Health Services (Private Hospitals and Day Procedure Centres) Amendment Regulations 2018 (Vic)

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Health Services (Private Hospitals and Day Procedure Centres) Amendment Regulations 2018

S.R. No. 83/2018

TABLE OF PROVISIONS

Regulation  Page

Part 1—Preliminary

1Objective

2Authorising provision

3Commencement

4Principal Regulations

5Title of Health Services (Private Hospitals and Day Procedure Centres) Regulations 2013 amended

6Objectives of Principal Regulations

7Regulation 5 substituted

Part 2—Prescribed health services

8Day procedure centres

9Private hospitals

10New regulation 7A inserted

Part 3—Forms of application and fees

11Application for approval in principle

12Application for registration

13Regulation 11 substituted

14Application for renewal of registration

15New regulation 13A inserted

Part 4—Senior appointments

16Director of Nursing must be appointed

17Acting Director of Nursing

18Secretary must be notified of appointment

19Chief Executive Officer and Medical Director

20Secretary to be notified of termination or vacancy

Part 5—Admission of patients

21Unit record number must be allocated

22Information about fees and services

23New Division 2A inserted

24Clinical record must be created

25Information to be included in clinical record

26Means of identifying patients

27Identification of infants

Part 6—Care of patients

28Respect, dignity and privacy

29Nurses must be registered and competent

30New regulations 26A and 26B inserted

31Sufficient nursing staff must be on duty

32Needs of patients must be met

33New regulation 28A inserted

Part 7—Complaints

34Nomination of complaints officer

35Dealing with a complaint

36Record of complaint

37Person making complaint must not be adversely affected

38New regulation 32A inserted

Part 8—Transfer and discharge of patients

39Transfer of patients

40Regulation 34 substituted and new regulation 34A inserted

Part 9—Registers and records

41Heading to Part 9 amended

42Patient Admission and Discharge Register

43Staff Register

44Operation Theatre Register

45Birth Register

46New Division 4 of Part 9 inserted

Part 10—Premises and equipment

47Identification of rooms

48Communications

49Prevention of scalding

50Repair and cleanliness of premises

51Suitability and cleanliness of facilities, equipment, furnishings and fittings

52New regulations 43A and 43B inserted

Part 11—Infection control and display of information

53Infection Control Management Plan

54Information to be prominently displayed

Part 12—Statistical returns

55Regulation 46 substituted

56New regulation 46A inserted

Part 13—Quality and safety review data and miscellaneous matters

57New Parts 15 and 16 inserted

Part 14—Schedules

58Schedule 2—Application for approval in principle of a private hospital or day procedure centre

59Schedule 3—Application for transfer or variation of certificate of approval in principle of a private hospital or day procedure centre

60Schedule 4—Application for the registration of a private hospital or day procedure centre

61Schedule 5—Application for renewal of registration of a private hospital or day procedure centre

62Schedule 6—Application for the variation of the registration of a private hospital or day procedure centre

63Schedule 7—Notice of seizure of document or thing from a private hospital or day procedure centre

64New Schedule 8 inserted

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Endnotes

STATUTORY RULES 2018

S.R. No. 83/2018

Health Services Act 1988

Health Services (Private Hospitals and Day Procedure Centres) Amendment Regulations 2018

The Governor in Council makes the following Regulations:

Dated: 26 June 2018

Responsible Minister:

JILL HENNESSY
Minister for Health

ANDREW ROBINSON

Clerk of the Executive Council

Part 1—Preliminary

1Objective

The objective of these Regulations is to amend the Health Services (Private Hospitals and Day Procedure Centres) Regulations 2013—

(a)to change the title of those Regulations; and

(b)consequent upon the amendments made to the Health Services Act 1988 by the Health Legislation Amendment (Quality and Safety) Act 2017.

2Authorising provision

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

3Commencement

These Regulations come into operation on


1 July 2018.

4Principal Regulations

In these Regulations, the Health Services (Private Hospitals and Day Procedure Centres) Regulations 2013[1] are called the Principal Regulations.

5Title of Health Services (Private Hospitals and Day Procedure Centres) Regulations 2013 amended

In the title of the Principal Regulations, for "Private Hospitals and Day Procedure Centres" substitute "Health Service Establishments".

6Objectives of Principal Regulations

(1)In regulation 1(a) of the Principal Regulations, for "in private hospitals and day procedure centres" substitute "in or from health service establishments".

(2)In regulation 1(b) of the Principal Regulations, for "private hospitals and day procedure centres" substitute "health service establishments".

7Regulation 5 substituted

For regulation 5 of the Principal Regulations substitute—

"5   Definitions

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;

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 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;

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

8Day procedure centres

For regulation 6(c) of the Principal Regulations substitute—

"(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.".

9Private hospitals

For regulation 7(c) of the Principal Regulations substitute—

"(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.".

10New regulation 7A inserted

After regulation 7 of the Principal Regulations insert—

"7A   Health 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

11Application for approval in principle

For regulation 8(2) of the Principal Regulations substitute—

"(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.".

12Application for registration

For regulation 10(2) of the Principal Regulations substitute—

"(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.".

13Regulation 11 substituted

For regulation 11 of the Principal Regulations substitute—

"11   Annual fees

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

14Application for renewal of registration

For regulation 12(2) of the Principal Regulations substitute—

"(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.".

15New regulation 13A inserted

After regulation 13 of the Principal Regulations insert—

"13A   Application 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

16Director of Nursing must be appointed

(1)In regulation 14(1) of the Principal Regulations, for "private hospital or day procedure centre" substitute "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)".

(2)For regulation 14(2) of the Principal Regulations substitute—

"(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.".

17Acting Director of Nursing

In regulation 15 of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

18Secretary must be notified of appointment

In regulation 16 of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

19Chief Executive Officer and Medical Director

In regulation 17 of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

20Secretary to be notified of termination or vacancy

In regulation 18 of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

Part 5—Admission of patients

21Unit record number must be allocated

In regulation 19 of the Principal Regulations, for "private hospital or day procedure centre" substitute "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)".

22Information about fees and services

(1)In regulation 20(1) of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

(2)In regulation 20(1)(a), (b) and (c) of the Principal Regulations, for "hospital or centre" substitute "health service establishment".

(3)In regulation 20(2)(a) of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

(4)In regulation 20(2)(k) of the Principal Regulations, for "hospital or centre" substitute "health service establishment".

23New Division 2A inserted

After Division 2 of Part 5 of the Principal Regulations insert—

"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.".

24Clinical record must be created

(1)In regulation 21 of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

(2)In regulation 21(a) and (b) of the Principal Regulations, for "hospital or centre" substitute "health service establishment".

25Information to be included in clinical record

(1)In regulation 22 of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

(2)In regulation 22(d)(ii) of the Principal Regulations, for "hospital or centre" substitute "health service establishment".

26Means of identifying patients

In regulation 23 of the Principal Regulations—

(a)for "private hospital or day procedure centre" substitute "health service establishment";

(b)for "hospital or centre" substitute "health service establishment".

27Identification of infants

(1)In regulation 24(1) of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

(2)In regulation 24(1)(b) of the Principal Regulations, for "hospital or centre" substitute "health service establishment".

(3)In regulation 24(2) of the Principal Regulations—

(a)for "private hospital or day procedure centre" substitute "health service establishment";

(b)for "hospital or centre" (where twice occurring) substitute "health service establishment".

Part 6—Care of patients

28Respect, dignity and privacy

(1)In regulation 25 of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

(2)In example 2 of the examples at the foot of regulation 25 of the Principal Regulations, for "hospital or centre" substitute "health service establishment".

29Nurses must be registered and competent

(1)In regulation 26 of the Principal Regulations—

(a)for "private hospital or day procedure centre" substitute "health service establishment";

(b)for "hospital or centre" substitute "health service establishment".

(2)For regulation 26(a) of the Principal Regulations substitute—

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

30New regulations 26A and 26B inserted

After regulation 26 of the Principal Regulations insert—

"26A   Post-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.".

31Sufficient nursing staff must be on duty

(1)In regulation 27(1) of the Principal Regulations—

(a)for "private hospital or day procedure centre" substitute "health service establishment";

(b)for "hospital or centre" substitute "health service establishment".

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

32Needs of patients must be met

In regulation 28 of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

33New regulation 28A inserted

After regulation 28 of the Principal Regulations insert—

"28A   Reversible 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

34Nomination of complaints officer

(1)In regulation 29(1) of the Principal Regulations—

(a)for "private hospital or day procedure centre" substitute "health service establishment";

(b)for "hospital or centre" substitute "health service establishment".

(2)In regulation 29(2) of the Principal Regulations—

(a)for "private hospital or day procedure centre" substitute "health service establishment";

(b)for "hospital or centre" substitute "health service establishment".

35Dealing with a complaint

In regulation 30(1), (2) and (3) of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

36Record of complaint

(1)In regulation 31(1) of the Principal Regulations—

(a)for "private hospital or day procedure centre" substitute "health service establishment";

(b)for "hospital or centre" substitute "health service establishment".

(2)In regulation 31(3) of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

37Person making complaint must not be adversely affected

In regulation 32 of the Principal Regulations—

(a)for "private hospital or day procedure centre" substitute "health service establishment";

(b)for "hospital or centre" substitute "health service establishment".

38New regulation 32A inserted

After regulation 32 of the Principal Regulations insert—

"32A   Open 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

39Transfer of patients

In regulation 33 of the Principal Regulations—

(a)for "private hospital or day procedure centre" substitute "health service establishment";

(b)for "hospital or centre" substitute "health service establishment from which the patient is transferred".

40Regulation 34 substituted and new regulation 34A inserted

For regulation 34 of the Principal Regulations substitute—

"34   Discharge 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 and records

41Heading to Part 9 amended

In the heading to Part 9 of the Principal Regulations, for "and records" substitute
", records and permits".

42Patient Admission and Discharge Register

In regulation 35 of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

43Staff Register

In regulation 36 of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

44Operation Theatre Register

(1)In regulation 37(1) of the Principal Regulations—

(a)for "private hospital or day procedure centre" substitute "health service establishment";

(b)for "hospital or centre" substitute "health service establishment".

(2)In regulation 37(2) of the Principal Regulations, for "hospital or centre" substitute "health service establishment".

(3)Regulation 37(2)(i) of the Principal Regulations is revoked.

45Birth Register

(1)In regulation 38(1) of the Principal Regulations—

(a)for "private hospital or day procedure centre" substitute "health service establishment";

(b)for "hospital or centre" substitute "health service establishment".

(2)In regulation 38(2) of the Principal Regulations, for "hospital or centre" substitute "health service establishment".

(3)In regulation 38(3) of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

46New Division 4 of Part 9 inserted

After regulation 38 of the Principal Regulations insert—

"Division 4—Permits

38ADrugs, Poisons and Controlled Substances Permit

For the purposes of ensuring the quality and safety of health services provided at a health service establishment, the proprietor of the 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.".

Part 10—Premises and equipment

47Identification of rooms

In regulation 39 of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

48Communications

In regulation 40(1) of the Principal Regulations—

(a)for "private hospital or day procedure centre" substitute "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)";

(b)for "hospital or centre" substitute "health service establishment".

49Prevention of scalding

In regulation 41 of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

50Repair and cleanliness of premises

In regulation 42 of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

51Suitability and cleanliness of facilities, equipment, furnishings and fittings

(1)In regulation 43(1) of the Principal Regulations—

(a)for "private hospital or day procedure centre" substitute "health service establishment";

(b)for "hospital or centre" (where twice occurring) substitute "health service establishment".

(2)In regulation 43(2) of the Principal Regulations—

(a)for "private hospital or day procedure centre" substitute "health service establishment";

(b)for "hospital or centre" substitute "health service establishment".

52New regulations 43A and 43B inserted

After regulation 43 of the Principal Regulations insert—

"43A   Premises, 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 and display of information

53Infection Control Management Plan

(1)In regulation 44(1) of the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

(2)In regulation 44(2) and (3)(b), (c) and (d) of the Principal Regulations, for "hospital or centre" substitute "health service establishment".

54Information to be prominently displayed

(1)In regulation 45 of the Principal Regulations—

(a)for "private hospital or day procedure centre" (where twice occurring) substitute "health service establishment";

(b)for "hospital or centre" substitute "health service establishment".

(2)In regulation 45(b) of the Principal Regulations after "Director of Nursing" insert "(if required to be appointed)".

Part 12—Statistical returns

55Regulation 46 substituted

For regulation 46 of the Principal Regulations substitute—

"46   Returns 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.".

56New regulation 46A inserted

After regulation 46 of the Principal Regulations insert—

"46A   Reporting 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.".

Part 13—Quality and safety review data and miscellaneous matters

57New Parts 15 and 16 inserted

After Part 14 of the Principal Regulations insert—

"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.".

Part 14—Schedules

58Schedule 2—Application for approval in principle of a private hospital or day procedure centre

(1)In the heading to Schedule 2 to the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

(2)In item 4 in Section A of Schedule 2 to the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

(3)After item 1 in Section B of Schedule 2 to the Principal Regulations insert—

"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.".

(4)For item 2 in Section B of Schedule 2 to the Principal Regulations substitute—

"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:".

(5)In item 3 in Section B of Schedule 2 to the Principal Regulations—

(a)for "private hospital or day procedure centre" (wherever occurring) substitute "health service establishment";

(b)for "on on the premises" substitute "on at the premises";

(c)for "prescribed health services." substitute "prescribed health services;".

(6)At the end of item 3 in Section B of Schedule 2 to the Principal Regulations insert—

"*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.".

59Schedule 3—Application for transfer or variation of certificate of approval in principle of a private hospital or day procedure centre

(1)In the heading to Schedule 3 to the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

(2)After item 1 of Section B of Schedule 3 to the Principal Regulations insert—

"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.".

(3)For item 2 in Section B of Schedule 3 to the Principal Regulations substitute—

"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:".

(4)In item 6 in Section B of Schedule 3 to the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

60Schedule 4—Application for the registration of a private hospital or day procedure centre

(1)In the heading to Schedule 4 to the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

(2)In item 4 in Section A of Schedule 4 to the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

(3)After item 1 of Section B of Schedule 4 to the Principal Regulations insert—

"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.".

(4)For item 2 in Section B of Schedule 4 to the Principal Regulations substitute—

"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:".

(5)For item 4 of section B of Schedule 4 to the Principal Regulations substitute—

"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".

61Schedule 5—Application for renewal of registration of a private hospital or day procedure centre

(1)In the heading to Schedule 5 to the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

(2)In item 4 in Section A of Schedule 5 to the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

(3)For item 1 in Section B of Schedule 5 to the Principal Regulations substitute—

"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:".

62Schedule 6—Application for the variation of the registration of a private hospital or day procedure centre

(1)In the heading to the Schedule 6 to the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

(2)In item 1 in Section B of Schedule 6 to the Principal Regulations, for "on on the premises" substitute "on at the premises".

(3)At the end of item 1 of Section B of Schedule 6 to the Principal Regulations insert—

"*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.".

63Schedule 7—Notice of seizure of document or thing from a private hospital or day procedure centre

(1)In the heading to Schedule 7 to the Principal Regulations, for "private hospital or day procedure centre" substitute "health service establishment".

(2)In Schedule 7 to the Principal Regulations, for "private hospital or day procedure centre" (where twice occurring) substitute "health service establishment".

64New Schedule 8 inserted

After Schedule 7 of the Principal Regulations insert—

"

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:

".

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Endnotes


[1] Reg. 4: S.R. No. 113/2013.

——

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 2018 is $14.45. 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.

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