Streamlined Research Governance Process

Research governance addresses the protection of research participants, the safety and quality of research, privacy and confidentiality, financial probity, legal and regulatory matters, risk management and monitoring arrangements whilst promoting good research culture and practice.

The RDGU at Epworth HealthCare has implemented a streamlined governance process. This process is designed to ensure all ethical, legal, regulatory, strategic and logistical requirements of research being conducted at Epworth are fulfilled within acceptable timelines.

Any research being conducted at or on behalf of Epworth must comply with the Epworth Research Policy and adhere to the requirements outlined in the Epworth Research Handbook and related SOPs (available on our Resources for Researchers webpage).

  • Helpful Tips
    • Familiarise yourself with the Research Policy, strategy, Governance Handbook and relevant SOPs on our Resources for Researchers webpage
    • Always refer to our Resources for Researchers webpage for the most current templates and guidance documents
    • Read all of the steps in the process (including information dropdowns) before commencing with your application
  • COVID-19 Guidance for Research Studies

    The COVID-19 pandemic is a rapidly evolving situation and the response measures required to effectively manage the impact of the pandemic on our patients and clinical trials must adapt accordingly. When implementing our response measures, at all times the safety of our patients and staff are our highest priority. Please refer to the Epworth Research Coronavirus (COVID-19) Contingency Plan – July 2020 for further details.

    The registration of new research projects with the Research Development and Governance Unit (RDGU) is encouraged. Development and governance activities will still be undertaken, however projects will only receive governance authorisation once the restrictions on research activity have been lifted.

    There may be projects that warrant exemption from the current COVID-19 research restrictions as outlined in the Epworth Research Coronavirus (COVID-19) Contingency Plan such as those involving treatments for acute or life threatening health condition or that can be conducted remotely. If your upcoming project fits this category, please complete the COVID-19 restriction research exemption form (DOC, 40KB) and submit with your registration request.

  • Defining Research at Epworth

    Research that meets any of the following criteria must be registered with the RDGU and authorised by Epworth prior to commencing:

    • the research involves Epworth patients (inpatients or outpatients);
    • Epworth is funding the research directly;
    • the project uses significant Epworth resources; and/or
    • the research could impact on Epworth’s reputation.
  • Strategic Fit

    As per Epworth Research Policy, all research at Epworth must be in alignment with Epworth values and strategic intent.

    All researchers are required to be familiar with the Epworth overarching strategy and Epworth Research Strategy when planning to undertake research at Epworth and are required to obtain evidence of approval from the relevant Director that a project meets this criteria as per the Epworth Research Governance Approval Hierarchy (see Epworth Research Governance Handbook Appendix A).

  • Study Feasibility

    The Principal Investigator should discuss feasibility of the project with all relevant Epworth stakeholders as per the Epworth Research Governance Approval Hierarchy (see Epworth Research Governance Handbook Appendix A).

    This should take place prior to registration with the RDGU. The feasibility process for interventional studies is outlined in the Feasibilities and Trial Start-Up SOP (SOP-TM-01).

    The RDGU can help further advise on the relevant departmental and hospital approvals at registration if required.

  • Project Registration

    All new research projects at Epworth must be registered with the RDGU.

    Registration should take place after feasibility is confirmed and prior to submitting a project for external ethics review on behalf of Epworth (see Research Governance SOP (SOP-RG-01) for further information).

    The following information is required to register a project:

    • Study title
    • Epworth PI (must have an Epworth appointment or affiliation)
    • Sponsor (if clinical trial)
    • Study Coordinator (if applicable)
    • Epworth site(s)
    • Project proposal or protocol (draft can be provided)
  • Researcher Credentialing

    Any researcher engaged in health and medical research involving Epworth patients, staff and/or resources must be authorised to conduct research at Epworth.

    The Researcher Credentialing Process ensures that all investigators conducting research at or for Epworth are qualified and authorised to do so. Research projects will not be granted governance authorisation until all listed researchers are authorised through this process.

    Further information regarding the credentialing process and requirements are outlined in the Researcher Credentialing SOP (SOP-RG-04).

    Researcher credentialing application to the RDGU are to be submitted through the online Researcher Credentialing Form.

    Should there be any issues accessing the online application the researcher credentialing form can be downloaded here and submitted to [email protected]

  • Mandatory SOP training

    All individuals involved in the conduct of clinical trials under the TGA Clinical Trial Notification (CTN) scheme at Epworth are required to complete and record their SOP training in SiteDocs prior to commencing any research activities (see also Documentation of Qualifications and Training Records SOP (SOP-QA-01).

    Access to the SiteDocs Portal is granted upon completion of the researcher credentialing process. If you are having issues accessing the system please contact the Epworth RDGU ([email protected]).

    For staff not involved in the conduct of clinical trials under the CTN scheme are required to maintain documentation of SOP training manually. Additional resources and templates can be found on our Resources for Researchers webpage including role based training curriculae and a template log for documenting training.

  • Insurance and Indemnity
    All studies must be able to provide evidence of adequate insurance coverage. For further information please refer to our Clinical Indemnity and Insurance SOP (SOP-RG-02).
  • Project Budget

    A detailed budget must be developed for research being conducted at Epworth. It is the Principal Investigator’s responsibility to ensure all institutional costings have been adequately accounted for.

    For investigator initiated studies the PI is responsible for ensuring all costs are covered by an identified funding source (i.e. research grant). This should be discussed with the Research Operations Manager or Clinical Institute Research Lead as early as possible to establish if the resourcing and operational requirements of the study can be met.

    For further guidance refer to Developing Contracts and Budget SOP (SOP-RG-03).

    Further information regarding opportunities for funding of research activities at Epworth can be found on the Epworth Medical Foundation Research Grants webpage.

  • Research Agreement

    Research agreements must be in place where projects involve multiple parties where the roles and responsibilities must be defined.

    The requirement for an agreement should be identified early in the application preparation process. For further guidance on research agreement templates approved for use at Epworth and Epworth details to be included in research agreements see the Developing Contracts and Budget SOP (SOP-RG-03).

    Only an authorised representative of Epworth is permitted to sign research agreements on behalf of Epworth.

    Research agreements signed by all parties except Epworth should be submitted as part of the governance application to Epworth. Submissions will not be considered complete or processed until all required documents including the agreement for signing is provided. Epworth will sign the agreement last as part of issuing governance authorisation.

  • Studies involving exposure to ionising radiation
    Please refer to Epworth SOP on conducting research involving ionising radiation (SOP-RG-05) for guidance on preparing and submitting documentation to demonstrate compliance with the legislative requirements for research involving ionising radiation.
  • Clinical Trial Notification Scheme (CTN)

    The Epworth HealthCare site(s) where trial procedures are to be conducted must be listed on the CTN.

    Please refer to Research Governance SOP (SOP-RG-01) Appendices for Epworth details to be included in the CTN.

  • HREC Review

    Ethical consideration is an integral part of research governance. Any research being undertaken at Epworth which is considered more than low-risk will require ethics review by a HREC certified under the National Health and Medical Research Council (NHMRC) National Mutual Acceptance (NMA) scheme. The NMA scheme is a widely adopted initiative which aims to reduce the duplication and streamline the ethical review process.

    Please refer to the Epworth Research Handbook for an overview of options and requirements for ethics review pathways accepted at Epworth.

    The RDGU can assist in identifying the appropriate review pathway at registration.

  • Non-HREC Review Pathways

    The RDGU oversees the review of Low and Negligible Risk projects deemed suitable for ethical consideration via the non-HREC review pathway as defined by the National Statement. Please see the Non-HREC Review SOP (SOP-RG-08) for further information.

    If the project meets the criteria for non-HREC review all ethics and governance considerations will be addressed as part of the review.

  • Site Specific Research Documents

    The Principal Investigator is responsible for ensuring the Participant Information and Consent Form (PICF) and other site-specific documents are based upon the current HREC approved Master documents and appropriately amended to include the site specific information.

    The PICF content checklist form (SOP-RG-01-FORM-01) must be referred to when preparing the site specific PICF.

  • Research Governance Applications – Submission Requirements

    Epworth does not use the Ethical Review Manager (ERM) system nor require completion of the Site-Specific Assessment (SSA) Form.

    All research governance applications must be submitted with a completed Researcher Project Declaration form (SOP-RG-01-FORM-02). This form must be completed by the Principal investigator.

    Submissions will only be considered complete and processed when all required documentation as outlined in SOP-RG-01 and the PI declaration form are provided.

    Please do not submit your governance application in multiple separate parts – all documentation must be submitted in one complete submission. 

  • Research Governance Authorisation

    The RDGU will provide written confirmation of Governance Authorisation to the Principal Investigator upon receipt of required documents and sign-off by the Group Chief Executive or delegate.

    The Principal Investigator must ensure all conditions of Governance Authorisation are met prior to commencement of the project.

  • Review Fees

    The following Research Governance Review fees apply to commercially sponsored clinical research conducted at Epworth HealthCare, effective from January 1st 2020.

    Commercially sponsored studies

    • Initial application: $5,500 Unit Cost (AUD) (exc GST)
    • Amendment Review Fee: $600 Unit Cost (AUD) (exc GST)
  • Post-Approval Governance
    The Principal Investigator is responsible for meeting all reporting requirements as outlined in the Research Governance SOP (SOP-RG-01).
  • Internal Audits of Research at Epworth

    Research conducted at Epworth HealthCare may be subject to internal auditing by the RDGU.

    It is the Principal Investigator’s responsibility to ensure that adequate records are maintained to demonstrate compliance with governance requirements.

    Further information regarding our quality management system can be found in our QMS protocol and associated Research Quality SOPs on our Resources for Researchers webpage.

  • Clinical Quality Registries

    The Academic & Medical Services Division is responsible for the institutional approval and subsequent oversight of Clinical Quality Registries (CQRs) at Epworth. The RDGU in consultation with the Clinical Outcomes and Analytics Unit manages the institutional approval and subsequent oversight of CQRs at Epworth.

    To register or discuss an existing CQR at Epworth please email: [email protected]

  • Quality Assurance and Quality Improvement Activities

    The Quality Team within the Clinical Services (Corporate) Division is responsible for oversight of Quality Assurance (QA) and Quality Improvement (QI) activities at Epworth.

    All internal QA/QI activities must be registered on the Epworth QI activity register on the intranet prior to commencing. The RDGU in consultation with the Quality Team provides additional support for projects that warrant further review.