with a function mentioned in paragraph (a) to (g) . Examples of functions for paragraph (h) — performance and resource management functions\n- (i) consistent with the organisational objectives of the Service; and\n- (ii) appropriate having regard to the Service’s funding;\n- • the accuracy of the valuation of fixed assets\n- • the adequacy of financial reserves","sortOrder":62},{"sectionNumber":"sec.47","sectionType":"section","heading":"Functions of an audit committee","content":"### sec.47 Functions of an audit committee\n\nAn audit committee established by a Service’s board has all of the following functions—\nadvising the board about the matters stated in paragraphs (b) to (h) ;\nassessing the adequacy of the Service’s financial statements, having regard to the following—\nthe appropriateness of the accounting practices used;\ncompliance with prescribed accounting standards under the Financial Accountability Act 2009 ;\nexternal audits of the Service’s financial statements;\ninformation provided by the Service about the accuracy and completeness of the financial statements;\nmonitoring the Service’s compliance with its obligation to establish and maintain an internal control structure and systems of risk management under the Financial Accountability Act 2009 , including—\nwhether the Service has appropriate policies and procedures in place; and\nwhether the Service is complying with the policies and procedures;\nif an internal audit function is established for the Service under the Financial and Performance Management Standard 2019 , part 2 , division 5 —monitoring and advising the Service’s board about its internal audit function;\noverseeing the Service’s liaison with the Queensland Audit Office in relation to the Service’s proposed audit strategies and plans;\nassessing external audit reports for the Service and the adequacy of actions taken by the Service as a result of the reports;\nmonitoring the adequacy of the Service’s management of legal and compliance risks and internal compliance systems, including the effectiveness of the systems in monitoring compliance by the Service with relevant laws and government policies;\nassessing the Service’s complex or unusual transactions or series of transactions, or any material deviation from the Service’s budget;\nany other function given to the committee by the Service’s board, if the function is not inconsistent with a function mentioned in paragraph (a) to (h) .\noverseeing improvements in the quality of the Service’s systems and procedures\nIn this section—\nexternal audit means an audit conducted by or for the Queensland Audit Office.\nQueensland Audit Office means the Queensland Audit Office established under the Auditor-General Act 2009 , section 6 (4) .\n(sec.47-ssec.1) An audit committee established by a Service’s board has all of the following functions— advising the board about the matters stated in paragraphs (b) to (h) ; assessing the adequacy of the Service’s financial statements, having regard to the following— the appropriateness of the accounting practices used; compliance with prescribed accounting standards under the Financial Accountability Act 2009 ; external audits of the Service’s financial statements; information provided by the Service about the accuracy and completeness of the financial statements; monitoring the Service’s compliance with its obligation to establish and maintain an internal control structure and systems of risk management under the Financial Accountability Act 2009 , including— whether the Service has appropriate policies and procedures in place; and whether the Service is complying with the policies and procedures; if an internal audit function is established for the Service under the Financial and Performance Management Standard 2019 , part 2 , division 5 —monitoring and advising the Service’s board about its internal audit function; overseeing the Service’s liaison with the Queensland Audit Office in relation to the Service’s proposed audit strategies and plans; assessing external audit reports for the Service and the adequacy of actions taken by the Service as a result of the reports; monitoring the adequacy of the Service’s management of legal and compliance risks and internal compliance systems, including the effectiveness of the systems in monitoring compliance by the Service with relevant laws and government policies; assessing the Service’s complex or unusual transactions or series of transactions, or any material deviation from the Service’s budget; any other function given to the committee by the Service’s board, if the function is not inconsistent with a function mentioned in paragraph (a) to (h) . overseeing improvements in the quality of the Service’s systems and procedures\n(sec.47-ssec.2) In this section— external audit means an audit conducted by or for the Queensland Audit Office. Queensland Audit Office means the Queensland Audit Office established under the Auditor-General Act 2009 , section 6 (4) .\n- (a) advising the board about the matters stated in paragraphs (b) to (h) ;\n- (b) assessing the adequacy of the Service’s financial statements, having regard to the following— (i) the appropriateness of the accounting practices used; (ii) compliance with prescribed accounting standards under the Financial Accountability Act 2009 ; (iii) external audits of the Service’s financial statements; (iv) information provided by the Service about the accuracy and completeness of the financial statements;\n- (i) the appropriateness of the accounting practices used;\n- (ii) compliance with prescribed accounting standards under the Financial Accountability Act 2009 ;\n- (iii) external audits of the Service’s financial statements;\n- (iv) information provided by the Service about the accuracy and completeness of the financial statements;\n- (c) monitoring the Service’s compliance with its obligation to establish and maintain an internal control structure and systems of risk management under the Financial Accountability Act 2009 , including— (i) whether the Service has appropriate policies and procedures in place; and (ii) whether the Service is complying with the policies and procedures;\n- (i) whether the Service has appropriate policies and procedures in place; and\n- (ii) whether the Service is complying with the policies and procedures;\n- (d) if an internal audit function is established for the Service under the Financial and Performance Management Standard 2019 , part 2 , division 5 —monitoring and advising the Service’s board about its internal audit function;\n- (e) overseeing the Service’s liaison with the Queensland Audit Office in relation to the Service’s proposed audit strategies and plans;\n- (f) assessing external audit reports for the Service and the adequacy of actions taken by the Service as a result of the reports;\n- (g) monitoring the adequacy of the Service’s management of legal and compliance risks and internal compliance systems, including the effectiveness of the systems in monitoring compliance by the Service with relevant laws and government policies;\n- (h) assessing the Service’s complex or unusual transactions or series of transactions, or any material deviation from the Service’s budget;\n- (i) any other function given to the committee by the Service’s board, if the function is not inconsistent with a function mentioned in paragraph (a) to (h) . Example of a function for paragraph (i) — overseeing improvements in the quality of the Service’s systems and procedures\n- (i) the appropriateness of the accounting practices used;\n- (ii) compliance with prescribed accounting standards under the Financial Accountability Act 2009 ;\n- (iii) external audits of the Service’s financial statements;\n- (iv) information provided by the Service about the accuracy and completeness of the financial statements;\n- (i) whether the Service has appropriate policies and procedures in place; and\n- (ii) whether the Service is complying with the policies and procedures;","sortOrder":63},{"sectionNumber":"pt.10","sectionType":"part","heading":"Confidentiality","content":"# Confidentiality","sortOrder":64},{"sectionNumber":"sec.48","sectionType":"section","heading":"Prescribed health professionals— Act , s 139","content":"### sec.48 Prescribed health professionals— Act , s 139\n\nFor section 139 of the Act , definition prescribed health professional , paragraph (a) , each of the following health professionals is prescribed—\na health professional—\nwho is registered under the Health Practitioner Regulation National Law in a health profession mentioned in schedule 7 , part 1 , column 1; and\nwhose registration under that Law is of a type mentioned opposite the health profession in column 2 of the schedule;\na health professional who—\nprovides a health service mentioned in schedule 7 , part 2 , column 1; and\nsatisfies the condition for provision of the health service mentioned opposite in column 2 of the schedule.\n- (a) a health professional— (i) who is registered under the Health Practitioner Regulation National Law in a health profession mentioned in schedule 7 , part 1 , column 1; and (ii) whose registration under that Law is of a type mentioned opposite the health profession in column 2 of the schedule;\n- (i) who is registered under the Health Practitioner Regulation National Law in a health profession mentioned in schedule 7 , part 1 , column 1; and\n- (ii) whose registration under that Law is of a type mentioned opposite the health profession in column 2 of the schedule;\n- (b) a health professional who— (i) provides a health service mentioned in schedule 7 , part 2 , column 1; and (ii) satisfies the condition for provision of the health service mentioned opposite in column 2 of the schedule.\n- (i) provides a health service mentioned in schedule 7 , part 2 , column 1; and\n- (ii) satisfies the condition for provision of the health service mentioned opposite in column 2 of the schedule.\n- (i) who is registered under the Health Practitioner Regulation National Law in a health profession mentioned in schedule 7 , part 1 , column 1; and\n- (ii) whose registration under that Law is of a type mentioned opposite the health profession in column 2 of the schedule;\n- (i) provides a health service mentioned in schedule 7 , part 2 , column 1; and\n- (ii) satisfies the condition for provision of the health service mentioned opposite in column 2 of the schedule.","sortOrder":65},{"sectionNumber":"sec.49","sectionType":"section","heading":"Prescribed information system— Act , s 139","content":"### sec.49 Prescribed information system— Act , s 139\n\nFor section 139 of the Act , definition prescribed information system , the information system provided by the department called ‘The Viewer’ and with asset number 604333 is prescribed.","sortOrder":66},{"sectionNumber":"sec.50","sectionType":"section","heading":"Prescribed designated person— Act , s 139A","content":"### sec.50 Prescribed designated person— Act , s 139A\n\nFor section 139A (1) (m) of the Act , each of the following persons is prescribed as a designated person—\nthe commissioner of the Queensland Ambulance Service appointed under the Ambulance Service Act 1991 , section 4 ;\na person employed under the Ambulance Service Act 1991 , section 13 .\n- (a) the commissioner of the Queensland Ambulance Service appointed under the Ambulance Service Act 1991 , section 4 ;\n- (b) a person employed under the Ambulance Service Act 1991 , section 13 .","sortOrder":67},{"sectionNumber":"sec.51","sectionType":"section","heading":"Disclosure of confidential information for purposes relating to health services— Act , s 150","content":"### sec.51 Disclosure of confidential information for purposes relating to health services— Act , s 150\n\nFor section 150 (b) of the Act , an entity stated in column 1 of the table in schedule 7A is prescribed in relation to disclosure of information for a purpose stated in column 2 of the table opposite the entity.\ns 51 sub 2024 SL No. 92 s 4","sortOrder":68},{"sectionNumber":"sec.52","sectionType":"section","heading":"Disclosure to Commonwealth, another State or Commonwealth or State entity— Act , s 151","content":"### sec.52 Disclosure to Commonwealth, another State or Commonwealth or State entity— Act , s 151\n\nFor section 151 (1) (a) (i) (B) of the Act , each agreement stated in schedule 8 , part 1 , is prescribed.\nFor section 151 (1) (b) (i) (B) of the Act , each agreement stated in schedule 8 , part 2 , is prescribed.\n(sec.52-ssec.1) For section 151 (1) (a) (i) (B) of the Act , each agreement stated in schedule 8 , part 1 , is prescribed.\n(sec.52-ssec.2) For section 151 (1) (b) (i) (B) of the Act , each agreement stated in schedule 8 , part 2 , is prescribed.","sortOrder":69},{"sectionNumber":"pt.11","sectionType":"part","heading":"Miscellaneous","content":"# Miscellaneous","sortOrder":70},{"sectionNumber":"sec.53","sectionType":"section","heading":"Major capital works","content":"### sec.53 Major capital works\n\nFor schedule 2 of the Act , definition major capital works , capital works are prescribed if the works—\nare structural works for the construction of a building; or\ninvolve alterations to the building envelope of an existing building; or\nconsist of work, other than excluded work—\nthat requires assessment, certification or approval under an Act; and\nbuilding work that requires assessment by a building certifier under the Building Act 1975\nfor which the estimated capital expenditure is $500,000 or more.\nIn this section—\nexcluded work means work that involves only routine maintenance of, or repairs to, an existing building or other structure.\n(sec.53-ssec.1) For schedule 2 of the Act , definition major capital works , capital works are prescribed if the works— are structural works for the construction of a building; or involve alterations to the building envelope of an existing building; or consist of work, other than excluded work— that requires assessment, certification or approval under an Act; and building work that requires assessment by a building certifier under the Building Act 1975 for which the estimated capital expenditure is $500,000 or more.\n(sec.53-ssec.2) In this section— excluded work means work that involves only routine maintenance of, or repairs to, an existing building or other structure.\n- (a) are structural works for the construction of a building; or\n- (b) involve alterations to the building envelope of an existing building; or\n- (c) consist of work, other than excluded work— (i) that requires assessment, certification or approval under an Act; and Example— building work that requires assessment by a building certifier under the Building Act 1975 (ii) for which the estimated capital expenditure is $500,000 or more.\n- (i) that requires assessment, certification or approval under an Act; and Example— building work that requires assessment by a building certifier under the Building Act 1975\n- (ii) for which the estimated capital expenditure is $500,000 or more.\n- (i) that requires assessment, certification or approval under an Act; and Example— building work that requires assessment by a building certifier under the Building Act 1975\n- (ii) for which the estimated capital expenditure is $500,000 or more.","sortOrder":71},{"sectionNumber":"sch.2-pt.1","sectionType":"part","heading":"Leases that may be granted","content":"# Leases that may be granted","sortOrder":72},{"sectionNumber":"sch.2-pt.2","sectionType":"part","heading":"Leases that may be taken","content":"# Leases that may be taken","sortOrder":73},{"sectionNumber":"sch.3-pt.1","sectionType":"part","heading":"Positions prescribed by classification level","content":"# Positions prescribed by classification level","sortOrder":74},{"sectionNumber":"sch.3-sec","sectionType":"section","heading":null,"content":"### Section sch.3-sec\n\nThe following classification levels under the ‘Medical Officers (Queensland Health) Award - State 2015’—\nL13 but only if the position has a pay point of C1-1 under the award\nL14 to L29\nMOPP 1-1\nMOPP 1-2\nMOPP 1-3\nMSPP 1-1\nMSPP 1-2\nMSPP 1-3\nMSPP 1-4\nMSPP 2-1\nMSPP 2-2.\nThe following classification levels under the health employment directive called ‘Health Employment Directive No. 6/20 (Medical Officers with Private Practice (MOPP) and Medical Superintendents with Private Practice (MSPP) classification levels)’—\nrural generalist medical officer with private practice\nsenior rural generalist medical officer with private practice\nrural generalist medical superintendent with private practice\nsenior rural generalist medical superintendent with private practice.\n(sch.3-sec-ssec.1) The following classification levels under the ‘Medical Officers (Queensland Health) Award - State 2015’— L13 but only if the position has a pay point of C1-1 under the award L14 to L29 MOPP 1-1 MOPP 1-2 MOPP 1-3 MSPP 1-1 MSPP 1-2 MSPP 1-3 MSPP 1-4 MSPP 2-1 MSPP 2-2.\n(sch.3-sec-ssec.2) The following classification levels under the health employment directive called ‘Health Employment Directive No. 6/20 (Medical Officers with Private Practice (MOPP) and Medical Superintendents with Private Practice (MSPP) classification levels)’— rural generalist medical officer with private practice senior rural generalist medical officer with private practice rural generalist medical superintendent with private practice senior rural generalist medical superintendent with private practice.\n- • L13 but only if the position has a pay point of C1-1 under the award\n- • L14 to L29\n- • MOPP 1-1\n- • MOPP 1-2\n- • MOPP 1-3\n- • MSPP 1-1\n- • MSPP 1-2\n- • MSPP 1-3\n- • MSPP 1-4\n- • MSPP 2-1\n- • MSPP 2-2.\n- • rural generalist medical officer with private practice\n- • senior rural generalist medical officer with private practice\n- • rural generalist medical superintendent with private practice\n- • senior rural generalist medical superintendent with private practice.","sortOrder":75},{"sectionNumber":"sch.3-pt.2","sectionType":"part","heading":"Other positions","content":"# Other positions","sortOrder":76},{"sectionNumber":"sch.4-pt.1","sectionType":"part","heading":"Authorised purposes— Act , section 85","content":"# Authorised purposes— Act , section 85","sortOrder":77},{"sectionNumber":"sch.4-sec.1","sectionType":"section","heading":"Administrative unit of the department responsible for coordinating improvements in the safety and quality of health services","content":"### sch.4-sec.1 Administrative unit of the department responsible for coordinating improvements in the safety and quality of health services\n\nimproving the effectiveness and outcomes of quality assurance activities undertaken in Services and the department\nfacilitating State-wide learning from quality assurance activities, including by issuing State-wide patient safety alerts, advisory documents and other information to support patient safety initiatives\ndeveloping, monitoring and evaluating patient safety initiatives and programs\nundertaking research on the operation and effectiveness of quality assurance committees\n- • improving the effectiveness and outcomes of quality assurance activities undertaken in Services and the department\n- • facilitating State-wide learning from quality assurance activities, including by issuing State-wide patient safety alerts, advisory documents and other information to support patient safety initiatives\n- • developing, monitoring and evaluating patient safety initiatives and programs\n- • undertaking research on the operation and effectiveness of quality assurance committees","sortOrder":78},{"sectionNumber":"sch.4-sec.2","sectionType":"section","heading":"Administrative unit of the department responsible for coordinating programs and activities for health service delivery in rural and remote areas","content":"### sch.4-sec.2 Administrative unit of the department responsible for coordinating programs and activities for health service delivery in rural and remote areas\n\ncontributing to the development, review and improvement of policies and standards relating to quality assurance activities in rural Services\nmonitoring and reporting on the implementation of recommendations contained in quality assurance committee reports or other documents in rural Services\ndeveloping and implementing patient safety initiatives in rural Services\n- • contributing to the development, review and improvement of policies and standards relating to quality assurance activities in rural Services\n- • monitoring and reporting on the implementation of recommendations contained in quality assurance committee reports or other documents in rural Services\n- • developing and implementing patient safety initiatives in rural Services","sortOrder":79},{"sectionNumber":"sch.4-sec.3","sectionType":"section","heading":"Executive committee established by the chief executive to oversee improvements in the safety and quality of health services","content":"### sch.4-sec.3 Executive committee established by the chief executive to oversee improvements in the safety and quality of health services\n\nreviewing patient safety and quality performance in Services and the department\nmonitoring, evaluating and promoting improvement in patient safety and quality performance in Services and the department\n- • reviewing patient safety and quality performance in Services and the department\n- • monitoring, evaluating and promoting improvement in patient safety and quality performance in Services and the department","sortOrder":80},{"sectionNumber":"sch.4-sec.4","sectionType":"section","heading":"Safety and quality committees","content":"### sch.4-sec.4 Safety and quality committees\n\ncontributing to the development, review and improvement of policies and standards of the committee’s board relating to quality assurance activities in the Service of the board that established the committee\nmonitoring and reporting to the committee’s board on the implementation of recommendations contained in quality assurance committee reports or other documents in the Service\ndeveloping and implementing patient safety initiatives of the committee’s board in the Service\n- • contributing to the development, review and improvement of policies and standards of the committee’s board relating to quality assurance activities in the Service of the board that established the committee\n- • monitoring and reporting to the committee’s board on the implementation of recommendations contained in quality assurance committee reports or other documents in the Service\n- • developing and implementing patient safety initiatives of the committee’s board in the Service","sortOrder":81},{"sectionNumber":"sch.4-pt.2","sectionType":"part","heading":"Authorised purposes— Act , section 112","content":"# Authorised purposes— Act , section 112","sortOrder":82},{"sectionNumber":"sch.4-sec.5","sectionType":"section","heading":"Administrative unit of the department responsible for coordinating improvements in the safety and quality of health services","content":"### sch.4-sec.5 Administrative unit of the department responsible for coordinating improvements in the safety and quality of health services\n\nimproving the effectiveness and outcomes of root cause analyses undertaken in Services and the department\nfacilitating State-wide learning from root cause analyses, including by issuing State-wide patient safety alerts, advisory documents and other information to support patient safety initiatives\ndeveloping, monitoring and evaluating patient safety initiatives and programs\nundertaking research on the operation and effectiveness of root cause analyses\n- • improving the effectiveness and outcomes of root cause analyses undertaken in Services and the department\n- • facilitating State-wide learning from root cause analyses, including by issuing State-wide patient safety alerts, advisory documents and other information to support patient safety initiatives\n- • developing, monitoring and evaluating patient safety initiatives and programs\n- • undertaking research on the operation and effectiveness of root cause analyses","sortOrder":83},{"sectionNumber":"sch.4-sec.6","sectionType":"section","heading":"Administrative unit of the department responsible for coordinating programs and activities for health service delivery in rural and remote areas","content":"### sch.4-sec.6 Administrative unit of the department responsible for coordinating programs and activities for health service delivery in rural and remote areas\n\ncontributing to the development, review and improvement of policies and standards relating to root cause analyses in rural Services\nmonitoring and reporting on the implementation of recommendations contained in RCA reports or chain of events documents relevant to rural Services\nusing information contained in RCA reports or chain of events documents to develop and implement patient safety initiatives in rural Services\n- • contributing to the development, review and improvement of policies and standards relating to root cause analyses in rural Services\n- • monitoring and reporting on the implementation of recommendations contained in RCA reports or chain of events documents relevant to rural Services\n- • using information contained in RCA reports or chain of events documents to develop and implement patient safety initiatives in rural Services","sortOrder":84},{"sectionNumber":"sch.4-sec.7","sectionType":"section","heading":"Executive committee established by the chief executive to oversee improvements in the safety and quality of health services","content":"### sch.4-sec.7 Executive committee established by the chief executive to oversee improvements in the safety and quality of health services\n\nreviewing patient safety and quality performance in Services and the department\nmonitoring, evaluating and promoting improvement in patient safety and quality performance in Services and the department\n- • reviewing patient safety and quality performance in Services and the department\n- • monitoring, evaluating and promoting improvement in patient safety and quality performance in Services and the department","sortOrder":85},{"sectionNumber":"sch.4-sec.8","sectionType":"section","heading":"Safety and quality committees","content":"### sch.4-sec.8 Safety and quality committees\n\ncontributing to the development, review and improvement of policies and standards relating to root cause analyses in the Service of the board that established the committee\nmonitoring and reporting to the committee’s board on the implementation of recommendations contained in RCA reports or other documents relevant to the board’s Service\nusing information contained in RCA reports or chain of events documents to develop and implement patient safety initiatives in the Service\n- • contributing to the development, review and improvement of policies and standards relating to root cause analyses in the Service of the board that established the committee\n- • monitoring and reporting to the committee’s board on the implementation of recommendations contained in RCA reports or other documents relevant to the board’s Service\n- • using information contained in RCA reports or chain of events documents to develop and implement patient safety initiatives in the Service","sortOrder":86},{"sectionNumber":"sch.4-sec.9","sectionType":"section","heading":"Quality assurance committees","content":"### sch.4-sec.9 Quality assurance committees\n\nassessing and evaluating the quality of health services, to the extent the services are relevant to a reportable event\nreporting and making recommendations concerning the quality of health services, to the extent the services are relevant to a reportable event\nmonitoring the implementation of its recommendations, to the extent its recommendations are relevant to a reportable event\n- • assessing and evaluating the quality of health services, to the extent the services are relevant to a reportable event\n- • reporting and making recommendations concerning the quality of health services, to the extent the services are relevant to a reportable event\n- • monitoring the implementation of its recommendations, to the extent its recommendations are relevant to a reportable event","sortOrder":87},{"sectionNumber":"sch.5-pt.1","sectionType":"part","heading":"Acute adult wards","content":"# Acute adult wards","sortOrder":88},{"sectionNumber":"sch.5-pt.2","sectionType":"part","heading":"Postnatal maternity wards","content":"# Postnatal maternity wards","sortOrder":89},{"sectionNumber":"sch.7-pt.1","sectionType":"part","heading":"Health professionals registered under the Health Practitioner Regulation National Law","content":"# Health professionals registered under the Health Practitioner Regulation National Law","sortOrder":90},{"sectionNumber":"sch.7-pt.2","sectionType":"part","heading":"Other health professionals","content":"# Other health professionals","sortOrder":91},{"sectionNumber":"sch.8-pt.1","sectionType":"part","heading":"Agreements with Commonwealth, State or entity","content":"# Agreements with Commonwealth, State or entity","sortOrder":92},{"sectionNumber":"sch.8-sec","sectionType":"section","heading":null,"content":"### Section sch.8-sec\n\nAgreement between Queensland and the Australian Capital Territory for the funding of health services provided to residents of Queensland by the Australian Capital Territory and vice versa, for the period 1 July 2020 to 30 June 2025.\nAgreement between Queensland and the Northern Territory for the funding of health services provided to residents of Queensland by the Northern Territory and vice versa, for the period 1 July 2020 to 30 June 2025.\nAgreement between Queensland and South Australia for the funding of health services provided to residents of Queensland by South Australia and vice versa, for the period 1 July 2020 to 30 June 2025.\nAgreement between Queensland and Tasmania for the funding of health services provided to residents of Queensland by Tasmania and vice versa, for the period 1 July 2020 to 30 June 2025.\nAgreement between Queensland and Western Australia for the funding of health services provided to residents of Queensland by Western Australia and vice versa, for the period 1 July 2020 to 30 June 2025.\nNational Health Information Agreement between the Commonwealth, State and Territory health, statistical and national authorities, commenced 1 October 2013.\nIntergovernmental Agreement on Federal Financial Relations, the schedules and any agreements under the schedules, between the Commonwealth of Australia and the States and Territories of Australia, commenced 1 January 2009.\nThe agreement of 2022 called ‘Agreement between Australian state and territory health departments and the Organ and Tissue Authority concerning the use and maintenance of the Electronic Donor Record to facilitate effective and efficient organ and tissue donation for transplantation across Australia’.\nThe agreement dated 28 April 2022 called ‘National Partnership Agreement on Specified Projects - Schedule E - Rheumatic Fever Strategy’ between Queensland and the Commonwealth of Australia.\nThe agreement made on 5 September 2025 called ‘Services Agreement for Information Exchange to Identify Women who are Eligible to receive Breast Screening Services in Queensland’ between the Commonwealth of Australia represented by Services Australia and the State of Queensland acting through Queensland Health.\nThe agreement made on 12 June 2020 called ‘Hospital services arrangement between the Commonwealth of Australia and the Repatriation Commission and the Military Rehabilitation and Compensation Commission and the State of Queensland’, as amended by the deed of variation, dated 2 April 2024, between Queensland and the Commonwealth.\nThe agreement made on 9 October 2023 called ‘Cross-border agreement between the State of Queensland and the Commonwealth of Australia for the funding of patient services provided by Queensland Health to residents of Norfolk Island’.\nThe agreement made on 24 July 2024 called ‘Agreement between Queensland and New South Wales for:\nFunding of health services provided to residents of Queensland by New South Wales and vice versa\nJoint support arrangements and governing principles to enhance services in the New South Wales-Queensland border region’.\nThe agreement made on 10 October 2024 called ‘Agreement between Queensland and Victoria for the funding of health services provided to residents of Victoria by Queensland and vice versa’.\n(sch.8-sec-ssec.1) Agreement between Queensland and the Australian Capital Territory for the funding of health services provided to residents of Queensland by the Australian Capital Territory and vice versa, for the period 1 July 2020 to 30 June 2025.\n(sch.8-sec-ssec.2) Agreement between Queensland and the Northern Territory for the funding of health services provided to residents of Queensland by the Northern Territory and vice versa, for the period 1 July 2020 to 30 June 2025.\n(sch.8-sec-ssec.3) Agreement between Queensland and South Australia for the funding of health services provided to residents of Queensland by South Australia and vice versa, for the period 1 July 2020 to 30 June 2025.\n(sch.8-sec-ssec.4) Agreement between Queensland and Tasmania for the funding of health services provided to residents of Queensland by Tasmania and vice versa, for the period 1 July 2020 to 30 June 2025.\n(sch.8-sec-ssec.5) Agreement between Queensland and Western Australia for the funding of health services provided to residents of Queensland by Western Australia and vice versa, for the period 1 July 2020 to 30 June 2025.\n(sch.8-sec-ssec.6) National Health Information Agreement between the Commonwealth, State and Territory health, statistical and national authorities, commenced 1 October 2013.\n(sch.8-sec-ssec.7) Intergovernmental Agreement on Federal Financial Relations, the schedules and any agreements under the schedules, between the Commonwealth of Australia and the States and Territories of Australia, commenced 1 January 2009.\n(sch.8-sec-ssec.8) The agreement of 2022 called ‘Agreement between Australian state and territory health departments and the Organ and Tissue Authority concerning the use and maintenance of the Electronic Donor Record to facilitate effective and efficient organ and tissue donation for transplantation across Australia’.\n(sch.8-sec-ssec.9) The agreement dated 28 April 2022 called ‘National Partnership Agreement on Specified Projects - Schedule E - Rheumatic Fever Strategy’ between Queensland and the Commonwealth of Australia.\n(sch.8-sec-ssec.10) The agreement made on 5 September 2025 called ‘Services Agreement for Information Exchange to Identify Women who are Eligible to receive Breast Screening Services in Queensland’ between the Commonwealth of Australia represented by Services Australia and the State of Queensland acting through Queensland Health.\n(sch.8-sec-ssec.10A) The agreement made on 12 June 2020 called ‘Hospital services arrangement between the Commonwealth of Australia and the Repatriation Commission and the Military Rehabilitation and Compensation Commission and the State of Queensland’, as amended by the deed of variation, dated 2 April 2024, between Queensland and the Commonwealth.\n(sch.8-sec-ssec.10B) The agreement made on 9 October 2023 called ‘Cross-border agreement between the State of Queensland and the Commonwealth of Australia for the funding of patient services provided by Queensland Health to residents of Norfolk Island’.\n(sch.8-sec-ssec.10C) The agreement made on 24 July 2024 called ‘Agreement between Queensland and New South Wales for: Funding of health services provided to residents of Queensland by New South Wales and vice versa Joint support arrangements and governing principles to enhance services in the New South Wales-Queensland border region’.\n(sch.8-sec-ssec.10D) The agreement made on 10 October 2024 called ‘Agreement between Queensland and Victoria for the funding of health services provided to residents of Victoria by Queensland and vice versa’.\n- • Funding of health services provided to residents of Queensland by New South Wales and vice versa\n- • Joint support arrangements and governing principles to enhance services in the New South Wales-Queensland border region’.","sortOrder":93},{"sectionNumber":"sch.8-pt.2","sectionType":"part","heading":"Agreements with State entity","content":"# Agreements with State entity","sortOrder":94},{"sectionNumber":"sch.8-sec-oc.2","sectionType":"section","heading":null,"content":"### Section sch.8-sec-oc.2\n\nThe agreement dated 15 June 2017 called ‘Memorandum of Understanding between The State of Queensland acting through Queensland Health and The State of Queensland acting through the Queensland Police Service, Mental Health Collaboration’.\nThe agreement dated 14 July 2023 called ‘Information sharing agreement— Confidential information sharing under the Hospital and Health Boards Act 2011 (Qld) and Corrective Services Act 2006 (Qld) between The State of Queensland acting through Queensland Health and The State of Queensland acting through Queensland Corrective Services’.\nThe agreement dated 2 November 2017 called ‘Memorandum of Understanding between the Chief Executive of Queensland Health and the Queensland Police Service, Confidential Information Disclosure’.\nThe agreement dated 5 July 2018 called ‘Agreement pursuant to section 151 (1) (b) of the Hospital and Health Boards Act 2011 (Qld) between The State of Queensland through the Chief Executive of Queensland Health and National Injury Insurance Agency Queensland’.\nThe agreement of May 2020 called ‘Agreement pursuant to section 151 (1) (b) of the Hospital and Health Boards Act 2011 (Qld) between the State of Queensland through the Chief Executive of Queensland Health and the State of Queensland through the Parole Board Queensland, Confidential Information Disclosure’.\nThe agreement dated 21 June 2024 called ‘Agreement under section 151 (1) (b) of the Hospital and Health Boards Act 2011 (Qld) between the State of Queensland through the Chief Executive of Queensland Health and the State of Queensland through the Department of Transport and Main Roads’.\n(sch.8-sec-oc.2-ssec.11) The agreement dated 15 June 2017 called ‘Memorandum of Understanding between The State of Queensland acting through Queensland Health and The State of Queensland acting through the Queensland Police Service, Mental Health Collaboration’.\n(sch.8-sec-oc.2-ssec.12) The agreement dated 14 July 2023 called ‘Information sharing agreement— Confidential information sharing under the Hospital and Health Boards Act 2011 (Qld) and Corrective Services Act 2006 (Qld) between The State of Queensland acting through Queensland Health and The State of Queensland acting through Queensland Corrective Services’.\n(sch.8-sec-oc.2-ssec.13) The agreement dated 2 November 2017 called ‘Memorandum of Understanding between the Chief Executive of Queensland Health and the Queensland Police Service, Confidential Information Disclosure’.\n(sch.8-sec-oc.2-ssec.14) The agreement dated 5 July 2018 called ‘Agreement pursuant to section 151 (1) (b) of the Hospital and Health Boards Act 2011 (Qld) between The State of Queensland through the Chief Executive of Queensland Health and National Injury Insurance Agency Queensland’.\n(sch.8-sec-oc.2-ssec.15) The agreement of May 2020 called ‘Agreement pursuant to section 151 (1) (b) of the Hospital and Health Boards Act 2011 (Qld) between the State of Queensland through the Chief Executive of Queensland Health and the State of Queensland through the Parole Board Queensland, Confidential Information Disclosure’.\n(sch.8-sec-oc.2-ssec.16) The agreement dated 21 June 2024 called ‘Agreement under section 151 (1) (b) of the Hospital and Health Boards Act 2011 (Qld) between the State of Queensland through the Chief Executive of Queensland Health and the State of Queensland through the Department of Transport and Main Roads’.","sortOrder":95}],"analysis":{"flash_summary":{"complexity_score":7,"scope_assessment":{"changed":false,"description":"The regulation primarily implements and specifies operational detail authorised by the Act rather than expanding substantive scope. It expressly continues prior service‑area declarations and names from the expired regulation (sec.4) and prescribes procedures, staffing minima and disclosure/committee rules under powers in the Act (e.g. staff movements secs 7–12; engagement and equity requirements secs 16–22; nurse/midwife ratios secs 39–40B; privacy and disclosures secs 15, 31–33, 49–52). No provision in the text purports to widen statutory subject‑matter beyond the Act’s delegated functions."},"complexity_factors":["Extensive cross-references and delegation to the Hospital and Health Boards Act (multiple sections throughout) increasing interpretive layering.","Detailed staff‑movement regime with different approvals, consultation and ‘significant risk’ discretion thresholds (secs 7–12).","Prescriptive operational standards and numeric formulas for staffing ratios and rounding rules (secs 39–40B, 40A).","Multiple mandatory strategies/protocols with required stakeholders and performance measures (secs 16–22).","Privacy, data‑sharing and designated‑person exceptions tied to schedules and external agreements (secs 15, 31–33, 49–52; schs 7, 7A, 8).","Complex committee governance, reporting and review duties with fixed retention and publication obligations (secs 23–36, 29, 33–35).","Schedules enumerating positions, facilities, patient‑safety entities and authorised purposes (schs 2–9) that operationalise many rules."],"plain_english_summary":"Mechanically, this regulation prescribes detailed operating rules for Hospital and Health Services: it continues prior service-area designations, sets which leases may be granted or taken, authorises staff movements and classification changes, requires boards and quality committees to adopt procedures and publish reports, outlines privacy and information‑sharing exceptions, sets clinician/consumer engagement and First Nations health equity requirements, lists reportable patient‑safety events, and fixes nurse/midwife and aged‑care staffing minima. It affects Services, boards, executives, clinical and support staff, patients and partner organisations by allocating decision rights, imposing staffing and reporting obligations and authorising specific data disclosures."},"issue_detection":{"absurdities":[{"type":"self_contradicting","section":"sec.5(2)(a)","severity":"high","reasoning":"Section 20A(2) of the Act authorises regulations to prescribe lease types that can be granted or taken without Minister's and Treasurer's approval. Section 5(1) purports to do exactly that. However, s.5(2)(a) then requires that any lease a Service grants under Part 1 of schedule 2 must still be 'approved by the Minister'. This renders the prescription meaningless for granted leases — the very approval the regulation was meant to dispense with is reintroduced by the same regulation.","confidence":0.82,"description":"Section 5(1) purports to prescribe lease types under s.20A(2) of the Act as not requiring Minister's approval, yet sec.5(2)(a) immediately conditions a Service's ability to grant such a lease on the granting having 'been approved by the Minister'. The entire purpose of the prescription is to exempt leases from ministerial approval, but the regulation then reintroduces that same approval requirement for Part 1 leases."},{"type":"self_contradicting","section":"sec.10(2) and sec.10(3)","severity":"medium","reasoning":"Sec.10(2) grants employees a genuine right to withhold consent to demotion. But under sec.11(4)(b), if an employee refuses a written-direction movement (which may include a demotion) without establishing reasonable grounds, the relevant chief executive MUST terminate employment. The employee's 'consent' to demotion is thus illusory — either consent to the demotion or face mandatory termination. The consent protection of sec.10(2) is structurally undermined by sec.11(4)(b) in the written-direction scenario.","confidence":0.75,"description":"Section 10(2) requires employee consent for movement to a lower classification level, but sec.10(3) removes that consent requirement for disciplinary action. However, sec.7(2)(b) and sec.8(3) already permit compelled movement by written direction for significant public risk reasons — creating a situation where a non-disciplinary compelled movement still requires consent for demotion, but the mechanism compelling the movement (written direction) overrides employee refusal under sec.11(4)(b) (mandatory termination). An employee can therefore be forced to either accept demotion or be terminated, rendering consent in sec.10(2) illusory in the written-direction context."},{"type":"impossible_compliance","section":"sec.11(1) and sec.11(4)(a)","severity":"medium","reasoning":"The movement has legal effect (sec.11(1)), meaning the employee is technically employed by the new employer. But if the chief executive declines to exercise the discretion to terminate under sec.11(4)(a), and the employee refuses to attend the new employer, no mechanism resolves the standoff. The employee is simultaneously legally employed by the new employer but physically working (or refusing to work) at neither. The mandatory outcome under sec.11(4)(b) for written directions highlights the intentional contrast, making the gap for agreement-based movements appear unintentional and problematic.","confidence":0.7,"description":"Under sec.11(1), an agreement-based movement has legal effect unless the employee establishes reasonable grounds to refuse it. However, sec.11(4)(a) provides that if the employee fails to establish reasonable grounds and refuses, the relevant chief executive 'may' (not must) end employment. This means an agreement-based movement can be simultaneously in legal effect AND indefinitely unimplemented if the chief executive chooses not to terminate — leaving the employee in an indeterminate legal status: legally moved but physically not moved, with employment at the original employer in legal limbo."},{"type":"self_contradicting","section":"sec.24(1) and sec.24(2)","severity":"low","reasoning":"Sec.24(3) requires entity approval for elected chairpersons, which mitigates but does not fully resolve the tension. However, the drafting of sec.24(2) as a standalone power ('at any time') without limiting it to vacancies or the absence of an entity-appointed chairperson means a committee could theoretically attempt to replace an entity-appointed chairperson through an election, subject only to entity approval — creating a circular approval loop where the entity must approve overriding its own earlier appointment.","confidence":0.55,"description":"Section 24(1) requires a committee to elect a chairperson if the establishing entity does not appoint one. Section 24(2) states 'also, a committee may elect a member to be chairperson at any time.' Read together, sec.24(2) permits a committee to hold an election to replace a validly appointed chairperson at any time, potentially in competition with the establishing entity's appointment power, creating an unresolved tension about which appointment prevails."},{"type":"other","section":"sec.33(2)","severity":"medium","reasoning":"The provision is designed to ensure transparency but is structured purely as a maximum deadline rather than a minimum standard. There is no 'at least annually' or 'within [shorter period] of significant changes' requirement. A committee that does nothing for 2 years and 11 months and then makes a disclosure is fully compliant. Given the health safety context and the annual activity statement requirement in sec.35, the 3-year window in sec.33 appears anomalously permissive and internally inconsistent with the annual reporting cadence of sec.35.","confidence":0.65,"description":"Section 33(2) requires specified information to be made available 'within 3 years after' establishment (first time) or 'within 3 years after' the last disclosure. This creates a rolling 3-year maximum disclosure cycle with no minimum frequency requirement. A committee could theoretically comply by disclosing information on day 1,095 (exactly 3 years) after establishment, then again on day 2,190, and so on — meaning the public could be waiting nearly 3 years between disclosures of a committee's membership, activities and outcomes. For a health quality assurance body, this is a substantively absurd transparency gap."},{"type":"impossible_compliance","section":"sec.37(1)(k) and sec.37(1)(l)","severity":"medium","reasoning":"The stillbirth definition at sec.37(3) includes all births of non-viable foetuses showing no signs of life at or after 20 weeks gestation or 400g. Many such events are clinically anticipated (e.g., known foetal abnormalities incompatible with life, severe intrauterine growth restriction). Prescribing every such event as a reportable event requiring root cause analysis, without a 'not reasonably expected' qualifier similar to sec.37(1)(l), is both clinically irrational and creates an enormous and potentially unmanageable compliance burden on health services. The contrast with the 'not reasonably expected' qualifier in sec.37(1)(l) makes the omission in sec.37(1)(k) appear particularly anomalous.","confidence":0.68,"description":"Section 37(1)(k) prescribes 'a stillbirth' as a reportable event triggering root cause analysis obligations. A stillbirth by definition (sec.37(3)) involves a child who shows no sign of life after completely leaving the mother's body. Section 37(1)(l) covers deaths 'not reasonably expected to be an outcome of the health service provided.' Applying root cause analysis obligations to every stillbirth — including those clinically anticipated in high-risk pregnancies — imposes a potentially impossible and clinically irrational compliance burden, since anticipated stillbirths would also trigger the catch-all in sec.37(1)(l)."},{"type":"circular_definition","section":"sec.13(2)(d)","severity":"low","reasoning":"The regulation bootstraps the no-payment outcome from the definitional fiction that movement is not termination, which is itself a regulatory declaration rather than a reflection of the contractual or factual reality. While this is a common legislative technique for continuity of employment provisions, the interaction with sec.9(3) — which overrides inconsistent contract terms — completes the circular loop: the movement overrides termination provisions (sec.9(3)), therefore it is not a termination (sec.13(2)(c)), therefore no termination payments are owed (sec.13(2)(d)).","confidence":0.5,"description":"Section 13(2)(c) states that a moved employee's appointment 'does not constitute a termination of employment' and sec.13(2)(d) states the employee 'is not entitled to a payment or other benefit because the employee is no longer employed by the first employer.' However, sec.9(3) provides that if a contract provision is inconsistent with a movement, the movement takes effect despite the inconsistency. If an employment contract provides for a termination payment on transfer, sec.9(3) overrides it. Yet sec.13(2)(d) is framed as a consequence of the movement 'not being a termination' — creating a circularity: the movement isn't a termination because the regulation says so, and no payment is owed because it isn't a termination."}],"contradictions":[{"severity":"medium","section_a":"sec.7(3)","section_b":"sec.11(1)","confidence":0.65,"description":"Section 7(3) permits the department chief executive to issue a written direction for movement only if the movement is 'necessary to mitigate a significant risk to the public sector health system.' Section 11(1) then allows the employee to establish 'reasonable grounds for refusing the movement.' These two provisions are in structural tension: if the chief executive has already determined the movement is necessary to mitigate a significant public risk, it is difficult to conceive of employee grounds that would be 'reasonable' to refuse such a movement — yet the regulation preserves that right, creating uncertainty about whether any grounds could ever be sufficient to override a significant-risk determination."},{"severity":"medium","section_a":"sec.8(2)","section_b":"sec.8(3)","confidence":0.7,"description":"Section 8(2) permits movement of a health service chief executive by agreement 'with the approval of the Minister.' Section 8(3) permits the Minister to compel movement by written direction on the recommendation of the department chief executive. Under sec.8(2), the Minister approves a consensual agreement. Under sec.8(3), the Minister directs movement without requiring consent. However, sec.8(2)(a) permits movement from a Service to the department by agreement between the Service board chair and the department chief executive — yet requires Minister approval. Sec.8(3) allows the Minister to direct the same movement on the department chief executive's recommendation alone. The Minister's role is thus duplicated and inconsistent: the Minister both approves consensual movements and can unilaterally direct the same movements, creating redundancy and potential for the Minister to bypass the board chair's agreement entirely by simply using sec.8(3) rather than sec.8(2)."},{"severity":"high","section_a":"sec.10(2)","section_b":"sec.11(4)(b)","confidence":0.78,"description":"Section 10(2) provides that an employee may only be moved to a lower classification level with their consent. Section 11(4)(b) mandates that the relevant chief executive MUST terminate the employee's employment if the employee refuses a written-direction movement without establishing reasonable grounds. Where a written direction includes a demotion, the employee must either consent (losing the sec.10(2) protection) or refuse (triggering mandatory termination under sec.11(4)(b)). The consent protection of sec.10(2) is therefore rendered practically ineffective for written-direction movements involving demotion."},{"severity":"low","section_a":"sec.33(2)","section_b":"sec.35(3)","confidence":0.6,"description":"Section 33 requires specified public information to be disclosed within 3 years of establishment (or 3 years after the last disclosure). Section 35 requires an annual activity statement to be given to the establishing entity and chief executive on or before each anniversary of establishment. The annual activity statement under sec.35 contains overlapping information to the sec.33 specified information (e.g., member details, meeting dates). The sec.35 annual obligation to the establishing entity conflicts with the sec.33 triennial public disclosure obligation — information provided annually to the entity is withheld from the public for up to 3 years, creating an internal inconsistency in the regulation's transparency framework."},{"severity":"medium","section_a":"sec.37(1)(l)","section_b":"sec.37(1)(a)-(k)","confidence":0.72,"description":"Section 37(1)(l) prescribes as a reportable event any death or serious/permanent harm 'not mentioned in paragraphs (a) to (i)' [note: the drafting references (a) to (i) but the list runs to (k)] that was not reasonably expected. The cross-reference to paragraphs '(a) to (i)' appears to exclude paragraphs (j) and (k) from the scope of the exclusion in (l), suggesting that deaths arising from events in (j) (discharge to unauthorised person) and (k) (stillbirth) could simultaneously be reportable under both the specific paragraph AND the catch-all in (l). The erroneous range reference creates an overlapping and duplicative reporting obligation for events under (j) and (k)."},{"severity":"medium","section_a":"sec.9(4)(a)","section_b":"sec.9(5)","confidence":0.62,"description":"Section 9(4)(a) permits an agreement or written direction to state a period for the moved employee's appointment. Section 9(5) provides that the period stated 'may not be more than the period remaining on the term of the employee's contract.' However, sec.9(3) provides that if a contract provision is inconsistent with a movement, the movement takes effect despite the inconsistency. Where the contract's fixed term has nearly expired, sec.9(5) caps the stated movement period at that remaining time — but if that remaining period is extremely short (e.g., days), sec.9(5) combined with sec.9(4)(b) (no period stated means remaining contract period applies) creates a situation where a movement for 'a significant risk' purpose becomes meaningless almost immediately. The interaction between sec.9(3) (override of inconsistent contract terms) and sec.9(5) (contract term as a hard cap) is internally contradictory: the regulation overrides contract terms but is simultaneously bound by the contract's term duration."}]},"summary":{"complexity_score":7,"scope_assessment":{"changed":true,"description":"The regulation goes beyond simply re-enacting the 2012 expired regulation. It introduces substantively new content not present in the original 2012 version, including: detailed health equity strategy requirements specifically focused on Aboriginal and Torres Strait Islander peoples (with measurable performance targets and named implementation partners); a new 'chief First Nations health officer' role; updated employment transfer provisions with clearer protections for workers (consent for demotion, anti-prejudice protections for refused transfers); and alignment with newer external frameworks like the National Agreement on Closing the Gap (2020) and the Human Rights Act 2019. The scope has expanded from basic administrative continuation to include a significant social equity and workforce mobility reform agenda."},"complexity_factors":["Multiple distinct subject matters crammed into one instrument (property leasing, employment law, engagement strategies, quality assurance, incident reporting)","Heavily cross-referenced — many provisions only make sense by reading the parent Act (Hospital and Health Boards Act 2011) and multiple schedules not reproduced here","Layered employment transfer regime with separate rules for ordinary employees vs. chief executives, different approval pathways, and consent requirements","Health equity strategy requirements are detailed and politically nuanced, referencing multiple external frameworks (National Agreement on Closing the Gap, Human Rights Act 2019, etc.)","Quality assurance committee rules create a parallel privacy and reporting regime that interacts with the Information Privacy Act 2009 and the Commonwealth Privacy Act 1988","Reportable events provisions require technical medical knowledge to interpret (e.g., ABO incompatibility, definitions of 'serious harm', 'stillbirth', 'mechanical restraint')","Extensive use of defined terms — many words have specific regulatory meanings that differ from everyday usage","Schedules (1–9) are integral to operation but not included in the excerpt, making the regulation difficult to apply without them"],"plain_english_summary":"The Hospital and Health Boards Regulation 2023 sets the day‑to‑day rules for Queensland’s public hospital network: who runs which regional Hospital and Health Services, how leases are handled, how staff (including executives) can be moved between employers, and mandatory processes for investigating serious clinical incidents. It also requires formal clinician, consumer and First Nations engagement and health‑equity strategies, plus protected quality‑assurance committees. It primarily affects health workers and executives, hospital boards and administrators, patients and communities—especially Aboriginal and Torres Strait Islander peoples."},"kimi_summary":{"_metrics":{"completionTokens":1336},"content_quality":"ok","complexity_score":7,"scope_assessment":{"changed":false,"description":"This appears to be a comprehensive re-enactment and update of the 2012 regulation, covering substantially the same scope of operational detail for hospital and health services. The regulation maintains the established structure of employment mobility, engagement strategies, quality assurance, and staffing ratios. While specific provisions have been updated (such as the addition of midwife-to-patient ratios in 2024 amendments), the overall scope remains consistent with the original framework established under the Hospital and Health Boards Act 2011."},"complexity_factors":["Multiple cross-references to schedules (at least 9 schedules referenced throughout)","Nested conditional logic in employee movement provisions (agreement vs direction pathways, different approvers for different movement types)","Extensive defined terms with multiple layers (e.g., 'health system employer' defined to include Services or department, with 'relevant chief executive' then defined by reference to employer type)","Duplicative but slightly different provisions for regular employees vs chief executives creating parallel structures","Detailed prescription of strategy contents across multiple engagement types (clinician, consumer, health equity, primary care) with overlapping but distinct requirements","Complex formulae for nurse/midwife ratios with shift-based variations and rounding rules","Multiple patient safety entities with different authorised purposes in different contexts (quality assurance vs root cause analysis)","Extensive schedule-based prescription of agreements, classification levels, health professionals, and facilities requiring external cross-referencing"],"plain_english_summary":"This regulation sets out detailed operational rules for Queensland's public hospital and health system under the *Hospital and Health Boards Act 2011*. It covers five main areas:\n\n**1. Hospital and Health Services continuation and property**\n- Continues existing Hospital and Health Services and their geographic areas from the expired 2012 regulation\n- Specifies which leases Services can grant or take without needing Minister and Treasurer approval (referencing detailed schedules)\n\n**2. Employment matters**\n- **Employee movement**: Allows health service employees (except chief executives) to be moved between Services or the department either by agreement between chief executives, or by written direction from the department's chief executive if needed to address significant risks to the health system. Employees can refuse with reasonable grounds.\n- **Chief executive movement**: Similar provisions for health service chief executives, but requiring Minister approval for agreed moves, or Minister direction on departmental recommendation for risk-mitigation moves.\n- **Contract protections**: Employees on fixed-term contracts retain their contract terms when moved\n- **Classification levels**: Employees can be moved to same or different levels, but not demoted without consent (unless disciplinary action)\n- **Refusal process**: Employees who refuse moves without reasonable grounds may have employment ended; those with reasonable grounds are protected from prejudice\n- **Entitlements continuity**: Leave, superannuation and service continuity are preserved when employees move between employers\n- **Senior positions**: Prescribes which medical officer classifications count as \"senior health service employees\"\n- **Privacy**: Allows disclosure of employee personal information between health system employers for employment purposes\n\n**3. Engagement strategies and protocols**\n- **Health equity strategies**: Requires Services to develop strategies with prescribed stakeholders including Aboriginal and Torres Strait Islander staff, consumers, community members, traditional custodians, and implementation partners. Must include performance measures addressing racism elimination, access improvement, cultural safety, and workforce representation targets.\n- **Clinician engagement**: Mandates strategies covering objectives, consultation methods (including senior councils and clinical networks), key issues (safety, standards, service planning), continuous improvement, and public reporting\n- **Consumer and community engagement**: Similar requirements focusing on patient and public involvement in service design and delivery\n- **Primary healthcare protocols**: Requires cooperation agreements with local primary care organisations on integration, public health, and information sharing\n\n**4. Quality assurance committees**\n- Establishes procedural rules for committees: chairperson election, meeting times, quorum (half members rounded up), voting, and minute-keeping\n- Requires privacy policies for handling committee information\n- Mandates public disclosure of committee functions, membership, activities and privacy policies every 3 years\n- Requires 3-yearly function reviews and annual activity statements\n- Prescribes which entities are \"patient safety entities\" and their authorised purposes for receiving quality assurance information\n\n**5. Root cause analyses**\n- Lists 12 categories of \"reportable events\" triggering mandatory root cause analysis, including: wrong-site/wrong-patient surgery, retained foreign objects, fatal transfusion reactions, suspected suicides in psychiatric units, medication errors causing serious harm, restraint-related deaths, and unexpected deaths\n- Defines key terms including \"serious harm,\" \"invasive procedure,\" and \"acute psychiatric unit\"\n- Prescribes patient safety entities authorised to receive root cause analysis information\n\n**6. Nurse and midwife ratios**\n- Sets minimum staffing ratios for acute adult wards: 1 nurse per 4 patients (morning and afternoon shifts), 1 per 7 patients (night shift)\n- Sets midwife ratios for postnatal wards: 1 midwife per 6 postnatal patients (mother and baby counted separately)\n- Specifies rounding rules (minimum 1 staff, round 0.5 down)\n\n**7. State aged care facilities**\n- Prescribes minimum nurse staffing: 50% of care staff must be nurses, 30% must be registered nurses\n- Sets minimum average daily resident care hours at 3.65 hours\n\n**8. Board committees**\n- Mandates three board committees: safety and quality; finance; and audit (with detailed functions for each)\n- Safety and quality committees advise on patient safety, monitor governance, promote improvements, and collaborate across the system\n- Finance committees oversee budgets, cash flow, financial performance and risk\n- Audit committees oversee financial statements, internal controls, external audit liaison, and compliance\n\n**9. Confidentiality and information sharing**\n- Prescribes which health professionals and information systems are covered by confidentiality provisions\n- Designates Queensland Ambulance Service commissioner and employees as authorised recipients\n- Lists entities and purposes for which confidential health information may be disclosed\n- Prescribes intergovernmental agreements permitting cross-border information sharing with Commonwealth, other states and territories\n\n**10. Major capital works**\n- Defines \"major capital works\" as structural construction, building envelope alterations, or other works requiring approval with estimated cost $500,000+ (excluding routine maintenance)"},"flash_summary_failed":{"failed":true,"reason":"A positive credit balance is required for all requests, including BYOK, so fallback providers remain available. Add credits at https://vercel.com/d?to=%2F%5Bteam%5D%2F%7E%2Fai%3Fmodal%3Dtop-up to continue.","source":"analysis-cron"}},"importantCases":[],"_links":{"self":"/api/acts/hospital-and-health-boards-regulation-2023","history":"/api/acts/hospital-and-health-boards-regulation-2023/history","analysis":"/api/acts/hospital-and-health-boards-regulation-2023/analysis","conflicts":"/api/acts/hospital-and-health-boards-regulation-2023/conflicts","importantCases":"/api/acts/hospital-and-health-boards-regulation-2023/important-cases","documents":"/api/acts/hospital-and-health-boards-regulation-2023/documents"}}