Information sheet: Health statutory agencies - key ... · Web viewHospital foundations – key compliance requirements. This purpose of this information sheet is to assist foundations

Information sheet

Hospital foundations – key compliance requirementsThis purpose of this information sheet is to assist foundations to identify the legal and administrative framework within which they operate, and describe key requirements with which foundations must comply. It also includes links to useful documents to assist foundations to identify and meet their legislated and broader compliance requirements.

This document has been prepared to accompany the ‘Hospital Foundations – compliance activity calendar’.

Legal and administrative framework for statutory body operation Hospital foundations (foundations) are separate legal entities and, more specifically, statutory, corporate

bodies established under the Hospitals Foundations Act 1982 (HF Act). As statutory bodies, their organisational structure provides flexible and independent oversight and the ability to control their own funds.

Foundations are governed by their enabling legislation (HF Act) and certain other legislative requirements common to Queensland government bodies.

As statutory bodies, the Financial Accountability Act 2009 (FA Act) and Statutory Bodies Financial Arrangements Act 1982 (SBFA Act) apply.

The table at Attachment 1 identifies key legislative and other requirements with which foundations must comply, and may assist in the development of a compliance register. Rows highlighted blue indicate that a requirement (or part thereof) may not apply to a particular foundation. Accordingly, each foundation should make its own assessment in that regard. If assistance is required, the Office of Health Statutory Agencies (OHSA) can be contacted to assist ([email protected]).

NB. Attachment 1 is not a comprehensive list of obligations and is therefore illustrative only. It should not be relied on as a source document in its own right – original documentation should be consulted.

AttachmentsAttachment 1 – Hospital foundations key compliance requirements template

Contact for further informationContact Telephone Email

Office of Health Statutory Agencies 3708 5034 [email protected]

Revision historyDate Version no. Description of change/revision

23/10/2015 v.1.0 Endorsed first version

Attachment 1 – Hospital foundations key compliance requirements template

Mandatory requirements for foundations Reference Date/timeframe Accountability1 Supporting documentsEnabling legislation – Hospitals Foundations Act 1982 and Hospitals Foundations Regulation 2015Register objects in the register maintained by the Department of Health (currently Cabinet and Parliamentary Services) and seek Ministerial approval before altering any registered objects

s9, s11 Board2 Hospitals Foundations Act 1982 (HFA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundA82.pdf)

Seek and obtain Ministerial approval before engaging in any of the following: -

- acquiring the whole or a share in a business; - entering into a partnership or arrangement for

sharing profits; - dealing with the shares, debentures or

securities of any corporation;- entering into arrangements with any

government, authority or person/s to discharge the foundation’s functions;

- making money or awards to persons concerned in inventions or discoveries;

- selling or otherwise disposing of its land or buildings;

- exchange its property for shares, debentures or securities in a corporation with similar objects;

- improving, developing, exchanging, leasing or turning to account its land or buildings; and

- entering into any contract, agreement or arrangement relating to any of the above

s15 Board Hospitals Foundations Act 1982 (HFA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundA82.pdf)

Foundations must consist of at least seven members including:

- the associated HHB’s chairperson or chairperson’s nominee

- an employee of an associated university or other body providing tertiary education;

s18 Board Hospitals Foundations Act 1982 (HFA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundA82.pdf)

1 When creating your own document this column could be used to identify the officer / staff member accountable for compliance with this requirement, e.g. Chief Executive Officer / Chief Finance Officer / all staff. Suggestions are made in some boxes. 2 ‘Board’ is used to refer to the members of the Foundation/body corporate. Information sheet: health statutory agencies – key compliance requirements - 2 -

Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documents- at least two officers or employees at an

associated hospital

Member resignations must be made in writing, signed, and addressed to the Minister for Health

s24 Members Hospitals Foundations Act 1982 (HFA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundA82.pdf)

Members must seek the Board’s prior approval for absences from board meetings

s24 Members Hospitals Foundations Act 1982 (HFA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundA82.pdf)

Members must disclose conflicts of interest related to matters under consideration at a meeting, record the disclosure in the minutes and, unless the foundation otherwise determines, the member must not be present during deliberation or decision making in relation to the matter.

s25 Members Hospitals Foundations Act 1982 (HFA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundA82.pdf )

Members must act honestly at all times in discharging their powers and must not make improper use of their office or information acquired by virtue of holding office to gain an advantage for themselves/others or to cause detriment to the foundation.

s25A Members Hospitals Foundations Act 1982 (HFA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundA82.pdf)

Chairperson or Deputy Chairperson resignations must be made in writing, signed, and addressed to the Minister for Health

s28(4) Chairperson or Deputy Chairperson

Hospitals Foundations Act 1982 (HFA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundA82.pdf)

Written notice of meetings must be given (by post or in person) to members at least seven days prior to the meeting date (unless the Chairperson or two members consider circumstances exist that constitute an emergency)

s33 Board Hospitals Foundations Act 1982 (HFA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundA82.pdf)

Exercise or performance of power, authority, function or duty of the foundation must be made by a majority vote of members present at a meeting and voting on the business in question.

s34 Board Hospitals Foundations Act 1982 (HFA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundA82.pdf)

Chairperson shall give effect to any resolution, minute or report that is passed or adopted by the foundation.

s34 Chairperson Hospitals Foundations Act 1982 (HFA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundA82.pdf)

Record of proceedings at meetings (i.e. minutes) must be kept

s35 Board Hospitals Foundations Act 1982 (HFA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundA82.pdf)

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Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documentsA Foundation Secretary must be a suitably senior officer of an associated hospital who is nominated by the health service chief executive of that HHS

s37 Secretary Hospitals Foundations Act 1982 (HFA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundA82.pdf)

The common seal of a foundation must be kept in the custody of the secretary of the body corporate or, where there is a vacancy in that position, the Chairperson

s39 Secretary or Chairperson

Hospitals Foundations Act 1982 (HFA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundA82.pdf)

Unless exempted by the Minister, as soon as practicable after a foundation is established, it shall effect insurance in respect of damage to property, death and bodily injury for which it may be held liable for an amount of cover prescribed by regulation or, if not prescribed, for an amount of $100,000 at the least and shall keep such insurance current at all times

NB. The Hospitals Foundations Regulation 2005 does not prescribe an amount, so the minimum is $100,000.

s41 Board Hospitals Foundations Act 1982 (HFA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundA82.pdf)

Hospitals Foundations Regulation 2015 (HFR):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundR15.pdf)

If required by the Minister, a foundation must frame, adopt and present to the Minister a statement showing estimates of its receipts and disbursements in respect of the balance of the financial year, and for each succeeding year thereafter do the same before 31 August (or by a later date with the Minister’s approval).

The foundation must not make disbursements not provided for in the statement without resolution by the Board and Minister’s approval.

If a disbursement is made without Minister’s approval, the members that voted for the disbursement are liable.

ss46, 47 & 49

Members Hospitals Foundations Act 1982 (HFA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundA82.pdf)

Secretary must present to each ordinary meeting statements of account in relation to receipts and disbursements of the month last concluded.

s48 Secretary Hospitals Foundations Act 1982 (HFA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundA82.pdf)

The foundation must establish and maintain a general fund at a financial institution (separate and distinct from any other accounts it has) to be used to meet its

s50 Board Hospitals Foundations Act 1982 (HFA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HospFoundA82.pdf)

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Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documentsobjects, to pay members’ fees or allowances, to pay salaries or wages of employees, and for any other necessary expenditure in discharge of its functions.

PlanningA Strategic Plan is to be developed, compliant with the Department of the Premier and Cabinet (DPC) ‘Agency Planning Requirements’.

s9 FPMS Annually reviewed – published by 1 July

Board Financial and Performance Management Standard 2009 (FPMS): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/F/FinAccPManSt09.pdf) Note: The Financial Accountability Act 2009 and this Standard establish the high level financial management and accountability obligations for all statutory bodies, including the Foundations.

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

Strategic Plans – Minimum Requirements Checklist (OHSA fact sheet): (http://www.health.qld.gov.au/ohsa/docs/sp-reqsv2.pdf)Hospital Foundation Strategic Plan Template: (http://www.health.qld.gov.au/ohsa/docs/hf-strategic-plan-template.doc)

Strategic Planning for Government Bodies Webcast 2013 (OHSA): (http://www.health.qld.gov.au/ohsa/html/sp-webcast.asp)

An Operational Plan is to be developed, which is compliant with DPC’s Agency Planning Requirements.

s9 FPMS Annually (monitored regularly; evaluated / reviewed at least six monthly)

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

Operational Plan – Minimum Requirements Checklist (OHSA fact sheet): (http://www.health.qld.gov.au/ohsa/docs/op-plan-reqsv2.pdf)

Annual financial statements are to be prepared, certified (refer note below) and tabled in Parliament in accordance with the prescribed requirements (i.e. have regard to the Financial Reporting Requirements; submitted to the Auditor-General on the date agreed to allow the financial statements to be certified by not later than two months from the end of the financial year).

ss61-62 FAA, s43, s45 FPMS

Annually (included in annual report)

Board Financial Accountability Act 2009 (FAA): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/F/FinAccountA09.pdf)

Queensland Treasury Financial Reporting Requirements (FRRs) for Queensland Government Agencies (including Accounting Policy Guidelines): (http://www.treasury.qld.gov.au/office/knowledge/docs/fin-reporting-req/index.shtml)

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Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documentsNB: some foundations are exempt from the requirement to use the Queensland Audit Office (QAO) for auditing and certification. Exempt foundations can use appropriately qualified private external auditors. A list of foundations exempt from QAO audit is available at: https://www.qao.qld.gov.au/our-business

Please note foundations that have been exempted from QAO audit have been exempted on the basis of being small in size and of low risk. If you wish for your foundation to be exempted, application should be made to the QAO in this regard. Unless exempted, a foundation must use the QAO for audit purposes.

Consider the Auditor-General’s report on audited financial statements, and any matters arising from the Auditor-General’s report.

s46 FPMS Annually Board

An annual report is to be prepared and given to the Minister for tabling. The report must be compliant with the FPMS and DPC’s Annual Report Requirements.

s61, s63 FAA,ss49-53 FPMS,

Annually,tabled in Parliament by 30 September

Board Annual Report Requirements for Queensland Government agencies: (http://www.premiers.qld.gov.au/publications/categories/guides/annual-report-guidelines.aspx)

Annual Reports – Online Publication Compliance Checklist (OHSA fact sheet): (https://www.health.qld.gov.au/ohsa/docs/annual-report-checklist.pdf)

Financial managementEstablish the following for efficiently, effectively and economically managing the financial resources of the foundation–

(a) a revenue management system;(b) an expense management system;(c) an asset management system;(d) a cash management system;(e) a liability management system;(f) a contingency management system;(g) a financial information management system;(h) a risk management system.

In establishing the systems, the foundation must have regard to the Financial Accountability Handbook.

s15 FPMS Board Financial Performance Management Standard 2009: (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/F/FinAccPManSt09.pdf )

Financial Accountability Handbook: (https://www.treasury.qld.gov.au/publications-resources/financial-accountability-handbook/index.php)

Queensland Treasury Financial Reporting Requirements (FRRs) for Queensland Government Agencies (including Accounting Policy Guidelines):(http://www.treasury.qld.gov.au/office/knowledge/docs/fin-reporting-req/index.shtml)

Queensland Treasury – A Guide to Risk Management: (https://www.treasury.qld.gov.au/publications-resources/risk-management-guide/index.php)

Department of Health Risk Management Policy and Standards Policy: (http://www.health.qld.gov.au/qhpolicy/docs/pol/qh-pol-070.pdf)Standard: (http://www.health.qld.gov.au/qhpolicy/docs/imp/qh-imp-070-1.pdf)

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Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documents

Information for Statutory Bodies (this document is designed to assist members of statutory bodies meet their statutory obligations) (https://www.treasury.qld.gov.au/publications-resources/information-for-statutory-bodies/statutory-bodies-information-overview.pdf)

Financial and Performance Management Standard 2009 Requirements (OHSA Fact Sheet): (https://www.health.qld.gov.au/ohsa/docs/fpms-requirements.pdf)

Regularly review systems for managing resources to ensure the systems remain appropriate for managing the financial resources of the Foundation.

s15 FPMS Regularly Board

Prepare and maintain a Financial Management Practice Manual (FMPM) that complies with related legislation, regulation and policies for use by staff in the performance of their financial management roles.

Each person involved in the financial management of a foundation is required to comply with the FMPM.

s16 FPMS Maintain Board FMPM Guidance Template for Hospital Foundations: (http://www.health.qld.gov.au/ohsa/html/hf-fmpm-guide.asp)

Note: The FMPM is the internal instructional manual for the foundation to ensure compliance with the mandated requirements and is the initial point of reference for employees in relation to the foundation’s financial policy.

The accounting practices presented in an FMPM must comply with the latest accounting standards and interpretations issued by the Australian Accounting Standards Board (AASB): (http://www.aasb.gov.au/Pronouncements/Current-standards.aspx)

Developed to assist foundations in the development of their own FMPM, the Guidance Template is 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.

Requirements in relation to establishing a revenue management and user charging system to ensure all revenue is promptly managed and customers are charged an appropriate amount for goods and services provided by the foundation.

s17, s18 FPMS

Board Financial Accountability Handbook: (https://www.treasury.qld.gov.au/publications-resources/financial-accountability-handbook/index.php)

The handbook has been designed to assist accountable officers of departments and statutory bodies discharge their obligations under the FAA, the FPMS, and the Financial Accountability Regulation 2009.

Expenses are to be managed with an expense management system which provides for promptly identifying, approving, managing and recording

s19 FPMS Board Queensland Procurement Policy (QPP) July 2013: (http://www.hpw.qld.gov.au/supplydisposal/governmentprocurement/ProcurementPolicyGuidance/StateProcurementPolicy/Pages/

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Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documentsexpenses and the timely paying of expenses.

To the extent they apply to a foundation, the foundation must comply with the following documents in developing the expense management system: the ‘Queensland Procurement Policy’, and the ‘Queensland Ministerial Handbook’.

Systems must be implemented for credit card facilities that are consistent with the ‘Treasurer’s Guidelines for the use of Queensland Government corporate purchasing card’.

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Note: The QPP provides the framework for all Queensland Government procurement. All statutory bodies (including foundations) are required to comply with the QPP and Queensland’s trade agreement obligations. Refer to the ‘Whole of Government Policy’ section on page 15.

Procurement/Purchasing Requirements (OHSA fact sheet): (http://www.health.qld.gov.au/ohsa/docs/procurement-info-sheet-v2.pdf)

Queensland Ministerial Handbook: (http://www.premiers.qld.gov.au/publications/categories/policies-and-codes/handbooks/ministerial-handbook.aspx)

Treasurer’s guidelines for the use of Queensland Government Corporate Purchasing card:(https://www.treasury.qld.gov.au/publications-resources/treasurers-guidelines-corporate-card/treasurers-guidelines-corporate-card.pdf)

The foundation’s expense management system keeps a record of special payments over $5,000.

s20 FPMS Board

Keep written records and notifications, where applicable, to loss of the foundation’s property as a result of an offence or misconduct or other reason as specified in sections 21 & 22 of the FPMS.

ss21-22 FPMS

Board

Assets managed in accordance with an asset management system that ensures evaluations (similar to business cases) are prepared before acquiring, maintaining or improving a significant physical asset, with a completion review undertaken to ensure that objectives contained in the evaluations were met.

An asset management system must ensure that assets are regularly maintained and must comply with or have regard to:

Non-current Asset Policies for the Queensland Public Sector

Queensland’s Project Assurance Framework Queensland’s Value for Money Framework.

s23 FPMS Board Queensland Treasury Statutory Body Guide - Guide Sheet 4: Evaluating and reviewing significant physical assets: (https://www.yumpu.com/en/document/view/16291438/guide-sheet-4-evaluating-and-reviewing-significant-physical-assets)

Non-Current Asset Policies for the Queensland Public Sector (NCAPS): (https://www.treasury.qld.gov.au/publications-resources/non-current-asset-policies/)

Transaction Policy: (http://www.statedevelopment.qld.gov.au/resources/glam-transaction-policy-dsd.pdf)

Queensland’s Project Assessment Framework (replaces the previous Project Assurance Framework and Value for Money Framework) :

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Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documents

(https://www.treasury.qld.gov.au/projects-infrastructure/initiatives/project-assessment-framework/index.php)

Manage the foundation’s cash in accordance with a cash management system which provides for control and recording of cash transactions.

s24 FPMS Board Financial Accountability Handbook: (https://www.treasury.qld.gov.au/publications-resources/financial-accountability-handbook/index.php)

Manage liabilities in accordance with a liability management system, which promptly and accurately records liabilities, e.g. for operational costs and capital expenditure, and complies with ‘Leasing in the Queensland Public Sector – Policy Guidelines’.

s25 FPMS Board Leasing in Queensland Public Sector Policy Guidelines: (http://www.treasury.qld.gov.au/office/knowledge/docs/leasing-in-qld/index.shtml) Note: These are mandatory guidelines that apply to the lease of all assets, but exclude tenancy leases of real property and leases of passenger or commercial motor vehicles obtained from Q-Fleet by a tied client.

Manage contingent assets and contingent liabilities in accordance with a contingency management system, which promptly identifies, records and reports on contingencies.

s26 FPMS Board Note: A contingent asset or liability crystallises as the result of a future event that is outside the control of the foundation.

Financial Accountability Handbook: (https://www.treasury.qld.gov.au/publications-resources/financial-accountability-handbook/index.php)

Comply with the mandatory principles stated in the Information Standards and ensure that its financial information management system aligns with the targets stated in the QGEA and complies with the Public Records Act 2002.

s27 FPMS Board Current Information Standards (refer also pages 16-17): (http://www.qgcio.qld.gov.au/products/qgea-documents)

Queensland Government Enterprise Architecture (QGEA) 2.0 (refer also pages 16-17 below): (http://www.qgcio.qld.gov.au/products/about-the-qgea)

Public Records Act 2002: (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/P/PublicRecA02.pdf) Provides for the management of public records in Queensland.

Manage strategic and operational risks in accordance with a risk management system.

s28 FPMS Board Queensland Treasury Audit Committee Guidelines – Improving Accountability and Performance: (https://www.treasury.qld.gov.au/publications-resources/improving-performance/index.php)

Establish an internal audit function if directed by the Minister or if the foundation considers it appropriate.

ss29-30 FPMS

Board Financial Accountability Handbook - Volume 2: Governance (2.6 Head of internal audit; 2.9 Internal audit):

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Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documentsSystems for ensuring the internal audit function operates efficiently, effectively and economically must be developed and implemented. The internal audit function must function under an internal audit charter.

(https://www.treasury.qld.gov.au/publications-resources/financial-accountability-handbook/volume-2-governance.php)

The internal audit function prepares a strategic audit plan that provides an overall strategy for the internal audit function for a period of at least one year. The plan must be approved by the foundation. The head of internal audit must consult with an authorised auditor during preparation of audit plans.

s31 FPMS Annually Board

The internal audit function prepares an audit plan for each year that sets out the audits intended to be carried out by the internal audit function during the year. The plan must be approved by the foundation. The head of internal audit must consult with an authorised auditor during preparation of audit plans.

s31 FPMS Annually Board

The internal audit function gives final audit reports to the foundation (to the audit committee if one is established). The foundation must consider the contents of all reports and take the actions considered necessary.

ss32-33 FPMS

As required Board

A foundation may establish an Audit Committee. If they do, they must have regard to the Queensland Treasury document ‘Audit committee guidelines – improving accountability and performance’, develop Terms of Reference, include members of the governing body, etc.

s35 FPMS Board Queensland Treasury Audit Committee Guidelines – Improving Accountability and Performance: (http://www.treasury.qld.gov.au/office/knowledge/docs/improving-performance/index.shtml)

Develop and implement a contract performance guarantee system. Sections 36-41 of the FPMS detail the obligations and responsibilities attaching to contract performance guarantees.

ss36-41 FPMS

Board Note: Contract performance guarantees are securities provided by a contractor, or on a contractor’s behalf, to ensure a contractor completes all obligations under a contract negotiated between an agency and a contractor.

Foundations must comply with Part 5 of the SBFAA in relation to borrowing.

Part 5 SBFAA,

Board Statutory Bodies Financial Arrangements Act 1982 (SBFAA): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/S/StatutryB

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Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documents

There are also requirements under the State Borrowing Program that statutory bodies (including the foundations) must satisfy: (https://www.treasury.qld.gov.au/publications-resources/overdraft/index.php )

Schedule 2 SBFAR

odA82.pdf)

Statutory Bodies Financial Arrangements Regulation 2007 (SBFAR): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/S/StatutryBodR07.pdf) Note: The primary purpose of the Act and regulation is to establish the borrowing and investment powers of statutory bodies (including the foundations). Provisions also address the role of the Treasurer in providing guarantees – under the SBFAA, the Treasurer may guarantee the performance of obligations of a statutory body under a financial arrangement entered into by the body (sections 16 and 76). The Treasurer can charge a fee for this guarantee. The Treasurer can delegate functions under this Act to another Minister.

* The ‘Overdraft Facilities: Operational Guidelines for the Public Sector’ provide guidelines for public sector entities, including statutory bodies entering into overdraft and short term funding facilities.

Foundations are allocated category 3 investment power under Schedule 4 of the SBFAR. The SBFAA provides that these investment powers are in addition to the investment powers provided to the foundations under the Hospitals Foundations Act 1982.

Where particular investments are not permitted under Part 6 of the Act, a foundation may seek approval from the Treasurer under Part 7A of the Act. Requests are considered on a case-by-case basis.

Part 6 SBFAA, Schedule 4 SPFAR

Board Statutory Bodies Financial Arrangements Act 1982 (SBFAA): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/S/StatutryBodA82.pdf)

Statutory Bodies Financial Arrangements Regulation 2007 (SBFAR): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/S/StatutryBodR07.pdf)

Statutory Bodies Financial Arrangements Act 1982 Operational Guidelines: (https://www.treasury.qld.gov.au/publications-resources/stat-bodies-op-guide/stat-bodies-op-guide.pdf)

Note: The guidelines provide a general outline of the impact of the SBFAA on the operations of statutory bodies and aim to assist statutory bodies in understanding their obligations under the Act and provide information to assist in developing better-practice policy frameworks for the investment of funds.

Foundations must keep a register of the Treasurer’s approvals under Division 3 of the SBFAA, being approvals by the Treasurer for foundations to exercise powers they are not otherwise permitted under the SBFAA.

s74, SBFAA

Board Statutory Bodies Financial Arrangements Act 1982 (SBFAA): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/S/StatutryBodA82.pdf)

Governance

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Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documents A governance framework appropriate for the agency must be established. Governance includes establishing a performance management system, a risk management system and an internal control system.

s7 FPMS Board FPMS: (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/F/FinAccPManSt09.pdf )

Governance Institute of Australia Website:(http://www.governanceinstitute.com.au/knowledge-resources/) Note: Provides a range of resources on best practice in board and organisational governance and risk management.

Cost-effective internal control structure established, including, for example, an organisation structure and delegations supportive of the objectives and operations of the foundation (the internal control structure must be included in the FMPM of the foundation).

s8 FPMS Recommended – annual check and test3

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

Financial Management Tools (provide guidance only, i.e. not mandatory): (https://www.treasury.qld.gov.au/publications-resources/financial-management-tools/index.php)

Information for Statutory Bodies – Overview of applicable legislation, policies and guidance documents: Appendix 1 ‘Compliance Checklists’ (see page 9): (http://www.treasury.qld.gov.au/office/knowledge/docs/information-for-statutory-bodies/statutory-bodies-information-overview.pdf)

Australian Accounting Standards Board – Accounting Standards: (http://www.aasb.gov.au/Pronouncements/Current-standards.aspx)

The performance of the foundation is managed compliant with the DPC document ‘A guide to the Queensland Government performance management framework’.

s11 FPMS Board A guide to the Queensland Government performance management framework: (http://www.premiers.qld.gov.au/publications/categories/guides/perf-manage-framework.aspx)

Queensland Audit Office – Better Practice Guides: Performance Reviews: (https://www.qao.qld.gov.au/better_practice)

Performance Reporting to Boards: A Guide to Good Practice (Chartered Institute of Management Accountants): (http://www.cimaglobal.com/Documents/ImportedDocuments/perfrpttoboards_techguides_2003.pdf)

Thirteen Ways to Improve Your Monthly Board Reports (ExcelUser):

Systems are in place for obtaining information to enable the foundation to decide whether it is:

(a) achieving the objectives stated in its strategic plan efficiently, effectively and economically; and

(b) delivering the services stated in its operational plan to the standard stated in the plan.

s12 FPMS Board

3 Note: Under s77(2) ‘Chief finance officer’ of the FAA each departmental CFO must produce to the accountable officer, for each financial year, a statement about whether the financial internal controls are operating efficiently, effectively and economically. This statutory requirement does not apply to statutory bodies, however, bodies should have a process in place to check and test financial internal controls.

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Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documents

(http://www.exceluser.com/tools/boardrpts.htm)

NHS Sample Board Papers:(http://www.rdehospital.nhs.uk/trust/board/boardpapers.html)

Performance systems allow reporting about performance to be provided.

s13 FPMS Report provided to the foundation at least every 3 months; and to the Minister annually or when requested

Board

Performance management system must allow the foundation to assess:

(a) the appropriateness of its objectives, and the services that it delivers to achieve its objectives

(b) whether the performance information is suitable to assess the extent to which the objectives have been achieved

(c) options to improve the efficiency, effectiveness and economy of the operations of the foundation.

s14 FPMS Board

Part 7 of the AIA outlines the operation of conferral; performance; delegation of statutory functions and powers; making of appointments; acting appointments; etc. E.g. section 27A ‘Delegation of functions or powers’ outlines how delegation of functions and powers works.

Part 7, AIA Board Acts Interpretation Act 1954 (AIA): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/A/ActsInterpA54.pdf)Note: The AIA prescribes the meanings of common terms used in Acts where those Acts do not in themselves provide a definition, or where the definitions provided in the Acts require further clarification (in other words, the AIA only applies to the extent of any inconsistency), and provides courts with clear directions to resolve a range of potential inconsistencies.

Public accountabilityThe Auditor-General of Queensland (or other authorised auditor, if a foundation is exempted from using the Queensland Audit Office) is required to audit each year the financial accounts of all foundations and to provide independent reports to the Queensland Parliament. Foundations must grant the audit team access to all records and stated information as and when requested by sections 46 & 47 of the AGA. In addition, each foundation is responsible for liaising directly with the Audit Manager and providing solutions to the audit issues raised.

ss46-47 AGA

As and when requested

Board Auditor-General Act 2009 (AGA): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/A/AttorneyGenA99.pdf) Note: Establishes the position of the Queensland Auditor-General and the Queensland Audit Office (QAO). The Act also confers on the Auditor-General and the QAO the functions and powers necessary to carry out independent audits of all Queensland public sector agencies.

Queensland Audit Office: (https://www.qao.qld.gov.au/)

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Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documentsThe PSEA outlines the ethical obligations of employees within the Queensland Public Sector. The PSEA provides four (4) ethics principles for the public sector:

(a) Integrity and impartiality (b) Promoting the public good (c) Commitment to the system of government

and (d) Accountability and transparency.

The PSEA also incorporates a range of “ethical values” associated with each of the ethics principles. These principles and values form the basis of the codes of conduct required to be developed by each foundation.

Part 3, PSEA

Board, employees, volunteers

Public Sector Ethics Act 1994 (PSEA): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/P/PublicSecEthA94.pdf) Declares the ethical principles that are fundamental to good public administration and covers requirements for codes of conduct for public officials. The PSEA ethics principles and values apply to all public service agencies and public sector entities, including statutory bodies and public officials.

Queensland Government Ethics Website: (http://www.ethics.qld.gov.au/)

Public Sector Ethics (OHSA fact sheet): (http://www.health.qld.gov.au/ohsa/docs/ethics-sheet.pdf)

The Chief Executive Officer of a public sector entity (defined to include foundations) must ensure a code of conduct is prepared for the entity and approved by the Minister for Health4. Employees, volunteers and members of the foundation must comply with the code of conduct in performing their official functions.

The Chief Executive Officer must also: ensure employees have reasonable access to a copy of the Code and any standards of practice; publish and keep available for inspection by any person copies of the ethics principles and the foundation’s approved code of conduct; ensure employees are given access to appropriate education and training about public sector ethics; ensure the administrative procedures and management practices of the Foundation have proper regard to the Act and the foundation’s code of conduct; and ensure the annual report includes an implementation statement as per s23.

Note: the Chief Executive Officer of a foundation is the person responsible to the Minister for the management of the foundation.

ss13-23 PSEA

Annually (statement included in annual report)

Chief Executive Officer

Public Sector Ethics (OHSA fact sheet):(http://www.health.qld.gov.au/ohsa/docs/ethics-sheet.pdf)

If a public official, being a CEO of a unit of public s38 CCA Chief Executive Crime and Corruption Act 2001 (CCA):

4 The foundations may elect to adopt the Code of Conduct for the Queensland Public Service (http://www.ethics.qld.gov.au/publications/Code_of_Conduct_060313.pdf) rather than develop a new code; however, in doing so, the foundation should ensure to engage in the appropriate consultations (section 16) and amend the Code to any extent necessary to ensure it relates to the foundation (section 13(1)(a)). For example, and at a minimum, references throughout the Code to its applicability to ‘Public Service Agencies’ should be changed to references to the foundation.

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Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documentsadministration (which the foundations are) suspects that a complaint, information or matter involves, or may involve, corrupt conduct, they must notify the Crime and Corruption Commission of the complaint.

Officer (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/C/CrimeandCorruptionA01.pdf)

Crime and Corruption Commission Queensland: (http://www.ccc.qld.gov.au/)

The CEO of a unit of public administration has a responsibility to deal with a complaint about, or information or matter involving, official misconduct that is referred to it by the commission.

s43-44 CCA

Chief Executive Officer

Section 44 of the CCA (see link above) outlines how complaints must be dealt with.

Deal with applications for information as per Chapter 3, Part 3 of the RTIA.

Chapter 3, Part 3, RTIA

Chief Executive Officer (principal officer)

Right to Information Act 2009 (RTIA): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/R/RightInfoA09.pdf) The Act gives the public a right of access to information held or controlled by government unless, on balance, providing access would be contrary to the public interest.

Further information is also available via (www.qld.gov.au/right-to-information/)

Policy documents are made available for inspection and purchase by the public.

s20 RTIA Board Note: An agency (which, by definition, includes foundations) must make copies of each of its policy documents available for inspection and purchase by the public. However, nothing in this section prevents an agency from deleting exempt information or contrary to public interest information from a copy of a policy document.

Publish a publication scheme, which is a scheme that sets out the classes of information that the foundation makes available and how the information can be accessed, including any charges. This may include a de-identified disclosure log of documents that have been released in response to Right to Information applications.

s21 RTIA Board Ministerial Guidelines and Links to Departmental Publication Schemes(http://www.rti.qld.gov.au/right-to-information-act/publication-schemes)

Comply with the Information Privacy Principles in relation to the collection, storage, use and disclosure of an individual’s personal information.

s27 IPA, Schedule 4 IPA

Foundation Information Privacy Act 2009 (IPA): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/I/InfoPrivA09.pdf) Note: The Act provides for the fair collection and handling in the public sector environment of personal information, and gives the public a right to apply to access and amend their own personal

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Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documentsinformation.

Office of the Information Commissioner (Queensland): (http://www.oic.qld.gov.au/information-for/government)

Recordkeeping – General, Digital, Cloud Computing (OHSA fact sheet): (https://www.health.qld.gov.au/ohsa/docs/recordkeeping-infosheet-v2.pdf)

A foundation may only transfer an individual’s personal information to an entity outside of Australia in certain circumstances specified in section 33 of the IPA.

s33, IPA Foundation

Make and keep full and accurate records of its activities.

s7 PRA Chief Executive Officer

Public Records Act 2002 (PRA): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/P/PublicRecA02.pdf) Note: The PRA provides for the management of public records in Queensland.

Recordkeeping – General, Digital, Cloud Computing (OHSA fact sheet): (https://www.health.qld.gov.au/ohsa/docs/recordkeeping-infosheet-v2.pdf)

Queensland State Archives:(http://www.archives.qld.gov.au/Pages/default.aspx)

Retention and Disposal Schedules (e.g. Health Sector (Clinical Records)): (http://www.archives.qld.gov.au/Recordkeeping/RetentionDisposal/Schedules/Pages/Retention-and-Disposal-Schedules.aspx)

General Retention and Disposal Schedule (GRDS) for Administrative Records: (http://www.archives.qld.gov.au/Recordkeeping/RetentionDisposal/Pages/GRDS.aspx)

General legislative requirementsA foundation is legally liable for compensation for injury sustained by a worker employed by it if the injury is sustained by the worker in their employment.

s46 WCRA Board Worker’s Compensation and Rehabilitation Act 2003 (WCRA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/W/WorkersCompA03.pdf )An Act to establish a workers’ compensation scheme for Queensland,

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Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documentsand for other purposes.

Every employer must, for each worker employed by the employer, insure and remain insured for compensation and damages relating to injury sustained by the worker.

s48 WCRA Board

If a foundation meets criteria prescribed under the WCRR, they must appoint a Rehabilitation and Return to Work Coordinator and have workplace rehabilitation policy and procedures.

Note: Historically, foundations have not met this criteria. The WCRR criterion is whether the wages of the employer in Queensland for the preceding financial year were more than $4.9M.

Ss226-227 WCRA, 115 WCRR

Policy and procedures reviewed at least every 3 years and provide evidence of the review to Q-COMP

Board Worker’s Compensation and Rehabilitation Act 2003 (WCRA):(https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/W/WorkersCompA03.pdf) An Act to establish a workers’ compensation scheme for Queensland, and for other purposes.

Workers’ Compensation and Rehabilitation Regulation 2014 (WCRR): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/W/WorkersCompR14.pdf)

Q-COMP (the Workers’ Compensation Regulatory Authority):(https://www.worksafe.qld.gov.au/about-us)

The Chief Executive and foundation members, as ‘officers’ as defined in the WHSA, will have certain work health and safety obligations under this Act, including due diligence, which is defined as taking reasonable steps:(a) to acquire and keep up-to-date knowledge of

work health and safety matters; and(b) to gain an understanding of the nature of the

operations of the business or undertaking of the person conducting the business or undertaking and generally of the hazards and risks associated with those operations; and

(c) to ensure that the person conducting the business or undertaking has available for use, and uses, appropriate resources and processes to eliminate or minimise risks to health and safety from work carried out as part of the conduct of the business or undertaking; and

(d) to ensure that the person conducting the business or undertaking has appropriate processes for receiving and considering information regarding incidents, hazards and risks and responding in a timely way to that information; and

(e) to ensure that the person conducting the

s27 WHSA Chief Executive Officer, Board members

Work Health and Safety Act 2011 (WHSA): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/W/WorkHSA11.pdf)

Note: The WHS Act provides a framework to protect the health, safety and welfare of all workers at work and of all other people who might be affected by the work. Nationally uniform laws ensure all workers in Australia have the same standard of health and safety protection, regardless of the work they do or where they work.

Work Health and Safety Regulation 2011 (WHSR): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/W/WorkHSR11.pdf)

Work Health and Safety (Codes of Practice) Notice 2011: (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/W/WorkHSCPN11.pdf)

Workplace Health and Safety Queensland (Department of Justice and Attorney-General): (https://www.worksafe.qld.gov.au/about-us)

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Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documentsbusiness or undertaking has, and implements, processes for complying with any duty or obligation of the person conducting the business or undertaking under this Act; and

(f) to verify the provision and use of the resources and processes mentioned in paragraphs (c) to (e).

s28 refers to duties of workers & s28 duties of other persons at the workplace.

The occupier of a building is obliged to: maintain means of escape from the building, prescribed fire safety installations, and a fire and evacuation plan; and provide instruction to persons in the building concerning the action to be taken by them in the event of a fire threatening the building; etc.

The Building Fire Safety Regulation includes provisions relating to keeping evacuation routes free from obstacles; occupancy limits for buildings; meaning of specific terms (e.g. evacuation route, common area); etc.

Part 9A Division 2 FESA, BFSR

Board Fire and Emergency Services Act 1990 (FESA): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/F/FireARescSeA90.pdf)

Note: The Act establishes the Queensland Fire and Rescue Service and provides for the prevention of and response to fires and certain other incidents endangering persons, property or the environment and related purposes.

Fire and Rescue Service Regulation 2011 (FRSR): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/F/FireRescueR11.pdf)

Building Fire Safety Regulation 2008 (BFSR): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/B/BuildgFireSR08.pdf)

Queensland Fire and Rescue Service: (https://www.fire.qld.gov.au/default.asp)

The obligation of an employer includes – (a) ensuring that all electrical equipment used in the

conduct of the person’s business or undertaking is electrically safe; and

(b) if the person’s business or undertaking includes the performance of electrical work, ensuring the electrical safety of all persons and property likely to be affected by the electrical work; and

(c) if the person’s business or undertaking includes the performance of work, whether or not electrical work, involving contact with, or being near to, exposed parts, ensuring persons performing the work are electrically safe.

s30, Division 3 ESA

Electrical Safety Act 2002 (ESA): ( https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/E/ ElectricalSA02.pdf ) (An Act about electrical safety, and for other purposes.)

Electrical Safety Regulation 2013: (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/E/ElectricalSR13.pdf)

Electrical Safety (Codes of Practice) Notice 2013: (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/E/ElectricalSN13.pdf)

Queensland Government Electrical Safety Office:

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Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documentsRegulations, ministerial notices and codes of practice may prescribe the way to discharge a person’s electrical safety obligations.

(https://www.worksafe.qld.gov.au/about-us)

The BA requires that buildings be constructed in accordance with the Building Code of Australia and, where Queensland-specific provisions are necessary, the Queensland Development Code. The Act also contains specific compliance requirements, for example, in relation to fire safety for residential care buildings built, approved or applied for before 1 June 2007 (Chapter 7A), and swimming pool safety (Chapter 8).

BA Board Building Act 1975 (BA): (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/B/BuildA75.pdf)

Note: The Building Act governs all building work in Queensland and empowers the regulation of certain aspects of buildings and structures.

Building Regulation 2006: (https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/B/BuildgR06.pdf)

Queensland Development Code: (http://www.hpw.qld.gov.au/construction/BuildingPlumbing/Building/BuildingLawsCodes/QueenslandDevelopmentCode/Pages/default.aspx)

Australian Building Codes Board – About the national Construction Code: (http://www.abcb.gov.au/about-the-national-construction-code)

Other legislationHospital foundations may have additional responsibilities and obligations placed upon them by a number of pieces of other State legislation (https://www.legislation.qld.gov.au/OQPChome.htm) and Commonwealth legislation (http://www.comlaw.gov.au/), for example:

Affirmative Action (Equal Employment Opportunity for Women) Act 1986 (Cth)Anti-Discrimination Act 1991Working with Children (Risk Management and Screening) Act 2000Criminal Code Act 1899Disability Discrimination Act 1992 (Cth)Disability Services Act 1986 (Cth)Disaster Management Act 2003Environmental Protection Act 1994Environmental Protection Regulation 2008Environmental Protection (Waste Management) Regulation 2000Human Rights and Equal Opportunity Commission Act 1986 (Cth)Income Tax Assessment Act 1936 (Cth)

Industrial Relations Act 1999Industrial Relations (Tribunal) Rules 2011 Judicial Review Act 1991Ombudsman Act 2001Privacy Act 1988 (Cth)Sex Discrimination Act 1984 (Cth)Statutory Authorities (Superannuation Arrangements) Act 1994Superannuation Guarantee (Administration) Act 1992 (Cth)Waste Reduction and Recycling Act 2011Waste Reduction and Recycling Regulation 2011Water Supply (Safety and Reliability) Act 2008

Whole of Government policyComply with the QPP.

All foundation employees are required to be aware of,

QPP All employees Queensland Procurement Policy (QPP) July 2013: (http://www.hpw.qld.gov.au/supplydisposal/governmentprocurement/ProcurementPolicyGuidance/StateProcurementPolicy/Pages/

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Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documentsand comply with, this policy. Accountable officers are responsible for ensuring the QPP is followed within their agencies; and managers and supervisors are responsible for ensuring that employees are aware of, and comply with, it.

Default.aspx)

Note: The QPP is the government’s overarching policy for the procurement of goods and services, including construction. Its purpose is to deliver excellence in procurement outcomes for Queenslanders.

Cabinet has mandated this Policy for application to budget sector agencies, statutory bodies and Special Purpose Vehicles. These entities are collectively referred to as ‘agencies’ within this Policy.

Procurement/Purchasing Requirements (OHSA fact sheet): (http://www.health.qld.gov.au/ohsa/docs/procurement-info-sheet-v2.pdf)

Financial and Performance Management Standard 2009 Requirements (OHSA fact sheet): (http://www.health.qld.gov.au/ohsa/docs/fpms-requirements-v2.pdf)

Implementation of the mandatory principles of the Information Standards (IS) is mandated as a key whole-of-Government ICT planning requirement. 

Specific Acts and regulations are referenced within each Information Standard. 

For more information please see the QGEA guideline on the authority and applicability of the QGEA.

QGEAIS31, IS40, &IS18

n/a (reporting focuses on core departments)

Board Queensland Government Enterprise Architecture (QGEA): (http://www.qgcio.qld.gov.au/products/about-the-qgea) Note: QGEA is the collection of ICT policies and associated documents that guide agency ICT initiatives and investments to improve the compatibility and cost-effectiveness of ICT across government. The framework unites ICT strategy, ICT policy, Information Standards and enterprise architecture across the Queensland Government.

Note: in order to determine the applicability of QGEA policies to an individual agency, it needs to be determined whether or not an agency is captured or exempted under the particular legislation underpinning QGEA policies. For example, Information Standard 18 – Information Security supports the FPMS 2009 and as such applies to all accountable officers and statutory bodies as defined in the FAA.

Current Information Standards: (http://www.qgcio.qld.gov.au/products/qgea-documents)

Executives and persons paid remuneration equivalent to a senior executive service level or above, including statutory office holders, (refer Directive 3/14 to determine if this applies) must provide on an annual basis, a Declaration of Interests to the relevant Chief Executive or, in the case of a statutory head, to the Minister for Health and/or Parliamentary Committee

PSC Policy ‘Declaration of Interests – Senior Executive Service

Annually Chief Executive Officer and/or SES equivalent employee/s

PSC Policy ‘Declaration of Interests – Senior Executive Service and Equivalent Employees including Statutory Office Holders’: (h http://www.psc.qld.gov.au/publications/policies.aspx )

Senior Executive Service – Employment Conditions (Directive number: 3/14): (http://www.psc.qld.gov.au/publications/directives/assets/2014-3-Senior-Executive-Service-Employment-Conditions.pdf)

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Mandatory requirements for foundations Reference Date/timeframe Accountability Supporting documentsand the Integrity Commissioner.

The declaration must include information required under the directive, including revisions to existing Declaration of Interests.

The policy requires full disclosure of any interests that may have a bearing, or be perceived to have a bearing, on the individual’s ability to properly and impartially discharge the duties of their office.

and Equivalent Employees including Statutory Office Holders’

Declaration of Interests Forms and FAQs: (http://www.psc.qld.gov.au/publications/subject-specific-publications/ceo-ses-resources.aspx#Declaration)

Queensland Integrity Commissioner Website:(http://www.integrity.qld.gov.au/page/about-us/index.shtml)

[insert Foundation name] Policy[insert details of what the policy mandates] [insert

policy name e.g. HR Policy]

[insert] [insert the title/s of who is accountable for compliance with the policy e.g. all staff]

[insert link to policy]

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