By Laws
Victorian Centre for Mental Health
These By-laws define the relationship and obligations between the Victorian Centre for Mental Health and its Accredited Practitioners.
This document sets out certain terms and conditions upon which Medical Practitioners may apply to be Accredited within the defined Scope of Practice granted, the basis upon which a successful applicant may admit Patients and/or care and treat Patients at the Facility, and the terms and conditions for continued Accreditation.
Every applicant for Accreditation will be given a copy of this document and Annexures before or at the time of making an application. It is expected that the By-laws are read in their entirety by the applicant as part of the application process.
Victorian Centre for Mental Health aims to maintain a high standard of patient care and to continuously improve the safety and quality of its services. The By-laws implement measures aimed at maintenance and improvements in safety and quality.
Health care in Australia is subject to numerous legislation and standards. The By-laws assist in compliance with certain aspects of this regulation but are not a substitute for review of the relevant legislation and standards.
About Victorian Centre for Mental Health
Victorian Centre for Mental Health is an innovative private mental health day hospital, that provides international standard, individually tailored mental health treatment services. We are committed to improved standards of mental health care, and providing the best standard treatment we can to our patients.
Victorian Centre for Mental Health will be registered by the Victorian State Government in compliance with Health Services (Health Service Establishments) Regulations 2013, amended 1 July 2018.
Victorian Centre for Mental Health will have interim accreditation for the National Safety and Quality Health Service Standards (NSQHSS), edition 1.
Mission Statement
The Victorian Centre for Mental Health and Melbourne DBT Centres are committed to international standard, evidenced-based mental health care.
We aim to provide an exceptional standard of mental health service to our patients that is personally tailored, diagnostically-driven, intensive and effective.
We support our patients to remain with their families and community during their mental health treatment journey and recovery.
We seek collaborative and transparent relationships with our patients, their families, and the professionals who engage with us.
Our team will be proud of their work and the achievements of our patients.
We encourage our staff to professionally challenge themselves towards excellence.
We are committed to ongoing improvement in our standard of professional excellence, to attain our highest value of supporting our patients to achieve the best mental health outcomes they can.
Values
1. commitment to international standard, evidenced-based mental health care
2. exceptional standard of mental health service
3. personally tailored, diagnostically-driven, intensive and effective multimodal treatments
4. collaborative and transparent professional relationships
5. pride in their work
6. proud of the achievements of patients
7. challenge themselves towards professional excellence
8. commitment to ongoing improvements excellence in what we do
9. highest value of supporting our patients to achieve the best mental health outcomes they can
Definitions
Accreditation means the process provided for in these By-laws by which a person is Accredited. The two conditions for Accreditation are an explicit definition of quality (ie standards) and an independent review process aimed at identifying the level of congruence between practices and quality standards.
Accredited means the status conferred on a Medical Practitioner or Allied Health Professional permitting them to provide services within Victorian Centre for Mental Health after having satisfied the Credentialing requirements provided in these By-laws.
Accredited Practitioner means a Medical Practitioner who has been Accredited to provide services within Victorian Centre for Mental Health.
Adequate Professional Indemnity Insurance means insurance, including run off/tail insurance, to cover all potential liability of the Accredited Practitioner, that is with a reputable insurance company acceptable to Victorian Centre for Mental Health, and is in an amount and on terms that Victorian Centre for Mental Health considers in its absolute discretion to be sufficient. The insurance must be adequate for Scope of Practice and level of activity.
Behavioural Sentinel Event means an episode of inappropriate or problematic behaviour which indicates concerns about an Accredited Practitioner’s level of functioning and suggests potential for adversely affecting Patient safety or Victorian Centre for Mental Health outcomes.
By-laws mean these By-laws.
CEO is the Proprietor of Victorian Centre for Mental Health.
Competence means, in respect of a person who applies for Accreditation, that the person is possessed of the necessary aptitude in the application of knowledge and skills in interpersonal relationships, decision making and Performance necessary for the Scope of Practice for which the person has applied and has the demonstrated ability to provide health services at an expected level of safety and quality.
Credentials means, in respect of a person who applies for Accreditation, the qualifications, professional training, clinical experience and training and experience in leadership, research, education, communication and teamwork that contribute to the person’s Competence, Performance and professional suitability to provide safe, high quality health care services. The applicant’s history of and current status with respect to professional registration, disciplinary actions, indemnity insurance and criminal regard are relevant to their Credentials.
Credentialing means, in respect of a person who applies for Accreditation, the formal process used to verify the qualifications, experience, professional standing and other relevant professional attributes of the applicant for the purpose of forming a view about their Credentials, Competence, Performance and professional suitability to provide safe, competent, ethical and high quality health care services within Victorian Centre for Mental Health.
Current Fitness is the current fitness required of an applicant for Accreditation to carry out the Scope of Practice sought or currently held. A person is not to be considered as having current fitness if that person suffers from any physical or mental impairment, disability, condition or disorder (including habitual drunkenness or addiction to deleterious drugs) which detrimentally affects or is likely to detrimentally affect the person’s physical or mental capacity to practice medicine, dentistry or allied health (as the case may be).
Director of Nursing means the person appointed to the position of Director of Nursing of Victorian Centre for Mental Health or any person acting, or delegated to act, in that position.
Disruptive Behaviour means aberrant behaviour manifested through personal interaction with Medical Practitioners, hospital personnel, health care professionals, Patients, family members, or others, which interferes with Patient care or could reasonably be expected to interfere with the process of delivering quality care or which is inconsistent with the values of Victorian Centre for Mental Health.
External Review means evaluation of the performance of an Accredited Practitioner by an appropriately qualified and experienced professional person(s) external to Victorian Centre for Mental Health.
Internal Review means evaluation of the performance of an Accredited Practitioner by an appropriately qualified and experienced professional person(s) internal to T Victorian Centre for Mental Health.
Medical Advisory Committee means the medical advisory committee of Victorian Centre for Mental Health.
Medical Practitioner means, for the purposes of these By-laws, a person registered under the applicable legislation to practise medicine in Victoria where Victorian Centre for Mental Health is located.
New Clinical Services means clinical services, treatment, procedures, techniques, technology, instruments or other interventions that are being introduced into the organisational setting of Victorian Centre for Mental Health for the first time, or if currently used are planned to be used in a different way, and that depend for some or all of their provision on the professional input of Medical Practitioners.
Organisational Need means the extent to which Victorian Centre for Mental Health is required to provide a specific clinical service, procedure or other intervention in order to provide a balanced mix of safe, high quality health care services that meet consumer and community needs and aspirations.
Patient means a person admitted to, or treated as a patient at Victorian Centre for Mental Health
Performance means the extent to which an Accredited Practitioner provides health care services in a manner which is consistent with known good Clinical Practice and results in expected patient benefits.
Re-accreditation means the process provided in these By-laws by which a person who already holds Accreditation may apply for and be considered for Accreditation after 3 years (or as required)
Scope of Practice means the extent of an individual Accredited Practitioner’s permitted Clinical Practice within Victorian Centre for Mental Health based on the individual’s Credentials, Competence, Performance and professional suitability, Professional Indemnity Insurance cover and the Organisational Capability and Organisational Need of the organisation to support the Accredited Practitioner’s scope of clinical practice.
Specialist Medical Practitioner means a Medical Practitioner who has been recognised as a specialist in their nominated category for the purpose of the Health Insurance Act 1973 (Cth) and is registered under the applicable legislation to practise medicine in that speciality in Victoria where Victorian Centre for Mental Health is located.
Temporary Accreditation means the process provided in By-laws whereby a Medical Practitioner, is Accredited to commence working at Victorian Centre for Mental Health but it has not yet been tabled at the Medical Advisory Committee.
Visiting Medical Practitioner means a Medical Practitioner who is not an employee of Victorian Centre for Mental Health who has been granted Accreditation and Scope of Practice pursuant to these By-laws. They are responsible for giving direct and appropriate medical care within the established policies and procedures set out in the By–laws of Victorian Centre for Mental Health.
Specific Roles and Responsibilities
Psychiatrist
To be designated admitting doctor for their patients.
Provide psychiatric assessment and clinical support when required.
Nurse Practitioner
Provide psychiatric assessment and nursing support.
Compliance with By-laws
It is a requirement for continued Accreditation that Accredited Practitioners comply with the By-laws at all relevant times when admitting, caring for or treating Patients, or otherwise providing services at the Victorian Centre for Mental Health.
Accredited Practitioners must comply with all policies and procedures of the Victorian Centre for Mental Health.
Accredited Practitioners must comply with all relevant legislation, including but not limited to legislation that relates to health, public health, drugs and poisons, privacy, coroners, criminal law, health practitioner registration, research, environmental protection, workplace health & safety, occupational health and safety, antidiscrimination, bullying, harassment, industrial relations, care of children, care of persons with a disability, substituted decision making and persons with impaired capacity, mental health, Medicare, health insurance, fair trading and trade practices, intellectual property, and other relevant legislation regulating the Accredited Practitioner, provision of health care or impacting upon the operation of Victorian Centre for Mental Health.
In addition, Accredited Practitioners must ensure compliance with, or assist Day Hospital to comply with, any Commonwealth or State mandated service capability frameworks or minimum standards.
Any non-compliance with the By-laws may be grounds for suspension, termination, or imposition of conditions.
Insurance, Registration, Notifications and Continuous Disclosure
Accredited Practitioners must at all times maintain Adequate Professional Indemnity Insurance.
Accredited Practitioners must at all times maintain registration with the Australian Health Practitioner Regulation Agency (AHPRA).
Accredited Practitioners must immediately advise the CEO, and follow up with written confirmation within 2 days, should:
– an investigation or complaint be commenced in relation to the Accredited Practitioner, or about his/her Patient (irrespective of whether this relates to a Patient of the Facility), by the Accredited Practitioner’s registration board, disciplinary body, Coroner, a health complaints body, or another statutory authority, State or Government agency;
– an adverse finding (including but not limited to criticism or adverse comment about the care or services provided by the Accredited Practitioner) be made against the Accredited Practitioner by a civil court, the practitioner’s registration board, disciplinary body, Coroner, a health complaints body, or another statutory authority, State or Government agency, irrespective of whether this relates to a Patient of the Facility;
– the Accredited Practitioner’s professional registration be revoked or amended, or should conditions be imposed, or should undertakings be agreed, irrespective of whether this relates to a Patient of the Facility and irrespective of whether this is noted on the public register or is privately agreed with a registration board;
– professional indemnity membership or insurance be made conditional or not be renewed, or should limitations be placed on insurance or professional indemnity coverage;
– the Accredited Practitioner’s appointment, clinical privileges or Scope of Practice at any other facility, hospital or day procedure centre alter in any way, including if it is withdrawn, suspended, restricted, or made conditional, and irrespective of whether this was done by way of agreement;
– any physical or mental condition or substance abuse problem occur that could affect his or her ability to practise or that would require any special assistance to enable him or her to practise safely and competently;
– the Accredited Practitioner be charged with having committed or is convicted of a sex, violence or other criminal offence. The Accredited Practitioner must provide the Facility with an authority to conduct at any time a criminal history check with the appropriate authorities;
– the Accredited Practitioner believe that Patient care or safety is being compromised or at risk, or may potentially be compromised or at risk, by another Accredited Practitioner of the Facility; or
– the Accredited Practitioner makes a mandatory notification to a health practitioner registration board (for example Medical Board) in relation to another Accredited Practitioner of the Facility.
The Accredited Practitioner must keep the CEO continuously informed of every fact and circumstances which has, or will likely have, a material bearing upon:
– the Accreditation of the Accredited Practitioner;
– the Scope of Practice of the Accredited Practitioner;
– the ability of the Accredited Practitioner to safely deliver health services to his/her patients within the Scope of Practice;
– the Accredited Practitioner’s registration or Professional Indemnity Insurance arrangements;
– the inability of the Accredited Practitioner to satisfy a medical malpractice claim by a Patient;
– adverse outcomes, complications or complaints in relation to the Accredited Practitioner’s Patients (current or former) of the Facility;
– the reputation of the Accredited Practitioner as it relates to the provision of Clinical Practice; and
– the reputation of Victorian Centre for Mental Health.
Subject to restrictions directly relating to or impacting upon legal professional privilege or statutory obligations of confidentiality, every Accredited Practitioner must keep the CEO informed and updated about the commencement, progress and outcome of compensation claims, coronial investigations or inquests, police investigations, Patient complaints, health complaints body complaints or investigations, or other inquiries involving Patients of the Accredited Practitioner that were treated at the Facility.
Accredited Practitioners are required to provide evidence annually, or at other times upon request, of Adequate Professional Indemnity Insurance and registration with the relevant health professional registration board, and all other relevant licences or registration requirements for the Scope of Practice granted. If further information is requested in relation to insurance or registration, the Accredited Practitioner will assist to obtain that information, or provide permission for Victorian Centre for Mental Health to obtain that information directly.
Standard of conduct and behaviour
The Facility expects a high standard of professional and personal conduct from Accredited Practitioners, who must conduct themselves at all times in accordance with:
– the Code of Ethics of the Australian Medical Association or any other relevant code of ethics;
– the Code of Practice of any specialist college or professional body of which the Accredited Practitioner is a member;
– the Values of the Victorian Centre for Mental Health;
– the strategic direction of Victorian Centre for Mental Health;
– the limits of their registration or any conditions placed upon Scope of Practice in accordance with these By-laws; and
– all reasonable requests made with regard to personal conduct in Victorian Centre for Mental Health.
Accredited Practitioners must continuously demonstrate Competence and Current Fitness, must not engage in Disruptive Behaviour, and must observe all reasonable requests with respect to conduct and behaviour.
Upon request by the CEO, the Accredited Practitioner is required to meet with the CEO and any other person that the CEO may ask to attend the meeting, to discuss matters above, or any other matter arising out of these By-Laws.
Accredited Practitioners will manage all matters relating to the confidentiality of information in compliance with the Facility’s policy, the ‘National Privacy Principles’ established by the Privacy Act (Cth), and other legislation and regulations relating to privacy and confidentiality, and will not do anything to bring Victorian Centre for Mental Health in breach of these obligations.
Accredited Practitioners will comply with the various legislation governing the collection, handling, storage and disclosure of health information.
Accredited Practitioners will comply with common law duties of confidentiality.
The confidentiality requirements continue with full force and effect after the Accredited Practitioner ceases to be Accredited.
Unless an Accredited Practitioner has the prior written consent of the CEO, an Accredited Practitioner may not use Victorian Centre for Mental Health’s name, letterhead, or in any way suggest that the Accredited Practitioner represents these entities.
The Accredited Practitioner must obtain the CEO’s prior approval before interaction with the media regarding any matter involving Victorian Centre for Mental Health or a Patient.
Consent
Accredited Practitioners must obtain fully informed consent for treatment from the patient or their legal guardian or substituted decision maker in accordance with accepted medical and legal standards (including applicable legislation) and in accordance with the policy and procedures of Victorian Centre for Mental Health.
The consent will be evidenced in writing and signed by the Accredited Practitioner and patient or their legal guardian or substituted decision maker.
Financial information and statistics
Accredited Practitioners must record all data required by Victorian Centre for Mental Health to meet health fund obligations, collect revenue and allow compilation of health care statistics.
Accredited Practitioners must ensure that all Pharmaceutical Benefits Scheme prescription requirements and financial certificates are completed in accordance with regulatory requirements.
Accredited Practitioners must ensure that:
– Patient records held by Victorian Centre for Mental Health are adequately maintained for Patients treated by the Accredited Practitioner;
– Patient records satisfy policy requirements for Victorian Centre for Mental Health legislative requirements, State based standards, the content and standard required by accreditation requirements, and health fund obligations;
– they maintain full, accurate, legible medical records,
– Centre;
– A discharge summary is completed where applicable.
Credentialing and Scope of Practice
It is essential that all medical practitioners are appropriately credentialed and have their scope of practice defined in accordance with their level of skill and experience as well as the capability and needs of Victorian Centre for Mental Health.
An Accredited Medical Practitioner may apply for an amendment or variation of their existing Scope of Practice or any term or condition of their Accreditation
The process for amendment or variation is the same for an application for Re-Accreditation, except the Medical Practitioner will be required to provide relevant documentation and references in support of the amendment or variation.
Before treating patients with New Clinical Services, an Accredited Practitioner is required to obtain the prior written approval of the CEO and what is proposed must fall within the Accredited Practitioner’s Scope of Practice or an amendment to the Scope of Practice has been obtained and must fall within the licensed service capability of the facility.
The Accredited Practitioner must provide evidence of Adequate Professional Indemnity Insurance to cover the New Clinical Service, and if requested, evidence that private health funds will adequately fund the New Clinical Services.
The CEO’s decision is final and there shall be no right of appeal from denial of requests for New Clinical Services
There are a number of documents that have been developed to comply with the Department of Health Victoria.
These include
– Application for accreditation and clinical privileges – new application |
– Application for accreditation and clinical privileges – Re-credentialing |
– VMO referee form |
– VMO Application Checklist |
– Application for accreditation and clinical privileges – new application |
Suspension, termination, imposition of conditions, resignation and expiry of Accreditation
The CEO may immediately suspend a Medical Practitioner’s Accreditation pending the outcome of the review should the CEO believe, or have a sufficient concern:
– it is in the interests of Patient care or safety
– the continuance of the current Scope of Practice raises a significant concern about the safety and quality of health care to be provided by the Medical Practitioner;
– it is in the interests of staff welfare or safety;
– the Medical Practitioner fails to observe the terms and conditions of his/her Accreditation;
– the behaviour or conduct is in breach of a direction or an undertaking, or T Victorian Centre for Mental Health’s By-Laws, policies and procedures;
– the behaviour or conduct of the Medical Practitioner is inconsistent with the values of Victorian Centre for Mental Health;
– the Medical Practitioner has been suspended by their registration board;
– there is a finding of professional misconduct, unprofessional conduct, unsatisfactory professional conduct or some other adverse professional finding (however described) by a registration board or other relevant disciplinary body or professional standards organisation for the Medical Practitioner;
– the Medical Practitioner fails to report to the CEO that his/her
· professional registration is amended, or conditions imposed
· accreditation, clinical privileges or Scope of Practice has been suspended, terminated, restricted or made conditional by another health care organisation;
– the Medical Practitioner fails to make the required notifications required to be given pursuant to these By-laws or based upon the information contained in a notification suspension is considered appropriate;
– the Medical Practitioner has made a false declaration or provided false or inaccurate information to the Facility, either through omission of important information or inclusion of false or inaccurate information;
– the Medical Practitioner is the subject of a criminal investigation about a serious matter (for example a drug related matter, or an allegation of a crime against a person such as a sex or violence offence) which, if established, could affect his or her ability to exercise his or her Scope of Practice safely and competently and with the confidence Victorian Centre for Mental Health and the broader community;
– the Medical Practitioner has been convicted of a crime which could affect his or her ability to exercise his or her Scope of Practice safely and competently and with the confidence of the Facility and the broader community;
The CEO shall notify the Medical Practitioner of his/her concerns and invite the Medical Practitioner to provide reasons why the suspension should be lifted.
Following receipt of the response the CEO will determine whether the Accreditation will be suspended in its entirety or be a specified part of the Scope of Practice.
The suspension is ended either by terminating the Accreditation or lifting the suspension. This will occur by written notification by the CEO.
If there is held, in good faith, a belief that the matters forming the grounds for suspension give rise to a significant concern about the safety and quality of health care provided by the Medical Practitioner including but not limited to patients outside of Victorian Centre for Mental Health, it is in the interests of Patient care or safety to do so, it is in the interests of protection of the Public (including patients at other facilities) to do so, it is required by legislation, or for other reasonable grounds, the CEO will notify the Medical Practitioner’s registration board and/or other relevant regulatory agency of the suspension and the reasons for it.
Accreditation shall be immediately terminated by the CEO if the following has occurred, or if it appears based upon the information available to the CEO the following has occurred:
– the Medical Practitioner ceases to be registered with their relevant registration board;
– the Medical Practitioner ceases to maintain Adequate Professional Indemnity Insurance covering the Scope of Practice;
– there are other unresolved issues or other concerns in respect of the Medical Practitioner that is considered to be a ground for termination.
The CEO shall notify the Medical Practitioner in writing of his/her concerns and invite the Medical Practitioner to provide reasons why he/she may consider termination is not appropriate
Following receipt of the response the CEO will determine whether the Accreditation will be terminated.
All terminations must be notified to the Board and Medical Advisory Committee.
If there is held, in good faith, a belief that the continuation of the unconditional right to practise in any other organisation would raise a significant concern about the safety and quality of health care for patients and the public, the CEO will notify the Medical Practitioner’s registration board and/or other relevant regulatory agency of the imposition of the conditions and the reasons the conditions were imposed.
At the conclusion of or pending finalisation of an Internal or External Review, or in lieu of a suspension, or in lieu of a termination, the CEO may elect to impose conditions on the Accreditation or Scope of Practice.
The CEO must notify the Medical Practitioner in writing of the imposition of conditions, the reasons for it, the consequences if the conditions are breached, and advise of the right of appeal, the appeal process and the timeframe for an appeal.
If the CEO considers it applicable and appropriate in the circumstances, they may also invite a written response from the Medical Practitioner as to why the Medical Practitioner may consider the conditions should not be imposed.
If the conditions are breached, then suspension or termination of Accreditation may occur, as determined by the CEO.
The affected Medical Practitioner shall have the rights of appeal established by these By-laws.
If there is held, in good faith, a belief that the continuation of the unconditional right to practise in any other organisation would raise a significant concern about the safety and quality of health care for patients and the public, the CEO will notify the Medical Practitioner’s registration board and/or other relevant regulatory agency of the imposition of the conditions and the reasons the conditions were imposed.
Safety and Quality
Accredited Practitioners are required to attend and participate in Victorian Centre for Mental Health’s safety, quality, risk management, education and training activities, including clinical practice review and peer review activities, and as required by relevant legislation, standards and guidelines (including those standards and guidelines set by relevant Commonwealth or State governments, health departments or statutory health organisations charged with monitoring and investigating safety and quality of health care).
Accredited Practitioners will report to Victorian Centre for Mental Health any incidents, complications, adverse events and complaints (including in relation to the Accredited Practitioner’s Patients) in accordance with Victorian Centre for Mental Health’s policy and procedures (Issues, Incidents and Improvement Request system) and where required by the CEO, will assist with incident management, investigation and reviews (including root cause analysis and other systems reviews), complaints management, and open disclosure processes.
Accredited Practitioners must provide all reasonable and necessary assistance in circumstances where Victorian Centre for Mental Health requires assistance from the Accredited Practitioner in order to comply with or respond to a legal request or direction, including for example where that direction is pursuant to a court order, or from a health complaints body, Coroner, Police, State Health Department and its agencies or departments, State Private Health Regulatory/Licensing Units, and Commonwealth Government and its agencies or departments.
Accredited Practitioners are required to work with and as part of a multi-disciplinary health care team, including effective communication – written and verbal, to ensure the best possible care for Patients. Accredited Practitioners must at all times be aware of the importance of effective communication with other members of the health care team, referring doctors, Victorian Centre for Mental Health’s management, patients and the patient’s family or next of kin, and at all times ensure appropriate communication has occurred, adequate information has been provided, and questions or concerns have been adequately responded to.
Adequate instructions and clinical handover is required to be given to the staff at T Victorian Centre for Mental Health and other practitioners to enable them to understand what care the Accredited Practitioner requires to be delivered.
Accredited Practitioners may only utilise surgical assistants’ practitioners who have been Accredited in accordance with these By-Laws.
Accredited Practitioners acknowledge the importance of, and will participate in, various measures aimed at ensuring Safety and Quality during intake and treatment which includes but is not limited to participating correct patient identification, hand hygiene and other infection control requirements to meet the NSQHS Standards.
Accredited Practitioners acknowledge the importance of ongoing safety and quality initiatives that may be instituted by Victorian Centre for Mental Health based upon its own safety and quality program, or Safety and Quality initiatives, programs or standards of State or Commonwealth health departments, statutory bodies or safety and quality organisations.
Accredited Practitioners will participate in and ensure compliance with these initiatives and programs (including if they are voluntary initiatives that Victorian Centre for Mental Health elects to participate in or undertake), whether these apply directly to the Accredited Practitioner or are imposed upon Victorian Centre for Mental Health and require assistance from the Accredited Practitioner to ensure compliance.
BY LAWS V1