Medical by-laws

Definitions

In these by-laws, unless the context requires otherwise:

• TDS means Templestowe Day Surgery, including all its facilities, plant and equipment, and the provision of all day surgery services.
• Governing Body means the Medical Advisory Committee of Templestowe Day Surgery.
• MAC means the Medical Advisory Committee. It comprises the Medical Director; an Independent Medical Advisor (without pecuniary interest), who chairs the MAC; the Director of Nursing; and the Office Manager. Additional members may be co-opted as required for advice on matters including, but not limited to, scope of practice and the introduction of new technology or procedures.
• CMP (Credentialed Medical Practitioner) means a practitioner accredited by the Governing Body to perform surgical procedures at TDS, who holds all requisite qualifications, registration, professional development and current CPD status, and professional indemnity insurance appropriate to the scope of practice applied for.
• Investigating Committee means a committee co-opted by TDS when deemed necessary, representing a range of disciplines with the skills and experience to provide informed and independent advice. It may include:
  • at least one medical practitioner who practises in the field relevant to the clinical scope being reviewed
  • a nominee of the relevant professional college, association or society
  • a medical practitioner nominated by the person who is the subject of the appeal.

Vision and mission

Vision

Our vision is to be the cosmetic day surgery of choice in the eastern suburbs of Melbourne, recognised as a centre of excellence for both patients and staff. This will be evidenced by the measurement and benchmarking of clinical and performance outcomes, patient and staff satisfaction results, and safety audit results.

Mission

Templestowe Day Surgery aims to enhance the wellbeing of all our clients. This will be achieved through the provision of safe, high-quality medical and surgical care that is sensitive to the individual needs and responsive to the personal situation of each client. The environment at Templestowe Day Surgery is one of warmth, dignity and high-quality care that does not discriminate on any basis. We are community focused and responsive to the evolving needs of our community.

All credentialed medical practitioners are expected to uphold this vision and mission at all times and in all dealings with and at TDS.

Powers of the Governing Body

The powers and duties of the Governing Body include, but are not limited to:

• delegating powers, duties and responsibilities to such persons or committees as it considers appropriate from time to time
• reviewing and approving the credentialing and scope of practice of medical practitioners and specialists applying to use TDS facilities
• discussing and making recommendations on clinical matters
• reviewing and making recommendations on new medical equipment and procedures
• assessing all applications for new procedures and guidelines in line with current Australian best-practice regulations and guidelines
• co-opting additional members as required for advice on access, scope of practice and the introduction of new equipment and procedures
• co-opting a consumer representative to be involved in credentialing and scope of clinical practice and service at TDS
• reviewing, analysing and making recommendations on clinical incidents and sentinel events
• contributing to making and amending the by-laws, rules and regulations for the management of TDS, and reviewing them annually.

The Governing Body meets quarterly.

Services and procedures

TDS will consider applications for credentialing to perform liposuction, blepharoplasty, gynaecomastia and skin treatment procedures. All procedures are to be performed under local anaesthesia, with or without intramuscular (IM) sedation.

1. For tumescent liposuction, the maximum lidocaine (Xylocaine) dose must not exceed 35 mg/kg, and the maximum total aspirate (the combined total of fat and fluid aspirated) is five litres in a single procedure. Any greater volume must be undertaken at a separate time.
2. Liposuction will be performed in accordance with the Department of Health Victoria’s Guideline for providers of liposuction.
3. Blepharoplasty, gynaecomastia and skin treatments will be performed in accordance with the Department of Health Victoria’s regulation of minor surgery in private facilities.
4. Procedures must be performed within the allowed limits of local anaesthesia, methoxyflurane (as per the TDS methoxyflurane protocol) and tumescent local anaesthesia (as per item 1). The patient’s vital signs must remain within normal limits throughout the procedure.
5. IM sedation is administered by the CMP only. The use of midazolam is directed by the MAC, and its effectiveness is monitored and reviewed.

Patient exclusion criteria

All CMPs must strictly adhere to the TDS Patient Selection for Day Surgery Policy, which sets out the following exclusion criteria for admission:

• age under 18 years
• weight over 110 kg, or a BMI of 35 or more
• assessment by the treating medical practitioner as American Society of Anesthesiologists (ASA) physical status class 3 or above
• surgery expected to extend beyond two hours
• inability to walk independently
• a suspected or confirmed infectious disease of any nature (patients must provide evidence of meeting clearance requirements under the National Health and Medical Research Council guidelines, 2019)
• a positive test for an active or untreated blood-borne virus (hepatitis B, hepatitis C or HIV)
• inability or unwillingness to understand or sign the required surgical, anaesthetic and financial consent forms (in rare instances, a legally authorised guardian or substitute decision-maker may assist where the procedure is expected to improve the patient’s health or wellbeing)
• absence of a support person to drive the patient home, where the treating medical practitioner considers one necessary
• current obstructive sleep apnoea
• a predisposing diagnosed psychiatric condition, unless cleared in advance by the treating psychiatrist
• known episodes of delirium, unless the patient is deemed suitable during the surgeon’s psychological assessment
• a residential address outside Victoria, unless temporary accommodation is confirmed for at least three days after surgery
• a higher than minimal bleeding risk (whether medical or due to current medications), as determined by the treating medical practitioner
• unsuitability for outpatient pain management
• an anticipated prolonged recovery period for any reason
• any other reason, as determined by the treating medical practitioner.

Categories of accreditation

The following categories of accreditation apply to CMPs:

• Surgeon
• Surgical assistant
• Medical practitioner

Credentialing of medical practitioners

To ensure that only professional, competent medical practitioners are appointed, TDS follows Safer Care Victoria’s policy Credentialing and scope of clinical practice for senior medical practitioners (May 2020).

Applicants must complete the TDS credentialing application form and provide:

• proof of identity
• national and, if applicable, international police checks
• original or certified copies of their qualifications
• original or certified copies of their specialist qualifications
• original or certified copies of their procedural qualifications
• current AHPRA registration
• current medical indemnity insurance that reflects the scope of practice applied for
• a current CV
• current evidence of continuing professional development (CPD)
• two professional referees relevant to the scope of practice applied for.

If a change in scope of practice is sought, a new application must be completed covering the new service or change in scope, with relevant qualifications and training. If a CMP wishes to narrow their scope to a subset of their current practice, they must advise the MAC in writing.

A CMP must notify the Medical Director or the Director of Nursing if any conditions are placed on their medical registration, or if any other change to their registration or insurance occurs.

All CMPs agree to participate in performance reviews to ensure their competence in the practice they undertake.

Any notice required under these by-laws may be given to a CMP personally or by registered mail to their address on the accreditation register. A notice sent by post is deemed to have been received three days after the date of posting.

Letters of accreditation, signed by the Medical Director or the Director of Nursing on behalf of the Governing Body, are issued for a maximum period of three years and recorded in a register kept for that purpose.

Tenure and re-credentialing

• After three years, the CMP must complete the TDS re-application for credentialing form.
• Applications for re-appointment are directed to the Medical Director.
• The application is presented to the MAC, which determines whether it is successful.
• Applicants are notified of the outcome in writing.

Urgent and temporary situations

TDS does not grant credentialing for urgent or temporary situations. Surgical procedures are performed only by CMPs.

In an emergency where a current CMP cannot perform a planned procedure, one of the following will occur, depending on the circumstances:

• cancellation or postponement of the planned procedure
• transfer of the patient to a suitable registered facility
• transfer of the patient by ambulance to an appropriate hospital.

Resignation

A CMP who wishes to resign their accreditation at TDS must give written notice to the Medical Director of the Governing Body, with a minimum of 14 days’ notice.

Code of conduct

CMPs must at all times observe the highest standards of personal and professional conduct. Without limiting this requirement, a CMP must:

• comply with any reasonable request made by the TDS Medical Director regarding personal conduct and the provision of services at TDS
• practise in accordance with all applicable codes of conduct, policies, procedures and protocols established by TDS and relevant professional bodies from time to time
• practise within the limits of their specialty and sub-specialty
• comply with all laws, rules, policies and procedures relating to occupational health and safety; anti-discrimination, bullying and harassment; and confidentiality, privacy and the management of personal and health information.

In addition:

• CMPs are expected to provide evidence of continuing efforts to improve their knowledge related to their credentialed scope of practice.
• CMPs are expected to report any knowledge of violations of these by-laws.
• CMPs should report new methods of, or innovations in, treatment to professional audiences for evaluation and authentication before release to public news media.
• Biomedical research will not be conducted at TDS.
• Products, devices and prostheses must have current TGA approval.
• Shareholders in TDS must disclose their financial interest in TDS.

Regulation of conduct

In accordance with these by-laws and the accreditation process, as amended from time to time, the Governing Body regulates the professional conduct of accredited CMPs, including by establishing an Investigating Committee in accordance with these by-laws.

Appeal process

A medical practitioner whose request for credentialing, re-credentialing or scope of clinical practice has been restricted, denied, withheld or varied from the original request has the right to appeal the decision.

Notice of the intention to appeal must be lodged in writing with the Governing Body within 10 working days of the decision. The appeal itself must then be lodged within one calendar month of receiving the decision.

TDS may co-opt additional nominees to form an Investigating Committee representing a range of disciplines with the skills and experience to provide informed and independent advice. This may include:

• at least one medical practitioner who practises in the field relevant to the clinical scope being reviewed
• a nominee of the relevant college, association or society
• a medical practitioner nominated by the person who is the subject of the appeal.

Every appeal is heard by the Governing Body. Members of the Investigating Committee that dealt with the case will not sit in judgement on an appeal. The Governing Body will notify the applicant and the Investigating Committee in writing of the time and place of the appeal hearing.

Suspensions

The Medical Director or, in their absence, the Director of Nursing is authorised to act for and on behalf of the MAC in suspending accreditation without notice until the next MAC meeting, at which the action will be ratified or reviewed. The process is set out in the TDS Medical Suspensions and Investigation Policy.

Responsibilities of credentialed medical practitioners

A CMP must:

• adopt TDS policies and procedures in all conduct, and comply with the National Safety and Quality Health Service (NSQHS) Standards and all TDS infection prevention policies and procedures
• practise within their scope of practice and adhere to regulatory guidelines set by the Department of Health Victoria
• be responsible and accountable for the admission of their patients to TDS
• take part in multidisciplinary collaboration with TDS management and staff
• where they call in another doctor in consultation, advise the Registered Nurse in Charge who will be responsible for the patient’s care and the point of contact after discharge.

Reporting adverse events

CMPs must notify the Medical Director within 24 hours of becoming aware of a post-operative adverse event in a patient treated at TDS within the previous 28 days. Adverse events include:

• the death of a patient
• admission to another hospital directly related to the procedure performed at TDS
• post-operative infection.

In addition, CMPs must:

• arrange bacteriological examination of all cases of post-operative infection in any patient treated at TDS
• notify the Medical Director and/or Director of Nursing within 24 hours of diagnosing a post-operative infection in a patient treated at TDS, report the results of related pathology investigations as soon as they are available, and provide copies to TDS as soon as practicable after receipt
• notify the Medical Director and/or Director of Nursing if a patient is admitted to another facility after discharge due to a decline or complication
• notify the Medical Director and/or Director of Nursing as soon as practicable after surgery where a carcinoma is diagnosed, in line with Victorian Admitted Episodes Dataset (VAED) statutory requirements.

Emergency situations

CMPs must advise the Medical Director in writing of any change to their details, such as contact numbers, address, and the back-up practitioner to be contacted if the CMP is unavailable in an urgent situation.

If the Registered Nurse in Charge determines that a patient is in an emergency situation:

• every effort will be made to contact the patient’s CMP
• TDS reserves the right to summon further help in the interest of patient safety, which may include calling another CMP or transferring the patient by ambulance to a suitable facility
• a full report will be made to the CMP as soon as practicable, and any doctor summoned in the emergency will be asked to contact the patient’s CMP directly.

Informed consent

The CMP must explain the nature of the intended surgery, its risks and potential findings to the patient, and their carer where applicable, as part of the informed consent process.

• CMPs admitting patients to TDS must ensure valid consent for the intended procedure is obtained, documented and signed on a TDS-approved consent form.
• CMPs must not add procedures on the day of surgery unless the patient was fully informed and consented before admission, and TDS staff have confirmed that time and equipment allow it.
• TDS staff will sight the consent form before the procedure begins, in accordance with relevant policies. Surgery will not proceed until valid consent has been sighted.

Informed financial consent

CMPs (or their delegate) must discuss surgical and other related fees with patients before treatment begins, ensuring informed financial consent has been obtained. Patients are given a seven-day cooling-off period.

TDS has not established fee schedules for its CMPs. CMPs are expected to charge fees commensurate with what is considered reasonable in the community for the service.

Patient management

The responsibilities of a CMP include:

• pre-operative diagnosis and care
• appropriate pre-operative screening
• performance of the procedure
• all related post-operative care.

Pre-admission assessments must be documented in the patient’s healthcare record and made available to TDS staff before admission.

Medical records

CMPs must complete all patient medical records in accordance with TDS guidelines and policies and the guidelines of their professional college.

• Concise, legible and relevant information must be documented in the patient’s medical record throughout their treatment at TDS.
• All orders for a patient’s treatment must be clearly conveyed to nursing staff by the CMP directing that treatment.
• All sections of the TDS Patient Care Record must be completed as close to the time of treatment as possible.
• Nursing staff and the patient must be given clear written instructions about discharge and follow-up arrangements.

Confidentiality

Every patient’s right to privacy must be respected. CMPs must maintain the confidentiality of information from and about the patient, except where information must be communicated for the patient’s proper care or is required by law.

Open disclosure

TDS has a policy of open disclosure for all clinical adverse events and follows the principles of the Australian Open Disclosure Framework (Australian Commission on Safety and Quality in Health Care).

It is the CMP’s responsibility to complete the open disclosure procedure set out in the TDS Open Disclosure Policy. All staff, including CMPs, must complete open disclosure training.

Antimicrobial stewardship

Antibiotics must be prescribed in accordance with the Australian Commission on Safety and Quality in Health Care’s Antimicrobial Stewardship Clinical Care Standard.

If antibiotics are prescribed or used, the time, route, dose, patient’s weight and indication must be documented in the TDS Patient Care Record. Antibiotic use is audited periodically by TDS.

Quality and safety

CMPs are expected to contribute to the ongoing quality and safety of TDS by participating in the quality management program, including peer review, collection of relevant clinical indicators and assistance with quality and safety activities as required. All CMPs must follow current TDS policies and procedures, the NSQHS Standards, infection control standards and Department of Health Victoria regulations.

Partnering with consumers

Patients and their carers are to be involved in shared decision-making, informed consent and all aspects of their care, including pre-admission and discharge planning. They must be given adequate written information before treatment and at discharge, including phone numbers to call if they have any concerns. Patients will be invited to take part in patient experience surveys.