Part 7 – Protected committees for quality improvement activities

Part 7 of the South Australian Health Care Act 2008 (the Act) provides for the declaration of activities to be authorised quality improvement activities or authorised research activities and for persons or groups of persons (committees) to be authorised entities for the purpose of carrying out such activities.

As detailed in Part 7 s63 (2) of the Act this involves:

Undertaking or making assessments, evaluations or recommendations with respect to the practices, procedures, systems, structures or processes of a health service:

  1. where the purpose of any such activity is wholly or predominantly to improve the quality and safety of health services; and
  2. where the public disclosure of, or public access to, information is restricted in order to achieve the best possible outcomes associated with the improvement of health services.

Only authorised Part 7 committee members can attend the committee meeting and any information that could be used to identify the patient or service provider cannot be disclosed to anyone who is not a Part 7 committee member.

Under the Act, committees must be established in accordance with the rules of the governing body of the prescribed health sector body and members must hold relevant qualifications.

Part 7 committee attendance

Part 7 committee attendees must be the nominated representative, or a standing appointment. There is no provision for proxies should members be unable to attend the meeting, unless the person attending is formally acting in the member's position.

Chief Executives, Board members or other hospital staff who are not a member of the Part 7 committee are not permitted to attend committee meetings on an ad-hoc basis. 

Experts who are invited to attend a Part 7 committee meeting must be advised of their responsibilities under Part 7 of the Act and acknowledge their obligations by signing the Agreement form for experts invited to a Part 7 committees.

This form is included in SA Health’s Information for members of committees authorised under part 7, section 64 of the Health Care Act 2008 (SA) (PDF 166KB).

Part 7 - Confidentiality and committee information

Protecting the confidentiality of information generated through Part 7 committees encourages open communication in assessing the management, processes and outcomes of the provision of health services.

As detailed in Part 7 s63 (1) of the Act, confidential information means:

(a) information relating to a health service in which the identity of a patient or person providing the service is revealed; (b) other information declared by the regulations to be confidential information for the purposes of this Part;

The Health Practitioner Regulation National Law (South Australia) Act 2010 states that members of quality assurance committees cannot disclose information because Part 7 of the Health Care Act prohibits such disclosure. Refer to Schedule 2, Part 8, Division 2 of this legislation for further details.

If any provision in any Act or law is inconsistent with the requirements of Part 7 of the Act, the requirements of Part 7 must be followed.

Information protected by Part 7 committee authorisation cannot be legally released to anyone who is not a committee member. This includes the release of information to any court proceeding.  

Information relating to Part 7 committee activities must be de-identified prior to circulation outside of the committee or included in any reports.

Part 7 Committee member responsibilities

The chair of a Part 7 committee must ensure that:

  • The committee only operates within its authorised terms of reference
  • All members are aware of their responsibilities under Part 7 of the Act
  • Systems are in place for the appropriate storage of confidential information
  • The necessary processes are undertaken to obtain reauthorisation (if required) prior to the lapse of authorisation.

Members of Part 7 committees must ensure that:

  • They comply with their responsibilities under Part 7 of the Act.
  • Acknowledge their obligations in writing by signing the Agreement Form for Part 7 Committee Members prior to joining the committee.
  • Information protected by Part 7 of the Act is not provided to any person who is not authorised to receive it.
  • All documents containing information protected by Part 7 of the Act are stored securely.

Part 7 committee - terms of reference

The following information must be included in the committee’s terms of reference:

  • Background section
  • The committee’s function
  • The committee’s membership
  • Statement that proxies are not permitted, unless someone is acting in a member’s position.
  • The process for keeping information confidential
  • Quorum statement.
  • Version control 
  • The date the committee approved the terms of reference

If an authorised committee is considering any changes to their authorised terms of reference, the proposed changes must be submitted to the Clinical Governance Unit for review.

The authorised Part 7 committee must continue to operate in accordance with the authorised terms of reference until the Clinical Governance Unit has provided advice on any proposed changes.

Application process

Committees seeking authorisation in accordance with Section 64 of the Act must demonstrate that they are conducting either quality improvement or research activities and provide information that defines the role and responsibilities of the committee in relation to these activities.

Applicants must submit the following documents to SA Health’s Clinical Governance Unit:

If an authorised Part 7 committee requires re-authorisation for a further three years, they will need to submit their application documents three months prior to the expiry of the declaration.

If an authorised committee has a sub-committee that views protected information, the sub- committee must be separately authorised to allow them to view the Part 7 committee information.

The Clinical Governance Unit will assess the application and liaise with the applicant to ensure that the application meets the requirements of the Act. When the application meets these requirements, the Clinical Governance Unit will submit a re-authorisation request to the Minister’s Office.

If the application is accepted by the Minister for Health and Wellbeing, the Part 7 committee will be authorised by publishing a Notice in the Government Gazette.

Following publication in the Government Gazette, the Clinical Governance Unit will email the applicant with a copy of the Gazette and the applicant’s documents that were used for the gazetting.

An authorisation made under the Act has effect for three years from the date the notice appears in the Gazette, unless the Minister places a notice in the Gazette revoking the authorisation at an earlier date.

Proposed committee changes

If an authorised Part 7 committee is considering any changes to the committee’s functions, name or terms of reference they will need to submit these changes to SA Health’s Clinical Governance Unit for review.

The authorised Part 7 committee must continue to operate in accordance with the functions as stated in the original gazetting application until the Clinical Governance Unit has provided advice on any proposed changes.

The Clinical Governance Unit will review the proposed changes and determine if there is a requirement to re-gazette the Committee.

Documents

Health Care Act 2008

The South Australian Health Care Act 2008 (the Act) is the relevant legislation regarding Part 7 committee activities. 

If any provision in any other Act, law or regulation is inconsistent with the requirements of Part 7 of the Act, the requirements of Part 7 must be followed.

Application form

Application Form (PDF 254KB) for the declaration of authorised activities and authorised persons in accordance with Section 64 of the South Australian Health Care Act 2008

General information for committee members

Information for members of committees authorised under Part 7, section 64 of the Health Care Act (2008)

This document has been prepared to provide Part 7 Committee members with an understanding of their responsibilities regarding Part 7 membership.

This document also contains the agreement forms for Part 7 committee members and invited experts. 

SA Health Policy Directive

Health Care Act (2008) Part 7 Committees Policy Directive (PDF 196KB)

This document has been prepared to ensure a uniform approach to the establishment and operation of protected committees across SA Health and provides governance outlining the responsibilities of committee members and health services.

For further information

See the information for committees (PDF 764KB) document which provides organisations with further information regarding Part 7 Committees or contact the Clinical Governance Unit 

Email: Health.DHWClinicalGovernanceEnquiries@sa.gov.au
Phone: (08) 8226 6304