Canberra Health Services does not know when a policy on cultural standards will be finalised, despite first discussing the need for it three years ago.
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Documents obtained under freedom of information laws have revealed ACT Health's clinical cultural committee brought up the idea of developing a statement of desired culture at one of its first meetings in November 2015.
The statement was one of several recommendations from a damning KPMG report into cultural failings at ACT hospitals, including bullying, harassment and management failures.
In its November 2015 meeting, the committee discussed how to develop the statement, which would include how to "draw a line in the sand to indicate that poor behaviour will be treated more actively", acknowledging past failures and the need for an extensive consultation process.
Minutes from an initial committee meeting said the statement "could have a powerful effect on staff and their engagement".
Documents also showed members of the 22-person committee agreed to hand in submissions for what the statement should contain by June 2016, yet only two committee members did.
A Canberra Health Services spokesman said a draft statement was developed in 2017 and involved consultation with ACT Health staff and focus groups.
"Further staff consultation was required to finalise the statement. However this work had not been finalised when it was announced in March 2018 that ACT Health would become two organisations," the spokesman said.
He said work will be undertaken by Canberra Health Service's new chief executive Bernadette McDonald in the next two to three months.
Bullying and harassment will be a key focus of an independent review into the ACT public health system, which is due to report to the ACT government by March next year.
The establishment of the clinical cultural committee was one of the recommendations in the KPMG report, and has been meeting monthly since November 2015.
In 2015 the members included then-ACT Health director-general Nicole Feeley and clinical director Denise Riordan.
The meeting documents also revealed a draft cultural communication strategy was developed in June 2016, aimed at eliminating inappropriate behaviour and bullying in hospitals, which had a two-year timeline to implement.
More than two years after it was brought up, work on the strategy has not progressed.
The committee also discussed the prospect of sharing information between ACT Health and the Royal Australasian College of Surgeons for investigations into staff misconduct.
However, the idea was scrapped after the college was not able to say what action would be taken once the information was shared, with it likely to launch its own investigation.
"The committee noted that subjecting the respondent to a second investigation process would not be a favourable option" the documents said.
There were also suggestions of performance management process for ACT Health staff who held academic titles at ANU be combined with the university.
The committee said information on individual staff in relation to bullying and harassment would be shared.
"While there would be overlap in relation to expected behaviours, ANU monitors staff performance in terms of research and teaching while ACT Health monitors clinical and related responsibilities," the committee said.
A Canberra Health Services spokesman said there had been significant work undertaken since March this year to improve workplace culture due to Canberra Hospital's accreditation process.
"Developing a high-performing culture where people feel valued, are able to effectively contribute and build effective partnerships is a high priority for the CHS executive," the spokesman said.
The next meeting of the committee is expected to take place in early December.
