Medicare LocaLs accreditation standards

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Medicare
Locals
Accreditation
Standards
– FEBRUARY 2013
A quality framework for Medicare Locals
Acknowledgements
The Medicare Locals Accreditation (MLA) Standards were developed by a Consortium
led by Quality Improvement Council (QIC) and including Australian General Practice
Accreditation Limited/Quality in Practice (AGPAL/QIP), Quality Management Services (QMS)
and Quality Improvement and Community Services Accreditation (QICSA) on behalf of the
Commonwealth Department of Health and Ageing. The contribution made by the Australian
Commission on Safety and Quality in Health Care (the Commission) in developing the MLA
Standards is also acknowledged.
Medicare Locals Accreditation Standards
ISBN: 978-1-74241-827-8
Online ISBN: 978-1-74241-828-5
Publications approval number: D0909
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this work in unaltered form for your own personal use or, if you are part of an organisation,
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reproduction for any commercial purpose and retain this copyright notice and all disclaimer
notices as part of that reproduction. Apart from rights to use as permitted by the Copyright
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allowed to reproduce the whole or any part of this work in any way (electronic or otherwise)
without first being given the specific written permission from the Commonwealth to do so.
Requests and inquiries concerning reproduction and rights are to be sent to the Online,
Services and External Relations Branch, Department of Health and Ageing, GPO Box 9848,
Canberra ACT 2601, or via e-mail to [email protected]
Medicare Locals Accreditation Standards – February 2013
Contents
Introduction
........................................................................................................................ 2
SECTION 1:
Corporate Governance Standards
Standard 1:
Governance and Leadership ......................................................................... 11
Standard 2:
Human Resource Management..................................................................... 21
Standard 3:
Knowledge and Information Management...................................................... 29
Standard 4:
Contracting and Subcontracting.................................................................... 35
SECTION 2:
Stakeholder Standard
Standard 5:
Stakeholder Relationships.............................................................................. 39
SECTION 3:
Service Standards
Standard 6:
Analysis and Planning.................................................................................... 45
Standard 7:
Health Promotion and Illness Prevention........................................................ 51
Standard 8:
Service Coordination and Integration............................................................. 57
Standard 9:
Service and Provider Support........................................................................ 61
Standard 10: Direct Health Service Delivery......................................................................... 65
SECTION 4:
Safety and Physical Resources Standards
Standard 11: Environmental Safety..................................................................................... 79
Standard 12: Asset Management........................................................................................ 83
Glossary
...................................................................................................................... 89
References
...................................................................................................................... 99
Appendices
.................................................................................................................... 103
Appendix 1:
Corporate Governance Self-assessment (Indicator 1.2.1)............................. 104
Appendix 1.1: Clinical Governance Self-assessment.......................................................... 105
Appendix 2:
Designated Responsibility Checklist (Indicator 1.2.6).................................... 106
Appendix 3:
Risk Management System Self-assessment................................................. 107
Appendix 4:
Policy and Procedure Checklist ................................................................... 108
Appendix 4.1: Policy and Procedure Checklist (Direct Health Service Delivery).................... 109
Appendix 5:
Summary of Human Resource Management Regulatory Requirements
(Indicator 2.7.1)............................................................................................ 110
Appendix 6:
National Privacy Principles Compliance Self-assessment (Indicator 3.3.1).... 112
Appendix 7:
Computer and Information Security Self-assessment (Indicator 3.4.1).......... 113
Appendix 8:
An Overview of Primary Health Care Quality Frameworks
(Indicator 9.1.1)............................................................................................ 115
Appendix 9:
Summary of Work Health and Safety Regulation in Australia
(Indicator 11.1.1).......................................................................................... 116
Appendix 10: Summary of Fire Safety Regulatory Requirements (Indicator 11.2.1)............. 117
Contents
1
Introduction
Medicare Locals have been established as a key
– identify and target gaps in primary health care for older
component of the Australian Government’s National
people, whether they live independently or in an aged
Health Reform agenda. They are primary health care
care facility;
organisations that work with local primary health care
– identify where local communities are missing out on
providers, Local Hospital Networks and communities
services they might need and coordinate services to
to ensure that patients receive the right care in the
address those gaps;
right place at the right time.
– support local primary health care providers, such as
GPs, practice nurses and allied health providers, to
Medicare Locals fill a previously empty space in the
Australian health system. They are designed to shift the
balance in health care away from acute interventions
toward prevention, early intervention and chronic disease
adopt and meet safety and quality standards; and
– are accountable to local communities for ensuring that
services are effective, affordable and of high quality.
management. They are focused on creating links and
Medicare Locals are independent companies limited by
connections to better serve the health care needs of
guarantee, and operate in an environment in which they
the community. Over time, their role will be to build
are accountable to the Commonwealth, to their local
increasingly effective systems in which individuals and
community and to their members.
families form a partnership with a particular primary health
Medicare Locals have five Strategic Objectives as follows:
care provider and other services “wrap around” that
partnership as they become necessary.
Medicare Locals operate as health system planners at
the regional level. They have primary responsibility for
identifying and assessing the health care needs of their
populations, addressing service gaps, and improving the
coordination and integration of primary health care in local
communities. In achieving this they will make it easier for
individuals, carers and service providers to navigate their
local health care system.
Specifically, Medicare Locals:
– make it easier for healthcare consumers to access the
services they need, by better linking and coordinating
local general practitioners (GPs), nursing, allied health
and other health professionals, hospitals and aged
care, and the broader social services system;
– work closely with Local Hospital Networks to make sure
that primary health care services and hospitals work
well together for the benefit of their patients;
– plan and support local after hours face-to-face GP
services;
2
Medicare Locals Accreditation Standards – February 2013
1.Improve the patient journey through developing
integrated and coordinated services.
2.Provide support to clinicians and service providers
to improve patient care.
3.Identify the health needs of local areas and
development of locally focused and responsive
services.
4.Facilitate the implementation and successful
performance of primary health care initiatives
and programs.
5.Be efficient and accountable with strong governance
and effective management.
The Australian Medicare Local Alliance (AML Alliance) has
been established to assist Medicare Locals to function
effectively and efficiently, to achieve the Medicare Locals
Strategic Objectives and to work as a cohesive network
that can be responsive to evolving health priorities.
The AML Alliance works closely with Medicare Locals
Ministers endorsed the model Australian Health Service
to lead and support them so that they can achieve their
Safety and Quality Accreditation (AHSSQA) Scheme in
objectives. It also works closely with the Commonwealth
November 2010 which provided for national coordination
to disseminate information and guidance to the Medicare
of accreditation schemes. The initial focus of the model
Locals network as a whole.
accreditation scheme was on the accreditation of hospitals
Medicare Locals Accreditation Scheme
The aim of the Medicare Locals Accreditation Scheme
(MLA Scheme) is to assist Medicare Locals in achieving
their Strategic Objectives. The scheme will support
Medicare Locals to enable them to meet best practice
organisational management and service delivery
processes. Accreditation is one aspect of a broader
quality framework for Medicare Locals that will seek to
promote transparency, information sharing and a culture
of continuous quality improvement.
and day procedure services. (NSQHS Standards, 2011)
The MLA Standards have been developed with reference
to the NSQHS Standards and are aligned to the objectives
of the AHSSQA Scheme. The clinical standards included
in these MLA Standards are transitional, representing
a starting point for implementing safety and quality
accreditation.
Closing the Gap in Indigenous Disadvantage
As primary health care organisations, Medicare Locals
will undertake population health analysis and planning
The Deed for Funding between the Commonwealth
and take increasing responsibility for integration and
(as represented by the Department of Health and
coordination of health services. They will play an integral
Ageing) and each Medicare Local requires Medicare
role in closing the gap in Indigenous disadvantage.
Locals to become accredited under the MLA Scheme
In December 2007, the Council of Australian Governments
against the Medicare Locals Accreditation Standards
(COAG) agreed to a partnership between all levels of
(MLA Standards). This process must be undertaken by
government to work with Aboriginal and Torres Strait
an agency approved by the Commonwealth to provide
Islander communities to close the gap in Indigenous
accreditation services to Medicare Locals, against the
disadvantage. In recognition that outcomes for Aboriginal
MLA Standards, in order to fulfil the requirements under
and Torres Strait Islander people remain well below those
the MLA Scheme. Detailed information about accreditation
of other Australians, COAG agreed to six targets relating to
against the MLA Standards is provided in the Medicare
life expectancy, child mortality, education and employment.
Locals Accreditation Guidelines.
COAG has identified seven building blocks that need to be
Australian Commission on Safety and Quality
in Health Care
addressed in a coordinated fashion if the targets are to be
achieved. These building blocks reflect the influence that
social, economic and environmental factors have on health
In September 2011, the Australian Health Ministers’
outcomes. They comprise early childhood, schooling,
Conference endorsed the National Safety and Quality
health, healthy homes, economic participation, safe
Health Service (NSQHS) Standards developed by the
communities, and governance and leadership.
Australian Commission on Safety and Quality in Health Care
(the Commission). These standards provide a framework for
safety and quality improvement for all health services.
Introduction
3
While there has been some progress, Aboriginal and
The Medicare Locals Accreditation Standards
Torres Strait Islander people still face a great number of
The MLA Standards have been developed to provide a
health challenges, experiencing more illness, disability
quality framework for Medicare Locals aimed at supporting
and injury than other Australians. Indigenous children
the establishment of best practice organisational
born today can expect to live shorter lives than non-
management and service delivery systems and a culture
Indigenous children – 11.5 years shorter for males, and
of quality improvement. The Commonwealth has funded
9.7 years shorter for females. (Australian Indigenous
the development of the MLA Standards to ensure that
Healthinfonet, 2011)
Medicare Locals are accredited against standards
The MLA Standards have been developed with reference
that are specifically tailored to their unique roles and
to these targets and in consultation with the National
responsibilities. The MLA Standards have been developed
Aboriginal Community Controlled Health Organisation
in consultation with the Commonwealth, Medicare
(NACCHO). The MLA Standards require Medicare Locals
Locals, the AML Alliance, the Australian Commission on
to address the needs and views of Aboriginal and Torres
Safety and Quality in Health Care, interested accrediting
Strait Islander people and communities represented
agencies, and other key stakeholders.
within their catchment area and provide for objective
The MLA Standards have four broad content areas, as
measurement of their effectiveness in doing this.
outlined below.
Corporate Governance Standards
Standard
Title
Objective
Standard 1
Governance and Leadership
Strong corporate governance and effective management
Standard 2
Human Resource Management
A competent, committed and achievement focused team
Standard 3
Knowledge and Information Management
Timely access to accurate information; effective
management of knowledge capital
Standard 4
Contracting and Subcontracting
Contracted services support the health needs of the
catchment community
Stakeholder Standard
Standard
Title
Objective
Standard 5
Stakeholder Relationships
Mutually beneficial partnerships with stakeholders
4
Medicare Locals Accreditation Standards – February 2013
Service Standards
Standard
Title
Objective
Standard 6
Analysis and Planning
A planned approach to service delivery informed by
adequate and appropriate research, analysis and
consultation
Health Promotion and Illness Prevention
Standard 7
Locally focused health promotion and illness prevention
activities that enable health gains in the community
Standard 8
Service Coordination and Integration
Continuity of comprehensive care for consumers
Standard 9
Service and Provider Support
Leadership and better practice in primary health care
Standard 10
Direct Health Service Delivery
Quality health services accessible to those who need them
Safety and Physical Resources Standards
Standard
Title
Objective
Standard 11
Environmental Safety
A safe environment
Standard 12
Asset Management
Asset management supports the effective functioning of
the Medicare Local
The MLA Standards have a three-level hierarchy
A standard is defined as a high level business system that
comprising standards, criteria and indicators.
is critical to the effective functioning of the Medicare Local
Each standard is comprised of criteria; each criterion
and the achievement of the Medicare Locals Strategic
is comprised of indicators. The MLA Standards are
Objectives. Each standard has a title which describes the
supported by explanatory notes which provide important
system overall and an objective which describes what the
information for Medicare Locals and accrediting agencies
standard is intended to achieve.
about how the MLA Standards should be applied.
Diagram 1: MLA Standards Structural Hierarchy
A criterion is defined as an essential component that
would be required for the objective of the standard to be
achieved. Each criterion has a title which describes the
process and an outcome statement which describes what
Standard
the criterion is intended to achieve.
An indicator is an activity, output or process that can be
objectively measured through the third party assessment
Criterion
Criterion
processes of interview, document review and/or
inspection. It will, in combination with other specified
indicators, provide assurance that the outcome specified
at criterion level is, or is likely to be, achieved. Indicators
Indicator
Indicator
Indicator
Indicator
are the level of measurement within the MLA Standards.
Introduction
5
MLA Standards Applicability Guidelines
Some indicators may not be applicable to all Medicare
Standards 1, 2, 3, 4, 5, 6, 7, 8, 9, 11 and 12 are
Locals. For example, Criterion 12.2 Fleet Management
applicable to all Medicare Locals, other than documented
would not be applicable to a Medicare Local that does
exclusions. These exclusions must be determined to be
not have fleet vehicles. Similarly, some indicators under
appropriate by an approved accrediting agency and based
Standard 10 Direct Health Service Delivery may not be
on the guidelines in this document.
applicable to all Medicare Locals that provide direct health
Standard 10 Direct Health Service Delivery is applicable
only to Medicare Locals that provide direct health services.
For the purpose of the MLA Standards, direct health
service delivery is defined as:
services; this will depend on the range and type of health
services that the Medicare Local provides. The applicability
of the criteria and indicators in Standard 10 will be
determined by the Medicare Local and their preferred
accrediting agency. The explanatory notes for Standard
The provision of a service that involves the assessment,
10 Direct Health Service Delivery will provide general
diagnosis, treatment or prevention of social, emotional,
guidance on applicability.
psychological and/or physical risk, illness or injury
to individual consumers, by a suitably skilled and/or
qualified person.
Some criterion/indicators are identified as developmental,
which indicates that they are applicable but will not initially
be mandatory to achieve accreditation. Developmental
Standard 10 Direct Health Service Delivery is also
criterion/indicators are identifiable by [Developmental] at
applicable where the Medicare Local:
the beginning of the indicator. Medicare Locals should
– acquires, stores, prescribes or administers medicines
consider developmental requirements as significant in the
of any type; or
– provides health promotion and illness prevention
activities individually or in small groups (excluding health
promotion provided at the population level, which is
covered in Standard 7).
provision of quality services and work towards meeting
these requirements. It is anticipated that developmental
requirements will become mandatory over time.
Table 1: MLA Standards Structural Hierarchy
Mandatory Developmental
Direct health services that are accredited under an
Total
existing quality framework are not required to be assessed
Standards
12
0
12
against Standard 10. For example, general practice
Criteria
43
3
46
services, medical deputising services and after hours
Indicators
149
8
157
medical services operated by Medicare Locals must be
accredited under the current edition of the Royal Australian
College of General Practitioners (RACGP) Standards for
Interpretation
general practices, and would not be assessed against
Terms used in the MLA Standards have the meaning
Standard 10. Similarly, mental health services accredited
provided in the explanatory notes and the glossary of
under the National Standards for Mental Health Services
terms. Where a definition is not provided in the glossary
would not be subject to assessment under Standard 10.
of terms, the term should be taken to have the term’s
Medicare Locals should discuss existing accreditations
usual dictionary meaning.
and certifications with their accrediting agency when
applying for accreditation.
6
Medicare Locals Accreditation Standards – February 2013
Rating Framework
– An indicator is not met if there is no objective evidence
Assessment is undertaken against indicators; however,
consistent with the requirement(s) of the indicator
ratings are applied at the level of the indicators, criterion
description (or no evidence of achievement equivalent
and standards. For the purpose of accreditation against
to requirements of the indicator).
the MLA Standards, there will be two ratings, met and not
– An indicator is partially met if there is objective evidence
met for mandatory indicators. A rating of partially met may
of some aspects of the requirements of the indicator or
be applied to developmental items. Partially met ratings for
progress towards the achievement of the indicator.
developmental indicators do not have any impact on the
rating for criteria and standards.
Note: Partially met ratings can only be applied to
developmental indicators, and are used to indicate that a
The algorithm for determining compliance and applying
Medicare Local has commenced activity aimed at meeting
ratings is as follows:
the requirement of the indicator.
Rating Standards
– The requirements of a standard are met if each
mandatory criterion for the standard is met.
– The standard is not met if one or more mandatory
criterion is not met.
Ratings for developmental indicators do not impact on
the rating of a criterion.
Rating Criteria
– A criterion is met if all of the mandatory indicators
Clinical Governance Framework
Clinical governance is an umbrella term that describes
processes and controls aimed at ensuring the safety and
quality of clinical services and the prevention of harm to
patients. Recognising the leadership role that Medicare
Locals play in the Australian health care system, the
MLA Standards incorporate a comprehensive clinical
governance framework.
Clinical governance is the system through which
organisations are accountable for continuously improving
for the criterion are met or if all the indicators for the
the quality of their services and safeguarding high
criterion are developmental.
standards of care. This is achieved by creating an
– A criterion is not met if one or more mandatory
indicators for the criterion are not met.
environment in which there is transparent responsibility
and accountability for maintaining standards and by
Ratings for developmental criteria do not impact on the
allowing excellence in clinical care to flourish. (Reference
rating of a standard.
11, NSQHS Standards 2011)
Rating Indicators
Medicare Locals have two discrete clinical governance
Indicators are the level of measurement for the purpose
of rating.
– An indicator is met if there is objective evidence
responsibilities. The first is an inward facing clinical
governance responsibility in respect of health services
it provides directly. The second is an outward facing
responsibility to promote and support the implementation
consistent with the requirement(s) of the indicator
of effective clinical governance systems in other primary
description as defined by the explanatory notes (or
health care services. (See Appendix 1.1)
evidence of achievement equivalent to the requirements
of the indicator).
Introduction
7
A summary of the clinical governance framework in the MLA Standards that applies to all Medicare Locals is provided in
the following table.
Table 2: MLA Standards Clinical Governance Framework applicable to all Medicare Locals
Clinical Governance Element
MLA Standards Criterion/Indicator
Risk management
Criterion 1.3 Risk Management, including clinical risk management
Clinical effectiveness
Criterion 2.1 Workforce Capability
Criterion 2.4 Performance Management and Supervision
Criterion 2.5 Credentialing and Screening
Criterion 10.3 Health Service Provision
Education, training and continuing
Criterion 2.3 Training and Professional Development
professional development
Use of Information
Criterion 3.1 Knowledge Management
Criterion 3.2 Information Systems
Employees and employee
Criterion 2.1 Workforce Capability
management
Criterion 2.2 Role Clarity
Criterion 2.4 Performance Management and Supervision
Criterion 2.5 Credentialing and Screening
Clinical audit
Criterion 10.9 Clinical Quality Improvement
Criterion 10.9.1 Clinical Audit
Consumer engagement
Criterion 5.1 Stakeholder Mapping and Analysis
Criterion 5.2 Stakeholder Engagement
Criterion 5.3 Stakeholder Feedback
Criterion 10.2 Care Planning and Evaluation
Research
8
Criterion 9.1.3 Research and Innovation
Medicare Locals Accreditation Standards – February 2013
Acronyms
The following acronyms are used throughout these Standards:
MLA Scheme
Medicare Locals Accreditation Scheme
MLA Standards
Medicare Locals Accreditation Standards
DoHA
Department of Health and Ageing
NHSD
National Health Services Directory
WHS
Work Health and Safety
AHPRA
Australian Health Practitioner Regulation Agency
ACSQHC
Australian Commission on Safety and Quality in Health Care
NSQHS Standards
National Safety and Quality Health Service Standards
Introduction
9
10
Medicare Locals Accreditation Standards – February 2013
Section 1
section 1
Corporate Governance
Standards
Corporate governance is an umbrella term that describes a range of controls within an
organisation aimed at ensuring compliance and positive performance. Standards 1, 2, 3 and
4 address key corporate governance processes and controls.
Standard 1
Governance and Leadership
Strong corporate governance and effective management
Criterion 1.1
Strategy and Planning
The Medicare Local has clear strategic direction aligned to the five Medicare Locals
Strategic Objectives.
Criterion 1.2
Organisational Accountability
Transparent assignment and monitoring of responsibility.
Criterion 1.3
Risk Management
Organisational risks are identified, assessed and controlled.
Criterion 1.4
Financial Management
Responsible financial management.
Criterion 1.5
Quality Management
A culture of quality supported by a quality management system.
Criterion 1.6
Complaint Management
A transparent and responsive complaint management process.
Standard 2
Human Resource Management
A competent, committed and achievement focused team
Criterion 2.1
Workforce Capability
Sufficient suitably skilled and qualified employees to meet organisational objectives.
Criterion 2.2
Role Clarity
Employees understand their roles and responsibilities.
Criterion 2.3
Training and Professional Development
Relevant and timely training and professional development opportunities are provided
for employees.
Criterion 2.4
Performance Management and Supervision
Employees are supported to understand and meet performance expectations.
Criterion 2.5
Credentialing and Screening
The credentials and suitability of all employees, contractors and subcontractors
are verified.
Criterion 2.6
Organisational Communication
Effective intra-organisational communication.
Criterion 2.7
Human Resource Management Compliance
Human resource management systems and processes are aligned to
regulatory requirements.
Standard 3
Knowledge and Information Management
Timely access to accurate information; effective management of knowledge capital
Criterion 3.1
Knowledge Management
Knowledge capital is identified and managed in a way that facilitates organisational
learning and development.
Criterion 3.2
Information Systems
Information held by the Medicare Local is accurate, secure and accessible.
Criterion 3.3
Information Privacy
Unauthorised access to personal information held by the Medicare Local is prevented.
Criterion 3.4
Computer and Information Security
Loss, corruption and unauthorised access to information held electronically are prevented.
Standard 4
Contracting and Subcontracting
Contracted services support the health needs of the catchment community
Criterion 4.1
Contracting and Subcontracting
Programs and services are subcontracted to appropriate third parties using clear,
comprehensive and legally binding contracts/agreements.
Criterion 4.2
Contract Compliance
Contracted and subcontracted services enhance efficiency and service quality.
Standard 1
Governance
and Leadership
Objective: Strong corporate governance and
effective management
Resources
The following resources may be useful for Medicare Locals in establishing effective organisational management systems:
– AS 8000 – 2003 Corporate Governance (Good
Governance Principles).
– AS 8001 – 2008 Fraud and Corruption Control.
– AS/NZS ISO 31000:2009 Risk Management –
Principles and Guidelines.
– IEC/FDIS 31010 Risk Management – Risk
Assessment Techniques; and
– ISO Guide 73:2009 Risk Management – Vocabulary.
– AS ISO 10002-2006 Customer Satisfaction –
guidelines for complaints handling in organizations.
– Commonwealth Ombudsman, 2009. Better Practice
Guide to Complaint Handling.
– ISO/IED Guide 73:2009, 2009.
– Corporations Act 2001 (Commonwealth).
– International Financial Reporting Standards.
– Accounting Standard s296.
Standard 1: Governance and Leadership
11
Corporate governance is an umbrella term that describes
– appropriate data collection, performance monitoring
a range of controls within an organisation aimed at
and reporting processes – including a commitment
ensuring compliance and positive performance. Standards
to participating within a nationally consistent
1, 2, 3 and 4 address key corporate governance
performance framework and monitoring of definitive
processes and controls.
outcomes related to Medicare Locals’ core business
Objective 5 of the Medicare Locals Strategic Objectives
requires Medicare Locals to be efficient and accountable,
requirements;
– decision making processes that are responsive to
with strong governance and effective management.
local health care needs and accountable across the
To achieve this objective, Medicare Locals are expected
spectrum of the local community and primary health
to have:
care providers; and
– appropriate company, Board and senior management
structures and processes – to manage risk, ensure
– capacity to remain flexible and responsive to evolving
circumstances.
compliance with all legal and fiduciary responsibilities,
Medicare Locals have a key leadership role to play in
ensure financial viability and accountability, and to
primary health care. Medicare Locals can promote and
attract and retain essential skills across the extent of
encourage good governance, including clinical governance
corporate and primary health care expertise;
across primary health care by ensuring governance
– capacity to drive more efficient use of health and
systems are implemented and operational internally.
administrative resources – including through contract
The quality framework for Standard 1 Governance and
management, resource allocation and acquittal, budget
Leadership includes the following criteria:
management, and contributing to efficiency and equity
across health sectors in the local area;
– sufficient capacity and expertise to effectively and
– 1.2 Organisational Accountability;
efficiently manage flexible funding to target services to
– 1.3 Risk Management;
their local community’s specific needs;
– 1.4 Financial Management;
– mechanisms to appropriately integrate information
relating to clinical priorities and governance – including
links with Local Hospital Networks and local Lead
Clinician Groups once established;
12
– 1.1 Strategy and Planning;
Medicare Locals Accreditation Standards – February 2013
– 1.5 Quality Management; and
– 1.6 Complaint Management.
Criterion 1.1
Strategy and Planning
Expected Outcome
Explanatory Notes
The Medicare Local has clear strategic
direction aligned to the five Medicare Locals
Strategic Objectives.
A strategy is a logically structured plan or method for
achieving long term goals. To meet the requirements of
the MLA Standards, Medicare Locals must have a
strategic plan and an annual business plan, both of
which are aligned to the five Medicare Locals Strategic
Indicators
Objectives as follows:
1.1.1 The Medicare Local’s vision, mission and values
1. Improve the patient journey through developing
are documented and implemented.
1.1.2 A strategic plan is documented and implemented,
aligned to the five Medicare Locals Strategic
Objectives, including performance measures.
1.1.3 The strategic plan is informed by consultation with
stakeholders, including consumers.
1.1.4 An annual business plan is documented and
implemented, that includes performance measures.
1.1.5 Achievement against the performance measures is
evaluated at least annually.
1.1.6 A Business Continuity Plan, including a Disaster
integrated and coordinated services.
2. Provide support to clinicians and service providers to
improve patient care.
3. Identify the health needs of local areas and
development of locally focused and responsive
services.
4. Facilitate the implementation and successful
performance of primary health care initiatives and
programs.
5. Be efficient and accountable with strong governance
and effective management.
The strategic plan and annual business plan required
Recovery Plan, is documented, implemented
under Criterion 1.1 of the MLA Standards are the
and tested.
same as the strategic plan and annual plan required
under the Medicare Locals Deed for Funding with the
Commonwealth (the Deed for Funding).
Standard 1: Governance and Leadership
13
Criterion 1.2
Organisational Accountability
Expected Outcome
Explanatory Notes
Transparent assignment and monitoring
of responsibility.
In the MLA Standards, the effectiveness of a Medicare
Indicators
1.2.1 A Board Charter aligned to AS 8000 – 2003
against AS 8000 – 2003 Corporate Governance (Good
Governance Principles). The purpose of this standard is
to assist Board members, chief executive officers and
senior managers to develop, implement and maintain
Corporate Governance - Good Governance
robust systems of governance that fit particular entities.
Principles is documented and implemented.
They also provide the mechanisms for an entity to
1.2.2 An organisational structure that defines
reporting lines and organisational relationships
is documented and implemented.
1.2.3 The organisational structure chart identifies the
person with overall responsibility for the safety and
quality of health services, including direct
health services.
1.2.4 A delegations framework that provides for
transparent and appropriate allocation of authority,
including financial delegations, is documented
and implemented.
1.2.5 A management reporting system aligned to
performance measures outlined in the strategic
and annual plan is implemented.
1.2.6 Designated responsibility for leading and
coordinating key critical processes has
been assigned.
14
Local’s corporate governance system is measured
Medicare Locals Accreditation Standards – February 2013
establish and maintain an ethical culture. (Standards
Australia, 2003) To meet the requirements of the MLA
Standards, Medicare Locals will need to demonstrate
skills-based criteria for selecting Board members.
(See Appendix 1)
Criterion 1.3
Risk Management
Expected Outcome
Explanatory Notes
Organisational risks are identified, assessed
and controlled.
Risk management is a process involving the identification,
Indicators
1.3.1 An organisational risk management process aligned
assessment and prioritisation of organisational risks. This
assessment is followed by coordinated and economical
application of resources to minimise, monitor, and control
the probability and/or impact of such risks. (International
Organization for Standardization, ISO, 2009) Risk
to AS/NZS ISO 31000:2009 Risk Management
management is a key feature of modern corporate and
- Principles and Guidelines is documented and
clinical governance. To meet the requirements of the MLA
implemented, and provides for management of
Standards, Medicare Locals are required to implement an
clinical risks (where relevant).
organisational risk management system aligned to AS/
NZS ISO 31000:2009 Risk Management - Principles and
Guidelines. The risk management system should include
a process for identifying, documenting and managing
risks and provide for regular review and evaluation
of organisational risk by the Medicare Local’s senior
management team. (Standards Australia, 2009)
As primary health care organisations, clinical risk
management will be a key component of effective
organisational risk management for Medicare Locals,
particularly those that provide health services directly.
Clinical risk management is the process of identifying risks
and potential risks that are relevant to the health services
the Medicare Local provides and implementing strategies
aimed at the elimination or control of risks such that the
likelihood of harm to consumers is removed or reduced.
To meet the requirements of the MLA Standards, Medicare
Locals will need to demonstrate:
– a single point of responsibility for clinical governance;
– awareness of the risks related to the health services
the Medicare Local provides;
– processes for monitoring clinical performance
including through clinical audit, complaint and incident
management;
Standard 1: Governance and Leadership
15
Criterion 1.4
Financial Management
– clinical risk management processes relevant to
the range of direct health services the Medicare
Local provides;
Expected Outcome
Responsible financial management.
– clinical governance representation (or sponsorship)
at senior management meetings; and
– reporting of clinical performance data to senior
management and the Board.
A clinical governance self-assessment is provided at
Indicators
1.4.1 Financial reporting occurs in accordance with the
Corporations Act 2001.
1.4.2 Fraud and corruption prevention strategies aligned
Appendix 1.1 to assist Medicare Locals to review the
to AS 8001—2008 Fraud and Corruption Control
effectiveness of clinical governance and clinical risk
are documented and implemented.
management processes.
1.4.3 An annual operating budget aligned to the strategic
and annual plan is documented and approved by
the Board.
1.4.4 Financial performance is routinely reported to those
with financial responsibility and to the highest level
of management and the Board.
1.4.5 Significant departures from budget forecasts are
identified, analysed and responded to in a timely
manner by the responsible person.
1.4.6 Purchasing is undertaken in accordance with
financial delegations.
1.4.7 Procurement decision making processes are
informed by safety, quality and best value
for money.
1.4.8 An asset register is used to track, monitor and
manage significant assets.
16
Medicare Locals Accreditation Standards – February 2013
Explanatory Notes
Medicare Locals receive significant funding from the
Commonwealth and are subject to financial reporting
obligations set out in the Corporations Act 2001.
(Commonwealth, 2001) Financial reports prepared in
accordance with the Corporations Act 2001 generally
must comply with Accounting Standards (s296).
Australian Accounting Standards meet the requirements
of International Financial Reporting Standards (IFRS)
which Australia adopted in 2005, with application for
financial periods beginning on or after 1 January 2005.
Effective procurement is an essential component
of corporate governance and responsible financial
management. Transparent procurement processes
enable organisations to demonstrate efficient use of
funds, maximise competition, increase value for money,
reduce the risk of corruption and enhance organisational
credibility. To meet the requirements of the MLA
Standards, Medicare Locals will need to demonstrate
that procurement processes and procurement decision
making are based on ethical principles and value for
money. They will also need to show that processes are in
place to recognise and deal with any conflict of interest
The requirements for an operating budget in the MLA
and perceived conflict of interest, including seeking
Standards have a broader focus than the requirements
probity advice as part of the procurement process. It is
of the Deed for Funding. A Medicare Local is required to
recognised that effective procurement decision making
give the Commonwealth a budget annually with respect
by Medicare Locals will require the balancing of best
to funding provided under the Deed for Funding, whereas
practice procurement principles against local factors
the operating budget required under the MLA Standards
related to market capability and past performance of
is required to address all sources of income, for example,
existing suppliers.
other sources of government funding (local, State and
Federal), member fees and fees for products and services.
The MLA Standards require Medicare Locals to adopt a
robust risk management approach to preventing fraud
and corruption, aligned to the AS 8001—2008 Fraud
and Corruption Control. (Standards Australia, 2008) This
Standard outlines an approach to preventing fraud and
corruption and is intended to apply to all entities including
Government sector agencies, publicly listed corporations,
private corporations, other business entities and not-forprofit organisations engaged in business or business-like
activities. Medicare Locals will need to demonstrate that
financial policies, procedures and protocols aligned to
AS 8001—2008 are in place.
Standard 1: Governance and Leadership
17
Criterion 1.5
Quality Management
Expected Outcome
Explanatory Notes
A culture of quality supported by quality
management systems.
Quality management is a systematic approach to
Indicators
1.5.1 Policies, procedures and protocols are documented
achieving quality outcomes — from a business’s inputs
and processes to outcomes and customer satisfaction.
The MLA Standards do not prescribe any particular
approach to quality management or quality improvement.
Medicare Locals should adopt quality systems and
and implemented for all aspects of the
processes that are most appropriate for their particular
MLA Standards.
size, structure and circumstances. The approach a
1.5.2 Policies, procedures and protocols are
comprehensive and up-to-date and aligned to
regulatory requirements.
1.5.3 Policies, procedures and protocols are readily
Medicare Local adopts should be documented in a
quality (or similar) policy and implemented throughout
the organisation. The quality policy should outline, as
a minimum, the Medicare Local’s approach to quality
management, quality objectives and quality improvement
accessible to those who need them throughout
methodology, including internal audit processes (such as
the organisation.
clinical audit, where direct health services are provided).
1.5.4 A system for identifying, implementing and
Documented policies and procedures are the foundation
monitoring compliance with applicable regulatory
of effective management and quality management
requirements is documented and implemented.
systems. Policies, procedures and protocols should be
1.5.5 A system of document control is documented
and implemented.
1.5.6 An evidence based approach to quality
improvement is documented and implemented.
relevant, comprehensive, accurate and accessible to
those who need them. To meet the requirements of the
MLA Standards, Medicare Locals will need to ensure
that policies and procedures are aligned to regulatory
requirements where applicable.
A key feature of an effective quality management
system is a structured quality improvement process.
The ISO definition of quality improvement provided
in ISO 9000:2005 Quality management systems —
Fundamentals and Vocabulary states that it is the
actions taken throughout the organisation to increase
the effectiveness of activities and processes to provide
added benefits to both the organisation and its customers.
In simple terms, quality improvement is anything which
causes a beneficial change in quality performance.
(Standards Australia, 2005)
18
Medicare Locals Accreditation Standards – February 2013
Criterion 1.6
Complaint Management
Effective quality improvement requires processes for
monitoring performance and service quality and then
evaluating information gathered to identify opportunities
to improve services. Evaluating improvements, including
Expected Outcome
A transparent and responsive complaint
management process.
consulting with those affected by the change, will
ensure that the desired effect is achieved without any
undesirable consequences.
Indicators
1.6.1 A complaint management system is in place
Document control is the process by which documents are
that provides for the recording and investigation
managed within an organisation. Effective management
of complaints from consumers and other
and control of documents and records is a cornerstone of
stakeholders.
effective quality management. To meet the requirements
of the MLA Standards, Medicare Locals are required to
implement document control systems and processes that
provide for:
– review and approval of key management systems’
1.6.2 Feedback is provided to complainants throughout
the complaint investigation processes.
1.6.3 Complaint data is analysed and used to inform
quality improvement.
documents prior to release;
– effective document change management, including
identifying changes and revisions to documents;
– document version control such that relevant versions of
documents are available to end users; and
– document storage, including processes to ensure that
documents are stored and organised in a secure way
and are readily accessible.
Standard 1: Governance and Leadership
19
Criterion 1.6 (Continued)
Complaint Management
Explanatory Notes
– acting on issues that arise from the investigation;
Effective complaint handling offers many practical benefits.
– providing feedback to complainants about the
Complaints deliver direct information from clients about
ineffective decisions, poor service delivery and faulty
outcome of their complaint; and
– escalating the complaint if the complainant is
systems and processes. Complaint data can be used to:
not satisfied with the outcome of the complaint
– provide a suitable remedy to a complainant;
investigation process.
– maintain good relations with stakeholders;
– evaluate the quality of programs and services; and
– inform decision making about future service delivery.
A complaint handling system should be modelled on
principles of fairness, accessibility, responsiveness and
efficiency. Complaint handling must be integrated with the
day-to-day operations of the Medicare Local. To meet the
requirements of the MLA Standards, Medicare Locals are
required to implement a complaint management system
for both internal and external stakeholders, including
consumers. This complaint management system should
incorporate mechanisms for:
– logging and recording complaints on a complaint
register;
– acknowledging complaints, including providing the
complainant with information about the Medicare
Local’s complaints management systems/processes;
– investigating complaints to determine the cause and
related issues;
20
Medicare Locals Accreditation Standards – February 2013
Standard 2
Human Resource
Management
Objective: A competent, committed and
achievement focused team
Human resource management is the function within an organisation that focuses on recruitment,
management and direction of the people who work in the organisation.
The human resource management framework within the MLA Standards incorporates the following processes:
– 2.1 Workforce Capability;
– 2.2 Role Clarity;
– 2.3 Training and Professional Development;
– 2.4 Performance Management;
– 2.5 Credentialing and Screening;
– 2.6 Organisational Communication; and
– 2.7 Human Resource Management Compliance.
Resources
The following resources may be useful for Medicare Locals in establishing effective human resource
management systems:
– Summary of employee relations legislation that may be applicable to Medicare Locals, Appendix 5.
– Australian Commission on Safety and Quality in Health Care, Open Disclosure Standard, Sydney, 2008.
Standard 2: Human Resource Management
21
Criterion 2.1
Workforce Capability
Expected Outcome
Explanatory Notes
Sufficient suitably skilled and qualified staff
to meet organisational objectives.
Workforce capability is the degree to which the
Indicators
requirements. Medicare Locals are required under the
knowledge, skills, qualifications and experience of the
organisation’s people align to strategic and operational
MLA Standards to undertake capability planning and
2.1.1 A workforce plan aligned to current and future
establish a documented workforce plan. A workforce plan
operational requirements is documented and
sets out the workforce capability required to achieve its
implemented.
business objectives, including future goals.
2.1.2 The skills and qualifications of employees are
appropriate to the functions they perform.
Workforce planning involves:
– examining the Medicare Local’s objectives;
– identifying the human resource capability required to
fulfil requirements;
– profiling the Medicare Local’s existing capability; and
– identifying capability gaps and planning to address any
capability gaps.
Workforce planning will also incorporate planning in
relation to the timing for staff appointments linked to plans
for commissioning of new services.
For Medicare Locals that provide direct health services,
a key component of ensuring appropriate workforce
capability is defining scope of practice. Defining scope of
practice involves the use of information gathered through
the credentialing process to delineate the extent of their
clinical practice within a particular context. (ACSQHC,
2005) Scope of practice should be defined for all
healthcare providers.
22
Medicare Locals Accreditation Standards – February 2013
Criterion 2.2
Role Clarity
Expected Outcome
Explanatory Notes
Employees understand their roles
and responsibilities.
To meet the requirements of the MLA Standards,
Indicators
2.2.1 A documented position description is in place for
all positions within the organisation.
2.2.2 Position descriptions include clear definition of roles
and responsibilities, including scope of practice for
health practitioners.
2.2.3 Position descriptions are reviewed whenever
employee performance is evaluated.
2.2.4 Employees can describe their roles, responsibilities
Medicare Locals are required to promote role clarity by
specifying the roles and responsibilities associated with
each position and documenting these requirements in a
position description. Poorly defined or conflicting roles in
an organisation can be a significant stressor for staff.
Poor role definition arises from a lack of clarity in
staff objectives, key accountabilities, expectations of
management and co-workers and the overall scope or
responsibilities of a position. Position descriptions will
be of optimal value in facilitating role clarity if they are
communicated to staff at the commencement of their
employment and reviewed in consultation with staff
whenever performance is formally evaluated.
and reporting line.
2.2.5 Induction, both organisational and role specific,
is provided to all new employees.
Standard 2: Human Resource Management
23
Criterion 2.3
Training and Professional Development
Expected Outcome
Explanatory Notes
Relevant and timely training and professional
development opportunities are provided for
employees.
Training and professional development is aimed at the
maintenance and development of knowledge and skills
in a specific profession. The capability of an organisation
is influenced significantly by the capability of its workforce.
Developing workforce capability is achieved by improving
Indicators
the capability of teams and individuals within the
2.3.1 An organisational professional development plan
organisation.
that guides training and development of employees
Professional development is continual learning aimed
is documented and implemented.
at the maintenance and development of knowledge
2.3.2 The learning and professional development needs
of individuals are identified and documented.
2.3.3 Employees are provided with training and
professional development to enable them to
perform effectively in their role.
and skills in a specific profession. The MLA Standards
require Medicare Locals to establish a formal professional
development process aimed at identifying and addressing
the training and professional development required
to enable staff to perform effectively in their roles.
Professional development needs can be met through
internally provided training programs, externally provided
training programs, provision of relevant literature, research,
journals and texts.
Professionals regulated by the AHPRA will have continuing
professional development (CPD) obligations associated
with continuing professional registration. However, training
and professional development is important for all Medicare
Local staff.
Providing opportunities for training and professional
development is a mutually beneficial process as it builds
workforce capability while enhancing staff satisfaction,
motivation and retention.
24
Medicare Locals Accreditation Standards – February 2013
Criterion 2.4
Performance Management and Supervision
Expected Outcome
Explanatory Notes
Employees are supported to understand and
meet performance expectations.
Performance management refers to employee
Indicators
2.4.1 The performance of individual employees is
management activities aimed at supporting employees
(and contractors and subcontractors) to achieve desired
standards of work performance. The focus of performance
management in Standard 2 is on Medicare Local
employees. Performance management of contractors
formally evaluated at least annually against
and subcontractors is addressed in Standard 4. To meet
mutually agreed measures.
the requirements of the MLA Standards, Medicare Locals
2.4.2 Supervision is provided to employees as required
to support quality and safety of service provision.
2.4.3 Performance that does not meet expectations is
identified and managed.
2.4.4 Positive performance is recognised and
acknowledged.
2.4.5 Managers and supervisors responsible for
performance evaluation have the required
knowledge and skills to conduct effective
performance evaluations.
are required to review and evaluate the performance
of employees on a regular basis. The frequency of
review is not prescribed as this should be determined
by managers and supervisors based on the needs of
individuals. However, annual performance review should
be considered to be a general guide in terms of frequency.
Performance evaluation processes used by Medicare
Locals should involve as a minimum:
– the opportunity for the person being evaluated to
reflect on their performance;
– evaluation of performance against the requirements
set out in position descriptions or other employee
documentation such as contracts or performance
plans;
– a meeting between the employee and their manager
or supervisor to discuss performance;
– a record of the performance evaluation process;
– review of the employee’s position description and
up-dating if identified as necessary; and
– the establishment and implementation of a
documented performance development plan
where performance is identified as not being of an
acceptable standard.
Standard 2: Human Resource Management
25
Criterion 2.5
Credentialing and Screening
Expected Outcome
Explanatory Notes
The credentials and suitability of all employees,
contractors and subcontractors are verified.
Credentialing is a formal process used to verify the
Indicators
2.5.1 The credentials and suitability of health practitioners
Australian Health Practitioner Regulation Agency
(AHPRA), where applicable;
c. verification of qualifications and certifications
required for the role;
d. verification of previous employment, experience
and performance;
e. criminal history checks (National Police
Certificate);
f. suitability to work with children (as applicable
credentialing and defining the scope of clinical practice
of medical practitioners, for use in public and private
hospitals. (ACSQHC, 2004)
Effective credentialing is a critical component of clinical
governance for healthcare organisations, including
primary health care organisations. It reduces the risk of
harm to patients by ensuring that health practitioners are
qualified, competent and suitable. Criterion 2.5 of the
MLA Standards requires Medicare Locals to undertake a
credentialing process as part of selecting and appointing
legislation); and
least annually. Where an appointment is made prior to the
g. driver’s licence, where relevant to role.
a. verification of professional registration with the
completion of required credential checks, employment
documentation must stipulate that continuation of
employment is subject to the satisfactory results of
required credential checks. Medicare Locals are equally
accountable for the quality of health services contracted
Australian Health Practitioner Regulation Agency
or subcontracted and for ensuring that health practitioners
(AHPRA), where applicable;
providing care through contracted or subcontracted
b. verification of qualifications and certifications
arrangements have appropriate credentialing checks
required for the role where the employee’s role
undertaken. Criterion 2.5 Credentialing and Screening
has changed;
cross references to Criterion 4.1 Contracting and
c. suitability to work with children (as applicable
to each role and as required by State/Territory
legislation); and
the Scope of Clinical Practice: a National standard for
health practitioners and a re-credentialing process at
undertaken at least annually that includes:
outlined in the Standard for Credentialing and Defining
to each role and as required by State/Territory
2.5.2 A health practitioner re-credentialing process is
within specific organisational environments. (ACSQHC,
Standards have been developed based on the principles
b. verification of professional registration with the
suitability to provide safe, high quality health care services
minimum:
about their competence, performance and professional
2005) Credentialing requirements set out in the MLA
a. verification of identity;
health practitioners for the purpose of forming a view
is verified prior to appointment, including as a
qualifications, experience, and professional standing of
d. driver’s licence(s), where relevant to the role.
Subcontracting (Indicator 4.1.7i) in relation to the minimum
requirements for contracts related to the outsourcing of
health services. In particular, Medicare Locals are required
to ensure that credentialing checks are undertaken in
respect of contracted and subcontracted services to at
least the level required by the MLA Standards Criterion 2.5
(where applicable).
26
Medicare Locals Accreditation Standards – February 2013
Criterion 2.6
Organisational
Communication
Verification checks undertaken during the credentialing
process must be completed to the standard outlined in
the Standard for Credentialing and Defining the Scope
of Clinical Practice: A National Standard for credentialing
Expected Outcome
Effective intra-organisational communication.
and defining the scope of clinical practice of medical
practitioners, for use in public and private hospitals.
(ACSQHC, 2004) For example, originals or certified copies
of original copies of qualification documents are required
when verifying qualifications.
Indicators
2.6.1 Communication mechanisms enable regular and
effective communication within and between teams.
Explanatory Notes
Koontz defines organisational communication as the
transfer of information from the sender to the receiver
with the information being understood by the receiver.
(Koontz, 2001) Communication typically occurs through
both formal and informal channels in an organisation.
Informal communication is generally associated with
interpersonal, horizontal communication between
co-workers. Formal, vertical or downward communication
is an approach used by management to communicate
organisational objectives, implement policies and to
seek feedback.
Computer-mediated communication such as e-mail
has become an important component of organisational
communication, and has opened the way for increased
volume and frequency of communications. However,
computer mediated communications have the potential
to diminish the relational benefits of organisational
communication which enables team building.
Effective organisational communication is positively
correlated with increased staff motivation, productivity,
satisfaction and retention and is critical to organisational
effectiveness. Medicare Locals are required under the MLA
Standards to establish intra-organisational communication
structures and methods that are appropriate to their size,
structure, location, staff profile and objectives.
Standard 2: Human Resource Management
27
Criterion 2.7
Human Resource Management Compliance
Expected Outcome
Explanatory Notes
Human resource management systems
and processes are aligned to regulatory
requirements.
Employee relations are regulated in each Australian State
and Territory, and some aspects of employee management
are regulated federally. Under the MLA Standards,
Medicare Locals are required to establish human resource
management policies, procedures and protocols that are
Indicators
aligned to applicable regulatory requirements. A summary
2.7.1 Human resource management policies, procedures
of legislation that may be applicable is provided at
and protocols are consistent with the requirements
of the Fair Work Act 2009 and applicable State/
Territory regulatory requirements.
28
Medicare Locals Accreditation Standards – February 2013
Appendix 5
Standard 3
Knowledge and
Information
Management
Objective: Timely access to accurate information;
effective management of knowledge capital
Information management is an umbrella term that encompasses the systems and processes within an
organisation for the creation and use of corporate information. Information management comprises
the information itself, the ‘content’, as well as the people, processes and technology used in the
information management process. Information management and knowledge management are interrelated.
Effective management of information will support and enhance the capacity for effective knowledge
management by capturing information that is relevant to the Medicare Local’s corporate knowledge and
facilitating the sharing and transmission of knowledge.
The knowledge and information management quality framework within the MLA Standards incorporates:
– 3.1 Knowledge Management;
– 3.3 Information Privacy; and
– 3.2 Information Systems;
– 3.4 Computer and Information Security.
Resources
The following resources may be useful for Medicare Locals in establishing effective computer and
information security systems:
– Privacy Act, 1988 and National Privacy Principles.
– AS/NZS 5037 – 2005 Knowledge management –
a guide.
– Divisions of General Practice: Information
Management Maturity Framework, 2007,
Commonwealth of Australia, and other resources.
– RACGP Computer and information security
standards, 2011.
– National eHealth Security and Access Framework
(NESAF).
– AS/NZS ISO/IEC 18044:2006 Information
Technology - Security techniques - Information
Security Incident Management.
Standard 3: Knowledge and Information Management
29
Criterion 3.1
Knowledge Management
Expected Outcome
Explanatory Notes
Knowledge capital is identified and managed
in a way that facilitates organisational learning
and development.
Knowledge management comprises a range of strategies
and practices used in an organisation to identify, create,
represent, distribute, and enable adoption of knowledge
(insights and experiences). These may be embodied in
individuals, or embedded in an organisation’s, processes
Indicators
or practices. Effective management of knowledge is a key
3.1.1 A knowledge management strategy is documented
way in which Medicare Locals will be able to enhance the
and implemented.
3.1.2 The knowledge management strategy identifies
key sources of knowledge capital and describes
how barriers to effective knowledge transmission
will be mitigated.
3.1.3 Information systems support effective management
of knowledge.
efficacy of their services and support activities.
To meet the requirements of the MLA Standards, Medicare
Locals will need to develop a knowledge management
strategy. A knowledge management strategy is a
documented plan that describes how an organisation
will manage its knowledge better for the benefit of
that organisation and its stakeholders. Developing a
knowledge management strategy involves identifying key
sources of knowledge capital. For Medicare Locals this
will include information related to stakeholders, population
health and service providers. Medicare Locals will need to
identify appropriate ways to capture and share knowledge
to enhance service provision.
30
Medicare Locals Accreditation Standards – February 2013
Criterion 3.2
Information Systems
Expected Outcome
Explanatory Notes
Information held by the Medicare Local is
accurate, secure and accessible.
An important measure of the effectiveness of a Medicare
Indicators
3.2.1 Policies, procedures and protocols that address
Local’s information systems, including electronic
information systems such as databases, is the availability
of data and information in a form that is appropriate to
enable monitoring and measurement of the Medicare
Local’s organisational performance and operations.
each step in the information management life cycle
The accuracy and reliability of information generated by
are documented and implemented.
information systems will be dependent on protocols that
3.2.2 If the Medicare Local provides direct health
services, it has identified and adopted relevant
eHealth technologies to enhance capacity, quality
and cost-effectiveness.
3.2.3 The Medicare Local has a website that provides
comprehensive, accurate information relevant to
the needs of each stakeholder group.
3.2.4 Data and information required for management
ensure the accuracy and correctness of the data entered.
To meet the requirements of the MLA Standards, Medicare
Locals will need to show how their information systems
provide information and reports that support monitoring of
organisation performance and quality improvement.
eHealth is an important consideration in planning and
implementing information systems for Medicare Locals
that provide direct health services. The World Health
Organization (WHO) defines eHealth as ‘the combined use
decision making and evaluation of organisational
of electronic communication and information technology
performance is readily available.
in the health sector’. (http://www.who.int/ehealth, January
3.2.5 Protocols are in place to ensure data quality.
2013) In more practical terms, eHealth is the means of
ensuring that the right health information is provided to
the right person at the right place and time in a secure,
electronic form. It can optimise both the quality and
efficiency of health care delivery. eHealth should be viewed
as the essential infrastructure which underpins information
exchange between all participants in the Australian health
care system. It is also a key enabler and driver of improved
health outcomes for all Australians.
To meet the requirements of the MLA Standards, Medicare
Locals that provide direct health services will need to
demonstrate that they have identified and adopted eHealth
initiatives and other health enabling technologies that are
relevant to the direct health services provided.
Standard 3: Knowledge and Information Management
31
Criterion 3.3
Information Privacy
Medicare Locals should have regard in particular to the
National Electronic Security and Access Framework
(NESAF) and emerging health enabling technologies such
as the Personally Controlled Electronic Health Record
Expected Outcome
Unauthorised access to personal information
held by the Medicare Local is prevented.
(PCEHR).
Another important measure of a Medicare Local’s
Indicators
information systems will be the availability and accessibility
3.3.1 Information privacy policies, procedures and
of information that is relevant to its various stakeholder
processes are established and aligned to the
groups. To meet the requirements of the MLA Standards,
requirements of the Privacy Act 1988 and the
Medicare Locals are required to establish and maintain a
National Privacy Principles.
website that contains relevant, accurate and up-to-date
information required by stakeholders.
Explanatory Notes
In Australia, information privacy is regulated under
the Privacy Act 1988 (Cth.), which incorporates the
National Privacy Principles (NPPs). The Privacy Act 1988
(Cth.) addresses the protection of a person’s personal
information, that is, information or an opinion (including
information or an opinion forming part of a database),
whether true or not, and whether recorded in a material
form or not, about an individual whose identity is apparent
or can reasonably be ascertained from the information
or opinion.
The Privacy Act 1988 regulates how personal information
is handled. For example, it covers the collection, use,
disclosure and accuracy of personal information an
organisation holds, including a person’s general right to
access personal information held about them.
Under the MLA Standards, Medicare Locals are required
to establish privacy policies, procedures and protocols
aligned to the requirements of the Privacy Act 1988 and
NPPs. Medicare Locals will also need to identify and
meet privacy requirements set out in State and Territory
legislation. A summary of privacy legislation in Australia is
provided at Appendix 6.
32
Medicare Locals Accreditation Standards – February 2013
Criterion 3.4
Computer and Information Security
Expected Outcome
Explanatory Notes
Loss, corruption and unauthorised access to
information held electronically are prevented.
Medicare Locals hold a wide variety of important information
Indicators
3.4.1 Information and computer security protocols
including employee information, salary information, financial
results, business objectives and plans as well as sensitive
health information where direct health services are provided.
Medicare Locals will also hold information that is critical
to delivering core business activities such as population
are consistent with the RACGP Computer and
health information, service and provider information and
information security standards, 2011.
stakeholder information. Therefore, the establishment of
systems to reduce the risks associated with information
loss, corruption and unauthorised access will be of critical
importance for Medicare Locals.
To meet the requirements of the MLA Standards, Medicare
Locals are required to establish computer security
protocols in accordance with the RACGP Computer and
information security standards, 2011 (CISS) and evaluate
the effectiveness of computer and information security
using the RACGP Computer and Information Security
Checklist (which forms part of the CISS). (RACGP, 2011)
The CISS provides resources and guidance to primary care
in the establishment of effective information security practices
and is readily available without cost from the RACGP
website. The CISS is aligned with the National eHealth
Security and Access Framework (NESAF), and both the
NESAF and the CISS are based on International Standards
Organization principles (ISO 27799 and ISO 27002).
The RACGP Computer and information security standards
cover processes that are critical to maintaining effective
computer and information security, as follows:
– computer and information security risk assessment;
– staff roles and responsibilities;
– access control and management;
– business continuity and disaster recovery plans;
– data backup, malware, viruses and email threats;
– network perimeter controls;
– asset registers;
– portable devices and wireless networks;
– physical, system and software protection; and
– governance processes.
Standard 3: Knowledge and Information Management
33
34
Medicare Locals Accreditation Standards – February 2013
Standard 4
Contracting and
Subcontracting
Objective: Contracted services support the health
needs of the catchment community
One of the five Medicare Locals Strategic Objectives is identification of the health needs of local areas
and development of locally focused and responsive services. Medicare Locals will either provide services
internally or contract services.
The quality framework within the MLA Standards for contracting includes the following processes:
– 4.1 Contracting and Subcontracting; and
– 4.2 Contract Compliance.
Resources
The following resources may be useful for Medicare Locals in establishing effective contracting and subcontracting
systems and processes:
– Medicare Local’s Deed for Funding.
Standard 4: Contracting and Subcontracting
35
Criterion 4.1
Contracting and Subcontracting
Expected Outcome
Explanatory Notes
Programs and services are sub-contracted
to appropriate third parties using clear,
comprehensive and legally binding
contracts/agreements.
Medicare Locals are required to address the health
service needs of their catchment community in a way that
is optimally safe, effective, and efficient. In some cases
this will mean commissioning a health service through
a contract or subcontract arrangement. To meet the
requirements of the MLA Standards, Medicare Locals will
Indicators
4.1.1 Contracts and subcontracts are established and
managed in accordance with the Medicare Local’s
Deed for Funding (where applicable).
4.1.2 Contestable tendering is undertaken in accordance
with the Medicare Local’s Deed for Funding.
4.1.3 The Medicare Local sub-contracts services and
need to demonstrate that instruments of engagement
align with the requirements set out in 4.1.7 and that
processes for managing contracts and subcontracts are
aligned to the requirements of the Deed for Funding with
the Commonwealth. Criterion 2.1 should be considered in
conjunction with Indicator 1.4.7 in relation to procurement.
Medicare Locals are required under the MLA Standards
to use contestable tendering processes. Contestable
programs to third parties that are, or are working
tendering is the process of seeking expressions of
towards being, accredited or certified against
interest from the market for the production of goods and/
relevant standards/quality frameworks (where
or delivery of services, through advertisement and then
standards/quality frameworks exist).
selecting a provider based on price and quality criteria.
4.1.4 Documented and properly executed contracts are
in place for subcontracted services and programs.
4.1.5 Designated responsibility for contract execution is
assigned.
A fundamental objective of contestable tendering is to
improve provider responsiveness by moving from supply
to demand driven provision. Notwithstanding the benefits
of contestable tendering, it is recognised that in areas
where market supply is limited, it may be appropriate
4.1.6 Contracts are legally sound and enforceable.
for Medicare Locals to establish preferred supplier
4.1.7 Contracts include as a minimum:
arrangements that ensure effective and efficient service
a. a designated contract manager;
provision.
b. objectives and performance measures linked
Medicare Locals must ensure that contracting and
to objectives;
c. a process for monitoring the performance of the
service/program;
d. the roles and responsibilities of each party;
e. a communication mechanism for both parties;
f. dispute resolution procedures;
g. procedures for managing inadequate
performance;
subcontracting instruments are legally sound by seeking a
legal opinion about the instrument of contract/agreement
used in the contracting process. As well as ensuring that
contracts are legally enforceable, Medicare Locals are
required to ensure that contracts specify as a minimum:
– a designated contract manager, i.e. the person who
is responsible for the day- to- day management of the
h. financial accountability procedures; and
contract and for monitoring the performance of the
i. the requirement for credentialing by sub-
contract;
contractors to at least the level required by the
MLA Standards Criterion 2.5 (where applicable).
36
Medicare Locals Accreditation Standards – February 2013
– objectives and performance measures that are linked
Medicare Locals are equally responsible for the quality of
to objectives, i.e. a way in which the performance of
contracted and subcontracted services as they are for
the contract can be monitored and evaluated;
the quality of services provided directly. Tender criteria
– a process for monitoring the performance of the
should set out any accreditation or certification that
service/program, i.e. how and when the performance
it is necessary. Where a Medicare Local contracts or
of the contract will be evaluated;
subcontracts a health service to a provider that is working
– the roles and responsibilities of each party, i.e. the
specific responsibilities of the service provider and the
Medicare Local in relation to the contract;
– a communication mechanism for both parties, i.e.
the nominated contact person for the contractor and
towards becoming accredited, the contract should
specify the date by which accreditation must be achieved.
Agreement documents should specify the requirements for
providers to maintain any accreditation or certification that
they are required to hold.
the Medicare Local and how each party should be
contacted;
– procedures for managing inadequate performance, i.e.
the implications and process if the contractor does not
provide the product or service to the level required;
– dispute resolution procedures, i.e. the process for
resolving any disputes that arise in a fair, transparent
and efficient way;
– financial accountability procedures, i.e. the fees and
charges associated with the contract and how and
when they will be paid; and
– the requirement for credentialing by subcontractors
to at least the level required by MLA Standards, i.e.
contractors must conduct the probity and credential
checks on their staff to the level outlined at Criterion
2.5, where this applies.
Standard 4: Contracting and Subcontracting
37
Criterion 4.2
Contract Compliance
Expected Outcome
Explanatory Notes
Contracted and subcontracted services
enhance efficiency and service quality.
The focus of Criterion 4.1 is the contracting process
Indicators
4.2.1 The performance of contracted and subcontracted
Criterion 4.2 is focused on the way the performance
of contracts is monitored and evaluated. To meet the
requirements of the MLA Standards, Medicare Locals
will need to demonstrate that contract performance is
services is monitored in accordance with
monitored in accordance with the procedure outlined in
documented and agreed performance measures
the contract. They must also demonstrate that where
set out in contracts.
contracted services are not provided to an acceptable
4.2.2 The performance of contracted healthcare services
and externally funded programs are reported in
accordance with delegations.
4.2.3 Contracted and subcontracted services that do not
meet performance expectations are managed in
accordance with contractual arrangements.
38
including the form of contract used and its content.
Medicare Locals Accreditation Standards – February 2013
standard, that action is taken to ensure quality service
provision, including terminating services if indicated.
The performance of contracted services should be
reported in accordance with organisational reporting
processes and delegations.
section 2
Standard 5 relates to the crucial area of stakeholder relationships. Engaging positively
and building links with its stakeholders will ensure that stakeholder needs are met and
will maximise opportunities for Medicare Locals to improve.
Standard 5
Stakeholder Relationships
Mutually beneficial partnerships with stakeholders.
Criterion 5.1
Stakeholder Mapping and Analysis
Stakeholders and stakeholder needs are identified.
Criterion 5.2
Stakeholder Engagement
Regular and mutually beneficial engagement with stakeholders.
Criterion 5.3
Stakeholder Feedback
Stakeholder feedback informs service improvement.
Section 2
Stakeholder Standard
Standard 5
Stakeholder
Relationships
Objective: Mutually beneficial partnerships
with stakeholders
Medicare Locals are primary health care organisations that work with local primary health care providers,
Local Hospital Networks and communities to ensure patients receive the right care at the right time.
As such, Medicare Locals will interact with a diverse range of stakeholders in the performance of their
functions. The quality framework for stakeholder management by Medicare Locals includes:
– 5.1 Stakeholder Mapping and Analysis;
– 5.2 Stakeholder Engagement; and
– 5.3 Stakeholder Feedback.
A stakeholder is an individual or group influenced by, and with an ability to significantly impact (positively
or negatively), an area of interest. (Glicken, 2000) Community participation can be broadly understood as
active involvement of people in making decisions about the implementation of processes, programmes and
projects which affect them. (Slocum et al, 1995)
Resources
The following resources may be useful for Medicare Locals in establishing effective stakeholder management systems:
– Aboriginal Cultural Competence Framework, 2008, Victorian Aboriginal Child Care Agency (VACCA).
Standard 5: Stakeholder Relationships
39
Criterion 5.1
Stakeholder Mapping and Analysis
Expected Outcome
Explanatory Notes
Stakeholders and stakeholder needs
are identified.
Medicare Locals have a complex and diverse stakeholder
Indicators
5.1.1 A stakeholder management plan is documented
and implemented, and includes, as a minimum:
a. identification of stakeholders;
b. analysis of the needs and influence of each
stakeholder group;
c. identification of appropriate engagement
strategies and mechanisms for consultation
with stakeholders;
d. consideration of the specific needs of
Aboriginal and Torres Strait Islander people
within the catchment community; and
e. mechanisms to seek feedback from
stakeholders.
profile. The stakeholder profile will vary across Medicare
Locals depending on the health and demographic profile
and needs of the catchment community. However, all
Medicare Locals will need to consider the influence and
needs of the following broad categories of stakeholders:
– residents of the Medicare Local’s catchment
community;
– primary health care service providers (public and
private) such as general practices, community health
services and allied health services (including service
providers and employees in such services);
– secondary health care service providers such as
medical specialists, diagnostic imaging services and
other specialist health services accessed by referral;
– tertiary care service providers (public and private);
– Local Health Networks;
– individual consumers of health services and consumer
groups, aged care service providers, including
retirement villages, community aged care services and
residential aged care services;
– mental health service providers;
– housing, community and social service providers;
– funding agencies, including Commonwealth, State,
Territory and local governments and their agencies;
– industry and professional peak bodies and
associations (national and state); and
– Medicare Local members.
40
Medicare Locals Accreditation Standards – February 2013
Criterion 5.2
Stakeholder Engagement
The above stakeholder list is not intended to be
exhaustive. Analysis of the health profile of the catchment
community will enable Medicare Locals to identify
stakeholders specific to their catchment community.
Expected Outcome
Regular and mutually beneficial engagement
with stakeholders.
Identification of stakeholders requires consideration by
Medicare Locals of the organisations, services, groups,
sectors and individuals in their catchment community
that are or may be affected by their activity. Medicare
Locals must also consider those that have or may have an
interest or stake in their activity or have or may influence
Indicators
5.2.1 Stakeholder engagement mechanisms are
implemented as planned.
5.2.2 Stakeholder engagement mechanisms are
their activity. Once the Medicare Locals have identified
evaluated and opportunities for improvement
their stakeholders, they will need to determine the
acted on.
influence of each stakeholder, including how the Medicare
Locals’ activity will affect the stakeholders and the effect
the stakeholders may have on the Medicare Locals.
5.2.3 Stakeholders are provided with feedback about
the outcomes of stakeholder engagement activities.
Stakeholder analysis is important because it assists the
Medicare Locals to identify:
– stakeholders’ needs, interests and influence;
– mechanisms to influence stakeholders;
– potential stakeholder risks;
– potential barriers to engagement; and
– mutually beneficial stakeholder engagement,
partnership and communication strategies.
Effective stakeholder analysis will provide Medicare Locals
with the information required to determine appropriate
methods of engagement and inform the development of a
stakeholder engagement strategy.
Standard 5: Stakeholder Relationships
41
Explanatory Notes
Having identified stakeholders and analysed their
respective needs, interests and influence, Medicare
Locals will need to establish adequate and appropriate
mechanisms to communicate with and engage
– the process of working together can strengthen
communities and build adaptive capacity. It can
reinforce local organisations by building confidence,
skills and capacity to cooperate, raising awareness and
facilitating critical appraisal;
stakeholders. Consultation with stakeholders is an
– participation in planning, learning about people’s
important component of determining engagement
priorities and preferences, and implementation of
mechanisms. Stakeholders are more likely to engage
projects by stakeholders accord with people’s rights to
positively when they are partners in determining the
participate in decisions that affect their lives; and
purpose and process of the engagement and when the
– the processes of engagement can improve equity in
purpose of the engagement is perceived to be mutually
decision-making and provide solutions for conflict
beneficial. There are different levels of participation and
situations.
engagement that will be appropriate in difference contexts
The process of engaging stakeholders may take longer.
and with different stakeholder groups. Medicare Locals
However, a planned process of engagement is likely to
will need to determine the level of participation that is
enhance long term benefits, partly because a stakeholder
appropriate, for example, whether it is appropriate to
process is more likely to be sustainable and because the
inform, consult, involve, collaborate or empower each
process allows ideas to be tried, tested and refined before
stakeholder group. A stakeholder engagement plan
adoption. (Twigg, 2001)
is a documented plan that sets out how and when
engagement activities occur and who is responsible for
each activity.
Cultural competence will be a key consideration for
Medicare Locals when engaging with Aboriginal and Torres
Strait Islander stakeholders. The Victorian Aboriginal Child
The benefits of stakeholder engagement are closely
Care Agency (VACCA) Aboriginal Cultural Competence
aligned to the Medicare Locals Strategic Objectives.
Framework (VACCA, 2008) is a useful resource for
For example:
Medicare Locals when designing engagement strategies.
– participatory initiatives are likely to be sustainable
because they build on local capacity and knowledge,
the participants have ‘ownership’ of them and they
are more likely to be compatible with long-term
development plans;
– working closely with local communities can help
decision-makers gain greater insight into the
communities they serve, enabling them to work
more effectively and produce better results. In turn,
the communities can learn how the decision-making
process works and how they can influence
it effectively;
42
Medicare Locals Accreditation Standards – February 2013
Criterion 5.3
Stakeholder Feedback
Expected Outcome
Explanatory Notes
Stakeholder feedback informs
service improvement.
Consistent with the principle of quality improvement,
Indicators
5.3.1 The Medicare Local gathers feedback from
Medicare Locals are required to seek feedback from
stakeholders about engagement processes and about the
Medicare Local’s activities generally, and to use feedback
to inform service improvement. Stakeholder feedback
processes should be designed in a way that is appropriate
stakeholders, including feedback about services,
for each stakeholder group.
providers and consumers, using valid and reliable
There is growing awareness in Australia and internationally
tools and methods.
of the importance of meaningful consumer feedback. The
5.3.2 Mechanisms are available that enable stakeholders
to provide anonymous feedback.
5.3.3 Stakeholder feedback is analysed and used to
inform service improvement.
5.3.4 Stakeholder feedback is reported to the highest
level of management and the Board.
MLA Standards require Medicare Locals to seek feedback
from stakeholders, including consumers. To meet the
requirements of the MLA Standards, Medicare Locals
are required to establish a planned approach to seeking
feedback from stakeholders, using valid feedback tools
and processes that improve data reliability. Reliability
is the degree to which results are replicable, and can
be depended upon to be accurate, repeatable and
measurable in relation to the topics surveyed.
Standard 5: Stakeholder Relationships
43
44
Medicare Locals Accreditation Standards – February 2013
section 3
Service Standards
Standard 6
Analysis and Planning
A planned approach to service delivery informed by adequate and appropriate
research, analysis and consultation
Criterion 6.1
Population Health Analysis (6.1.2 Developmental)
A comprehensive understanding of the health status and health needs of the
catchment community.
Criterion 6.2
Health Service Mapping and Analysis
Health service supply and demand is understood relative to the needs of the
catchment community.
Criterion 6.3
Needs Assessment and Planning
A planned approach to health service provision.
Standard 7
Health Promotion and Illness Prevention
Locally focused health promotion and illness prevention activities that enable health
gains in the community
Criterion 7.1
Intersectoral Collaboration (Developmental)
Intersectoral partnerships focused on addressing the determinants of health in the
catchment community.
Criterion 7.2
Health Literacy and Health Behaviour (Developmental)
Health literacy and health behaviour programs and initiatives contribute to health gains
in the catchment community.
Criterion 7.3
Illness Prevention and Management (7.3.2 Developmental)
The Medicare Local has programs and initiatives aimed at preventing illness and disease.
Section 3
Service standards apply to the key functions of the Medicare Locals in providing
primary health care within a best practice framework to fit the needs of their community.
Standard 6 focuses on understanding the health needs of the community and planning
how best to meet them. Having identified the needs of their catchment community,
Medicare Locals will need to determine how best to respond to identified needs.
Standards 7, 8, 9 and 10 set out service response options.
Standard 8
Service Coordination and Integration
Continuity of comprehensive care for consumers.
Criterion 8.1
Service Integration
Coordinated care and streamlined care pathways.
Criterion 8.2
Primary Health Care Networks
There is an integrated primary health care workforce.
Standard 9
Service and Provider Support
Leadership and better practice in primary health care.
Criterion 9.1
Better Practice Resources (9.1.3 Developmental)
Relevant better practice resources are readily accessible to services and providers
within the catchment community in primary health care.
Criterion 9.2
Capacity Building
Leading learning in primary health care.
Standard 10
Direct Health Service Delivery
Quality health services accessible to those who need them.
Criterion 10.1
Equitable Access
Consumers have equitable access to health services.
Criterion 10.2
Care Planning and Evaluation
Continuity of timely and appropriate care.
Criterion 10.3
Health Service Provision
Quality health service delivery based on best available evidence.
Criterion 10.4
Care Coordination
Health care provided by the Medicare Local is integrated with the consumer’s
broader health care.
Criterion 10.5
Medicines Safety
Safe and quality use of medicines.
Criterion 10.6
Consumer Health Records
Comprehensive, integrated and accessible consumer health records.
Criterion 10.7
Healthcare Associated Infection
Healthcare associated infection risks are minimised.
Criterion 10.8
Clinical Equipment and Supplies
Adequate and appropriate clinical equipment and supplies are available in relation
to the range of health services provided.
Criterion 10.9
Clinical Quality Improvement
Clinical incidents inform improvements in quality and safety.
Standard 6
Analysis and
Planning
Objective: A planned approach to service delivery
informed by adequate and appropriate research,
analysis and consultation.
One of the five Medicare Locals Strategic Objectives is to identify the health needs of local areas and
develop locally focused and responsive services. This will require Medicare Locals to:
– understand the health of their catchment population;
– identify health needs and gaps in services at the local level;
– examine opportunities for better targeting of services; and
– establish formal and informal linkages with the acute and aged care sectors,
and other services in the primary healthcare sector.
The healthcare analysis and planning framework within the MLA Standards incorporates:
– 6.1 Population Health Analysis;
– 6.2 Health Service Mapping and Analysis; and
– 6.3 Needs Assessment and Planning.
Resources
The following resources may be useful for Medicare Locals in establishing population health analysis and
planning processes:
– Australian Bureau of Statistics (ABS).
– Australian Institute of Health and Welfare (AIHW).
– Australian Institute for Primary Care and Ageing.
– Primary Health Care Research and Information
Service (PHC RIS).
– National Health Service Directory
(www.nhsd.com.au).
Standard 6: Analysis and Planning
45
It is important to note that a ‘health service’ in this context
documented in a Service Needs Assessment, which is also
is not limited to the delivery of health care to a client, but
a requirement under the Medicare Locals Deed for Funding.
is intended to encompass a broad range of appropriate
responses to an identified service gap or health need.
Having identified the needs of its catchment community,
each Medicare Local will need to determine how best to
The focus of Standard 6 is on how a Medicare Local
respond to identified needs. Standards 7, 8, 9 and 10
determines needs within its catchment community. The
set out service response options. Diagram 3 summarises
main inputs into identifying service needs will be population
the analysis, planning and service delivery model that
health profiles and service and provider mapping.
underpins the quality framework in the MLA Standards.
Analysing this information will enable a Medicare Local
to identify health needs and service gaps and then to
consider appropriate responses. This information must be
Population health planning involves making informed
choices about priorities. Determining what a Medicare Local
will not do is as important as determining what it will do.
Diagram 2
Analysis, Planning and Service Delivery Framework
Population
Health Analysis
Needs
Assessment
Service Mapping
and Analysis
(Criterion 6.1)
(Indicator 6.3.1)
(Criterion 6.2)
Service
Delivery Plan
(Indicator 6.3.3)
POSSIBLE POPULATION HEALTH RESPONSES
Respond to the
social determinants
of health, risk and
protective factors.
46
Respond to poor or
inadequate service
integration and
interface issues.
Respond to health
service capability
needs/gaps.
Respond to health
service capacity
needs/gaps.
Standard 2
Outsource (contract/
subcontract) health
promotion services,
e.g. health literacy
programs.
Standard 2
Outsource (contract/
subcontract) service
coordination and
integration activities.
Standard 2
Outsource (contract/
subcontract), e.g.
research, training,
resource development.
Standard 2
Outsource (contract/
subcontract) direct
health services, e.g.
after hours GP services.
Standard 7
Provide health
promotion
services directly,
e.g. intersectoral
collaboration, healthy
public policy, personal
skills development.
Standard 8
Coordinate and
integrate services
directly, e.g. liaison
officers, partnerships.
Standard 9
Build capability
and promote better
practice, e.g. clinical
leadership forums,
networks.
Standard 10
Medicare Locals Accreditation Standards – February 2013
Provide health
services directly, e.g.
vaccination programs,
health assessments.
Criterion 6.1
Population Health Analysis
Expected Outcome
Explanatory Notes
A comprehensive understanding of the
health status and health needs of the
catchment community.
Population health analysis is the systematic collection,
collation, assessment and interpretation of health data
aimed at understanding the population health profile,
population health needs and health determinants.
The ultimate aim of population health analysis is to improve
Indicators
the health outcomes of the population in question.
6.1.1 The population health profile of the catchment
Population health analysis will identify the health profile of
community is identified and documented using
the catchment community and the factors that determine
valid and reliable sources of data and information,
the health profile (the social determinants of health).
including health risk factors and protective factors.
Indicator 6.1.2 is developmental because it will take
6.1.2[Developmental] Population health analysis is used
to gain an understanding of the social determinants
of health in the catchment community.
6.1.3 Population health analysis is undertaken in
collaboration with stakeholders relevant to
the population health profile of the catchment
community, including Aboriginal and Torres Strait
Islander people.
6.1.4 Population health profiling and analysis methods
are evaluated and improved.
6.1.5 Population health information is updated at
least annually.
Medicare Locals some time to gain a comprehensive
understanding of the social determinants of health in their
catchment community. However, Medicare Locals should
undertake population analysis in a way that will enable
them to gain a picture of the social determinants of health
over time.
The social determinants of health are the conditions in
which people are born, grow, live, work and age, including
the health system. These circumstances are shaped by
the distribution of money, power and resources at global,
national and local levels. The social determinants of health
are mostly responsible for health inequities - the unfair
and avoidable differences in health status seen within and
between countries. (WHO, 1997)
A key component of improving the health of populations is
improving the health of the most disadvantaged groups in
the population. Low income, locational disadvantage and
poor accessibility to resources and services are aspects
of inequality that can disadvantage individuals regardless
of their background, age or gender. There are some
groups that are more at risk of long term disadvantage
and social exclusion than others. These groups include
Aboriginal and Torres Strait Islander people, people
with disabilities, people recently settled as refugees or
humanitarian entrants and children in jobless households.
People who are experiencing homelessness and long term
unemployed people also experience multiple disadvantage
and social exclusion.
Standard 6: Analysis and Planning
47
Criterion 6.2
Health Service Mapping
and Analysis
It is anticipated that the methods, tools and data used by
Medicare Locals to conduct population health analysis will
increase in quality and sophistication over time. As each
Medicare Local’s understanding of the health needs of its
catchment community grows, effectiveness and efficiency
Expected Outcome
Health service supply and demand is
understood relative to the needs of the
catchment community.
of service responses will improve. Where a Medicare Local
outsources aspects of the population health analysis
process, monitoring and evaluation of the processes used
by the contracted service provider must be undertaken to
ensure the quality of such services.
The health of a population is not static. Medicare Locals
will need to undertake population health surveillance,
which focuses on the ongoing and systematic collection,
Indicators
6.2.1 Health services and providers in the catchment
community are identified and documented.
6.2.2 Health services are documented in the National
Health Services Directory and updated regularly.
6.2.3 The capacity of health services and providers in the
analysis and interpretation of health data to understand
catchment community is analysed in relation to the
population health determinants and changing population
population health profile.
health status. In addition the profile, relationships and
capability of Medicare Locals will grow over time. This
will expand the degree of stakeholder engagement and
contribute to the Medicare Local’s understanding of the
needs of the catchment community.
Explanatory Notes
Service mapping is the process of identifying and
documenting the range of health care and community
services that are available within the Medicare Local’s
catchment community and any relationships that
exist between services. Developing an accurate and
comprehensive service map is important for:
– identifying service supply issues, including under
supply and over supply issues; and
– communicating available services to consumers within
the catchment community.
48
Medicare Locals Accreditation Standards – February 2013
Criterion 6.3
Needs Assessment and Planning
Expected Outcome
Explanatory Notes
A planned approach to health
service provision.
Health service planning is recognised as a core
Indicators
6.3.1 A service needs assessment is documented,
component of health system governance in the healthcare
sector because it influences the way the health services
are provided. (Rand Europe 2010)
Standard 6 provides a high-level quality framework
for the functions of Medicare Locals related to service
aligned to the findings of population health analysis
planning. Population health analysis, service mapping
and service mapping.
and consultation with stakeholders within the catchment
6.3.2 Service responses are prioritised.
6.3.3 A service delivery plan is documented that
identifies how the Medicare Local will respond to
identified needs.
community will enable Medicare Locals to identify the
needs of the catchment community. Medicare Locals will
need to consider statistical information about health
needs and health services and the demands of their
catchment community when determining needs.
Medicare Locals must:
– prioritise identified needs;
– identify which needs the Medicare Local can meet and
which it cannot; and
– plan appropriate responses for high priority needs.
To meet the requirements of the MLA Standards,
Medicare Locals will need to establish criteria for
prioritising identified needs based on how optimal health
outcomes can be achieved in their catchment community.
Medicare Locals are accountable to stakeholders and their
community. They should therefore be transparent about
decision making processes related to the setting
of priorities.
Standard 6: Analysis and Planning
49
A Medicare Local’s service delivery plan should identify
how it will respond to high priority needs, including, but
not limited to:
– contracting and subcontracting (Standard 4);
– health promotion and illness prevention services
(Standard 7);
– helping health services work better together
(Standard 8);
– building primary healthcare capacity (Standard 9); and
– providing health services directly (Standard 10).
Medicare Locals will not be able to meet all identified
needs. The MLA Standards require Medicare Locals
to have a transparent approach to prioritisation based
on achieving the best possible health outcomes for the
catchment community. Medicare Locals will need to
balance the demand for services against finite resources.
In developing service delivery plans, Medicare Locals
will need to have regard to available financial resources
and how services can be met through contracting
and subcontracting, including ensuring that quality
requirements set out in Indicators 4.1.1 and 4.1.2 related
to contestable tendering and value for money are met.
50
Medicare Locals Accreditation Standards – February 2013
Standard 7
Health Promotion
and Illness
Prevention
Objective: Locally focused health promotion and
illness prevention activities that enable health gains
in the community
As outlined in Diagram 3: Analysis, Planning and Service Delivery Framework, health promotion and illness
prevention initiatives are ways that Medicare Locals will address the needs of their catchment community.
Standard 7 is focused on ways that Medicare Locals can contribute to addressing the social and systemic
determinants of health in their catchment communities and implement primary prevention strategies.
Resources
The following resources may be useful for Medicare Locals in establishing health promotion strategies and programs:
– Australian Bureau of Statistics, Adult Literacy and
Life Skills Survey Report, 2007.
– Declaration of Alma Ata, World Health
Organization, 1978.
– Milestones in Health Promotion, Statements
– RACGP, Putting prevention into practice: Guidelines
for the implementation of prevention in the general
practice setting (Green Book) 2nd edition, 2006.
–RACGP, Guidelines for preventive activities in
general practice (Red Book) 8th edition.
from Global Conferences, World Health
Organization, 2009.
Standard 7: Health Promotion and Illness Prevention
51
Health promotion initiatives are those that enable people
The quality framework in the MLA Standards for the
to increase control over and improve their health and to
provision of health promotion services by Medicare
prevent illness. Health promotion involves the population
Locals includes:
as a whole in the context of their everyday life, as well
– 7.1 Intersectoral Collaboration;
as focusing on people at risk for specific diseases.
Health promotion is directed towards action on the
determinants or causes of health status. It combines
– 7.2 Health Literacy and Health Behaviour; and.
– 7.3 Illness Prevention and Management.
diverse but complementary methods or approaches,
including communication, education, legislation,
It is recognised that it will take some time for Medicare
fiscal measures, organisational change, community
Locals to gain an accurate and comprehensive
development and community activity. Health professionals,
understanding of the health profile of their catchment
particularly in primary care, have an important role in
community and of the social and other determinants
nurturing and enabling health promotion. (WHO, 2009)
of health and therefore some aspects of Standard 7
The global context for health promotion has changed
markedly since the development of the Ottawa Charter.
Research and case studies from around the world
provide convincing evidence that health promotion is
effective and has the ability to develop and change
lifestyles, and have an impact on the social, economic
and environmental conditions that determine health.
(WHO, 1997; Jakarta Declaration)
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Medicare Locals Accreditation Standards – February 2013
are developmental.
Criterion 7.1
Intersectoral Collaboration
Expected Outcome
Explanatory Notes
Expected Outcome: Intersectoral partnerships
focused on addressing the determinants of
health in the catchment community.
Intersectoral collaboration is the process of establishing
formal linkages and relationships between different sectors
of society beyond the immediate healthcare sector. It is
aimed at addressing health issues and outcomes in a
more effective, efficient or sustainable way than might be
Indicators
7.1.1 [Developmental] Intersectoral partnerships
achieved by working within the healthcare sector alone.
(WHO, 1997)
are established as indicated by population
The 1978, Declaration of Alma Ata, Article VII (4)
health analysis.
identified that effective primary healthcare requires a
coordinated effort between the health sector and all
7.1.2 [Developmental] planned approach to
related sectors and aspects of national and community
partnership activities, including documented
development, in particular agriculture, animal husbandry,
objectives and evaluation of outcomes.
food, industry, education, housing, public works and
communication. (WHO, 1978) Intersectoral collaboration
and action to address determinants of health is a critical
component of achieving long term improvement in the
health of a population.
It will take some time for Medicare Locals to establish
intersectoral partnerships relevant to the needs of their
catchment community and for this reason Criterion 7.1
is developmental. Medicare Locals should work towards
the establishment of intersectoral partnerships aimed
at addressing the social determinants of health in their
catchment community, and do so in a way that enables
the efficacy of such partnerships to be evaluated.
Standard 7: Health Promotion and Illness Prevention
53
Criterion 7.2
Health Literacy and Health Behaviour
Expected Outcome
Explanatory Notes
Health literacy and health behaviour programs
and initiatives contribute to health gains in the
catchment community.
Health literacy is a person’s or community’s capacity
(knowledge and skills) to understand and use healthrelated information. It is awareness of a wide range
of health issues such as drugs and alcohol, disease
prevention and treatment, safety and accident prevention,
Indicators
7.2.1[Developmental] Health literacy, including health
first aid, emergencies and staying healthy. (Canadian
Council on Learning, 2007)
education initiatives are implemented as indicated
The Adult Literacy and Life Skills Survey (ALLS), an
by population health analysis.
international survey developed by the Canadian Council
on Learning (under the auspice of the Australian Bureau of
7.2.2[Developmental] A planned approach to
health literacy, including health education
initiatives, documented objectives and evaluation
of outcomes.
Statistics), identified five broad domains of health-related
life skills:
– health promotion – the ability to enhance and maintain
health, for example, plan an exercise regime or
purchase healthy foods by accessing and assimilating
appropriate information;
– health protection – the ability to safeguard individual
or community health, for example, the ability to make
healthy life choices;
– disease prevention – the ability to take preventive
action and engage in early detection, for example,
determine risks, seek screening or other diagnostic
tests and follow up on the results of tests;
– healthcare maintenance – the ability to seek and form a
partnership with healthcare providers; and
– health systems navigation - the ability to understand
and access required health services.
In planning health literacy and health behaviour initiatives,
including health education materials, Medicare Locals will
need to consider the relationship between health literacy
and other skills such as reading level, numeracy level,
language barriers, cultural factors, format and style.
Criterion 7.2 is developmental because it will take
Medicare Locals some time to establish health literacy and
health behaviour programs aligned to the needs of their
catchment community.
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Medicare Locals Accreditation Standards – February 2013
Criterion 7.3
Illness Prevention and Management
Expected Outcome
Explanatory Notes
Programs and initiatives aimed at preventing
illness and disease.
While the focus of health promotion focuses mainly on
Indicators
7.3.1 Illness prevention programs and initiatives are
role in undertaking and promoting illness prevention
within their catchment communities, including primary,
secondary and tertiary prevention activities.
Prevention can be defined as action to reduce or eliminate
implemented, as indicated by population health
the onset, causes, complications or recurrence of disease.
status, including the following:
(AIHW, 2004) In general, the concept of prevention is
a. primary prevention programs aimed at
characterised by activities that are designed to reduce the
preventing illness and disease;
promoting health, Medicare Locals also have a significant
b. secondary prevention programs and initiatives
likelihood that something harmful will occur, or to minimise
that harm if it does occur.
aimed at early intervention for people with illness
In public health it has been common practice to categorise
and disease; and
the different goals or levels of prevention across the
c. tertiary prevention programs and initiatives
aimed at optimising the health status of people
with chronic illness.
7.3.2 [Developmental] A planned approach to
continuum of disease in terms of primary, secondary and
tertiary prevention.
The Royal Australian College of General Practitioners
(RACGP), provides the following definition of the three
illness prevention and management, including
levels of prevention, as they relate to the role and function
documented objectives and evaluation
of general practitioners:
of outcomes.
– Primary: the promotion of health and the prevention of
illness, for example, immunisation and making physical
environments safe.
– Secondary: the early detection and prompt intervention
to correct departures from good health or to treat the
early signs of disease, for example, cervical screening,
mammography, blood pressure monitoring and blood
cholesterol checking.
– Tertiary: reducing impairments and disabilities,
minimising suffering caused by existing departures
from good health or illness, and promoting patients’
adjustment to chronic or irremediable conditions, for
example, prevention of complications. (RACGP, 2006)
Standard 7: Health Promotion and Illness Prevention
55
The goal of primary prevention is to: limit the incidence
of disease and disability in the population; eliminate or
reduce causes or determinants of departures from good
health; control exposure to risk; and, promote factors that
are protective of health. An example of primary prevention
activity is a vaccination program. Secondary prevention
aims to reduce progression of disease through early
detection, usually by screening at an asymptomatic stage,
and early intervention. The goal of tertiary prevention
is to improve function and includes minimisation of the
impact of established disease and prevention or delay of
complications and subsequent events, through effective
management and rehabilitation. (National Public Health
Partnership NPHP, 2006)
To meet the requirements of the MLA Standards,
Medicare Locals are required to develop a planned
approach to illness prevention linked to population health
needs. Strategies may include the implementation of
prevention initiatives and programs by the Medicare
Locals. Indicator 7.3.2 is developmental because it will
take some time for Medicare Locals to formalise their
approach to illness prevention and management, including
evaluating the effectiveness of programs in achieving
documented objectives.
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Medicare Locals Accreditation Standards – February 2013
Standard 8
Service
Coordination
and Integration
Objective: Continuity of comprehensive care
for consumers
Two of the five Medicare Locals Strategic Objectives include:
– improving the patient journey through developing integrated and coordinated services; and
– providing support to clinicians and service providers to improve healthcare.
The quality framework within the MLA Standards for the coordination and integration of health services by
Medicare Locals includes:
– 8.1 Service Integration; and
– 8.2 Primary Health Care Networks.
Resources
The following resources may be useful for Medicare Local when considering strategies aimed at enhancing health
service integration:
– Integrated Health Services – What and Why, World Health Organization, 2008.
– Ten Key Principles for Successful Health Systems Integration, Esther Suter, Nelly D. Oelke, Carol E. Adair and
Gail D. Armitage. Healthcare Quarterly, 13(Sp) 2009: 16-23.
Standard 8: Service Coordination and Integration
57
Criterion 8.1
Service Integration
Expected Outcome
Explanatory Notes
Coordinated care and streamlined
care pathways.
Medicare Locals are responsible for making it easier for
consumers and service providers to navigate the health
care system. They support health professionals to provide
more coordinated care, while maintaining the important
role that general practice plays in the primary care sector.
Medicare Locals facilitate improved access to services for
consumers and encourage greater integration between the
primary, hospital and aged care sectors. By coordinating and
integrating health services, Medicare Locals can reduce the
overlap and duplication of services, leading to more effective
and more efficient services.
Indicators
8.1.1 Service integration risks, issues and gaps are
identified including, but not limited to:
a. acute care transition issues;
b. access to health services for older people; and
c. integration of mental health services.
8.1.2 Service integration strategies are implemented to
address identified risks, issues and gaps.
8.1.3 Service integration strategies are developed
in collaboration with stakeholders and
relevant services.
8.1.4 Service integration strategies are evaluated and
improvement opportunities acted on.
To meet the requirements of the MLA Standards, Medicare
Locals will need to demonstrate a range of strategies aimed
at enhancing service integration, including the establishment
of relationships across all sectors of healthcare, such as
primary, secondary and tertiary healthcare services and
aged care services. In particular, Medicare Locals will need
to establish close working relationships with Local Hospital
Networks focused on enhancing integration and coordination
of services across primary and acute healthcare. Important
areas where Medicare Locals and Local Hospital Networks
will need to work together include ensuring that there are
appropriate clinical pathways between different settings.
Areas to be considered include pathways for clinical
handover or on discharge from hospital; better integration
of services; and identifying and addressing service gaps
especially at the interface between primary and acute care.
Medicare Locals will have a specific role in coordinating local
face-to-face after hours general practice services by working
with local general practices and other health professionals to
ensure these services are available in the Medicare Local’s
catchment community. Medicare Locals will also provide a
platform for supporting better coordination of mental health
services.
Supporting inter-disciplinary clinical education across
different areas of healthcare is another way that Medicare
Locals can support integration of healthcare services. The
goal of interdisciplinary clinical education is to enable clinical
service providers to better understand the variety of roles
and practices in other settings so that services can work
together better to deliver higher quality care within a true
system. (McEwan, 1994)
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Medicare Locals Accreditation Standards – February 2013
Criterion 8.2
Primary Care Networks
Expected Outcome
Explanatory Notes
An integrated primary care workforce.
Medicare Locals have a key role to play in creating an
integrated primary care network. Examples of ways
Indicators
8.2.1 A planned approach to networking the primary
they will do this are by establishing mechanisms and
forums for primary health care providers to interact and
communicate. To meet the requirements of the MLA
care workforce is established, that includes:
Standards, Medicare Locals will need to demonstrate that
a. identification of key workforce segments; and
appropriate networking mechanisms are in place and are
b. mechanisms designed to connect key
segments of the primary care workforce.
8.2.2 Networking mechanisms are communicated to
target audiences, including via the Medicare
Local’s website.
managed effectively. Medicare Locals should consider
the need for primary care networks in conjunction with
developing their stakeholder engagement plans and
strategies, and primary care networks will be a key way
in which Medicare Locals engage primary health care
services and providers.
8.2.3 Networking mechanisms occur as scheduled.
8.2.4 Networking mechanisms are evaluated and
improvements implemented where indicated.
8.2.5 Networking mechanism(s) provide(s) for feedback
to participants about actions and outcomes.
Standard 8: Service Coordination and Integration
59
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Medicare Locals Accreditation Standards – February 2013
Standard 9
Service and
Provider Support
Objective: Leadership and better practice in
primary health care
Two of the five Medicare Locals Strategic Objectives include:
– improving the patient journey through developing integrated and coordinated services; and
– providing support to clinicians and service providers to improve patient care.
The quality framework for the delivery of health services by Medicare Locals includes:
– 9.1 Better Practice; and
– 9.2 Capacity Building.
Resources
The following resources may be useful for Medicare Locals when developing and sourcing learning and
development resources:
– National Safety and Quality Health Service Standards, 2011.
– Website of the Australian Commission on Safety and Quality in Health Care.
– Website of the Royal Australian College of General Practitioners.
– Website of the National eHealth Transition Authority.
Standard 9: Service and Provider Support
61
Criterion 9.1
Better Practice Resources
Expected Outcome
Explanatory Notes
Relevant better practice resources are readily
accessible to services and providers within the
catchment community in primary health care.
To meet the requirements of the MLA Standards,
Medicare Locals will need to demonstrate that a range
of support services and resources, appropriate to various
segments of the primary care sector, are available.
The type of support services and resources required will
Indicators
vary dependent on the characteristics of each catchment
9.1.1 Services, resources and tools are provided to
community. However, services and resources in the
support primary health care providers and services
following areas will be relevant to all Medicare Locals:
in the Medicare Local’s catchment community,
– standards relevant to primary health care;
including:
–accreditation;
a. standards relevant to primary health care,
– clinical governance; and
including the National Safety and Quality Health
–eHealth.
Service Standards, where applicable;
b. achieving and maintaining accreditation;
Standards and Accreditation
c. credentialing and scope of practice;
A summary of key standards and accreditation schemes
d. clinical governance; and
e. eHealth initiatives.
9.1.2 Services, resources and tools are evaluated and
relevant to primary health care is provided at Appendix 8.
The list is not intended to be exhaustive, but provides a
general overview of the main quality frameworks applicable
to the primary care sector. Medicare Locals are well
improved as indicated by feedback from services
placed to support the adoption of quality and accreditation
and providers.
in primary health care. Examples of the types of services
9.1.3 [Developmental] The Medicare Local is actively
involved in research and innovation in primary
health care.
and resources that a Medicare Local might provide in
relation to quality standards and accreditation include:
– advice about applicable standards;
– resources and services to support accreditation
readiness such as training, gap assessment and
improvement planning;
– advice on implementing improvements aimed at
enhancing compliance;
– accreditation related forums; and
– partnerships with accrediting agencies to better
understand the quality frameworks and accreditation
processes relevant to primary care.
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Medicare Locals Accreditation Standards – February 2013
Criterion 9.1 (continued)
Better Practice Resources
The National Safety and Quality Health
– the PCEHR, including electronic transfer of
Service Standards
prescriptions (ETP), shared health summaries and
On 12 November 2010, the Australian Health Ministers’
event summaries;
Conference endorsed a Model National Accreditation
– secure messaging for all electronic communication that
Scheme and the development of the National Safety and
includes a patient’s personal information aligned to the
Quality Health Services (NSQHS) Standards. Both the
requirements of the Australian Standard for Secure
Standards and Accreditation Scheme were developed by
Messaging;
the Australian Commission on Safety and Quality in Health
– patient, provider and organisational identifiers to verify
Care (the Commission).
identity when information is shared electronically to
A key aim of the NSQHS Standards is the establishment
reduce mismatching risks;
of effective clinical governance systems. Clinical
– standardised clinical terminology, for example, the use
governance is defined in the NSQHS Standards as the
of nationally agreed medical dictionaries for at least
systems through which health service organisations are
diagnosis;
accountable for continuously improving the quality of
their services and safeguarding high standards of care.
(Reference 11 NSQHS Standards, 2010)
Medicare Locals are well placed to lead and support
– e-Discharge, e-Referrals and e-Specialist letters;
– electronic prescribing systems and clinical decision
support systems;
– computer and information security protocols aligned
clinical governance initiatives in primary health care
the with the RACGP Computer and information
through the provision of advice, training and resource
security standards, 2011; and
development.
eHealth
– clinical safety assessment whenever new eHealth
technologies are introduced.
Significant advances in technology over the past
Beyond support services and resources, Medicare
decade have led to the development of eHealth. These
Locals are required to be actively involved in research
technologies can support care integration, improve
and innovation in primary healthcare, including but not
health outcomes and enhance capacity, quality and
limited to:
cost-effectiveness across the health care system. The
– conducting research in areas relevant to the needs of
National eHealth Transition Authority Limited (NeHTA)
was established by the Australian, state and territory
governments to develop better ways of electronically
collecting and securely exchanging health information.
The Personally Controlled Electronic Health Record
(PCEHR) in particular will have a significant influence on
care coordination and services integration.
Examples of the types of services and resources that a
Medicare Local might provide in relation to eHealth include
supporting the adoption and implementation of:
the catchment community;
– disseminating research relevant to services and
practitioners; and
– identifying and supporting the adoption of innovative
primary healthcare initiatives.
Research is a key way in which Medicare Locals can lead
better practices and innovation in primary health care.
However, it is recognised that it will take some time for
Medicare Locals to determine where research activities are
best directed. Indicator 9.1.3 is therefore developmental.
Standard 9: Service and Provider Support
63
Criterion 9.2
Capacity Building
Expected Outcome
Explanatory Notes
Leading learning in primary health care.
Medicare Locals have an important role in building
capacity in primary health care and assisting primary
Indicators
9.2.1 A learning and development plan is documented
health care providers and practitioners to meet safety
and quality standards for service delivery. To meet the
requirements of the MLA Standards, Medicare Locals
and implemented that addresses the learning and
are required to establish and implement a learning and
development needs of primary health care services
development plan that addresses the learning and
and providers within the catchment community.
development needs of primary health care providers,
9.2.2 Learning and development activities and resources
are communicated to target audiences, including
via the Medicare Local’s website.
9.2.3 Learning and development activities occur
as scheduled.
9.2.4 Learning and development activities and resources
are evaluated and improvements implemented
where indicated.
practitioners and staff within the catchment community.
Medicare Locals will need to identify and prioritise the
learning needs of the various workforce segments in their
catchment community. For example, general practice staff,
allied health services and practitioners, and community
health services and staff.
Training and professional development initiatives should be
tailored to best meet identified needs, and may include:
– face to face training workshops and seminars provided
directly by the Medicare Local or by contracted
external content experts;
– promotion of training and professional development
initiatives and activities provided by other organisations;
– clinical leadership forums facilitated by Medicare Locals;
– dissemination of research and better practice information;
– development of self-directed learning resources; and
– facilitating and supporting student placement
and supervision.
Medicare Locals will need to establish appropriate
mechanisms to communicate learning and professional
development activities and resources including, as
a minimum, through the Medicare Local’s website.
Consistent with the principle of quality improvement,
Medicare Locals should seek feedback about their training
and professional development initiatives and use feedback
to identify opportunities to improve the quality of training
and professional development resources provided.
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Medicare Locals Accreditation Standards – February 2013
Standard 10
Direct Health
Service Delivery
Objective: Quality health services accessible
to those who need them
One of the five Medicare Locals Strategic Objectives is to facilitate the implementation and successful
performance of primary health care initiatives and programs. One of the ways that Medicare Locals will
do this is by providing health services directly where there is a market failure in a particular area, or where
providing a health service directly is the most efficient and effective solution to meeting a local health need.
Resources
The following resources may be useful for Medicare Locals in establishing direct health services:
– National Safety and Quality Health Service
Standards, 2011.
– Website of the Australian Commission on Safety and
Quality in Health Care.
– RACGP Standards for general practices, 2010.
–ACSQHC, Open Disclosure Standard, 2008.
– National Standards for Mental Health Standards, 2010.
–ACSQHC, Australian Charter for Healthcare Rights.
Sydney, 2008.
– National Vaccine Storage Guidelines: Strive for
Five, 2005.
– Working Together: Aboriginal and Torres Strait
Islander Mental Health and Wellbeing Principles and
Practice, 2010. Purdie, Dudgeon and Walker (Eds);
Commonwealth of Australia.
– Scally G, Donaldson LJ, Clinical governance and
the drive for quality improvement in the new NHS in
England, British Medical Journal 998; 317 61.
Standard 10: Direct Health Service Delivery
65
Direct health services that are accredited under an existing
Standard 10 is also applicable where a Medicare Local:
quality framework are not required to be assessed against
– acquires stores, prescribes or administers medicines of
Standard 10. For example, general practice services,
medical deputising services and after hours medical
services operated by Medicare Locals must be accredited
under the current edition of the RACGP Standards for
general practices, and would not be assessed against
Standard 10. Similarly, mental health services accredited
any type; and/or
– provides health promotion and illness prevention
services individually or in groups (excluding health
promotion provided at the population level, which is
covered in Standard 7).
under the National Standards for Mental Health Services
The quality framework in the MLA Standards for the
would not be subject to assessment under Standard 10.
delivery of health services by Medicare Local’s includes:
Also note that even where a Medicare Local is providing
– 10.1 Equitable Access;
health services directly, not all of the criteria/indicators in
Standard 10 may be applicable, and that non-applicable
– 10.2 Care Planning and Evaluation;
criteria/indicators will be determined by the accrediting
– 10.3 Health Service Provision;
agency in consultation with the Medicare Local.
– 10.4 Care Coordination;
The clinical standards included in these MLA Standards
– 10.5 Medicines Safety;
are transitional, representing a starting point for the MLA
– 10.6 Consumer Healthcare Records;
program of accreditation in clinical safety and quality.
Medicare Locals providing direct health care services are
– 10.7 Healthcare Associated Infection;
encouraged to use the NSQHS Standards as an internal
– 10.8 Clinical Equipment and Supplies; and
safety and quality tool, prior to their use more broadly in
– 10.9 Clinical Quality Improvement.
primary care health services.
For the purpose of the MLA Standards, direct health
service delivery is defined as:
The provision of a service that involves the
assessment, diagnosis, treatment or prevention of
social, emotional, psychological and/or physical risk,
illness or injury to individual consumers, by a suitably
skilled and/or qualified person.
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Medicare Locals Accreditation Standards – February 2013
Criterion 10.1
Equitable Access
Expected Outcome
Explanatory Notes
Consumers have equitable access to
health services.
Equitable access refers to processes aimed at addressing
Indicators
10.1.1 Information resources are available that describe
social and economic imbalances so that people from
disadvantaged groups have the same opportunity
to access and use services as those who are not
disadvantaged. Population health analysis undertaken
by Medicare Locals will identify the type and extent of
the type of health services provided, and for
disadvantage within the Medicare Local’s catchment
each service the eligibility criteria, out-of-pocket
community. Low income, locational disadvantage and
costs to the consumer and consumer rights and
lack of accessibility to resources and services are aspects
responsibilities are clearly described.
10.1.2 Health services are planned and delivered in
ways that promote equitable access and prevent
discrimination on the basis of age, gender identity,
sexual orientation, disability, culture, ethnicity
or religion.
10.1.3 The range of health services provided is
of inequality that can disadvantage individuals regardless
of their background, age or gender. Equitable access is
achieved by ensuring the absence of discrimination but
also through active inclusion, that is, the identification
and elimination of obstacles to access for disadvantaged
groups and individuals.
Equitable access does not mean that all consumers are
entitled to access all services. Some services provided by
communicated to consumers, including via the
Medicare Locals will be targeted at particular segments of
Medicare Local’s website.
the catchment community and it will be appropriate and
necessary for Medicare Locals to establish eligibility criteria
for those services. Where eligibility criteria are applicable
to a particular healthcare service, Medicare Locals are
required to document and communicate such criteria in an
open and transparent way, and ensure equitable access
within the parameters of established eligibility criteria.
A key way in which Medicare Locals can facilitate access
to the health services they provide is through advertising
and communicating available health care services through
the Medicare Local’s website. To meet the requirements
of the MLA Standards, Medicare Locals will also need to
establish information resources that describe the range of
health services provided, including eligibility criteria, costs
and consumer rights and responsibilities. Consistent with
the principles of inclusion and equitable access, Medicare
Locals will need to identify the best ways to communicate
about health services aimed at addressing needs of
disadvantaged groups, including where literacy levels
are lower and printed literature may not be an effective
method of communication.
Standard 10: Direct Health Service Delivery
67
Criterion 10.2
Care Planning and Evaluation
Expected Outcome
Explanatory Notes
Consumers receive timely and
appropriate care.
The quality framework for direct health service provision
Indicators
10.2.1 A baseline health history is undertaken for all new
health service consumers.
10.2.2 Where the health service will be provided on an
on-going basis to the consumer by the Medicare
outlined in the MLA Standards is based on the nursing
process. The nursing process is a cyclic process of
assessment, diagnosis, planning, intervention and
evaluation. The nursing process provides an appropriate
framework for multidisciplinary direct health service
provision because it focuses on ways to improve health by
addressing physical, mental, social and emotional needs
and because it is:
Local, an individual care/management plan is
– cyclic and dynamic;
established in partnership with the consumer, that
– goal directed and client centred;
includes as a minimum:
– interpersonal and collaborative;
a. the presenting need or problem;
– universally applicable; and
b. the health service provided; and
–systematic. (Kozier et al., 2004)
c. the goals of the health service or treatment.
10.2.3 Consumers are assisted to make informed
decisions about their care including provision
of information about the purpose, importance,
benefits, risks and possible costs of health care.
10.2.4 Consumers are assisted to understand their rights
and responsibilities within the care partnership.
10.2.5 The care/management plan is evaluated as
planned in consultation with the consumer.
10.2.6 For once-only health services, a contemporaneous
record of the health service is recorded in the
consumer’s health record.
In applying this model, health practitioners should consider
and apply diagnosis as applicable to their professional
discipline and scope of practice.
To meet the requirements of the MLA Standards,
Medicare Locals are required to ensure that baseline
health assessment is undertaken for all new consumers
prior to providing a health service. A baseline health
assessment is a collection of information obtained from
the consumer at the commencement of health service
provision. It includes physical status, psychological and
social functioning and any other matter relevant in the
context of the health service to be provided. Baseline
health care assessment provides the starting point for
determining health care needs (and/or the appropriateness
of a proposed treatment). The scope and type of baseline
health assessment used will vary depending on the type of
health service(s) being provided.
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Medicare Locals Accreditation Standards – February 2013
Direct health services provided by Medicare Locals may
The development of a documented care/management
be one-off services such as vaccinations, mid-term
plan is not required for once-only health services such as
treatments such as counselling services or long term
vaccinations. However, Medicare Locals are required to
programs aimed at consumers with chronic conditions.
ensure that adequate and appropriate assessment and
Where a health service will be provided on an on-going
planning processes are in place relative the nature of the
basis, Medicare Locals are required to establish an
health service. As a minimum, a contemporaneous record
individual care/management plan in partnership with the
of the health service should be made in the consumer’s
client. This should include as a minimum:
health record for once only treatments.
– the presenting need or problem;
– the health service provided; and
– the goals of the health service or treatment.
It is important that consumers of health services (and
carers, where relevant) are partners in their care and are
enabled to make informed decisions about the plan or
program of care or treatment. As a minimum, Medicare
Locals are required to ensure that consumers are provided
with information about the purpose, importance, benefits,
risks and possible costs of the proposed care, including
their rights and responsibilities within the care partnership.
Regular review and evaluation of the care/management
plan in partnership with consumers (and carer, where
relevant) will enable Medicare Locals to evaluate the
degree to which the health service is achieving the desired
goals and identify the need for modification of treatment
where necessary to enhance outcomes.
Standard 10: Direct Health Service Delivery
69
Criterion 10.3
Health Service Provision
Expected Outcome
Explanatory Notes
Quality health service delivery based on best
available evidence.
Medicare Locals are accountable for the quality and
Indicators
10.3.1 Health services are provided in accordance with
best available evidence.
10.3.2 Health care consumers are identified using three
approved identifiers prior to the provision of
healthcare services.
10.3.3 Identification of health care consumers is
safety of health care services provided directly. To meet
the requirements of the MLA Standards, Medicare Locals
are required to ensure that health services are provided
in accordance with best available evidence, that is,
based on valid and relevant research from the basic
sciences. Medicare Locals are also required to ensure
that documented procedures or clinical pathways are
established to support the delivery of health services
as well as providing relevant and appropriate clinical
guidelines and resources for the reference of health
practitioners providing health services. Both procedures
documented prior to the provision of interventional
and clinical resources must be readily available and
procedures.
accessible to health practitioners.
10.3.4 Clinical pathways or procedures are available for
the range of health services provided.
10.3.5 Clinical guidelines/resources are readily available
Patient misidentification is identified as a root cause of
many errors in health care. (WHO, 1997) Medicare Locals
are required to establish a consumer identification process
to clinical care providers relevant to the range of
that uses three approved identifiers, and to ensure that
health services provided.
consumers are identified using the process before the
provision of health services. An approved identifier is
an item of information accepted for use in consumer
identification. These include patient name (family and
given names), date of birth, gender, address, medical
record number and/or Individual Healthcare Identifier.
(ACSQHS, 2011) For interventional procedures, it is
recommended that the consumer identification process
is documented in the consumer health record. It is
recognised that there will be some contexts of primary
health care in which formal identification using three
approved identifiers will not be possible and/or practical.
Medicare Locals should establish a process of consumer
identification and ensure it is used wherever possible.
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Criterion 10.4
Care Coordination
Expected Outcome
Explanatory Notes
Health care provided by the Medicare Local
is integrated with the consumer’s broader
health care.
A key role of Medicare Locals is supporting effective care
coordination across primary care. Medicare Locals are
required under the MLA Standards to support continuity
of comprehensive care by reporting the outcome of health
services to the consumer’s general practitioner (subject to
Indicators
the consumer providing consent for this to occur). Where
10.4.1 Subject to the consent of the health care
consumers have a Personally Controlled Electronic Health
consumer, a report of the health care provided by
Record (PCEHR), such reports can be made by recording
the Medicare Local is provided to the health care
an event summary in the consumer’s PCEHR.
consumer’s usual medical/healthcare practitioner.
Where health needs are identified that cannot be met
10.4.2 Consumers are supported to access health care
services related to needs that cannot be met by
the Medicare Local.
10.4.3 A clinical handover process is used whenever care
is transferred.
through the Medicare Local, the Medicare Local is required
to provide advice and/or support to enable the consumer
to access appropriate health care, that is, to refer the
consumer to an appropriate service or service provider.
Reporting the outcomes of health service provision to a
consumer’s usual healthcare practitioner and referring
consumers to other services or providers are significant
contexts of clinical handover. To meet the requirements
of the MLA Standards, Medicare Locals are required to
ensure timely and appropriate clinical handover, including
the use of three approved identifiers during the
handover process.
Standard 10: Direct Health Service Delivery
71
Criterion 10.5
Medicines Safety
Expected Outcome
Explanatory Notes
Safe and quality use of medicines
A medicine is a drug or other preparation used for the
treatment or prevention of disease. Medication is the
Indicators
10.5.1 Medicines are acquired, stored, prescribed,
process of prescribing, supplying or administering a
medicine to a consumer. Medicines safety is the process of
identifying and mitigating risks associated with the storage
administered and disposed of in accordance with
and management of medicines and/or the prescription,
State/Territory legislative requirements.
supply or administration of medicines to consumers.
10.5.2 Prescribers have access to current therapeutic
The type and extent of medicines management and
guidelines.
10.5.3 Consumers are provided with information about
any prescribed medicines.
10.5.4 Consumers are assisted to make informed
decisions about proposed medicines including
information about the purpose, importance,
benefits, risks and possible costs of the medicines.
10.5.5 Vaccines are managed in accordance with the
current edition of the National Vaccine Storage
Guidelines: Strive for Five.
medication will vary across Medicare Locals. To meet the
requirements of the MLA Standards, Medicare Locals are
required to assess the risks associated with medicinesrelated direct health services and establish systems
and processes aimed at reducing risks and enhancing
safety. As a minimum, medicines/medication safety risk
assessment should consider processes associated with:
– acquisition, storage, prescription, administration,
disposal and stock level management; and
– regulatory requirements that apply to the state or
territory in which the Medicare Local operates.
Where direct health services provided by Medicare
Locals involve prescription of medication, current
therapeutic guidelines must be available and readily
accessible to prescribers.
Medicare Locals must ensure that consumers are provided
with information about any medicines prescribed, supplied
or administered to them. This includes information about
the purpose, importance, benefits, risks and possible
costs of the proposed treatment.
Where Medicare Locals provide vaccination services,
vaccines must be stored and managed in accordance
with the current edition of the National Vaccine Storage
Guidelines: Strive for Five.
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Criterion 10.6
Consumer Health Records
Expected Outcome
Explanatory Notes
Comprehensive, integrated and accessible
consumer health records.
Medicare Locals that provide direct health services are
Indicators
10.6.1 An accurate, integrated, individual consumer health
record is maintained for each health care recipient.
10.6.2 Consumer health records include the following
information as a minimum:
a. all information held by the Medicare Local about
the consumer;
b. contact and demographic information, including
name, address, date of birth and gender;
c. cultural or ethnic identification, including
required to establish a consumer health records system
that provides for the establishment and maintenance
of an integrated, individual consumer health record for
each person who receives a health service through the
Medicare Local, which is used to record any subsequent
health services that may be provided to the person. The
consumer health record must be a comprehensive record
that contains all of the information the Medicare Local
holds about a person. An individual consumer health
record is required irrespective of the nature of the health
service provided.
As lead organisations in primary health care, Medicare
Locals have an important function in leading and
supporting the adoption of eHealth initiatives throughout
Aboriginal and/or Torres Strait Islander status;
primary care. While not mandatory to meet the
and
requirements of the MLA Standards, Medicare Locals
d. the person to be contacted in an emergency.
10.6.3 Consumer health records are readily accessible to
health service providers as required.
10.6.4 Consumer health records are stored such that
unauthorised access is prevented.
should establish a consumer health records system
aligned to the NESAF and capable of integrating with the
Personally Controlled Electronic Health Record (PCEHR)
when it is fully operational.
Medicare Locals are required to adopt standardised
national dictionaries for, at a minimum, diagnosis and to
collect demographic and contact information for each
client that will facilitate patient identification using three
approved identifiers, and effective clinical handover.
Consumer health records must include as a minimum,
the consumer’s name, address, date of birth and gender/
gender identity. Information about cultural or ethnic
identification, including Aboriginal and/or Torres Strait
Islander status and the person to be contacted in an
emergency should also be collected.
The consumer health records systems must provide for
ready access to consumer healthcare records by health
practitioners. Storage of the consumer health records
must prevent unauthorised access and provide for the
privacy of sensitive health information as required by the
Privacy Act 1988. (Commonwealth 1988)
Standard 10: Direct Health Service Delivery
73
Criterion 10.7
Healthcare Associated Infection
Expected Outcome
Explanatory Notes
Healthcare associated infection risks
are minimised.
Medicare Locals are required to establish an infection
Indicators
10.7.1 An infection control program is documented
control program that is appropriate to the range of direct
health services it provides. Effective infection control is
particularly important for Medicare Locals that provide
direct health services involving interventional procedures
or any form of physical assessment or examination.
and implemented relevant to the range of health
Infection control policies, procedures and protocols should
services provided.
be developed in accordance with the current edition of
10.7.2 Infection control policies and processes are
consistent with the current edition of the Australian
Guidelines for the Prevention and Control of
Infection in Healthcare.
the Australian Guidelines for the Prevention and Control
of Infection in Healthcare. (National Health and Medical
Research Council, 2010) Successful infection control
requires a range of strategies across all levels of a health
service and a collaborative approach for successful
implementation. These strategies include standard
and transmission based precautions, hand hygiene,
infection surveillance, antimicrobial stewardship, sharps
management, reprocessing of reusable clinical equipment,
aseptic technique, environmental cleaning, waste
management and linen management. Medicare Locals
will need to undertake an infection control risk assessment
focused on identifying the infection control risks and
issues that are relevant to the range of the health
services provided.
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Criterion 10.8
Clinical Equipment and Supplies
Expected Outcome
Explanatory Notes
Adequate and appropriate clinical equipment
and supplies are available in relation to the
range of health services provided.
Medicare Locals must ensure that there are sufficient
clinical equipment and supplies to support the range of
health services provided. Clinical equipment must be
managed and maintained in such a way as to ensure the
safe and efficient functioning of the equipment, including
Indicators
ensuring that recommended maintenance is conducted
10.8.1 There is sufficient clinical equipment and supplies
in accordance with manufacturer’s instructions. Adequate
to support the range of health services provided.
10.8.2 Clinical equipment is clean, safe, functional and fit
for purpose.
and appropriate stock of required medical consumables
and other supplies must be readily available to enable the
provision of safe and effective care.
10.8.3 Clinical equipment is maintained in accordance
with manufacturer’s recommendations.
10.8.4 A clinical equipment maintenance schedule is
documented and implemented.
Standard 10: Direct Health Service Delivery
75
Criterion 10.9
Clinical Quality Improvement
Expected Outcome
Explanatory Notes
Clinical incidents inform improvements in
quality and safety.
Clinical incident management is a key aspect of an
Indicators
10.9.1 A clinical audit program is implemented and
effective clinical governance system. Clinical incident
reporting increases safety and decreases the likelihood
of harm by examining departures from expected clinical
process or outcome and identifying opportunities to
improve service delivery. Medicare Locals that provide
operational, relevant to the range of health services
direct health services are required to establish a clinical
provided by the Medicare Local.
incident reporting mechanism including as a minimum:
10.9.2 A clinical incident management system is
implemented and operational.
10.9.3 An open disclosure policy aligned to the
– incident management policies, procedures and
protocols;
– incident reporting form/method;
requirements of the ACSQHC, Open Disclosure
– incident register;
Standard 2008 is documented and implemented.
– regular review and analysis of incident data;
10.9.4 A clinical quality improvement plan is in place and
records planned improvements to care and
service delivery.
– identification of the person responsible for reviewing
clinical incident data; and
– planned improvements in response to clinical
incident data.
A clinical audit program is also an important component
of an effective clinical governance system. To meet the
requirements of the MLA Standards, Medicare Locals
must establish a clinical audit program that provides for
regular monitoring of clinical processes. It is important that
the clinical audit program is aligned to the risks and issues
that are relevant to the range of clinical services provided
by the Medicare Local. The clinical audit program must
include as a minimum:
– clinical audit tools;
– a clinical audit plan which outlines the frequency with
which each audit will be conducted and the person
responsible for conducting each audit;
– analysis of audit findings; and
– implementation of planned improvements
where indicated.
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Open disclosure is frank and open discussion with
patients, their families and carers following harm that has
resulted from health care. Since the 1980s, doctors, other
healthcare professionals and health service organisations
have started to accept that open disclosure is ethical,
appropriate and necessary. (ACSQHC, 2008)
In 2003, the national Open Disclosure Standard was
released by the Australian Commission on Safety and
Quality in Health Care as a guide for Australian healthcare
practitioners and health service organisations on
communicating with patients after health care has resulted
in harm. Indicator 10.9.3 requires Medicare Locals to
develop and implement an open disclosure policy. Open
disclosure, as the name suggests, requires transparency
in relation to clinical incidents, and includes expression
of regret and a factual explanation of what happened, the
potential consequences, and the steps being taken to
manage the event and prevent recurrence.
(ACSQHC, 2008)
Standard 10: Direct Health Service Delivery
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section 4
Safety and Physical
Resources Standards
Safety and physical resources standards are concerned with practices and
management to ensure a safe and healthy workplace, where assets are managed
effectively and a developing commitment to environmentally responsible business
practices is in evidence.
Standard 11
Environmental Safety
A safe environment
Criterion 11.1
Work Health and Safety
Criterion 11.2
Fire Safety
Effective fire safety infrastructure.
Standard 12
Asset Management
Asset management supports the effective functioning of the Medicare Local
Criterion 12.1
Asset Management
Asset management supports the effective functioning of the Medicare Local.
Criterion 12.2
Fleet Management
Fleet management supports the effective functioning of the Medicare Local.
Criterion 12.3
Preservation of Natural Resources (Developmental)
Environmentally responsible business practices.
Section 4
A safe and healthy workplace and work practices.
Standard 11
Environmental
Safety
Objective: A safe environment
The quality framework for the delivery of work health and safety by Medicare Locals is focused on the
implementation of systems and processes aligned to State/Territory regulatory requirements in relation to:
– 11.1 Work Health and Safety; and
– 11.2 Fire Safety.
Resources
The following resources may be useful for Medicare Locals in establishing effective work health and safety systems:
– Overview of AS 3745-2010 Planning for Emergencies in Facilities.
– Summary of work health and safety legislation that may be applicable to Medicare Locals (Appendix 9).
– Summary of fire protection legislation that may be applicable to Medicare Locals (Appendix 10).
Standard 11: Environmental Safety
79
Criterion 11.1
Work Health and Safety
Expected Outcome
Explanatory Notes
A safe and healthy workplace and
work practices.
Work health and safety is concerned with protecting
the safety, health and welfare of people engaged in
work or employment. Work health and safety refers to
the identification and mitigation of work related risks in
Indicators
11.1.1 A work health and safety system is in place as
required by State/Territory regulatory requirements.
11.1.2 Employees are aware of their rights and
responsibilities in relation to work health and safety.
consultation with employees, aimed at the establishment
of safe work practices and a safe work place. In July 2008,
the Council of Australian Governments formally committed
to the harmonisation of work health and safety law. An
Australian Government agency, Worksafe Australia, was
established in 2009 to lead the harmonisation process by
establishing a model regulatory framework for work health
and safety. The model regulatory framework was adopted
by the Commonwealth, Queensland, Australian Capital
Territory and the Northern Territory from 1 January 2012
and will be implemented progressively in other states. A
summary of work health and safety legislation that may be
applicable to Medicare Locals is provided at Appendix 9.
To meet the requirements of the MLA Standards, Medicare
Locals are required to establish a work health and
safety program that is aligned to the applicable State/
Territory legislation. This should include work health and
safety policies, procedure and protocols appropriate to
workplace risks relevant to the Medicare Local’s activities.
While regulation of work health and safety is undergoing
significant change and reform, the following principles
remain the cornerstone of an effective work health and
safety program:
– management commitment;
–consultation;
– management of risk;
– training and instruction;
– safety reporting; and
– return to work and workers compensation.
It is vital that Medicare Local employees are aware of
their rights and responsibilities in relation to work health
and safety and are engaged in the process of identifying
and managing workplace risks and the establishment of
strategies aimed at safe work practices and a
safe workplace.
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Criterion 11.2
Fire Safety
Expected Outcome
Explanatory Notes
Effective fire safety infrastructure.
Beyond their general obligation to safeguard the health
and safety of employees and provide a safe workplace,
Indicators
11.2.1 Fire safety systems are implemented as required
Medicare Locals are required under law to establish fire
safety systems. A summary of the regulatory framework
related to fire safety is provided at Appendix 10.
by State/Territory regulatory requirements.
11.2.2 Employees are aware of the procedure to follow in
the event of fire or fire alarm.
Standard 11: Environmental Safety
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Standard 12
Asset
Management
Objective: Asset management supports the
effective functioning of the Medicare Local
Medicare Locals will need to acquire a range of assets in order to meet their strategic objectives.
Objective five of the Medicare Locals Strategic Objectives requires Medicare Locals to be efficient and
accountable, with strong governance and effective management. The quality framework for physical
resources in the MLA Standards includes:
– 12.1 Asset management;
– 12.2 Fleet management; and
– 12.3 Preservation of natural resources.
Resources
The following resources may be useful for Medicare Locals in establishing systems and processes for effective
management of physical resources:
– Summary of fire protection legislation that may be applicable to Medicare Locals (Appendix 10).
– Better Practice Guide on the Strategic and Operational Management of Assets by Public Sector Entities:
Delivering agreed outcomes through an efficient and optimal asset base. Australian National Audit Office, 2009.
– Guide to Integrated Strategic Asset Management, AAMCoG, 2011.
– Website of the Australian Government: www.australia.gov.au (environmental sustainability).
Standard 12: Asset Management
83
Criterion 12.1
Asset Management
Expected Outcome
Explanatory Notes
Asset management supports the effective
functioning of the Medicare Local.
Asset management is the process of organising,
Indicators
12.1.1 A strategic asset management plan is
documented and implemented.
12.1.2 Buildings, facilities, plant and equipment are
planning, designing, and controlling the acquisition, care,
refurbishment and disposal of assets to support delivery
of services. It is a systematic, structured process covering
the whole life of the physical asset. (Australian Asset
Management Collaborative Group, 2011)
Strategic asset management involves:
– Analysing and identifying asset needs, including
sufficient to support the effective functioning of
considering non-asset solutions. Asset management
the Medicare Local.
decisions should be integrated with strategic planning.
12.1.3 A program of planned preventative and corrective
– Considering the costs and benefits of asset acquisition
maintenance is in place to ensure that buildings,
versus non-asset solutions. It is important to consider
facilities, plant and equipment are safe and fit
the costs across the entire life cycle of the asset.
for purpose.
– Establishing accountability for asset management,
including use, maintenance and performance.
– Disposing of assets in a way that will provide best
available net return and least harm to the environment.
To meet the requirements of the MLA Standards,
Medicare Locals are required to establish a strategic asset
management plan. A strategic asset management plan
is a documented plan for managing an organisation’s
infrastructure and other assets in a way that optimises
efficiency, safety and service provision. Effective strategic
asset management will ensure that sufficient buildings,
facilities and other equipment are available to support
achievement of the Medicare Local’s business objectives.
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Medicare Locals Accreditation Standards – February 2013
Criterion 12.2
Fleet Management
Medicare Locals are also required to establish a program
of planned preventative maintenance (and corrective
maintenance) to ensure that buildings, facilities and
equipment are safe, functional and fit for purpose.
Expected Outcome
Fleet management supports the effective
functioning of the Medicare Local.
This criterion cross references to indicator 1.4.8 which
requires Medicare Locals to establish an asset register.
Maintenance planning can be integrated with asset
registration or a separate schedule of planned
preventative maintenance can be established.
Indicators
12.2.1 A fleet management plan is documented and
implemented.
Maintenance planning should incorporate, as a minimum,
12.2.2 Motor vehicles are clean, safe and fit for purpose.
the name of the item, the type of maintenance required,
12.2.3 Motor vehicles are registered in accordance with
the frequency of maintenance and any reference to the
requirement for maintenance by a person with specific
skills or qualifications.
State/Territory regulatory requirements.
Explanatory Notes
This criterion is applicable only to Medicare Locals
that own or lease motor vehicles, including cars,
vans and buses. An effective fleet management plan
includes financing, maintenance, driver management,
fuel management, health and safety management and
regulatory compliance. Medicare Locals that have a
vehicle fleet will need to decide whether to undertake fleet
management internally or outsource.
Standard 12: Asset Management
85
Criterion 12.3
Preservation of Natural Resources
Expected Outcome
Explanatory Notes
Environmentally responsible
business practices.
There is growing focus on the importance of preserving
Indicators
12.3.1[Developmental] Initiatives aimed at preservation
our natural resources. Effective management of natural
resources improves the quality of our life and lifestyle
while degradation of natural resources may threaten lifesustaining processes.
It has become popular for organisations to consider
of natural resources are documented and
sustainability in terms of the triple bottom line of people,
implemented.
planet and profits. Under this approach, the aim is to
develop strategies that remain profitable while empowering
and inspiring people and preserving precious natural
resources. By measuring and reporting financial, social
and environmental performance, organisations provide
a solid foundation for measuring progress in these
areas. Environmentally responsible business practices
demonstrate to the community an organisation’s
commitment to performance against the triple bottom line.
Implementing environmentally responsible business
practices does not need to be a costly activity; there are
many simple, practical initiatives that can be implemented.
For example:
– clearly label recycling and waste bins and consider
using colour coding and/or pictures to indicate the
purpose of each bin;
– remove disposable cups from the workplace and
provide glasses and mugs for staff;
– install a function for saving emails directly to a server or
database and ensure staff are aware of how and where
to save information;
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– set office printers and photocopiers to use the doublesided function wherever possible;
– recycle paper from your shredder;
– implement online submission of forms wherever
possible;
– implement computer-based filing systems - this will not
only save paper, but also space in the office;
– activate ‘sleep mode’ for Energy Star products and
– use zoning functions on heating and cooling system;
– close off unused rooms if the zoning function is
not available;
– seal off unused areas and close doors to rooms that
don’t need to be cooled or heated; and
– consider product durability and reparability
when purchasing.
Indicator 12.3.1 is developmental in recognition that
make regular checks to ensure that the function
Medicare Locals’ priorities will be focused on the
remains operational, or no savings will be achieved;
implementation of core service delivery systems during
– purchase a single business machine that photocopies,
the transition period.
faxes, scans and prints to save on maintenance and
operating costs;
– set up fax numbers to go directly to a computer file
instead of printing faxes on paper;
– instead of setting computers to have a screen saver
come on after a period of inactivity, set it to shut down
the monitor and save energy;
– use the ‘energy saver’ or ‘standby’ mode on
photocopiers when not in use;
– use refillable ink and toner cartridges;
– switch to energy efficient lighting – natural daylight or
fluorescent tubes - although initially more expensive
than incandescent lamps to install, fluorescent tubes
last ten times longer and are 70% more efficient;
– maximise the use of natural daylight;
Standard 12: Asset Management
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Glossary
Glossary
89
Glossary
Term
Definition
Accountability
Accountability is the acknowledgment and assumption of responsibility for actions,
products, decisions, and policies including the administration, governance,
and implementation within the scope of the role or employment position and
encompassing the obligation to report, explain and be answerable for resulting
consequences. (Williams, 2006)
Accreditation
Recognition that an organisation or an individual has met the requirements of defined
standards through a process of independent third party assessment.
Adverse drug reaction
A drug response that is noxious and unintended, and which occurs at doses normally
used or tested in humans for the prophylaxis, diagnosis or therapy of disease, or for
the modification of physiological function. (Reference 4, NSQHS Standards, 2011)
Approved consumer
Items of information accepted for use in patient identification, including patient name
(family and given names), date of birth, gender, address, medical record number and/
or Individual Healthcare Identifier. (NSQHS Standards, 2011)
identifiers
Asset management
Asset management is the process of organising, planning, designing, and controlling
the acquisition, care, refurbishment and disposal of infrastructure and engineering
assets to support to delivery of services. (AAMCoG, 2011)
Baseline health assessment
A collection of information obtained from the consumer at the commencement their
health care concerning the consumer’s physical status, psychological and social
functioning and any other matter relevant to the health service to be provided.
Best available evidence
Evidence from valid and practically relevant research, often from the basic sciences.
Board charter
A specification of the functions and responsibilities of a Board, along with procedures
aimed at the effective operation of the Board and that support each member in
fulfilling his or her duties as a Director.
Business continuity plan
A collection of contingency procedures and information developed and maintained
in readiness for use in the event of an emergency or disaster aimed at enabling the
continuation or restoration of an organisation’s functions.
Business equipment
Computers, keyboards, visual display units, printers, photocopiers, facsimile
machines, telephones, scanners and audio-visual devices such as televisions and
data projectors.
Care plan
A documented overview of the health care a consumer will receive, including
the health care service(s), the goals of the health care and the frequency of the
health care.
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Medicare Locals Accreditation Standards – February 2013
Term
Definition
Carer
People who provide unpaid care and support to family members and friends who
have a disability, mental illness, chronic condition, terminal illness or general frailty.
Carers include parents and guardians caring for children. (Reference 9, NSQHS
Standards 2011)
Clinical audit
A quality improvement process that seeks to improve clinical care and services
through systematic review of care processes against specified quality criteria such as
clinical standards or procedures.
Clinical audit program
A documented and prospective plan for the conduct of clinical audits over a period of
time that outlines the type, scope and frequency of clinical audits to be conducted.
Clinical equipment
Any non-consumable item or device used in the support or provision of health care.
Clinical governance
A system through which organisations are accountable for continuously improving the
quality of their services and safeguarding high standards of care. This is achieved by
creating an environment in which there is transparent responsibility and accountability
for maintaining standards and by allowing excellence in clinical care to flourish.
(Reference 11, NSQHS Standards, 2011)
Clinical guidelines
Systematically developed statements to assist practitioner and patient decisions
about appropriate health care for specific circumstances.
Clinical handover
The transfer of professional responsibility and accountability for some or all aspects of
care for a patient, or group of patients, to another person or professional group on a
temporary or permanent basis. (Reference 12, NSQHS Standards, 2011)
Clinical incident
An event or circumstance arising from the provision of health care that resulted, or
could have resulted, in unintended and/or unnecessary harm to a person and/or a
complaint, loss or damage.
Clinical pathways
A documented, multidisciplinary and evidence based tool that defines the flow
of health care tasks or interventions required to optimise consumer health care
outcomes relevant to the health care to be provided.
Clinical workforce
Nursing, medical and allied health employees required to be professionally registered
by the Australian Health Practitioner Regulation Agency. (AHPRA website, 2011)
Complaint
An expression of dissatisfaction, provided in writing or verbally, from or on behalf of
an employee, contractor, subcontractor, consumer or other stakeholder.
Consultation
A formal or informal process designed to provide and receive information and
opinions through discussion or through written or electronic information transactions.
Consumer
A person in the Medicare Local’s catchment community that utilises goods and /or
services produced by the Medicare Local, including health care goods and services.
Glossary
91
Term
Definition
Consumer health record
Consists of, but is not limited to, a record of the patient’s medical history, treatment
notes, observations, correspondence, investigations, test results, photographs,
prescription records and medication charts for an episode of care.
Contemporaneous
Originating, existing, or happening during the same period of time.
Contestable tendering
Seeking expressions of interest from the market for the production of goods and/or
delivery of services, through advertisement and then selecting providers based on
price and quality criteria.
Continuing professional
development
A structured approach to ongoing knowledge and skill maintenance and
development in a profession.
Contracting
Establishment of a legally binding contract.
Corporate governance
An umbrella term that describes a range of corporate controls within an organisation
aimed at ensuring compliance and positive performance.
Credentialing
The formal process used to verify the qualifications, experience, and professional
standing of health practitioners for the purpose of forming a view about their
competence, performance and professional suitability to provide safe, high quality
health care services within specific organisational environments.
Criminal history check
Review of a person’s criminal history based on a National Police Certificate provided
by the police service in the relevant State or Territory.
Data quality
Data quality is the degree to which data is fit to serve its purpose in a given context.
Deed for Funding
The contract through which Medicare Locals are engaged and funded by the
Commonwealth.
Delegations framework
An organisation’s system for allocating power and/or authority to people within an
organisation to perform certain functions.
Designated responsibility
A person assigned responsibility and accountability for a specific function or process.
Disaster recovery plan
Disaster recovery is the process, policies and procedures related to preparing for
recovery or continuation of technology infrastructure critical to an organisation after a
natural or human induced disaster.
Document control
The process by which documents are managed within an organisation, including
reviewing and approving documents prior to release; ensuring changes and revisions
to documents are clearly identified; ensuring relevant versions are available to end
users and ensuring documents are stored and organised in a way that ensures they
are readily accessible.
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Medicare Locals Accreditation Standards – February 2013
Term
Definition
eHealth
The World Health Organization defines eHealth as ‘the combined use of
electronic communication and information technology in the health sector.’
(http://www.who, January 2012) In more practical terms, eHealth is the means of
ensuring that the right health information is provided to the right person at the right
place and time in a secure, electronic form for the purpose of optimising the quality
and efficiency of health care delivery. eHealth should be viewed as both the essential
infrastructure underpinning information exchange between all participants in the
Australian health care system and as a key enabler and driver of improved health
outcomes for all Australians.
Employee
A person who performs work tasks or activities for wages or salary.
Equitable access
Processes aimed at addressing social and economic imbalances so that people from
disadvantaged groups have the same opportunity to access and use services.
Financial delegations
A dollar amount to which a person in an organisation is authorised to commit and/or
make expenditure in respect of an individual transaction.
Financial delegations
A documented overview of the financial delegations within an organisation.
framework
Financial performance
Business results related to a company’s financial health, such as revenues, expenses,
and profits.
Fleet (vehicle)
Motor vehicles owned or leased by a business.
Fleet management plan
A documented framework for the strategic management of an organisation’s vehicle
fleet that provides for the development and analysis of fleet assets to meet an
organisation’s needs and to ensure safe and cost effective operation and utilisation.
Hazard
An event, item or situation that poses a level of threat to life, health, property, or
environment.
Health
A state of complete physical, mental and social well-being.
(http://www.who.int/en/, January 2012)
Health care service
The provision of a service that involves the assessment, diagnosis, treatment or
prevention of social, emotional, psychological and/or physical risk, illness or injury to
individual consumers, by a suitably skilled and/or qualified person.
Health service mapping
The process of identifying and documenting the health services available in a
Medicare Local’s catchment community.
Health service organisation
A separately constituted health service that is responsible for the clinical governance,
administration and financial management of a service unit(s) providing health care.
(NSQHS Standards, 2011)
Glossary
93
Term
Definition
Health service provider
A nursing, medical or allied healthcare practitioner that provides healthcare services
to consumers.
Healthcare associated
Infections that are acquired in healthcare facilities - nosocomial infections; or that
occur as a result of healthcare interventions - iatrogenic infections. (Reference 19,
NSQHS Standards, 2011)
infection
Incident
An event or circumstance that resulted, or could have resulted, in unintended and/
or unnecessary harm to a person and/or a complaint, loss or damage. (NSQHS
Standards, 2011)
Orientation
A formal process of informing and training workforce upon entry into a position or
organisation, which covers the policies, processes and procedures applicable to the
organisation. (NSQHS Standards, 2011)
Infection control
Actions to prevent the spread of pathogens between people in a healthcare setting.
Examples of infection control measures include targeted healthcare associated
infection surveillance, infectious disease monitoring, hand hygiene and personal
protective equipment. (Reference 6, NSQHS standards, 2011)
Information management
The collection, processing, storage, and distribution of information from one or more
sources and the controls within the information infrastructure.
Information systems
Complementary networks of hardware and software that people and organisations
use to collect, filter, process, create, and distribute information.
Information technology
Computers and other electronic devices used to store, retrieve, and transmit
information.
Informed decisions
Decisions made based upon a clear appreciation and understanding of the facts,
implications, and future consequences of the decision.
Internal communication
Communication occurring between employees and other internal stakeholders of an
organisation.
Interventional procedure
Any procedure used for diagnosis or treatment that penetrates the body.
These procedures involve incision, puncture, or entry into a body cavity.
(NSQHS Standards, 2011)
Knowledge capital
The unique and intrinsically valuable strategies, information, experience, skills, and
innovations that enable an organisation to better meet its strategic objectives.
Knowledge management
Strategies, practices and technologies used by an organisation to identify, create,
represent, distribute, and enable adoption of insight and experiences.
Locally focused
Directed towards the needs of the Medicare Local’s catchment community.
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Medicare Locals Accreditation Standards – February 2013
Term
Definition
Management report
Information about performance against organisational objectives reported to a higher
level of management.
Medication
The prescription, supply or administration of a medicine to a consumer.
Medicines
A drug or other preparation used for the treatment or prevention of disease.
(Reference 26, NSQHS Standards, 2011)
Medication history
An accurate recording of a patient’s medicines. It comprises a list of all current
medicines including all current prescription and non-prescription medicines,
complementary healthcare products and medicines used intermittently; recent
changes to medicines; and past history of adverse drug reactions. (Reference 25,
NSQHS Standards, 2011)
Medicines safety
The identification and mitigation of risks associated with the storage and
management of medicines and/or the prescription, supply or administration of
medicines to consumers.
Minutes
The instant documented record of the proceedings of a meeting.
Mission statement
A statement of the purpose of an organisation.
Natural resources
Resources derived from nature including soil, water, geological features, landscapes,
vegetation and animals.
Open disclosure
The provision of information to a patient about an incident(s) that resulted in harm
to that patient while receiving health care. The criteria of open disclosure are an
expression of regret and a factual explanation of what happened, the potential
consequences and the steps being taken to manage the event and prevent
recurrence. (ACSQHC, 2008)
Operating budget
A detailed account of all estimated income and expenses based on forecast revenue
during a given period of time (usually one year).
Operating software
Computer programs and applications used to support an organisation’s
business functions.
Operational report
Data and information that provides a measure of the performance of business
processes against targets.
Organisational structure
The hierarchical structure within an organisation that defines lines of reporting,
authority and communication.
Patient identification
The process of verifying the identity of a person. In healthcare this is often for the
purpose of matching the person to their intended therapy or treatment.
Glossary
95
Term
Definition
Performance evaluation
Processes aimed at determining the extent to which an employee, contractor or
subcontractor is achieving desired results.
Performance expectations
The standard of work and work results required of an employee, contractor or
subcontractor.
Performance management
Activities aimed at supporting employees, contractors and subcontractors to achieve
desired standards of work and work results.
Performance measurement
Processes for collecting and reporting information that provides insight into the
performance of an individual or process.
Personal information
Personal information is information or an opinion (including information or an opinion
forming part of a database) whether true or not, and whether recorded in a material
form or not, about an individual whose identity is apparent, or can reasonably be
ascertained, from the information or opinion.
Policy
A set of principles that reflect the organisation’s mission and direction. All procedures
and protocols are linked to a policy statement. (NSQHS Standards, 2011)
Population health
The health profile and health outcomes of a group of individuals, including the
distribution of such outcomes within the group.
Population health analysis
The systematic collection, collation, assessment and interpretation of health data
aimed at understanding population health determinants and needs.
Position description
A documented statement outlining the roles, responsibilities and work requirements
of a specific position.
Primary care
The component of the healthcare sector that provides care outside a hospital setting
that a person can access independently as a first point of healthcare enquiry, such
as general practitioners, pharmacies, allied health services, community and social
services.
Primary health care
Primary healthcare is socially appropriate, universally accessible, scientifically sound
first level care provided by health services and systems with a suitably trained
workforce comprised of multi-disciplinary teams supported by integrated referral
systems in a way that: gives priority to those most in need and addresses health
inequalities; maximises community and individual self-reliance, participation and
control; and involves collaboration and partnership with other sectors to promote
public health. Comprehensive primary health care includes health promotion, illness
prevention, treatment and care of the sick, community development, and advocacy
and rehabilitation. (Australian Government. Primary Health Care Reform in Australia:
Report to Support Australia’s First National Health Care Strategy, 2009, page 22)
Privacy officer
A person delegated responsibility for privacy matters related to their organisation.
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Medicare Locals Accreditation Standards – February 2013
Term
Definition
Probity
Complete and confirmed integrity, uprightness and honesty.
Procedure
The set of instructions to make policies and protocols operational and are specific
to an organisation. (NSQHS Standards, 2011)
Procurement
Procurement is the acquisition of goods or services.
Professional development
Continuing learning aimed at the maintenance and development of knowledge and
skills in a specific profession.
Professional development
A documented plan outlining the education and training an individual requires to
maintain or develop knowledge and skills.
plan
Protocol
An established set of rules used for the completion of tasks or a set of tasks.
(NSQHS Standards, 2011)
Quality
A measure of excellence or a state of being free from defects and deficiencies.
Quality culture
An organisational ethos characterised by pursuit of excellence.
Quality framework
The standards, measures and assessment processes used to monitor quality.
Quality improvement
A cyclic process monitoring performance and identifying and acting on opportunities
to enhance performance.
Quality management
Management activities aimed at the achievement of quality objectives.
Quality policy
A documented policy outlining an organisation’s approach to quality management,
quality objectives and quality improvement methodology.
Reparability
The extent to which something is able to be repaired.
Reporting lines
The supervisory hierarchy in an organisation.
Risk management
Risk management is a process involving the identification, assessment and
prioritisation of risks, followed by coordinated and economical application of
resources to minimise, monitor, and control the probability and/or impact of
unfortunate events.
Role clarity
An accurate and complete understanding by an employee of work objectives,
accountabilities, co-workers’ expectations and the overall scope of their position.
Scope of practice
Use of credentialing information to delineate the extent of a person’s clinical practice
in a particular context or setting. (ACSQHS, 2005)
Secondary health care
Health care services provided outside a hospital setting that a person can access
upon referral such as medical specialists or diagnostic imaging services.
Glossary
97
Term
Definition
Sensitive information
Sensitive information is a subset of personal information. It means information or
opinion about an individual’s racial or ethnic origin, political opinions, membership of a
political association, religious beliefs or affiliations, philosophical beliefs, membership
of a professional or trade association, membership of a trade union, sexual
preferences or practices, criminal record or health information about an individual.
Service needs analysis
Has the meaning provided in a Medicare Local’s Deed for Funding with the
Commonwealth Department of Health and Ageing.
Stakeholder
A person, group or organisation that impacts on and/or may be impacted by an
organisation’s activities.
Strategy
A strategy is a plan of action designed to achieve an organisation’s vision.
Subcontracting
Subcontracting is a type of contract used to outsource tasks within a contract for a
broader task or project. In these Standards subcontracting has the meaning provided
within the Medicare Locals Deed for Funding.
Therapeutic guidelines
Independent and evidence-based recommendations for clinical management.
Valid
Supporting the intended point or claim.
Values
Organisational values define acceptable standards for employer and employee
behaviour within an organisation.
Verification
The process by which truth, accuracy, authenticity or validity is established.
Vision statement
A statement about what an organisation is working to become.
Workforce plan
A process used to align the organisation’s workforce to the needs and priorities of the
organisation, to facilitate the meeting of legislative, service and business objectives.
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Medicare Locals Accreditation Standards – February 2013
References
References
99
References
Author/Publisher
Document/Reference/Publication Title
Australian Asset Management Collaborative
Group (AAMCoG), 2011.
Guide to Integrated Strategic Asset Management.
Australian Bureau of Statistics, 2007.
Adult Literacy and Life skills Survey Report.
Australian Institute of Health and Welfare,
2004.
Australia’s Health. Canberra, AIHW Cat. No. AUS 44, p.496.
Australian Commission on Safety and Quality
in Health Care, 2008.
Open Disclosure Standard.
Australian Commission on Safety and Quality
in Health Care, 2011.
National Safety and Quality Health Service Standards.
Australian Council for Safety and Quality in
Healthcare, 2004.
Standard for Credentialing and Defining the Scope of Clinical Practice:
A National Standard for credentialing and defining the scope of clinical
practice of medical practitioners, for use in public and private hospitals.
Australian Council for Safety and Quality in
Healthcare, 2005.
Credentialing and Defining the Scope of Clinical Practice Handbook.
Australian Indigenous HealthInfoNet, 2011
Overview of Australian Indigenous health status.
Australian Institute of Health and Welfare
(AIHW), 2004.
The geography of disability and economic disadvantage in Australian
capital cities.
Canadian Council on Learning, 2007.
Survey of Canadian Attitudes toward Learning.
Commonwealth, 2001.
Corporations Act.
Commonwealth, 2009.
Fair Work Act.
Commonwealth, 1988.
Privacy Act.
Commonwealth Department of Health and
Ageing, 2012.
Medicare Locals Deed for Funding.
Commonwealth Department of Health and
Ageing, 2005.
National Vaccine Management Guidelines: Strive for Five.
Commonwealth Department of Health and
Ageing, 2013.
Medicare Locals Accreditation Guidelines.
Commonwealth Department of Health and
Ageing, 2007.
Divisions of General Practice: Information Management Maturity
Framework and Resources.
Glicken, J., 2000. Environmental Science and
Policy, 3, 305-310.
Getting stakeholder participation ‘right’: a discussion of the participatory
processes and possible pitfalls.
100
Medicare Locals Accreditation Standards – February 2013
Author/Publisher
Document/Reference/Publication Title
International Accounting Standards Board,
2012.
International Financial Reporting Standards.
International Organisation for Standardization
(ISO), 2009.
Risk Management – Vocabulary ISO/IEC Guide 73:2009.
Johnson and Scholes, 2009.
Exploring Corporate Strategy.
Koontz, H., 2001. New York: McGraw-Hill.
Management: A global perspective. 10th Ed.
Kozier, Barbara, et al., 2004.
Fundamentals of nursing: concepts, process and practice, 2nd ed.
McEwen, M., 1994. Nurs. Health. Care, 15,
304-307.
Promoting interdisciplinary collaboration.
National Health and Medical Research
Council, 2010.
Australian Guidelines for the Prevention and Control of Infection
in Healthcare.
National Public Health Partnership, 2006.
The Language of Prevention. Melbourne.
National Health and Medical Research
Council, 2008.
The Australian Immunisation Handbook 9th Edition.
Purdie (et. al.), 2010.
Working Together: Aboriginal and Torres Strait Islander Mental Health
and Wellbeing Principles and Practice.
Royal Australian College of General
Practitioners (RACGP), 2011.
Computer and Information Security Standards (CISS).
Royal Australian College of General
Practitioners (RACGP), 2006
Putting prevention into practice: Guidelines for the implementation of
prevention in the general practice setting (Green Book) 2nd edition.
Royal Australian College of General
Practitioners (RACGP), 2012.
Guidelines for Preventative Activities in general practice (Red Book)
8th edition.
Rand Europe, 2010.
Technical Report.
Slocum Rocheleau, Dianne and Rachel
Slocum, 1995.
Participation in context: key questions in Power, process and participation:
tools for change.
Standards Australia, 2003.
AS 8000 – 2003 Corporate Governance (Good Governance Principles).
Standards Australia, 2008.
AS 8001:2008, Fraud and Corruption Control.
Standards Australia, 2005.
AS/NZS 5037:2005, Knowledge Management, A Guide.
Standards Australia, 2006.
AS/ ISO 10002:2006, Customer Satisfaction – Guidelines for Complaints
Handling in Organisations.
Standards Australia, 2009.
AS/NZS ISO 31000:2009, Risk Management – Principles and Guidelines.
Suter (et. al.), 2009.
Ten Key Principles for Successful Health Systems Integration, Healthcare
Quarterly 13.
References
101
Author/Publisher
Document/Reference/Publication Title
Twigg, J. (et. al.), 2001.
Guidance Notes on Participation and Accountability.
Benfield Grieg Hazard Research Centre,
University College, London
(http://www.bghrc.com)
Victorian Aboriginal Child Care Agency
(VACCA), 2008.
Aboriginal Cultural Competence Framework.
Williams, Reyes, 2006. London:
Palgrave Macmillan.
Leadership accountability in a globalizing world.
World Health Organization, 1978.
Declaration of Alma Ata, in proceedings of the International Conference
on Primary Health Care, Geneva, Switzerland.
World Health Organization, 2009.
Milestones in Health Care Promotion.
World Health Organization, 1997.
Jakarta Declaration.
World Health Organization, 2008.
Integrated Health Services – What and Why.
World Health Organization, 1997.
Intersectoral action for health: a cornerstone for health for all in the twenty
first century in proceedings of the International Conference on Intersectoral
Action for Health, Halifax, Canada.
102
Medicare Locals Accreditation Standards – February 2013
Appendices
Appendices
103
Appendix 1
Corporate Governance Self-assessment
(Indicator 1.2.1)
The following self-assessment has been developed in accordance with AS 8000 – 2003 Corporate Governance (Good
Governance Principles) to assist Medicare Locals to self-assess the effectiveness of corporate governance systems and
processes following implementation of AS 8000 – 2003 Corporate Governance (Good Governance Principles).
Corporate Governance Process
Self-Assessment
Are the powers and responsibilities of the governance structure and its members documented?
Yes
No
Are delegations defined and accountabilities for the organisation communicated?
Yes
No
Are position descriptions and/or role and responsibility statements for Board
members documented?
Yes
No
Is a formal induction program operational for new Board members?
Yes
No
Are Board members provided with regular, relevant training?
Yes
No
Have the organisation’s mission, values, goals and service priorities been articulated
and communicated?
Yes
No
Are strategic/annual plans and budgets approved by the Board?
Yes
No
Is the strategic direction routinely reviewed at Board level and documented?
Yes
No
Does the structure of the Board provide for appropriate consumer representation?
Yes
No
Are the interests of consumers and stakeholders represented at Board meetings?
Yes
No
Do Board meetings occur regularly and as scheduled?
Yes
No
Are minutes and actions arising from Board meetings documented and retained?
Yes
No
Is there a process in place to allow staff, at all levels, to contribute to the achievement of goals
and objectives as outlined in the strategic directions document(s)?
Yes
No
Are management reporting arrangements in place to ensure the Board is informed of monitoring,
planning and decision making?
Yes
No
Are a full set of financial management statements (Balance Sheet/Profit and Loss Statements etc.)
provided to and reviewed by the Board at least monthly?
Yes
No
Is the effectiveness of the governance structure reviewed regularly?
Yes
No
Is the performance of the CEO formally evaluated regularly?
Yes
No
Is a process in place at Board level to ensure compliance with all regulatory, statutory and
contractual requirements?
Yes
No
104
Medicare Locals Accreditation Standards – February 2013
Appendix 1.1
Clinical Governance Self-assessment
The following self-assessment has been developed in accordance with a clinical governance model developed by Scally and
Donaldson, (1998) to assist Medicare Locals to self-assess the effectiveness of clinical governance systems and processes.
Clinical Governance Element MLA Standards Criterion/Indicator
Self-assessment
An organisational risk management process is implemented.
(Criterion 1.3 Risk Management)
Yes
No
A clinical risk management process is implemented if the
Medicare Local provides direct health services.
(Criterion 1.3 Risk Management)
Yes
No
N/A
A process for aligning the capability of the clinical workforce with
the functions they perform.
(Criterion 2.1 Workforce Capability)
Yes
No
N/A
A performance management and supervision program is in
place for clinical service providers.
(Criterion 2.4 Performance Management and Supervision)
Yes
No
The credentials and suitability of new employees, contractors
and subcontractors is assessed.
(Criterion 2.5 Credentialing and Screening)
Yes
No
Health services are provided in accordance with best available
evidence. (Criterion 10.3 Health Service Provision)
Yes
No
Education, training and
continuing professional
development
Regular and relevant professional development is provided for
health practitioners
(Criterion 2.3 Training and Professional Development).
Yes
No
Use of Information
Sources of knowledge capital are identified and managed
effectively (Criterion 3.1 Knowledge Management).
Yes
No
Information supports service quality.
(Criterion 3.2 Information Systems)
Yes
No
Employees and
employees management
Human resource management systems and processes are in
place. (Standard 2)
Yes
No
Quality improvement
A clinical quality improvement plan is in place and records
planned improvements to care and service delivery.
(Indicator 10.9.4)
Yes
No
Clinical audit
Clinical audits that are relevant to the the range of health
services provided by the Medicare Local are conducted.
Indicator 10.9.1
Yes
No
Patient/consumer
engagement
Stakeholder relationships are managed effectively.
(Standard 5 Stakeholder Relationships)
Yes
No
Consumers are consulting about the care they receive.
(Criterion 10.2 Care Planning and Evaluation)
Yes
No
Research and innovation initiatives are undertaken.
(Criterion 9.1 Better Practice Resources)
Yes
No
Risk management
Clinical effectiveness
Research
Appendices
105
Appendix 2
Designated Responsibility Checklist
(Indicator 1.2.6)
The following checklist has been designed to assist Medicare Locals to review how responsibility for key critical processes
related to the MLA Standards is assigned within the Medicare Local.
Criterion
106
Process
Responsible Person
1.3
Coordinating risk management
–
1.5
Management of policies, procedures and protocols
–
1.6
Complaint management
–
2.5
Credentialing (initial and ongoing)
–
3.1
Knowledge management
–
3.4
IT - computer and information security
–
3.2.3
Website management
–
4.1
Contracting and sub-contracting
–
4.2
Contract/subcontract performance management
–
5.2
Stakeholder relationship management
–
6.1
Population health analysis
–
6.2
Health service mapping
–
9.2
Service and provider continuing professional development
–
1.2.3
Clinical governance
–
10.7
Coordinating the infection control program
–
10.8
Maintenance of clinical equipment
–
11.1
Work health and safety
–
11.2
Fire safety systems
–
12.2
Fleet management
–
12.3
Projects aimed at preserving natural resources
–
Medicare Locals Accreditation Standards – February 2013
Appendix 3
Risk Management System Self-assessment
The following self-assessment has been developed in accordance with AS/NZS ISO 31000:2009 Risk Management
– Principles and Guidelines to assist Medicare Locals to self-assess the effectiveness of organisational risk management
systems and processes.
AS/NZS ISO 31000:2009 Requirements
Self-assessment
Is a risk management policy in place?
Yes
No
Has the risk management policy been ratified by the Board?
Yes
No
Are all types of risk considered? – e.g. business/financial/safety/IT etc.
Yes
No
Is there a system for identifying risks?
Yes
No
Is there a system for analysing risks?
Yes
No
Is there a system for evaluating risks?
Yes
No
Is there a system for treating risks?
Yes
No
Are the risks identified and the controls in place listed in a register?
Yes
No
Are procedures or processes in place to control the risks you identified?
Yes
No
Have authorities and responsibilities for acting on risk issues been defined in a document so
that everyone understands them?
Yes
No
Is relevant data collected and used to inform management on whether risk controls in place
are effective?
Yes
No
Do you regularly review risk controls in place to ensure they continue to minimise or eliminate
the risk identified?
Yes
No
Is risk management an agenda item at the Board level?
Yes
No
Is training provided to staff on risk management and control?
Yes
No
Have adequate resources been allocated to manage and control the risks identified?
Yes
No
Have internal communication and reporting mechanisms been established?
Yes
No
Have relevant external communication and reporting mechanisms been established?
Yes
No
Are all staff members aware of the need to manage risk in their everyday work?
Yes
No
Appendices
107
Appendix 4
Policy and Procedure Checklist
The following checklist has been developed to provide a summary of policy and procedure requirements related to the
MLA Standards and to assist Medicare Locals with self-assessment related to policy and procedure. The list of policy topics
that follows is not intended to be exhaustive.
Standard
Policy Topic
Self-assessment
1.2.1
Corporate governance framework
Yes
No
1.4
Financial management
Yes
No
1.5
Quality management
Yes
No
1.2.4
Delegations framework
Yes
No
1.6
Complaint management
Yes
No
1.1.6
Business continuity planning
Yes
No
1.5.5
Document control
Yes
No
1.4.7
Procurement
Yes
No
2.3
Employee training and professional development
Yes
No
2.4
Performance management and supervision
Yes
No
2.5.1
Employee screening and appointment
Yes
No
2.5.2
Credentialing and re-credentialing
Yes
No
2.6
Organisational communication
Yes
No
3.1
Knowledge management
Yes
No
3.2
Information systems
Yes
No
3.3
Information privacy
Yes
No
3.4
Computer and information security
Yes
No
4.1/2
Contracting and subcontracting
Yes
No
5.1/2/3
Stakeholder relationships
Yes
No
6.1
Population health analysis
Yes
No
6.2
Health service mapping
Yes
No
6.3
Health service planning
Yes
No
7.1/2/3
Health promotion and illness prevention
Yes
No
8.1/2
Service coordination and integration
Yes
No
9.1/2
Service and provider support
Yes
No
11.1
Work health and safety
Yes
No
11.2
Fire safety
Yes
No
12.1
Asset management
Yes
No
12.2
Fleet management
Yes
No
12.3
Preservation of natural resources
Yes
No
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Medicare Locals Accreditation Standards – February 2013
Appendix 4.1
Policy and Procedure Checklist
(Direct Health Service Delivery)
The following checklist has been developed to provide a summary of policy and procedure requirements related to the
MLA Standards and to assist Medicare Locals with self-assessment related to policy and procedure. The list of policy topics
that follows is not intended to be exhaustive.
Criterion
Policy Topic
Self-assessment
10.1
Equitable access
Yes
No
10.2
Care planning and evaluation
Yes
No
10.3.3
Health care consumer identification
Yes
No
10.3.4
Health service provision, including clinical procedure, guidelines/pathways
Yes
No
10.4
Coordinated care, including referral and clinical handover
Yes
No
10.5
Medicines safety (as applicable to the health services provided by the Medicare
Local, including vaccine storage if applicable)
Yes
No
10.6
Consumer health records
Yes
No
10.7
Healthcare associated infection
Yes
No
10.8
Clinical equipment and supplies
Yes
No
10.9.1
Clinical quality improvement, including clinical audit
Yes
No
10.9.2
Clinical incident management
Yes
No
10.9.3
Open disclosure policy
Yes
No
Appendices
109
Appendix 5
Summary of Human Resource Management
Regulatory Requirements
(Indicator 2.7.1)
The following table provides a summary of the Commonwealth, State and Territory employee relations legislation that may be
applicable to Medicare Locals. The information was correct at the time of printing the MLA Standards. Medicare Locals should
seek advice about the currency and applicability of the regulatory frameworks set out below.
Jurisdiction
Instrument
Commonwealth Government
Fair Work Act 2009
Fair Work (Transitional Provisions and Consequential Amendments) Act 2009
Independent Contractors Act 2006
Privacy Act 1988
New South Wales
Privacy and Personal Information Protection Act 1998
Health Records and Information Privacy Act 2002
Freedom of Information Act 1989
State Records Act 1998
Criminal Records Act 1991 (Spent Convictions)
Listening Devices Act 1984
Workplace Surveillance Act 2005
Telecommunications (Interception and Access) (New South Wales) Act 1987
Crimes (Forensic Procedures) Act 2000
Queensland
Right to Information Act 2009
Public Records Act 2002
Criminal Law (Rehabilitation of Offenders) Act 1986 (spent convictions)
Invasion of Privacy Act 1971 (listening devices, invasion of privacy of the home)
Whistleblowers Protection Act 1994
Police Powers and Responsibilities Act 2000 (Chapter 4 deals with covert
evidence-gathering powers)
Private Employment Agents (Code of Conduct) Regulation 2005 (provisions
14 and 15 deal with work seekers' information and the need to ensure it is not
disclosed or improperly used).
Victoria
Information Privacy Act 2000
Health Records Act 2000
Charter of Human Rights and Responsibilities Act 2006
Freedom of Information Act 1982
Public Records Act 1973
Surveillance Devices Act 1999
Telecommunications (Interception) (State Provisions) Act 1988
110
Medicare Locals Accreditation Standards – February 2013
Appendix 5
(CONTINUED)
Summary of Human Resource Management
Regulatory Requirements
(Indicator 2.7.1)
The following table provides a summary of the Commonwealth, State and Territory employee relations legislation that may be
applicable to Medicare Locals. The information was correct at the time of printing the MLA Standards. Medicare Locals should
seek advice about the currency and applicability of the regulatory frameworks set out below.
Jurisdiction
Instrument
Tasmania
Personal Information Protection Act 2004
Freedom of Information Act 1991
Archives Act 1983
Annulled Convictions Act 2003 (spent convictions)
Listening Devices Act 1991
Telecommunications (Interception) Tasmania Act 1999
Western Australia
Freedom of Information Act 1992
Health Services (Conciliation and Review) Act 1995
State Records Act 2000
Spent Convictions Act 1988
Surveillance Devices Act 1998
Telecommunications (Interception) Western Australia Act 1996
Australian Capital Territory
Privacy Act (1988)
Australian Capital Territory Government Service (Consequential Provisions) Act 1994
Health Records (Privacy and Access) Act 1997
Human Rights Act 2004
Freedom of Information Act 1989
Territory Records Act 2002 (public records)
Human Rights Act 2004 (right to privacy)
Spent Convictions Act 2000
Listening Devices Act 1992
South Australia
Freedom of Information Act 1991
State Records Act 1997
Listening and Surveillance Devices Act 1972
Telecommunications (Interception) Act 1988
Northern Territory
Information Act 2002 (privacy, FOI and public records)
Criminal Records (Spent Convictions) Act 1992
Surveillance Devices Act 2007
Telecommunications (Interception) Northern Territory Act 2001
Appendices
111
Appendix 6
National Privacy Principles Compliance
Self-assessment
(Indicator 3.3.1)
The following self-assessment checklist has been developed from Guidelines for the National Privacy Principles published by
the Office of the Australian Information Commissioner to assist organisations to undertake self-assessment compliance with
the National Privacy Principles (NPP) and will assist Medicare Locals to undertake self-assessment compliance with the MLA
Standard 4 in relation to information privacy.
National Privacy Principles Requirement
Self-assessment
Where it is lawful and practicable to do so, we give people the option of interacting anonymously.
This may involve allocating a pseudonym to individuals.
Yes
No
We only collect Personal Information that is necessary for the functions or activities of the business.
Yes
No
We collect Personal Information in fair and lawful ways.
Yes
No
We collect Personal Information directly from individuals where it is reasonable and practicable to do
so and take reasonable steps to ensure the individual is aware of information if we have collected it
from someone else.
Yes
No
We seek consent to collect Sensitive Information unless specified exemptions apply.
Yes
No
At the time that Personal Information is collected or as soon as practicable afterwards, we take
reasonable steps to make an individual aware of why Personal Information is being collected and to
whom it might be disclosed.
Yes
No
We only use or disclose Personal Information for the primary purpose of collection unless one of the
exceptions in NPP 2.1 applies.
Yes
No
We take reasonable steps to ensure the Personal Information that is collected, used or disclosed is
accurate and up to date. This may require correction from time to time.
Yes
No
We take reasonable steps to protect the Personal Information that is held from misuse, loss and
unauthorised access or disclosure.
Yes
No
We take reasonable steps to destroy or permanently de-identify Personal Information if it is no
longer needed.
Yes
No
We have a Privacy Policy statement that sets out the policies on the way that Personal Information
is managed and is made available to any individual who requests it.
Yes
No
If requested, we take reasonable steps to let the person know, generally, of the Personal
Information collected about them and how it is used and disclosed.
Yes
No
We provide access to the Personal Information held on a particular individual to that individual
unless particular circumstances apply that allows limitations- these include emergency situations,
specified business imperatives and law enforcement or other public interests.
Yes
No
We do not use or disclose a Commonwealth Government identifier if particular circumstances apply.
Yes
No
We only transfer Personal Information overseas if the requirements of NPP 9 are met.
Yes
No
112
Medicare Locals Accreditation Standards – February 2013
Appendix 7
Computer and Information Security
Self-assessment
(Indicator 3.4.1)
The following self-assessment has been adapted from a self-assessment template provided as part of the RACGP Computer
and information security standards, 2011 (CISS) to assist Medicare Locals to self-assess the adequacy of computer and
information security systems and processes. The self-assessment should be read and used in conjunction with the CISS.
Person conducting assessment:
–
Assessment date:
–
CATEGORY
TASKS
1. Risk Assessment
Computer and information security risk assessment conducted
AUDIT RESULT
Met
Not Met
Computer security coordinator appointed
Met
Not Met
Computer security coordinator role documented
Met
Not Met
Computer security coordinator trained/qualified
Met
Not Met
Computer security policies and procedures documented
Met
Not Met
Computer security policies and procedures implemented
Met
Not Met
Individual confidentiality agreements signed by all staff
Met
Not Met
Computer and information access controls established
Met
Not Met
Each member of staff has an individual password
Met
Not Met
Passwords are changed on a regular basis
Met
Not Met
Confidentiality agreements signed by third party providers
Met
Not Met
Business continuity plan documented and implemented
Met
Not Met
Disaster recovery plan documented and implemented
Met
Not Met
Disaster recovery plan tested
Met
Not Met
Staff trained on disaster recovery plans
Met
Not Met
Disaster recovery plan reviewed and updated annually
Met
Not Met
Internet and e-mail policies and procedures established
Met
Not Met
Staff trained in internet and email policy
Met
Not Met
Data backed up daily (weekly/monthly/yearly copies retained)
Met
Not Met
Backed up data is encrypted
Met
Not Met
Backup of data is stored securely offsite
Met
Not Met
Backed up data tested by performing restoration
Met
Not Met
Disaster recovery plan included in Business Continuity Plan
Met
Not Met
and action plan developed
2. Staff roles and
responsibilities
3. Practice security
policies and
procedures
4. Access control
and management
5. Business continuity
and disaster recovery
plans
6. Staff internet and
email usage
7.Backup
Appendices
113
Appendix 7
(CONTINUED)
Computer and Information Security
Self-assessment
(Indicator 3.4.1)
CATEGORY
TASKS
8. Malware, viruses and
email threats
Antivirus/anti-malware software installed on all computers
Met
Not Met
Antivirus/anti-malware definitions updated automatically
Met
Not Met
Staff trained in antivirus/anti-malware procedures
Met
Not Met
Automatic weekly antivirus/anti-malware scans conducted
Met
Not Met
Hardware/ software network perimeter controls installed
Met
Not Met
Hardware/ software network perimeter controls tested
Met
Not Met
Intrusion activity logs monitored and breaches reported
Met
Not Met
Mobile device policy and procedures implemented
Met
Not Met
Portable devices (memory devices, backup media) are secure
Met
Not Met
Wireless networks configured securely
Met
Not Met
Remote access protection in place (e.g. VPN)
Met
Not Met
Physical security of the server and network maintained
Met
Not Met
Uninterruptible power supply and surge protectors installed
Met
Not Met
Confidentiality protocols (e.g. clear screen/ desk) implemented
Met
Not Met
Preventative system maintenance undertaken regularly
Met
Not Met
Timely implementation of software updates and patches
Met
Not Met
Secure messaging system (involving encryption) used for the
Met
Not Met
Met
Not Met
9. Network perimeter
controls
10.Portable devices and
wireless networks
11.Physical, system and
software protection
12.Secure electronic
communication
electronic transfer of confidential information
Safe and secure use of email, internet and the service’s
website policy developed and reviewed periodically
114
AUDIT RESULT
Medicare Locals Accreditation Standards – February 2013
Appendix 8
An Overview of Primary Health Care
Quality Frameworks
(Indicator 9.1.1)
Primary Health care Service
Quality Framework
Accreditation Scheme
General Practices, Medical
Deputising Services and After
Hours Medical Services.
– RACGP Standards for general practices,
including guidelines for medical deputising
service and after hours medical services.
General Practice
Accreditation Scheme.
– RACGP Standards for infection control in
office based practices.
Health care services that
perform invasive procedures
such as dental practices, multidisciplinary health services and
specialist medical practices.
– National Safety and Quality Health
Service Standards.
Diagnostic imaging services
– Diagnostic Imaging Standards.
Diagnostic Imaging
Accreditation Scheme (DIAS).
Community and social services,
including community based
mental health services and
alcohol and drug services.
– QIC Standards.
QIC Standards and
Accreditation Program.
Physiotherapy practices
– APA Standards for Physiotherapy Practices.
QIP Physiotherapy
Accreditation Program.
Pharmacies
– QCPP Standards.
Pharmacy Guild of Australia
Quality Care Pharmacy
Program.
General
– ISO QMS Certification.
Various.
– National Standard for Mental Health Services.
– Australian Service Excellence Standards.
The Australian Health
Service Safety and Quality.
Accreditation Scheme
(AHSSQA Scheme).
Appendices
115
Appendix 9
Summary of Work Health and Safety
Regulation in Australia
(Indicator 11.1.1)
The following table provides a summary of State and Territory work health and safety legislation that may be applicable to
Medicare Locals. The information was correct at the time of printing the MLA Standards. Medicare Locals should seek advice
about the currency and applicability of the regulatory frameworks set out below.
Jurisdiction
Regulatory Framework
Queensland
The Work Health and Safety Act 2011 and Work Health and Safety Regulation 2011.
Administered by Workplace Health and Safety Queensland
(www.deir.qld.gov.au).
New South Wales
The Work Health and Safety Act 2011 and Work Health and Safety Regulation 2011.
Administered by the Work-Cover Authority of New South Wales
(www.workcover.nsw.gov.au).
Victoria
The Occupational Health and Safety Act 2004 and Occupational Health and Safety
Regulations 2007. Administered by WorkSafe Victoria
(www.worksafe.vic.gov.au).
Tasmania
The Work Health and Safety Act 2012 and the Work Health and Safety Regulations
2012. Administered by Workplace Standards Tasmania
(www.wst.tas.gov.au).
South Australia
The Occupational Health, Safety and Welfare Act 1986 and Occupational Health,
Safety and Welfare Regulations 2010. Administered by SafeWork South Australia
(www.safework.sa.gov.au).
Western Australia
The Occupational Safety and Health Act 1984 and Occupational Safety and Health
Regulations 1996. Administered by WorkSafe Western Australia
(www.safetyline.wa.gov.au).
Australian Capital Territory
The Work Health and Safety Act 2011 and Work Health and Safety Regulation 2011.
Administered by WorkSafe Australian Capital Territory
(www.worksafe.act.gov.au).
Northern Territory
The Work Health and Safety (National Uniform Legislation) Act 2011 and the Work
Health and Safety (National Uniform Legislation) Regulation 2011. Administered by
WorkSafe Northern Territory
(www.worksafe.nt.gov.au).
Commonwealth
The Work Health and Safety Act 2011 and Work Health and Safety Regulations 2011.
Administered by Comcare
(www.comcare.gov.au).
116
Medicare Locals Accreditation Standards – February 2013
Appendix 10
Summary of Fire Safety Regulatory Requirements
(Indicator 11.2.1)
The following table provides a summary of state and territory fire safety legislation that may be applicable to Medicare Locals.
The information was correct at the time of printing the MLA Standards. Medicare Locals should seek advice about the currency
and applicability of the regulatory frameworks set out below.
Jurisdiction
Regulatory Framework
Queensland
Fire safety in Queensland is regulated under the Fire and Rescue Service Act 1990
and the Building Fire Safety Regulation 2008. Administered by the Queensland Fire
and Rescue Service (QFRS)
(www.fire.qld.gov.au).
The Queensland Fire and Rescue Service have produced a guideline titled Fire Safety
Management Tool for Owner/Occupiers which is designed to assist owners and
occupiers in managing their compliance with the Queensland regulations.
New South Wales
Fire safety in New South Wales is regulated under the Environmental Planning
& Assessment Regulations 2000. Administered by Fire Safety NSW
(www.fire.nsw.gov.au).
Victoria
Fire safety in Victoria is regulated under the Building Regulations 2006. Administered
by the Metropolitan Fire and Emergency Services Board (MFB) (www.mfb.vic.gov.au)
and the Country Fire Authority (CFA) (www.cfa.vic.gov.au).
The CFA has produced a Workplace Emergency Management Manual online tool that
assists small to medium workplaces to create plans for emergencies.
Tasmania
Fire safety in Tasmania is regulated under the General Fire Regulations 2000.
Administered by the Tasmania Fire Service
(www.fire.tas.gov.au).
The Tasmania Fire Service has produced a publication titled Fire Safety in Buildings
– Obligations of Owners and Occupiers to assist owners and occupiers in managing
their compliance with the Tasmanian legislation.
South Australia
Fire safety in South Australia is regulated under the Fire and Emergency Services
Act 2005. Administered by the South Australian Metropolitan Fire Service and the
Community Fire Service.
(www.mfs.sa.gov.au)
Western Australia
Fire safety in Western Australia is regulated under the Building Fire Safety Regulations
2008. Administered by the Fire and Emergency Services Authority of Western Australia
(FESA) (www.fesa.wa.gov.au).
Australian Capital Territory
Fire safety in the Australian Capital Territory is regulated under the Emergencies
Act 2004. Administered by the ACT Emergency Services Agency
(www.esa.act.gov.au).
Northern Territory
Fire safety in the Northern Territory is regulated under the Fire and Emergency
Act 2012. Administered by the Northern Territory Fire and Rescue Service
(www.pfes.nt.gov.au/Fire-and-Rescue.aspx).
Appendices
117
118
Medicare Locals Accreditation Standards – February 2013
All information in this publication is correct as at February 2013
D0909 February 2013
www.health.gov.au
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