Advisory Committees

Membership:

• 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)

The Medical Advisory Committee is an advisory committee to the General Manager.  The role of the Medical Advisory Committee is:

• 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.

Membership:

• 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)

The role of the Credentials and Scope of Clinical Practice Committee shall be to:

• 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:
  • the qualifications, experience, professional standing and other relevant professional attributes of each Health Practitioner for the purposes of forming a view about their competence, performance, Current Fitness, character of and confidence held in the applicant and professional suitability; and
  • the needs and capabilities of the Service;
• 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.

Membership:

• 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

The role of the Clinical Review Sub-Committee is:

• 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.

Membership:

• Director of Clinical Services
• ICU Medical Director
• ICU Clinical Manager
• ICU Educator

The Intensive Care Business Committee has the broad responsibility to drive a quality based system of a local clinical integrated risk, quality and safety management system in line with national policies.  It is accountable for implementing the integrated risk, quality and safety management strategy from a clinical perspective at local service level.

Membership:

• 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

The Operating Suite Sub-Committee shall be responsible for the following matters:

• 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.

Membership:

• 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

The purpose of the Calvary North Adelaide Hospital Perinatal Committee is to provide oversight and monitoring of systems of care, quality processes, NSQHS standards, Level One and Two risks, Risk trends, risk register items, accreditation recommendations and other clinical issues related specifically to the perinatal arena.  Its roles and responsibilities include:

• 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.

Membership:

• 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

The Infection Control Committee has the broad responsibility to drive a quality based system of a local clinical integrated risk, quality and safety management system in line with national policies and National Standard 3.

It is accountable for Infection control issues within Calvary Risk Management strategy through the application of the risk management framework to all clinical and non-clinical issues by:

• 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

Consistent with our values of hospitality, healing, stewardship and respect, Calvary Health Care South Australia is committed to respecting the dignity and privacy of all individuals. The Calvary Healthcare South Australia Human Research Ethics Committee (HREC) acts as a forum for consideration of research proposals from an ethics perspective and to discuss and recommend action with respect to ethical issues, both actual and possible.

The objectives of the HREC are to:

(a) Protect the rights, mental & physical wellbeing, dignity & safety of participants in research;

(b) Promote ethical principles in human research;

(c) Review research in accordance with the National Statement on Ethical Conduct in Human Research, 2007 (updated 2018);

(d) Facilitate ethical research through efficient and effective review processes;

(e) Protect the privacy and confidentiality of participants and/or their personal health information, either directly or indirectly, in the proposals referred to it;

(f) Promote and endorse ethical standards of research and information privacy in proposals referred to it, by provision of guidance to researchers and others as appropriate.

The core membership of the HREC, in accordance with the National Statement, includes as far as possible men and women are represented in equal numbers and at least one third of the members are external to the institution for which the HREC is reviewing research. The core membership comprises representatives from each of the following categories:

(a) A Chairperson with suitable experience whose other responsibilities will not impair the HREC capacity to carry out its obligations under the National Statement;

(b) At least two members who are lay people, one man and one woman, who have no affiliation with the institution, and are not currently involved in medical, scientific or legal work;

(c) At least one member with knowledge of, and current experience in, the professional care, counselling or treatment of people, for example a nurse, or a social worker;

(d) At least one member who performs a pastoral care role in a community, for example a minister of religion or an Aboriginal Elder;

(e) At least one member who is a lawyer, where possible one who is not engaged or employed to advise the institution; and

(f) At least two (2) members with current research experience relevant to the research proposals to be considered at the meetings they attend. These two members may be selected, according to need, from a pool of further members.