Private Hospitals Regulation 1996

Part 1 Preliminary

1 Name of Regulation

This Regulation is the Private Hospitals Regulation 1996.

2 Commencement

This Regulation commences on 1 September 1996.

3 Application

This Regulation applies to and in respect of all private hospitals.

4 Definitions

(1)  In this Regulation:

admission form means an admission form referred to in clause 15.

approved means approved for the time being by the Director-General, either generally or in any particular case or class of cases.

child means a person who is under the age of 14 years.

clinical records means clinical records referred to in Schedule 1, 2 or 3.

Director-General means the Director-General of the Department of Health.

in-patient statistics form means an in-patient statistics form referred to in clause 15.

patient’s representative means:

(a)  if the patient is under the age of 16 years—a parent or guardian having legal custody of the patient, or

(b)  if the patient is under guardianship—the patient’s guardian, or

(c)  if the patient has died—the executor or administrator of the patient’s estate,

and includes any other person who, according to approved guidelines, is the patient’s representative.

primary care means the provision of non-urgent medical care, such as that generally provided by general practitioners.

the Act means the Private Hospitals and Day Procedure Centres Act 1988.

(2)  In this Regulation, a reference to a particular class of private hospital is a reference to a private hospital that is licensed as a private hospital of that class.

(3)  In this Regulation, a reference to a Form is a reference to a Form set out in Schedule 4.

5 Notes

The explanatory note and table of contents do not form part of this Regulation.

Part 2 Licensing of private hospitals

6 Licensing standards

(1)  For the purposes of section 7 of the Act, the following standards are prescribed:

(a)  for all private hospitals—the standards specified in Schedule 1,

(b)  for surgical class private hospitals—the standards specified in Part 1 of Schedule 2,

(c)  for obstetric class private hospitals—the standards specified in Part 2 of Schedule 2,

(d)  for rehabilitation class private hospitals—the standards specified in Part 3 of Schedule 2,

(e)  for psychiatric class private hospitals—the standards specified in Part 4 of Schedule 2.

(2)  For the purposes of section 7 of the Act, the following additional standards are prescribed:

(a)  for private hospitals authorised to provide cardiac catheterisation services—the standards specified in Part 1 of Schedule 3,

(b)  for private hospitals authorised to provide emergency services—the standards specified in Part 2 of Schedule 3,

(c)  for private hospitals authorised to provide intensive care—the standards specified in Part 3 of Schedule 3,

(d)  for private hospitals authorised to provide dialysis, haemofiltration or haemoperfusion services—the standards specified in Part 4 of Schedule 3,

(e)  for private hospitals authorised to provide neonatal intensive care—the standards specified in Part 5 of Schedule 3,

(f)  for private hospitals authorised to provide open heart surgery—the standards specified in Part 6 of Schedule 3.

(3)  The licensee must conduct the private hospital in accordance with the provisions of Schedules 1, 2 and 3 applicable to the private hospital.

Maximum penalty: 5 penalty units.

(4)  The licensee is not guilty of an offence under this clause if the licensee:

(a)  was not aware of the circumstances giving rise to the alleged offence, and

(b)  could not reasonably be expected to have been aware of those circumstances.

(5)  A contravention of a provision of Schedule 1, 2 or 3 by any person other than the licensee does not constitute an offence under this Regulation.

7 Applications for licences

For the purposes of section 8 of the Act:

(a)  the prescribed form of application is Form 1, and

(b)  the prescribed application fee is $690.

cl 7: Am 11.12.1996; 16.12.1998; 22.12.1999; 19.12.2001; 11.12.2002; 12.12.2003.

8 Classes of private hospitals

For the purposes of section 13 of the Act, the following classes of private hospitals are prescribed:

(a)  general (that is, a private hospital used for a purpose other than the purposes of a surgical, obstetric, rehabilitation or psychiatric class hospital),

(b)  surgical (that is, a private hospital used for the purpose of conducting surgical operations or endoscopic procedures, other than those that would normally be conducted by a medical practitioner in his or her consulting rooms),

(c)  obstetric (that is, a private hospital used for the purpose of providing obstetric care),

(d)  rehabilitation (that is, a private hospital used for the purpose of providing long-term or specialised physical rehabilitation),

(e)  psychiatric (that is, a private hospital used for the purpose of providing psychiatric care).

9 Annual licence fees

For the purposes of section 17 of the Act, the prescribed annual licence fee for a private hospital licensed to accommodate a number of persons within a range specified in Column 1 of the Table to this clause is the fee specified opposite that range in Column 2 of that Table.

Table

Column 1	Column 2
Number of persons licensed to be accommodated	Licence fee $
Fewer than 40	1,265
40–49	1,755
50–59	2,260
60–69	2,765
70–79	3,295
80–89	3,775
90–99	4,260
100 or more	4,780

cl 9, table: Subst 11.12.1996; 16.12.1998; 22.12.1999; 19.12.2001; 11.12.2002; 12.12.2003.

10 Transfer of licence

For the purposes of section 18 of the Act:

(a)  the prescribed form of application is Form 2, and

(b)  the prescribed application fee is $690.

cl 10: Am 11.12.1996; 16.12.1998; 22.12.1999; 19.12.2001; 11.12.2002; 12.12.2003.

11 Alterations or extensions

For the purposes of section 19 of the Act, the prescribed form of application is Form 3.

12 Application for review of Director-General’s decision

For the purposes of section 28 of the Act, the prescribed form of application is Form 4.

13 Chief nurse of private hospital

(1)  For the purposes of section 41 (1) of the Act, the prescribed qualifications to be held by a registered nurse who carries out the duties of chief nurse at a private hospital are:

(a)  current registration on List “A” of the Register kept under the Nurses Act 1991, and

(b)  5 years’ post-basic or post-graduate nursing experience, and

(c)  2 years’ administrative experience in a position of, or more senior than that of, nursing unit manager in a hospital.

(2)  For the purposes of section 41 (2) of the Act, the prescribed number of days is 7.

(3)  For the purposes of section 41 (4) of the Act, the prescribed particulars in respect of a person who carries out the duties of chief nurse are particulars of the person’s current authority to practise.

14 Register of patients

(1)  For the purposes of section 44 (1) of the Act, the prescribed form for a register of patients is a series of forms, each form being in or to the effect of Form 5, completed in respect of each patient and maintained in strict admission date order.

(2)  For the purposes of section 44 (2) (e) of the Act, the prescribed particulars to be entered in the register of patients are such of the particulars required to complete Form 5 as are relevant to a private hospital.

(3)  For the purposes of section 44 (3) of the Act, a particular required to be entered in the register of patients must be entered by the licensee:

(a)  in the case of a particular relating to the admission of a patient, at the time of admission of the patient, and

(b)  in the case of a particular relating to the separation of a patient, at the time the person ceases to be a patient, and

(c)  in either case:

(i)  in such manner as may be directed by the senior nurse on duty at the private hospital at the time the particulars are obtained, and

(ii)  subject to subparagraph (i), by hand or by use of an approved electronic data processing system.

15 Records

(1)  In addition to the register of patients, the licensee must keep the following records in respect of each patient:

(a)  an admission form, in the approved form,

(b)  an in-patient statistics form, in the approved form,

(c)  such other records as are required by Schedule 1, 2 or 3.

Maximum penalty: 5 penalty units.

(2)  Such records may be kept by hand or by use of an approved electronic data processing system.

Part 3 Disclosure of pecuniary interests

16 Definition of pecuniary interest

(1)  For the purposes of this Part:

pecuniary interest in a private hospital means any one or more of the following interests:

(a)  a pecuniary interest in the licence to conduct the private hospital, being:

(i)  an interest as the holder of the licence to conduct the private hospital, or as one of the holders of such a licence, or

(ii)  an interest in any corporation (other than a public company) which is the licensee of the private hospital, or

(iii)  a holding of 5 per cent or more of the issued share capital of a public company which is the licensee of the private hospital,

(b)  a pecuniary interest in the premises on which the private hospital is conducted, being:

(i)  an interest (whether at law or in equity) in the premises at which the private hospital is conducted, or

(ii)  an interest in any corporation (other than a public company) which has any interest (whether at law or in equity) in the premises at which the private hospital is conducted, or

(iii)  a holding of 5 per cent or more of the issued share capital of any public company which has any interest (whether at law or in equity) in the premises at which the private hospital is conducted,

(c)  a pecuniary interest in the services provided to the private hospital, being:

(i)  an interest in any clinical or administrative services provided to the private hospital (other than an interest being fees from medical or dental services provided by the person to any patient in the private hospital), or

(ii)  an interest in any corporation (other than a public company) which has an interest in any clinical or administrative services provided to the private hospital, or

(iii)  a holding of 5 per cent or more of the issued share capital of any public company which has an interest in any clinical or administrative services provided to the private hospital.

relative of a practitioner means the spouse, de facto partner, parent, child, brother or sister of the practitioner.

(2)  For the purposes of section 46 (4) of the Act, a practitioner has a pecuniary interest in a private hospital if the practitioner has a pecuniary interest within the meaning of this Part.

(3)  For the purposes of section 46 (5) of the Act, a pecuniary interest in a private hospital of a relative of a practitioner is a pecuniary interest of the practitioner.

17 Manner in which pecuniary interest to be notified

(1)  For the purposes of section 46 (1) of the Act, the manner in which a practitioner is to notify a person of the practitioner’s pecuniary interest is:

(a)  by telling the person of that fact by word of mouth, and

(b)  by giving written notice of that fact to the person, and

(c)  by displaying a written notice of that fact at the private hospital, surgery or other premises at which the relevant advice or treatment is given or the relevant arrangements are made.

(2)  The notification must identify the practitioner to which it relates and must specify the nature and extent of the pecuniary interest.

(3)  The written notice referred to in subclause (1) (c) must comply with the following requirements:

(a)  the notice must have a surface area of at least 2 500 square centimetres,

(b)  the information on the notice must be printed in plain, bold letters at least 1 centimetre high on a contrasting background,

(c)  in the case of a notice displayed at a private hospital, the notice must be displayed in a prominent place in the waiting room or in every room in which the practitioner to whom the notice relates attends to patients or other persons,

(d)  in the case of a notice displayed at a surgery or other premises, the notice must be displayed in a prominent place.

Part 4 Miscellaneous

18 Evidentiary certificates

An officer of the Department of Health who holds an authorisation for the purposes of section 51 of the Act, being a written authorisation signed by the Director-General, is a prescribed officer for the purposes of that section.

19 Display of licence

At all times while a private hospital is being conducted, the licensee must cause the licence (or a full-size copy of the licence) to be displayed in a prominent place in the entrance foyer of the private hospital.

Maximum penalty: 5 penalty units.

20 Information to be furnished with annual licence fee

(1)  When paying an annual licence fee referred to in section 17 of the Act, the licensee must furnish to the Director-General:

(a)  a copy of the chief nurse’s current authority to practise, and

(b)  a certificate in the approved form, and

(c)  information in the approved form in respect of the nursing staff at the private hospital.

Maximum penalty: 5 penalty units.

(2)  The certificate referred to in subclause (1) (b) must contain the information required to complete the approved form and (in the case of a licensee that is a corporation) must also be accompanied by the following information:

(a)  the full name of the corporation,

(b)  the address of the registered office of the corporation,

(c)  the full name, residential address, date and place of birth and position of:

(i)  each current director of the corporation, and

(ii)  the principal executive officer of the corporation, and

(iii)  the secretary or, if there is more than one, each secretary of the corporation,

(d)  in the case of a corporation limited by shares:

(i)  the types of shares and the number of shares of each type issued,

(ii)  in the case of a private corporation, the full name of, and the number of shares held by, each shareholder,

(iii)  in the case of a public corporation, a list of the 20 largest shareholdings and of the full names of the holders of each of those shareholdings,

(e)  if the shares are held by another corporation, the name of the ultimate holding corporation.

cl 20: Am 19.12.2001.

21 Change of ownership or control

(1)  A licensee that is a corporation must furnish to the Director-General, as soon as practicable after the change occurs, particulars of any change in the directors or major shareholders of the corporation.

Maximum penalty: 5 penalty units.

(2)  In this clause, major shareholder of a corporation means a shareholder whose shareholding exceeds 20 per cent of the total shareholding in the corporation.

22 Information to be furnished periodically

(1)  The licensee must, for each month, furnish to the Director-General a statistical statement in the approved form.

Maximum penalty: 5 penalty units.

(2)  The statement must contain the information required to complete the approved form and must be furnished to the Director-General within 14 days after the end of the month to which the information relates.

23 Repeal

(1)  The Private Hospitals Regulation 1990 is repealed.

(2)  Any act, matter or thing that, immediately before the repeal of the Private Hospitals Regulation 1990, had effect under that Regulation continues to have effect under this Regulation.

Schedule 1 Licensing standards for all private hospitals

(Clause 6)

Part 1 Design and construction of premises

1 Ambulance access

A private hospital must have adequate access for the emergency transfer of patients by ambulance.

2 Orders under the Local Government Act 1993

The licensee of a private hospital must ensure that notice is immediately given to the Director-General of any order made under section 124 of the Local Government Act 1993 in relation to the premises of the private hospital.

Part 2 Facilities and equipment

3 Furnishing and equipping of wards generally

(1)  All furniture, furnishings and bed linen provided by a private hospital must be:

(a)  of suitable quality and quantity, and

(b)  suitable for their intended use, and

(c)  comfortable for patients, and

(d)  able to be readily cleaned.

(2)  Any hot or warm water system supplying those areas of a private hospital that are used by patients for accommodation, ablutions, recreation or dining must be a system that has been installed in accordance with the prescribed installation requirements under section 45 of the Public Health Act 1991.

4 Beds

(1)  A suitable hospital-type bed must be provided for each patient other than a cot patient.

(2)  This clause does not apply to a psychiatric or rehabilitation ward if a suitable domestic-type bed is provided for each patient.

5 Other bedroom furniture

(1)  Each bed must be provided with at least one bedside locker, situated within easy reach of the bed, and having a top surface which has rounded corners and is washable and impervious to liquids.

(2)  Each bed must be provided with an overbed table which:

(a)  is of adjustable height, and

(b)  is of safe design and robust construction, and

(c)  has washable surfaces impervious to liquids.

(3)  At least one chair with arms must be provided for each bed and must be made of materials that facilitate the chair’s being kept clean and hygienic.

(4)  At least one wardrobe of suitable size must be provided for each bed for the storage of the clothes of the patient occupying the bed.

(5)  Individual draw screens must be provided for patient privacy for each bed in each multiple bed ward, and each such draw screen:

(a)  must be of suitable, washable, fire-resistant materials, and

(b)  must be suspended from strong overhead tracking, and

(c)  must extend from not more than 450 millimetres above the floor to at least 1 800 millimetres above the floor and 450 millimetres below the ceiling.

6 Furnishing and equipping of lounge areas

Patient lounge areas must be furnished with an adequate number of appropriate chairs.

7 Equipping of kitchen and serveries

(1)  Adequate food storage containers and food preparation, cooking and serving utensils must be provided.

(2)  Suitable eating and drinking utensils of a sufficient number must be provided for the use of patients.

8 Medical, surgical and nursing equipment

(1)  Medical, surgical and nursing equipment, appliances and materials that are necessary for the type and level of patient care in the private hospital must be provided.

(2)  Without limiting subclause (1), the following equipment must be provided in a private hospital:

(a)  a resuscitation trolley containing a complete set of adult resuscitation and monitoring equipment in each of the following areas:

(i)  each ward area supervised from a single nurse station,

(ii)  in a private hospital approved to provide intensive care—the intensive care area,

(b)  in a private hospital approved to admit child patients—a resuscitation trolley containing a complete set of paediatric resuscitation and monitoring equipment (suitable for the various age ranges of children approved to be admitted) in the children’s ward area,

(c)  oxygen and suction facilities at appropriate locations.

(3)  Without limiting subclause (1), a suitable medication trolley must be provided in each clean utility room or other suitable area.

9 Fire blankets

A fire blanket must be provided in each kitchen and each nurse station in a private hospital.

10 Utility rooms

(1)  Each private hospital must have both clean utility rooms and dirty utility rooms.

(2)  Unless otherwise approved, each dirty utility room must be provided with:

(a)  a suitable flusher-sanitiser for emptying, rinsing and sanitising bed-pans, commode-pans and urinal vessels, and

(b)  a suitable washer-sanitiser for washing and sanitising denture cups, tooth bowls, sputum cups and washing bowls, and

(c)  mobile soiled linen containers, and

(d)  a garbage receptacle fitted with a lid.

11 Open fires and portable heaters prohibited

Open fires and portable heaters must not be provided in areas used by patients.

12 Maintenance of buildings, facilities and equipment

(1)  The buildings, facilities and equipment of a private hospital (including all furniture, fittings and bed linen) must be maintained in good repair and operational order.

(2)  Without limiting subclause (1), a suitable maintenance program (consistent with the manufacturer’s specifications, if any) must be current at all times for:

(a)  all hot and warm water systems, and

(b)  all air-conditioning, heating, warming and cooling systems and appliances, and

(c)  all sterilising equipment, and

(d)  all communication, alarm and emergency call systems.

(3)  Gas cylinders must be stored in accordance with the distributor’s recommendations in cool, dry areas when not needed for immediate use.

(4)  If a designated area is provided for the storage of medical gases, all medical gas cylinders must be stored in that area when not needed for immediate use.

Part 3 Clinical standards

13 Medical advisory committee

(1)  The licensee must appoint a medical advisory committee for the private hospital.

(2)  The medical advisory committee must be appointed in accordance with the approved guidelines (if any) and must consist of at least 5 persons who are each medical practitioners or dentists.

(3)  The medical advisory committee is to be responsible for:

(a)  advising the licensee on the accreditation of medical practitioners and dentists to provide services at the private hospital and the delineation of their clinical responsibilities, and

(b)  advising the licensee on matters concerning clinical practice at the private hospital, and

(c)  advising the licensee on matters concerning patient care and safety at the private hospital.

(4)  The medical advisory committee is to have power to co-opt other health care providers, who may include nominees or representatives of learned colleges or other relevant professional organisations.

(5)  It is a function of the medical advisory committee to report to the Director-General any persistent failure by the licensee of the private hospital to act on the committee’s advice on matters specified in subclause (3).

14 Responsibilities of medical practitioners and dentists

(1)  Each procedure performed at the private hospital is to be performed by an appropriately accredited medical practitioner or dentist.

(2)  If a procedure involves the administration of a general, spinal, epidural, major field block or large field infiltration anaesthetic or intravenous sedative, the patient is to be attended throughout the procedure by a second appropriately accredited medical practitioner.

(3)  A medical practitioner or dentist is to be responsible for selecting patients suitable for treatment by the practitioner or dentist at the private hospital, subject to:

(a)  the class or classes of the private hospital and the limitations (if any) on the services that may be provided there, and

(b)  the clinical responsibilities of the medical practitioner or dentist, and

(c)  the maintenance of high professional standards.

15 Quality assurance

(1)  The licensee is to cause written procedures to be established for evaluating and recording the quality of clinical service and care provided at the private hospital and for correcting identified problems.

(2)  Such procedures are to take account of relevant external standards and programs recommended by learned colleges and other relevant professional organisations.

16 Experimental treatment

(1)  Experimental treatment must not be carried out otherwise than in accordance with the document entitled Statement on Human Experimentation issued by the National Health and Medical Research Council.

(2)  The licensee must refer any proposed new or experimental treatment to an institution ethics committee, constituted in accordance with that Statement, and the treatment must not be carried out otherwise than in accordance with the recommendations of the committee.

Part 4 Staffing

17 Staffing

(1)  The nursing staff of a private hospital must at all times be sufficient in number, and have appropriate experience, to perform the nursing duties necessary for the proper care of patients.

(2)  The nursing staff of a private hospital must include persons having qualifications and experience appropriate for each class of private hospital specified in the licence for the private hospital.

(3)  The licensee must cause a register to be kept in which are recorded the following particulars:

(a)  the name of each person employed in nursing duties in the private hospital,

(b)  the residential address of each such person,

(c)  in respect of each such person who is a registered or enrolled nurse:

(i)  the person’s nursing qualifications, and

(ii)  the number and expiry date shown on the person’s current authority to practise, and

(iii)  a statement that the person’s current authority to practise has been seen by the chief nurse.

(4)  Sufficient staff with appropriate qualifications must be provided in a private hospital to provide allied health services necessary for good patient care.

(5)  Sufficient domestic and maintenance staff or services must be provided in a private hospital to carry out the cooking, cleaning, laundering, maintenance and other duties necessary for the proper conduct of the private hospital.

(6)  The licensee must cause staff rosters to be prepared for the nursing and other staff of the private hospital and must cause written copies of the staff rosters to be kept available for inspection at the private hospital.

Part 5 Operational matters

18 Child patients

(1)  A child must not be admitted to a private hospital as a patient unless the private hospital is approved to admit child patients and the licence is endorsed accordingly.

(2)  A licensee who applies for an endorsement of the licence for the purposes of this clause must indicate:

(a)  the age range of children to be admitted, and

(b)  the types of investigation and treatment to be performed on children, and

(c)  the maximum duration of stay of children, and

(d)  the maximum number of children to be accommodated at any one time, and

(e)  the facilities to be provided for the treatment and care of children, and

(f)  the arrangements that exist for transferring children to hospitals providing appropriate treatment and care in the event of any medical complications arising,

for consideration in determining the conditions (if any) to be endorsed on the licence.

(3)  In the case of a child patient who requires special paediatric facilities or services (whether because of the child’s age, general state or medical condition, because of the proposed investigation, treatment or duration of stay, or otherwise), the licensee:

(a)  must arrange for a paediatric physician to be readily available for consultation at all times, and

(b)  unless otherwise approved, must have a registered nurse with post-basic or post-graduate paediatric experience or qualifications on duty at all times while the child is a patient in the private hospital, and

(c)  for neonates and children under the age of 12 months, must arrange for microchemistry to be readily available for analysis of capillary blood specimens.

(4)  In the case of all child patients:

(a)  the parents and guardians of the child (and any person having the care of the child) must have easy access to the child at all times except while the child is undergoing surgery, and

(b)  if the child is undergoing surgery, each such person must have easy access to the child in the pre-anaesthetic and recovery areas unless, in the opinion of the attending medical practitioner or dentist, the presence of such persons in these areas is detrimental to the child’s welfare, and

(c)  facilities must be made available for such a person to remain with the child throughout the period of hospitalisation, unless otherwise approved.

(5)  A child who is less than 2 years of age must be accommodated in a cot that complies with Australian Standard 2130-1981 entitled Metal Dropside Cots for Day Nurseries, Hospitals and Institutions (Safety Requirements), as published on 17 August 1981 by the Standards Association of Australia.

19 Specialised hospital services

(1)  The following specialised services must not be performed at a private hospital unless its licence authorises the provision of that service:

(a)  cardiac catheterisation,

(b)  emergency services,

(c)  intensive care,

(d)  dialysis, haemofiltration or haemoperfusion,

(e)  neonatal intensive care,

(f)  open heart surgery.

(2)  For the purposes of this clause, an emergency service does not include pre-arranged emergency admissions.

20 Patient programs

The licensee must ensure that the pursuit of cultural and religious interests of patients is not unnecessarily obstructed by staff of the private hospital.

21 Admission and separation of patients

(1)  On the admission of a patient to a private hospital:

(a)  a record of the patient’s personal particulars and reason for admission must be made, and

(b)  the attention of the patient or a person responsible for the patient must be drawn to the existence of, and the patient or person responsible must be given:

(i)  written information concerning the policy of the licensee in respect of the conduct of the private hospital, including charging for services, smoking by patients and staff and the handling of complaints about the private hospital, and

(ii)  written information concerning the procedure for lodging a complaint.

(2)  On a person’s ceasing to be a patient (whether by discharge, transfer or death), a summary is to be made of the person’s personal and clinical particulars, together with the reasons for the person’s so ceasing to be a patient.

(3)  The records referred to in this clause are to be made:

(a)  in the register of patients, and

(b)  in the admission form for the patient concerned, and

(c)  in the in-patient statistics form for the patient concerned.

(4)  On completion of the admission details, and again on completion of the separation details, the records are to be signed by the chief nurse (or by some other person authorised by the chief nurse for that purpose) and are to be dealt with as follows:

(a)  the register of patients form is to be retained in a loose-leaf file with all other completed register of patients forms,

(b)  the admission form is to be retained as the front sheet of the patient’s clinical record,

(c)  the in-patient statistics form is, unless otherwise approved, to be submitted to the Director-General within 6 weeks after the discharge of the person to whom the record relates.

22 Quality assurance

(1)  The licensee must cause written procedures to be established for evaluating and recording the quality of non-clinical services provided at the private hospital and for correcting identified problems.

(2)  Such procedures are to take account of relevant external standards and programs recommended by learned colleges and other relevant professional organisations.

23 Identification of patients

Each patient in a private hospital who is unable to clearly establish his or her identity to other persons must have the name and telephone number of the private hospital:

(a)  marked indelibly and legibly on each change of clothing, or

(b)  engraved or written legibly on a bracelet, anklet or necklace worn by the patient.

24 Notification of missing patients

If a patient appears to be missing from a private hospital, the patient’s representative or next of kin, and the patient’s medical practitioner and the police, must immediately be told of that fact.

25 Patient cleanliness and comfort

(1)  All practicable measures (including the prompt removal and replacement of soiled clothing and linen) must be taken to keep each patient clean and comfortable at all times.

(2)  Heating and cooling facilities must be used as necessary to maintain the comfort of each patient.

26 Dispensaries

The following provisions apply to any dispensary conducted at a private hospital:

(a)  the dispensary must be under the control of a pharmacist at all times,

(b)  all dispensing must be personally supervised by a pharmacist,

(c)  the dispensary must comply with the requirements of the regulations under the Pharmacy Act 1964 in relation to equipment, appliances and reference books,

(d)  the functions of the dispensary are to be limited to the provision of a service to the private hospital and its patients,

(e)  the services provided by the pharmacist in control of the dispensary must include:

(i)  the provision of all medication for patients, whether on prescription or otherwise, in a form that is suitable, as far as practicable, for direct administration or utilisation, and

(ii)  the provision of advice on drug compatibility, possible adverse drug reactions, appropriate doses for different classes of patients and medication policy, and

(iii)  regular inspection of drug stocks and records to ensure proper storage of medication, proper stock rotation, withdrawal of stock that is outdated or no longer required and proper recording of drug use, and

(iv)  the establishment of written policies and procedures on the procurement, preparation, distribution and administration of medication and other therapeutic goods,

(f)  the pharmacist in control of the dispensary must make adequate provision for emergency drugs to be available to staff of the private hospital outside the normal hours of operation of the dispensary.

27 Infection control

(1)  The licensee must have a written infection control policy approved by the Director-General.

(2)  The licensee must ensure that the private hospital has sufficient resources to enable the work practices of persons working in the private hospital to comply with that policy.

28 Hygiene

(1)  Adequate facilities, equipment and stores must be maintained in a private hospital for the effective cleaning and disinfection of the buildings and their fixtures and fittings.

(2)  Buildings of a private hospital, together with their fixtures and fittings, must be maintained in a clean and sanitary condition.

(3)  Without limiting subclause (2):

(a)  all furniture, furnishings, fittings, bedsteads and bedding must be kept in a clean and sanitary condition, and

(b)  eating, drinking or cooking utensils or food storage containers which are cracked, chipped, scored, stained or defective must not be used, and

(c)  each bed-pan, commode-pan, urinal vessel, wash basin and vomit bowl must be sanitised after each use, and

(d)  each tooth mug, denture container and sputum mug must, while in use, be sanitised at least once every 24 hours.

(4)  All necessary measures must be taken:

(a)  to exclude flies and other vermin from a private hospital, and

(b)  to destroy any flies or other vermin that are within a private hospital.

(5)  A pan sluice or flusher-sanitiser (but not a toilet facility) must be used for disposal of the contents of bed-pans, commode-pans and urinal vessels.

(6)  Receptacles with close-fitting lids must be provided for the collection of general refuse.

(7)  General refuse must be disposed of by the use of a service provided by the local authority or in some other suitable manner.

(8)  Contaminated wastes must be disposed of in accordance with the licensee’s infection control policy.

(9)  The grounds of a private hospital must be maintained in a clean, tidy and safe condition.

29 Smoking

(1)  There must be a written policy on smoking in the private hospital by patients and staff.

(2)  The policy on smoking must provide:

(a)  that neither patients nor staff are allowed to smoke in wards or dining areas, and

(b)  that, if patients or staff are allowed to smoke within the private hospital, smoking is confined to designated areas that allow other patients to avoid exposure to smoke without unduly restricting their activities, and

(c)  that frail patients are to be kept under direct supervision of a member of staff while smoking.

30 Telephones

(1)  A telephone (not being coin-operated and not fitted with any locking device) must be available at all times in a private hospital for use by staff in order to deal with emergencies.

(2)  At least one other telephone must be provided on each floor in a private hospital for use by patients and their next of kin for both incoming and outgoing calls.

(3)  The location of telephones provided for use by patients must take account of the need for access and privacy of patients and their next of kin when making telephone calls.

31 Visiting hours

(1)  Patients in a private hospital must be allowed to receive visitors at any reasonable time.

(2)  However, a medical practitioner or the senior nurse on duty may, if necessary for the care of a patient:

(a)  restrict the hours for visiting the patient and, if necessary, other patients in the same ward, and

(b)  restrict the number of persons who may visit the patient at any one time.

32 Meal times

(1)  Meals must be served to patients at the following times:

(a)  breakfast—not earlier than 6.30 am,

(b)  mid-day meal—not earlier than noon,

(c)  evening meal—not earlier than 5.00 pm.

(2)  Morning and afternoon tea and supper must be provided for patients at the appropriate times.

33 Storage, preparation and serving of food

(1)  A kitchen in a private hospital must be used solely for the purposes of:

(a)  storing, preparing, cooking and distributing food, and

(b)  washing dishes and utensils used in connection with the storage, preparation, cooking or serving of food.

(2)  An area of a private hospital, other than a kitchen, must not be used for the purposes specified in subclause (1), except that:

(a)  a servery may be used for the preparation of beverages and light snacks, and

(b)  a scullery may be used for washing dishes and utensils.

(3)  Laundry and waste (other than kitchen waste) must not be taken through a kitchen.

(4)  Meals at a private hospital must be prepared and served:

(a)  in accordance with a planned menu of at least one week, and

(b)  in sufficient variety, quality and quantity:

(i)  to be attractive and palatable to and edible by patients, and

(ii)  to provide the dietary allowances recommended from time to time by the National Health and Medical Research Council.

(5)  Any special diet prescribed or requested for a patient by the medical practitioner or dentist in charge of the patient’s care must be provided.

34 Overcrowding

(1)  Unless otherwise approved, a patient must not be lodged in any part of a private hospital other than a ward.

(2)  If in an emergency the number of patients in a ward exceeds the number of patients specified in the licence in relation to that ward, the licensee of the private hospital:

(a)  must, as soon as practicable, cause the excess patient or patients to be removed from that ward, and

(b)  must, as soon as practicable, notify the Director-General verbally of the fact, and

(c)  must, as soon as practicable, send to the Director-General notice in writing of the fact and of all the relevant details of the circumstances in which it occurred.

35 Removal of bodies

The body of a dead person must not be left for more than one hour in any ward or other room occupied by other patients.

36 Injuries, transfers and deaths

(1)  This clause applies to the following incidents:

(a)  any injury requiring medical attention that is sustained by a patient as a result of any accident at the private hospital,

(b)  the transfer of a patient to another hospital as a result of any injury or iatrogenic condition,

(c)  the death of any patient at a private hospital.

(2)  As soon as practicable after such an incident occurs:

(a)  details of the incident must be entered in the approved form, and in the patient’s clinical record, and must be reported to the chief nurse and to the patient’s medical practitioner, and

(b)  the incident must be investigated, and the results of the investigation must be entered in the approved form, and

(c)  if the patient was transferred to another hospital, details of the transfer must be entered in the approved form, and

(d)  if the patient was transferred to another hospital, or the incident was life-threatening or fatal:

(i)  the patient’s representative or next of kin, and the Director-General, must be notified verbally of the incident, and

(ii)  a copy of the completed approved form must be forwarded to the Director-General.

37 Fire safety and emergency evacuation

(1)  The licensee must have a written policy outlining the procedures to be adopted in the event of fire or other emergency (including contingency arrangements for the transfer of patients where necessary).

(2)  The licensee must ensure that all staff, immediately on commencing employment at the private hospital, are instructed in the procedures (including emergency evacuation procedures) to be adopted in the event of fire or other emergency.

(3)  An evacuation diagram must be displayed at each nurses’ station and at each exit to the private hospital.

(4)  The licensee must appoint a member of staff to be the fire safety officer for the private hospital and must ensure that the fire safety officer is provided with appropriate fire safety training.

(5)  All of the staff of a private hospital are to participate in an evacuation exercise at least once every 6 months.

(6)  All of the staff of a private hospital must attend fire safety training, provided by New South Wales Fire Brigades or by some other recognised fire safety training organisation, at least once every year.

(7)  A record of each such fire safety training, showing the name of each person attending and signed by the training officer for the fire safety training organisation, must be maintained.

(8)  If a fire occurs in a private hospital, the licensee, as soon as practicable and regardless of whether or not the fire brigade has been called to extinguish the fire:

(a)  must notify the Director-General verbally of the fact, and

(b)  must send to the Director-General written notice of the fact and of all the relevant details of the circumstances in which the fire occurred.

38 Storage of non-prescription drugs

(1)  In this clause:

drug of addiction means a substance specified in Schedule 8 of the Poisons and Therapeutic Goods List under the Poisons and Therapeutic Goods Act 1966.

non-prescription drug means a medication that is not a restricted substance or a drug of addiction.

restricted substance means a substance specified in Schedule 4 of the Poisons List under the Poisons and Therapeutic Goods Act 1966.

(2)  Non-prescription drugs must be stored in accordance with such of the requirements of the regulations under the Poisons and Therapeutic Goods Act 1986 as relate to the storage of restricted substances in hospitals generally.

Part 6 Clinical records

39 Application of Part

This Part applies to a former patient and to the records relating to a former patient in the same way as it applies to a patient and to the records relating to a patient.

40 Clinical records

(1)  A record of the medical condition of each patient in a private hospital and all medical, nursing and other care provided to the patient must be maintained by an entry in a patient clinical record system made by the appropriate medical, nursing or other health care provider.

(2)  Without limiting subclause (1), the clinical record of a patient must include the following:

(a)  the patient’s admission form,

(b)  the patient’s medical history, and results of any physical examination, which may be contained in any referral document,

(c)  medical consultation reports,

(d)  the patient’s medication sheet,

(e)  a record of planned nursing management, including all other treatment and diet orders,

(f)  a record of allergies and other factors requiring special consideration,

(g)  progress notes including:

(i)  a current principal diagnosis and other significant diagnoses, and

(ii)  a daily record of all medical and nursing care given in relation to the patient’s medical, physical, psychological and social needs and responses,

(h)  reports of all laboratory tests performed,

(i)  reports of all X-ray and other medical imaging examinations performed,

(j)  the name of any person whose consent to the carrying out of medical or dental treatment is necessary,

(k)  consent or request forms, if applicable,

(l)  a discharge statement, completed by the medical practitioner or dentist attending the patient, that specifies any major procedures performed, the final diagnosis, the patient’s condition and recommendations and arrangements for the patient’s future care.

(3)  Any records relating to medical or dental treatment must identify the medical practitioner or dentist by whom that treatment was provided.

(4)  A discharge statement referred to in subclause (2) (l) must be completed prior to the patient’s discharge unless verbal discharge instructions are given, in which case the statement must be completed within 48 hours after the patient’s discharge.

41 Retention of records

(1)  The register of patients, together with the patients’ clinical records, must be retained as follows:

(a)  the register of patients must be kept indefinitely,

(b)  clinical records relating to patients (other than obstetric patients) aged 18 years or over at the date of last separation must be kept for 7 years from the date of last separation,

(c)  clinical records relating to patients (other than obstetric patients) aged under 18 years at the date of last separation must be kept until the patient to whom the record relates attains, or would have attained, the age of 25 years.

(2)  The documents referred to in subclause (1) must be given to the transferee if the licence for the private hospital is transferred to another person.

(3)  If the licence for the private hospital is surrendered or cancelled, the licensee must deal with the register and records in accordance with the instructions of the Director-General.

(4)  Unless otherwise approved, the register and records are to be kept at the private hospital.

42 Patient’s right of access to clinical records

(1)  A patient or the patient’s representative may, by written application to the licensee, request access to the patient’s clinical record.

(2)  The licensee must, as soon as practicable after receipt of such an application, make the clinical record available to:

(a)  the patient or the patient’s representative, or

(b)  a person nominated by the patient or patient’s representative.

(3)  However, the licensee may refuse a request by a patient or by the patient’s representative for access to the patient’s clinical record:

(a)  if the medical practitioner or dentist in charge of the patient’s care advises that the request should be refused, and

(b)  if the licensee is satisfied that access by the patient or representative would be prejudicial to the patient’s physical or mental health.

(4)  An application under this clause is to be retained in the patient’s clinical record.

43 Manner of providing access

(1)  Access to a clinical record may be given by making the record available for inspection or by providing a copy of the record, as specified by the applicant.

(2)  If a person to whom access to a clinical record is given so requests, the person must be given assistance in the interpretation of the record (including any test results, findings and comments contained in the record) by a person qualified to do so.

(3)  If a patient or the patient’s representative requests particular clinical information (such as test results or details of past treatment) rather than access to the patient’s clinical record, the information may be provided by the medical practitioner or dentist in charge of the patient’s care or, subject to the advice of that medical practitioner or dentist, by a medical practitioner or registered nurse on the staff of the private hospital.

(4)  If a patient or the patient’s representative disagrees with information contained in the patient’s clinical record, the licensee must, on request by the patient or representative, attach the patient’s or patient’s representative’s own comments in the form of an addendum to the record.

(5)  The licensee may charge a fee (not exceeding the relevant fee, if any, determined by the Director-General) to cover the licensee’s costs of complying with this clause.

(6)  The Director-General may determine a scale of fees generally, or a fee payable in a particular case, in relation to a licensee’s costs of complying with this clause.

44 Procedure on refusal of request for access

(1)  If the licensee refuses a request by a patient or by the patient’s representative for access to the patient’s clinical record, the licensee:

(a)  must inform the patient or representative in writing of the reason for the refusal and of any rights of appeal that may exist in relation to the refusal, and

(b)  must include in the patient’s clinical record a written note of the refusal and the reason given for the refusal.

(2)  A patient or the patient’s representative may appeal in writing to the Director-General against a decision of the licensee to refuse access to the patient’s clinical record.

(3)  The Director-General may, in determining such an appeal:

(a)  confirm the decision of the licensee, or

(b)  direct that the licensee grant the patient or the patient’s representative access to the patient’s clinical record under such conditions as the Director-General may direct.

(4)  A determination made by the Director-General is to be conveyed in writing to the licensee and retained in the clinical record of the patient to whom it relates.

45 Confidentiality of records

(1)  The licensee must ensure that, except as provided by this clause, personal information concerning a patient is not released from the private hospital except with the consent of the patient or the patient’s representative or with other lawful excuse.

(2)  Subclause (1) does not affect the operation of any other law requiring, prohibiting or restricting the release of any such information.

(3)  All clinical records must be stored in a secure place to which unauthorised persons are not to be permitted to have access.

sch 1: Am 19.12.2001.

Schedule 2 Additional licensing standards for particular classes of private hospital

(Clause 6)

Part 1 Surgical hospitals

1 Support services

A surgical class private hospital must have access to basic pathology and radiography services within a period of time appropriate to clinical need.

2 Clinical records

The clinical record of a patient in a surgical class private hospital is, if a surgical procedure has been performed, to include:

(a)  in a case where anaesthesia has been employed—the anaesthetic record, which must comply with the recommendations of the Australian and New Zealand College of Anaesthetists in its publication The Anaesthetic Record, and

(b)  the procedural report, including pre-procedural and post-procedural diagnoses, and a description of the findings, technique used and tissue removed or altered, and

(c)  in a case where tissue or body fluid was removed—a pathological report on the tissue or body fluid, and

(d)  a record of the swab, sponge and instrument count, and

(e)  the post-procedural recovery record.

3 Staffing

Staff are to be provided to assist an anaesthetist in accordance with the recommendations of the Australian and New Zealand College of Anaesthetists in its publication Minimum Assistance Required for the Safe Conduct of Anaesthesia.

4 Child patients

If a child is undergoing surgery, the parents and guardians of the child (and any person having the care of the child) must have easy access to the child in the pre-anaesthetic and recovery areas unless, in the opinion of the attending practitioner, the presence of the parents in those areas is detrimental to patient welfare.

5 Identification of patients

(1)  An identification band must be fitted around a wrist or an ankle of each surgical patient.

(2)  The patient’s name and date of birth, and the attending medical practitioner’s name, must be indelibly and legibly written on the band.

6 Medical, surgical and nursing equipment

The following equipment must be provided in a surgical class private hospital in the operating suite:

(a)  an electrosurgical unit for each operating room,

(b)  adequate instrument sets for elective use,

(c)  sterile instrument sets available for emergency procedures,

(d)  anaesthetic equipment recommended by the Australian and New Zealand College of Anaesthetists in its publication Recommended Minimum Facilities for Safe Anaesthetic Practice in Operating Suites,

(e)  monitoring equipment recommended by the Australian and New Zealand College of Anaesthetists in its publication Monitoring During Anaesthesia,

(f)  recovery equipment and drugs recommended by the Australian and New Zealand College of Anaesthetists in its publication Guidelines for the Care of Patients Recovering from Anaesthesia in the Recovery Area.

Part 2 Obstetric hospitals

7 Definition

In this Part:

obstetric care includes:

(a)  antenatal care related to childbirth, and

(b)  assistance and care involved in normal childbirth, and

(c)  surgical intervention in achieving childbirth, and

(d)  care of a mother admitted with a baby immediately following childbirth.

8 Medical advisory committee

The medical advisory committee of an obstetric class private hospital must include at least one specialist obstetrician.

9 Design and construction

An obstetric unit of an obstetric class private hospital:

(a)  must include an adequate number (relative to the size of the unit) of delivery rooms that:

(i)  are separate from any operating room, and

(ii)  will accommodate the presence of at least 2 support persons (in addition to attending staff) during a birth, and

(iii)  are suitably finished and fitted for birthing, and

(iv)  have adjacent bath and shower facilities for use by a patient, and

(b)  must include a nursery for the newly born (of a size appropriate to the size of the unit) with a separate isolation facility, and

(c)  must have facilities for medical consultations with patients.

10 Conduct of hospitals

An obstetric class private hospital:

(a)  must have a written policy in relation to the following matters:

(i)  the private hospital’s criteria for admission to obstetric services,

(ii)  normal childbirth,

(iii)  breast feeding,

(iv)  rooming in,

(v)  the accommodation by the private hospital of the individual needs of patients and their families,

(vi)  the numbers and qualifications of medical practitioners and nursing staff available to the private hospital and the numbers of any such staff on duty for each shift,

(vii)  the quality assurance programs established by the private hospital,

(viii)  provision made by the private hospital for the transfer of patients to another hospital providing a higher level of medical service, and

(b)  must have an obstetrician, an anaesthetist and a paediatrician on close call at all times, and

(c)  must have a suitable number of registered nurses with obstetric qualifications on duty at all times, and

(d)  must have contingency arrangements for the transfer of mothers and babies to a hospital providing a higher level of care in an emergency.

11 Clinical records

(1)  The clinical record of a patient in an obstetric class private hospital must include the childbirth labour record if an obstetric delivery has been performed.

(2)  An obstetric patient’s clinical record must be retained for at least 25 years from the date of the patient’s separation from the private hospital.

12 Record of births

(1)  Details of the birth of a baby (whether live or stillborn) born in a private hospital or admitted to a private hospital as a newborn baby (otherwise than by transfer from another hospital) must be recorded in the approved form.

(2)  The record must be signed:

(a)  by the medical practitioner or midwife attending the birth, or

(b)  by the chief nurse or a person authorised by the chief nurse for the time being for that purpose.

(3)  Copies of the record are to be distributed as follows:

(a)  the first copy is to be retained at the private hospital with the mother’s clinical record,

(b)  the second copy, unless otherwise approved, is to be forwarded to the Director-General within 6 weeks after the separation of the mother or baby from the private hospital, whichever occurs first,

(c)  the third copy is to be made available to the local community nurse, but only with the consent of the mother,

(d)  other copies of the record are to be forwarded to the mother’s referring medical practitioner and consulting specialist (if any), unless the mother objects.

13 Identification of patients

(1)  An identification band must be fitted around a wrist or an ankle of each obstetric patient and baby.

(2)  The patient’s name and date of birth, and the attending medical practitioner’s name, must be written indelibly and legibly on the patient’s band.

(3)  The baby’s name and date of birth, and the attending medical practitioner’s name, must be written indelibly and legibly on the baby’s band.

14 Furnishing of wards

Each maternity ward in an obstetric class private hospital must have one bassinette for each maternity bed and one reserve bassinette for each 10 (or portion of 10) maternity beds.

15 Medical, surgical and nursing equipment

The delivery suite of an obstetric class private hospital must be equipped in accordance with the recommendations of the Australian and New Zealand College of Anaesthetists in its publication entitled Recommended Minimum Facilities for Safe Anaesthetic Practice in Delivery Suites.

Part 3 Rehabilitation hospitals

16 Medical advisory committee

The medical advisory committee of a rehabilitation class private hospital must include among its members at least one specialist in rehabilitation medicine.

17 Conduct of rehabilitation class private hospitals

A rehabilitation class private hospital:

(a)  must have a written policy on the provision of rehabilitation services, including:

(i)  a statement of the private hospital’s philosophy of service, and

(ii)  details of the liaison to be established with community based services to ensure continuity and co-ordination of care, and

(b)  must have clear, written criteria and assessment procedures for the admission of both inpatients and outpatients to rehabilitation programs, and

(c)  must have a written rehabilitation plan for each patient that:

(i)  is based on the assessment of that patient, and

(ii)  states the needs and limitations of the patient and the goals of the rehabilitation plan, and

(iii)  is prepared by a multi-disciplinary team with the active participation of the family of the patient, and

(iv)  includes provision for discharge, continuing care and review, and

(d)  must have procedures for regularly evaluating the progress of each patient against the written rehabilitation plan, and

(e)  must have a formal and planned discharge procedure, and

(f)  must have regular case management meetings, involving the treating medical practitioner and appropriate therapists, to review individual rehabilitation plans, and

(g)  must have access to specialists for consultation, and

(h)  must have sufficient appropriate therapists for the services provided, and

(i)  must have sufficient registered nurses with appropriate rehabilitation qualifications or experience on duty at all times, and

(j)  if patients with brain impairment are being treated, must have access to the services of a neuro-psychologist, and

(k)  if patients with chronic pain are being treated, must have access to the services of a clinical psychologist.

18 Clinical records

The clinical record of a patient in a rehabilitation class private hospital must include:

(a)  a clear statement by the treating medical practitioner giving details of the reason for admission and the perceived need for rehabilitation which is consistent with the admission policy, and

(b)  a rehabilitation plan based on the assessment of the patient, and

(c)  a record of each evaluation of the patient’s progress, and

(d)  a discharge plan.

19 Areas for dining, therapy and other activities

A rehabilitation class private hospital must have patient activity areas which are adequately equipped for dining, therapy and other activities.

Part 4 Psychiatric hospitals

20 Design and construction

(1)  A psychiatric class private hospital must be designed to meet the needs of mentally ill and mentally disordered persons, with:

(a)  suitable arrangements for patient safety and protection, and

(b)  areas for observation of patients, and

(c)  accommodation providing personal privacy, consistent with the treatment being provided.

(2)  If electroconvulsive therapy is to be administered, the private hospital must have treatment and recovery areas set aside for that purpose.

21 Medical advisory committee

The medical advisory committee of a psychiatric class private hospital must include at least one psychiatrist among its members.

22 Conduct of psychiatric class private hospitals

A psychiatric class private hospital:

(a)  must have a written policy on the provision of psychiatric services, including a statement of the private hospital’s philosophy of service, and

(b)  must have a written policy and procedure for:

(i)  supporting the functions of the Mental Health Review Tribunal, and

(ii)  supporting the functions of official visitors, authorised officers and welfare officers, and

(iii)  supporting the administration of the Guardianship Act 1987, and

(iv)  the management of patients’ trust funds, and

(c)  must have clear, written criteria and assessment procedures for the admission of both inpatients and outpatients to psychiatric programs, and

(d)  must have a written treatment plan for each patient that:

(i)  is based on the assessment of that patient, and

(ii)  includes provision for discharge, continuing care and review, and

(e)  must have access at all times to a psychiatrist, and

(f)  must have access to a general practitioner and relevant specialists for consultation, and

(g)  must have sufficient registered nurses with appropriate psychiatric qualifications or experience on duty at all times.

23 Clinical records

The clinical record of a patient in a psychiatric class private hospital:

(a)  must comply with the requirements of the Mental Health Act 1990, and

(b)  must include:

(i)  a clear statement of the reason for admission, consistent with the admission policy, and

(ii)  a treatment plan based on the assessment of the patient, and

(iii)  a record of each evaluation of the patient’s progress, and

(iv)  a discharge plan.

24 Areas for dining, therapy and other activities

A psychiatric class private hospital must have patient activity areas which are adequately equipped for dining, therapy and other activities.

25 ECT equipment

The equipment and drugs provided in areas in which electroconvulsive therapy is administered must comply with the recommendations of the Australian and New Zealand College of Anaesthetists in its publication Recommended Minimum Facilities for Safe Anaesthetic Practice for Electro Convulsive Therapy.

Schedule 3 Additional licensing standards for private hospitals authorised to provide specialised services

(Clause 6)

Part 1 Cardiac catheterisation

1 Definition

In this Part:

cardiac catheterisation means the procedure of passing a catheter (or other instrument) through a major blood vessel to the heart for a diagnostic or therapeutic purpose.

2 Medical advisory committee

The medical advisory committee of a private hospital authorised to provide cardiac catheterisation services is to include a cardiologist trained in cardiac catheterisation techniques and an anaesthetist experienced in cardiac procedures while matters relating to cardiac catheterisation are being discussed.

3 Planning and location

(1)  Cardiac catheterisation services must be performed in a separate unit that:

(a)  is dedicated, as a cardiac catheterisation unit, to the performance of those services, and

(b)  is air-conditioned and adequate in size for the services performed, and

(c)  is so located as to allow quick access, when those services are performed, to a cardiac care unit or intensive care unit located in the same hospital, and

(d)  has an emergency call system linked to at least one of those units, and

(e)  is close to a staff station, and

(f)  includes a short-term recovery area that has accommodation for at least 2 trolleys from each procedure room in the unit, and

(g)  has a scrub up area, and

(h)  has a clean utility room with a refrigerator for the storage of drugs, and

(i)  has access to a central sterilising supply service (unless only sterile disposable equipment is used in the unit), and

(j)  has access to facilities for linen and general storage, and

(k)  has access to facilities near the unit for recording images of cardiac catheterisation services, and

(l)  has access to a dirty utility room, staff change rooms and staff toilets, all of which are near the unit.

(2)  If the cardiac catheterisation services performed are therapeutic, the private hospital must have a cardiac care unit or intensive care unit from which the transfer of a patient to a theatre equipped and staffed for open heart surgery can be completed within 30 minutes (whether that theatre is in the same or in another hospital).

(3)  If a private hospital where therapeutic cardiac catheterisation services are performed does not itself have a theatre equipped and staffed for open heart surgery, the private hospital must have access to a readily available, suitably equipped ambulance when those services are performed.

4 Conduct of cardiac catheterisation unit

A private hospital authorised to provide cardiac catheterisation services:

(a)  must have a written policy in relation to all of the following matters:

(i)  the criteria for the admission of patients to cardiac catheterisation,

(ii)  the program of care for patients following cardiac catheterisation,

(iii)  the numbers and qualifications of medical practitioners and nursing staff available to the private hospital and the numbers of any such staff on duty for each shift,

(iv)  the qualifications of those practitioners and staff,

(v)  the provision made for the transfer of patients to another hospital that provides a higher level of medical service, and

(b)  must have a written policy that details the quality assurance programs established by the private hospital concerning cardiac catheterisation services, and

(c)  must have a suitable number of appropriate staff, including a specialist director of cardiac catheterisation services, registered nursing staff with relevant experience and allied health staff, and

(d)  must have an in-patient orientation and education program, and

(e)  if the private hospital is not authorised to carry out open heart surgery, must have contingency arrangements with a nearby hospital capable of performing open heart surgery for the transfer of patients in an emergency.

5 Retention of clinical records

The films or other archival media on which a cardiac catheterisation procedure is recorded must be kept for at least 3 years from the date when the procedure was carried out.

6 Identification of patients

(1)  An identification band must be fitted around a wrist or an ankle of each cardiac catheterisation patient.

(2)  The patient’s name and date of birth, and the attending medical practitioner’s name, must be indelibly and legibly written on the band.

7 Medical, surgical and nursing equipment

Each procedure room in a cardiac catheterisation unit must have its own resuscitation equipment including a defibrillator.

Part 2 Emergency services

8 Definition

In this Part:

emergency service means a service for the care of persons injured in accidents, or for those suffering from medical or other emergencies, through the provision of reception, resuscitation, medical and surgical facilities and life support systems.

9 Design and construction

An emergency service must be provided in or from a separate unit that is dedicated to that service and that:

(a)  is clearly signposted, and

(b)  has separate access, protected from the weather, for patients arriving by ambulance, and

(c)  is air-conditioned to cope with the planned maximum patient load, and

(d)  has sufficient space to cope with the planned maximum patient load, and

(e)  has a reception area with facilities for the initial assessment of patients, and

(f)  has a waiting area for the relatives and friends of patients, and

(g)  has access to the private hospital’s medical records service, and

(h)  has access to one or more operating theatres, an intensive care unit and medical imaging facilities, and

(i)  has appropriate treatment areas including resuscitation bays, treatment cubicles, examination and consulting rooms, a procedure room and a plaster room, and

(j)  provides for privacy in all patient areas, and

(k)  has a nurse station, and

(l)  has a clean utility room, and

(m)  has access to a dirty utility room, and

(n)  has access to ancillary facilities including toilets, storage and offices, and

(o)  has appropriate communication arrangements with the Ambulance Service of New South Wales.

10 Conduct of emergency service

A private hospital approved to provide an emergency service:

(a)  must have a written policy covering all of the following matters:

(i)  the co-ordination of the service with other emergency services in the same district as the private hospital,

(ii)  the integration of the emergency service with the clinical and educational activities of the private hospital,

(iii)  the admission and discharge of patients and the review of the care provided to patients,

(iv)  the provision of information and counselling to relatives and friends of patients, and

(b)  must have an appropriately qualified and experienced medical practitioner appointed as director of the emergency service, and

(c)  must have arrangements for appropriate specialists to be available on close call at all times, and

(d)  must have sufficient appropriately trained and experienced staff on duty and immediately available at all times, and

(e)  must have an effective system of triage which separates patients needing emergency services from patients needing primary health care, and

(f)  must have arrangements for the provision of primary health care in appropriate cases, and

(g)  must have contingency arrangements for the transfer of patients by retrieval teams to a hospital providing a higher level of care if needed.

11 Clinical records

The private hospital’s clinical record for each emergency patient must include:

(a)  the date and time of arrival and separation, and

(b)  a description of significant clinical, laboratory and radiological findings, and

(c)  accurate details of any treatment provided, and

(d)  the identity and signature of the attending medical officer.

12 Medical and nursing equipment

An emergency service must be equipped with:

(a)  suitable monitors and ventilators, and

(b)  resuscitation and diagnostic equipment and drugs,

adequate for the planned maximum numbers of child and adult patients who may be undergoing examination or treatment by the service at any one time.

Part 3 Intensive care

13 Definition

In this Part:

intensive care means the observation, care and treatment of patients with life-threatening or potentially life-threatening illnesses, injuries or complications, from which recovery is possible, in a separate intensive care unit that is specially staffed and equipped for that purpose.

14 Medical advisory committee

The medical advisory committee of a private hospital authorised to provide intensive care must be joined by a medical practitioner with experience in intensive care, unless the committee already includes such a person, when matters relating to intensive care are being discussed.

15 Design and construction

An intensive care service must be provided in an integrated hospital unit that:

(a)  is located in a self-contained area with easy access to the emergency department (if any), operating theatres, organ imaging and pathology services at all times, and

(b)  has access to the private hospital’s medical records service, and

(c)  is air-conditioned to cope with the planned maximum patient, staff and equipment load, and

(d)  has sufficient floor area for each bed space, and

(e)  has sufficient numbers of non-manual hand washing and drying facilities to allow direct access from each bed, and

(f)  has sufficient oxygen, air and suction outlets for the level of care to be provided, and

(g)  has sufficient power outlets for the level of monitoring and care to be provided, and

(h)  has adequate and appropriate lighting for clinical observation, and

(i)  has a work area, from which patients may be kept under direct observation, provided with:

(i)  a workbench and chairs, and

(ii)  telephone equipment for communication both within and outside the private hospital, and

(iii)  sufficient storage space for stationery, X-rays, drugs and resuscitation equipment, and

(iv)  a refrigerator, and

(v)  patient monitors, and

(j)  has an equipment storage area for monitors, ventilators, infusion pumps and syringes, dialysis equipment, disposable items, fluids, drip stands, trolleys, blood warmers, suction apparatus, linen and other equipment, and

(k)  has access to a dirty utility area suitably equipped for cleaning appliances, urine testing, and emptying and cleaning bed pans and urinal bottles, and

(l)  has access to sufficient office space for the medical officer on duty in the unit and the nurse for the time being in charge of the unit, and

(m)  has access to a nearby waiting area for relatives, and

(n)  has access to staff facilities, and

(o)  has access to a mobile X-ray machine, and

(p)  has access to a cleaner’s area for storage of cleaning equipment and materials.

16 Conduct of an intensive care unit

A private hospital authorised to provide intensive care:

(a)  must have a written policy in relation to all of the following matters:

(i)  the private hospital’s criteria for admission to intensive care,

(ii)  the care of patients admitted to intensive care,

(iii)  the numbers and qualifications of medical practitioners and nursing staff available to the private hospital and the numbers of any such staff on duty for each shift,

(iv)  the quality assurance programs established by the private hospital,

(v)  provision made by the private hospital for the transfer of patients to another hospital providing a higher level of medical services, and

(b)  must have a medical practitioner with appropriate qualifications appointed as director of the unit, the appropriate qualifications being (in the case of a private hospital that is licensed as a Level 2 unit) a recognised post-graduate qualification in intensive care, and

(c)  in the case of a private hospital that is licensed as a Level 1 unit, must have a medical practitioner on duty at the private hospital at all times, with priority for attendance on patients in the intensive care unit, and

(d)  in the case of a private hospital that is licensed as a Level 2 unit, must have a medical practitioner with an appropriate level of experience present in the unit at all times, and

(e)  sufficient nursing staff on duty in the unit at all times, with a nursing staff to patient ratio of 1:1 for all critically ill patients and, in the case of a private hospital that is licensed as a Level 2 unit, of whom a majority are registered nurses with intensive care certification.

17 Identification of patients

(1)  An identification band must be fitted around a wrist or an ankle of each patient admitted to the intensive care unit.

(2)  The patient’s name and date of birth, and the attending medical practitioner’s name, must be indelibly and legibly written on the band.

18 Medical, surgical and nursing equipment

An intensive care unit must have the following:

(a)  ventilators,

(b)  hand ventilating assemblies,

(c)  suction apparatus,

(d)  airway access equipment, including bronchoscopic equipment,

(e)  vascular access equipment,

(f)  monitoring equipment, both non-invasive and invasive,

(g)  defibrillation and pacing equipment,

(h)  equipment to control patients’ temperatures,

(i)  chest drainage equipment,

(j)  infusion and specialised pumps,

(k)  transport monitoring equipment,

(l)  specialised intensive care beds.

Part 4 Dialysis, haemofiltration and haemoperfusion

19 Definitions

In this Part:

continuous ambulatory peritoneal dialysis means the form of peritoneal dialysis in which dialysing fluid is run into the abdominal cavity, left for some hours, drained out and replaced with fresh fluid.

dialysis means the procedure for the removal of certain elements from the blood or lymph by virtue of the difference in their rate of diffusion through an external semipermeable membrane or, in the case of peritoneal dialysis, through the peritoneum.

haemodialysis means the process by which certain molecules are removed from circulating blood of uraemic patients by diffusion through a semipermeable membrane.

haemofiltration means the extracorporeal process by which the fluid and solute composition of blood and body fluids can be corrected by a combination of ultrafiltration and convective solute loss and dilution with physiologic saline solution.

haemoperfusion means the removal of substances from the blood by passage through a column containing a substance over the surface of which the blood passes and comes into contact before leaving the column and returning to the patient.

peritoneal dialysis means the process by which dialysing fluid is instilled into the abdominal cavity, left for a period of time, then drained.

20 Medical advisory committee

The medical advisory committee of a private hospital authorised to provide dialysis, haemofiltration or haemoperfusion must be joined by a specialist nephrologist or a consultant renal physician trained in dialysis, haemofiltration and haemoperfusion techniques, unless the committee already includes such a person, when matters relating to dialysis, haemofiltration or haemoperfusion are being discussed.

21 Design and construction

Dialysis, haemofiltration or haemoperfusion services must not be provided otherwise than in and from a unit that:

(a)  is air-conditioned and of adequate size for the functions performed, and

(b)  has a reception and waiting area, and

(c)  has rooms for consultation and examination, and

(d)  has access to patient change facilities, and

(e)  has access to patient toilets, and

(f)  has a clean utility room, and

(g)  has access to a dirty utility room, and

(h)  has a soundproof area for the reverse osmosis unit, and

(i)  is located close to a station for nurses and technicians, and

(j)  has access to pathology services, and

(k)  has access to an appropriately qualified and trained specialist for the insertion of vascular access catheters, and

(l)  has a fully equipped cardiac arrest trolley.

22 Conduct of dialysis, haemofiltration and haemoperfusion units

A unit for dialysis, haemofiltration and haemoperfusion:

(a)  must have a written policy covering all of the following matters:

(i)  the provision of information and counselling to patients and their relatives,

(ii)  admission, discharge and review of care,

(iii)  patient transport,

(iv)  the maintenance and replacement of all medical equipment associated with dialysis, haemofiltration and haemoperfusion,

(v)  cardiac arrest, and

(b)  must have sufficient and appropriately trained and experienced staff including a program director and visiting medical officers and consultants, and

(c)  must have appropriate specialists available on call at all times, and

(d)  must have procedures for other specialists to be readily available for consultation, and

(e)  must have access to trained dialysis, haemofiltration and haemoperfusion technicians at all times, and

(f)  must have a contingency arrangement for the transfer of patients, if appropriate, to a hospital providing a higher level of care in the event of complications.

23 Clinical records

The clinical record of a patient admitted for dialysis, haemofiltration or haemoperfusion in a hospital must include a record of the dialysis, haemofiltration or haemoperfusion.

Part 5 Neonatal intensive care

24 Definition

In this Part:

neonatal intensive care means life support, monitoring and care for newly born children suffering from life-threatening prematurity, illness or disability at birth.

25 Medical advisory committee

The medical advisory committee of a private hospital authorised to provide neonatal intensive care must be joined by a specialist paediatrician with neonatal experience, unless the committee already includes such a person, when matters relating to neonatal intensive care are being discussed.

26 Design and construction

A neonatal intensive care nursery of a private hospital:

(a)  must be separate from any nursery provided for babies not requiring intensive care, and

(b)  must be air-conditioned and of an adequate size for the number of neonatal intensive care cots provided.

27 Conduct of a neonatal intensive care nursery

A private hospital authorised to provide neonatal intensive care:

(a)  must have a written policy in relation to all of the following matters:

(i)  the private hospital’s criteria for admission to the neonatal intensive care unit,

(ii)  the care of children admitted for neonatal intensive care,

(iii)  the numbers and qualifications of medical practitioners and nursing staff available to the private hospital and the numbers of any such staff on duty for each shift,

(iv)  the quality assurance programs established by the private hospital,

(v)  provision made by the private hospital for the transfer of patients to another hospital providing a higher level of service, and

(b)  must have a specialist paediatrician or paediatric registrar on close call at all times, or a resident medical officer on duty at all times and a specialist paediatrician or paediatric registrar on call at all times, and

(c)  must have a sufficient number of registered nurses, a majority of whom are specially trained and permanently attached to the unit, on duty in the neonatal intensive care unit at all times, and

(d)  must have contingency arrangements for the transfer of patients to a hospital providing a higher level of neonatal intensive care in an emergency.

28 Identification of patients

(1)  An identification band must be fitted around a wrist and an ankle of each neonatal intensive care patient.

(2)  The patient’s name and date of birth, and the attending practitioner’s name, must be indelibly and legibly written on the band.

29 Medical, surgical and nursing equipment

A neonatal intensive care unit:

(a)  must have at least half the approved number of cots fitted as humidicribs, and

(b)  must have cardio-respiratory monitoring equipment for each cot, and

(c)  must have sufficient intravenous fluid therapy equipment, and

(d)  must have sufficient tube feeding equipment, and

(e)  must have sufficient phototherapy equipment, and

(f)  must have a resuscitation trolley containing a complete set of paediatric resuscitation and monitoring equipment.

Part 6 Open heart surgery

30 Definition

In this Part:

open heart surgery means any surgical procedure requiring the use of a heart-lung machine for circulatory support during procedures within or on the heart.

31 Medical advisory committee

The medical advisory committee of a private hospital authorised to conduct open heart surgery must be joined by a cardiothoracic surgeon, an anaesthetist experienced in anaesthesia for open heart surgery and a physician experienced in cardiac intensive care, unless the committee already includes such persons, when matters relating to open heart surgery are being discussed.

32 Design and construction

A private hospital providing open heart surgery:

(a)  must have at least one intensive care unit that complies with the requirements of Part 3 of this Schedule, and

(b)  must be so designed that each operating suite in which open heart surgery is performed has access to an intensive care unit that complies with those requirements, and

(c)  must have at least two operating rooms equipped for major general surgical procedures.

33 Conduct of an open heart surgical unit

A private hospital with an approved open heart surgical unit must have a written policy on the provision of an open heart surgery service.

34 Medical, surgical and nursing equipment

(1)  A theatre used for open heart surgery must be equipped with appropriate specialist instruments and equipment.

(2)  An open heart surgical unit must be equipped with an adequate supply of appropriate specialist equipment for the maximum number of patients that may be accommodated in the unit at any one time.

Schedule 4 Forms

Form 1   Application for licence for a private hospital

(Clause 7)

(Private Hospitals and Day Procedure Centres Act 1988)

I/We, ............................................................

(full name of applicant[s])

date of birth: ............... place of birth: ............................................................
of ............................................................

(address of applicant[s])

apply for a licence for a private hospital of the
following class[es] ............................................................

The private hospital will be known as
............................................................

(proposed name)

and will be situated at
............................................................

(proposed location)

and will accommodate ............... patients.

The applicant[s] is/are/will be
* owner[s]
* lessee[s]

of the private hospital.

* Delete whichever is not applicable

I/We attach the following information:

(1)  In the case of an application by a corporation:

(a)  a copy of the certificate of incorporation,

(b)  the address of the registered office of the corporation,

(c)  the full name, date and place of birth, residential address and position of:

(i)  each current director of the corporation,

(ii)  the principal executive officer of the corporation,

(iii)  the secretary or, if there is more than one, each secretary of the corporation,

(d)  in the case of a corporation limited by shares:

(i)  the types of shares and the number of shares of each type issued,

(ii)  in the case of a private corporation—the full name of, and the number of shares of each type held by, each shareholder,

(iii)  in the case of a public corporation—a list of the 20 largest shareholdings and of the full names of the holders of each of those shareholdings,

(e)  if the shares are held by another corporation, the name of the ultimate holding corporation.

(2)  If the private hospital is leased, a copy of the lease.

(3)  If the private hospital is proposed to be leased, a description of the proposed lease arrangements.

(4)  In the case of a rehabilitation class private hospital, the additional information in Annexure A.

(5)  In the case of a psychiatric class private hospital, the additional information in Annexure B.

I/We also enclose the prescribed application fee.

.........................	..............................
(Print name)	(Signature)
..............................	..............................
(Position)	(Date)

Annexure A

Additional information to be supplied for a rehabilitation class licence

(1)  The nature of the rehabilitation services to be provided.

(2)  The staff and facilities to be provided for rehabilitation.

(3)  The support services to be provided in association with the rehabilitation service.

(4)  The criteria to be used in assessing the suitability of patients to be admitted to the hospital for rehabilitation.

(5)  The arrangements to be made for the transfer of patients to appropriate facilities in the event of unexpected complications.

(6)  The liaison to be established with community based services to ensure continuity and co-ordination of care.

Annexure B

Additional information to be supplied for a psychiatric class licence

(1)  The nature of the psychiatric services to be provided.

(2)  The staff and facilities to be provided for psychiatric care.

(3)  The support services to be provided in association with the psychiatric services.

(4)  The criteria to be used in assessing the suitability of patients to be admitted to the hospital for psychiatric care.

(5)  The arrangements to be made for the transfer of patients to appropriate facilities in the event of unexpected complications.

(6)  The liaison to be established with community based services to ensure continuity and co-ordination of care.

Form 2   Application for transfer of licence for a private hospital

(Clause 10)

(Private Hospitals and Day Procedure Centres Act 1988)

I/We, ............................................................

(full name of applicant[s])

date of birth: ............... place of birth: ............................................................
of ............................................................

(address of applicant[s])

apply for a transfer to me/us of the licence for the private hospital known as
............................................................

(name of private hospital)

at ............................................................

(address of private hospital)

The applicant[s] is/are/will be
* owner[s]
* lessee[s]

of the private hospital.

* Delete whichever is not applicable

I/We attach the following information:

(1)  In the case of an application by a corporation:

(a)  a copy of the certificate of incorporation,

(b)  the address of the registered office of the corporation,

(c)  the full name, date and place of birth, residential address and position of:

(i)  each current director of the corporation,

(ii)  the principal executive officer of the corporation,

(iii)  the secretary or, if there is more than one, each secretary of the corporation,

(d)  in the case of a corporation limited by shares:

(i)  the types of shares and the number of shares of each type issued,

(ii)  in the case of a private corporation—the full name of, and the number of shares of each type held by, each shareholder,

(iii)  in the case of a public corporation—a list of the 20 largest shareholdings and of the full names of the holders of each of those shareholdings,

(e)  if the shares are held by another corporation, the name of the ultimate holding corporation.

(2)  If the private hospital is leased, a copy of the lease.

(3)  If the private hospital is proposed to be leased, a description of the proposed lease arrangements.

I/We also enclose the prescribed application fee.

.........................	..............................
(Print name)	(Signature)
.........................	..............................
(Position)	(Date)

TO BE COMPLETED BY CURRENT LICENSEE

I/We agree to the transfer of the license to the abovenamed applicant(s).

.........................	..............................
(Print name)	(Signature)
.........................	..............................
(Position)	(Date)

Form 3   Application for approval to alter or extend a licensed private hospital

(Clause 11)

(Private Hospitals and Day Procedure Centres Act 1988)

I/We, ............................................................

(name of licensee)

of ............................................................

(address of licensee)

being the holder of the licence (No ..........) for the private hospital known as
............................................................

(name of private hospital)

at ............................................................

(address of private hospital)

apply for approval to alter or extend the private hospital.

I/We attach the following documents:

(1)  Two copies of a site plan of the private hospital, drawn to scale and showing the lot number and deposited plan number or other relevant particulars that identify the site.

(2)  Two copies of sketch plans of the private hospital, drawn to a scale of 1:100 and showing the dimensions of each part of the private hospital and the use to which each part is to be put (the proposed alterations or extensions to the private hospital are shown by distinctive colouring or cross-hatching).

.........................	..............................
(Print name)	(Signature)
.........................	..............................
(Position)	(Date)

Form 4   Application for review of Director-General’s decision

(Clause 12)

(Private Hospitals and Day Procedure Centres Act 1988)

I/We, ............................................................

(name of applicant)

of ............................................................

(address of applicant)

apply for a review of the decision of the Director-General to:
............................................................

(nature of decision)

I/We enclose a copy of the Director-General’s letter notifying the decision.

The grounds for my/our request for review are as follows:
............................................................
............................................................
............................................................

I/We understand that this application will be referred to a Committee of Review, which may make such investigation as it considers necessary in relation to this application before reporting to you. I/We agree, for this purpose, to allow any member of the Committee access to documentation, staff and patients, as judged necessary by the Committee. I/We also agree to relevant documentation held by the Department of Health being made available to members of the Committee for the purposes of its investigation.

.........................	..............................
(Print name)	(Signature)
.........................	..............................
(Position)	(Date)

Form 5   Register of patients

(Clause 14)

(Private Hospitals and Day Procedure Centres Act 1988)