Policy: Quality and Safety Requirements Applying to Medical Practitioners with “Medical Indemnity – Version 2 (2004-2005)”

Applicable to: Salaried and non-salaried medical practitioners who have signed the Application for Medical Indemnity - Version 2 (2004-2005)

This policy clarifies the quality and safety requirements applying to Clause 8 of the Terms and Conditions of the Medical Indemnity - Version 2 (2004-2005).

Policy: Quality and Safety Requirements Applying to Medical Practitioners with “Medical Indemnity"

Purpose

This Policy outlines responsibilities and obligations in respect to Clause 8 "Quality & Safety Requirements" as set out in the Medical Indemnity - Version 2 (2004-2005). See http://www.health.wa.gov.au/indemnity/indemnity/.

Clause 8 (a) Without limiting your other reporting requirements in these Terms and Conditions, you must report a Claim or Potential Claim on the Hospital's then current incident reporting system.

Reporting

1. Following an incident involving a patient under the care of the Medical Practitioner, the Medical Practitioner must ensure the patient involved in the incident is safe and that all necessary steps have been taken to support and treat the patient and to prevent injury to others. The Medical Practitioner must document the incident in the patient's medical record. The entry should be a strictly factual account of the incident, the outcome and any treatment required. The factual account of the incident should avoid speculative comments on the cause of the incident.
2. As soon as reasonably practicable after the incident occurring, the Medical Practitioner should notify the local Chief Executive (CE)/Regional Director (RD)/Facility Manager (FM) equivalent or their delegate, of incident details.
3. If the reported clinical incident has the potential to result in a medico-legal claim, the hospital/health service shall, within three (3) working days notify:
  3.1 For non-teaching hospitals: the Department of Health, Legal and Legislative Services.
  3.2 For teaching hospitals: RiskCover of an incident occurring after 30/06/1997 and State Solicitor's Office of an incident occurring prior to 01/07/1997.
4. If the incident was a Sentinel Event, it must be notified to the Chief Medical Officer at the Department of Health within seven (7) working days. Please refer to the "Statewide Sentinel Event Reporting Policy" for reporting requirements. This document is available from http://www.health.wa.gov.au/safetyandquality/.
5. Following notification of potential claims and/or Sentinel Events, the Medical Practitioner should ensure that pages 1 and 2 of an Australian Incident Monitoring System (AIMS) form are completed and forwarded to the Departmental Head/Director of Medical Services or their delegate.
6. The Medical Practitioner is required to participate in any investigation of the reported incident that may arise.

For a summary of the incident reporting process please refer to the flow chart at Attachment 1.

Clause 8(b) You must cooperate with the Hospital and participate in clinical governance, clinical quality assurance, quality improvement and risk management processes, projects or activities as reasonably required by the Hospital.

Clinical governance processes require the Medical Practitioner to maintain their professional credentials to a standard acceptable to the relevant professional college and the local Health Service's Credentialling Committee and to practice within the scope and conditions of his/her individually specified clinical privileges at each particular location. This does not preclude the exercise of a wider scope of medical services in a medical emergency.

Clinical governance processes require the Medical Practitioner to satisfy the Credentialling Committee that they are adequately trained in any new procedure prior to using that procedure on patients.

Clause 8 (c)(i) participating in Medical Advisory, Quality Improvement and Morbidity and Mortality Committees, and clinical audit activities;

Medical Practitioners should be aware of and participate in clinical and other approved specialty audits, Medical Advisory, Quality Improvement and Morbidity and Mortality Committees. For example, if a patient dies while under the care of a surgeon, the Medical Practitioner is required to participate in the Western Australian Audit of Surgical Mortality (WAASM). This involves completing the proforma (which will be sent to the Medical Practitioner automatically by the WAASM office) and returning it to the WAASM office. The Medical Practitioner must also participate in first and second line assessments of other surgical deaths that are reported to WAASM.

Clause 8 (c)(ii) participating in investigations of serious adverse events, and serious near misses, to identify their root causes;

The Medical Practitioner is required to participate in external and internal investigations of serious adverse events.

Clause 8 (c) (iii) reporting Sentinel Events;

Please refer to the "Statewide Sentinel Event Reporting Policy" for reporting requirements. This document is available from http://www.health.wa.gov.au/safetyandquality/.

Clause 8 (c )(iv) adopting and using evidence-based best practice based on either locally approved guidelines, pathways and protocols where these are available or in local use or as otherwise required by the Hospital; and

The Medical Practitioner must comply with locally approved and available guidelines, pathways and protocols unless individual patient needs dictate otherwise.

Clause 8 (c )(v) obtaining written or other patient consent prior to any treatment or procedural intervention and providing patients with an explanation of the planned treatment or procedure including material risks in accordance with Hospital policies and procedures. The key points of the consent discussion must be appropriately documented. Where appropriate procedure specific consent forms are available for the planned treatment or procedure these must be used or such other consent forms as required by the Hospital.

Ms Suzanne Hillier
ACTING DIRECTOR
LEGAL AND LEGISLATIVE SERVICES

Date of effect: 14 October 2004 to

Policy Framework

Related documents