header background

Policy & Position Paper Development

Home / About Us / Governance / College Policies / Policy & Position Paper Development
Reference: Policyand Position Paper Development_v.1.2Final

1.            PURPOSE & SCOPE

This policy defines the process for the development, approval and uploading to the web of policies, and position papers for the Royal Australasian College of Medical Administrators

2.            OBJECTIVES

Policies are an official position statement of the College and establish the key principles and provisions that govern decision-making processes. Policies are required and include details of the College’s expectations and how it will act. While some policies can stand alone, most will be accompanied by associated procedures and/or guidelines to explain how the policy is to be implemented across the College

The Policy & Position Paper Development Policy establishes

4.            INTENT

RACMA is committed to the development of high quality policies in a range of areas relevant to its governance, operations and its broader role in the health care system. 

RACMA will prioritise its health system policy development in areas in which it has specific expertise and interest.

Where possible, RACMA will develop its policies through a consultative and evidence-based process.

RACMA policies will be transparent and unless specific contraindications apply, they will be promulgated publicly.

RACMA will develop a standing policy platform which will assist it to respond in a timely manner to external requests for policy advice

5.            KEYWORDS

                Policies, Position Papers, Guidelines

6.            BODY OF POLICY

6.1.         RACMA has the following types of policies

                i.              The Board policies that define the way in which the Board conducts its business

                  Examples may include:

ii.             The Board policies that define the operational control framework.

                  Examples may include:

iii.            The Board policies that define RACMA’s position(s) on key strategic issues of broader significance in the health care sector.  These policies are high level and will guide RACMA’s response to external inquiries

iv.           Operational policies which are developed by management and define the way in which management conducts RACMA business.  Examples may include organisational privacy policies, cash-handling policies, leave management policies and policies addressing the management of media inquiries.

6.1.1.    Principles for the development and maintenance of RACMA policies

               The following principles apply to the development of RACMA policies:

 i.              RACMA policies will always comply with applicable legislation and with RACMA’s constitutional instruments.

ii.             RACMA policies will be based on thorough research and evidence.

iii.            RACMA Board policies will be developed in a consultative manner, providing meaningful opportunities for stakeholders (in particular, Fellows, Candidates, and Members) to contribute to policy development

6.1.2.     The following individuals and groups are responsible for leading policy development:

The Board reserves the discretion to query or change operational policies but will do so only in exceptional circumstances, respecting the role of the Chief Executive and the responsibility of The Board to establish an appropriate distinction between governance and management roles

A policy register will be maintained, with The Board policies separately identified from operational policies.  All policies will be dated and endorsed by the President or Chief Executive according to the authorisation level

RACMA Board policies will be available on the College website for all stakeholders unless The Board determines otherwise

All RACMA policies will be reviewed on a regular basis and updated where necessary and at least annually, by the individual or body responsible for their endorsement


6.2.1.     Governing Authority

Is one of the following:

i.              The Board

ii.             Policy & Advocacy Committee

iii.            Chief Executive

6.2.2.     Approval Authority

Is one of the following:

i.              The Board

ii.             Policy & Advocacy Committee

iii.            Chief Executive

The Approval Authority is responsible for Approving all new and amended policies and procedures. In the case of approving amendments, only major amendments (as defined) need to be approved by the Approval Authority

6.2.3.     Governing authority is responsible for:

Ensuring the policy or procedure is developed or amended in accordance with the Policy and Position Paper Development Policy

Endorsing the final version of new policies and procedures for approval by the Approval Authority

Endorsing major and minor amendments (as defined) to existing policies and procedures for recommendation to the Approval Authority

Ensuring the new or amended policies and procedures can be applied consistently across the college

6.2.4.     Responsible Officer

Overseeing the development of new or amended policies and procedures and ensuring that the process complies with the Policy Development Review Policy and Procedure. Note:  the Responsible Officer may delegate the drafting to a member of staff within their area of responsibility

Seeking endorsement and approval on new or amended policies and procedures from the Governing Authority and Approval Authority respectively

Seeking endorsement and approval from the Governing Authority and Approval Authority respectively for major and minor amendments (as defined)

Seeking approval from the Governing Authority for the rescission of policies or procedures which have been deemed invalid or no longer in effect

Managing implementation, communications and interpretation of the approved new or amended policies and procedures in the College through appropriate staff channels. This includes ensuring that any relevant stakeholders are kept up to date on necessary changes

Ensuring that previous versions of the amended policy and procedure, or rescinded policies and procedures, are archived appropriately where necessary, the Policy & Projects Officer should ensure that the most updated copy of the policy or procedure is accessible to relevant stakeholders via the College website

Ensuring that the relevant policy and procedure are monitored and reviewed in accordance with the appropriate timeframes

Approving any necessary associated documents which are developed or amended (e.g. Guidelines, Local Protocols) in line with the approved new or amended policies and procedures maintain a register of policies and procedures at various stages throughout the Development and Review Cycle

6.2.5.     Format of Policy

The initial draft is prepared using the Policy template. (Doc ID DR315)


Definition: a report that explains or recommends a particular course of action. 

A position paper describes a particular view or opinion on a specific action or practice which College has developed. It is not necessarily binding on the Fellowship

The initial draft is prepared using either the Policy template or the Guidelines and Position Papers template, as appropriate. The initial draft should provide sufficient information within the background and body of the policy for subsequent discussion and approval.

6.3.1.     Policy and position paper development

The initial draft is prepared using the Position Papers template. (Doc.ID…) The Process is as follows:

Chief Executive

Policy & Advocacy Committee

First Draft

Proof & Edit

Second Draft

Proof & Edit


President of Board (or Board) Approval & Authorisation Sign off

Format & Version Control

Publish and/or Submission

6.3.2.     Version Control

All policies, forms, processes and position statements/papers must be version controlled. Version control is the logical management of organising and controlling changes to documents. Changes are identified by numeric sequencing, such as v_1,2,3. Changes are decimally placed, such as 0.1,0.2,0.3 etc, with the ratified version being a whole number such as 1.0,2.0,3.0 etc

6.3.3.     Responding to external policy requests or invitations to make submissions

 RACMA will make every effort to monitor the external health policy environment and respond to relevant policy-based requests by external stakeholders, recognising the responsibility and opportunity to contribute to policy and practice in the broader health care system, particularly in areas in which RACMA has specific expertise.

RACMA will make every effort to provide high quality, timely submissions and consultation responses in areas in which RACMA holds specific expertise

 RACMA will make every effort to provide high quality, timely submissions and consultation responses in areas in which RACMA holds specific expertise.

These areas include but are not limited to:

The Chief Executive, in consultation with the President if considered necessary by the Chief Executive, coordinates the development of and authorises RACMA submissions and consultation responses

In general, jurisdictional committees should limit their submissions and consultation responses to issues that are relevant only at a jurisdictional level.  If an issue has broader relevance, or a requesting body operates at a multi-jurisdictional or national level, submissions and consultation responses should be coordinated by the Chief Executive, with the Board input if necessary

For quality and consistency purposes, jurisdictional committees that are asked to make submissions and consultation responses should consult with the Chief Executive to ascertain if there is an existing RACMA policy.  If so, jurisdictional submissions and consultation responses should be consistent with that policy unless otherwise approved by RACMA Board

A copy of each jurisdictional submission and consultation response should be submitted to the Chief Executive for inclusion in a central repository of all RACMA submissions and consultation responses, which will be maintained by the Chief Executive

7.            Finalising the documents for upload to the web and to SharePoint

 The Chief Executive will inform the Policy & Projects Office of the ratified and approved policies and position statements / papers.

The Chief Executive ensures the policy or position paper is sent to their EA/PA for publishing within two weeks of Board approval.

Policies and Position Papers will be loaded onto the website and SharePoint within two weeks of being received            

8.            Access to RACMA policies and related documents

8.1.         Policies will be accessible on request by all RACMA Fellows, Candidates and Members. All policies will be published on RACMA’s website unless the board specifically decides that a policy will not be published.

Public access via RACMA’s website will be the preferred mode of broader promulgation of RACMA’s submissions and consultation responses, unless the Chief Executive, in consultation with the board if necessary, identifies specific sensitivities associated with a submission or consultation response that preclude its publication


Never miss a RACMA moment