Governance and Operational Management Policy and Procedure

NDIS Policies and Procedures Manual – Core Module

Document Number: CM-POL-006

Document Control

This table shows a record of significant changes to the document.

Legal Name:	Holistic Healthcare Management Services
ABN:	20695058096
ACN:	695058096
Primary address/head office:	15 Agasse Way, Tapping WA 6065
Document Name:	NDIS Policies and Procedures Manual – Core Module
Document Number:	CM-POL-006
Approved by:	Director
Date Approved:	February 2026
Version No:	1.0
Comments:	Initial Release of the Policies and Procedures Manual
Next Review Date:	May 2026

Purpose

The Governance and Operational Management Policy ensures that Holistic Healthcare Management Services adheres to the highest standards of organizational management, accountability, and operational effectiveness.

The policy has been developed in alignment with the National Disability Insurance Scheme (NDIS) Practice Standards and Quality Indicators, ensuring compliance with legislative requirements while fostering a culture of continuous improvement.

By establishing clear governance structures and operational frameworks, this policy aims to deliver quality services, uphold participant rights, and enhance stakeholder trust.

Scope

This policy applies to all levels of management, staff, contractors, and volunteers involved in the delivery of supports and services under the NDIS framework.

It governs the organization’s operations, including decision-making processes, risk management practices, staff training, and stakeholder engagement. It is applicable to:

Executive Management: Responsible for strategic oversight and organizational performance.
Operational Staff: Responsible for the day-to-day delivery of services in line with the organization’s mission and standards.
Participants and Stakeholders: Ensuring their feedback is incorporated into governance practices to maintain transparency and accountability.

Definition

Term	Definition
Governance	It means the process by which organisations are directed, controlled and held to account. It encompasses authority, accountability, delegation of authority, directions and controls exercised within the organisation.
Organisational structure	A system used to define a hierarchy within an organisation. It identifies each job, its function and where it reports to within the organisation. This structure is developed to establish how an organisation operates and assists an organisation in obtaining its goals to allow for future growth. The structure is illustrated using an organisational chart.
Governing Body	The Governing Body refers to the group of individuals entrusted with the overarching responsibility for directing, controlling, and holding the organisation accountable. It embodies the core principles of governance, including authority, accountability, and delegation of decision-making powers. The Governing Body ensures the organisation operates within its defined framework of authority and adheres to established directions and controls. The Governing Body plays a critical role in enabling the organisation to achieve its goals, foster future growth, and ensure compliance with operational, legislative, and regulatory requirements.

Outcomes and Indicators

Term	Description
Each participant’s support is overseen by robust governance and operational management systems relevant (proportionate) to the size, and scale of the provider and the scope and complexity of supports delivered.	Opportunities are provided by the governing body for people with disability to contribute to the governance of the organisation and have input into the development of organisational policy and processes relevant to the provision of supports and the protection of participant rights. A defined structure is implemented by the governing body to meet a governing body’s financial, legislative, regulatory and contractual responsibilities, and to monitor and respond to quality and safeguarding matters associated with delivering supports to participants. The skills and knowledge required for the governing body to govern effectively are identified, and relevant training is undertaken by members of the governing body to address any gaps. The governing body ensures that strategic and business planning considers legislative requirements, organisational risks, other requirements related to operating under the NDIS (for example Agency requirements and guidance), participants’ and workers’ needs and the wider organisational environment. The performance of management, including responses to individual issues, is monitored by the governing body to drive continuous improvement in management practices. The provider is managed by a suitably qualified and/or experienced persons with clearly defined responsibility, authority and accountability for the provision of supports. There is a documented system of delegated responsibility and authority to another suitable person in the absence of a usual position holder in place. Perceived and actual conflicts of interest are proactively managed and documented, including through development and maintenance of organisational policies.

Term

Description

Each participant’s support is overseen by robust governance and operational management systems relevant (proportionate) to the size, and scale of the provider and the scope and complexity of supports delivered.

Opportunities are provided by the governing body for people with disability to contribute to the governance of the organisation and have input into the development of organisational policy and processes relevant to the provision of supports and the protection of participant rights.
A defined structure is implemented by the governing body to meet a governing body’s financial, legislative, regulatory and contractual responsibilities, and to monitor and respond to quality and safeguarding matters associated with delivering supports to participants.
The skills and knowledge required for the governing body to govern effectively are identified, and relevant training is undertaken by members of the governing body to address any gaps.
The governing body ensures that strategic and business planning considers legislative requirements, organisational risks, other requirements related to operating under the NDIS (for example Agency requirements and guidance), participants’ and workers’ needs and the wider organisational environment.
The performance of management, including responses to individual issues, is monitored by the governing body to drive continuous improvement in management practices.
The provider is managed by a suitably qualified and/or experienced persons with clearly defined responsibility, authority and accountability for the provision of supports.
There is a documented system of delegated responsibility and authority to another suitable person in the absence of a usual position holder in place.
Perceived and actual conflicts of interest are proactively managed and documented, including through development and maintenance of organisational policies.

Guiding Principles

The Governance and Operational Management Policy is founded on the following principles, which guide its implementation and ensure alignment with organisational values and regulatory obligations:

Leadership and Accountability: Effective governance begins with strong leadership. The organisation is committed to creating a culture of transparency, ethical decision-making, and accountability at all levels. Leaders set the tone, ensuring organisational goals align with the mission, vision, and legal requirements.
Participant-Centred Focus: Governance and operations are designed to prioritise the needs, preferences, and rights of participants. This includes engaging participants in decision-making processes, respecting their autonomy, and ensuring supports are delivered effectively and safely.
Compliance and Risk Management: The organisation adheres to all relevant Australian legislation, regulations, and standards. Proactive risk management frameworks are in place to identify, evaluate, and address risks, ensuring operational stability and participant safety.
Continuous Improvement: The organisation fosters a culture of learning and adaptation. Governance structures and operational processes are regularly reviewed and updated to reflect best practices, feedback from stakeholders, and changes in the regulatory landscape.
Transparency and Communication: Clear and open communication is critical for building trust with participants, staff, and stakeholders. Governance processes are designed to ensure transparency in decision-making, resource allocation, and organisational performance.
Staff Empowerment and Development: The organisation recognises that effective operational management depends on a skilled and empowered workforce. Policies support ongoing staff development, equitable resource distribution, and a collaborative work environment.

Policy

Participant Involvement in Governance (Quality Indicator 1)

Holistic Healthcare Management Services actively involves people with disabilities in its governance processes to ensure their voices shape organizational policies and practices. Participants are invited to contribute through advisory committees, focus groups, and direct representation on the Board. The organization ensures that feedback provided by participants is not only heard but acted upon, influencing decisions on service delivery, quality improvements, and safeguarding initiatives. Policies and procedures are in place to facilitate meaningful participation, including reasonable adjustments to accommodate participants’ needs. Participants’ input is documented and integrated into strategic planning, ensuring that their perspectives remain central to the organization’s goals.

Governance Structure and Responsibilities (Quality Indicator 2)

Holistic Healthcare Management Services implements a defined governance structure to meet its financial, legislative, regulatory, and contractual responsibilities. The Board of Directors or equivalent governing body is responsible for strategic oversight, ensuring that all decisions align with organizational goals and regulatory compliance. Committees, such as finance, audit, and risk, are established to oversee specific functions and ensure accountability at all levels. To ensure responsibilities are effectively met, the Board regularly reviews performance metrics, financial statements, and compliance reports. Quality and safeguarding measures are monitored through established mechanisms, such as participant feedback, incident reports, and external audits. These reviews are integral to ensuring that the organization’s operations meet the standards set by the NDIS Practice Standards.

Strategic and Business Planning (Quality Indicator 4)

Strategic and business planning at Holistic Healthcare Management Services incorporates legislative requirements, organisational risks, participant and worker needs, and the broader operational environment. The Board leads the development of strategic plans, ensuring they address NDIS registration obligations, compliance with relevant laws, and long-term sustainability. Operational plans are developed to align with strategic objectives, with input from participants, staff, and stakeholders. Regular reviews of these plans ensure they remain relevant and responsive to changing circumstances. The Board oversees these processes, ensuring that planning activities reflect the organization’s commitment to quality and participant-centred services.

Skills and Knowledge of the Governing Body (Quality Indicator 3)

The governing body’s effectiveness is built upon the skills and knowledge of its members. Holistic Healthcare Management Services maintains a skills matrix to identify the competencies required for effective governance. Gaps in knowledge or expertise are addressed through targeted recruitment, professional development, and training programs. Board members participate in regular training on topics such as NDIS compliance, risk management, and participant safeguarding. This ensures that the governing body remains informed about legislative changes, emerging risks, and best practices, enabling it to make informed decisions and provide effective oversight.

Performance Monitoring and Continuous Improvement (Quality Indicator 5)

The performance of the management team, including the CEO, is closely monitored by the governing body. Performance plans and key performance indicators (KPIs) are established to evaluate leadership effectiveness, with regular reviews conducted to assess progress. Findings from performance reviews are used to identify areas for improvement and professional development. Continuous quality improvement initiatives are driven by insights gathered from participant feedback, incident management, and compliance audits. The Board ensures that these initiatives align with organizational goals and regulatory requirements.

Management Qualifications and Accountability (Quality Indicator 6)

Holistic Healthcare Management Services ensures that its management team, including the CEO, possesses the qualifications and experience necessary for effective leadership. Responsibilities, authorities, and accountabilities are clearly defined in position descriptions, performance plans, and organizational policies. The CEO’s performance is reviewed regularly, with outcomes reported to the Board. This process ensures that the CEO’s leadership aligns with the organization’s mission, strategic goals, and compliance obligations. Regular reporting from the CEO to the Board provides transparency and facilitates informed decision-making.

Compliance and Reporting

Compliance with NDIS standards, legislative requirements, and contractual obligations is a priority for Holistic Healthcare Management Services. Regular audits and compliance reviews are conducted to ensure adherence to relevant frameworks. Findings are reported to the governing body, which takes corrective actions as necessary.

Transparent reporting mechanisms are in place to provide stakeholders with insights into organizational performance and compliance activities. Annual reports, compliance registers, and strategic plan reviews are used to demonstrate accountability and foster trust with participants, staff, and the broader community.

Procedures

The following procedures are in place to ensure Holistic Healthcare Management Services meets its objective of implementing robust governance and operational management systems in compliance with NDIS requirements.

Governing Body

The Governing Body at Holistic Healthcare Management Services is responsible for overseeing governance and operational management systems in accordance with organisational policies, procedures, and NDIS-related rules. The Governing Body provides leadership and direction to the organisation and includes members Governing Body Members.

The Governing Body adopts a rights-based governance approach, ensuring individuals with disabilities are involved in decision-making processes that directly affect the programs and services they access.

The Governing Body’s performance is periodically reviewed by an external consultant, focusing on areas such as mission alignment, strategic performance, legislative compliance, quality and safeguards adherence, operational processes, stakeholder relationships, and individual and collective competencies. To address skill gaps, members undertake training in fields such as disability services, NDIS operations, financial management, and corporate governance. This ensures they possess the expertise needed to govern effectively and fulfill responsibilities under the NDIS framework.

Business, Strategic, And Operational Planning

The Governing Body ensures that all business, strategic, and operational planning aligns with legislative requirements, organisational risks, and NDIS rules while reflecting the needs of participants and staff. Holistic Healthcare Management Services maintains business, strategic, and operational plans that outline goals, strategies, and steps required for achieving them. These plans also incorporate risk management outcomes and monitoring metrics.

The Strategic Plan, developed every three years, identifies priorities, key performance indicators, and objectives aligned with the organisation’s mission, vision, and values. It is reviewed annually to incorporate participant feedback and address changes in the NDIS environment. Operational Plans translate the Strategic Plan into actionable steps for specific teams and areas. These plans are reviewed biannually by the Senior Management Team to ensure alignment with organisational goals.

The Governing Body oversees these plans to ensure they support governance objectives, while the Senior Management Team communicates organisational objectives to new staff and participants. Planning progress is regularly shared with staff and stakeholders, ensuring clarity on roles, responsibilities, and organisational changes.

Organisational Structure

Holistic Healthcare Management Services maintains a comprehensive organisational structure designed to facilitate effective service delivery and operational management. This structure is documented in the Staff Handbook, which provides a clear overview of roles, responsibilities, and delegated authority across all levels of the organisation.

Each staff member’s Position Description outlines their specific duties, qualifications, and reporting lines, ensuring clarity and accountability. This includes defining responsibilities related to participant-related work, operational management, and compliance. The Position Descriptions are reviewed regularly to ensure alignment with the organisation’s goals and NDIS requirements.

To ensure service continuity, backup staff are identified and recorded in the Human Resource Register. This includes detailed contingency plans for key roles to address unexpected absences or transitions, minimising disruptions to participant support. The Human Resource Register also maintains records of staff qualifications, training, and ongoing professional development.

Regular reviews of the organisational structure are conducted by the Senior Management Team and the Governing Body to adapt to changes in operational needs, regulatory requirements, and participant feedback. Any adjustments to the structure are communicated organisation-wide, ensuring transparency and understanding among staff. This approach ensures that Holistic Healthcare Management Services operates efficiently while maintaining a focus on quality service delivery and participant-centred outcomes.

Responsibilities

The Governing Body is accountable for overall governance, strategic and operational planning, and continuous improvement. Responsibilities include:

Governance: Establishing policies and procedures to ensure robust operational management and participant involvement in governance.
Structure: Defining and monitoring the organisational structure to meet financial, legislative, and quality requirements.
Performance Management: Evaluating the performance of management and ensuring qualified individuals hold key positions.
Strategic Planning: Aligning business plans with legislative, risk, and participant needs.

The Representative Position Title oversees service delivery, operational management, and compliance. Responsibilities include monitoring performance, managing risks, ensuring financial stability, and addressing incidents or disputes. The Senior Management Team supports feedback management, operational planning, and ensuring service continuity.

Participant Feedback

Holistic Healthcare Management Services recognises that participant feedback is essential for delivering high-quality, responsive services. Feedback mechanisms are designed to empower participants and their families to actively contribute to service improvement and organisational management.

Participants and their families are encouraged to provide feedback at any point during service delivery, either informally or through structured channels such as satisfaction surveys, focus groups, or individual consultations. Annual Participant Satisfaction Surveys are conducted to gather insights into the quality of supports provided, the effectiveness of communication, and the overall participant experience.

Feedback is reviewed regularly by the Senior Management Team, and relevant information is incorporated into service planning, evaluation, and continuous improvement efforts. When feedback results in significant changes to policies, procedures, or services, participants are informed of the outcomes to ensure transparency. Additionally, participant feedback is used to assess and develop new programs, recruit staff, and enhance existing services.

A complaints and feedback management process ensures that participants and their families have accessible avenues for raising concerns or suggestions. Feedback outcomes are documented and shared during staff and management meetings to foster a culture of continuous improvement.

Compliance

Compliance is a cornerstone of Holistic Healthcare Management Services’s governance framework. Adherence to legislative, regulatory, and NDIS Practice Standards is maintained through systematic monitoring, training, and reviews. The Representative Position Title is responsible for ensuring compliance across all operational areas by:

Conducting regular internal audits to identify gaps in compliance and address them promptly.
Updating organisational policies and procedures to reflect changes in legislation, industry standards, or operational requirements.
Training staff on compliance obligations, including privacy, safeguarding, and reporting requirements. Training is provided during induction and refreshed annually to ensure ongoing awareness.
Facilitating external audits as required by regulatory bodies to validate compliance and inform improvements.

Non-conformities or breaches identified during audits are documented and addressed through the Continuous Improvement Plan. The Representative Position Title ensures that compliance-related findings are communicated to staff and stakeholders, fostering a culture of accountability and improvement.

Notice Of Changes And Events To The NDIS Commission

Holistic Healthcare Management Services ensures full compliance with its obligation to notify the NDIS Commission of significant changes or events. Notifications are submitted promptly via the NDIS Commission Portal in accordance with the National Disability Insurance Scheme (Provider Registration and Practice Standards) Rules 2018.

Changes requiring notification include, but are not limited to:

Governance modifications, such as changes in key personnel, legal structure, or business ownership.
Operational impacts, such as temporary or permanent service disruptions, significant workforce shortages, or extended participant wait times.
Financial capacity issues, including insolvency risks, inability to meet payroll obligations, or legal proceedings related to financial instability.

The Representative Position Title is tasked with maintaining records of all notifications and ensuring that required updates are submitted in a timely manner. This includes reporting annual participant numbers, workforce changes, and geographical service expansions or reductions. By adhering to these requirements, Holistic Healthcare Management Services demonstrates its commitment to accountability and quality service delivery under the NDIS framework.

Roles and Responsibilities

Ref No	Roles	Responsibilities
1	Board of Directors	Strategic Oversight: The Board is responsible for setting the strategic direction of the organisation, ensuring alignment with its mission and values. They establish organisational priorities and monitor progress toward strategic goals. Risk Management and Compliance: The Board oversees the implementation of risk management frameworks and ensures compliance with all relevant laws, regulations, and standards. Performance Monitoring: Regularly reviews operational and financial performance reports to ensure the organisation is achieving its objectives efficiently and sustainably. Stakeholder Engagement: Ensures open communication with participants, families, and other stakeholders, integrating their feedback into governance decisions.
2	Executive Management Team	Policy Development and Implementation: Responsible for developing and enforcing policies and procedures that support effective governance and operational management. Operational Oversight: Monitors day-to-day operations to ensure they align with organisational objectives, regulatory requirements, and participant needs. Staff Leadership and Support: Provides guidance, resources, and training to staff to ensure effective service delivery and compliance with policies. Risk Mitigation: Identifies and mitigates risks through the implementation of risk management strategies, incident reporting, and quality improvement initiatives.
3	Workers	Service Delivery: Implements operational processes in line with organisational policies, ensuring participants receive high-quality and safe support. Feedback and Reporting: Identifies challenges in daily operations and reports them to management, contributing to continuous improvement initiatives. Compliance Adherence: Ensures all actions and decisions comply with organisational policies, participant plans, and regulatory requirements.
4	Participants and Stakeholders	Active Engagement: Participants and stakeholders are encouraged to provide feedback, raise concerns, and participate in organisational decision-making processes. Rights Advocacy: Advocates and representatives of participants are supported to voice their concerns and work collaboratively with the organisation to enhance service quality.

Record Keeping

Governance Documentation

Board Meeting Minutes: Detailed minutes of all board meetings are maintained, including decisions made, actions agreed upon, and follow-up responsibilities. These records ensure transparency and accountability.
Policy and Procedure Records: Up-to-date versions of all governance and operational policies are securely stored, with a review history documenting any changes or updates.
Strategic and Operational Plans: Records of strategic objectives, operational plans, and progress reports are maintained to track organisational performance.

Risk and Compliance Records

Risk Assessments and Registers: Documentation of identified risks, mitigation strategies, and risk monitoring activities is maintained as part of the organisation’s proactive risk management approach.
Incident and Complaint Logs: Detailed records of incidents, complaints, and actions taken to address them are securely stored to ensure proper resolution and compliance with reporting obligations.
Audit Trails: Internal and external audit reports, including findings and follow-up actions, are recorded to demonstrate compliance with regulatory standards and continuous improvement efforts.

Participant and Stakeholder Engagement Records

Feedback and Consultation Records: All feedback, surveys, and consultation activities involving participants and stakeholders are documented, including how feedback was used to improve governance and operations.
Advocacy Support Records: Records of participants’ use of advocacy services, including contact details and outcomes, are maintained to demonstrate the organisation’s support for participant rights.

Staff Training and Performance Records

Training Records: Comprehensive documentation of all governance-related training, including attendance, content covered, and competency evaluations, is securely maintained.
Performance Reviews: Records of staff performance reviews and professional development plans are documented to support workforce empowerment and continuous improvement.

Continuous Improvement Records

Quality Improvement Logs: Records of quality improvement initiatives, including goals, implementation steps, and outcomes, are maintained to track organisational progress.
Policy Review Documentation: Changes to policies and procedures are documented with justifications for updates, ensuring transparency and accountability.

Data Security and Confidentiality

Secure Storage: All governance and operational management records are stored securely in compliance with Australian data protection laws. Physical records are stored in locked cabinets, and electronic records are encrypted and password-protected.
Access Control: Records are accessible only to authorised personnel, with access logs maintained to ensure confidentiality and data integrity.