Medical Staff Bylaws
Index
- Mission Statement and Values. 2
- Medical Advisory Committee. 2
- Appointment of Medical Practitioner 2
- Responsibilities of Credentialled Medical Practitioner 2
- Consent for Medical Treatment 2
- Pre Admission Advise. 2
- Medical Record Documentation. 2
- Disclosure of Patient Information. 2
- Open Disclosure of Adverse Patient Events. 2
- Antimicrobial Stewardship. 2
- Conduct of Procedures. 2
- Allocation of Theatre Sessions. 2
- Anaesthetics. 2
- Quality & Safety. 2
- Other Matters. 2
1. Mission Statement and Values
The Management and staff of Reservoir Private Hospital Day Procedure Centre are committed to:
- Achieve consistently safe, high quality, patient-centred care.
- Providing the best available care to our patients,
- Providing the best available service to our doctors,
- Provide a competitive, affordable and safe health care service to our community
- Provide a culture that supports staff to pursue safe practice and speak up for safety.
Reservoir Private Hospital Day Procedure Centre is committed to continuously complying with our Management System which is based on Quality Management and the National Safety and Quality Health Service (NSQHS) Standards.
Reservoir Private Hospital Day Procedure Centre is also committed to continuously improving, through reviewing practice in response to established best practice, internal systems review and education.
Reservoir Private Hospital Day Procedure Centre has developed processes for planning to facilitate a transparent management system which involves all team members. The outcome of the planning process is a set of objectives reviewed and updated at least yearly.
2. Medical Advisory Committee
The Medical Advisory Committee shall have the following responsibilities:-
- To oversee the medical, professional and ethical activities of the Centre, including medical staff appointments and re-appointments and the granting of medical staff privileges, accreditation and credentialing in accordance with the current standard for 'credentialing and defining the scope of practice of medical practitioners'.
- To make recommendations to the CEO and/or the DON regarding the kinds, quality and conduct of service to be made available at the Centre.
- To encourage programs for medical, nursing and administrative staff to encompass clinical review and educational programs.
- To promote Reservoir Private Hospital Day Procedure Centre as a centre of excellence in private health care.
- To advise on and implement appropriate disciplinary actions.
- the planning, implementation, monitoring and evaluation of all safety and quality systems throughout the organisation
- Clinical policy reviews and approval
- Implementation of a new service and equipment
- Review, analyse and make recommendations on incidents and sentinel events
- Review Risk register and assess controls in place
- Session Utilization
- Patient & Carer feedback/ complaints and Consumer engagement
- New equipment purchases
- Ensures that processes conducted within the day surgery strive to meet best practice
- Approves and measures the quality objectives
- Sets quality standards and relates expectations to all staff
- Financial decisions in relation to the day surgery budget
- Ensuring the organization remains solvent, and can fulfill its financial obligations
- HR issues
- Review of infection control audits and reports including hand hygiene
- Clinical Indicators
- OH&S
- Review of internal and external audits
The Medical Advisory Committee may delegate some or all of these tasks to appropriately qualified committee members.
Members of the Medical Advisory Committee shall be appointed by the Chairman. Members shall be appointed for 5 years and shall be eligible for re-appointment.
The Medical Advisory Committee may co-opt additional members as required for advice regarding access, scope of practice an introduction of new technology or new procedure.
3. Appointment of Medical Practitioner
The Medical Advisory Committee shall appoint only professional, competent Medical Practitioners who are Fellows of their college and/or members of their professional organisation. The applicant must complete an Application for Credentialing form and provide proof of identity, national police history check, Working with children check, original qualifications or certified copies, current AHPRA registration, current medical indemnity insurance that reflects scope of practice, current CV, CPD evidence and referees.
Two professional referees must be supplied by the applicant and references will checked prior to consideration of appointment. Referees must work largely within the speciality of the applicant and be in a position to judge performance during the previous three years.
Persons so appointed shall be assigned clinical privileges for the speciality requested and have full responsibility for the treatment of individual Centre patients.
If a change in scope of practice is sort, a complete credentialing application for the proposed new service / change in scope of practice must be completed and will be submitted to the MAC for consideration. The new service cannot commence until the applicant receives confirmation of credentialled status from the MAC. The applicant must provide evidence of Medical Idemnity insurance that covers the change, additional procedure qualifications or experience related to the requested change and CPD evidence.
All Medical Practitioners must notify the CEO or DON immediately if any conditions have been placed on their Medical Registration or any other changes to registration or insurance occur.
All credentialed Medical Practitioners agree to participate in performance reviews to ensure their competence in the practice that they undertake.
Tenure
The tenure of Accreditation shall be for 3 years. After the 3 years, the applicant must complete a Re-application for credentialing and provide current AHPRA medical registration, current medical indemnity insurance,CPD evidence and updated CV (if applicable). The application will be presented at MAC and MAC will decide if the Medical Practitioner application is successful. All applicants will be notified in writing of the outcome.
All applications for appointment to the Medical Staff shall be made to the Medical Advisory Committee through the CEO or DON.
The Committee retains the absolute discretion to take any action it deems to be in the best interests of the Centre and the decision of the Committee shall be final.
The CEO or in his absence the DON is authorised to act for and on behalf of the Medical Advisory Committee in granting interim Accreditation such as in an emergency credentialing situation and in suspending Accreditation without prior notice until the next meeting of the Committee at which time ratification or review of such action can take place. In the event of emergency credentialing, a current AHPRA medical registration and current medical indemnity insurance certificate must be sighted along with a 100 point ID check. If possible, verbal confirmation should be obtained by at least 1 referee. The medical practitioner must then go through the formal credentialing process at the next MAC meeting.
Appeals against decisions of the Medical Advisory Committee may be made and will be considered by the full committee who will ensure that all decisions comply with the rules of natural justice.
4. Responsibilities of Credentialled Medical Practitioner
The responsible Credentialled Medical Practitioner shall be -
- the Credentialled Medical Practitioner who arranged the admission of the patient to the Centre; or
- where no Credentialled Medical Practitioner arranged such admission the Credentialled Medical Practitioner who has assumed responsibility for the medical care and treatment of the patient; or
- The Credentialled Medical Practitioner as a result of a change notified to the CEO by both Practitioners.
Assistants, Locums and Non-Credentialled Consultants
The Responsible Medical Practitioner may obtain assistance from Medical Practitioners who are not Credentialled Medical Practitioners. This assistance may take the form of consultation, locums, or the provision of special diagnostic, surgical or therapeutic procedures, but the primary responsibility for the care and treatment of the patient shall remain with the patient's Responsible Medical Practitioner.
The Centre reserves the right to refuse access to any Medical Practitioner who is not Credentialled Medical Practitioner.
Inability to Contact Responsible Credentialled Medical Practitioner
Where a situation arises where, in the opinion of the Registered Nurse who is in charge of the patient at the time, requires the attention of the Responsible Credentialled Medical Practitioner, every reasonable effort will be made to communicate with the Responsible Credentialled Medical Practitioner with regard to the situation and consult with him as to the care and treatment of the patient. However, if Responsible Credentialled Medical Practitioner cannot be contacted, the Centre has the right to take whatever action it considers necessary in the interest of the patient. This may include the calling of another credentialled medical practitioner to care for the patient, or the transfer of the patient to hospital. In either case the Responsible Credentialled Medical Practitioner will be advised of the action as soon as possible.
5. Consent for Medical Treatment
The Centre provides facilities and nursing care and aids for the treatment and management of patients of Credentialled Medical Practitioners. It is the responsibility of the Responsible Credentialled Medical Practitioner to ensure that the consent of his/her patients to the nature and form of all treatment is obtained. Surgery will not proceed until consent is obtained. Patients must be involved in consent and shared-decision making.
6. Pre Admission Advise
The Responsible Credentialled Medical Practitioner shall provide details of all patients to be admitted under his care to the Administrative staff at least 1 week prior to admission. All patient paperwork must be received by the centre at least 1 one week prior to admission to undergo a pre-admission assessment by the Nurse. An exclusion criteria is in place, should a patient have a condition that falls within this criteria, they cannot be admitted to RPHDPC. Screening questions are in place during booking and paperwork to ensure to the best of our knowledge that an issues or risk of harm as identified as early as possible before the patients admission.
7. Medical Record Documentation
During the course of a patient's treatment at the Centre, concise, pertinent and relevant information shall be documented in the patient’s medical record.
All orders for treatment of the patients shall be clearly conveyed to the nursing staff by the Responsible Credentialled Medical Practitioner directing such treatment.
On conclusion of treatment a procedure report shall be written by the Responsible Credentialled Medical Practitioner containing a description of the procedure performed, all relevant findings, including relevant history and details of prescriptions written or changes to the patient’s current medications.
The nursing staff must be provided with clear written instructions regarding discharge of patients and the arrangements for follow-up.
8. Disclosure of Patient Information
Reservoir Private Hospital Day Procedure Centre is committed to the protection of personal privacy of our patients, staff and other clients. Our policy is based on the Health Privacy Principles as detailed in the Health Records Act 2001, (VIC) and the Australian Privacy Principles as detailed in the 'The Privacy (Private Sector Amendment) Act 2000 as amended'. The policy deals with the collection, use and disclosure of personal health information as well as access and correction, data security and data retention.
9. Open Disclosure of Adverse Patient Events
Reservoir Private Hospital Day Procedure Centre has a policy of open disclosure for all clinical adverse events and follows the open disclosure principles of the Open Disclosure Standard 2011 Australian Commission on Safety and Quality in Healthcare. It is the responsibility of the Credentialled Medical Practitioner
- Code of Conduct
It is expected that in line with the Occupational and Safety Regulations 2007 (as amended 2014), all credentialed Medical Practitioners will adhere to the hospital code of conduct when dealing with all staff, visitors
and contractors at RPHDPC. Serious breaches of the code of conduct will result in a review of credentialed status at RPHDPC.
11. Antimicrobial Stewardship
It is the policy of Reservoir Private Hospital Day Procedure Centre that prescribing of antibiotics will be in accordance with Therapeutic Guidelines - Antibiotics. Antibiotics are not routinely prescribed for patients. Should antibiotics be used or prescribed, it must be documented in the Antibiotic Register.
12. Conduct of Procedures
Responsible Credentialled Medical Practitioner shall adopt the Centre's policies and procedures in the conduct of patient treatment at the Centre.
Histology specimens shall be sent for pathological examination whenever necessary and results followed up accordingly by the responsible medical practitioner.
A copy of the pathologists report shall be retained in the Centre's medical history.
13. Allocation of Theatre Sessions
Sessions shall be allocated to Responsible Credentialled Medical Practitioners on an agreed basis depending on times that are suitable.
The patient's name, provisional diagnosis, the nature of procedure to be performed, the patient's age, telephone number, health insurance details etc. shall be notified to the Administrative Staff at least one week prior to the session.
When a Responsible Credentialled Medical Practitioner wishes to cancel a session for any reason, it is required that 4 weeks notice of such cancellation be given to the Centre.
The Centre reserves the right to make casual bookings for any session where there are no bookings 7 days ahead of any allocated session, or part of session not fully utilised.
14. Anaesthetics
The Responsible Credentialled Medical Practitioner who is to administer the anaesthetic shall ensure that he or she is fully acquainted with the patient's full medical history, has documented details of the medical history and is fully oriented to the emergency equipment and all polices and procedures of the Centre.
15. Quality & Safety
Responsible Credentialled Medical Practitioner are expected contribute to the ongoing quality and safety of the Centre by participation in the quality management program through peer review , collection of relevant clinical indicators and assitance with quality and safety activities as required. All Credentialed Medical Practitioners are to follow RPHDPC policies and procedures and adhere to the National Safety and Quality Healtth Service Standards.
16. Other Matters
The Centre encourages Responsible Credentialled Medical Practitioners to assist the Centre in other ways, including help in emergency cases, work on committees, participation in special programs and attendance at meetings.
Medical Staff Bylaws
Index
- Mission Statement and Values. 2
- Medical Advisory Committee. 2
- Appointment of Medical Practitioner 2
- Responsibilities of Credentialled Medical Practitioner 2
- Consent for Medical Treatment 2
- Pre Admission Advise. 2
- Medical Record Documentation. 2
- Disclosure of Patient Information. 2
- Open Disclosure of Adverse Patient Events. 2
- Antimicrobial Stewardship. 2
- Conduct of Procedures. 2
- Allocation of Theatre Sessions. 2
- Anaesthetics. 2
- Quality & Safety. 2
- Other Matters. 2
1. Mission Statement and Values
The Management and staff of Reservoir Private Hospital Day Procedure Centre are committed to:
- Achieve consistently safe, high quality, patient-centred care.
- Providing the best available care to our patients,
- Providing the best available service to our doctors,
- Provide a competitive, affordable and safe health care service to our community
- Provide a culture that supports staff to pursue safe practice and speak up for safety.
Reservoir Private Hospital Day Procedure Centre is committed to continuously complying with our Management System which is based on Quality Management and the National Safety and Quality Health Service (NSQHS) Standards.
Reservoir Private Hospital Day Procedure Centre is also committed to continuously improving, through reviewing practice in response to established best practice, internal systems review and education.
Reservoir Private Hospital Day Procedure Centre has developed processes for planning to facilitate a transparent management system which involves all team members. The outcome of the planning process is a set of objectives reviewed and updated at least yearly.
2. Medical Advisory Committee
The Medical Advisory Committee shall have the following responsibilities:-
- To oversee the medical, professional and ethical activities of the Centre, including medical staff appointments and re-appointments and the granting of medical staff privileges, accreditation and credentialing in accordance with the current standard for 'credentialing and defining the scope of practice of medical practitioners'.
- To make recommendations to the CEO and/or the DON regarding the kinds, quality and conduct of service to be made available at the Centre.
- To encourage programs for medical, nursing and administrative staff to encompass clinical review and educational programs.
- To promote Reservoir Private Hospital Day Procedure Centre as a centre of excellence in private health care.
- To advise on and implement appropriate disciplinary actions.
- the planning, implementation, monitoring and evaluation of all safety and quality systems throughout the organisation
- Clinical policy reviews and approval
- Implementation of a new service and equipment
- Review, analyse and make recommendations on incidents and sentinel events
- Review Risk register and assess controls in place
- Session Utilization
- Patient & Carer feedback/ complaints and Consumer engagement
- New equipment purchases
- Ensures that processes conducted within the day surgery strive to meet best practice
- Approves and measures the quality objectives
- Sets quality standards and relates expectations to all staff
- Financial decisions in relation to the day surgery budget
- Ensuring the organization remains solvent, and can fulfill its financial obligations
- HR issues
- Review of infection control audits and reports including hand hygiene
- Clinical Indicators
- OH&S
- Review of internal and external audits
The Medical Advisory Committee may delegate some or all of these tasks to appropriately qualified committee members.
Members of the Medical Advisory Committee shall be appointed by the Chairman. Members shall be appointed for 5 years and shall be eligible for re-appointment.
The Medical Advisory Committee may co-opt additional members as required for advice regarding access, scope of practice an introduction of new technology or new procedure.
3. Appointment of Medical Practitioner
The Medical Advisory Committee shall appoint only professional, competent Medical Practitioners who are Fellows of their college and/or members of their professional organisation. The applicant must complete an Application for Credentialing form and provide proof of identity, national police history check, Working with children check, original qualifications or certified copies, current AHPRA registration, current medical indemnity insurance that reflects scope of practice, current CV, CPD evidence and referees.
Two professional referees must be supplied by the applicant and references will checked prior to consideration of appointment. Referees must work largely within the speciality of the applicant and be in a position to judge performance during the previous three years.
Persons so appointed shall be assigned clinical privileges for the speciality requested and have full responsibility for the treatment of individual Centre patients.
If a change in scope of practice is sort, a complete credentialing application for the proposed new service / change in scope of practice must be completed and will be submitted to the MAC for consideration. The new service cannot commence until the applicant receives confirmation of credentialled status from the MAC. The applicant must provide evidence of Medical Idemnity insurance that covers the change, additional procedure qualifications or experience related to the requested change and CPD evidence.
All Medical Practitioners must notify the CEO or DON immediately if any conditions have been placed on their Medical Registration or any other changes to registration or insurance occur.
All credentialed Medical Practitioners agree to participate in performance reviews to ensure their competence in the practice that they undertake.
Tenure
The tenure of Accreditation shall be for 3 years. After the 3 years, the applicant must complete a Re-application for credentialing and provide current AHPRA medical registration, current medical indemnity insurance,CPD evidence and updated CV (if applicable). The application will be presented at MAC and MAC will decide if the Medical Practitioner application is successful. All applicants will be notified in writing of the outcome.
All applications for appointment to the Medical Staff shall be made to the Medical Advisory Committee through the CEO or DON.
The Committee retains the absolute discretion to take any action it deems to be in the best interests of the Centre and the decision of the Committee shall be final.
The CEO or in his absence the DON is authorised to act for and on behalf of the Medical Advisory Committee in granting interim Accreditation such as in an emergency credentialing situation and in suspending Accreditation without prior notice until the next meeting of the Committee at which time ratification or review of such action can take place. In the event of emergency credentialing, a current AHPRA medical registration and current medical indemnity insurance certificate must be sighted along with a 100 point ID check. If possible, verbal confirmation should be obtained by at least 1 referee. The medical practitioner must then go through the formal credentialing process at the next MAC meeting.
Appeals against decisions of the Medical Advisory Committee may be made and will be considered by the full committee who will ensure that all decisions comply with the rules of natural justice.
4. Responsibilities of Credentialled Medical Practitioner
The responsible Credentialled Medical Practitioner shall be -
- the Credentialled Medical Practitioner who arranged the admission of the patient to the Centre; or
- where no Credentialled Medical Practitioner arranged such admission the Credentialled Medical Practitioner who has assumed responsibility for the medical care and treatment of the patient; or
- The Credentialled Medical Practitioner as a result of a change notified to the CEO by both Practitioners.
Assistants, Locums and Non-Credentialled Consultants
The Responsible Medical Practitioner may obtain assistance from Medical Practitioners who are not Credentialled Medical Practitioners. This assistance may take the form of consultation, locums, or the provision of special diagnostic, surgical or therapeutic procedures, but the primary responsibility for the care and treatment of the patient shall remain with the patient's Responsible Medical Practitioner.
The Centre reserves the right to refuse access to any Medical Practitioner who is not Credentialled Medical Practitioner.
Inability to Contact Responsible Credentialled Medical Practitioner
Where a situation arises where, in the opinion of the Registered Nurse who is in charge of the patient at the time, requires the attention of the Responsible Credentialled Medical Practitioner, every reasonable effort will be made to communicate with the Responsible Credentialled Medical Practitioner with regard to the situation and consult with him as to the care and treatment of the patient. However, if Responsible Credentialled Medical Practitioner cannot be contacted, the Centre has the right to take whatever action it considers necessary in the interest of the patient. This may include the calling of another credentialled medical practitioner to care for the patient, or the transfer of the patient to hospital. In either case the Responsible Credentialled Medical Practitioner will be advised of the action as soon as possible.
5. Consent for Medical Treatment
The Centre provides facilities and nursing care and aids for the treatment and management of patients of Credentialled Medical Practitioners. It is the responsibility of the Responsible Credentialled Medical Practitioner to ensure that the consent of his/her patients to the nature and form of all treatment is obtained. Surgery will not proceed until consent is obtained. Patients must be involved in consent and shared-decision making.
6. Pre Admission Advise
The Responsible Credentialled Medical Practitioner shall provide details of all patients to be admitted under his care to the Administrative staff at least 1 week prior to admission. All patient paperwork must be received by the centre at least 1 one week prior to admission to undergo a pre-admission assessment by the Nurse. An exclusion criteria is in place, should a patient have a condition that falls within this criteria, they cannot be admitted to RPHDPC. Screening questions are in place during booking and paperwork to ensure to the best of our knowledge that an issues or risk of harm as identified as early as possible before the patients admission.
7. Medical Record Documentation
During the course of a patient's treatment at the Centre, concise, pertinent and relevant information shall be documented in the patient’s medical record.
All orders for treatment of the patients shall be clearly conveyed to the nursing staff by the Responsible Credentialled Medical Practitioner directing such treatment.
On conclusion of treatment a procedure report shall be written by the Responsible Credentialled Medical Practitioner containing a description of the procedure performed, all relevant findings, including relevant history and details of prescriptions written or changes to the patient’s current medications.
The nursing staff must be provided with clear written instructions regarding discharge of patients and the arrangements for follow-up.
8. Disclosure of Patient Information
Reservoir Private Hospital Day Procedure Centre is committed to the protection of personal privacy of our patients, staff and other clients. Our policy is based on the Health Privacy Principles as detailed in the Health Records Act 2001, (VIC) and the Australian Privacy Principles as detailed in the 'The Privacy (Private Sector Amendment) Act 2000 as amended'. The policy deals with the collection, use and disclosure of personal health information as well as access and correction, data security and data retention.
9. Open Disclosure of Adverse Patient Events
Reservoir Private Hospital Day Procedure Centre has a policy of open disclosure for all clinical adverse events and follows the open disclosure principles of the Open Disclosure Standard 2011 Australian Commission on Safety and Quality in Healthcare. It is the responsibility of the Credentialled Medical Practitioner
- Code of Conduct
It is expected that in line with the Occupational and Safety Regulations 2007 (as amended 2014), all credentialed Medical Practitioners will adhere to the hospital code of conduct when dealing with all staff, visitors
and contractors at RPHDPC. Serious breaches of the code of conduct will result in a review of credentialed status at RPHDPC.
11. Antimicrobial Stewardship
It is the policy of Reservoir Private Hospital Day Procedure Centre that prescribing of antibiotics will be in accordance with Therapeutic Guidelines - Antibiotics. Antibiotics are not routinely prescribed for patients. Should antibiotics be used or prescribed, it must be documented in the Antibiotic Register.
12. Conduct of Procedures
Responsible Credentialled Medical Practitioner shall adopt the Centre's policies and procedures in the conduct of patient treatment at the Centre.
Histology specimens shall be sent for pathological examination whenever necessary and results followed up accordingly by the responsible medical practitioner.
A copy of the pathologists report shall be retained in the Centre's medical history.
13. Allocation of Theatre Sessions
Sessions shall be allocated to Responsible Credentialled Medical Practitioners on an agreed basis depending on times that are suitable.
The patient's name, provisional diagnosis, the nature of procedure to be performed, the patient's age, telephone number, health insurance details etc. shall be notified to the Administrative Staff at least one week prior to the session.
When a Responsible Credentialled Medical Practitioner wishes to cancel a session for any reason, it is required that 4 weeks notice of such cancellation be given to the Centre.
The Centre reserves the right to make casual bookings for any session where there are no bookings 7 days ahead of any allocated session, or part of session not fully utilised.
14. Anaesthetics
The Responsible Credentialled Medical Practitioner who is to administer the anaesthetic shall ensure that he or she is fully acquainted with the patient's full medical history, has documented details of the medical history and is fully oriented to the emergency equipment and all polices and procedures of the Centre.
15. Quality & Safety
Responsible Credentialled Medical Practitioner are expected contribute to the ongoing quality and safety of the Centre by participation in the quality management program through peer review , collection of relevant clinical indicators and assitance with quality and safety activities as required. All Credentialed Medical Practitioners are to follow RPHDPC policies and procedures and adhere to the National Safety and Quality Healtth Service Standards.
16. Other Matters
The Centre encourages Responsible Credentialled Medical Practitioners to assist the Centre in other ways, including help in emergency cases, work on committees, participation in special programs and attendance at meetings.