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CORNERSTONE - General Practice Accreditation Programme - Aiming for Excellence - 2011

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Detailed below are the areas HealthyPractice® has developed against specific criteria in the 2011 assessment tool. These documents are for you to use and customise to your own particular situation – they are not intended to be the final solution, merely a resource.

INDICATOR CRITERIA HealthyPractice® RESOURCE
SECTION 1 PATIENT EXPERIENCE AND EQUITY- Needs and Rights of Patients
Indicator 1 The practice team complies with the Code of Health and Disability services Consumers’ Rights 1996
1.1** There is a copy of The Code of Health and Disability Services Consumers’ Rights 1996 (The Code) in the practice HDC Overview
1.2** The Code of Health and Disability Services Consumers’ Rights 1996 is displayed where the patients can view the content HDC Overview
1.3** The practice team has received training to implement ‘The Code’ HDC checklist and practical tips, Cultural Competence, Informed consent, Disgruntled patients
1.4** The practice team is able to demonstrate their role in implementing ‘The Code’ HDC checklist and practical tips
Indicator 2 Health Information Privacy

The practice maintains the privacy of patient information in accordance with the Health Information Privacy Code 1994
2.1** There is a copy of the Health Information Privacy Code 1994 in the practice HIPC overview
2.2** The practice team has received training to implement the principles of the Health Information privacy Code 1994. HIPC Principles, FAQ’s, Privacy Officer
2.3* The practice team is able to demonstrate their role in implementing the Health Information Privacy Code 1994. Privacy Officer, HIPC principles, FAQ’s
2.4** The collection, use, storage, disposal and disclosure of individual patient information complies with the Health Information Privacy Code 1994 HIPC Overview, Retention of Information, Disclosure of Information, Children’s Information, and Brochure for Patients
Indicator 3 Complaints

The practice upholds patient’s right to complain
3.1** There is a documented policy that describes how complaints will be managed in line with Right 10 of ‘The Code’ Complaints, Complaints process,
3.2** Practice team members are able to describe their role in managing the complaints process Complaints Officer, Complaints procedure
3.3** The complaints officer can demonstrate that the complaints process complies with Right 10 of The Code Complaints Officer, Complaints Process
3.4* Complaints and their resolutions are used as opportunities for learning and quality improvement Disgruntled patients, Significant Event Management
Indicator 4 Informed Consent

Patients are provided with information to enable them to make informed choices about their health care
4.3** Informed consent is obtained from a patient or legally designated representative, when agreeing to a treatment or procedure Informed consent
Indicator 5 Te Tiriti o Waitangi

The practice acknowledges and is responsive to the special status, health needs and rights of Maori whanau
5.1* The practice has a documented Maori Health Plan Cultural Competence, MCNZ, Discrimination,Local PHO or DHB
5.3* The practice addresses the health needs of its enrolled Maori population to reduce health inequalities. MoH, DHB or local PHO, RNZCGP Cultural Competence resource, Tips page
Indicator 6 Cultural competence & responsiveness

The practice provides services that are responsive to the cultural needs of diverse patient groups.
6.1** All members of the practice team are trained in cultural competence and cultural safety Cultural competence, MCNZ, RNZCGP, Discrimination, Induction
6.3* The practice team can access interpreters and resources for people with limited English proficiency Interpretation services, PHO
Indicator 7 Access and availability

24 hour health care is available to the practice population
7.1** The practice makes provision for 24 hour health care. Patient Access 24/7
7.3* The practice acts on health information received about patients seen afterhours Flow chart for after hours notes - Tips
Indicator 9 Patient involvement

The practice includes patient input into service planning
9.1* The practice obtains feedback from patients at least 3 yearly Patient satisfaction survey
9.4* Information about the use of patient feedback or any changes to services is communicated to patients and the practice team. Marketing, newsletter
Indicator 10 Planning for Continuous Quality Improvement

The practice undertakes strategic planning to inform business and clinical activities in the practice
10.1* The strategic plan is a living document that is reviewed every 3 – 5 years Strategic Planning, Business Planning
10.3* Practice team members have input into service planning. Strategic planning, Business Planning
SECTION 2 - Physical Access to the practice
Indicator 11 The practice premises are safely accessible and clearly identifiable
11.1** External signage is clear, visible and well placed to be read from a distance Marketing
11.2** External lighting facilitates security and safety of access Building security
Indicator 12 The practice facilities meet the comfort, safety and privacy needs of patients
12.3** There are safeguards in the reception area to ensure confidentiality of patient information Tips page
Indicator 13 Information management

The practice uses a Practice Management System
13.3** The practice can demonstrate implementation of its policy for security of electronic information. IT security, internet policy
13.4** The practice has a reliable back up and retrieval system to protect electronic patient information IT security
Indicator 15 Sharps, contaminated materials and hazardous waste

There is safe storage and disposal of healthcare waste
15.4 The practice has an active waste management programme Hazardous waste
Indicator 16 Infection Control

Effective infection control measures protect the safety of patients and team members
16.1** The practice can demonstrate that it’s infection control policy and procedures align with the AS/NZS 4815 2006 standard Infection control policy
Indicator 19 Disaster response

The practice has planned response and recovery procedures for fire, disaster or emergency
19.1** The practice has a documented evacuation scheme or evacuation procedure as required by the Fire and Safety Evacuation of Buildings regulations 2006 Fire safety, obligation of building owners, fire wardens
19.3* The practice has an Emergency Response plan which identifies risk and formulates contingencies to address the practice response to disasters or events in the community. Disaster planning, disaster plan checklist, armed robbery, other security risks, pandemic planning
19.4* The practice has a Business Continuity Plan that prioritises support and recovery of critical and non critical functions of practice processes and activities Business Continuity
Indicator 20 Health and Safety

The practice team is committed to ensuring health and safety in the workplace
20.1** The practice team is able to demonstrate how they comply with Health & Safety in Employment Act 1992 and 2002 Amendment HSE Policy Guidelines, HSE representatives, Hazards, Reporting and recording accidents, Armed robbery, other security risks, Workplace harassment, workplace stress, induction, pandemic planning
20.2** The practice has a designated health & safety Officer who manages compliance with the Health & Safety in Employment Act 1992 and the 2002 Amendment HSE representatives, Duties to employees, Duties to non-employees, Employee participation
20.3** The practice team conduct an annual health and safety review and makes policy amendments as required Hazard identification, Accident reporting, HSE policy guidelines
20.4** Health and safety accidents and incidents are reported, recorded, investigated and followed up Recording and reporting of accidents
SECTION 3 Group 1 CLINICALEFFECTIVENESS PROCESSES

- Patient enrolment
Indicator 21 Continuity of care is facilitated by enrolment of new patients and timely transfer of medical records
21.1 ** There is a patient registration process that collects demographic and health information PHO enrolment and population based funding
21.2** There is an effective and timely system to obtain and transfer medical records between practices within 10 days. Transferring patient records, request for information, disclosure of information, children's health information, patient consent
21.3** There is a system to manage tracking and retrieval of medical records to and from within the practice Transferring patient records
21.4** Receipt of records transferred from the practice is confirmed Transferring patient records
Indicator 33 Clinical and Practice Risk Management

The practice demonstrates a commitment to the Health and Safety in the Workplace
33.1** The practice has an Incident Management Policy Significant event management
SECTION 4 PROFESSIONAL DEVELOPMENT

- Continuing Professional Development
Indicator 34 The practice team complies with the Health Practitioners Competency Act 2003
34.1** All clinical team members have current annual practising certificates as required under the Health Practitioners Competence Assurance Act 203. MCNZ registered doctor, NZNC registration, Administration
34.2* Medical staff employed long term in the practice are vocationally registered in general practice or working towards this Vocational registration page
34.3 ** All clinical team members participate in Continuing Professional Development Training register, skills assessment, training needs analysis
34.4* There is planned professional development and peer review for the clinical team Skills assessment, training needs analysis
Indicator 35 Teamwork

There is a culture of teamwork in the practice
35.1* The practice undertakes a regular assessment of team functionality. Focusing on core competencies, Leadership, Resilience, Motivating your team, Creating confident employees
35.2* The practice has evidence of regular meetings involving the practice team. Meetings
35.4* The practice can demonstrate the orientation process used for new team members and locums. Induction
35.5* There is a resource with information about the practice available to new team members Induction manual
Indicator 36 Human Resources

All practice team members have employment agreements and current position descriptions
36.1** Practice team members have signed employment agreements with terms and conditions Sample agreements, Collective, New employees. Practice Agreements.
36.2** Practice team members have position descriptions that include key tasks, functional relationships and annual review dates Position descriptions
36.3** Practice team members and others who have access to identifiable patient information have a signed confidentiality agreement. Sample agreements, Staff confidentiality agreement.
36.4** Each member of the clinical team is insured to cover liability Professional indemnity insurance
36.5* There is evidence of continuing education for the practice manager PMAANZ, Training for the manager
36.6* Performance reviews are conducted annually and used to guide continuing education for all practice team members Appraisals, Appraisal models, GP appraisals, skills assessments, training needs analysis

 

**Identify and manage significant risk, legal and safety or those that pose significant risk as defined by the RNZCGP

*Considered best practice and important by the RNZCGP

 



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