GP, Primary Care & Health Services Collaboration. Credentials and Clinical Privileges Process for Medical Practitioners

Transcription

1 GP, Primary Care & Health Services Collaboration Credentials and Clinical Privileges Process for Medical Practitioners

2 CONTENTS Introduction. 3 General Principles....4 Credentials and Clinical Privileges Process Applying for Clinical Privileges Interim Privileges Credentialing Process Probationary Period Duration of Clinical Privileges Review of Clinical Privileges Locum Practitioner Appointments Transfer of Clinical Privileges to another Primary Health Care Facility Suspension of Clinical Privileges Termination of Clinical Privileges Appeals Medical Practitioner File Emergencies Emergency Credentialing...17 Types of Clinical Privileges General Practice General Practice + Emergency Medicine Extended General Practice Glossary..20 Attachments: Attach 1. - Credentials and Clinical Privileges Application Form Attach 2. - Terms of Reference Credentials and Clinical Privileges Committee Attach 3. - Non-Disclosure, Conflict of Interest, and Confidentiality Agreement Attach 4. - Statewide Quality Assurance Appeals Committee Establishment and Terms of Reference Version 4 Oct 13 Page 2 of 41

3 INTRODUCTION These Guidelines provide a standardised framework for the review of credentials and the delineation of clinical privileges (defining scope of practice) for medical practitioners with a clinical role in a Tasmanian Health Organisation operated or contracted rural and/or community health care facility. The review of credentials and the delineation of clinical privileges as outlined in these guidelines is the process of determining what activities a practitioner may undertake in a Tasmanian Health Organisation operated or contracted rural and/or community health care facility. The credentials and clinical privileges process is a formal mechanism for ensuring that quality health services are provided within the range and scope of resources available. The process is related to quality assurance, risk management and the improvement of health outcomes. Through the credentialing and clinical privileging process only those medical practitioners who are appropriately qualified, trained and experienced, undertake clinical care within the scope of the delineated role of the health care facility. The credentialing and clinical privileging is a peer assessment process undertaken by medical practitioners in relation to other medical practitioners. Version 4 Oct 13 Page 3 of 41

4 GENERAL PRINCIPLES 1. All medical practitioners treating public and/or private patients within a rural and/or community health care facility shall have the appropriate level of training, experience and ability to perform medical practice within their level of competence, with consideration of the resources available at each facility. 2. All medical practitioners appointed to a rural and/or community health care service shall undergo a credentials assessment and delineation of clinical privileges on appointment and on a regular basis thereafter. 3. A General Practice Credentials and Clinical Privileges Committee undertake the credentialing and clinical privileges process. 4. The General Practice Credentials and Clinical Privileges Committee act on behalf of the management of the Tasmanian Helath Organisations. 5. The credentialing and delineation of privileges process is based upon consideration of the following: the definition of the qualifications, training and experience required for positions or specific procedures the medical practitioner s curriculum vitae, post graduate qualifications/college fellowship, training and experience, and recertification and log of procedures or treatments where relevant evidence of maintaining continuing professional development and training, incorporating continuing medical education and where appropriate, experience and competence in the performance of specific procedures or treatments requirements for supervision availability, commitment and reasonable ability to attend the health facility delineated role of the health facility, the designated services provided, infrastructure and support, resources and the needs of the community for a given services analysis of clinical outcomes incorporating regular peer review and clinical audit, adverse events and also clinical indicator evaluation. 6. The clinical privileges of all medical practitioners will be defined and notified to the applicant in writing prior to the practitioner commencing at a rural and/or community health care facility. 7. Clinical privileges are granted for a specific period of time and periodically reviewed. 8. The principles underlying the credentials and clinical privileges process include: it is a peer review process; all proceedings of the Committee are strictly confidential; credentialing criteria have been designed to assure both the Tasmanian Health Organisations, the Department of Health and Human Services and the practitioners that clients will receive high quality care. Consideration has been given to clinical privileges granted in respect of like positions at other health care facilities; credentialing criteria are uniformly applied to all applicants; the process is underpinned by the principles of natural justice such that the Credentials and Clinical Privileges Committee acts fairly, in good faith and without bias; and equity and merit shall form the basis of all phases of the process of assessment of credentials and delineation of clinical privileges Version 4 Oct 13 Page 4 of 41

5 practitioners are not employed to perform duties that exceed their clinical skills or training. 9. The credentials and clinical privileges process involves five steps. 1) Applying for Clinical Privileges 2) Credentialing Process 3) Granting Interim Privileges - if required 4) Approval and Delineation of Clinical Privileges 5) Re-credentialing 10. In some circumstances privileges may be granted subject to the applicant undertaking a period of supervised practice or a period of training to address deficiencies in appropriate credentials. Version 4 Oct 13 Page 5 of 41

6 11. Clinical privileges available at each health care facility are determined by the process of role delineation for each health care facility where criteria are established which reflect the needs and resources of each health care facility, including staff, equipment, and the physical resources available. Tier Availability Requirement Criteria Communities T1 Rostered GP: Sites with: Oatlands who has clinical privileges appropriate to the role of the hospital, and who is continuously contactable, and who is able to attend the hospital within 15 minutes of being contacted, and who is familiar with the clinical management of any current obstetric and/or at risk inpatient. a) sufficient numbers of appropriately credentialed GPs such that they are able to meet the availability requirements and, b) with acute inpatient beds meeting the criteria of: obstetric practice and/or identified in the role delineation study as providing emergency stabilisation and GPs endorsed by the clinical privileges committee as having expertise in emergency management and/or Scottsdale Smithton Swansea Flinders Island Queenstown King Island St Helens sites with a minimum of twenty acute inpatient beds that are staffed and equipped to provide management of stable acute medical and/or surgical conditions. T2 Rostered GP: Sites with: Beaconsfield who has clinical privileges appropriate to the role of the hospital, and who is generally continuously contactable but may be uncontactable by prior arrangement with the hospital for an aggregate period not exceeding two hours in any twenty-four hour period, and who is able to attend the hospital within 30 minutes of being contacted a) sufficient numbers of appropriate credentialed GPs such that they are able to meet the availability requirements and b) with not more than 20 inpatient beds that are staffed and equipped to provide management of acute and/or stable medical conditions Campbell Town Deloraine Esperance George Town Huon Eldercare New Norfolk Nubeena St Marys T3 Rural community GP who agrees to make arrangements with other appropriate service providers to provide continuously staffed telephone service when he/she is Version 4 Oct 13 Page 6 of 41 Rural communities, without overnight inpatient beds, in which there is historical and ongoing collaboration, generally within a collocated facility, between DHHS staff and local GP(s) in planning Bicheno Bruny Island Ouse

7 unavailable for any period exceeding two hours. This may include arrangements with other GPs in adjacent towns and/or statewide telephone triage services and ensures that the alternative service arrangements, when in use, are made known to anyone contacting the surgery in person or by telephone and co-ordinating the health care needs of the local community and/or individual clients. Triabunna Rosebery 12. Generally clinical privileges granted are specific to a specified rural and/or community health care facility and are not automatically transferable to another facility. The extent of privileges may vary from facility depending on the role of the service. 13. Statewide privileges may be granted to locums who intend working in more than one site in Tasmanian Rural hospitals. Privileges for Tier 1 sites (Flinders Island, King Island, May Shaw (Swansea), Midlands, Queenstown, Scottsdale, Smithton and St Helens) require evidence of recent attendance at Emergency Medicine training course (ELS, ALS or accredited emergency courses). Version 4 Oct 13 Page 7 of 41

8 CREDENTIALS AND CLINICAL PRIVILEGES PROCESS 1. APPLYING FOR CLINICAL PRIVILEGES Medical Practitioners 1.1 Medical practitioners seeking clinical privileges at a rural and/or community health care facility shall request an application form (Attachment 1) from the office of GP, Primary Care & Health Services Collaboration. 1.2 The signed and completed application form for clinical privileges shall be submitted to GP, Primary Care & Health Services Collaboration. The Application shall contain the following information: the specific category of clinical privileges required Copies of 3 documents of Evidence of Identity to meet 100 Point Identification Check Current curriculum vitae Copies of relevant visa documents (if applicable) A copy of your current medical indemnity insurance certificate A copy of your current triennium college Continuing Professional Development Statement (CPD/CME) or evidence of relevant continuing professional developed (such as copies of participation certificates). Copies of all specialist or other qualifications A completed Record of Conviction Consent Form (attached) and Statuary Declaration (if required), or a copy of a Police Check conducted within the last 12 months. Emergency Training Certificate (College Category 1 Activity) less than 3 years old (for Tier 1 Facilities only) Prior to employment, or extension of current contract, DHHS policy requires a Pre-employment Conviction Check (Police Check) to be undertaken. In order for this to occur a Record of Conviction Consent Form and Statuary Declaration (if required) must be completed, and returned to the GP, Priamry Care & Helath Services Collaboration office. This check is a mandatory requirement of granting clinical privileges. If a Police Check has been conducted within the last 12 months a copy of the results will address this. 1.3 The completed application form together with attachments is to be sent to the GP, Primary Care & Health Services Collaboration shall: verify information on the application in accord with its procedures ensure that all sections are completed and that the supporting documents and other information are available. 2. INTERIM PRIVILEGES 2.1 The Medical Director, GP, Primary Care & Health Services Collaboration may grant interim clinical privileges for a period of up to three (3) months. 2.2 Prior to granting interim clinical privileges the Medical Director, GP, Primary Care & Health Services Collaboration shall: Version 4 Oct 13 Page 8 of 41

9 review the practitioner s application to ensure that all criteria relating to the clinical privileges applied for are met; and contact the referees of the applicant and seek information as detailed in 3.2 below. 2.3 The medical practitioner will be notified in writing of the interim clinical privileges to be granted and the period of time for which they have been granted not greater than three (3) months. 2.4 All medical practitioners granted interim privileges shall have their application for clinical privileges reviewed at the next meeting of the Credentials and Clinical Privileges Committee (see Terms of Reference Credentials and Clinical Privileges Committee Attachment 2) for confirmation of privileges or extension of the interim period. 3. CREDENTIALING PROCESS Review of Application 3.1 The Medical Director, GP, Primary Care & Health Services Collaboration shall review all applications against criteria relating to the clinical privileges applied for prior to the Credentials and Clinical Privileges Committee meeting. Referee Reports 3.2 The Medical Director, GP, Primary Care & Health Services Collaboration will contact the referees of an applicant and seek: an expression of opinion as to the applicant s technical skills information as to the applicant s involvement in education and peer review activities an expression of opinion as to the standing of the applicant in the discipline an expression of opinion as to whether, on the basis of the referees knowledge of the applicant, the applicant would be recommended the basis of the referee s knowledge of the applicant. Presentation of the Application to the Committee 3.3 The application for clinical privileges, together with the supporting documentation and the referee report (if required), will be tabled at the next meeting of the Credentials and Clinical Privileges Committee. 3.4 The Committee will consider the application and all accompanying material against the criteria relating to the privileges applied for. Interview 3.5 On seeking clinical privileges the medical practitioner may, only if required be interviewed by the Medical Director, GP, Primary Care & Health Services Collaboration. Recommendation 3.6 The Credentials and Clinical Privileges Committee shall make a recommendation as to whether or not clinical privileges shall be granted If recommended for privileges the Committee shall specify details of the clinical privileges to be granted, the duration and if there are any conditions under which they are granted in writing. Version 4 Oct 13 Page 9 of 41

10 Approval 3.7 The Medical Director, GP, Primary Care & Health Services Collaboration has the delegated authority to approve the recommendation. 3.8 GP, Primary Care & Health Services Collaboration shall within twenty eight (28) days of the Credentials and Clinical Privileges Committee meeting advise the applicant in writing of the decision. 3.9 If the Credentials and Clinical Privileges Committee recommend that privileges not be granted GP, Primary Care & Health Services Collaboration shall advise the applicant in writing and details of the Appeals Procedure shall be provided. 4. PROBATIONARY PERIOD 4.1 The Credentials and Clinical Privileges Committee may recommend a probationary period to be served by a practitioner with respect to clinical privileges. This probationary period is to be for a defined period of time pending review. 4.2 The Committee shall determine the purpose of the probationary period and method of evaluation at the end of the probationary period. 5. DURATION OF CLINICAL PRIVILEGES 5.1 Clinical privileges can be granted for up to three (3) years. Except for the following categories of doctors Pre-vocational General Practice Placement Program (PGPPP) medical practitioners can be granted clinical privileges for six (6) months. The PGPPP enables resident rotations between the 3 major Tasmanian Hospitals and DHHS rural facilities. The posts should not be available to an overseas trained doctor in the intern year. Condition of privileges detailing special supervision requirements will be issued for the term of the placement in the rural hospital. Evidence of participation in the PGPPP program is required Registrars can be granted privileges for twelve (12) months under supervision. Doctors who provide evidence of being registered in a training program (e.g. General Practice Training Tasmania (GPTT), Remote Vocational Training Scheme (RVTS) etc.) do not need to supply CPD statement Recently arrived (<3 years) International Medical Graduates (IMGs) without Australian Fellowship or equivalent can be granted clinical privileges for a period of twelve (12) months. The annual renewal of clinical privileges will be influenced by satisfactory participation in continuing professional development (CPD) activities during the current credentialing year and meeting the APHRA requirements Doctors with Limited Registration appearing on their current Australian Health Practitioner Regulation Agency (AHPRA) Registration must achieve 30 Category 1 CPD points in every 12 month period that they have limited registration. Version 4 Oct 13 Page 10 of 41

11 5.1.5 Doctors aged will be granted privileges in line with the current FRACGP/ACCRM triennium Doctors aged 74 will be granted privileges for twelve (12) months Once a Doctor has reached the age of 75 or when a Doctor aged 75 or over initially applies for clinical privileges an assessment of review of current practice will be required as determined by the Committee. This assessment may include all or some of these elements: An interview with the doctor seeking re-credentialing regarding their future plans for continuing practice Information from RMP practice colleagues (where applicable/ appropriate) information from the Director of Nursing/ Nurse Unit Manager of the rural health facility information from the Department of Emergency Medicine of the relevant major regional hospital an audit of inpatient care notes an audit of emergency treatment patient notes (where applicable) an audit of prescribing information Information from ward nursing staff Discussion with RMP s personal general medical practitioner (with permission from RMP) Other information sources as required. A documented assessment will be sent to CCPC membership for agreement on duration of privileges. After initial review an annual review will take place which will include: A phone interview with the doctor seeking re-credentialing regarding their future plans for continuing practice Information from the Director of Nursing/ Nurse Unit Manager of the rural health facility If any concerns/ issues are raised prior to or during the above review processes or through contact with associated persons (e.g. staff, patients, etc) then the Committee may commission a more comprehensive assessment. The membership of this comprehensive assessment shall be independent of previous review/ assessment processes. Note: Tier 1 Requirements Emergency training (acat 1 40 cpd activity or equivalent) will be accepted up to 3 years since participation. 6. REVIEW OF CLINICAL PRIVILEGES A process for re-credentialing must be available within all Tasmanian health services/ facilities where individual healthcare practitioners work. An individual healthcare practitioner should not retain their appointment if, on review, they do not maintain the requirements for credentialing or scope of clinical practice. Basic credentials such as registration to practice must be updated annually and the healthcare practitioner s scope of clinical practice should be reviewed in line with the regular performance development appraisal which is the responsibility of the DHHS facility at which the healthcare practitioner is practising. A healthcare practitioner s credentials should only be renewed for a period commensurate with the term of his/her employment/engagement or for a maximum of five years where the healthcare practitioner holds a permanent appointment. A review must be undertaken whenever there are concerns about safety and efficacy, changes to the role or scope of practice of the healthcare practitioner or to the facility or health service s capability to provide the appropriate support. Where performance issues are identified they must be dealt with outside the Version 4 Oct 13 Page 11 of 41

12 credentialing process and through normal human resources management processes designed for managing performance, disciplinary and/or capability issues. Facilities and health services within the Area Health Services have a duty of care to patients and must be able to review healthcare practitioners credentials and their defined scope of clinical practice when required. 6.1 A review of the clinical privileges of practitioners shall occur in the following circumstances: Routine at the end of any probationary period upon the expiry of the current term of privileges as specified in the practitioner s letter confirming clinical privileges upon the request of the individual practitioner to whom the privileges apply upon confirmation of Fellowship of the relevant professional college upon completion of a satisfactory course to gain privileges for a Tier 1 facility. Non-Routine a change in the role delineation of the health care facility; at the request of a relevant professional group, relevant Area Health Services Manager, Chief Executive Officer, Deputy Secretary, or the Secretary, where legitimate and verifiable concerns are expressed concerning an individual practitioner s clinical performance; or where there are indicators of decreasing clinical competence which may include insufficient procedures to maintain clinical skills, outdated practices, reduced clinical interest and poor outcomes, decreasing physical and/or mental health as shown by behavioral abnormalities, drug or alcohol dependency or health breakdown. where CPD requirements are not maintained. where conditions are not met. Review at the end of a Specified Probation Period 6.2 The practitioner shall be notified in writing by GP, Primary Care & Health Services Collaboration twenty eight (28) days prior to the expiry of specified probation period. 6.3 The practitioner shall be responsible for submitting documentation as requested to GP, Primary Care & Health Services Collaboration. 6.4 The Medical Director GP, Primary Care & Health Services Collaboration or his delegate shall complete a probation report. 6.5 The probation report together with the supporting documentation shall be tabled at the next meeting of the Credentials and Clinical Privileges Committee. 6.6 The Credentials and Clinical Privileges Committee shall either: confirm the appointment terminate the appointment Version 4 Oct 13 Page 12 of 41

13 extend the probation period. Routine Review for Re-credentialing of Clinical Privileges 6.7 The re-granting of clinical privileges requires that practitioners provide evidence that they have participated in quality assurance/professional development activities relevant to their privileges. 6.8 Each practitioner due for re-credentialing of clinical privileges shall be notified in writing by GP, Primary Care & Health Services Collaboration twenty eight (28) days prior to the expiry of the current term of clinical privileges. 6.9 Each practitioner who wishes to be reappointed shall be responsible for completing the Application Form sections for Extension and Re-defining scope of clinical practice applicants and submitting it together with the required documentation to the GP, Primary Care & Health Services Collaboration by the due date The completed application form together with attachments is to be sent to GP, Primary Care & Health Services Collaboration. GP, Primary Care & Health Services Collaboration shall : verify information on the re-application in accord with its procedures ensure that all sections are completed and that the required supporting documents and other information are available. Request from Practitioner to Vary Privileges 6.11 A practitioner may make application at any time to change their clinical privileges Such applications shall be in writing and include the following: a completed Extension / Variation to Clinical Privileges application form; an outline of the new privileges requested; and evidence that the applicant has acquired the necessary training and experience The application shall be sent to GP, Primary Care & Health Services Collaboration and processed in the same manner as specified in section (3) above. Change in Health Care Facility Role Delineation 6.14 The practitioner shall be notified in writing of the intent of the Credentials and Clinical Privileges Committee to review their clinical privileges, in line with the change of the health care facility role delineation The practitioner shall be advised in writing regarding the outcome of the review. Other Non-routine Review 6.16 Prior to proceeding to a non-routine review by the Credentials and Clinical Privileges Committee the Medical Director, GP, Primary Care & Health Services Collaboration shall undertake a preliminary inquiry. Version 4 Oct 13 Page 13 of 41

14 6.17 Where a preliminary inquiry is undertaken the Medical Director, GP, Primary Care & Health Services Collaboration in consultation with the relevant Area Health Service Manager and Area Director of Medical Services shall determine whether there is factual basis for a report or complaint and as to whether the matter shall be referred to the Credentials and Clinical Privileges Committee If the matter is to be referred to the Committee the practitioner shall be contacted by the Medical Director, GP, Primary Care & Health Services Collaboration and shall be notified in writing of the intent of the Committee to review their clinical privileges The practitioner shall be provided twenty eight (28) days to provide any information relevant to their case to the Committee The Committee shall respond to the review by determining to recommend whether the practitioner s present clinical privileges shall be: continued amended revoked Where revocation or amendment to clinical privileges is being considered the Committee shall observe the rules of procedural fairness, and give the practitioner an opportunity to address, either verbally or in writing any material or information before the Committee which might be considered to be prejudicial to the interest of the practitioner and upon which the Committee is proposing to rely The Committee may refer matters (as per APHRA requirements) that arise in the course of a review to the Medical Council The Committee may obtain external professional advice on medical matters where it considers it appropriate to do so The Committee may form a sub-committee made up of medical practitioners to investigate and report to it. 7. LOCUM PRACTITIONER APPOINTMENTS 7.1 All practitioners applying for locum appointments shall apply for clinical privileges as per 1 above. 7.2 In general, specialist staff may not nominate a locum with fewer qualifications unless this is clearly specified and the locum is given clinical privileges at a lesser level. 7.3 Where the information provided is satisfactory, the the Medical Director, GP, Primary Care & Health Services Collaboration, may appoint a locum for a maximum of three months with defined interim clinical privileges. 7.4 All locum practitioners granted interim privileges shall have their application for clinical privileges reviewed at the next meeting of the Credentials and Clinical Privileges Committee for endorsement and/or extension of the interim period. 7.5 All locum practitioners shall receive written confirmation of the extent of clinical privileges and the time limits of the appointment. Version 4 Oct 13 Page 14 of 41

15 7.6 Following the completion of a locum the health care facility manager may be asked by GP, Primary Care & Health Services Collaboration to provide feedback in relation to the locum practitioner s performance. 8. TRANSFER OF CLINICAL PRIVILEGES TO ANOTHER PRIMARY HEALTH CARE FACILITY 8.1 Where required a medical practitioner with existing clinical privileges may have those privileges transferred to another rural and/or community health care facility In this instance the Medical Director, GP, Primary Care & Health Services Collaboration, may grant interim clinical privileges for a period of up to three (3) months The medical practitioner will be notified in writing of the interim clinical privileges to be granted and the period of time for which they have been granted not greater than three (3) months All medical practitioners granted interim privileges shall have their application for clinical privileges reviewed at the next meeting of the Credentials and Clinical Privileges Committee for confirmation of privileges or extension of the interim period. 9. SUSPENSION OF CLINICAL PRIVILEGES An Extraordinary meeting (quorum of voting members) will be called by the Medical Director, GP, Primary Care & Health Services Collaboration along with discussion with the relevant Manager of Area Health Services and Director of Medical Services in circumstances of required decisions to suspend clinical privileges. Such meetings will be called and may temporarily suspend or restrict clinical privileges, in the following circumstances: if the service cannot provide the support services necessary for safe service provision if the service no longer needs the services, procedures or other interventions for which clinical privileges have previously been granted if a medical practitioner is not registered with APHRA, for whatever reason if a medical practitioner is found to have made a false declaration, with or through omission of important information or inclusion of false information if a medical practitioner is subject to a criminal investigation about a serious matter (for example, a drug-related matter, or an allegation of a crime against a person) which, if established, could affect his or her ability to exercise his or her clinical privileges safely and competently and with the confidence of the community if there is a belief, held in absolute good faith, by the persons authorised to suspend clinical privileges that the competence and/or performance of a medical practitioner is such that continuation of existing clinical privileges would constitute a serious threat to public health and safety. PM flagged Clause 9 (Page 15) discussion as to who should have power of suspension. Decision - Extraordinary meeting to be held of voting members quorum to make this decision. NB1 to be removed NB2 to remain. NB 1: Performance issues should be dealt with outside the credentialing process. Version 4 Oct 13 Page 15 of 41

16 9.1 Should it be determined that a medical practitioner s clinical privileges should be suspended or restricted the following shall occur: The reasons for the decision are to be fully documented The medical practitioner is to be immediately advised in writing of the decision including specific reasons, and or his or her right to an immediate review of the decision by the Credentials and Clinical Privileges Committee All relevant areas of the organisation which will be impacted on by the decision are to be advised A meeting of the Credentials and Clinical Privileges Committee is to be convened as soon as practically possible to review the decision The provision of any necessary personal or professional support to the medical practitioner is to be facilitated. Review by the Credentials and Clinical Privileges Committee 9.2 The review shall be commenced as soon as practicable but within twenty eight (28) days of the temporary suspension. 9.3 The Committee should review comprehensive information and documentation about the factors that led to the decision to suspend the medical practitioner s clinical privileges. 9.4 The Committee should seek advice from one or more independent medical practitioners who practice in the same field as the medical practitioner whose privileges have been suspended or are under review. 9.5 Legal and human resources advice should be sought if required. 9.6 The medical practitioner should be given the opportunity to consider and respond directly to any information, material and allegations that are before the Committee and be provided with the opportunity to present additional relevant information The medical practitioner is to be advised that they may provide this information to the Committee in writing or make his or her response in person If the medical practitioner elects to address the Committee in person they may be accompanied by a support person (refer Committee Procedures P24). 9.7 The Committee having considered all the available information and having heard the medical practitioner, shall make a final decision to either confirm the suspension of clinical privileges, reinstate the clinical privileges with or without specific conditions or confirm the continuation of the clinical privileges, with or without specific conditions. 9.8 The Committee should advise the medical practitioner in writing of the final decision, together with providing information of appeal procedures. 10. TERMINATION OF CLINICAL PRIVILEGES 10.1 Clinical privileges shall be terminated immediately if the practitioner ceases to be legally entitled to practice. Version 4 Oct 13 Page 16 of 41

17 10.2 The Committee may recommend the termination of clinical privileges following a review of clinical privileges as per section (6) of these Guidelines Clinical privileges are terminated automatically when the practitioner ceases to be employed by the Department or by those organizations funded by the Department for the provision of inpatient beds Clinical Privileges are terminated when expiry date lapses and a invitation to extend or vary Clinical Privileges is not responded to by the medical practitioner. 11. APPEALS 11.1 Where a recommendation is made to deny, amend or revoke the clinical privileges of a practitioner, the practitioner has the right of appeal against the recommendation. Appeals Process 11.2 Appeals must be made by notice in writing to the Medical Director, GP, Primary Care & Health Services Collaboration within twenty eight (28) days of receipt of notification of a recommendation that clinical privileges have been denied, amended or revoked. The notice of appeal is to specify the reasons why the appellant contends that the recommendation is in error The Credentials and Clinical Privileges Committee is to use its best endeavours to reconsider, within twenty eight (28) days of receipt of the appeal, its recommendation The Committee may seek further submission from the appellant If the reconsidered recommendation is not acceptable to the Appellant, the Appellant may within twenty eight (28) days of being notified of the reconsidered recommendation lodge an appeal by notice in writing to the Secretary of DHHS. A notice of appeal must set out the grounds upon which the appeal is based A notice of appeal must set out the grounds upon which the appeal is based Natural justice requires the establishment of an appeals body that is independent of the CDSCP committee. This body should advise the governing body directly The Secretary will appoint a CDSCP Appeals Committee, which may be the DHHS Clinical Governance Committee, within 14 days. It should meet within 28 days of its appointment to hear the appeal unless a delay is accepted by all parties Pending determination of an appeal, the appellant will not have the credentials and scope of clinical practice under review The unsuccessful appellant may reapply for their credentials and scope of clinical practice when able to satisfactorily demonstrate clinical competence in the field involved The appeal process is intended to allow for reconsideration of any adverse decision and for new information to be brought forward if available Assurance Appeals Committee will act in accordance with its establishment and terms of reference (Attachment 4). Version 4 Oct 13 Page 17 of 41

18 Appeals General Principles The appeal process is intended to allow for reconsideration of any adverse decision and for new information to be brought forward if available. 12. MEDICAL PRACTITIONER FILE 12.1 At the time of the application a Medical practitioner file shall be established by GP, Primary Care & Health Services Collaboration to contain pertinent information related to the application for clinical privileges, re-credentialing and practitioner clinical review activities This file is a confidential peer review file and shall be used in the course of credentialing, granting clinical privileges, re-appointment or other clinical peer review for a practitioner A practitioner may review his/her file upon request The file may not be amended and no documents copied or removed without the specific consent of the Medical Director, GP, Primary Care & Health Services Collaboration If a practitioner has a concern regarding the contents of the file, this concern may be expressed in writing to the Credentials and Clinical Privileges Committee. These concerns will be reviewed at the next meeting of the Committee. The practitioner will be advised in writing regarding the Committee s decision. 13. EMERGENCIES 13.1 In the case of an emergency any practitioner is permitted and is expected to do everything possible to save the patient s life or save the patient from serious harm to the extent permitted by his or her registration and regardless of privileges. Emergency is defined as any condition in which serious harm could result to a patient or in which the life of a patient is in immediate danger and any delay in administering treatment could add to that danger. 14. EMERGENCY CREDENTIALLING 14.1 Emergency credentialing of medical practitioners may be necessary in times of disaster or major emergency. It should always precede emergency definition of the scope of clinical practice, which should be conducted only on an exceptional basis. It should enable medical practitioners whose credentials have not been formally reviewed and verified according to the General Practice Credentials and Clinical Privileges processes to assist in the provision of clinical care at times of disaster or major emergency It should involve, at a minimum: Verification of identity, through inspection of relevant documents (e.g. drivers licence with photograph); Immediate contact with a member of senior management of the organisation either nominating or nominated by the medical practitioner to verify the medical practitioner s competence, good standing and claimed employment history; Verification with the relevant professional registration board as soon as practicable of the medical practitioner s registration history, good standing and past record of professional sanctions or disciplinary action. Version 4 Oct 13 Page 18 of 41

19 14.3 It should involve, where practicable, an assessment of the medical practitioner s available credentials by the Medical Director, GP, Primary Care & Health Services Collaboration All medical practitioners granted emergency credentials shall have their application for clinical privileges reviewed at the next meeting of the Credentials and Clinical Privileges Committee for endorsement All medical practitioners granted emergency credentials shall receive written confirmation of the extent of clinical privileges and the time limits of appointment. Version 4 Oct 13 Page 19 of 41

20 TYPES OF CLINICAL PRIVILEGES As a general guide reference is made to the criteria established by Clinical Colleges, Faculties or Associations. These are available from those bodies and are updated from time to time. Broadly these fall into three groups, general practice and specialist privileges. In all categories, in a lifethreatening emergency situation, there should be no limitation on clinical privileges. 1. GENERAL PRACTICE 1.1 Requirements for clinical privileges General Practice have been referenced to guidelines developed by the Royal Australian College of General Practice (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM). It is recognised that rural general practitioners by nature of their geographical isolation may be called upon to undertake a much wider range of practice than general practitioners in urban or provincial settings. 2. GENERAL PRACTICE + EMERGENCY MEDICINE a. Requirements for clinical privileges General Practice as per item 1. above in conjunction with relevant qualification in Advanced Life Support and emergency care experience. 3. EXTENDED GENERAL PRACTICE 3.1 Extended general practice includes privileges in the following areas: General practice anesthesia General practice obstetrics and gynaecology General practice radiology. 3.2 Privileges may be granted in a broad way according to the specialty, for example, privileges in general practice surgery, and may be modified to include or exclude specific new technologies. 3.3 In recommending the granting of such privileges note shall be taken of the resources of the health care facility (as defined by service levels under role delineation) to support the clinical work to be undertaken. 3.4 Guidelines developed by Joint Consultative Committee between the Royal Australian College of General Practice (RACGP), Australian College of Rural and Remote Medicine (ACCRM) and relevant professional colleges will be used as basis for verification and credentialing for General practice anesthesia General practice obstetrics and gynaecology General practice radiology. 3.5 The medical practitioner will practice with care and diligence within the bounds of his/her competency and experience. 3.6 Emergency life saving procedures outside these bounds are to be covered. Version 4 Oct 13 Page 20 of 41

21 GLOSSARY Appointment The result of an initial application for medical staff appointment. The process of appointment is the formal mechanism, separate from the credentials and clinical privileges process, which grants a practitioner the right to practice within a health care facility. Appointment Process The process of appointment is the formal mechanism, separate from the credentials and clinical privileges process, which grants a medical practitioner the right to practice within a health facility. It involves the selection of a preferred candidate from among competing applicants and the setting of terms and conditions of appointment consistent with relevant industrial awards or other determinations. This involves checking current medical registration, medical insurance status, clinical experience and professional referees. The preferred candidate is then reviewed under the credentialing and clinical privileges process which seeks to reach agreement on the appropriate privileges to be granted. Clinical Privileging The formal process which follows on from credentialing and involves the delineation of the scope of an individual medical practitioner s practice within the particular health service based on the individual s credentials, competence and performance, and the needs and capability of the health service. Clinical Privileges Represent the range and scope of clinical responsibility that a practitioner may exercise in a health care facility. Clinical privileges are specific to the individual, usually in a single health care facility, and relate to the individual s capacity as well as to the role delineation of the health care service. Credentialing The formal process to verify and evaluate the qualifications and experience of medical practitioner prior to appointment and at other times required by the organisation, for the purpose of forming an opinion about the medical practitioner s training, skills, experience and competence. Credentials Represent the formal qualifications, training, experience and clinical competence of the medical practitioner. They are evidenced by documentation such as university degrees, fellowships/memberships of professional colleges or associations, registration by professional bodies, certificates of service, certificates of completion of special courses, periods of verifiable formal instruction or supervised training, validated competence, Version 4 Oct 13 Page 21 of 41

22 information contained in confidential professional referee reports and professional indemnity history and status. Credentials and Clinical Privileges Committee Established and approved under Section 4 of the Health Act For medical practitioners the Committee comprises of medical practitioners and includes representatives of relevant medical colleges and other representatives. The Credentials and Clinical Privileges Committee will be informed by an initial assessment of the application for credentials. The Committee will then further assess the application often including an interview to determine appropriate privileges to be granted. A recommendation for appointment is then made to the relevant Area Health Service CEO. Health Care Facility The term health care facility is used in this document to reflect all rural and /or community health services including, district hospitals, multi purpose services and centres and community health centres. Medical Practitioner A person who is legally qualified to practice medicine within the State. Re-credentialing The continuing review and evaluation of each member of the medical staff. The goal of the evaluation is to ensure that competence consistent with privileges is maintained, and that there is an on-going commitment to match resources available at facility level with the agreed privileges of the practitioner. Role delineation Role delineation is a separate process, which determines what level of care, facilities and procedures a health care facility offers. The process of role delineation assesses health care facilities both as whole institutions and as individual clinical services provided against pre-determined criteria. It takes account of direct clinical service plus support services available. Temporary Clinical Privileges Privileges which may be granted to medical practitioners for a limited time or to undertake a specific procedure. Temporary privileges may be granted to a medical practitioner who is waiting for their application to be approved or whilst waiting to be re-credentialed. Version 4 Oct 13 Page 22 of 41

23 Attachment 3 RURAL MEDICAL PRACTITIONER CREDENTIALS AND DEFINING SCOPE OF CLINICAL PRACTICE FORM This is a: Initial application Extension Application Request to Re-define Scope of Clinical Practice 1. Applicant Details (All applicants) Surname First name Middle name Date of Birth Place of Birth Postal Address Postcode Phone (BH) Phone (AH) Mobile Residency status Australian citizen Permanent resident Temporary resident 2. Application for scope of clinical practice (All applicants) Practice Location Required Facility Start Date: Locum: Yes No End Date: Please specify in which areas of practice scope of clinical practice are sought - General Practice 1 PGPPP 2 Registrar (a) Basic Term (b) Advanced Extended General Practice or Specialist (a) Radiology (b) Obstetrics- uncomplicated deliveries (c) Subsequent Other (please specify ) Do you have a Medicare provider number for this location? Yes (Details) No (if No please be aware that you will be required to obtain one) 1 General Practice includes all other primary care areas including geriatrics, antenatal care, psychiatry, internal medicine and minor procedures. 2 PGPPP (Prevocational General Practice Placements Program) Version 4 Oct 13 Page 23 of 41

24 3. All qualifications including your primary medical degree Initial applicants list all qualifications. Extension and Re-defining scope of clinical practice applicants list new qualifications Qualifications University/Organisation Year obtained Primary Medical Degree Others ( list below) If you are seeking Extended General Practice or Specialist Scope of Clinical Practice in the area of Obstetrics or Radiology please list clinical experience and post qualification training in these areas: Qualifications/Clinical Experience University/Organisation Year obtained If you are seeking Extended General Practice or Specialist in the area of Obstetrics or Radiology please list the types of procedures you wish to undertake: 4. Clinical appointments (All applicants) Please provide details on all current and previous clinical appointments held within the past three years: Clinical Appointment Organisation Term of Role to to to to Version 4 Oct 13 Page 24 of 41

25 5. Medical registration and other matters (Initial applicants only) What is your AHPRA (Australian Health Practitioner Regulation Agency) registration number? NOTE - The Credentialing and Scope of Clinical Practice Committee will verify your medical registration on the AHPRA website. Is this general registration? Yes No Is this specialist registration? Yes No If specialist registration, please specify Do you currently have any conditions, restrictions, undertakings, reprimands or notations placed on your registration or your clinical practice either in Australia or any other country? Yes No Have you ever had any conditions, restrictions, undertakings, reprimands or notations placed on your registration either in Australia or elsewhere? Yes No Have you ever been formally disciplined (by an employer or other organisation) in the course of your work as a medical practitioner? Yes No Have you ever been the subject of prior disciplinary decision(s) or ruling(s) imposed by any registration board either in Australia or elsewhere? Yes No Has your right to practise ever been withdrawn, suspended, terminated or reduced by an organisation, employer or professional body? Yes No If you have answered Yes to any off the above please provide a brief description: (All applicants) Have you ever been convicted or found guilty of any criminal offence, including a drug- or alcohol-related offence? Yes No Are you the subject of current or pending criminal charges? Yes No If you answered yes to any of the above, please provide full details. Or, if you prefer, provide the information in a sealed envelope marked Confidential for Medical Director only appended to this application, and indicate here that additional information is provided separately in this manner. If you require further space to answer any questions, please attach separate pages, identified with the relevant section number. NOTE - Prior to defining scope of clinical practice, DHHS policy requires a Pre-employment Conviction Check (Police Check). In order for this to occur please complete a Conviction Consent Form (attached), and return it with copies of 3 documents of Evidence of Identity (as listed on Page 3 of Conviction Check Consent Form) with this completed form. If you have had a Police Check conducted within the last 12 months, please forward a copy of the results and disregard the attached form. Version 4 Oct 13 Page 25 of 41

26 6. Medical indemnity insurance information (Initial applicants) Current private medical indemnity insurance cover details - Policy Number Name or Insurer Expiry Date Please attach a copy of your current policy Is your proposed scope of clinical practice reflected in or covered by your current medical indemnity insurance? Yes No Have there ever been, or are there currently pending, medical indemnity claims, settlements or judgements against you? Yes No Has your current or any previous medical defence organisation/insurer ever excluded or reduced any specific area of practice, or terminated or denied coverage? Yes No If the answer to either of the above two questions is Yes, please provide a detailed explanation and specify the name of the relevant medical defence organisation/insurer. If you require further space to answer any questions, please attach separate pages, identified with the relevant section number. 7. Academic appointments/teaching experience Initial applicants list experience. Extension and Re-defining scope of clinical practice applicants list new experience Please provide details of university or hospital teaching appointments held within the past three years (including organisations and dates of appointment). Organisation Status/Level Term of Role to to to to Version 4 Oct 13 Page 26 of 41

27 8. Continuing professional development (All Applicants) Have you met the continuing professional development requirements of the Medical Board of Australia? (Refer to registration standard for details at Yes No Please provide a copy of your current triennium college Continuing Professional Development Statement (CPD/CME) or evidence of relevant continuing professional development (such as copies of participation certificates). 9. Quality activities (Extension and Re-defining scope of clinical practice applicants only) Participation in the Performance and Development Review process is required on an annual basis (see DHHS Performance and Development Agreement Policy) Have you participated in a Performance and Development Review process in a/the Tasmanian site which you hold clinical privileges for? Yes No Name the DON/Site Manager who worked with you on this Review: 10. Health status (Initial applicants only) Do you have a disability or health issue that: may impact on your ability to perform any of the cognitive and physical functions that would fall within the scope of practice that you are seeking in this application? Yes No may require special equipment, facilities or work practices to enable you to perform any aspect of the scope of practice you are seeking in this application? Yes No may be relevant to determining your scope of practice? Yes No If you answered yes to any of the above, please provide full details. Or, if you prefer, provide the information in a sealed envelope marked Confidential for Medical Director only appended to this application, and indicate here that additional information is provided separately in this manner. Note - This information is sought to enable an assessment to be made as to whether you can safely perform the inherent and reasonable requirements of the work that you seek to perform at the health service or whether any reasonable adjustments might be required to ensure you can work at the health service in a way that ensures patient safety. Version 4 Oct 13 Page 27 of 41

28 11. Referees (Initial applicants) Please provide details of at least three PROFESSIONAL referees who preferably work largely within the specialty being applied for, who have been in a position to judge your experience and performance during the previous three years and who have no conflict of interest in providing a reference. Surname First name Current position Postal Address Postcode Mobile Phone (BH) Phone (AH) Surname First name Current position Postal Address Postcode Mobile Phone (BH) Phone (AH) Surname First name Current position Postal Address Postcode Mobile Phone (BH) Phone (AH) Version 4 Oct 13 Page 28 of 41

29 12. Agreement/undertakings (All applicants please initial appropriate response) Initial I understand the Health Service will conduct a routine police check. Yes No Initial I authorise the Health Service to seek information from my referees as to my past experience, performance and current fitness to practise. I agree to familiarise myself with relevant hospital/ facility by-laws, policies and procedures and to abide by them. I accept that the Health Service will obtain information relevant to my application from AHPRA and any other authority that regulates health practitioners. I authorise the Health Service to obtain information relevant to my application from my current and any previous medical indemnity organisations/ insurer. I authorise the Health Service to obtain information relevant to my supervision requirements (where applicable). I authorise the Health Service to seek information from other persons as they consider appropriate, including any relevant health service, college or other professional organisation. I agree to abide by the Health Service, state and national confidentiality and privacy laws and policies and understand that breaches may result in the cessation of my appointment. I agree to notify the Medical Director, GP & Primary Care of any event/ situation that may impact on my ability to exercise my scope of clinical practice, whether it be due to medical registration matters, or otherwise. This includes matters which I consider the Medical Director would wish to be informed and, as a minimum, includes the kinds of information covered in this application (such as any criminal charges or convictions, or reductions in registration or insurance). I agree to participate in this Heath Services performance and development review and support process. I agree to promptly notify the Hospital / Facility Manager/Director of Nursing of any adverse clinical incident that I am involved in, or become aware of. I agree to work within my defined scope of clinical practice and to make a further application should I seek to extend this approved scope. Should any question as to my scope of clinical practice arise, I agree that the Health Service may make enquiries as it considers necessary to assess whether my current scope of clinical practice is appropriate. Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No 13. Declaration I hereby declare that the information contained in this application is true and correct. Signature of applicant Date Version 4 Oct 13 Page 29 of 41

30 If, for any reason, you are unable to sign the declaration above, please explain the circumstances. Please note: the information collected on this form will be used by the Department of Health and Human Services Tasmania Credentialling and Scope of Clinical Practice Committee to assist in the determination of your application. Information provided on this form will not be used, or disclosed, for any other purpose. Department of Health and Human Services Tasmania operates in accordance with federal and state privacy legislation, including adherence to the national privacy principles. Please ensure the following certified copies are attached to this form: Copies of 3 documents of Evidence of Identity to meet 100 Point Identification Check (initial applications) Current curriculum vitae (initial applications) Copies of relevant visa documents (if applicable) (initial applications) A copy of your current medical indemnity insurance certificate (initial applications) A copy of your current triennium college Continuing Professional Development Statement (CPD/CME) or evidence of relevant continuing professional developed (such as copies of participation certificates). (all applications) Copies of all specialist or other qualifications (all applications) A completed Record of Conviction Consent Form (attached) and Statuary Declaration (if required), or a copy of a Police Check conducted within the last 12 months. (all applications) Emergency Training Certificate (College Category 1 Activity) less than 3 years old (for Tier 1 Facilities only (listed below)) (all Tier 1 applicants) St Helens District Hospital Smithton District Hospital King Island District Hospital Midlands District Hospital - Oatlands, Health West ( Queenstown) May Shaw Hospital - Swansea Flinders Island District Hospital North East Soldiers Memorial Hospital -Scottsdale Please forward this completed form along with the certified copies listed above to: GP, Primary Care & Health Services Collaboration Project Support (or fax to:) GP, Primary Care & Health Services Collaboration Project Support Anne O Byrne Centre Cnr Charles and Howick Streets Launceston Tas 7250 Version 4 Oct 13 Page 30 of 41

31 If you have any queries please contact GP, Primary Care & Health Services Collaboration Project Support on (03) Attachment 2 Department of Health and Human Services Credentialing and Clinical Privileges Committee Terms of Reference Background The credentials and clinical privileges process is a formal mechanism for ensuring that quality health services are provided within the range and scope of resources available. The process is related to quality assurance, risk management and the improvement of health outcomes. Through the credentialing and clinical privileging process only those medical practitioners who are appropriately qualified, trained and experienced, undertake clinical care within the scope of the delineated role of the health care facility. This committee follows a standardised framework for the review of credentials and the delineation of Clinical privileges (defining scope of practice) for medical practitioners with a clinical role in a Department of Health and Human Services operated or contracted rural and/or community health care facility. The credentialing and clinical privileging is a peer assessment process undertaken by medical practitioners in relation to other medical practitioners. Purpose The General Practice Credentialing and Scope of Clinical Practice Committee through the credentialing and defining the scope of clinical practice process contribute to ensuring that all practitioners utilising rural and/or community health care facilities practice safe, high quality care. The Committee provides peer review and expert advice in order to make recommendations to the three Area Health Service Chief Executive Officers on matters pertaining to medical credentials, scope of clinical practice and current competencies of General Practitioners. Role and Function To undertake the process of reviewing credentials and recommending the appropriate scope of clinical practice for all new applicants applying for scope of clinical practice at a rural and/or community health care facility. To periodically review the scope of clinical practice of all appointed practitioners and, if necessary recommend variations to the scope of clinical practice of practitioners practicing within a rural and/or community health care facility. To undertake upon request from authorised individuals or bodies unplanned review of a practitioner s credentials or scope of clinical practice, and, if necessary recommend variations to the scope of clinical practice of practitioners practicing within a rural and/or community health care facility. Version 4 Oct 13 Page 31 of 41

32 To establish and use specific criteria in the evaluation of credentials and defining the scope of clinical practice for rural and/or community health care facilities. To develop and review policy and procedures for the credentialing, re-credentialing and defining the scope of clinical practice for rural and/or community health care facilities. To communicate as may be necessary or appropriate with any other committee declared by the Minister under s 4(1) of the Health Act 1997 to be a Quality Assurance Committee for the purposes of that Act in relation to any matter which falls within the functions of either committee. To report in relation to the exercise of its functions to the Secretary of DHHS in accordance with these terms of reference. The role of the Quality Assurance Committee does not include involvement in any process relating to performance management or disciplinary proceedings. Where such issues arise the Quality Assurance Committee may refer them to the Area Health Service Chief Executive Officer and/or Secretary or appropriate authority (such as the Australian Health Practitioner Regulation Authority) for further review as appropriate according to the circumstances of each case. Membership Chair: Dr G Cerchez - Medical Director, GP & Primary Care Membership: Dr P Renshaw - Director of Clinical Services DHHS (without voting rights); Mr P Morris AHS Manager DHHS (without voting rights); Dr T Tymms - A rural medical practitioner Dr R Barnes - A rural medical practitioner Dr V Powell - A rural medical practitioner Dr S Singh - A rural medical practitioner Dr A Grove - A rural medical practitioner Prof A Bell - Chief Medical Officer STAHS, Director Clinical Services NAHS, Dr A Ip - Director Medical Services NWAHS Dr G Cerchez - Medical Director, GP & Primary Care Executive Officer: Ms K Jenssen, Project Support GP & Primary Care All nominations for appointment to the Committee and all appointments to the Committee are to be in writing. Each member of the Committee is to execute a Non-Disclosure, Conflict of Interest, and Confidentiality Agreement in the terms of the attached document, as soon as practicable after the appointment of the person as a member. Version 4 Oct 13 Page 32 of 41

33 The Medical Director, GP & Primary Care (Chair will appoint an alternate member for each Standing Member of the Committee, in writing. An Alternate Member may take the place of their Standing Member on the Committee whenever the Standing Member is for any reason unable or unwilling to sit as a member. When considering credentials and Scope of Clinical Practice for a sub specialty area such as general practice, obstetrics, surgery and anaesthetics representation from the relevant learned colleges shall be sought to assist with the Committee s deliberations Member Roles The Committee shall: Maintain a record of all decisions, including the reasons therefore and evidence on which they are based ; however circulated minutes should only contain information as to recommendations; Ensure any material generated by the Committee is appropriately notated statutorily immune and stored separately and securely; and Ensure that any request for advice, assistance or support from another QAC is recorded and any material generated in response to such a request is appropriately notated statutorily immune with director to store separately and securely The Committee shall observe the rules of procedural fairness (i.e. natural justice). Meeting Times Meetings shall be held as required but should occur at least four times in each calendar year. Meeting Protocols Every 2 years Medical Director, GP & Primary Care (Chair) will call for nominations from the relevant learned colleges and organisations identified as making up the membership of this Committee. The Committee Chair shall appoint an Executive Officer to serve the Committee, who need not be a member of the Committee. The duties of the Executive Officer are to include: preparing agendas and minutes for the Committee managing paperwork associated with the membership of the operations of the Committee maintaining appropriate records of the work of the Committee in a secure location The Committee shall seek legal advice as it considers appropriate from the Solicitor General s Office. In cases where it may be necessary to seek advice from specialist practitioners, or any person who has specialised knowledge based on the person s training, study or experience, advice to the Committee may take the form of written comment. Where required the Committee may convene a working group made up of clinicians and other members, as appropriate to the matter under review to investigate and report it. Version 4 Oct 13 Page 33 of 41

34 The Committee may establish one or more working groups to prepare information or documents for the purposes of the Committee, including as a consequence of the consideration of specific cases. A working group may include persons who are not members of the Committee, but any person who is not a member of the Committee is required, before participation, to execute a Non-Disclosure, Conflict of Interest, and Confidentiality Agreement. The working group will be directed by the Chair of the Committee and will act in accordance with the Terms of Reference prepared for the purpose of the review. The Terms of Reference of a working group are to be recorded in the minutes of the Committee. The Committee may engage medical/dental specialists, or any person who has specialised knowledge based on the person s training, study or experience, to provide expert advice to the Committee. The quorum of the Committee shall be at least four (4) members. Decisions of the Committee shall be by majority of those present and voting. In the event of an equality of votes upon a proposition put to the Committee, the proposition shall be determined in the negative. A member who has a conflict of interest in relation to a matter being considered or due to be considered by the Committee must absent himself or herself from the deliberations and take no further part in any decision of the Committee in relation to that matter. Such a member s alternate may attend in their stead and take part in the deliberations and decision making of the Committee, unless the alternate also has a conflict of interest. Any issue as to whether there is a conflict of interest is to be determined by the Committee. The Committee shall report annually to the Secretary, DHHS using exclusively de-identified data in regard to the work of the Committee and shall include recommendations for the future about the work of the Committee and the continuing suitability of the Committee s Terms of Reference. Occasional reports of a confidential nature, including identifying information, may also be made to the Secretary, DHHS where the work of the Committee identifies a matter which requires the attention of management for example, a problem with the performance of a member of staff, as provided under s 4(3) of the Health Act In the event that the Secretary DHHS is satisfied that because of special circumstances which exist, the Committee as constituted above may be perceived to be biased in relation to a particular issue which falls for its determination or is otherwise unsuitable to determine such an issue, its membership for the purposes of considering and determining that issue will instead consist of not less than four (4) and not more then eight (8) persons appointed by the Secretary. Review of Terms of Reference The Committee will continue in existence until the Minister revokes the declaration of it as a Quality Assurance Committee under s 4(1) of the Health Act 1997, whereupon it shall by reason of that revocation forthwith cease to exist. Version 4 Oct 13 Page 34 of 41

35 * - Level Description Site Tier 1 Tier 2 Tier 3 Tier 4 Rostered doctor has clinical privileges appropriate to the role of the hospital, and who is continuously contactable, and who is able to attend the hospital within 15 minutes of being contacted, and who is familiar with the clinical management of any current obstetric and/or at risk inpatient. Rostered doctor has clinical privileges appropriate to the role of the hospital, and who is generally continuously contactable but may be un-contactable by prior arrangement with the hospital for an aggregate period not exceeding two hours in any twenty-four hour period, and who is able to attend the hospital within 30 minutes of being contacted. Rostered doctor has clinical privileges appropriate to the role of the hospital and who is generally continuously contactable but may be un-contactable by prior arrangement with the hospital for an aggregate period not exceeding four hours in any twenty-four hour period. (not relevant to inpatient sites) Smithton, Queenstown, Scottsdale, St Helens, Midlands, Swansea, Flinders Island, King Island Deloraine/Westbury, Campbell Town, Beaconsfield, George Town, St Marys/ Fingal, New Norfolk, Dover, Nubeena, Huon/Franklin. Bicheno, Triabunna, Bruny Island, Cygnet, Ouse, Rosebery Version 4 Oct 13 Page 35 of 41

36 Attachment 3 Non-Disclosure, Conflict of Interest, and Confidentiality Agreement General Practitioner Credentialling and Defining the Scope of Clinical Practice- Rural Health Committee In order to demonstrate your commitment to the statutory obligations, roles and responsibilities required of your Committee membership; and your commitment to declare any conflict of interest, please read and complete the following: I, the undersigned, as a member of the Credentialling and Defining the Scope of Clinical Practice- Rural Health Committee understand and acknowledge that - 1. I must not make a record of, or divulge or communicate (either in writing, fax, or verbally) to any person, any information gained by or conveyed to me as a member, except to the extent necessary for the performance of the functions of the Committee or of myself as such a member; 2. I must not make use of any such information except to the extent necessary for the performance of the functions of the Committee or of myself as a member; 3. any information I receive as a member must be kept in a secure place; 4. If I have an interest, whether by reason of personal involvement or pecuniary interest or otherwise, in a matter which is being or is to be considered by the Committee, I will disclose that interest to the Committee as soon as practicable. 5. I am aware that breach of an obligation specified in paragraph (1) or (2) above may expose me to prosecution. Agreed to and accepted: Signature... Date... Name (Please Print)... Phone... Receipt acknowledged by: Signature of... Date... Committee Chair Name (Please Print) Phone Version 4 Oct 13 Page 36 of 41

37 Attachment 4 Statewide Quality Assurance Appeals Committee Establishment and Terms of Reference I, Martyn Forrest, Secretary of the Department of Health and Human Services (DHHS), hereby establish the Statewide Quality Assurance Appeals Committee (SQAAC) upon the following basis: Functions of Committee The Committee is to contribute to the overall administration of Quality Assurance Committees (QACs) as declared under s4(1) of the Health Act 1997 by considering and determining any appeal lodged against a decision made by a committee declared by the Minister under s4(1) of the Health Act 1997 to be a Quality Assurance Committee for the purposes of that Act; recommending to the Secretary, endorsement of, substitution of or reference back to a decision appealed; recommending to the Secretary conditions which might apply to the restoration of clinical privileges (such as a period of supervised practice or a period of training); in light of discharging the preceding functions, making any other recommendations to the Secretary as the committee considers necessary or appropriate; communicating as may be necessary or appropriate with any other committee declared by the Minister under s 4(1) of the Health Act 1997 to be a Quality Assurance Committee for the purposes of that Act in relation to any matter which falls within the functions of either committee; and reporting in relation to the exercise of its functions to the Secretary of the DHHS in accordance with these Terms of Reference. Membership The Committee shall consist of the following Members: A Deputy Secretary as nominated by the Secretary (DHHS), who is to be the Chair of the Committee. One member of the relevant professional body (e.g. Australian Medical Association, Australian Nursing Federation). Chief Health Officer or Chief Nursing Advisor or Allied Health Advisor of DHHS as appropriate. Two senior health care professionals of the professional discipline involved, nominated by the Chair and appointed to the Committee by the Chair. A professional nominee of the relevant college or specialist association.

38 A professional nominee of the appellant. In addition, the Chair is empowered to co-opt not more than four (4) additional members as full voting members of the Committee if the chair considers this to be warranted in any particular case. All nominations for appointment to the Committee and all appointments to the Committee are to be in writing. Alternate Members The Chair will appoint an alternate member for each Member of the Committee, in writing. An Alternate Member may take the place of their Standing Member on the Committee whenever the Standing Member is for any reason unable or unwilling to sit as a member. Executive support The Chair of the Committee is to appoint an executive support officer to serve the Committee, who need not be a member of the Committee. The duties of the executive officer are to include - serving as the minutes secretary to the Committee; managing paperwork associated with the membership of and operations of the Committee; and maintaining appropriate records of the work of the Committee. Subcommittees The Committee may establish one or more subcommittees to prepare information or documents for the purposes of the Committee, including as a consequence of the consideration of specific cases. A subcommittee may include persons who are not members of the Committee, but any person who is not a member of the Committee is required, before participation, to execute a Non-Disclosure, Conflict of Interest and Confidentiality Agreement in the form attached, suitably adjusted to apply to a nonmember. The terms of reference of a sub-committee are to be recorded in the minutes of the Committee. Expert Assistance The Committee may engage medical specialists, or any person who has specialised knowledge based on the person's training, study or experience, to provide expert advice to the Committee. Version 4 DRAFT (Oct 13) Page 38 of 41

39 Non-Disclosure, Conflict of Interest, and Confidentiality Agreement Each member of the Committee and the executive support officer is to execute a Non- Disclosure, Conflict of Interest, and Confidentiality Agreement in the terms of the attached document, as soon as practicable after the appointment of the person as a member and in any case before the member takes their seat on the committee. Quorum A quorum of the Committee shall be 6 Members including the Chairperson or their Alternates. Provided a quorum is present, decisions will not be delayed by the absence of any member. Committee procedures An appellant is entitled to attend before the SQAAC and to be accompanied by another person. An accompanying person may not represent the appellant but may act in an advisory capacity to the appellant. The committee shall observe the rules of procedural fairness (i.e. natural justice). Documentation The committee shall maintain documentation of all decisions including the reasons and evidence on which they are based. Circulated minutes should be limited to recommendations only. Sufficient details of proceedings shall be recorded so that the reasons for decision-making can be clearly identified. A decision shall be given in writing to the Appellant and also to the Respondent to the appeal. Voting Decisions of the Committee shall be determined by a majority of those present and voting. In the event of an equality of votes upon a proposition put to the Committee, the proposition shall be determined in the negative. Conflict of Interest A member who has a conflict of interest in relation to a matter being considered or due to be considered by the Committee must absent himself or herself from the deliberations and take no further part in any decision of the Committee in relation to that matter. Such a member s alternate may attend in their stead unless the alternate also has a conflict of Version 4 DRAFT (Oct 13) Page 39 of 41

40 interest. Any issue as to whether there is a conflict of interest is to be determined by the committee. Meeting Frequency The committee shall meet as frequently as required to complete an appeals process within 60 days of lodgement of the appeal. Process for lodging an appeal An appeal is to be made by notice in writing, lodged with the Secretary of the DHHS within 28 days of receipt by the practitioner of written notification of the decision being appealed. A notice of appeal must set out the grounds upon which the appeal is based. The Secretary will appoint a committee within 14 days and it should meet within 28 days of its appointment to hear the appeal unless a delay is accepted by all parties. Pending determination of an appeal, the Appellant should not have clinical privileges which are the subject of the appeal. The unsuccessful Appellant may reapply for clinical privileges when able to satisfactorily demonstrate clinical competence in the field involved. Life of Committee The Committee will continue in existence until the Minister revokes the declaration of it as a Quality Assurance Committee under s 4(1) of the Health Act 1997, whereupon it shall by reason of that revocation forthwith cease to exist. Special Circumstances In the event that the Secretary DHHS is satisfied that because of special circumstances which exist, the Committee as constituted above may be perceived to be biased in relation to a particular issue which falls for its determination or is otherwise unsuitable to determine such an issue, its membership for the purposes of considering and determining that issue will instead consist of not less than five (5) and not more than nine (9) persons appointed by the Secretary for those purposes. Martyn Forrest Secretary Department of Health and Human Services Version 4 DRAFT (Oct 13) Page 40 of 41

41 CONTACT DETAILS Department of Health and Human Services GPO Box 125 HOBART TAS 7001 Version 4 DRAFT (Oct 13) Page 41 of 41