• About us
• Clinical governance
• Clinical risk management
• Policies & procedures
• Hospital clinical guidelines & paths
• New Technology or Clinical Practice
• Quality improvement & evaluation
• Feedback & complaints
• Freedom of information
• Medico legal
• Resources
• CQS team
• Contact us

Clinical Policies and Procedures

There are different ways to guide clinicians so they can provide the best care to their patients. This includes clinical practice guidelines, policies and Standard Treatment Orders.

What is policies and protocol/procedure?

Policy

Policies are overarching statements which reflects the organisation's position on an issue and must be adhered to by all staff within the organisation.

Procedure

A prescribed course of actions that reflects the operational standards required to enforce policy principles.

Who can develop a Policy?

All Policies must be sponsored by an Executive Director. Any RCH staff member can identify an area requiring policy development.  At the outset this should be discussed with the relevant team or department, then, with their approval, with the relevant Policy Coordinator and Executive Director.

Who can approve a Policy?

All Policies must be approved by the Hospital Executive.

Developing a Policy 

• For all policies and procedures please contact the Quality and Improvement Department 9345 4021