Medical Advisory Committees

Under the HSE Regulations, a licensee of a private hospital or day procedure centre is required to appoint a Medical Advisory Committee (MAC) for their facility, or to have an alternative arrangement in place, that has been reviewed and approved by the Secretary.

Functions of the Medical Advisory Committee

The MAC is responsible for advising the licensee on the accreditation of practitioners necessary to provide services at the facility, and the delineation of their clinical responsibilities; matters concerning clinical practice at the facility; matters concerning the care and safety of patients at the facility; and any other matter relating to the safety and quality of services at the facility.

The functions of a medical advisory committee are further defined under Schedule 1,Part 2(5) of the HSE Regulations.

Membership of Medical Advisory Committee

The MAC should have a membership of at least 5 medical practitioners (unless otherwise approved by the Secretary), including at least 1 member that has no pecuniary interest in the facility.

Membership may also include nominees or representatives of other health care providers, academic institutions or other relevant professional organisations. Schedule 5 of the HSE Regulations has effect with respect to the membership and procedure of Medical Advisory Committees.

Note: Certain additional requirements for MAC membership will apply in respect of certain classes of private hospitals – for example: maternity, rehabilitation and psychiatric class hospitals must ensure specialist representation. Additional requirements may also apply where a facility has been licensed to provide specialised services, such as cardiac catheterisation, intensive care and neonatal intensive care. Please refer to Schedule 2 and 3 of the HSE Regulations for more information.

Appointment of members to the Medical Advisory Committee

Please note that the licensee of a private hospital or day-procedure centre must, as soon as is reasonably practicable, notify the Secretary in writing of:

  1. the name, contact details and qualifications of each person who becomes a member of the medical advisory committee for the facility; and
  2. the date on which each such person becomes a member, or ceases to become a member, of the medical advisory committee.

Medical Advisory Committee and Credentialling

A licensee must ensure that the credentials of all medical practitioners and dentists at their facility are reviewed in accordance with the national Standard for Credentialling and Defining the Scope of Clinical Practice, which was published by the former Australian Council for Safety and Quality in Health Care in 2004. This national standard is applied in all jurisdictions across both the public and private sector, and is administered by the current Australian Commission on Safety and Quality in Health Care.
See: for more information.

Medical practitioners and dentists should have credentials reviewed and approved to the relevant standards in each 5 year period of practice.

Responsibility of the Medical Advisory Committee to disclose risk to health or safety

Under the HSE Regulations, a medical advisory committee must - as soon as is reasonably practicable - report to the Secretary of the Department any repeated failure by the licensee to act on any advice given, if the failure is likely to adversely impact on the health or safety of patients or staff.

This report can be made in writing by email to, and/or by post to the following address:

The Secretary, Department of Health
C/O Regulation Unit
Department of Health
GPO Box 125

Applying for alternative arrangements

The Secretary can approve an alternative arrangement (ie an alternative to a Medical Advisory Committee). This can be requested by:

  1. Applying to the Secretary in writing, detailing the proposed alternative arrangements; and
  2. Providing evidence which will prove, to the satisfaction of the Secretary, that the proposed alternative arrangements will meet the functions and responsibilities of a medical advisory committee, as set out in Schedule 1, Part 2(4) of the HSE Regulations.

Please note that despite the requirement for the medical advisory committee, the licensee retains responsibility for the safety of patients at the facility, and the clinical governance of the facility.


Health Service Establishments Regulations 2011, Schedule 1, Part 2; Schedule 5

Standard for Credentialling and Defining the Scope of Clinical Practice