Hospital and Health Boards Regulation 2023

Hospital and Health Boards Regulation 2023

1Short title

This regulation may be cited as the Hospital and Health Boards Regulation 2023.

2Commencement

This regulation commences on 1 September 2023.

3Definitions

The dictionary in schedule 9 defines particular words used in this regulation.

4Continuation of Hospital and Health Services—Act, s 17

(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.

(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.

(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.

(4)In this section—

expired regulation means the expired Hospital and Health Boards Regulation 2012.

5Power to grant or take lease without Minister’s and Treasurer’s approval—Act, s 20A

(1)For section 20A(2) of the Act, a lease of a type mentioned in schedule 2 is prescribed.

(2)For schedule 2—

(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

(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.

6Definitions for part

In this part—

health system employer means a Hospital and Health Service or the department.

relevant chief executive, of a health system employer, means—

(a)if the employer is a Hospital and Health Service—the Service’s health service chief executive; or

(b)if the employer is the department—the chief executive of the department.

7Movement of health service employees, other than health service chief executives, between health system employers

(1)This section applies to a health service employee other than a health service chief executive.

(2)A health service employee may be moved from a health system employer to another health system employer—

(a)by agreement between the relevant chief executives of the employers; or

(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.

(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.

(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.

(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—

(a)for a movement under subsection (2)(a)—in the agreement mentioned in that subsection; or

(b)for a movement under subsection (2)(b)—in the written direction given under that subsection.

8Movement of health service chief executives between health system employers

(1)This section applies to a health service chief executive.

(2)A health service chief executive may, with the approval of the Minister, be moved—

(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

(b)between Hospital and Health Services by agreement between the chairs of the boards of the Services.

(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—

(a)the health service chief executive; and

(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.

(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.

(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.

(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—

(a)for a movement under subsection (2)—in the agreement mentioned in that subsection; or

(b)for a movement under subsection (3)—in the written direction mentioned in that subsection.

(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.

9Movement of health service employees employed on a contract

(1)This section applies to the movement of a health service employee to another health system employer—

(a)under section 7 if, immediately before the movement, the employee was appointed on a contract; or

(b)under section 8.

(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.

(3)If a provision in the employee’s contract is inconsistent with a movement under this part, the movement takes effect despite the inconsistency.

(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—

(a)if a period is stated in the agreement or written direction given under section 7 or 8 for the movement—the period stated;

(b)if no period is stated in the agreement or written direction—the period remaining on the term of the employee’s contract.

(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.

10Movement between classification levels

(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.

(2)The employee may be moved to another health system employer at a lower classification level only if the employee consents to the movement.

(3)However, subsection (2) does not prevent movement to a lower classification level as a result of disciplinary action against the employee.

11Effect of movement of health service employees other than health service chief executives

(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—

(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

(b)if the movement is by written direction under section 7(2)(b)—the chief executive of the department.

(2)The health service employee must be given a reasonable time to establish reasonable grounds for refusing the movement.

(3)Subsection (4) applies if the health service employee refuses the movement after failing to establish reasonable grounds for refusing the movement.

(4)The relevant chief executive of the health system employer from which the employee is moved—

(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

(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.

(5)If the employee establishes reasonable grounds for refusing the movement—

(a)the movement is cancelled; and

(b)the refusal must not be used to prejudice the employee’s prospects for future promotion or advancement.

12Effect of movement of health service chief executives

(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—

(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;

(b)if the movement is by written direction under section 8(3)—the Minister.

(2)A health service chief executive must be given a reasonable time to establish reasonable grounds for refusing the movement.

(3)Subsection (4) applies if the health service chief executive refuses the movement after failing to establish reasonable grounds for refusing the movement.

(4)The chair of the board for the Service from which the health service chief executive is moved—

(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

(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.

(5)If the health service chief executive establishes reasonable grounds for refusing the movement—

(a)the movement is cancelled; and

(b)the refusal must not be used to prejudice the health service chief executive’s prospects for future promotion or advancement.

13Continuation of entitlements of health service employees

(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.

(2)The following apply for the employee—

(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

(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;

(c)the employee’s appointment does not constitute a termination of employment or a retrenchment or redundancy;

(d)the employee is not entitled to a payment or other benefit because the employee is no longer employed by the first employer.

(3)This section applies to rights accrued and service undertaken before or after the commencement.

14Senior health service employees—Act, s 74A

For section 74A(1) of the Act, each of the following positions is prescribed as a senior health service employee position—

(a)a position at a classification level mentioned in schedule 3, part 1;

(b)a position mentioned in schedule 3, part 2.

15Disclosure of personal information of health service employees and departmental public service employees in particular circumstances

(1)This section applies to a person’s personal information held by a health system employer if the person—

(a)is or was a health service employee; or

(b)is or was a public service employee employed in the department (a departmental public service employee); or

(c)is being, or was, considered for appointment as a health service employee or departmental public service employee.

(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—

(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

(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.

(3)This section applies—

(a)to personal information held by a health system employer before or after the commencement; and

(b)to matters not dealt with in section 274 of the Act.

(4)For this section, a person is considered for appointment as a health service employee or departmental public service employee if—

(a)the person applied or otherwise expressed an interest in being appointed; and

(b)the person’s suitability for employment has not been finally assessed.

(5)In this section—

personal information see the Information Privacy Act 2009, section 12.

16Definitions for part

In this part—

Aboriginal and Torres Strait Islander community-controlled health organisation means a body corporate that—

(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

(b)has rules preventing the distribution of the body corporate’s property to its members; and

(c)delivers health services to the local Aboriginal or Torres Strait Islander community.

chief First Nations health officer means the public service officer employed in the department who is appointed as the chief First Nations health officer.

community includes a group or organisation consisting of individuals with a common interest.

Examples of common interest—

•an interest in delivery of health services in a particular geographic location

•an interest in particular health issues

•a common cultural background, religion or language

consumer includes the following entities—

(a)an individual who uses or may use a health service;

(b)the family members, carers and representatives of an individual mentioned in paragraph (a);

(c)a group of, or organisation for, individuals mentioned in paragraph (a) or (b);

(d)a representative of the group or organisation mentioned in paragraph (c).

implementation stakeholders, for a Service’s health equity strategy, see section 21.

service-delivery stakeholders, for a Service’s health equity strategy, means the following organisations—

(a)Aboriginal and Torres Strait Islander community-controlled health organisations in the Service’s health service area;

(b)local primary healthcare organisations for the Service.

17Prescribed persons—developing health equity strategies

For section 40(2)(c) of the Act, the following persons are prescribed for the health equity strategy—

(a)Aboriginal and Torres Strait Islander members of the Service’s staff;

(b)Aboriginal and Torres Strait Islander consumers of health services delivered by the Service;

(c)Aboriginal and Torres Strait Islander members of the community within the Service’s health service area;

(d)traditional custodians and native title holders of land and waters in the Service’s health service area;

(e)the implementation stakeholders for the strategy.

18Prescribed requirements for clinician engagement strategies

For section 40(3)(a) of the Act, a clinician engagement strategy of a Service must—

(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

(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

(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

(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.

19Prescribed requirements for consumer and community engagement strategies

For section 40(3)(a) of the Act, a consumer and community engagement strategy of a Service must—

(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

(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

(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

(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.

20Prescribed requirements for health equity strategies

For section 40(3)(a) of the Act, a health equity strategy of a Service must—

(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

(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

(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)

21Prescribed persons—giving effect to health equity strategies

For section 40(5) of the Act, the following persons (the implementation stakeholders) are prescribed—

(a)the service-delivery stakeholders for the health equity strategy;

(b)the chief First Nations health officer;

(c)Queensland Aboriginal and Islander Health Council ABN 97 111 116 762;

(d)Health and Wellbeing Queensland established under the Health and Wellbeing Queensland Act 2019.

22Prescribed requirements for protocol with local primary healthcare organisations

For section 42(2)(a) of the Act, a protocol of a Service agreed with local primary healthcare organisations must—

(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

(b)have regard to national and State strategies, policies, agreements and standards; and

(c)outline the relationship between the Service’s protocol and its consumer and community engagement strategy, clinician engagement strategy and health equity strategy; and

(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.

23Definitions for part

In this part—

committee means a quality assurance committee established under section 82 of the Act.

member means a member of a committee.

privacy policy see section 31.

specified information see section 33.

24Chairperson

(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.

(2)Also, a committee may elect a member to be chairperson of the committee at any time.

(3)The member elected under subsection (1) or (2) is appointed as chairperson when the entity establishing the committee approves the appointment.

(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—

(a)the member’s full name;

(b)the date the member was appointed as chairperson.

25Times and places of meetings

(1)Committee meetings are to be held at the times and places the chairperson decides.

(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.

(3)Also, a committee must hold its first meeting within 3 months after its establishment.

26Quorum

A 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.

27Presiding at meetings

(1)The chairperson is to preside at all meetings of a committee at which the chairperson is present.

(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.

28Conduct of meetings

(1)A question at a committee meeting is decided by a majority of the votes of the members present.

(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.

29Minutes

(1)A committee must keep the minutes of a meeting of the committee for 10 years after the meeting.

(2)Subsection (1) does not apply to the extent that the minutes are a public record under the Public Records Act 2002.

30Other procedures

Subject to this division—

(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

(b)otherwise, the committee may conduct its business, including its meetings, under procedures decided by the committee.

31A committee must adopt a privacy policy

A committee must adopt, by resolution, a written privacy policy (a privacy policy).

32Content of privacy policy

(1)A committee’s privacy policy must state the ways the committee, or a member of the committee, may do any of the following—

(a)acquire and compile relevant information;

(b)securely store relevant information;

(c)disclose relevant information;

(d)ask an individual for consent to disclose the individual’s identity under section 83(2) of the Act.

(2)The privacy policy also must state the circumstances under which a record containing relevant information may be copied or destroyed.

(3)Nothing in this section affects the operation of the Information Privacy Act 2009 or the Privacy Act 1988 (Cwlth).

(4)In this section—

relevant information means information acquired or compiled by the committee in the performance of its functions.

33Specified information to be made available to the public

(1)A committee must make available to the public the information stated in subsection (3) (the specified information).

(2)The specified information must—

(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

(b)otherwise—be made available within 3 years after, and relate to the period since, the committee last made the specified information available.

(3)For subsection (1), the information is—

(a)a statement of the committee’s functions; and

(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

(c)a summary of the activities undertaken in, and any outcomes of, the performance of the committee’s functions; and

(d)a summary of the committee’s privacy policy.

(4)The committee must give the specified information to the entity that established the committee before the committee makes it available to the public.

(5)A committee may make the specified information available in a form the committee considers appropriate.

Example of an appropriate form for the specified information—

The specified information may be included in the annual report of the entity that established the committee.

34Review of functions

(1)A committee must carry out a review of its functions—

(a)within 3 years after the committee is established; and

(b)afterwards—within 3 years after the previous review.

(2)As soon as practicable after each review is carried out, the committee must give a report about the review to—

(a)the entity that established the committee; and

(b)if the committee was established by an entity other than the chief executive—the chief executive.

35Annual activity statement

(1)A committee must prepare an annual activity statement.

(2)The statement must include all of the following for the committee—

(a)the chairperson’s full name;

(b)each member’s full name;

(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;

(d)if a person stopped being a member during the reporting period—the date the individual stopped being a member;

(e)the dates of each meeting held by the committee during the reporting period.

(3)The annual activity statement must, on or before each anniversary of the day the committee was established, be given to—

(a)the entity that established the committee; and

(b)if the committee was established by an entity other than the chief executive—the chief executive.

36Prescribed patient safety entities and authorised purposes

(1)Each of the following is a patient safety entity for section 85(3) of the Act, definition prescribed patient safety entity—

(a)the administrative unit of the department responsible for coordinating improvements in the safety and quality of health services;

(b)the administrative unit of the department responsible for coordinating programs and activities for health service delivery in rural and remote areas;

(c)an executive committee established by the chief executive to oversee improvements in the safety and quality of health services;

(d)each safety and quality committee established by a board.

(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.

37Reportable events

(1)For section 94 of the Act, definition reportable event, each of the following events is prescribed—

(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;

(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;

(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;

(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;

(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;

(f)the suspected suicide of a patient within an acute psychiatric unit or ward;

(g)an error relating to a patient’s medication resulting in serious harm to the patient or the death of the patient;

(h)the use of physical or mechanical restraint resulting in serious harm to a patient or the death of a patient;

(i)the use of an incorrectly positioned orogastric or nasogastric tube resulting in serious harm to a patient or the death of a patient;

(j)the discharge or release of a patient who is a child under the age of 15 years to an unauthorised person;

(k)a stillbirth;

(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.

(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—

(a)is specifically designed with fixtures and fittings that minimise the opportunity for patient suicide; and

(b)is specifically designed to prevent any unauthorised ingress or egress; and

(c)is subject to protocols for the observation of patients within the unit or ward.

(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—

(a)that requires life-saving surgical or medical intervention; or

(b)shortens the patient’s life expectancy; or

(c)that is permanent or long-term physical harm; or

(d)that is a permanent or long-term loss of a physical function.

stillbirth means the birth of a child—

(a)who shows no sign of respiration or heartbeat, or other sign of life, after completely leaving the child’s mother’s body; and

(b)who—

(i)has been gestated for 20 weeks or more; or

(ii)weighs 400g or more.

unauthorised person, in relation to a child, means a person who—

(a)is not a parent or legal guardian of the child; or

(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

(c)is prevented from having access to the child by an order of a court or tribunal.

38Prescribed patient safety entities and authorised purposes

(1)Each of the following is a patient safety entity for section 112(7) of the Act, definition prescribed patient safety entity—

(a)the administrative unit of the department responsible for coordinating improvements in the safety and quality of health services;

(b)the administrative unit of the department responsible for coordinating programs and activities for health service delivery in rural and remote areas;

(c)an executive committee established by the chief executive to oversee improvements in the safety and quality of health services;

(d)each safety and quality committee established by a board;

(e)each quality assurance committee.

(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.

39References to shifts

(1)In this part—

(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

(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

(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.

(2)However—

(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.

(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

(c)if a shift falls equally across the periods mentioned in subsection (1)(a) and (c), it is taken to be a morning shift.

40Nurse-to-patient and midwife-to-patient ratios applying to particular acute adult wards—Act, s 138B

(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—

(a)the facility is listed in the first column; and

(b)a dot point appears opposite the facility in the column for the type of ward.

(2)The minimum number of nurses or midwives who must be engaged in delivering health services to patients in the ward is—

(a)for the morning shift—the number of patients divided by 4; or

(b)for the afternoon shift—the number of patients divided by 4; or

(c)for the night shift—the number of patients divided by 7.

(3)If the number worked out under subsection (2) is less than 1, the number is taken to be 1.

(4)Otherwise, if the number worked out under subsection (2) is not a whole number, the number must be rounded to the nearest whole number (rounding one-half downwards).

Example—

For the morning shift in a ward with 7 patients, the number worked out under subsection (2)(a) is 1.75, so the minimum number of nurses or midwives required is 2.

(5)In this section—

acute adult ward means an acute ward in which health services are provided to adult patients.

41State aged care facilities—Act, ss 138H and 138I

For sections 138H and 138I of the Act, the State aged care facilities mentioned in schedule 6 are prescribed.

42Minimum nurse and registered nurse percentages—Act, s 138H

(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.

(2)At least 50% of the care staff must be nurses.

(3)At least 30% of the care staff must be registered nurses.

43Minimum average daily resident care hours—Act, s 138I

The minimum average daily resident care hours at a State aged care facility prescribed under section 41 is 3.65 hours.

44Prescribed committees

(1)For schedule 1, section 8(1)(b) of the Act, each of the following committees is prescribed—

(a)a safety and quality committee;

(b)a finance committee;

(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.

(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.

45Functions of a safety and quality committee

A safety and quality committee established by a Service’s board has the following functions—

(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

(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;

(c)promoting improvements in the safety and quality of health services provided by the Service;

(d)monitoring the safety and quality of health services being provided by the Service using appropriate indicators developed by the Service;

(e)monitoring the workplace culture of the Service in relation to the safety and quality of health services provided by the Service;

(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;

(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

46Functions of a finance committee

A finance committee established by a Service’s board has the following functions—

(a)advising the board about the matters stated in paragraphs (b) to (g);

(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;

(c)monitoring the Service’s cash flow, having regard to the revenue and expenditure of the Service;

(d)monitoring the financial and operating performance of the Service;

(e)monitoring the adequacy of the Service’s financial systems, having regard to its operational requirements and obligations under the Financial Accountability Act 2009;

(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

(g)assessing the Service’s complex or unusual financial transactions;

(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

47Functions of an audit committee

(1)An audit committee established by a Service’s board has all of the following functions—

(a)advising the board about the matters stated in paragraphs (b) to (h);

(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;

(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;

(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;

(e)overseeing the Service’s liaison with the Queensland Audit Office in relation to the Service’s proposed audit strategies and plans;

(f)assessing external audit reports for the Service and the adequacy of actions taken by the Service as a result of the reports;

(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;

(h)assessing the Service’s complex or unusual transactions or series of transactions, or any material deviation from the Service’s budget;

(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

(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).

48Prescribed health professionals—Act, s 139

For section 139 of the Act, definition prescribed health professional, paragraph (a), each of the following health professionals is prescribed—

(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;

(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.

49Prescribed information system—Act, s 139

For 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.

50Prescribed designated person—Act, s 139A

For section 139A(1)(m) of the Act, each of the following persons is prescribed as a designated person—

(a)the commissioner of the Queensland Ambulance Service appointed under the Ambulance Service Act 1991, section 4;

(b)a person employed under the Ambulance Service Act 1991, section 13.

51Disclosure of confidential information for purposes relating to health services—Act, s 150

(1)For section 150(b) of the Act, each of the following entities is prescribed for evaluating, managing, monitoring or planning health services stated for the entity—

(a)Alfred Health ABN 27 318 956 319 and Monash University ABN 12 377 614 012 for collecting data about a relevant trauma patient for use in the Australian Trauma Registry;

(b)Services Australia for maintaining the Australian Immunisation Register;

(c)the Australian Orthopaedic Association ACN 000 759 795 for collecting data about joint replacement surgery for use in the Australian Orthopaedic Association National Joint Replacement Registry;

(d)the Australasian Cardiac Surgery Research Institution ABN 44 099 817 106 and Monash University ABN 12 377 614 012 for collecting data about cardiac surgery for use in the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database;

(e)the Florey Institute of Neuroscience and Mental Health ABN 92 124 762 027 for collecting data about eligible stroke and transient ischaemic attack patients for use in the Australian Stroke Clinical Registry and for community based follow-up;

(f)Alfred Health ABN 27 318 956 319 for collecting data about a relevant asplenic patient for use in the Spleen Australia registry.

(2)Also for section 150(b) of the Act, each of the following entities is prescribed for evaluating, managing, monitoring or planning health services relating to the implementation and management of the National Disability Insurance Scheme—

(a)National Disability Insurance Agency;

(b)the following departments of government—

(i)the department in which the Disability Services Act 2006 is administered;

(ii)the department in which the Housing Act 2003 is administered;

(iii)Queensland Treasury.

(3)In this section—

injury severity score, for a person, means an overall score of the severity of the person’s physical injuries worked out using an anatomical scoring system.

National Disability Insurance Scheme see the National Disability Insurance Scheme Act 2013 (Cwlth), section 9.

relevant asplenic patient means a person with—

(a)asplenia; or

(b)reduced spleen function due to a medical condition or intervention.

relevant trauma patient means a person who attends a public sector hospital for treatment of a physical injury and—

(a)dies as a direct or indirect result of the injury—

(i)after receiving treatment in the hospital’s emergency department; or

(ii)at any time during admission to the hospital; or

(b)has an injury severity score greater than 12.

52Disclosure to Commonwealth, another State or Commonwealth or State entity—Act, s 151

(1)For section 151(1)(a)(i)(B) of the Act, each agreement stated in schedule 8, part 1, is prescribed.

(2)For section 151(1)(b)(i)(B) of the Act, each agreement stated in schedule 8, part 2, is prescribed.

53Major capital works

(1)For schedule 2 of the Act, definition major capital works, capital works are prescribed if the works—

(a)are structural works for the construction of a building; or

(b)involve alterations to the building envelope of an existing building; or

(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.

(2)In this section—

excluded work means work that involves only routine maintenance of, or repairs to, an existing building or other structure.

section 4

section 5

Each of the following leases if the granting of the lease has been approved by the Minister—

Each of the following leases—

section 14

1The 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.

2The 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.

A position, known as a visiting medical officer position, in which a health service employee is employed if the employee—

(a)is registered under the Health Practitioner Regulation National Law to practise in the medical profession; and

(b)incurs ongoing private practice costs.

sections 36 and 38

1Administrative unit of the department responsible for coordinating improvements in the safety and quality of health services

•improving the effectiveness and outcomes of quality assurance activities undertaken in Services and the department

•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

•developing, monitoring and evaluating patient safety initiatives and programs

•undertaking research on the operation and effectiveness of quality assurance committees

2Administrative unit of the department responsible for coordinating programs and activities for health service delivery in rural and remote areas

•contributing to the development, review and improvement of policies and standards relating to quality assurance activities in rural Services

•monitoring and reporting on the implementation of recommendations contained in quality assurance committee reports or other documents in rural Services

•developing and implementing patient safety initiatives in rural Services

3Executive committee established by the chief executive to oversee improvements in the safety and quality of health services

•reviewing patient safety and quality performance in Services and the department

•monitoring, evaluating and promoting improvement in patient safety and quality performance in Services and the department

4Safety and quality committees

•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

•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

•developing and implementing patient safety initiatives of the committee’s board in the Service

5Administrative unit of the department responsible for coordinating improvements in the safety and quality of health services

•improving the effectiveness and outcomes of root cause analyses undertaken in Services and the department

•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

•developing, monitoring and evaluating patient safety initiatives and programs

•undertaking research on the operation and effectiveness of root cause analyses

6Administrative unit of the department responsible for coordinating programs and activities for health service delivery in rural and remote areas

•contributing to the development, review and improvement of policies and standards relating to root cause analyses in rural Services

•monitoring and reporting on the implementation of recommendations contained in RCA reports or chain of events documents relevant to rural Services

•using information contained in RCA reports or chain of events documents to develop and implement patient safety initiatives in rural Services

7Executive committee established by the chief executive to oversee improvements in the safety and quality of health services

•reviewing patient safety and quality performance in Services and the department

•monitoring, evaluating and promoting improvement in patient safety and quality performance in Services and the department

8Safety and quality committees

•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

•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

•using information contained in RCA reports or chain of events documents to develop and implement patient safety initiatives in the Service

9Quality assurance committees

•assessing and evaluating the quality of health services, to the extent the services are relevant to a reportable event

•reporting and making recommendations concerning the quality of health services, to the extent the services are relevant to a reportable event

•monitoring the implementation of its recommendations, to the extent its recommendations are relevant to a reportable event

section 40

section 41

•Cooinda House, Kippa-Ring

•Dr E A F McDonald Residential Aged Care, Oakey

•Eventide Home Rockhampton

•Eventide Residential Aged Care, Charters Towers

•Forest View Residential Aged Care, Wondai

•Gannet House, Brighton Health Campus

•Glenbrook Residential Aged Care, Nambour

•Karingal Residential Aged Care, Dalby

•Milton House, Miles

•Mt Lofty Residential Aged Care, Toowoomba

•North Rockhampton Nursing Centre

•Parklands Residential Aged Care, Kirwan Community Health Campus

•Redland Residential Care Facility

•The Oaks Residential Aged Care, Warwick

•Waroona Multipurpose Centre, Charleville

•Westhaven Aged Care Facility, Roma

section 48

section 52

1Agreement 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.

2Agreement 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.

3Agreement 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.

4Agreement 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.

5Agreement 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.

6National Health Information Agreement between the Commonwealth, State and Territory health, statistical and national authorities, commenced 1 October 2013.

7Intergovernmental 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.

8The 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’.

9The agreement dated 28 April 2022 called ‘National Partnership Agreement on Specified Projects - Schedule E - Rheumatic Fever Strategy’ between Queensland and the Commonwealth of Australia.

10The agreement of 2019 called ‘Agreement pursuant to section 151(1)(a) of the Hospital and Health Boards Act 2011 (Qld) between State of Queensland through the Chief Executive of Queensland Health and Commonwealth of Australia represented by the Department of Human Services for information exchange between Queensland Health and the Department of Human Services to identify women who are eligible to receive breast screening services in Queensland’.

11The 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’.

12The agreement of 2017 called ‘Memorandum of Understanding between the Chief Executive of Queensland Health and the State of Queensland acting through the Department of Justice and Attorney-General represented by Queensland Corrective Services, Confidential Information Disclosure’.

13The agreement dated 2 November 2017 called ‘Memorandum of Understanding between the Chief Executive of Queensland Health and the Queensland Police Service, Confidential Information Disclosure’.

14The 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’.

15The 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’.

section 3

Aboriginal and Torres Strait Islander community-controlled health organisation, for part 4, see section 16.

afternoon shift, for part 7, see section 39.

Australian Standard Geographical Classification means the Australian Standard Geographical Classification (Cat. No. 1216.0), July 2011 edition published by the Australian Bureau of Statistics.

Australian Statistical Geography Standard means the Australian Statistical Geography Standard (Cat. No. 1270.0.55.001), July 2021 edition published by the Australian Bureau of Statistics.

chief First Nations health officer, for part 4, see section 16.

committee, for part 5, see section 23.

community, for part 4, see section 16.

community of Cardwell means the area consisting of statistical area level 1 (SA1) 3116116, 3116117, 3116118, 3116119, 3116106, 3116122, 3116123, 3116139.

community of Taroom means the area consisting of statistical area level 1 (SA1) 3119407, 3119408, 3119410.

community of Urandangi means the area consisting of mesh blocks 30023480000 and 30023490000.

consumer, for part 4, see section 16.

health system employer, for part 3, see section 6.

implementation stakeholders, for a Service’s health equity strategy, for part 4, see section 21.

local government area means a local government area under the Australian Standard Geographical Classification.

member, for part 5, see section 23.

mesh block means a mesh block under the Australian Statistical Geography Standard.

morning shift, for part 7, see section 39.

night shift, for part 7, see section 39.

privacy policy, for part 5, see section 31.

relevant chief executive, for part 3, see section 6.

residential premises see the Residential Tenancies and Rooming Accommodation Act 2008, section 10.

rural Service means each of the following Hospital and Health Services—

(a)Central West;

(b)North West;

(c)South West;

(d)Torres and Cape.

safety and quality committee means a safety and quality committee established by a board under schedule 1, section 8(1)(b) of the Act and section 44(1)(a).

service-delivery stakeholders, for a Service’s health equity strategy, for part 4, see section 16.

specified information, for part 5, see section 33.

statistical area level 1 (SA1) means a statistical area level 1 (SA1) under the Australian Statistical Geography Standard.

statistical local area means a statistical local area under the Australian Standard Geographical Classification.