20 The Avenue, Windsor VIC 3181
03 9520 9520
03 9520 9520



Board of Management Committee (BOM)

The Board of Management Committee is considered the highest level of governance at Windsor Private Hospital.

The BOM committee includes the CEO, Medical Director, DON, and Finance Manager, other staff may be asked to attend as required. The committee meets at least quarterly or more frequently as required.

The committee encompasses the roles of many committees including –

  • Review of management strategies
  • OH&S
  • Medication safety
  • Staffing safety through credentialing process and training controls
  • Infection control and prevention strategies
  • Risk management that includes clinical governance with reporting systems and outcomes
  • Preventative maintenance programme.

The Medical Advisory Committee to assist with clinical decisions. The Medical Advisory agenda item includes, but not limited to surgeon’s from different craft groups, anaesthetists and Infection Prevention consultant.


The committee may second experts to attend meetings to assist in the decision making process when the need arises. Typically the committee reviews but is not limited to:

  • Credentialing
  • Reviews Policy and procedures
  • All Issues, Incidents and Improvement Requests.
  • Infection prevention and control Reports
  • Patient, staff and VMO complaints
  • Patient feedback results
  • New equipment purchases
  • Ensures that processes conducted within the hospital strive to meet world’s best practice
  • Approves and measures the quality objectives
  • Sets quality standards and relates expectations to all staff
  • Responsible for approving any financial decision in relation to the hospital budget
  • Ensuring the organisation remains solvent, and can fulfill its financial obligations
Management Policies

The Board of Management (BOM) at Windsor Private Hospital encourages all staff to contribute to the continual improvement of the management system.  The clinical governance is managed by the Director of Nursing (DON) and supported by the Chief Executive Officer (CEO). All quality systems are in place and subject to scrutiny through a rigorous auditing process that is the framework for our accreditation.

The BOM discusses such items as clinical practices, Visiting Medical Officer (VMO) applications & contracts, ethical issues, the quality system, risk, complaints / feedback and issue / incidence improvement requests, management system, internal audit outcomes, corrective and preventative actions, infection control, Occupational Health and Safety (OHS) issues, consumer engagement and staff issues.

The BOM discusses reviews and aims to improve the effectiveness of the management system.



Applicable Statutory documents

When creating this management system the following documents were used but not limited to the following:

  • ISO 9001:2015 “Quality Systems-Model for quality assurance in production, installation and servicing and continual improvement of the quality management system”
  • Health  Care Services – Guide to ISO 9001 : 2000  HB90.8-2000
  • Australian Day Surgery Nurses Association ‘Best Practice Guidelines for Ambulatory Services Procedures’ 2013
  • ACORN Standards for Perioperative Nursing 2014-2015
  • AS/NZ 4187:2014
  • Health Services (Private Hospitals and Day Procedures Centre’s) Regulations 2013
  • National Safety and Quality Health Service Standards 2011

Please note that other documents are also relevant and are or will be incorporated into the management system as they become applicable.