BY-LAWS for MEDICAL STAFF

Transcription

1 BY-LAWS for MEDICAL STAFF 1. KEY POINT SUMMARY 1.1. All Accredited Medical Officers (AMOs) are expected to: (a) Respect and support SAH s Mission, Vision and Values (see appendix A); (b) Attain and maintain excellence in all episodes of patient care through individual and collective activity and close co-operation with SAH, staff and Administration; (c) Treat all staff members with professionalism and respect (d) Abide by these By-Laws (e) Be available for contact at all times, either in person or by his or her deputy who must also be accredited to use SAH; (f) Notify the relevant Nursing Unit Manager or delegate (eg senior-in-charge or duty manager) if AMO will be unavailable at any time and nominate an alternative who will care for the patient during AMO s absence or unavailability. (g) Use the Ward Career Medical Officer only for emergency care of patients and not for routine care (h) Provide all required entries to the medical record including: Doctors Referral Letter, Medication and Intravenous Fluid orders, record assessment and management plan in the Integrated Progress Notes or Clinical Pathway, Final Diagnosis, Operation Report with CMBS items numbers, Not-For-Resuscitation Directive, and Discharge Summaries (i) Sign telephone orders for medication within 24 hours of being given, as prescribed by Government regulation (j) Provide their patients with a full explanation about the patient s proposed treatment and ensure that the patient or their authorised representative sign an appropriate Consent Form. (k) Admit only patients who require acute care to the SAH (l) Keep their patients length of stay to the minimum required to provide the acute care (m) Clear patients for discharge by 10am if clinically possible (n) Strictly adhere to SAH s Infection Control Committee procedures relating to patient care and isolation (o) Make themselves aware of SAH s emergency procedures (p) Notify the DMS in writing if their professional indemnity insurance lapses; their accreditation is withdrawn from any hospital or medical institution; or any restrictions are placed on their registration to practice or their registration is suspended or cancelled. 2. ABBREVIATIONS 2.1. Abbreviations used in by-laws refer to the following: (a) CMBS Commonwealth Medicare Benefits Schedule (b) CMO Career Medical Officer (c) AMO Accredited Medical Officer Board & MAC-approved SAH By-Laws Dec 08 Page 1 of 19

2 (d) VMO Visiting Medical Officer (e) CEO Chief Executive Officer (f) DMS Director of Medical Services (g) MAC Medical Advisory Committee (h) SAH Sydney Adventist Hospital 3. SYDNEY ADVENTIST HOSPITAL MISSION EXPECTATIONS 3.1. Sydney Adventist Hospital (SAH) is part of the Seventh-day Adventist Church s worldwide chain of 166 health care institutions. It was established in Wahroonga in 1903 to serve the community through its mission Christianity In Action" to continue the healing ministry of Jesus Christ Integral to the effectiveness of SAH is: (a) its emphasis on excellence in whole person care (b) its commitment to educate in the principles of healthful living and disease prevention (c) its celebration of the Seventh-day Sabbath from sunset Friday until sunset Saturday. 4. ORGANISATION OF MEDICAL SERVICES Medical Advisory Committee (MAC) 4.1. MAC is the senior coordinating body of medical services supplied by SAH. It is responsible, and reports to, the Hospital s Board of Directors (Board). Its Terms of Reference are to: (a) advise the Board on: i. clinical matters; ii. all applications for accreditation and re-accreditation of AMOs, following assessment of each applicant s qualifications, clinical experience and performance necessary for accreditation (and it may appoint selection sub committees for this purpose); iii. policies that MAC formulates relating to the supply of medical services at SAH; iv. the content of these By-Laws; v. issues of professional ethics; vi. measures to ensure, through appropriate selection procedures and clinical review activities, a high level of professional performance of all AMOs; (b) undertake the functions of review, evaluation, communication and education in relation to medical practice at SAH; (c) review: i. any matters of concern, which may lead to disciplinary measures being taken by SAH; ii. medical quality management activities and reports and the form and content of medical records; (d) foster and maintain an effective channel of communication between SAH s AMOs, its Departments, CEO and the Board on all clinical matters; (e) promote educational opportunities and activities for AMOs; (f) promote co-operation of the AMOs in fulfilling the hospital s requirements for accreditation The membership of MAC is reaffirmed annually by the Board. The Board nominates the chairperson of the MAC. Other members of the Committee are appointed from the various clinical Departments of the Hospital. The Chairperson is appointed for a period of five years. All other members of MAC are appointed for a period of three years. A member who has served on MAC Board & MAC-approved SAH By-Laws Dec 08 Page 2 of 19

3 is not eligible for re-election until a period of three years has elapsed from his or her previous appointment. A representative from the University of Sydney must be a member of MAC. The CEO and the Chief Operations Officer are permanent invitees. The DMS is the permanent Secretary of the MAC. CMO representation at MAC is by invitation MAC meets every four to six weeks or as deemed necessary by call of the Chair and Secretary. A quorum is five members. Departments 4.4. SAH s medical services are divided into a number of clinical Departments. Each Department comprises all AMOs in a particular specialty or sub-specialty in which SAH supplies medical services. Each Department meets at least every quarter, and AMOs are encouraged to attend a majority of meetings of their Department each year. Members elect the chairperson and secretary of each Department every three years. Each may serve for a maximum of one term of 3 years, of which term at least one year should be served AMOs may attend meetings of Departments other than their own. However, such attendance is only by invitation or approval of the chairperson of that particular Department and that AMO will be present in the capacity of observer only All formally established Department committees must keep minutes of each Department meeting. Minutes of the meetings should be kept and made available to the DMS on request Each Department is responsible for seeing that an after-hours roster is drawn up or other arrangements for cover as agreed by the DMS, CEO or delegate. 5. ACCREDITATION OF MEDICAL OFFICERS AND VISITING HEALTH PRACTITIONERS TO SYDNEY ADVENTIST HOSPITAL Determination of the need for new appointments 5.1. The Board of Directors determines annually the number of new practitioners to be appointed in each specialty for the following year. Factors to be considered in making this determination include, but are not limited to: (a) Utilisation of available procedural lists and the projected change in available procedural lists over the following twelve months (b) Utilisation of available overnight and day only beds and the projected change in available beds over the following twelve months (c) SAH Corporate strategy (d) SAH needs, resources and facilities (e) Projected retirement of existing practitioners 5.2. Applications will be sought via invitation or advertising for practitioners in the specialties determined by the Board of Directors as having a need for new appointments 5.3. Should the Board of Directors determine that a specialty area needs no further applications for the next twelve months; practitioners may provide an expression of interest for application The Board of Directors may consider applications in excess of the predetermined need for appointments in a speciality if a practitioner through expression of interest is able to demonstrate; Board & MAC-approved SAH By-Laws Dec 08 Page 3 of 19

4 (a) Unique skills and experience that would be of benefit to SAH (b) That they would make a significant contribution to teaching, research or patient quality and safety programs at SAH (c) That they would make a significant contribution to the growth of services at SAH Accreditation Requirements 5.5. Accreditation to SAH is a privilege that will be extended only to professionally competent individuals who continuously meet the qualifications, standards and requirements contained in these By-Laws and in such policies as are adopted from time to time by Board Only practitioners who are accredited to SAH may admit or care for and treat patients at SAH Practitioners will be considered for accreditation to SAH only if they demonstrate that they are the most suitable applicant for the available positions and can document their background, experience, training and demonstrated competence, their adherence to the ethics of their profession, their good reputation and character and their ability to work harmoniously with others sufficiently to convince SAH that all patients treated by them in SAH will receive quality care and that SAH and its staff will be able to operate in an effective manner The Board has complete discretion as to whether to grant accreditation and is not bound to accept any application By applying for accreditation to SAH, applicants agree to: (a) Accept these By-Laws as published, revised and circulated from time to time. No medical officer or visiting health practitioner will be accredited unless he or she has signed an undertaking on the application form to observe at all times the By-Laws and regulations of SAH, and (b) Respect and support SAH s Mission Continued accreditation to SAH depends on mutual goodwill, mutual benefit and satisfactory outcome between SAH and AMO or VHP in terms of services provided to patients. Both SAH and the AMO or VHP are free to withdraw from the association at any time Credentialing occurs on a Tiered basis. Tier One accreditation determines in which speciality classification the practitioner is credentialed. Tier 2 accreditation determines in which subspecialty (if any) the practitioner is credentialed. Tier 3 accreditation is necessary for certain procedures as outlined in the Medical and Associated Services Policy and Procedure Manual Admitting rights do not apply to all categories of appointment as outlined in the Medical and Associated Services Policy and Procedure Manual It is a requirement that all procedural AMOs or VHPs can demonstrate competence according to accepted professional standards An AMO or VHP may resign his or her appointment by giving SAH at least one month s notice in writing. Board & MAC-approved SAH By-Laws Dec 08 Page 4 of 19

5 Application for Accreditation The process for accreditation and the process for any change to accreditation is confidential and should not be disclosed to any person not involved in the process under these by-laws All applications must be submitted to the DMS on the prescribed form and be complete Applicants must: (a) be registered medical or dental practitioners in the State of New South Wales or registered with of the relevant professional boards or body for VHPs; (b) submit evidence with their application of Registration and their membership of a professional indemnity insurance (or equivalent); and (c) maintain registration, radiation and laser licences (if relevant) and adequate professional indemnity insurance and consent for SAH to obtain renewal status from the relevant body each year or alternatively to submit written evidence of these to SAH; (d) sign the declaration required by the Child Protection (Prohibited Employment) Act 1998 and amending regulations; (e) notify the DMS of any conditions of registration. (f) must state specifically the Tier 1, Tier 2 and Tier 3 clinical privileges that they wish to be credentialed for at SAH Other than the groups listed below applicants in a specialty will be interviewed along with other applicants in the same specialty by a Selection Sub Committee and then considered by MAC, which will then make a recommendation to the Board as to the preferred applicants for appointment The following applicants may not be interviewed by the MAC selection sub-committee: (a) Employed medical officers may be interviewed in accordance with the normal Human Resources Policy and Procedures. (b) Contracted medical officers will be managed in accordance with the Corporate Governance Manual (c) Surgical assistants and General Practitioners may be interviewed by the DMS (d) Visiting health practitioners (other than medical, dental and podiatry) will be interviewed in accordance with the Corporate Governance Manual and will be referred to the Executive Committee for appointment If they undertake further training that qualifies them to perform additional procedures then application for these privileges should be made, via the practitioner s Department, to the MAC that will make a recommendation to Board. No practitioner will be permitted to perform any procedure for which they are not accredited The Board is not bound to accept a recommendation of MAC in relation to applications for accreditation but will consider the merit of an application, including but not limited to the following matters: (a) SAH s needs, requirements and resources; (b) The applicant s skills and recent experience; (c) The applicant s competence and clinical judgement; (d) The applicant s professional capability and knowledge; (e) The applicant s current fitness to practice and good character; (f) The use made or proposed to be made of SAH s facilities by the applicant; Board & MAC-approved SAH By-Laws Dec 08 Page 5 of 19

6 (g) (h) (i) The applicant s commitment to respect SAH s religious practices; The conduct of the applicant in any previous dealings with SAH, and In relation to applicants who have previously been accredited by SAH: i. Their involvement in quality management activities and continuous medical education; and ii. Whether they have maintained adequate medical records The Board may request an applicant to attend for an interview or invite an applicant to make a presentation to it, before making a decision about that applicant s accreditation. Following the Board s decision: The practitioner will be advised of the decision in relation to his or her accreditation status by letter from the DMS If the applicant is successful, the AMOs or VHPs name will be added to SAH s AMO and VHP list in the category of practice or specialty approved by the Board, with the privileges accorded. Period of Accreditation The Board may grant accreditation for whatever period it sees fit up to a maximum of five years. New AMOs or VHPs will normally be granted accreditation for a period of not more than twelve months At the expiration of a period of accreditation, the AMO or VHP must apply for re-accreditation in accordance with these By-Laws. The Board may dispense with the requirement for a new application form, where the AMOs or VHPs previous application is not more than twelve months old. Locums, Temporary Accreditation and Special Consultations Short term or temporary accreditation is required before a locum is permitted to arrange the admission of, or treat patients on behalf of an AMO The DMS, CEO or delegate may approve short-term accreditation up to a period of one month or Temporary accreditation for a period up to twelve months after discussion with the Department Chairman and/or Chairman of the MAC and following the completion of appropriate documentation and reference checks. After that procedure, the applicant must apply for accreditation in the usual course A consultant called in for an opinion only by the attending AMO need not necessarily be a medical practitioner accredited to SAH. However, administrative approval should be obtained from the DMS for such consultations. Expression of Interest for Accreditation A practitioner may provide a written expression of interest for accreditation at any time however they will only be invited to apply for accreditation if the Board of Directors determines a need for new appointments in that speciality or where the Board of Directors have determined the individual practitioner meets the requirements outlined at paragraph 5.4 Board & MAC-approved SAH By-Laws Dec 08 Page 6 of 19

7 New Interventional Procedures Practitioners wishing to be credentialed in a new interventional procedure must apply for approval according to the Policy for the Introduction for a New Interventional Procedure. Emeritus Consultant A practitioner may be appointed an Emeritus Consultant if recommended by the Department and MAC and approved by the Board of Directors. A practitioner may be considered for this appointment where they have provided distinguished services to the hospital and has retired from active practice. Distinguished service includes service of outstanding merit or extraordinary accomplishment An emeritus consultant does not have admitting rights and is not entitled to stand for MAC membership. 6. SUSPENSION OR WITHDRAWAL OF ACCREDITATION PRIVILEGES 6.1. The Board may suspend or withdraw the accreditation of an AMO at any time, and may delegate this responsibility to the DMS, CEO or other delegate The factors that may give rise to suspension or withdrawal of accreditation include, but are not limited to: (a) failure by an AMO to observe the terms and conditions of his or her appointment, including these By-Laws; (b) notification of any circumstance pursuant to By-Law 11.8; (c) inappropriate conduct by an AMO, such as unco-operative or disruptive conduct, harassment, discriminatory behaviour, disregard of SAH s religious practices or an inability to work harmoniously with others; (d) if, after due hearing by MAC, an AMO is found guilty of unprofessional conduct, negligence or wilful misconduct, and that recommendation is endorsed by the Board; (e) if Board otherwise considers that withdrawal or suspension of an AMOs privileges is in the interests of patients or SAH. Procedure for Review 6.3. When deciding whether to suspend or withdraw an AMOs accreditation privileges, SAH will adopt the following procedure: (a) A meeting will be convened between the AMO, MAC Chairperson or delegate, the DMS or delegate (MAC Secretary) and Chairperson or Secretary of the Department to which the AMO belongs. (b) If the meeting does not resolve the matter to the satisfaction of SAH, or if the AMO fails to comply with any conditions laid down on behalf of SAH at the meeting, a SAH representative will consult with the Chairperson on MAC to discuss what action is appropriate. (c) If SAH considers further action is warranted, the matter will be referred to MAC to make a recommendation to the Board or its delegate, CEO, on whether the AMOs privileges should be suspended or withdrawn pursuant to these By-Laws. (d) Board will then consider the matter and MAC s recommendation and make a decision. Board will notify the practitioner in writing of its decision. The AMO then has the right Board & MAC-approved SAH By-Laws Dec 08 Page 7 of 19

8 (e) under these By-Laws to request a review by MAC of any decision of Board to suspend or withdraw privileges, and may make submissions to MAC. Following its review of Board s decision, MAC may make a further recommendation to Board in respect of the decision. Board must then re-consider the matter at its next meeting and either confirm or vary its decision. Board is under no obligation to follow the recommendation of MAC. At this point the Board s decision becomes final. 7. REINSTATEMENT OF ACCREDITATION PRIVILEGES 7.1. Provided accreditation is not permanently withdrawn, and after the period of suspension, or after conditions for reaccreditation are met, a suspended AMO may re-apply for reaccreditation. (a) Any conditions of registration of the NSW Medical Board must be disclosed to the DMS who will put them before the MAC for consideration. They may need to be made known to the relevant Head of Department in order for it to be determined that they can be complied with. (b) The MAC may add further conditions as they see fit, or may recommend that reaccreditation is inappropriate despite conditional re-registration The MAC will make a recommendation to the Board for its consideration. The Board will make a decision on the matter. 8. LEAVE OF ABSENCE 8.1. If an AMO will be away for a period greater than three months during a period of accreditation, the AMO should notify the DMS or MAC. Theatre or procedural lists may be reallocated in consultation with the Theatre Management Committee. Reinstatement after Leave of Absence 8.2. The AMO is to notify the DMS or MAC of their intention to return from leave of absence. If the leave of absence period has not exceeded the Board-approved accreditation period, MAC may reinstate the AMO without a new application form or interview. However, MAC may request a new application or refer the request for reactivation of accreditation to the Board. 9. RE-ACCREDITATION 9.1. Employed Medical and Dental Practitioners will have accreditation assessed near the completion of their three-month probationary period. If accreditation is approved the employee will be accredited for their period of tenure. The Director of Medical Services may refer employees to the Medical Advisory Committee for accreditation review if performance management processes dictate the need Contracted Medical and Dental Practitioners will have accreditation reviewed near the completion of the contract period. If accreditation is approved, it will cover the remaining and subsequent contract period For all other Medical and Dental Practitioners accreditation to the Hospital will be reviewed prior to completion of the term of accreditation. Board & MAC-approved SAH By-Laws Dec 08 Page 8 of 19

9 9.4. The Re-accreditation Review the Medical Advisory Committee and Board of Directors will consider whether the practitioner meets the requirements for re-accreditation. Those requirements include, but are not limited to, (a) the practitioner adequately using the Hospital s facilities (eg at least 20 patients per year for surgical specialties or as determined by the Board), (b) being involved in quality management, (c) continuing medical education activities, (d) maintaining adequate medical records and (e) having an acceptable standard of quality in his or her clinical services (f) attendance at Department Meetings Indicators of Performance 9.5. Information or documents provided to the DMS, other Director or Executive, CEO or the MAC may be reviewed to indicate whether the requirements of the by-laws have been satisfactory performed Examples of documents that may be reviewed are: (a) complaint and incident monitoring systems (b) medical record audit (c) on-call rosters (d) number of patients admitted per year (e) records of section meetings attendance (f) PBS and authority scripts (g) Day Only (Type B & C), Variation and Acute Care certificates (h) length of stay data 9.7. Should there by any concern regarding performance, this will be discussed with the AMO either by the DMS, CEO or other Director or Executive member or by a Review Committee as per section 4.3. The AMO must be afforded the opportunity to reply to any matters of concern. An indicator of performance cannot be used to determine the appropriateness of continued accreditation or reaccreditation unless documented evidence of discussion with the AMO is available. 10. CLINICAL RESPONSIBILITIES An AMO admitting a patient to SAH is responsible for the continuity of care and for the discharge of that patient. Amongst other things, he or she must: (a) be available for contact at all times, either in person or by his or her deputy who must also be accredited to use SAH; (b) notify the relevant Nursing Unit Manager or delegate (e.g. senior-in-charge or duty manager) if AMO will be unavailable at any time and nominate an alternative who will care for the patient during AMO s absence or unavailability. The office of the DMS should also be notified and the notification should be recorded and signed in the patient s clinical record. (c) admit only patients who require acute care to the SAH (d) keep their patients length of stay to the minimum required to provide the acute care (e) clear patients for discharge by 10am if possible and promptly provide Discharge Summaries for all patients (f) record CMBS numbers at the time of theatre bookings Board & MAC-approved SAH By-Laws Dec 08 Page 9 of 19

10 10.2. AMO must visit patients within 24 hours of admission. AMOs must visit their patients in SAH with reasonable frequency, as judged by the clinical needs of the case. In most cases this will be at least every second day. Where a second AMO has been asked to consult in the case, and visits the patient, this would normally be regarded as a patient visit but it is important for the patient s own AMO or the AMO in charge of the case to maintain close communications with the patient SAH expects AMOs to communicate regularly and fully with patients about all aspects of their treatment and to treat patients with courtesy and sensitivity. SAH stresses the fundamental importance of AMOs to responding to patient complaints AMOs must encourage and support clinical and patient care review, evaluate their own services and performance and use such information to supply optimal patient care. AMOs should send all copies of quality management activity reports (either formal review studies and/or topics of clinical meetings) to the DMS Should an AMO become aware of a clinical situation, which may pose a medico-legal risk for the SAH they should put in an incident report or advise Hospital management AMOs must strictly adhere to SAH s Infection Control Committee procedures relating to patient care and isolation. SAH Infection Control must be immediately made aware of any DOH notifiable diseases All AMOs are required to keep copies of SAH s policies on the management of patients with Hepatitis B, Hepatitis C, Tuberculosis, HIV, SARS and Herpes infections. These can be obtained from the infection Control office. AMOs must also familiarise themselves with SAH s policies in relation to health care workers who are carriers of the above or other infectious diseases All SAH policies regarding Infection Control can be found on the SAH intranet AMOs are expected to comply with SAH s Occupational Health & Safety policies and procedures to ensure the safety of themselves, staff and patients. AMOs must not place themselves or others at risk. Workplace accidents or incidents should be notified to medical administration to ensure appropriate risk management procedures are implemented SAH reserves the right to request that AMO transfer a patient to another institution in appropriate cases Every patient has the right to request transfer of his or her care to another AMO. In such cases it is expected that the original treating AMO should communicate with the requested AMO to ensure continuity of care, as well as notify and involve the patient s GP. Medical Records Complete, accurate, legible and timely medical records are necessary to maintain high standards of medical care and are the responsibility of the treating AMO The adequacy of AMOs medical records is an important consideration when SAH reviews accreditation privileges. Medical records must be sufficient for present and future care of the patient and for review of patient care by formal study. Important and specific responsibilities of the treating AMO include the recording or completion of: Board & MAC-approved SAH By-Laws Dec 08 Page 10 of 19

11 (a) (b) (c) (d) (e) (f) (g) admission notes / letters on a patient s condition and a plan of treatment (Doctor's Referral Letter); therapeutic orders, including pre-hospital medications, current medications, intravenous medications and drug sensitivities; particulars of all procedures and investigations required; progress observations; special problems / complications; and discharge notes prompt completion of discharge summary, and a note on outcome and follow-up needs, such as medication, discharge status and destination of the patient which the hospital will fax to the patient's GP letter of referral if a patient is transferred to another institution All diagnostic and therapeutic orders must be given in writing, dated and signed. Telephone orders for medications must be given to a Registered Nurse, who will read the order back to the AMO for confirmation. As prescribed by Government regulation, the record of these orders must be entered in the notes and signed by the AMO within 24 hours of being given by telephone AMOs must complete, date and sign the MR1A AMOs must make appropriate entries in the integrated notes at the time they visit their patients. Every entry in a medical record must include the time and date and the signature of the attending AMO AMOs must complete, date and sign all relevant health insurance forms relating to a patient s treatment within 48 hours of ordering or performing the treatment or service All medical records are confidential and remain the property of SAH. However, patients have the right to access a copy of their notes. Medical records do not leave the hospital, except where required by the Coroner, court subpoena or by search warrant If a patient is re-admitted to SAH, all previous records held by SAH will be available for the use of attending AMO. This applies whether or not the patient is attended by the same AMO. Clinical Pathways SAH has defined a Clinical Pathway as: A timeline for management of a specific disease process, diagnosis or treatment / procedure that includes expected interventions, procedures and outcomes SAH actively promotes the use of Clinical Pathways in the treatment of patients by its AMOs because they: (a) Improve the quality of patient care; (b) Increase patient awareness and satisfaction as patients are provided with their own specific Clinical Pathway; (c) Improve resource utilisation Clinicians from the appropriate clinical groups undertake the development of SAH s Clinical Pathways. All AMOs are encouraged to participate in the development, implementation and improvement of Clinical Pathways. To assist these processes SAH has established a Clinical Pathways Management Team. This team supports the development and implementation of Board & MAC-approved SAH By-Laws Dec 08 Page 11 of 19

12 Clinical Pathways by providing casemix information, clinical research assistance, a development methodology and standardised forms and documents All AMOs must note the following points in relation to the use of Clinical Pathways at SAH: (a) It is SAH s policy that only Clinical Pathways that have been developed at SAH and approved by the DMS can be used at SAH. (b) Clinical Pathways are a broad guide for care only. AMOs must make relevant changes to the medical management of their patients where required. (c) If changes to the medical management of a patient are required, the AMO must ensure that he or she notes the change on the Clinical Pathway. (d) The Clinical Pathway is an important part of the patient s medical record. It must be completed accurately and legibly, and signed by the responsible AMO to show that he or she has approved the care to be given to the patient. (e) Periodically, SAH will provide AMOs with an updated Clinical Pathways list that will describe the Clinical Pathways available, patients eligibility guidelines for the Pathway, and whether or not patients that satisfy the criteria should be placed on the Pathway by default. (f) Admitting RN will place an AMO's patient on a Clinical Pathway by default when: i. A suitable Clinical Pathway exists (based on the primary diagnosis); ii. Patient satisfies the criteria for following the Clinical Pathway, and iii. AMO has not ticked the Patient NOT to be placed on Clinical Pathway box on Doctors Referral Letter. (g) If the AMO has ticked the Patient NOT to be placed on Clinical Pathway box, he or she must state, in the space provided, the reasons why a Clinical Pathway should not be used. Consent AMOs must provide their patients with a full explanation about the patient s proposed treatment, including an explanation of material risks and side effects, any alternatives, any pre-operative screening that is to be undertaken and any other relevant information, such as the possibility of a blood transfusion AMOs must also ensure that each patient (where possible) consents to the proposed treatment. In all cases, the patient or his or her authorised representative must sign an appropriate Consent Form. The doctor obtaining consent must complete and sign the form For children under 14, consent must be obtained from a parent or legal guardian. For children aged 14 or 15, consent should be obtained from both the child and a parent or guardian, unless circumstances prevent this or there is a special reason not to obtain consent from the parent or guardian. Children aged 16 and over can give valid consent themselves as long as they are able to understand the proposed treatment and its ramifications, although a parent, guardian or other accompanying adult would normally be involved in the decision-making process For non-english speaking patients, a translator may have to be obtained. If a translator has been obtained the name and position of the translator must be recorded in the patient s record. The relatives of a non-english speaking patient cannot sign the consent for the patient AMOs must comply with their obligations under the Privacy Amendment (Private Sector) Act 2000 and Health Records and Information Privacy Act 2002 (NSW), particularly in relation to obtaining patient consent for the use and disclosure of the patient s personal health information. Board & MAC-approved SAH By-Laws Dec 08 Page 12 of 19

13 11. OBLIGATIONS OF AMOs Committees AMOs have important roles in many activities of SAH and may be members of, amongst others, the following committees: (a) Endoscopy Advisory, Ethics, Infection Control, Medical Records, Operating Theatre, Pharmacy and Drug, Quality Care Review AMOs are expected to agree to any reasonable requests by SAH to serve on a committee. The Medical and Associated Services Policy and Procedure Manual lists the committees and their membership. Conduct SAH aims to provide a work environment that promotes courtesy, trust, equity and mutual respect across the workforce. All acts of threatening behaviour, bullying, harassment, intimidation, threats, verbal and physical abuse / violence and discrimination are expressly prohibited AMOs must comply with SAH s policies in relation to abuse, bullying and internal violence, harassment and discrimination as amended from time to time AMOs must be aware of SAH s Code of Behaviour, and must sign a document acknowledging that they have read and understood the Code of Behaviour and agree to uphold it AMOs must be aware of the importance of maintaining patient confidentiality, and must not disclose confidential patient information except as required by law AMOs must comply with SAH's media policy Notification of Certain Circumstances AMOs must notify the DMS in writing if any of the following occurs during the period of their accreditation: (a) their professional indemnity insurance lapses; (b) their accreditation is withdrawn from any hospital or medical institution;(c) any restrictions are placed on their registration to practise or their registration is suspended or cancelled Notice must be given within seven days of the AMO becoming aware of the circumstance When notice of a circumstance is received SAH may review the AMOs accreditation in accordance with the procedure set out in these By-Laws. 12. CONDUCT OF SURGERY Regular operating sessions may be granted to AMOs by Hospital Management but will usually be maintained only where they are being adequately utilised. Open sessions will generally be available on a first call basis for all surgeons Surgeons must familiarise themselves with Operating Room procedures as outlined in Theatre Policy Manual which is available from the Theatre Office and on the SAH intranet. Board & MAC-approved SAH By-Laws Dec 08 Page 13 of 19

14 12.3. All surgeons must conduct adequate pre-operative investigations and preparation on their patients. Surgeons are encouraged to refer all overnight stay patients to the pre-admission clinic. Surgeons are encouraged to refer all patients with significant medical co-morbidities to specialist physicians or general physicians for pre-operative medical optimisation Where examination of tissue is necessary or advisable to diagnose or treat a case, or for audit purposes, AMOs should submit such tissue for histological examination by a Pathologist. This is required in almost all cases, with a very limited number of recognised exceptions (e.g. hernial sacs, varicose veins, fatty lobules, etc.). In all instances, a copy of the Pathologist s report must be placed in the case notes of patients The surgeon is responsible for ensuring that SAH procedure for monitoring swabs and other surgical equipment is followed and for ensuring the accuracy of the swab and surgical equipment count. The required procedure to be followed is outlined in the Theatre Policy Manual. 13. ANAESTHETIC CARE The administration of anaesthetics to patients of SAH must only be by AMOs duly qualified and accredited for that purpose No general anaesthetic may be commenced unless the surgeon who is to perform the surgery or procedure for which the anaesthetic is being administered is present on the premises The anesthetist must maintain a complete anaesthetic record including evidence of preanaesthetic evaluation, intra-anaesthetic drugs administered, progress and post-anaesthetic follow-up of the patient s condition. It is expected that post-operative orders be documented for pain relief after narcotic infusion is discontinued. An ASA rating must be recorded for every patient undergoing a procedure. 14. EMERGENCY CARE In cases of emergency of in other exceptional circumstances SAH (an Administrator, AMO or Nursing Unit Manager) may take such action as it deems fit in the interests of the patient. This may include a request for attention by an available AMO. In such cases the following applies: (a) the patient s AMO, and the DMS or Nursing Executive Officer, will be advised of the circumstances of the patient and of the action taken as soon as possible; and (b) the patient will generally be returned to the care of the AMO in charge of the case as soon as possible, who will then give his or her own instructions regarding further care and consultations The Hospital requires all AMOs to: (a) make themselves aware of SAH s emergency procedures (see the Emergency Manual in the VMP Lounge); (b) assist SAH where necessary in case of emergency or special demand; and (c) participate in out of hours rosters where necessary to provide adequate patient care In regard to the after hours rosters: (a) The DMS shall determine the need for a roster to be provided by any Department. (b) The Chairman or Secretary of any such Department should draw up a roster using an equitable contribution from all the members of the Department. Board & MAC-approved SAH By-Laws Dec 08 Page 14 of 19

15 (c) (d) (e) (f) The Departments retain the rights to excuse certain of their members from after-hours rosters if agreed by properly constituted Department meetings. Rosters must be submitted at least one month in advance of their commencement to the DMS, whose secretary will notify the participants. Cover is the responsibility of the Department and its members and not of the Medical Administration, and changes to a published roster are for the Department Secretary and the doctor seeking the change to resolve. The doctor duly rostered is responsible for fulfilling the duties of being on call. Admission of General Practitioner Referred Patients Any patient sent by a general practitioner for admission must be assessed in Emergency Care, unless a specialist has seen the patient within 24 hours prior to referral. If the general practitioner has discussed the case with a specialist, but the specialist has not personally seen the patient, Emergency Care staff should assess the patient to ensure that appropriate investigations and treatment are performed and that admission is warranted. If Emergency Care medical staff believe that discharge and outpatient treatment is warranted, they MUST discuss the case with the referring general practitioner. If a specialist has been informed of the case, Emergency Care staff should also discuss the issues with the specialist involved On rare occasions this policy may be over-ridden. This would apply only if a general practitioner has discussed the case with a specialist who knows the patient well, in which there are no immediate life threatening medical or surgical problems, and if there is a clear documented plan of management and a bed is available in the ward A general practitioner must make direct contact with the Specialist if he or she requires that specific specialist to admit the patient. This specific specialist should advise the Emergency Department of the impending admission. Dermatological Emergencies There are few true dermatological emergencies that require Hospital admission. Most of these emergencies are acute bullous diseases or exfoliative diseases. Examples would include: bullous pemphigus and pemphigoid, toxic epidermal necrolysis; staphylococcal scalded skin syndrome, Stevens Johnson syndrome and exfoliative dermatitis It is a policy of SAH that patients who are admitted with extensive bullous or exfoliative disease should be cared for by a dermatologist or consulted by a dermatologist within 24 hours of their admission. This should be arranged with the agreement of their principal attending medical practitioner. In cases of widespread skin loss, as occurs with extensive bullous disease or epidermal necrolysis, consideration of transfer to a burns unit should be made. Upper Airway Obstruction in Emergency Care Upper airway obstruction is an uncommon but potentially life threatening clinical problem in Emergency Care. An ENT surgeon should care for patients with actual or potential upper airway obstruction, after first aid and stabilisation in Emergency Care. This would apply if the cause were a foreign body, infective, malignant, traumatic or allergic. Board & MAC-approved SAH By-Laws Dec 08 Page 15 of 19

16 Paediatric Admissions All children eight years of age and younger who are admitted to SAH as a surgical emergency must be admitted under a Paediatric Surgeon or be admitted under the joint care of a Surgeon and Paediatrician. 15. INTENSIVE CARE UNIT Director of Intensive Care heads the Intensive Care Unit that supplies intensive care medical services and advice 24 hours a day The Intensivist on duty makes the final decision in relation to admission and discharge of all patients in the Intensive Care Unit, after consultation with the attending AMO and (if necessary) with SAH management All Intensive Care patients will be seen by an Intensivist, and treatment of all patients will be managed jointly with the patient s primary care specialist. 16. PSYCHIATRY All psychiatric patients must be under the care of a Psychiatrist. If an AMO admits a psychiatric patient, a Psychiatrist should be engaged as soon as possible SAH will not accept patients who are severely disturbed or psychotic or who could be considered a danger to themselves or others within the meaning of the New South Wales Mental Health Act A patient will not be accepted for psychiatric care on transfer from a psychiatric unit SAH will admit overdose patients in emergency cases where there is an immediate risk to the life or health of a patient, but once resuscitation and recovery have occurred, they should be transferred to an appropriate institution Patients with a medical emergency complicating a psychiatric illness, e.g. anorexia nervosa with a life threatening cardiac arrhythmia, will be admitted for treatment of the medical emergency under an appropriate physician, surgeon or Drug and Alcohol Physician, who will consult with the patient s Psychiatrist. Once the medical emergency is treated, the patient will be transferred to an appropriate institution Children with a primary psychiatric illness will not be accepted, as SAH does not have the necessary facilities for the care of such patients. 17. ACUPUNCTURE Acupuncture should be limited to the treatment of pain and pain-associated disorders. The general use of acupuncture is NOT permitted within SAH Acupuncture must be performed only by a registered medical practitioner who is accredited to the medical staff of SAH. Board & MAC-approved SAH By-Laws Dec 08 Page 16 of 19

17 17.3. Such medical practitioners must produce documented evidence to the DMS that they have successfully completed a registered course in acupuncture and are accredited by the appropriate training authority Practitioners performing acupuncture must notify SAH s Medical Administration of each case. 18. ETHICS SAH expects from members of the accredited medical and dental staff high standards of personal and professional conduct in accordance with the codes of ethics of the NSW Medical Board, Dental Board, Australian Medical Association, the learned colleges and SAH SAH may also establish guidelines or requirements in relation to ethical matters and may take any action appropriate to maintain and preserve the standards it upholds Surgical operations and invasive investigative procedures may be performed only after SAH has been supplied with a signed document from the patient indicating valid informed consent, unless there is a valid reason that this is not possible Board appoints SAH s Ethics Committee constituted according to the guidelines laid down by the National Health & Medical Research Council to: (a) assist with planning and policy development in relation to ethical issues; (b) formulate guidelines for protocols and procedures where ethical concerns are involved; (c) ensure procedures relating to the obtaining of informed consent are adequate; (d) consider, make recommendations on, and monitor research proposals and clinical trials; (e) enhance awareness of ethical concerns in relation to patient care and contribute to education on ethical aspects of health care; and (f) provide guidance on ethical concerns to SAH and its AMOs in specific clinical situations All proposals for research to be undertaken at or in association with SAH must be forwarded via the relevant Department to SAH s Ethics Committee for consideration and approval. 19. TERMINATION OF PREGNANCY This may be performed only in the following circumstances: (a) where continuation of pregnancy may threaten the life of the woman or significantly impair her mental or physical health; (b) where circumstances or indications are such that it is believed pregnancy may or will result in the birth of a child with serious physical deformities or mental retardation; (c) where conception has occurred as a result of criminal assault or incest; or (d) where circumstances of particular human need or distress are judged to be present. In these circumstances, the case must be referred to a subcommittee of the Ethics Committee The patient s Medical Practitioner must call the DMS to obtain permission to perform the procedure, before the procedure is booked. That call must outline the circumstances of the case, and they must be immediately confirmed in writing In all cases the procedure, together with the reason why it is to be performed, should be entered in the medical record before the termination. In cases where the circumstances appear more than usually confidential, this should be specified in the case notes of the lodgement of Board & MAC-approved SAH By-Laws Dec 08 Page 17 of 19

18 particulars with the DMS. In no case should termination of pregnancy be performed under the name of another procedure When termination of pregnancy is performed it should be done as early as possible in the pregnancy. All tissues removed must be sent to the Pathologist for histopathological examination and the report must appear in the patient s notes All decisions with respect to termination of pregnancy must be free of coercion. Informed consent to the procedure must be obtained. Patients should be made aware of the alternative options Patients are to be informed of the availability of counselling and support services prior to the procedure. SAH s Chaplains and Social Workers are available for this purpose. 20. NOT-FOR-RESUSCITATION GUIDELINES Not-for-Resuscitation Guidelines have been developed by SAH Ethics Committee and are consistent with the New South Wales Department of Heath Guidelines, March 1993, Dying with Dignity Not-for-Resuscitation directive has been developed which must be included in the patient s medical record. This is to be used for patients who are terminally ill This Directive enables nursing staff and AMOs to ascertain if the patient s prime carer has ordered that the patient is not for resuscitation. AMOs must, each week, review and assess any Not-for-Resuscitation orders for their patients The document deals with: (a) Assessment of patient status (b) Specific procedures to be omitted (c) Therapy to be maintained (d) Patient s wishes in relation to therapy (e) Healthcare personnel with whom discussion should take place (f) Response of relatives to the situation. APPENDIX A. MISSION, VISION & VALUES Our Mission Christianity in Action Our Vision Innovative Excellence in Adventist Christian Healthcare through: An Adventist Christian Environment Enabled, accountable and competent management Open and honest communication Appreciated, committed and professional staff Total customer service Commitment to quality Board & MAC-approved SAH By-Laws Dec 08 Page 18 of 19