Are you templating or tailoring your organisational frameworks, policies and procedures?

Stephen Ratcliffe, Senior Risk Consultant at Ansvar

In this guest post, Stephen Ratcliffe, Senior Risk Consultant at Ansvar Insurance, discusses the impact of the Royal Commission on the care sector, and the emergence of third-party companies to assist with compliance.

He looks at the challenges faced in the implementation of policies and the important role of management in developing implementation plans, conducting a gap analysis and regularly engaging with third-party providers to ensure the advice aligns with actual practises, as failure poses substantial risks and liabilities for organisations and leadership.

A series of Royal Commissions, both past and present are bringing significant shifts in the legislative and operational landscapes of care sector organisations – but not everyone is ready for these shifts.

It’s not surprising then that numerous third-party companies have stepped in to assist organisations in meeting the growing burdens of compliance. Ansvar’s observation has been that clients taking up these services are either new businesses or organisations that have fallen behind in maintaining their policies and procedures with contemporary practices.

At face value, third-party support can be a lifeline for organisations, especially if they’ve had staffing vacancies in roles that would usually have responsibility for developing or updating procedures, or establishing organisational frameworks. Perhaps they don’t have the specific expertise to develop frameworks and procedures in-house. Tools and templates are a valuable support for organisations to guide them in the right direction.

Often third-party documents are compliance-based and seek to address sector standards for the purposes of achieving accreditation or referring back to Australian and International Standards to provide a theoretical basis for organisational frameworks. It is worth noting though that compliance sets the minimum standard required in order to operate, it should not be interpreted as evidence of operational excellence.

Where Ansvar is starting to see issues with third-party developed documents is the vast differences in how organisations choose to tailor (or not) these templated policies and frameworks to their organisation.

Our consulting experience with clients suggests very few of the clients with third-party procedures have been able to demonstrate that they actually follow the procedures and policies as they are documented. Sometimes we see policies and procedures are viewed as just a document on the shelf and do not reflect actual practices at all. This creates significant liability risk for organisations.

So much so that the use of third-party templates is beginning to raise red flags rather than provide comfort that policies and procedures are in place. This is not because of the quality of the templates, but rather a significant failure of organisations to bring these templated procedures and frameworks to life.

It is the duty of management teams to ensure that policies, procedures and frameworks are being enacted and the role of boards to hold management to account for doing this.

Here are our 3 top tips when using third-party policy and framework templates:

1. Conduct gap analyses against critical organisational frameworks

  • Are the policies and procedures detailed enough?
  • Do they reflect actual practice in the organisation? How do you know?
  • Do the committee structures and reporting requirements in the frameworks occur
    as described?

Assess your practice against your policies and frameworks for these high-priority areas:

  • Governance documents (Board Charter, Delegations of Authority, Board-Sub Committee Terms of Reference.
  • Enterprise Risk Management Framework – including methods used to identify risk and the practical steps used to assess risk and develop risk controls.
  • Financial management plans and critical controls – including fraud prevention, procurement, and contract management.
  • Quality and Improvement Framework.
  • Work Health and Safety policies and procedures, including Return to Work.
  • Clinical Governance Frameworks.
  • Safeguarding to prevent abuse – policies, procedures, related training, recruitment practices, and Code of Conduct.

2. Develop Implementation plans for critical organisational frameworks

  • Do you have clearly defined plans to establish the priorities for policy and procedure?
  • Implementation and focus the organisation on what matters most?
  • Are you reporting periodically to the Board on the progress of implementation plans?
  • Is management held to account to ensure delivery?

3. Engage regularly with your third-party provider

  • Do you ensure your policies and procedures are regularly updated (by you) and reflect current practices at your organisation?
  • Do you ensure that you have the capacity to make edits or modifications to your policies and procedures independently when you need to? (as opposed to relying on the provider to make changes or edits)

Key point summary

  • Third-party providers can offer vital support to organisations with templated policies,
  • procedures and frameworks.
  • Policies and procedures are only useful when they are effectively implemented.
  • Organisations are responsible for ensuring that policies and procedures accurately reflect practice.
  • Failure to implement critical organisational frameworks can give rise to risk for organisations, and individual liability for executives and board directors.


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