Information sheet: Health statutory agencies - key ...



|Information sheet | |

Hospital foundations – key compliance requirements

This purpose of this information sheet is to assist foundations to identify the legal and administrative framework within which they operate, and describe key requirements with which foundations must comply. It also includes links to useful documents to assist foundations to identify and meet their legislated and broader compliance requirements.

This document has been prepared to accompany the ‘Hospital Foundations – compliance activity calendar’.

Legal and administrative framework for statutory body operation

• Hospital foundations (foundations) are separate legal entities and, more specifically, statutory, corporate bodies established under the Hospitals Foundations Act 1982 (HF Act). As statutory bodies, their organisational structure provides flexible and independent oversight and the ability to control their own funds.

• Foundations are governed by their enabling legislation (HF Act) and certain other legislative requirements common to Queensland government bodies.

• As statutory bodies, the Financial Accountability Act 2009 (FA Act) and Statutory Bodies Financial Arrangements Act 1982 (SBFA Act) apply.

• The table at Attachment 1 identifies key legislative and other requirements with which foundations must comply, and may assist in the development of a compliance register. Rows highlighted blue indicate that a requirement (or part thereof) may not apply to a particular foundation. Accordingly, each foundation should make its own assessment in that regard. If assistance is required, the Office of Health Statutory Agencies (OHSA) can be contacted to assist (statutoryagencies@health..au).

• NB. Attachment 1 is not a comprehensive list of obligations and is therefore illustrative only. It should not be relied on as a source document in its own right – original documentation should be consulted.

Attachments

Attachment 1 – Hospital foundations key compliance requirements template

Contact for further information

|Contact |Telephone |Email |

|Office of Health Statutory Agencies |3708 5034 |statutoryagencies@health..au |

Revision history

|Date |Version no. |Description of change/revision |

|23/10/2015 |v.1.0 |Endorsed first version |

Attachment 1 – Hospital foundations key compliance requirements template

|Mandatory requirements for foundations |

|Register objects in the register maintained by the Department of Health |s9, s11 | |Board[2] |Hospitals Foundations Act 1982 (HFA): |

|(currently Cabinet and Parliamentary Services) and seek Ministerial | | | |() |

|approval before altering any registered objects | | | | |

|Seek and obtain Ministerial approval before engaging in any of the |s15 | |Board |Hospitals Foundations Act 1982 (HFA): |

|following: - | | | |() |

|acquiring the whole or a share in a business; | | | | |

|entering into a partnership or arrangement for sharing profits; | | | | |

|dealing with the shares, debentures or securities of any corporation; | | | | |

|entering into arrangements with any government, authority or person/s to| | | | |

|discharge the foundation’s functions; | | | | |

|making money or awards to persons concerned in inventions or | | | | |

|discoveries; | | | | |

|selling or otherwise disposing of its land or buildings; | | | | |

|exchange its property for shares, debentures or securities in a | | | | |

|corporation with similar objects; | | | | |

|improving, developing, exchanging, leasing or turning to account its | | | | |

|land or buildings; and | | | | |

|entering into any contract, agreement or arrangement relating to any of | | | | |

|the above | | | | |

|Foundations must consist of at least seven members including: |s18 | |Board |Hospitals Foundations Act 1982 (HFA): |

|the associated HHB’s chairperson or chairperson’s nominee | | | |() |

|an employee of an associated university or other body providing tertiary| | | | |

|education; | | | | |

|at least two officers or employees at an associated hospital | | | | |

|Member resignations must be made in writing, signed, and addressed to |s24 | |Members |Hospitals Foundations Act 1982 (HFA): |

|the Minister for Health | | | |() |

|Members must seek the Board’s prior approval for absences from board |s24 | |Members |Hospitals Foundations Act 1982 (HFA): |

|meetings | | | |() |

|Members must disclose conflicts of interest related to matters under |s25 | |Members |Hospitals Foundations Act 1982 (HFA): |

|consideration at a meeting, record the disclosure in the minutes and, | | | |( ) |

|unless the foundation otherwise determines, the member must not be | | | | |

|present during deliberation or decision making in relation to the | | | | |

|matter. | | | | |

|Members must act honestly at all times in discharging their powers and |s25A | |Members |Hospitals Foundations Act 1982 (HFA): |

|must not make improper use of their office or information acquired by | | | |() |

|virtue of holding office to gain an advantage for themselves/others or | | | | |

|to cause detriment to the foundation. | | | | |

|Chairperson or Deputy Chairperson resignations must be made in writing, |s28(4) | |Chairperson or Deputy |Hospitals Foundations Act 1982 (HFA): |

|signed, and addressed to the Minister for Health | | |Chairperson |() |

|Written notice of meetings must be given (by post or in person) to |s33 | |Board |Hospitals Foundations Act 1982 (HFA): |

|members at least seven days prior to the meeting date (unless the | | | |() |

|Chairperson or two members consider circumstances exist that constitute | | | | |

|an emergency) | | | | |

|Exercise or performance of power, authority, function or duty of the |s34 | |Board |Hospitals Foundations Act 1982 (HFA): |

|foundation must be made by a majority vote of members present at a | | | |() |

|meeting and voting on the business in question. | | | | |

|Chairperson shall give effect to any resolution, minute or report that |s34 | |Chairperson |Hospitals Foundations Act 1982 (HFA): |

|is passed or adopted by the foundation. | | | |() |

|Record of proceedings at meetings (i.e. minutes) must be kept |s35 | |Board |Hospitals Foundations Act 1982 (HFA): |

| | | | |() |

|A Foundation Secretary must be a suitably senior officer of an |s37 | |Secretary |Hospitals Foundations Act 1982 (HFA): |

|associated hospital who is nominated by the health service chief | | | |() |

|executive of that HHS | | | | |

|The common seal of a foundation must be kept in the custody of the |s39 | |Secretary or |Hospitals Foundations Act 1982 (HFA): |

|secretary of the body corporate or, where there is a vacancy in that | | |Chairperson |() |

|position, the Chairperson | | | | |

|Unless exempted by the Minister, as soon as practicable after a |s41 | |Board |Hospitals Foundations Act 1982 (HFA): |

|foundation is established, it shall effect insurance in respect of | | | |() |

|damage to property, death and bodily injury for which it may be held | | | | |

|liable for an amount of cover prescribed by regulation or, if not | | | |Hospitals Foundations Regulation 2015 (HFR): |

|prescribed, for an amount of $100,000 at the least and shall keep such | | | |() |

|insurance current at all times | | | | |

| | | | | |

|NB. The Hospitals Foundations Regulation 2005 does not prescribe an | | | | |

|amount, so the minimum is $100,000. | | | | |

|If required by the Minister, a foundation must frame, adopt and present |ss46, 47 & 49 | |Members |Hospitals Foundations Act 1982 (HFA): |

|to the Minister a statement showing estimates of its receipts and | | | |() |

|disbursements in respect of the balance of the financial year, and for | | | | |

|each succeeding year thereafter do the same before 31 August (or by a | | | | |

|later date with the Minister’s approval). | | | | |

| | | | | |

|The foundation must not make disbursements not provided for in the | | | | |

|statement without resolution by the Board and Minister’s approval. | | | | |

| | | | | |

|If a disbursement is made without Minister’s approval, the members that | | | | |

|voted for the disbursement are liable. | | | | |

|The foundation must establish and maintain a general fund at a financial|s50 | |Board |Hospitals Foundations Act 1982 (HFA): |

|institution (separate and distinct from any other accounts it has) to be| | | |() |

|used to meet its objects, to pay members’ fees or allowances, to pay | | | | |

|salaries or wages of employees, and for any other necessary expenditure | | | | |

|in discharge of its functions. | | | | |

|Planning |

|A Strategic Plan is to be developed, compliant with the Department of |s9 FPMS |Annually reviewed – |Board |Financial and Performance Management Standard 2009 (FPMS): |

|the Premier and Cabinet (DPC) ‘Agency Planning Requirements’. | |published by 1 July | |() |

| | | | |Note: The Financial Accountability Act 2009 and this Standard establish the high level |

| | | | |financial management and accountability obligations for all statutory bodies, including the |

| | | | |Foundations. |

| | | | |Agency Planning Requirements: |

| | | | |() |

| | | | |Strategic Plans – Minimum Requirements Checklist (OHSA fact sheet): |

| | | | |() |

| | | | |Hospital Foundation Strategic Plan Template: |

| | | | |() |

| | | | |Strategic Planning for Government Bodies Webcast 2013 (OHSA): |

| | | | |() |

|An Operational Plan is to be developed, which is compliant with DPC’s |s9 FPMS |Annually (monitored |Board |Agency Planning Requirements: |

|Agency Planning Requirements. | |regularly; evaluated / | |() |

| | |reviewed at least six | | |

| | |monthly) | |Operational Plan – Minimum Requirements Checklist (OHSA fact sheet): |

| | | | |() |

|Annual financial statements are to be prepared, certified (refer note |ss61-62 FAA, |Annually (included in |Board |Financial Accountability Act 2009 (FAA): |

|below) and tabled in Parliament in accordance with the prescribed |s43, s45 FPMS |annual report) | |() |

|requirements (i.e. have regard to the Financial Reporting Requirements; | | | |Queensland Treasury Financial Reporting Requirements (FRRs) for Queensland Government |

|submitted to the Auditor-General on the date agreed to allow the | | | |Agencies (including Accounting Policy Guidelines): |

|financial statements to be certified by not later than two months from | | | |() |

|the end of the financial year). | | | | |

| | | | |Please note foundations that have been exempted from QAO audit have been exempted on the |

|NB: some foundations are exempt from the requirement to use the | | | |basis of being small in size and of low risk. If you wish for your foundation to be exempted,|

|Queensland Audit Office (QAO) for auditing and certification. Exempt | | | |application should be made to the QAO in this regard. Unless exempted, a foundation must use |

|foundations can use appropriately qualified private external auditors. | | | |the QAO for audit purposes. |

|A list of foundations exempt from QAO audit is available at: | | | | |

| | | | | |

|Consider the Auditor-General’s report on audited financial statements, |s46 FPMS |Annually |Board | |

|and any matters arising from the Auditor-General’s report. | | | | |

|An annual report is to be prepared and given to the Minister for |s61, s63 FAA, |Annually, |Board |Annual Report Requirements for Queensland Government agencies: |

|tabling. The report must be compliant with the FPMS and DPC’s Annual |ss49-53 FPMS, |tabled in Parliament by | |()|

|Report Requirements. | |30 September | |Annual Reports – Online Publication Compliance Checklist (OHSA fact sheet): |

| | | | |() |

|Financial management |

|Establish the following for efficiently, effectively and economically |s15 FPMS | |Board |Financial Performance Management Standard 2009: |

|managing the financial resources of the foundation– | | | |( ) |

|(a) a revenue management system; | | | |Financial Accountability Handbook: |

|(b) an expense management system; | | | |(

|(c) an asset management system; | | | |ex.php) |

|(d) a cash management system; | | | |Queensland Treasury Financial Reporting Requirements (FRRs) for Queensland Government |

|(e) a liability management system; | | | |Agencies (including Accounting Policy Guidelines): |

|(f) a contingency management system; | | | |() |

|(g) a financial information management system; | | | |Queensland Treasury – A Guide to Risk Management: |

|(h) a risk management system. | | | |() |

|In establishing the systems, the foundation must have regard to the | | | |Department of Health Risk Management Policy and Standards |

|Financial Accountability Handbook. | | | |Policy: () |

| | | | |Standard: () |

| | | | |Information for Statutory Bodies (this document is designed to assist members of statutory |

| | | | |bodies meet their statutory obligations) |

| | | | |(

| | | | |utory-bodies-information-overview.pdf) |

| | | | |Financial and Performance Management Standard 2009 Requirements (OHSA Fact Sheet): |

| | | | |() |

|Regularly review systems for managing resources to ensure the systems |s15 FPMS |Regularly |Board | |

|remain appropriate for managing the financial resources of the | | | | |

|Foundation. | | | | |

|Prepare and maintain a Financial Management Practice Manual (FMPM) that |s16 FPMS |Maintain |Board |FMPM Guidance Template for Hospital Foundations: |

|complies with related legislation, regulation and policies for use by | | | |() |

|staff in the performance of their financial management roles. | | | |Note: The FMPM is the internal instructional manual for the foundation to ensure compliance |

|Each person involved in the financial management of a foundation is | | | |with the mandated requirements and is the initial point of reference for employees in |

|required to comply with the FMPM. | | | |relation to the foundation’s financial policy. |

| | | | |The accounting practices presented in an FMPM must comply with the latest accounting |

| | | | |standards and interpretations issued by the Australian Accounting Standards Board (AASB): |

| | | | |() |

| | | | |Developed to assist foundations in the development of their own FMPM, the Guidance Template |

| | | | |is modelled on the financial management methods of a range of public sector entities. The |

| | | | |template provides questions, prompts and directions to guide the development of a financially|

| | | | |sound and robust FMPM. |

|Requirements in relation to establishing a revenue management and user |s17, s18 FPMS | |Board |Financial Accountability Handbook: |

|charging system to ensure all revenue is promptly managed and customers | | | |(

|are charged an appropriate amount for goods and services provided by the| | | |ex.php) |

|foundation. | | | |The handbook has been designed to assist accountable officers of departments and statutory |

| | | | |bodies discharge their obligations under the FAA, the FPMS, and the Financial Accountability |

| | | | |Regulation 2009. |

|Expenses are to be managed with an expense management system which |s19 FPMS | |Board |Queensland Procurement Policy (QPP) July 2013: |

|provides for promptly identifying, approving, managing and recording | | | |(

|expenses and the timely paying of expenses. | | | |teProcurementPolicy/Pages/Default.aspx) |

|To the extent they apply to a foundation, the foundation must comply | | | |Note: The QPP provides the framework for all Queensland Government procurement. All |

|with the following documents in developing the expense management | | | |statutory bodies (including foundations) are required to comply with the QPP and Queensland’s|

|system: the ‘Queensland Procurement Policy’, and the ‘Queensland | | | |trade agreement obligations. Refer to the ‘Whole of Government Policy’ section on page 15. |

|Ministerial Handbook’. | | | |Procurement/Purchasing Requirements (OHSA fact sheet): |

|Systems must be implemented for credit card facilities that are | | | |() |

|consistent with the ‘Treasurer’s Guidelines for the use of Queensland | | | |Queensland Ministerial Handbook: |

|Government corporate purchasing card’. | | | |(

| | | | |ial-handbook.aspx) |

| | | | |Treasurer’s guidelines for the use of Queensland Government Corporate Purchasing card: |

| | | | |(

| | | | |treasurers-guidelines-corporate-card.pdf) |

|The foundation’s expense management system keeps a record of special |s20 FPMS | |Board | |

|payments over $5,000. | | | | |

|Keep written records and notifications, where applicable, to loss of the|ss21-22 FPMS | |Board | |

|foundation’s property as a result of an offence or misconduct or other | | | | |

|reason as specified in sections 21 & 22 of the FPMS. | | | | |

|Assets managed in accordance with an asset management system that |s23 FPMS | |Board |Queensland Treasury Statutory Body Guide - Guide Sheet 4: Evaluating and reviewing |

|ensures evaluations (similar to business cases) are prepared before | | | |significant physical assets: |

|acquiring, maintaining or improving a significant physical asset, with a| | | |(

|completion review undertaken to ensure that objectives contained in the | | | |ficant-physical-assets) |

|evaluations were met. | | | |Non-Current Asset Policies for the Queensland Public Sector (NCAPS): |

|An asset management system must ensure that assets are regularly | | | |() |

|maintained and must comply with or have regard to: | | | |Transaction Policy: |

|Non-current Asset Policies for the Queensland Public Sector | | | |() |

|Queensland’s Project Assurance Framework | | | | |

|Queensland’s Value for Money Framework. | | | |Queensland’s Project Assessment Framework (replaces the previous Project Assurance Framework |

| | | | |and Value for Money Framework) : |

| | | | |(

| | | | |work/index.php) |

|Manage the foundation’s cash in accordance with a cash management system|s24 FPMS | |Board |Financial Accountability Handbook: |

|which provides for control and recording of cash transactions. | | | |(

| | | | |ex.php) |

|Manage liabilities in accordance with a liability management system, |s25 FPMS | |Board |Leasing in Queensland Public Sector Policy Guidelines: |

|which promptly and accurately records liabilities, e.g. for operational | | | |() |

|costs and capital expenditure, and complies with ‘Leasing in the | | | |Note: These are mandatory guidelines that apply to the lease of all assets, but exclude |

|Queensland Public Sector – Policy Guidelines’. | | | |tenancy leases of real property and leases of passenger or commercial motor vehicles obtained|

| | | | |from Q-Fleet by a tied client. |

|Manage contingent assets and contingent liabilities in accordance with a|s26 FPMS | |Board |Note: A contingent asset or liability crystallises as the result of a future event that is |

|contingency management system, which promptly identifies, records and | | | |outside the control of the foundation. |

|reports on contingencies. | | | |Financial Accountability Handbook: |

| | | | |(

| | | | |ex.php) |

|Comply with the mandatory principles stated in the Information Standards|s27 FPMS | |Board |Current Information Standards (refer also pages 16-17): |

|and ensure that its financial information management system aligns with | | | |() |

|the targets stated in the QGEA and complies with the Public Records Act | | | |Queensland Government Enterprise Architecture (QGEA) 2.0 (refer also pages 16-17 below): |

|2002. | | | |() |

| | | | |Public Records Act 2002: |

| | | | |() |

| | | | |Provides for the management of public records in Queensland. |

|Manage strategic and operational risks in accordance with a risk |s28 FPMS | |Board |Queensland Treasury Audit Committee Guidelines – Improving Accountability and Performance: |

|management system. | | | |() |

|Establish an internal audit function if directed by the Minister or if |ss29-30 FPMS | |Board |Financial Accountability Handbook - Volume 2: Governance (2.6 Head of internal audit; 2.9 |

|the foundation considers it appropriate. Systems for ensuring the | | | |Internal audit): |

|internal audit function operates efficiently, effectively and | | | |(

|economically must be developed and implemented. The internal audit | | | |ume-2-governance.php) |

|function must function under an internal audit charter. | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

|Foundations must comply with Part 5 of the SBFAA in relation to |Part 5 SBFAA, | |Board |Statutory Bodies Financial Arrangements Act 1982 (SBFAA): |

|borrowing. |Schedule 2 SBFAR| | |() |

|There are also requirements under the State Borrowing Program that | | | |Statutory Bodies Financial Arrangements Regulation 2007 (SBFAR): |

|statutory bodies (including the foundations) must satisfy: | | | |() |

|( | | |Note: The primary purpose of the Act and regulation is to establish the borrowing and |

|php ) | | | |investment powers of statutory bodies (including the foundations). Provisions also address |

| | | | |the role of the Treasurer in providing guarantees – under the SBFAA, the Treasurer may |

| | | | |guarantee the performance of obligations of a statutory body under a financial arrangement |

| | | | |entered into by the body (sections 16 and 76). The Treasurer can charge a fee for this |

| | | | |guarantee. The Treasurer can delegate functions under this Act to another Minister. |

| | | | |* The ‘Overdraft Facilities: Operational Guidelines for the Public Sector’ provide guidelines|

| | | | |for public sector entities, including statutory bodies entering into overdraft and short term|

| | | | |funding facilities. |

|Foundations are allocated category 3 investment power under Schedule 4 |Part 6 SBFAA, | |Board |Statutory Bodies Financial Arrangements Act 1982 (SBFAA): |

|of the SBFAR. The SBFAA provides that these investment powers are in |Schedule 4 SPFAR| | |() |

|addition to the investment powers provided to the foundations under the | | | | |

|Hospitals Foundations Act 1982. | | | |Statutory Bodies Financial Arrangements Regulation 2007 (SBFAR): |

|Where particular investments are not permitted under Part 6 of the Act, | | | |() |

|a foundation may seek approval from the Treasurer under Part 7A of the | | | | |

|Act. Requests are considered on a case-by-case basis. | | | |Statutory Bodies Financial Arrangements Act 1982 Operational Guidelines: |

| | | | |(

| | | | |uide.pdf) |

| | | | |Note: The guidelines provide a general outline of the impact of the SBFAA on the operations |

| | | | |of statutory bodies and aim to assist statutory bodies in understanding their obligations |

| | | | |under the Act and provide information to assist in developing better-practice policy |

| | | | |frameworks for the investment of funds. |

|Foundations must keep a register of the Treasurer’s approvals under |s74, SBFAA | |Board |Statutory Bodies Financial Arrangements Act 1982 (SBFAA): |

|Division 3 of the SBFAA, being approvals by the Treasurer for | | | |() |

|foundations to exercise powers they are not otherwise permitted under | | | | |

|the SBFAA. | | | | |

|Governance |

| A governance framework appropriate for the agency must be established. |s7 FPMS | |Board |FPMS: ( ) |

|Governance includes establishing a performance management system, a risk| | | |Governance Institute of Australia Website: |

|management system and an internal control system. | | | |() |

| | | | |Note: Provides a range of resources on best practice in board and organisational governance |

| | | | |and risk management. |

|Cost-effective internal control structure established, including, for |s8 FPMS |Recommended – annual |Board |Financial Accountability Handbook: |

|example, an organisation structure and delegations supportive of the | |check and test[3] | |(

|objectives and operations of the foundation (the internal control | | | |.shtml) |

|structure must be included in the FMPM of the foundation). | | | |Financial Management Tools (provide guidance only, i.e. not mandatory): |

| | | | |()|

| | | | | |

| | | | | |

| | | | |Information for Statutory Bodies – Overview of applicable legislation, policies and guidance |

| | | | |documents: Appendix 1 ‘Compliance Checklists’ (see page 9): |

| | | | |(

| | | | |ory-bodies-information-overview.pdf) |

| | | | |Australian Accounting Standards Board – Accounting Standards: |

| | | | |() |

|The performance of the foundation is managed compliant with the DPC |s11 FPMS | |Board |A guide to the Queensland Government performance management framework: |

|document ‘A guide to the Queensland Government performance management | | | |() |

|framework’. | | | |Queensland Audit Office – Better Practice Guides: Performance Reviews: |

| | | | |() |

| | | | |Performance Reporting to Boards: A Guide to Good Practice (Chartered Institute of Management |

| | | | |Accountants): |

| | | | |() |

| | | | |Thirteen Ways to Improve Your Monthly Board Reports (ExcelUser): |

| | | | |() |

| | | | |NHS Sample Board Papers: |

| | | | |() |

| | | | | |

| | | | | |

|Systems are in place for obtaining information to enable the foundation |s12 FPMS | |Board | |

|to decide whether it is: | | | | |

|achieving the objectives stated in its strategic plan efficiently, | | | | |

|effectively and economically; and | | | | |

|delivering the services stated in its operational plan to the standard | | | | |

|stated in the plan. | | | | |

|Performance systems allow reporting about performance to be provided. |s13 FPMS |Report provided to the |Board | |

| | |foundation at least | | |

| | |every 3 months; and to | | |

| | |the Minister annually or| | |

| | |when requested | | |

|Performance management system must allow the foundation to assess: |s14 FPMS | |Board | |

|the appropriateness of its objectives, and the services that it delivers| | | | |

|to achieve its objectives | | | | |

|whether the performance information is suitable to assess the extent to | | | | |

|which the objectives have been achieved | | | | |

|options to improve the efficiency, effectiveness and economy of the | | | | |

|operations of the foundation. | | | | |

|Part 7 of the AIA outlines the operation of conferral; performance; |Part 7, AIA | |Board |Acts Interpretation Act 1954 (AIA): |

|delegation of statutory functions and powers; making of appointments; | | | |() |

|acting appointments; etc. E.g. section 27A ‘Delegation of functions or | | | |Note: The AIA prescribes the meanings of common terms used in Acts where those Acts do not in|

|powers’ outlines how delegation of functions and powers works. | | | |themselves provide a definition, or where the definitions provided in the Acts require |

| | | | |further clarification (in other words, the AIA only applies to the extent of any |

| | | | |inconsistency), and provides courts with clear directions to resolve a range of potential |

| | | | |inconsistencies. |

|Public accountability |

|The Auditor-General of Queensland (or other authorised auditor, if a |ss46-47 AGA |As and when requested |Board |Auditor-General Act 2009 (AGA): |

|foundation is exempted from using the Queensland Audit Office) is | | | |() |

|required to audit each year the financial accounts of all foundations | | | |Note: Establishes the position of the Queensland Auditor-General and the Queensland Audit |

|and to provide independent reports to the Queensland Parliament. | | | |Office (QAO). The Act also confers on the Auditor-General and the QAO the functions and |

|Foundations must grant the audit team access to all records and stated | | | |powers necessary to carry out independent audits of all Queensland public sector agencies. |

|information as and when requested by sections 46 & 47 of the AGA. In | | | |Queensland Audit Office: () |

|addition, each foundation is responsible for liaising directly with the | | | | |

|Audit Manager and providing solutions to the audit issues raised. | | | | |

|The PSEA outlines the ethical obligations of employees within the |Part 3, PSEA | |Board, employees, |Public Sector Ethics Act 1994 (PSEA): |

|Queensland Public Sector. The PSEA provides four (4) ethics principles | | |volunteers |() |

|for the public sector: | | | |Declares the ethical principles that are fundamental to good public administration and covers|

|Integrity and impartiality | | | |requirements for codes of conduct for public officials. The PSEA ethics principles and values|

|Promoting the public good | | | |apply to all public service agencies and public sector entities, including statutory bodies |

|Commitment to the system of government and | | | |and public officials. |

|Accountability and transparency. | | | |Queensland Government Ethics Website: () |

|The PSEA also incorporates a range of “ethical values” associated with | | | |Public Sector Ethics (OHSA fact sheet): |

|each of the ethics principles. These principles and values form the | | | |() |

|basis of the codes of conduct required to be developed by each | | | | |

|foundation. | | | | |

|The Chief Executive Officer of a public sector entity (defined to |ss13-23 PSEA |Annually (statement |Chief Executive |Public Sector Ethics (OHSA fact sheet): |

|include foundations) must ensure a code of conduct is prepared for the | |included in annual |Officer |() |

|entity and approved by the Minister for Health[4]. Employees, volunteers| |report) | | |

|and members of the foundation must comply with the code of conduct in | | | | |

|performing their official functions. | | | | |

|The Chief Executive Officer must also: ensure employees have reasonable | | | | |

|access to a copy of the Code and any standards of practice; publish and | | | | |

|keep available for inspection by any person copies of the ethics | | | | |

|principles and the foundation’s approved code of conduct; ensure | | | | |

|employees are given access to appropriate education and training about | | | | |

|public sector ethics; ensure the administrative procedures and | | | | |

|management practices of the Foundation have proper regard to the Act and| | | | |

|the foundation’s code of conduct; and ensure the annual report includes | | | | |

|an implementation statement as per s23. | | | | |

|Note: the Chief Executive Officer of a foundation is the person | | | | |

|responsible to the Minister for the management of the foundation. | | | | |

|If a public official, being a CEO of a unit of public administration |s38 CCA | |Chief Executive |Crime and Corruption Act 2001 (CCA): |

|(which the foundations are) suspects that a complaint, information or | | |Officer |() |

|matter involves, or may involve, corrupt conduct, they must notify the | | | |Crime and Corruption Commission Queensland: () |

|Crime and Corruption Commission of the complaint. | | | | |

|The CEO of a unit of public administration has a responsibility to deal |s43-44 CCA | |Chief Executive |Section 44 of the CCA (see link above) outlines how complaints must be dealt with. |

|with a complaint about, or information or matter involving, official | | |Officer | |

|misconduct that is referred to it by the commission. | | | | |

|Deal with applications for information as per Chapter 3, Part 3 of the |Chapter 3, Part | |Chief Executive |Right to Information Act 2009 (RTIA): |

|RTIA. |3, RTIA | |Officer (principal |() |

| | | |officer) |The Act gives the public a right of access to information held or controlled by government |

| | | | |unless, on balance, providing access would be contrary to the public interest. |

| | | | |Further information is also available via (.au/right-to-information/) |

|Policy documents are made available for inspection and purchase by the |s20 RTIA | |Board |Note: An agency (which, by definition, includes foundations) must make copies of each of its |

|public. | | | |policy documents available for inspection and purchase by the public. However, nothing in |

| | | | |this section prevents an agency from deleting exempt information or contrary to public |

| | | | |interest information from a copy of a policy document. |

|Publish a publication scheme, which is a scheme that sets out the |s21 RTIA | |Board |Ministerial Guidelines and Links to Departmental Publication Schemes |

|classes of information that the foundation makes available and how the | | | |() |

|information can be accessed, including any charges. This may include a | | | | |

|de-identified disclosure log of documents that have been released in | | | | |

|response to Right to Information applications. | | | | |

|Comply with the Information Privacy Principles in relation to the |s27 IPA, | |Foundation |Information Privacy Act 2009 (IPA): |

|collection, storage, use and disclosure of an individual’s personal |Schedule 4 IPA | | |() |

|information. | | | |Note: The Act provides for the fair collection and handling in the public sector environment |

| | | | |of personal information, and gives the public a right to apply to access and amend their own |

| | | | |personal information. |

| | | | |Office of the Information Commissioner (Queensland): |

| | | | |() |

| | | | |Recordkeeping – General, Digital, Cloud Computing (OHSA fact sheet): |

| | | | |() |

|A foundation may only transfer an individual’s personal information to |s33, IPA | |Foundation | |

|an entity outside of Australia in certain circumstances specified in | | | | |

|section 33 of the IPA. | | | | |

|Make and keep full and accurate records of its activities. |s7 PRA | |Chief Executive |Public Records Act 2002 (PRA): |

| | | |Officer |() |

| | | | |Note: The PRA provides for the management of public records in Queensland. |

| | | | |Recordkeeping – General, Digital, Cloud Computing (OHSA fact sheet): |

| | | | |() |

| | | | |Queensland State Archives: |

| | | | |() |

| | | | |Retention and Disposal Schedules (e.g. Health Sector (Clinical Records)): |

| | | | |(

| | | | |-Disposal-Schedules.aspx) |

| | | | |General Retention and Disposal Schedule (GRDS) for Administrative Records: |

| | | | |() |

| | | | | |

|General legislative requirements |

|A foundation is legally liable for compensation for injury sustained by |s46 WCRA | |Board |Worker’s Compensation and Rehabilitation Act 2003 (WCRA): |

|a worker employed by it if the injury is sustained by the worker in | | | |( ) |

|their employment. | | | |An Act to establish a workers’ compensation scheme for Queensland, and for other purposes. |

|Every employer must, for each worker employed by the employer, insure |s48 WCRA | |Board | |

|and remain insured for compensation and damages relating to injury | | | | |

|sustained by the worker. | | | | |

|If a foundation meets criteria prescribed under the WCRR, they must |Ss226-227 WCRA, |Policy and procedures |Board |Worker’s Compensation and Rehabilitation Act 2003 (WCRA): |

|appoint a Rehabilitation and Return to Work Coordinator and have |115 WCRR |reviewed at least every | |() An Act to |

|workplace rehabilitation policy and procedures. | |3 years and provide | |establish a workers’ compensation scheme for Queensland, and for other purposes. |

| | |evidence of the review | |Workers’ Compensation and Rehabilitation Regulation 2014 (WCRR): |

|Note: Historically, foundations have not met this criteria. The WCRR | |to Q-COMP | |() |

|criterion is whether the wages of the employer in Queensland for the | | | |Q-COMP (the Workers’ Compensation Regulatory Authority): |

|preceding financial year were more than $4.9M. | | | |() |

|The occupier of a building is obliged to: maintain means of escape from |Part 9A Division| |Board |Fire and Emergency Services Act 1990 (FESA): |

|the building, prescribed fire safety installations, and a fire and |2 FESA, BFSR | | |() |

|evacuation plan; and provide instruction to persons in the building | | | |Note: The Act establishes the Queensland Fire and Rescue Service and provides for the |

|concerning the action to be taken by them in the event of a fire | | | |prevention of and response to fires and certain other incidents endangering persons, property|

|threatening the building; etc. | | | |or the environment and related purposes. |

|The Building Fire Safety Regulation includes provisions relating to | | | |Fire and Rescue Service Regulation 2011 (FRSR): |

|keeping evacuation routes free from obstacles; occupancy limits for | | | |() |

|buildings; meaning of specific terms (e.g. evacuation route, common | | | |Building Fire Safety Regulation 2008 (BFSR): |

|area); etc. | | | |() |

| | | | |Queensland Fire and Rescue Service: () |

|The obligation of an employer includes – |s30, Division 3 | | |Electrical Safety Act 2002 (ESA): |

|ensuring that all electrical equipment used in the conduct of the |ESA | | |() |

|person’s business or undertaking is electrically safe; and | | | |(An Act about electrical safety, and for other purposes.) |

|if the person’s business or undertaking includes the performance of | | | |Electrical Safety Regulation 2013: |

|electrical work, ensuring the electrical safety of all persons and | | | |() |

|property likely to be affected by the electrical work; and | | | | |

|if the person’s business or undertaking includes the performance of | | | |Electrical Safety (Codes of Practice) Notice 2013: |

|work, whether or not electrical work, involving contact with, or being | | | |() |

|near to, exposed parts, ensuring persons performing the work are | | | |Queensland Government Electrical Safety Office: () |

|electrically safe. | | | | |

| | | | | |

|Regulations, ministerial notices and codes of practice may prescribe the| | | | |

|way to discharge a person’s electrical safety obligations. | | | | |

|The BA requires that buildings be constructed in accordance with the Building Code of Australia and, where Queensland-specific provisions are necessary, the Queensland Development Code. The Act also contains specific compliance |

|requirements, for example, in relation to fire safety for residential care buildings built, approved or applied for before 1 June 2007 (Chapter 7A), and swimming pool safety (Chapter 8). |

|Hospital foundations may have additional responsibilities and obligations placed upon them by a number of pieces of other State legislation () and Commonwealth legislation |

|(), for example: |

|Affirmative Action (Equal Employment Opportunity for Women) Act 1986 (Cth) |Industrial Relations Act 1999 |

|Anti-Discrimination Act 1991 |Industrial Relations (Tribunal) Rules 2011 |

|Working with Children (Risk Management and Screening) Act 2000 |Judicial Review Act 1991 |

|Criminal Code Act 1899 |Ombudsman Act 2001 |

|Disability Discrimination Act 1992 (Cth) |Privacy Act 1988 (Cth) |

|Disability Services Act 1986 (Cth) |Sex Discrimination Act 1984 (Cth) |

|Disaster Management Act 2003 |Statutory Authorities (Superannuation Arrangements) Act 1994 |

|Environmental Protection Act 1994 |Superannuation Guarantee (Administration) Act 1992 (Cth) |

|Environmental Protection Regulation 2008 |Waste Reduction and Recycling Act 2011 |

|Environmental Protection (Waste Management) Regulation 2000 |Waste Reduction and Recycling Regulation 2011 |

|Human Rights and Equal Opportunity Commission Act 1986 (Cth) |Water Supply (Safety and Reliability) Act 2008 |

|Income Tax Assessment Act 1936 (Cth) | |

|Whole of Government policy |

|Comply with the QPP. |QPP | |All employees |Queensland Procurement Policy (QPP) July 2013: |

| | | | |(

|All foundation employees are required to be aware of, and comply with, | | | |teProcurementPolicy/Pages/Default.aspx) |

|this policy. Accountable officers are responsible for ensuring the QPP | | | |Note: The QPP is the government’s overarching policy for the procurement of goods and |

|is followed within their agencies; and managers and supervisors are | | | |services, including construction. Its purpose is to deliver excellence in procurement |

|responsible for ensuring that employees are aware of, and comply with, | | | |outcomes for Queenslanders. |

|it. | | | |Cabinet has mandated this Policy for application to budget sector agencies, statutory bodies |

| | | | |and Special Purpose Vehicles. These entities are collectively referred to as ‘agencies’ |

| | | | |within this Policy. |

| | | | |Procurement/Purchasing Requirements (OHSA fact sheet): |

| | | | |() |

| | | | |Financial and Performance Management Standard 2009 Requirements (OHSA fact sheet): |

| | | | |() |

|Implementation of the mandatory principles of the Information Standards |QGEA |n/a |Board |Queensland Government Enterprise Architecture (QGEA): |

|(IS) is mandated as a key whole-of-Government ICT planning requirement. |IS31, IS40, |(reporting focuses on | |() |

|Specific Acts and regulations are referenced within each Information |&IS18 |core departments) | |Note: QGEA is the collection of ICT policies and associated documents that guide agency ICT |

|Standard.  | | | |initiatives and investments to improve the compatibility and cost-effectiveness of ICT across|

|For more information please see the QGEA guideline on the authority and | | | |government. The framework unites ICT strategy, ICT policy, Information Standards and |

|applicability of the QGEA. | | | |enterprise architecture across the Queensland Government. |

| | | | |Note: in order to determine the applicability of QGEA policies to an individual agency, it |

| | | | |needs to be determined whether or not an agency is captured or exempted under the particular |

| | | | |legislation underpinning QGEA policies. For example, Information Standard 18 – Information |

| | | | |Security supports the FPMS 2009 and as such applies to all accountable officers and statutory|

| | | | |bodies as defined in the FAA. |

| | | | |Current Information Standards: () |

|Executives and persons paid remuneration equivalent to a senior |PSC Policy |Annually |Chief Executive |PSC Policy ‘Declaration of Interests – Senior Executive Service and Equivalent Employees |

|executive service level or above, including statutory office holders, |‘Declaration of | |Officer and/or SES |including Statutory Office Holders’: (h |

|(refer Directive 3/14 to determine if this applies) must provide on an |Interests – | |equivalent employee/s |) |

|annual basis, a Declaration of Interests to the relevant Chief Executive|Senior Executive| | |Senior Executive Service – Employment Conditions (Directive number: 3/14): |

|or, in the case of a statutory head, to the Minister for Health and/or |Service and | | |(

|Parliamentary Committee and the Integrity Commissioner. |Equivalent | | |loyment-Conditions.pdf) |

|The declaration must include information required under the directive, |Employees | | |Declaration of Interests Forms and FAQs: |

|including revisions to existing Declaration of Interests. |including | | |(

|The policy requires full disclosure of any interests that may have a |Statutory Office| | |Declaration) |

|bearing, or be perceived to have a bearing, on the individual’s ability |Holders’ | | |Queensland Integrity Commissioner Website: |

|to properly and impartially discharge the duties of their office. | | | |() |

|[insert Foundation name] Policy |

|[insert details of what the policy mandates] |[insert policy |[insert] |[insert the title/s of|[insert link to policy] |

| |name e.g. HR | |who is accountable for| |

| |Policy] | |compliance with the | |

| | | |policy e.g. all staff]| |

| | | | | |

-----------------------

[1] When creating your own document this column could be used to identify the officer / staff member accountable for compliance with this requirement, e.g. Chief Executive Officer / Chief Finance Officer / all staff. Suggestions are made in some boxes.

[2] ‘Board’ is used to refer to the members of the Foundation/body corporate.

[3] Note: Under s77(2) ‘Chief finance officer’ of the FAA each departmental CFO must produce to the accountable officer, for each financial year, a statement about whether the financial internal controls are operating efficiently, effectively and economically. This statutory requirement does not apply to statutory bodies, however, bodies should have a process in place to check and test financial internal controls.

[4] The foundations may elect to adopt the Code of Conduct for the Queensland Public Service () rather than develop a new code; however, in doing so, the foundation should ensure to engage in the appropriate consultations (section 16) and amend the Code to any extent necessary to ensure it relates to the foundation (section 13(1)(a)). For example, and at a minimum, references throughout the Code to its applicability to ‘Public Service Agencies’ should be changed to references to the foundation.

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