The document below provides a suggested Governance Framework template Hospital Foundations may wish to adapt for their own use.

Statutory bodies are required to establish a Governance Framework under section 7 of the Financial and Performance Management Standard 2009 (http://www.legislation.qld.gov.au/LEGISLTN/CURRENT/F/FinAccPManSt09.pdf).

Additional governance resources and templates are available on the OHSA website at: (http://www.health.qld.gov.au/ohsa/html/resources.asp).

[Insert Foundation Name]

Governance FrameworkOverview Governance is aimed at achieving organisational goals and objectives, and can be described as the set of responsibilities and practices, polices and procedures used to provide strategic direction, ensure objectives are achieved, manage risks and use resources responsibly and with accountability1.

Good governance is fundamental to achieving our mission. The [insert Foundation name] Governance Framework is designed to assure adequate accountability to our many stakeholders and to encourage performance improvement while meeting our obligations and legislative requirements. It is intended that the Framework will assist [insert Foundation Name] staff to understand and apply the principles of good governance, and to assess the strengths and weaknesses of current governance practice and improve it.

The principlesThe framework is based on six (6) good governance principles:

1. a common sense of purpose and direction2. the organisation is functionally and structurally aligned to achieve its objectives3. clear understanding of expectation in roles and responsibilities4. being clear about the responsibility and authority of individuals and groups5. outcomes are expressed in measurable terms and reported upon in an accurate, reliable and

timely manner6. there are consequences for good and poor performance with emphasis on recognition, learning

and improving.

The mechanismsThe mechanisms are the practices, policies, processes and documents associated with each of the principles, which are used to drive and support good governance in practice. The mechanisms and their alignment to the six governance principles are noted in the figure below. Some of these mechanisms are mandatory for the Foundation, for example, because they are required under legislation, whilst others represent good practice.

1 Australian Public Service Commission. 2007. Building Better Governance. Australian Government.Hospital Foundation Governance Framework Template Page 1 of 10

The Financial and Performance Management Standard 2009 (FPMS) (s7) prescribes the requirement for a statutory body, such as a Hospital Foundation, to establish a governance framework.

- Planning

- Stakeholder Engagement

- Risk Management

- Board

- Organisation Structure

- Committee Structure

- Role Descriptions

- Code of Conduct

- Probity and Ethics

- Delegations

- Performance Framework

- Performance Management Framework

- Legislation

- Committee Terms of Reference

- Annual Reports

- Monitoring and Reporting

- Annual Financial Statements

- Patient, Family, Volunteer and Staff Experience

- Evaluation

- Risk Management

- Audit

- Organisational Development

Governance maturity matrix (appendix 1)The maturity matrix enables the [insert Foundation Name] (Board and Executive) to assess its governance standards against best practice. Use of the matrix provides an overview of the strengths and weaknesses of current governance practice, and assists with prioritising activities that will strengthen governance standards. The maturity matrix identifies three levels of maturity – developing, established and mature – and some corresponding indicators that may demonstrate the Foundation is functioning at that level. This is intended to allow the Foundation to identify strengths and areas that require development, track progress and identify a pathway towards achieving best practice.

Resources and Tools (appendix 2)Appendix 2 provides a list of useful resources and tools to assist in operationalising the governance mechanisms.

ACNC Governance StandardsThe [insert Foundation Name] is aware that the Australian Charities and Not-for-profits Commission Act 2012 (ACNC Act) establishes a framework for a set of minimum governance standards applicable to registered charities from 1 July 2013.

The [insert Foundation Name]’s has reviewed the standards to ensure the Foundation is meeting the proposed standards and has practices and procedures in place to cover them. [It may be beneficial to list the standards and expand on how the Foundation meets each standard. Information on the minimum governance standards is available on the ACNC website at: (http://www.acnc.gov.au/ACNC/Manage/Ongoing_Obs/Governance/ACNC/Edu/GovStds_overview.aspx).]

Standard 1: Purposes and not-for-profit nature of a registered entity

Standard 2: Accountability to members

Standard 3: Compliance with Australian laws

Standard 4: Suitability of responsible persons

Standard 5: Duties of responsible persons

Hospital Foundation Governance Framework Template Page 2 of 10

Appendix 1 – Governance Maturity Matrix

Progress Levels DevelopingMinimum mandated requirements metPrinciples accepted and commitment to action / Documented processes in place

EstablishedFirm progress in development of good systems / processesResults being achieved

MatureComprehensive assurance framework in placeOngoing review and improvement evidentGovernance Principles

1. Common sense of purpose and direction

Governance Mechanisms: Planning Stakeholder Engagement Risk Management

Organisational purpose debated and agreed.

Values and priorities identified and agreed with stakeholders.

Strategic Plan developed that complies with Queensland Government requirements (including identification of risks) and affirms Foundation purpose and vision.

Operational Plan(s) in place that document key delivery areas for each team/service area.

Any non-compliance with strategic plan/priorities is explained.

Informal/ad hoc processes for engaging stakeholders are in place.

Stakeholder Engagement Strategy developed.

Enabling plans developed focusing on key activities that underpin the Foundation’s activities, e.g. events, relationship management, marketing and communications, workforce, volunteers, corporate services.

A Risk Management and Assurance Framework is in place across the Foundation. Known risks are identified and treatment plans are in place.

Foundation plans (operational, enabling etc.) are clearly aligned to the Strategic Plan and support the Plan’s delivery.

Key targets and objectives within Foundation plans are reflected in Executive staff performance agreements (or equivalent).

Evidence that targets and priorities are being met.

Regular reporting to Board and Executive in place.

Process for regular review of Foundation strategic Plan/directions is in place.

Formal links/processes for engaging relevant stakeholders are in place and documented.

Formal strategies for ensuring appropriate engagement with the workforce and workforce stakeholders are in place.

A high degree of understanding and awareness of risk can be demonstrated across the Foundation. Operational risks are managed at point of delivery. Key strategic risks have been identified and recorded and are reviewed regularly by the Board.

The Foundation’s risk appetite (tolerance) has been discussed and agreed by the Board. This has been communicated across the Foundation and built into plans.

Board schedules annual debate on organisational purpose, in light of achievement of purpose during the year, and sets the future strategic direction of the Foundation.

Foundation has an integrated planning process in place which aligns strategic, operational and other planning with resource allocation.

Evidence that effective partnership working and mutually beneficial relationships with stakeholders have been established. Staff, supporters and the community trust the organisation.

The Board is confident that it has intelligent analysis and assurance regarding the risks faced by the Foundation. Foundation risk profile informs the Board’s review of strategy.

The Board is engaged in evaluation of fundraising/business failures elsewhere and potential applicability /occurrence within the Foundation.

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Progress Levels DevelopingMinimum mandated requirements metPrinciples accepted and commitment to action / Documented processes in place

EstablishedFirm progress in development of good systems / processesResults being achieved

MatureComprehensive assurance framework in placeOngoing review and improvement evident

Governance Principles

2. The organisation is functionally and structurally aligned to achieve its objectives

Governance Mechanisms: Board Organisation Structure Committee Structure

Organisational structure is documented based on the main functions required to raise funds (consistent with the Hospital Foundations Act 1982) and to achieve the strategic direction of the Foundation.

Committee structure in place that is aligned to organisational structure and functions.

Annual cycle of Board activity established.

Board and committee support role/s (secretariat) identified and defined.

Workforce strategy developed and documented.

Organisational structure is established that provides clear reporting lines and clarity on functional area responsibilities.

All positions report to a higher position.

Committee structure in place with clear terms of reference and scheme of delegation and reporting. Committees contain work at a devolved level, except where tolerances are breached requiring escalation.

All committees report to a higher level committee or position.

Annual cycle of Board activity is in place, including reporting processes.

A dedicated resource(s) is in place to support the administration and effectiveness of the Board and its committees.

Workforce strategy is clearly aligned to the Strategic Plan and supports the Plan’s delivery. Strategies to develop organisational capability and capacity in place across the Foundation.

Committee structure and functions are reviewed. Committees are working effectively. Board is able to focus on strategic decisions.

Temporary committees/project groups report on progress and conclude when their purpose/objectives are delivered.

The Board is leading, rather than following, agendas.

Wider community resources are leveraged to improve organisational capability/performance.

There is an identified position providing acompliance and tracking role for the Board and its business.

The Foundation can demonstrate that it is an employer of choice. Formalised succession planning is in place.

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Progress Levels DevelopingMinimum mandated requirements metPrinciples accepted and commitment to action / Documented processes in place

EstablishedFirm progress in development of good systems / processesResults being achieved

MatureComprehensive assurance framework in placeOngoing review and improvement evident

Governance Principles

3. Employees and Officers have a clear understanding of expectations in roles and responsibilities

Governance Mechanisms: Role Descriptions Code of Conduct Probity and Ethics Delegations Performance Framework

Induction and orientation programs developed to inform new staff and Board Members of key topics of culture, values, organisational structure and mission, as well as Foundation policies, procedures and contacts.

Every position has a corresponding role description documented.

Staff and Board Members are familiar with their ethical obligations under the Public Sector Ethics Act 1994 and their responsibility to uphold the ethics principles and values and the Foundation’s code of conduct.

The Board has explicit and accepted standards of conduct in place.

A conflict of interest register is in place and is updated by the Board and staff regularly. Identified conflicts are reviewed and appropriate action taken. Board members are clear about when to absent themselves from Board discussions and decisions.

Delegations are in place to ensure that responsibilities are matched with the necessary authority.

Instruments of delegation are easily accessible and understandable to those required to perform delegated functions or those impacted by these delegated functions.

A performance management framework for the Foundation’s staff is in place.

Performance and development agreements (PDAs are in place for Foundation staff.

Induction and orientation programs are promoted and delivered to new staff and Board Members.

Role descriptions clearly articulate how an individual’s role assists in achieving organisational objectives.

Identified conflicts of interest and inappropriate behaviour are properly considered and the Board is confident that any appropriate actions are followed through.

Systems and processes are in place to assess the level of adherence to delegations.

Instruments of delegation and delegation manuals are kept current.

Accountability for delivery of the Foundation’s strategic objectives is articulated through executive staff objectives. Operational plans and staff objectives are informed by executive staff objectives and accountabilities.

Performance and development plans align individual staff objectives with the objectives within the team/service area’s operational plan. The PDA process is used to clarify roles and responsibilities, performance expectations and developmental requirements/opportunities.

Induction programs are in place which convey expectations specific to teams/service areas.

The Foundation has acquired a reputation for its good governance practice.

Role descriptions are consistent with Foundation objectives and operational plans.

The Board and executive team demonstrate and uphold the principles and values of the code of conduct and promote an organisational culture that values high ethical standards and behaviour.

Effective procedures are in place for review of delegations.

Changes to delegations are communicated clearly and in a timely manner to affected employees.

Evidence that the Foundation’s strategic direction is being achieved through executive staff objectives. All members of the Board and Foundation executive team are recognised as adding value.

Evidence that team/service area operational plans are being achieved through individual staff objectives.

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Progress Levels DevelopingMinimum mandated requirements metPrinciples accepted and commitment to action / Documented processes in place

EstablishedFirm progress in development of good systems / processesResults being achieved

MatureComprehensive assurance framework in placeOngoing review and improvement evident

Governance Principles

4. Individuals and groups (committees) are clear about their respective responsibility and authority

Governance Mechanisms: Performance

Management Framework Legislation Committee Terms of

Reference

The Board is familiar with its statutory and other obligations.

The roles, responsibilities and obligations of Board members are clear, agreed and specified.

Board induction and development program in place.

Terms of reference in place for all committees and project groups.

Staff are able to access information on the legislative requirements of their position.

Performance Management Framework for the Foundation agreed, which includes KPIs/metrics that allow monitoring against the Foundation’s strategic objectives and the service standards specified within the operational plan.

Board competencies agreed. Gaps identified and training/development in place.

Board self-assessment of performance annually.

Committee terms of reference are reviewed annually.

Process for tracking compliance in place with regular reports provided to the Board (including compliance with legislation).

Non-compliance with statutory and other obligations is identified and addressed in a timely manner.

Performance Management Framework for the Foundation implemented and performance expectations communicated to staff through performance agreements (or equivalent) and staff objectives.

Performance of committees and project groups against terms of reference/objectives reviewed on regular basis (+/- annually). Business of the committee reflects the committee’s functions as per the terms of reference.

Governance systems and structures are reviewed to ensure they remain fit for purpose.

A resource is identified to provide expert advice to the Board and Foundation staff on compliance.

Changes to statutory and other obligations are communicated to the Board and staff proactively and clearly.

5. Outcomes are expressed in measurable terms and reported in an accurate, reliable and timely manner

Governance Mechanisms: Annual Reports Monitoring and Reporting Annual Financial

Statements Patient, Family, Volunteer

and Staff experience

Procedures developed to monitor, measure and report performance results.

Foundation meets reporting requirements set by Government.

Information and reporting requirements have been communicated to the Board and Foundation Committees.

Board receives regular performance reports and is notified of variance to performance.

Formal and coordinated reporting to monitor performance against fundraising and donations /& volunteer services targets is in place with a clearly defined governance pathway.

Processes in place to ensure data quality and integrity.

High quality information is routinely generated for the Board and Board Committees.

The Board takes decisions based on evidence.

Formalised processes in place to seek patient, family, volunteer, and staff experience and feedback.

Decision taking is improved through high quality, timely information.

Performance monitoring is aligned to the planning cycle and debate on organisational purpose.

Reporting arrangements are reviewed to ensure effectiveness/usefulness.

Patient, family, volunteer, and staff feedback and experience is considered as part of performance monitoring cycle and within the Foundation’s planning activities.

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Progress Levels DevelopingMinimum mandated requirements metPrinciples accepted and commitment to action / Documented processes in place

EstablishedFirm progress in development of good systems / processesResults being achieved

MatureComprehensive assurance framework in placeOngoing review and improvement evident

Governance Principles

6. There are consequences for good and poor performance with emphasis on recognition, learning and improvement

Governance Mechanisms: Evaluation Risk Management Audit Organisational

Development

There is a process in place to prospectively evaluate risks.

Mechanisms in place to provide Board with assurance that risks are being effectively managed.

Audit Committee established. (not mandatory)

Documented process for dealing with good and poor organisational performance that is consistent with the Foundation’s Performance Management Framework.

Escalation protocol for performance variance agreed.

Individual performance is monitored against agreed performance and development plans.

Commitment to organisational development made by Board. Strategy under development.

Continuity plans are regularly tested and there is a sound understanding of risks and opportunities.

Audit Committee role developed to provide independent scrutiny of Foundation’s activities.

Opportunities for staff training and development are identified, including opportunities for recognition and success sharing.

Organisational development strategy is in place, with an emphasis on developing capability and capacity across the Foundation.

The Board is confident that it can respond in a timely fashion to serious crises, should the need arise.

Audit Committee is recognised for playing a key role in scrutiny of the Foundation’s activities.

Good performance is acknowledged. Strategies are in place to support the recognition and sharing of success, and promote learning and improvement.

The Board and Foundation Executive promote through example an organisational culture that supports continuous improvement in outcomes/service delivery.

The Board allows others to observe and challenge its ways of working.

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Appendix 2 – Resources and Tools

Governance Principle

Document name Purpose Location/Link

Principle 1:

Purpose and Direction

Agency Planning Requirements

This document provides agencies with information for strategic planning, operational planning and other specific purpose planning. Compliance with this document is mandated under the Financial and Performance Management Standard 2009.

Department of the Premier and Cabinet (Performance and Delivery Office)

Email: pm@premiers.qld.gov.au

(http://www.premiers.qld.gov.au/publications/categories/plans/planning-requirements.aspx)

Strategic Plans – Minimum Requirements Checklist

Operational Plans – Minimum Requirements Checklist

Strategic Planning for Government Bodies - Webcast

These fact sheets provide a summary of the minimum requirements (taken from the Agency Planning Requirements) for a statutory body in relation to developing a strategic and an operational plan.

The webcast also provides guidance on the strategic planning process and requirements.

Office of Health Statutory Agencies

http://www.health.qld.gov.au/ohsa/html/resources.asp

A Guide to Risk Management

These guidelines have been prepared as an information reference and contain the minimum principles and procedures of a basic risk management process.

The guide is not mandatory, however, application of the guide will encourage better practice.

Queensland Treasury and Trade

(http://www.treasury.qld.gov.au/office/knowledge/docs/risk-management-guide/index.shtml)

Principle 3:

Roles and Responsibilities

‘Governing Queensland’ Handbooks, including ‘Welcome Aboard’

A suite of five handbooks and a guide for members of Queensland government boards, committees and statutory authorities which explain the process of government in Queensland and the responsibilities of key participants.

‘Welcome Aboard: A guide for members of government boards, committees and statutory authorities’ sets out the role of these bodies and the responsibilities of those serving as government board members, including their fiduciary duties.

Department of the Premier and Cabinet (State Affairs Branch)

(http://www.premiers.qld.gov.au/publications/categories/policies-and-codes/handbooks.aspx)

Public Sector Ethics Fact Sheet

This fact sheet provides Health statutory agencies with information on the minimum requirements they are obliged to comply with under the Public Sector Ethics Act 1994.

Office of Health Statutory Agencies

http://www.health.qld.gov.au/ohsa/html/resources.asp

Principle 4:

Responsibility and Authority

Statutory Body Guide The Statutory Body Guide has been designed to assist members of a statutory body’s board, management and administrative team in assessing their obligations under the Financial Accountability Act 2009, the Financial and Performance Management Standard 2009 and the Financial Accountability Handbook. The guide is not mandatory but is considered to be best practice.

Queensland Treasury and Trade (Financial Management Branch)

Email: fmhelpdesk@treasury.qld.gov.au

(http://www.treasury.qld.gov.au/office/knowledge/docs/statutory-body-guide/index.shtml)

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Governance Principle

Document name Purpose Location/Link

Financial Accountability Handbook

The Financial Accountability Handbook is designed to assist accountable officers and statutory bodies discharge their responsibilities under the Financial Accountability Act 2009, the Financial and Performance Management Standard 2009 and the Financial Accountability Regulation. Section 15(2) of the Financial Accountability Act 2009 requires accountable officers and statutory bodies to have regard to the Financial Management Handbook published by Queensland Treasury.

Queensland Treasury and Trade

(http://www.treasury.qld.gov.au/office/knowledge/docs/financial-accountability-handbook/index.shtml)

Financial Reporting Requirements for Queensland Government Agencies

These annual financial statement requirements include the minimum reporting requirements and assist statutory bodies in the preparation of their financial statements.

Queensland Treasury and Trade

(http://www.treasury.qld.gov.au/office/knowledge/docs/fin-reporting-req/index.shtml)

Financial Management Tools

The financial management tools contain a number of examples and consideration points to assist statutory bodies in assessing their obligations under the current financial legislation in Queensland and the Financial Accountability Handbook. The tools provided are not mandatory and may be adapted or modified to meet the needs of individual organisations.

Queensland Treasury and Trade

(http://www.treasury.qld.gov.au/office/knowledge/docs/financial-management-tools/index.shtml)

Financial Management Practice Manual (FMPM) Guidance Template for Hospital Foundations

The Office of Health Statutory Agencies has developed the FMPM Guidance Template to assist Hospital Foundations in the development of their own FMPM. Modelled on the financial management methods of a range of public sector entities, the template provides questions, prompts and directions to guide the development of a financially sound and robust FMPM.

Office of Health Statutory Agencies

(http://www.health.qld.gov.au/ohsa/html/hf-fmpm-guide.asp)

Queensland Procurement Policy

The Queensland Procurement Policy (QPP) provides an overarching principles-based framework that seeks to deliver excellence in procurement outcomes for Queenslanders. All statutory bodies are required to comply with the Queensland Procurement Policy and Queensland's trade agreement obligations.

Department of Housing and Public Works

(http://www.hpw.qld.gov.au/supplydisposal/governmentprocurement/ProcurementPolicyGuidance/StateProcurementPolicy/Pages/Default.aspx)

Office of Health Statutory Agencies – Procurement/Purchasing Requirements Fact Sheet (under review to align with the QPP):

http://www.health.qld.gov.au/ohsa/html/resources.asp

Principle 5:

Outcomes

Queensland Government Performance Management Framework and Guide to the Queensland Government Performance Management Framework plus on-line tools

The Guide to the Queensland Government Performance Management Framework presents a practical overview of the key concepts within the Performance Management Framework. It assists government agencies develop a greater understanding of the Performance Management Framework and provides assistance in the following areas:

planning

resource management

performance management and monitoring

Department of the Premier and Cabinet (Performance & Delivery Office)

Email: pm@premiers.qld.gov.au

(http://www.premiers.qld.gov.au/publications/categories/guides/perf-manage-framework.aspx)

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Governance Principle

Document name Purpose Location/Link

performance reporting.

Better Practice Guide: Output Performance Measurement and Reporting

This better practice guide provides a checklist to support effective output performance measurement and reporting, recommendations on what to include in a performance measures or ‘data’ dictionary and provides signposting to further reference material and information on the compilation and reporting of performance information.

Queensland Audit Office

(http://www.qao.qld.gov.au/downloadables/publications/best_practice/qao_bpg_output_report.pdf)

Annual Report Requirements for Queensland Government Agencies

This document provides information about the legislative and reporting requirements for annual reports for all Queensland Government agencies, including statutory bodies.

Department of the Premier and Cabinet (Performance and Delivery Office)

(http://www.premiers.qld.gov.au/publications/categories/guides/annual-report-guidelines.aspx)

Better Practice Guide: Performance Reviews

This better practice guide has been developed to assist organisations to adopt a performance review system that enables analysis and interpretation of performance information, facilitates discussions on how performance can be improved and translates these discussions into action. It will help agencies to satisfy the objectives of the Queensland Government Performance Management Framework.

Queensland Audit Office

(http://www.qao.qld.gov.au/downloadables/publications/best_practice/qao_bpg_performance%20_reviews.pdf)

Principle 6:

Consequences

Audit Committee Guidelines: Improving Accountability and Performance

These guidelines have been prepared to assist agencies with the establishment and maintenance of audit committees.

Queensland Treasury and Trade

(http://www.treasury.qld.gov.au/office/knowledge/docs/improving-performance/index.shtml)

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