SCHEDULE 2 - Additional Licensing Standards for Particular Classes of Private Hospitals

Regulation 6(2) , (3) , (4) and (5)

PART 1 - Surgical Hospitals

1.    Support services

A surgical class private hospital is to have access to basic pathology and radiography services within a period of time appropriate to clinical need.

2.    Clinical records

The clinical record of a patient in a surgical class private hospital is to include, if a surgical procedure has been performed –

(a) in a case where anaesthesia has been employed, the anaesthetic record, which is to comply with the recommendations contained in The Anaesthesia Record. Recommendations on the Recording of an Episode of Anaesthesia Care as published by the ANZCA; and

(b) the procedural report, including pre-procedural and post-procedural diagnoses, and a description of the findings, technique used and tissue removed or altered; and

(c) in a case where tissue or body fluid was removed, a pathological report on the tissue or body fluid; and

(d) a record of the swab, sponge and instrument count; and

(e) the post-procedural recovery record.

3.    Staffing

Staff are to be provided to give adequate assistance to an anaesthetist in accordance with the recommendations contained in the Guidelines on the Assistant for the Anaesthetist as published by the ANZCA.

4.    Identification of patients

(1) An identification band is to be fitted around a wrist or an ankle of each surgical patient.

(2) The patient’s name and date of birth and the attending medical practitioner’s name are to be written indelibly and legibly on the band.

5.    Medical, surgical and nursing equipment

(1) The following equipment is to be provided in the operating suite of a surgical class private hospital:

(a) an electrosurgical unit for each operating room;

(b) adequate instrument sets for elective use;

(c) sterile instrument sets available for emergency procedures;

(d) anaesthetic equipment and facilities as recommended by the Recommendations on Minimum Facilities for Safe Administration of Anaesthesia in Operating Suites and Other Anaesthetising Locations as published by the ANZCA;

(e) monitoring equipment recommended in the Recommendations on Monitoring During Anaesthesia as published by the ANZCA;

(f) recovery equipment, facilities and drugs recommended in the Recommendations for the Post-Anaesthesia Recovery Room as published by the ANZCA.

(2) There is to be calibration and regular testing of sterilising and processing equipment.

PART 2 - Maternity Hospitals

1.    Interpretation

In this Part –

maternity care includes –

(a) antenatal care related to childbirth; and

(b) assistance and care involved in normal childbirth; and

(c) surgical intervention in achieving childbirth; and

(d) care of a mother admitted with a baby immediately following childbirth; and

(e) postnatal care for mothers or babies who are readmitted for treatment or management of breastfeeding complications or other neonatal or maternal complications.

2.    Medical advisory committee

The medical advisory committee of a maternity class private hospital is to include at least one specialist obstetrician.

3.    Conduct of hospitals

A maternity class private hospital –

(a) is to have an approved policy in respect of the following matters:

(i) the private hospital’s criteria for admission to maternity services;

(ii) normal childbirth and the criteria for interventions to assist birth;

(iii) breastfeeding;

(iv) rooming-in;

(v) the accommodation by the private hospital of the individual needs of patients and their families;

(vi) the numbers and qualifications of medical practitioners and nursing staff available to the private hospital and the numbers of any such staff on duty for each shift;

(vii) the quality assurance programs established by the private hospital;

(viii) provision made by the private hospital for the transfer of patients to another hospital providing a higher level of medical service; and

(b) is to have an obstetrician, an anaesthetist and a paediatrician on close call at all times; and

(c) is to have a suitable number of midwives on duty at all times; and

(d) is to have contingency arrangements in case of an emergency for the transfer of mothers and babies to a hospital that is capable of providing a higher level of care.

4.    Clinical records

(1) The clinical record of a patient in a maternity class private hospital is to include the childbirth labour record if obstetric childbirth has occurred.

(2) A maternity patient’s clinical record is to be retained for at least 25 years after the date of the patient’s separation from the private hospital.

5.    Record of births

(1) Details of the birth of a baby (whether live or stillborn) born in a private hospital or admitted to a private hospital as a newborn baby (otherwise than by transfer from another hospital) is to be recorded in an approved form.

(2) The record is to be signed –

(a) by the medical practitioner or midwife attending the birth; or

(b) by the director of nursing or a person authorised by the director of nursing for the time being for that purpose.

(3) Copies of the record are to be distributed as follows:

(a) the first copy is to be retained at the private hospital with the mother’s clinical record;

(b) the second copy, unless otherwise approved, is to be forwarded to the Secretary within 6 weeks after the separation of the mother or baby from the private hospital, whichever occurs first;

(c) the third copy is to be made available to the local child health nurse, but only with the consent of the mother;

(d) other copies of the record are to be forwarded to the mother’s referring medical practitioner and consulting specialist (if any), unless the mother objects.

6.    Identification of patients

(1) An identification band is to be fitted around a wrist or an ankle of each maternity patient and baby.

(2) The patient’s name and date of birth and the attending medical practitioner’s name are to be written indelibly and legibly on the patient’s band.

(3) The baby’s name and date of birth and the attending medical practitioner’s name are to be written indelibly and legibly on the baby’s band.

7.    Furnishing of wards

Each maternity ward in a maternity class private hospital is to have one bassinette for each maternity bed and one reserve bassinette for each 10 (or portion of 10) maternity beds.

8.    Medical, surgical and nursing equipment

The delivery suite of a maternity class private hospital is to be equipped in accordance with the recommendations contained in the Recommendations on Minimum Facilities for Safe Administration of Anaesthesia in Operating Suites and Other Anaesthetising Locations as published by the ANZCA.

PART 3 - Rehabilitation Hospitals

1.    Medical advisory committee

There is to be a medical advisory committee of a rehabilitation class private hospital which is to include at least one specialist in rehabilitation medicine.

2.    Conduct of rehabilitation class private hospitals

A rehabilitation class private hospital –

(a) is to have a written policy on the provision of rehabilitation services, including –

(i) a statement of the private hospital’s philosophy of service; and

(ii) details of the liaison to be established with community-based services to ensure continuity and coordination of care; and

(b) is to have clear, written criteria and assessment procedures for the admission of both inpatients and outpatients to rehabilitation programs; and

(c) is to have a written rehabilitation plan for each patient that –

(i) is based on the assessment of that patient; and

(ii) states the needs and limitations of the patient and the goals of the rehabilitation plan; and

(iii) is prepared by a multi-disciplinary team with the active participation of the patient and the family of the patient; and

(iv) includes provision for discharge, continuing care and review; and

(d) is to have procedures for regularly evaluating the progress of each patient having regard to the written rehabilitation plan; and

(e) is to have a formal and planned discharge procedure; and

(f) is to have regular case management meetings, involving the treating medical practitioner and appropriate therapists, to review individual rehabilitation plans; and

(g) is to have access to specialists for consultation; and

(h) is to have sufficient appropriate therapists for the services provided; and

(i) is to have sufficient registered nurses with appropriate rehabilitation qualifications or experience on duty at all times; and

(j) if patients with brain impairment are being treated, is to have access to the services of a neuropsychologist; and

(k) if patients with chronic pain are being treated, is to have access to the services of a clinical psychologist.

3.    Clinical records

The clinical record of a patient in a rehabilitation class private hospital is to include –

(a) a clear statement by the treating medical practitioner giving details of the reason for admission and the perceived need for rehabilitation which is consistent with the admission policy; and

(b) a rehabilitation plan based on the assessment of the patient; and

(c) a record of each evaluation of the patient’s progress; and

(d) a discharge plan.

PART 4 - Psychiatric Hospitals

1.    Medical advisory committee

There is to be a medical advisory committee for a psychiatric class private hospital which is to include at least one psychiatrist.

2.    Conduct of psychiatric class private hospitals

A psychiatric class private hospital –

(a) is to have a written policy on the provision of psychiatric services, including a statement of the private hospital’s philosophy of service; and

(b) is to have a written policy and procedure for –

(i) supporting the functions of the Mental Health Tribunal; and

(ii) supporting the functions of official visitors, authorised officers and welfare officers; and

(iii) supporting the administration of the Guardianship and Administration Act 1995 ; and

(iv) the management of patients’ trust funds; and

(c) is to have clear, written criteria and assessment procedures for the admission of both inpatients and outpatients to psychiatric programs; and

(d) is to have a written treatment plan for each patient that –

(i) is based on the assessment of that patient; and

(ii) includes provision for discharge, continuing care and review; and

(e) is to have access at all times to a psychiatrist; and

(f) is to have access to a general practitioner and relevant specialists for consultation; and

(g) is to have sufficient registered nurses with appropriate psychiatric qualifications or experience on duty at all times.

3.    Clinical records

The clinical record of a patient in a psychiatric class private hospital is to include –

(a) a clear statement of the reason for admission, consistent with the admission policy; and

(b) a treatment plan based on the assessment of the patient; and

(c) a record of each evaluation of the patient’s progress; and

(d) a discharge plan.

4.    ECT equipment

The equipment and drugs provided in areas in which electroconvulsive therapy is administered is to comply with recommendations contained in the Recommendations on Minimum Facilities for Safe Administration of Anaesthesia in Operating Suites and Other Anaesthetising Locations as published by the ANZCA.