Compliance at MAT Health Clinic

Mission Statement

Our mission is to provide the highest standard of patient care whilst incorporating a holistic approach toward diagnosis and management of illness.

We are committed to promoting health, wellbeing and disease prevention to all patients. We do not discriminate in the provision of excellent care, and we aim to treat all patients with dignity and respect.


MAT Health Clinic (MHC) is accredited against standards set by the Royal Australian College of General Practitioners (RACGP). To view CLICK HERE

Accreditation is a process which acknowledges that our practice has met the set of industry standards. It shows that we are committed to safe, high quality health care. Accreditation is a voluntary process undertaken and is renewed every three years. 

Accreditation Bodies are Australian General Practice Accreditation Limited (AGPAL) or Quality Practice Association (QPA)

Policies in our workplace

Our full policy and procedure manual can be found here.
Here’s some of our other policies and procedures in the workplace:


Work Health and Safety (WHS) policies and procedures are important as they set clear standards and expectations for how WHS issues are to be managed. They also clarify which individuals hold certain obligations for managing WHS issues.

Having a policy shows a commitment to safety and preventing work-related injury and illness. It also sets the rules and standards you expect everyone to follow.

For medical practices, consideration should be given to developing appropriate policies and procedures which relate to the risks which exist in each medical practice.

Typical WHS policies and procedures that could be developed for a medical practice include:

  1. Work health and safety policy
  2. Procedures that deal with:
    1. security and staff safety,
    2. dealing with patients,
    3. ergonomic set-ups and assessments,
    4. manual handling,
    5. electrical safety,
    6. the storage and handling of drugs, medicines and other chemicals,
    7. incident/accident reporting,
    8. cash handling,
    9. first aid,
    10. fire safety and emergency procedures – including the location of fire extinguishers, how to use them and an emergency evacuation route and assembly point,
    11. working practices including the use of personal protective equipment (PPE) and other safety equipment, access/egress issues including the requirement to keep entry and exit points clear from congestion, and dealing with slips, trips and falls,
    12. worker training and competency assessment,
    13. anti-bullying, Equal Employment Opportunity (EEO) and harassment.

MHC WHS Policy Click Here
MHC PPE Policy Click Here


Effective infection control is central to providing high quality support for clients and a safe working environment for MAT Health Clinic employees, patients, and visitors.

Staff and patients are most likely sources of infectious agents and are also the most common susceptible hosts. Other people visiting the premises may be at risk of both infection and transmission.

The main modes for transmission of infectious agents are contact (including blood borne), droplet and airborne. Transmission of infection may also occur through sources such as contaminated food, water, medications, devices or equipment.

Infection control is integral to client support, not an additional set of practices.

Infection Control Policy Click Here


This privacy policy is to provide information to our patient, on how their personal information (which includes health information) is collected and used within our practice, and the circumstances in which we may share it with third parties.

Privacy Policy and Procedure CLICK HERE


This policy has been developed to provide guidance when faced with an ethical dilemma.

MHC Ethical Dilemma Policy


This policy sets out the minimum requirements for implementing open disclosure within a Health facilities and describes when open disclosure is required.

MAT HC Open Disclosure Policy


A human rights policy shows that a company understands its responsibility to respect human rights.

How to develop a Human rights Policy View here


This policy aims to establish a fair, equitable and consistent process for addressing unsatisfactory work performance and behaviour at MAT Health Clinic (MHC).

View Discipline Policy View here


This policy has been provided to ensure the working environment is safe for children and young people present at MAT Health Clinic.

MHC Children in the Workplace Policy


Our code of conduct is a set of rules around behaviour for our employees to follow within the organisation. The code acts as a standard that staff need to meet and provides written rules and behavioural guidelines for employees.

MHC Code of Conduct


  • The Therapeutic Goods Administration looks at prescription medicines, vaccines, sunscreens, vitamins and minerals, medical devices, blood and blood products.
  • The Private Health Insurance Ombudsman protects the interests of private health insurance consumers.
  • Safe Work Australia (SWA) is an Australian government statutory body, they work in partnership with governments, employers and employees—to drive national policy development on WHS and workers’ compensation matters.
  • has information and services for work health and safety and workers’ compensation in Queensland.
  • The purpose of the Fair Work Ombudsman is to promote harmonious, productive, cooperative and compliant workplace relations in Australia.
  • Services Australia provides Services, payments and programs for health professionals, practice staff, health workers and pharmacy staff.
  • The purpose of the Australian Commission on Safety and Quality in Healthcare is to contribute to better health outcomes and experiences for all patients and consumers, and improved value and sustainability in the health system by leading and coordinating national improvements in the safety and quality of health care.
  • The Office of the Australian Information Commission (OAIC) are the independent national regulator for privacy and freedom of information. They promote and uphold your rights to access government-held information and have your personal information protected.
  • Information about anti-discrimination and equal opportunity measures can be obtained by contacting the Australian Humans Rights Commission
  • The Australian Health Practitioner Regulation Agency (AHPRA) is the national organisation responsible for implementing the National Registration and Accreditation Scheme (the National Scheme) across Australia.

Codes of Practice

Codes of practice provide information on a specific issue and help us achieve legal standards. The Medical Board of Australia has developed codes and guidelines to guide the profession. These also help to clarify the Board’s expectations on a range of issues. View Here

Some Codes of Practice that we follow are:

Legal Framework

To view our list of relevant Healthcare legislation Click here

Education Hub

Translation & Interpreter Service

We offer translation services on request to our patients from a non-English speaking background. We can organise to have a translator by phone hook up with 24 hours’ notice to interpret a consultation.  The patient on their consent may have a third party at their consultation to assist in communicating their needs with their Doctor.

Please see below a list of web-links and phone numbers for Translation & Interpreter Services:
PH: 131 202 (Languages)

TIS – Translation & Interpreter Service
PH: 131 450 To Pre-Book: 1300 655 081

NRS – National Relay Service
PH: 1800 555 660 (Help line)
TTY/Voice Calls: 133 677
Speak & Listen: 1300 555 727
SMS Relay: 0423 677 767


Workplace Diversity and Inclusion training

To complete our workplace diversity and inclusion training CLICK HERE

Find out more about Human Rights

What are human rights?

Human rights recognise the inherent value of each person, regardless of background, where we live, what we look like, what we think or what we believe. View Fact Sheet here

How does healthcare relate to human rights?

It entitles people to a system of health protection, including the prevention, treatment and control of diseases and access to essential medicines. The right to health means that functioning public health care facilities, goods and services must be available and accessible, equally, to all

What is the Universal Declaration of Human Rights?

The Universal Declaration of Human Rights articulates fundamental rights and freedoms for all. The General Assembly of the United Nations adopted the Declaration on 10 December 1948. 

What is the relationship between human needs and rights?

The common factor between Human rights and Human needs is that both are equally essential for leading a quality human life. Human rights stem from what we need.
Human rights can be achieved only if human needs are met with the common factor between the two being both are equally essential for leading a quality human life.

The Australian Human Rights Commission is an independent statutory organisation, established by an act of Federal Parliament. We protect and promote human rights in Australia and internationally. View here

How to develop a Human rights Policy View here

How to comply with your Medicare obligations
Patient Rights

The National Safety and Quality Health Service (NSQHS) Standards provide a nationally consistent statement of the level of care consumers can expect from health service organisations.

The Australian Charter of Healthcare Rights describes what consumers, or someone they care for, can expect when receiving health care.

Patient consent

Informed consent is a person’s decision, given voluntarily, to agree to a healthcare treatment, procedure or other intervention that is made

Generally, a provider can only collect your health information when you consent to them doing so, and the information is reasonably necessary for them to carry out their functions or activities (such as diagnosing or treating your illness) or
when a provider requires a patients consent to collect their health information for a particular purpose, they generally should ensure the patient understands what will happen to the information and what they are consenting to. A patient must provide their consent for the collection, use or disclosure of their personal health information.

A patient’s consent can be either implied or express.

Implied consent is not given by a patient in writing, but is understood from the circumstances surrounding their medical care.  It is consent that is inferred from actions, or facts, or even by inaction or silence.  For example raising your arm when your doctor takes your blood pressure.

Express consent is permission for something that is given specifically (usually in writing). If express consent is in writing, it should include the doctor’s details, any authorized treatment (or details the patients consent to their records being released to a third party) and the date. In most situations, the signing of a consent form that includes all of this information evidences express consent.

In some circumstances, it may be impossible to obtain valid consent. For example if the patient is unconscious.

Sometimes the patient will give permission for someone else to manage their medical record. In most cases this is done by giving another party an enduring power of attorney.

Express consent example

If a patient wants their records transferred to another Doctor they must give written or express consent. Likewise if another party such as an employer, insurance company etc. requires personal or health information it is necessary for the patient to provide written and signed consent before information can be released.

Implied consent example

There may be times where the consent to a provider collecting the health information can be implied. For example, a GP would not normally need to specifically ask you for permission to make notes of symptoms you describe during an appointment because your consent can be implied from your conduct in attending the appointment and describing your symptoms.

The patient’s consent should be given voluntarily. They also need to have the capacity to consent to their health information being collected.

Practitioner/patient boundaries

Doctors and nurses are some of the most trusted and respected professions in the community. Our patients expect us to act in their best interests and to respect their dignity. A breach of professional boundaries may lead to a violation of the practitioner’s professional responsibility.

What are professional boundaries?

Professional boundaries are defined as limits which protect the space between the professional’s power and the client’s vulnerability. They are the borders that mark the edges between a professional, therapeutic relationship and a non‑professional or personal relationship between a health practitioner and a person in their care.

Examples of boundary violations by health practitioner, include:

  • having sex with a patient (consent is not a defence);
  • breaches of patient confidentiality or privacy;
  • use of social media between the parties – blurring the lines between professional and personal lives;
  • accepting gifts or benefits from patients and/or their families;
  • developing a personal or intimate relationship with a patient (going out together on weekends or exchanging personal telephone numbers);
  • financial exchanges (the lending or giving of money);
  • favouritism of any kind;
  • excessive personal/self-disclosure or secrecy;
  • seductive, sexually demeaning or harassing conduct; and
  • flirtatious communication, employing sexual innuendo, off‑colour jokes or offensive language.
Mandatory Reporting and Statutory Notifications

Data breaches

When an organisation or agency the Privacy Act 1988 covers has reasonable grounds to believe an eligible data breach has occurred, they must promptly notify any individual at risk of serious harm. They must also notify the Office of the Australian Information Commissioner.

Health Practitioners Mandatory Notifications

The Ahpra guidelines Click Here  have been developed to provide direction to registered health practitioners, employers of practitioners and education providers about the requirements for mandatory notifications under the National Law.

Statutory Notifications

All Australian states and territories have legislation that requires medical practitioners to report cases of child abuse to the appropriate child protection service. In some cases, workers and professionals are also required to report instances of exposure to sexual, domestic and family violence, in recognition of the seriousness of this type of harm to the developing child.

There is a mandatory legal requirement that health professionals report certain medical events, conditions and diseases. The Queensland health website provides a list of conditions which must be reported to your local health unit View the list here

Cold chain breaches

A cold chain breach occurs when vaccine storage temperatures have been outside the recommended range of +2 degrees Celsius and +8 degrees Celsius. The optimal storage temperature for vaccine is 5 degrees Celsius. Many vaccines are damaged or destroyed if stored at temperatures outside this range.

All temperatures recorded below +2 degrees Celsius or above +8 degrees Celsius involving government funded vaccines must be reported to the Queensland Health Immunisation Program (QHIP)

Data Breaches

A data breach happens when personal information is accessed or disclosed without authorisation or is lost.

View our action plan here

Here are some information sources:

Memberships and Affiliations

MAT Health Clinic is a member of:

  • The Australian Medical Association (AMA) is the peak professional body for doctors in Australia. 
  • The Australian Primary Health Care Nurses Association (APNA) is the peak professional body for nurses working in primary health care. 
  • The Australian Association of Practice Management AAPM is a not-for-profit, national peak association recognised as the professional body dedicated to supporting effective Practice Management in the healthcare profession. 
  • Brisbane North PHN – are one of 31 Primary Health Networks across Australia. They support clinicians and communities in Brisbane’s northern suburbs, Moreton Bay Regional Council and parts of Somerset Regional Council.
  • The Australian Network on Disability – a national, membership based, for-purpose organisation that supports organisations to advance the inclusion of people with disability in all aspects of business.
  • Pride in Diversity the national not-for-profit employer support program for LGBTQ workplace inclusion, specialising in HR, organisational change and workplace diversity.
  • The Diversity Council of Australia – the independent not-for-profit peak body leading diversity and inclusion in the workplace.
  • As Australia’s leading medical defence organisation and medical indemnity insurance provider, Avant has more members, more claims experience and is backed by the largest in-house specialist medico-legal team.