Health Services (Health Service Establishments) Regulations 2013 (Vic)

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Version No. 005

Health Services (Health Service Establishments) Regulations 2013

S.R. No. 113/2013

Version incorporating amendments as at


8 August 2023

TABLE OF PROVISIONS

Regulation  Page

Part 1—Preliminary

1Objectives

2Authorising provision

3Commencement

4Revocation

5Definitions

Part 2—Prescribed health services

6Day procedure centres

7Private hospitals

7AHealth service establishment protocols for quality and safety

Part 3—Forms of application and fees

8Application for approval in principle

9Application for transfer or variation of certificate of approval in principle

10Application for registration

11Annual fees

12Application for renewal of registration

13Application for variation of registration

13AApplication for approval of alterations to clinical area

Part 4—Senior appointments

Division 1—Director of Nursing

14Director of Nursing must be appointed

15Acting Director of Nursing

16Secretary must be notified of appointment

Division 2—Other appointments

17Chief Executive Officer and Medical Director

18Secretary to be notified of termination or vacancy

Part 5—Admission of patients

Division 1—Unit record number

19Unit record number must be allocated

Division 2—Information to be given to patients

20Information about fees and services

Division 2A—Pre-admission requirements

20APre-admission assessment

Division 3—Clinical records

21Clinical record must be created

22Information to be included in clinical record

Division 4—Identification of patients

23Means of identifying patients

24Identification of infants

Part 6—Care of patients

Division 1—Management of patient care

25Respect, dignity and privacy

Division 2—Nursing and professional care

26Nurses must be registered and competent

26APost-operative care of surgery patients

26BCare of maternity, obstetric and neonatal patients

27Sufficient nursing staff must be on duty

28Needs of patients must be met

28AReversible agents must be available

Part 7—Complaints

29Nomination of complaints officer

30Dealing with a complaint

31Record of complaint

32Person making complaint must not be adversely affected

32AOpen disclosure policy

Part 8—Transfer and discharge of patients

33Transfer of patients

34Discharge information to be given to patients

34AInformation provided to patient transport

Part 9—Registers, records and permits

Division 1—Patient Register

35Patient Admission and Discharge Register

Division 2—Staff Register and records

36Staff Register

Division 3—Other Registers

37Operation Theatre Register

38Birth Register

Division 4—Permits

38APermit issued under section 19 of the Drugs, Poisons and Controlled Substances Act 1981

Part 10—Premises and equipment

39Identification of rooms

40Communications

41Prevention of scalding

42Repair and cleanliness of premises

43Suitability and cleanliness of facilities, equipment, furnishings and fittings

43APremises, staff and equipment outside health service establishment

43BEvacuation plan

Part 11—Infection control

44Infection Control Management Plan

Part 12—Display of information

45Information to be prominently displayed

Part 13—Statistical returns

46Returns and reports to be given to the Secretary

46AReporting of sentinel events

46BReporting of compliance with the duty of candour

Part 14—Enforcement

47Form of notice of seizure

Part 15—Quality and safety review data

48Review of quality and safety of health services provided

49Patient experience survey data

50Staff safety culture survey data

Part 16—Miscellaneous

51Change of title provision

Schedules

Schedule 1—Revocations

Schedule 2—Application for approval in principle of a health service establishment

Schedule 3—Application for transfer or variation of certificate of approval in principle of a health service establishment

Schedule 4—Application for the registration of a health service establishment

Schedule 5—Application for the renewal of registration of a health service establishment

Schedule 6—Application for the variation of the registration of a health service establishment

Schedule 7—Notice of seizure of document or thing from a health service establishment

Schedule 8—Application for approval of alterations to a clinical area

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Endnotes

1      General information

2      Table of Amendments

3      Explanatory details

Version No. 005

Health Services (Health Service Establishments) Regulations 2013

S.R. No. 113/2013

Version incorporating amendments as at


8 August 2023

PART 1—PRELIMINARY

1Objectives

The objectives of these Regulations are—

(a)to provide for the safety and quality of care of patients receiving health services in or from health service establishments by prescribing—

(i)requirements for staffing; and

(ii)procedures for the handling of complaints; and

(iii)records to be kept; and

(iv)other requirements to ensure the welfare of patients; and

(b)to prescribe fees, forms and other matters required or permitted to be prescribed or necessary to be prescribed under the Health Services Act 1988 in relation to health service establishments.

2Authorising provision

These Regulations are made under section 158 of the Health Services Act 1988.

3Commencement

These Regulations come into operation on 8 September 2013.

4Revocation

The Regulations listed in Schedule 1 are revoked.

5Definitions

In these Regulations—

admission means the recording in writing of a person's admission as a patient to a health service establishment under the care of—

(a)a registered medical practitioner; or

(b)a registered dental practitioner; or

(c)a registered medical radiation practitioner; or

(d)a registered podiatrist;

anaesthesia—

(a)means any of the following—

(i)general anaesthesia;

(ii)a major regional anaesthetic block;

(iii)intravenous sedation;

(iv)a high dose of local anaesthetic that has the potential to cause systemic toxicity; and

(b)does not include a dental nerve block;

bed includes any of the following—

(a)an emergency bed;

(b)an intensive care unit bed;

(c)an in-patient overnight or day bed;

(d)an in-patient overnight or day cot;

(e)a stage 1 recovery bed;

(f)a stage 2 recovery bed;

(g)an oncology chair;

(h)a renal treatment chair;

duty of candour requirements means the requirements set out in section 128ZC(1) of the Act;

emergency medicine means the medical or surgical treatment of patients as a matter of urgency for the purpose of—

(a)saving life; or

(b)preventing further serious damage to health; or

(c)preventing suffering or the continuation of suffering of significant pain or distress;

emergency stabilisation treatment means treatment of a patient to stabilise and manage a serious or life-threatening condition or to manage significant pain while waiting to transport the patient to an appropriate health service establishment;

enrolled nurse means a person registered in Division 2 of the Register of Nurses under the Health Practitioner Regulation National Law to practise in the nursing and midwifery profession (other than as a student);

medical health service means a health service (other than emergency stabilisation treatment) that—

(a)is provided to a patient by a registered medical practitioner; and

(b)involves diagnosis and treatment that requires—

(i)nursing supervision and care; or

(ii)the use of anaesthesia;

registered dental practitioner means a person registered under the Health Practitioner Regulation National Law to practise in the dental profession (other than as a student);

registered health practitioner means an individual registered under the Health Practitioner Regulation National Law to practise in a health profession (other than as a student);

registered medical radiation practitioner means a person registered under the Health Practitioner Regulation National Law to practise in the medical radiation profession (other than as a student); and

registered midwife means a person registered in the Register of Midwives under the Health Practitioner Regulation National Law to practise in the nursing and midwifery profession (other than as a nurse or student);

registered nurse means a person registered in Division 1 of the Register of Nurses under the Health Practitioner Regulation National Law to practise in the nursing and midwifery profession (other than as a midwife or student);

registered podiatrist means a person registered under the Health Practitioner Regulation National Law to practise in the podiatry profession (other than as a student);

renal dialysis means (haemodialysis) treatment that uses a dialyzer machine to remove waste and excess water from the blood;

reporting period, in relation to compliance with the duty of candour requirements, means each of the following—

(a)the period beginning on 1 October and ending on 31 March;

(b)the period beginning on 1 January and ending on 30 June;

(c)the period beginning on 1 April and ending on 30 September;

(d)the period beginning on 1 July and ending on 31 December;

sentinel event means an unexpected and adverse event that occurs infrequently in a health service establishment and results in the death of, or serious physical or psychological injury to, a patient as a result of system and process deficiencies at the health service establishment;

speciality health service means a health service (other than emergency stabilisation treatment) that—

(a)is ordinarily undertaken by, or under the supervision of, a registered medical practitioner, a registered dental practitioner, a registered medical radiation practitioner or a registered podiatrist; and

(b)requires one or both of the following—

(i)specialist equipment;

(ii)an area that is specifically fitted out for the kind of service provided;

surgical health service means a health service (other than emergency stabilisation treatment) that—

(a)is ordinarily provided by a registered medical practitioner, registered dental practitioner, registered medical radiation practitioner or a registered podiatrist; and

(b)involves the use of surgical instruments and an operating theatre, procedure room, or treatment room; and

(c)uses or requires one or more of the following—

(i)anaesthesia; or

(ii)the attendance of at least one other registered health practitioner; or

(iii)post-operative observation of the patient by nursing staff;

the Act means the Health Services Act 1988;

unit record number means an identifying number unique to a patient that is allocated under regulation 19.

PART 2—PRESCRIBED HEALTH SERVICES

6Day procedure centres

For the purposes of paragraph (a) of the definition of day procedure centre in section 3(1) of the Act, the following are health services of a prescribed kind or kinds—

(a)medical health services;

(b)surgical health services;

(c)speciality health services for the provision of one or more of the following—

(i)anaesthesia;

(ii)bariatric procedures;

(iii)cataract surgery;

(iv)endoscopy;

(v)liposuction (removing in total at least 200 ml of lipoaspirate);

(vi)mental health services;

(vii)oncology (chemotherapy);

(viii)oncology (radiation therapy);

(ix)oocyte retrieval;

(x)paediatric services (provided to patients aged at least 28 days and under 18 years when admitted);

(xi)renal dialysis;

(xii)specialist rehabilitation services.

7Private hospitals

For the purposes of the definition of private hospital in section 3(1) of the Act, the following are health services of a prescribed kind or kinds—

(a)medical health services;

(b)surgical health services;

(c)speciality health services for the provision of one or more of the following—

(i)alcohol or drug withdrawal (detoxification—acute phase);

(ii)anaesthesia;

(iii)bariatric procedures;

(iv)cardiac catheterisation;

(v)cardiac surgery;

(vi)cataract surgery;

(vii)emergency medicine;

(viii)endoscopy;

(ix)intensive care;

(x)liposuction (removing in total at least 200 ml of lipoaspirate);

(xi)mental health services;

(xii)neonatal services (provided to patients aged 28 days and under when admitted);

(xiii)neurosurgery;

(xiv)obstetrics;

(xv)oncology (chemotherapy);

(xvi)oncology (radiation therapy);

(xvii)oocyte retrieval;

(xviii)paediatric services (provided to patients aged at least 28 days and under 18 years when admitted);

(xix)renal dialysis;

(xx)specialist rehabilitation services.

7AHealth service establishment protocols for quality and safety

(1)For the purpose of ensuring the quality and safety of health services provided at a health service establishment, the proprietor of a health service establishment must prepare health service establishment protocols in accordance with this regulation.

(2)The health service establishment protocols must be—

(a)documented in writing; and

(b)published on the health service establishment's website; and

(c)made available to the Secretary on request.

(3)The health service establishment protocols must include the following—

(a)processes for assessing every 3 years the credentials of each health professional practising at the health service establishment;

(b)processes for setting the scope of practice for each health professional practising at the health service establishment;

(c)processes for continually assessing the competence and performance of each health professional practising at the health service establishment;

(d)processes for continually assessing and reviewing health services provided by each health professional at the health service establishment;

(e)processes for continually assessing the capacity of the health service establishment to provide safe, patient‑centred and appropriate health services to patients at each of its premises;

(f)setting the frequency of, and procedures for, meetings of committees of the health service establishment with responsibility for the quality and safety of health services provided at, or from, the health service establishment;

Note

Relevant committees may include, but are not limited to, a medical advisory committee, a quality and safety committee and the board of the health service establishment.

(g)processes for ensuring that appropriate arrangements have been made for evaluating, monitoring and improving the quality and safety of health services provided at each premises of the health service establishment.

(4)The proprietor of a health service establishment must ensure that the health service establishment's quality and safety protocols are implemented and complied with.

(5)In this regulation—

health professional means a registered medical practitioner, a registered dental practitioner, a registered medical radiation practitioner or a registered podiatrist.

PART 3—FORMS OF APPLICATION AND FEES

8Application for approval in principle

(1)For the purposes of section 70(2)(a) of the Act, the prescribed form is the form in Schedule 2.

(2)For the purposes of section 70(2)(b) of the Act, the following fees are prescribed—

(a)for an application to construct premises for use as a private hospital—325 fee units;

(b)for an application to make alterations or extensions to a premises used or proposed to be used as a private hospital—290 fee units;

(c)for an application to construct premises for use as a day procedure centre—285 fee units;

(d)for an application to make alterations or extensions to a premises used or proposed to be used as a day procedure centre—276 fee units;

(e)for an application to use premises as a health service establishment from which health services are to be provided at premises other than the first-mentioned premises—


91 fee units;

(f)for an application to vary the registration of a health service establishment—16·1 fee units.

9Application for transfer or variation of certificate of approval in principle

For the purposes of section 74(2) of the Act—

(a)the prescribed form is the form in Schedule 3; and

(b)the prescribed fee is 16×1 fee units.

10Application for registration

(1)For the purposes of section 82(2)(a) of the Act, the prescribed form is the form in Schedule 4.

(2)For the purposes of section 82(2)(b) of the Act, the following fees are prescribed—

(a)for a health service establishment with 0 to 26 beds—366 fee units;

(b)for a health service establishment with 27 to 50 beds—405 fee units;

(c)for a health service establishment with 51 to 75 beds—445 fee units;

(d)for a health service establishment with 76 to 100 beds—484 fee units;

(e)for a health service establishment with 101 to 150 beds—543 fee units;

(f)for a health service establishment with 151 to 200 beds—623 fee units;

(g)for a health service establishment with 201 to 300 beds—701 fee units;

(h)for a health service establishment with 301 to 400 beds—820 fee units;

(i)for a health service establishment with 401 to 500 beds—978 fee units;

(j)for a health service establishment with 501 or more beds—1175 fee units.

11Annual fees

For the purposes of section 87(2)(a) of the Act, the prescribed annual fee is nil fee units.

12Application for renewal of registration

(1)For the purposes of section 88(2)(a) of the Act, the prescribed form is the form in Schedule 5.

(2)For the purposes of section 88(2)(b) of the Act, the following fees are prescribed—

(a)for a health service establishment with 0 to 26 beds—366 fee units;

(b)for a health service establishment with 27 to 50 beds—405 fee units;

(c)for a health service establishment with 51 to 75 beds—445 fee units;

(d)for a health service establishment with 76 to 100 beds—484 fee units;

(e)for a health service establishment with 101 to 150 beds—543 fee units;

(f)for a health service establishment with 151 to 200 beds—623 fee units;

(g)for a health service establishment with 201 to 300 beds—701 fee units;

(h)for a health service establishment with 301 to 400 beds—820 fee units;

(i)for a health service establishment with 401 to 500 beds—978 fee units;

(j)for a health service establishment with 501 or more beds—1175 fee units.

13Application for variation of registration

(1)For the purposes of section 92(2)(a) of the Act, the prescribed form is the form in Schedule 6.

(2)For the purposes of section 92(2)(b) of the Act, the prescribed fee—

(a)in the case of an application for the transfer of the certificate to another person who intends to become the proprietor is 47×8 fee units; and

(b)in any other case is 16×1 fee units.

13AApplication for approval of alterations to clinical area

(1)For the purposes of section 108(2)(a) of the Act, the prescribed form is the form in Schedule 8.

(2)For the purposes of section 108(2)(b) of the Act, the prescribed fee is nil fee units.

PART 4—SENIOR APPOINTMENTS

Division 1—Director of Nursing

14Director of Nursing must be appointed

(1)The proprietor of a health service establishment (other than a health service establishment which provides health services solely at premises other than the premises for which it is registered) must appoint a suitably qualified person as the Director of Nursing.

Penalty:50 penalty units.

(2)For the purposes of subregulation (1), a person is suitably qualified if the person—

(a)is a registered nurse; and

(b)has at least 12 months' practical experience in nursing management; and

(c)has at least 5 years' clinical experience as a registered nurse.

15Acting Director of Nursing

If the Director of Nursing is absent or incapacitated, or the position is vacant, the proprietor of a health service establishment must appoint a person to act as the Director of Nursing during the period of the absence, incapacity or vacancy.

Penalty:50 penalty units.

16Secretary must be notified of appointment

Within 28 days after making the appointment, the proprietor of a health service establishment must notify the Secretary in writing of the name, qualifications and experience of any person appointed by the proprietor—

(a)as the Director of Nursing; or

(b)to act as the Director of Nursing for a period of more than 28 days.

Penalty:20 penalty units.

Division 2—Other appointments

17Chief Executive Officer and Medical Director

If the proprietor of a health service establishment appoints a Chief Executive Officer or Medical Director (however titled), the proprietor must notify the Secretary in writing of the name, qualifications and experience of the person appointed within 28 days of the appointment.

Penalty:20 penalty units.

18Secretary to be notified of termination or vacancy

If the proprietor of a health service establishment terminates the appointment of a Chief Executive Officer or Medical Director (however titled), or the position otherwise becomes vacant, the proprietor must notify the Secretary in writing within 28 days of the termination or vacancy.

Penalty:20 penalty units.

PART 5—ADMISSION OF PATIENTS

Division 1—Unit record number

19Unit record number must be allocated

The proprietor of a health service establishment (other than a health service establishment which provides health services solely at premises other than the premises for which it is registered) must ensure that a unit record number is allocated to a patient on or as soon as practicable after the admission of the patient to the hospital or centre.

Penalty:30 penalty units.

Division 2—Information to be given to patients

20Information about fees and services

(1)The proprietor of a health service establishment must ensure that on or before admission each patient of the hospital or centre is given—

(a)a statement containing information in relation to the health care services provided at the health service establishment that complies with subregulation (2); and

(b)information about fees to be charged by the health service establishment and any likely out of pocket expenses which may be incurred by the patient; and

(c)a clear explanation of the treatment and services to be provided to the patient at the health service establishment.

Penalty:50 penalty units.

(2)A statement referred to in subregulation (1) must contain information about the following matters—

(a)the quality or standard of health care and services provided in the health service establishment;

(b)courteous treatment of patients;

(c)consideration of a patient's beliefs and ethnic, cultural and religious practices;

(d)consideration of a patient's special dietary needs (if any);

(e)a patient's privacy;

(f)that a patient may request the names and roles of the key health workers involved in the patient's care;

(g)a patient's entitlement to ask for a referral if he or she wants to seek another medical opinion;

(h)that any personal information or identifying material about a patient is dealt with in a confidential manner except—

(i)if necessary to enable another health care worker to assist in the patient's care; or

(ii)if authorised by or under a law;

(i)a patient's consent to treatment;

(j)that a patient may refuse the presence of health workers not directly involved in the patient's care;

(k)that a patient may discharge himself or herself at any time despite the advice of the attending registered health  practitioner or staff of the health service establishment;

(l)that a patient may comment on or complain about the treatment or the quality of the health services or care being provided, including to whom any complaint should be made.

Division 2A—Pre-admission requirements

20APre-admission assessment

For the purpose of ensuring the quality and safety of health services provided at a health service establishment, the proprietor of the health service establishment must ensure in relation to each non-emergency patient admitted to the health service establishment that—

(a)a pre-admission clinical risk assessment is carried out for each patient before admission; and

(b)the results of the pre-admission clinical risk assessment are recorded in writing, not less than 24 hours before admission; and

(c)the procedure for which the patient is admitted is assessed in relation to the scope of practice of the relevant registered health practitioner providing health services to that patient at the health service establishment.

Division 3—Clinical records

21Clinical record must be created

The proprietor of a health service establishment must ensure that a separate clinical record for each patient is—

(a)created on or as soon as practicable after the admission of the patient to the health service establishment; and

(b)maintained whenever patients are receiving health services from the health service establishment.

Penalty:30 penalty units.

22Information to be included in clinical record

The proprietor of a health service establishment must take reasonable steps to ensure that each clinical record contains the following information—

(a)the patient's unit record number;

(b)the patient's name, address, date of birth and sex;

(c)the name and contact details of a relative or friend nominated by the patient;

(d)relevant clinical details of the patient including—

(i)clinical history on admission;

(ii)progress notes whenever patients are receiving health services from the health service establishment;

(iii)any medication ordered or given;

(iv)known allergies and drug sensitivities;

(v)current medication;

(vi)pre-procedure assessment;

(vii)results of any relevant diagnostic tests;

(e)if a procedure is carried out on a patient—

(i)the consent form for the procedure and anaesthesia;

(ii)the date of the procedure;

(iii)the names and signatures of the registered health practitioners carrying out the procedure;

(iv)the type of procedure carried out;

(v)the pre-procedure check list by the attending practitioner or by the assisting nurse;

(vi)administered drugs and dosages;

(vii)a record of any monitoring undertaken;

(viii)a record of any intravenous fluids administered;

(ix)a procedure room report including any procedure findings;

(x)the final diagnosis of the patient on discharge.

Penalty:30 penalty units.

Note

The Health Records Act 2001 contains provisions relating to the retention of records. See HPP 4 of the Health Privacy Principles in that Act.

Division 4—Identification of patients

23Means of identifying patients

The proprietor of a health service establishment must ensure that a patient can be readily identified at all times when the patient is receiving health care or other services at the health service establishment by—

(a)an identity band or other suitable device attached to the patient; or

(b)a photograph, a copy of which must be attached to the clinical record of the patient.

Penalty:40 penalty units.

24Identification of infants

(1)The proprietor of a health service establishment must ensure that if an infant is born at the hospital or centre, at least 2 identity bands or other suitable devices which contain the birth information are attached to that infant—

(a)as soon as practicable after the birth and before leaving the delivery room; and

(b)while the infant remains in the health service establishment.

Penalty:30 penalty units.

(2)If, immediately after giving birth to an infant, a mother is admitted as a patient of a health service establishment for—

(a)the receipt of medical services in connection with the birth; or

(b)the provision of nursing services by a suitably qualified nurse that are directly related to the birth—

the proprietor of the health service establishment must ensure that at least 2 identity bands or other suitable devices which contain the birth information are attached to the infant for as long as the infant remains in the health service establishment.

Penalty:30 penalty units.

(3)For the purposes of subregulations (1) and (2), the birth information is—

(a)the surname of the infant;

(b)the full name of the mother;

(c)the unit record number of the mother.

PART 6—CARE OF PATIENTS

Division 1—Management of patient care

25Respect, dignity and privacy

The proprietor of a health service establishment must ensure that a patient—

(a)is treated with dignity and respect, and with due regard to his or her religious beliefs and ethnic and cultural practices; and

(b)is given privacy; and

(c)is not subjected to unusual routines, particularly with respect to the timing of meals and hygiene procedures, unless the routines are for the benefit of the patient.

Examples

1     Facilities are provided to allow patients to undertake personal activities, including bathing, toileting and dressing in private.

2     Facilities are designed to ensure auditory and visual privacy for patients whenever patients are receiving health services from the health service establishment.

3     Where facilities are shared, provision is made to ensure patient privacy.

4     Patients are provided with meals in accordance with their religious beliefs and ethnic and cultural practices.

Division 2—Nursing and professional care

26Nurses must be registered and competent

The proprietor of a health service establishment must ensure that each nurse at the health service establishment—

(a)is an enrolled nurse or a registered nurse; and

(b)is professionally competent through education or experience to provide nursing care at the health service establishment having regard to the kind or kinds of health services being provided.

Penalty:50 penalty units.

26APost-operative care of surgery patients

If the Director of Nursing is not present at a health service establishment on a day on which a surgical health service is provided at the health service establishment, for the purpose of ensuring the quality and safety of that health service, the proprietor of the health service establishment must ensure that a registered nurse with at least 3 years' relevant clinical experience is present to supervise the provision of the surgical health services to, and the post-operative care of, surgical patients.

26BCare of maternity, obstetric and neonatal patients

If maternity services, obstetric services or neonatal services are provided at a health service establishment, for the purposes of ensuring the quality and safety of those health services, the proprietor of the health service establishment must ensure that a registered midwife with at least 3 years' relevant clinical experience is present to provide clinical oversight of those health services.

27Sufficient nursing staff must be on duty

(1)The proprietor of a health service establishment must ensure that whenever patients are receiving health services from the health service establishment, a sufficient number of nursing staff are on duty to provide care for those patients.

Penalty:50 penalty units.

(2)For the purposes of subregulation (1), a sufficient number of nursing staff is—

(a)in the case of a private hospital—

(i)at least one registered nurse for every 10 patients or fraction of that number during day and evening shifts; and

(ii)at least one registered nurse for every 15 patients or fraction of that number during night shifts; or

(b)in the case of a day procedure centre, at least one registered nurse for every 10 patients or fraction of that number.

(3)Despite subregulation (2), in determining the number of nurses on duty, if 3 or more nurses are on duty at a health service establishment during a shift, up to one-third may be enrolled nurses.

28Needs of patients must be met

The proprietor of a health service establishment must take reasonable steps to ensure that the needs of patients are met promptly and effectively by nursing staff and other professionally competent registered health practitioners.

Penalty:50 penalty units.

28AReversible agents must be available

If health services are provided at a health service establishment involving the use of anaesthesia or other sedation for which there are reversible agents, the proprietor of the health service establishment must ensure that these reversible agents are available for immediate access at the premises of the health service establishment.

PART 7—COMPLAINTS

29Nomination of complaints officer

(1)The proprietor of a health service establishment must nominate a person to receive and deal with any complaints that may be made by, or on behalf of, a patient of the health service establishment.

Penalty:50 penalty units.

(2)The proprietor of a health service establishment must take reasonable steps to ensure that every patient and member of the staff of the health service establishment is informed of the name of the person nominated by the proprietor to receive and deal with complaints.

Penalty:50 penalty units.

30Dealing with a complaint

(1)The proprietor of a health service establishment must ensure that a complaint is responded to as soon as practicable after the complaint has been made.

Penalty:40 penalty units.

(2)The proprietor of a health service establishment must ensure that a complaint is dealt with as discreetly as possible in the particular circumstances.

Penalty:40 penalty units.

(3)The proprietor of a health service establishment must ensure that the person who made the complaint is informed of the action taken in respect of the complaint.

Penalty:40 penalty units.

31Record of complaint

(1)The proprietor of a health service establishment must ensure that a written record is kept of every complaint made by, or on behalf of, a patient of the health service establishment.

Penalty:30 penalty units.

(2)For the purposes of subregulation (1), the written record must contain the following information—

(a)the nature of the complaint;

(b)the date of the complaint;

(c)the action taken in respect of that complaint.

(3)The proprietor of a health service establishment must ensure that the written record is kept in a secure place for a period of 7 years after the complaint has been made.

Penalty:30 penalty units.

32Person making complaint must not be adversely affected

The proprietor of a health service establishment must take reasonable steps to ensure that a patient of the health service establishment or a person making a complaint on behalf of the patient is not adversely affected because the complaint has been made.

Penalty:60 penalty units.

32AOpen disclosure policy

(1)For the purpose of ensuring the quality and safety of health services provided at a health service establishment, the proprietor of a health service establishment must prepare an open disclosure policy in accordance with this regulation.

(2)The open disclosure policy must be—

(a)documented in writing; and

(b)published on the health service establishment's website.

(3)The open disclosure policy must include processes by which open discussion between the health service establishment and a patient and the patient's family and carers are to occur following any adverse event that results in harm to the patient.

(4)The proprietor of a health service establishment must ensure that the open disclosure policy is implemented.

PART 8—TRANSFER AND DISCHARGE OF PATIENTS

33Transfer of patients

If a patient is transferred from a health service establishment to another health service establishment or health care agency, the proprietor of the health service establishment from which the patient is transferred must ensure that all information and copies of any documents relating to the patient's medical condition and treatment necessary for the establishment or agency to provide appropriate ongoing treatment or care are sent with the patient.

Penalty:40 penalty units.

34Discharge information to be given to patients

(1)The proprietor of a health service establishment must ensure that, at the discharge of an admitted patient from the health service establishment, the following is provided to the patient—

(a)the name and contact details in writing of whom to contact for post-procedure medical advice;

(b)a copy of the patient's discharge summary in accordance with subregulation (3).

(2)The proprietor of a health service establishment must ensure that a written copy of the patient's discharge summary—

(a)is provided to the patient's registered medical practitioner as soon as practicable after discharge; or

(b)is given to the patient at discharge for the patient to provide to the patient's registered medical practitioner.

(3)A patient's discharge summary must include the following information—

(a)the full name of the patient;

(b)the date of birth of the patient;

(c)a description of the health service that the patient received at the health service establishment;

(d)the post-discharge instructions for patient care;

(e)a list of all medications currently prescribed for the patient, irrespective of whether the medication is in relation to the heath service received at the health service establishment.

34AInformation provided to patient transport

The proprietor of a health service establishment must ensure that the crew of a vehicle used to transport a patient from the health service establishment by a non-emergency patient transport service or by an ambulance service is provided with—

(a)handover notes in writing in relation to the patient's clinical condition; and

(b)a copy of any advance care directive given by the patient in accordance with the Medical Treatment Planning and Decisions Act 2016.

PART 9—REGISTERS, RECORDS AND PERMITS

Division 1—Patient Register

35Patient Admission and Discharge Register

For the purposes of section 109(1) of the Act, with respect to persons who receive care in the health service establishment—

(a)the prescribed manner is in writing; and

(b)the prescribed period is 7 years; and

(c)the prescribed particulars are—

(i)the unit record number of the patient;

(ii)the full name of the patient;

(iii)the sex of the patient;

(iv)the address and telephone number of the patient;

(v)the patient's date of birth;

(vi)the date of the patient's admission and discharge;

(vii)a description of care received and the status of the patient at discharge;

(viii)if the patient is transferred to another health service establishment or health care agency, the name of that establishment or agency and the reason for the transfer.

Division 2—Staff Register and records

36Staff Register

For the purposes of section 109(1) of the Act, with respect to staff employed in the health service establishment—

(a)the prescribed manner is in writing; and

(b)the prescribed period is 2 years; and

(c)the prescribed particulars are—

(i)the full name of every member of the nursing staff and other registered health practitioners;

(ii)the date of birth of every member;

(iii)the designation of every member;

(iv)the qualifications of every member;

(v)if applicable, the registration number or code of every member.

Division 3—Other Registers

37Operation Theatre Register

(1)The proprietor of a health service establishment at which surgical health services or speciality health services for the provision of endoscopy may be carried on must ensure that an Operation Theatre Register is kept at the health service establishment.

Penalty:30 penalty units.

(2)For the purposes of subregulation (1), an Operation Theatre Register must be in writing and contain the following information with respect to each procedure performed at the health service establishment—

(a)the date and time of the procedure;

(b)the unit record number of the patient;

(c)the full name of the patient, his or her sex and date of birth;

(d)the nature of the procedure;

(e)the name of the registered health practitioner undertaking the procedure and assistant (if any);

(f)the name of the anaesthetist and assistant (if any);

(g)the names of attending theatre staff;

(h)any remarks concerning the outcome of the procedure;

*                *                *                *                *

(j)any anaesthetic or procedural complications encountered.

Note

The Health Records Act 2001 contains provisions relating to the retention of records. See HPP 4 of the Health Privacy Principles in that Act.

38Birth Register

(1)The proprietor of a health service establishment in which speciality health services for the provision of obstetrics may be carried on must ensure that a Birth Register is kept at the health service establishment.

Penalty:30 penalty units.

(2)For the purposes of subregulation (1), a Birth Register must be in writing and contain the following information with respect to each birth at the health service establishment—

(a)the date and time of the birth;

(b)the full name of the mother;

(c)the unit record number of the mother;

(d)the sex of the infant;

(e)the names of all health care personnel in attendance at the birth.

(3)The proprietor of a health service establishment must retain a Birth Register for at least 25 years after the date of the last entry.

Penalty:30 penalty units.

Division 4—Permits

38APermit issued under section 19 of the Drugs, Poisons and Controlled Substances Act 1981

(1)Subject to subregulation (2), the proprietor of a health service establishment is required to hold a permit issued under section 19 of the Drugs, Poisons and Controlled Substances Act 1981 by which the proprietor is authorised under section 20(3) of that Act to purchase or otherwise obtain certain poisons or controlled substances for the provision of health services.

(2)Subregulation (1) does not apply to the following—

(a)a proprietor of a health service establishment at or from which the prescribed health services provided do not usually require, for the provision of those services, the purchase or otherwise obtaining of any poisons or controlled substances, other than a patient's own medicine;

Example

Drug and alcohol withdrawal treatment services and dialysis services.

(b)a proprietor of a health service establishment—

(i)that provides prescribed health services solely at premises other than the premises for which it is registered; and

(ii)where only one registered health practitioner (other than the additional nursing staff required under regulation 27 or one or more additional registered midwives) provides prescribed health services.

(3)In this regulation, patient's own medicine means a poison or controlled substance that has been supplied to a patient by a registered health practitioner other than—

(a)the proprietor of the health service establishment; or

(b)a registered health practitioner employed by or contracted to provide health services prescribed under Part 2 for or at the health service establishment.

PART 10—PREMISES AND EQUIPMENT

39Identification of rooms

The proprietor of a health service establishment must ensure that each room in which beds or recovery chairs are provided for the accommodation of patients is clearly identified at the entrance to that room by a sign stating—

(a)the letter or number of that room; and

(b)the number of beds and recovery chairs ordinarily in that room.

Penalty:10 penalty units.

40Communications

(1)The proprietor of a health service establishment (other than a health service establishment which provides health services solely at premises other than the premises for which it is registered) must ensure that an effective electronic communication system is provided and kept operational at the health service establishment.

Penalty:60 penalty units.

(2)For the purposes of subregulation (1), an electronic communication system must—

(a)enable patients and staff to summon assistance; and

(b)enable calls to be made from—

(i)each bed;

(ii)any recovery chair in a recovery room;

(iii)each toilet, shower or bath or other facility used for the bathing of patients;

(iv)any common room, recreational or rest area or other place where patient care is provided.

41Prevention of scalding

The proprietor of a health service establishment must ensure that every bath, shower and hand basin used by patients is installed with a system or mechanism to avoid the risk of scalding by controlling the outlet temperature of hot water.

Penalty:50 penalty units.

42Repair and cleanliness of premises

The proprietor of a health service establishment must ensure that the premises are kept—

(a)in a clean and hygienic condition; and

(b)in a proper state of repair; and

(c)free of hazards or the accumulation of materials which may become offensive, injurious to health or likely to facilitate the outbreak of fire.

Penalty:80 penalty units.

43Suitability and cleanliness of facilities, equipment, furnishings and fittings

(1)The proprietor of a health service establishment must ensure that facilities, equipment, furnishings and fittings at the health service establishment are suitable for the kind or kinds of health services being provided by the health service establishment.

(2)The proprietor of a health service establishment must ensure that facilities, equipment, furnishings and fittings at the health service establishment are—

(a)kept in a proper state of repair and maintained in good working order; and

(b)kept in a clean and hygienic condition.

Penalty:80 penalty units.

43APremises, staff and equipment outside health service establishment

For the purpose of ensuring the quality and safety of health services provided by a health service establishment at premises other than the premises for which it is registered, the proprietor of the health service establishment must ensure that—

(a)those other premises are suitable for the provision of safe patient care; and

(b)persons with appropriate training and experience provide those health services; and

(c)the equipment used to provide those health services is suitable for the type of health services provided.

43BEvacuation plan

The proprietor of a health service establishment must ensure that—

(a)an evacuation plan for all patients and members of staff at the health service establishment is prepared; and

(b)the evacuation plan is displayed in a prominent position at the entrance foyer or reception area of the health service establishment and in each common room, recreational or rest area or other place where patient care is provided; and

(c)all staff are trained in its implementation.

PART 11—INFECTION CONTROL

44Infection Control Management Plan

(1)The proprietor of a health service establishment must implement and maintain an Infection Control Management Plan.

Penalty:80 penalty units.

(2)For the purposes of subregulation (1), an Infection Control Management Plan must provide for the surveillance, prevention and control of infection at the health service establishment.

(3)Without limiting subregulation (2), an Infection Control Management Plan must—

(a)state its objectives;

(b)identify and assess all the infection risks specific to the health service establishment which the proprietor knows, or can reasonably be expected to know, exists or may exist, and state how these risks are to be minimised;

(c)provide for an ongoing infection control education program for the staff of the health service establishment;

(d)state the particulars of training for persons who provide services at the health service establishment that involve infection control risks;

(e)set out how the proprietor will monitor and review the implementation and effectiveness of the plan.

PART 12—DISPLAY OF INFORMATION

45Information to be prominently displayed

The proprietor of a health service establishment must display in a prominent position at the entrance foyer or reception area of the health service establishment the following information—

(a)the certificate of registration of the premises as a health service establishment or a full size copy of the certificate;

(b)the name of the Director of Nursing (if required to be appointed) and, if a Chief Executive Officer or Medical Director (however titled) has been appointed, the name of the Chief Executive Officer or Medical Director;

(c)the name and contact telephone number of the person nominated under regulation 29 to receive and deal with complaints.

Penalty:20 penalty units.

PART 13—STATISTICAL RETURNS

46Returns and reports to be given to the Secretary

(1)The proprietor of a health service establishment must prepare a return for each month containing data in relation to each patient admitted as directed by the Secretary.

(2)The proprietor of a health service establishment must ensure that a return prepared under subregulation (1) is given to the Secretary—

(a)in the case of admission and discharge data, within 17 days after the end of the month to which the return relates; and

(b)in the case of clinical care data, within 47 days after the end of the month to which the return relates.

(3)From 1 July 2019, the proprietor of a private hospital must prepare a return for each month containing the following—

(a)data about infections acquired by patients and staff at the private hospital and infection prevention and surveillance activities implemented at the private hospital;

(b)data in relation to any electroconvulsive treatment (within the meaning of the Mental Health Act 2014) provided at the private hospital;

(c)data about patients who presented at the private hospital's emergency department, if any, as directed by the Secretary.

(4)The proprietor of a health service establishment must ensure that a return prepared under subregulation (3) is given to the Secretary within 17 days after the end of the month to which the return relates.

(5)The proprietor of a health service establishment must ensure that a return prepared under this regulation does not include the name or address of a patient.

(6)The proprietor of a health service establishment must provide a copy of each report received from the accreditation scheme applicable to the health service establishment and approved by the Secretary under section 107(1) of the Act, to the Secretary within 14 days of the receipt of the report.

46AReporting of sentinel events

The proprietor of a health service establishment must report in writing a sentinel event that occurred at the health service establishment to the Secretary within the time determined by the Secretary.

Penalty:40 penalty units.

46BReporting of compliance with the duty of candour

(1)The proprietor of a private hospital or day procedure centre must submit a report to the Secretary concerning compliance by that private hospital or day procedure centre with the duty of candour requirements for each reporting period within 14 days after the end of a reporting period.

(2)The proprietor of a private hospital or day procedure centre must include the following information in the report submitted to the Secretary under subregulation (1)—

(a)data specifying the number of serious adverse patient safety events suffered by patients in the course of receiving health services from that private hospital or day procedure centre, where the event was identified in the first 3 months of a reporting period;

(b)in relation to the serious adverse patient safety events specified for the purposes of paragraph (a), the following data for the reporting period—

(i)the number of serious adverse patient safety events where the duty of candour requirements were commenced in the reporting period;

(ii)the number of serious adverse patient safety events where the patient has been provided with the information specified in section 128ZC(1)(a) of the Act in the reporting period;

(iii)the number of serious adverse patient safety events where the patient chose not to receive the information specified in section 128ZC(1) of the Act for the purposes of section 128ZC(2) of the Act.

(3)The proprietor of a private hospital or day procedure centre must ensure that the report prepared for the purposes of this regulation is submitted to the Secretary in the form and manner determined by the Secretary.

PART 14—ENFORCEMENT

47Form of notice of seizure

For the purposes of section 147(2)(a) of the Act, the prescribed form is the form in Schedule 7.

PART 15—QUALITY AND SAFETY REVIEW DATA

48Review of quality and safety of health services provided

The proprietor of a health service establishment must ensure the following information is recorded in writing and reviewed at least every 3 months—

(a)information in relation to the decisions and actions taken for the purposes of improving the quality and safety of health services provided;

(b)if applicable, information in relation to—

(i)all adverse events occurring at the health service establishment; and

(ii)all sentinel events occurring at the health service establishment; and

(iii)mortality and morbidity occurring at the health service establishment; and

(iv)compliance with the health service establishment's protocols; and

(v)results from surveys about patient experience and about staff safety culture.

49Patient experience survey data

The proprietor of a health service establishment must ensure that at each premises of the health service establishment—

(a)patient experience survey data is collected; and

(b)the patient experience survey data is reviewed; and

(c)the patient experience survey data is made available to the Secretary on request.

50Staff safety culture survey data

The proprietor of a health service establishment must ensure that at each premises of the health service establishment—

(a)staff safety culture survey data is collected; and

(b)the staff safety culture survey data is reviewed; and

(c)the staff safety culture survey data is made available to the Secretary on request.

PART 16—MISCELLANEOUS

51Change of title provision

On the commencement of regulation 5 of the Health Services (Private Hospitals and Day Procedure Centres) Amendment Regulations 2018, in any instrument made under any Act or in any other document of any kind, any reference to the Health Services (Private Hospitals and Day Procedure Centres) Regulations 2013 is taken to be a reference to the Health Services (Health Service Establishments) Regulations 2013 so far as it applies to any period on or after that commencement, unless the contrary intention appears.

SCHEDULES

SCHEDULE 1—REVOCATIONS

Regulation 4

S.R. No. Name
79/2002 Health Services (Private Hospitals and Day Procedure Centres) Regulations 2002
113/2005 Health Services (Private Hospitals and Day Procedure Centres) (Fees) Regulations 2005
176/2009 Health Services (Private Hospitals and Day Procedure Centres) Amendment Regulations 2009
88/2010 Health Services (Private Hospitals and Day Procedure Centres) Amendment Regulations 2010

SCHEDULE 2—APPLICATION FOR APPROVAL IN PRINCIPLE OF A HEALTH SERVICE ESTABLISHMENT

Regulation 8(1)

SECTION A

1.   Full name of applicant:

2.   Postal address of applicant:

3.   The name, telephone and facsimile numbers and email address of a contact person for the purposes of the application:

4.   If the applicant is a body corporate, the name and address of a director or officer of the body corporate who may exercise control over the health service establishment:

SECTION B

1.   The kind of health service establishment to which the application relates is:

*a private hospital

*a day procedure centre

1A. Whether any or all of the health services are to be provided by the health service establishment at premises other than the premises for which it is or is to be registered.

2.   The name (or proposed name) of the health service establishment, its street address and the municipal district in which the health service establishment is, or is to be, located or, if the health services are to be provided by the health service establishment at premises other than the premises for which it is or is to be registered, the business address of the health service establishment:

3.   This application is for an approval in principle for:

*the use of particular land or premises as a health service establishment;

*premises proposed to be constructed for use as a health service establishment;

*alterations or extensions to premises used, or proposed to be used, as a health service establishment;

*a variation of the registration of a health service establishment to alter the number of beds to which the registration relates;

*a variation of the registration of a health service establishment to vary the kinds of prescribed health services that may be carried on at the premises;

*a variation of the registration of a health service establishment to vary the number of beds that may be used for the specified kinds of prescribed health services;

*use of a premises as a health service establishment from which health services are to be provided at premises other than the first-mentioned premises;

*a variation of registration of a health service establishment to vary the kinds of prescribed health services that may be provided at premises other than the premises for which the health service establishment is registered.

SECTION C

In accordance with section 70(3) of the Health Services Act 1988, I have given notice in writing of this application to any other person who has an interest in the land as owner or lessee.

Signature of applicant:

Name of each signatory (in BLOCK LETTERS):

Date:

*(Strike out whichever does not apply)

SCHEDULE 3—APPLICATION FOR TRANSFER OR VARIATION OF CERTIFICATE OF APPROVAL IN PRINCIPLE OF A HEALTH SERVICE ESTABLISHMENT

Regulation 9(a)

SECTION A

1.   Full name of applicant:

2.   Postal address of applicant:

3.   The name, telephone and facsimile numbers and email address of a contact person for the purposes of the application:

SECTION B

1.   The kind of health service establishment to which the application relates is:

*a private hospital

*a day procedure centre

1A. Whether any or all of the health services are to be provided by the health service establishment at premises other than the premises for which it is or is to be registered.

2.   The name (or proposed name) of the health service establishment, its street address and the municipal district in which the health service establishment is, or is to be, located or, if the health services are to be provided by the health service establishment at premises other than the premises for which it is or is to be registered, the business address of the health service establishment:

3.   This application is for approval in principle for:

*variation of the certificate of approval in principle or any condition to which it is subject;

*transfer of the certificate of approval in principle to another person.

4.   Reason for the proposed variation:

5.   If the application relates to the transfer of the certificate to another person—

(a)    the name of that person; and

(b)    the postal address of that person; and

(c)     that person's telephone and facsimile numbers and email address.

6.   If the transferee is a body corporate, the name and address of any director or officer of the body corporate who may exercise control over the health service establishment:

SECTION C

In accordance with section 70(3) of the Health Services Act 1988, I have given notice in writing of this application to any other person who has an interest in the land as owner or lessee.

Signature of applicant:

Name of each signatory (in BLOCK LETTERS):

Date:

*(Strike out whichever does not apply)

SCHEDULE 4—APPLICATION FOR THE REGISTRATION OF A HEALTH SERVICE ESTABLISHMENT

Regulation 10(1)

SECTION A

1.   Full name of applicant:

2.   Postal address of applicant:

3.   The name, telephone and facsimile numbers and email address of a contact person for the purposes of the application:

4.   If the applicant is a body corporate, the name and address of any director or officer of the body corporate who may exercise control over the health service establishment:

SECTION B

1.   The kind of health service establishment for which registration is sought:

*a private hospital

*a day procedure centre

1A. Whether any or all of the health services are to be provided by the health service establishment at premises other than the premises for which it is to be registered.

2.   The name (or proposed name) of the health service establishment, its street address and the municipal district in which the health service establishment is, or is to be, located or, if the health services are to be provided by the health service establishment at premises other than the premises for which it is to be registered, the business address of the health service establishment:

3.   The proposed number of beds:

4.   The kind or kinds of health services for which registration is sought:

*Medical health services

*Surgical health services

*Speciality health services for the provision of—

*alcohol or drug withdrawal (detoxification—acute phase)

*anaesthesia

*bariatric procedures

*cardiac catheterisation

*cardiac surgery

*cataract surgery

*emergency medicine

*endoscopy

*intensive care

*liposuction (removing in total at least 200 ml of lipoaspirate)

*mental health services

*neonatal services (provided to patients aged under 28 days when admitted)

*neurosurgery

*obstetrics

*oncology (chemotherapy)

*oncology (radiation therapy)

*oocyte retrieval

*orthopaedic surgery

*paediatric services (provided to patients aged at least 28 days and less than 18 years when admitted)

*renal dialysis

*specialist rehabilitation services

5.   Is the applicant the owner or tenant of the premises?

6.   If the applicant is not the owner, please state the name and address of the owner:

Signature of applicant:

Name of each signatory (in BLOCK LETTERS):

Date:

*(Strike out whichever does not apply)

SCHEDULE 5—APPLICATION FOR THE RENEWAL OF REGISTRATION OF A HEALTH SERVICE ESTABLISHMENT

Regulation 12(1)

SECTION A

1.   Full name of applicant:

2.   Postal address of applicant:

3.   The name, telephone and facsimile numbers and email address of a contact person for the purposes of the application:

4.   If the applicant is a body corporate, the name and address of any director or officer of the body corporate who may exercise control over the health service establishment:

SECTION B

1.   The name of the health service establishment and its street address or, if the health services are to be provided by the health service establishment at premises other than the premises for which it is registered, the business address of the health service establishment:

2.   Date of expiry of current registration:

SECTION C

In accordance with section 88(3) of the Health Services Act 1988, I have given notice in writing of this application to any other person who has an interest in the land as owner or lessee.

Signature of applicant:

Name of each signatory (in BLOCK LETTERS):

Date:

SCHEDULE 6—APPLICATION FOR THE VARIATION OF THE REGISTRATION OF A HEALTH SERVICE ESTABLISHMENT

Regulation 13(1)

SECTION A

1.   Full name of applicant:

2.   Postal address of applicant:

3.   The name, telephone and facsimile numbers and email address of a contact person for the purposes of the application:

SECTION B

1.   The nature of the variation sought:

*change of the kind of establishment to which the registration applies

*transfer of the certificate of registration to another person who intends to become the proprietor of the establishment

*variation of any condition to which the registration is subject

*an alteration in the number of beds to which the registration relates

*variation of the kinds of prescribed health services that may be carried on at the premises

*variation of the number of beds that may be used for specified kinds of prescribed health services

*a variation of registration of a health service establishment to vary the kinds of prescribed health services that may be provided at premises other than the premises for which the health service establishment is registered.

2.   Details of the variation sought:

3.   If the application relates to the transfer of the certificate of registration to another person, the name, postal address, telephone and facsimile numbers and email address of the proposed transferee.

SECTION C

In accordance with section 92(3) of the Health Services Act 1988, I have given notice in writing of this application to any other person who has an interest in the land as owner or lessee.

Signature of applicant:

Name of each signatory (in BLOCK LETTERS):

Date:

*(Strike out whichever does not apply)

SCHEDULE 7—NOTICE OF SEIZURE OF DOCUMENT OR THING FROM A HEALTH SERVICE ESTABLISHMENT

Regulation 47

Health Services (Private Hospitals and Day Procedure Centres) Regulations 2013

Name of health service establishment:

Address of health service establishment:

I,  , being an authorised officer of the Department, am


               (print full name)

seizing under section 147 of the Health Services Act 1988 the document or thing listed below.

The seized document or thing will be returned to the place of seizure within 48 hours from the time of seizure.

DOCUMENT OR THING SEIZED

1.

2.

3.

Signed:

Date:

Time:
(Authorised Officer)

Signed:

Date:

Time:
(Proprietor/staff member)

DOCUMENT OR THING RETURNED

Signed:

Date:

Time:
(Authorised Officer)

Signed:

Date:

Time:
(Proprietor/staff member)

SCHEDULE 8—APPLICATION FOR APPROVAL OF ALTERATIONS TO A CLINICAL AREA

Regulation 13A

SECTION A

1.Full name of applicant:

2.Postal address of applicant:

3.The name, telephone and facsimile numbers and email address of a contact person for the purposes of the application:

SECTION B

1.Name of registered health service establishment:

2.Address of registered health service establishment:

SECTION C

1.The nature of the alternations to a clinical area sought:

2.Details of the alterations to a clinical area sought:

3.Certificate of Approval in Principle number:

SECTION D

Signature of applicant:

Name of each signatory (in BLOCK LETTERS):

Date:

═══════════════

ENDNOTES

1   General information

See for Victorian Bills, Acts and current Versions of legislation and up-to-date legislative information.

The Health Services (Private Hospitals and Day Procedure Centres) Regulations 2013, S.R. No. 113/2013 were made on 3 September 2013 by the Lieutenant-Governor, as the Governor's Deputy, with the advice of the Executive Council under section 158 of the Health Services Act 1988, No. 49/1988 and came into operation on 8 September 2013: regulation 3.

The title of these Regulations was changed from the Health Services (Private Hospitals and Day Procedure Centres) Regulations 2013 to the Health Services (Health Service Establishments) Regulations 2013 by regulation 5 of the Health Services (Private Hospitals and Day Procedure Centres) Amendment Regulations 2018, S.R. No. 83/2018.

The Health Services (Health Service Establishments) Regulations 2013 will sunset on 1 September 2024: see Subordinate Legislation (Health Services (Health Service Establishments) Regulations 2013) Extension Regulations 2023, S.R. No. 79/2023.

INTERPRETATION OF LEGISLATION ACT 1984 (ILA)

Style changes

Section 54A of the ILA authorises the making of the style changes set out in Schedule 1 to that Act.

References to ILA s. 39B

Sidenotes which cite ILA s. 39B refer to section 39B of the ILA which provides that where an undivided regulation, rule or clause of a Schedule is amended by the insertion of one or more subregulations, subrules or subclauses the original regulation, rule or clause becomes subregulation, subrule or subclause (1) and is amended by the insertion of the expression "(1)" at the beginning of the original regulation, rule or clause.

Interpretation

As from 1 January 2001, amendments to section 36 of the ILA have the following effects:

•     Headings

All headings included in a Statutory Rule which is made on or after


1 January 2001 form part of that Statutory Rule.  Any heading inserted in a Statutory Rule which was made before 1 January 2001, by a Statutory Rule made on or after 1 January 2001, forms part of that Statutory Rule.


This includes headings to Parts, Divisions or Subdivisions in a Schedule; Orders; Parts into which an Order is divided; clauses; regulations; rules; items; tables; columns; examples; diagrams; notes or forms. 


See section 36(1A)(2A)(2B).

•     Examples, diagrams or notes

All examples, diagrams or notes included in a Statutory Rule which is made on or after 1 January 2001 form part of that Statutory Rule.  Any examples, diagrams or notes inserted in a Statutory Rule which was made before 1 January 2001, by a Statutory Rule made on or after 1 January 2001, form part of that Statutory Rule.  See section 36(3A).

•     Punctuation

All punctuation included in a Statutory Rule which is made on or after


1 January 2001 forms part of that Statutory Rule.  Any punctuation inserted in a Statutory Rule which was made before 1 January 2001, by a Statutory Rule made on or after 1 January 2001, forms part of that Statutory Rule.


See section 36(3B).

•     Provision numbers

All provision numbers included in a Statutory Rule form part of that Statutory Rule, whether inserted in the Statutory Rule before, on or after


1 January 2001.  Provision numbers include regulation numbers, rule numbers, subregulation numbers, subrule numbers, paragraphs and subparagraphs.  See section 36(3C).

•     Location of "legislative items"

A "legislative item" is a penalty, an example or a note.  As from 13 October 2004, a legislative item relating to a provision of a Statutory Rule is taken to be at the foot of that provision even if it is preceded or followed by another legislative item that relates to that provision.  For example, if a penalty at the foot of a provision is followed by a note, both of these legislative items will be regarded as being at the foot of that provision.  See section 36B.

•     Other material

Any explanatory memorandum, table of provisions, endnotes, index and other material printed after the Endnotes does not form part of a Statutory Rule.  See section 36(3)(3D)(3E).

2   Table of Amendments

This publication incorporates amendments made to the Health Services (Health Service Establishments) Regulations 2013 by statutory rules, subordinate instruments and Acts.

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Health Services (Private Hospitals and Day Procedure Centres) Amendment Regulations 2018, S.R. No. 83/2018[1]

Date of making: 26.6.18
Commencement Date: 1.7.18: reg. 3

Health Services (Health Service Establishments) Amendment Regulations 2019, S.R. No. 99/2019

Date of Making: 22.10.19
Date of Commencement: 22.10.19

Health Services (Health Service Establishments) Amendment Regulations 2023, S.R. No. 57/2023

Date of Making: 20.6.23
Date of Commencement: 1.7.23: reg. 3

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3   Explanatory details

[1] Table of Amendments: The amendment to regulation 27(3) proposed by regulation 31(2) of the Health Services (Private Hospitals and Day Procedure Centres) Amendment Regulations 2018, S. R. No. 83/2018 is not included in this publication because the words "private hospital or day procedure centre" do not appear in regulation 27(3).

Regulation 31(2) reads as follows:

31Sufficient nursing staff must be on duty

(2)In regulation 27(3) of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

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Fee Units

These Regulations provide for fees by reference to fee units within the meaning of the Monetary Units Act 2004.

The amount of the fee is to be calculated, in accordance with section 7 of that Act, by multiplying the number of fee units applicable by the value of a fee unit.

The value of a fee unit for the financial year commencing 1 July 2023 is $15.90. The amount of the calculated fee may be rounded to the nearest 10 cents.

The value of a fee unit for future financial years is to be fixed by the Treasurer under section 5 of the Monetary Units Act 2004.  The value of a fee unit for a financial year must be published in the Government Gazette and a Victorian newspaper before 1 June in the preceding financial year.

Penalty Units

These Regulations provide for penalties by reference to penalty units within the meaning of section 110 of the Sentencing Act 1991. The amount of the penalty is to be calculated, in accordance with section 7 of the Monetary Units Act 2004, by multiplying the number of penalty units applicable by the value of a penalty unit.

The value of a penalty unit for the financial year commencing 1 July 2023 is $192.31. The amount of the calculated penalty may be rounded to the nearest dollar.

The value of a penalty unit for future financial years is to be fixed by the Treasurer under section 5 of the Monetary Units Act 2004.  The value of a penalty unit for a financial year must be published in the Government Gazette and a Victorian newspaper before 1 June in the preceding financial year.


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