Implementation guidelines for non-government community services

Standard 8. Governance, leadership and management

Page last updated: 2010

The MHS is governed, led and managed effectively and efficiently to facilitate the delivery of quality and coordinated services.

The intent of this standard is to ensure that structures are in place to facilitate effective governance of the service.

Governance obligations are different for the non government community mental health service sector. However, even within the sector, not all organisations are legally structured the same way. Many will be associations incorporated under the applicable state and territory Associations Incorporation legislation. Others might be companies or companies limited by guarantee.

Legal structure is a key determinant of what is required in terms of an organisation's governance and accountability responsibilities. It is the responsibility of each organisation to understand its legal structure and obligations. This section provides general information only.

The ACT Council of Social Services ( has identified five duties of board or management committee members. They are as follows:

  1. Fiduciary duty - the duty to act in the best interest of the organisation.
    Within fiduciary duty is the expectation that board or management committee members will act with a duty of care, loyalty and obedience to purpose, in keeping with the philosophy and objectives of the organisation. Staff and perhaps volunteers run the daily affairs of the organisation, but the board or management committee is ultimately responsible for maintaining financial and legal responsibilities.

  2. Duty to act honestly - to apply reasonable skills, act in good faith and in the best interests of the organisation.

  3. Duty of care and diligence - the duty to abide by the constitution of the organisation and to know and comply with all legal requirements.
    This includes taking all reasonable steps to minimise risk for the organisation. It also includes working on a positive public perception of the organisation. It also means the board making sure it has enough information to make decisions.

  4. Duty of confidentiality - the duty to keep confidential all organisational and board or management committee information.
    This includes not expressing dissent about a decision with which an individual member disagrees; the board or management committee should speak as one voice. If a member cannot live with a decision that has been debated and voted on, they need to leave the board. Once a decision is made it is a decision of the board and management committee as an entity.

  5. Duty to declare any conflict of interest - the duty of each member to inform the board or management committee of any personal interest in any matter before it, and to absent themselves from issues where there is the possibility of a perceived or real personal or financial interest.
Integration and coordination (criterion 8.1)
Promotion and prevention (criterion 8.2) (partially applicable to the sector)
Development and review of strategic plan (criterion 8.3)
Compliance with legislation and related acts (criterion 8.4)
Resources (criterion 8.5)
Recruitment, selection and staff development (criteria 8.6, 8.7)
Critical incidents (criterion 8.8)
Information management (criterion 8.9)
Risk management (criterion 8.10)
Formal quality improvement program (criterion 8.11) Top of page

Integration and coordination (criterion 8.1)

As appropriate for the size of the organisation providing the services and where the mental health service sits in its total suite of services, there should be evidence of the links between the service and the wider organisation in the organisation's strategic and operational plans.

The board or management committee is the final point of accountability across all of the organisation's settings and programs.

The board or management committee delegates authority to senior executives and managers and defines their responsibility for the operation of clinical and non clinical services to achieve goals and ensure service integration, coordination and effective outcomes for its consumers.

Evidence that this criterion is met could include:
  • the content of the organisation’s strategic and operational plans
  • documenting the roles and responsibilities of the board, its office bearers and CEO for corporate and (as appropriate to the nature of the services provided) clinical governance.
  • documenting delegations.

Promotion and prevention (criterion 8.2) (partially applicable to the sector)

Service providers should develop plans that identify the person or position responsible for developing promotion and prevention strategies at the organisation and individual staff levels.

This criterion will only be relevant to service providers with funding expressly to undertake promotion and prevention activities.

Evidence that this criterion is met could include:

Development and review of strategic plan (criterion 8.3)

Service provider strategic plans need to be consistent with legislative requirements, and national, state and territory level mental health policies and related documents.

Strategic plans should include the following components:
  • the organisation's purpose, principles and values
  • the key outcomes to be achieved across the years covered by the plan
  • the key strategies through which the outcomes will be achieved
  • the information that will be used to monitor progress and report on outcomes.
Its development should be informed by an analysis of the needs of consumers and the catchment community, ongoing service delivery obligations as determined in funding agreements, the contributions of staff, consumers, carers and other stakeholders identified by the organisation.

Evidence that this criterion is met could include:
  • documenting the contribution of staff, consumers, carers, and representatives of key groups within the catchment community, to the development and review of the strategic plan
  • the strategic plan document
  • documenting that the plan is regularly reviewed and adjustments made when necessary (for example in board or management committee minutes, reports of planning meetings)
  • according to the size and structure of the service, an operational plan for the mental health service which is linked to the strategic plan.

Compliance with legislation and related acts (criterion 8.4)

Commonwealth, state and territory legislation and acts and service funding agreements guide the development of policies and procedures.

There should be a system to disseminate information when changes are made to mental health legislation. The system to ensure compliance with legislation should include, but not be limited to, identifying and disseminating new or amended standards, codes of practice, guidelines and legislation.

Evidence that this criterion is met could include:
  • a compliance framework for monitoring and evaluating compliance with the organisation's policies and procedures
  • qualification free audits. Top of page

Resources (criterion 8.5)

Service providers have sound financial management practices and demonstrate a clear budget allocation for the delivery of services.

Evidence that this criterion is met could include:
  • qualification free audits
  • services delivered within budget allocation
  • a planning and monitoring cycle that demonstrates that expenditure is always within available funds, and that the organisation is always aware of its overall financial position
  • a record keeping system for financial transactions that meets accounting standards, and provides accurate and useful financial reports
  • a control and risk management system that ensures procedures protect the organisation against fraud or insolvency.

Recruitment, selection and staff development (criteria 8.6, 8.7)

Staff recruitment practices should conform to applicable equal opportunity legislation.

Job descriptions should accurately reflect the skills, qualifications, experience and personal attributes required to perform duties effectively. The organisation must have an ongoing commitment to the supervision and ongoing training and development of all staff.

Evidence that these criteria are met could include:
  • job description documentation
  • recruitment documentation
  • working with children and other police clearances
  • the staff orientation program
  • documenting that staff supervision is undertaken and poor performance is adequately managed
  • documenting that staff performance reviews are completed every year
  • the staff training and development calendar
  • the staff code of conduct. Top of page

Critical incidents (criterion 8.8)

The service provider should have a formal process to review critical incidents. The process should support both staff and others within the service provider affected by the critical incident. The outcomes of the review of incidents should be used to inform ongoing prevention plans.

Further information on critical incidents is available in the guidelines for standard 2.

Evidence that this criterion is met could include:
  • a critical incident reporting and response system.

Information management (criterion 8.9)

Information management includes consumer records in both individual and aggregated formats that can be understood by those involved in the delivery of services. The National Privacy Principles are the base line standards some private sector organisations need to comply with under the Privacy Act 1988 in relation to personal information they hold. This includes non-government community mental health service providers. Copies are available from the information sheets page on the the Privacy website (

Evidence that this criterion is met could include:
  • information audits that confirm compliance with legislative requirements
  • a control and risk management system that documents the information security measures that ensure physical (hard copy) information security, computer and network information security, other communications security and personnel security. Top of page

Risk management (criterion 8.10)

Risk management is a key responsibility of the board or management committee, but one in which the CEO and staff must also be involved. It is a process which involves:
  • identifying the risks
  • assessing and evaluating the risks (for example by considering the likelihood of an identified risk event occurring and its consequences)
  • deciding on the response to the risk, how it will be treated (accepted, avoided, reduced or transferred) and the action to be taken
  • monitoring and reviewing the effectiveness of the response or treatment.
At all stages, good organisational communication at all levels is an essential success factor.

Information gathered through feedback, complaints, incidents and adverse reporting should be part of corporate governance and, as applicable to the types of services provided, clinical governance including risk management processes.

Service providers must have documented systems that are evaluated to ensure effective corporate and, as applicable to the types of services provided, clinical risk management practices are in place.

Further information on risk management is available from the guidelines for standard 2 safety and standard 4 diversity responsiveness.

Evidence that this criterion is met could include:
  • risk management being documented as a standing item on board and management committees, and actions taken after risks have been considered
  • the board and management committee code of conduct
  • documenting what training is provided to board and management committee members and staff in corporate and, as applicable to the types of services provided, clinical risk management practice
  • the corporate and, as applicable to the types of services provided, clinical risk management plans
  • risk assessment reviews and actions taken following reviews. Top of page

Formal quality improvement program (criterion 8.11)

Service providers should analyse data and information to promote effective services for consumers and carers, to assist with the evaluation of service delivery and to develop staff training programs. Data management systems can be used to provide evidence of quality improvement activities as a result of data evaluation.

Quality improvement programs should include capacity to use consumer and carer feedback, complaints, adverse events and critical incidents to improve service quality. Programs should include service level evaluation and evaluation of individual outcomes, including the extent to which the service has contributed towards the consumer achieving recovery goals. Staff, consumers, carers, key groups within its community and other service providers, should be involved in service evaluation.

Evidence that this criterion is met could include:
  • the quality improvement framework.
Policies and procedures to demonstrate compliance with standard 8 will include, but not necessarily be limited to, those that address:
  • organisational governance including the roles and responsibilities of the board, office bearers and the Chief Executive Officer
  • the development and review of the strategic plan and associated operational plans as appropriate for the size and service complexity of the organisation
  • financial management and organisational accountability and reporting
  • information management
  • service quality and continuous quality improvement
  • corporate and, as applicable to the types of services provided, clinical risk management.
It is important to remember that policies and procedures alone are not sufficient to demonstrate that a service provider is meeting a standard's requirements. It is also necessary to demonstrate how the policies and procedures have been implemented and guide organisational practices and behaviours.