BY-LAWS AND

PRACTITIONER POLICY MANUAL

INTRODUCTION

Mt Lawley Private Hospital and the Walcott Street Surgical Centre are privately
owned and managed facilities with the aim of providing contemporary and efficient
health services to the community.

The purpose of this document is to outline the responsibilities of the individuals who
have been granted access to provide clinical care within either or both of these
facilities.

Recognising that every Practitioner is responsible for the quality of care provided,
each must accept and assume the obligation with respect to their patient’s rights, in a
manner determined by their respective Colleges, the Australian Health Practitioner
Regulation Agency (AHPRA) and in accordance with national accreditation
standards.

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PHILOSOPHY AND OBJECTIVES

The Governing Body of Mt Lawley Private Hospital and the Walcott Street Surgical Centre
strive to provide quality, best practice health care services to the community who are referred
for care and treatment. Only those Practitioners who are credentialed can provide care and
treatment.

The Governing Body recognises its duty of care to patients, staff and Practitioners in
providing a safe, quality environment, where best practice is encouraged at all times.

The philosophy is achieved through the following objectives:-

To provide a safe, quality environment that allows the consumer and provider to utilise
available resources to achieve high quality health care outcomes

To establish and maintain an organisational structure that provides co-ordination in the

planning, implementation and evaluation of all services.

To recruit and select suitably qualified health care personnel for the provision of services.

To encourage health care personnel to continually develop skills and competencies in a

supportive environment.

To have a Code of Conduct that outlines duties and responsibilities in the delivery of
health care.

To provide and encourage information systems to monitor and objectively evaluate the
outcomes of health care.

To promote and encourage networking with other health care professionals and facilities.

To show commitment to external service providers and visiting Practitioners by respecting

their right to courtesy, co-operation and effective communication, to work together and
support mutual quality business outcomes and to provide a structured process to facilitate
business dealings.

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CODE OF CONDUCT

The Governing Body has a code of conduct and an expectation that all employees and
visiting Practitioners work standards will reflect the objectives of the Code of Conduct. This is
in order that professional conduct in all areas is maintained and the vision, mission statement
and values of the organisation are achieved.

VISION MISSION AND VALUES.

The VISION is to provide boutique private hospital clinical services which meet best practice.

The MISSION is to provide our surgical and medical patients with optimal cost effective health
care in a safe, personalised environment and return them to the community in a state of well
being.

Our VALUES are honesty, respect, innovation, integrity, patient advocacy, quality, safety,
caring for the environment, and empowerment of staff.

PROTOCOL

All employees, visiting medical, dental, podiatric practitioners and other allied health,
complementary therapists are required to;

Provide an effective, efficient, prompt and courteous service to all patients, colleagues,
visiting medical officers, members of the public and contractors.

Deal with issues, grievances and concerns promptly and effectively and to be aware of
and utilise the mechanisms in place to facilitate this process.

Fulfil their lawful obligations and service aims, and organisation objectives with regard to
their professionalism and integrity, and ensure their own personal or business interests do
not conflict with these obligations.

Perform their duties in an honest, respectful manner.

Co-operate, work harmoniously and treat colleagues, visiting medical officers with
courtesy, not use their position to cause intentional disgrace, hurt or humiliation.

Ensure that instructions given are clear, ethical and reasonable and do not contravene
any legislative requirements.

Report any issues, incidents (including medication incidents) and adverse events in
accordance with policy requirements.

Participate in the Quality Program including external accreditation.

Not compromise the organisation by seeking private gain from their appointed position,
nor accept gifts, rewards or benefits that may compromise their integrity.

Not discriminate directly or indirectly against people on the basis of sex, marital status,
pregnancy, race, physical impairment, religious, political beliefs or age. Sexual and racial
harassment and victimisation is unacceptable and illegal under the Equal Employment
Act 1994.

Comply with all provisions of the Occupational Health and Safety Welfare Act (1984) and
Regulations (1996).

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Be effective and efficient in the use of organisation resources and to use resources
appropriately and with regard to the safety and security of themselves and the
organisation’s property.

Not comment to or provide the media with information relating to the organisation or
clients on any issue.

Be aware of the Mt Lawley Private Hospital/Walcott Street Privacy Policy and Privacy
Statement and be aware of responsibilities and obligations.

Respect patient/medical Practitioner confidence and not disclose patient or other

information in an unauthorised manner noting that under the provisions of the
Criminal code a patient is able to take legal action for any unauthorised disclosure of
confidential information concerning the patient.

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HOSPITAL BY LAWS

In order to achieve our philosophy the following By-Laws and Regulations act as a reference
and are specific to Mt Lawley Private Hospital and the Walcott Street Surgical Centre. These
By-Laws outline the administrative and clinical structures and processes that are necessary to
facilitate the effective, competent and safe delivery of care.

BY–LAW QUALIFICATIONS

All Practitioners are required to be registered with the Australian Health Practitioner
Regulation Agency (AHPRA); have a current financial membership with their appropriate
College and have documented evidence of training and experience.

All practitioners must have current professional indemnity insurance and disclose if they have
any restrictions.

Each application for appointment and reappointment as a Practitioner shall contain a request
for specific clinical privileges desired by the applicant, which shall be accompanied by
documentation of training and experience which supports the request.

Clinical privileges shall be evaluated on the basis of the Practitioner’s education, training,
recency of practice and references.

Proof of current registration and indemnity insurance is required to be submitted to the

Director of Nursing annually/or when due.

BY-LAW MEMBERSHIP
A Practitioner may only consult, attend or admit patients to Mt Lawley Private Hospital or the
Walcott Street Surgical Centre subject to accreditation being granted in accordance with the
Governing Body By-laws.

The Governing Body grants membership of Practitioners to Mt Lawley Private Hospital and or
the Walcott Street Surgical Centre after receiving an application and recommendations from
the Credentialing and Scope of Practice Sub Committee to the Medical Advisory Committee.

No Clinician shall automatically become a member because he/she is registered as a

specialist. In addition, no Practitioner shall be denied membership on the basis of race,
gender, creed or colour.

When reaching the recognised retirement age, Practitioners may continue services in
accordance to his/her competency, but must reapply for membership each year.

All initial memberships granted shall be provisional and for a period of twelve months.

PROCEDURE FOR APPLYING FOR MEMBERSHIP AND RE-APPOINTMENT

Application for membership and clinical privileges must be made on the official application
form available from the Director of Nursing.

Information submitted with application is as per the By Laws Qualification clauses.

Applicants for accreditation shall submit a detailed list of procedures or treatments they will
be involved in.

All applications for membership and clinical privileges shall be considered, but some
restrictions may apply ie. The Credentialing and Scope of Practice Sub Committee and the

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Medical Advisory Committee may not automatically grant procedures of a specialty nature
unless qualified in that specialty or where the procedure is not in accordance with the
strategic directions of the Governing Body.

All applicants for accreditation shall be notified in writing of the outcome which will either
confirm appointment or not.

In the event of the Clinician application being refused, he/she has the right of appeal to the
Credentialing Committee

All approved applicants upon appointment shall abide by the By-Laws, Policies and
Procedures.

Practitioners who are due for re appointment will be notified within three (3) months of the
need to re submit all required documentation.

Practitioners who fail to submit their paperwork at the end of this three month period are no
longer permitted to admit patients.

CHANGES TO APPROVED SCOPE OF PRACTICE

Any changes to approved procedures or treatments will be subject to a new application.

INTERIM ACCREDITATION
.
To ensure efficiency and effectiveness of hospital business and patient care interim
accreditation may be granted until the next formal Credentialing Committee meeting.

Interim accreditation requires the same level of information to be submitted. The Director of
Nursing will consult with the Chairperson of the Credentialing committee and/or other
members as they deem necessary in order to grant interim accreditation.

Interim accreditation is only granted for the period to the next meeting of the Credentialing
and Scope of Practice Sub Committee.

AVAILABILITY OF ACCREDITED PRACTITIONERS

Every Practitioner who admits a patient to the Mount Lawley Private Hospital or the Walcott
Street Surgical Centre must be available for contact at all times. Relevant and current contact
numbers must be given to Director of Nursing and nursing staff.

If a Practitioner is unavailable, or in case of emergency, they must nominate an alternative

qualified Practitioner to act in their absence and who must also be accredited by the
Governing Body.

WITHDRAWAL OF ACCREDITATION

Withdrawal of accreditation or restrictions may occur when;

Activities or professional conduct by any Practitioner is proven to be detrimental to patient

care or disruptive to facility operations.

A complaint or matters of serious concern is made to the Director of Nursing concerning

the standard of practice of a Practitioner and is proven to be detrimental to patient care or
disruptive to facility operations.

In such a situation the Director of Nursing in consultation with the Chairperson of the MAC
and the Chief Executive Officer may consider immediate withdrawal of accreditation or
put in place restrictions prior to the full review by the Medical Advisory Committee.

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Where required a report to AHPRA, the Medical Board, College, or other

regulatory/legislative body shall be lodged.

In some situations temporary or alternative medical care may be need to be implemented.

Except in serious/urgent circumstances no suspension of a Clinician accreditation shall

occur without the Clinician being afforded a reasonable opportunity to present a written
submission to the Medical Advisory Committee or Appeals Committee on each matter of
concern.

APPEAL AND HEARING PROCESS

The hearing process provided in these By-Laws is for the purpose of resolving, on an intra
professional basis, matters concerning professional competency and conduct.

A request for a hearing must be submitted in writing and forwarded to the Director of Nursing.
The hearing is not a court of law and neither the affected Practitioner nor the Medical
Advisory Committee shall be represented by legal counsel.

The Medical Advisory Committee has an obligation at the hearing to present appropriate
evidence and reasoning in support of their action.

The affected Practitioner shall thereafter be responsible for defending his/her action or
supporting his/her challenges to the adverse recommendation or decision by an appropriate
showing that the grounds involved lack any factual basis is either arbitrary, unreasonable or
capricious.

If no written notification for appeal is received from the Practitioner involved within 14 days of
notification, the Practitioner waives the right to appeal and accepts the decision of the
Governing Body.

Upon conclusion of the presentation of evidence, the hearing shall be closed. The Medical
Advisory Committee will conduct its deliberation outside the presence of the Practitioner for
whom the hearing was convened.

Within ten (10) days after the hearing the recommendations of the Medical Advisory
Committee and the Governing Body will be sent to the affected Practitioner.

NEW TECHNIQUES AND TECHNOLOGIES

Practitioners must apply to the Director of Nursing if they wish to use new technologies or
new procedures using the prescribed application form. The Director of Nursing will make a
recommendation to the Credentialing and Scope of Practice Sub Committee in respect to the
capacity and capability of the facilities to introduce new technologies or new procedures and
the evidence to support introduction.

Where College guidelines recommend the undertaking of training to support new technology
or procedures evidence to support the completion of practice must be supplied.

The Credentialing and Scope of Practice Sub Committee makes recommendations to the
Medical Advisory Committee and the Governing Body to grant or reject such privileges, or
instigate any necessary guidelines for introduction.

MEDICAL ADVISORY COMMITTEE (MAC)

A Medical Advisory Committee shall be established and responsible for the activities outlined
in the by-laws.
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Functions of the Medical Advisory Committee shall be to consider, investigate and report,
make recommendations to and advise the Management with regard to:

 Regulations, by-laws, rules and procedures applying or to be applied to credentialed

practitioners. This includes noting recommendations from the Credentialing Sub
Committee which has responsibility for credentialing of new clinicians and recredentialing
of existing clinicians on a three yearly basis.

 To monitor and review standards and policies relating to the care of patients at Mount
Lawley Private Hospital and the Walcott Street Surgical Centre.

 To annually review all procedures carried out over the preceding twelve months to
confirm their appropriateness for Mount Lawley Private Hospital and the Walcott Street
Surgical Centre.

 Ensure that each credentialed practitioner participates in an annual review which includes
demonstration of continuing professional development.

 Initiating a performance review in the event of a serious complaint, incident or sentinel

event or as deemed necessary by the MAC.

 To consider the implementation of new treatments or technologies including the impact on

patients and the organisation.

 Providing advice and input into the purchase of new clinical equipment and or
consumables where such advice is required.

 The conduct of medical research, investigation and experimentation, and referral to a

registered Australian Health Ethics Committee.

 Participate in the organisation’s quality program including external Accreditation.

 Monitoring compliance with new National Accreditation standards which include but are
not limited to;

 Applied competencies in non touch aseptic technique

 Antimicrobial stewardship programs
 Applied competencies in hand hygiene
 Use of Open Disclosure
 Use of consent
 Management of discharge summaries

 Monitoring compliance with Medical Record Policies and Procedures with particular
emphasis on clinical content in the record.

 The promotion of the facilities and services generally.

MEMBERSHIP OF THE MAC

There shall be a minimum of six members representing the following Professional groups and
functional roles:

Surgeon, Allied Health Professional, Anaesthetist, General Clinician, Director of Nursing or

Deputy, Quality Coordinator, Chief Executive Officer.

TERMS OF OFFICE

Members shall serve a term of three years. Members may stand for re-election.

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ELECTION OF MEMBERS

Before retirement a letter shall be sent to those members who are due to retire seeking
advice as to their intentions to renominate or not. Following this a determination of vacant
positions will be made.
Nominations will then be called for from current practicing clinicians. If more nominations are
received than required an election shall be held.

Ballot papers will be lodged with the Director of Nursing prior to the commencement of the
Annual meeting and signed by proposer, seconder and nominee. All current practicing
clinicians are eligible to vote.

Retiring members shall hold office until the conclusion of the Annual General Meeting.

Replacement of vacancies occurring midterm shall be at the discretion of the full Medical
Advisory Committee.

The Annual Meeting shall be held in November each year.

CHAIRPERSON

At the first meeting following the Annual General Meeting a Chairperson and a Deputy
Chairperson shall be elected from the Committee members.

QUORUM

A Quorum shall be at least four members three of whom must represent the clinical
specialities.

FREQUENCY OF MEETINGS

A minimum of two (2) meetings shall be held in March and September. Meetings may be
called more frequently as required.

AGENDA AND MINUTES

An agenda, previous minutes and papers shall be prepared no later than seven days before
the planned meeting.

Minutes of the previous meeting are to be circulated within 30 days.

CREDENTIALING AND SCOPE OF PRACTICE SUB

COMMITTEE
A Credentialing and Scope of Practice Sub Committee shall be established and responsible
for the activities outlined in the by-laws.

The Credentialing and Scope of Practice Sub Committee shall:

 Review the credentials and suitability of appointment of all Practitioner applicants

prior to the appointment process and of all Practitioners with existing privileges at
prescribed intervals.

 Ensure verification of each clinician’s credentials, scope of practice, skills, experience

and competencies and the matching of these with the needs and capabilities of Mt
Lawley Private Hospital and the Walcott Street Surgical Centre in relation to staffing,
facilities equipment and support systems available.

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 Confirm on an annual basis that each credentialed practitioner is operating within
their approved scope of practice.

 Monitor and take action when necessary that ensures all practitioners required by
legislation hold annual registration with the Australian Health practitioner Regulation
Agency (AHPRA) have provided documented evidence confirming currency of their
registration.

 Monitor and take action when necessary that ensures clinicians hold required
professional indemnity insurance relevant to their credentialing and approved scope
of practice.

 Review applications for new procedures/interventions and make recommendations to

the Medical Advisory Committee.

 Review temporary clinical privileges awarded to Practitioners to ensure

appropriateness prior to full accreditation privilege recommendations.

 Review clinical privileges when there are legitimate and verifiable concerns about the
level of a practitioner’s clinical performance, such as inadequate maintenance of
skills, outdated practices substandard outcomes, inordinate numbers of complaints or
decreasing mental or physical health.

 Confirm the performance of an accredited practitioner on the due date and make
recommendations for re appointment.

 Assess the effectiveness of the Credentialing and Scope of Practice sub Committee
against the identified key performance indicators annually.

The Chief Executive Officer, the Director of Nursing and the Quality Manager shall remain
members of the Medical Advisory Committee so long as they hold those respective positions
and shall be deemed to vacate their membership of the MAC immediately on ceasing to hold
these positions.

MEMBERSHIP OF THE CREDENTIALLING AND SCOPE OF PRACTICE SUB

COMMITTEE

Members of the Medical Advisory Committee shall form the membership of the Credentialing
and Scope of Practice Sub Committee.

Where required an ex officio member may be co opted to represent a specialty not covered
by the membership.

TERMS OF OFFICE

The term of Office shall be the same as for members of the Medical Advisory Committee.

ELECTION OF MEMBERS

Members of the Medical Advisory Committee are automatically appointed to the membership
of the Credentialing and Scope of Practice Sub Committee.

In addition an ex officio member may be temporarily appointed to represent a particular

specialty if required.

CHAIRPERSON

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The Chair of the Medical Advisory Committee shall chair the Credentialing Committee.

QUORUM

A Quorum shall be at least four members three of whom must represent the clinical
specialities.

FREQUENCY OF MEETINGS

A minimum of two (2) meetings shall be held in March and September. Meetings may be
called more frequently as required.

AGENDA AND MINUTES

An agenda, previous minutes and papers shall be prepared no later than seven days before
the planned meeting.

Minutes of the previous meeting are to be circulated within 30 days.

The Chief Executive Officer, the Director of Nursing and the Quality Manager shall remain
members of the Credentialing and Scope of Practice Sub Committee so long as they hold
those respective positions and shall be deemed to vacate their membership of the
Credentialing and Scope of Practice Sub Committee immediately on ceasing to hold these
positions.

APPEALS
A Clinician who has clinical privileges denied, withdrawn or granted in a different form to that
requested has a right to appeal the decision. A separate committee independent of the
Medical Advisory Committee and Credentialing and Scope of Practice Sub Committee shall
be established to consider the appeal.

SPECIAL MEETINGS
All active Practitioners may be invited or request presence/representation at the MAC meeting
or call a special meeting if required.

Written notice of this special meeting stating place, day and hour shall be mailed to each
active Practitioner 7 days prior to a meeting. Special meetings shall be minuted. No
business outside the reasons for the calling of a special meeting shall be addressed at the
meeting.

PRIVACY POLICY STATEMENT

The Governing Body is committed to respecting the privacy of personal information collected
as required by the Privacy Amendment (Private Sector) Act 2000, December 2001.

Personal Information will be managed according to the 10 National Privacy Principles.

COLLECTION

The organisation will collect personal information that is necessary for the primary function of
patient care.

This information collected is through various medical record pre and post admission
documents, telephone messages, emails, facsimiles and other lawful and fair means of
collection.
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Government, state or statutory provisions may require the Governing Body to disclose your
personal information to these agencies.

USE AND DISCLOSURE

The Governing Body will use the personal information collected for the primary purpose of
patient care and health care delivery.

Use and disclosure of information so collected for a secondary purpose will only be done
upon express or implied consent having been obtained from the practitioner concerned.

In emergency circumstances and or a requirement for disclosure to law enforcement agencies

the Governing Body may be required or compelled to provide information that has been
collected.

DATA QUALITY

The Governing Body will take reasonable steps within its control to make sure that the
personal information it collects uses or discloses is accurate, complete and current.

DATA SECURITY

The Governing Body will take reasonable steps to protect the personal information it holds
from misuse, loss, unauthorised access, modification or disclosure.

The Governing Body will take reasonable steps to destroy or permanently identify personal
information, which is no longer required.

OPENNESS

The Governing Body has a policy on its management of personal information. A copy will be
made available to anyone who requests for it.

ACCESS AND CORRECTION

The Governing Body will allow access to the personal information collected on request by the
individual except in certain circumstances.

Access will be provided in most instances within 30 days unless further investigation is
required but the person requesting access will be informed of any delays and the reason for.

A cost will be charged for any administrative costs associated with the request.

Prior to providing access a request form “access to a patient record form” must be completed
in order to obtain
 patient details,
 name of applicant,
 requesting proof of identity,
 acknowledgment of costs,
 reason for access and
 The Director of Nursing and/or Privacy Officer must complete determining
authorisation or denied access and grounds for.

If any material within a medical record is requested to be amended a “request to amend a

patient record” form is to be completed by the person/patient requesting the amendment and
then included permanently as part of the medical record. At no time is the original record to
be altered.

Circumstances where access may be withheld include:-

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 Where release of the information with no explanation could present a serious threat to
the life or health of the individual or another person.

 When an individual’s record contains information about another person, and it may
breach that persons privacy if the information is released.

 When the request is frivolous or vexatious

 When there are existing or anticipated legal proceedings

 When providing access would ground an action for breach of confidentiality.

 When denying access is required or authorised by or under law.

 When law enforcement or government authorities have an interest in the information

held.

 When access may reveal sensitive information about the commercial decision making
process of the health provider.

IDENTIFIERS

The Governing Body will not use identifiers assigned by other agencies or others as its own
identifier except for purposes of establishing the identity of the individual.

The Governing Body will utilise its own system of identifiers for patient records.

ANONYMITY

Wherever possible and practicable to do so, the Governing Body will allow individuals the
option of not identifying themselves.

TRANSFER OF INFORMATION

Information will only transferred if the individual consents, the recipient is subject to a law,
scheme or contract which upholds the NPP principles, it is for implementation of a contract
between the individual and Mt Lawley Private Hospital or the Walcott Street Surgical Centre
and it is in the interest of the individual.

SENSITIVE INFORMATION

The Governing Body will collect sensitive information only with the consent of the individual as
required by law or legal proceedings or if there is a threat to the life or health of any individual.

CLINICAL RESPONSIBILITIES

The Practitioner admitting the patient will be regarded as responsible for that patient until
such time as the nurse in charge is notified of the transfer of the patient to the care of
another accredited Practitioner and the latter has visited the patient.

Practitioners are expected to visit their patients with reasonable frequency as judged by
the needs of the case.

Only the Practitioner responsible for the patient or his deputy (who must also be
accredited) may authorise discharge.

Information on the essential features of the patient’s history, condition and treatment shall
be maintained. (Refer medical record content)

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Instructions for the treatment of patients must be given in writing. In urgent
circumstances the Practitioner may give telephone orders to a Registered Nurse on duty
who will verify by utilising the speaker-phone with another registered nurse or enrolled
nurse. The Practitioner must sign the record of the orders within 24 hours of the time of
the phone order.

The Governing Body reserves the right to refuse access to Practitioners who have not
arranged for clinical privileges.

In the event of an emergency situation arising in the opinion of the senior nurse on duty
the following procedures will be adopted;

In the event of cardiac arrest, the staff will comply with policy.

Every endeavour will be made to ensure the Clinician of the patient is contacted.

If the Practitioner is unavailable the Practitioner’s partner (if applicable), patient’s

anaesthetist or one of the emergency contacts will be notified.

If the emergency could be a problem relating to anaesthesia the Anaesthetist may be

notified first.

If an emergency is such that it warrants the immediate attention of a medical Practitioner

and there is one on site the hospital reserves the right to summon such help. In this
instance a full report will be made to the Practitioner in charge as soon as practicable. In
addition the Practitioner who was summoned will be asked to make contact with the
Practitioner in charge of the patient.

The Governing Body assumes willingness upon the part of accredited Practitioner to
assist the facilities where possible and necessary in cases of emergency.

Practitioners may be requested by the Medical Advisory Committee to participate in

committees to review and evaluate clinical activities and patient care standards outcomes

ADMISSIONS

The Governing Body has an exclusion policy for both Mount Lawley Private Hospital and the
Walcott Street Surgical Centre. For Mount Lawley Exclusions relate to children under 2 and
patients with a weight of > 120kg for surgical procedures and > 150kg for sleep studies. For
WSSC weights of up to 150kg can be accepted.

In addition to arranging admission by telephone the Practitioner shall ensure the patient
receives a Patient Information Brochure, which includes a pre admission form and a pre
admission history and treatment acknowledgment form. The Practitioner ensures that these
documents are completed prior to admission and forwarded to the hospital either at time of
consultation by email, faxing, delivering or mailing to us so as the information is received at
least 24 hours prior to admission.

The Practitioner shall advise the patient of all aspects of the proposed treatment and when to
attend the Mount Lawley Private Hospital or Walcott Street Surgical Centre. Consideration
should also be given as to advice with regard patient fasting if their anaesthetists prior to
admission will not see them.

The Practitioner knowing the facility and its resources admits patients that are suitable and
will benefit from admission to the facility.

All admissions into the facilities are required to conform to current Infection Control screening
procedures. (Refer to Infection Control)

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Medical Admissions - accredited Practitioners can admit patients for medical care or a
surgical Practitioner may utilise the option of co management of patient’s medical conditions
by the Emergency/Site Medical Officer or an accredited general Practitioner or Physician of
their choice. Only Mount Lawley Private Hospital can accept medical admissions. If said
Practitioner is not an accredited Practitioner, the matter must be taken up with the Director of
Nursing who may be able to instigate interim accreditation as per by-laws.

Emergency Admissions although the facilities do not have an emergency department,

urgent admissions can be accommodated if it is within the facilities’ capacity and capability to
do so. The Practitioner must contact the Director of Nursing or Nurse in charge to arrange
the patient admission and organise the necessary requirements.

Consent - All patients admitted either to the Mount Lawley Private Hospital or the Walcott
Street Surgical Centre must be informed by the admitting Clinician of all aspects of treatment
or surgery. Informed consent includes the knowledge of treatment/surgery, alternative
treatment/surgery, risks associated with the treatment or surgery, outcomes of
treatment/surgery, ancillary services, anaesthetics, and must be signed for using the
Treatment Acknowledgment form specific to Mt Lawley Private Hospital and the Walcott
Street Surgical Centre.

CONDUCT OF SURGERY

Practitioners shall make themselves familiar with approved policies and procedures, including
those that apply to Infection Control and the Operating Room Manual in relation to all surgical
interventions. In particular practitioners must be able to demonstrate competencies in non
touch aseptic technique, hand hygiene, and basic life support. In addition the Governing Body
may require a nominated practitioner to hold and demonstrate competencies in advanced life
support.

Practitioners must be present in the operating suite before the commencement of the general
anaesthetic.

Practitioners can use a surgical assistant if required..

Signed consent forms indicating informed advice by a Practitioner must be completed for all
surgical procedures planned to be performed and discussed with the patient and forwarded to
the respective facility prior to the planned admission date.

In the case of a request by a patient to retain an explanted item a disclaimer must be signed
and forwarded with the consent form associated with the procedure.

Where pertinent to the diagnoses a copy of the histological report shall be placed in the case
notes or forwarded to the Medical Records Office within fourteen days.

All children aged 2 – 5 must be scheduled as first cases and recovered to consciousness by a
specialist Anaesthetist with paediatric experience who shall not leave the OR. Area until the
child is suitably recovered.

All Practitioners using Operating Theatres at Mount Lawley Private Hospital and or Walcott
Street Surgical Centre shall comply with policies which involve Surgical Safety Check Lists
and Time Out.
.
ALLOCATION AND USE OF THEATRE SESSIONS

The Director of Nursing is responsible for the efficient management of theatres and will
allocate theatre sessions according to operational requirements. Every effort will be made to
accommodate Practitioner preferences.

Clinicians must make maximum use of their allotted sessions. Should utilisation fall below a
reasonable level of the total time allocated the right is reserved to re allocate some or all of
the session time.
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Planned bookings for elective surgery shall be communicated by fax or email and shall
include information which identifies the patient name, the procedure, the planned operation
date and time and any relevant infection control or medical information that may require pre or
perioperative interventions.

Theatre times can be amended in consultation with the Area Manager OR Services however
as much advance notice is required to reduce the administrative nursing costs.

The Governing Body as part of its quality program will monitor, usage, late starts, cancelled
procedures after arrival, unplanned returns to theatres, post operative infection rates and any
incidents reported.

Emergency add on cases can be accommodated but need to be agreed with the Director of
Nursing. Absolute emergencies (ie unplanned returns to theatre) take priority over a booked
list.

Clinicians are consulted and given the opportunity to review equipment and pending
equipment purchases relevant to their area of expertise.

ANAESTHETICS

Practitioners must be specifically accredited by the Governing Body to administer

anaesthesia.

An anaesthetic consent is required and the anaesthetic record must be completed by the
Anaesthetist including the results of the pre-operative anaesthetic examination.

The Anaesthetist before leaving the facility will ensure that the post operative or anaesthetic
related condition of the patient is known and that there are no issues identified by the
Registered Nurse in charge of the recovery room.

The length of stay post anaesthetic is determined by the surgeon, recovery from an
anaesthetic is governed by recovery criteria rather than hours. Any concerns regarding
patient condition and discharge are to be brought to the Anaesthetist’s attention immediately
on identification of an issue.

PAEDIATRIC ANAESTHETICS

The minimum age for admissions of children at Mt Lawley Private Hospital and the Walcott
Street Surgical Centre has been set by the Medical Advisory Committee at two years of age
with recommendations associated with procedures and anaesthetic administration.

A risk evaluation shall be undertaken by the Admitting Practitioner/Anaesthetist prior to

admitting a child to the facility. This shall involve assessment of the child's medical history,
current health, type of procedure and the facilities present are suitable for the elective surgery
and post operative management of the child.

CLINICAL DOCUMENTATION REQUIREMENTS

Practitioners must document the following for each episode of care:

 Admitting diagnosis.
 Relevant medical, surgical, family etc history.
 Results of physical examination.
 Proposed treatment plan.
 Treatment Acknowledgement.
 Anaesthetic record- completed by the Anaesthetist.

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 Operation record – completed by the Surgeon, a duplicate copy is provided for the
surgeon’s records.
 All pathology, radiology, consultation reports.
 Progress notes documented regularly for patients.
 Medication charts must be completed and the Practitioner must ensure the script copies
are duplicated on writing.
 In case of emergency phone orders for medication the Practitioner must sign the order
within 24 hours; if this is not performed the nursing staff must contact the Practitioner for a
further phone order to cover the next 24 hours.
 Discharge Summary.
 The Quality program includes audits of clinical content, legibility of documentation
including signatures.
 The Medical Advisory Committee is provided with data from audits.

INFECTION CONTROL
The Governing Body has a clearly defined infection control program including collection of
clinical indicators and surveillance of Hospital and Community Acquired infections.

All Practitioners shall comply with Infection Control policies and procedures of which hand
hygiene is a key component.

As required patients may be screened prior to admission or specific measures for at risk
patients may be implemented as required.

Practitioners shall also identify any personal information which may compromise the safety of
patients and other staff they may come into contact with.

Surveillance also extends post discharge by post discharge follow up phone calls on high risk
patients.

Practitioners will be provided with information on any Infection issues via the Medical Advisory
Committee.

CLINICAL GOVERNANCE, CLINICAL RISK AND

ACCREDITATION
st
From the 1 January 2013 a new national accreditation program will be implemented and all
acute facilities are required to meet ten defined standards which form the basis of the
accreditation program.

The Governing Body is committed to external assessment to provide assurance that systems
and processes are of the highest quality standards and which ensures safe patient care at all
times.

The Quality program associated with Accreditation involves monitoring of clinical indicators,
review of all deaths, transfers, unplanned returns to theatre, re admissions and other clinical
incidents considered to be of a serious nature.

The Medical Advisory Committee and its members are specifically required to ensure clinical
governance objectives are achieved; clinical risks are identified and managed and that only
evidence based care and practice is provided by approved Practitioners.

All Practitioners are required to report incidents and to participate in the accreditation
requirements and quality programs as required.

OCCUPATIONAL SAFETY HEALTH

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The Governing Body is committed to a policy of providing, as far as practicable, a safe
working environment for all employees and Clinicians by complying with all provisions of the
Occupational Safety and Health Act (1984) Regulations (1996) and Australian Standards.

All Practitioners are responsible for protecting their own safety and health and that of others
by identifying and reporting hazards, reporting accidents and incidents, using personal
protective equipment and complying with established safe work practices and procedures.

The Occupational Health and Safety Program aims to manage services and facilities and to
identify and manage health and safety risks to ensure the safety and health of all persons.

AMENDMENTS
These by-laws, rules and regulations may be amended after submission and endorsement by
the Medical Advisory Committee and the Credentialing and Scope of Practice Sub
Committee.

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