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Policies and Procedures

Visiting Volunteer Program

  • 1. Overview/procedure description

    The Royal Children's Hospital (RCH) aims to provide and maintain an environment that is safe for all patients, families, staff and volunteers.

    With this in mind, and in valuing the contribution that can be made to patient and family centred care, the VVP will provide a formalised screening and approval process for  Volunteer Groups and associated volunteers. A copy of the current Ward Visiting Schedule for approved Visiting Volunteer groups can be accessed here

    This program will form part of the hospital's broader risk management strategy to protect children, families and staff.

    This program will identify and ensure appropriate credentials for all Volunteer Groups and associated volunteers that are currently entering the hospital.

    This procedure applies to RCH staff members, all employees or Volunteer Groups and all Visiting Volunteers.

    2. Related Policy

    Consumer Focused Care

    Quality Improvement & Risk Management

    3. Definition of Terms

    Volunteer Group: Any charity, company or other entity that sends Visiting Volunteers to the RCH on a regular or periodic basis to provide patients and families with support services on a volunteer basis under an arrangement with the RCH.

    Visiting Volunteer:  Any person, whether paid or unpaid, who is recruited and trained by a Volunteer Group and who will make visits to The RCH as a representative of the Volunteer Group.

    Visiting Volunteer Program (VVP):the program under which Volunteer Groups are approved and Visiting Volunteers registered to provide volunteer support services at the RCH.

    Patient Areameans any inpatient or outpatient area which is attended by patients of the RCH.

    4. Procedure details

    Approval of Volunteer Groups

    • All Volunteer Groups must be approved by the RCH Executive to be part of the VVP.
    • Volunteer Groups will be approved to visit particular Patient Areas on particular days.
    • Staff must not allow a Visiting Volunteer to access a Patient Area on behalf of a Volunteer Group which has not been approved by the RCH Executive for access to that Patient Area on that day or time.
    • All approved Volunteer Groups must sign a Volunteer Service Agreement with the RCH before any Visiting Volunteers will be permitted access to any Patient Areas on their behalf.
    • Non-approved Volunteer Groups requested by parents will be denied access to the RCH. 

    Pre-approved Volunteer Groups

    • The Volunteer Groups that have been approved by Executive to attend the RCH as at the date of publication of this procedure, the Patient Areas, days and times they are approved for are set out in the Approved Volunteer Groups list which is maintained by the VVP Coordinator.

    Process for Approving New Volunteer Groups

    1. Complete New Volunteer Group form
      a) The RCH staff member requesting approval of a new Volunteer Group must complete an internal RCH New Volunteer Group form and have the form signed by the Head of Department and/or Nurse Unit Manager responsible for the relevant Patient Area.   
      b) In deciding whether to refer or approve an application from a new Volunteer Group consideration should be given to things such as the days and times that the new Volunteer Group wishes to attend, the services they wish to provide, how many other Volunteer Groups are already providing those services or attending the Patient Area on those days.
    2. Referral to VVP Coordinator
      a) The completed and signed internal RCH New Volunteer Group form must be forwarded to the VVP Coordinator.
      b) The VVP Coordinator will then liaise with the new Volunteer Group to obtain all necessary documentation from the Volunteer Group and complete the application.
      c) The Volunteer Group must cooperate entirely with this process, including providing all requested information and participating in any other due diligence required by the RCH, including attending an interview if requested.
    3. Approval by Executive Director
      a) The application for approval will then be considered by the responsible RCH Executive Director who will determine whether the application will be approved in whole or with conditions.
    4. After approval
      a) The Volunteer Group must sign a Volunteer Service Agreement and all Visiting Volunteers must be registered before attending the hospital.
      b) The VVP Coordinator will ensure that the Volunteer Group and the Visiting Volunteers are provided will all relevant documentation.

    Review of Approved Volunteer Groups

    • The approval of all Volunteer Groups will be reconsidered by the RCH Executive every two years and they will be required to sign a new Volunteer Service Agreement if reapproved.
    • Volunteer Groups must cooperate with this process and provide any information requested by the RCH.

    Registration of Visiting Volunteers

    • No Visiting Volunteer is to attend the hospital unless they have completed individual registration with the VVP, to the satisfaction of the VVP Coordinator.
    • Visiting Volunteers must be at least 18 years of age.
    • A VVP checklist must be completed in full and signed by the Visiting Volunteer and a representative of the Volunteer Group prior to their first visit.
    • Visiting Volunteers will be required to undertake Police and Working With Children checks, and consent to the release of these results to RCH.
    • An RCH  Privacy, Confidentiality & Security Agreement will be completed and signed by each individual prior to their first visit.
    • Each individual must make themselves available to be photographed by Security staff in order that an RCH identification tag stating the name of the Volunteer Group represented can be produced.
    • The Volunteer Group must ensure that each Visiting Volunteer is appropriately oriented to their role, including such areas as rights, responsibilities, expectations, codes of conduct, ID badges, privacy/confidentiality, photography and video consent, infection control, OH&S policies and emergency procedures.
    • All Visiting Volunteers must also complete such orientation and training that is deemed necessary by RCH staff.
    • It is strongly recommended that Visiting Volunteers are immunised for whooping cough, tetanus and seasonal influenza before attending any Patient Area.

    Attendance by Visiting Volunteers at the Hospital

    Access to Patient Areas

    • All Visiting Volunteers must wear their individualised RCH identification and lanyard at all times whilst attending the hospital.
    • RCH Identifications are not transferable, will remain in the hospital and will not be taken home, unless other arrangements have been agreed upon.
    • Visiting Volunteers must sign or swipe in and out at the beginning and end of each visit.
    • RCH staff members must not permit a Visiting Volunteer entry to a Patient Area unless they are wearing their RCH identification and lanyard and have signed or swiped in.
    • RCH staff must be aware of the Volunteer Groups who should be in attendance in their area on any particular day.  A Visiting Volunteer who is not approved for attendance in the area on a particular day should not be permitted access. For further information, please refer to the Visiting Volunteer Program web-page
    • Any queries about access of particular Volunteer Groups to Patient Areas should be directed to the VVP Coordinator.

    Conduct of Visiting Volunteers

    • All Visiting Volunteers will be responsible for their own costs, including uniforms, meals and parking.
    • Visiting Volunteers will be mindful of the values of The RCH: 
      • Unity - we work together to achieve our goals;
      • Integrity - we act with honesty in all we do;
      • Excellence - we strive for the highest quality in every aspect of our work;
      • Respect - for everyone in our care and for each other.
    • Visiting Volunteers must comply with the RCH Code of Conduct, RCH Privacy Policy and Procedures and all other relevant procedures of the RCH at all times whilst in attendance.
    • Visiting Volunteers are requested to appear neat and tidy, with minimal jewellery.  Long hair should be tied back and strong perfume should not be worn.
    • Visiting Volunteers must only provide the Volunteer Services in a manner that causes no undue interruption to the work of the RCH's staff, students or invitees and causes no inconvenience, interruption or distress to any of the RCH's patients, families or visitors.
    • Staff members must not disclose any personal information relating to patients or their families (including names, contact details, diagnoses, period of admission etc) to Visiting Volunteers, without the patient and/or parent's consent. 
    • Visiting Volunteers must not disclose any personal information they receive regarding RCH patients and families to any other person without the patient and/or parent's consent. 
    • If a child/family tells the Visiting Volunteer that something is worrying them, the Visiting Volunteer should inform the professional RCH staff caring for the child.  Genuine complaints must always be passed onto RCH staff.
    • Visiting Volunteers must not discuss treatment or treatment options or offer advice or medicine to patients or families.
    • Visiting Volunteers must not give any gifts to patients or families nor accept any gifts from patients or families.
    • Visiting Volunteers are reminded to stay away from the hospital if they feel unwell or have a rash, including seemingly minor ailments such as a sore throat.

    Activities of Volunteer Groups

    • Volunteer Groups must not recruit members or conduct any fundraising activities at the RCH.  Such activities must be initiated and consented to by patients and/or parents.  
    • Volunteer Groups must never bring unauthorised persons to the hospital, including celebrities or sports persons volunteering their time or their own children or other family members.  If a Volunteer Group wishes to bring a guest to the hospital, they must obtain prior written authorisation from RCH Corporate Communications.  
    • Volunteer Groups must not publish or authorise publication of any material promoting their relationship with the RCH or the services provided at the hospital, or containing any information whatsoever regarding the RCH or its patients, families or staff without prior written authorisation from RCH Corporate Communications.
    • Any enquiries from the media in relation to RCH or RCH patients, families, or staff must be immediately directed to the VVP Coordinator or RCH Corporate Communications. 
    • Any Volunteer Group identified as acting inappropriately (including by breaching patient privacy, failing to comply with this procedure and/or the Volunteer Service Agreement or pressuring or inconveniencing families) will immediately have their visiting privileges suspended and must not send any Visiting Volunteer to any Patient Area until the matter has been addressed by the hospital Executive in accordance with the Volunteer Service Agreement.

    Administration of Visiting Volunteer Program

    • The VVP is coordinated by the VVP Coordinator.  This staff member will be the contact point for all enquiries regarding the VVP, including application forms, coordination of visits and sign in/sign out procedures.
    • Details of all groups and individuals will be kept on a database held by the VVP Coordinator.
    • The VVP Coordinator will make regular contact with a person of responsibility at each Volunteer Group to relay information pertinent to their representatives who visit the hospital.
    • The VVP Coordinator will perform an audit of attendance records periodically and will provide a report to a person of responsibility at each Volunteer Group and person responsible for each Patient Area or department regarding Visiting Volunteer attendance. 
    • In the spirit of collaboration and cooperation, Visiting Volunteers and Volunteer Groups should, in the first instance, raise any concerns or questions promptly with the VVP Coordinator.  In the event that the concern is not satisfactorily addressed, the Volunteer should contact the organisational coordinator at the Volunteer Group.

    5. Reference

    Checklist to register Visiting Volunteers
    RCH  Privacy, Confidentiality & Security Agreement

    RCH Visiting Volunteer program web-page 

    6. Contacts

    • Kiley Kavanagh, Volunteer Services Manager, 9345 4366
    • David Tonge, Director Family Services and Volunteers, 9345 5440