Manual: Policy and Procedures
Section: One Governance
Subject: Medical By-Laws
Ref: See below
V7
Reviewed: May 2014
Review Date: May 2018
Authorised EN
BUNBURY DAY
SURGERY
MEDICAL BY-LAWS
Page 1 of 11
Manual: Policy and Procedures
Section: One Governance
Subject: Medical By-Laws
Ref: See below
V7
Reviewed: May 2014
Review Date: May 2018
Authorised EN
INDEX
INDEX
PAGE
1.
Definitions
3
2.
Management Philosophy
3
3.
Management Committee
3
INDEX
9.
4.
Visiting Medical Staff
4.1 Application for Accreditation
4.2 Accreditation
4.3 Temporary Accreditation
4.4 Scope of Practice
4.5 Guidelines for Medical Procedures
4.6 Policy and Procedures
4.7 Withdrawal of Accreditation
4.8 Observing Medical By Laws and
Policies and Procedures
Patient Care
9.1 Medical Responsibility
9.2 Emergency Care
9.3 Documentation
9.4 Medication Regimes
9.5 Electrical Equipment
7
7
7
7
8
8
4
4
4
4
5
5
5
5
5
10. Surgical Care– Procedure Guidelines
10.1 Pre procedure preparations
10.2 Request for Treatment
10.3 Correct Patient, Site, Procedure
10.4 Operating Sessions
10.5 Pathology
10.6 Session Utilization
8
8
8
8
8
8
8
10.7 Bookings
10.8 Cancellations
10.9 Infection
10.10 Use of Blood /Blood products
10.11 Advance Care Directives
11. Anaesthetic Care
11.1 Anaesthetics
11.2 Pre and Post Operative Care
11.3 Documentation
9
9
9
9
9
9
9
9
9
12.
Other Matters
12.1 Evaluation and Peer Review
12.2 By Law Review
12.3 Medical Indemnity
12.4 Professional Registration
10
References
10
5.
Medical Advisory Committee
5.1 Membership
5.2 Frequency of Meetings
5.3 Quorum
5.4 Chairman
5.5 Terms of Reference
5
5
5
5
5
5
6.
Credentialing Committee
6.1 Membership
6.2 Frequency of Meetings
6.3 Quorum
6.4 Chairman
6.5 Terms of Reference
6
6
6
6
6
6
7.
Medical Records
7.1 Responsibility
7.2 Contents
7.3 Legibility
7.4 Confidentiality
6
6
6
6
7
8.
Admission Requirements
8.1 Diagnosis
8.2 Documentation
8.3 Weight Restriction
7
7
7
7
Page 2 of 11
10
10
10
Manual: Policy and Procedures
Section: One Governance
Subject: Medical By-Laws
Ref: See below
V7
Reviewed: May 2014
Review Date: May 2018
Authorised EN
8.4 Paediatric Patients
7
DEFINITIONS:
Bunbury Day Surgery is licensed by the Department of Health in Western Australia as a
Day Hospital – Class A with a licence to operate 23 hours and is accredited by ISC to
ISO9001:2008 and Australian Commission on Safety and Quality in Health Care, National
Safety and Quality Health Services Standards.
The Senior Management Committee is the governing body of the Day Surgery and is
composed of the Chief Executive Officer, Director of Nursing and Clinical Nurse
Manager.
The Medical Advisory Committee is composed of the Medical Director, Director of
Nursing, Clinical Nurse Manager and at least one other Accredited Practitioner and
other appointed members.
2. MANAGEMENT PHILOSOPHY
To ensure patient care of the highest standard is delivered and create a health service
that is responsive to patient, carers and consumer input and needs.
The Senior Management is committed to:








Adopting and implementing the Australian Charter of Healthcare Rights;
The provision of individualised quality care for all patients;
Partnering with consumers;
Maintaining day surgery facilities at a high standard;
Providing secure, pleasant and rewarding employment for staff;
Maintaining a quality program;
Encouraging professional development of staff; and
Reviewing of privileges granted to medical practitioners using the day surgery.
3. MANAGEMENT COMMITTEES
The Director’s Management Review is convened to monitor the effectiveness of the
quality management system.
Function

To assess the effectiveness of key processes of the quality management system.
Page 3 of 11
Manual: Policy and Procedures
Section: One Governance
Subject: Medical By-Laws
Ref: See below
V7
Reviewed: May 2014
Review Date: May 2018
Authorised EN

To identify any barriers to the sustainability of the quality management system.

To ensure resources are provided and are adequate to maintain the quality
management system.

To ensure the organisation is certified to ISO 9001 and maintains ongoing
certification and licences.

Meet the requirements of the National Safety and Quality Health Service
Standards.
The Senior Management Committee is responsible for the general management of the
facility including:
Function










Policy determination;
The quality of services and maintaining Certification;
Meeting the requirements of the NSQHS;
Effective use of resources;
Partnering with consumers;
Maintenance of the facility;
Financial management;
Infection Control and Microbial Stewardship
Occupational Health and Safety; and
Adherence to the Department of Health licensing requirements.
4. VISITING MEDICAL STAFF
4.1 Application for Accreditation
Those legally qualified medical practitioners who wish to be granted visiting
privileges must submit an application for accreditation and clinical privileges on
the approved form to the CEO. This application will be discussed at the next
Credentialing Committee.
4.2 Accreditation
Accreditation will be for up to 5 years. All medical practitioners must be
registered with the AHPRA and hold sufficient medical indemnity insurance to
cover their practice at Bunbury Day Surgery. Evidence of Registration and
Page 4 of 11
Manual: Policy and Procedures
Section: One Governance
Subject: Medical By-Laws
Ref: See below
V7
Reviewed: May 2014
Review Date: May 2018
Authorised EN
Medical Indemnity cover MUST be given to Bunbury Day Surgery each year.
Practitioners will only be accredited within their speciality.
4.3 Temporary Accreditation
The Medical Director has the authority to grant temporary approval to practice
in the Day Surgery until the next Credentialing Committee meeting.
4.4 Scope of Practice
Medical Practitioners will only be permitted to perform duties for which they
have been accredited by the Senior Management Committee on the advice of the
Credentialing Committee.
4.5 Guidelines for Medical Procedures
Guidelines for medical procedures will be considered as part of the Day Surgery
By-Laws and must be adhered to by all visiting practitioners.
4.6 Policy and Procedures
All accredited medical practitioners are to abide by Bunbury Day Surgery’s
Policy and Procedures. Medical Practitioners are responsible for self education
with regards to ensuring their practise is in line with the requirements of the
NSQHS Standards. Educational links to assist are provided on BDS web site.
4.7 Withdrawal of Accreditation
Failure to observe Bunbury Day Surgery Medical By Laws, Policies and
Procedures
will
lead
to
withdrawal
of
accreditation.
The Senior Management Committee reserves the right to withdraw visiting
privileges at any time. The Senior Management Committee also reserves the
right to suspend visiting privileges to enable investigation of an incident. The
medical practitioner concerned has the right to appeal and should direct such an
appeal to the CEO.
5. MEDICAL ADVISORY COMMITTEE
5.1 Membership
The Committee shall consist of the Medical Director, Director of Nursing,
Clinical Nurse Manager and at least one appointed Accredited Practitioner. The
Committee shall co-opt additional members for specific purposes.
5.2 Frequency of Meetings
The Committee shall meet at the discretion of the Medical Director, but not less
than three times per year.
5.3 Quorum
Page 5 of 11
Manual: Policy and Procedures
Section: One Governance
Subject: Medical By-Laws
Ref: See below
V7
Reviewed: May 2014
Review Date: May 2018
Authorised EN
A Quorum shall be 50% members.
5.4 Chairman
A Chairman shall be the Medical Director.
5.5 Terms of Reference
There shall be Terms of Reference reviewed every 4 years.
6.
CREDENTIALING COMMITTEE
6.1 Membership
The Committee shall consist of the Medical Director, Director of Nursing, CEO
and at least one other appointed member. The Committee shall co-opt additional
members for specific purposes.
6.2 Frequency of Meetings
The Committee shall meet at the discretion of the Medical Director when an
application has been made for accreditation.
6.3 Quorum
A quorum shall be all 50% members
6.4 Chairman
A Chairman shall be the CEO.
6.5 Terms of Reference
There shall be Terms of Reference reviewed every 4 years.
7. MEDICAL RECORDS
7.1 Responsibility
The Medical Practitioner is responsible for keeping a sufficient patient record of
the essential features of the patient’s condition and treatment. This shall be in
keeping with the guidelines for the medical record provided by the Colleges of
Surgeons and Anaesthetists.
7.2 Contents
A sufficient record is seen to contain:
 Diagnosis and surgical investigatory intent;
 Therapeutic orders recorded on appropriate forms;
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Manual: Policy and Procedures
Section: One Governance
Subject: Medical By-Laws
Ref: See below
V7
Reviewed: May 2014
Review Date: May 2018
Authorised EN




Particulars of all procedures;
Progress observations;
Special problems or complications and
Discharge notes when applicable.
7.3 Legibility
Orders must be written clearly and legible. Orders which are illegible or
improperly written will not be carried out until rewritten or clarified.
7.4 Confidentiality
Bunbury Day Surgery complies with and abides by the Australian Privacy
Principles.
Medical Practitioners must keep confidentiality of all matter relation to the
clinical care of patients in the Day Surgery. All records are considered
confidential. All records remain the property of Bunbury Day Surgery. Records
are not to be removed without the permission of the Medical Director. Anyone
wishing to view the Medical Records must arrange viewing with the Medical
Director who may request completion of necessary privacy documentation.
8. ADMISSION REQUIREMENTS
8.1 Diagnosis
A provisional diagnosis is to be stated with each admission
8.2 Documentation
The patient pre-admission questionnaire must be completed by the patient and
sent to the Day Surgery prior to admission
8.3 Weight restriction
Patients whose weight is GREATER THAN 130 kg can be treated at Bunbury
Day Surgery at the discretion of specialists in consultation with the CNM and
DON after a medical assessment.
8.4 Paediatric Patients
Paediatric patients must be at least 10 years of age, 120cm in height and classified
ASA2 or less.
9. PATIENT CARE
9.1 Medical Responsibility
The Medical Practitioner shall be responsible for the care of their patients. When
the practitioner is unavailable, then another accredited doctor shall be available.
9.2 Emergency Care
Page 7 of 11
Manual: Policy and Procedures
Section: One Governance
Subject: Medical By-Laws
Ref: See below
V7
Reviewed: May 2014
Review Date: May 2018
Authorised EN
In an emergency and after every reasonable effort has been made to contact the
patient’s medical practitioner, the Director of Nursing or the Clinical Nurse
Manager has the right to call in another doctor or take action as necessary in the
interest of the patient.
Where the support facilities of the Day Surgery are inadequate for the care of a
particular patient, the medical practitioner is required to arrange transfer of the
patient to a hospital where the necessary supportive therapy is available.
9.3 Documentation
Medical Practitioners are required to record relevant information in the patient’s
medical record at BDS.
9.4 Medication Regimes
Written medication regimes are to be accompanied by appropriate complete
prescriptions. Admitting doctors are to assume responsibility for medication for
their patients, including those medications brought into Bunbury Day Surgery by
patients. Antimicrobial prescribing must be in line with Therapeutic guidelines:
antibiotic.
9.5 Electrical equipment
Medical Practitioners who supply their own electrical equipment are responsible
for the safety standards of such equipment. The equipment should be of an
approved design according to Australian Standards and should display yearly
evidence of electrical service by an experience and acknowledged
Biomedical/electrical service agent.
10. SURGICAL CARE – PROCEDURE GUIDELINES
10.1 Pre-procedure preparations
All patients admitted shall have adequate pre-procedure investigation and
preparation.
10.2 Requests for Treatment
In the case of patients who are minors, an informed, signed request for treatment
must be obtained from the parent or guardian. Patients other than minors will
complete a Consent Form.
10.3 Correct Patient, Site and Procedure
Medical Practitioners must adopt the Bunbury Day Surgery ‘Time Out’ policy.
10.4 Operating Sessions
Sessions are expected to begin on time. In the event of an unforseen delay, the
medical practitioner shall inform the Clinical Nurse Manager of the expected
time of arrival.
Page 8 of 11
Manual: Policy and Procedures
Section: One Governance
Subject: Medical By-Laws
Ref: See below
V7
Reviewed: May 2014
Review Date: May 2018
Authorised EN
10.5 Pathology
Whenever a pathological specimen is taken, the medical practitioner will provide
a request form for the relevant company. If the medical practitioner requires a
different company, than already picks up from Bunbury Day Surgery, the
medical practitioner will call the company for pick up.
10.6 Session Utilization
Where utilization of a session is consistently low, Bunbury Day Surgery reserves
the right to re-allocate some or all of the session. Adequate notice will be given.
10.7 Bookings
Bookings for each session will be forwarded to Admissions Liaison at Bunbury
Day Surgery at least 48 hours prior to the operating session or at the discretion of
the CNM. The bookings will contain the patient’s name, date of birth, address,
contact details and proposed procedure.
10.8 Cancellations
If any session is cancelled the medical practitioner must notify the Director of
Nursing or Clinical Nurse Manager as soon as possible.
If a patient cancels a booking, Admission Liaison must be informed as soon as
possible.
10.9 Infection
Medical Practitioners must agree that all cases of suspected hospital acquired
wound infection may be subjected to bacteriological examination.
10.10 Blood and Blood Products
No blood or blood products will be available or used at Bunbury Day Surgery
10.11 Advance Care Directives
All surgery at Bunbury Day Surgery is elective surgery. Advance Care Directives
do not apply to patients having elective surgery.
11. ANAESTHETIC CARE
11.1 Anaesthetists
The administration of General Anaesthesia to patients will only be by
practitioners who are Specialist Anaesthetists holding fellowship of the
Australian and New Zealand College of Anaesthetics (FANZCA).
11.2 Pre and Post Operative Care
Page 9 of 11
Manual: Policy and Procedures
Section: One Governance
Subject: Medical By-Laws
Ref: See below
V7
Reviewed: May 2014
Review Date: May 2018
Authorised EN
The responsible medical practitioner will ensure that the necessary liaison with
the Anaesthetist takes place for the proper pre and post operative care of the
patient, including knowledge of drug sensitivities and current therapy.
11.3 Documentation
The pre operative patient examination should be recorded in the medical
records. An anaesthetic record must be completed and signed for anaesthesia
administered.
12. OTHER MATTERS
12.1 Evaluation/Peer review
Clinical and peer review is to be encouraged by the medical staff who should
regularly evaluate medical care and use such information to create and maintain
optimum clinical activities.
12.2 By Law Review
Review of By-Laws will be undertaken annually. Revision may take place at any
time at the initiation of the Medical Advisory Committee or the Senior
Management Committee.
12.3 Medical Indemnity
Evidence of Medical Indemnity must be provided each year. In the event of a
medical practitioner who does not show evidence of Professional Indemnity, the
doctor will be refused to admit patients to this facility.
12.4 Professional Registration
Evidence of Professional Registration must be provided each year. In the event of
a medical practitioner who does not show evidence of Professional Registration,
the doctor will be refused to admit patients to this facility.
References:
Page 10 of 11
Manual: Policy and Procedures
Section: One Governance
Subject: Medical By-Laws
Ref: See below
V7
Reviewed: May 2014
Review Date: May 2018
Authorised EN
Royal Australian College of Surgeons Appointments and Credentialing Committees
Review 2009 Royal Australian College of Surgeons Day Surgery Report and
Recommendations Revised 2004
ANZCA Policy Documents (various 1996-2009).
NHMRC Guidelines for Infection Control. (2010).
National Privacy Principles. (December 2001).
Licensing Standards for the Arrangements for Management, Staffing & Equipment Day
Procedure Facilities Class A Review January 2006. (Health Dept. of WA)
Australian Commission on Safety and Quality in Health Care. Australian Charter of
Healthcare Rights. Sydney. ACSQHC, 2008.
Antibiotic Expert Group, editor, Therapeutics guidelines: antibiotic. Version 13 ed.
Melbourne. Therapeutic Guidelines Limited, 2006.
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