Department: Head Office Description: Standard Procedure Document Name: Aged Care Document and
Intranet Data Control Procedure
Issue Date: 06/06/2012
Adventist
Aged Care
Document ID: RC-3-02-0020Aged Care Document and Intranet
Data Control Procedure
1. Purpose and Scope 2. Document Status 3. Document Protocols
4. Document Control Overview 5. Document Development 6. Document Identification
A. Coding Controlled Document Policies and Procedures – Residential Aged Care
B. Coding Controlled Document Policies and Procedures – All other Documents
C. Coding Duplications of Policies and Procedures 7. Document Control 8. Masterfile Use 9. Document back-up 10. Appendix 1 11. Appendix 2 12. Appendix 3
REVISED BY: Chrystal Gibson
AUTHORISED BY: ECM Signed
APPROVED BY: CEO
1. Purpose and Scope
1.1 To identify, record and control the development, issue and modification of Official Administrative documentation.
1.2 To electronically upload Controlled Documents to the SDAAC (SQ) website to allow authorized personnel from all four ARV South Qld villages and the SDAAC (SQ) Head Office to access key policies, procedures, and forms related to the day to day workings of the company.
2. Document Status
Documents can be in one of three status groups: 2.1. Controlled
A controlled document is an official administrative document which is subject to the process of approval and review. Controlled documents are issued by the Document Controller or back up person.
Initially this will include policies, procedures, job descriptions and business-critical forms selected by authorising person.
2.2. Uncontrolled
Uncontrolled documents are documents which are not subject to approval and review and are not covered by the formal document control system. An uncontrolled document must not be used for any business critical purposes. 2.3. Draft
A document that contains the word “Draft” in the control status box is not in its completed form. The word Draft should also be present in significant sized letters as a backdrop on at least the first page.
Documents under review should not be used for any business critical purposes.
3. Document Protocols
3.1 Aged Care controlled documents shall not be photocopied and then restamped “controlled”.
3.2 Externally controlled documents (those issued by other entities) may be photocopied, over-stamped “Adventist Aged Care” and then distributed. External documents marked in this way are also controlled. Only the latest version of any document subject to document control may be used for reference in any business critical manner.
3.3 Replacement and updated documents are obtained from the Document Controller, the company server, or the Intranet website.
4. Document Control Overview
4.1 Any staff member may request a document to be developed and published. Authorising function (Board of Directors / CEO / ECM / Manager) will decide if the document is warranted.
4.2 Documents relating to specific areas of business are authorised by the ECM, CEO, or Manager.
4.3 All Organisation-wide policy and procedure documents are approved by the Board of Directors. A delegate of the Board of Directors, the CEO, or ECM may approve other documents with the exception of Human Resources Management documents such as job descriptions which must be approved by the Board of Directors.
4.5 Documents are:
a. Registered in Word format and located in a folder on the head office company server (in this case T:\\Aged Care\Chrystal’s Documents\Controlled Documents\Intranet Word) and
b. in PDF format on the company server (in this case T:\\Aged Care\Controlled Documents\Intranet PDFs.
c. PDF documents placed in this folder will be deemed to have been published to all staff.
d. File names must correspond to the document control number.
e. Facilities that do not have direct access to the company server are required to email a PDF copy to the ECM / CEO for approval and filing in a folder on the server.
f. Where a signature for approval is required, a signed PDF document will be returned to the relevant Document Controller as the official controlled document.
g. The following minimum information is recorded: Document Name, Document Identification (code number), document Description, issue date, and effective date.
4.6 Review of documentation and the need to upgrade documents is determined in management review meetings, by regular revue schedules and also may be flagged as a result of audits or incidents.
4.7 When a document is superseded or becomes obsolete it is withdrawn from use. The Document Controller will remove the copy from the Intranet and archive the electronic copy of the document where applicable.
4.8 The hard copies of obsolete or superseded documents will be disposed of in an appropriate manner to ensure confidentiality.
5. Document Development
5.1 Stakeholders of the document or an individual will draft the document. Other stakeholders, such as the Board of Directors, Managers, Executives, and the Document Controller are notified that a document is being reviewed. This notification is by email. 5.2 Once changes are made to the document a draft copy is uploaded electronically via the intranet for review, and an email is sent out to all relevant personnel to notify them of the changes. The agreed time period for responses is 1 week.
5.3 At the end of the period all responses are printed and given to the document authoriser for consideration. The Authoriser will either make the decision on the document upgrade or where there is need for negotiation, arrange for a forum for the responses to be negotiated and a final draft agreed to. The document development process through to final issue will not be delayed unduly.
a. The Board of Directors for all Organisation Wide policy and procedure documents. b. The company ECM for all documents related to Human Resources Management such as job descriptions, as well as documents related to the clinical care of Residential Aged Care Residents.
c. The CEO for all other relevant documents.
5.5 The Final Draft is then given to the Document Controller for issue, distribution and control. Document issue is flagged by an email to the document stakeholders from the Document Controller.
5.6 The initiation and coordination of training arising from changed to the document is the responsibility of the document Authoriser. Training is synchronised with the issue of the document into the system. If there is a specific need to have all team members trained prior to the issue of the document, it is the responsibility of the document authoriser to work with the Document Controller to achieve this.
6. Document Identification
The file name is the identifying feature of each Controlled Document. Please see Appendix 1 and Appendix 2 for correct coding abbreviations.
D. Coding Controlled Document Policies and Procedures – Residential Aged Care 1. RAC documents are coded in the following format: AAA-1-23-4560 (example
only).
2. “AAA” would then be the Category of the document.
3. The next digit, “1” of the policy, is the Standard that the policy qualifies under. These standards are outlined under the Department of Health And Aging website and are only numbered 1-4.
4. The next two digits, “23”, is the outcome that is expected under the standards outlined above.
5. “4560” is simply a number that is only affiliated with the order in which each Policy/Procedure has been published within each Category and Standard, and is numbered in sets of ten. It has no particular significance other than this. For instance, “4560” would be the 456th policy/procedure applied to the Intranet
database, within Standard 1 of RAC. If the number was, instead, ILU-1-23-4560, it would the 456th policy/procedure within the ILU Standard 1. RAC Standard 2 would again start from the beginning (ie. “0010”), and continue up.
6. You must be sure to check the Masterfile to ensure that the code you are giving the document is not being used already, as some files are not uploaded to the Intranet (See Procedure D – Updating the Masterfile).
B. Coding Controlled Document Policies and Procedures – All other Documents 1. Documents that do not have Standards or Outcomes will have an abbreviated
2. They would then be listed numerically in the order they are entered onto the Intranet.
3. You must be sure to check the Masterfile to ensure that the code you are giving the document is not being used already, as some files are not uploaded to the Intranet (See Procedure D – Updating the Masterfile).
C. Coding Duplications of Policies and Procedures
1. Occasionally there is a controlled document that is required in two different categories. For instance, sometimes a document like “Harrassment in the Workplace”, would be an HR document, but also fall under the category of Residential Aged Care. Because they are in two different places, you must first ensure that it is documented for both areas in the Masterfile (see Procedure – Updating the Masterfile).
2. When the document is from Residential Aged Care, first follow steps outlined in A. For the secondary copy (for instance, placing it on the Intranet under the heading “HR”), keep the exact same numerical code, but change the “RAC”, to “HR”, or whichever particular one it applies to. This will tell you at a glance that it is not just an HR document, but also a “RAC’s” document, because of the format of the serial code.
3. For all other documents, again ensure that it is shown in the Masterfile, as that is the crucial place in which all other information about that document can be derived.
7. Document Control
A. Saving Word and pdf Controlled Documents
1. All Word documents that have been approved as a Controlled Document are to be found in the relevant folder: T:\\Aged Care\Chrystal’s Folder\Controlled
Documents\Intranet Word, and then divided according to category (which is reflected on the Adventist Aged Care Intranet Website).
2. Word Controlled Documents are to remain with the Document Controller. They may only be given to the Board of Directors, ECM,CEO, or those specified by these representatives. All Word documents, to be considered Controlled, are to be converted to PDF.
3. Word documents can be converted to PDF by: • Opening the relevant document.
• Clicking on the File Menu. • Dropping down to “Save As” • Clicking on “Adobe PDF”.
4. PDF documents are to be saved in: T:\\Aged Care\Controlled Documents\Intranet PDF, and then dividd according to category (which is reflected on the Adventist Aged Care Intranet Website.
Example of PDF and Word folders with address:
5. A hard copy is to be printed off of any new or updated controlled document. A new document is to be filed according to its category in the folders located on the Admin desk. An updated controlled document is to replace the existing hard copy, and the hard copy is to be disposed of in an appropriate manner.
8. Masterfile Use
The Masterfile is an essential tool for the Document Controller. It is an extensive list of all Controlled Documents within Adventist Aged Care, South Queensland, as well as uncontrolled documents of importance and of supplementary nature to the day to day processes of the company (see Example A below):
Example A:
8.1 The Masterfile is in Excel format.
8.2 The Masterfile spreadsheet is divided into sections for easier use and accessibility. Categories can be found on the lower tabs of the Excel sheet (see example A). These tabs roughly reflect the categories as shown on the Intranet Website and the green levels of Appendix 3.
8.3 The following are the sections that need to be addressed when adding a controlled document: a. Document ID – This is the serial code for the document. Please see 6.“Document Identification”. b. Document Name – This is the title of the Controlled Document. Please write it in full, as some titles can be of similar nature.
c. Date Reviewed – This is the last date the document has been reviewed.
d. Date to Review – For documents to remain current and effective they need to be regularly reviewed for accuracy and validity. The following timeframes govern the document review process for controlled documents within Adventist Aged Care SQ Ltd;
Policies 3 Yearly
Guidelines 3 Yearly
Forms Annually (or as needed) Manuals Annually (or as needed) Procedures Annually – 3 yearly Reference Material Annually
These review periods are to be considered maximum review periods and where conditions
governing the use of these documents change, then a review will need to be conducted at that time. e. Also Located In – When documents are located in two sections of the Intranet, it is imperative to document what other area they are, including any change to the serial code. This should be reflected at both sides of the Excel, so that they reflect each other.
f. Initials of Individual Changing – Should changes be made by anyone other than the designated Document Controller, they need to initial this section, as well as insert a comment of any relevant changes, for the Document Controller to review and approve or modify as needed. No one is authorised to make changes to the Masterfile except the Document Controller without consent of either the Document Controller, the ECM, the CEO, or the Board of Directors.
Document Backup
In the case of Seventh-day Adventist Church (South Queensland Conference ) Ltd, this will be an automatic backup process which is currently in place for ‘T’ Drive. the event of a Word document being lost for any reason, the published controlled document in PDF form must be used to create a replacement. All Controlled Documents currently in use are also found on the Intranet from the
Appendix 1 – Abbreviations and Coding Table for the different kinds of Controlled Documents on the Intranet:
Category Sub-Categories Abbreviation
Organisation Wide – Human Resources
NA HR-0 or HR-0-00-000 with RAC’s duplicates.
Organisation Wide – Human Resources
Workplace Agreements HR-WA-0 Organisation Wide Workplace Health and Safety WHS-0-00-0000
Link to RAC 4.5 Residential Aged Care –
Standard One
Outcomes 1.1-1.9 RAC-1-00-0000 Residential Aged Care –
Standard Two
Outcomes 2.4-2.17 RAC-2-00-0000 Residential Aged Care –
Standard Three
Outcomes 3.4-3.10 RAC-3-00-0000 Residential Aged Care –
Standard Four
Outcomes 4.4-4.8 RAC-4-00-0000
Clinical Governance Clinical Governance Policy CP-0-00-0010 Clinical Governance Implementation Guidelines CP-0-00-0020
Clinical Governance Clinical Policies (link to RAC standards) Clinical Governance CQI Forms (link to Forms)
Clinical Governance - Audits Audit Schedule AUD-0-0-0000 Clinical Governance - Audits System Audits AUD-S-0-0000 Clinical Governance - Audits Clinical Audits AUD-C-0-0000 Clinical Governance - Audits Resident Lifestyle Audits AUD-RL-0-0000 Clinical Governance - Audits Health and Safety Audits AUD-HS-0-000 Clinical Governance Executive Care Manager
Themes
Clinical Governance HR Policies (Link to Organisation Wide) Clinical Governance Competencies COMP-0
Clinical Governance Risk Management (Link to Community Care) Forms Audits (Link to Clinical
Governance-Audits)
Behaviour Management F-0-BM
Clinical Forms F-0-CLIN
CQI Forms F-0-CQI
HR Forms F-0-HR
Risk Management Forms F-0-MISC
Appendix 2 – Abbreviations and Coding Table for the different kinds of Uncontrolled Documents on the Intranet
Category Sub-Categories Abbreviation
Reference Material ACFI ACFI-REF-0
Clinical CLIN-REF-0
Fire and Emergency FA-REF-0 Workplace Health and Safety WHS-REF-0 Aged Care Act and Standards ACA-REF-0 Dep’t of Health and Aging DHA-REF-0
Industrial Relations IR-REF-0
Community COM-REF-0
Appendix 3: Intranet Map Headings – Seventh Day Adventist Aged Care (South QLD)
Organisation Wide Home Page:
Human Resources Organisation Wide
Finance & Admin
Residential Aged Care Independent Living Community Care Packages
Finance & Administration Clinical Governance Forms Reference Material Drafts (HR-#, HR-#-##-####) Workplace Agreements (HR-WA-#)
Workplace Health and Safety (WHS-#-##-###, RAC 4.5) Residential Aged Care Standard One Standard Two Standard Three Standard Four Independent Living Empty Community Care Packages Governance (links) Care& Lifestyle (links) Human Resources (links)
Risk Management (links) Business Services (links)
Empty
Clinical Governance
Clinical Governance Policy Implementation Guidelines Clinical Policies CQI Forms Audits (AUD-LETTER-####) • Audit Schedule • System Audits • Clinical Audits • Resident Lifestyle Audits
• Health & Safety Audits
• Focus Audits
Executive Care Manager Themes • CP-0-00-0030 HR Policies
Competencies Risk Management
Clinical Policies
Link back to Residential Aged Care Documents
Section
Forms
CQI Forms
Links to Forms Section
Human Resources
Links back to Audits (link back)
Behaviour Management (F-#-BM) Clinical Forms (F-#-CLIN) Community Forms (F-#-COM)
CQI Forms (F-#CQI) HR Forms (F-#-HR) Risk Management Forms
(F-#-MISC) WHS Forms (F-#-WHS) Competencies Lists Competencies 1-9 (COMP-#) Risk Management Risk Management Reference Material ACFI (ACFI-REF-#) Clinical (CLIN-REF-#) Fire and Emergency (FE-REF-#) Workplace Health and Safety
(WHS-REF-#)
Aged Care Act & Standards (ACA-REF-#)
Dep’t Health and Aging (DHA-REF-#) Industrial Relations (IR-REF-#)
Standard One Outcome 1.1-1.9 (RAC-#-##-####) Standard Two Outcome 2.4-2.17 (RAC-#-##-####)
