Victorian Consolidated Regulations

HEALTH SERVICES (HEALTH SERVICE ESTABLISHMENTS) REGULATIONS 2013

TABLE OF PROVISIONS

   PART 1--PRELIMINARY

   1.      Objectives  
   2.      Authorising provision  
   3.      Commencement  
   4.      Revocation  
   5.      Definitions  

   PART 2--PRESCRIBED HEALTH SERVICES

   6.      Day procedure centres  
   7.      Private hospitals  
   7A.     Health service establishment protocols for quality and safety  

   PART 3--FORMS OF APPLICATION AND FEES

   8.      Application for approval in principle  
   9.      Application for transfer or variation of certificate of approval in principle  
   10.     Application for registration  
   11.     Annual fees  
   12.     Application for renewal of registration  
   13.     Application for variation of registration  
   13A.    Application for approval of alterations to clinical area  

   PART 4--SENIOR APPOINTMENTS

           Division 1--Director of Nursing

   14.     Director of Nursing must be appointed  
   15.     Acting Director of Nursing  
   16.     Secretary must be notified of appointment  

           Division 2--Other appointments

   17.     Chief Executive Officer and Medical Director  
   18.     Secretary to be notified of termination or vacancy  

   PART 5--ADMISSION OF PATIENTS

           Division 1--Unit record number

   19.     Unit record number must be allocated  

           Division 2--Information to be given to patients

   20.     Information about fees and services  

           Division 2A--Pre-admission requirements

   20A.    Pre-admission assessment  

           Division 3--Clinical records

   21.     Clinical record must be created  
   22.     Information to be included in clinical record  

           Division 4--Identification of patients

   23.     Means of identifying patients  
   24.     Identification of infants  

   PART 6--CARE OF PATIENTS

           Division 1--Management of patient care

   25.     Respect, dignity and privacy  

           Division 2--Nursing and professional care

   26.     Nurses must be registered and competent  
   26A.    Post-operative care of surgery patients  
   26B.    Care of maternity, obstetric and neonatal patients  
   27.     Sufficient nursing staff must be on duty  
   28.     Needs of patients must be met  
   28A.    Reversible agents must be available  

   PART 7--COMPLAINTS

   29.     Nomination of complaints officer  
   30.     Dealing with a complaint  
   31.     Record of complaint  
   32.     Person making complaint must not be adversely affected  
   32A.    Open disclosure policy  

   PART 8--TRANSFER AND DISCHARGE OF PATIENTS

   33.     Transfer of patients  
   34.     Discharge information to be given to patients  
   34A.    Information provided to patient transport  

   PART 9--REGISTERS, RECORDS AND PERMITS

           Division 1--Patient Register

   35.     Patient Admission and Discharge Register  

           Division 2--Staff Register and records

   36.     Staff Register  

           Division 3--Other Registers

   37.     Operation Theatre Register  
   38.     Birth Register  

           Division 4--Permits

   38A.    Permit issued under section 19 of the Drugs, Poisons and Controlled Substances Act 1981  

   PART 10--PREMISES AND EQUIPMENT

   39.     Identification of rooms  
   40.     Communications  
   41.     Prevention of scalding  
   42.     Repair and cleanliness of premises  
   43.     Suitability and cleanliness of facilities, equipment, furnishings and fittings  
   43A.    Premises, staff and equipment outside health service establishment  
   43B.    Evacuation plan  

   PART 11--INFECTION CONTROL

   44.     Infection Control Management Plan  

   PART 12--DISPLAY OF INFORMATION

   45.     Information to be prominently displayed  

   PART 13--STATISTICAL RETURNS

   46.     Returns and reports to be given to the Secretary  
   46A.    Reporting of sentinel events  
   46B.    Reporting of compliance with the duty of candour  

   PART 14--ENFORCEMENT

   47.     Form of notice of seizure  

   PART 15--QUALITY AND SAFETY REVIEW DATA

   48.     Review of quality and safety of health services provided  
   49.     Patient experience survey data  
   50.     Staff safety culture survey data  

   PART 16--MISCELLANEOUS

   51.     Change of title provision  
           SCHEDULE 1
           SCHEDULE 2
           SCHEDULE 3
           SCHEDULE 4
           SCHEDULE 5
           SCHEDULE 6
           SCHEDULE 7
           SCHEDULE 8
           ENDNOTES