Medical By-laws

 

By-laws summary

Dr Joni Feldman of the Clinic of Cosmetic Medicine operates at South Yarra Day Surgery under by-laws that support and facilitate a quality health service that delivers safe care.

The By-laws:

  • establish the principles applying to the accreditation and defining scope of practice of practitioners
  • govern the relationship of the Clinic of Cosmetic Medicine with its accredited practitioners
  • set out rules for the conduct of accredited practitioners at the Clinic of Cosmetic Medicine
  • outline the obligations on accredited practitioners in relation to the safety and the quality of care of patients
  • ensure that a clinical governance framework is in place to evaluate, monitor and improve the quality and safety of the health services provided
  • set out the scope of practice for services the facility can safely support

 

South Yarra Day Surgery By-laws (in full)

Index

  1. Medical Advisory Committee3
  2. Appointment of Medical Practitioner4
  3. Responsibilities of Medical Practitioners6
  4. Consent for Medical Treatment6
  5. Pre Admission 6
  6. Medical Record Documentation6
  7. Disclosure of Patient Information7
  8. Open Disclosure 7
  9. Code of Conduct7

It is expected that in line with the Occupational and Safety Regulations 2007 (as amended 2014),  all credentialed Medical Practitioners will adhere to the hospital code of conduct when dealing with all staff, patients and contractors. Serious breaches of the code of conduct will result in a review of credentialed status.      7

  1. Antimicrobial Stewardship7
  2. Quality & Safety7

 

  1. Medical Advisory Committee

The Medical Advisory Committee is committed to ensuring patients receive high quality services. The Medical Advisory Committee is responsible for:

  • Reviewing and approving Credentialing and Scope of Clinical Practice for Medical Practitioners
  • Ensuring the safety and quality of service delivery across the organisation for all patients through practice of high clinical standards
  • Identification of risks. Understanding key risks and ensuring controls and mitigation strategies are in place to mitigate them. Review of the risk register.
  • Adherence to relevant legislative and regulatory requirements and for the planning, implementation, monitoring and evaluation of the safety and quality systems.
  • Being accountable for the quality and safety of the care provided by the organisation setting a clear vision, strategic direction and ‘just’ organisational culture that drives consistently high-quality care and facilitates
  • Effective employee and consumer engagement and participation, staying engaged, visible and accessible to staff
  • Ensuring it has the necessary skill set, composition, knowledge and training to actively lead and pursue quality and excellence in healthcare
  • Monitoring and evaluating all aspects of the care provided through regular and rigorous reviews of benchmarked performance data and information
  • Ensuring robust clinical governance structures and systems across the health service
  • Effectively support and empower staff to provide high-quality care
  • To approve, review and implement new clinical procedures, services or equipment
  • Review, analyse and make recommendations and improvements on clinical incidents and sentinel events
  • Discuss and make recommendation regarding any clinic matters
  • Review Infection Control Audits and Reports
  • Review Internal Audits

 

The Medical Advisory Committee is the highest level of Governance at South Yarra Day Surgery.

Members of the Medical Advisory Committee will be appointed by the Medical Director. Appointments will be for a term of three years after which point the member can be re-elected.

2. Appointment of Medical Practitioner

Visiting Medical Officers who wish to work at South Yarra Day Surgery are required to have their qualifications and experience screened by Medical Advisory Committee.

VMOs only permitted to perform duties and tasks, including operations, which are within their qualifications and approved appointment credentials.

  • Obtain training in new procedures
  • Must inform South Yarra Day Surgery if they have been involved in a critical incident or there have been major complications from surgery resulting in the need for intervention by other specialist in another hospital or if any conditions are imposed on their AHPRA Registration

 

NEW APPOINTMENTS

Upon application for Credentialing, all Medical Practitioners are required to submit to the Medical Director:

  • Proof of Identity – 100 points of ID
  • National Policy History Check
  • Working with Children Check (if applicable)
  • Original Qualifications or certified copy
  • Original or certified copy of Specialist Qualification
  • Evidence of current compliance with all maintenance of professional standard requirements as determined by the specialist college
  • Current AHPRA Registration including confirmation of the presence or absence of conditions, undertakings, endorsements, notations and reprimands.
  • Copy of current Medical Indemnity Insurance certificate ensuring the cover reflects the requested scope of clinical practice.
  • Health Status
  • Continuing Professional Development (CPD) statements that are college approved or relevant to scope
  • Current CV with employment history
  • At least 2 References. Referees must be someone who has worked largely within the specialty of the applicant and have been in the position to judge the experience and performance of the applicant within the previous 3 years and have no conflict of interest.

This information will be provided to the The Medical Advisory Committee who will consider the following:

  • Training and recent experience
  • Competence and clinical judgment
  • Professional capability and knowledge
  • Current fitness to practice and good character
  • Confidence in applicant’s capability and knowledge
  • Referees reports

Following the MAC meeting, the Medical Practitioner will be notified in writing if the application was successful. A letter outlining the terms of their appointment will be sent to the VMO to be signed and one copy to be sent back to the South Yarra Day Surgery to be filed in their personnel file.

A Medical Practitioner who has their application denied has the right to appeal the decision.

RE-CREDENTIALING

The formal process used to Re-appoint a Medical Practitioner with no change of scope to clinical practice and to re-confirm the qualifications, experience and professional standing (including history of and current status with respect to professional registration, disciplinary actions, indemnity insurance and criminal record) of medical practitioners, for the purpose of forming a view about their ongoing competence, performance and professional suitability to provide safe, high quality healthcare services within specific organisational environments.

Re-credentialing is required every three years. A Re–application form for credentialing is to be completed and the applicant must provide the following:

  • Currency of Working with Children Check (if applicable)
  • Current AHPRA Registration including confirmation of the presence or absence of conditions, undertakings, endorsements, notations and reprimands.
  • Copy of current Medical Indemnity Insurance certificate ensuring the cover reflects the requested scope of clinical practice.
  • CPD- College certificate or evidence of relevant CPD
  • Health Status
  • Updated CV (if applicable)

 

ANNUAL REQUIREMENTS

To fulfil credentialing requirements, each year the Medical Practitioner must provide the centre with:

  • Current AHPRA Registration confirming the presence or absence of conditions, notations, undertakings or reprimands.
  • Relevant CPD
  • Current Medical Indemnity Insurance that reflects the scope of practice
  • Annual Hand Hygiene certificate

Where new services are introduced or where a Medical Practitioner wishes to extend their scope of clinical practice, they must formally undergo appropriate credentialing specifically for the new service or practice. They must provide the MAC with:

  • The change to the scope of clinical practice requested
  • Additional procedural qualifications or experience needed for the requested change
  • Medical Indemnity Insurance that reflects the requested change to scope of clinical practice
  • CPD- College certificate or evidence of relevant CPD

The MAC is responsible for confirming that the requested changes fit the need and capability of The Clinic of Cosmetic Medicine

A scope of clinical practice may also be reduced for example due to underperformance or if CPD requirements have not been met, When this occurs, the MAC must notify the Practitioner in writing and provide an amended position description.

In case of unforeseen circumstances such as severe illness of the surgeon or anaesthetist, emergency Clinical Privileges will be granted to the nominated Medical Practitioner temporarily. The CEO has the responsibility of undertaking credentialing and defining the scope of clinical practice in this situation.

In this Situation the ‘Application for credentialing and scope of clinical practice- urgent situations’ must be completed and the applicant must provide:

  • Current Medical Indemnity Insurance certificate relevant to scope of clinical practice
  • Current AHPRA Registration
  • 100 points of ID
  • Current CV
  • Working with Children Check (if applicable)

Temporary credentialing must be followed-up as soon as practical in line with the formal credentialing process and should not exceed 3 months.

 

EMERGENCY CLINICAL SITUATION

Should the need arise, a credentialed Medical Practitioner has the authority to administer necessary treatment outside their scope of clinical practice in an emergency situation when the interest of the patient are best served. Should this occur, a IIIR should be raised and the incident discussed at the next MAC meeting.

4. Responsibilities of Medical Practitioners

The Credentialed Medical Practitioner:–

  • Has responsibility for the medical care and treatment of the patient and has overall accountability for patients care
  • Must work as part of multidisciplinary collaboration and work as a team
  • Must include patients in shared decision making in all aspects of their treatment and care4. Consent for Medical Treatment

 

It is the responsibility of the Surgeon to ensure that the informed consent of patients to the nature and form of all treatment is obtained prior to the day of surgery. Consent must be informed and patients advised of any side effects and complications of the procedure. Surgery will not proceed until consent is obtained

5. Pre-admission 

All patients must complete pre-admission paperwork and undergo Pre-admission screening with the Surgeon prior to procedure day to ensure they are suitable for the facility and do not fall within the exclusion criteria. Pre-admission assessment must be documented in the patients’ healthcare record. All Surgeons must adhere to the the South Yarra Day Surgery Pre-admission policy and exclusion criteria.

6. Medical Record Documentation

During the course of a patient’s treatment at the Centre, clear, legible and relevant information shall be documented in the patient’s medical record.

All orders for treatment of the patients shall be clearly conveyed to the nursing staff by the Surgeon Practitioner directing such treatment.

Ambulatory Report must be completed for each procedure including documentation of medications given and vital observations, procedure notes and post procedure notes.

The nursing staff must be provided with clear written instructions regarding discharge of patients and the arrangements for follow-up.

All pre-medication and procedure medication must be documented in the medical record.

All paperwork in the medical record must be completed.

7. Disclosure of Patient Information

South Yarra Day Surgery is committed to the protection of personal privacy of our patients.  Our policy is based on the Health Privacy Principles as detailed in the Health Records Act 2001, (VIC) and the Australian Privacy Principles as detailed in the ‘The Privacy (Private Sector Amendment) Act 2000 as amended’.  The policy deals with the collection, use and disclosure of personal health information as well as access and correction, data security and data retention.

All staff employed are required to sign a confidentiality agreement.

South Yarra Day Surgery complies with the Notifiable Data Breach scheme. We notify affected individuals and the Office of the Australian Information Commissioner (OAIC) when a data breach is likely to result in serious harm to individuals whose personal information is involved in the breach.

A data breach occurs when personal information held by an organisation is lost or subjected to unauthorised access or disclosure.

8. Open Disclosure 

An open disclosure policy is in place for all clinical adverse events (*Please see below).  It is the responsibility of the Surgeon  to complete the Open Disclosure Procedure as soon as possible after the event.

9. Code of Conduct

It is expected that in line with the Occupational and Safety Regulations 2007 (as amended 2014),  all credentialed Medical Practitioners will adhere to the hospital code of conduct when dealing with all staff, patients and contractors. Serious breaches of the code of conduct will result in a review of credentialed status.

10. Antimicrobial Stewardship

Antibiotics are not to be routinely prescribed at South Yarra Day Surgery. If Antibiotics are prescribed or used, they must be documented in the Antibiotic Register. An audit of antibiotic use will be audited by our Infection Prevention Australia Infection Control Consultant.

11. Quality & Safety

Credentialed Medical Practitioners are expected contribute to the ongoing quality and safety of the Centre by participation in the quality management program through peer review , collection of relevant clinical indicators and assistance with quality and safety activities as required. All Credentialed Medical Practitioners are to follow South Yarra Day Surgery policies and procedures, National Safety & Quality Health Service Standards, Infection Control Standards and Dept of Health regulations.

12. Partnering with Consumer

Patients and their carers are to be involved in shared decision making and all aspects of their care in relation to the procedure and discharge planning. They must be provided with adequate written information for pre-procedure and discharge. Patient goals and needs should be taken into consideration when care planning.

 

SOUTH YARRA DAY SURGERY

*Open Disclosure 1.2

Purpose

Open disclosure will be used in the event that things go wrong, the patient and their family will be provided with information about what happened in a timely, open and honest manner.

Process

The South Yarra Day Surgery acknowledges when an adverse event has occurred or something has gone wrong and initiate open disclosure. Communication will occur in an honest and timely manner. The patient and their family will receive an apology or expression of regret for any harm that has resulted from an adverse event as early as possible. An apology or expression of regret will contain the words ‘I am sorry’ or ‘we are sorry’ but will not contain speculative statements, admission of liability or blame. The patient and their family can expect to be:

  • Fully informed of the facts surrounding an adverse event, including the known facts and consequences of the adverse event
  • Treated with empathy, respect and consideration
  • Supported in a manner appropriate to their needs
  • Be provided with information in a timely matter
  • Have an opportunity to tell the clinicians their story about the adverse event to explain their viewson what happened and ask questions.

All staff are encouraged to recognise and report to adverse events, are educated in open disclosure and are supported through the open disclosure process.

An open disclosure plan should be agreed upon and recorded in writing which outlines what the patient and their family hopes to achieve from the process and any questions they would like answered. A written account of any open disclosure meetings should be provided to the patent and their family. The patient and their family should be told the name and the role of everyone who attends the meetings and should be informed of any further reviews, the proposed process and the expected time frame.

An offer of support to the patient and their family should include:

  • Information about how to take the matter further
  • Assurance that the necessary follow-up care or investigation will be prompt and efficient
  • Contact details for services they may need to access
  • Ongoing support which may include reimbursement of out of pocket costs as a result from the adverse event.

Related Policies and Forms

  • Open disclosure checklist and plan
  • Open disclosure patient questionnaire

 

Legislation, Standards and References

·         National Safety and Quality Health Service Standards, Australian Commission for Safety and Quality Version 2

·         Australian Open Disclosure Framework 2014

·         Australian Commission on Quality & Safety