What are organisational policies and procedures?
Organisational policies and procedures, including governance, guide how organisations operate and behave. They ensure consistency and maintain accountability. [1]
Policies are high-level formal statements that establish rules, principles and expectations to guide decision-making and behaviour across the organisation. [1]
Procedures provide detailed, step‑by‑step instructions for implementing those policies. They explain how specific tasks should be carried out in practice. [1]
Governance refers to the overarching system by which an organisation is directed and controlled. Governance includes the structures, roles and processes that ensure accountability, compliance and effective decision‑making. [2] Together, governance establishes oversight, policies set direction and procedures operationalise these directives so organisations can function effectively and responsibly.
How are organisational policies and procedures barriers to rights-based care?
Organisational policies and procedures that act as barriers to rights-based care include:
- vague and inconsistent organisational policies and procedures to uphold rights
- poor documentation practices
- top-down policy development processes without consultation with staff and older people. [3-12]
Vague and inconsistent organisational policies on rights, especially in relation to expressing sexuality and intimacy, inclusion of animals in residential aged care facilities and supported decision‑making, limit staff members’ ability to apply rights‑based principles. [3, 4, 6] Where policies are unclear, inconsistent or not well embedded, staff may rely on their own judgement or adopt practices that prioritise organisational protection over the rights, autonomy and dignity of older people.
Poor documentation practices reduce transparency and continuity of care. They weaken compliance with procedures, legislative and regulatory expectations and prevent the delivery of safe, person-centred and rights-focused services. These practices also increase the risk that older people’s preferences, consent and decision-making rights are not effectively recorded or upheld. [3, 5]
Top-down policy development without consultation with staff may lack operational relevance, resulting in limited staff ownership, reduced confidence and inconsistent application in practice. Similarly, insufficient engagement with older people can limit opportunities to incorporate lived experience into policies. It undermines principles of participation, inclusion and co-design that are central to rights-based approaches. [6]
Residential aged care settings are commonly characterised by institutional rigidity and standardised routines, including fixed schedules for meals, personal care and daily activities. These fixed routines are designed to support consistent care delivery, operational efficiency and resident safety. However, they limit residents’ capacity to exercise choice and control over their daily lives. In addition, limited participation in decision-making, including unclear or rushed communication, reduces opportunities for residents to understand options and participate meaningfully in decisions about their care. [9-12] As a result, policies may not fully reflect the needs, preferences, or rights of those they are intended to support.
How are organisational policies and procedures enablers of rights-based care?
Organisational policies and procedures that are clear, rights‑focused and support practical guidance and governance promote autonomy, dignity, participation and informed decision‑making.
Policies that embed respect, equality, dignity, autonomy and participation support rights‑based care by providing a clear values-based framework that guides service delivery. Such policies shape staff behaviour and decision‑making ensuring that care is aligned with fundamental human rights. [13, 14]
Clear policies and procedures on areas such as sexual expression provide staff with practical direction in complex or sensitive situations. These policies reduce uncertainty, promote confidence and support consistent practice. They ensure that residents’ rights are respected while balancing safety and care needs. In doing so, they help normalise discussions and practices that uphold dignity, choice and quality of life. [15-17]
A clear organisational commitment to residents’ rights in decision‑making, supported by accurate and standard document processes and regular review, reinforces accountability and continuous improvement. [3, 4, 6] Regular review processes also ensure that policies and procedures remain responsive and consistent with evolving standards and expectations. [6]
Organisational and staff practices that prioritise active listening, respect for individual preferences, opportunities for staff and residents to contribute to decision-making and the development of trusting relationships enable a rights-based care approach. [9, 18-20] These practices lead to flexibility in care delivery. Adjusting routines to reflect residents’ preferences, health status and daily needs supports autonomy and respect for individual circumstances. [9]
Risk and management systems that enable participation while documenting mitigation strategies are important enablers. These systems help balance safety and autonomy. Rather than restricting older people’s choices and preferences, such as inclusion of animals in care, these systems support positive risk‑taking by identifying and managing potential risks in a transparent and structured way. This approach allows residents to exercise their rights and participate in meaningful activities, while ensuring appropriate safeguards are in place. [4]
Collectively, these enablers contribute to achieving the intent of Standard 2 – The organisation of the Strengthened Quality Standards.
What can be done?
Develop and embed clear policies and procedures in everyday activities
Organisations and aged care leaders:
- Develop organisational policies that clearly translate rights‑based standards into procedures for care situations that are common and sensitive (such as sexual rights).
- Embed rights principles into everyday operational documents, such as care planning, consent processes and incident review tools.
The evidence:
- Clear guidelines and structured guidance explaining how to implement a rights-based approach in aged care are needed. [13]
Improve documentation practices
Organisations and aged care leaders:
- Develop and regularly review standard documentation practices including risk mitigation strategies. Provide clear communication pathways within the organisation and between staff and residents, and families.
The evidence:
- Organisations can mitigate organisational liability by implementing robust risk assessment documentation and maintaining clear communication with residents and their families. [4]
Regularly engage with older people, families and other stakeholders
Organisations and aged care leaders:
- Engage with older people, families and other stakeholders such as professional groups and peak bodies regularly in policy and procedures development. Embed this in operational activities.
The evidence:
- Engaging staff, older people, families and other key stakeholders in the development of policies and procedures would support continuous quality improvement within the organisation. [3, 4, 6, 8]
Embed a rights-based approach into governance systems
Organisations and aged care leaders:
- Embed a comprehensive governance framework to clearly define roles, responsibilities, decision‑making processes and accountability mechanisms supporting a rights-based approach.
The evidence:
- Implementing a human rights‑based approach necessitates coordinated, system‑wide reform supported by strong leadership across policy, regulatory frameworks and organisational governance. [13]
Introduce flexible care delivery models
Organisations and aged care leaders:
- Review and adapt organisational routines to support greater flexibility in daily schedules. This includes offering residents choice in the timing of personal care (such as showering) and participation in activities. This approach enables care delivery to respond to residents’ preferences, health status and individual circumstances and supports greater autonomy.
The evidence:
- Flexibility in care routines supports residents’ autonomy and sense of respect. Residents value the ability to make decisions based on their changing mood, health status or personal preferences. [9]
Strengthen resident participation in decision-making
Care teams:
- Implement structured opportunities for residents to take part in making decisions about their care and daily living. This includes regular care planning discussions, resident meetings and inclusive decision-making processes.
- Tailor communication approaches to individuals and provide information in accessible formats. This may include the use of images or any visual support with clear and simple explanations.
The evidence:
- Collaborative approaches between staff and families support shared understanding. Ensuring residents are actively included in discussions and decision-making processes, even where communication is limited, reinforces their role in care and supports person-centred practice. [9, 19, 20]
- Accessible communication and supportive relationships enable effective decision‑making in residential aged care. Tailored communication approaches improve understanding and allow residents to make informed choices. [9, 20]
Want to learn more?
Read more about governance and processes in the following documents from the Australian Government:
- Governance obligations for all registered aged care providers
- Provider governance guidance, processes and definitions
Explore the Governing for reform in aged care program for leaders.
ARIIA has developed resources to support clinical governance and included the following:
Learn how to effectively communicate with residents in the aged care sector.