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Insert your logo here Welcome to the QIP Consulting Policy and Procedure Manual (Version 1, 1 July 2011 – aligned with the RACGP 4th edition Standards). This manual has been developed to assist practices with the policies and procedures that are required for accreditation and the day-to-day running of a general practice. Please note: this manual is a generic template, designed for general practices in Australia. It must be adapted and changed to make it relevant to your individual practice situation and state/country. there are additional procedures included in this manual that are not directly required to meeting the flagged RACGP standards for General Practice. These are included because the authors believe practices should be aiming to exceed the minimum standards. please delete or amend the procedures as required. However, deleting some parts may jeopardise your opportunity to obtain reduced insurance subsidies, accreditation or maintain compliance with legal obligations and standards. please refer to the RACGP 4th edition Standards when amending policies. always refer to local, State or Territory and/or Federal legislation to ensure that your policies and procedures are aligned with these requirements. Customising this manual (Select Option X) As this is a generic manual the best practice or current practice guidelines have been used where possible to determine the procedures listed. However, in some cases the equipment available can determine the way something is achieved. The option choices (usually written in italic font) will guide you to select the correct procedure for your situation. It is important to delete the other options according to the instructions, as they will not be applicable to your practice. (*Insert Name) Sometimes the specific name of a person or the supplier of a service needs to be added. Delete this symbol after adding the name or details required. Quality in Practice Consulting would like to acknowledge and thank Dandenong Casey General Practice Association (DCGPA) and the members of the Dandenong Accreditation Advisory Group for developing this manual. Whilst every effort is made to ensure accuracy, Quality in Practice Pty Ltd do not accept any liability for any injury, loss or damage incurred by use of, or reliance on the information included within this document. Users of this document are required to customise it according to local, State or Territory and/or Federal legislative requirements as well as that which is listed in the latest version of the RACGP Standards for General Practices. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page i of 260 Insert your logo here (*Practice Name) Policy & Procedure Manual (*Date of Creation) (*Date of Revision) Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page ii of 260 Insert your logo here Table of Contents 1 Introduction 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Mission Statement ........................................................................................................ 1 Practice background .................................................................................................... 1 Practice profile .............................................................................................................. 1 Practice team................................................................................................................. 2 Practice services........................................................................................................... 3 Practice hours ............................................................................................................... 3 Practice consultation fees ........................................................................................... 3 2 Human Resources 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 Awards & Entitlements................................................................................................. 4 Position Evaluation and Recruitment ......................................................................... 8 Staff Employment Records ........................................................................................ 14 Staff Induction ............................................................................................................. 18 Privacy ......................................................................................................................... 21 Performance Review .................................................................................................. 21 Disciplinary Process .................................................................................................. 26 Staff Code of Conduct ................................................................................................ 33 Staff Presentation ....................................................................................................... 35 Equal Opportunity, Bullying & Harassment............................................................. 36 3 Occupational Health & Safety 3.1 Manual Handling ......................................................................................................... 46 3.1.2 Incidents and Injury and Adverse Patient Events ....................................................... 48 3.1.3 Sharps Injury Management and Other Body Fluid Exposure..................................... 50 3.1.4 Staff Immunisation ...................................................................................................... 53 3.1.5 Smoking, Drugs & Alcohol .......................................................................................... 56 3.1.6 Staff Health and Wellbeing (including GPs) ............................................................... 57 3.2 Practice Facilities........................................................................................................ 59 3.2.1 Consulting Rooms ...................................................................................................... 60 3.2.2 Hand Washing Facilities ............................................................................................. 61 3.2.3 Waiting Area ............................................................................................................... 62 3.2.4 Toilets ......................................................................................................................... 62 3.2.5 Telecommunication System ....................................................................................... 63 3.2.6 Unauthorised Access Areas ....................................................................................... 64 3.3 Security ........................................................................................................................ 65 3.4 Non Medical Emergencies ......................................................................................... 67 4 Infection Control 4.1 4.2 4.3 4.4 4.5 4.6 Principles of infection control ................................................................................... 69 Blood and body fluid spills ........................................................................................ 71 Hand washing and hand hygiene .............................................................................. 74 Handling and use of chemicals ................................................................................. 77 Single Use Equipment ................................................................................................ 79 Instrument and equipment processing area............................................................ 80 Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page iii of 260 Insert your logo here 4.7 4.8 4.8.1 4.8.2 4.8.3 4.8.4 4.8.5 4.8.7 4.8.8 4.9 4.10 4.11 4.12 4.13 4.14 4.15 4.16 5 Cleaning reusable Instruments and equipment ...................................................... 83 Provision of sterile items ........................................................................................... 86 Loading the steriliser ................................................................................................... 93 Sterilisation cycle parameters ..................................................................................... 95 Unloading the steriliser ............................................................................................... 96 Documentation of the Cycle. ....................................................................................... 98 Maintenance of the steriliser ....................................................................................... 99 Monitoring the Sterilisation Process ......................................................................... 100 Validation of the sterilisation processes.................................................................... 101 Storage of sterile items ............................................................................................ 104 Management of waste .............................................................................................. 105 Sharps Management................................................................................................. 108 Standard Precautions............................................................................................... 110 Transmission Based Precautions ............................................................................ 111 Personal Protective Equipment (PPE) .................................................................... 112 Laundry ...................................................................................................................... 115 Safe handling of pathology specimens .................................................................. 116 Practice Management 5.1 Access & Parking...................................................................................................... 117 5.2 Appointments ............................................................................................................ 119 5.3 Home Visits ............................................................................................................... 122 5.4 Telephone .................................................................................................................. 124 5.4.1 Communication with patients via electronic means .................................................... 128 5.5 Visitors ....................................................................................................................... 131 5.6 Medical Emergencies & Urgent Queries ................................................................ 132 5.7 After Hours Service .................................................................................................. 134 5.8 Practice Meetings ..................................................................................................... 136 5.9 Patient Rights ............................................................................................................ 139 5.10 Complaints ................................................................................................................ 141 5.11 Non English Speaking Patients ............................................................................... 144 5.11.1 Culturally Appropriate Care........................................................................................ 146 5.12 Directory of Local Health and Community Services............................................. 148 5.13 Provision of Brochures, Leaflets and Pamphlets for Patients ............................ 149 5.13.1 Practice Information Sheet ........................................................................................ 151 5.14 Office Supplies .......................................................................................................... 153 5.15 Environmental Cleaning Service............................................................................. 154 6 Privacy and Personal Health Information 6.1 6.1.1 6.1.2 6.2 6.3 6.3.1 6.3.2 6.4 6.4.1 Privacy and Security of Personal Health Information .......................................... 158 Computer Information Security ................................................................................... 163 Practice Privacy Policy ................................................................................................ 165 3rd Party Requests for Access to Medical Records/Health Information ............. 167 Request for Access to Personal Health Information ............................................ 172 Privacy Officer........................................................................................................... 177 Privacy Audit ............................................................................................................. 178 Medical Records Administration Systems............................................................. 179 Creating a New Medical Record ............................................................................... 180 Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page iv of 260 Insert your logo here 6.4.2 6.4.3 6.4.4 6.4.5 6.4.6 6.4.7 6.4.8 7 Retrieving a Medical Record for a Current Patient................................................... 180 Filing Reports (Pathology, X-Ray, Consultant’s etc) ................................................ 180 Errors in Medical Record ......................................................................................... 181 Allergies & Alerts...................................................................................................... 181 Back Up of electronic medical records .................................................................... 181 Retention of Records and Archiving ........................................................................ 182 Transfer of Medical Records ................................................................................... 184 Clinical Management 7.1 Clinical Autonomy .................................................................................................... 186 7.2 Clinical Content of Medical Records ...................................................................... 187 7.3 Informed Consent ..................................................................................................... 193 7.4 Referral Protocols .................................................................................................... 196 7.5 Clinical Handover..................................................................................................... 199 7.6 Patient Identification ................................................................................................ 200 7.7 Follow up of Tests, Results and Referrals ............................................................. 202 7.8 Reminder Systems for Preventative Care .............................................................. 206 7.9 Notifiable Diseases ................................................................................................... 208 7.10 3rd Party Observing or Clinically involved in the Consultation .......................... 210 7.12 Management of a Patient Refusing Treatment or Advice .................................... 213 7.13 Refusal to Treat a Patient......................................................................................... 214 7.14 Practice Equipment .................................................................................................. 215 7.14.1 Medical Equipment and Resources ......................................................................... 216 7.14.2 Doctor’s Bag ............................................................................................................ 218 7.14.4 Vaccine Administration ............................................................................................ 221 7.14.5 Drug Storage, Supply and Administration ............................................................... 222 7.14.6 Clinical References and Resources......................................................................... 230 7.14.7 Checking and Rotating Medical Supplies ................................................................ 231 8 Continuous Improvement 8.1 Risk Assessment & Management .................................................................................. 232 8.1.1 Review of Policies & Procedures.............................................................................. 234 8.1.2 Continuing Staff Education ....................................................................................... 235 8.1.3 Accreditation & Continuous Improvement ................................................................ 239 8.1.4 Patient Feedback ...................................................................................................... 242 8.1.5 Management of Potential Medical Defence Claims .................................................. 244 8.1.6 Continuity of Care ..................................................................................................... 245 8.1.7 Clinical Governance.................................................................................................. 247 Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page v of 260 Insert your logo here Table of Contents a) b) Reverse Index: 4th Edition RACGP Standards and relevant Protocols Notes to Policy and Procedure Manual Forward / Disclaimer 1. Introduction 1.1 1.2 1.3 1.4 1.5 1.6 Mission Statement Practice Philosophy Practice Background Practice Structure Organisational Chart Services 2. Human Resource Management 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 Awards and Entitlements Position Evaluation and Recruitment Staff Employment Records Staff Induction Privacy Performance Review Disciplinary Process Staff code of Conduct Staff Presentation Equal Opportunity Bullying and Harassment Forms, Templates and Checklists 4.1.1 3.1.3 & 4.1.1 3.2.1, 3.2.3, 3.2.2 & 4.1.1 4.1.1 & 5.3.3 4.2.1 4.1.1 4.1.1 5.3.3, 3.1.2 & 4.1.1 4.1.2 & 4.1.1 3. Workplace Health & Safety 3.1 3.1.1 3.1.2 3.1.3 3.1.4 3.1.5 3.1.6 3.2 3.2.1 3.2.2 3.2.3 3.2.4 3.2.5 3.2.6 Occupational Health and Safety Manual Handling Incidents and Injury and Adverse Patient Events Sharps injury Management and other Body fluid Exposure Staff Immunisation Smoking, Drugs and Alcohol Staff & GP Wellbeing Practice Facilities Consulting Rooms Hand washing Facilities Waiting Area Toilets Telecommunication System Unauthorised Access Areas 4.1.2, 5.3.3 & 3.1.3 5.1.1 & 4.1.2 1.5.2, 3.1.4 & 3.1.2 5.3.3 5.3.3 4.1.2 5.1.1 & 5.1.2 5.1.1 & 5.1.2 5.3.3 5.1.1 & 5.1.2 5.1.1 5.1.2 5.1.1 Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page vi of 260 Insert your logo here 3.3 3.4 3.5 Security Non Medical Emergencies Forms, Templates and Checklists 5.1.1 & 4.1.2 4.1.2 & 3.1.2 4. Infection Control 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 Principles of Infection control Blood and body fluid spills Hand Washing and Hand Hygiene Handling and use of Chemicals Single use equipment Instrument and Equipment processing area Cleaning reusable Instruments and Equipment Provision of Sterile items Storage of Sterile items Management of Waste Sharps Management Standard Precautions Transmission Based Precautions Personal Protective equipment PPE Laundry Safe Handling of Pathology specimens Forms, Templates and checklists 5.3.3 5.3.3 5.3.3 5.3.3 & 4.1.2 5.3.3 5.3.3 5.3.3 5.3.3 5.3.3 5.3.3 5.3.3 5.3.3 5.3.3 5.3.3 5.3.3 5.3.3 5. Practice Administration 5.1 5.2 Access and Parking Appointments 5.3 5.4 5.4.1 5.5 5.6 5.7 5.8 5.9 5.10 5.11 5.11.1 5.12 5.13 Home Visits Telephone Communication with Patients via Electronic Means Visitors Medical Emergencies and Urgent Queries After Hours Service Practice Meetings Patient Rights Complaints Non English Speaking Patients Culturally Appropriate Care Directory of Local Health and Community Services Provision of Brochures, Leaflets and Pamphlets for Patients Practice Information Sheet Office Supplies Environmental Cleaning Service 5.13.1 5.14 5.15 5.1.3 & 5.1.1 1.1.1, 1.2.4, 3.1.4, 1.4.2 & 2.1.1 1.1.3 1.1.1, 1.1.2, 1.1.4 & 1.2.3 1.1.2 & 1.2.1 5.1.1 1.1.1, 1.2.4 & 1.1.4 1.1.1, 1.1.4, 1.2.4 & 1.5.2 1.4.1, 3.1.2 & 4.1.1 1.2.1, 1.2.2 & 2.1.1 2.1.2 2.1.2, 1.2.3 & 2.1.1 1.4.1, 1.7.1 & 2.1.1 1.6.1 1.2.3 & 1.3.1 1.2.1, 1.2.3 & 1.2.4 5.3.3 Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page vii of 260 Insert your logo here 6. Privacy and Medical Records 6.1 6.1.1 6.1.2 6.2 6.3 6.3.1 6.3.2 6.4 6.4.1 6.4.2 6.4.3 6.4.4 6.4.5 6.4.6 6.4.7 6.4.8 Privacy and Security of Personal Health Information Computer Information Security Practice Privacy Policy 3rd Party Requests for Access to Medical Records / Health Information Patients Request for Access to Personal Health Information Under the Privacy Legislation Privacy Officer Privacy Audit Medical Records Administration Creating a new Medical Record Retrieving a Medical Record for a current Patient Filing Reports (Pathology, X-Ray, Consultant’s etc) Errors in Medical Record Allergies & Alerts Back Up of electronic medical records Retention of Records and Archiving Transfer of Medical Records 4.2.1 & 3.1.4 4.2.1 & 4.2.2 4.2.1 4.2.1, 3.1.4 & 4.2.2 4.2.1 4.2.1 3.1.4 4.2.1 1.7.2 4.2.2 4.2.2, 4.2.1 & 1.7.1 4.2.1 & 4.2.2 7. Clinical Management 7.1 7.2 Clinical Autonomy Clinical content of Medical Records 7.3 7.3.1 Informed Consent Referral Protocols 7.3.2 7.4 7.5 7.6 7.7 7.8 Clinical Handover Patient Identification Follow Up of Tests, results and referrals Reminder Systems for preventative care Notifiable Diseases 3rd Party Observing or Clinically involved in the consultation Research Projects Management of a patient refusing treatment or advice Refusal to treat a patient Practice Equipment Medical equipment and Resources Doctors bag Vaccine Storage Vaccine Administration 7.9 7.10 7.11 7.12 7.12.1 7.12.2 7.12.3 7.12.4 1.4.2 1.7.1, 1.7.2, 1.7.3, 1.1.3, 1.1.4, 5.3.1, 1.5.1 & 3.1.4 1.2.2, 1.2.4 & 5.3.1 1.2.4, 3.1.4, 1.5.2, 1.6.1, 5.3.1 & 1.6.2 1.5.2 & 5.3.1 3.1.4 & 5.3.1 1.1.4, 3.1.4 & 1.5.3 1.3.1 4.2.1 1.2.3 & 2.1.3 4.2.1 2.1.1 2.1.1 5.2.1 1.4.2 & 5.2.1 5.2.2 5.3.1 & 5.3.2 5.3.1 & 1.5.2 Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page viii of 260 Insert your logo here 7.12.5 7.12.6 7.12.7 7.13 Drug Storage Supply and administration Clinical References and resources Checking and Rotating Medical supplies Forms, Templates and Checklists 5.3.1 1.3.1, 1.4.1 & 5.3.1 5.3.1 8. Continuous Improvement and Education 8.1 8.1.1 8.1.2 8.1.3 8.1.4 8.1.5 8.1.6 8.1.7 Risk Assessment & Management Review of Policies & Procedures Continuing Staff Education Accreditation & Continuous Improvement Patient Feedback Management of Potential Medical defence claims Continuity of Care Clinical Governance 3.1.2 & 4.1.2 3.1.1 & 5.3.3 3.2.1, 3.2.2, 3.2.3 & 5.3.3 4.2.1, 2.1.2, 3.1.1 & 3.1.3 2.1.2 3.1.2 1.1.1, 1.4.1, 1.5.1 & 1.5.2 3.1.3, 5.3.1, 5.3.2, 5.3.3, 4.1.1 & 4.2.2 Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page ix of 260 Insert your logo here Reverse Index RACGP 4th edition Standard Location of written protocols in AGPALs Policy and Procedure manual Section 1 - Practice services Standard 1.1 Access to Care 1.1.1 Scheduling care in opening hours 1.1.2 Telephone & Electronic advice 1.1.3 Home & Other visits 1.1.4 Care Outside Normal opening hours Standard 1.2 Information about the practice 1.2.1 Practice information 1.2.2 Informed Patient Decisions 1.2.3 Interpreter and other communication services 1.2.4 Costs associated with care initiated by the practice 5.2, 5.4, 5.6, 5.7 & 8.1.6 5.4 & 5.4.1 5.3 & 7.2 5.4, 5.6, 5.7,7.2 & 7.5 5.4.1, 5.9 & 5.13.1 5.9 & 7.3 5.4, 5.13, 5.13.1, 7.8 & 5.11 5.2, 5.6, 5.7, 5.13.1, 7.3 & 7.3.1 Standard 1.3 Health Promotion & Prevention of Disease 1.3.1 Health Promotion and Preventative care 5.13, 7.6 & 7.12.6 Standard 1.4 Diagnosis & Management of Health Problems 1.4.1 Consistent Evidence Based Practice 5.8, 5.11.1, 7.12.6 & 8.1.6 1.4.2 Clinical Autonomy for General Practitioners 5.2, 7.1 & 7.12.1 Standard 1.5 Continuity of care 1.5.1 Continuity of Comprehensive care and the 7.2 & 8.1.6 Therapeutic relationship 1.5.2 Clinical Handover 3.1.2, 5.7, 7.3.1, 7.3.2, 7.12.4 & 8.1.6 1.5.3 System for follow up of tests and results 7.5 Standard 1.6 Coordination of Care 1.6.1 Engaging with other services 5.12 & 7.3.1 1.6.2 Referral Documents 7.3.1 Standard 1.7 Content of Patient Health Records 1.7.1 Patient Health records 5.11.1, 6.4.7 & 7.2 1.7.2 Health summaries 7.2 & 6.4.5 1.7.3 Consultation notes 7.2 Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page x of 260 Insert your logo here Section 2 - Rights and needs of patients Standard 2.1 Collaborating with Patients 2.1.1 Respectful & Culturally appropriate care 2.1.2 2.1.3 Patient feedback Presence of a third party 5.2, 5.9, 5.11, 5.11.1, 7.10 & 7.11 5.10, 5.11, 8.1.3 & 8.1.4 7.8 Section 3 - Safety quality improvement and education Standard 3.1 Safety and Quality 3.1.1 Quality Improvement activities 3.1.2 Clinical Risk Management system 3.1.3 Clinical Governance 3.1.4 Patient Identification Standard 3.2 Education & Training 3.2.1 Qualifications of general practitioners 3.2.2 Qualifications of clinical staff other than medical practitioners 3.2.3 Training of administrative staff 8.1.1 & 8.1.3 2.8, 3.1.2, 3.4, 5.8 & 8.1 2.2, 3.1, 8.1.3 & 8.1.7 3.1.2, 5.2, 6.1, 6.2, 6.4, 7.2, 7.3.1, 7.5 & 7.4 2.3 & 8.1.2 8.1.2 & 2.3 2.3 & 8.1.2 Section 4 – Practice management Standard 4.1 Practice Systems 4.1.1 Human Resource System 4.1.2 Occupational Health and Safety Standard 4.2 Management of Health Information 4.2.1 Confidentiality & privacy of health information 4.2.2 Information security 2.10, 2.1, 2.2, 2.3, 2.4, 2.6, 2.7, 2.8, 5.8 & 8.1.7 3.1, 3.1.1, 3.1.6, 3.3, 3.4, 4.4, 8.1 & 2.10 8.1.3, 2.5, 6.1, 6.1.1, 6.1.2, 6.2, 6.3, 6.3.1, 6.4.2, 6.4.7, 6.4.8, 7.7 & 7.9 8.1.7, 6.1.1, 6.2, 6.4.6, 6.4.7 & 6.4.8 Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page xi of 260 Insert your logo here Section 5 – Physical factors Standard 5.1 Facilities and Access 5.1.1 Practice Facilities 5.1.2 Physical Conditions conductive to confidentiality & privacy 5.1.3 Physical Access Standard 5.2 Equipment for Comprehensive care 5.2.1 Practice Equipment 5.2.2 Doctors Bag Standard 5.3 Clinical Support Processes 5.3.1 Safe and quality use of medicines 5.3.2 5.3.3 Vaccine Potency Healthcare associated infections 5.5, 3.3, 3.2.6, 5.1, 3.1.1, 3.2, 3.2.1, 3.2.2, 3.2.3 & 3.2.4 3.2, 3.2.1, 3.2.3 & 3.2.5 5.1 7.12 & 7.12.1 7.12.2 7.2, 7.3, 7.3.1, 7.3.2, 7.4, 7.12.3, 7.12.4, 7.12.5, 7.12.6, 7.12.7 & 8.1.7 7.12.3 & 8.1.7 Section 4, 2.4, 2.8, 3.1, 3.1.3, 3.1.4, 3.2.2, 5.15, 8.1.1, 8.1.2 & 8.1.7 Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page xii of 260 Insert your logo here 1 Introduction 1.1 Mission Statement Option 1: Use the sample practice mission statement below Our mission is to provide the highest standard of patient care whilst incorporating a holistic approach toward diagnosis and management of illness. We are committed to promoting health, wellbeing and disease prevention to all patients. We do not discriminate in the provision of excellent care and aim to treat all patients with dignity and respect. Option 2: Add your own practice mission statement here 1.2 Practice background Write a short description of your practice here. Areas you may wish to include are the history behind your practice, location, particular interest areas, communities the practice services and other important information you would like to add. 1.3 Practice profile Name of practice * name of practice Street address * street address Postal address * postal address In hours phone number * in hours phone number After hours phone number * after hours phone number Fax number * fax number Email address * email address Web address * web address Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 1 of 260 Insert your logo here 1.4 Practice team Medical * Medical position * name of medical person * Medical position * name of medical person * Medical position * name of medical person * Medical position * name of medical person * Medical position * name of medical person Allied health * Allied health professional * name of allied health professional * Allied health professional * name of allied health professional Nursing * Nursing position * name of nurse * Nursing position * name of nurse Administrative * Administrative position * name of administrative person * Administrative position * name of administrative person * Administrative position * name of administrative person * Administrative position * name of administrative person Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 2 of 260 Insert your logo here 1.5 Practice services In addition to general medical consultations, our practice offers the following services: * insert practice services * insert practice services * insert practice services * insert practice services * insert practice services * insert practice services * insert practice services * insert practice services * insert practice services * insert practice services * insert practice services * insert practice services (* customise this section as appropriate) There is a range of posters, leaflets, and brochures about health issues relevant to the community available for all of our patients in: the waiting room the consultation rooms. 1.6 Practice hours Monday to Friday * Monday to Friday hours Saturday * Saturday hours Sunday Home visits * Sunday hours * Regular hours that home visits are conducted Home visit appointments can be made outside these times by prior arrangement with the receptionist at the discretion of the doctor. 1.7 Practice consultation fees (* customise this section as appropriate) An up-to-date copy of our schedule of fees is located: at reception in the practice information sheet. Further information about informing patients of the cost of care can be found in Practice fees. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 3 of 260 Insert your logo here 2 Human Resources Medical practices are advised to be continually informed and up to date in respect of workplace relations legislation, regulations and decisions of Fair Work Australia. As the Fair Work Act 2009 is new, it is subject to amendment. 2.1 Awards & Entitlements Policy This practice complies with all its legal obligations towards its employees. These include: provision of rates of pay, leave and other entitlements as set out in the relevant Award or workplace agreement; a safe and healthy workplace; equal opportunity and freedom from discrimination and harassment protection of employee and patient privacy; and maintenance of appropriate staff records. Additionally, this practice follows established procedures and policies for employment and management of staff, including: clear communication of expectations and standards, using position descriptions and job specifications as well as staff codes for conduct and presentation. recruitment procedures which are fair, thorough and facilitate selection of the best candidate. a formal induction procedure for all staff, to familiarise them with important practice procedures relating to patient care, occupational health and safety, emergencies, confidentiality and conduct. regular feedback and opportunities for development through performance review. Research from both general practice and other industries supports the importance of attention to human resources. For example, the alignment of role, competence and (where required) licensing was identified by the authors of a study of high performing clinical teams as a common element. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 4 of 260 Insert your logo here Procedure Under the Fair Work Act 2009, medical practices are bound by Workplace Agreements or Federal Awards which set out minimum employee entitlements. If medical practices are not bound by a workplace agreement, then they must abide by the relevant awards. From 1 January 2010, the 10 National Employment standards (NES) became law and replaced the Australian Fair Pay and Conditions Standards. All modern Awards, Enterprise Agreements, contracts of employment, ITEA’s and old Workplace Agreements must provide for these 10 NES as minimum conditions. The NES applies to all employees covered by the national workplace relations system, however only certain entitlements apply to casual employees. Under the NES, employees have certain minimum conditions. Together with pay rates in modern awards (which also generally take effect from 1 January 2010) and minimum wage orders, the NES makes up the safety net that cannot be altered to the disadvantage of the employee. In addition to the NES, generally an employee’s terms and conditions of employment come from a modern award, agreement, award and agreement based transitional instruments, minimum wage orders, transitional minimum wage instruments, state or federal laws. The NES are set out in the Fair Work Act 2009 and comprise 10 minimum standards of employment. In summary, the NES involve the following minimum entitlements: Maximum weekly hours of work – 38 hours per week, plus reasonable additional hours. Requests for flexible working arrangements – allows parents or carers of a child under school age or of a child under 18 with a disability, to request a change in working arrangements to assist with the child’s care. Parental leave and related entitlements – up to 12 months unpaid leave for every employee, plus a right to request an additional 12 months unpaid leave, plus other forms of maternity, paternity and adoption related leave. Annual leave – 4 weeks paid leave per year, plus an additional week for certain shift workers. Nurses are classified as shift workers entitled to an additional week of annual leave. Personal / carer’s leave and compassionate leave – 10 days paid personal / carer’s leave, two days unpaid carer’s leave as required, and two days compassionate leave (unpaid for casuals) as required. Community service leave – unpaid leave for voluntary emergency activities and leave for jury service, with an entitlement to be paid for up to 10 days for jury service. Long service leave – a transitional entitlement for certain employees who had certain LSL entitlements before 1/1/10 pending the development of a uniform national long service leave standard. Public holidays – a paid day off on a public holiday, except where reasonably requested to work. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 5 of 260 Insert your logo here Notice of termination and redundancy pay – up to 4 weeks notice of termination (5 weeks if the employee is over 45 and has at least 2 years of continuous service) and up to 16 weeks redundancy pay, both based on length of service. Provision of a Fair Work Information Statement – From 1 January 2010, all employers covered by the national workplace relations system have an obligation to give each new employee a Fair Work Information Statement (the Statement) before, or as soon as possible after, the employee starts employment. It contains information about the NES, modern awards, agreement-making, the right to freedom of association, termination of employment, individual flexibility arrangements, rights of entry, transfer of business, and the respective roles of Fair Work Australia and the Fair Work Ombudsman Option 1: Employment under Awards (Select the appropriate option/s depending on what you use at your practice and list staff groups employed under each option). Awards provide for minimum rates of pay and a safety net of employment terms and conditions. Often employers will negotiate additional over-award terms and conditions in order to attract, retain and reward their staff. Awards Applicable to Medical Practices Health Professionals and Support Services Award 2010 (Award code MA000027) Reception staff, practice managers, bookkeepers, payroll people, and cleaners Nurses Award 2010, (Award code MA000034). (ii) Medical Practitioners Award 2010 (Award code MA000031). Royal Australian College of General Practitioners & General Practice Training Employees Award 2003 (transitional) Award (MAA000027). Copies of awards and lots of other information is available from the Fair Work Australia web site: www.fairwork.gov.au or telephone 131394. Option 2: Workplace Agreements (Select the appropriate option/s depending on what you use at your practice and list staff types employed under each option). Employers and employees may enter an agreement to override or vary award provisions to provide greater flexibility in respect of entitlements and conditions of employment, e.g. working hours, salary packaging or work-life balance initiatives. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 6 of 260 Insert your logo here The previous Work Choices legislation provided for two forms of Agreement. 1. Australian Workplace Agreement, (AWA’s). The making of new AWA’s is no longer allowed under the Fair Work Act 2009. AWA’s made in accordance with the old Work Choices Legislation will continue for their nominated life up to a maximum period of 5 years. Upon the attainment of the nominal expiry date, the AWA’s cease to operate and the employee and the employer are bound by the terms of the respective Award. 2. Collective Agreements (CA). Collective Agreements made under the previous work Choices legislation continue on until replaced by a new Agreement or are cancelled by Fair work Australia. The new Fair Work Act 2009 provides for three forms of agreements. 1. Individual Transitional Employment Agreements (ITEA’s). The making of new ITEA’s was permitted under the Fair Work Act 2009 until 31 December 2009 ITEA’s made in accordance with the new Fair Work Act 2009 continue until they are replaced by an Enterprise Agreement or are cancelled by Fair work Australia. In the absence of an Enterprise Agreement, the ITEA having been cancelled, the employee and the employer are bound by the terms of the respective Award. 2. Enterprise Agreements (EA). Enterprise Agreements are made between the Employer and a group of employees, (i.e. more than one employee), must satisfy the Better Off Overall Test, (the “BOOT”), and be approved by Fair Work Australia. 3. Individual Flexibility Agreements The Employer and the employee may enter into an Individual flexibility Agreement which is based on the employee’s Award. The Award lists the conditions which may be varied and any variation agreed must ensure that the minimum Award conditions are met and for the employer is Better Off Overall; (the BOOT). RACGP 4th edition Standards 4.1.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 7 of 260 Insert your logo here 2.2 Position Evaluation and Recruitment Policy Effective selection and management of staff is critical to the success of this practice. Our ability to care for patients and operate a successful medical practice depends upon attracting, developing and retaining the right people. All new positions are evaluated in terms of the current needs and future goals of the practice. Practice members need clarity regarding their role and responsibilities in the practice. A job description is developed, to clearly communicate the responsibilities and expectations of the position. A position description establishes the role of the employee within the organisation documents the parameters of the responsibilities and duties associated with that position and forms the basis for evaluation and lines of accountability. Recruitment, training and development, performance evaluation, remuneration management and succession planning can all be based on the parameters of a position description. Selection criteria are developed based on the job description. The selection procedure is non-discriminatory and all candidates treated with courtesy and respect. The successful candidate is provided with a Letter of Offer of Employment prior to commencement, which is signed by both the candidate and the employer. This ensures both parties have a clear understanding and a written record of the agreed terms and conditions of employment. Procedure General practitioners and other staff need documented position descriptions that outline and define their current roles, responsibilities and conditions of employment. Position descriptions are signed by employees to indicate that roles and responsibilities are acknowledged and understood. Included within our position descriptions are any designated areas of responsibility and that all members of our practice team take responsibility for a multidisciplinary culture of safety, quality and open communication. Practice team members need to know who is responsible for various aspects of the practices operations, including who has primary responsibility and who has delegated responsibility. (Refer Section 8 Clinical governance). Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 8 of 260 Insert your logo here Designated areas of responsibility and leadership include: RACGP STD 3.1.2 Clinical Risk management systems including receiving and disseminating any important communication or updates (e.g. health alerts) and contingency plans. RACGP STD 3.1.3 Clinical leadership. RACGP STD 4.1.1 Leader of quality improvement and risk management processes (non clinical). RACGP STD 4.1.1 Clinical care. RACGP STD 4.1.1 Information management. RACGP STD 4.1.1 Human resources. RACGP STD 4.1.1 Coordinates the seeking of feedback and the investigation and resolution of administrative and/or other complaints. RACGP STD 4.1.2 Occupational Health and Safety (Health and Safety representative). RACGP STD 4.2.1 Privacy Officer. RACGP STD 4.2.2 Electronic systems and computer security. RACGP STD 5.3.1 Proper storage and security of medicines RACGP STD 5.3.2 Cold chain management. RACGP STD 5.3.3 Infection control Infection control processes within our practice. (e.g. sterilisation process, staff immunisation, staff education). RACGP STD 5.3.3 Environmental cleaning. Recruitment process Our recruitment process includes the following: Step 1: Position evaluation Look at the position in relation to other staff and the future needs of the practice. There may be an opportunity for existing staff to develop new skills. Can some jobs be redistributed to increase efficiency or even eliminate the need for this position? Are there additional skills which may be incorporated into this position to assist the practice achieve its goals for the future? Is there room for the new person to work at the practice, or can the position include some off-site work? Speak to your division about options. Consult with current staff and include them in the decision-making process. Consider the long-term goals of the practice and use this as an opportunity to plan strategically towards achieving them. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 9 of 260 Insert your logo here Step 2: Job description Determine the key requirements of the position, considering which ones are essential and which are desirable and use this information to compile a job description with clear specifications for the position. Include the following: skills: what skills does the position require? Is training an option? qualifications: what is the minimum required? Are there others which would be an advantage? personal attributes: what personal attributes are needed? Are there physical requirements essential to the position such as the ability to lift and bend? hours per week: full time or part time? Is there weekend or night work? is the position permanent, casual or fixed-term contract? How long is the qualifying or probationary period (usually 3-6 months)? remuneration: what award is applicable? What award/agreement classification will the position be (if applicable)? What is the salary range or hourly rate? Are there any other benefits offered, such as flexible hours, family friendly options, training, salary packaging or incentive payments. Step 3: Advertising the vacancy Write the advertisement, ensuring it complies with EEO legislation – see procedure 2.10. Include information about duties, required skills, qualifications, hours and location. For practice nurses, the award requires that the salary grade classification be included in all job advertisements (Refer to the hints below for more information). Consider how candidates are to apply – by email, mail, fax, or telephone? Is there a closing date for applications? Vacancies can be advertised in a number of ways: advertisements can be placed in newspapers (local and/or state) on the internet or in professional journals. professional associations and networks may also advertise vacancies in their newsletters or web sites, such as the DCGPA web site. for non-clinical staff local Job Network organisations will find candidates at no charge. employment agencies and recruitment consultants will handle the entire recruitment process. junior or graduate staff may be sourced from local schools and educational institutions. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 10 of 260 Insert your logo here Step 4: Selection of applicants to interview Selection criteria form: Compile a list of selection criteria based on the job description and other factors (e.g. previous stability of employment), making sure of compliance with EEO - procedure 2.10. selection: Compare all applications received against the selection criteria, and select those who best fit the criteria. arrange interviews: Contact the candidates selected to arrange an interview. Candidates may be required to bring documents to the interview, such as proof of qualifications, samples of previous work or evidence of their right to work in Australia (for nonresidents). Step 5: Prepare for Interviews forms & Information: Prepare application forms (see sample following) and documents to be given to applicants – this should include the job description and may also include information about the practice, code of conduct, dress code etc. interview procedure and location. decide who will conduct the interview – an individual or a panel? what questions will be asked? (Remember EEO - procedure 2.10.) Set aside a suitable place for the interviews, free from interruptions. Step 6: Conduct the Interviews When the candidate arrives, provide them with an application form to fill in and a copy of the job description. Make sure all interviews are conducted by the same people and similar questions are asked, although it is acceptable to include additional questions related to the candidate’s resume or in response to comments made in the interview. Allow the candidate to ask questions. View original copies of qualifications, proof of membership of professional organisations, professional indemnity insurance or right to work in Australia if the candidate has been required to bring these to the interview. Note down document numbers on the application form, or photocopy and attach to the form. Discuss the impressions of each candidate after each interview and make brief notes on their application form to record any employment arrangements or salary agreed upon. Do not make notes which are in breach of EEO guidelines or are not relevant to the position. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 11 of 260 Insert your logo here Step 7: Reference checks Contact the referees nominated by the best candidates to confirm information given in the interview or resume and find out about previous job performance. Step 8: Medical examination, police checks or other tests If relevant to the position, candidates may be required to take a pre-employment medical examination, police checks and personality or skills tests. For more information on preemployment testing contact your division, employer group or a specialist recruitment agency. These tests must be conducted prior to the job offer, as they are used to confirm suitability to the position. These tests must only examine characteristics which are directly relevant to the job, or they could be in breach of EEO legislation. Step 9: Job Offer Once the successful candidate has been chosen they may be contacted by telephone to confirm their acceptance of the position but this must be confirmed by a written Letter of Offer of Employment. Getting the contract or letter of appointment right in the first place means both parties are much less likely to have problems later on. As a minimum it should state: employees name/address position title and reference to the job description. pay rate including which specific Award/agreement employed under including classification or relevant Qualifications/Allowances. full time/part time or casual, details such as days, shifts & minimum hours per week to be worked. name of employer. workplace location/campus/ other work sites. date of commencement. probationary period any other special terms or conditions which have been negotiated outside the award e.g. acknowledgement of prior service/entitlements (sick leave, long service). The letter of offer is provided prior to commencement, allowing the candidate time to read through the offer and sign it to indicate their acceptance. This letter of offer should be written carefully – a poorly worded phrase, a typing mistake or the omission of an important item may prove to be very costly to the practice. The official employment agreement should be provided Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 12 of 260 Insert your logo here upon commencement of employment. This should refer to the award which covers the employee and also any other items which are not listed within the award. Take a photocopy of the Letter of Offer of Employment and keep it on file at the practice as a record of the contract until a signed Letter of Offer is received from the candidate. It is recommended that the practice compile an employee handbook containing all terms and conditions of employment and the major policies of the practice as well as introductory information about the practice and this is sent with the Letter of Offer of Employment. If a handbook is not used, the Letter of Offer must inform new employees of the hours of work and practice policies in relation to staff conduct, staff induction, privacy, occupational health & safety and termination of employment, as described in the sample letter of offer at the end of this section. This means the new employee is aware of all their key legal obligations and entitlements before commencement. The Letter of Offer of Employment should include a section for the employee to sign and return to the practice indicating that they have read the Letter and Handbook and they accept all the terms and conditions contained in them. Once the signed letter is returned it should be filed in the employee’s personnel file and the copy may be destroyed, if desired Step 10: Notification of unsuccessful applicants Unsuccessful candidates should be notified as soon as possible after the position is filled. Care must be taken when advising unsuccessful applicants, to ensure equal opportunity or discrimination legislation is not breached. In line with the Privacy Act 1998, applicant’s details are kept for a specified period of time and then disposed of as confidential documents. Step 11: Prepare for the new employee Prior to commencement, ensure facilities and resources such as a computer, desk, chair and stationery are prepared for the new employee. Is the necessary software set up on their computer? (Make sure passwords and software access for previous employees have been removed, if applicable). Will they need a uniform or name tag? Set up a Staff employment record file for the person. Refer to procedure 2.3 Step 12: Induction of new staff member Please refer to procedure 2.4. RACGP 4th edition Standards 3.1.3 & 4.1.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 13 of 260 Insert your logo here 2.3 Staff Employment Records Policy A range of information must be made and kept for each employee as prescribed by the Fair Work Act 2009 and Fair Work Regulations 2009. Our practice understands that penalties apply to employers who fail to comply with the record-keeping requirements of the Fair Work Act 2009. Therefore we maintain staff employment records which comply with all legal and statutory obligations. These include: employment Records: Personnel files are kept for each employee recording employment arrangements, clinical qualifications & registrations, professional development, performance reviews and any other agreements or documents which are relevant to employment relationship and the functions of the practice. payroll records and pay slips: Which comply with regulations under the Fair Work Act 2009. currency of Records: Employment records are reviewed at least annually to ensure currency of clinical qualifications & registrations, professional indemnity insurance, training records, immunisations and personal contact details. confidentiality: Employment records are kept confidential, as required by the Privacy Act 1998. retention: Employment records are kept for 7 years. In addition other staff records relating to professional standards or to provide documentary evidence of meeting the RACGP Accreditation requirements are also maintained and kept (e.g. staff education and training plans or evidence of qualification and competence). Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 14 of 260 Insert your logo here Procedure Employment records Documentation which is relevant to the employment relationship and practice functions is retained on each employee, including but not limited those itemised in the Employee Records checklist provided at the end of this section. Our employee records are: in a form that is readily accessible to a Fair Work Inspector legible and in English (preferably in plain, simple English) kept for seven years not altered unless for the purposes of correcting an error not false or misleading to the employer’s knowledge. private and confidential. Generally, no one can access them other than the employee, their employer, and relevant payroll staff. made available at the request of an employee or former employee (copy only). Payroll Records and Pay slips In addition to the information kept in each individual employee’s file the practice maintains records on payroll, taxation and superannuation transactions, as required by the Fair work Act 2009. These include: Time and Wages Records 1) 2) 3) 4) 5) 6) The name of the employer and the name of the employee. From 1 January 2010 - the Australian Business Number (ABN) (if any) of the employer. Date the employee started employment. If the employee is full-time, part-time. If the employee is permanent, temporary or casual. The employee's pay rate, including gross and net amounts paid and any deductions from the gross amount. 7) Any loadings, monetary allowances, bonuses, incentive-based payments, penalty rates or other entitlements paid that can be singled out. 8) If a penalty rate or loading must be paid for overtime hours actually worked, the number of hours of overtime worked, or when the employee started and finished working overtime. 9) Hours worked if the employee works casual or irregular part-time hours and is guaranteed a pay rate set by reference to a period of time worked. 10) A copy of the written agreement if you and your employee have agreed to average the employee's work hours. 11) If you and your employee have agreed to an individual flexibility arrangement, a copy of that agreement, and, if the agreement is terminated, a copy of the termination. 12) Leave information for all types of leave, including: a. leave taken Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 15 of 260 Insert your logo here b. leave balance c. a copy of any agreement to cash out accrued leave, the rate of payment for the leave and when the payment was made. 13) Employees paid superannuation (excluding payments to a defined benefit fund): a. amount paid b. pay period c. date(s) paid d. name of super fund e. reason you paid super into the fund (e.g. a record of the employee's super fund choice and the date that choice was made). 14) If the employee or employer terminates their employment: a. name of the person who terminated the employment b. how the termination took place - by consent, by notice, summarily or in some other way (need to include details). 15) If the employee has been provided with a written guarantee of annual earnings for an amount over $108,300 a year (indexed annually): a. a copy of the written agreement Pay Slips Pay slips are given to each employee and these include the following, as required by the Fair Work Act 2009. the name of the employer and ABN (if any). the name, position & classification of the employee. the period to which the pay relates and the date it is paid. the hourly rate (or annual rate, if applicable). the hours worked, itemised as normal hours, overtime, penalty rates & loadings, leave payments, etc, and the amount paid per hour for each income type. details of any additional allowances or deductions. the gross amount of the pay, taxation deducted and the net payment made. superannuation contributions for the period with the fund name and employer & employee contributions itemised separately. Currency of Records At least once per year the employment records for each staff member are reviewed. Each employee is asked to provide: evidence of appropriate current national registration, if applicable. for GPs evidence of satisfactory participation in the RACGP QI&CPD program or equivalent. for practice nurses evidence of sufficient hours of CPD to meet re-registration requirements. for all our staff, evidence that they have completed appropriate CPR training at least once in the last 3 years. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 16 of 260 Insert your logo here evidence of current professional indemnity insurance, if applicable. evidence of currency of immunisations, or refusal. evidence of competency in relevant infection control processes. Training records and personal contact details are also reviewed annually to ensure the employment records are current and correct. Confidentiality This practice complies with the requirements of the Privacy Act 1998, in keeping and maintaining employment records: only information directly relevant to the activities of each employee or the functioning of the practice is kept in employee files. all information kept in employment records is obtained by lawful and fair means. personal and sensitive information about employees is kept confidential and employment records are stored in a secure place. Paper files are kept in a locked filing cabinet and electronic records are password protected. employees are entitled to view their personal files, with exceptions as allowable under the Act Retention Under the Fair Work Act 2009 all employment records including payroll and personnel files must be are kept for 7 years. These records must be kept in English and made available for inspection by workplace inspectors if required. RACGP 4th edition Standards 3.2.1, 3.2.2 & 3.2.3 & 4.1.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 17 of 260 Insert your logo here 2.4 Staff Induction Policy Practices need a system for assisting new members of the practice team to learn their role. This includes new GPs (including registrars and locums) and other new staff. This practice has an induction program for all new General Practitioners and practice staff which includes ongoing monitoring of progress in their new role. To ensure staff and patient safety, new members of the general practice team must be able to demonstrate knowledge of the key procedures in the Policy and Procedure Manual and key operating systems relevant to their role within the practice by the end of the induction period. In some cases it may be appropriate to have a program where other contractors using rooms in the facility are also provided an overview of relevant practice systems. Staff are also expected to familiarise themselves with the Policy and Procedure Manual and use it as a resource in the course of their employment. All new staff must complete a full induction program including OH&S as detailed on the Staff Induction Checklist as part of their orientation. A sample Staff Induction Checklist is included at the end of this section. In-house training is provided to staff members responsible for inducting new employees to ensure they understand the requirements of the induction process and the importance of an effective induction program in relation to job performance, legal liability and OHS. This is recorded on their training records to show they are authorised to induct new employees. It is essential that new staff understand the day-to-day operations of the practice including the occupational health and safety issues relevant to their role, the practice code of conduct, infection control policies and the processes by which the privacy of patient health information. It is useful for new staff to have an understanding of the local health and cultural environment in which the practice operates. For example, if the practice is located in an area with a high level of problems caused by illicit drug use, it is useful for new staff to understand the practice’s policy concerning management of Schedule 8 medicine prescribing. Furthermore, staff and GPs in particular need to be aware of key public health regulations (such as reporting requirements for communicable diseases or mandatory reporting of child abuse) that will affect how they work. General practitioners need to be made aware of local health and community services including pathology, hospital and other services they are likely to refer to in the course of normal consulting. The Staff Induction Checklist provides the general knowledge essential for any position within a medical practice. Job specific orientation and induction will also need to be undertaken and documented. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 18 of 260 Insert your logo here As each stage of the induction program is completed the new staff member and their induction supervisor sign the Staff Induction Checklist and the completed document is filed in the employee’s Staff Record file. This written record of induction is important to protect the practice against legal liability and injury claims in the future. New staff members are not permitted to work independently until competency in specific areas of induction such as infection control, confidentiality and OHS have been demonstrated and signedoff. Procedure The following overview and checklist can be customised to reflect the practice’s needs. Process Before the first day. First day First week First month Description Ensure all staff members responsible for induction are trained and have sufficient time allocated. Assign a staff member to be responsible for the induction of the new employee. Prepare Staff Induction Checklist and have copy of procedures manual & job description available to refer to. A sample Induction Checklist is provided at the end of this section. Make the new staff member feel welcome. Go through all items on the Staff Induction Checklist Prepare Staff Induction Checklist - Induction &Training Plan Sign the Staff Induction Checklist Part 1 - First Day to show all items have been completed File Staff Induction Checklist Part 1 - First Day and a copy of Part 2 Induction &Training Plan in the new employee’s staff records file. Give a copy of all induction forms including Staff induction Checklist Key policies and procedures to the employee. Make time each day to go through key policies, procedures and other training needs identified on the Induction &Training Plan Arrange induction and training with other staff members in areas such as reception systems, record-keeping, sterilisation/infection control & spills, doctor’s requirements, customer service and complaints, patient privacy, triage. Provide opportunities for the new staff member to ask questions, and make sure they receive plenty of feedback and encouragement. Tick off each item on the Induction &Training Plan as it is completed. Continue to provide the new employee with opportunities to ask questions as well as encouragement and support with regular informal meetings. Link the new staff member into local networks and professional organisations, such as those at the division. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 19 of 260 Insert your logo here After 3 months Continue Induction &Training Plan until all items are completed. Sign the Induction &Training Plan to show it has been completed. Give a copy to the employee and file the original in the employee’s Staff Records File. Review the induction and training plan and their performance. Provide recognition for the areas which they are performing well in and develop a new plan to resolve any remaining training needs or provide skills enhancement – Performance Review. RACGP 4th edition Standards 4.1.1, 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 20 of 260 Insert your logo here 2.5 Privacy Policy All patient information is private and confidentiality of patient information must be maintained at all times. The rights of every patient are to be respected. All information collected by this practice in providing a health service is deemed to be private and confidential. This practice complies with Federal and State privacy regulations including the Privacy Act 1998, the Privacy Amendment (Private Sector) Act 2000 and Victorian Health Records Act 2001 as well as the standards set out in the RACGP Handbook for the Management of Health Information in Private Medical Practice 1st Edition (2002). (Refer Section 6 Privacy and Security of Health Information). Under no circumstances are employees of this practice to discuss or in any way reveal patient conditions or documentation to unauthorised staff, colleagues, other patients, family or friends, whether at the practice or outside it, such as in the home or at social occasions. This includes patient’s accounts, referral letters or other clinical documentation. General Practitioners and staff are aware of confidentiality requirements for all patient encounters and recognise that significant breaches of confidentiality may provide grounds for disciplinary action or dismissal. Every employee of this practice is aware of the privacy policy and has signed a privacy statement as part of their terms and conditions of employment. This privacy statement continues to be binding on employees even after their employment has terminated. Procedure All employees of this practice are issued with the privacy policy and sign a privacy statement as part of their terms and conditions of employment. The policies and procedures of the practice are further explained during the induction of new staff members, and the induction form is signed by the new employee as confirmation that they understand and accept their obligations in relation to patient privacy and the confidentiality of medical information. A sample Privacy Statement Form to sign can be found in the Job Package forms provided at the end of this section. RACGP 4th edition Standards 4.2.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 21 of 260 Insert your logo here 2.6 Performance Review Policy Annual staff reviews are conducted to ensure continuing high levels of work performance and to assist in job enrichment. The review is part of a continuous process of feedback to individual staff on their work performance. It is extended to include performance improvement and career development. Performance reviews benefit the practice and its employees by: ensuring all staff know what is expected of them and how their work is important to the practice. providing staff with formal recognition and appreciation for their work. providing an opportunity to review goals, celebrate achievements and set objectives for the future. helping staff to develop their skills and performance to achieve practice goals and further their own career. dealing with problems and resolving grievances – see also Grievance Procedure in 2.10 Equal Opportunity, Bullying and Harassment. A review involves identifying, evaluating and developing the work performance of staff so that Practice goals are more effectively achieved. At the same time the process benefits staff in terms of recognition, receiving feedback, catering for work needs and offering career guidance and support. The relevant position description forms the basis for evaluation and lines of accountability. The performance review document, including comments concerning current progress and future goals, is signed by both parties, with a copy retained by the staff member. The original is filed in the Staff Record File. Reviews are not directly linked to salary levels nor is it the forum for seeking a pay increase. The performance review should not be the forum for sorting out issues which have occurred over the previous year. Any issues which may arise should be addressed immediately. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 22 of 260 Insert your logo here Procedure A review is conducted 3 months after commencement of the position and at least annually thereafter. A performance review checklist to assist with planning and to ensure all steps are completed is provided at the end of this section. A detailed description of each step and hints follows. Step 1: Plan & prepare An effective performance review process can increase productivity, staff motivation and morale, but a badly handled review can have a damaging effect on the employee and result in decreased performance. Provide staff responsible for conducting performance reviews with basic training in giving feedback, using specific examples and evidence rather than vague comments and the legal restrictions on what can be said (see Procedure 2.7). Guidelines on giving feedback can be downloaded from the DCGPA web site. Notify the employee of the impending review at least 1 week in advance, at which time a mutually convenient time can be arranged for the meeting. Allow at least one hour which should be free from interruptions, if possible. Provide the employee with a self-appraisal questionnaire and a copy of their current job description to help them prepare for the review, and have an opportunity to reflect on examples of their achievements, problems they have encountered and areas they would like to improve. This encourages employee ownership and involvement in the process as well as changing the review relationship towards counselling and coaching instead of judgement. A sample selfappraisal questionnaire is included at the end of this section. Review the employee’s job description, their self-appraisal and records of previous performance reviews. If appropriate, speak to co-workers and others the employee has contact with in the course of their work to get feedback on their performance. Plan what to say and how to say it during the appraisal. Focus on productivity, quality of work, reliability and team work. Be objective and provide supporting evidence, examples and documentation, especially in relation to poor performance. Use positive reinforcement to encourage desired behaviours. Step 2: Conduct the review Reviews should be conducted in a quiet location away from distractions and interruptions. Begin with a description of the aim and process of the review, to help the employee feel comfortable and non-defensive, as described on the Self-appraisal questionnaire. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 23 of 260 Insert your logo here Performance reviews give employees an opportunity to receive appreciation and recognition for their achievements, raise problems and resolve grievances, set goals for the future and discuss the training and development opportunities they need to do their job better and further their career. Performance reviews provide practice management with a chance to re-motivate employees, refocus attention on practice goals and strategies, acknowledge employee achievements, deal with problems, align employee goals with those of the practice, assess staff development needs, learn more about each employee and determine those who are ready for additional responsibilities. Set a positive tone for the discussion by starting the review with a brief account of the employee’s strengths, recognition of their achievements and appreciation for their contribution to the practice. Discuss the employee’s self-appraisal, listening carefully to show genuine interest. Do not disagree with their assessment, unless they have underestimated their performance. Ask them for suggestions on how they could improve their performance or develop their skills – even when they have performed well there may still be opportunities for improvement. Deal with any issues arising sensitively and constructively, following the guidelines for giving feedback which can be downloaded from the DCGPA web site. Remain calm at all times, focusing on the facts and not personalities. If the discussion is getting out of control, suggest taking a 10-minute break, bring in another member of staff who may be able to act as a mediator or arrange another time to continue the review. (See also hints below on dealing with various types of employee responses and the guidelines for dealing with poor performance which can be downloaded from the DCGPA web site) If communication is regular and open there should be no surprises for either party in performance appraisals. However, if an issue is raised for which one party is not prepared, listen carefully to the problem and ask for specific examples and evidence. Arrange to respond at a later time, once there has been an opportunity to consider the problem and conduct further investigations if required. Do not be tempted to make hasty decisions or ignore problems, hoping they will go away. Review the job description and the targets or goals set in previous reviews. Ask about the employee’s plans and goals for the future, looking at their career development. Discuss the future needs of the practice, seeking to find opportunities for the employee to achieve their goals in ways which will also add value to the practice. Work together to set new goals for the future, using the SMART principle for goals: Specific, Measurable, Achievable, Relevant (to both the needs of the practice and the employee) and Timely. Establishing mutually agreed goals will result in greater employee ownership and commitment to achievement of the goals. Identify areas where the employee’s performance or career development would benefit from training, additional resources or equipment, a different allocation of responsibilities for better use Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 24 of 260 Insert your logo here of time etc. For both parties it is important to only make promises and commitments which can be kept, or a loss of trust will result. Adjust the job description to reflect any new responsibilities or role changes. Document any agreed goals and targets as well as commitments to training or support made by the practice. Agree on a time line for completion of agreed tasks and for the next review. Generally the time frame for the next review will be 12 months but if an employee has been given new responsibilities or an improvement in performance is required the next review may be in 1-3 months. Record the details of discussions and any agreements made on the Performance Review Form. Allow the employee to read the record of the review and suggest any changes or additions. Once both parties are satisfied that the document is a correct record of the discussions, sign the last page of the Performance Review Form and date it. Give a copy to the employee and file the original on their Staff Records File. Finish the review by thanking the employee for their participation in the review process, concluding with a positive statement about what has been achieved and the benefits anticipated in the future. Step 3: Follow through Ensure the practice keeps all commitments made in the review, ranging from promises for additional training and career development or consequences for continued poor performance (such as written warnings, as per Procedure 2.7). After the review these commitments should be incorporated into the staff member’s planning schedule. Issue an updated job description, if required. Give a copy of the new job description to the employee and let them check it before adding it to the employee’s Staff Records file and marking the previous job description ‘superseded’. If promises made by the practice are not kept the employee may lose trust in the practice management, which will lead to a loss of motivation and commitment and any improvements in performance will not be sustained. If unsatisfactory behaviour continues after the practice has taken all reasonable steps to address possible causes including provision of adequate instructions, training, resources and time, disciplinary action may be required. RACGP 4th edition Standards 4.1.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 25 of 260 Insert your logo here 2.7 Disciplinary Process Whilst this procedure is advised, there is no longer the requirement of three warnings. However, the employee must be given ‘a fair go’ and have an opportunity to improve within a reasonable time frame. Always document these issues. Policy The Practice Manager has the day to day responsibility for ensuring that employees meet the required standards for work performance and conduct. Generally the focus is on positive ways of motivating staff, including: communicating clearly what has to be done. setting joint goals or targets. coaching staff. resolving problems as they occur. informal feedback and counselling about poor performance. If this approach is not sufficient, or when a serious breach of policy occurs, the disciplinary process will be followed. The purpose of the disciplinary process is to: avoid repetition of mistakes or unacceptable behaviour – it is corrective, not punitive. ensure fairness in the treatment of all employees. provide a clear, written statement about the expectations of the practice in relation to conduct and behaviour at work. encourage an improvement in work performance and behaviour. provide support or training to assist in improvement. advise of the consequences of failure to comply with expectations, including written warnings and termination of employment. For the process to be effective the following points need to be considered: listen carefully. gather the facts. remain objective. don’t avoid the problem. document all discussions and evidence. be fair and reasonable, balancing the safety and privacy of patients and staff with the rights of the employee. Under the Fair Work Act 2009 there have been changes to unfair dismissal laws. An employee is eligible to make an application for unfair dismissal if they have completed the minimum employment period of: one year – where the employer employs less than 15 full-time equivalent employees (a small business employer). six months – where the employer employs 15 or more full-time equivalent employees. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 26 of 260 Insert your logo here employees are still entitled to sue for unlawful dismissal, on the grounds of a breach of the “general protections”, e.g. discrimination, bullying or harassment, employee making a claim or joining a union etc. dismissal provisions in Workplace agreements will continue to apply for the life of the agreement. treating staff fairly and having appropriate systems is important for workplace morale. Research clearly shows that perceptions of management unfairness decrease employee commitment, motivation & performance. More information about dismissals and the changes under the Fair Work Act 2010 http://www.fwa.gov.au/index.cfm?pagename=dismissalsabout. Procedure Counselling or disciplining problem employees is a difficult component of any Manager’s role. This process is usually stressful and unpleasant for those involved, and can lead to anger and resentment. This can be minimised by: treating the employee with respect and dignity, focussing on specific behaviours and not the person. preserving the employee’s self-esteem by acknowledging their good points such as useful skills or pleasant personality but recognising that the current job may not be a good match for their talents, interests and abilities. Try to avoid making the employee feel ‘not good enough’ – they simply may not be a good fit with this position. Success in any job is reliant on the right combination of the attributes of the employee, the position and the practice. understanding that most employees desire the satisfaction of performing their job well and will not be happy in a position which does not suit their skill-level or abilities. Helping them through the disciplinary process in a respectful and affirming way will provide a greater understanding of their strengths and limitations and assist them to find a more satisfying position in the future. providing all reasonable assistance to help employees improve their performance. See ‘Giving and receiving Feedback’ which also includes guidelines on dealing with poor performance. Avoiding the issue will not make the problem go away. Failure to deal with employee problems can send ‘messages’ to the problem employee and other employees that poor performance or behaviour is condoned. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 27 of 260 Insert your logo here Counselling and Disciplinary Action The disciplinary process involves four steps: 1) counselling (optional) 2) first written warning 3) second written warning 4) termination These steps may not always be followed in full. For example, in some cases counselling will be sufficient to resolve the problem. Although a minimum of two written warnings are usually provided prior to termination, severe misconduct may warrant immediate dismissal. At each step, the following procedure occurs: problem arises or incident occurs. investigation of facts, including collecting witness statements. In some circumstances the employee may be stood down (asked not to remain at the workplace) with pay while the investigation takes place. the allegations and supporting evidence are presented to the employee. The employee is entitled to have a representative present, such as another staff member or union representative. It is advisable for the manager to have a witness present in all interviews related to disciplinary procedure. Preferably this should be a staff member with mediation skills or who is trusted by both parties. the employee is given an opportunity to respond, including requesting any reasonable assistance which would prevent a reoccurrence. a decision is made – this could range from deciding to take no action, to agreeing upon clear guidelines about expected future behaviour or even termination of employment. the process is documented and the employee is given a copy with the original being placed in the Staff Records File. Step 1: Counselling Counselling is usually the first formal step in the disciplinary process. It can be used to discuss poor performance, grievances raised by other employees or to deal with a breach of policy. Details of the problem, available evidence, the employee’s response and decisions taken are documented on an Employee Counselling/Written Warning Form. A sample Employee Counselling/Written Warning Form can be found at the end of this section. For more serious incidents or breaches of policy a written warning may be issued at the same time as counselling. The Grievance Procedure in 2.10 Equal Opportunity, Bullying and Harassment may also be used to resolve grievances, especially those involving more than one employee. Agree upon a timeframe for improvement and the next review date. Allow sufficient time for the employee to improve - usually 2 weeks to one month. If the behaviour continues it will be necessary to move on to a written warning. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 28 of 260 Insert your logo here Step 2: First Written Warning should outline the problem with the employee’s performance. the evidence arising from investigation including statements from any witnesses (A sample Witness Statement Form is included at the end of this section). the employee’s response for the problem. the agreed plan for improvement. any assistance, support or training to be provided by the practice to facilitate improved performance. This includes reasonable requests for reduced hours or changes to duties. the timeframe for improvement and the next review date. Allow sufficient time for the employee to improve - usually 2 weeks to one month. the consequences of failure to improve (usually one more warning and then termination). the process should be documented on the Employee Counselling / Written Warning Record – tick the box to indicate that this is a first written warning (A sample form is provided at the end of this section). The content and outcome of the interview must be documented with a copy each for the employee and employer. Ensure any resources or assistance agreed upon in the interview are promptly provided. Step 3: The Second and Final Written Warning The second and final written warning is issued when there has been no improvement or change following the first warning. The interview should follow the same format as the first warning, including reference to the first warning and the previous plan for improvement. The employee must be made aware of the likelihood of termination, and this should be documented, with a copy each for the employee and the employer. If the improvement in employee performance, attitude or behaviour is still not made then a Notice of Termination of Employment (as per the Award or employment agreement- ensure the correct wording is provided to avoid confusion) is given to the employee. Step 4: Termination Termination as a result of the disciplinary process. If the unsatisfactory behaviour continues after two written warnings, termination may be necessary. The employee will be well aware of the likelihood of this consequence. Before terminating an employee, all employers must ensure that the termination meets the minimum requirements as set out in the Small Business Fair Dismissal Code. Whilst this code is applicable to employers who have less than 15 employees, it is recommended that all employers use this code as a minimum set of procedural steps. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 29 of 260 Insert your logo here A copy of the Small Business fair Dismissal Code is at http://www.fwa.gov.au/documents/dismissals/Small_Business_Fair_Dismissal_Code.pdf. For general information on dismissals from fair work Australia http://www.fwa.gov.au/index.cfm?pagename=dismissalscoverage#harsh. Termination of employment may also occur due to: Summary Dismissal: Employees may be summarily dismissed without any warnings for serious breaches of policies, misconduct or illegal activity. Employees must be informed of behaviours which would justify summary dismissal as part of their terms and conditions of employment. In this manual this information has been included in the staff handbook. Some examples include: negligence or carelessness which could affect patient safety. actual or threatened assault, serious abuse or harassment. fraud or theft, including falsification of records and unauthorised possession of property belonging to the practice or another employee. breaches of the practice’s privacy policy. unauthorised use or possession of alcohol or drugs at work. attending work in a condition which is a risk to the health or safety of patients, colleagues or the employee concerned. serious and willful disobedience (seek advice first). In many cases an employee will be stood down on full pay while an investigation is undertaken prior to summary dismissal, to ensure the dismissal is warranted. Redundancy: This occurs when a particular job is no longer required at the practice or less people are needed to perform the amount of work available. It is a requirement of the Fair Work Act 2009 and the relevant Award for the Employer to consult with the employee prior to the redundancy occurring. Generally, an employee who is made redundant will not be replaced. Employees who are made redundant are often entitled to several weeks’ severance pay, depending on their age and the length of time they have been employed at the practice – check the relevant award or workplace agreement. Seek advice from your division or employer group before proceeding with a redundancy to ascertain whether the situation will qualify as a valid redundancy and the severance pay applicable. Abandonment of employment: Abandonment of employment occurs when an employee fails to attend his/her place of employment for three days or more without having prior authorisation for the absence and has not contacted the employer to explain the reason for the absence. During the 3 days the practice should attempt to contact the employee by telephone and if this is unsuccessful a letter should be sent by registered mail to the employee’s last known address stating that the employee's unauthorised absence is unacceptable, seeking an explanation for the absence and advising that if the employee fails to return by a set time and date it will be determined that he/she has abandoned his/her employment. If there is no response after 3-4 Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 30 of 260 Insert your logo here days send a second notice, and if there is still no response after a further 3-4 days a third letter should be sent advising that as a result of his/her failure to return to his/her place of employment the practice has determined that he/she has abandoned his/her employment. At this stage the employment is terminated and all entitlements should be paid. Under some awards the employee forfeits annual leave and notice entitlements if they abandon their employment. Any personal effects left at the practice can be sent with the final letter. For more information and sample letters contact DDGP. Employee initiated termination, such as resignation: All employees are required to notify the practice in writing of their intention to resign from their employment, giving at least the amount of notice required under the relevant award or workplace agreement. Employees who fail to give the required notice may forfeit some of their entitlements. Note: Despite changes to the law on unfair dismissal, the legislation relating to unlawful termination remains in place. This means employees cannot be terminated because of: temporary absence from work because of illness or injury, trade union membership/non-membership or participation in trade union activities, the filing of a complaint, or the participation in proceedings, against an employer, race, colour, sex, sexual preference, age, physical or mental disability, marital status, family responsibilities, pregnancy, religion, political opinion, national extraction or social origin, refusing to negotiate, sign, extend, vary or terminate an AWA, absence from work during maternity leave or other parental leave, and temporary absence from work because of the carrying out of a voluntary emergency management activity. Procedure for termination: The following will need to be considered as part of the termination of any employee: Notice period: The practice can require an employee to work out their notice or it can be paid in advance, so they leave immediately. If an employee refuses to work out their notice they may lose some of their entitlements. The required notice period and entitlements upon termination will be determined by the relevant award or workplace agreement. Termination pay: Amounts payable on termination include accrued pay in lieu of notice (if applicable), redundancy pay, annual leave, outstanding wages and long service leave entitlements. In some cases, such as summary dismissal, failure to give notice on resignation or abandonment of employment, employees may forgo some of their entitlements. Check the relevant award or workplace agreement to ensure all relevant entitlements are included in the employee’s termination pay. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 31 of 260 Insert your logo here Administrative matters: A number of administrative matters should be attended to at the time of termination: the arrangements for termination, including reason for the termination and notice. arrangements should be documented – a sample Termination form is included at the end of this section. all keys and other practice property should be returned. the components of the employee’s termination pay should be explained. it is advisable to obtain the employee’s permission for the practice to provide written or verbal references on the employee’s performance. the employee should be reminded about their continuing obligations under the practice’s privacy policy. centrelink may need to be notified if the person wishes to register for unemployment. benefits or there have been payroll garnishee arrangements in place, such as child support payments. RACGP 4th edition Standards 4.1.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 32 of 260 Insert your logo here 2.8 Staff Code of Conduct Policy We encourage an environment that fosters robust general practice teams. Our staff conducts themselves in a manner that promotes the attributes we believe are desirable characteristics of general practice team: a just, supportive, transparent, cohesive and collaborative culture, which is associated with improved patient outcomes and enhanced patient safety. defined goals, including an identifiable overall practice ‘mission’ and specific, measurable operational objectives that are shared by all team members. a ‘systems’ approach that includes the development of both clinical systems and administrative systems. division of labour, including the delegation of tasks and assignment of tasks among team members, based on the principles outlined earlier in these Standards. effective training, both for the functions that people routinely perform and cross training to substitute for other roles in cases of absences or changed/increased work demands. excellent communication, including supportive interpersonal communication through well designed communication structures and processes. Procedure It is expected that all employees will behave in a courteous manner, which portrays the image of the practice in a positive and professional way, while maintaining the levels of service and care which our patients expect. Any staff member who interacts with patients, other visitors or employees is expected to behave according to acceptable professional and social standards at all times. Clinical and non-clinical staff perform duties within their legal scope of responsibilities and maintain their knowledge, skills and attitudes through their professional specialty organisations such as the AMA, ANF or AAPM. Staff do not discuss patients outside the practice and are mindful of the sensitive nature of patient’s private medical information while at work. Staff avoid making judgemental comments about patient’s treatment by other staff or medical practitioners inside and outside work. It is expected that all employees act in accordance with specific practice policies and procedures and/or the specific details contained in the job description or employment contract. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 33 of 260 Insert your logo here The entire practice team is committed to encouraging quality improvement and identifying opportunities to make changes that will increase the quality and safety for patients. All staff have an individual responsibility to identify any potential infection risks within the practice and to be familiar with and implement the relevant infection control procedures of our practice. All staff are required to be punctual when starting and finishing work each day. The consumption of food or drink is not permitted at reception. Employees failing to meet acceptable codes of conduct will be counselled or disciplined in accordance with the Disciplinary Procedures outlined in Section 2.7 RACGP 4th edition Standards 5.3.3, 3.1.2, 4.1.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 34 of 260 Insert your logo here 2.9 Staff Presentation Policy It is expected that all staff maintain a clean, neat and tidy appearance and dress in a manner which is not likely to be offensive to the patients attending this practice. Jewellery and makeup should not be excessive. Procedure Staff are required to wear the prescribed uniform whilst on duty. In cases where a uniform is not able to be worn, staff should wear neat clothing similar to the prescribed uniform or clothing which conforms to acceptable standards of professional dress. Clothing should be ironed, clean and kept in good condition. Staff should maintain high levels of personal hygiene paying particular attention to excessive body odours and general cleanliness. All staff with long hair should have it tied back neatly. Make up and jewellery should be kept to a minimum. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 35 of 260 Insert your logo here 2.10 Equal Opportunity, Bullying & Harassment Policy Our practice is committed to the principles of merit, fairness and respect for all people. This practice seeks to provide a working environment in which all employees are able to perform their duties without being subject to discrimination or inappropriate behaviour. Our practice complies with our legal obligations and has a range of policies and procedures to encourage Equal Opportunity and prevent discrimination, bullying and harassment. These include: a policy preventing bullying and harassment of any kind, including sexual harassment, in this workplace. a procedure to deal with the personal threat of violence. (This is available in the Non medical emergency procedure manual that is recommended to download form the DCGPA web site as part of the OH&S requirements). an Anti-discrimination policy which is complemented by a Family-friendly Workplace policy. a grievance procedure for complaints arising from breaches of these policies. For serious breaches the practice’s disciplinary procedures may be used, including termination of employment. Workplace discrimination, bullying and harassment can occur: during employment procedures such as recruitment, performance review and termination of employment. in the way people are treated at work and the allocation of resources such as training, privileges and responsibilities. at work-related functions. when calling a work colleague at home. between people working in the same building, even if they have different employers in the provision of goods and services – for example it is illegal to discriminate against a patient or a supplier on the basis of an irrelevant characteristic. All staff working at this practice have the responsibility to: treat all people in this workplace fairly and with respect. refrain from behaviour which could constitute harassment, bullying or discrimination report any incidents of harassment, bullying or discrimination to the Practice Principal or Practice Manager. maintain confidentiality if they are involved in complaints. Additionally, the Practice Principal and Practice Manager are expected to: follow appropriate procedures when a complaint is reported to them, making sure they are taken seriously, properly investigated, treated confidentially and resolved in a timely manner. ensure staff are aware of their obligations and the practice’s policies and procedures relating to harassment, bullying or discrimination. promote a work environment free from harassment, bullying or discrimination. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 36 of 260 Insert your logo here Bullying and Harassment Policy There are a number of laws in Australia dealing with issues related to bullying and harassment including EEO legislation, OHS requirements, criminal law, defamation and common law provisions such as negligence. These laws all require the employer to take all reasonable steps to stop bullying and harassment in the workplace, including: 1) Policies and procedures to prevent bullying and harassment 2) Dealing with grievances in a fair, appropriate and timely manner. Bullying and harassment is defined as any unwelcome behaviour or communication which has no legitimate function in the workplace and intimidates, humiliates or offends another person. Any form of bullying or harassment is totally unacceptable in this practice. Bullying and harassment includes, but is not limited to: name-calling and insults directed at another employee. writing of notes which are personally offensive to another. practical jokes (this may also be a safety issue). unwanted physical contact of any kind. interfering with the personal property of any other employee. remarks or written comments which are personally insulting or offensive to other employees based on their race, background, gender, religion, sexual preference, appearance or any other personal attribute. unwelcome sexual advances, requests for sexual favours and other verbal or physical conduct of a sexual nature. interfering with the equipment, property or work of another employee in a way which is outside the normal course of your duties. (Also a safety issue). bullying can include isolating or excluding a person, psychological abuse, setting impossible deadlines, being overly critical and using aggressive language. Behaviour is inappropriate and may constitute harassment if it is offensive to another person, even if this was not the intention of the one initiating the behaviour. Bullying and harassment may be a once-off incident or a pattern of behaviour. (*Insert Practice Name) regards these actions and any similar behaviour as serious misconduct and any person who is found to be behaving in this manner may have their employment terminated. Any employee who is subjected to bullying, harassment or intimidation by a fellow employee, manager or supervisor should notify the Practice Principal or the Practice Manager. All complaints of harassment will be promptly and confidentially investigated using the practice’s grievance procedure. Any employee or manager who violates this policy will be subjected to disciplinary action, as described above. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 37 of 260 Insert your logo here Anti-discrimination policy This practice does not discriminate on the basis of: race (including colour, nationality and ethnic origin). family status including marital status and responsibilities as a carer. sexual orientation and lawful sexual activity. age. gender and gender identity. physical Features. political beliefs or activity. religious beliefs or activity. breastfeeding. impairment including physical, intellectual or psychiatric. pregnancy or potential pregnancy. political opinion or activity. criminal record. union membership or industrial activity. personal association with a person with any of the above characteristics. As with the practice’s harassment policy, any behaviour which is discriminatory is unacceptable in this practice. This includes racist, sexist or ageist remarks and making fun of people’s differences. Discriminatory behaviour will lead to disciplinary action and may result in termination of employment. This practice will take all reasonable steps to ensure all policies, procedures and practices comply with EEO principles. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 38 of 260 Insert your logo here Family Friendly Workplace Policy Policy This practice values its employees and aims to provide a family friendly culture that promotes life work balance with a management philosophy that fosters a sense of fun and camaraderie & promotes self care for all staff. This policy recognises that all employees have varying family responsibilities. It recognises a broad definition of family including family as defined by various legislative & industrial instruments, people in same sex relationships and other close personal relationships. We are committed to ensuring that family-friendly policies are developed, endorsed, implemented and monitored. We endeavor to work in partnership with its staff to identify work practices that support arrangements to find the best possible match between the interests of the organization and those of individual employees. These practices can include: flexi time; leave such as carers’ and parental leave. Workplaces can also be made more family friendly through the way jobs are designed, in how work is organized and having supportive and understanding staff & managers. Good communication and co-operation are essential for the achievement of a successful family friendly organisation. Key Principles The following key principles underpin this policy: this practice operates using the minimum standards as outlined in our (insert whichever applicable e.g. Workplace agreement/ enterprise bargain/contracts). provision of entitlements will be made equally available to men & women provision of entitlements will be made available to all employees in a fair manner. this practice has a social responsibility to organise work in a manner that assists employees to meet family responsibilities Procedure Family friendly practice will be considered in all policies and procedures. Points to guide the development of family friendly policies include: benefit the organisation and its employees acknowledge that the needs of both the organisation and employees are not static but change over time encourage a partnership approach to meeting the needs of both the organisation and employees highlight the need for management, employees and where applicable employee representatives to discuss workable solutions Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 39 of 260 Insert your logo here be fair and consistent be economically feasible takes into account the equality implications of any policies introduced Developments and changes to policies will be communicated to all staff at regular intervals. Grievance Procedure If you or any employee of this practice is exposed to any form of behaviour which constitutes discrimination, bullying or harassment, the following procedure must be adopted. Do not ignore harassment – ignoring the behaviour could be interpreted as consent. This procedure may also be used for handling of other workplace grievances such as complaints about working conditions, wages or work colleagues. Grievances undermine morale and affect teamwork and need to be dealt with promptly. 1) Inform the offender that the behaviour is offensive and unacceptable. 2) Seek assistance in having the behaviour stopped by reporting the incident to your Practice Principal or Practice Manager. 3) The Practice Principal or Practice Manager will conduct a detailed investigation of the incident(s) to assist in the resolution of the grievance. Witness statements and evidence may be collected. For the investigation to be properly conducted confidentiality must be maintained, it must be impartial, the person reporting the incident must not be victimised or experience adverse repercussions and the complaint must be dealt with as quickly as possible. 4) Actions taken to resolve the grievance will depend on the circumstances and the results of the investigation. Generally the main aim will be to ensure the incident does not occur again. Possible solutions may include: an apology. an undertaking that the behaviour will cease. formal counselling of the alleged harasser, using the disciplinary procedure (2.7) disciplinary action, including termination for serious misconduct. training for groups of staff or the whole staff to raise awareness of EEO obligations. covering costs associated with the harassment, such as medical or psychology expenses. notifying the police. if the complaint cannot be substantiated when it is investigated it must still be taken seriously, including attempting to find a resolution of the mater with the employees involved. it may be appropriate to take action against a complainant who makes a serious allegation against a work colleague which is found to be false or frivolous after investigation. This could include termination of employment. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 40 of 260 Insert your logo here 5) A record is kept of the complaint, its investigation and actions taken. A sample Staff Grievance Record is included at the end of this section. 6) After action has been taken and the problem appears to have been resolved there is a need for occasional monitoring and follow-up to ensure that those involved are satisfied with the outcome, and the problem has not reoccurred or surfaced in a different form. 7) If the matter remains unresolved, the grievance provisions in the relevant awards or workplace agreements require that it be referred to an external party. This party may be specified in the award or agreement. Seek advice from your division or employer group. Instructions for the Practice Principal or Practice Manager in handling of grievances: The following four steps will assist with handling grievances. 1) Listen with an open mind listen, no matter how trivial the grievance may seem to you. be patient and show a sincere interest in the employee’s grievance. do not argue. 2) Get all of the facts encourage the person to repeat the substance of the grievance to ensure the facts are understood. discuss any solution the employee may have to solve the problem. question any discrepancies. discuss with others if necessary. do not jump to conclusions. consult senior management if necessary. 3) Take action promptly do not delay taking action. do not make any rash decisions. advise all relevant employees of the action. do not use your authority to force a decision unless there is no alternative. 4) Follow up check that those involved are satisfied with the outcome. consider whether preventative action can be taken to avoid a reoccurrence. This may include training, awareness raising or changes to systems and procedures. refer to an external party if the matter remains unresolved. RACGP 4th edition Standards 4.1.1, 4.1.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 41 of 260 Insert your logo here 3 Occupational Health & Safety Policy This practice is committed to preventing workplace injury and illness and ensuring a safe and secure working environment for doctors, staff, patients and all other visitors. We recognise that health and safety is an integral part of every activity we perform and as such we maintain current knowledge of our obligations under State/Territory and Federal OH&S legislation and we understand that non compliance with these legal requirements can result in being prosecuted and fined. It is a legal duty of every workplace to maintain standards to protect the health, safety and welfare of every person within the workplace This includes staff, patients, visitors and anyone else who may enter the premises. As an employer we must provide a safe and healthy workplace for our workers and contractors. All our workers have a duty of care to ensure that they work in a manner that is not harmful to their own health and safety and the health and safety of others. The Occupational Health and Safety Act 2004 is the cornerstone of legislative and administrative measures to improve occupational health and safety in Victoria. The Act sets out the key principles, duties and rights in relation to occupational health and safety. The Occupational Health and Safety Regulations 2007 are made under the Act. They specify the ways duties imposed by the Act must be performed, or prescribe procedural or administrative matters to support the Act, such as requiring licenses for specific activities, keeping records, or notifying certain matters. Effective OHS regulation requires that WorkSafe provides clear, accessible advice and guidance about what constitutes compliance with the Act and Regulations. To find out your obligations for your state go to: http://www.business.gov.au/BusinessTopics/Occupationalhealthandsafety/pages/Employero bligationsinyourstateorterritory.aspx. For detailed examples relating to the Health and aged care sector go to: http://www.worksafe.vic.gov.au/wps/wcm/connect/wsinternet/worksafe/home/safety+and+pr evention/your+industry/health+and+aged+care+sector/d_health+and+aged+care+sector. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 42 of 260 Insert your logo here Procedure This practice has a designated elected health and safety representative (HSR). The name and telephone extension of our HSR is kept on the staff notice board. Information relating to OH&S issues are posted on the notice board/conveyed to all members of staff and updated regularly by the HSR. We consult with employees on matters that may directly affect their health, safety or welfare and the HSR, is also involved in the consultation We have current workplace Injury Insurance. We keep a Register of Injuries to keep track of work-related injuries and illnesses and for workplace incidents that cause or could have caused serious injury or death we understand that we must notify WorkSafe on 13 23 60. When an injured worker records an injury or illness in the Register of Injuries, we acknowledge this registration in writing to the worker. the Practice Manager informs new staff, in writing of the nature of their work and asks if they have any pre-existing injury that may be affected by the new job. New staff are also notified, in writing that failure to inform or hiding a pre-existing injury which might be affected by the nature of the proposed new job, could result in that injury not being eligible for future compensation claims. we ensure workers have adequate information, instruction, training and supervision to work in a safe and healthy manner. we maintain the workplace in a safe condition (such as ensuring fire exits are not blocked, emergency equipment is serviceable, and the worksite is generally tidy) and provide staff with adequate facilities (such as clean toilets and hygienic eating areas). To support the safety health and wellbeing of our practice team we have policies and procedures in the following areas: tasks involving manual handling are identified and measures are taken to reduce or eliminate the risk of injury to doctors and staff as far as reasonably practical. incidents and all injuries involving all staff and patients and others that occur in the workplace are documented and managed professionally and ethically, according to relevant medical standards and guidelines. at induction and periodically all staff are instructed in safety and infection control protocols ensuring risks are known and precautions taken, including staff immunisation. we strive to work together to maintain a safe physical work environment and that supports the health and wellbeing of Doctors, staff, patients and visitors. Including ensuring regular breaks, adequate staffing levels and a smoke free environment. we have a duty of care to safeguard the health of employees which also covers psychological as well as physical health. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 43 of 260 Insert your logo here we strive to encourage consultation between management and staff on all matters pertaining to OH&S matters as obligated under the legislation. we endeavour to provide a working environment in which all Doctors, staff, patients and visitors are not subject to unlawful discrimination, sexual harassment, violence or bullying. audits are undertaken to ascertain that all practice and office equipment is appropriate for its purpose. Records of maintenance, including electrical safety checks and calibration schedules are maintained. records of updates and training provided to all staff in relevant equipment operation and maintenance, manual handling skills, and compliance with OH&S requirements are maintained. we strive to ensure the practice environment and facilities are adequate, and provide for the comfort, safety and security of Doctors, staff, patients and visitors. we will not tolerate violence of any nature. non medical emergency procedures and fire safety precautions are clearly documented and designated members of the emergency team have a reference and a basis for their decisions and actions within that role. we have appointed one member of staff with primary responsibility for the development and consistent implementation of our infection control systems and procedures which includes environmental cleaning. (Refer Section 4 Principles of Infection control) Specific areas of responsibility may be delegated to nominated members of the practice team and these particular responsibilities should be documented in the relevant position descriptions. to minimise harm to our patients we have clear lines of accountability and responsibility for the delivery of safe and effective quality care. we have a requirement for two members of the staff to be present during the normal opening hours of the practice. Visit Work safe website for up to date information on your obligations: www.workcover.vic.gov.au. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 44 of 260 Insert your logo here Hazardous Substances we implement arrangements for the safe use, handling, storage and transport of chemicals and hazardous substances. (Refer Section 4 Handling and Use of Chemicals). regular audits of products used by the practice are undertaken and hazardous substances are stored, handled and documented according to assessed risk. material safety data sheets (MSDS) and Product Data sheets (PDS) are maintained and visibly placed on equipment and hazardous substances, to describe them and give clear instructions for their use. a Material Safety Data Sheet (MSDS), also referred to as a Safety Data Sheet (SDS), is a document that describes the chemical and physical properties of a material and provides advice on its safe storage, handling and use. It includes details of health and physicochemical hazards, exposure controls, personal protective equipment, safe handling and storage instructions, emergency procedures and disposal advice. It is a requirement under the legislation to have MSDS available. MSDS sheets can be obtained by the supplier’s website or by phoning the supplier. Free MSDS search http://www.msds.com/. Remember chemicals and hazardous materials are not only in cleaning products for example - consider toners in printers/photocopiers, liquid nitrogen, oxygen etc. the current manufacturer’s, importer’s or supplier’s copy of the MSDS is used by the practice and this information is never altered. the practice endeavours to control risk associated with the use of hazardous substances which are stored in labelled containers. a register of hazardous substances is kept and maintained by the practice. (see hint above about this). staff members are instructed on how to handle hazardous substances appropriately and documentation and ongoing training is provided regarding this. regular risk assessment is undertaken by this practice in order to control risk associated with the use of hazardous substances. RACGP 4th edition Standards 4.1.2 & 5.3.3 & 3.1.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 45 of 260 Insert your logo here 3.1 Manual Handling Policy Manual handling is any activity requiring the use of force exerted by a person to lift, push, pull, carry, or otherwise move or restrain any animate or inanimate object. It includes activities involving awkward posture and repetitive actions. Manual handling injuries account for nearly 50% of all Workcover claims. The objectives of the Occupational Health and Safety Manual Handling Regulations 1999, are to reduce the number and severity of musculoskeletal disorders associated with tasks involving manual handling. Under these regulations, this Practice aims to identify tasks involving hazardous manual handling and to undertake risk assessments. Risks to staff are thus reduced or eliminated as far as practicable. Risk factors likely to cause manual handling injuries and therefore include in Practice Risk Assessments include: force applied. actions & movements used. range of weights. how often & for how long, manual handling is done. where the load is positioned & how far it has to be moved. availability of mechanical aids. layout & condition of the work environment. work organisation. position of the body whilst working. analysis of injury statistics. age, skill & experience of workers. nature of the object handled. any other risk factor considered relevant. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 46 of 260 Insert your logo here Procedure avoid tasks that involve: o twisting, bending or extensive reaching o repeated or prolonged stooped posture o lifting requiring extended reach o repetitive lifts from below mid thigh or using forceful movements o prolonged bent neck posture when working on low flat bench o repetitive tasks for a prolonged time o using excessive force to push, pull or hold object reduce the size or weight of objects to be lifted or carried. prevent slips or falls by wearing appropriate footwear. ensure adequate lighting. clean area regularly; spills should be wiped up immediately. check equipment is in good working order and there is adequate space in which to work. weight limits: Seated – 4.5 kg. Standing – 16 to 20 kg. (For ideal conditions and with a compact load held close to the body and with a short carrying distance). Before doing any type of manual handling assess the situation ask the following questions: should two people be lifting this or am I able to lift this safely and without risk or injury? is my pathway clear of all objects? what distance am I going to be going? can I see clearly? can I split the load to make it lighter? size up the load – if in doubt seek assistance. Our practice has one or more height adjustable examination couch/s to assist in the care of patients with a disability, and to reduce the risk of staff injuring themselves when assisting patients on or off the examination couch. Where our practice facilities are inadequate for staff and visitors to safely assist patients with a disability we make alternative arrangements. e.g. Home visits. Staff Responsibility If you identify a task, piece of equipment, or work area that may be a risk, report it to the Practice Manager or the OH&S representative. A further detailed risk assessment will be conducted and if necessary, changes will be made to reduce the risk of injury with training for staff as needed. RACGP 4th edition Standards 5.1.1 & 4.1.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 47 of 260 Insert your logo here 3.1.2 Incidents and Injury and Adverse Patient Events Policy This practice has designated (*insert staff members name) with primary responsibility for clinical risk management including following up on incidents, injuries and adverse patient events and near misses. It is a legal requirement under the Occupational Health & Safety legislation and for insurance purposes, to report any injury sustained or thought to be sustained in the workplace, recognizing that good reporting also leads to effective prevention. Our practice encourages the identification, analysis and prevention of errors, failure or inadequate systems that can potentially be a risk to patient safety to assist with risk management strategies not to apportion blame. Incidents that should be reported (regardless of whether harm has occurred) to assist with making improvements to minimise the risk of recurrence, include: needle stick injury or mucous membrane exposure to blood or bodily fluids. slip or fall. drug or vaccine incident (loss, misplacement or other). adverse patient outcome. failure or inadequate patient handover or identification of a patient at the point of transfer of care. delayed treatment or delayed follow up or unnecessary repeat of tests. medication errors. any deviations from standard clinical practice. Accidents or incidents may involve the following: staff (employed directly by this practice). non-staff (patients, visitors, contractors). events (e.g. theft, non-patient assault, gas leak, bomb hoax, security breach, medication error or patient complication following medical intervention, breakdown in clinical handover). Actual and potential risks are identified and actions are taken to increase the safety and improve quality care. The privacy of individuals involved is maintained. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 48 of 260 Insert your logo here Procedure Reporting Staff use the “Adverse Outcome Report” to report any slips, lapses or near misses in clinical care or deviations in patient care that might result in harm. The medical defence organisation is contacted for events that might give rise to a claim. Completed “Adverse Outcome Reports” are: completed as soon as possible after incident occurs, preferably within 24 hours. filed in the “significant event register” folder. Any additional medical or other certificates, reports or pathology related to the accident/incident are dealt with as soon as possible original documents are submitted. For injury occurring in the practice or course of work, WorkCover reporting protocols must also be followed. It is a legal requirement to report all injuries sustained in the workplace The Doctor should refer patients to another practitioner if there is a possible conflict of interest, for example a staff WorkCover claim being managed by the employing practitioner. Risk assessment The designated staff member conducts a thorough review of all the hazards relevant to the cause(s) of any injury that has occurred with a view to identifying appropriate controls. (Refer Section 8 Risk Assessment and Management). Risk control Involves identifying and implementing all the practicable strategies to minimise subsequent similar events or eliminate/ reduce the causes(s) of the injury or incident. Informing relevant staff are about changes and why they have been implemented (usually at the staff meeting) to reduce the likelihood of recurrences. Retaining any documentation or evidence of the implementation of any improvements. Conducting subsequent review/s to ascertain whether the implementation of the improvements was successful. Documentation Retain documentation of the investigation process and any agreed actions implemented to minimise the re-occurrence of the incident and to log trends. RACGP 4th edition Standards 1.5.2 & 3.1.4 & 3.1.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 49 of 260 Insert your logo here 3.1.3 Sharps Injury Management and Other Body Fluid Exposure Policy The employer is responsible to ensure that all staff: are familiar with the practice policy regarding management of blood and body fluid exposure. consider the blood and body substances of all patients as potential sources of infection. understand how to prevent exposure to blood and body fluids. have access to education and regular in service training in infection control matters. have documented their immunisation status and have been offered NHMRC recommended immunisations appropriate to their role. analyse any incidents and modify procedures as required to reduce the risk of recurrence. In our practice, we understanding that the management of occupational exposure to blood or body fluids includes: rapid assessment of the staff member and the source patient. documentation of the incident. counselling for the staff member. timely administration of medications where appropriate. investigation of the incident to enable modification of procedures if required. Occupational exposure to needle stick injuries and body substances can be prevented by using standard precautions, wearing personal protective equipment (PPE) and implementing safe work processes. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 50 of 260 Insert your logo here Procedure Preventing blood and body fluid exposure Use standard Precautions where there is a risk or blood or body fluid exposure. Implement Safe work practices around the handling of sharps, specimens, and waste, cleaning of environment and reusable items. Assess and manage any blood and body fluid exposure immediately. Following Occupational Exposure In our practice, we follow this procedure after occupational exposure: 1. Clean/decontaminate skin: wash with soap and water mouth/nose/eyes: rinse well with water or saline. 2. Notify the practice principal or GP on duty immediately The source: explain and reassure the source and offer pre test counselling. obtain consent to have the source patient’s blood tested for Hepatitis B, Hepatitis C and HIV the results should be available in 1-2 hrs if marked “urgent – needle stick” and received at an appropriate testing laboratory. take a history from the source – maintain the source patient’s confidentiality and do not interview them in front of relatives o unprotected sexual intercourse o sharing needles, tattoos, body piercing o sharing razor blades or toothbrushes o blood or body fluid exposure of mucous membranes or non intact skin. o blood transfusion before Feb 1990 (for HCV) o infection with HIV, HBV, HCV o if the source patient has a history of at - risk activities inform them about the window period in diagnosis. if any of the staff member’s blood went into the patient or onto instruments that were then used, the staff member also needs to be listed as a source. The Exposed person if the source is unknown the person needs to be tested and post exposure prophylaxis (PEP) needs to be considered obtain consent from the exposed person for urgent baseline testing for Hepatitis B, Hepatitis C and HIV to establish if the staff member has previously acquired an infection from other exposures. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 51 of 260 Insert your logo here the exposed person’s confidentiality must be maintained especially if a staff member. the exposed person may elect to have these tests performed at a different facility or their own GP advise them to practice safe sex until their results and the source’s results and history have been reviewed give the exposed person the telephone number for the state/territory Health department communicable disease contact and other advisory services. 3. Treatment needs to be commenced if it is anticipated that the sources blood test results will not be available within 24hrs and the source patient could be HIV positive or in the window period. if the HBV status of the exposed person is not known, and the sources HBV status will not be available within 24-48 hrs then give: o Hepatitis B immunoglobulin o Hepatitis B Vaccination 1st Dose o ADT (Adult Diphtheria and Tetanus) the exposed health care worker should be referred for immediate consultation with an infectious diseases specialist for consideration of PEP for HIV : o if the injury is classified as high risk, or o if the source patient has participated in at risk activities, or o If the source patient is positive for HIV or other significant blood borne infections. o If the source patient is unknown 4. Document Exposure: We have appointed one member of staff with primary responsibility for the development and consistent implementation of our infection control systems and procedures. (Refer Section 4 Principles of Infection control). Report any exposure to this person or delegated authority in addition to normal incident reporting protocols. what procedure was being undertaken how the injury happened and the name of anyone that witnessed it the nature and extent of the injury exactly what you were injured with (specify gauge of the needle) the body substance involved how much blood or body fluid was the health professional exposed to. what personal protective equipment was being used? the full name and address of the source. If the source cannot be identified document “source patient not known”. RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 52 of 260 Insert your logo here 3.1.4 Staff Immunisation Policy We have appointed one member of staff with primary responsibility for the development and consistent implementation of our infection control systems and procedures which includes staff immunisation. (Refer Section 4 Principles of Infection control). Specific areas of responsibility may be delegated to nominated members of the practice team and these particular responsibilities should be documented in the relevant position descriptions All practice staff should be advised of the risks of infection and be encouraged to be immunised against vaccine-preventable diseases to prevent transmission of disease to and from practice staff and patients. Staff should be offered additional vaccinations where appropriate depending upon the likelihood of their contact with patients and/or blood supply substances. These vaccinations may include Hepatitis A and other disease vaccinations. The practice will keep an extensive and up-to-date record of the immunisation history of each staff member. This will assist in identifying non immune staff to ensure they are excluded from contact with patients during disease outbreaks. Subject to informed consent, the immunisation status of staff is known and recorded including the documentation of any refusal. Procedure 1. A vaccination history is sought from all new staff at orientation. 2. Staff should receive the vaccines they require within the first few weeks of employment with the exception of influenza which should be administered annually between March and May. 3. Each staff should be individually assessed for specific vaccines, taking possible contraindications into account. 4. Staff immunisation history will be recorded on the “Staff Immunisation consent/refusal and record form” located at the end of this procedure. Hint - this form is also located in Section 2 in the “Job Package”. 5. Informed consent should be obtained before screening and vaccination. 6. Staff will be given a personal immunisation record that documents vaccinations given and test results. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 53 of 260 Insert your logo here Guidelines for immunisation Staff members are offered NHMRC recommended immunisations as appropriate to their duties. The following vaccines should be considered for practice staff: Diphtheria, Tetanus If not immunised, give three doses of ADT at one monthly intervals followed by booster doses at 10 and 20 years after primary course. It is recommended to give Boostrix as the first dose to provide immunisation against Pertussis. Give a further dose at age 50 if no booster dose in past 10 years. Boostrix is also recommended although not funded, to be used when giving a booster against Tetanus as it will give the added protection of Pertussis immunity. Pertussis Single dose of dTpa given for practice staff/healthcare workers in paediatric settings especially maternity and neonatal. Poliomyelitis Offer single dose to staff that may be exposed to polio and have not received a booster vaccination within the past 10 years. (Page 255 The Australian Immunisation Handbook 9th Edition.) Measles Mumps & Rubella Staff, with no known history of Measles, Mumps or Rubella, or vaccination should receive 2 doses of MMR one month apart. Antibody testing to ensure immunity should follow a few months after. Generally, those born prior to 1966 are considered immune. Women, however, should not be vaccinated whilst pregnant or if there is a chance that they may be pregnant. Pregnancy should be avoid for 28 days after vaccination. (pg 279 The Australian Immunisation Handbook 9th Edition) Meningococcal Type C Meningococcal infections are transmitted via respiratory droplets and have the capacity to have a rapidly fatal course in previously healthy individuals. Staff members not immunised should be offered immunisation. Influenza Due to the highly transmissible nature of the influenza virus and possible serious consequences for the young and elderly, offer all practice staff an annual influenza vaccine for their own and their patient’s protection. Hepatitis B All staff should be vaccinated. This is a course of 3 injections at 0, 1 & 6 months. Female staff that are or may be pregnant should not be vaccinated. For staff who may deal with contaminated medical equipment and blood or body fluid spills, Hepatitis B vaccination is essential. All staff should have their Hepatitis B antibody status documented. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 54 of 260 Insert your logo here Chicken Pox Varicella history or serology to confirm immunity is recommended for all staff. If seronegative, vaccination should be offered in a 2 dose schedule. (pg 315. The Australian Immunisation Handbook 9th Edition) Staff Records records are initiated for all staff employed detailing their immunisation status. These will be maintained and include details of: o disease history. o vaccination. o antibody results. o test (e.g. Serology results) results. o a record of vaccines consented/refused. these records remain confidential, secure and accessible by authorised practice staff 24 hours a day, 7 days a week. records are maintained by a designated staff member and are routinely updated whenever new vaccinations, tests or disease occur. for all work related immunisations, staff should be given a verbal explanation about each disease (and its effects), from the General Practitioner. to further enhance informed consent, It is strongly recommended that staff are given a ‘Fact Sheet’ for all work related immunisations, similar to those which are available on the Immunise Australia Program website (Refer to Hints at end of this section) staff are required to sign the forms attached, providing written consent for either: o Vaccination. o Serology. o Supply of record. o Refusal of vaccination. if vaccination is given the following details must be recorded: o informed written consent. o date vaccine administered. o brand name. o batch number. o expiry date. RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 55 of 260 Insert your logo here 3.1.5 Smoking, Drugs & Alcohol Policy As a prominent health care provider our aim is to promote the health and well being of all staff, patients and others whilst they are on our premises. Smoking is therefore not permitted in this practice and is discouraged on the premises or the surrounding environs. The use of illegal drugs and alcohol is prohibited on and around the site. Staff should not present for work if under the adverse effects of alcohol or illegal drugs. Procedure Staff members who are smokers should make an effort to remove any nicotine odour on or about clothing and self prior to returning to duty. No smoking signs are visible in the waiting and reception area. Signs are not to be removed, except to replace worn or frayed items. Brochures and posters for ‘QUIT’ and related no smoking, drug free strategies are to be placed in waiting room and visibly displayed to ensure our valued patients are aware of our commitment to better health strategies. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 56 of 260 Insert your logo here 3.1.6 Staff Health and Wellbeing (including GPs) Policy This practice is committed to providing and maintaining a safe and healthy workplace for doctors, staff, patients and all other visitors. This includes psychological as well as physical health. Health and safety is an integral part of every activity we perform, and as such, the occupational health and safety of General Practitioners and practice staff is a priority of this practice, and is governed by Occupational Health & Safety State/Territory and Federal legislation and regulations. The practice has implemented strategies to ensure the occupational health and safety of the General Practitioners and staff, and in addition, there should be current information on programs that support the health and wellbeing of General Practitioners. This practice recognises that that breaks may reduce fatigue and support the health and wellbeing of both the General Practitioner and practice staff, as well as enhancing the quality of patient care. Our Doctors and practice team can discuss concerns about violence in the practice and we have to right to discontinue care. (Refer to Section 7 Refusal to treat a patient) Procedure when staff of this practice require a break or are unexpectedly absent, the practice should have strategies in place for managing work flow, that are known to all staff. Cover should be organised by the Practice Manager or another senior member of the team. regular breaks should be scheduled for all staff members, dependent upon the hours or shifts worked, and during consulting sessions for General Practitioners. The practice should schedule appropriate breaks for all staff both during and/or between the sessions undertaken by the same General Practitioner. when a work break has been organised, where possible, a relieving staff member will complete the workload of an absent staff member, in addition to their own workload. strategies should be been implemented to manage workflow whenever a General Practitioner or practice staff member is unexpectedly absent, or scheduled for leave. Unplanned leave will be covered by existing practice staff or by agency or locum staff as required. the practice should ensure that staff take regular leave and that leave is not permitted to accrue to an excessive amount. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 57 of 260 Insert your logo here the practice should have current information on programs that support the health and wellbeing of staff, including General Practitioners. occasionally staff may be confronted by physically or verbally aggressive patients or other stressful incidents or situations, including assisting with emergencies. The practice should provide emotional debriefing or counselling in these situations within a reasonable period of time after the incident. during normal practice hours at least one staff member, who is trained to take telephone calls and make appointments, assess the urgency of requests for appointments and assist with medical emergencies and CPR, must be present in addition to the GP(s). outside normal practice opening hours, for emergency surgeries, appropriate staffing is encouraged to assist in providing security and safety for patients and doctors. RACGP 4th edition Standards 4.1.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 58 of 260 Insert your logo here 3.2 Practice Facilities Policy The practice premises, including the facilities and equipment are safe and adequate to meet the needs of the staff and patients. The facilities at our practice make adequate provision for, and encourage patient auditory and visual privacy. Facilities are well maintained and visibly clean with surfaces accessible for cleaning. Every reasonable effort is made to make the environment safe and comfortable for staff and people who use the practice. Where possible the practice has heating and/or air conditioning to assist in the comfort of staff, patients and visitors. Our waiting area/s are sufficient to accommodate the usual numbers of patients who would usually be waiting at any given time. Our practice has one or more height adjustable beds. The physical conditions in our practice support patient privacy and confidentiality. RACGP 4th edition Standards.5.1.1 & 5.1.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 59 of 260 Insert your logo here 3.2.1 Consulting Rooms Policy practice facilities should be safe for General Practitioners, staff and patients. the practice has at least one dedicated consulting or examination room for every doctor working at any one time. Areas where consultations or treatment occur are appropriate for the health and safety of General Practitioners, staff and patients. the consulting rooms should have sufficient space, and are free from excessive extraneous noise and have adequate lighting for observation. the temperature in the consulting rooms should be maintained at a comfortable range to allow for the patient to undress if necessary for an examination. there must be an examination couch in each consulting room or an attached examination room (at a minimum one examination couch in the practice must be height adjustable). consultations with patients must be confidential and private. The practice ensures that both visual and auditory privacy is afforded to all patients in all examination areas, treatment rooms and consulting rooms. provision must be made in the examination areas and treatment rooms for maintaining patient privacy when undressing or receiving treatment. Where required a gown or sheet is made available to patient to the privacy during an examination or procedure. visual privacy will be afforded to patients during clinical examinations and when patients are required to undress/dress in the presence of the General Practitioner or the general practice nurse. In situations where there is a door opening to an area where the public may have access a curtain or screen is used. the practice should provide appropriate care and privacy for patients and others in distress during the consultation, examination or treatment of a patient. privacy and confidentiality of patient information should be considered at all times, including during telephone conversations between staff and patients. computer screens are not readily visible to patients and visitors and screen savers are activated. patient health information is treated with respect and letters, forms or notes concerning patients are not readily visible to other patients. examination couches should be able to be cleaned and are cleaned regularly. linen (including gowns and sheets), curtains and screens should be laundered or cleaned regularly by the practice. the consulting room should be well maintained and visibly clean with surfaces accessible for cleaning. storage areas for sterile/non sterile items should be dust proof and dry and be able to maintain their sterility and prevent exposure to blood and body substances. the security of the practice (and the staff) is an important issue and strategies should be in place in the event of a breach of security. RACGP 4th edition Standards.5.1.1& 5.1.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 60 of 260 Insert your logo here 3.2.2 Hand Washing Facilities Dedicated hand washing facilities with hot and cold water, liquid soap and single use paper towel should be readily available in every clinical management or treatment area. Ideally every consulting room should also have a basin dedicated for the purpose of washing hands. Where this is not possible, washbasins are situated within close proximity. Appropriate facilities for drying hands are provided. Hot air dryers are not used in clinical areas. Single use towels (paper or cloth) are provided in shared locations and clinical areas. Disposable paper towel is used prior to aseptic procedures. Hand disinfectants designed for use without water, such as alcohol based hand gel are available in: The Doctors Bags to use when hand washing facilities are inadequate, e.g. home visits in all treatment and examination areas to encourage hand hygiene in addition to hand washing facilities. in patient and staff areas during flu season to encourage hand hygiene. All new staff are informed about our Hand washing procedures (Refer Section 4) and we provide regular updates and training in infection prevention. RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 61 of 260 Insert your logo here 3.2.3 Waiting Area the practice waiting room area is sufficient to accommodate the usual number of patients and others who would be waiting at any one time. the health and safety of GPs, staff, patients and visitors is considered when selecting seating, furniture and toys for the waiting room, and the area is kept tidy and clean to maintain a safe environment. the practice is able to provide appropriate and respectful care for patients and others in distress. Strategies should be in place to deal with distressed patients. i.e. vomiting, upset or in severe pain. Privacy for such patients could be provided by allowing them to sit in an unused room, staff room or other designated area, rather than waiting in the general waiting area. auditory privacy within the waiting area can be enhanced by staff discretion and the use of background music or a television to mask conversations. conversations with a member of the clinical team cannot be overheard by patients in the waiting room. privacy and confidentiality of patient health information is considered when staff are discussing patients health information at the reception area. computer screens are not readily visible and screen savers are used. where appropriate our waiting area caters for the specific needs of children with play equipment or toys that can be washed regularly. the waiting room furniture and toys are in good condition, without sharp edges, and the room is maintained in a clean and tidy state with surfaces easily accessible for cleaning. a range of posters, leaflets or brochures about health issues relevant is available or on display in the waiting room for patients to self select. RACGP 4th edition Standards 5.1.1 & 5.1.2. 3.2.4 Toilets toilets should be located within the practice. Where this is not possible they need to be adjacent or within very close proximity. the toilets need to be easily accessible and well signposted. hand washing facilities, including liquid soap and single use paper towel or hand air dryers need to be readily available for use by patients and others and situated in close proximity to the toilets. there should be separate toilets for staff and patients if possible. the toilets should be well maintained and visibly clean with surfaces accessible for cleaning and if a baby change room is provided then that also must be kept adequately maintained and located close to hand washing facilities. RACGP 4th edition Standards 5.1.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 62 of 260 Insert your logo here 3.2.5 Telecommunication System Our practice’s telecommunication system facilitates patient access to the practice services and aims to adequately meet the needs of patients and staff. It is recognised that the telecommunications needs of the practice may change over time, in line with staffing changes and growth of the practice. Strategies should be in place, designed to monitor, review and make the appropriate changes to the telecommunications system as required. This may include patient and staff feedback. The auditory privacy and confidentiality needs of patients have been considered when locating our telephones and facilities for electronic communication. a telephone line must be available for staff to summon assistance in an emergency. A dedicated line is provided for this purpose. (*insert details of how to access this line). the telephone system must provide sufficient inward and outward call capacity and needs to have the capacity for electronic communication (either email or Facsimile). the practice has (*insert number) of lines dedicated for telephone calls and (*insert number) of lines for electronic communication. patient feedback is sought on a regular basis to ensure that ‘access’ to the practice facilities and services is easily available by telephone. RACGP 4th edition Standards 5.1.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 63 of 260 Insert your logo here 3.2.6 Unauthorised Access Areas General Practitioners and staff need to ensure the confidentiality and security of patient health information and other sensitive practice materials. signage is present to prevent unauthorised public access to specified areas in the practice where patient health information and other sensitive practice materials are stored. the presence of an additional person in the practice (besides the GP(s) on duty) will increase security and safety for patients, GPs & staff and reduces the risk of unauthorised access to patient health information or sensitive practice materials. the confidentiality and security of medical records, prescription pads/paper, letterhead, administrative records and other official documents must be maintained by all staff and storage in a restricted access area is recommended. patient personal health information is stored in an area or manner that is not accessible to unauthorised persons. facsimile machines, printers and other communication devices are not readily accessible to people other than the General Practitioner(s) and authorised staff. all sensible security measures are taken to prevent unauthorised access to medications and the Doctor’s bag. RACGP 4th edition Standards 5.1.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 64 of 260 Insert your logo here 3.3 Security Policy Our practice ensures as much as possible that our facilities provide appropriate security for patients, staff and visitors. All practice staff are aware of, and are able to, implement protocols to ensure the safety and security of all persons within the practice. Procedure The premises are protected by a computerised alarm system that has motion detection sensors located at various points on the site. Refer to plan in the office for further details. A ‘Panic’ button, linked to the security system, is located under the reception desk. Our security firm also patrols the site after hours. During routine practice hours at least one other practice staff member, in addition to the General Practitioner(s), is present in the practice. Another staff member, in addition to the General Practitioners can provide practical help in an emergency situation, reduce the risk of unauthorised access to patient health information, ensure the security of sensitive practice resources, and provide security and safety for patients, General Practitioners and staff. Staff rosters are checked daily and staffing is then planned for the next workday. Where possible, this same strategy is strongly encouraged to be implemented outside of normal working hours (e.g. at weekends and on public holidays or when non-routine ‘emergency surgeries’ are conducted for patients needing urgent care). Equipment on site is engraved with practice name and item number. The Practice Manager maintains the number register. Contracts and warranties for medical, office and other site equipment are securely locked, maintained and updated by the Practice Manager. Security codes are routinely changed for computers and the security system. Patients, visitors and trades people are to report to the reception desk. Where appropriate visitor’s and trades people should wear an identification name badge on site. The Reception staff and Practice Manager are informed of the presence of all visitors (except patients and relatives who report to reception only). Confidential waste is placed in a locked storage box prior to shredding or secure destruction by our security documentation storage and destruction firm. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 65 of 260 Insert your logo here All drugs of dependency and Schedule 8 medications are locked in the safe. See Section 7: Clinical Management – Drug Storage. Staff members are encouraged to be vigilant whilst on duty and act to ensure the continuing safety of all GPs, patients, visitors and other staff. Open and Lock up protocol At start of day: after unlocking premises, deactivate security alarm system, using security code check all exits for unimpeded access and unlock/open windows as required for routine practice operation turn on lights, heating/cooling system, computers, photocopier, unlock medical record filing cabinets, checking for items out of place or for any unusual objects not in correct placement turn off answering machine and retrieve messages left after hours check fax machine for any incoming messages and action as required report unusual issues or missing items to Practice Manager or Principal, documenting same At end of day: lock all windows and doors ensure computer back up is complete or scheduled after hours as required switch off designated computers, photocopier, heating/cooling system check drug cabinet & safe is locked check that bins are empty check that no-one is in toilets and windows are locked check offices for unsecured confidential documents including medical and finance records. Lock medical record filing cabinets ensure prescription pads, prescription computer generated paper, letterhead, medications, health records, and other administrative records or official documents are out of view. secure the cash box check that answering machine is on turn off all lights, keeping the security lights on Activate security system RACGP 4th edition Standards 5.1.1 & 4.1.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 66 of 260 Insert your logo here 3.4 Non Medical Emergencies Policy Non medical emergencies may occur that will require a quick, informed and effective staff response. Types of non-medical emergencies include: failure of electricity supply, telephone or water, fire or false fire alarm, property damage, break-in, abusive or threatening telephone calls or persons at the practice, leakage of toxic chemicals, bomb threats and letter bombs. We also have a contingency plan for unexpected events such as natural disasters, national or local infection outbreaks or the sudden, unexpected absence of clinical staff or computer system failures. (Refer to 8.1 Risk Assessment and Management and 6.1.1 Computer Information security) We have mechanisms in place to ensure the timely acquisition and dissemination of information (including regular updates) about alerts, emerging diseases, local disasters or emergencies. The practice has appointed a designated member of staff to have primary responsibility for our risk management systems. These may include clinical and non clinical risks and events. Specific areas of responsibility can be delegated to other nominated members of the practice team and these particular responsibilities should be documented in the relevant position descriptions. Procedure Our practice has a “Non medical Emergency Manual’ which reflects the relevant Australian Standards, as per occupational health and safety regulations e.g. Fire protocols. (*insert where to find your practices Non medical Manual) The purpose of this manual is to formalise emergency procedures, and fire safety precautions within the practice, so that those who are required to take actions related to the protection of life and property have a reference and a basis for their decisions and actions. Designated members of the Emergency team are familiar with procedures in the manual and all staff knows the correct emergency procedures and are able to carry them out in times of emergency. We also have a business continuity plan for unexpected events that may disrupt care or stretch practice resources to the limit, including disasters (e.g. bushfires, prolonged power failure) or Infectious disease outbreak (e.g. pandemic), or unexpected staff absenteeism. e.g. illness. This includes how we notify our staff and patients of such events or local disasters or emergencies. (*insert where to find your practices business continuity plan). Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 67 of 260 Insert your logo here We have a system for monitoring and obtaining information and alerts about national and local infection outbreaks, disasters, emergencies and other relevant matters. We are registered on local networks to receive alerts and we check on a daily basis for any new or updated alerts and disseminate these to all staff. (*insert your procedure for the timely receiving and dissemination of any important communication or updates. Include the name of the designated staff member who has this responsibility) RACGP 4th edition Standards 4.1.2, 3.1.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 68 of 260 Insert your logo here 4 Articl e II. Infection Control 4.1 Principles of infection control Policy Because many infectious agents are present in health care settings, patients may be infected while receiving care, health care workers and others such as receptionists and cleaners may be infected during the course of their duties or when working or interacting with patients and other people. Potential infection risks to the practice team and our patients need to be reduced. Our practice has implemented systems that minimise the risk of health care associated infections. We have appointed one member of staff with primary responsibility for the development and consistent implementation of our infection control systems and procedures. (Refer to Section 8 Clinical Governance). Specific areas of responsibility may be delegated to nominated members of the practice team and these particular responsibilities should be documented in the relevant position descriptions (e.g.. infection control processes, sterilisation process, environmental cleaning, staff immunisation, staff education). (Refer Section 2 - Position Evaluation and Recruitment). Our practice has written polices relating to key infection control processes which are reviewed and updated regularly. (Refer section 8 - Review of policies and procedures). All staff has an individual responsibility to identify any potential infection risks within the practice and to be familiar with and implement the relevant infection control procedures of our practice. (Refer Section 2 - staff code of conduct). New staff, including contracted staff and casuals, are familarised with our infection control policies that are appropriate to their duties as part of their induction to our workplace. Where appropriate their competency is assessed and this assessment recorded or evidence of previous competency is obtained and recorded. Mechanisms are in place to ensure ongoing education and competency on a regular basis and when changes occur to our procedures. (Refer to Section 8 - Continuing Staff Education). Subject to informed consent, the immunisation status of staff is known and recorded including the documentation of any refusal. Staff members are offered NHMRC recommended immunisations as appropriate to their duties. (Refer Section 3 - Staff Immunisation). Our practice remains alert to changes to guidelines for infection control, and can implement them accordingly in a timely manner. We have a system for monitoring and obtaining information about national and local infection outbreaks, as well as about emerging new risks of cross Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 69 of 260 Insert your logo here infection and we have an effective mechanism for timely receiving and dissemination of any important communication or updates about emerging diseases or infection control measures to all relevant staff. (Refer Section 8 - Risk Assessment and Management). Procedure We have a designated staff member (*insert staff member/s name) who has responsibility for co coordinating and sustaining our infection control processes. This includes: continually modifying and improving our procedures and written policies in accordance with the most recent evidence and guidelines and adopting a risk management approach when implementing infection control measures. ensuring the timely dissemination of information concerning changes to infection control procedures or information about national and local infection control outbreaks. maintaining staff knowledge, education and competency in infection control activities and ensuring the consistent implementation of our infection control policies and procedures. ensuring the practice remains visible clean and environmental cleaning processes are documented. appropriate delegation of infection control responsibilities and documentation of such delegation To ensure consistency of workplace practices our policy and procedure manual contains the following written infection control protocols: prevention of disease in the workplace by serology and immunisation. (Refer to Section 3). blood and body fluid spills management. blood and body fluid exposure & sharps injury management (Refer to Section 3) hand hygiene. a cleaning schedule for clinical and non clinical areas of the practice which describes the frequency of cleaning, products to use and person responsible. Where appropriate we have documented evidence of cleaning activity.(Refer to section 5). procedures for the all aspects of the provision of sterile instruments whether by the use of disposables, or by onsite or offsite sterilisation. safe storage and stock rotation of sterile products. procedures for waste management including the safe storage and disposal of clinical waste and general waste. the appropriate use and application of standard and transmission based precautions. access for patients and staff to PPE including evidence of education on the appropriate application, removal and disposal of PPE. triage of patients with potential communicable diseases. pathology testing done within the practice. ongoing education and training provided to each staff member and the mechanism for assessing staff competency in infection control procedures. RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 70 of 260 Insert your logo here 4.2 Blood and body fluid spills Policy Our practice has management systems for dealing with blood and body substance spills. blood and body fluids, include blood, vomit, urine, faeces, sputum and body tissue are treated a potentially infectious substances that can transmit disease should contact occur. doctors, Nurses, other health professionals, practice staff and external contractors (e.g. cleaners) consistently use standard precautions to achieve a basic level of infection control regardless of the known or perceived infection status of the patient. any spillage needs to be treated promptly to reduce the potential for contact with other patients, staff or visitors. the employer is responsible to ensure all staff are familiar with the practice’s policy and procedure for the management of blood and body fluid spills and staff receive adequate training on how to appropriately clean blood and body substance spills which is appropriate for the tasks they are expected to perform. staff are also familiar with the actions to take in the event of exposure to blood or body fluids while cleaning a spill. (Refer to Section 3 - Sharps injury Management and other Body fluid Exposure.) Our practice has a spills kit readily available consisting of a rigid walled container with a lid containing: 1 small bucket (with water level marked) and pre-measured amount of detergent * (in a labelled container) to be made up when necessary. utility rubber gloves. face and eye protection: Goggles/safety glasses/face shield/mask. disposable or reusable impermeable/plastic apron/gown. roll of paper towelling (that retains strength when wet). scrapers (2 pieces of firm cardboard or plastic). hazard/cleaning sign. biohazard bag. polymerising beads or other absorbent material. list of contents to assist restocking after use. copy of the instructions for cleaning spills. *The detergent used for general cleaning is satisfactory for treating most spills (Source: Infection control standards for office based practices, 4th Edition) Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 71 of 260 Insert your logo here Procedure As part of the induction process all staff are provided with information about our practice’s protocol for managing spills of blood and body fluids and what to do in the event of a needle stick injury or exposure to blood or body fluid (Refer section 3 Sharps Injury Management and other body fluid exposure). In our practice, the Spills Kit is located (*insert the location of the Spills Kit here). It is the responsibility of (*insert staff member here e.g. the practice nurse) to maintain the Spills Kit and to ensure all items are replaced after each use and the items are not expired. The management of spills should be flexible enough to cope with different types of spills, taking into account the following factors: the nature of the spill, for example sputum, vomit, faeces, urine or blood. the pathogens most likely to be involved in these different types of spills, for example stool. samples may contain viruses or bacteria, whereas sputum may contain Mycobacterium tuberculosis. the size of the spill, such as a spot, small or large spill. the type of surface, for example carpet or vinyl flooring. the area involved, such as whether the spill occurs in a contained area such as a consultation room or in a public area such as the waiting area. the possibility of some material remaining on a surface where cleaning is difficult (e.g. between tiles) and of bare skin contact with that surface. The affected area must be left clean and dry. Disposable items in the Spills Kit must be replaced after each use and reusable items cleaned according to protocol. Only staff with confirmed vaccination status and training are permitted to clean spills of blood or body fluid and perform other high risk activities such as instrument reprocessing. (Refer to Section 3 Staff Immunisation) Method for cleaning spills standard precautions apply. Use Personal Protective equipment. get the practice spills kit. prepare detergent and water. tear off enough paper towel. prepare rubbish bag. If the spill is on a hard surface wipe up any solid matter and excess material. clean with detergent and water using a clean piece of paper towel each time. dry the surface. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 72 of 260 Insert your logo here If the spill is on a soft fabric or carpet use polymerising beads or other absorbent material. scrape up residue. dispose of contaminated material. clean with detergent and water using a fresh piece of paper towel each time. quarantine the area until dry. consider arranging for the carpet to be ‘steam’ cleaned. a disinfectant may be used after cleaning. RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 73 of 260 Insert your logo here 4.3 Hand washing and hand hygiene Policy Effective Hand hygiene has been proven to reduce the spread of infection. This minimises the risk of cross-contamination through physical contact with patients and co-workers, and touching inanimate objects which include door handles and telephones. Gloves are not a substitute for hand cleaning. Fingernails are kept short and clean and Jewellery to a minimum as these may harbour bacteria. Cuts and abrasions are covered with water resistant dressings. Nailbrushes are not used. The employer is responsible to ensure all staff members have been educated on effective hand hygiene and hand care. Staff must wash their hands: before and after examining and treating patients before and after and between performing any procedure before and after taking blood, before and after giving an injection after handling pathology specimens after handling any equipment that might have been soiled with blood or other body substance after routine use of gloves before and after eating before and after smoking after blowing your nose after going to the toilet when visibly soiled or perceived to be soiled Easy access to hand hygiene facilities is promoted with dedicated hand washing facilities (with hot and cold water, liquid soap and single use paper towel) readily available in every clinical management or treatment area. Hand disinfectants designed for use without water, such as alcohol based hand gel can be used in the following situations: emergency situations where there may be insufficient time and/or facilities e.g. in the doctors bags. when hand washing facilities are inadequate, e.g. reception areas, home visits. in all treatment and examination areas to encourage hand hygiene in addition to hand washing facilities. In patient and staff areas during flu season to encourage hand hygiene. Visible soil must be removed with detergent based wipes first. If significant direct physical contact with a patient or patient’s blood or body fluids is likely to occur this should ideally take place in an area where access to hand washing facilities is available. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 74 of 260 Insert your logo here Hand Hygiene products need to be selected with consideration of the following factors: type of hand hygiene requires i.e. routine, aseptic (clinical), or surgical. the location of the product. compatibility of agents if multiple agents are used e.g. hand creams, ointments. care and protection of staff hands and sensitivities. There are no soap bars utilised in our practice. Where possible liquid hands wash dispensers with disposable cartridges, including a disposable dispensing nozzle, are used; where these are not available a pump pack is used. These are never topped up and are ideally discarded when empty. Should they need to be refilled, the container is washed and dried thoroughly prior. The nozzle is kept clean and free of dried soap. Appropriate facilities for drying hands are provided. Hot air dryers are not used in clinical areas. Single use towels (paper or cloth) are provided in shared locations and clinical areas. Disposable paper towel is used prior to aseptic procedures. Hand moisturiser is made available for staff use. Procedure Routine hand cleaning for soiled hands The following procedure is followed for a routine hand wash: 1. wet hands thoroughly and lather vigorously using liquid soap. 2. wash for 10-15 seconds. 3. rinse thoroughly. 4. dry with paper towel or single use cloth towel. 5. use paper towel to turn taps off if not ‘hands free’. Hand Washing for aseptic (non-surgical or clinical) procedures The following procedure is followed for a non-surgical hand wash: 1. wash hands thoroughly using neutral liquid soap or an anti-microbial cleaner (e.g. 2% Chlorohexidine). 2. wash for 1 minute. 3. rinse thoroughly. 4. dry thoroughly with paper towel or single use cloth towel. 5. use paper towel to turn taps off if not ‘hands free’. Hand washing prior to surgical (invasive) procedures The following procedure is followed for a surgical hand wash: 1. Remove Jewellery 2. Wet hands and forearms 3. Wash hands, nails and forearms thoroughly with an antimicrobial cleaner i. (e.g. 4% chlorohexidine, 0.75% detergent based povidine or 1% aqueous povidine) Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 75 of 260 Insert your logo here 4. 5. 6. 7. First wash 5 minutes and each subsequent wash 3 minutes Rinse carefully keeping hands above the elbows Do not touch taps (ask another staff member to do this if not ‘hands free’. Dry thoroughly with sterile paper or cloth towels. Location hand washing facilities Patient toilets Liquid soap Paper towel/air dryer Liquid Soap Antimicrobial cleaner (2% Chlorhexidine) Paper towel Liquid Soap Antimicrobial cleaner (4% Chlorhexidine) Paper towel Sterile towel Consulting rooms Treatment room Equipped for routine hand washing yes Equipped for aseptic hand washing no Equipped for Surgical hand washing no yes yes no yes yes yes RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 76 of 260 Insert your logo here 4.4 Handling and use of chemicals Policy Our practice does not use cleaning agents or other chemicals, which are known to be toxic to the user, such as glutaraldehyde and chlorine based products. Chemicals and cleaning agents used in our practice are used according to the manufacturer’s instructions. Cleaning solution (detergents) that is mixed with other liquids by our practice is made at the beginning of each working day and discarded at the end of each working day with the container rinsed and left upside down to dry overnight. This is to avoid the spread of micro-organisms, which may have contaminated the solution. To avoid wastage, only enough solution is made up for the day. All containers of chemical agents are appropriately labelled. This is to ensure that the contents of containers can be readily identified and used correctly. For this reason, labels must be kept fixed to the container at all times and clearly understood. Specifically, it is recommended that a container with diluted cleaning agent state: name, type and purpose of chemical agent instructions on preparing and discarding the solution warnings and/or health and safety instructions. Material Safety Data Sheets (MSDS) are made available for all substances used in our practice as required by State or Territory legislation. The use and handling of chemicals, including cleaning agents, must comply with the manufacturer’s instructions, and these can be found on the label or MSDS. It is also important that chemicals are stored in a safe area, to prevent unauthorised access. Check local, state or territory legislation for specific handling and storage requirements. Containers of chemicals are stored in a cupboard out of the reach of children. If the cupboard is below the waist, a childproof lock should be fitted. Staff members who are required to handle chemicals are trained in their correct and safe use, and this includes the correct use of personal protective equipment (PPE). All chemicals and cleaning equipment is used for the purpose intended and in accordance with the manufacturers instructions and dilution ratios are strictly adhered to. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 77 of 260 Insert your logo here Procedure Our practice has the listed chemical and cleaning products for the following uses: Product Use Storage location MSDS available Material safety data sheets are located (*Insert where your practice stores Material Safety Data Sheets). RACGP 4th edition Standards 5.3.3, 4.1.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 78 of 260 Insert your logo here 4.5 Single Use Equipment Policy Equipment and medications labelled by the manufacturer as disposable or single patient use are not reprocessed (cleaned) or re-used in this Practice. This includes, but is not limited to: Oxygen masks and tubing, nebulizer sets, spacers, razors, spatulas, auriscope tips, liquid nitrogen applicators, pins for sensory testing and medications such as eye drops and ointment, lancets for blood testing, Spirometer and peak flow mouthpieces and disposable instruments. Single use packaging is the only acceptable presentation for dressings, suture materials, suture needles, hypodermic needles, syringes and scalpels. Single use vials should be used in preference to multi dose vials of injectable substances as multi dose vials present an infection hazard if incorrectly used. If multi dose vials are used, education and ongoing compliance with prescribed protocols are required to prevent the potential transmission of infectious diseases, to minimise the potential risk of vial contamination, to minimise the potential risk of medical errors, to reduce potential wastage associated with the use of multi-dose vials, and in the case of vaccines to ensure the delivery of a potent vaccine to the patient. Items marked by the manufacturer as “single use” must never be reused under any circumstances. Some items may be reprocessed for use by the same patient if labelled “single patient use” and in this case the manufacturer’s instructions for reuse must be followed. These may include cleaning requirements and limitations to the number of times the item can be reprocessed. Single use items or equipment contaminated with blood or body fluid are clinical waste and are disposed of accordingly. Where possible saline solution and skin preps are purchased in single use sachets or containers; larger containers, if used, are dated when opened and changed regularly. RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 79 of 260 Insert your logo here 4.6 Instrument and equipment processing area Policy The RACGP Standards recommend a designated area should be used for processing all instruments and equipment for reuse to prevent possible contamination of processed items. A workflow pattern, systematically moving from dirty to clean, must be established within the designated area. All staff must understand and adhere to the designated work flow pattern. The workflow pattern must enable items to progress from the cleaning area to the steriliser packaging/unloading and sterile stock storage area without re-contamination. The equipment processing area needs to include: adequate bench space with surfaces made of a smooth, non-porus material without cracks or crevices to allow for cleaning good lighting bins for specific waste adequate storage space for materials and equipment. Specified cleaning equipment such as: 1. heavy duty utility gloves, plastic apron to protect clothing, protective eyewear and if items are grossly soiled, a mask or visor. 2. a non-corrosive, non-abrasive, free rinsing and mildly alkaline detergent in the original container or a clean, well labelled bottle. 3. cleaning brushes of a suitable size to effectively reach all parts of the item being cleaned. 4. low-linting towelling for drying the cleaned items. This area, including sinks and containers need to be cleaned daily. Procedure In our practice, our equipment processing area is located (*insert location here) and our facilities include: (Select from option 1, 2 or 3 depending on which best describes your practice equipment cleaning facilities. Delete other options and return italic text to normal) (Option 1). Dedicated double sink with adequate bench space either side for work to flow from dirty to clean area. A separate hand washing area is also available elsewhere in the room. use the sink on the dirtiest side (according to the workflow pattern) to wash the dirty instruments with the plug inserted. This is the dirty sink. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 80 of 260 Insert your logo here use the other sink to initially rinse the instruments and then for the final rinse. Do not insert the plug but rinse under running water. use the separate hand washing area for hand cleansing (Option 2). A double sink with adequate bench space either side for work to flow from dirty to clean area. This sink is also the only area available for hand washing. obtain and label a large plastic container to act as the dirty sink and place this on the dirtiest side (according to the workflow pattern) of the existing sink. Use this container to wash the dirty instruments in. use the sink directly adjacent to initially rinse the instruments and then for the final rinse. Do not insert the plug. use the second adjacent sink as a dedicated hand washing area. OR use sink can also be used for washing hands. However, it must be cleaned after washing the sink on the dirtiest side (according to the workflow pattern) to wash the dirty instruments with the plug inserted. This is the dirty sink. use the other sink to initially rinse the instruments and then for the final rinse. Do not insert the plug but rinse under running water. This is the clean sink. the clean instruments to render it suitable for hand washing. (Option 3). A single sink available to use for cleaning items, Separate hand washing facilities are available. obtain and label a large plastic container to act as the dirty sink and place this on the dirtiest side (according to the workflow pattern) of the existing sink .Use this container to wash the dirty instruments in. use the sink to initially rinse the instruments and then for the final rinse. Do not insert the plug. use the separate hand washing area for hand cleansing (Option 4). A single sink is available to use for cleaning items and washing hands. obtain and label a large plastic container to act as the dirty sink and place this on the dirtiest side (according to the workflow pattern)of the existing sink .Use this container to wash the dirty instruments in. use the sink to initially rinse the instruments and then for the final rinse. Do not insert the plug the sink can also be used for washing hands. However, it must be cleaned after washing instruments to render it suitable for hand washing. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 81 of 260 Insert your logo here Environmental Issues The area and equipment associated with instrument and equipment processing: is only cleaned or managed by appropriately trained Practice Staff. must remain in a clean and tidy manner throughout the day. is thoroughly cleaned at the end of the day. Section 2.01 If a plastic utility container is used as the Dirty sink for washing the instruments this container must be treated with due care. The container is not touched with ungloved hands and it is thoroughly washed at the end of the day as part of the practice’s routine cleaning. This container is not to be used for any purpose other than instrument pre-cleaning RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 82 of 260 Insert your logo here 4.7 Cleaning reusable Instruments and equipment Policy A basic risk assessment is required to determine the appropriate level of processing required for specific instruments. The site/manner where an instrument will be used can assist in determining the risk of infection. This analysis determines the level of processing required to minimise the probability of infection to the patient. More information to assist with this risk assessment can be obtained from RACGP Infection Control Standards for Office Based Practices, 4th Edition (page 51). Staff whose duties require them to process equipment for reuse must have received adequate training and competency assessment in this area. More information about aspects that require training and competency can be obtained from RACGP Infection Control Standards for Office Based Practices, 4th Edition (page 52). Thorough physical cleaning of items to remove blood and other debris is needed if effective disinfection or sterilisation is to be achieved. Preliminary cleaning must be done as soon as possible during or after use to prevent coagulation of blood and other proteins. Any delay will increase the bio-burden (through bacterial multiplication) and also increases the difficulty of removing adherent soil. The effectiveness of sterilisation is dependent on the bioburden being as low as possible. Procedure All staff cleaning reusable items: wear appropriate PPE. use equipment as specified. have received appropriate formal or in house training. are appropriately immunised. Our practice follows this procedure for all instruments and equipment that is going to be reused for patient care. This includes items that need to be: clean but are not required to be sterile for re-use e.g. kidney dishes, ear syringes. sterilised after use, but not used as sterile e.g. vaginal speculums. sterile for re-use e.g. surgical instruments. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 83 of 260 Insert your logo here Step 1 Wash hands with liquid soap and dry thoroughly with paper or single use towel. Step 2 Put on personal protective equipment including goggles, plastic apron and heavy duty kitchen gloves. Step 3 During or immediately after use open instruments and, dry- or damp-wipe off gross soil. Rinse the item under gently running tepid water over the clean sink. Step 4 If unable to clean instruments immediately, open instruments and soak in a container with a lid in tepid water and detergent until they can be cleaned. Clean instruments as soon as possible as prolonged soaking damages instruments. Use fresh water and detergent Step 5 Prepare dirty sink/basin by filling with sufficient tepid water and the correct amount of detergent to cover the items being washed. Step 6 Thoroughly wash each instrument in the dirty sink/basin to remove all organic matter. Open and disassemble items to be cleaned. Keeping items under the waterline to minimise splashing and droplets, scrub items with a clean, firm-bristled nylon brush. Use a thin brush to push through lumens, holes or valves. Step 7 Rinse the washed instruments in gently running hot water over the clean sink/basin. Step 8 Inspect instruments to ensure they are clean. Look at hinges, handles and working surfaces. Step 9 Place each washed instrument on a clean lint free cloth or surface and repeat the above process until all instruments have been cleaned and rinsed. Step 10 Carefully discard dirty water down the sink. If using a container, aim to pour the dirty water directly into the plughole rinsing the sink afterwards with running water. Step 11 Wash cleaning brushes/cloths with detergent and tepid water after every use. Hang to dry. Can consider sterilising these in the last load of the day. Step 12 Wash the dirty and clean sink/basin by rinsing it with tepid water and detergent. Wipe down the sink/basin with a disposable towel. Step 13 Remove kitchen gloves and replace with non sterile disposable gloves...Carefully dry each instrument with a clean, lint free cloth. Do not allow to air dry. Step 14 Remove and Clean personal protective equipment by washing or wiping Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 84 of 260 Insert your logo here down and drying. Step 15 Wash hands with liquid soap and dry thoroughly with paper or single use towel. RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 85 of 260 Insert your logo here 4.8 Provision of sterile items There are 3 options for the provision of sterile items. 1. Single use disposable items are purchased 2. Items are transported to an off site facility for sterilisation 3. Items are sterilised on site. Please select the appropriate option (and delete the others) to personalise this section according to how your practice provides sterile items. Option 1. Select if “single use disposable” instruments are used. Delete options 2 & 3 and proceed to “4.10 Storage of Sterile Equipment". Policy This practice is able to provide assurance that any items provided for procedures into normally sterile tissue, sterile cavities or the bloodstream are sterile. This practice understands that the process of sterility assurance includes all aspects of equipment procurement storage and use, and staff education. Procedure This practice purchases single use sterile disposable instruments to use where appropriate. It is the responsibility of all staff to ensure that disposable instruments are placed in the correct waste bins (yellow topped contaminated waste bins) following use. This waste must be removed from our practice in such manner to prevent patient-to-patient or patient-to-staff cross contamination. Appropriate PPE is worn when handling waste. The batch number of all instruments used is recorded to enable tracking of the instruments if necessary. The Class 1 Chemical Indicator and packaging integrity is checked prior to opening an instrument pack for use. After using an instrument, replacement stock is ordered to maintain an adequate stock of instruments for our requirements. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 86 of 260 Insert your logo here Option 2. Select if an “off site facility is used to provide sterilisation services. Delete Options 1 & 3 and proceed to “4.10 Storage of Sterile Items" procedure. Policy This practice is able to provide assurance that any items provided for procedures into normally sterile tissue, sterile cavities or the bloodstream are sterile. This practice understands that sterilisation is more than simply putting loads through a steriliser and the process of sterility assurance includes all aspects of equipment reprocessing, and staff education. Our practice has a supply of reusable instruments that are maintained in good working order and are free of rust and surface damage. The correct procedures must be followed to ensure that these instruments are cleaned and sterilised after each use. We do not have a Steriliser on our premises therefore we have arranged for the instruments to be autoclaved offsite. Our practice has contracted (*Insert name of the off site sterilisation providers) to provide this service. The following documentation is maintained: a copy of the offsite facilities current accreditation certificate (e.g. accredited general practice or ACHS accredited hospital). our procedures for safe transport of instruments and equipment to and from the offsite facility. an agreement between our practice and off site sterilisation facility stating who is responsible for, washing packaging items, transport, turnaround time, quoted prices and names of contact people for both organisations. evidence that the offsite facility correctly performs the sterilisation and validates it processes. e.g. validation documentation or certification provided annually. our practice has appropriate policies and procedures to ensure preliminary cleaning of items, packaging and transportation arrangements including evidence of staff training and competency. Procedure It is the responsibility of (*Insert staff member’s name) to co-ordinate the off site sterilisation arrangements. ensure that all instruments that require sterilisation are cleaned in accordance with the steps outlined in the Cleaning of reusable items” procedure. items are packaged and labelled prior to despatch to the facility in accordance with the “Packaging of Instruments” procedure below. place all instruments in a plastic container labelled “contaminated” with a firmly fitting lid. If items are not cleaned prior, standard precautions must be adhered to when handling this container and contents. document all instruments leaving the practice. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 87 of 260 Insert your logo here telephone to inform the offsite sterilisation service provider that a cycle of instrument sterilisation needs to be undertaken for our practice and to arrange a delivery and pick-up time use a different plastic container “labelled sterilised items” to collect the items from the sterilisation facility on return of the instruments following sterilisation, check the packages for damage thoroughly before signing off. Packaging of Items for offsite sterilisation. Policy Our practice ensures the packaging of items for sterilisation provides an effective barrier against sources of potential contamination in order to maintain sterility and to permit aseptic removal of the contents at point of use. A copy of the procedure for packaging items is located with the packaging materials so all staff can readily refer to these instructions. All staff follow this procedure when packaging instruments. The designated area for packaging items is (*Insert description in accordance with your work flow e.g. the bench on the Left side of the instrument washing area) Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 88 of 260 Insert your logo here Procedure Step 1 Visually check items have been cleaned and dried, and are in good working condition and free of rust or surface damage Step 2 If your workplace uses specific sets then group items according to your protocols. Step 3 Insert the items into the package considering the following principles Step 4 Ensure package is the appropriate size for required items. Open and unlock items with hinges or ratchets. Package in a manner that prevents damage to items or injury to end user and facilitates steam movement across the surface of items. Use tip protectors if necessary to prevent sharp instruments from perforating the packaging. Check each package has a class 1 indicator integrated on the packaging. (Steriliser indicator tape or a separate class 1 indicator must be used if absent on the packaging material.) Step 5 Select Option 1 Remove peel-off strip from pouch, and fold precisely along the marked line to seal the pouch Or Option 2: Cut packaging from roll and fold each end over twice. Apply sterilisation tape (usually has a class 1 indicator stripe) to seal over the fold extending it around the edge of the package. Step 6 Use a felt-tip, non-toxic, solvent-based marker pen to label the pack with Initials of the person packaging the item Date of sterilisation & load number (this may be added prior to loading the steriliser if not known). Contents of the package (if opaque packaging). Step 6 Inspect pack to ensure packaging material is intact. Step 7 Store item/s in a container with lid, cupboard or drawer, clearly marked as “unsterile items” until ready to load into the steriliser. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 89 of 260 Insert your logo here Option 3. Select if the practice’s own steriliser is used to provide sterile items. Delete Option 1 & 2. Policy This practice is able to provide assurance that any items provided for procedures into normally sterile tissue, sterile cavities or the bloodstream are sterile. This practice understands that sterilisation is more than simply putting loads through a steriliser and the process of sterility assurance includes all aspects of equipment reprocessing, and staff education. Our practice has a supply of reusable instruments that are maintained in good working order and are free of rust and surface damage. The correct procedures must be followed to ensure that these instruments are cleaned and sterilised after each use. Our practice uses steam at high temperature under pressure for sterilising cleaned instruments. This is the most reliable and cost effective method of sterilisation and is recommended for use in general practice. Specific instructions on the packaging and use of the autoclave must be displayed next to the machine. These instructions must include a comprehensive workflow schedule to ensure that there is no possible contamination of the clean areas where the sterile instruments are unloaded and stored. All items to be sterilised must be thoroughly cleaned first. Our practice documents each cycle in a sterilisation log. Our portable steam steriliser has a closed door drying cycle that must be used when processing wrapped articles so as to ensure that instrument packs are dry before unloading. Our practice validates our sterilisation process annually at the servicing of the steriliser. Refer to “Validation of the sterilisation process”. (*Insert name of staff member) is responsible for correct operation and training staff on how to process instruments. All staff are aware of the processing time required and the maximum load limits as determined by the validation process Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 90 of 260 Insert your logo here Holding times for steam sterilisation All times are based on the assumption that the items to be sterilised are thoroughly clean. Temperatur e @ C Pressure Holding time for steam sterilisation (this includes safety factor) KPa psi 121C 103 15 15 minutes 126C 138 20 10 minutes 134C (wrapped items) 203 30 3 minutes Penetration time if applicable (as determined by technician) Total Sterilisation Time The “holding time” does not include: the time taken for heating the load to the desired temperature any large volumes of material or heavily wrapped/packaged items included in a given load, and time taken to allow the inside of the packs to achieve the desired temperature. This is the “Penetration time” and must be added to the holding time. STERILISATION TIME = PENETRATION TIME + HOLDING TIME. Packaging of items for sterilisation Policy Our practice ensures the packaging of items for sterilisation provides an effective barrier against sources of potential contamination in order to maintain sterility and to permit aseptic removal of the contents at point of use. A copy of the procedure for packaging items is located with the packaging materials so all staff can readily refer to these instructions. All staff follow this procedure when packaging instruments. The designated area for packaging items is (*Insert description in accordance with your work flow e.g. the bench on the Left side of the steriliser). Items that are being sterilised for disinfection but do not need to be kept sterile for reuse can be processed unwrapped e.g. vaginal speculums Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 91 of 260 Insert your logo here Procedure Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 6 Step 7 Visually check items have been cleaned and dried, and are in good working condition and free of rust or surface damage If your workplace uses specific sets then group items according to your protocols. Insert the items into the package considering the following principles Ensure package is the appropriate size for required items open and unlock items with hinges or ratchets Package in a manner that prevents damage to items or injury to end user and facilitates steam movement across the surface of items use tip protectors if necessary to prevent sharp instruments from perforating the packaging Check each package has a class 1 indicator integrated on the packaging. (Steriliser indicator tape or a separate class 1 indicator must be used if absent on the packaging material.) Select Option 1. Remove peel-off strip from pouch, and fold precisely along the marked line to seal the pouch Or Option 2. Cut packaging from roll and fold each end over twice. Apply sterilisation tape (usually has a class 1 indicator stripe) to seal over the fold extending it around the edge of the package. Use a felt-tip, non-toxic, solvent-based marker pen to label the pack with initials of the person packaging the item date of sterilisation & load number (this may be added prior to loading the steriliser if not known) contents of the package (if opaque packaging). Inspect pack to ensure packaging material is intact. Store item/s in a container with lid, cupboard or drawer, clearly marked as “unsterile items” until ready to load into the steriliser. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 92 of 260 Insert your logo here 4. 8.1 Loading the steriliser Policy Correct loading of sterilisers is needed for successful sterilising to: allow efficient air removal permit total steam penetration of the load allow proper drainage of condensation and to prevent wet loads prevent damage to items in the load maximise efficient utilisation of steriliser when loading the steriliser, care needs to be taken that the steam can circulate effectively and that all surfaces are accessible and exposed to steam. never exceed the validated load (*insert location where details of the validated load can be found e.g. on the wall near the steriliser) Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 93 of 260 Insert your logo here Procedure Our practice follows this process when loading the steriliser: Step 1 Load items into the steriliser following these points: allow enough space between each item to allow air removal, steam penetration and drying to occur do not crush items together do not allow items to touch the floor, top or walls of the chamber Follow the pattern of loading described in the practice validation protocol when doing a full load. Step 2 Fill the chamber with or ensure reservoir has sufficient deionised/demineralised water as per the manufacturer’s instructions. Step 3 If the steriliser allows you to select different loads check that the appropriate load parameters are selected. Step 4 Monitor the sterilisation process by one of the following: automatic printout or computerised data logger download (records at a minimum of 60 second intervals). use of a class 4, 5 or 6 chemical indicator with every cycle. Manually record time and temperature throughout the cycle at least every 30 seconds. Step 5 Close and secure chamber door as per manufacturer’s instructions. Step 6 Press “Start” button or relevant button to commence the cycle as per manufacturer’s instructions. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 94 of 260 Insert your logo here 4.8.2 Sterilisation cycle parameters The steriliser settings used at our practice are based on the manufacturer recommendations and Instructions for use, and the results of the validation of the sterilisation process. All staff operating the steriliser are conversant with the sterilisation cycle parameters required to yield sterile items at our practice and the settings/ operation of our steriliser required to achieve this. *Insert the parameter settings used at your practice (refer to the validation documentation) and any instructions if these need to be manually set by the operator. Parameter Confirmed parameter setting for routine wrapped load 134oC Temperature Total Processing Time: (TPT=PT+H) Pressure Drying Cycle activated Article III. Staff members are able to interpret printouts or loggers and other monitoring requirements to ensure these required parameters have been met for every cycle. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 95 of 260 Insert your logo here 4.8.3 Unloading the steriliser Policy For packaged items, the period of time between their removal from a steriliser (any type) and their return to room temperature is recognised as being the most critical time with respect to assurance of sterility. Cooling generates a tiny flow of room air into the pack at flow rates demonstrated to breach porous packaging materials leading to their failure to provide a microbiological barrier. Correct cooling practice is needed to maintain sterility. When a sterile item is not cooled in the correct manner the article can have moisture build up, which can contaminate stock. The item must be reprocessed if the packaging is torn, punctured or wet. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 96 of 260 Insert your logo here Procedure Our practice follows this process when unloading the steriliser: Step 1 When cycle is complete, check printout, data logger, or Class 4, 5 or 6 chemical indicator to ensure the temperature has reached the parameters of at least 3 minutes at 134c and stayed above 134c for the specified period determined during penetration study. Note a minimum of 3 minutes at 134c is required for unwrapped goods. For wrapped, packed or pouched items, these measurements need to be confirmed by a technician, known as penetration time and time at temperature testing at validation. Step 2 Circle and sign these parameters on the printout and attach to the sterilisation log. Step 3 Open the steriliser door to its maximum to allow contents to cool. Step 4 Turn off electricity or as per manufacturer’s instructions. Step 5 Wash hands with liquid soap and dry thoroughly with paper or single use towel or put on clean, dry gloves. Use gloves specifically designed for removing hot sterilising racks from the chamber to prevent staff receiving burns. Step 6 Visually examine packages to ensure that: the load is dry the packages are intact The indicators have changed colour. Any items that are dropped on the floor, torn, wet or have broken or incomplete seals are contaminated and must be repackaged and reprocessed. Step 7 Take items from the sterilising chamber and place on a cooling rack on a clean field until cool (or allow items to cool inside the chamber once packages have been checked). Step 8 Record details in the sterilisation log. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 97 of 260 Insert your logo here 4.8.4 Documentation of the Cycle. Policy A sterilisation log is maintained which contains details of: date of cycle. steriliser Identification (only if more than 1 steriliser in the practice). load Number. contents of the load. identification of the person who prepared the load. class 1 Chemical indicator change. condition of the packs. (dry with seals and package integrity intact). evidence of the process such as a print out or class 4,5 or 6 Chemical Indicator or if a data download logger is used, sign off that it was viewed and is correct. signature of the person releasing the load. any comments or problems such as failed cycles and actions taken. Procedure the Loading section of the sterilisation log is completed and signed when the steriliser is loaded. the unloading section of the sterilisation log is completed and signed when the steriliser is unloaded. sterilisation log sheets are retained and filed according to the procedures for medical records. Failed cycle In the event of a failed cycle: document failed cycle with a brief summary of the problem in the Steriliser General Logbook. notify appropriate staff members. do not use items from the steriliser until the error is rectified. refer to the troubleshooting guide on the operating instructions. replace the packaging and re-process the instruments. if fault occurs again contact the service technician for advice and record any actions in the Steriliser Maintenance Log Sheet. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 98 of 260 Insert your logo here 4.8.5 Maintenance of the steriliser Policy It is critical that the steriliser is maintained by practice staff and service personnel, in accordance with the steriliser manufacturer’s instructions and that routine servicing by suitably qualified person occurs at least annually. The maintenance procedures must be clearly documented, performed and recorded on an ongoing basis (daily, weekly and monthly) by practice staff and service technicians. The operating instructions are located next to the steriliser. (*insert location). Procedure Changing the water Deionised or distilled water is used and the water reservoir is checked prior to use and drained and refilled weekly Cleaning the steriliser Scale build up and corrosion in the chamber is regularly cleaned using a phosphoric acid or citric acid solution or paste. Outlet drains are visually checked to ensure they are free of debris and seals are visually checked for signs of wear and tear. 4.8.6 Servicing the steriliser A maintenance contract for servicing of the steriliser is established with (*insert name of organisation) the steriliser is serviced at least 12 monthly or more frequently if required and is next due (*insert month and year). The servicing companies contact number is (*Insert number and contact person's name if known). Validation of the sterilisation process Performed at least annually or more frequently if required. Usually this is following the service. Validation is undertaken, according to the validation protocol. Documentation All maintenance and servicing is documented in the maintenance log. This includes maintenance performed by staff such as changing the water, cleaning and checking the door seal and outlet drain. Evidence of validation is documented and retained. The 3 validation cycles are recorded in the sterilisation log. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 99 of 260 Insert your logo here 4.8.7 Monitoring the Sterilisation Process Policy Monitoring is a programmed series of checks and challenges, repeated periodically, and carried out according to a documented protocol, which demonstrates that the process being studied is both reliable and repeatable. If the temperature or pressure of the steam inside the autoclave is above or below what it should be, the steam will not be able to condense and sterilisation will be unreliable. The efficiency of the sterilisation process should therefore be checked on a regular basis according to the manufacturer’s specifications or those documented in the current edition of AS/NZS 4815. Procedure Our practice follows these methods of monitoring: Test – Processed Method Class 1 chemical indicator Frequency A class 1 chemical indicator must be used for: every wrapped item (external), or every load, if unwrapped. Test – Time, temperature and pressure Method Frequency Time, temperature and pressure can be measured by using: a steriliser with a print out facility, or data logger/computer download, or manually recording of temperature and pressure throughout the cycle, or Class 4, 5 or 6 chemical indicator (time and temperature only). Every load Test – Calibration Method By a qualified service technician Frequency 6 – 12 monthly (or more frequently as per manufacturer’s instructions) Test – Validation Method See definition and process below Frequency 12 monthly and as required RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 100 of 260 Insert your logo here 4.8.8 Validation of the sterilisation processes Policy “Validation” is a documented procedure for obtaining, recording and interpreting results required to establish that the sterilisation protocols/procedures followed by our practice will consistently yield sterile instruments and equipment, as exactly the same procedure is followed for every part of each sterilisation process. “Sterilisation” is more than simply putting loads through a steriliser. Successful sterilisation to achieve and maintain sterility of equipment and instruments reliably and repeatedly is a process which begins with pre-cleaning of equipment after use, cleaning of the instruments, drying, packaging, loading the chamber, the sterilisation cycle, unloading the chamber, monitoring of each cycle, recording cycle details and monitoring in the log book, storage and traceability of the sterilised equipment, detection of abnormalities in the process and corrective appropriate action, and daily, weekly and annual steriliser maintenance. Validation covers three activities, which are: installation qualification (‘commissioning’) operational qualification (‘commissioning’) performance qualification. The validation process must be carried out by our practice on installation and annually in conjunction with a maintenance contractor. A qualified service technician must ensure that all gauges and process recording equipment fitted to the steriliser are calibrated using independent test equipment. The contractor must also document results of heat distribution studies on an empty chamber and conduct a penetration test using our practice’s challenge pack. Validation of the sterilisation processes must be completed as soon as possible after the routine annual calibration and service and immediately after any of the events listed below: commissioning a new steriliser (a service technician should install the steriliser according to manufacturer’s instructions and should then check the operation of the machine) significant changes are made to the existing steriliser, such as major repairs or recalibration, which could adversely affect the result of the sterilisation process changes to any part of the sterilisation process, such as changes to the contents, packing or packaging of the “challenge pack” or to loading details of the “challenge load”. If validation of the sterilisation process is successful then any load subsequently processed over the next twelve months can be treated as sterile. This is provided that: all the validated documented sterilisation procedures continue to be followed exactly the pack contents, packing, and packaging and chamber loading do not exceed the parameters of the validated packs/loading Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 101 of 260 Insert your logo here each cycle is monitored correctly and no changes are made to any part of the sterilisation process, which could adversely affect it. Procedure Our practice follows this procedure when conducting validation: Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Review and perform your infection control policies and procedures including: workflow issues cleaning of instruments pack contents, packing and packaging loading of the steriliser sterilisation cycle unloading the steriliser storage of sterile items maintenance of the steriliser. Check that the procedures were successful in terms of performance and reliability and sign-off each one using the validation methodology checklist. Attach the validation methodology checklist to the validation record. Select the hardest to sterilise items (challenge pack) in terms of product or pack density to create your challenge pack and record details on the validation record. At time of routine service, request the service person to: calibrate the machine conduct a heat distribution or “cold spots” study in an empty chamber (usually performed only on installation, or available from the manufacturer or otherwise determined by the sterilisation technician) obtain the penetration time using a thermocouple or data logger by choosing the hardest to sterilise items in terms of product or pack density to create your challenge pack undertake a time at temperature analysis to ensure the temperature is maintained throughout the entire sterilisation phase. provide servicing/testing documentation detailing the outcome. Where onsite technical support is not immediately available, please refer to the current edition of the AS/NZS 4815. Using the validation record template, record the following details: date of annual validation batch number and biological indicators cycle that is being used for validation temperature and time at which validation is being done attach your servicing/testing documentation to the validation record. Select the items that you will include in the load and record details on the validation record including the “challenge pack”. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 102 of 260 Insert your logo here Step 7 Step 8 Step 9 Step 10 Step 11 Step 12 Step 13 Step 14 Label the biological indicators to reflect cycle as follows: 1st Cycle label one Indicator 1M (for the 1st Indicator placed in the 1st cycle challenge pack in the middle of the pack) and the other 1C (for the non packed Indicator placed on the tray nearest the coldest part of the steriliser chamber) nd 2 Cycle label one Indicator 2M (for the 2nd Indicator placed in the 2nd cycle challenge pack in the middle of the pack) and the other 2C (for the non packed Indicator placed on the tray nearest the coldest part of the steriliser chamber) 3rd Cycle label one Indicator 3M (for the 3rd Indicator placed in the 3rd cycle challenge pack in the middle of the pack) and the other 3C (for the non packed Indicator placed on the tray nearest the coldest part of the steriliser chamber) the 7th Indicator can be labelled Z. This indicator is never sterilised and is usually placed beside the steriliser whilst the three (3) consecutive cycles are being run. This 7th indicator will prove that the batch of indicators was active. Place the biological indicators inside the challenge pack and in the coldest spot of the chamber and outside of the steriliser. Record the location in the test indicator diagram on your validation record. Load the steriliser as documented above and draw or photograph details in the loading diagram on your validation record. Perform three consecutive, identical loads and cycles including the test indicators as marked. With each load, unpack and repack the challenge pack. All items for each load must be at room temperature. Send the biological indicators for testing/incubation to the pathology company or use an in-house incubator set at correct temperature for incubation. Document the findings and investigate any failures (a pass result is 100%). Any load run subsequently and which does not exceed the parameters of the validated load can be treated as a load not requiring biological test indicators. Attach this checklist to the validation record. RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 103 of 260 Insert your logo here 4.9 Storage of sterile items Policy All sterile items, including those processed in the practice facility and those procured from commercial supplies, shall be stored and handled in a manner that maintains the sterility of the packs and prevents contamination from any source. Factors that influence shelf life are event-related (not time-related) and are dependent on storage and handling conditions. Procedure Instruments in our practice are stored: in a clean, dry and well ventilated area in an area free from draughts in an area where there is reduced chance of contamination from dust and water with dust covers should items be stored for a long period of time in a manner which allows stock rotation, e.g. place recently used items at the back and take from the front with the contents of the package clearly visible to reduce handling of instruments. Instruments and items used for procedures in other locations such as aged care facilities and home visits are transported to the facility in a separate rigid walled container with a lid labelled sterile items. Care is taken to maintain the sterility of these while transporting to the facility. Waste and sharps or disposable single use instruments are disposed of into the appropriate waste stream according to the waste protocols. Instruments and items requiring cleaning for reuse are wiped of gross soil at the time of use and placed in a separate rigid walled container with a lid labelled “dirty items”. These are cleaned as soon as possible in accordance with the cleaning of reusable items protocol. This dirty container and items within are managed using standard precautions. RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 104 of 260 Insert your logo here 4.10 Management of waste Policy Since the introduction of the RACGP Standards for General practices (3rd Edition) The National Health and Medical Research Council (NHMRC) National Guidelines for Waste Management in the Health Care Industry published in 1999 have been rescinded. The RACGP Infection Control Standards for Office Based Practices outline policies and procedures to assist our practice to safely manage waste. We are also aware of any relevant local, State or Territory and/or Federal regulations that impact on our waste management. Our waste policies include: use of Standard precautions when handling waste correct segregation of waste into three streams: “Clinical”, “Related” and “General” waste. storage of waste disposal of waste Effective and safe waste management is important for infection control and also to reduce the impact on the environment and reduce costs. All staff receives education regarding the management and handling of waste, appropriate to their role, including the safe use and disposal of sharps. These categories are defined as: clinical waste has the potential to cause sharps injury, infection or public offence and includes: discarded sharps, human tissues (but excluding hair, teeth, urine and faeces) and materials or solutions containing free flowing or expressible blood. It also includes related waste such as cytotoxic waste, pharmaceutical waste, chemical waste and radioactive waste general Waste is any waste that does not fall into the clinical or related category. And may include office waste, Kitchen waste, urine, faeces, teeth, hair, nails, sanitary napkins, tampons, disposable nappies, used tongue depressors, disposable vaginal specula, cervical cytology spatulas and plastic cytology brushes, nonhazardous pharmaceutical waste (e.g. out of date saline). NB: General waste contaminated with blood or body substances (though not to such an extent that it would be considered clinical waste, i.e. not contaminated with ‘expressible blood’) must be stored in out of reach or access to children. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 105 of 260 Insert your logo here Procedure All staff use appropriate personal protective equipment which always includes gloves as a minimum when handling waste. Clinical waste is removed by trained staff. Waste, either general or clinical is not compressed by hand. Clinical waste includes sharps disposal containers and designated biohazard bins. These are located in each area where clinical waste is generated. They are emptied at the end of each day or when full. Containers used for “non sharp” Clinical Waste in our practice: have a good sealing lid. hand free operation (e.g. wide open mouth, foot pedal or sensor operated) rigid walls should be lined with a plastic bag (preferably a yellow biohazard identified bag) have a biohazard sign affixed to the outside. are located away from the reach of children. While awaiting collection non sharp clinical waste is double bagged using a biohazard identified yellow bag and stored securely inside a locked yellow biohazard identified bin in an area that is separate from clean stores and with restricted access. Sharps are defined as anything that can penetrate the skin and some examples include: needles, scalpels, stitch cutters, glass ampoules, sharp plastic items, punch biopsy equipment, lancets, wire cytology brushes, razors, scissors and disposable surgical instruments. Containers used for disposal of “sharp” clinical waste: comply with Australian standards are placed out of reach of children cannot be knocked over are located so that the neck is clearly visible to health professionals when disposing on items have scalpel blade removers securely mounted to the walls are closed and replaced when the full indicator is reached. While awaiting collection sharps containers are never reopened and are stored with the other clinical waste for collection. Related waste cytotoxic products are disposed of into the sharps containers. pharmaceutical waste is disposed of in accordance with the state/ regulations. Refer to Drugs and Poisons Unit website for more information. Usually it is taken to the pharmacy for appropriate disposal. chemical waste such as formalin need to be disposed of according to state/territory and local government regulations and OH&S requirements. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 106 of 260 Insert your logo here This practice has a service agreement, with (*insert name of company), who are contractors specifically licensed to dispose clinical waste through special burial and high temperature incineration. The bins are collected every (*Insert frequency of clinical waste collection). (*Insert name or title, e.g. principle Doctor, nurse, practice manager) is delegated responsibility to ensure adequate stock levels of clinical waste containers are maintained and collection schedules are timely. General Waste General waste is segregated at the point of use into recyclable, non recyclable and shred only waste at the point of use according to the local regulations and being mindful of privacy. waste contaminated with blood or body fluids, that are not considered clinical waste, cannot be recycled and is placed into a bin lined with a bag which kept out of reach of children. This is disposed of into the normal garbage collection. waste containing sensitive information is shredded in accordance with privacy requirements. all other eligible recyclable waste is disposed of into the recycle bin. Contaminated general waste and clinical waste is not accessible to children. (Reference: RACGP, 4th edition Standards, p. 76) RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 107 of 260 Insert your logo here 4.11 Sharps Management Policy Our practice makes every attempt to minimise the risk of injury to both staff and patients, and prevent the possible transmission of disease by discarded sharps. Sharps represent the major cause of accidents involving potential exposure to blood-borne diseases. All sharp items contaminated with blood and body fluids are regarded as a source of potential infection. Safe handling and disposal of sharps is essential to protect the operator and staff from injury and possible transmission of disease. Sharps may be defined as any object or device that could cause a penetrative injury. Consideration is given to the purchase and use of devices that significantly reduce the risk of sharps injury. The staff member who generates or uses a sharp is responsible for the safe use and disposal of that sharp. This responsibility cannot be delegated. The employer is responsible to ensure all staff are familiar with the practice’s policy and procedure for the safe handling and disposal of sharps and staff are also familiar with the actions to take in the event of a sharps injury. (Refer to Section 3 Sharps injury Management and other Body fluid Exposure) Procedure Sharps disposal containers are placed in all areas where sharps are generated. Where possible they are located between hip and shoulder height. Sharps are placed into rigid-walled, punctureresistant yellow containers that meet the relevant Australian Standard. Containers are not in a location accessible to children either when in use or when awaiting collection. The following procedures are undertaken when disposing of sharps: the person using the sharp is legally responsible for its safe disposal. sharps must be disposed of immediately or at the end of the procedure whichever is most appropriate. sharps must be placed in a yellow puncture-resistant container bearing the black biohazard symbol (AS 4031). used sharps must not be carried about unnecessarily. injection trays must be used to transport the needle and syringe to and from the patient. needles and syringes must be disposed of as one unit. needles must not be recapped. needles must not be bent or broken prior to disposal. containers must not be overfilled as injuries can occur whilst trying to force the sharp into an overfilled container – close container securely when at the fill line. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 108 of 260 Insert your logo here the lid must be sealed once the container is full. For push-on lids, use both hands and apply pressure only to the edges of the lid. sharps disposal units must be conveniently placed in all areas where sharps are generated and should be mounted on a wall or on a bench to prevent spillage. sharps containers must not be placed on the floor or in areas where unauthorised access or injury to children can occur. sharps containers must not be placed directly over other waste or linen receptacles assistance must be obtained when taking blood or giving injections to an uncooperative patient or to a child. For removal and disposal of the sharps container, refer to the instructions detailed under ‘Waste Disposal’ above. This practice assumes an active role in reducing the opportunities for sharps injury by purchasing safe equipment whenever such an option is available without compromising the quality and safety of patient care. Examples include: self retracting single use lancets for blood glucose testing self retracting canula insertion devices and needleless. IV administration systems. vacuum blood collection tubes scalpel blade removal devices plastic ampoules Our induction process includes information about the safe disposal of sharps and actions to take in the event of a sharps injury. (Refer to Section 3 Sharps injury Management and other Body fluid Exposure) RACGP 3rd edition Standards 5.3.4. RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 109 of 260 Insert your logo here 4.12 Standard Precautions Policy Standard precautions apply to work practices that assume that all blood and body substances, including respiratory droplet contamination, are potentially infectious. The NHMRC recommends the use of personal protective equipment including heavy duty protective gloves, gowns, plastic aprons, masks, eye protection or other protective barriers when cleaning, performing procedures, dealing with spills or handling waste Standard precautions are standard operating procedures that apply to the care and treatment of all patients, regardless of their perceived or confirmed infectious status. Standard precautions also apply to the handling of blood and other body fluids. Standard precautions are work practices that are used consistently to achieve a basic level of infection control in all health care settings and all situations. Standard precautions are designed to protect both patients and staff, and comprise the following measures: hand washing use of appropriate personal protective equipment (PPE) for example gloves, plastic aprons and eyewear use of aseptic technique to reduce patient exposure to microorganisms safe management of sharps, blood and body fluid spills, linen and clinical waste appropriate immunisation of GPs, clinical and administrative staff routine environmental cleaning effective reprocessing of reusable equipment and instruments evironmental controls such as design and maintenance Procedure All staff involved in Patient care or who may have contact with blood or body fluids are required to understand and use standard precautions when they are likely to be in contact with: blood other body fluids, secretions or excretions, except sweat (e.g. urine, faeces) non intact skin mucous membranes RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 110 of 260 Insert your logo here 4.13 Transmission Based Precautions Policy Transmission based precautions are used for patients known or suspected to be infected with highly transmissible pathogens. Transmission based precautions are measures used in addition to standard precautions when extra barriers are required to prevent transmission of specific infectious diseases. Our staff are educated in how to triage and apply transmission based precautions for patients known or suspected or with a potential communicable disease. Transmission based precautions require: ‘isolation’ of the infectious source to prevent transmission of the infectious agent to susceptible people in the health care setting a means for alerting people entering an isolation area of the need to wear particular items to prevent disease transmission. There are three Transmission based precautions categories based on routes of infection transmission in a health care environment. These are: contact precautions droplet precautions airborne precautions. Procedure Transmission based precautions are used for patients known or suspected to be infected with highly transmissible pathogens (e.g. influenza). In general practice the main goal is minimising exposure to other patients and staff. This may be achieved through: the use of PPE distancing techniques (one metre between patients in the waiting room, isolating the patient in a separate room or their car) effective triage and appointment scheduling including putting these patients ahead of others hand hygiene encouraging cough etiquette and respiratory hygiene surface cleaning avoid touching your nose & mouth To help prevent the transmission of communicable diseases our patients are educated in respiratory etiquette, hand hygiene, our practice precautionary techniques (e.g. phoning reception first if they suspect they may have flu) and our distancing techniques by posters and information leaflets in the waiting room and via our recorded “on hold” message. RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 111 of 260 Insert your logo here 4.14 Personal Protective Equipment (PPE) Policy Our practice has available Personal Protective Equipment (PPE) which includes heavy duty protective gloves, gowns, plastic aprons, masks (surgical & P2), eye protection; or other protective barriers in all cases where there is potential for contact with blood or body fluids such as when cleaning, performing procedures, dealing with spills or handling waste and when dealing with infectious diseases. Procedure All staff and patients have easy access to appropriate PPE. In areas where PPE is used there are posters providing education on the appropriate application, removal and disposal of PPE PPE is also used when handling chemicals such as cleaning products or Liquid Nitrogen. Our practice ensures and documents that all staff receive education, at induction and on an ongoing basis, as to the appropriate use of various types of PPE, and where to access PPE. PPE includes: gloves (sterile, non sterile and standard rubber type). face masks including standard surgical and P2 masks. face and eye shields. gowns (long and short sleeved). plastic aprons. All staff understands and are competent in: determining the appropriate use and selecting the correct type of PPE for the presenting situation. explaining the purpose of different PPE equipment. demonstrating the correct fitting and removal of PPE and the safe disposal of these items. PPE is located (*Insert the location of Personal Protective equipment) maintenance and reordering of PPE is the responsibility of (*insert staff member name). Type of personal protective equipment and its appropriate use Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 112 of 260 Insert your logo here PPE Appropriate use Disposable gloves Disposable gloves should be used: Sterile gloves Heavy duty gloves Surgical Masks when handling blood and body substances or when contact with such is likely when handling equipment or surfaces contaminated with such substances during contact with non-intact skin during venipuncture – although needlestick injury may still occur, the presence of the glove layer could reduce the volume of any inoculum. Sterile gloves should be used: during any surgical procedure involving penetration of the skin or mucous membrane and/or other tissue when venipuncture is performed for the purpose of collecting blood for culture. Heavy duty gloves should be used: during general cleaning and disinfection during instrument processing during cleaning blood or body fluid and other substance spills. Surgical Masks can be used: during procedures or activities that might result in splashing and the generation of droplets of blood, body substances or bone fragments When there is a risk of droplet transmission of disease. To protect unimmunised staff and patients Worn by the patient to prevent the spread of disease (suspected or known) P2 or N95 Masks (Particulate filter masks) Worn by staff when there is a risk of airborne transmission of disease (suspected or known) Tuberculosis and pandemic influenza. Protective eyewear Protective eyewear should be used to prevent splashing or spraying of blood and body fluids into the wearers eyes such as during surgical procedures, venipuncture, or cleaning of spills, contaminated areas or instruments. Worn by staff when there is a risk of airborne/droplet transmission of disease (suspected or known). Gowns and plastic aprons Gowns and plastic aprons should be used when there is a risk of contamination of wearer’s clothing or skin with blood and body substances such as during surgical procedures, venipuncture, or Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 113 of 260 Insert your logo here cleaning of spills, contaminated areas or instrument processing. Worn by staff when there is a risk of airborne/droplet transmission of disease (suspected or known). Sterile gowns Sterile gowns should be used during procedures that require a sterile field. All staff use appropriate PPE when undertaking any of the following procedures: any examinations requiring contact with mucous membranes. cleaning or dressing wounds, taking down bandages. cleaning up after procedures. preparing instruments and equipment for sterilisation. assisting with or performing procedures. cleaning of contaminated surfaces. cleaning spills of blood & body fluids. using chemicals. taking blood. handling all pathology specimens before they are bagged. controlling bleeding. RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 114 of 260 Insert your logo here 4.15 Laundry Policy All staff members at our practice have received education regarding the management of soiled linen, including when to change linen, the use of appropriate precautions during handling, the washing, drying and storage of linen. Procedure Linen needs to be changed if: a patient requires the use of contact precautions, (e.g. known or suspected of having CAMRSA, scabies or lice) blood or body fluid has been spilt on the linen it is visibly soiled. before an operative procedure. When changing linen: staff use PPE and standard precautions as required care is taken to ensure sharps are not caught up in the linen Clean linen is located in a clean, dry dust free location away from dirty linen and items. (*insert location) Option 1: (select if you purchase all disposable linen for your practice) This practice uses only disposable linen on all examination couches and patient treatment areas. Linen is changed regularly and, provided it does not contain expressible blood or body fluid, it is disposed of into the normal domestic rubbish. Any linen that is contaminated with expressible blood or body fluid is disposed of immediately into the clinical infectious waste bin. (Please delete the rest of this procedure) Option 2: Select you wash launder and reuse your linen (delete Option 1) Used linen is stored in a covered, lined container which is located away from clean items in the (*insert location) before laundering. Any linen that is contaminated with blood or body fluids is collected in a plastic bag before being (*insert option), (A) placed in the used linen receptacle and rinsed in cold water with oxygenated stain removal at the earliest opportunity or (B) disposed of according to the management of waste procedure. All linen is transported in a leak proof container and a separate clean, container or basket is used to return laundered linen to the practice. Linen is washed in a washing machine on a hot or cold cycle using activated oxygen based laundry detergent and dried in the dryer. OR Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 115 of 260 Insert your logo here The laundering is contracted out to a commercial laundry service. A copy of our agreement is available. RACGP 4th edition Standards 5.3.3. 4.16 Safe handling of pathology specimens Procedure The following process is followed when handling pathology specimens: label and name containers before use to avoid the need for extensive handling after the specimen has been collected. after collection of blood and body substances these should be placed in the appropriate specimen container, as specified by the testing laboratory. wipe the container clean to remove any visible soiling and check specimen is correctly identified. securely seal to prevent any leakage during transport. place the container upright in a waterproof bag or container. take care to avoid contamination of pathology slips by keeping them separate from the clinical specimens. for transport between institutions and interstate, pack the primary specimen, surrounded by sufficient material to absorb its contents, in a sealable inner container and provide a sealable outer container of waterproof, robust material. Label in accord with postal and other transport regulations. Keep cool if necessary. RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 116 of 260 Insert your logo here 5 Practice Management 5.1 Access & Parking Policy The General Practitioners and staff recognise that access to the General Practice facilities is important to our patients. make all reasonable efforts to facilitate physical access to the premises and services offered. are committed to considering how best to meet the needs of our patients that have with physical disabilities or other special needs. Where possible wheelchair access, suitable parking and pictorial signage is provided to assist patients with a physical or intellectual disability. Where physical access is limited to the practice and its facilities or where physically attending the practice could result in an adverse outcome for the patient the practice provides off site or home visits. (Refer to Section 5 Home Visits). Car parking facilities are available within a reasonable distance from the practice for staff, visitors and patients and where possible there are designated spots for disabled drivers. External and internal lighting is sufficient to facilitate safe access for staff, visitors and patients at night. Sufficient signs are provided externally and internally to assist Staff, visitors and patients in accessing the practice facilities. Procedure Designated staff parking is provided. Please ensure other areas are kept clear for patients. This practice provides physical access to patients, visitors and staff via the main entrance. (*insert additional). Ambulance trolley access is also provided to the practice reception, toilets and consulting/treatment rooms via (*insert location). Our practice has a height adjustable examination couch located in (*insert location) to assist in the care of patients with a disability, and to reduce the risk of patients injuring themselves when getting on or off the examination couch or staff when assisting patients. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 117 of 260 Insert your logo here Doorways and walkways are to be kept free of clutter, boxes etc. to ensure a clear pathway for all persons and in an emergency Prominent signs at the front of the site: allow the public to easily locate the Practice and the parking facilities from the street. display the Practice name, address, hours open, telephone numbers (work & after hours). If external lights are not operating please notify the Practice Manager immediately. Option 1 (Please select correct option) Access for patients with disabilities. wheelchair access is provided to reception, toilets and consulting rooms. the practice has installed ramps and railings as required to assist patients with disabilities designated disabled parking is provided in close proximity to the entrance Option 2 As our practice has limited access to all facilities and services, home or other visits are available for patients with disabilities or that may be otherwise unable to access a practice service or facility. RACGP 4th edition Standards 5.1.3, 5.1.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 118 of 260 Insert your logo here 5.2 Appointments Policy Our patient scheduling system is flexible enough to accommodate patients with urgent, non-urgent, complex and planned chronic care, and preventative needs. The individual preference, of our General Practitioners or other health care providers such as our nurses, is accommodated and members of the clinical team are consulted about the length and scheduling of appointments. Patients can request to see their preferred doctor or member of the health team. The length of clinical consultations will vary according to individual patients needs. Our aim is to provide enough time for adequate communication between patients and their doctors to facilitate preventative care, effective record keeping and patient satisfaction. Patients are encouraged to ask for a longer appointment if they think it is necessary. Our practice endeavours to accommodate patients with urgent medical matters even when fully booked. Staff members are trained to have the skills and knowledge to assist patients in determining the most appropriate length and timing of consultations and to recognise and act accordingly for patients with urgent medical matters. Where possible information is provided in advance about the cost of healthcare and the potential for out of pocket expenses. We endeavour to respect patients cultural background and where possible meet their needs including providing privacy for patients and others in distress. Procedure Each doctor or other health care providers such as nurses and allied health has specific times allocated to his/her consulting sessions with documented needs for interval times, short & long consultations, diagnostic tests, procedures etc. Generally not more than 6 appointments are made for any 1 hour period and normally there will not be any appointments scheduled for less than 10 minutes. Each doctor has a designated time allocated for home visits to see patients that are unable to attend the Practice. One appointment is required for each family member requesting to be seen. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 119 of 260 Insert your logo here If a third party is to be present during an examination, whether requested by the doctor or accompanying the patient, consent from the patient will be obtained prior to the consultation. Patients are able to request their preferred doctor when making an appointment, and staff will endeavour to ensure that patients generally see the same doctor. If patients are unable to obtain an appointment with the doctor of their choice they are advised of the availability of other doctors at this time. A patient can expect to see their doctor, or an alternative as approved, within 2 working days. Our Practice Information Brochure outlines the types of consultations that may require a longer consultation and the costs. Patients can readily request a longer time when making an appointment. Our staff have the skills and knowledge to assist in determining the most appropriate length and timing of appointments. Should a longer consultation be requested or determined by information received from the patient, then our staff will endeavour to allocate the appropriate time for a longer consultation. Patients generally wait less than 30 minutes and patients are advised of any delays when a doctor is running late. Wherever possible scheduled patients are called at home to advise delay. As a priority staff members are vigilant of the need to detect and place urgent callers or walk in patients for immediate or earlier attention by a doctor. Patients are routinely asked if the matter is urgent before being put on hold. Our practice accommodates urgent patients even if we are fully booked. Should the matter be urgent please refer to Section 5 – “Medical Emergencies & Urgent Queries” Cancellations and ‘no-shows’ are monitored and marked accordingly in the Appointments Book/Diary and these patients are followed up as appropriate. Attempts to contact patients that fail to attend appointments are documented in the patient file. Appointments made for patients required to attend a recall or periodic medical review appointments are flagged and it is imperative the no shows are contacted and another appointment re-scheduled. Procedure (making an appointment) Obtain patient’s name and correctly identify the patient using 3 approved identifiers determine the urgency of the appointment and if the patient requests an urgent appointment refer. determine the length of the appointment required. Does the patient have complex medical or communication needs or multiple health matters they want to discuss? Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 120 of 260 Insert your logo here advise of any potential for additional or out of pocket costs associated with longer, urgent or missed consultations. patient new? Inform of Practice location, parking, costs & payment methods. Obtain contact phone number, address and other demographics. Ask to bring list of current medications and child health record (blue book) if applicable. is doctor requested available at time requested? Give nearest available time; is this to be a long consult? if doctor not available, ask if another doctor would be suitable or another time slot or date? give suggested time and alternatives if needed. write patient surname, given name in agreed timeslot for chosen doctor. reconfirm patient name, time and doctor. Note: appointments made for a periodic review (e.g. blood pressure check) or medical recall (e.g. abnormal pathology result) are denoted as such so follow up procedures can be instigated if the patient does not attend. Cancellations & Missed appointments Option 1 – Manual appointment book Patients that miss appointments are phoned to remind them, if the patient cannot attend the same day, cross through patients name, write your initials and record the patient as a cancellation or no show. Option 2 – Computerised appointment book Patients that miss appointments are phoned to remind them. If the patient cannot attend the same day use computer program instructions to delete appointments to track cancellations for medico legal purposes. Patients that fail to attend a recall or periodic medical review appointment For significant appointments a follow up letter is sent if the patient could not be contacted by the phone call. If the appointment is flagged as ‘recall’ it is imperative every attempt is made to contact these patients and such attempts are documented in the medical record and also in the recall book if applicable. persist in telephoning the patient over a few days at different times and, should the patient not respond then send a letter asking that the patient ring the Practice. If no response from the patient to the first letter, then send it again using registered mail. Patients in distress We respectfully manage patients and others in distress by providing privacy. (*Insert your procedure for managing patients and others in distress). RACGP 4th edition Standards 1.1.1, 1.2.4, 3.1.4, 1.4.2, 2.1.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 121 of 260 Insert your logo here 5.3 Home Visits Policy Doctors and other practice staff make visits to regular patients of our practice where it is safe and reasonable. These visits may be to patients in their homes, residential aged care facility, residential care facility, or hospital both within and outside normal opening hours where such visits are deemed safe, and where the patients are acutely ill, immobile and elderly or have no means of transport to the practice. All patients are made aware that home visits or a suitable care alternative, are available both within and outside normal opening hours. Regular patients who meet the eligibility criteria are offered home visits. For regular patients whose circumstances are deemed not safe and reasonable, e.g. the patient is located too far away for a home or other visit, the practice ensures that there is an alternate system of care that these patients can access. There are arrangements to exchange clinical details about patient care for doctors who perform home and other visits on behalf of the patient’s regular doctor and the care provided is documented in the patient’s medical records. Home and other visits are provided by appropriately qualified health professionals who have received information and advice about safety and security when conducting home visits. Any anticipated costs associated with home visits or alternative care systems are discussed with the patient. Procedure A patient can arrange for a home visit or the doctor may request home visits if the criteria below are met. regular patients of this practice live within a (*Insert km radius of the practice). where it is safe and reasonable has provided a phone number that you have called them back on patient has the type of problem that necessitates a home visit such as: acutely ill immobile elderly have no means of transport unable to access the practice facilities due to disability (*Insert your practice requirements here) Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 122 of 260 Insert your logo here refer to triage protocols and list of urgent conditions when determining if a caller needs a visit urgently. When in doubt (to make a home visit booking) ask to put caller on hold and refer to patient’s doctor for advice. Refer to Section 5 – “Medical Emergencies & Urgent Queries Our doctors home visit schedules, are recorded in the appointment record at reception. Appointments for home visits can be made by either the patient or doctor. A doctor may ask reception staff to note daily, weekly, fortnightly visits. Any requests for home visits outside these scheduled times are referred to the doctor. If another doctor or agent is conducting the visit ensure make arrangements to ensure they are able to obtain and access to the patient health record for the timely exchange of clinical information. All visits provided within or outside normal opening hours are documented in the patient’s medical records. If information is held about the patient in different records (electronic & paper based or at a residential aged care facility) there must be a record made for every consultation in each system indicating where the clinical notes for the consultation are recorded to ensure patient health information is available when required. All staff undertaking home visits are given information and advice about protecting their safety. There may be occasions where it is unsafe or unreasonable to provide a patient requesting care at home with a home visit. There may also be regular patients who can no longer attend the practice due to disability. This may apply after hours or within opening hours. Our practice advises the following options (*insert the alternate system of care that these patients can access in your area.e.g. name, telephone number and location of the nearest emergency department of the local hospital and ambulance) This advice is documented in the patient records, along with evidence of the subsequent care provided. RACGP 4th edition Standards 1.1.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 123 of 260 Insert your logo here 5.4 Telephone Policy An incoming telephone call is the principle method for initial and subsequent communication by a patient and most other persons to this Practice. As such the telephone is recognised as a vital vehicle for creating a positive first impression, displaying a caring, confident attitude and acting as a reassuring resource for our patients and all others. Our aim is to facilitate optimal communication opportunities with our patients. General Practitioners and staff members are aware of alternative modes of communication used by patients with a disability or a language barrier. Some patients may be anxious, in pain or distracted by their own or a family member’s or friends medical condition and our staff act to provide a professional and empathetic service whilst attempting to obtain adequate information from the patient or caller. Staff should not argue with, interrupt or patronise callers. Courtesy should be shown to all callers and allow them to be heard. Every call should be considered important. Staff members are mindful of confidentiality and respect the patient’s right to privacy. Patient names are not openly stated over the telephone within earshot of other patients or visitors. This Practice prides itself on the high calibre of customer service we provide, especially in the area of patient security, confidentiality, and right to privacy, dignity and respect. It is important for patients telephoning our practice to have the urgency of their needs determined promptly. Staff should try to obtain adequate information from the patient to assess whether the call is an emergency before placing the call on hold. Staff members have been trained initially, and on an ongoing basis, to recognise urgent medical matters and the procedures for obtaining urgent medical attention. Reception staff members have been informed of when to put telephone calls through to the nursing and medical staff for clarification. Patients of our practice are able to access a doctor by telephone (*insert other if applicable e.g. electronic) to discuss their clinical care. When telephone (or electronic) communication is received, it is important to determine the urgency and nature of the information. Staff members are aware of each doctor’s policy on accepting or returning calls. In non urgent situations patient calls need not interrupt consultations with other patients but it is necessary to ensure the information is given to the person in a timely manner. Patient messages taken for subsequent follow-up by a doctor or other staff member are documented for their attention and action, or in their absence to the designated person who is responsible for that absent team members workload. Staff inserts the details of all calls and telephone conversations assessed to be significant in a telephone call log. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 124 of 260 Insert your logo here The doctor needs to determine if advice can be given on the phone or if a face to face consultation is necessary, being mindful of clinical safety and patient confidentiality. Patients are advised if a fee will be incurred for phone advice. Non medical Staff does not give treatment or advice over the telephone. Results of tests are not given out, unless cleared with the Doctor. Staff do not give out details of patients who have consultations here nor any other identifying or accounts information, except as deemed necessary by government legislation or for health insurance funds. Staff should be familiar with each doctor's policy of returning or accepting calls. Our doctors preferences are available (*Insert location e.g. reception desk). Personal calls should be kept brief, mindful of engaging telephone lines. A comprehensive phone answering message is maintained and activated to advise patients of how to access medical care outside normal opening hours. This includes advising patients to call 000 if it is an emergency. Staff are aware of alternative modes of communication that may be used by patients with a disability or special needs. Important or clinically significant communications with or about patients are noted in the patients health record. We have provisions for Doctors to be contacted after hours for life threatening or urgent matters or results. All electronic communication or telephone messages are returned confirming receipt of the message and if possible any actions taken to convey or respond to the message. Incoming Call pick up receiver within 3 rings and state, (*Insert Practice Name), this is (*say your name), How can I help you? if caller has not identified themselves – ask their name. if call is for an appointment then refer to Section 5. “Appointments” procedure if the call is assessed as an emergency or urgent query staff should refer to the steps outlined in Section 5- “Medical Emergencies and urgent queries” if the caller is inquiring about pathology or imaging results do not disclose any results and refer to the Section 7 “Review and Management of Pathology Results” if the caller requests to speak with a specific Doctor refer to the Doctors policy on receiving and returning phone calls. (*insert the practice policy for doctors receiving and returning phone calls and also outline this in the practice information sheet or on individual doctors business cards) if taking a message or when assessing what the caller wants, do not hurry the caller, nor speak with an urgent, loud voice. If necessary repeat your questions or message clearly. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 125 of 260 Insert your logo here (*Insert your practice policy for ensuring that telephone and electronic messages from patients and others are given to the person for whom they are intended on the day of receipt or in that persons absence, to the person who is caring for that absent team members patients. e.g. place a note on the patient’s medical record, or in doctor’s in tray or send an email or after hours numbers for Doctors). never attempt to diagnose or recommend treatment over the phone. when relaying a message from the doctor, stress his/her involvement in that patient's care, even though he/she isn’t speaking directly to the patient. encourage the caller to write down any instructions and advice given. have the caller repeat any instructions given back to you to assess their understanding of what you have said. ensure you obtain the callers consent prior to placing them on hold in case the call is an emergency. Documentation of telephone calls A log book or computer entry is used to record all significant and important telephone conversations or electronic communications including after hours contacts and medical emergencies and urgent queries. All the information can later be written into the patient's chart if required. The log records: the name and contact phone number of the patient/caller. the date and time of the call. the urgent or non urgent nature of the call. important facts concerning the patient’s condition. the advice or information received from the doctor. details of any follow up appointments. Call on Hold it is important to try to obtain adequate information from the patient to assess whether the call is an emergency before placing the call on hold. if another incoming call registers and no other staff members are available to take it, ask to put caller on hold or seek to terminate the call and ring caller back after first taking their number. do not leave the caller on hold for long periods. Return to reassure caller that we haven’t forgotten them and thank them for waiting. whilst on hold ensure music or Practice information tapes are working and can be clearly heard. where possible our practice “on hold” message provides advice to call 000 in case of an emergency. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 126 of 260 Insert your logo here Alternative modes of communication Alternative modes of communication may be used, including; electronic (email or SMS) national Relay Service (NRS) for hearing impaired translation and Interpreter Service (TIS) for non English speaking background Ensure their use is conducted with appropriate regard for the privacy and confidentiality of health information and that patients are made aware of any risks these modes may pose to the privacy and confidentiality of their health information or any additional out of pocket costs e.g. the requirement for a longer appointment. After Hours at the end of the day/session if a weekend, turn on the answer machine to take calls and switch telephone service to night service. telephone messages on the machine are to be updated as needed for changes to consultation hours and locum service numbers. test the message to ensure it is clear and easily understood. RACGP 4th edition Standards 1.1.1, 1.1.2, 1.1.4, 1.2.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 127 of 260 Insert your logo here 5.4.1 Communication with patients via electronic means Policy Staff are mindful that even if patients have provided electronic contact details they may not be proficient in communicating via electronic means and patient choice should be obtained before using electronic communication. Patients are able to obtain advice or information related to their care or appointment reminders by electronic means, where the doctor determines that a face-to-face consultation is unnecessary. Electronic communication includes: email, fax, and SMS. Practice staff and doctors determine how they communicate electronically with patients, both receiving and sending messages. All significant electronic contact with patients is recorded in the patient health records. Patients are informed of any costs incurred prior to electronic consultations. Practice staff and doctors should be aware of alternative modes of communication used by the disabled. Patients are advised in the Practice Information sheet that they can request our written policy on receiving and returning electronic communication. Communication with patients via electronic means (e.g. email and Fax) is conducted with appropriate regard to the privacy Laws relating to health information and confidentiality of the patients health information. (Refer section 6) Staff and Patients using email/SMS or other forms of electronic messaging should be aware that it is not possible to guarantee that electronic communications will be private. All personal health information or sensitive information sent by email must be securely encrypted. (Refer to section 6). When an email message is sent or received in the course of a person's duties, that message is a business communication and therefore constitutes an official record. Internal or external parties, including patients may send electronic messages. Messages from patients or those of clinical significance require a response to confirm receipt and should be documented in the patient medial record if appropriate. Employees should be aware that electronic communications could, depending on the technology, be forwarded, intercepted, printed and stored by others. Electronic mail is the equivalent of a post card. Staff members have full accountability for emails sent in their name or held in their mailbox, and are expected to utilise this communication tool in an acceptable manner. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 128 of 260 Insert your logo here This includes (but is not limited to): limiting the exchange of personal emails refraining from responding to unsolicited or unwanted emails deleting hoaxes or chain emails email attachments from unknown senders should not be opened virus checking all email attachments maintaining appropriate language within e-communications ensuring any personal opinions are clearly indicated as such confidential information (e.g. patient information) must be encrypted. The Practice reserves the right to check individual email as a precaution to fraud, viruses, workplace harassment or breaches of confidence by employees. Inappropriate use of the Email facility will be fully investigated and may be grounds for dismissal. The practice uses an email disclaimer notice on outgoing emails that are affiliated with the practice. (*Insert message here). Accessing the Internet The Internet is a vast computer network, comprised of individual networks and computers all around the world that communicate with each other to allow information sharing between users. It is important to adopt secure practices when accessing and using the Internet. The Internet can be accessed by all members of staff; however, excessive use of the Internet is not acceptable. Staff members are encouraged to use the Internet for research activities pertaining to their role, however, should be aware that usage statistics are recorded and submitted to Management as required. Staff members have full accountability for Internet sites accessed on their workstations, and are expected to utilise this tool in an acceptable manner. This includes (but is not limited to): limiting personal use of the Internet accessing ONLY reputable sites and subject matter verifying any information taken off the Internet for business purposes prior to use not downloading any unnecessary or suspect information being aware of any potential security risks - i.e. access / viruses not disclosing any confidential information via the Internet without prior permission from the practice manager - i.e. Credit Card number maintaining the Practices confidentiality and business ethics in any dealings across the Internet Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 129 of 260 Insert your logo here observing copyright restrictions relating to material accessed/downloaded. The Practice reserves the right to check individuals Internet history as a precaution to fraud, viruses, workplace harassment or breaches of confidence by employees. Inappropriate use of the Internet facility will be fully investigated and may be grounds for dismissal. The Practice Website In complying with the Privacy Amendment (Private Sector) Act 2000, our practice provides the following advice to users of our website about the collection, use and disclosure of personal information. The aim of this advice is to inform users of this site about: What personal information is being collected Who is collecting personal information How personal information is being used Access to personal information collected on this site Security of personal information collected on this site. The practice privacy policy is posted on the website and available for download. The website is continually monitored to ensure it is kept current and up to date. It contains the minimum information required on the practice information sheet. Refer Section 5 Practice information sheet. Any changes to the practice information sheet are also reflected on the website. If it contains any advertising the practice should include a disclaimer that the practice does not endorse any advertised services or products. Advertising must comply with the MBA Code of Conduct on advertising available at: http://goodmedicalpractice.org.au/. RACGP 4th edition Standards 1.1.2 & 1.2.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 130 of 260 Insert your logo here 5.5 Visitors Policy Patients and other visitors are welcome to the Practice. Doctors and staff value the principles of good relations whether it is in person, via written or electronic form, or on the telephone. Persons including all types of visitors e.g. patients, relatives, friends, health care providers, students, pharmaceutical and other business service representatives, food service suppliers and tradesmen are shown friendly, courteous recognition and assistance. Procedure When a person presents at reception or lingers in the main entrance or other areas of the Practice and remain unidentified, ask if you may help and elicit the reason for their presence on the site. Ask the person to wait in the waiting room. If the visitor looks suspicious, call a Doctor or other staff member to assist. If the person is booked to see a Doctor or staff member, check with them and their appointment diary to ensure the visitor can be seen at that time. If the visitor is an unsolicited representative with no appointment pre arranged, then check the policy for each Doctor/staff member and request the visitor to come back at another pre booked time. Visitors who will require moving throughout the building are to sign the Visitors Book and enter times of arrival and departure. A visitors badge is supplied whilst on the premises. The Practice Manager is to be advised when these visitors are in the Practice. RACGP 3rd edition Standards 4.1.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 131 of 260 Insert your logo here 5.6 Medical Emergencies & Urgent Queries Policy This Practice classifies patients seeking medical consultations, according to priority of need. Our triage system ensures that clinical care is provided to patients with urgent medical problems as a priority. Patients telephoning the practice have the urgency of their needs determined promptly. Where possible our phone messages include a recommendation to call 000 if the matter is an emergency. Staff members know and use the triage process, a copy of which is accessible at reception. Administrative staff and members of the clinical team have the skills and knowledge to assess the urgency of the need for care and can describe our procedures for dealing with urgent medical matters including when the practice is fully booked. Our induction process includes an orientation to our triage system and staff members are given training to its effective use and are encouraged to regularly update CPR and other first aid skills. Our practice has a pandemic plan which outlines our response to and management of patients with possible infectious diseases such as influenza. The doctors and staff provide appropriate care and privacy for patients and others in distress. We have provisions for Doctors to be contacted after hours for life threatening or urgent matters or results. Procedure Staff members receive regular training and update’s in CPR which is appropriate for their duties at least every 3 years. All Staff members receive information at induction and on an ongoing basis about our triage guidelines and protocols for medical emergencies and possible communicable diseases e.g. Pandemic Influenza. Documentation of training is retained in the individual staff training record. In accordance with these guidelines reception staff try to obtain adequate information from the patient to assess the nature and urgency of their problem. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 132 of 260 Insert your logo here This occurs: when making an appointment (for phone calls or walk ins) before placing the call on hold while observing the patient in the waiting room Patients are informed that they will be asked about the nature of urgent problems to assist with prioritising the scheduling of their appointment. Should the matter be urgent patients are advised of any potential for out of pocket costs e.g. use of equipment or longer consultation. A log book or computer entry is used to record all significant telephone conversations or actions including medical emergencies and urgent queries. The log records: the name and contact phone number of the patient/caller the date and time of the call the urgent or non urgent nature of the call important facts concerning the patient’s condition the advice or information received from the doctor details of any follow up appointments RACGP 4th edition Standards 1.1.1, 1.2.4, 1.1.4. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 133 of 260 Insert your logo here 5.7 After Hours Service Policy This practice ensures reasonable arrangements for medical care, including the follow up of seriously abnormal and life threatening pathology results for our patients are in place outside our normal opening hours. The arrangements for medical care outside normal opening hours, how to access this care and the possibility of out of pocket costs, is communicated clearly to patients of this practice. Feedback about the quality and timeliness of after hours care provided to our patients by a deputising service is obtained. Patient satisfaction with our after hours service is regularly evaluated and improvements implemented if necessary. When the practice doctors are unable to deliver care outside normal opening hours, timely, safe and reliable care is provided that is in line with after hours care provided by other practices in our local area. The practice coverage is provided by Doctors of a similar speciality and if a Locum service is used, it is well known to the practice and an accredited service. The practice has a formal written arrangement with this provider of after hour’s care that outlines how it receives information about any care provided to their patients, and how the GP providing the care can contact the practice for clarification or help regarding background information relating to that patient, especially in an emergency. Our patient health records contain reports or notes pertaining to consultations occurring outside the normal opening hours for care provided on behalf or by our practice. Our practice has provisions enabling designated providers of after hours care or pathology providers to contact a patients Doctor, or in that persons absence, the person who is caring for that absent team members patients. Procedure Our normal opening hours are (*insert your opening hours here). Advice to our patients on how to access after hours care, including the potential for out of pocket expenses is available: on the telephone (*insert appropriate option; answering machine, call diversion system or paging system) message in the practice information brochure on a sign visible from outside the practice practice website Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 134 of 260 Insert your logo here Outside of normal hours the practice has a comprehensive message on the answering machine, call diversion or paging system via our main telephone number. This message includes recommending patients call 000 if the matter is an emergency. This is maintained for all incoming calls when this Practice is closed. The Patient feedback tool contains questions concerning adequate information being given to patients about after hour’s services. The results of patient feedback are evaluated and improvements implemented if indicated. When the practice Doctors cannot deliver care outside normal opening hours formal written arrangements exist with: (*select option/s) an accredited medical deputising service arrangements through a cooperative of one or more local practices an appropriately accredited local hospital or after hours facility. Sometimes our doctors may need to be contacted outside normal working hours by the after hours care provider or the pathology service about a serious or life threatening matter or pathology result. These organisations include: (* insert list applicable for your practice). We have provided the above organisations with a list of the after hours contact numbers of our doctors, and in the event they cannot be contacted an alternative person to contact in their absence. We have clearly explained that these numbers are for “exceptional circumstances” and are not the “on call” contact for the practice should they need to use them. This list is reviewed and updated on a regular basis to ensure the numbers and contacts remain current. A date of last update is inserted in the footer to designate the most recent version. Any correspondence or notification received about after hours care provided to a patient is documented in their medical record. Details of our written policy for after hour’s care arrangements are attached to ensure the information is easily accessible to staff if required. (*Insert a summary of how you provide after hours service and include any copies of after hours agreements with external providers or detail your specific arrangements.) Include the following: adequate information to ensure the provider is familiar with the practices requirements especially in regard to receiving urgent and life threatening results for a patient or managing an emergency or complex problem a defined means of access for the after hours service provider to the patient’s medical records and in “exceptional circumstances” to the patients GP (or designated GP in their absence). reference to the timely reporting of the care provided or handover of the patient back to the patients nominated practice evidence that the care will be provided by appropriately qualified health professionals evidence of the accreditation status of the after hours service provider. RACGP 4th edition Standards 1.1.1& 1.1.4 & 1.2.4 & 1.5.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 135 of 260 Insert your logo here 5.8 Practice Meetings Policy Regular discussions where all staff are encouraged to have input are important in building a high performing team. We aim to cultivate a just, open and supportive culture where individual accountability and integrity is preserved, but there is a whole-of- team approach to the quality of patient care. Practice meetings are conducted on a regular basis or more frequently as required to facilitate the exchange of practice news, other general administration and protocol issues, complaints and to discuss risk management issues arising out of the practice. Matters pertaining to clinical care may be discussed at these meeting if appropriate, or at the practices clinical meetings. Urgent daily notices and other general items for immediate attention are written in the communication book which is kept at reception. All staff should read and initial for each work session. Procedure Staff meetings It is important that all members of the practice team have the opportunity to discuss administrative issues with the practice directors and/or owners when necessary therefore staff are supported and encouraged to attend staff meetings. Staff meetings are held every two to three months and minutes are recorded. Items for the agenda may be submitted to the Practice Manager up to one week prior to the scheduled meeting. All staff are expected to attend unless on annual or sick leave. Administrative and Occupational Health and Safety practices are regularly reviewed at these meetings. Staff members are given the opportunity to discuss administrative matters with the doctor(s), Practice Manager when necessary. Discussion and suggestions for improvement to quality, patient safety or policies and procedures associated with risk management is a standing item on our practice meeting agenda. Practice discussions about near misses or slips or lapses, with the intention of identifying what went wrong and how to reduce the likelihood of it happening again are also included in practice and clinical meetings where appropriate. The decisions made at staff meetings should be documented along with the person responsible for implementing the related action. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 136 of 260 Insert your logo here Clinical Meetings Good communication between members of the clinical team is important for ensuring a consistent approach to clinical care. Doctors and clinical staff, such as nurses and in house allied health meet face to face at least quarterly, to discuss clinical matters. In between meetings a communication book and emails are used to consider and communicate clinical issues. The Practice Principal, Practice Nurse or Doctor responsible for leading the clinical improvement chairs the meetings. Guest speakers are invited from time to time to speak on latest developments or products. Practice protocols, near misses or latest literature may be discussed. The meetings are recorded on the practice meeting schedule to ensure staff can arrange to attend. A clinical component is included to ensure consistency by doctors, practice nurses, allied health workers and all clinical staff within the practice, in the diagnosis and management of our patients. There is also a standing discussion item about clinical issues, support systems, new guidelines and evidence. This includes a review of patient information brochures used for preventative activities and to support management or treatment choices to ensure they are an appropriate quality and all members of the team are giving consistent information. Clinical issues, updates, case studies and reports of Continuous Quality Improvement (CQI) activities, complaints and incident reviews are presented, discussed and action taken as required helping improve processes and patient outcomes. Drug representatives may from time to time arrange a lunch or breakfast meeting, providing a specialist to speak on a particular topic. Practice Manager is required to authorise availability of times for these meetings RACGP 4th edition Standards 1.4.1, 3.1.2, 4.1.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 137 of 260 Insert your logo here 5.9 Patient Rights Policy The practice staff members respect the rights and needs of all patients. No patient is refused access clinical assessment or medical treatment on the basis of gender, race, disability, Aboriginality, age, religion, ethnicity, beliefs, sexual preference or medical condition. Provisions are implemented to ensure patients with a disability can access our services. The practice identifies important/significant cultural groups within our practice including non English speaking background patients, religious groups and those of Aboriginal and Torres Strait Islander background. We endeavour to continue to develop any strategies required to meet their needs. The practice provides respectful care at all times and is mindful of patient's personal dignity. We have a plan in place to respectfully manage patients in distress Visual and auditory privacy for patients is provided in the waiting room and during the consultation. The waiting room provides soft music or TV to assist patient auditory privacy. Each doctor’s consulting room and the treatment room has a curtain around the examination couch for patient privacy and the door is closed for each consultation. Patient privacy and confidentiality is assured for consultations and in medical and accounts records, appointments, telephone calls and electronic media including computer information. Doctors and staff do not leave patient information in any format in areas of the Practice or surrounds for unauthorised access by the public. Staff members sign a privacy agreement upon acceptance of employment and risk immediate dismissal should a breach of this agreement occur. Information no longer required that contains any reference to patients, including diagnosis reports, specialist’s letters, accounts etc. is securely disposed of via shredding. Patients have a right to access their personal health information and may request to view their record or obtain a copy. Our privacy policy for the management of health information is displayed in the waiting room and also on the practice information sheet. It should be made available to anyone who asks. This policy includes information about the type of information this practice collects, how we collect it, use and protect it and to whom we disclose it. Patients have the right to refuse any treatment, advice or procedure. Our doctors discuss all aspects of treatment and will offer alternatives should a patient seek another medical opinion. (Refer section 7 - Clinical Management of a patient refusing advice and informed consent). Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 139 of 260 Insert your logo here For ongoing management of patients, should they leave the area, our doctors will ask for the forwarding doctor’s or Practice address. A copy of the patient’s medical record or the health summary (if the record is bulky) will be sent directly to the new location via secure priority post. This Practice acknowledges a patient’s right to complain. We provide mechanisms to ensure that this feedback in addition to positive comments and suggestions are freely received and implemented where possible. Patients are provided with sufficient information about the purpose, importance, benefits, risks and possible costs associated with proposed investigations, referrals or treatments to enable patients to make informed decisions about their health. Patients are provided with adequate information about our practice to facilitate access to care including our arrangements for care outside the normal opening hours . This Practice participates in the RACGP Training Program and regularly has registrars on site. Patients are advised of this with a notice in the waiting room. If undergraduate students are on practice placement here and observe doctors’ consultations, then the patient is asked for his/her consent. Each patient is given a written note describing our involvement in this medical training program with details of the process we follow. The patients consent is sought for participation in health reminder systems and research projects. Consent can be withdrawn at any time by the patient. RACGP 4th edition Standards 1.2.1 & 1.2.2 & 2.1.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 140 of 260 Insert your logo here 5.10 Complaints Policy Opportunities are available for patients and other visitors to tell us, ‘How we are doing” and we collect systematic patient experience feedback at least every 3 years. The practice information brochure provides patients with information on how to provide feedback, including how to make a complaint. We have a complaints resolution process which all staff can describe, and we also make the contact details for the state or territory health complaints agencies readily available to patients if we are unable to resolve their concerns ourselves. Patients have a ‘right to complain’ and where possible patients and others are encouraged to raise any concerns directly with the practice team who are trained to make sure patients of the practice feel confident that any feedback or complaints made at the practice will be handled appropriately. We believe most complaints can be responded to and resolved at the time the patient or other people such as carers (relative, friend other consumer) makes them known to us. Under the Health Services (Conciliation & Review) Act 1987 people with complaints should try to resolve them directly with the health service provider. If a satisfactory outcome is not achieved then the complaint can go directly to the Health Services Commissioner for action. The public may also call the Office of the Health Services Commissioner at any time concerning a query or to report a complaint. Under national and state privacy laws: Commonwealth Privacy Act - Privacy Amendment (Private Sector) Act 2000 and Victorian Health Records Act 2001, this practice must provide and adhere to a complaints process for privacy issues and those related to the National Privacy Principles (NPPs)/Health Privacy Principles (HPPs). All staff should be prepared to address complaints as they arise. Depending on the nature of the complaint and advice received from medical indemnity company, complaints are recorded and actioned, with a copy placed in the patient’s medical record if related to patient care. All clinical staff and the practice manger are aware of their professional and legal obligations regarding the mandatory reporting of unprofessional conduct. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 141 of 260 Insert your logo here Procedure Patients and others have opportunities to register their complaints either verbally to staff, in writing (letter) or via our suggestion box. Patients should feel free to complain anonymously if desired. All staff should be prepared to address complaints as they arise. When receiving complaints staff should keep in mind the following in order to minimise further patient anxiety and hostility, possible leading to litigation: handle all complaints seriously, no matter how trivial they may seem. verbal complaints made in person should be addressed in a private area of the practice where possible. use tactful language when responding to complaints. don’t blame other staff. Patients may not have all the facts or may distort them. address the patient’s expectations regarding how they want the matter resolved. assure the patient that their complaint will be investigated and the matter not overlooked. offer the patients the opportunity to complete a formal complaint form. (They may accept or decline). document or Log all complaints and other relevant information and place this in the complaint folder so the designated complaints staff member is informed of the complaint. (even if you believe the matter has been resolved). alert the doctor or relevant clinical staff about disgruntled or hostile patients so he/she can diffuse the situation immediately. always inform the designated complaints officer if you become aware of any significant statements made by the patient or significant change in patient attitude. Often patients will tell staff when they are reluctant to tell the doctor. The practice has identified a staff member to be the team leader responsible for feedback collection and analysis and handling complaints. (*insert the person’s name here). This person coordinates the investigation and resolution of complaints. acknowledge the patients right to complain use the Acknowledgment of Complaint letter provided and respond to complaints in writing within 2 working days telephone the patient to let him/her know that you are working on the problem respond to all complaints promptly in an open and constructive manner including an explanation and if appropriate an apology. work with the patient to resolve the complaint and communicate the outcome with the patient including any changes made as a result of the complaint. if the complaint is of a medical nature always refer it to a doctor. Refer procedure section 8 -”Management of potential medical defence claims”. where a complaint is made against a staff member provide them with an opportunity to discuss the details in a private setting. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 142 of 260 Insert your logo here as a routine contact the practices insurer when there is a complaint about a member of the clinical team in order to seek advice on resolving the complaint before any action is taken. ensure the complaint does not adversely affect the patents care. record the complaint, investigation, and actions, with a copy placed in the patient’s medical record if related to patient care and the details also retained in the complaints file. ensure where appropriate complaints are reviewed at staff meetings. Analyse trends and discuss the methods of resolution. Other types of patient feedback - i.e. surveys, suggestion box are also reviewed at staff meetings a record of improvement made in response to patient feedback or complaints is maintained as evidence of quality assurance activity. where appropriate inform the patient/s about practice improvements made as a result of their input. If the matter cannot be resolved advise the patient about how to contact the Health Complaints commissioner. The National Privacy Commissioner is able to receive complaints concerning privacy issues. Complaints here will have a response within 28 days. National Privacy Commissioner Privacy hotline 1300 363 992. GPO Box 5218 Sydney NSW 2001 http://www.privacy.gov.au/complaints Members of the public may make a notification to Australian Health practitioner regulation agency (AHPRA) http://www.ahpra.gov.au/ (AHPRA) about the conduct, health or performance of a practitioner or the health of a student. Practitioners, employers and education providers are all mandated by law to report notifiable conduct relating to a registered practitioner or student to AHPRA. RACGP 4th edition Standards 2.1.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 143 of 260 Insert your logo here 5.11 Non English Speaking Patients Policy Our Doctors and staff have a professional obligation to ensure they understand our patients and that the patients understand any verbal instructions or written information. Patients who do not speak or read English or who are more proficient in another language, or who have special communication needs are offered the choice of using the assistance of a language service to communicate with the Doctor or clinical team members. We are also aware that alternative modes of communication may be used by our patients with a disability and we endeavour to inform ourselves of how to access and use these services or technology to achieve effective communication with these patients. A contact list of translator and interpreter services and services for patients with a disability is maintained, updated regularly and readily available to all staff. For example the National Relay Service (NRS) for patients that are deaf or the translation and Interpreter service (TIS) Doctors Priority Line (1300 131 450) for patients from a not English speaking background. Procedure Once you have determined that the patient may have special communication needs ask the patient consent to use assistance. Check the patient’s medical record to see what if any services have been used before. The patient may consider that a family member or friend could interpret at the consultation. A member of the patient’s family may not be a suitable translator especially for sensitive clinical situations or where serious decisions have to be made. The use of children as interpreters is not encouraged. An appropriate staff member can act as interpreter if the patient consents. Some of our staff members are bilingual, but not all are accredited interpreters and should not be used as such. Qualified medical interpreters are our preferred option and their use should be encouraged especially for sensitive clinical situations. Note this on the medical records the patient’s nominated interpreter or any professional services that have been used and arrange these prior to the consultation. A list of translator and interpreter services and other communication services used by this practice is available (*Insert how to access this list). Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 144 of 260 Insert your logo here Each doctor is registered with the interpreter service and allocated a code number. Registrations are renewed annually to ensure quick access when an interpreter is required. Other clinical staff should access the service via the treating doctor. If TIS National is the chosen option book an interpreter by ringing the Doctor Priority Line Tel: 1300 131 450 (free service) or booking on line or by fax. This 24 hour service is available via telephone at the time of consultation, or if appropriate advance notice is given (usually 48 hours), the interpreter can be on site at the practice during a consultation (subject to availability) or at the patients home. If an interpreter is attending the practice or home it is important to ensure the appointment starts on time. RACGP 4th edition Standards 2.1.1 & 2.1.2 & 1.2.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 145 of 260 Insert your logo here 5.11.1 Culturally Appropriate Care Policy We aim to identify important and significant cultural groups within our practice and have implemented strategies to meet their needs. We also aim to accommodate the specific needs of patients who experience disadvantage and increased disease risk whether due to socioeconomic factors, educational or literacy issues, cultural background, or disability. (Refer section 5 Patient Rights). In order to improve health outcomes we: encourage our patients to self-identify their Aboriginal or Torres Strait Islander origin or cultural background to practice staff. encourage our practice staff to ask the Aboriginal or Torres Strait Islander or other cultural background of our patients. We are sensitive and aware that there may be many reasons why patients are reluctant to identify their Aboriginal or Torres Strait Islander or other cultural background and equally there are reasons why practice staff are reluctant to ask about the cultural background of our patients. When patients are distressed we provide appropriate care and privacy which also respects their cultural practices. (Refer section 5 Appointments). We know how to communicate with patients who do not speak the primary language of our staff or who have communication impairment, and our practice has a list of contact details for interpreter and other communication services including the Translating and Interpreter Services (Refer Section 5 Non English Speaking Patients). The entry of information about the Aboriginal or Torres Strait Islander or other cultural background of patients into health records is undertaken in a standardised manner that enables the extraction of data. Procedure Our practice is working towards identifying and recording the cultural background of our new and existing patients. Cultural background and ethnicity e.g. Aboriginal and Torres Strait Islander background, can be an important indication of clinical risk factors and can assist GPs and clinical staff in providing disease prevention and delivering culturally appropriate care. We have identified the main cultural groups in our practice and endeavour to provide culturally appropriate written health information. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 146 of 260 Insert your logo here We collect information about the country of birth and languages spoken. We have a system to regularly update our patient information using a standard ‘update your details form’ to help collect additional cultural information from our patients. (*Insert or describe where a copy of your form/s to obtain patient information are located-Refer to Section 7 Clinical Content of the medical records). The standard indigenous status question asked is ‘Are you of Aboriginal or Torres Strait Islander origin?’ This question should be asked of all patients, irrespective of appearance, country of birth or whether the staff know of the client or their family background. Our practice collects this information as part of our ‘new patient’ questionnaire. (Refer to Section 7 Clinical content of the medical records). Where our software has the option to input Aboriginal and/or Torres Strait Islander status or cultural background/s we use the drop down options rather than free text to assist with extracting the information for accreditation purposes or preventative activities. (*Insert any protocols or rules you have developed around the documentation Aboriginal and/or Torres Strait Islander status or cultural background/s in patients medical records.) To encourage Aboriginal or Torres Strait Islander origin patients to self identify we have (*insert any measures you have taken e.g. Self identification posters in the waiting room, Displaying the Aboriginal and Torres Strait Islander flags on brochures, or having the Koori Mail in your waiting room http://www.koorimail.com). RACGP 4th edition Standards 1.4.1, 1.7.1, 2.1.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 147 of 260 Insert your logo here 5.12 Directory of Local Health and Community Services Policy Our practice engages with a range of health, community and disability services to plan and facilitate optimal patient care to patients whose health needs require integration with other services. A readily accessible written or computerised directory of health and community services, utilised by patients within our area, including how to refer or contact these agencies, is maintained and updated regularly. Clinical staff are encouraged to co ordinate patient care across the general practice setting with other health services and to build good working relationships with these providers to facilitate collaborative care Procedure This directory is located (*Insert how to access your directory of services). The contact numbers in this list are checked and updated annually or more often if required by the practice manager. The practice manager is notified of new providers to include on the list. All new staff are made aware of how to access this list. The directory of local health and community services lists: local medical/diagnostic services. local hospitals and specialist consulting services. primary healthcare nurses. pharmacists. disability and community services. health Promotion and public health services and programs. relevant Government departments in the Region. local allied health services. community, social or self help groups in the area. culturally appropriate services for non English speaking background and Aboriginal and Torres Strait Islander patients. A brief explanation about any fees applicable, contact numbers or names and procedures for interacting with these services is included on this list. Referral information may differ for public and private providers. See Section “Referral Protocols”. Practice staff and doctors need to ensure requirements outlined in the Chronic Disease initiatives are met if these item numbers are to be claimed. RACGP 4th Edition Standards 1.6.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 148 of 260 Insert your logo here 5.13 Provision of Brochures, Leaflets and Pamphlets for Patients Policy There is a range of posters, leaflets or brochures available or on display in the waiting room, reception and or consulting rooms. Where appropriate these are available in more than one language or in formats to assist patients with physical or intellectual disabilities. (Refer to Section 5 Non English speaking Patients) Leaflets, brochures and pamphlets can vary considerably in quality. The brochures used by this practice are carefully selected and screened to ensure they are culturally appropriate and contain current, evidence based information. The quality and accuracy of any Audio visual resources or internet sites recommended to patients or used to provide printed information to patients is also considered. The brochures, posters, leaflets and pamphlets available include information about health promotion, and illness prevention, specific diseases and medical procedures and privacy and rights. The doctors and clinical staff use written information during a consultation to: support diagnosis and management of conditions. for health promotion and illness prevention Brochures and educational materials are also available for patients to self select. Procedure We are selective about the leaflets and brochures we provide both in the waiting room for patients to self select and for clinical staff to use to support information provided during a consultation. To ensure they contain current and evidence based information, items are obtained from reputable sources. Where possible items should be dated, contain the name of the source and referenced to supportive evidence. At least annually we try to conduct an audit of our brochures, leaflets and patient information sheets to ascertain if they are current and if better options are available. Brochures and leaflets are displayed in the waiting room in brochure holders and are checked monthly (more frequent if new or altered information becomes available) that stocks are sufficient and up to date. New brochures (e.g. seasonal, flu injections etc) are to be incorporated into collection. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 149 of 260 Insert your logo here Information that is no longer current or damaged brochures is promptly discarded. Low stocks to be reordered and note made in order book. Also check for brochures in other languages if required. The provision of specific written material to support advice given in consultations is encouraged to help patients remember the key messages from the consultation and address individual patients’ needs. (Refer to Section 7 Clinical references and resources.) Verbal and written information is provided to patients about health promotion and specific disease prevention. to support a diagnosis and choice of treatment RACGP 4th Edition Standards 1.2.3 & 1.3.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 150 of 260 Insert your logo here 5.13.1 Practice Information Sheet Policy The Practice Information Sheet provides our patients with information about our practice facilities and how to access care. It is also a useful way to inform patients of current practice information or changes to our services. We endeavour to ensure all patients, new and existing, are provided with the most up to date version to ensure the information they have is accurate. If a patient is unable to read or understand our practice information sheet an alternative method is used to supply this information. These may include: verbally. larger font versions. through the National Relay Service or AUSLAN for patients who are deaf. through the translation and Interpreter service (TIS) for patients who speak languages other than English. getting our sheets translated into languages commonly used at our practice. (Refer to section 5 Non English speaking patients). Telephone messages, the on hold recording and our website is also used, where possible, to reinforce some of the information about our practice and our services Procedure The practice information sheet is kept at reception; it is available to all patients and handed to each new patient on their first visit. Staff ensure essential information contained in the sheet is made available to all patients whether new to our practice or existing patients. Where patients are unable to read or understand our written sheet we use other means to communicate the essential information. (Refer to Section 5 Non English speaking patients.) To maintain the accuracy of our information sheet it is reviewed regularly and updated as required. When this sheet is updated the date is inserted in the footer to denote the latest version. Reception staff are advised there has been a change and are encouraged to bring this new version to the attention of our patients The Practice information sheet is must contain at a minimum: practice address and phone numbers consulting hours and arrangements for care outside our normal opening hours, including a contact telephone number. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 151 of 260 Insert your logo here our practice’s billing principles such as bulk billing, accounts settlement, opproximate cost for treatment, potential out of pocket expenses. our practice’s communication policy including receiving and returning phone calls and electronic communication (e.g. SMS & email). our practices policies for the management of patient health information including that patients can obtain a copy of their health information and where additional posters or the full privacy policy can be obtained from the practice. the process for the follow up of results e.g. who will contact whom and by when. how to provide feedback or make a complaint to the practice (include the contact for the local state health complaints conciliation body and the name of the person responsible for feedback and complaints). Other information it could contain includes: names and qualifications or special interests of doctors, nurses, allied health and other practice team members (subject to their consent). clinical and other services available. that they can request a summary of the policy on home, hospital, and nursing home visits. inform patients that longer consultations are available on request. encourage ways in which patients can give feedback (e.g. tell patients if you have a suggestion box). how patients are able to request their preferred doctor. inform patients about your reminder systems and the option of opting out of receiving reminders. information about how patients can assist by telling the practice if their personal information changes e.g. changed address or provide any court documentation to advise any child custody arrangements. where the practice has a website it should contain at a minimum, the information required in the practice information sheet. The website information should be accurate and updated regularly. Information provided either on the practice information sheet, website or in general interest health articles and posters may contain advertising. If this is the case the practice should include a disclaimer that the practice does not endorse any advertised services or products. Advertising must comply with the MBA Code of Conduct on advertising available at: http://goodmedicalpractice.org.au/. RACGP 4th edition Standards 1.2.1 & 1.2.3 & 1.2.4. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 152 of 260 Insert your logo here 5.14 Office Supplies Policy Supplies of stationery, other office and Practice stores including prescription pads, letterhead, certificates etc. are accessible only to authorised persons. The Practice Manager, or delegate, checks and maintains stock ensuring perishable materials are rotated so oldest is used first. Procedure Stock is checked monthly and items are re-ordered when supplies are low. Incoming goods are checked against orders and invoices. When a staff member takes a supply of stationery e.g. pen, sticky notes etc. They are to tick off the item as having been removed from the cupboard. See supply list on inside of cupboard. When extra supplies or new items are needed, direct the request to the Practice Manager or delegate. RACGP 3rd edition Standards 5.1.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 153 of 260 Insert your logo here 5.15 Environmental Cleaning Service 1) Policy All areas of our practice environment are visibly clean. Regular cleaning of work areas is necessary because dust, soil and microbes on surfaces can transmit infection. Cleaning of our practice clinical and non clinical areas must be regular and scrupulous. We have a cleaning policy that sets out a schedule and responsibilities for cleaning all areas of the practice in accordance with the requirements outlines in Chapters 2–5 of the RACGP Infection control standards for office based practices (4th edition). We have appointed one member of staff with primary responsibility for the development and consistent implementation of our infection control systems and procedures which includes environmental cleaning. (Refer Section 4 Principles of Infection control) Specific areas of responsibility may be delegated to nominated members of the practice team and these particular responsibilities should be documented in the relevant position descriptions. The practice team member with delegated responsibility for environmental cleaning can describe the process for the routine cleaning of all areas of the practice and can provide documentation on the practice’s cleaning policy. A good neutral detergent can be used for most of the cleaning requirements in a health care setting, and this includes floors, walls, toilets and other surfaces. The use of disinfectants is discouraged because they are expensive, often toxic and require contact times to be effective. All work surfaces are made of smooth, non-porous material without cracks or crevices to allow for efficient cleaning. Any gross soiling or body substance spills must be cleaned as soon as possible. Sinks and wash basins must be either sealed to the wall or sufficiently far from the wall to allow cleaning of all surfaces. Damp dusting and wet mopping is used in the cleaning of the environment. Dry dusting and sweeping will disperse dust and bacteria into the air and then resettle. It is potentially hazardous and inefficient, and must be avoided in patient treatment or food preparation areas. All cleaning equipment is stored in a clean and dry condition, and in an area not accessible to the public. Our practice has a cleaning schedule with procedures for cleaning clinical and non-clinical areas of our practice. All cleaning staff must receive training in occupational health and safety issues appropriate to general practice and the immunisation status of all cleaning staff is documented. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 154 of 260 Insert your logo here All staff involved in cleaning receives ongoing education in our infection control policies including Hand Hygiene and the correct use of Personal Protective Equipment (PPE) and Waste management. Procedure (*Insert name) has the delegated responsibility for the development and consistent implementation of our environmental cleaning processes. This includes education of staff and following up any issues with the quality of environmental cleaning. Our cleaning schedule below describes the frequency of cleaning, products to use and person responsible for cleaning specific clinical and non clinical areas of the practice. Where appropriate we have documented evidence of cleaning activity. Additional and specific cleaning may be required in areas where patients known or suspected to be infected with highly transmissible agents (e.g. influenza) have been. Option 1: (Select if your practice is cleaned by staff and contract cleaners then delete all other options) Practice staff and contract cleaners are responsible for cleaning the premises as specified in the attached cleaning guide. Practice staff undertake daily cleaning and the contract cleaners provide general cleaning in all areas of the Practice on a (*insert frequency) basis. An annual contract with (*Insert contract cleaners name) is negotiated and reviewed every June. Option 2. (Select if all cleaning is performed by practice staff. Then delete all other options) Practice staff members are responsible for cleaning the premises as specified in the attached cleaning guide. Option 3 (select if cleaning is only performed by a contracted cleaning service. Then delete all other options) An external cleaning service (*Insert contract cleaners name) is responsible for cleaning the premises as specified in the attached cleaning guide. This service is contracted to provide general cleaning in all areas of the Practice on a daily basis (Mon – Fri). An annual contract is negotiated and reviewed every June. The cleaning service operates after 5pm. Spills that occur during normal consulting hours are the responsibility of the health practitioner (doctor, nurse) or if in non-clinical areas, the practice nurse. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 155 of 260 Insert your logo here Cleaning staff should adhere to the following principles when cleaning: don personal protective equipment (PPE) such as gloves and a waterproof apron make up water and detergent solution each day use clean dry cloths and mops wash and dry all surfaces promptly dispose of used cleaning solution in the dirty utility area, not in hand basins or clinical sinks wash and dry buckets, cloths, mops and PPE after use wash hands when each task is completed. Areas which are only cleaned/ managed by appropriately trained practice staff are: spillage of blood or body fluids medical instruments or items for re-use are cleaned according to the procedure for cleaning instruments and re-usable items. treatment room benches and trolleys consulting room benches containing medical equipment infectious waste and sharps containers All practice staff responsible for cleaning have been appropriately immunised as documented in their staff records. Should cleaning not conform to the expectations of staff it should be reported to the Practice Manager. The Practice Manager, or delegate, conducts routine audits to ensure a high standard of cleaning. Audits are done every two months or more frequently as required, using items as defined in the cleaning contract. Safety data sheets of cleaning solutions, disinfectants etc are kept on file in case of a medical emergency i.e. swallowing, splashed in eyes. The attached cleaning guide contains descriptions of all areas to be cleaned, frequency, method and responsible person. RACGP 4th edition Standards 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 156 of 260 Insert your logo here Routine Cleaning Guide Surface Method and cleaning agents to be used Frequency Cleaner Responsible Treatment room benches and trolleys Wash with hot water and detergent. Dry thoroughly Nightly and more often if required Authorised practice staff Benches/drawers containing medical Items Wash with hot water and detergent. Dry thoroughly Weekly and more often if required Authorised practice staff Re-usable medical items and instruments Refer to procedure in Section 4 As required Authorised practice staff Benches and tables in kitchen Wash with hot water and detergent Nightly Sinks, hand basins and toilets Hot water & detergent. An abrasive cream cleanser may be a useful stain remover Daily Hard floors - Treatment Room Vacuum and wet mop with hot water and detergent Daily Hard floors - Other areas Vacuum and wet mop with hot water and detergent Daily - weekly depending on use Carpeted areas Vacuum Daily – weekly depending on use 6 –12 monthly Steam Cleaned Office desks, benches and furniture Damp mop with hot water and detergent / Vacuum Weekly Examination couches Hot water and detergent Daily Toys Dishwasher / Hot water and detergent Daily - Weekly depending on use Waiting Room furniture Hot water and detergent/ Vacuum Daily Curtains - Cubicle Machine hot wash 3 monthly Windows and window furnishings Dry clean / Vacuum Annually Walls and ceilings Hot water and detergent Annually Storerooms Hot water and detergent 3 monthly Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 157 of 260 Insert your logo here 6 Privacy and Personal Health Information 6.1 Privacy and Security of Personal Health Information Policy This practice is bound by the Federal Privacy Act 1998 and National Privacy Principles, and also complies with the Victorian Health Records Act 2001. ‘Personal health information’ a particular subset of personal information and can include any information collected to provide a health service. This information includes medical details, family information, name, address, employment and other demographic data, past medical and social history, current health issues and future medical care, Medicare number, accounts details and any health information such as a medical or personal opinion about a person’s health, disability or health status. It includes the formal medical record whether written or electronic and information held or recorded on any other medium e.g. letter, fax, or electronically or information conveyed verbally. Our practice has a designated person (*Insert name) with primary responsibility for the practice’s electronic systems, computer security and adherence to protocols as outlined in our Computer Information Security policy (Refer 6.1.1). This responsibility is documented in the Position Description. Tasks may be delegated to others and this person works in consultation with the privacy officer. Our Security policies and procedures regarding the confidentiality of patient health records and information are documented and our practice team are informed about these at induction and when updates or changes occur. The practice team can describe how we correctly identify our patients using 3 patient identifiers, name, and date of birth, address or gender to ascertain we have the correct patient record before entering or actioning anything from that record. For each patient we have an individual patient health record (paper, electronic or a combination of both, “Hybrid”) containing all clinical information held by our practice relating to that patient. The Practice ensures the protection of all information contained therein. Our patient health records can be accessed by an appropriate team member when required. We also ensure information held about the patient in different records (e.g. at a residential aged care facility) is available when required. Procedure Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 158 of 260 Insert your logo here Doctors, allied health practitioners and all other staff and contractors associated with this Practice have a responsibility to maintain the privacy of personal health information and related financial information. The privacy of this information is every patient’s right. The maintenance of privacy requires that any information regarding individual patients, including staff members who may be patients, may not be disclosed either verbally, in writing, in electronic form, by copying either at the Practice or outside it, during or outside work hours, except for strictly authorised use within the patient care context at the Practice or as legally directed. There are no degrees of privacy. All patient information must be considered private and confidential, even that which is seen or heard and therefore is not to be disclosed to family, friends, staff or others without the patient’s approval. Sometimes details about a person’s medical history or other contextual information such as details of an appointment can identify them, even if no name is attached to that information. This is still considered health information and as such it must be protected under the Privacy Act 1998. Any information given to unauthorised personnel will result in disciplinary action and possible dismissal. Each staff member is bound by his/her privacy clause contained with the employment agreement which is signed upon commencement of employment at this Practice. (Refer Section 2). Personal health information should be kept where staff supervision is easily provided and kept out of view and access by the public e.g. not left exposed on the reception desk, in waiting room or other public areas; or left unattended in consulting or treatment rooms. Practice computers and servers comply with the RACGP computer security checklist and we have a sound back up system and a contingency plan to protect the practice from loss of data. (Refer 6.1.1 Computer information security) Care should be taken that the general public cannot see or access computer screens that display information about other individuals. To minimise this risk automated screen savers should be engaged. Members of the practice team have different levels of access to patient health information. (Refer Section 6 Compute Information security) To protect the security of health information, GPs and other practice staff do not give their computer passwords to others in the team. Reception and other Practice staff should be aware that conversations in the main reception area can often be overheard in the waiting room and as such staff should avoid discussing confidential and sensitive patient information in this area. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 159 of 260 Insert your logo here Whenever sensitive documentation is discarded the practice uses an appropriate method of destruction (*Insert method e.g. shredding or security bin) or computer drive, memory sticks etc are reformatted) Correspondence Electronic information is transmitted over the public network in an encrypted format using secure messaging software. Where medical information is sent by post the use of secure postage or a courier service is determined on a case by case basis. Incoming patient correspondence and diagnostic results are opened by a designated staff member. Items for collection or postage are left in a secure area not in view of the public. Facsimile Facsimile, printers and other electronic communication devices in the practice are located in areas that are only accessible to the general practitioners and other authorised staff. Faxing is point to point and will therefore usually only be transmitted to one location All faxes containing confidential information are sent to fax numbers after ensuring the recipient is the designated receiver. Confidential information sent by fax has Date, Patient Name, Description and Destination recorded in a log book. Write, “Confidential” on the fax coversheet Check the number dialled before pressing ‘SEND’ Keep the transmission report produced by the fax as evidence that the fax was sent. Also confirm the correct fax number on the report. Faxes received are managed according to incoming correspondence protocols The practice uses a fax disclaimer notice on outgoing faxes that affiliates with the practice. (*Insert message here). Emails Emails are sent via various nodes and are at risk of being intercepted. Patient information may only be sent via email if it is securely encrypted according to industry and best practice standards. Patient Consultations Patient privacy and security of information is maximised during consultations by closing consulting room doors. All Examination couches, including those in the treatment room, have curtains or privacy screens. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 160 of 260 Insert your logo here When, consulting, treatment room or administration office doors are closed prior to entering staff should either knock and wait for a response or alternatively contact the relevant person by internal phone or email. Where locks are present on individual rooms these should not be engaged except when the room is not in use It is the doctor’s/health care professional’s responsibility to ensure that prescription paper, sample medications, medical records and related personal patient information is kept secure, if they leave the room during a consultation or whenever they are not in attendance in their consulting/treatment room. Medical Records The physical medical records and related information created and maintained for the continuing management of each patient are the property of this Practice. This information is deemed a personal health record and while the patient does not have ownership of the record he/she has the right to access under the provisions of the Commonwealth Privacy and State Health Records Acts. Requests for access to the medical record will be acted upon only if received in written format. Our patient health records can be accessed by an appropriate team member when required. (*Insert details or where they are located) about how you ensure the protection of all information contained in medical records e.g. passwords, access details, storage and how you ensure information held about the patient in different records (e.g. at a residential aged care facility) is available when required. Both active and inactive patient health records are kept and stored securely. A patient health record may be solely electronic, solely paper based, or a combination (hybrid) of paper and electronic records Select the appropriate options, either paper based record security or electronic record security or both depending on the systems used at your practice for the management of personal health information and delete others. Paper based Records Security is maintained for paper based medical files at all times. During Practice hours the reception and filing areas are supervised. These records are only retrieved by authorised Practice staff and are secured when the practice is closed. Patient health records are easily accessed by the authorised staff at time of consultation. Paper based medical records are stored in the (*insert locations of Paper based medical records in your practice). Folders are filed as follows: (*insert summary of Paper based medical records filing system). Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 161 of 260 Insert your logo here Medical records are not placed on top of the reception counter. When doctors and other Practice staff request a record or are to see a patient the medical record is placed in their intray, away from public view and access. Records are not left in public or unauthorised areas of the Practice. If a doctor has borrowed a record, it is to be kept locked inside the consulting room cupboard or returned to be filed if no longer in use. Computerised Records Our practice is considered paperless and has systems in place to protect the privacy, security, quality and integrity of the personal health information held electronically. Appropriate staff members are trained in computer security policies and procedures. Hybrid Records Our practice utilises records comprised of a combination of physical paper, scanned documentation and electronic digital records. We recognise that a hybrid approach creates additional management and risk issues. There must be a record made for every consultation in each system indicating where the clinical notes for the consultation are recorded. Security is maintained for paper based medical files at all times. During Practice hours the reception and filing areas are supervised. These records are only retrieved by authorised Practice staff and are secured when the practice is closed. Patient health records are easily accessed by the authorised staff at time of consultation. Paper based medical records are stored in the (*insert locations of Paper based medical records in your practice). Folders are filed as follows: (*insert summary of Paper based medical records filing system). Medical records are not placed on top of the reception counter. When doctors and other Practice staff request a record or are to see a patient the medical record is placed in their intray, away from public view and access. Records are not left in public or unauthorised areas of the Practice. If a doctor has borrowed a record, it is to be kept locked inside the consulting room cupboard or returned to be filed if no longer in use. RACGP 4th edition Standards 4.2.1 & 3.1.4. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 162 of 260 Insert your logo here Section 3.02 6.1.1 Computer Information Security Policy Our practice has systems in place to protect the privacy, security, quality and integrity of the data held electronically. Doctors and staff are trained in computer use and our security policies and procedures and updated when changes occur. A staff member (*insert name) has designated responsibility for overseeing the maintenance of our computer security and our electronic systems. All clinical staff have access to a computer to document clinical care. For medico legal reasons, and to provide evidence of items billed in the event of a Medicare audit, staff, especially nurses always log in under their own passwords to document care activities they have undertaken. Our practice ensures that our practice computers and servers comply with the RACGP computer security checklist and that: computers are only accessible via individual password access to those in the practice team who have appropriate levels of authorisation. computers have screensavers or other automated privacy protection devices are enabled to prevent unauthorised access to computers. servers are backed up and checked at frequent intervals, consistent with a documented business continuity plan. back up information is stored in a secure off site environment. computers are protected by antivirus software that is installed and updated regularly computers connected to the internet are protected by appropriate hardware/software firewalls. we have a business continuity plan that has been developed, tested and documented. Electronic data transmission of patient health information from our practice is in a secure format. Our practice has the following information to support the computer security policy: current asset register documenting hardware and software including software licence keys logbooks/print-outs of maintenance, backup including test restoration, faults, virus scans folder with warranties, invoices/receipts, maintenance agreements This Practice reserves the right to check individual’s Computer System history as a precaution to fraud, workplace harassment or breaches of confidence by employees. Inappropriate use of the Practices Computer Systems or breaches of Practice Computer Security will be fully investigated and may be grounds for dismissal. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 163 of 260 Insert your logo here This practice has a sound backup system and a contingency plan to protect practice information in the event of an adverse incident, such as a system crash or power failure. This plan encompasses all critical areas of the practice’s operations such as making appointments, billing patients and collecting patient health information. This plan is tested on a regular basis to ensure backup protocols work properly and that the practice can continue to operate in the event of a computer failure or power outage. Procedure The RACGP Computer security guidelines: A self assessment guide and checklist for general practice (3rd edition) is available at www.racgp.org.au/ehealth/csg. The accompanying template for developing a policy and procedure manual should be completed by the designated staff member responsible for the practice’s computer security. (*Insert the location of your practice computer security manual and protocols). Our disaster Box stocked with items to enable the practice to operate in the event of a power failure is located (*Insert location). torches. paper prescription pads/sick certificates etc. appointment schedule printout and manual book. letterhead. consultation notes. manual credit card/payment/Medicare processing equipment. emergency numbers. RACGP 4th edition Standards 4.2.1 & 4.2.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 164 of 260 Insert your logo here 6.1.2 Practice Privacy Policy Policy National Privacy Principle 5 requires our practice to have a document that clearly sets out its policies on handling personal information, including health information. This document, commonly called a privacy policy, outlines how we handle personal information collected (including health information) and how we protect the security of this information. It must be made available to anyone who asks for it and patients are made aware of this. The collection statement informs patients about how their health information will be used including other organisations to which the practice usually discloses patient health information and any law that requires the particular information to be collected. Patient consent to the handling and sharing of patient health information should be provided at an early stage in the process of clinical care and patients should be made aware of the collection statement when giving consent to share health information. In general, quality improvement or clinical audit activities for the purpose of seeking to improve the delivery of a particular treatment or service would be considered a directly related secondary purpose for information use or disclosure so we do not need to seek specific consent for this use of patients’ health information, however we include information about quality improvement activities and clinical audits in the practice policy on managing health information.(Refer Section 8 Accreditation and Continuous Improvement) Procedure We inform our patients about our practice’s policies regarding the collection and management of their personal health information via: a sign at reception. brochure/s in the waiting area. our patient information sheet. new patient forms – ‘Consent to share information’. verbally if appropriate. the practice website. (* Insert copies of your practices privacy policy and your collection statement. You may have a combined statement. Use the points below as a guide or templates are available on the web). The privacy policy should outline: the practice’s contact details. what information is collected. why information is collected. how the practice maintains the security of information held at the practice. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 165 of 260 Insert your logo here the range of people within the practice team (e.g. GPs, general practice nurses, general practice registrars and students and allied health professionals), who may have access to patient health records and the scope of that access. the procedures for patients to gain access to their own health information on request. the way the practice gains patient consent before disclosing their personal health information to third parties. the process of providing health information to another medical practice should patients request that. the use of patient health information for quality assurance, research and professional development. the procedures for informing new patients about privacy arrangements. the way the practice addresses complaints about privacy related matters. the practice’s policy for retaining patient health records. A ‘collection statement’ sets out the following information: the identity of the practice and how to contact it. the fact that patients can access their own heath information. the purpose for which the information is collected. other organisations to which the practice usually discloses patient health information. any law that requires the particular information to be collected (e.g. notifiable diseases). the main consequence for the individual if important health information is not provided. Prior to a patient signing consent to the release of their health information patients are made aware they can request a full copy of our privacy policy and collection statement. Patient consent for the transfer of health information to other providers or agencies is obtained on the first visit. A copy of our consent form is included below. Once signed this form is scanned into the patient’s record and its completion noted. Note: Consent for transfer of information differs from procedural consent. RACGP 4th edition standards 4.2.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 166 of 260 Insert your logo here 6.2 3rd Party Requests for Access to Medical Records/Health Information Policy Requests for 3rd Party access to the medical record should be initiated by either receipt of correspondence from a solicitor or government agency or by the patient completing a Patient Request for Personal Health Information Form. Where a patient request form or and signed authorisation is not obtained the practice is not legally obliged to release. Where requests for access are refused the patient or third party may seek access under relevant privacy laws. An organisation ‘holds’ health information if it is in their possession or control. If you have received reports or other health information from another organisation such as a medical specialist, you are required to provide access in the same manner as for the records you create. If the specialist has written ‘not to be disclosed to a third party’ or ‘confidential’ on their report, this has no legal effect in relation to requests for access under the Health Records Act 2001. You are also required to provide access to records which have been transferred to you from another health service provider. Requests for access to the medical record and associated financial details may be received from various 3rd Parties including: 1. Subpoena/court order/coroner/search warrant 2. Relatives/Friends/carers 3. External doctors & Health Care Institutions 4. Police /Solicitors 5. Health Insurance companies/Workers Compensation/Social Welfare agencies 6. Employers 7. Government Agencies 8. Accounts/Debt Collection 9. Students (Medical& Nursing) 10. Research /Quality Assurance Programs 11. Media 12. International 13. Disease registers 14. Telephone Calls We only transfer or release patient information to a third party once the consent to share information has been signed and in specific cases informed patient consent has may be sought. Where possible de identified information is sent Our practice team can describe the procedures for timely, authorised and secure transfer of patient health information in relation to valid requests. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 167 of 260 Insert your logo here Procedure The practice team can describe how we correctly identify our patients using 3 patient identifiers, name, date of birth, address or gender to ascertain we have the correct patient record before entering, actioning or releasing anything from that record. Patient consent for the transfer of health information to other providers or agencies is obtained on the first visit and retained on file in anticipation of when this may be required. As a rule no patient information is to be released to a 3rd Party unless the request is made in writing and provides evidence of a signed authority to release the requested information, to either the patient directly or a third party. Where possible de identified data is released. Written requests should be noted in the patient's medical record and also documented in the practice’s Request Register. Requests should be forwarded to the designated person within the practice for follow-up. Requested records are to be reviewed by the treating medical practitioner or principal doctor prior to their release to a third party. Where a report or medical record is documented for release to a third party, having satisfied criteria for release, (including the patients written consent and where appropriate written authorisation from the treating doctor), then the practice may specify a charge to be incurred by the patient or third party, to meet the cost of time spent preparing the report or photocopying the record. Section 3.03 The practice retains a record of all requests for access to medical information including transfers to other medical practitioners. Where hard copy medical records are sent to patients or 3rd Parties copies are forwarded not original documentation wherever possible. If originals are required copies are made in case of loss. Security of any health information requested is maintained when transferring requested records and electronic data transmission of patient health information from our practice is in a secure format. Subpoena, Court Order, Coroner Search Warrant Note the date of court case and date request received in the medical record. Depending on whether a physical or electronic copy of the record is required follow procedures as described above. Refer also to section 8 “Management of potential Medical defence claims’ On occasions a member of staff is required to accompany the medical record to court or alternatively a secure courier service may be adequate. If the original is to be transported, ensure a copy is made in case of loss of the original during transport. Ensure that the record is returned after review by the court. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 168 of 260 Insert your logo here Relatives/Friends A patient may authorise another person to be given access if they have the legal right and a signed authority. See 6.3 Patient Requests for Personal Health Information. See also NPP2 Use & Disclosure. In 2008 the Australian Law Reform Commission recognised that disclosure of information to ‘a person responsible for an individual’ can occur within current privacy law. If a situation arises where a carer is seeking access to a patient’s health information, practices are encouraged to contact their medical defence organisation for advice before such access is granted. Individual records are advised for all family members but especially for children whose parents have separated where care must be taken that sensitive demographic information relating to either partner is not recorded on the demographic sheet. Significant court orders relating to custody and guardianship should be recorded as an alert on the children’s records. External Doctors and Health Care Institutions Direct the query to the patient’s doctor and or the practice manager/principal doctor. Police/ Solicitors Police and solicitors must obtain a case specific signed patient consent (or subpoena, court order or search warrant) for release of information. The request is directed to the doctor. Health Insurance Companies /Workers Compensation/ Social Welfare Agencies Depending on the specific circumstances information may be need to be provided. It is recommended that these requests are referred to the Doctor. It is important that organisations tell individuals what could be done with their personal health information and if it is within the reasonable expectation of the patient then personal health information may be disclosed. Doctors may need to discuss such requests with the patient and perhaps their medical defence organisation. Employers If the patient has signed consent to release information for a pre-employment questionnaire or similar report then direct the request to the treating doctor. Government Agencies - Medicare/Dept. Veterans Affairs Depending on the specific circumstances information may be need to be provided. It is recommended that doctors discuss such issues with the medical defence organisations. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 169 of 260 Insert your logo here State Registrar of Births, Deaths and Marriages Death certificates are usually issued by the treating doctor. Centrelink There are a large number of Centrelink forms (treating doctor’s reports) which are usually completed in conjunction with the patient consultation Accounts/ Debt Collection The practice must maintain privacy of patient's financial accounts. Accounts are not stored or left visible in areas where members of the public have unrestricted access. Accounts must not contain any clinical information. Invoices and statements should be reviewed prior to forwarding to third parties such as insurance companies or debt collection agencies. Outstanding account queries or disputes should be directed to the practice manager/bookkeeper or principal. Hint: Practices may like define an adequate period of time between the initial account and pursuing aggressive collection. Students (Medical & Nursing) This practice does/ does not participate in medical/nursing student education. The practice acknowledges that some patients may not wish to have their personal health information accessed for educational purposes. The practice always advises patients of impending student involvement in practice activities and seeks to obtain patient consent accordingly. The practice respects the patient’s right to privacy. Researchers/Quality Assurance Programs Where the practice seeks to participate in human research activities and/or continuous quality improvement (CQI) activities, patient anonymity will be protected. The practice will also seek and retain a copy of patient consent to any specific data collection for research purposes. Research requests are to be approved by the Practice Principal/ practice partners and must have approval from a Human Research Ethics Committee (HREC) constituted under the NH&MRC guidelines. A copy of this approval will be retained by the practice. Practice accreditation is a recognised peer review process and the reviewing of medical records for accreditation purposes has been deemed as a "secondary purpose" by the Office of the Federal Privacy Commissioner. As a consequence patients are not required to provide consent. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 170 of 260 Insert your logo here Patients should be advised of the ways in which their health information may be used (including for accreditation purposes) via a sign in the waiting room and the practice information brochure. Media Please direct all enquiries to Practice Manger/ Principal. Staff must not release any information unless it has been authorised by the Practice Manager/ Principal and patient consent has been obtained. International Where patient consent is provided then information may be sent overseas however the practice is under no obligation to supply any patient information upon receipt of an international subpoena. NPP9 Transborder Data Flows Disease Registers This practice submits patient data to various disease specific registers (cervical, breast bowel screening etc) to assist with preventative health management. Consent is required from the patient with the option of opting in or opting out. Patients are advised of this via a sign in the waiting area and in the practice’s information leaflet. Telephone Calls Requests for patient information are to be treated with care and no information is to be given out without adherence to the following procedure: Take the telephone number, name (and address) of the person calling and forward this onto the treating doctor/principal or Practice Manager where appropriate, RACGP 3rd edition Standards 4.2.1. RACGP 4th edition Standards 4.2.1 & 3.1.4 & 4.2.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 171 of 260 Insert your logo here 6.3 Request for Access to Personal Health Information Policy Patients at this practice have the right to access their personal health information (medical record) under legislation. Commonwealth Privacy Amendment (Private Sector) Act 2000 and the Health Records Act 2001 (Victoria.) The HRA gives individuals a right of access to their personal health information held by any organisation in the private sector in Victoria in accordance with Health Privacy Principle 6 (HPP 6). This principle obliges health service providers and other organisations that hold health information about a person to give them access to their health information on request, subject to certain exceptions and the payment of fees (if any). Public sector organisations continue to be subject to the Freedom of Information Act 1982. This practice complies with both laws and the National and Health Privacy Principles (NPPs & HPPs) adopted therein. See summary headings of Principles in this section. Both Acts give individuals the right to know what information a private sector organisation holds about them, the right to access this information and to also make corrections if they consider data is incorrect. National Privacy Principles NPP 1: Collection of personal information by an organisation. NPP 2: How an organisation may use and disclose personal information in its possession. NPP 3: Relates to the quality of the data held by an organisation. NPP 4: Organisation must take reasonable steps to make sure the personal information it holds is secure. NPP 5: Requires an organisation to be open about what personal information it holds and its policy on the management of personal information. NPP 6: Relates to access and correction of personal information held by an organisation about an individual, by that individual. NPP 7: The use of identifiers assigned by a Commonwealth Agency. NPP 8: Individuals have the option of not identifying themselves when entering transactions with organisations. NPP 9: Regulates the transfer of personal information held by an organisation in Australia. NPP10: Limits on when an organisation is permitted to collect sensitive information. As adopted within Commonwealth Privacy Amendment (Private Sector) Act (2000): We have a privacy policy in place that sets out how to manage health information and the steps an individual must take to obtain access to their health information. This includes the different forms of access and the applicable time frames and fees. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 172 of 260 Insert your logo here Reports by Specialists This information forms part of the patient's medical record, hence access is permitted under privacy law. Diagnostic Results This information forms part of the patient's medical record, hence access is permitted under privacy law. Note: Amendments to the Privacy Act 1998 apply to information collected after 21st December 2001, however they also apply to data collected prior to this date provided it is still in use and readily accessible. We respect an individual's privacy and allow access to information via personal viewing in a secure private area. The patient may take notes of the content of their record or may be given a photocopy of the requested information. A GP may explain the contents of the record to the patient if required. An administrative charge may be applied, at the GPs discretion and in consultation with the Privacy Officer, e.g. for photocopying record, X-rays and for staff time involved in processing request. Procedure A notice is displayed in our waiting room and on our web site advising patients and others of their rights of access and of our commitment to privacy legislation compliance. An information brochure is also available that provides further details if required. Release of information is an issue between the patient and the doctor. Information will only be released according to privacy laws and at doctor's discretion. Requested records are reviewed by the medical practitioner prior to their release and written authorisation is obtained. Request Received When our patients request access to their medical record and related personal information held at this practice, we document each request and endeavour to assist patients in granting access where possible and according to the privacy legislation. Exemptions to access will be noted and each patient or legally nominated representative will have their identification checked prior to access being granted. A patient may make a request verbally at the practice, via telephone or in writing e.g. fax, email or letter. No reason is required to be given. The request is referred to the patient's doctor or delegated Privacy Officer. A Request for Personal Health Information form is completed to ensure correct processing. Once completed a record of the request is logged in the Access Register and the form filed/scanned in the patient record. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 173 of 260 Insert your logo here Request by another (not patient) An individual may authorise another person to be given access, if they have the right e.g. legal guardian, and if they have a signed authority. Under NPP 2 Use & Disclosure, a 'person responsible' for the patient (including a partner, family member, care, guardian or close friend), if that patient is incapable of giving or communicating consent, may apply for and be given access for appropriate care and treatment or for compassionate reasons. Identity validation applies. The Privacy Act 1998 defines a 'person responsible' as a parent of the individual, a child or sibling of the individual, who is at least 18 years old, a spouse or de facto spouse, a relative (at least 18 years old) and a member of the household, a guardian or a person exercising an enduring power of attorney granted by the individual that can be exercised for that person's health, a person who has an intimate relationship with the individual or a person nominated by the individual in case of emergency Children Where a young person is capable of making their own decisions regarding their privacy, they should be allowed to do so according to Federal Privacy Commissioner's Privacy Guidelines. The doctor could discuss the child's record with their parent. Each case is dealt with subject to the individual's circumstances. A parent will not necessarily have the right to their child's information. Deceased Persons A request for access may be allowed for a deceased patient's legal representative if the patient has been deceased for 30 years or less and all other privacy law requirements have been met. Ref: Sec 28 Health Records Act. No mention is made of deceased patient’s access in Commonwealth privacy legislation. Acknowledge Request Each request is acknowledged with a letter sent to the patient, confirming request has been received. Send the letter within 14 days or sooner as recommended by the National Privacy Commissioner. Acknowledgment will include a statement concerning charges involved in processing the request. Fees Charged Discuss with the individual what information they want access to, and the likely fees, before undertaking their request for access. The fees which an organisation can charge for providing access must not be excessive and must not apply to the mere lodgment of a request for access. National Privacy Principle (NPP) 6.4 Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 174 of 260 Insert your logo here aims to prevent organisations from using excessive charges to discourage individuals from making requests for access to their medical records. If an organisation incurs substantial costs in meeting a request for access, then the organisation could charge a reasonable fee to meet the administrative costs involved. For example, an organisation could recover some of the costs of photocopying or of the staff time involved. Collate & Assess Information Retrieve patient's hardcopy medical record or arrange for the treating doctor or practice principal to access the computer record. Refer to the patient request form to help identify what information is to be given to the patient. Data may be withheld under privacy legislation NPP6 Access & Correction for the following reasons. where access would pose a serious threat to the life or health of any individual where the privacy of others may be affected if a request is frivolous or vexatious if information relates to existing or anticipated legal proceedings if access would prejudice negotiations with the individual if access would be unlawful where denying access is required or authorised by law See National Privacy Principles in full for comprehensive list of exclusions. Access Denied Reasons for denied access must be given to the patient in writing. Note these on request form. In some cases refusal of access may be in part or full. Use of Intermediary When Access Denied If request for access is denied an intermediary may operate as facilitator to provide sufficient access to meet the needs of both the patient and the doctor. Provide Access Personal health information may be accessed in the following ways: view and inspect information view, inspect and talk through contents with the doctor take notes obtain a copy (can be photocopy or electronic printout from computer) listen to audio tape or view video information may be faxed to patient check Identity of Patient Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 175 of 260 Insert your logo here ensure a visible form of ID is presented by the person seeking access. E.g. driver's lecence, passport, other photo identification. Note details on request form. does the person have the authority to gain access? Check age, legal guardian documents; is person authorised representative? If the patient is viewing the data, supervise each viewing so that patient is not disturbed and no data goes missing. If a copy is to be given to the patient ensure all pages are checked and this is noted in the request form. If the doctor is to explain the contents to a patient then ensure an appointment time is made. Requests to Correct Information A patient may ask to have their personal health information amended if he/she considers that is not up to date, accurate and complete. (NPP 6.5/6/6) Our practice must try to correct this information. Corrections are attached to the original health record. Where there is a disagreement about whether the information is indeed correct, our practice attaches a statement to the original record outlining the patients' claims. Time Frames Acknowledge request - within 14 days. Complete the request - within 30 days RACGP 4th edition Standards 4.2.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 176 of 260 Insert your logo here 6.3.1 Privacy Officer Policy This practice has a designated Privacy Officer who implements and monitors adherence to all privacy legislation in this practice. The Privacy Officer acts as liaison for all privacy issues and patient requests for access to their personal health information. If staff members have any queries concerning privacy law i.e. Commonwealth Privacy Act Privacy Amendment (Private Sector) Act 2000 or Victorian Health Records Act 2001 then refer to the Privacy Officer. The privacy officer is responsible for ensuring compliance with relevant Privacy principles and legislation and for developing and maintaining our written protocols. The privacy officer liaises with the person responsible for Computer security and systems. RACGP 4th edition Standards 4.2.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 177 of 260 Insert your logo here 6.3.2 Privacy Audit Policy From time to time or in the event of any issues or complaints relating to privacy matters, this practice conducts a review of privacy policies and procedures. Procedure The Privacy Officer reviews the following items: what is the primary purpose of this practice? what data do we collect and document? NPP1/HPP1 how do we store this information? NPP5 what data do we disclose and to whom? NPP2 when and how do we obtain patient's consent? NPP2/HPP2 Information is collected from hard copy and electronic storage devices and issues discussed with GPs and staff to gain the most current information. National and state privacy laws are referenced with any updates being noted and acted upon. Policy Manual, Patient Access Forms/Register, Brochures and Poster At this time the Practice policy & procedure manual may be reviewed and updated for privacy items, if not already done. Forms related to 'Patient Access to Health Information," including request for access and access register forms can also be reviewed at this time. Detailed patient privacy brochures, stating our practice privacy policy in general as per privacy legislation is reviewed and updated as necessary. Obtain additional copies (in English or other languages) or re-print as needed. A general patient privacy wall poster, advising patients of our privacy policy is reviewed and updated as necessary. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 178 of 260 Insert your logo here 6.4 Medical Records Administration Systems The practice team can describe how we correctly identify our patients using 3 patient identifiers, name, date of birth, address or gender to ascertain we have the correct patient record before entering or actioning anything from that record. Select the appropriate option for the medical records at your practice, throughout this section. Our practice uses paper based medical records for the storage or management of patient health information. Our practice uses (*Insert name of software) for the storage or management of patient health information. Our practice uses a Hybrid system to manage Patient medical information. This system comprises of paper based records and computer records. (*insert the name of you software program and any cut off dates for paper based records) RACGP 4th edition Standards 3.1.4. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 179 of 260 Insert your logo here 6.4.1 Creating a New Medical Record Once patient name, address, date of birth and related demographic details are received by reception, enter this information into the patient record. It is practice policy where papers files are utilised records contain a patient index number. 6.4.2 Retrieving a Medical Record for a Current Patient Authorised Practice staff retrieve paper records prior to each consulting session or as required. (*Insert procedure utilised at your practice if different). Using the patient’s surname as a key, find the patient number using the patient number index. Go to the medical record filing area and pull out the correct patient record. Insert a trace card in its place; write the patient number, surname, date retrieved and destination (doctor’s name). Computerised patient records are only accessed by authorised doctors and staff via secure login/password. RACGP 4th edition Standards 4.2.1. 6.4.3 Filing Reports (Pathology, X-Ray, Consultant’s etc) Paper based diagnostic test results and other incoming patient correspondence must be dated and passed on to the patient’s treating doctor or Practice Principal, if the doctor is not in on the day, for follow-up. Once the doctor has actioned and initialled the document it should be followed up accordingly. This practice scans/ does not scan all patient paper based correspondence with copies of this data securely stored. Original copies are retained/ not retained If results are received electronically, they are to be checked by the referring doctor or Practice Principal daily, and the appropriate action box marked. The doctor will ensure that the action is completed. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 180 of 260 Insert your logo here 6.4.4 Errors in Medical Record If an error occurs in the paper medical record, then it is corrected by crossing through as a single line for the course of the entry, initialled and dated by the author with an explanatory note beside or below the original item. Thus the reason for the incorrect entry is clearly documented with the new entry underneath or in the next available position. The new entry is signed or initialled and dated. Liquid paper/whiteout is not used in the medical record. Corrections in the electronic record should be recorded by referring to the date of the original entry and the associated amendment. Refer to NPP6/HPP6 Access & Correction, which refers to the patients right’s to have their personal health information amended if he/she can establish that it is not accurate, complete, misleading or up to date. 6.4.5 Allergies & Alerts Alert notification may be required for allergic responses, drug reactions, and previous aggressive behaviour or guardianship/custody arrangements. It is practice policy to ensure that all patients have their allergic status recorded especially any allergies to medications to facilitate safer prescribing. In computer based records “no known allergies” is recorded in the absence of any allergies to note. Alert notifications are documented in the electronic medical record Health Summary. Alerts are also noted on the front cover of the paper based medical record. RACGP 4th edition Standards 1.7.2. 6.4.6 Back Up of electronic medical records In order to avoid lengthy down time, disruption, and medico-legal issues frequent backups are essential and form a critical component of the practice disaster recovery plan. A formal policy for the back up of the practice computer systems must be in place. (Refer 6.1.1 Computer Information security) RACGP 4th edition Standards 4.2.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 181 of 260 Insert your logo here 6.4.7 Retention of Records and Archiving Patient Health Records must be kept until the patient is 25 years of age, if a child, or a minimum of 7 years following the last year of the patients attendance, whichever is greater. This Practice retains paper medical records for a minimum of (*Insert) years. Inactive electronic patient records are retained indefinitely or as stipulated by the relevant national, state or territory legislation. Patient accounts records are also retained for a minimum of 7 years. Records of Drugs of Addiction stock and administration must be retained for a minimum of 3 years. Sterilisation Cycle records and evidence of vaccine fridge temperature monitoring are retained as per patient health records. Where our patients have chronic conditions or genetic diseases, or at the doctors discretion their records are kept for (*Insert) years. Records of patients that have been sought for legal purposes are retained for (*Insert) years. Records of deceased patients are kept for (*Insert) years following the year of death. Outdated paper based test results that no longer have clinical relevance are culled to assist with storage. This is done in consultation with the medical defence organisations and in compliance with state legislation. The practice has a process in place to allow for the timely identification, of information to be culled, stored or archived and to enable timely retrieval of paper based patient health records. Procedure (*This is an example of one way to do this, please insert the protocol relevant to your practice below.) Prior to filing a medical record, reception staffs mark record cover with the current year of attendance. The doctor will advise staff via a note on the front cover of the medical record of the number of years it is to be held if special criteria applies. Staff identify the record to ensure it is held permanently. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 182 of 260 Insert your logo here Deceased records are marked, “DECEASED” on the record and filed in the Deceased section of the inactive file storage area. Annually, a record cull is conducted for old records not accessed within the last two years. These records are removed from active file and filed in the inactive file area. Patient’s accounts records are culled after each End of Financial year. Privacy will be maintained during the destruction process to ensure information contained in the records is not divulged or seen by unauthorised persons. Records will be destroyed by shredding or pulping, in a secure environment. Where an outside bureau undertakes this task, the Practice manager retains a copy of the contract with the bureau and any certificates of destruction. We consult with our GPs’ medical defence organisations when deciding on the practice’s policy with respect to the retention of records or when we are unsure about culling or archiving medical information. RACGP 4th edition Standards 1.7.1 & 4.2.1 & 4.2.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 183 of 260 Insert your logo here 6.4.8 Transfer of Medical Records Policy Transfer of medical records from this Practice can occur in the following instances: for medico-legal reasons e.g. record is subpoenaed to court. when a patient asks for their medical record to be transferred to another Practice, due to moving residence or for other reasons. where an individual medical record report is requested from another source. where the Doctor is retiring and the practice is closing. Our practice team can describe the procedures for timely, authorised and secure transfer of patient health information to other providers and in relation to valid requests. Procedure Requests for Transfer of medical records for medico legal reasons Receiving a request to transfer medical records to a patient’s new clinic In accordance with state and federal privacy regulations, a request to transfer medical records must be signed by the patient giving us authority to transfer their records. The request form should contain: the name of the receiving practitioner or practice. the name, address (both current and former if applicable) and date of birth the patient whose record is required. the reason for the request. When fulfilling a request, this practice may choose to either prepare a summary letter (manually or via clinical software) and include copies of relevant correspondence and results pertinent to the ongoing management of the patient. make a copy of the medical record and dispatch the copy to the new Practice, retaining the original on site for a minimum of 7 years. The requesting clinic is advised if we propose to transfer a summary or a copy of the full medical record. If they have a preference the format can be negotiated or they can choose not to proceed with the transfer and seek a copy through a separate access request. If there is going to be any expenses related to the transfer the requesting clinic is advised prior to sending the medical records and once the fee has been paid we process the request as soon as possible. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 184 of 260 Insert your logo here Any charges must not exceed the prescribed maximum fee. The patients’ signed request letter/form and a notation that the patient has transferred is made on the medical record. Include the name and address of the new Practice and the dispatch details (e.g. via priority mail or confidential courier or in an electronic form) Electronic data transmission of patient health information from our practice is in a secure format. Note: There are a number of ways the information can be transferred, depending on the request from the patient and clinic: via secure post; encrypted email (if computerised records), or, if the practice is releasing copies of the entire record and the patient requests access (Health Records Act), the practice may wish to make an appointment time with the patient to offer an appropriate explanation and counsel from the GP or as an alternative may choose to supply a summary of the history. All reasonable steps are taken to protect the health information from loss and unauthorised disclosure during the transfer. This practice does not allow individuals to collect the file and take it to their new provider. Making a request for a patient medical record from another source. Access to a new patient’s previous record can assist with maintaining the continuity of care of the patent. When requesting records from another clinic a standard request for transfer of medical records template (see sample below) should be used. This should contain: the patient’s details, the patient should be identified by name address (both current and former if applicable) and date of birth. the reason for request including the name of the Doctor making the request. the request for transfer of patient files should be authorized by the patient. If the files will be requested electronically, specific details of the format needs to be included such as HTML or XML If the clinic advises you that the patients are likely incur out of pocket expenses related to transfer please advise the patient prior to accepting the transferred medical records When a Doctor is retiring and the practice is closing. RACGP 4th edition Standards 4.2.1 & 4.2.2 . Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 185 of 260 Insert your logo here 7 Clinical Management 7.1 Clinical Autonomy Policy Doctors in this Practice are free to make decisions that affect the management of their patients in accordance with accepted clinical judgement, best available evidence and adherence to valid clinical care guidelines. Doctors exercise full autonomy in determining: the appropriate clinical care of their patients. the health professionals including specialists, other general practitioners and para-medical practitioners to whom they refer. the pathology, diagnostic imaging or other investigations they order and the provider they use. how and when to schedule follow up appointments with individual patients. whether to accept new patients provided that this action is non-discriminatory and does not apply to emergencies. GPs and clinical staff of our practice are consulted prior to the scheduling of appointments and the purchase of new equipment and supplies. Feedback is sought from doctors and other staff concerning the use of practice equipment, appointment scheduling and other matters relating to professional autonomy. All members of the clinical team comply with their professional and ethical obligations and practice within the boundaries of their knowledge, skills and competence and their role within the practice team. RACGP 3rd edition Standards 1.4.2. RACGP 4th edition Standards 1.4.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 186 of 260 Insert your logo here 7.2 Clinical Content of Medical Records Policy Patients at our practice have their own individual patient health record containing all the health information held by our practice about that patient. All patients that have attended the practice/service in the last 2 years should have essential information in their health summary and active patients i.e. those attending 3 or more times in 2 years should have a comprehensive health summary. All staff endeavour to keep the information in patients’ health records up to date and where possible data is entered using accepted coding or drop down selections rather than free text to assist with practice audits and chronic disease registers. Care is taken when entering sound alike or look alike medicines, particularly when using the “drop down” boxes in electronic prescribing programs. Medical records are essential to provide evidence of all services billed under the Medical Benefits Schedule (Medicare) and the continuing care of our patients. The contents are confidential and covered by privacy legislation. Doctors and staff have a responsibility to maintain the confidentiality of every medical record, which is each patient’s right. Recording of patient health information should be to the standard that a locum or another doctor could easily and efficiently take over the care of the patient. As a key component for the continuing management of our patients, contemporaneous, legible, accurate and complete records are kept. To ensure optimum documentation of medical care and to meet our legal risk obligations all staff involved in clinical care are able to document their care activities in the medical records logging in using their own password. Training appropriate to their level of access should be provided to all staff recording clinical management in the medical records or utilising the records for clinical management activities e.g. reminder/recall. Our staff are also well aware of the importance of recording the cultural background of patients since this background can be an important indication of clinical risk factors and can assist GPs and other staff in providing relevant and culturally appropriate care. (Refer Section 5 Culturally Appropriate Care). An active patient health record is defined as the record of a patient that has attended the practice/service three or more times in the last two years. Our practice can demonstrate that: at least 75% of our active patient records have a current health summary containing all the required information outlined below. at least 90% of our active patient health records contain a record of known allergies. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 187 of 260 Insert your logo here To assist in the provision of optimum care to patients, our practice integrates with other services. Information, including referral arrangements for these public and private providers, and contact details are maintained on a central register which is accessible to all practice staff. Details of referrals are documented in the patient medical record. The patient health records contain evidence of a system to review and follow up test results. We are working towards a systematic approach to the entry of patient data in the medical records to facilitate the search, extraction and utilisation of patient information for our prevention and screening activities. This includes comprehensive patient health summaries and documentation of preventative activities in the patient’s medical records. Procedure Before accessing or entering information into a patient’s health record we check for three approved patient identifiers (full name, DOB, address) to ensure we have the correct patient matched with the correct health record. (Refer section 7 Patient Identification). Each patient has a dedicated individual medical record containing all health information held by us about that person. The record incorporates: the patients full name, DOB, address and gender (or additional information to assist with correct patient identification). where appropriate patient contact and demographic information. medical history. clearly visible documentation of any allergies. a health summary. an updated problem list. progress or consultation notes (including care outside normal opening hours and home visits). clinical correspondence including referrals made and letters or other responses received including pathology, X-ray. documentation of telephone calls, home and hospital visits and after hour’s communication and visits. it may also contain other relevant information such as WorkCover or insurance information or legal reports. The active patient health records also demonstrate that the practice routinely records: aboriginal and Torres Strait Islander status. the person the patient wishes to be contacted in an emergency (Not necessarily the next of kin). and that we are working towards recording the cultural backgrounds of all our patients. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 188 of 260 Insert your logo here (*Delete as appropriate) Option 1 Our practice has an active hybrid medical record system, and there is a record made in each system for each consultation or interaction indicating where the clinical notes are recorded. (Retain option 2 & 3). Option 2 Our practice medical Information is placed in an A4 record cover and filed in order. Written medical records should not be altered by “whiting out” but corrections made by crossing out and re-writing with time and date of alteration if not done contemporaneously. (Delete other options). Option 3 Information is stored electronically in the practice’s computer system Computerised medical records should be alterable only if an audit trial is automatically kept by the system otherwise once created a lock-out facility must apply and any corrections made by recording additional information separately. (Delete other options). Doctors, Practice Nurses, allied health practitioners and authorised students of this Practice are responsible for documenting the care provided by them to their patients. Reception and practice management staff are responsible for documenting significant phone contacts and evidence of attempting to contact patients. Plans for the management of patients with complex or chronic conditions, that are consistent with best available evidence, are documented in the patient’s health record to ensure there is a consistent and co-ordinated approach to care between the Doctor/s, Practice nurse/s and other allied health care workers. Patient health records also document the role the patient takes in their health care & evidence that education and counselling on illness prevention is provided. Where the person making the entry is not identified by an electronic log in, entries are identified by initials or name and date e.g. scanned documents or notes. All entries must be able to be read and understood by another practitioner should they need to review or take on the patients care. This includes scanned documents. Medical records should be in ink or on the computer and only standard common abbreviations are used. Information in the medical record is not prejudicial, derogatory nor irrelevant and is legible, being able to be read by other health care practitioners for the ongoing management of the patient. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 189 of 260 Insert your logo here Consultation notes Each of our patient health records contains sufficient legible and understandable information about each consultation to allow another member of our clinical team to safely and effectively carry on the management of the patient. Reports or notes of consultations occurring off-site, such as to home visits or after-hours, whether by or on behalf of our practice, are notated to enable identification of place and time of consultation and the details of the care provided. Important or significant telephone or electronic communication between practice and patient is recorded in the patient health records. At the time of each consultation or as soon as practical or when information becomes available (e.g. test results) the doctor or clinical team member (e.g. nurse) providing the care notes the following details either in the paper record or on the computer: date of consultation who conducted the consultation (e.g. by initial in the notes, or audit trail in an electronic record and qualification if relevant). patient reason for consultation or the problem(s) managed. relevant clinical and examination findings. diagnosis and or differential diagnosis. recommended management plan and, where appropriate, expected process of review. any medicines prescribed for the patient (including name, strength, directions for use/dose frequency, number of repeats and date medicine started/ceased/changed). complementary or over-the-counter medicines used by the patient (to minimise drug interactions). any relevant preventive care undertaken. any referral to other healthcare providers or health services. any special advice or other instructions. follow up of any problems raised in previous consultations. that we are working toward recording preventive care status (e.g. currency of immunisation, smoking, nutrition, alcohol, physical activity, blood pressure, height and weight [body mass index]). Referrals The medical records contain evidence of patient referrals to other health care providers such as diagnostic services, hospital and specialist consultation, allied health services, disability and community services and health promotion and public health services and programs. Health Summaries A current up to date patient health summary assists in providing ongoing care, both within the practice and when referring to other health care providers, Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 190 of 260 Insert your logo here Health summaries are developed progressively and need to be accessible during consultations for doctors, nurses and other health care providers who all contribute to keeping them up to date. Care is taken to enter data using accepted coding or drop down selections rather than free text to assist with practice audits and chronic disease registers or CQI activities that require identifying patients with risk factors or particular chronic diseases. 90% or more health records of patients who have attended our practice on a regular basis (3 or more times in the last two years), have their known allergies recorded in the health summary and 75% or more or more have a comprehensive health summary that has been updated to reflect recent important events. It is recommended that GPs clarify a patient’s current medicines list and known allergies art every patient contact and patients on multiple medicines should be provided with the most recent list of their medicines. A Health Summary should contain documentation of: known drug allergies and sensitivities including any adverse medicines events. accurate and current medicines list (include prescription, non prescription and complementary products if known). current health problems/ diagnoses. relevant past health history including immunisations and positive family history of disease. any health risk factors (e.g. smoking, nutrition, alcohol, and physical activity). relevant social history including cultural background immunisation status. Tests and results Pathology results, imaging reports, investigations reports and clinical correspondence received by the practice are reviewed by the GP before being retained in the patient’s medical records. Follow up of clinically significant results is documented in the patient’s medical records. Collecting Information from patients Practice staff provide all new patients with a “New Patient” form and a copy of our “consent for the collection and use of information” for patients to complete and sign. The signed consent forms are scanned into the notes The completed new patient information forms are (*Insert how you transfer this information into the patients Health summary and medical records). Additional information is added to the patient’s medical record during the first and subsequent consultations. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 191 of 260 Insert your logo here The standard indigenous status question asked is ‘Are you of Aboriginal or Torres Strait Islander origin?’ This question should be asked of all patients, irrespective of appearance, country of birth or whether the staff know of the client or their family background. Our practice collects this information as part of our “new patient’ questionnaire. We are also working towards a system whereby patient information is updated regularly so that it remains current and accurate using a standard “update your details form”. (*Insert or describe where a copy of your form/s to obtain patient information are located). RACGP 4th edition Standards 1.7.1, 1.7.2, 1.7.3, 1.1.3, 1.1.4; 1.5.1, 3.1.4 & 5.3.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 192 of 260 Insert your logo here 7.3 Informed Consent Policy Our doctors, nurses and other healthcare workers inform their patients of the purpose, importance, benefits, risks and possible costs of proposed investigations referrals or treatments, including medicines and medicine safety. We believe that patients need to receive sufficient information to allow them to make informed decisions about their care. Our Doctors and staff have a professional obligation to ensure they understand our patients and that the patients understand any verbal or written information. patients who do not speak or read English or who are more proficient in another language, or who have special communication needs are offered the choice of using the assistance of a specialised service to communicate with the Doctor or clinical team members. (Refer section 5 Non English speaking patients). the clinical team uses information that is clear and given in a format that is easy to understand, with verbal information supported by a diagram with explanation, brochure, leaflet or poster, electronic information or website referral. (Refer Section 5 Provision of Brochures, Leaflets and Pamphlets for Patients). the patient’s competence to give consent is ascertained by establishing whether the patient is able to understand, retain and weight the information they have been given to arrive at an informed choice. Such a process is applied to all adults, mature minors (within the Gillick test), intellectually and mentally impaired patients or guardian or power of attorney for the patient. In situations where patients are dependent on a third party for their ongoing care we endeavour to provide all appropriate information to the carer. Issues of personality, personal fears and expectations, beliefs and values are also considered. There is no coercion by our doctors, nurses or other allied health care workers. Our patients can choose to reject their advice or seek a second opinion. Patient’s refusal of treatment is documented in the medical record. (Refer Section 7 Management of a Patient refusing treatment). The cost of treatment or investigations is an important component of informed decision making. Patients are advised of possible costs involved, including additional out of pocket costs, for procedures, investigations and treatments conducted on site prior to them being conducted. For referred services where costs are not known the patients are advised of the potential for out of pocket expenses and encouraged or assisted to make their own enquiries. If the patient indicates that the costs pose a barrier to the suggested treatment or investigation alternatives may need to be discussed (e.g. referral to public services). Patients are asked to be open and are able to feel free to discuss all health issues and proposed treatments, without fear. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 193 of 260 Insert your logo here The Privacy Act 1998 states that consent may be 'express' or 'implied', i.e. Express Consent - clear and unmistakably states, obtained in writing, orally or in any clear other form where consent is clearly communicated. Implied Consent - e.g. patient presents to doctor, discloses health information and this is written down by the doctor/entered on computer during the consultation; e.g. doctor collects specimen and sends it to pathology, reason to consider that the patient is giving implied consent to passing necessary information to the laboratory. See also Sec 6.1 Patient Privacy and Access to Information. Ref: Guidelines on Privacy in Private Sector Oct 2000. Procedure To encourage patients to actively discuss their health care and to help create an understanding of shared responsibility between the patient and our practice we use the publication “10 tips for safer healthcare” to guide our discussion. This is available at www.health.gov.au/internet/safety/publishing.nsf/content/10-tips. Clear communication is provided about the potential for out of pocket costs including any unexpected developments and the possible costs of additional treatments or procedures before proceeding. Consent Forms “Consent for medical treatment, procedure or examination” form attached is used for patient consent to on site health services. The doctor explains the form to the patient and completes it with the patient signature. Written consent does not take the place of the doctor’s personal communication when dealing with the risks benefits and alternatives of the procedure with the patient. This task should never be delegated to office staff and they should direct any questions regarding procedures to the doctor. Office staff may witness a patient’s written consent provided they believe that the patient is competent (not confused or disorientated), acknowledges the conversation with the doctor and that the signature is the patients Where immediate treatment is necessary to preserve a life or prevent serious injury, all attempts are made to provide information and gain the patient’s consent. This may not be successful in all cases prior to administering emergency care. Using a range of brochures, leaflets or written information that is tailored to suit individual patients needs to support their explanation of the diagnosis and management of conditions, including medication safety Doctors, practice nurses and allied health care workers inform patients of the following issues concerning treatment and investigations: Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 194 of 260 Insert your logo here possible nature of illness/disease. proposed approach to investigation, diagnosis and treatment including describing if it is conventional or experimental, common side effects and the clinician undertaking the procedure/treatment. purpose, importance, expected benefits and risks. other options for investigations, diagnosis and treatment. length of procedure/treatment. potential for out of pocket expenses. degree of uncertainty of a) any diagnosis found and b) therapeutic outcome. potential result of not undertaking the specified procedure/treatment or any other treatments. any significant long term physical, emotional, mental, social, sexual, or other outcome which may be associated with a proposed intervention. the costs involved, including out of pocket costs. We recognise that patients need to understand the purpose and importance of medicines and this assists them to comply with the recommended treatment plan. To assist patients to make informed decisions about their medicines or understand any medication safety requirements we support our verbal information with leaflets from the consumer medicines information (CMI) website. These online versions of the information produced by pharmaceutical companies, for consumers are available at www.nps.org.au/consumers. The informed consent process (including use of interpreter), consent form, and details of any information or post procedure instructions provided to a patient are documented in the medical record. Patient consent regarding the expected benefits, possible risks and possible cost is obtained for the following: all procedural interventions on site (written consent). patient’s participation in research projects (written consent). clinical Training Program (by waiting room sign and verbal consent prior to entering the consulting room). third Party observation or participation in patient consultation (by waiting room sign and verbal consent prior to entering the consulting room). Medical treatment or preventative activities (e.g. Childhood Vaccinations or prescribed medications). At the time of childhood immunisations, careful documentation of parental consent needs to be considered, including details of Australian Standard Vaccination Schedule (ASVS) recommendations discussed and parent’s decisions regarding these recommendations. The Practice offers the recommended vaccines for whom they are applicable to, regardless of cost to the client. The decision to accept or reject the vaccine must be made by the parent, after receiving full details of the risks, benefits and costs from the GP or nurse immuniser. RACGP 4th edition Standards 1.2.2 & 1.2.4 & 5.3.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 195 of 260 Insert your logo here 7.4 Referral Protocols Policy Patients are referred for diagnostic testing or to another medical specialist, general practitioner or allied health professional which may be better placed to deliver a service that may benefit the patient. The practice has an up to date written or computerised directory of local allied health providers, community and social services and also local specialists to assist when choosing practitioners to facilitate optimal patient care. This information includes different referral arrangements and how to engage with these providers to plan and facilitate care. Referral documents (i.e. letters and pre-printed forms) to other health care providers are legible and contain relevant and sufficient information to facilitate optimal patient care. This should include at least 3 approved patient identifiers. (Refer section 7 Patient identification) and an accurate and current medication list (Refer section 7 Clinical content of the Medical records). Clinical handover needs to occur when all or some aspects of the patients care is transferred to another provider such as when a patient is referred. Patients are made aware that patient health information is being disclosed in the referral documents. The medical records contain evidence of patient referrals to other health care providers such as diagnostic services, hospital and specialist consultation, allied health services, disability and community services and health promotion and public health services and programs. Patients are made aware that their health information is being disclosed in referral letters and documents. Procedure Suggesting a referral to a particular practitioner or allied health professional carries with it an implicit endorsement that the receiving practitioner or service provider is appropriately skilled and qualified to administer the treatment or service. Generally this is not an issue, but if it is, the referral is qualified (e.g.: if a patient requests a referral to a fringe practitioner the referral could read patient requests referral to you regarding xyz) Our directory of local allied health providers, community and social services and also local specialists is available (*insert how to access this). The patient is given information about the purpose, importance, benefits and risks associated with investigations, referrals or treatments proposed by their doctor to enable the patient to make informed decisions. The doctor may use leaflets, brochures or written Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 196 of 260 Insert your logo here information to support their explanation where appropriate. Clear communications about unexpected developments can assist the patient to understand the need for additional costs. Patients are advised of possible costs involved, including additional out of pocket costs, for procedures, investigations and treatments conducted on site prior to them being conducted. For referred services where costs are not known the patients are advised of the potential for out of pocket expenses and encouraged or assisted to make their own enquiries. If the patient indicates that the costs pose a barrier to the suggested treatment or investigation alternatives may need to be discussed (e.g. referral to public services). Special care is taken to advise patients of the costs of consultations or procedures that do not attract a government subsidy. Letters of referral may be paper or computer based. Referrals sent electronically should be encrypted. Plain paper or practice letterhead is considered appropriate stationery. Routine use of drug company notepads or prescription pads is unacceptable. For medico legal and clinical reasons practices need to keep copies of important (non-routine) referral letters in the patient health record. In the case of an emergency or other unusual circumstance a telephone referral may be appropriate. A telephone referral needs to be documented in the patient’s health record. Referral letters should: be legible (preferably typed) on appropriate practice stationary. contain relevant background social information and history. contain the present problem and reason for the referral and additional relevant or sufficient information for continuing health management and to avoid duplication. include relevant health problems, key examination findings and current management. include any allergies, adverse drug reactions and a current accurate medications list. include the reason/purpose for the referral and expectation of the referral. identify the Doctor or clinical staff member making the referral. identify the setting from which the referral is being made and also the setting to which the referral is being sent. if known, identify the healthcare provider to whom the referral is being made be dated. contain at least 3 of the approved patient identifiers e.g. name, date of birth and address. be electronically transmitted in a secure manner if appropriate. Requests for pathology, diagnostic or other investigations should: be legible. contain relevant clinical information. contains at least 3 of the approved patient identifiers e.g. name, date of birth and address. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 197 of 260 Insert your logo here For medico-legal and clinical reasons copies of any clinically significant referral letters, pathology, diagnostic or other investigation requests and especially those which contain significant clinical details, are retained by the practice and documented in the patients medical record. a copy of all significant or non-routine referrals is kept in the medical record through the use of NCR pads, photocopying or electronically on the computer. results of referrals and continuation notes or letters received from consultants and hospitals are also retained in the patient health records. Clinically significant referrals are followed up. Patients seeking a further clinical opinion from another healthcare provider are encouraged to notify their General practitioner to allow an opportunity to reinforce any potential risks of the decision. Any advice or actions taken when a patient seeks a further clinical opinion, or refuses recommended clinical management are documented in the patients’ health record.. RACGP 4th edition Standards 1.2.4 & 3.1.4 & 1.5.2 & 1.6.1 & 5.3.1 & 1.6.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 198 of 260 Insert your logo here 7.5 Clinical Handover Policy Clinical handover has been defined by the Australian Medical Association as ‘the transfer of professional responsibility and accountability for some or all aspects of a patient’s or a group of patients’ care to another person or professional group on a temporary or permanent basis’. Failure or inadequate handover of care is a major risk to patient safety and a common cause of serious adverse patient outcomes. It can lead to delayed treatment, delayed follow up of significant test results, unnecessary repeat of tests, medication errors and increased risk of medico legal action. Clinical handover communications can be face-to-face, written, via telephone and also by electronic means. All staff are informed about our policy on clinical handover to ensure standard processes are followed. Clinical handover of patient care occurs frequently in general practice both within the practice to other members of the clinical team, and to external care providers. We have standard and documented processes for timely clinical handover with services that provide care outside normal opening hours. Procedure Clinical handover needs to occur whenever there is a change of care providers. Examples of clinical handover include: a GP covering for a fellow GP who is on leave or is unexpectedly absent. a GP covering for a part time colleague. a GP handing over care to another health professional such as a practice nurse, physiotherapist, podiatrist or psychologist. a GP referring a patient to a service outside the practice. a shared care arrangement (e.g. team care of a patient with mental health problems). When appropriate, the clinical handover is documented in the consultation notes including that the patient has shared in decision making and has been informed. Written or verbal clinical handover between GPs occurs on a formal arranged basis when doctors cover for those working on a sessional basis or when a GP or other clinical staff member is away because of annual leave or illness. In addition to a formal handover, adequate clinical records, including a health summary, enable the routine care of patients to Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 199 of 260 Insert your logo here continue. Practitioners relieving for another should read the patient’s preceding clinical records. Our practice recognises that an accurate and current medication list helps to minimize errors and promote safety when clinical handover occurs. Patients with multiple medications may be provided with a copy of their medication list and encouraged to show the list to other providers of health care. Clinical handover of a patient’s care outside the practice occurs in many ways. It includes but is not limited to: referral for an investigation, referral to an ancillary healthcare provider, referral to a specialist and referral to a hospital, as an outpatient or as an in-patient. Referral letters include sufficient information to facilitate optimal patient care, including details of the purpose of the referral and clarification of who will manage the follow up of investigations. The practice should ensure that sufficient information is provided to the emergency department about the clinical condition of an inbound patient, to facilitate prompt and appropriate care. This may be directly to the ambulance service or to the hospital. We have arrangements in place with our pathology service to ensure abnormal and life threatening results identified by pathology outside normal opening hours can be conveyed to a medical practitioner in a timely way. Where complex or high risk patients, such as suicidal patients, or patients on complex medication regimens are handed over to another provider for all or part of their care, it is important for the handing over provider to request notification if the new provider ceases to care for the patient. Equally, a provider treating a patient on a handover basis has an obligation to notify others in the treating team if they stop seeing the patient. (This issue has been the subject of several coroners’ recommendations). Our doctors notify the deputising care provider of patients that they anticipate may need care and ensure the deputising service has a defined means of timely contact with the GP or another from the practice who is aware of the patient’s condition should they need to access more detailed health information. Deputising services are responsible for handing the care of a patient back to the patient’s regular medical practitioner in a timely and appropriate manner. When errors in clinical handover occur, every member of the practice team is encouraged to report the incident, so the event can be analysed and processes introduced to reduce the risk of a recurrence and harm occurring to other patients (Refer to section 3.1.2 Incidents and Injuries and Adverse Patient events). RACGP 4th edition Standards 1.5.2 & 5.3.1. 7.6 Patient Identification Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 200 of 260 Insert your logo here Policy Correct patient identification is vital for patient safety and the maintenance of patient confidentiality. Our patients are correctly identified at each encounter with our practice team using 3 approved patient identifiers. All members of the practice team are trained in how to correctly identify a patient using 3 identifiers. Procedure Approved Patient identifiers include: patient name (Family and given name) date of birth gender (as identified by the patient themselves) address patient record number (where it exists) Patients identification using 3 approved identifiers should be established or confirmed: when making an appointment or checking off arrival at the practice when commencing the consultation or treatment or investigation when opening or entering data into the medical records when a clinical handover occurs at the interface of care by different providers. when confirming signed consent for medical treatment when following up test results or communicating with the patient, especially by electronic means. when managing the patients treatment without the patient attending the practice e.g. ordering repeat prescriptions on referral documentation When asking for patient identification practice staff should ask the patient to state their name, date of birth and address. Staff should not volunteer the information from the records and ask the patient to confirm as nervous or hearing impaired patients may agree and verify incorrect information. When patients are noticed to have similar names or other identifiers (e.g. DOB), a notation is entered in the medical record to flag this. It is important to ensure the correct patient gets the correct procedure. A useful resource for GPs undertaking procedural work and minor surgery, is the Ensuring Correct Patient (3 identifiers) , Correct Site, Correct Procedure Protocol from the Australian Commission on Safety and Quality in Health Care, or an equivalent protocol that incorporates these five steps. www.safetyandquality.org/5stpcorectpatnt.pdf. An Incident form is completed when any errors in patient identification are noted (Refer Section 3 Incidents, injury and adverse patient events) RACGP 4th edition Standards 3.1.4 & 5.3.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 201 of 260 Insert your logo here 7.7 Follow up of Tests, Results and Referrals Policy Our practice’s system for the follow up of tests, results and referrals has a strong focus on risk management. Our practice team can describe: how patients are advised of the process for follow up of results. the system by which pathology results, imaging reports, investigations reports and clinical correspondence received by our practice is reviewed by a GP, signed, acted upon in a timely manner and incorporated into the patient’s medical record. how we follow up and recall patients when we order important or clinically significant tests, investigations or important referrals. how we follow up and recall patients with clinically significant tests, results or correspondence. All test results, including pathology results, diagnostic imaging and investigation reports, and clinical correspondence received is reviewed, initialled (or electronic equivalent) and, where appropriate acted upon in a timely manner. This is all incorporated into the patient health record. The nature and extent of the practices responsibility for following up test results, diagnostic imaging and investigation reports, and clinical correspondence/referrals depends on what is reasonable in the circumstance and the clinical significance of the test, referral or result. Whether something requires follow up is determined by: the probability that the patient will be harmed if follow up does not occur. the likely seriousness of the harm. the burden of taking steps to avoid the risk of harm. Important referrals for consultations or tests ordered are followed up, by the patient’s doctor or delegated authority, in a timely manner. This may include checking the patient has attended the referred consultation or the expected investigation. That correspondence or test results have been received and reviewed. A record of any follow up and subsequent actions or recall process is incorporated into the patient health record. Results of tests and investigations requiring follow up can be “abnormal” or “normal”. Correspondence from referred specialists and other health providers may also need to be followed up. The clinical significance needs to be considered in the overall context of the patients presenting problem and history. There is a system to enable the practice to determine that: ordered tests and investigations were actually performed. results/reports have been received by the practice. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 202 of 260 Insert your logo here results/reports or correspondence were seen by a General Practitioner, dated and signed (or the equivalent if in an electronic patient health record). results/reports/correspondence has been filed in the patient’s record. results/reports/correspondence have been acted upon, in a timely manner where appropriate. results/reports have been reported to the patient (or where this did not occur, that attempts were made to do so). any follow up required has occurred. this is documented in the patient records or similar. Sometimes our doctors may need to be contacted outside normal working hours by the pathology service about a serious or life threatening result. We have provisions for Doctors to be contacted after hours for life threatening or urgent results. Refer to Section 5 After Hours Service. Our patients (or their carers) are made aware of their obligations and responsibilities for their own healthcare. This includes being informed about how to obtain their results and the seriousness of not attending for ordered appointments/investigations and any recall or subsequent follow up. Where appropriate this advice may be documented in the patient’s medical records. Where a patient indicates they do not intend to comply with a recommended test or referral the patient is deemed to have refused medical treatment or advice and is managed according to the practice procedure for a patient refusing treatment or advice. In addition to an appreciation of the need for timeliness when following up and actioning referrals, tests and results our staff members are also aware of the need for confidentiality and discretion, with regard to referrals, diagnostic tests and results or correspondence. Procedure (The procedures used by general practice to review, follow up and recall patients are complex and varied. The system needs to be designed in a way that anticipates that individual cases will require different levels of follow up depending on the clinical significance or importance of the case. *Insert the Procedure or outline the process that occurs in your individual practice. Some prompts have been provided below to assist. When ordering diagnostic tests: how do you ensure requests for tests, investigations or referral correspondence is correctly identified to assist with ensuring the results from any test ordered are matched up with the correct patient. how do you encourage patients to make an informed decision about the investigation, referral or test. Refer to Section 7 Informed Consent & Section 7 Referral protocols. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 203 of 260 Insert your logo here how do you advise patients about: o the significance of the investigations, results or referral & any costs. o how to obtain results and who is responsible for follow up. Review of all results, reports and clinical correspondence received what is the role of staff receiving and filing these? how do you demonstrate they have been reviewed by a doctor before filing/scanning or saving these in the medical records. Consider actions for electronic, faxed, posted, verbal results. how do you ensure the results for Doctors not on duty are reviewed and followed up in a timely manner e.g. allocate another Doctor to do this. how do you ensure any urgent results are communicated to the practice or a Doctor in and outside opening hours? how do you follow up normal and/or abnormal results? Normal results may still require further investigation or patient follow up. how does the doctor reviewing the results, reports or correspondence know they are important or clinically significance. Especially if these were ordered by another Doctor. how does the Doctor clearly communicate in writing with reception/nursing staff any action delegated and the urgency or expected timeframe? Communicating with patients about tests, results and referrals how do patients get their results? how do you inform patient about the expected timeframe for getting tests or investigations or appointments with specialists or allied health providers. do patients know about how and when to get their results. Do you make an appointment for them? how do you maintain privacy if a patient calls about a test, investigation, report or result, e.g. Patient identification required, who speaks to the patient or decides when this is appropriate. how do you confirm they have been notified of their results? consider documenting the content of discussions with the patient in the health record. Identification for follow up of clinically significant investigations and referrals that have been ordered how do your doctors identify when referral, tests or investigations ordered are clinically significant. how are received clinically significant results, reports or correspondence identified? how do you follow up tests, reports, results, correspondence that are expected, but have not been received e.g. Recall system how do you define or know what is a timely manner to expect a response or start to follow these up how do you differentiate the level of follow up required Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 204 of 260 Insert your logo here What is your system to recall patients with clinically significant results, reports and clinical correspondence? how do you contact recall patients e.g. phone calls at different times/numbers. Letter - registered mail or other electronic communication. how do you determine urgency and timeliness? how do you ensure the patient makes and attends any follow up medical appointments? how do you document your follow up and subsequent actions in the patients health record for medico legal reasons. RACGP 4th edition Standards 1.1.4, 3.1.4, 1.5.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 205 of 260 Insert your logo here 7.8 Reminder Systems for Preventative Care Policy For the continuing management of our patient’s health we utilise a systematic reminder system to provide health promotion, preventative care and early detection of disease. Our system is based on the best available evidence and where possible incorporates clinical guidelines. All members of the practice team participate in CQI and PDSA activities to improve our systematic approaches to health promotion and prevention of disease. Where opportunities exist we also coordinate with other health professionals and key agencies to achieve health promotion and preventative care objectives. Our reminder systems and notifications are mindful of protecting the privacy and confidentiality of patient information and we consider the needs of patients with a physical or intellectual disability. We also consider our responsibility to patients if we cease or significantly change our reminder systems. We are working towards a systematic approach to the entry of patient data in the medical records to facilitate the search, extraction and utilisation of patient information for our prevention and screening activities. This includes comprehensive patient health summaries and documentation of preventative activities in the patient’s medical records. Consideration of patient’s individual circumstances is encouraged when providing information about health promotion and illness prevention for patients (and carers). Verbal and written information is provided to patients about health promotion and specific disease prevention. This is distinct from the education and information that is provided to patients to support a diagnosis and choice of treatment. Procedure Patient presentations at the practice are used as an opportunity to identify risk factors and provide health promotion and illness prevention. pamphlets and brochures from a variety of sources are available for patients to self select or to be provided by staff to reinforce health promotion messages from a consultation. patients are encouraged to self identify information that is recorded on the health summary to assist with early identification of the patients main health issues or risk factors e.g. Aboriginal and Torres Strait Islander or family medical history. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 206 of 260 Insert your logo here clinical data is routinely and opportunistically collected by members of the clinical team and this is entered into the medical records in a manner that assist with data extraction for preventative activities. doctors seek the patient's consent before placing their details on a formal reminder system for preventative care. This consent is documented in the patient’s medical record. patients are advised of the availability of reminder systems and how to opt out via the practice information brochure or notice board the patient’s privacy and confidentiality is protected and patients are notified in writing when reminder systems which they participated in are discontinued. (*insert the procedural details of how your practice identifies patients and administers your reminder system.) You may want to include the following: an outline of the roles of administrative and clinical staff, how you select patients, how you collect information e.g. health assessments, self identification of risk factors how you document and record information e.g. Software fields to use, specific coding how you search clinical data e.g. any data extraction tool used, list any screening programs you participate in e.g. bowel cancer screening program, list any registers you provide data to e.g. ACIR for immunisations, how you ensure all staff are aware of preventative activities, samples of letters, and list specific risk factors or diseases you target RACGP 4th edition Standards 1.3.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 207 of 260 Insert your logo here 7.9 Notifiable Diseases Policy National Privacy Principle 5 requires our practice to have a document that clearly sets out its policies on handling personal information, including health information. This document, commonly called a privacy policy, must be made available to anyone who asks for it and patients must be informed about how their health information will be used including other organisations to which the practice usually discloses patient health information and any law that requires the particular information to be collected. Patient consent to the handling and sharing of patient health information should be provided at an early stage in the process of clinical care. Under the Health (Infectious Diseases) Regulations 2001, Medical Practitioners are to report specified infectious diseases to the Department of Human services. | The diseases are classified into groups (A, B, C & D) and listed on what to notify and how to notify information can be located at: www.health.vic.gov.au/ideas/notifying/whatto.htm Procedure Step 1 Immediate notification by phone. (Mandatory for Group A diseases) Notify Group A diseases by phone immediately at the time of initial or presumptive diagnosis. These are bolded on the form and marked with a symbol. Priority number: ph 1300 651 160 Advice regarding appropriate additional precautions to implement, while waiting for patient transfer to hospital, should be sought for each case For urgent notifications outside office hours, please telephone the departments after hours service on 1300 790 733 and advise the operator that you wish to make an 'urgent infectious disease notification'. Step 2 Written notification (Mandatory for all diseases) Written notification of all diseases is required within 5 days of diagnosis. Group D diseases, include HIV & AIDS, requires using a separate notification form, which is forwarded to the diagnosing medical practitioner with the laboratory confirmation of diagnosis. Group C diseases include STI’s, and to preclude identification of the patient, only the first two letters of the family and given name of the patient and the postcode of the residence are required. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 208 of 260 Insert your logo here Patient consent is not required but they should be informed that their condition is being reported as required by legislation. (Note that the pathology service also has this requirement). Patient privacy information forms, available from the department, should be given to patients. For certain diseases patients may need to be contacted by the department to obtain more detailed information. Patients will not be contacted without seeking the consent of the notifying doctor prior. RACGP 4th edition Standards 4.2.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 209 of 260 Insert your logo here 7.10 3rd Party Observing or Clinically involved in the Consultation Policy Consent must always be obtained from patients prior to a 3rd Party Observing or being clinically involved in the consultation. This includes medical or nursing students, a person included at the doctor’s request, an interpreter or person to assist with communication, a chaperone, or someone accompanying the patient to the consultation at the patient’s request such as a care rot relative. In some circumstances the patient or the GP may feel more comfortable if there is a chaperone present during the consultation. For medico legal reasons it is recommended to consider offering a chaperone for unaccompanied children. In some cases it may be necessary to provide the 3rd Party with access to the patient’s medical records. Consent may be required. Procedure Ideally we ask the patient to consent to a 3rd Party being present during the consultation when making the appointment and re check that this consent remains upon arrival for their appointment. Record their consent in the consultation notes. A notice is displayed in the waiting room in the case of teaching programs and patients are handed a slip describing the program on arrival then permission is sought and documented. It is not acceptable to ask permission for a 3rd party to be present during the consultation in the consulting room as some patients may feel unable to refuse. For patients requiring the presence of a 3rd party to assist with communication during a consultation, Refer to section 5- Non English Speaking Patients Practice staff are mindful of the particular needs of people with intellectual disabilities who may not be able to provide consent. In such cases a legal guardian or advocate may need to be appointed to oversee the interests of the patient. RACGP 4th edition Standards 1.2.3 & 2.1.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 210 of 260 Insert your logo here Research Projects National Privacy Principle 5 requires our practice to have a document that clearly sets out its policies on handling personal information, including health information. This document, commonly called a privacy policy, must be made available to anyone who asks for it and patients must be informed about how their health information will be used including other organisations to which the practice usually discloses patient health information and any law that requires the particular information to be collected. Patient consent to the handling and sharing of patient health information should be provided at an early stage in the process of clinical care. Policy Research activity, both within the practice and through reputable external bodies is encouraged. Patients consent is essential for involvement in research projects. Whenever any member of our practice team is conducting research involving our patients, we can demonstrate that the research has appropriate approval from an ethics committee. The research protocol, consent procedures and process for resolving problems should be retained by the practice. Research activities are distinct from audits undertaken by the practice as part of Quality improvement activities. Research projects require approval from an Ethics committee but “in house” practice audits do not. When we collect patient health information for quality improvement audits or professional development activities, we only transfer de-identified patient health information to a third party once informed patient consent has been obtained. Privacy and confidentiality is particularly important especially when considering involvement in commercial market research activities. Our practice considers how identifiable their patient information will be using the following: identifiable patient information - by which individual patients can be identified. de-identified patient information - which can not be traced back to the individual potentially identifiable information - could possibly be traced back to individuals or groups of individuals Procedure Research projects involving patient care: must have the explicit and documented written consent of the patient the patient must receive a written and oral explanation about the research and be able to withdraw consent at any time the project must be approved by a relevant human research ethics committee (HREC) established under the NH&MRC guidelines. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 211 of 260 Insert your logo here privacy laws must be adhered to Research Projects involving research or clinical audits using de-identified data should ideally have patients consent. This can be in more general terms such as by waiting room notice or practice information sheet. extreme care must be taken not to allow patient identification from small and/or unusual cohorts. For QA&CPD activities that require the transfer of patient information outside the practice (e.g. NPS activities) we need to: ensure the activity complies with relevant guidelines on QA&CPD (issued by an appropriate specialist medical college) ensure the activity is approved by that college retain a copy of the QA&CPD approval for the activity obtain patient consent if transferring identifiable patient information. transfer data in accordance with the written procedure in Section 6 of this manual ensuring electronic transmission over a public network is encrypted The practice should retain a record of the request for participation in any research project, including the research protocol, consent procedures and process for resolving problems should be retained by the practice. RACGP 4th edition Standards 4.2.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 212 of 260 Insert your logo here 7.12 Management of a Patient Refusing Treatment or Advice Policy This practice takes an active approach to ensure the best outcomes for patients at all times even if they choose to reject investigation and/or management advice. Our practice endeavors to help our patients understand the importance of medicines and treatment advice to help them make informed decisions about their health care. Our clinical team can demonstrate how we provide care for patients who refuse a specific treatment, advice or procedure. Procedure Staff and doctors are to respect the right of all patients to make investigation and treatment choices or to seek a further clinical opinion. Patients should be advised to notify the doctor or nurse if they want to refuse a specific advice or procedure. An appropriate risk management strategy to be followed includes ensuring that: the patient has been provided with the full range of options available, including the risks and benefits of each to enable them to make an informed choice. the consequences of the choices made are explained including those of non-investigation and treatment. the patient is offered continued monitoring, support or timely referral appropriate to their choices. This may be to another GP within our practice or to another practice. full documentation of the actions taken above and any referrals (including dates) to other care providers in the medical record is essential. RACGP 4th edition Standards 2.1.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 213 of 260 Insert your logo here 7.13 Refusal to Treat a Patient Policy The practice or individual clinical team members have the right to refuse to treat patients in defined circumstances and ensures arrangements are made for the timely transfer of the patients care to another member of the clinical team in our practice or to another practice. Procedure Any refusal to treat a patient is done for substantial reasons not based on discrimination (gender, sexual preference, religion, race, illness type) Patients in emergency situations will always be treated to the best of our ability. Emergency medical treatment is defined as treatment that is necessary to: save a patient’s life prevent serious damage to health prevent or alleviate significant pain or distress Reasons that may give rise for a GP or other member of the clinical team to no longer consider it appropriate to treat a particular patient include breakdown in the doctor patient relationship, patient threats or aggressive behaviour, overloaded practice or patients with conditions outside the range treated by the doctor An appropriate risk management strategy to be followed includes ensuring that the patient has been provided reasons why they cannot have ongoing treatment at this clinic. the patient has been provided with alternative possible treatment locations and written referral if appropriate. any complaints that may arise are dealt with according to the complaints procedure. full documentation of the actions taken above in the medical record is essential. Our practice will endeavor to assist such patients with ongoing care including referral to other health care providers and transfer of any medical history. RACGP 4th edition Standards 2.1.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 214 of 260 Insert your logo here 7.14 Practice Equipment Policy The medical equipment, furniture and resources of this practice are appropriate and adequate to ensure: comprehensive primary care and resuscitation patient, staff and visitors safety. Any legislative requirements are met and complied with. We maintain a register of equipment which includes the scheduling requirements for service or maintenance. Any maintenance and calibration requirements are undertaken on a regular basis in accordance with the manufacturer’s instructions to ensure the equipment is maintained in good working order. Our staff are informed and educated about any relevant standards or guidelines relating to the operation or use of specific practice equipment. Procedure Practice staff members are instructed in the use of the practice equipment to ensure equipment is used and maintained in a competent manner. Electrical safety checks and biomedical checks are performed annually or as required. Maintenance, repairs, electrical and biomedical checks are documented in the equipment register. This register is retained as proof of the practices quality control and preventative maintenance program. Furniture used by the staff and in the patient waiting areas is maintained in good condition, is ergonomically effective and can be easily cleaned and wiped down. RACGP 4th Edition Standards 5.2.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 215 of 260 Insert your logo here 7.14.1 Medical Equipment and Resources Policy The practice has all basic equipment and emergency drugs expected in a general practice. The practice ensures that these are maintained, safe and in a serviceable condition at all times. The available equipment is sufficient for the procedures commonly performed within our practice and meets the needs of our patients. Our practice maintains our key equipment according to a documented schedule Members of the clinical team are consulted about the equipment and supplies the practice uses or purchases. Procedure The practice has the necessary medical equipment to ensure comprehensive primary care and resuscitation, including the following: auriscope blood Glucose monitoring equipment disposable syringes and needles equipment for resuscitation, equipment for maintaining an airway (including airways for children and adults), equipment to assist ventilation (including bag & mask), IV access, and emergency medicines examination Light eye examination equipment (e.g. fluorescein eye staining) gloves (sterile & non-sterile) height measurement device at least one height adjustable patient examination couch measuring tape monofilament for sensation testing (10g Nylon) ophthalmoscope oxygen patella hammer peak flow meter or Spirometer scales spacer for inhaler specimen collection equipment sphygmomanometer (small, med and large cuffs) stethoscope surgical Masks thermometer torch Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 216 of 260 Insert your logo here tourniquet urine testing strips vaginal Specula visual acuity charts x Ray viewing facilities Our practice has timely access to a spirometer electrocardiograph (*insert description of your arrangements for timely access to Spirometery & ECG if it is not located in your practice). (* Insert any additional equipment the practice may have depending on the type of practice and the interests and requirements of the doctors & the maintenance of such equipment. E.g. defibrillator). Relevant staff are trained in the care, use and maintenance of equipment and where appropriate to analyse and interpret any results. Liquid Nitrogen and oxygen are hazardous materials and are therefore stored securely and staff are trained in their safe use. Maintenance schedule Key clinical equipment is present and in working order and is appropriately maintained in accordance with the maintenance schedule recommended by manufacturer and checked regularly by suitably trained practice staff. (*insert you practice equipment maintenance sheet) RACGP 3rd Edition Standards 5.2.1. RACGP 4th Edition Standards 1.4.2 & 5.2.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 217 of 260 Insert your logo here 7.14.2 Doctor’s Bag Policy All of our doctor’s have access to a fully equipped Doctor’s Bag for emergency care and routine off site visits. When not in use the doctor’s bag is stored securely. In some instances doctors may share a doctor’s bag or items may be kept in two smaller bags. Required items may be added to the bag prior to use to avoid doubling up on equipment. The practice nurse, in conjunction with the Doctor regularly reviews the contents of doctors the bags and in addition to checking the condition and expiry date of equipment, consideration is given to the addition of any items depending on the practice location, clinical conditions encountered, the shelf life and climatic vulnerability of various medications and the size of the bag. Where doctors’ bags are shared, the arrangements are reviewed on an ongoing basis to ensure that doctors have access the bag when required. Additional bags are purchased if required. Sensible security measures are taken at all times and any relevant legislation or regulations relating to S8, S4 and drugs of dependence are adhered to. (Refer section 7 Drug Storage, supple and administration) In addition to containing the required equipment the bag also contains the recommended medications. Additional items and medications may also be added after consideration of the clinical conditions likely to be encountered. The contents of our Doctors Bag are checked regularly to ensure items remain in date and are restocked and medication administration records are maintained. (Refer section 7 Checking and rotating medical supplies) Procedure When attending an off site consultation or emergency each doctor has a fully equipped Doctor’s Bag containing: auriscope disposable gloves equipment for maintaining an airway in both adults and children in date medicines for medical emergencies opthalmoscope practice stationary (including prescription pads and letterhead) sharps container Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 218 of 260 Insert your logo here sphygmomanometer stethescope syringes and needles in a range of sizes thermometer tongue depressors torch Each doctor maintains the Bag by replacing used items and maintaining the dangerous drug register including keeping the supplies of drugs at optimum levels. Three monthly reviews of Bag’s contents are undertaken by the Practice Nurse in conjunction with the doctor. The bag contents, including equipment and stock levels of drugs, are systematically checked. All drugs must be “in date” and the dangerous drug register accurate and completed. Any out of date items are discarded as per policy. The contents and availability of Doctors bags are a standing item on the agenda of our clinical meetings. A list of mandatory items and others as per Practice policy are kept inside the Doctor’s bag with a copy held in the Practice Nurse’s office. If the doctor’s bag does not contain all the mandated items as dedicated equipment then the doctor must routinely add such items before leaving the practice. Commonly this applies to the otoscope and opthalmoscope as these items are expensive to duplicate. Annually, the Practice Nurse works with each doctor to conduct a major review of the items to determine if current equipment is adequate based on accepted good clinical practice. When not in use the doctor’s bag is stored securely in the practice or remains in the boot of the Doctors car. When the doctor is going on leave arrangements are made for the secure storage of the bag. When selecting emergency drugs in the doctors bag consider: the health needs of the community, the location of the practice, the types of emergencies likely to be encountered the shelf life and climatic vulnerability of medicines also needs to be considered. the availability of emergency drugs at the practice if the doctor’s bag has been taken by another doctor. RACGP 4th Edition Standards 5.2.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 219 of 260 Insert your logo here Vaccine Storage December 2012 The vaccine storage section of this policy and procedure manual has been superseded by the Vaccine Management Policy and Procedure Template located in AGPAL’s resource area QbAY under Standard 5.3Clinical support processes. Please refer to the vaccine management policy and procedure template. The above template can be combined with this policy and procedure manual if you wish to create one manual. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 220 of 260 Insert your logo here 7.14.4 Vaccine Administration Policy Vaccines are administered and recorded according to the Australian Standard Vaccination Schedule Guidelines to ensure individuals and the general public are protected from preventable diseases. To assist patients to make informed decisions about their medicines and to understand any medication safety requirements we recognise that patients need to understand the purpose and importance of medicines. We believe this also helps our patients to comply with the recommended treatment plan. We support our verbal information with leaflets where possible. The clinical team ensures that medicines (including vaccines) are acquired, stored, administered, supplied and disposed of in accordance with manufacturers’ directions to maintain the potency of our vaccines. Vaccines are classified as Schedule 4 medications and we comply with drugs and poisons regulations and legislation. We observe the principles of correct patient identification and handover during the process of vaccination. Procedure follow the Australian Standard Vaccination Schedule and the recommendations of the NHMRC at all times for routine immunisations. Specific evidence, guidelines and the manufacturer’s instructions should be followed for travel and other more specialised immunisation. prior to administering any vaccines ensure there are adequately trained staff, emergency equipment and drugs available to deal with serious adverse post-vaccination complications. RACGP 4th edition Standards 5.3.1, 1.5.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 221 of 260 Insert your logo here 7.14.5 Drug Storage, Supply and Administration Please note: RACGP 4th Edition Standards state “Practices must comply with jurisdictional requirements on Schedule 4 and Schedule 8 medicines.” The requirements can vary in different states and Territories of Australia. Failure to comply with the legislation renders individuals and practice entities liable to prosecution. Compliance with legislation does not ensure compliance with other professional standards and other accreditation requirements which should also be observed. Policy The clinical team ensures that medicines (including samples, vaccines and medical consumables) are acquired, stored, administered, supplied and disposed of in accordance with manufacturers’ directions and Legislative requirements applicable to the state of (*insert name of state), where our practice is located. Our practice does not hold a Health Services Permit (HSP) therefore all Schedule 8, 4, 2 & 3 medications are stored, prescribed and administered in line with the requirements of the Drugs, Poisons and Controlled Substances Act 1981 and the Drugs, Poisons and Controlled Substances Regulations 2006. In line with accreditation standards: our patients are informed about the purpose, importance, benefits and risks of their medicines and are made aware of their own responsibility to comply with the recommended treatment plan. our clinical team can access current information on medicines and review our prescribing patterns in accordance with best available evidence. our clinical team works towards maintaining a current and accurate medication list for our patients, especially those on multiple medications. our clinical team can demonstrate how we ensure other health providers to whom we refer or hand over our patients can access an accurate medicines list. the use by date of all drugs is checked on a systemic basis. we observe the principles of correct patient identification Procedure To reduce the risk of errors when prescribing or referring, general practitioners ensure the patient’s medication list is up-to-date. Prior to prescribing or changing treatment our doctors and other clinical staff clarify a patient’s current medicines list and known allergies. Single use medications, including antibiotics, should be removed from patients’ records when they are no longer required. Care is taken with sound-alike or look alike medicines, particularly when using ‘drop down’ boxes in electronic prescribing programs. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 222 of 260 Insert your logo here We also encourage reviewing the medicines list with the patient to provide an opportunity to assess the patient’s compliance with a medication regime and to identify the need for any further education/support. Where appropriate doctors provide patients with a copy of their medicines list which is updated when their medicines are changed. It is useful to include all medicines (prescription and non-prescription medicines and complementary healthcare products, if known) on the medication list. General practitioners need to be aware of the use of complementary medicines and the potential for side effects and drug interactions with conventional medicines. This should be noted on letters of referral including those for hospital admissions. All clinical staff ensure correct patient and patient record using 3 accepted patient identifiers, name, DOB, address & gender before administering any medications, or writing any prescriptions. When patients ask for a repeat of their medications without attending the practice we require the request in writing and it must contain the name, address and DOB. We also correctly identify patients when they come to collect their prescriptions by asking the person collecting to sign We help our patients to understand the Medication purpose, options, benefits and risks. Where possible we use written material to support this. Where patients cannot understand written language or where information is not available in the patient’s language, the use of pictorial media or translators may be appropriate. It is particularly important that patients understand the difference between generic drugs and trade named drugs so dosage problems are avoided. Our clinical staff can access the Therapeutic Guidelines and other references to refer to where appropriate. We also encourage the use of the Home medications reviews for eligible patients. Consumer information about the practice prescribing policy is available to patients and displayed in the waiting room. Definitions: “Schedule 8 drugs” (Labelled controlled Drug) are drugs with more strict legislative controls. A permit might be required before prescribing Schedule 8 poisons. E.g. morphine(Kapanol, MS-Contin), pethidine, oxycodone(Oxycontin, Endone), methadone(Physeptone), hydromorphone(Dilaudud), flunitrazepam(Hypnodorm), fentanyl(Sublimaze), “Schedule 4 drugs” (Labelled Prescription only medication) include all other drugs for which prescriptions are required e.g. diuretics, oral Contraceptives, antibiotics, some compound analgesics (Panadeine Forte), vaccines and many others Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 223 of 260 Insert your logo here The term “Drugs of Dependence” is used to describe all Schedule 8 plus those Schedule 4 poisons that are subject to misuse or trafficking e.g. benzodiazepines, propoxyphene(Digesic, Doloxene), anorectic drugs (Tenuate Dospan, Duromine), and anabolic. Steroids .Doctors should take additional precautions before prescribing S4drugs of dependence. Prostaglandins, Ovulatory Stimulants and Retinoids (e.g. isotretinoin, acitretin, clomiphene, dinoprost) are Schedule 4 poisons that may only be prescribed by a medical practitioner with the appropriate qualifications and expertise and who holds a warrant to prescribe the drug or by a medical practitioner acting in accordance with the direction of the warrant holder (prescription to be endorsed with the name of the warrant holder). “Schedule 2 & 3 drugs” are those labelled Pharmacy medication or pharmacist only medicine. These can only be supplied in an open shop by pharmacists. Doctors must use and supply these in a similar manner to S4 drugs. Storage & Access Requirements Schedule 4 and Schedule 8 poisons (inc. Doctor’s Bag Emergency Drugs, Professional Samples and vaccines) are obtained on the authorisation of the medical practitioner(s). These drugs are the responsibility of the medical practitioner(s) and subject to regulatory controls. in relation to drugs in a general practice, a nurse is not authorised to possess Schedule 4 or Schedule 8 poisons except when required for administration to a specific patient, under the care of that nurse. Unless it is an emergency written authorization by a medical practitioner is required prior. registered Nurses can only access locked drug storage facilities to assist the doctor with necessary activities, such as medical treatment, stock checks and reordering, under the direction/supervision of a doctor who is personally present. Schedule 8 drugs Storage: S8 poisons must be stored in a locked facility, fixed to the floor or wall and meeting the minimum security requirements detailed in Regulation 35(1.) Storage facilities for Schedule 8 poisons must remain locked at all times except when it is necessary to open it to carry out an essential operation such as medical treatment, stock checks and reordering. Keys & combinations must not be accessible to or known by unauthorised persons. when required to be transported for use in other locations, S8 drugs must be stored in a locked receptacle (e.g. doctors Bag), in the doctors possession. If the receptacle is necessarily out of the doctor’s immediate possession it should be secured, out of sight, in a lockable facility (e.g. locked cupboard or locked vehicle) to prevent unauthorised access. up to 6 divided doses (e.g. amps) of a S8 poison, for emergency use, may be stored in a locked facility that does not comply with Regulation 35(1). Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 224 of 260 Insert your logo here Schedule 4 drugs Schedule 4 poisons including sample packs may be stored in a filing cabinet, cupboard or drawer, usually in the treatment room, (or other area e.g. storeroom). If an authorized person (usually a medical practitioner) is present the storage facility may remain unlocked at their discretion. This option requires the storage facility to be locked when the authorized person/s are not present. S4 drugs of dependence are either stored in the same manner as other S4 poisons or in the drug cabinet with S8 poisons again at the discretion of the authorised person. Schedule 4 vaccines that require refrigeration must be stored in either: a lockable refrigerator that is locked when an authorized person (usually a medical practitioner) is not present. or in a refrigerator secured within a lockable room that is locked when an authorized person is not present. nurse Immunisers are authorised to have access to specific vaccines and medications to manage anaphylaxis. Schedule 2 & 3 drugs It is recommended these are stored and handled in a similar manner to Schedule 4 drugs to prevent unlawful supply. Prescription pads and pages for computer generated prescriptions are stored in a similar manner to S4 drugs. Administration & Records Nursing Depending on professional scope and competencies, Division 1 registered nurses or Medication endorsed Enrolled Nurses (formally Division 2) can only administer S4 or S8 medications when there is a recent written instruction from a medical practitioner identifying the patient, medication, dose, time, date and route of administration and date the order was written. an oral instruction from a medical practitioner if an emergency exists with written confirmation ASAP by the doctor and nurse. on the written transcription of the oral instruction (given by a doctor in an emergency) by the nurse who received those instructions. Must be countersigned ASAP by the doctor to the designated patient in accordance with the directions on the label when the medications have been dispensed to the patient by a pharmacist or medical practitioner. Registered nurses must document any medications administered in the patient’s medical records, and sign the entry or use their individual log in. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 225 of 260 Insert your logo here Enrolled nurses may have limitations on the routes of drug administration or types of drugs they can administer depending on the endorsements they have attained in their training. (may not be able to administer via the IV route). Nurse Immunisers, employed or contracted by medical practitioners, may have access to vaccines that are specifically approved by the Secretary (Department of Health) for use in vaccinations and to Schedule 4 poisons necessary for the treatment of anaphylactic reactions to the vaccines. For further information and the list of vaccines, please refer to the DPRG website (www.health.vic.gov.au/dpu/approve.htm). Nurse Immunisers should familiarise themselves with legislative issues that are applicable to their situation. Records Records of all transactions (administration and/or supply) in S4 and S8 poisons must be true and accurate*, retained in a readily retrievable form for 3 years. S4 records must contain the patients name and address, the date of the transaction, the identity of the person administering the medication and information that unambiguously identifies the medication (including dose and route of administration if applicable). Additional records for S8 drugs are kept to personally account for every dose of a S8 drug. Transaction records of all S8 drugs received, transferred to the Doctors Bag, administered or disposed of must be maintained. A separate record (usually a drug register or administration book) is required, in a form that shows the true and accurate balance remaining after each transaction and that cannot be altered without detection. (Loose-leaf books are not acceptable). Each medical practitioner should have their own record book. (these are available from the RACGP). Appropriate documentation includes the date of transaction, the name of the doctor authorizing the administration of the drug, the name and address of the patient to whom the drug was administered, the quantity used a progressive balance of each drug on hand at the conclusion of the transaction, and the initials of the authorized person who administered the drug. It must also record additions to stock levels from the pharmacy and disposal of expired items. Vaccine Administration Division 1 nurses that have completed the accredited nurse immuniser course can administer vaccines (including off site) independently of the medical practitioner. Division 1 nurses or medication endorsed Enrolled Nurses that are not accredited nurse immunisers must have a written authorisation and the doctor must be physically available to assist with anaphylaxis and/or adverse events (including off site). Enrolled nurses that have not completed medication endorsement are not authorized to administer vaccines in any circumstances. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 226 of 260 Insert your logo here Disposal of expired medications WhenS2, S3 & S4 drugs reach their “Use by Dates’ then disposal is into the sharps or infectious waste containers or via the pharmacy. If a medical practitioner wishes to destroy expired or unwanted S8 poisons, the destruction must be witnessed by a pharmacist, dentist, veterinary practitioner, nurse or another medical practitioner. Their destruction must be recorded in the S8 record book by the medical practitioner and the witness. Prescribing/supplying When a doctor supplies S2, S3, S4 or S8 medications (including professional samples), the medication is labeled and a record of the supply is made. S4 and S8 labels will require: the name of the patient, directions for the correct use of the medicine the date of dispensing and if necessary an identifying code, the name , address and telephone number of the medical clinic or doctor providing supply including the name of the prescribing doctor directions for storage and expiry date (may be those on the packet if left uncovered). the brand and generic names of the drug including strength and form. the words “KEEP OUT OF THE REACH OF CHILDREN” ancillary labels as specified in the “Australian Pharmaceutical Formulary”. S2 and S3 labels will require the name, address and telephone number of the medical clinic or doctor providing supply. When prescribing or supplying S4 and S8 medications the doctor takes all reasonable steps, given the time and circumstances that exist at the consultation to ensure a therapeutic need exists. Prescribing to maintain an addiction is not a therapeutic need and is illegal. Doctors do not prescribe to support drug dependence or for the purpose of self administration. (Regardless of whether the treatment was initiated by another medical practitioner). Doctors check if the patient has any drug allergies or sensitivities prior to prescribing. In addition, for drugs of dependence, the identity of the patient must be ascertained. For patients that are not regular clinic patients the doctor may need to: consult a previous prescriber. contact DHS. or insist on a further means of identification. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 227 of 260 Insert your logo here Doctors must notify DHS if they believe a patient is drug dependent. DHS treats such notifications as confidential. Doctors are reminded that they are not obliged to prescribe the maximum PBS quantity of a drug. A smaller quantity can often address an immediate need whilst minimising the potential risks associated with drug-seeking behaviour. Doctors should refrain from prescribing medications for family members and drugs of dependence must not be prescribed to family members except in an emergency. Prescription pads and paper is stored securely in area where patients do not have unrestricted access or in the same manner as S4 poisons. Software for prescribing is secured by passwords that remain strictly confidential to individual prescribers. Prescriptions contain; the full details of the prescriber (including an address and phone number). the name and address of the patient. the medication (unambiguously). the quantity and maximum number of repeats(written in words and figures for S8). the prescribers signature (preferably in a manner that prevents a patient adding another item above the signature). precise directions. (Scripts for S8 and S4 drugs are not legal without these). Computer generated prescriptions for drugs of dependence must also contain key elements in the prescribers’ handwriting and include dosage amounts in figures and words Doctors are to obtain permits from the Department of Human Services (DHS) prior to: treating a drug dependent person with a Schedule 8 drug. prescribing dexamphetamine, methylphenidate or methadone (exemptions may apply, e.g. pediatricians treating ADHD; patients in oncology or pain clinics at hospital). treating a person with any Schedule 8 poison for a period greater than 8 weeks (except where specifically exempt). These permits should be filed/ scanned into the patient’s medical record. The police and DHS will be notified of: lost or stolen drugs. lost or stolen S8 records. when a doctor has reason to believe a person has obtained S8 or S4 poisons (or prescription for same) by false pretences. if a doctor suspects a patient is attempting to procure a prescription under false pretences. loss or theft of prescription pads or paper. Patients going overseas or patients who find it difficult to access the pharmacy Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 228 of 260 Insert your logo here The PBS will allow the repeats to be dispensed with the original supply. The Doctor must make endorse the prescription with the words “regulation 24” for this to occur. Note: It is illegal to supply medications: to Australian citizens not within the country at the time the prescription is written. for use other than the designated purpose for which it was prescribed. for anyone other than the person named on the prescription. RACGP 4th edition Standards 5.3.1. For information on jurisdictional requirements refer to the drugs and poisons branch of the relevant jurisdiction: Australian Capital Territory Pharmaceutical Services, ACT Health Telephone: 02 6205 1700 Fax: 02 6205 0997 Northern Territory Poisons Control, Department of Health & Families Telephone: 08 8922 7341 Fax: 08 8922 7200 New South Wales Pharmaceutical Services Branch NSW Health Telephone: 02 9391 9944 Fax: 02 9424 5860 Queensland Drugs and Poisons Policy and Regulation, Environmental Health Unit, Queensland Health Telephone: 07 3328 9310 Fax: 07 3328 9354 South Australia Pharmaceutical Services and Strategy, Department of Health Telephone: 08 8204 1942 Fax: 08 8226 9837 Tasmania Pharmaceutical Services Branch, Department of Health and Human Services, Tasmania Telephone: 03 6233 2064 Fax: 03 6233 3904 Victoria Drugs and Poisons Regulation Group, Department of Health Telephone: 1300 364 545 Fax: 03 9096 9168 www.health.vic.gov.au/dpu Western Australia Pharmaceutical Services Branch, Disaster Managements, Regulation and Planning Directorate, Department of Health, Western Australia Telephone: 08 9222 6883 Fax: 08 9222 2463 The RACGP has produced summaries of the jurisdictional requirements in relation to Schedule 8 medicines, available at www.racgp.org.au/standards/factsheets. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 229 of 260 Insert your logo here 7.14.6 Clinical References and Resources Policy Consistency and quality of care can be assisted by the use of current resources, access to clinical guidelines and communication between team members. This process is encouraged and facilitated by the practice clinical leader. (Refer Section 8 Clinical governance). This practice provides medical, nursing and allied Health workers access to a range of resources and materials for reference on clinical matters and items of interest for professional development. General practitioners can access current information on medicines to enable best practice prescribing. We are selective about the resources clinical staff to use to support information provided during a consultation. We aim to ensure they contain culturally appropriate, current and evidence based information and are obtained from reputable source. Where possible these resources should be dated, contain the name of the source and referenced to supportive evidence. The references available contain information that is consistent with current practice guidelines or based on best available evidence. In the absence of well conducted trials or other higher order evidence the opinion of consensus panels of peers is acceptable. References and resources including practice guidelines should be accessible at the point of care. There is an organised system of access for all practice staff to journals, clinical guidelines and other reference material. The clinical references available and any new additions, deletions or updated versions is communicated to all staff and clinical team members to assist with consistency in the approach to diagnosis and management of patient care. Procedure (*Insert the guidelines and references available at your practice and how or where they can be accessed). At least annually we conduct an audit of our clinical resources and references to ascertain if they comply with current practices and are providing consistent management and information to patients across the practice team. It is a standing item at our clinical meetings to discuss any new clinical issues, resources or clinical practice guidelines. Medical publications such as AFP, Modern Medicine and Current therapeutics are kept in the common room for 1 year and then discarded. RACGP 4th edition Standards 1.3.1 & 1.4.1, 5.3.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 230 of 260 Insert your logo here 7.14.7 Checking and Rotating Medical Supplies Policy Perishable medical supplies including vaccines, pharmaceutical and medical consumables are correctly stored, stock rotated and discarded if past expiry dates. Our practice had appointed a designated person to take primary responsibility for the proper storage and security of medicines, vaccines and other healthcare products. Procedure (*insert name and position title of the designated person) maintains a log of areas to be checked such as the drug cupboard, doctors’ bags, and fridge and other cupboards containing perishable medical stock kept. The log documents the location, date and initials of the staff member checking the stock and is kept in the Practice Nurse’s office. New stock is marked with a coloured dot to indicate the year of expiry to make checking quicker and encourage easy identification of the oldest stock so it can be used first. Stock is also rotated in a uniform manner with oldest nearest to the front of the shelf, drawer etc. All sites are checked 3 monthly with note made in the log to re-check if items will pass expiry date before the next review. i.e. name of item, location and expiry date. Items with expired ‘use by dates’ are to be withdrawn from active storage location and disposed of immediately (according to manufacturer’s instructions or see 7.12.5 for drug destruction/disposal). Necessary and regularly used items should be re-ordered on our supply form. RACGP 4th edition Standards 5.3.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 231 of 260 Insert your logo here 8 Continuous Improvement 8.1 Risk Assessment & Management Policy This practice has multiple systems to regularly monitor, identify and report near misses and mistakes in clinical care and to identify deviations from standard clinical practice that may result in patient harm. The practice has appointed a designated member of staff (*insert name) to have primary responsibility for our risk management systems. These may include clinical and non clinical risks and events. Specific areas of responsibility can be delegated to other nominated members of the practice team and these particular responsibilities should be documented in the relevant position descriptions. The aim of risk assessment and management is to: identify all strategic risks using a risk management process. ensure risk management becomes part of day to day management. co-ordinate the undertaking of regular formal risk assessments and reviews with staff involved. provide staff with education and policies and procedures necessary to manage risk. ensure employees are aware of risks and how to manage them. assign responsibility for overseeing the practice risk management systems to designated staff, and document this in their position description. document and regularly review our risk management systems. monitor risk profile and implement a continuous improvement approach to risk management. ensure successful implementation of changes and improvements made to our risk management systems. Our practice has a documented system for dealing with near misses and mistakes and we ensure that Doctors, Nurses and other staff involved in clinical care are educated in what to do and whom to notify when a slip, lapse or mistake occurs, or when there is an unanticipated adverse outcome. Any improvements that are implemented to prevent identified slips, lapses and mistakes or potential risks are documented and the practice team is informed. Our practice has protocols for Non Medical Emergencies such as failure of electricity supply, telephone or water, fire or false fire alarm, property damage, break-in, abusive or threatening telephone calls or persons at the practice, leakage of toxic chemicals, bomb threats and letter bombs, natural disasters and the sudden unexpected absence of staff. We also have a contingency plan for unexpected events such national or local infection outbreaks or the sudden, unexpected absence of clinical staff. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 232 of 260 Insert your logo here These include a mechanism to ensure the timely acquisition and dissemination of information (including regular updates) about alerts, emerging diseases, local disasters or emergencies. Procedure Staff use the “Adverse Outcome Report” to report any slips, lapses or near misses in clinical care or deviations in patient care that might result in harm. The medical defence organisation is contacted for events that might give rise to a claim. Some of the tools and strategies used in this practice to manage risk include: achievement of RACGP standards via the accreditation process regular staff and clinical meetings and effective communication with our staff. appropriate staff qualifications, induction and training. patient feedback obtained via surveys/Suggestion Box /logbook of complaints/ comments. documentation of sterilisation procedures including servicing, details of individual loads/cycles and staff training comprehensive medical records and back up of electronic data. documentation/ tracking of abnormal results. regular reviews of systems and procedures especially as a result of any analysis of reported near misses. logging/recording of telephone exchanges with patients ensuring correct identification of patients at each face to face, telephone and electronic encounter and on correspondence by using “name”, “date of birth”, “gender” or “address”. documented contingency plans for events that may disrupt care or stretch practice resources to the limit, including disasters (e.g. bushfires, prolonged power failure, sudden staff absence) and disease outbreaks (e.g. pandemic flu). (*insert where to find your practice contingency plan/s for adverse and unexpected events.) RACGP 4th edition Standards 3.1.2, 4.1.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 233 of 260 Insert your logo here 8.1.1 Review of Policies & Procedures Policy Policies and procedures relating to the administration of this Practice are formally reviewed on an annual basis or when changes occur requiring earlier review or revision (e.g. equipment changes). Our practice has written polices relating to key infection control processes which are reviewed and updated regularly Our practice encourages and promotes sharing information about quality improvement and patient safety including protocol and policy/procedure review or suggestions. Procedure Discussion and suggestions for improvement to quality, patient safety or policies and procedure is a standing item on our practice meeting agenda. Staff may informally approach the Practice Principal or Manager with suggestions for new policies and procedures or with revisions to existing policies and procedures. We have a designated staff member who has responsibility for co coordinating and sustaining our infection control processes. This includes continually modifying and improving our procedures and written policies in accordance with the most recent evidence and guidelines and ensuring the timely dissemination of information concerning changes to infection control procedures or information about national and local infection control outbreaks. The Practice Principal, in consultation with the Practice Manager and staff approve all policies and procedures. Once approved, documentation is amended in this manual and elsewhere as necessary. e.g. in patient information brochures, clinical manual, and patient forms. Analysis of practice data may also inform any changes to services or other practice activities to improve the health outcomes of our patients. These quality improvement activities may necessitate a new or revised written protocol. Formal revision and final approval of all new and revised policies and procedures is presented at a staff meeting. To ensure all staff are aware of new policies and recent changes we have a distribution plan. RACGP 4th Edition Standards 3.1.1 & 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 234 of 260 Insert your logo here 8.1.2 Continuing Staff Education Policy Continuing Education The practice GP’s, nurses and other health care providers or administrative staff employed by this practice and involved in clinical care: are appropriately qualified, trained and competent. are able to provide evidence of training qualifications and of appropriate current national medical or nursing registration. participate in continuing education relevant to their roles and can provide evidence of this. have undertaken training in CPR within the last 3 years and in the case of GPs this training must be in accordance with the RACGP QI&CPD recommendations. Staff education is crucial to effective infection control within the practice. Education needs to be relevant to the role of particular staff members and needs to start with the staff induction program. (Refer Section 2 Staff Induction). Staff education and the evaluation of staff competency needs to be recorded in line with chapter 1 RACGP Infection control standards for office based practices (4th edition). The administrative staff such as receptionists and practice managers, who do not provide clinical care: have undertaken training in CPR within the last 3 years. have undertaken training relevant to their role within the past 3 years. can describe or provide records of such training. The practice employs doctors who are recognised GPs. Note: The only exception to this, are other specialists practicing within their specialty, or trainees undertaking a placement to gain experience in general practice as part of some other specialist training program. Where recruitment of recognised General Practitioners has been unsuccessful, the practice ensures that doctors have the qualifications and training necessary to meet the needs of the patients of the practice. This practice ensures that it’s General Practitioner(s) maintain and improve the quality of care they provide to their patients by participating in the RACGP QA & CPD Program. where this is not the case, the practice is able to provide evidence that doctors participate in quality improvement and continuing professional development to at least the same standard as the RACGP QA & CPD Program. In addition, medical staff should participate in Hospital and or Divisions of general practice affiliated programs and other programs, as relevant. Refer to ‘Training Schedule’ in Section 8.1.2 for further details of training. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 235 of 260 Insert your logo here Records of GP continuing professional development activities including CPD points and activity details are retained by individual GP’s and a copy must be given to the Practice Manager to retain for the practice records annually. The practice supports continuing professional development for all of the staff it employs. Details of activities & dates are recorded and should be retained by the Practice Manager. Copies of these records or an annual summary should be given to staff for their own personal records. All Doctors, Nurses and staff involved in clinical care practice within their legal scope of responsibilities. We encourage our staff to maintain their knowledge, skills and attitudes through membership to their professional specialty organisations. e.g. RACGP, AMA, APNA, AAPM. Both in house and external training programs are utilised. Staff should obtain a certificate of attendance or evidence of participation and completion for all training, even informal training sessions (e.g. provided by the General Practitioners or other staff in the practice). Certificates should include the main aims or expected learning outcomes of the training, the number of hours and the qualifications of the person delivering the training. It is acknowledged that some crucial areas for staff training exist, depending on the staff member’s role and responsibilities. These training requirements are met according to the training schedule and documented in each staff member’s employment record. Education is not limited to professional technical skill updates but includes a variety of training and educational activities in areas of need as they arise. Staff are encouraged to identify any training needs they may have and seek to find training to meet these needs. Usually this occurs in consultation with their supervisor and this process should be documented. Staff training may include: education at formal institutions. educational seminars attended. online training. in service education given by company sales representatives or other staff. reading Journals, evidence based guidelines or researching information for the practice. New staff are supported with any training they may require to perform their role. This may be identified prior to commencement or during the induction phase. (Initial 3 months) Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 236 of 260 Insert your logo here Procedure The practice GP’s, nurses and other health care providers involved in clinical care must provide evidence of current registration each year. The practice manager then copies and retains this on file. If a staff member locates a course, education session, workshop, or a meeting that they wish to attend, they should advise the Practice Manager who will consult with the Practice Principle and, if approved, authorise attendance and payment. Time may be granted on full pay for certain meetings, education sessions and courses. The Practice Principal and / or Practice Manager formally approves the education session in writing and places details on the Continuing Education file, held in the Administration office. The Practice Manager liaises with the staff member for application, fees etc. In seeking time off to attend external sessions, staff should consider other staff and workloads, to ensure adequate Practice coverage. An application for study/conference leave form should be lodged with as much advance notice as possible. Evidence of all staff training will be documented in the ‘Staff Training Plan’ and ‘Staff Education Form’. Training schedule It is acknowledged that to maintain the staff competency required for the efficient and smooth running of this practice, and for medico legal reasons, all staff are required to undertake ongoing training and up skilling and where appropriate competency assessment. The type of training and up skilling that occurs will be dependent on their position and role within the practice as detailed in the form below. Other identified training needs for individual staff members can occur in addition to this list. The ‘Staff Training Plan’ is adhered to and reviewed at the annual performance appraisal. As other clinical staff may be present during a medical emergency, they need to be trained in CPR to assist the medical team therefore, at least every 3 years, all members of the practice team undertake CPR training appropriate to their level. The CPR training provided to GPs must be: consistent with the Australian Resuscitation Council (ARC) guidelines a minimum of 1 hour duration. delivered by a trainer that has a current CPR instructor’s certificate that complies with the ARC guidelines. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 237 of 260 Insert your logo here CPR training for other clinical staff may be conducted by: medical staff and preferably those who have a current CPR instructor’s certificate that complies with ARC guidelines on instructor competencies, or, by an accredited training provider. CPR training for administrative staff may be conducted by medical staff or other clinical staff who feel competent to train colleagues and preferably those who have a current CPR instructor’s certificate that complies with ARC guidelines on instructor competencies. OR by an accredited training provider. Administrative staff and other relevant non clinical staff should receive triage training in order to recognise medical emergencies and prioritise appointments for patients with urgent clinical needs. Triage training may be delivered by clinical staff within the practice or by appropriate external providers. The practice team member with delegated responsibility for staff education on infection control documents in each individual staff training records how the induction program and additional ongoing training provided (as identified through discussion and competency assessment) covers infection control as relevant to each staff members role. Training and regular updates should include: hand Hygiene. standard precautions & Transmission based precautions including PPE use and the triage of patients with potential communicable diseases. dealing with blood and body fluid spills and managing exposure to blood or body fluids. principles of environmental cleaning and reprocessing of medical equipment. where to find information on other aspects of infection control in the practice. safe handling and disposal of clinical and general waste. RACGP 4th edition Standards 3.2.1 & 3.2.2 & 3.2.3 & 5.3.3. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 238 of 260 Insert your logo here 8.1.3 Accreditation & Continuous Improvement Policy This Practice is committed to attaining and where possible exceeding the Standards for General Practice 4th Edition as defined by RACGP and as such AGPAL is our chosen accreditation organisation. The practice team is committed to encouraging quality improvement and identifying opportunities to make changes that will improve the clinical care of patients and activities to promote health in the overall practice population. The practice uses patient and practice data to identify opportunities for improvement and to monitor evidence of improvement occurring. Quality improvement or clinical audit activities for the purpose of seeking to improve the delivery of a particular treatment or service is considered a directly related secondary purpose for information use or disclosure. Therefore we do not need to seek specific consent for this use of patients’ health information. However we include information about quality improvement activities and clinical audits in our practice consent form for the collection and use of health information. Our practice can demonstrate improvements we have made in response to the analysis of patient and others feedback, including complaints, and where appropriate we provide information to patients about improvements made as a result of their input or feedback. Our practice undertakes quality review activities such as audits, routine data checks, accounts reviews and medical record reviews. Our Practice has a planned approach for improvements where possible using the Plan Do Study Act (PDSA) Cycle to provide evidence that the practice has implemented a quality improvement plan, and that the outcome has been reviewed Procedure Discussion and suggestions for improvement to quality and patient safety is a standing item on our practice meeting agenda. Patient feedback is an essential component of our quality improvement activities. Accreditation via a peer assessment of our performance against the RACGP 4th Edition standards is a driver of quality improvement. (*Delete this section in italics if you are a non computerised practice) Our practice utilises information management techniques that allow us to collect and analyse our data. Consistent data coding systems are used to facilitate this process including using “drop Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 239 of 260 Insert your logo here down box” functionality where possible instead of “free text” entries. We also use the search tools in our clinical software and the (*insert which tool/s you use here) data extraction tool. We utilise national registers to assist with quality improvement activities including our quarterly PIP statements, reports from the Australian Childhood Immunisation Register and PAP screening data. Quality improvement is a team activity and provides opportunities for all staff members to contribute to achieving improvements. We can describe and have documented aspects of our practice that we have improved in the past 3 years including examples of where we have used relevant patient data to implement the Plan Do Study Act (PDSA) Cycle of quality improvement. The Plan Do Study Act (PDSA) Cycle of Quality Improvement The Plan Do Study Act cycle is a tool that provides a framework for developing, testing and implementing changes. The four steps in the PDSA cycle are as follows; Step 1: Plan Planning the improvement activity involves identifying: what the improvement activity is who needs to be involved, or made aware of the activity when will the activity take place where the activity will take place what outcomes are predicted what data will be collected to measure the outcomes of the activity. Step 2: Do Implementing the improvement activity includes: involving the appropriate staff documenting the steps taken seeking feedback from all involved. Step 3: Study Studying the improvement activity involves: analysing and reflecting on the results reviewing whether the activity was successful determining if the results meet expectations identifying whether further improvements need to be implemented. Step 4: Act Acting on the improvement involves: identifying what will be taken forward from this cycle will something else be tested using a new PDSA cycle. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 240 of 260 Insert your logo here If the CQI activity has been successful the practice looks at: how new policies or procedures will be incorporated into the way the practice team works. how staff will be made aware of the change. where the new activity will be documented. how the new activity will be monitored to ensure all staff are participating. If the CQI activity has been unsuccessful the practice looks at: what the activity has shown. what different improvements might be able to be made. RACGP 4th edition Standards 2.1.2, 3.1.1, 3.1.3, 4.2.1. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 241 of 260 Insert your logo here 8.1.4 Patient Feedback Policy Our practice encourages patients and other people to give feedback, both positive and negative, as part of our partnership approach to healthcare, and we have processes in place for responding to feedback In order to respond to patient feedback and make improvements, practices need to identify the person in the practice with primary responsibility for examining issues raised by patients and facilitating improvements in the practice. (*insert the name of the staff member with this responsibility in your practice). Opportunities are available for patients and other visitors to tell us, ‘How we are doing.’ Our Suggestion Box in the waiting room allows patients to give us personal feedback on a day to day basis. We aim to follow-up ideas and acknowledge notes of appreciation where we can. Where possible patients are encouraged to raise any concerns directly with the practice team and attempts are made for a timely resolution of such concerns within the practice in accordance with our complaints resolution process. We seek structured /systematic patient experience feedback at least once every 3 years which meet the requirements outlines in the RACGP publication “Learning from our patients”. Feedback collected includes, but is not limited to, the following 6 categories that are considered critical to patient’s experiences within healthcare facilities. access and availability information provision privacy and confidentiality continuity of care communication skills of the clinical staff interpersonal skills of clinical staff The data collected is analysed and the findings, including any improvements made, are communicated back to our patients. As part of our Risk Management Activity, a log of incidents, including complaints, is maintained in an event log and the incident is noted on the patient’s history. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 242 of 260 Insert your logo here Procedure At any time patients may provide feedback or make a complaint. a notice is displayed in the waiting room and in the practice information sheet advising how to make a complaint to our practice. We also advise the contact information for the State/Territory health complaints agency and the commonwealth agency. the Suggestion Box is located at reception and reception staff ensure there is an attached pen and paper available. staff are trained to ensure patients of the practice feel confident that any feedback or complaints made at the practice will be handled appropriately. At least every 3 years we use a systematic method for collection patient experience feedback. We have purchased or downloaded a copy of the RACGP publication “Learning from our patients” (*insert where this is located) and we meet the requirements outlined in this publication. We collect feedback using: (Practices have four options for collecting patient experience feedback select option/s used and delete others) an RACGP approved questionnaire an individual practice specific questionnaire we have developed* a series of focus groups with patients* a series of interviews with patients.* *Note: Where practices choose to collect patient feedback using methods other than an RACGP approved questionnaire, these methods need to meet the requirements outlined in the RACGP Patient feedback guide- Learning from our patients. Data collected is analysed to identify potential opportunities for quality improvement. (Refer Section 8 Accreditation and Continuous Improvement) We communicate the findings of our feedback and any improvements made back to our patients using either a poster in the waiting room, newsletters, the website or individually as appropriate. RACGP 4th edition Standards 2.1.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 243 of 260 Insert your logo here 8.1.5 Management of Potential Medical Defence Claims Policy In line with the Common Law system of damages and taking into account reforms which came into effect in Victoria on October 1st 2003, this practice undertakes to notify their Medical Defence Organisation (MDO) immediately if there is suspicion that a claim will be initiated by a party against the practitioner or practice, or upon receipt of an Impairment Certificate served upon the practice or practitioner by a party making a claim. This practice understands that, since the reforms, the organisation or person against whom the claim is made has only 60 days from receipt of the impairment certificate to accept or challenge the claim. Procedure All staff should forward any legal documents delivered to the practice, or any complaints that could result in a claim, directly to the Practice Manager who will notify the parties concerned. The case is not discussed with anyone other than the relevant medical defence organisation, and personal notes and communication with the insurance organisation are not kept in the patient’s practice record. Subpoena to produce records: check the description of what is to be produced the original records must be provided, but keep a photocopy place the original records in an envelope with the patients name clearly marked, plus the court number which will be shown on the subpoena). Mark the envelope “confidential Medical records”. Seal the envelope and attach a copy of the subpoena to the envelope. arrange for a courier to deliver the records to the court. NOT TO THE REQUESTING SOLICITOR. Discuss courier arrangements with the solicitor who has served the subpoena. If they do not provide the courier you are entitled to charge for the courier service. Make sure you use a reliable firm and that they sign for the records and the records go directly to the court. the court will return the records in due course. Should an Impairment Certificate be served, both the Victorian Managed Insurance Authority (VMIA) and the practice’s MDO will be notified and forwarded a copy of the Impairment Certificate. Members of the public may make a notification to AHPRA about the conduct, health or performance of a practitioner or the health of a student. Practitioners, employers and education providers are all mandated by law to report notifiable conduct relating to a registered practitioner or student to AHPRA. RACGP 4th edition Standards 3.1.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 244 of 260 Insert your logo here 8.1.6 Continuity of Care Policy This practice aims to encourage patients to develop a positive relationship with their doctor and practice staff over time to enhance the provision of high quality comprehensive patient care including effective health promotion and strategies for the early detection of disease. This practice has strategies and policies that encourage continuity of comprehensive care by facilitating: relational continuity: the sense of affiliation between the patient and the doctor ‘my doctor’. management continuity: consistency of care by various people involved in the patients care. informational continuity: Maintenance of information across health care events through documentation, handover and review. Our medical notes demonstrate relational, management and informational continuity of comprehensive care. In addition 50% of our active patient health records have entries extending back over two years. Our practice provides home visits for our patients and has an agreement with an after hours provider who provides communication back to the practice about the nature of any after hours care delivered. Procedure Relational continuity All members of the practice team appreciate that it is important that our patients have an opportunity to develop an ongoing relationship with the practice, Doctors, nurses, allied health workers and staff members. our appointment schedule has a separate appointment list for each general practitioner, nurse or allied health worker. patients are able to request their preferred General practitioner or other health care provider when making an appointment and this request is accommodated if possible. where possible “walk ins” are also able to see the doctor of their choice, or the doctor they saw on previous visit/s. should the GP be retiring or leaving or taking extended leave we endeavour to minimise the disruption to care. Patients are given at least 4 weeks notice and are informed of who will take over their care in the absence of their usual Doctor and a clinical handover either written, face to face or via the telephone is provided. special consideration is given to patients with high needs and, in the event of practice closure or should these patients be taking a vacation we endeavour to assist these patients with finding alternative appropriate care and consideration is given to measures to make their records available. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 245 of 260 Insert your logo here Management continuity General practitioners, nurses and allied health workers co ordinate the management of individual patient care and endeavour to maintain a consistent and cohesive approach. plans for the management of patients with complex clinical conditions are documented in the patient health record to ensure consistent clinical care and advice is provided to the patient. clinical handover occurs when the patients care is handed over to another health professional both within and external to the practice. patient resources to support preventative activities or to assist with providing information about specific diseases or management choices are shared by all Doctors, nurses and allied health professionals to ensure as much as possible patients receive consistent information and advice from all involved in their care. to ensure clinical care is consistent with the best available evidence, culturally sensitive and consistent throughout the practice, Doctors, nurses and allied health professionals regularly attend clinical meetings or staff in-service together. health summaries are updated to reflect recent significant events as information is gathered by staff providing clinical care, so that care remains responsive to individual patient needs. issues raised in consultations are documented in the patient health record to enable other doctors, nurses or allied health workers providing subsequent clinical care to follow up previous problems. patients are enrolled in diseased prevention and health promotion activities where eligible and receive reminders for health checks. children receiving immunizations are recorded on the practice immunization reminder schedule and notified when future vaccinations are due. where preventative activities such as Pap screening or immunization are provided the patient is bulk billed. Informational continuity Doctors, nurses and allied health workers involved in the care of patients within the practice have access to the patient’s health record and a clinical handover occurs whenever there is an interface of care by different providers. clinical care administered by members of the practice team is documented in the patient health records by the health professional administering the care. letters and correspondence from other external care providers e.g. Allied health can be read by all members of the practice team providing care. external care providers are notified should the planned management of a patient change or be reviewed. clinical handover of patient occurs both within the practice, to other members of the team and to external care providers whenever there is an interface of care by different providers. This may be face to face, written, via telephone and by electronic means. RACGP 4th edition Standards 1.1.1, 1.4.1, 1.5.1, 1.5.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 246 of 260 Insert your logo here 8.1.7 Clinical Governance Policy The RACGP 4th Edition Standards describe Clinical governance as a ‘system through which organisations are responsible for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish’. We recognise that good clinical leadership is required to engage the entire practice team in a commitment to excellence by nurturing a culture of openness and mutual respect that allows just and open discussions about areas for improvement. We aim to develop an organisational culture where participation and leadership in safety and quality improvement are resourced, supported, recognised and rewarded and all staff feel accountable and involved in monitoring and improving care and services. To promote clear lines of accountability and responsibility for encouraging improvement in safety and quality of clinical care and the sharing of information about quality improvement and patient safety within the practice team we have appointed leaders who have designated areas of responsibility for safety and quality improvement systems within the practice. Our leaders promote a multidisciplinary team approach to endorse a climate of safety and quality that does not blame, but rather seeks to solve problems. Our practice leaders oversee the delegation of tasks to others but retain accountability for quality and safety. Roles and responsibilities are specified in our position descriptions and all members of the practice team are aware of the designated leadership responsibilities of key staff. Our leaders promote compliance with the RACGP 4th Edition Standards for general practice and relevant jurisdictional legislation or accepted industry requirements. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 247 of 260 Insert your logo here Procedure We have nominated key staff with primary responsibility for the clinical governance of specific areas. Our leaders are resourced and supported to make improvements in their specified areas of responsibility through the coordination of practice activities such as: education and information sharing clinical audits/research/data analysis promoting evidence based practices risk management analysis-clinical and general openness to suggestions and feedback policy and Procedure development and review Our leaders can delegate specific areas of responsibility to other nominated members of the practice team and these particular responsibilities should be documented in position descriptions. All members of our practice team can identify the staff members with primary or delegated responsibility for: RACGP STD 3.1.2 Clinical Risk management systems including receiving and disseminating any important communication or updates (e.g. health alerts) and contingency plans RACGP STD 3.1.3 Clinical leadership RACGP STD 4.1.1 Quality improvement and risk management (non clinical) RACGP STD 4.1.1 Clinical care RACGP STD 4.1.1 Information management RACGP STD 4.1.1 Human resources RACGP STD 4.1.1 Feedback and complaints RACGP STD 4.1.2 Occupational Health and Safety (Health and Safety representative) RACGP STD 4.2.1 Privacy Officer RACGP STD 4.2.2 Electronic systems and computer security RACGP STD 5.3.1 Proper storage and security of medicines RACGP STD 5.3.2 Cold chain management RACGP STD 5.3.3 Infection control within our practice. (e.g. sterilisation process, staff immunisation, staff education). RACGP STD 5.3.3 Environmental cleaning, These responsibilities are noted in position descriptions. RACGP 4th edition Standards 3.1.3, 5.3.1, 5.3.2, 5.3.3, 4.1.1, 4.2.2. Developed by Dandenong Casey General Practice Association and purchased under licence by QIP Consulting as a resource for AGPAL accredited general practices. Page 248 of 260
