Embed Size (px)
DESCRIPTION
Citation preview
0
Healthscope Limited
Hospital By-Laws
Adopted 1 July 2012
1111316046 \ 03062376480415 \ 117801 Revised July 2012 1
Table of Contents
Foreword........................................................................................................................................... 3
Background....................................................................................................................................... 4About Healthscope Limited .................................................................................................... 4
These By-Laws.................................................................................................................................. 4What are these By-Laws? ....................................................................................................... 4How are these By-Laws changed?.......................................................................................... 4What are the purposes of these By-Laws? ............................................................................ 4What do the By-Laws contain? .............................................................................................. 5How to read these By-Laws .................................................................................................... 5What these By-Laws are not................................................................................................... 8
Medical Advisory Committee.......................................................................................................... 8Creation of a MAC.................................................................................................................. 8Other committees..................................................................................................................... 9External members of MAC..................................................................................................... 9Indemnity to members of committees.................................................................................... 9
Accreditation .................................................................................................................................. 10Generally ................................................................................................................................ 10Health Practitioner must be accredited with respect to admit patients ........................... 10Application for Accreditation............................................................................................... 11Compliance with By-Laws.................................................................................................... 11Process on receipt of application for Accreditation............................................................ 11Credentials Committee ......................................................................................................... 12Process of the Credentials Committee ................................................................................. 12Decision by General Manager .............................................................................................. 13Term of Accreditation........................................................................................................... 14Temporary Accreditation ..................................................................................................... 14Re-Credentialling .................................................................................................................. 15Lapse of Accreditation .......................................................................................................... 15
Resignation, Variation, Suspension or Termination of Accreditation ...................................... 15Resignation or Extended Absence of an Accredited Health Practitioner......................... 15Accredited Health Practitioner may request variation of Accreditation ......................... 16Allegations Concerning Accredited Health Practitioners.................................................. 16Suspension of Accreditation by General Manager............................................................. 17Termination of Accreditation............................................................................................... 18Effect of suspension or termination of Accreditation at other Healthscope Hospitals ... 20
Appeals............................................................................................................................................ 20No right of appeal unless specifically conferred ................................................................. 20Right to appeal a decision of a General Manager............................................................... 20Procedure for appeal............................................................................................................. 21
General Conditions of Accreditation............................................................................................ 23Accreditation is Personal ...................................................................................................... 23Accreditation permits a delineated Scope of Practice ........................................................ 23
1111316046 \ 03062376480415 \ 117801 Revised July 2012 2
Compliance with ‘General Conditions' and ‘Special Conditions' of Accreditation ........ 23Compliance with Laws, Policies and Professional Standards ........................................... 24Professional Malpractice Insurance..................................................................................... 24Quality Assurance ................................................................................................................. 24Respect for Colleagues and Staff.......................................................................................... 25
Continuous disclosure.................................................................................................................... 25Continuous Disclosure Requirements.................................................................................. 25
Clinical Responsibilities................................................................................................................. 26Admission of patients ............................................................................................................ 26Allocation of operating room sessions ................................................................................. 27Care of admitted patients ..................................................................................................... 27Patient Records and Discharge of Patients ......................................................................... 28Surgical Assistants................................................................................................................. 32
Additional rules, policies and procedures.................................................................................... 33
Confidentiality................................................................................................................................ 33General ................................................................................................................................... 33What Accredited Health Practitioner must keep confidential .......................................... 33What Healthscope must keep confidential .......................................................................... 34When confidentiality can be breached................................................................................. 34What confidentiality means .................................................................................................. 34Confidentiality obligations continue .................................................................................... 35
Forms and paperwork ................................................................................................................... 35General Manager may prescribe forms and paperwork ................................................... 35
Schedule 1 ....................................................................................................................................... 36
Schedule 2 ....................................................................................................................................... 38
Schedule 3 ....................................................................................................................................... 39
Schedule 4 ....................................................................................................................................... 41
Schedule 5………………………………………………………………………………………... 42
1111316046 \ 03062376480415 \ 117801 Revised July 2012 3
FOREWORD
Clinical Governance is a field where Healthscope Limited, its hospitals and the accredited medicalstaff practising in those hospitals as represented by the Medical Advisory Committees have a richhistory of collaboration and cooperation. This is based on a shared interest in clinical standards,quality and patient safety and a common interest in ensuring that the best medical specialists seek topractise in Healthscope's hospitals.
Hospital General Managers, the Medical Advisory Committees and their Chairmen and I haveworked closely and harmoniously in key areas of clinical governance, including the consideration ofapplications for accreditation at the hospital, monitoring/improving standards of patient care andmanaging sub-optimal clinical outcomes, particularly where associated with impaired or under-performing clinicians.
The recognition of the clinical autonomy of our accredited health professionals is central toHealthscope's philosophy. Our hospitals have a vital interest in the standard of health care practisedin our hospitals as this determines the quality of care received by patients and ultimately thereputation of the hospital. Healthscope itself does not provide medical services to its patients (otherthan in very limited ways). It is not funded to provide medical services and is not accountable orotherwise liable at law for the provision of these services. Healthscope does not determine standardsof medical practice, nor does it direct its medical specialists in the practice of medicine and in thetreatment of their private patients. Instead, Healthscope encourages the clinical independence of theaccredited health professionals and acknowledges the accountability that accompanies thisindependence. This accountability is both personal and collegiate – through the workings of theMedical Advisory Committee, its sub-committees and Departments, the medical staff provideessential advice to hospital management, oversee functions such as accreditation and credentiallingand monitor and improve the quality and safety of care provided by the medical community of thehospital.
The Healthscope Limited Hospital By-Laws are the formal expression of the relationship betweenthe accredited health professionals and the hospital. The new By-Laws replace those introduced in2006. Changes have been kept to a minimum and where changes have been made they haveoccurred as a result of changes in the regulatory environment or as a result of suggestions forimprovement made by doctors and hospitals over the last six years. In particular, I would like toacknowledge and thank those doctors and MACs who responded to the formal consultation processundertaken in September – December 2010.
The relationship between Healthscope Hospitals and accredited doctors is based on mutualrecognition of, respect for and support for each other's clinical and commercial objectives. I amconfident that the Healthscope Limited Hospital By-Laws (2012) will further enrich thisrelationship.
Dr Michael CoglinChief Medical OfficerHealthscope LimitedJune 2012
1111316046 \ 03062376480415 \ 117801 Revised July 2012 4
BACKGROUND
About Healthscope Limited
1 Established in 1985, Healthscope Limited is a leading integrated Australian health carecompany. It owns and operates private hospitals, pathology services and medical centresthroughout Australia and internationally. A core component of Healthscope's business isto provide hospital care to private patients. Day-to-day management and control of everyHealthscope Hospital is delegated by the Board of Directors of the Healthscope Companythat owns or operates that hospital to the General Manager of that hospital.
2 This document sets out what are described as the current 'By-Laws' for use in relation tohospitals owned or operated by Healthscope Limited or a Healthscope Company.
THESE BY-LAWS
What are these By-Laws?
3 These By-Laws are created by Healthscope Limited to assist in understanding someimportant current policies of its Board of Directors. They indicate how those policies areproposed to be carried into effect by the Healthscope Company that owns or operates eachHealthscope Hospital, and in particular, by the General Manager of each hospital.
4 These By-Laws are intended by Healthscope Limited to be adopted by every HealthscopeCompany that owns or operates a Healthscope Hospital.
5 These By-Laws are intended for use by both Healthscope Company employees and alsoby Health Practitioners who are accredited with respect to a Healthscope Hospital.
How are these By-Laws changed?
6 These By-Laws are changed by a resolution of the Board of Directors of HealthscopeLimited.
7 Every change to these By-Laws takes effect from the time of any resolution by the Board,and General Managers of Healthscope Hospitals will then be notified of the change.
8 Changes to the By-Laws can have retrospective effect because any arrangements basedupon superseded By-Laws are not ‘grandfathered' by subsequent By-Laws (unless theBoard specifically determines to do so).
What are the purposes of these By-Laws?
9 These By-Laws have many purposes. Specifically they:
9.1 serve to maintain and improve the safety and quality of the delivery of hospitalservices;
9.2 protect Healthscope Hospitals and their Accredited Health Practitioners byensuring that the environment in which hospital and medical services aredelivered supports and facilitates both safety and quality;
9.3 define the relationship between a Healthscope Hospital and its AccreditedHealth Practitioners and serve to clarify the mutual prerogatives and obligationsof those parties; and
1111316046 \ 03062376480415 \ 117801 Revised July 2012 5
9.4 assist in compliance with Commonwealth and State laws, regulations andstandards; and in particular the 'Standard for Credentialling and Defining theScope of Clinical Practice' and the National Safety and Quality Health ServiceStandards as promulgated by the Australian Commission for Safety and Qualityin Health Care (ACSQHC).
What do the By-Laws contain?
10 The By-Laws reflect the current environment in which Healthscope Hospitals areoperating. Changes to the law, altered perceptions of clinical best practice, the economicand risk environments in which health care is delivered and the governance structures(both clinical and corporate) of Healthscope Hospitals are all factors which influence theBy-Laws and their implementation.
11 These By-Laws contain policies on the following:
11.1 the terms and conditions on which Health Practitioners will be accredited;
11.2 the processes that lead to Accreditation and defining the ‘Scope of Practice' ofAccredited Health Practitioners;
11.3 the role of the Medical Advisory Committee and its sub-committees in theprocesses of Accreditation at Healthscope Hospitals;
11.4 the administrative and clinical responsibilities of Accredited HealthPractitioners.
How to read these By-Laws
12 Certain words and expressions in these By-Laws are capitalised to indicate a specialmeaning. Those special meanings are:
12.1 Accreditation means the authorisation of a Health Practitioner to treat patientsat a Healthscope Hospital within the Health Practitioner's Scope of Practice inaccordance with clause 52 of these By-Laws.
12.2 Accreditation Notification means the notification by a General Manager of aHealthscope Hospital to a Health Practitioner that the Health Practitioner isentitled to treat Patients at that hospital within the Scope of Practice specified inthat notification in accordance with clause 51 of these By-Laws.
12.3 Accredited Health Practitioner means a Health Practitioner who has beenauthorised to treat patients at a Healthscope Hospital within the HealthPractitioner's Scope of Practice as set out in clause 22 of these By-Laws andwhose Accreditation has not lapsed, been suspended or been terminated.
12.4 Appellant means a Health Practitioner who as appealed a decision further to aright of appeal conferred by these By-Laws.
12.5 Attending Health Practitioner means an Accredited Health Practitioner whoprovides treatment to a Patient, including but not limited to the Attending HealthPractitioner who admitted the Patient.
1111316046 \ 03062376480415 \ 117801 Revised July 2012 6
12.6 Career Medical Officer means a Medical Practitioner employed or engaged bya Healthscope Hospital to assist Accredited Health Practitioners in the care ofPatients.
12.7 Chief Medical Officer means the person designated by the Board ofHealthscope Limited to hold that title and to perform senior functions in clinicalmanagement as determined under contract with Healthscope Limited.
12.8 Board means the Board of Directors of Healthscope Limited (ACN 006 405152).
12.9 Classification means one of the nominated classifications in Schedule 5 of theseBy-Laws.
12.10 Credentialling means the formal process used to verify the qualifications,experience and professional standing of a Health Professional for the purpose offorming a view about his or her competence, performance and professionalsuitability to provide safe, high quality health care services in accordance withthe needs and capability of a Healthscope Hospital. Credentialling includes bothInitial Credentialling and Re-Credentialling.
12.11 Dental Practitioner has the same meaning as the expression 'dental practitioner'is defined in s5 of the Health Practitioner Regulation National Law from time totime.
12.12 Department means a service or specialty at a Healthscope Hospital designatedas such by the General Manager on the advice of the MAC. All accreditedPractitioners in that specialty are deemed to be members of the Department atthe Healthscope Hospital in which they are accredited.
12.13 General Conditions means the conditions of Accreditation that are applicableto all Accredited Health Practitioners, as set out under clauses 114 to 184 ofthese By-Laws.
12.14 General Manager means a person who is known by that title and has beenengaged by a Healthscope Company to manage a Healthscope Hospital.
12.15 Health Practitioner means an Other Health Practitioner or a Registered HealthPractitioner.
12.16 Healthscope Limited means Healthscope Limited (ACN 006 405 152).
12.17 Healthscope Company means Healthscope Limited and its related entities.
12.18 Healthscope Hospital means any acute, sub-acute, rehabilitation or psychiatrichealth care facility (inpatient or ambulatory care) operated within Australia by aHealthscope Company.
12.19 Initial Credentialling means the review of all previous and relevant education,qualifications, experience, employment, and the review of existing registrationunder the Health Practitioner Regulation National Law and insurance status. Itincludes reference checking, with the intention of forming a view on thecompetence, performance and professional suitability of a Health Practitionerfor Accreditation.
1111316046 \ 03062376480415 \ 117801 Revised July 2012 7
12.20 MAC means a Medical Advisory Committee.
12.21 Major Specialty and Service means those specialties and services determinedto be such by the General Manager from time to time.
12.22 Medical Practitioner has the same meaning as the expression 'medicalpractitioner' is defined in s5 of the Health Practitioner Regulation National Lawfrom time to time.
12.23 Other Health Practitioner means a person involved in the provision of clinicalservices to patients who is not a registered Health Practitioner.
12.24 Patient means a patient admitted to a Healthscope Hospital.
12.25 Professional Association means the recognised peak professional organisationin respect of:
12.25.1 a Registered Health Practitioner who is not a Medical Practitioner:
12.25.2 an Other Health Practitioner.
12.26 Re-credentialling means the process of reviewing an application to renew anexisting Accreditation of an Accredited Health Practitioner. Re-credentiallingoccurs annually. It includes examination and verification of any relevantchanges to the status of an Accredited Health Practitioner since the date of anyprevious declarations to the Healthscope Company that owns or operates theHealthscope Hospital where the Health Practitioner is accredited. The intentionof Re-credentialling is to form a view as to the continuing competence,performance and professional suitability of a Health Practitioner forAccreditation.
12.27 Registered Health Practitioner has the same meaning as the expression'registered health practitioner' is defined in s5 of the Health PractitionerRegulation National Law from time to time, except that:
12.27.1 it does not include junior Medical Practitioners such as interns,residents, registrars, Career Medical Officers or clinical fellows (forwhom separate arrangements apply)
12.27.2 it does not include pathologists and radiologists whose credentialshave been verified by either:
(a) a Healthscope Company that provides diagnostic andradiology services to patients at a Healthscope Hospital;
(b) any other entity that provides diagnostic and radiologyservices to Patients at a Healthscope Hospital
and whose credentials comply with the requirements of theHealthscope Company that owns or operates that hospital.
12.28 Scope of Practice means the delineated extent of clinical practice that a HealthPractitioner is authorised to undertake within a Healthscope Hospital, based onthe individual's credentials, competence, performance and professional
1111316046 \ 03062376480415 \ 117801 Revised July 2012 8
suitability and the needs and capability of the Healthscope Hospital to supportthe Health Practitioner's Scope of Practice. Scope of Practice may relate solelyto areas of approved clinical practice, but may also relate to the use of facilitiesor specialised equipment, or the performance of specific operations orprocedures. The Scope of Practice granted to an Accredited Health Practitionermay vary between the different Healthscope Hospitals in respect of which he orshe is accredited.
12.29 Special Conditions means any additional conditions of Accreditation imposedon an Accredited Health Practitioner by the General Manager having consultedthe Credentials Committee.
12.30 Specialist means a Medical Practitioner with an Australian fellowship orequivalent post-graduate qualification approved by the Australian MedicalCouncil and who is eligible for specialist recognition pursuant to the HealthInsurance Act 1973 (Cth) and Schedule 4 of the Health Insurance Regulations1975 (Cth).
What these By-Laws are not
13 Although these By-Laws refer to specific policies that have a direct relevance to theprocesses of accreditation and defining an Accredited Health Practitioner's Scope ofPractice, these By-Laws do not:
13.1 communicate every policy of Healthscope Limited; or
13.2 prevent the Board from making decisions that will have an effect on these By-Laws.
MEDICAL ADVISORY COMMITTEE
Creation of a MAC
14 The General Manager of each Healthscope Hospital must create and maintain a MACdrawn from the Health Practitioners who have been accredited with respect to thehospital, as well as other persons as required (see clause 20 of these By-Laws).
15 The purposes of a MAC are:
15.1 to advise the General Manager with respect to the clinical and related issuesplaced before it;
15.2 to make recommendations on the Credentialling and Accreditation of HealthPractitioners at the hospital;
15.3 to represent the collective views of the Accredited Health Practitioners who areaccredited with respect to the hospital;
15.4 to provide a representative forum for communication from/on behalf of theGeneral Manager to the Accredited Health Practitioners who are accredited withrespect to the hospital;
15.5 to both plan and manage the continuing education program within the hospital;and
1111316046 \ 03062376480415 \ 117801 Revised July 2012 9
15.6 in consultation with the General Manager, to refer matters of clinical safety andquality of care to expert review by either the hospital's own clinical governancecommittees or to external authorities or professional organisations.
16 A MAC (and every sub-committee of it) has the powers, authorities and responsibilitiesdelegated to it by the General Manager. Every power, authority and responsibility of asub-committee is subject to the conditions, constraints and limitations imposed upon itsexercise by the General Manager. Each delegation by the General Manager will dependupon the circumstances.
17 A MAC will be subject to specific ‘Terms of Reference’ that give guidance both to theduties of the MAC and the administrative rules under which they are to be undertaken.The Terms of Reference set out at Schedule 1 of these By-Laws apply to a MAC in theabsence of, or to the extent of any deficiency in other Terms of Reference created by theGeneral Manager. It is the responsibility of the General Manager to formulateadministrative rules that support the efficient operation of the MAC. These rules must beincluded within the Terms of Reference that is specific to each Healthscope Hospital.
18 A MAC may appoint a sub-committee to investigate or consider any matter that has comebefore it. The members of the sub-committee, and other administrative matters concerningthat sub-committee, will be determined by the Chairman of the MAC in consultation withthe General Manager.
Other committees
19 Notwithstanding clause 18 of these By-Laws, if the General Manager considers that theMAC is inappropriate or insufficient for some purpose, the General Manager may createanother committee for that purpose. The members of that committee are not limited toAccredited Health Practitioners who have been accredited with respect to the hospital.The General Manager will determine the powers, authorities and responsibilities that aredelegated to that committee, and the administrative rules by which it is to operate.
External members of MAC
20 The General Manager may appoint one or more external persons (who are not AccreditedHealth Practitioners accredited with respect to the hospital) to the MAC, whether for aspecific time or issue, or generally if the General Manager considers that the MACrequires the assistance of those persons. External persons must be in the minority.
Indemnity to members of committees
21 Healthscope Limited will keep the members of the MAC and its committees indemnifiedagainst every cost, claim and demand which is made against any of them in relation to theperformance of their functions on a committee provided that:
21.1 they have performed their functions in good faith and without demonstratedmalice; and
21.2 they have not engaged in wilful misconduct in carrying out their committeefunctions.
1111316046 \ 03062376480415 \ 117801 Revised July 2012 10
ACCREDITATION
Generally
22 The General Manager of a Healthscope Hospital may authorise a Health Practitioner touse that hospital's facilities for the treatment of the Health Practitioner's patients if theGeneral Manager is satisfied as to all of the following:
22.1 that each treatment of a Patient is supported by the credentials of the HealthPractitioner;
22.2 that the Health Practitioner will continue to observe the current processes of thehospital;
22.3 that the hospital is able to provide appropriate staff, facilities and support to theHealth Practitioner in each treatment of a Patient; and
22.4 that each treatment of a Patient must be amenable to the safe and efficientfunctioning of the hospital as a whole.
23 The General Manager of a Healthscope Hospital cannot authorise a Health Practitioner touse that hospital's facilities for the treatment of a Patient if:
23.1 the Health Practitioner has not applied for Accreditation at the hospital inaccordance with these By-Laws;
23.2 the process for considering the Health Practitioner's application forAccreditation as set out in these By-Laws has not been followed;
23.3 that treatment of the Patient is not supported by the credentials of the HealthPractitioner; or
23.4 if that treatment is outside the conditions of the hospital 's licence.
24 A Health Practitioner can use the facilities of the Healthscope Hospital in respect of whichhe or she is accredited for the treatment of his or her patients only while the HealthPractitioner has the continuing authority of the General Manager to do so.
Health Practitioner must be accredited with respect to admit patients
25 A Health Practitioner may treat patients at a Healthscope Hospital only if he or she isaccredited to undertake that treatment at that hospital.
26 Accreditation of a Health Practitioner is limited to:
26.1 the Healthscope Hospital or Healthscope Hospitals named in the AccreditationNotification; and
26.2 the Scope of Practice identified in the Accreditation Notification.
27 Accreditation of a Health Practitioner with respect to a Healthscope Hospital does notgive the Health Practitioner any right or entitlement to or guarantee of:
27.1 any level of availability of bed access at the hospital;
27.2 any allocation of operating session time; or
1111316046 \ 03062376480415 \ 117801 Revised July 2012 11
27.3 the allocation of any Patient.
28 Accreditation of a Health Practitioner with respect to a Healthscope Hospital within aspecified Scope of Practice gives no entitlement for the Health Practitioner to that Scopeof Practice with respect to any other Healthscope Hospital in respect of which he or shemay be accredited.
Application for Accreditation
29 A Health Practitioner who wishes to apply for Accreditation with respect to a HealthscopeHospital must submit a completed application (in the form used by the hospital for thispurpose) to its General Manager.
30 The application must:
30.1 specify what scope of practice from Schedule 5 of these By-Laws is sought bythe applicant; and
30.2 include every document specified in the prescribed form (Schedule 5).
31 A Health Practitioner is entitled to apply for Accreditation at more than one HealthscopeHospital in a single application form where provision to do so is made within that formand is authorised by the General Manager(s) of the hospitals concerned.
Compliance with By-Laws
32 Every applicant for Accreditation must acknowledge in writing that he or she will complywith and be bound by these By-Laws.
Process on receipt of application for Accreditation
33 Subject to clause 34, on first receiving an application for Accreditation at a HealthscopeHospital, the General Manager of that hospital may reject the application in his or her soleand absolute discretion and is not required to assign any reason for so doing. The GeneralManager is not required to give to an applicant any reason for the refusal of theapplication, but must notify the applicant in writing of his or her decision to refuse theapplication.
34 A General Manager may not reject an application for Accreditation in accordance withclause 33 of these By-Laws if the application is to renew an existing Accreditation of anAccredited Health Practitioner.
35 If the General Manager:
35.1 does not reject the application for Accreditation on first receiving it; and
35.2 considers the application is likely to meet the general principles of clauses 36,37 and 38 of these By-Laws;
he or she must then forward it to the Credentials Committee of the hospital and, whererelevant, to the General Manager of any other Healthscope Hospital in respect of whichAccreditation is sought in the same application.
1111316046 \ 03062376480415 \ 117801 Revised July 2012 12
Credentials Committee
36 The functions of considering applications for Accreditation, and of formulatingrecommendations to the General Manager on Credentialling, Re-Credentialling anddefining the clinical Scope of Practice of Health Practitioners, must be performed by aCredentials Committee.
37 The Credentials Committee must be a sub-committee of the MAC that has been convenedfor that purpose. At Healthscope Hospitals of less than 100 licensed beds, the GeneralManager may determine that the MAC is to be the Credentials Committee when it isconvened for that purpose.
38 The General Manager will endeavour to furnish the Credentials Committee with onlythose Accreditation applications that are likely to meet the needs of the Hospital and arealigned closely both with its recurrent operating plan and long-term strategic directions.
Process of the Credentials Committee
39 The Credentials Committee must consider every application without undue delay.
40 The Credentials Committee may invite oral submissions from the applicant whenconsidering an application for Accreditation.
41 The Credentials Committee may co-opt other Health Practitioners:
41.1 from the Accredited Health Practitioners at the Healthscope Hospital where theCredentials Committee performs its functions; or
41.2 who are suitably experienced and qualified and independent of the hospital toassist in the Credentials Committee's deliberations.
42 Members of the Credentials Committee must declare and where necessary refrain fromparticipation in the deliberations of the Committee where a situation of conflict of interestexists.
43 In considering an application for Accreditation, the Credentials Committee must takeaccount of all of the following:
43.1 Whether, and to what extent, the qualifications, experience, skills and training ofthe applicant support the Classification sought by the application.
43.2 The character and standing of the applicant, and whether the applicant is asuitable person to practise at that Healthscope Hospital.
43.3 Whether the hospital has the facilities to support the fields of practice proposedby the applicant.
43.4 Whether in its opinion the applicant will continue to observe the currentprocesses of the hospital.
43.5 Credentialling guidelines promulgated by learned specialist Colleges andProfessional Bodies. In considering these guidelines, Credentials Committeesmay be guided but must not be bound by guidelines. In particular, CredentialsCommittees must consider the strength of evidence in support of volume-outcome relationships imputed by the guidelines.
1111316046 \ 03062376480415 \ 117801 Revised July 2012 13
44 In making recommendations for Re-Credentialling, the Credentials Committee must haveregard for matters including but not limited to:
44.1 the clinical performance of the applicant, including patient outcomes, adverseevents, complaints, participation in internal and external audit and qualityassurance activities and continuing professional development programmes oflearned Colleges and Professional Bodies; and
44.2 significant and persistent non-compliance with the By-Laws.
45 The Credentials Committee may decline to make a recommendation to the GeneralManager following its consideration of an application for Accreditation.
46 Prior to making a recommendation to the General Manager on an application forAccreditation that is adverse to the applicant, the Credentials Committee may seek adviceon the application from a nominee of the relevant learned College or Professional Bodywho is independent of the hospital and has no conflict of interest with the applicant.
47 In addition to its recommendation to the General Manager, the Credentials Committeemay make recommendations concerning any Special Conditions which it believes shouldapply to the Accreditation of the Health Practitioner.
Decision by General Manager
48 Where the General Manager has referred an application for Accreditation to theCredentials Committee, he or she must take into account any recommendation made bythe Credentials Committee before making a decision on the application.
49 Notwithstanding clause 48 of these By-Laws, the General Manager may refuse theapplication for accreditation in his or her sole and absolute discretion.
50 Upon taking into account of any recommendation of the Credentials Committee, theGeneral Manager must make a decision on the application.
51 The General Manager must notify the applicant of his or her decision in writing.
52 If the notification confirms the Accreditation of the Health Practitioner, the notificationmust set out the particulars of that Accreditation, including:
52.1 the Health Practitioner's Scope of Practice;
52.2 any Special Conditions that will apply to the Accreditation; and
52.3 the term of the Accreditation.
53 The General Manager is not required to give the applicant any reason for making his orher decision on the application.
54 If the General Manager:
54.1 refuses the applicant's application; or
54.2 makes the applicant's Accreditation subject to any Special Conditions;
and
1111316046 \ 03062376480415 \ 117801 Revised July 2012 14
54.3 the application is to renew an existing Accreditation of an Accredited HealthPractitioner;
the applicant may appeal the General Manager's decision in accordance with clauses 96 to113 of these By-Laws.
Term of Accreditation
55 Subject to clauses 56 and 57 of these By-Laws, a Health Practitioner is accredited only forthe period specified in the Accreditation Notification.
56 Where the Health Practitioner is not an Accredited Health Practitioner at the HealthscopeHospital at the time he or she applies for Accreditation, the term of his or herAccreditation is 12 months from the date of Accreditation.
57 Where the Health Practitioner is an Accredited Health Practitioner at the HealthscopeHospital at the time he or she applies for Accreditation, the term of his or herAccreditation may be up to 5 years from the date of Accreditation.
Temporary Accreditation
58 Subject to clause 60, the General Manager of a Healthscope Hospital specified in a HealthPractitioner's application for Accreditation may authorise the Health Practitioner to treatpatients at the hospital before the application has been finally determined. This is atemporary Accreditation.
59 Temporary Accreditation enables a Health Practitioner to treat patients at the specifiedHealthscope Hospital until the earlier of the following:
59.1 The General Manager has notified the Health Practitioner of his or her decisionon the Health Practitioner's application for Accreditation.
59.2 A specified date.
60 A General Manager cannot authorise the temporary Accreditation of a Health Practitionerif the Health Practitioner is an Accredited Health Practitioner at the Healthscope Hospitalin respect of which the application relates at the time he or she makes the application.
61 The General Manager must confer with the Chairperson of the Credentials Committee orMAC before authorising a temporary Accreditation.
62 The maximum period of temporary Accreditation that can be authorised by the GeneralManager is 90 days from the date of advice to the applicant that temporary Accreditationhas been granted.
63 The granting of temporary Accreditation must be reported to the next meeting of theCredentials Committee and documented in the minutes of the Credentials Committee.
64 A Health Practitioner who treats his or her patients at the Healthscope Hospital where heor she has been given temporary Accreditation must comply with the terms of thattemporary Accreditation and these By-Laws.
1111316046 \ 03062376480415 \ 117801 Revised July 2012 15
Re-Credentialling
65 A Health Practitioner who is an Accredited Health Practitioner with respect to aHealthscope Hospital must apply for renewal of that Accreditation not less than 90 daysbefore the end of the Accreditation period specified in the Accreditation Notification.
66 The administrative processes for a renewal must be the same as for an initial applicationfor Accreditation, other than where these requirements have been waived by the GeneralManager pursuant to clause 67 of these By-Laws.
67 The General Manager may waive any requirements with respect to an application forrenewal of a previous or existing Accreditation if those requirements appear unnecessaryor irrelevant.
68 Not less than 3 months before the date fixed for renewal of the Accreditation of anAccredited Health Practitioner, the General Manager must notify the Accredited HealthPractitioner of any specific requirements that are to apply in that year.
Lapse of Accreditation
69 Where an Accredited Health Practitioner does not seek renewal of his or her Accreditationprior to the expiration of the term of Accreditation, the Accredited Health Practitioner'sAccreditation will lapse on the last day of the period for which he or she has beenaccredited.
RESIGNATION, VARIATION, SUSPENSION OR TERMINATION OF ACCREDITATION
Resignation or Extended Absence of an Accredited Health Practitioner
70 An Accredited Health Practitioner who intends to cease treating patients eitherindefinitely or for an extended period at a Healthscope Hospital in respect of which he orshe is accredited must notify that intention to the General Manager of that hospital.
71 Where an Accredited Health Practitioner gives notice in according with clause 70 of theseBy-Laws:
71.1 the Accreditation of the Accredited Health Practitioner ends on the date he orshe gives the notice;
71.2 the Accredited Health Practitioner must:
71.2.1 whenever practicable, give that notice to the General Manager priorto the cessation of the Accredited Health Practitioner's normal patientbookings and clinical activities at the hospital;
71.2.2 ensure that, upon ceasing to treat patients, any remaining Patients areeither discharged or referred with appropriate consent to the care ofanother equivalent Accredited Health Practitioner who is accreditedin respect of that hospital to ensure continuous cover;
71.2.3 advise his or her own patients, and any known carers or legalguardians of those patients, of any proposed changes to the patients'care arrangements.
1111316046 \ 03062376480415 \ 117801 Revised July 2012 16
Accredited Health Practitioner may request variation of Accreditation
72 An Accredited Health Practitioner may request a variation to his or her Accreditation inrespect of a Healthscope Hospital any time.
73 Subject to clause 74 of these By-Laws, the processes for variation of Accreditation are thesame as for an application for Accreditation by an Accredited Health Practitioner.
74 The General Manager of the Healthscope Hospital in respect of which the variation ofAccreditation may waive the requirement for the Accredited Health Practitioner to submitan application form if the General Manager is satisfied that there has been no change toany relevant information provided to the Healthscope Hospital since the date on which theAccredited Health Practitioner was last accredited.
Allegations Concerning Accredited Health Practitioners
75 The General Manager of a Healthscope Hospital may investigate an allegation against anAccredited Health Practitioner if the General Manager considers that, if the allegationwere true, it could result in any of these outcomes:
75.1 the health or safety of any Patient could be compromised;
75.2 the efficient operation of the hospital could be threatened;
75.3 the rights of a Patient or someone engaged in or working at the hospital could beinfringed; or
75.4 the Accredited Health Practitioner may be found to have breached any law.
76 An Accredited Health Practitioner against whom an allegation has been made:
76.1 must be informed of the allegation in the presence of the General Manager andthe Chairman of the MAC
76.2 must be given a reasonable opportunity to provide an explanation to the GeneralManager in response to the allegation.
77 If the General Manager:
77.1 is not satisfied that the allegation is false after hearing any explanation by theAccredited Health Practitioner in response to the allegation;
77.2 considers that additional information is required to form a view as to whetherthe allegation is true or false; or
77.3 is unsure whether the allegation, if true, would lead to any of the outcomes inclause 75, then:
77.3.1 the General Manager in consultation with the Chairman of the MACof the hospital may convene a committee to assist him or her toinvestigate the allegation further;
77.3.2 the Accredited Health Practitioner must be invited to provide awritten response to the allegation, including any details or particulars
1111316046 \ 03062376480415 \ 117801 Revised July 2012 17
that the General Manager considers necessary to consider theallegation; and
77.3.3 the General Manager may terminate, suspend or impose conditionson the Accreditation of the Accredited Health Practitioner until suchtime as the General Manager is satisfied that the allegations havebeen resolved.
78 The committee assisting the General Manager:
78.1 must not be the MAC;
78.2 must be competent to consider the allegation;
78.3 must be unbiased;
78.4 must execute confidentiality agreements if required in a form prescribed by theGeneral Manager;
78.5 is entitled, if it wishes, to question the Accredited Health Practitioner in relationto those allegations; and
78.6 must provide the General Manager with its written conclusions and/or opinionssupported by reasons.
79 The General Manager must advise the Accredited Health Practitioner of his or herdecision as soon as reasonably possible after receiving the committee's writtenconclusions and/or opinions.
80 If a General Manager decides to terminate or suspend an Accredited Health Practitioner'sAccreditation in respect of the hospital in accordance with clause 77.3.3 of these ByLaws, the Health Practitioner may appeal that decision in accordance with clauses 96 to113 of these By-Laws..
81 In addition to or as an alternative to the provisions of clauses 75 to 78 of these By-Laws,the General Manager:
81.1 if required to do so by any law, must notify the Australian Health PractitionerRegulation Agency of the alleged facts, matters or circumstances that are thesubject of the allegation;
81.2 may notify the Australian Health Practitioner Regulation Agency of the allegedfacts, matters or circumstances that are the subject of the allegation if theGeneral Manager considers such notification to be:
81.2.1 in the best interests of patient care or safety in any place to do so;
81.2.2 necessary to protect the reputation of a Healthscope Company or aHealthscope Hospital.
Suspension of Accreditation by General Manager
82 In consultation with the Chairperson of the MAC, the General Manager of a HealthscopeHospital may suspend an Accredited Health Practitioner's Accreditation in respect of thathospital if the General Manager forms the view that:
1111316046 \ 03062376480415 \ 117801 Revised July 2012 18
82.1 to do so would be in the interests of patient care or safety;
82.2 to do so would be in the interests of staff welfare or safety;
82.3 serious and unresolved allegations have been made in relation to the HealthPractitioner;
82.4 the Accredited Health Practitioner has breached any General Conditions orSpecial Conditions of Accreditation;
82.5 the conduct of the Accredited Health Practitioner compromises the efficientoperation or the interests of the hospital; or
82.6 there are other unresolved issues in respect of the Accredited Health Practitionerthat the General Manager, the Board of Healthscope Limited and/or the Board ofthe Healthscope Company that owns or operates the hospital in questionconsider are a ground for suspension.
83 The General Manager must not suspend an Accredited Health Practitioner's Accreditationunless the General Manager reasonably believes that the cause of the suspension can beresolved, and in a timely manner.
84 The General Manager must notify an Accredited Health Practitioner in writing of:
84.1 the suspension of his or her Accreditation, including the period of it and reasonsfor it;
84.2 any actions that must be performed for the suspension to be lifted and the periodwithin which those actions must be completed;
84.3 the Health Practitioner's right to appeal the General Manager's decision tosuspend the Health Practitioner's Accreditation.
85 The suspension of a Health Practitioner's Accreditation ends when:
85.1 the General Manager notifies the Health Practitioner in writing that the HealthPractitioner's Accreditation is terminated; or
85.2 the General Manager notifies the Health Practitioner in writing that thesuspension of the Health Practitioner's Accreditation is lifted.
86 The resumption of Accreditation by a (previously) suspended Health Practitioner isalways subject to the Health Practitioner observing the requirements for continuousdisclosure in these By-Laws.
87 A Health Practitioner may appeal the suspension of his or her Accreditation in accordancewith clauses 96 to 113 of these By-Laws.
Termination of Accreditation
88 The General Manager of a Healthscope Hospital may, by written notice, immediatelyterminate an Accredited Health Practitioner's Accreditation in respect of that hospital if:
88.1 the Accredited Health Practitioner ceases to be a 'Health Practitioner' as definedby s5 of the Health Practitioner Regulation National Law;
1111316046 \ 03062376480415 \ 117801 Revised July 2012 19
88.2 the Accredited Health Practitioner's registration is suspended under HealthPractitioner Regulation National Law;
88.3 the registration of the Accredited Health Practitioner under the HealthPractitioner Regulation National Law becomes subject to any condition which,in the General Manager's opinion, cannot be adequately satisfied at the hospital;
88.4 the Accredited Health Practitioner fails to observe a General Condition orSpecial Condition of Accreditation;
88.5 the General Manager forms the view that the Accredited Health Practitioner hasfailed to meet the continuous disclosure requirements of these By-Laws;
88.6 the General Manager forms the view that there is a serious and unresolvedallegation concerning the Accredited Health Practitioner and that suspension ofthe Accreditation would be an insufficient response in the circumstances;
88.7 the General Manager forms the view in consultation with the Chairman of theMAC of the hospital that the findings of any group investigating an allegation inrelation to the Accredited Health Practitioner are such as to warrant terminationof the Accreditation;
88.8 the Accredited Health Practitioner has been unable to perform his or her Patientcare and treatment duties at the hospital for a continuous period of 6 months;
88.9 (if the Accredited Health Practitioner has admission rights at the hospital), theHealth Practitioner has not exercised admission rights for a continuous period of6 months;
88.10 the Accredited Health Practitioner is found guilty of unprofessional conductand/or unsatisfactory professional conduct by any inquiry, investigation orhearing by any disciplinary body or professional standards organisation;
88.11 the Accredited Health Practitioner is found guilty of any offence which in thereasonable opinion of the General Manager is likely to bring that HealthPractitioner into professional disrepute or likely to harm the reputation of thehospital or a Healthscope Company;
88.12 the hospital ceases to provide support services required within the Scope ofPractice in which the Health Practitioner is accredited.
89 The General Manager must not terminate an Accredited Health Practitioner'sAccreditation unless the General Manager reasonably believes that the cause of thetermination cannot or should not be resolved by suspension.
90 The General Manager must notify an Accredited Health Practitioner in writing of:
90.1 the termination of his or her Accreditation, including the reasons for it;
90.2 the Health Practitioner's right to appeal the General Manager's decision toterminate the Health Practitioner's Accreditation.
91 A Health Practitioner may appeal the termination of his or her Accreditation inaccordance with clauses 96 to 113 of these By-Laws.
1111316046 \ 03062376480415 \ 117801 Revised July 2012 20
Effect of suspension or termination of Accreditation at other Healthscope Hospitals
92 If the General Manager of a Healthscope Hospital suspends an Accredited HealthPractitioner's Accreditation in respect of that hospital (first hospital) and the HealthPractitioner is an Accredited Health Practitioner who is accredited with respect to anyother Healthscope Hospital (other hospital), the Health Practitioner's Accreditation at theother hospital is contemporaneously suspended and on the same terms as the suspensionof the Health Practitioner's Accreditation at the first hospital.
93 Clause 92 applies even if the Health Practitioner is accredited at the other hospital afterhis or her Accreditation is suspended in respect of the first hospital.
94 Subject to clause 95 of these By-Laws, if the General Manager of a Healthscope Hospitalterminates an Accredited Health Practitioner's Accreditation in respect of that hospital(first hospital) and the Health Practitioner is an Accredited Health Practitioner who isaccredited with respect to any other Healthscope Hospital (other hospital), the HealthPractitioner's Accreditation at the other hospital is contemporaneously terminated.
95 Clause 94 of these By-Laws does not apply if the General Manager of the first hospitalterminates an Accredited Health Practitioner's Accreditation in respect of that hospitalonly because the first hospital ceases to provide support services required within theScope of Practice in which the Health Practitioner is accredited.
APPEALS
No right of appeal unless specifically conferred
96 A Health Practitioner has no right to appeal:
96.1 any decision made in accordance with these By-Laws; or
96.2 any decision purportedly made in accordance with these By-Laws;
unless these By-Laws expressly give the Health Practitioner a right to appeal that specificdecision.
97 A Health Practitioner has no right to appeal the exercise of any discretion conferred bythese By-Laws.
Right to appeal a decision of a General Manager
98 If a Health Practitioner wishes to appeal a decision of a General Manager in respect ofwhich these By-Laws give the Health Practitioner a right of appeal, the HealthPractitioner must lodge an appeal in writing with the General Manager who made thedecision within 30 days of being notified of the decision.
99 It is sufficient to lodge an appeal in writing for the Health Practitioner to:
99.1 state that he or she appeals a decision of the General Manager in respect ofwhich these By-Laws give the Health Practitioner a right of appeal; and
99.2 specify the decision the subject of the appeal.
1111316046 \ 03062376480415 \ 117801 Revised July 2012 21
100 If a Health Practitioner who has a right to appeal a decision of a General Manager underthese By-Laws does not lodge an appeal in writing in accordance with clauses 98 and 99of these By-Laws, the Health Practitioner's right of appeal is extinguished.
Procedure for appeal
101 The General Manager must refer every appeal to the Chief Medical Officer as soon aspracticable after receiving the appeal.
102 On being referred an appeal, the Chief Medical Officer must decide as soon as practicablewhether the appeal is to be determined:
102.1 by the Chief Medical Officer alone; or
102.2 by an Appeals Committee constituted in accordance with clauses 104 to 107 ofthese By Laws.
103 If the Chief Medical Officer decides that the appeal is to be determined by him or heralone, the Chief Medical Officer must follow the procedure set out in clauses 109 to 113of these By-Laws.
104 If the Chief Medical Officer decides that the appeal is to be determined by an AppealsCommittee, the Chief Medical Officer must constitute and convene the AppealsCommittee as soon as practicable.
105 Subject to clauses 106 and 107, when constituting an Appeals Committee, the ChiefMedical Officer:
105.1 must be a member of the Appeals Committee;
105.2 will be the Chairman of the Appeals Committee;
105.3 may seek nominations from any relevant learned College, Professional Body,association or society that he or she sees fit to include on the AppealsCommittee;
105.4 may appoint any individual who can bring specific expertise to the AppealsCommittee;
105.5 must try to avoid appointing persons who have a conflict of interest orcommercial competitive relationship with the Appellant.
106 If the appeal is made further to a right of appeal conferred by clause 54 of these By-Laws,the Chief Medical Officer must not appoint to the Appeals Committee anyone who ismember of the Credentials Committee that provided a recommendation to the GeneralManager in respect of the Appellant's application for Accreditation.
107 If the appeal is made further to a right of appeal conferred by clause 87 or clause 91 ofthese By-Laws, the Chief Medical Officer must not appoint to the Appeals Committee anymember of the MAC of the Healthscope Hospital that is managed by the General Managerwho made the decision the subject of the appeal.
1111316046 \ 03062376480415 \ 117801 Revised July 2012 22
108 If the Chief Medical Officer decides that the appeal is to be determined by an AppealsCommittee, the Chief Medical Officer must follow the procedure set out in clauses 109to113 of these By-Laws once the Appeals Committee has been constituted.
109 Subject to clause 109 of these By-Laws, prior to the Chief Medical Officer or an AppealsCommittee (as the case may be) determining an appeal, the Chief Medical Officer must:
109.1 invite the General Manager to provide to the Chief Medical Officer, within atime period the Chief Medical Officer considers reasonable and which isspecified in the invitation:
109.1.1 written submissions setting out the basis upon which the GeneralManager made the decision the subject of the appeal; and
109.1.2 the evidence upon which the General Manager based his or herdecision;
109.2 give to the Appellant a copy of any written submissions and evidence the ChiefMedical Officer receives from the General Manager further to clause 109.1 ofthese By-Laws as soon as practicable after the Chief Medical Officer receivesthose submissions and/or evidence;
109.3 invite the Appellant to provide to the Chief Medical Officer, within a timeperiod the Chief Medical Officer considers reasonable and which is specified inthe invitation, written submissions setting out the basis upon which theAppellant contends that the General Manager's decision was not reasonablyopen to the General Manager at the time the decision was made;
109.4 invite the Appellant to make, at a time and place nominated by the ChiefMedical Officer, any additional oral submissions the Appellant wishes to maketo the Chief Medical Officer or the Appeals Committee (as the case may be) inaddition to, or to supplement, any written submissions the Appellant may havemade with respect to why the Appellant contends the General Manager'sdecision should be reversed or varied.
110 When making any oral submissions to the Chief Medical Officer or an AppealsCommittee (as the case may be) further to an invitation made in accordance with clause109.4 of these By-Laws:
110.1 the Appellant is not entitled to legal representation;
110.2 the Appellant is not entitled to have a legal representative present.
111 If the decision of the General Manager that is the subject of an appeal is a decision which:
111.1 the General Manager made after receiving a recommendation from a CredentialsCommittee on an application for Accreditation; or
111.2 the General Manager was required by these By-Laws to make in consultationwith the Chairman of a MAC;
the Chief Medical Officer may, in lieu of the procedure set out in clause 109.1 of theseBy-Laws, invite the General Manager and the Chairman of the Credentials Committee orMAC (as the case may be) (Committee Chairman) to provide to the Chief Medical
1111316046 \ 03062376480415 \ 117801 Revised July 2012 23
Officer, within a time period the Chief Medical Officer considers reasonable and which isspecified in the invitation:
111.3 joint written submissions setting out the basis upon which the General Managermade the decision the subject of the appeal; and
111.4 the evidence upon which the General Manager based his or her decision.
112 When determining an appeal:
112.1 the Chief Medical Officer or Appeals Committee (as the case may be) mustdecide whether, on the basis of the evidence available to the General Manager atthe time the General Manager made the decision, it was reasonably open for theGeneral Manager to have made that decision;
112.2 the Chief Medical Officer or Appeals Committee (as the case may be) does notneed to consider or decide whether, on the basis of the evidence available at thetime of determining the appeal, it would have been reasonably open for theGeneral Manager to have made that decision.
113 Upon determining the appeal:
113.1 the Chief Medical Officer or Appeals Committee (as the case may be) must setout his, her or its decision on the appeal in writing, and state the reasons for thedecision on the appeal; and
113.2 the Chief Medical Officer must provide a copy of the decision on the appeal andreasons for decision on the appeal to:
113.2.1 the Appellant; and
113.2.2 the General Manager who made the decision that was the subject ofthe appeal;
as soon as practicable after the appeal is determined.
GENERAL CONDITIONS OF ACCREDITATION
Accreditation is Personal
114 The Accreditation of a Health Practitioner is personal and cannot be transferred to, or beexercised by, any other person.
Accreditation permits a delineated Scope of Practice
115 An Accredited Health Practitioner must admit and treat patients only within the delineatedScope of Practice in his or her Accreditation Notification.
Compliance with ‘General Conditions' and ‘Special Conditions' of Accreditation
116 An Accredited Health Practitioner must comply with the General Conditions and anySpecial Conditions. To the extent of any inconsistency between the General Conditionsand the Special Conditions, the Special Conditions prevail.
1111316046 \ 03062376480415 \ 117801 Revised July 2012 24
Compliance with Laws, Policies and Professional Standards
117 An Accredited Health Practitioner must comply with:
117.1 these By-Laws;
117.2 all applicable laws concerning the provision of health care services to patients atprivate hospitals;
117.3 the policies, rules and procedures of Healthscope Limited;
117.4 the policies, rules and procedures of the Healthscope Hospital(s) in respect ofwhich he or she is accredited; and
117.5 accepted professional and ethical standards and relevant codes of conduct.
Professional Malpractice Insurance
118 An Accredited Health Practitioner must maintain and hold professional malpracticeliability insurance from a professional indemnity insurer operating in Australia.
119 The professional malpractice liability insurance must indemnify the Practitioner for theentirety of his or her Scope of Practice.
120 Unless exempted by the General Manager, such insurance must have no exclusions ordeductibles relevant to the Accredited Health Practitioner's Scope of Practice at theHealthscope Hospital in respect of which he or she is accredited.
121 The limits of indemnity the policy must be adequate in the opinion of the GeneralManager.
122 An Accredited Health Practitioner must, if requested by the General Manager, provide theGeneral Manager with an authority directed to the Accredited Health Practitioner'sprofessional malpractice liability insurer authorising that insurer to provide to the GeneralManager evidence of the terms of that practitioner's insurance, including the limits andcurrency of that insurance.
Quality Assurance
123 An Accredited Health Practitioner must:
123.1 participate in continuing professional development programmes concerning hisor her discipline or specialty not less than once in each period of 3 years or morefrequently if required by the General Manager, Chairman of the MAC orDepartment Head of the Healthscope Hospital in respect of which he or she isaccredited;
123.2 provide to the General Manager, Chairman of the Medical Advisory Committeeor Departmental Head evidence of his or her participation in those continuingprofessional development programmes;
123.3 participate in quality assurance (including clinical audit) programmes approvedby the MAC or relevant Department;
123.4 participate in the review of clinical performance indicators and other measuresof clinical care;
1111316046 \ 03062376480415 \ 117801 Revised July 2012 25
123.5 (if the Accredited Health Practitioner is a Medical Practitioner) participate inaudit and educational activities as required by the clinical College orProfessional Body awarding the qualifications upon which the AccreditedHealth Practitioner's Accreditation is based;
123.6 assist the Healthscope Hospital in respect of which he or she is accredited inachieving accreditation standards as set by the Australian Council on HealthcareStandards, the Australian Commission on Safety and Quality in Health Care andother bodies charged with the accreditation and licensing of hospitals;
123.7 advise the General Manager of any Healthscope Hospital in respect of which heor she is accredited as soon as practicable of any incident which may lead to aclaim brought against that hospital on the grounds of negligence, breach oflicensing conditions or a failure to provide safe working conditions;
123.8 assist in the resolution of complaints against:
123.8.1 any Healthscope Hospital in respect of which he or she is accredited;
123.8.2 the Accredited Health Practitioner himself or herself.
Respect for Colleagues and Staff
124 An Accredited Health Practitioner must treat fairly and with respect:
124.1 all Health Practitioners who are accredited with respect to the HealthscopeHospital in respect of which the Accredited Health Practitioner is accredited;
124.2 all staff and all other people working at or engaged by or working at thehospital.
125 An Accredited Health Practitioner must not abuse, assault (sexually or otherwise), bully,harass or intimidate any person referred to in clause 124.
CONTINUOUS DISCLOSURE
Continuous Disclosure Requirements
126 An Accredited Health Practitioner must keep the General Manager of every HealthscopeHospital in respect of which he or she has been accredited continuously informed of everyfact and circumstance which has a material bearing upon:
126.1 the Credentials of the Accredited Health Practitioner;
126.2 the Scope of Practice of the Accredited Health Practitioner;
126.3 the ability of the Accredited Health Practitioner to safely deliver health careservices to his or her patients within that Scope of Practice; and
126.4 the ability of the Accredited Health Practitioner to satisfy a medical malpracticeclaim made against him or her by a patient.
1111316046 \ 03062376480415 \ 117801 Revised July 2012 26
127 Without limiting clause 126, an Accredited Health Practitioner must advise the GeneralManager of the Healthscope Hospital(s) in respect of which he or she has been accreditedif:
127.1 he or she ceases to be registered, or is suspended from registration, under theHealth Practitioner Regulation National Law;
127.2 he or she has any conditions, limitations or restrictions imposed upon his or herregistration under the Health Practitioner Regulation National Law;
127.3 he or she is subject to an investigation initiated in respect of any aspect of his orher practice by any registration, disciplinary, investigative or professional body;
127.4 he or she is found guilty of professional misconduct and/or unsatisfactoryprofessional conduct by any inquiry, investigation or hearing by any disciplinaryor professional body or is subject to an adverse finding by any such body;
127.5 his or her appointment to, accreditation at or scope of clinical practice at anyother facility, hospital or day procedure centre is altered in any way or becomessubject to any conditions or restrictions;
127.6 he or she suffers from illness, disability or impairment that may adversely affecthis/her fitness to practise;
127.7 he or she is charged with or convicted of any serious criminal offence;
127.8 he or she ceases to hold professional malpractice liability insurance inaccordance with the requirements of these By-Laws;
127.9 his or her billing privileges are withdrawn or restricted under the MedicareAustralia Act 1973 (Cth) because of his/her conduct, professional performanceor health;
127.10 his/her authority under a law of a state or territory to administer, obtain, possess,prescribe, sell, supply or use a scheduled medicine or class of medicine iscancelled or restricted.
CLINICAL RESPONSIBILITIES
Admission of patients
128 The admission of an Accredited Health Practitioner's patient to a Healthscope Hospital issubject to:
128.1 bed availability; and
128.2 the availability or adequacy of nursing or allied health staff or facilities at thehospital;
relevant to the type of treatment proposed to be conducted by the Accredited HealthPractitioner.
129 Except in an emergency, when a diagnosis or reasons for admission must be recorded assoon as practicable after admission, no patient must be admitted to a Healthscope Hospital
1111316046 \ 03062376480415 \ 117801 Revised July 2012 27
until a provisional diagnosis or valid reason for admission has been stated by theAccredited Health Practitioner who has admitted the patient.
Allocation of operating room sessions
130 Sessions for the use of operating rooms are allocated by the General Manager toAccredited Health Practitioners on the basis that they will be fully utilised.
131 Wherever possible, an Accredited Health Practitioner must give to the General Managernot less than 28 days notice of any times during which he or she will not fully utilise anyoperating sessions that have been assigned to him or her.
132 The General Manager may:
132.1 modify or change the allocation of operating sessions having regard toutilisation or the demands for urgent surgery;
132.2 allow casual bookings for the whole or part of any allocated operating sessionwhich is not fully utilised;
132.3 upon 28 days notice to the Accredited Health Practitioner reduce or terminatethe Accredited Health Practitioner's allocation of operating sessions.
133 An Accredited Health Practitioner must give the General Manager 28 days notice of his orher intention to reduce or terminate use of allocated operating sessions.
Care of admitted patients
134 Healthscope Limited and Healthscope Companies believe that national clinical guidelinesdeveloped collaboratively by organisations such as:
134.1 the National Health and Medical Research Council;
134.2 the National Institute of Clinical Studies;
134.3 the Australian Safety and Efficacy Register of New Interventional Procedures –Surgical (ASERNIPS);
134.4 recognised authorities in evidence-based medicine, such as the CochraneCollaboration;
134.5 specialist training colleges and organisations accredited by the AustralianMedical Council;
134.6 the learned Colleges, Professional Bodies and other clinical professionalorganisations and societies;
134.7 various peak clinical non-government organisations (such as the National HeartFoundation, Diabetes Australia, National Stroke Foundation, Australian KidneyFoundation, Asthma Foundation, Cancer Foundation);
represent the current clinical ‘best practice' for many areas of medicine, and shouldwhenever possible and practicable, be consulted for guidance to support informed clinicaldecision-making and the development of pathways of care that yield optimal clinicaloutcomes.
1111316046 \ 03062376480415 \ 117801 Revised July 2012 28
135 While all clinical decisions are, ultimately, the prerogative and responsibility of thetreating Health Practitioner, Healthscope Limited and Healthscope Companies encouragethe use of evidence-based clinical guidelines at Healthscope Hospitals.
136 Each Accredited Health Practitioner is responsible for the care and treatment of his or herpatients in the hospital. If the Health Practitioner is unable to provide that care personally,he or she must secure the agreement of another Accredited Health Practitioner to providethat care and treatment.
137 When an Accredited Health Practitioner has made an agreement to transfer responsibilityfor the care and treatment of his or her patient to another Accredited Health Practitioner,the first Accredited Health Practitioner must:
137.1 note the details of the transfer on the patient's medical record; and
137.2 communicate the transfer to the Nurse Unit Manager or other responsiblenursing staff member at the Healthscope Hospital to which the patient has beenor is to be admitted.
138 An Accredited Health Practitioner must give adequate instructions to hospital staff toenable staff to understand what care the Accredited Health Practitioner wants to bedelivered to any patient that he or she treats at the Healthscope Hospital in respect ofwhich he or she has been accredited.
139 An Accredited Health Practitioner who admits a patient to a Healthscope Hospital must:
139.1 give all information to the hospital as may be necessary to assess the patient'srisk of self-harm or harm to others; and
139.2 advise hospital staff on steps necessary to manage the risk of self harm and toassure the protection of other patients at the hospital.
Patient Records and Discharge of Patients
140 An Accredited Health Practitioner must maintain full, accurate and legible medicalrecords for all patients treated by him or her at a Healthscope Hospital.
141 The records must include all information necessary to enable the hospital staff to providenecessary care and treatment to patients.
142 The records must comply with National Standards developed by the AustralianCommission on Safety and Quality in Health Care and be in the form determined by therelevant Healthscope Hospital.
143 An Accredited Health Practitioner who admits a patient to a Healthscope Hospital mustobtain a ‘consent for treatment' form from the patient or the patient's legal guardian on orbefore the patient is admitted to the hospital, with the exception of emergency cases.
144 Where an Accredited Health Practitioner who admits a patient to a Healthscope Hospitalhas not obtained a ‘consent for treatment ' form from the patient or the patient's legalguardian on or before the patient is admitted to the hospital in accordance withHealthscope policy:
1111316046 \ 03062376480415 \ 117801 Revised July 2012 29
144.1 the hospital must notify the Accredited Health Practitioner that a 'consent fortreatment' form has not been obtained
144.2 except in emergency cases, the Accredited Health Practitioner must obtainwritten informed consent before the patient receives any treatment at theHospital.
145 In emergency cases where possible, the signature of two Accredited Health Practitionerswho are either Medical Practitioners or Dental Practitioners should be obtained on theconsent for treatment form attesting to the fact that, in both their opinions, the situation athand is considered an emergency and that the patient is incapable of giving valid consent.
146 For the purposes of these By-Laws, an emergency exists in any situation where, in theopinion of the treating Medical Practitioner, immediate treatment is necessary in order toavert a serious and imminent threat to a patient's life or physical or mental health.
147 Admission criteria forms authorised by the Healthscope Hospital to which a patient isadmitted must be completed within 24 hours of the patient's admission.
148 The Attending Health Practitioner must record an appropriate patient history, physicalexamination and treatment plan before an operation or any potentially hazardousdiagnostic procedure is undertaken. In situations where this has not occurred, theprocedure must be delayed:
148.1 until the situation is clarified to the satisfaction of all persons who will beinvolved in the care of the patient; or
148.2 unless the Attending Health Practitioner states in writing that such a delay wouldbe detrimental to the life and recovery of the patient.
Post operative/procedural completion of the medical record is mandatory in these cases.
149 Operative reports must:
149.1 include a detailed account of the findings at surgery;
149.2 include details of the surgical technique undertaken;
149.3 be written or dictated immediately and the report signed by the Attending HealthPractitioner; and
149.4 be made part of the patient's medical record.
150 An Accredited Health Practitioner who performs anaesthesia on a patient must:
150.1 obtain consent to anaesthesia; and
150.2 maintain a complete anaesthesia record that includes evidence of pre-anaestheticevaluation and post-anaesthetic follow-up of the patient's condition.
151 Subject to clause 152:
151.1 all orders for the treatment of a Patient must be:
1111316046 \ 03062376480415 \ 117801 Revised July 2012 30
151.1.1 recorded legibly in writing noting the date and time the order ismade;
151.1.2 signed by the Accredited Health Practitioner who ordered thetreatment
151.2 any order for treatment that does not comply with clause 151.1 must not becarried out until:
151.2.1 the order complies with clause 151.1; or
151.2.2 the order is understood clearly by those involved in the care of thepatient.
152 A verbal order for the treatment of a Patient that is given by an Accredited HealthPractitioner may be acted on when:
152.1 it is given to a duly authorised person functioning within the scope of theirclinical competence;
152.2 the order is understood clearly by those involved in the care of the patient .
153 A verbal order for the treatment of a Patient that is made in accordance with clause 152must be recorded in writing and signed by the Accredited Health Practitioner who gavethe verbal order within 24 hours of making the verbal order.
154 The repeated failure of an Accredited Health Practitioner to comply with clause 153 mustbe brought to the attention of the MAC of the Healthscope Hospital where the verbalorders were given.
155 Consultations made by any Accredited Health Practitioner in the care of a patient mustshow documented evidence of a review of the patient's record by the Health Practitioner,including any opinions or recommendations made. Where operative procedures areinvolved, any consultation notes made by another consultant Health Practitioner must,except in an emergency situation, be verified on the medical record and recorded prior tothe operation. The Attending Health Practitioner is primarily responsible for requestingand organising any consultations by other Health Practitioners. The Attending HealthPractitioner must provide written authorisation to permit another Health Practitioner toattend or examine their patient in all cases other than emergency situations or where thepatient exercises the right to a second opinion according to Healthscope policy.
156 Where a specimen is removed from a Patient by an Accredited Health Practitioner at aprocedure:
156.1 the specimen must be sent to a pathologist for such examination necessary toarrive at a tissue diagnosis;
156.2 the authenticated report prepared by the pathologist must be included in thePatient's medical record as soon as practicable after it is received by theHealthscope Hospital where the patient was admitted when the specimen wasremoved.
1111316046 \ 03062376480415 \ 117801 Revised July 2012 31
157 There must be an automatic stop order for ‘drugs of dependence and addiction' after 10days of administration unless the duration of the order specifies a different period. It isthe responsibility of the Attending Health Practitioner to provide prescriptions as required.
158 The frequency of attendance and review a Patient is a matter for the Accredited HealthPractitioner who is treating the Patient based on his or her assessment of the Patient'srequirements.
159 An Accredited Health Practitioner's attendance on a Patient must be documented in thePatient's medical record, especially where:
159.1 there has been a change in the Patient's condition since he or she was lastreviewed;
159.2 if the Accredited Health Practitioner initiates a change in the Patient'smanagement.
160 Pertinent progress notes must be recorded at the time of observation sufficient to permitcontinuity of care, communication of clinically relevant information to nursing and otherstaff and transferability of the Patient. Wherever possible, each of the Patient's clinicalproblems should be clearly identified in the progress notes and correlated with specificorders and the results of any tests and treatments undertaken.
161 Progress notes must be written daily for critically ill patients and those where there isdifficulty in the diagnosis or management of the clinical problems.
162 All clinical entries in a Patient's medical record must be accurately dated, timed andauthenticated.
163 An Accredited Health Practitioner's routine orders must be reproduced in detail on theorder sheet of the patient's medical record, and dated and signed by the Accredited HealthPractitioner.
164 All medical imaging and pathology reports must be included in a Patient's medical recordwithin 24 hours of receipt by the Healthscope Hospital where the Patient is or wasadmitted. Before being included in the record, the report must be initialled or otherwiseendorsed signifying that they have been sighted by the ordering Medical Practitioner or aMedical Practitioner acting as his or her delegate.
165 The medical record of a Patient is the property of the company that owns or operates theHealthscope Hospital to which the Patient has been admitted when the record was made.
166 An Accredited Health Practitioner must not destroy, or remove from a HealthscopeHospital's premises any medical record or part of a medical record without the priorconsent of the General Manager.
167 Where a Patient is readmitted to a Healthscope Hospital, that part of the medical recordrelating to the Patient's previous admissions must be available to the any AccreditedHealth Practitioner involved in the Patient's treatment during the readmission.
168 An Accredited Health Practitioner must:
168.1 comply with the patient discharge policy of the Healthscope Hospital to whichthe Patient is admitted; and
1111316046 \ 03062376480415 \ 117801 Revised July 2012 32
168.2 complete all patient discharge documents required by that hospital.
If the hospital is in the State of Queensland, the Health Quality and ComplaintsCommission requires that 'a patient's discharge should not be affected without a dischargesummary (including a medication profile) being provided by the treating/dischargingmedical practitioner (unless circumstances exist where such a summary cannot beprovided, it must be provided as soon as practicable by the treating/discharging medicalpractitioner)'.
169 A Patient must be discharged only on the order of the Attending Health Practitioner (orhis or her approved delegate).
170 When a Patient chooses to leave the Healthscope Hospital to which the Patient is admittedagainst the advice of the Attending Health Practitioner:
170.1 a notation of the incident must be made in the Patient's medical record;
170.2 whenever possible, the Patient should be asked to sign the notation;
170.3 any refusal by the Patient to sign such a notation should be recorded in thePatient's medical record.
These details should whenever possible be countersigned by a second person, such as amember of the hospital's nursing staff.
171 In the event of a Patient's death:
171.1 the death must be confirmed and recorded by the Attending Health Practitioneror their approved delegate as soon as possible;
171.2 the policies for the release of cadavers from the Healthscope Hospital where thePatient died must conform to local government and state government lawsapplicable to the jurisdiction of that hospital.
172 Accredited Health Practitioners must comply with:
172.1 Healthscope Policy 2.15 'Correct Patient, Correct Procedure, Correct Site'; and
172.2 the Royal Australasian College of Surgeons policy entitled 'Surgical SafetyChecklist'.
Surgical Assistants
173 A Medical Practitioner accredited as a surgical assistant:
173.1 cannot admit a Patient
173.2 must practise under the supervision of the admitting Medical Practitioner;
173.3 may assist in theatre and visit a Patient in ward areas
173.4 may examine a Patient's medical records
173.5 cannot initiate or change a treatment order relating to a Patient
1111316046 \ 03062376480415 \ 117801 Revised July 2012 33
173.6 may have his or her Scope of Practice limited to a particular specialty or surgeon
173.7 may not:
173.7.1 assume or be assigned the care of a Patient in place of anotherMedical Practitioner;
173.7.2 prescribe medication for a Patient;
173.7.3 complete or witness consent for procedures.
174 The admitting Medical Practitioner must maintain responsibility for the completion ofintra operative records at all times.
ADDITIONAL RULES, POLICIES AND PROCEDURES
175 Subject to clause 176, the General Manager of a Healthscope Hospital may, acting on theadvice of the MAC of that hospital, develop and implement at the hospital any rules,policies or procedures the General Manager considers necessary or desirable to improve:
175.1 the quality of care provided to Patients;
175.2 the safety of Patients, Accredited Health Practitioners, Other HealthPractitioners, staff and/or all other people working at or engaged by or workingat the hospital.
176 The General Manager must not make any rule, policy, procedure that is inconsistent withthese By-Laws.
177 The Board of every Healthscope Company endorses and encourages the GeneralManagers of the hospitals that each company owns or operates to develop and implementrules, policies and procedures further to clause 175.
CONFIDENTIALITY
General
178 Healthscope Limited, Healthscope Companies and their Accredited Health Practitionersmanage all matters related to the confidentiality of information in compliance with the‘National Privacy Principles' set out in Schedule 3 of the Privacy Act 1998 (Cth), withparticular attention to sub-clauses 10.2 to 10.4 inclusive of Schedule 3 which contemplatethe collection and handling of sensitive information and health information.
179 In addition, Healthscope Limited, Healthscope Companies and their Accredited HealthPractitioners recognise and comply with the various statutes governing the collection andhandling of health information within different Australian State and Territoryjurisdictions.
What Accredited Health Practitioner must keep confidential
180 Subject to clause 182 of these By-Laws, every Accredited Health Practitioner must keepconfidential the following information:
1111316046 \ 03062376480415 \ 117801 Revised July 2012 34
180.1 business information concerning Healthscope Limited, every HealthscopeCompany and the Healthscope Hospital in respect of which he or she isaccredited;
180.2 the particulars of these By-Laws;
180.3 information concerning the insurance arrangements of Healthscope Limited orany Healthscope Company;
180.4 information concerning any Patient;
180.5 any information gained by or conveyed to the Accredited Health Practitioner inthe course of quality assurance activities of the Healthscope Hospital in respectof which he or she is accredited.
What Healthscope must keep confidential
181 Subject to clause 183 of these By-Laws, Healthscope Limited and every HealthscopeCompany must keep confidential the following information:
181.1 information supplied to Healthscope Limited or any Healthscope Company byan Accredited Health Practitioner or some other person for the purpose ofAccreditation;
181.2 information concerning an Accredited Health Practitioner's business;
181.3 information concerning an adverse medical outcome with respect to aAccredited Health Practitioner.
When confidentiality can be breached
182 The confidentiality requirements of clauses 180 and 181 of these By-Laws do not apply inthe following circumstances:
182.1 where disclosure is required by law;
182.2 where disclosure is required by a regulatory body in connection with theAccredited Health Practitioner, a Healthscope Hospital, Healthscope Limited ora Healthscope Company;
182.3 where the person benefiting from the confidentiality consents to the disclosureor waives the confidentiality; or
182.4 where disclosure is required in order to perform some requirement of these By-Laws.
What confidentiality means
183 The confidentiality requirements of clauses 180 and 181 of these By-Laws prohibit therecipient of the confidential information from using it, copying it, disclosing it to someoneelse, reproducing it or making it public.
1111316046 \ 03062376480415 \ 117801 Revised July 2012 35
Confidentiality obligations continue
184 The confidentiality requirements of these By-Laws continue with full force and effectafter the Accredited Health Practitioner ceases to be accredited with respect to anyHealthscope Hospital.
FORMS AND PAPERWORK
General Manager may prescribe forms and paperwork
185 A General Manager may prescribe forms (written or electronic) and other administrativeprocesses to be completed and performed by an Accredited Health Practitioner in thetreatment of a Patients in connection with the Patient's admission to or treatment at aHealthscope Hospital.
186 An Accredited Health Practitioner must accurately complete those forms and performthose processes and then deal with them in accordance with the General Manager'sprescription.
1111316046 \ 03062376480415 \ 117801 Revised July 2012 36
SCHEDULE 1
MEDICAL ADVISORY COMMITTEES
FUNCTIONS
Every Healthscope Hospital Medical Advisory Committee (MAC) is charged with the followingfunctions:
Communication
1 To facilitate communication between the General Manager and Health Professionals.This communication includes:
1.1 recommendations by the MAC in relation to policies for the clinical organisationof the hospital;
1.2 plans and management of the continuing education program within the hospital.
Monitor and Review of Clinical Services
2 To advise General Manager in relation to:
2.1 services to meet the health needs of the community;
2.2 optimising the delivery of patient care based on both research and current bestpractice;
2.3 establishment and maintenance of a mechanism for formally reviewing clinicaloutcomes and management (including a peer review process);
2.4 the introduction of new surgical and medical procedures within the hospital;
2.5 proposals for research and clinical trials to be performed at the hospital;
2.6 the formulation of local rules, policies and procedures with a view to best-practice clinical governance and improvement of patient quality and safetyconsistent with these By-Laws.
Hospitals in New South Wales
3 Notwithstanding any other provision in these By-Laws, if the hospital is in New SouthWales, the Medical Advisory Committee is to be responsible for:
3.1 advising the licensee on the accreditation of Health Practitioners to provideservices at the hospital and the delineation of their clinical responsibilities,
3.2 advising the licensee on matters concerning clinical practice at the hospital,
3.3 advising the licensee on matters concerning patient care and safety at thehospital;
3.4 any other matter that may be prescribed by the NSW regulations;
1111316046 \ 03062376480415 \ 117801 Revised July 2012 37
3.5 reporting to the Director-General any repeated failure by the licensee of thehospital to act on the Committee's advice on matters specified in 3.1 to 3.4above where that failure is likely to adversely impact on the health or safety ofpatients.
Credentialling
4 To form a ‘Credentials Committee' and to make recommendations to the General Managerwith regard to any application for Accreditation or renewal of accreditation (Re-Credentialling) in accordance with these By-Laws.
ADMINISTRATIVE MATTERS
Term of office
5 Members of a MAC will be appointed for a term of 2 years.
6 An individual can be appointed for multiple and successive terms on a MAC.
Membership
7 The MAC must consist of representatives from each Major Specialty and Serviceprovided by the hospital (representative members) and must also include the GeneralManager and Director of Nursing .
8 In the State of New South Wales, the MAC and its Credentials Committee must consist of5 persons to achieve a quorum, or more persons if the General Manager of the hospital sodetermines.
9 In the State of Queensland, the MAC and its Credentials Committee must consist of 4persons to achieve a quorum, or more persons if the General Manager of the hospital sodetermines.
10 In the State of Queensland, the Credentials Committee of the MAC must include as an ex-officio member the Director of Nursing of the hospital or his/her delegate, who willcontribute to achieving a quorum at meetings of the Credentials Committee of the MAC.
11 In all States other than Queensland, it is the decision of the General Manager as towhether the MAC or Credentials Committee of the MAC will include the Director ofNursing or his or her delegate.
12 In States other than New South Wales and Queensland, the MAC and its CredentialsCommittee will consist of the number of persons prescribed by the General Manager ofthe hospital.
Electing Members
13 The representative members of a MAC are to be elected by and from among those HealthPractitioners who have been accredited by the Hospital.
14 The members of each Major Speciality and Service will elect a representative of thatMajor Speciality and Service to membership of the MAC.
1111316046 \ 03062376480415 \ 117801 Revised July 2012 38
15 Prior to the annual meeting of the MAC, the General Manager will call for nominationsfor election to the MAC. Each nomination requires a proposer and a seconder andconfirmation from the nominee of acceptance of nomination.
16 Voting for representative members of a MAC:
16.1 is to be done at the annual meeting of the MAC;
16.2 must be done in person, with no entitlement to appoint a proxy;
16.3 will be decided by a show of hands or, at the discretion of the Chairman of theMAC, a secret ballot.
Chairman
17 The representative members of a MAC must elect a Chairman from amongst theirnumber.
Frequency of MAC Meetings
18 The Chairman of the MAC will determine the time and place of ‘Ordinary Meetings'.
19 There must be no less than 4 Ordinary Meetings per annum.
20 Subject to the approval of the General Manager of a hospital, the Chairman of its MACmay hold a ‘Special Meeting'.
21 Unless at least 75% of the members of the MAC agreed to shorter notice:
21.1 Ordinary Meetings require not less than 14 days prior notice to the members ofthe MAC; and
21.2 Special Meetings require not less than 7 days prior notice to the members of theMAC.
Resignation
22 Pending the next annual meeting of the MAC, the Chairman of a MAC may appoint aHealth Practitioner who has been accredited at that hospital to replace any representativemember of the MAC who has resigned or is indefinitely unable to continue in the role.The appointee must belong to the same major specialty or service as the representativebeing replaced.
Additional Administration of the MAC
23 In consultation with the General Manager of the hospital, the Chairman of an MAC maycreate additional rules for the proper administration of that MAC.
SCHEDULE 2
General Practice Anaesthetics
This guideline applies to all Accredited Health Practitioners who are Medical Practitioners registered
39
in general practice who provide anaesthesia to patients in a Healthscope Hospitals (see Schedule 5 of
these By-Laws).
General
An Accredited Health Practitioner who is a Medical Practitioner registered in general practice and
accredited to perform anaesthesia at a Healthscope Hospital (GP Anaesthetist) will practise with
care and diligence within the Scope of Practice indicated in their Accreditation Notification
consistent with their clinical competency and experience. Emergency life-saving procedures
performed outside these bounds are an exception to this requirement.
The GP Anaesthetist must maintain his or her anaesthetics skills and knowledge with a caseload
commitment to anaesthesia that must be no less than any annual minimum set by the General
Manager of the Healthscope Hospital at which they are accredited, and participate in an ongoing
professional development in the field of anaesthetics.
Accredited Health Practitioner who is a Medical Practitioner registered in general practice who is
seeking to practise anaesthesia in rural hospitals require a certificate of competency' from a
supervising anaesthetist who holds a Fellowship of the Australian and New Zealand College of
Anaesthetics. If that Accredited Health Practitioner has been practicing anaesthetics without a
supervising anaesthetist, then a certificate of competency should be obtained from the medical
superintendent or Chairman of the MAC of his or her previous hospital.
Quality Assurance and Continuing Professional Development
Every GP Anaesthetist must participate in a triennial quality assurance and continuing professional
development program in line with the Maintenance of Professional Standards (MOPS) program
drawn up and agreed to by the Joint Consultative Committee on Anaesthesia (JCCA), a tripartite
committee of the Australian and New Zealand College of Anaesthetists (ANZCA), the Australian
College of Rural and Remote Medicine (ACRRM) and The Royal Australian College of General
Practitioners (RACGP).
Every GP Anaesthetist must maintain a log book or similar record of his or her anaesthesia caseload
and continuing professional development activities consistent with the requirements of the JCCA.
At a minimum, log books should contain de-identified information on the age and gender of each
patient, the date and anaesthesia performed, and the outcome and any complications.
Special conditions may be imposed by the General Manager having received the advice of the
Credentials Committee on a GP Anaesthetist.
SCHEDULE 3
General Practice Obstetrics
40
This guideline applies to all Accredited Health Practitioners who are Medical Practitioners registered
in general practice who provide obstetrics services to patients in a Healthscope Hospital (see
Schedule 5 of these By-Laws).
General
A Health Practitioner who is a Medical Practitioner registered in general practice and accredited to
perform obstetrics at a Healthscope Hospital (GP Obstetrician) will practise with care and diligence
within the Scope of Practice indicated in their Accreditation Notification consistent with their
clinical competency and experience. It is expected that such a GP Obstetrician will hold a diploma
or advanced diploma through the Royal Australian and New Zealand College of Obstetricians and
Gynaecologists, or will have had extensive experience in obstetrics (preferably in their third or
subsequent postgraduate year). Emergency life-saving procedures performed outside these bounds
are an exception to this requirement.
The GP Obstetrician must maintain his or her obstetrics skills and knowledge with a caseload
commitment to obstetrics that must be no less than any annual minimum set by the General Manager
of the Healthscope Hospital at which he or she is accredited, and participate in an ongoing
professional development in the field of obstetrics.
Quality Assurance and Continuing Professional Development
Every GP Obstetrician must participate in a triennial quality assurance and continuing professional
development program in line with the Maintenance of Professional Standards (MOPS) program
drawn up and agreed to by the Joint Consultative Committee on Obstetrics (JCCO), a tripartite
committee of the Royal Australian and New Zealand College of Obstetricians (RANZCOG), the
Australian College of Rural and Remote Medicine (ACCRM) and The Royal Australian College of
General Practitioners (RACGP).
Every GP Obstetrician must maintain a log book or similar record of his or her obstetrics caseload
and continuing professional development activities consistent with the requirements of the JCCO.
At a minimum, log books should contain de-identified information on the age of each patient, the
date and obstetric procedure performed, and the outcome and any complications.
Special conditions may be imposed by the General Manager having received the advice of the
Credentials Committee on GP obstetrician.
41
SCHEDULE 4
General Practice Surgery
This guideline applies to all Health Practitioners who are Medical Practitioners registered in general
practice who provide surgical services to patients in Healthscope Hospitals (see Schedule 5 of these
By-Laws).
General
A Health Practitioner who is a Medical Practitioner registered in general practice and accredited to
perform surgery at a Healthscope Hospital (GP Surgeon) will practise with care and diligence
within the Scope of Practice indicated in his or her Accreditation Notification consistent with their
clinical competency and experience. This Schedule does not endorse, reflect on or prejudge the
matter of the kind of surgery being undertaken in these circumstances, although it is assumed that an
appropriately trained and Accredited Health Practitioner who is a Medical Practitioner with training
in surgery as mandated by these By-Laws will perform such surgery.
The GP Surgeon must maintain his or her surgery skills and knowledge with a caseload commitment
to surgery that must be no less than any annual minimum set by the General Manager of the
Healthscope Hospital at which he or she is accredited, and participate in ongoing professional
development.
Quality Assurance and Continuing Professional Development
Every GP Surgeon must participate in a triennial quality assurance and continuing professional
development program in line with the guidelines drawn up by the Joint Consultative Committee on
Surgery (JCCS) or its equivalent. The JCCS is a tripartite committee of the Royal Australasian
College of Surgery (RACS), The Royal Australian College of General Practitioners (RACGP) and
the Australian College of Rural and Remote Medicine (ACRRM). Information about the program of
the JCCS is available through the RACGP (http://www.racgp.org.au).
Each GP Surgeon must maintain a log book or similar record of his or her surgery caseload and
continuing professional development activities consistent with the requirements of the JCCS or its
equivalent. At a minimum, log books should contain de-identified information on the age and
gender of each patient, the date and operation performed, and the outcome and any complications.
Special conditions may be imposed by the General Manager having received the advice of the
Credentials Committee on a GP Surgeon.
42Created 2006 HSPADM docref # 40019Last Updated 1 July 2012
ACCREDITATION FORM – SCHEDULE 5
APPLICATION FOR APPOINTMENT AS AN ACCREDITED PRACTITIONER
Please submit completed application form to the General Manager at your Healthscope Limited Hospital.
Application may be made for Accreditation at more than one Healthscope Hospital on this form. Applications for Accreditation at more than one HealthscopeLimited Hospital will be copied and forwarded to the relevant General Manager at each hospital for separate and independent consideration. Please list the
Hospitals to which you wish this form to be forwarded.
To the General Manager, (Hospital name) Private Hospital, (place hospital address)
Please copy and forward this application and supporting documents for Accreditation to the following additional Hospital(s) for consideration:
Name of additional Hospital(s):
1. Initial Accreditation / Renewal of Accreditation(delete whichever is not applicable)
2. Initial Accreditation / Renewal of Accreditation(delete whichever is not applicable)
3. Initial Accreditation / Renewal of Accreditation(delete whichever is not applicable)
4. Initial Accreditation / Renewal of Accreditation(delete whichever is not applicable)
Contact Name
Title: □DR □MR □MISS □A/PROF □PROF □OTHER: (please specify) Date of Birth:
Surname of Applicant:
First Name in full:
Contact Addresses (please indicate which is preferred for correspondence)
Residential Address: Tick here if preferred address for correspondence: □
Street: ___________________________________________________________________________________________________________
Suburb: State: Post Code:
Home Telephone: Home Fax:
Professional Address (Primary Consulting Rooms): Tick here if preferred address for correspondence:□
Street: ___________________________________________________________________________________________________________
Suburb: State: Post Code:
Rooms Telephone: Rooms Fax:
Pager Telephone: Pager Number:
Mobile Number: Email Address:
Provider Number:For renewal of accreditation: If this is an application for renewal of accreditation only and there are no changes to the information required as advised by theGeneral Manager, you are required to indicate by ticking the “Renewal of Accreditation Only” box below, and sign this application in the space provided.
□Renewal of Accreditation Only – no further information required
_________________________________________________________ ______________________
Signature of Applicant Date
Healthscope Limited
43Created 2006 HSPADM docref # 40019Last Updated 1 July 2012
Please attach Curriculum Vitae with details of:
Undergraduate Qualifications, University, Year of Graduation
Postgraduate Qualifications, Degrees, Diplomas, Fellowships (including awarding body, qualification and year obtained)
Hospital appointments within the last 5 years (dates, hospitals, positions held)
Ongoing postgraduate education/CPD in the past 3 years
Publications
SCOPE OF PRACTICE
You must tick the specialty and then all sub-specialties for which you are seeking accreditation:
□ ADDICTION MEDICINE
□ ANAESTHESIA□ Adult□ Obstetric□ Paediatric (>1 year old)□ Cardiac
□ CARDIOLOGY□ Diagnostic procedures□ Interventional procedures□ Electrophysiology studies□ Implantable electronic devices□ Other, e.g. Valvuloplasty, PFO/ASD
Closure□ Peripheral Endovascular Therapy
□ CARDIOTHORACIC SURGERY□ Adult□ Valvular Procedures□ Coronary Artery Bypass□ Arrhythmia Surgery□ Thoracic Aorta Procedures□ Thoracic/Lung Procedures□ Insertion of Pacemaker□ Other, please specify:
□ DENTAL□ General Dentistry□ Oral Surgery□ Oral and Maxillofacial Surgery□ Special Needs Dentistry
□ DERMATOLOGY
□ EMERGENCY MEDICINE
□ ENT SURGERY□ Adult□ Paediatric□ Adenoidectomy□ Bronchial Procedures□ Ear Procedures□ Facial Nerve□ Laryngeal Procedures□ Nasal Procedures□ Otolaryngology – Head & Neck□ Pharyngeal Procedures□ Tonsillectomy□ Tracheal Procedures□ Other, please specify:
□ GASTROENTEROLOGY□ Diagnostic Upper Gastrointestinal
Endoscopy□ Therapeutic Upper Gastrointestinal
Endoscopy□ Sclerotherapy□ Oesophageal Banding & Placement of
Oesophageal Prostheses□ Oesophageal Dilation□ Flexible Sigmoidoscopy□ Diagnostic Colonoscopy□ Therapeutic Colonoscopy□ Endoscopic Retrograde
Cholangiopancreatography (ERCP) &associated therapeutic interventions
□ Biliary Stenting□ Percutaneous Endoscopic Gastronomy
(PEG)
□ GENERAL PRACTICE□ Non-procedural□ GP Anaesthetics□ GP Obstetrics□ GP Surgical
□ GENERAL SURGERY□ Obesity
□ Lap Banding□ Modified Roux-en-Y□ Sleeve Gastrectomy
□ Breast Surgery□ Colorectal Surgery□ Endocrine Surgery
□ Adrenalectomy□ Thyroidectomy
□ Endoscopic Surgery□ Gastrointenstinal Surgery□ Hepatobiliary & Pancreatic Surgery□ Laparoscopic Surgery
□ Diagnostic□ Interventional
□ Oesophagectomy□ Sentinel Node Biopsy□ Upper GI Surgery
□ GYNAECOLOGY□ Advanced Endoscopic Surgery□ Gynaecology General□ Prolapse Surgery□ Ultrasound□ Assisted Reproductive Services (IVF)□ Gynaecological Oncology□ Uro-Gynaecology
□ INTENSIVE CARE MEDICINE□ Adult□ Paediatric
□ INTERNAL MEDICINE□ Clinical Genetics□ Clinical Pharmacology□ Endocrinology□ Geriatric Medicine□ Haematology□ Hepatology□ Immunology & Allergy□ Infectious Diseases□ Medical Oncology□ Nephrology□ Neurology□ Nuclear Medicine□ Radiation Oncology□ Respiratory Medicine
□ Bronchoscopy - Diagnostic□ Bronchoscopy - Therapeutic□ Sleep Medicine
□ Rheumatology□ Other, please specify:
□ NEUROSURGERY□ Nerve Procedures□ Spinal Procedures□ Intracranial Procedures
□ OTHER HEALTH PRACTITIONER,please specify:
□ OBSTETRICS□ Maternal Fetal Medicine□ Obstetrics□ Ultrasound
□ OCCUPATIONAL ANDENVIRONMENTAL MEDICINE
□ OPHTHALMOLOGY□ Adult□ Paediatric□ Cataract Surgery□ Corneal Transplantation□ Eyelid Surgery□ Glaucoma Surgery□ Lacrimal Surgery□ Oculoplastic□ Orbital Surgery□ Pterygium Surgery□ Refractive Surgery□ Squint Surgery□ Vitreoretinal Surgery
□ ORAL & MAXILLOFACIAL SURGERY□ Adult□ Paediatric□ Maxillofacial Surgery□ Mandibular Osteotomy□ Other, please specify:
Healthscope Limited
44Created 2006 HSPADM docref # 40019Last Updated 1 July 2012
□ ORTHOPAEDIC SURGERY□ Adult□ Paediatric□ Arthroscopy□ Fracture Management□ Major Joint Replacement□ Reconstructive Surgery□ Spinal Surgery
□ PAEDIATRIC MEDICINE□ General Medicine□ Neonatology Level II (34 weeks or
later)
□ PAEDIATRIC SURGERY
□ PAIN MEDICINE
□ PALLIATIVE MEDICINE
□ PATHOLOGY□ Anatomical/Cytopathology□ Biochemistry□ Chemical Pathology□ General Pathology□ Haematology□ Immunology□ Microbiology
□ PLASTIC & RECONSTRUCTIVESURGERY□ Adult□ Paediatric□ Otoplasty□ Repair of Lacerations□ Revision of Scars□ Abdominal Reductions□ Breast Augmentation□ Breast Reduction□ Cosmetic Rhinoplasty□ Brow Surgery□ Facial Surgery□ Gender Reassignment□ Laser Ablation□ Liposuction□ Neurovascular Flaps□ Other, please specify:
□ PSYCHIATRY□ General□ Adolescent□ Psychogeriatric□ ECT□ TMS
□ RADIATION ONCOLOGY
□ RADIOLOGY□ Diagnostic Radiology□ Diagnostic Ultrasound□ Nuclear Medicine□ Peripheral Endovascular Therapy
□ REHABILITATION MEDICINE
□ SURGICAL ASSISTANT
□ UROLOGY – GENERAL□ Adult□ Paediatric□ Endoscopic Urology□ Laparoscopic Urology□ Laser□ Open Urological Procedures□ Brachytherapy□ HiFU□ Lithotripsy□ Other, please specify:
□ VASCULAR SURGERY□ Anastomosis□ Arterial Patch□ Bypass□ Decompression□ Embolectomy□ Endarterectomy□ Ligation of Aneurysms□ Repair□ Replacement□ Thrombectomy□ Vascular Trauma□ Abdominal
□ Aortic□ Mesenteric□ Open
□ Axillary, Subclavian□ Carotid Surgery – Open□ Peripheral Endovascular Therapy□ Femoral□ Iliac□ Jugular□ Renal□ Temporal□ Thoracic
□ REGISTERED HEALTH PRACTITIONER(NON-MEDICAL)□ Aboriginal & Torres Strait Islander
Health Practitioner□ Chinese Medicine Practitioner□ Medical Radiation Practitioner□ Occupational Therapist□ Chiropractor□ Dental Practitioner□ Nurse / Midwife□ Optometrist□ Osteopath□ Pharmacist□ Physiotherapist□ Podiatrist□ Psychologist
For Surgical Assistant applicants only:
Name of accredited Health Professional at each applicable Hospital who will provide a reference for you. (Attach document if insufficient space)
Name: Contact Number: Hospital:
Accreditation Sought (Please Tick):
□ Permanent □ Temporary Specified Dates:
Healthscope Limited
45Created 2006 HSPADM docref # 40019Last Updated 1 July 2012
Please provide the contact details of two referees who are practitioners within the intended specialty or sub-specialty in Australia who can attest to yourrecent clinical practice and who are not related to you nor financially linked with or financially dependent on you (Not applicable to surgical assistants).
Name of Referee 1: Name of Referee 2:
Contact Details (telephone / email): Contact Details (telephone / email):
Registered health practitioners please provide your current AHPRAregistration number:
Are there any conditions attached to this registration? □Yes □No
If yes, provide details of conditions:
Please state the name of your medical defence organisation or your professional indemnity insurance provider and provide photocopy:
Name:
Membership Number:
Category of membership (insert specialty; for example “Full Surgeon”):
Does your membership fully cover the scope of practice you have applied for?
□Yes □No
Healthscope Limited
46Created 2006 HSPADM docref # 40019Last Updated 1 July 2012
Check List – please ensure that the following is forwarded to the Hospital:
□ Completed Schedule 5
□ Curriculum Vitae
□ Medical Indemnity Insurance Certificate of Currency or equivalent
Has your Scope of Practice (clinical privileges) and/or accreditation at any hospital or day procedure centre ever been reduced, suspended or revoked orhave you had conditions attached to that appointment for any reason?
□Yes □No
If yes, give dates and particulars:
Medical Practitioners Only - Please nominate two medical practitioners accredited at the Hospital in your specialty available for contact by the Hospitalin case of an emergency if you are unavailable:
Name: Name:
Specialty: Specialty:
Listing of Health Practitioners: (not applicable to surgical assistants)
I authorise the Hospital(s) to include my details in any listing of Health Practitioners □Yes □No
Authority:
I hereby apply for accreditation at the hospital(s) I have specified with the Scope of Practice (clinical privileges) I have also specified.
I authorise my medical indemnity insurer to provide a Certificate of Currency or equivalent including details of my medical indemnity insurance coverto the Hospital.
In making this application I acknowledge and agree:
- I have received a copy of the Healthscope Limited Hospital By-Laws ___________ (please initial)
- I will abide by the By-Laws __________ (please initial)
- The Hospital(s) General Manager(s), its officers and the Medical Advisory Committee(s) or its/their Credentials Committee may seek informationabout my past experience, clinical performance and current fitness and current insurance/indemnity status. _____________ (please initial)
Signature: ____________________________________________________ Date: _______________________________
