Legislative Compliance

East Grampians Health Service has a statutory obligation to report legislative compliance status on a range of matters.

Audit & Risk Committee
East Grampians Health Service Audit & Risk Committee’s role is to oversee and advise the Board on matters of accountability and internal controls affecting the operations of the Health Service

The Committee consists of Board Directors and community representatives and meets quarterly.

Finance Risk Audit and Capital Development Committee – TOR 6.07

Equal Opportunity
East Grampians Health Service has a commitment to the principles of merit and equality in employment and people management.

The staff recruitment and selection procedure was reviewed during the year ensuring ongoing compliance with the Public Sector and Employment Act 1988, and contemporary employment practice.

Equal Employment Opportunity – SOPP 35.13

Occupational Health & Safety
The multidisciplinary Occupational Health & Safety Committee initiates and co-ordinates development of workplace safety policies and procedures, identifies and assesses workplace hazards, and provides for relevant education and training.

Occupational Health and Safety – SOPP 72.09

Clinical Governance and Risk Management
The development of a service-wide Clinical Governance and Risk Management strategy continues.

At the core of this exercise is the development of a culture which:

  • Puts the focus on patient, resident and clients needs;
  • Links the values and strategic objectives to the way we do business;
  • Adheres to the principals of Acute, Aged Care and Disability Services Outcome Standards.

Clinical Governance – SOPP 7.03

Risk Management – SOPP 74.01


It’s important for the quality of our organisation to encourage consumer feedback.  It provides constructive information and helps us plan for the future.  We give consumers every opportunity to contact us to let us know when things go well or when they don’t meet expectations.

We acknowledge that we don’t always ‘get it right’, however we are committed to addressing concerns and improving the way we deliver services.

The Complaints Officer manages all community concerns confidentially.

All formal complaints are directed to the Chief Executive and are dealt with according to guidelines laid down by the Health Complaints Commissioner.

Both compliments and concerns are equally as important in shaping our future service delivery.

Management of Compliments and Concerns – SOPP 16.01

Any problem is usually best solved at the point of service in the hospital. However, if you remain dissatisfied with our response, you may contact the Health Complaints Commissioner (HCC).  The HCC responds to complaints about health services and the handling of health information in Victoria.  Their service is free, confidential and impartial.  To lodge a complaint with the HCC fill out a complaint form online at www.hcc.vic.gov.au or phone 1300 582 113 between 9am and 5pm, Monday to Friday to discuss your complaint.

Statutory Duty of Candour

[Health Legislation Amendment (Quality and Safety) Act 2022]

We continually strive to improve and learn if we have not met your expectations. If you experience serious harm while in our care, it is a legal requirement under Victoria’s

Statutory Duty of Candour that we make an apology and explain openly and honestly what went wrong. We must also let you know what action will be taken and what improvements will be put in place. We will provide you with timely information, answer your questions the best we can and involve you in the investigation to the extent you wish.

Statutory Duty of Candour and associated reforms

Open Disclosure (incorporating Duty of Candour) – SOPP 74.02

Competitive Neutrality
Market changes are monitored and reviewed according to the guidelines of the Victorian Government Competitive Neutrality Policy with additional benchmarking being conducted where applicable tenders were received.

The East Grampians Health Service makes available to all interested persons any of its publications and produces a range of brochures aimed at informing the public of the range of services available.

No consultancies were undertaken during the year which exceeded $100,000.

Privacy Legislation commenced July 1st 2002 and comprises:

• Health Record Act 2001 and
• Information Privacy Act 2001

Information Privacy Act 2001 covers the privacy principles of:

• collection of health information
• use and disclosure of health information
• data quality
• data security and retention of information
• openness
• access to own health information

East Grampians Health Service has policies in place to ensure that personal health information remains confidential and secure, will only be used by non-Service staff with the consent of the patient, and is accessible by the patient under Freedom of Information guidelines.

Patients, residents and clients are informed of their rights regarding their health information, on first contact with the Health Service.

All fees charged by East Grampians Health Service are regulated by the Commonwealth Department of Health and Ageing, the Commonwealth Department of Family Services and the Hospitals and Charities (Fees) Regulations, 1986, or as otherwise determined by the Victorian Department of Health.