Calvary Health Care

At least five (5) Accredited Practitioners which must include representation of at least one from major speciality groups and anaesthetic services

General Manager (non-voting)

Director of Clinical Services (non-voting)

Director of Mission (non-voting)

to be the formal organisational structure through which the views of the Accredited Medical Practitioners and Dentists of the Service are formulated and communicated to the Service;

to provide a means whereby Accredited Medical Practitioners and Dentists can participate in the policy-making and planning processes of the Service;

to plan and manage a continuing education program for members of the Medical Association or junior medical staff where appropriate;

to advise the Chief Executive Officer on the clinical organisation of the Service;

to assist in identifying health needs of the community and to advise the Chief Executive Officer on services that may be required to meet those needs;

to participate in the planning and implementation of patient safety and quality programs and the monitoring of safety and quality of care;

to endeavour to ensure that the level of patient care provided by the Service is optimised given local resources;

to ensure that a process for review of clinical outcomes and patient management is established and executed according to these By-Laws;

to lead and monitor the implementation of a comprehensive program of peer review by Medical Practitioners and Dentists across all clinical departments, service areas and major specialty groups;

to monitor the performance of Medical Practitioners and Dentists including by monitoring clinical indicators and other indicators of performance, and advise the Chief Executive Officer through the Medical Advisory Committee of the appropriate action to be taken in respect of these results; and

to review the recommendations of the Credentials and Scope of Clinical Practice Committee and

to establish a Clinical Review Sub-Committee in accordance with clause 31 of these By-Laws.

At least one (1) Accredited Practitioners from each of the clinical departments or service areas of anaesthetics, medicine, obstetrics and surgery

General Manager (non-voting)

Director of Clinical Services (non-voting)

advise the Chief Executive Officer through the Medical Advisory Committee on the application of Little Company of Mary Health Care’s policies for verification of credentials of applicants for Accreditation or re-Accreditation or when considering a request for a review of Scope of Clinical Practice of an Accredited Practitioner;

develop criteria for and plan and monitor the effectiveness of a programme for the delineation of Scope of Clinical Practice of Health Practitioners, where required by the Board;

consider, in relation to applications for Accreditation or review of an Accredited Practitioner’s Scope of Clinical Practice which are referred to it:

and make recommendations to the Medical Advisory Committee on Accreditation or re-Accreditation and the appropriate Scope of Clinical Practice for each applicant;

consider applications by Accredited Practitioners for review of their authorised Scope of Clinical Practice and make recommendations to the Medical Advisory Committee;

if requested by any of the Chief Executive Officer, the Director of Clinical Services, the Director of Medical Services, the chairperson of the Medical Association, the head of the clinical department or service area in which an Accredited Practitioner practises, the National Chief Executive Officer or the Board, review the current Scope of Clinical Practice of the Accredited Practitioner and, following due consideration and taking into account the qualifications, experience, competence, professional performance, Current Fitness, professional suitability of and confidence held in the Accredited Practitioner and the needs and capabilities of the Service, make recommendations concerning amendment or revocation of the Accredited Practitioner’s Scope of Clinical Practice and/or Accreditation to the Service; and

ensure that each of its members is aware of their obligations to act fairly and without bias and to avoid conflicts of interest.

At least one Accredited Practitioner where each clinical department or service is established

General Manager

Director of Clinical Services

Risk, Quality and Safety Manager

Director of Mission

conduct quality activities and investigations which may include monitoring clinical audit, medical record audit, morbidity and mortality review and adverse clinical incident review;

critically analyse the circumstances that surround a clinical incident, recommend process improvement to management, and advise the appropriate action for process improvement and monitor progress;

demonstrate leadership in and advise the Medical Advisory Committee on safety and quality issues relevant to the delivery of medical and dental services;

monitor and encourage the engagement of Medical Practitioners and Dentists in multidisciplinary quality assurance and improvement activities;

Advise the Chief Executive Officer through the Medical Advisory Committee of actions that need to be taken in relation to medical and dental services to assure and improve effective clinical review and safety and quality improvement activities and programs at the Service.

Director of Clinical Services

ICU Medical Director

ICU Clinical Manager

ICU Educator

Five (5) Surgeons/ Proceduralist appointed from each speciality

Two (2) Anaesthetists

Director of Clinical Services

Clinical Manager – Perioperative Services

Clinical Manager – Day Procedure Suite

Infection Control Coordinator

Monitoring theatre utilization to co-relate activity with adverse event incidence, with the objective of reduction of adverse events to ensure a safe environment for patients;

Review and advice for consideration of Operating Suite and anaesthetic equipment and facility requirements, to minimize risk to patients.

The Committee will at times provide reports, communication and advice to unauthorized persons, groups and bodies.

The review of Operating Suite practices and procedures to ensure the adoption of the most appropriate procedures and practices for quality patient care.

Monitor and trend Operating Suite incidents with an expected outcome of a safer environment for patients and staff.

Obstetrician – Member of Medical Advisory Committee

Obstetrician – Member of Clinical Review Committee

Three (3) Obstetricians

Two (2) Paediatricians

One (a) Anaesthetists

Director of Clinical Services

Clinical Manager – Maternity

Clinical Nurse – Maternity

Develop, evaluate and maintain minimum standard for identified high risk obstetric procedures and practices.

Review, evaluate and disseminate ongoing audit results related to perinatal services, ensuring action plans are developed and implemented to ensure contemporaneous practices are achieved by Calvary North Adelaide Hospital.

Review, evaluate and action Obstetric Clinical Indicators, clinical incidents and provide recommendations regarding further policy development or modification and or development of system controls where required.

Ensure quality improvement is a core focus of all activities conducted in all areas of the Perinatal Service

Provide a platform for clinical networking to ensure current practices and policies reflect legislative and corporate requirements.

Regularly evaluate relevant policies, procedures and audit processes to ensure they reflect all requirements of current practices.

Develop and maintain appropriate quality improvement activities to ensure the delivery of quality care with the multi disciplines of the Maternity Unit.

the perinatal arena.

Surgeon (Chairperson)

Director of Clinical Services

Infectious Disease Physician

Infection Control Coordinator

Clinical Manager – Medical Oncology

Clinical Manager – Surgical

Clinical Manager – Maternity

Clinical Manager – Perioperative Services

Clinical Manager – Day Procedure Suite

Intensive Care Representative

Sterilising Services Manager

Hospitality Services Manager

Pharmacist

Review and analysis of clinical and non-clinical data and use of such data to undertake quality improvement projects to reduce the occurrence of adverse events

Ensuring that all relevant risk areas are considered, analysed and reported on for inclusion in the Risk Register

Ensuring that all sentinel events are reported to the Risk Manager for inclusion in reports to the National Risk Management Team.

Developing an annual Infection Control Service Program to direct activities of the service supporting management of risk and measurement of achievement.

Advising Medical and clinical governance committees as required