CORNERSTONE - General Practice Accreditation Programme - Aiming for Excellence 2008

INDICATOR

CRITERIA

HealthyPractice® RESOURCE

SECTION AGroup 1

FACTORS AFFECTING PATIENTS- Needs and Rights of Patients

A.1.1

The practice demonstrates its commitment to the Code of Health and Disability Services Consumers Rights 1996

A.1.1-1**

The practice has a documented policy that describes how the Code of Health and Disability Services Consumers’ Rights 1996 will be implemented.

HDC Overview, HDC Checklist and Practical Tips

A.1.1-2 *

All practice team members have received training within the last 3 years to implement‘The Code’.

HDC Checklist and Practical Tips

A.1.1-4**

The Code of Health & Disability Services Consumers’ Rights 1996 is displayed.

Patient Rights Policy and Patient Rights Brochure

A.1.2

The practice team ensures that patients are provided with information to enable them to make informed choices about their care

A.1.2.2**

Informed Consent is obtained from the patient or legally designated representative, when agreeing to a treatment or procedure

Informed Consent

A.1.3

The practice maintains the privacy of patient information in accordance with the Health Information Privacy Code 1994

A.1.3-1 **

The practice has a documented policy that describes how the requirements of the HIPC will be implemented.

Privacy Notice, Disclosure of Information and Brochure for Patients

A.1.3-2 **

The practice has a designated Privacy Officer to manage compliance with the HIPC 1994.

Privacy Officer

A.1.3-3 **

All practice team members have received training within the last 3 years on the principles of the Health Information Privacy Code 1994.

Overview of HIPC 1994, HIPC Principles, HIPC Tips

A.1.3-4 **

The practice collection, use, storage, disposal and disclosure of individual patient information comply with Health Information Privacy Code 1994.

HIPC overview, Transferring patient records, Disclosure and Retention of Information

A.1.4

The practice layout enhances patient privacy in reception and waiting areas

A.1.4. -1

There are adequate and effective safeguards in the reception area to ensure confidentiality of patient information ( includes verbal, documented and electronic)

Tips

A.1.5

The practice upholds patients’ right to complain

A.1.5-1**

The practice has a documented complaints protocol.

Complaints Procedure and Complaints Template

A.1.5-2 **

The practice has a designated team member to manage compliance with Right 10 of the Code of Health and Disability Consumers’ Rights 1996.

Complaints Officer

A.1.5-3 **

The designated team member can demonstrate that the complaints process complies with Right 10 of “the Code”.

Complaints and Complaints procedure

A.1.5-5 *

Complaints and their resolution are used as opportunities for learning and quality improvement.

Significant Event Management

A.1.6

The practice includes patient input into service planning

A.1.6-1 *

The practice encourages patient feedback about service provision and development.

Patient Satisfaction Survey

A.1.6-3 *

The practice obtains feedback from patientsthat reflects the view of the practice population to determine satisfaction in the last 3 years.

Patient Satisfaction Survey

A.1.6-4 *

Information about the practice’s use of patient input is communicated to the practice team and patients.

Practice newsletter

A.1.7

The practice demonstrates its commitment to recognising diversity of culture and background

A1.7-2 *

All practice team members have received training to maintain cultural competence within the last 3 years.

Discrimination

A.1.8

The practice acknowledges and is responsive to the special status, health needs and rights of Maori whanau

A.1.8 -1**

Members of the practice team have had training in the principles of the Treaty of Waitangi – Tiriti o Waitangi – Partnership, Participation and Protection

Cultural CompetenceSee also MCNZ

A.1.8 – 2*

The practice has a documented Maori Health Plan that states how it implements measures to address the priority areas as stated in He Korowai Oranga Maori Health Strategy 2002

MOH, DHB or your local PHO

A.1.8 – 3*

The practice effectively addresses the health needs of its enrolled Maori population

MOH or PHO, Tips

Group2

- Access and Availability

A.2.1

The practice makes provision to ensure patients are able to access 24-hour medical care

A.2.1-1**

The practice population is provided with information about access to 24-hour medical cover.

Patient Access 24/7

A.2.2

The practice identifies and responds appropriately to all patients with clinically urgent medical conditions

A.2.2 -1-4**

For help with this criteria see tips page

Tips

A.2.3

Information about practice services is available for patients

A.2.3-1 *

Practice information is displayed where it canbe read by patients.

Marketing

A.2.3-2 *

Practice information is routinely given to new patients.

Newsletter

A.2.3-4 *

Information about practice services is current.

Marketing, newsletter

A.2.4

Prescribing in the absence of direct patient contact is accurate, appropriate and timely

A.2.4 -2*

The Practice implements a policy on prescribing in the absence of face-to-face consultation

Repeat prescribing template

Group 3

- Absence of physical barriers to access

A.3.2

The practice premises are clearly signposted and physically accessible

A.3.2-1**

External practice signs are clear, visible and well placed to read from a distance.

Marketing

A.3.2-4 **

Lighting outside the practice facilitates safe entry and exit to the practice.

Premises security

A.3.2-6

A designated person monitors general maintenance of the building and acts on any issues arising.

Building WoF

SECTION B

Group 4

PHYSICAL FACTORS AFFECTING THE PRACTICE

- Physical factors affecting the Practice

B 4.3

The practice ensures infection control to protect the safety of patients and team members

B.4.3-1 **

Documented practice policies and procedures outline infection control practices for cleaning, disinfection and sterilisation of equipment and facilities

Infection Control Policy template

B.4.3-5 **

Within the last year, appropriate members of the practice team have received training related to disinfection and sterilisation policies and practice

Training Register

B.4.7

The practice demonstrates a commitment to the Health and Safety in the Workplace

B.4.7-1 **

The practice has designated policies that describe how the Health and Safety in Employment Act 1992 and 2002 will be implemented.

Health and Safety in the Workplace, Health and Safety Policy Guidlines

B.4.7-2 **

The practice has a designated Health and Safety Officer to manage compliance with the Health and safety in the Workplace Act 1992 and 2002 amendment.

HSE Representatives

B.4.7-3 **

Members of the practice team comply with the health and safety policies and procedures to identify and manage hazards.

Hazards

B.4.7-5**

Health and Safety accidents and incidents are recorded, investigated, followed up and reported.

Recording and Reporting Accidents

B.4.8

The practice has planned for fire, disaster or emergency preparation, response and recovery

B.4.8 -1**

The practice implements a fire safety and evacuation scheme or procedure.

Fire Safety

B.4.8-2 *

There is a plan for emergency management planning in the event of a disaster or event that would severely impair the practice’s ability to maintain normal services.

Disaster recovery, disaster recovery checklist, pandemic planning, insurance

SectionC

Group 6

CLINICAL PRACTICE SYSTEMS

- Comprehensiveness and co-ordination of care

C.6.2

Continuity of care is facilitated by enrolment of new patients and transfer of medical records

C.6.2-2 **

At enrolment the practice requests patients written consent to transfer unidentifiable patient data to health agencies for contract requirements.

Patient consent

C.6.2-3 **

New patients have provided written consent to enable the practice to obtain their previous medical records.

Transferring patient records

C.6.2-4 **

Details of transfer of medical records to and from practices are recorded.

Transferring patient records

C.6.7

Appropriate Clinical management guidelines are used to ensure consistent quality healthcare

C.6.7 -1*

The clinical team can demonstrate appropriate use of current evidence based clinical management guidelines

NZ Guidelines Group, BPac, CDC, BMJ,

Section D Group 10

PRACTICE AND PATIENT INFORMATION MANAGEMENT
- Information Management

D.10.1

Medical records are stored of filed safely or securely

D.10.1 **

The content of medical records and documents (paper or electronic) is not identifiable in public areas.

Confidentiality of information

D.10.3

There is a system to manage patient test results and medical reports

D10.3.1**

There is a practice policy describing how patient test results, medical reports and investigations are tracked and managed

RNZCGP, HDC, FSA

Group 11

- Human Resource Management

D.11.1

All members of the practice team are qualified or trained for their position

D.11.1-1*

Clinical staff have current annual practising certificates demonstrating their competence and fitness to practise their profession under the HPCA Act 2003.

Vocational Registration Register, Training Register, HPCA

D.11.2

All members of the practice team have employment agreements and current job descriptions

D.11.2-1 *

The practice has documented workplace policies, including recruitment and appointment procedures, disciplinary procedures and orientation.

Recruitment, Discipline and Induction

D.11.2-2 **

Practice team members have written and signed employment agreements with terms and conditions.

Employment Agreements, Contractor vs Employee, Sample Agreements, Variations

D.11.2-3 *

Practice team members have job descriptions that include key tasks, functional relationships and annual review dates.

Position Descriptions

D.11.2-4 *

Performance reviews are conducted annually and are used to guide professional development for all practice team members.

Staff Performance section, skills assessments and training and development

D.11.2-5 **

Members of the practice team and others who have access to medical records have signed a confidentiality agreement.

Staff Confidentiality agreement and Duties to non employees

D.11.2-6 **

Every member of the clinical staff is insured to cover liability.

Professional Indemnity

D.11.2-7 *

There is a practice information resource available to new practice team members and locums.

Induction

D11.3

Practice meetings are used as a communication tool to enable all practice team members to participate effectively

D.11.3-1 *

The practice has evidence of regular meetings involving the practice team.

Effective meetings and agenda templates

D.11.4

Clear lines of communication, responsibility and accountability operate in the practice

D.11.4-1 *

There is an understanding of the roles and responsibilities of the practice team within the practice.

Position descriptions, management structures, practice governance

D.11.4-2 *

There are clear lines of accountability and reporting structures that include all team members.

Position descriptions, management structures, practice governance

D.11.5

The practice contributes to the development of health promoting environments

D.11.5-1 *

There is a workplace policy that encourages the team to consider a healthy workplace.

HSE, Stress, OOS

SECTION E
Group 12

QUALITY IMPROVEMENT AND PROFESSIONAL DEVELOPMENT
- Continuous Quality Improvement and professional development

E.12.1

The practice promotes continuing professional development

E.12.1-1 **

Professional team members participate in continuing professional development to meet the requirements of the HPCA Act 2003.

HPCA, Training Register

E.12.1-2 *

The learning needs of the members of the practice team are reviewed annually.

Skills assessments, training needs analysis

E.12.1-4

The practice keeps a record of continuing professional development for each team member.

Training Register

E.12.3

The practice has a Significant Event Management system to address serious or potentially serious practice problems

E.12.3-1 **

There is a process to manage Significant Events.

Significant Event Management

E.12.5

The practice has a documented strategic plan

E.12.5-1*

The practice has a documented long-term strategic plan.

Strategic Planning section

E.12.5-2 *

The practice has a documented annual business plan that includes six monthly quality objectives.

Business Planning section

E.12.5-3 *

Practice team members have input into the strategic plan.

Strategic Planning, planning team