Glen Eira Day Surgery Medical Bylaws

To be read by all credentialed Visiting Medical Officers

Version 9 – September 2024

1. Purpose

This document outlines the requirements for credentialing and defining the scope of clinical practice at Glen Eira Day Surgery to ensure that 

• services are provided within the capability and role of the health service 
• medical practitioners appointed to the health service are competent and able to fulfil the tasks and responsibilities of their appointment 
• a positive environment for medical practitioners, with a clear recognition of the resources required to support high quality services 
• appropriate and effective clinical governance 

Glen Eira Day Surgery is a day surgery facility undertaking endoscopy and iron infusion procedures from Monday to Friday. Its hours of operation are between 0700 and 1900 hours. From time to time the facility may undertake procedures on Saturday. 

Glen Eira Day Surgery aims to provide a high standard of medical care for its patients. The primary relationship concerning medical treatment is between the patient and his/her doctor. 

Use of the Glen Eira Day Surgery facilities by medical practitioners and is subject to acceptance of these by-laws as published. Copies of the by-laws are available from the Director of Nursing. 

2. Responsibilities 

The Chief Executive or delegate (the Chair of the Medical Advisory Committee) has accountability for authorising the credentialing and scope of practice for medical practitioners. 

The Medical Advisory Committee has oversight responsibility for credentialing and approving scope of practice for medical practitioners. 

Director of Nursing is responsible for maintaining the systems for credentialing and Scope of Practice at Glen Eira Day Surgery. 

3. Definitions 

Credentialling refers to the formal process used to verify the qualifications, experience, professional standing and other relevant professional attributes of medical practitioners for the purpose of forming a view about their competence, performance and professional suitability to provide safe, high quality health care services at Glen Eira Day Surgery. 

Defining the scope of clinical practice follows on from credentialling and involves delineating the extent of an individual medical practitioner’s clinical practice within Glen Eira Day Surgery based on the individual’s credentials, competence, performance and professional suitability and the needs and the capability of the facility to support the medical practitioner’s clinical practice. 

Appointment is defined as the employment or engagement of a medical practitioner to provide services within Glen Eira Day Surgery according to conditions defined by general law and supplemented by contract. 

4. Procedure 

4.1. Credentialed Medical Practitioners 

Only a medical practitioner who has been formally credentialled by the Medical Advisory Committee shall be entitled to engage in the care and treatment of patients at the Glen Eira Day Surgery and to have the use of the Glen Eira Day Surgery facilities. 

Those practitioners who wish to be credentialled should apply to the Medical Advisory Committee through the Chief Executive Officer. The Medical Advisory Committee shall have sole discretion as to whether an applicant shall be credentialled and as to the terms of such credentialling. 

Applicants must: 

• Complete the Application for Credentialing and Defining the Scope of Clinical Practice form 
• A current curriculum vitae 
• Current Medical Board of Australia (AHPRA) registration – confirmation of the presence or absence of conditions, undertakings, endorsements, notations, and reprimands and confirmation of type of registration 
• Current professional indemnity certificate ensuring the cover reflects the requested scope of practice. 
• Provide Proof of Identity (100-point check of original documents) 
• National Police Check or international police check if applicant has been living overseas for 12 months or longer during the last 10 years 
• Working with Children check (where applicable) 
• Original qualifications or certified copy 
• Continuing Professional Development (CPD) Statements that are college approved or relevant to the scope of clinical practice 
• Referee checks that: 
• – must not be limited to unsolicited written references 
• – if undertaken by verbal contact must be documented, preferably in a structured format 
• – may be undertaken by templates sent to nominated referees 
• – consider the appropriateness and the bona fides of referees 
• – include referees who work largely in the specialty of the applicant practitioner and have been in a position to judge the practitioner’s experience and performance during the previous three years and have no conflict of interest in providing a reference 
• health status, this may be discussed privately with the director of medical services (or equivalent), who will then be responsible for deciding how this will affect the scope of clinical practice) 

The MAC will take into account appointments at public or private teaching hospital when assessing doctors for Credentialing at GEDS. 

The tenure shall be three (3) years with scope of practice review annually.  

Doctors are free to resign from the position of credentialled Medical Practitioner, and the Medical Advisory Committee reserves the right to withdraw credentialling at any time upon not less than 14 days’ notice being given and reason for withdrawal explained in writing. 

The Chief Executive Officer, or in his absence the Director of Nursing or delegate, is authorised to act for and on behalf of the Medical Advisory Committee in appointing and in suspending the appointment without prior notice, until the next meeting of the Committee at which time ratification or review of such action can take place as per By-Laws governing the Medical Advisory Committee. Appeal against any decisions made by the CEO on behalf of the Medical Advisory Committee can be made before the Chairman of the Medical Advisory Committee. 

In the event that no credentialed medical proceduralist are available for a scheduled operating list it is permissible for temporary credentialing to be granted to a proceduralist, providing he or she is known by a proceduralist that is currently credentialed at Glen Eira Day Surgery, supplies their current professional medical indemnity certificate and AHPRA registration. The Chief Executive and Chairman must be informed and provide verbal approval for such a proceduralist to practice on a temporary basis at Glen Eira Day Surgery. If he or she wishes to continue to practice at Glen Eira Day Surgery, then the procedure as outlined above must be followed. 

4.2. Responsible Medical Practitioners 

1. “Responsible Medical Practitioner” means the Credentialled Medical Practitioner who is responsible for the medical care and treatment of a patient at Glen Eira Day Surgery. 

The responsible Medical Practitioner shall be – 

1. the credentialled Medical Practitioner who arranged such admission of the patient to the Glen Eira Day Surgery; or 
2. where no credentialled Medical Practitioner arranged such admission the credentialled Medical Practitioner who has assumed the responsibility for the medical care and treatment of the patient; or 
3. The names of the Responsible Medical Practitioners shall be entered on the patient’s notes. 
4. Where a Responsible Medical Practitioner is to be changed from one Credentialled Practitioner to another, the patient’s medical record shall be changed accordingly. 

4.3. Other medical practitioners 

• In the event that a locum is appointed due to absence of the Responsible Medical Practitioner then the locum must be fully credentialed prior to engaging in any work at the Glen Eira Day Surgery. 
• The Glen Eira Day Surgery reserves the right to refuse access to the Glen Eira Day Surgery to any medical practitioner who is not a Credentialled Medical Practitioner. 
• Following approval from the Medical Advisory Committee the medical practitioner will receive a letter of confirmation of appointment. 

4.4. Annual requirements for ongoing appointment 

Each year appointed medical practitioners must provide to the Director of Nursing: 

To fulfil credentialing requirements, each year appointed medical practitioners must provide to the Director of Nursing: 

• Current professional indemnity certificate ensuring the cover reflects the requested scope of practice. 
• Current Medical Board of Australia (AHPRA) registration – confirmation of the presence or absence of conditions, undertakings, endorsements, notations, and reprimands and confirmation of type of registration 
• CPD college certificate or evidence of relevant CPD 

4.5. Re-Credentialing with no change to scope of practice 

Each three years an appointed medical practitioner will be required to be re-credentialled. This will require the practitioner to provide: 

• A completed application form for re-credentialling 
• Current professional indemnity certificate ensuring the cover reflects the requested scope of practice. 
• Current Medical Board of Australia (AHPRA) registration – confirmation of the presence or absence of conditions, undertakings, endorsements, notations, and reprimands and confirmation of type of registration 
• CPD college certificate or evidence of relevant CPD 
• A review of the medical practitioners practice at GEDS 
• health status, this may be discussed privately with the director of medical services (or equivalent), who will then be responsible for deciding how this will affect the scope of clinical practice) 

Following approval from the Medical Advisory Committee the practitioner will receive a letter of confirmation of appointment including scope of clinical practice, period of privileges and requirements to maintain clinical privileges.

Appeals process. 

A medical practitioner who has had their request for credentialing, recredentialing, or scope of clinical practice restricted, denied, withheld, or varied from the original request has the right to appeal the decision. An appeals process must be managed independently of the credentialing and scope of clinical practice committee (or equivalent). 

The appeals process should allow for reconsideration of any decision made and for new information to be presented. 

The intention to appeal must be lodged within 10 working days of the decision. The appeal must be lodged within one calendar month of receiving the decision. The credentialing and scope of clinical practice appeals committee should be convened and: comprise a majority of medical practitioners from a range of disciplines who have the necessary skills and experience to provide informed and independent advice include at least one medical practitioner who practises in the field relevant to the clinical scope being reviewed include a nominee of the relevant college, association or society include a nominee (medical practitioner or dentist) of the person who is the subject of the appeal. The appeals committee should consider all relevant material including any information the senior medical practitioner or dentist may wish to present, as well as information from the credentialing and scope of clinical practice committee. Details of the proceedings of the appeals committee are confidential. The findings are provided to the Medical Advisory Committee), which makes a final determination and informs the medical practitioner and the credentialing and scope of clinical practice committee in writing. Legal advice may be sought by either the appeals committee or the senior medical practitioner.

Urgent and Temporary Staffing Situations 

When health services urgently need senior medical practitioners temporarily, and in the event that the relevant committee cannot be immediately convened, the Medical Advisory Committee delegate the responsibility for undertaking credentialing and defining the scope of clinical practice to the director of medical services (or equivalent) on a temporary basis. Temporary credentialing and defining the scope of clinical practice decisions need to be followed as soon as practicable, in line with the formal processes undertaken by the credentialing and scope of clinical practice committee. Temporary credentialing should not exceed three months. 

Emergency Clinical Situations 

Policies and processes related to credentialing and scope of clinical practice should include provision for credentialed senior medical practitioners to administer necessary treatment outside their authorised scope of clinical practice in emergency situations where the interests of a patient are best served. This may be where a patient may be at risk of serious harm if treatment is not provided and no medical practitioner with an appropriate authorised scope of clinical practice is available and where more appropriate options for alternative treatment or transfer are not available. All such instances should be formally reviewed by the credentialing and scope of clinical practice committee (or equivalent) and a formal report issued. 

4.6. Medical Care 

The Glen Eira Day Surgery provides facilities, nursing care and aid for the treatment and management of patients of Credentialled Medical Practitioners. It is the responsibility of the Credentialed Medical Practitioner to ensure that the written consent of his/her patients to all treatment medical, surgical, or otherwise is obtained. The Responsible Medical Practitioner shall provide, whenever possible before admission, a provisional diagnosis and relevant past history and examination in the patient’s medical record. During the course of the patient’s admission concise, pertinent, and relevant information shall be documented in the patient’s medical record. 

• In the event of an order for treatment being given by telephone, it shall only be given to a registered nurse or medical practitioner who shall write such orders in the notes. Such orders should be documented in the patient’s medical record by the Registered Nurse who took the order and signed and dated when completed. 
• Procedural reports shall contain pre-procedure symptoms, a description of the findings, the procedure that has been carried out, any tissue removed, or biopsies taken and any post-procedure diagnosis and management. This should be completed on the day of the procedure. 
• It is expected that, in the interest of high-quality patient care, the Responsible Medical Practitioner will speak with his or her patient following their procedure and if requested by the nursing staff at any time throughout their admission. 
• Where a situation arises which, in the opinion of the Registered Nurse who is in charge of the patient at the time, requires the attention of the Responsible Medical Practitioner, every reasonable effort will be made to communicate with the Responsible Medical Practitioner with regard to the situation and to consult with him/her as to the care and treatment of the patient. However, if the Responsible Practitioner cannot be contacted, the Glen Eira Day Surgery has the right to take whatever action it considers necessary in the interests of the patient. This may include the calling of another medical practitioner to care for the patient, or the transfer of the patient to another hospital. In either case, the Responsible Medical Practitioner will be advised of the action as soon as possible. 
• All Medical Practitioners credentialled at Glen Eira Day Surgery shall have admission rights to other acute care facilities that provide extended hours care. This is to ensure effective and efficient after hours support if the patient requires such admission. 
• In the event that a credentialed medical practitioner wishes to undertake any new procedures at the Glen Eira Day Surgery he or she must make application to the Medical Advisory Committee and seek extension to Scope of Practice. Following approval by the committee the medical practitioner will receive written confirmation as to the change in their scope of practice. 

4.7. Open Disclosure 

The process of Open Disclosure is undertaken by the patient’s medical practitioner at GEDS along with the Medical Director /Director of Nursing or delegate. 

The main elements of open disclosure are: 

• an apology or expression of regret, which should include the words ‘I am sorry’ or ‘we are sorry’ 
• a factual explanation of what happened 
• an opportunity for the patient to relate their experience of the adverse event 
• a discussion of the potential consequences of the adverse event 
• an explanation of the steps being taken to manage the adverse event and prevent recurrence. 

Open disclosure is a discussion and an exchange of information that may take place in one conversation or over one or more meetings. Examples of phrases that may be useful include: 

“I am very sorry this has happened”; 

“I am sorry that this hasn’t turned out as expected” 

4.8. Statutory Duty of Candour 

Health services are required to provide a patient with a Statutory Duty of Candour (SDC) when they have suffered a serious adverse patient safety event (SAPSE) while receiving healthcare at their facility. The SDC builds on the principles and elements of open disclosure within the Australian Open Disclosure Framework, currently used for all cases of harm and near miss. 

When a patient has suffered a SAPSE, the health service (GEDS) is legally required to provide the patient, and/or their next-of-kin (NOK)/carer, with: 

• a written account of the facts regarding the SAPSE 
• an apology for the harm suffered by the patient 
• a description of the health services response to the event 
• the steps that the health service has taken to prevent re-occurrence of the event

The health service is required to comply with timelines and requirements set out in the Victorian Duty of Candour Guidelines (legislative instrument), as set out within the SDC Process Flowchart (Policy 15A). 

If the event is classified as a sentinel event, they must also comply with any relevant timelines within the Victorian sentinel event guide (See Sentinel Event Policy G24) 

The Statutory Duty of Candour process uses the documents Safer Care Victoria documents and guidance. Patient documentation packs have been provided within the SDC folder that is kept in the nurse’s station in recovery. 

4.9. Infection Control 

All Visiting Medical Practitioners will be expected to meet the requirements of the Hand Hygiene and Aseptic Technique Procedures. 

4.9.1. Hand Hygiene 

Hand hygiene must be performed before and after every episode of patient contact. This includes: 

1. before touching a patient. 
2. before a procedure. 
3. after a procedure or body substance exposure risk. 
4. after touching a patient; and 
5. after touching a patient’s surroundings. 

4.9.2. Aseptic Technique 

Differentiation between Standard and Surgical ANTT is intended to provide clarity and structure to aid understanding, but not polarise practice. ANTT guidelines help standardise practice, technique, and equipment levels. 

Standard ANTT — Clinical procedures managed with Standard ANTT will characteristically be technically simple, short in duration (approximately less than 20 minutes) and involve relatively few and small key sites and key parts. Standard ANTT requires a main general aseptic field and non-sterile gloves. The use of critical micro aseptic fields and a non-touch technique is essential to protect key parts and key sites. At GEDS, Standard ANTT is used for simple dressings and Invasive Device Insertion. 

Surgical ANTT — Surgical ANTT is demanded when procedures are technically complex, involve extended periods of time, large open key sites or large or numerous key parts. To counter these risks, a main critical aseptic field and sterile gloves are required and often full barrier precautions (Pratt et al, 2007). Surgical ANTT should still utilise critical micro aseptic fields and non-touch technique where practical to do so. 

4.10. Management of Medicines 

All medications to be administered to patients shall be clearly documented and signed for on the Medication Chart in the medical record except for anaesthetic drugs which must be recorded on the Anaesthetic Record and medications given during a procedure the treating doctor which must be accurately in the Operation Report. Alternatively, these medications should be recorded on the Medication Chart. 

Prescriptions shall be completed for all drugs required by the patient for use upon discharge following their procedure. Glen Eira Day Surgery does not have facility for the dispensing of any drugs or medications; these must be obtained from a pharmacy by the patient. 

It is not acceptable for medical practitioners to use the same ampoule or vial for multiple patients. There is a considerable risk of cross contamination between patients and/or contamination of the ampoule or vial which may be left open for a period of time. 

A new ampoule or vial of medicine must be opened for each patient. It is opened only when needed and disposed of following the conclusion of each procedure. 

4.10.1. Schedule 8 and 4 medicines 

In the case of Schedule 8 and 4 medications the patient’s name and unit record number must be recorded against the drug used and any amount not used MUST be discarded and this amount recorded in the Drug of Addiction administration book in the notes/comments section provided. This is a Department of Health Regulation 

4.11. Surgical Procedures 

Conduct of Surgical Procedures: 

• Any specimens taken from the patient during the procedure shall be sent for pathological examination. A copy of the pathologist’s report shall be kept in the patient’s medical record. 
• Proceduralists shall adopt the Glen Eira Day Surgery Operating Room procedures, this includes participating in the Time Out Procedure before commencing each case in order to ensure correct procedure, correct side & side (if applicable) and correct patient. 

Allocation of Operating Room Sessions: 

• Sessions are allocated to proceduralists on an agreed basis either weekly or as suitable for that proceduralist. 
• The patient’s name, address, telephone number and date of birth, provisional diagnosis, and the nature of the procedure to be performed, shall be provided to the admissions clerk as early as possible prior to the sessions. 
• When a proceduralist wishes to cancel a session for any reason it is required that adequate notice is given to the Director of Nursing and the Director of Operations so that the session time may be allocated to another proceduralist if possible and that staff and patients can be notified of the changes. 
• The Glen Eira Day Surgery reserves the right to make casual bookings for any session where there are no bookings ahead of any allocated session, or part of session not fully utilised. 
• The Glen Eira Day Surgery facilities will, as far as practicable, be available to Credentialed Medical Practitioners within the normal operating hours. 

4.12. Anesthetics 

• Only credentialed anaesthetists are entitled to practice at Glen Eira Day Surgery, and it is his or her responsibility to ensure they are acquainted with the patient’s drug sensitivities and current therapy before administering any drugs. 
• The administration of anaesthetics (excluding local anaesthetic procedures requiring local anaesthetic only) to a patient shall be given only by the anaesthetist, or under his/her direct supervision. 
• The medical practitioner who is to perform the procedure for which an Intravenous sedation is to be administered to the patient shall be in attendance in the Operating Room before the sedation is administered. 
• In the event that no credentialed anaesthetists are available for a scheduled operating list it is permissible for temporary credentialing to be granted to an anaesthetist providing he or she supplies their current professional medical indemnity certificate and AHPRA registration. The Chief Executive and Chairman must be informed and provide verbal approval for such an anaesthetist to practice on a temporary basis at Glen Eira Day Surgery. If he or she wishes to continue to practice at Glen Eira Day Surgery, then the procedure as outlined in 4.1 must be followed.

4.13. Admission of Children 

Children under the age of 16 years are not admitted to Glen Eira Day Surgery 

4.14. Admission of High-Risk patients 

Glen Eira Day surgery reserves the right to refuse admission to patients in the following high-risk categories/ Exclusion Criteria 

• BMI greater than 45 
• Weight greater than 150kgs 
• Patients at risk of self -harm 
• Patients requiring restraints or seclusion
• Patients with a level of cognitive impairment that may result in patient harm or inability to be able to follow instructions/risk of delirium 
• Patients at risk of violence or aggression 
• Pregnant women 
• Patients deemed at end of life 
• Patients aged under 16 years of age  
• Patients aged 90 years and above
• Patients that are deemed above ASA PS3 

Patients whose Body Mass Index (BMI) is 45 or above cannot be admitted for any procedure at the Glen Eira Day Surgery. It is the responsibility of the responsible medical practitioner to arrange for their patient’s treatment in an acute care facility providing extended hours care. 

Patients who are aged 90 years or above must be assessed by the responsible Anaesthetist or the Medical Director before being accepted for admission to the Glen Eira Day Surgery. The admission of such patients is subject to permission from the anaesthetist or Medical Director. 

4.15. Introduction of a new technology / patient intervention / service 

A comprehensive business case is required to be approved by the Medical Advisory Committee prior to the introduction of any new technology, patient intervention or service. 

Medical practitioners must contact the Chief Executive or Director of Clinical Services for a business case application. 

4.16. Changing, extending or reducing the scope of clinical practice 

Where new services are introduced, or when a medical practitioner wishes to extend their scope of clinical practice, they must formally undergo appropriate credentialing and scope of clinical practice processes specifically for the new service or practice. Changes must align with the ‘Requirements for medical practitioners who are changing their scope of practice’ in the Medical Board of Australia’s Registration Standard – Recency of Practice. 

The credentialing committee must be provided with the following information: 

• the change to the scope of clinical practice requested 
• additional procedural qualifications or experience related to the requested change 
• Medical Indemnity Insurance, ensuring the cover reflects the scope of practice. 
• CPD: college certificate or evidence of relevant CPD, confirming with the relevant college if indicated. 

The Medical Advisory Committee is responsible for confirming that the requested changes fit with the needs and capability of GEDS. 

In line with relevant capability frameworks, the scope of clinical practice of a senior medical practitioner at GEDS may be reduced. The scope of clinical practice may also be reduced if the Chief Executive or delegate (the Chair of the Medical Advisory Committee) determine that the requirements for relevant CPD have not been met. If this occurs, the Chief Executive or delegate (the Chair of the Medical Advisory Committee) must notify the practitioner in writing and provide them with an amended position description, ideally with a minimum of four weeks’ notice. 

A practitioner may wish to change to a subset of their current practice – that is, narrowing their scope of practice. They must formally advise the Medical Advisory Committee, who will consider the effects of the reduction on the health service and decide if an alternative source of the previously provided services is required 

4.17. Quality Assurance 

Credentialled Medical Practitioners are expected to assist their peers in the conduct of quality care and the appropriate use of resources. The Glen Eira Day Surgery will assist Specialist Groups in this work and provide the appropriate use of resources and relevant documentation. 

Glen Eira Day Surgery conducts a range of clinical internal audits. During the year, reports from these audits will be provided to the Medical Advisory Committee. These reports may indicate areas for process improvement by any clinician. The Chair of the Medical Advisory Committee will bring these areas for improvement to the attention of a medical clinician. 

4.18. Other Matters 

The Glen Eira Day Surgery encourages Credentialed Medical Practitioners to assist the Glen Eira Day Surgery in other ways. This may include help on emergency cases, work on committees, participation in post-graduate education programs and the attendance at meetings of medical staff. 

5. Evaluation of the procedure 

The Medical Advisory Committee will review the Medical Bylaws once every three years. 

6. References and Standards 

National Standard for Credentialing and Defining the Scope of Clinical Practice 2004 

Clinical Engagement, Department of Health, Victoria 2012 

Credentialing and defining the scope of clinical practice for senior medical practitioners, Safer Care Victoria, April 2020 

Credentialing and scope of clinical practice for senior medical practitioners policy | Safer Care Victoria 

Australian Commission on Safety and Quality in Health Care – National Safety and Quality Health Service Standards. 2nd edition – version 2, 2021 

Safer Care Victoria. Victorian Duty of Candour Framework. Victoria: SCV; October 2022 

Safer Care Victoria. Victorian Duty of Candour Guidelines. Victoria: SCV; October 2022 

7. Related Legislation 

Health Service Act 1988 (amended 1st March 2022) 

Health Services (Private Hospitals and Day Procedure Centre’s) Regulations 2002 (Amended 2018) 

Health Services (Health Service Establishments) Regulations 2013 (amended 2024) 

Health Legislation Amendment (Quality and Safety) Act 2022 

8. Forms and appendices 

Application for Credentialing 

Application for Re-credentialing 

Scope of Practice Guides 

VMO Reference check 

Medication Chart 

Anaesthetic Record 

Operation Report 

9. Document History 

Date	Changes	Authorisation
12 October 2012	Document created.	CEO
November 2014	Added Radiographers.  Added changed medication chart, added open disclosure.  Added reference to Infection Control requirements.  Added required for introduction of new technology, procedure or service.	CEO
March 2019	Removed Metro spinal references, changed the re-credentialling period to 3 years, and added schedule 4 drugs to the schedule 8 drug reference.	To be reviewed at MAC. April 2019
April 2020	Removed 2 mentions of radiographers.	DON
7 November 2022	Removed ISO reference and update.	DON
8 November 2022	Minor changes following review of Medical Director and Chair of MAC and update of standards and related legislation.	DON & QC
18th November 2022	Additional of a credentialing requirement following DHHS Licencing Inspection.	DON, QC, MD, Chair of MAC
2nd February 2023	Addition of Statutory Duty of Candor process.	DON, QC, MD, Chair of MAC
30th September 2024	Updated Credentialing requirements to match updated credentialing policy and added exclusion criteria.	QC, CEO, MAC