<<Insert Practice Name>> Policy & Procedure Manual <<Date of Creation>> <<Date of Review>> 1 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Disclaimer This manual has been developed to assist practices with the policies and procedures required for accreditation and the day-to-day management of a general practice. This manual has been developed by IWSML based on the V11 July 2011 template published by Quality in Practice (QIP)/AGPAL and written by Dandenong Casey General Practice Association (DCGPA). CSGPN would like to acknowledge the work completed by DCGPA and the members of their accreditation advisory committee in putting this manual together. This manual has been designed to comply with the RACGP 4th Edition Standards for General Practice. It is intended to be a generic manual only. It must be adapted and changed to reflect the current situation within your practice. Please amend or delete policies and procedures as required however be mindful that deletion of some policies and procedures may jeopardize your compliance with the RACGP Standards and therefore your accreditation status. Always refer to the RACGP 4th Edition Standards and relevant State and Federal legislation when amending the manual template. IWSML does not accept any liability for loss, injury or damage incurred or reliance on the information contained within. The practice has a responsibility to ensure that it meets it’s State and Federal legal obligations as a general practice. Instructions This manual has been developed with best practice guidelines to develop a generic template for wide spread use. Due to the vast differences between general practices in Australia, you are required to amend the policies and procedures according to your own practice situation including staff, equipment and methodology. Sections highlighted in BLUE represent areas where practice-specific information must be entered. It is recommended that all sections, even those not highlighted, be reviewed to ensure they are accurate and correct. It is suggested that once all sections have been amended, that you remove the highlighted sections and symbols for customization. 2 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Table of Contents 1 Introduction ................................................................................................. 6 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Mission Statement ........................................................................................................ 6 Practice background .................................................................................................... 6 Practice profile .............................................................................................................. 6 Practice team................................................................................................................. 7 Practice services .......................................................................................................... 8 Practice hours ............................................................................................................... 8 Practice consultation fees ........................................................................................... 9 2 Human Resources ..................................................................................... 10 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 Awards & Entitlements............................................................................................... 10 Staff Recruitment ........................................................................................................ 11 Position Descriptions ................................................................................................. 12 Staff Employment Records ........................................................................................ 13 Staff Induction ............................................................................................................. 15 Privacy ......................................................................................................................... 17 Performance Review .................................................................................................. 18 Staff Code of Conduct ................................................................................................ 20 Equal Opportunity, Bullying & Harassment ............................................................ 21 Anti-discrimination policy ......................................................................................... 22 3 Occupational Health & Safety .................................................................. 25 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 Manual Handling ......................................................................................................... 29 Incidents and Injury and Adverse Patient Events ................................................... 31 Sharps Injury Management and Other Body Fluid Exposure ................................ 33 Staff Immunisation ..................................................................................................... 35 Smoke-Free Environment .......................................................................................... 37 Staff Health and Wellbeing (including GPs) ............................................................ 37 Practice Facilities ....................................................................................................... 38 Security ........................................................................................................................ 39 Non Medical Emergencies ......................................................................................... 40 4 Infection Control ............................................................................................... 42 4.1 4.2 4.3 4.4 4.5 4.6 Principles of infection control ................................................................................... 42 Blood and body fluid spills ........................................................................................ 44 Hand washing and hand hygiene.............................................................................. 47 Single Use Equipment ................................................................................................ 50 Offsite Sterilisation ..................................................................................................... 51 Onsite Sterilisation ..................................................................................................... 55 4.7.1 Instrument and equipment processing area ..................................................................................... 57 4.7.2 Cleaning reusable Instruments and equipment ............................................................................... 60 4.7.3 Loading the steriliser ............................................................................................................................ 64 4.7.4 Unloading the steriliser ........................................................................................................................ 66 4.7.5 Documentation of the Cycle ................................................................................................................ 68 4.7.6 Monitoring the Sterilisation Process .................................................................................................... 69 4.7.7 Validation of the sterilisation processes ........................................................................................ 70 4.7.8 Maintenance of the steriliser .......................................................................................................... 74 4.7.9 Servicing the steriliser .................................................................................................................... 74 4.9 4.10 Storage of sterile items .............................................................................................. 75 Management of waste ................................................................................................ 76 3 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 4.11 Sharps Management.............................................................................................. 78 4.12 Transmissible and Notifiable Diseases ................................................................... 80 4.13 Standard Precautions................................................................................................. 82 4.14 Additional Precautions.................................................................................................. 83 4.15 Personal Protective Equipment (PPE)...................................................................... 84 4.16 Laundry ........................................................................................................................ 87 4.17 Safe handling of pathology specimens.................................................................. 89 4.18 Environmental Cleaning Service .............................................................................. 89 5 Practice Management ............................................................................... 94 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10 5.11 Access & Parking ....................................................................................................... 94 Appointments .............................................................................................................. 95 Home Visits ............................................................................................................... 100 Telephone .................................................................................................................. 102 Electronic Communication ...................................................................................... 104 Medical Emergencies & Urgent Queries ................................................................ 105 After Hours Service .................................................................................................. 107 Practice Meetings ..................................................................................................... 108 Patient Rights ............................................................................................................ 111 Complaints ................................................................................................................ 112 Non English Speaking Patients............................................................................... 115 5.11.1 Culturally Appropriate Care ............................................................................................................ 116 5.12 5.13 5.14 5.15 Directory of Local Health and Community Services............................................. 117 Provision of Brochures, Leaflets and Pamphlets for Patients ............................ 118 Practice Information Sheet ...................................................................................... 120 Office Supplies .......................................................................................................... 122 6 Privacy and Personal Health Information ............................................. 123 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 Privacy and Security of Personal Health Information .......................................... 123 Computer Information Security............................................................................... 125 Practice Privacy Policy ............................................................................................ 127 3rd Party Requests for Access to Medical Records/Health Information ............. 129 Request for Access to Personal Health Information ............................................ 131 Medical Records Administration Systems............................................................. 133 Retention of Records and Archiving ...................................................................... 135 Transfer of Medical Records ................................................................................... 136 7 Clinical Management .............................................................................. 138 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 7.10 7.11 7.12 Clinical Autonomy .................................................................................................... 138 Clinical Content of Medical Records ...................................................................... 139 Informed Consent ..................................................................................................... 141 Referral Protocols.................................................................................................... 142 Clinical Handover ..................................................................................................... 144 Follow up of Tests, Results and Referrals ............................................................. 146 Reminder Systems for Preventative Care .............................................................. 148 3rd Party Observing or Clinically involved in the Consultation .......................... 149 Practice Participation in Research Projects .......................................................... 150 Management of a Patient Refusing Treatment or Advice .................................... 151 Refusal to Treat a Patient ........................................................................................ 152 Practice Equipment .................................................................................................. 153 4 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 7.13 Doctor’s Bag.............................................................................................................. 155 7.14 Vaccine Storage ....................................................................................................... 156 7.15 Medication Prescribing and Administration ............................................................... 157 7.16 Controlled Substances............................................................................................. 159 7.17 Clinical References and Resources............................................................................. 161 7.18 Drug Storage and Disposal .................................................................................... 162 8 Continuous Improvement .............................................................................. 164 8.1 Risk Assessment & Management .................................................................................. 164 8.2 Review of Policies & Procedures ............................................................................ 166 8.3 Continuing Staff Education ............................................................................................ 167 8.4 Accreditation & Continuous Improvement ............................................................ 170 8.5 Patient Feedback ...................................................................................................... 171 8.6 Continuity of Care..................................................................................................... 173 8.7 Clinical Governance ................................................................................................. 174 5 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 1 Introduction 1.1 Mission Statement Option 1: Use the sample practice mission statement below Our mission is to provide the highest standard of patient care whilst incorporating a holistic approach toward diagnosis and management of illness. We are committed to promoting health, wellbeing and disease prevention to all patients. We do not discriminate in the provision of excellent care and aim to treat all patients with dignity and respect. Option 2: Add your own practice mission statement here 1.2 Practice background Write a short description of your practice here. Areas you may wish to include are the history behind your practice, location, particular interest areas, communities the practice services and other important information you would like to add. 1.3 Practice profile Name of practice * name of practice Street address * street address Postal address * postal address In hours phone number *in hours phone number After hours phone number * after hours phone number Fax number * fax number Email address * email address Web address * web address 6 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 1.4 Practice team Medical * Medical position * name of medical person * Medical position * name of medical person * Medical position * name of medical person * Medical position * name of medical person * Medical position * name of medical person Allied health * Allied health professional * name of allied health professional * Allied health professional * name of allied health professional Nursing * Nursing position * name of nurse * Nursing position * name of nurse Administrative * Administrative position * name of administrative person * Administrative position * name of administrative person * Administrative position * name of administrative person * Administrative position * name of administrative person 7 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 1.5 Practice services In addition to general medical consultations, our practice offers the following services: * insert practice services * insert practice services * insert practice services * insert practice services * insert practice services * insert practice services * insert practice services * insert practice services * insert practice services * insert practice services * insert practice services * insert practice services (Customise as appropriate) There is a range of posters, leaflets, and brochures about health issues relevant to the community available for all of our patients in: the waiting room the consultation rooms. 1.6 Practice hours Monday to Friday * Monday to Friday hours Saturday * Saturday hours Sunday Home visits * Sunday hours * Regular hours that home visits are conducted Home visit appointments can be made outside these times by prior arrangement with the receptionist at the discretion of the doctor. 8 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 1.7 Practice consultation fees (Customise as appropriate) <<A schedule of our fees is listed below>> OR <<All services performed at this practice are bulk-billed>> An up-to-date copy of our schedule of fees is located: at reception in the practice information sheet. 9 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 2 Human Resources Research from both general practice and other industries supports the importance of attention to human resources. Good human resource management supports good clinical care (RACGP 4th Edition Standards 2010). 2.1 Awards & Entitlements (Customise as appropriate) Policy This practice complies with all its legal obligations under the Fair Work Act 2009 with regard to employees. These include: provision of rates of pay, leave and other entitlements as set out in the relevant Award or workplace agreement; a safe and healthy workplace; equal opportunity and freedom from discrimination and harassment protection of employee and patient privacy; and maintenance of appropriate staff records compliance with the National Employment Standards Additionally, this practice follows established procedures and policies for employment and management of staff, including: clear communication of expectations and standards, using position descriptions and job specifications as well as staff codes for conduct and presentation. recruitment procedures which are fair, thorough and facilitate selection of the best candidate. a formal induction procedure for all staff, to familiarise them with important practice procedures relating to patient care, occupational health and safety, emergencies, confidentiality and conduct. regular feedback and opportunities for development through performance review. 10 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure In our practice, all staff members have a signed employment contract which complies with their relevant Modern award and the National Employment Standards (NES). Records of staff contracts can be found <<insert location of staff contract records>>. The Modern awards used by this practice to employ staff are as follow: <<customise as appropriate>> Health Professionals and Support Services Award 2010 Nurses Award 2010 Medical Practitioners Award 2010 Our practice has obtained advice to ensure that all employee contracts comply with the relevant legislation. RACGP 4th edition Standards 4.1.1. 2.2 Staff Recruitment (Customise as appropriate) Policy Effective selection and management of staff is critical to the success of this practice. Our ability to care for patients and operate a successful medical practice depends upon attracting, developing and retaining the right people. Before the recruitment process begins, our practice analyses the position requirements by asking the following questions: What are the most important tasks this position will be carrying out? Are there any additional tasks that they could be doing? What knowledge, skills, qualifications are required to perform the role? Are there any particular attributes which are necessary for the role? Who will the position report to and who is responsible for this supervision? Will the position be full-time or part-time and how will it be renumerated? 11 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Can these tasks not already be performed by current staff? Once these questions have been answered, the information is used to develop the following documents: Position description Job vacancy advertisement Performance appraisal outline Selection criteria Procedure The recruitment process of our practice is thorough and conducted in a way that is fair and complies with relevant legislation. Once a suitable candidate has been selected, the applicant is notified in writing and supplied with copies of: The employment contracts Position description Confidentiality agreement Personal details form Tax file declaration form Super Choice form Banking details form Current immunisation status declaration form Information about recommended vaccinations It is the responsibility of <<insert person responsible>> to coordinate and carry out all the practice recruitment functions. When required, this person will consult other relevant members of the practice. 2.3 Position Descriptions (Customise as appropriate) Policy General practitioners and other staff need documented position descriptions that outline and define their current roles, responsibilities and conditions of employment. 12 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Position descriptions are signed by employees to indicate that roles and responsibilities are acknowledged and understood. Included within our position descriptions are any designated areas of responsibility. All members of the practice team are able to identify the person(s) who have designated responsibility in the following areas: Cleaning Complaints management Quality Improvement Infection Control Information technology Risk management systems Sterilisation Vaccine management Procedure The position description outlines: Key selection criteria, skills, qualifications, etc. required for the role Duties, responsibilities and hazards associated with the position Remuneration and entitlements Timetable for annual performance reviews Position descriptions are reviewed regularly during performance appraisals or on a needs basis whenever a member of the team leaves the practice. RACGP 4th edition Standards 4.1.1, 5.3.2, 5.3.3, 4.2.2 2.4 Staff Employment Records (Customise as appropriate) Policy A range of information must be made and kept for each employee as prescribed by the Fair Work Act 2009 and Fair Work Regulations 2009. Our practice understands that penalties apply to employers who fail to comply with the record-keeping requirements of the Fair Work Act 2009. 13 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Therefore we maintain staff employment records which comply with all legal and statutory obligations. The following information is kept as part of the mandatory employment records of all staff working in this practice: Details of the employer including ABN, employee commencement date and basis of employment (ie. Full-time, part-time.) Pay records including the rate of pay, gross and net amounts, and details of financial incentives Hours of work including any overtime Leave records Superannuation contribution records Individual flexibility arrangements (if applicable) Guarantee of annual earnings record (if applicable) Termination records Transfer of business records All clinical staff including GPs must be able to provide evidence of appropriate national registration and evidence of satisfactory participations in prescribed professional development activities in accordance with their relevant vocation. All staff must have undertaken CPR training in accordance with the Australian Resuscitation Council very 3 years. Procedure Our employee records are: in a form that is readily accessible to a Fair Work Inspector legible and in English (preferably in plain, simple English) kept for seven years not altered unless for the purposes of correcting an error not false or misleading to the employer’s knowledge. private and confidential. Generally, no one can access them other than the employee, their employer, and relevant payroll staff. made available at the request of an employee or former employee(copy only). 14 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Evidence of staff qualifications are kept as part of the staff employment records. Copies of national registration and current CPR training can be found <<insert location that records are kept>>. RACGP 4th edition Standards 3.2.1, 3.2.2 & 3.2.3 & 4.1.1. 2.5 Staff Induction (Customise as appropriate) Policy Practices need a system for assisting new members of the practice team to learn their role. This includes new GPs, registrars and locums, and other new staff. Our practice has an induction program for all new General Practitioners and practice staff which includes ongoing monitoring of progress in their new role. To ensure staff and patient safety, new members of the general practice team must be able to demonstrate knowledge of the key procedures in the Policy and Procedure Manual and key operating systems relevant to their role within the practice by the end of the induction period. Where appropriate, we have provided other contractors using rooms in the facility with an overview of relevant practice systems. Staff are also expected to familiarise themselves with the Policy and Procedure Manual and use it as a resource in the course of their employment. All new staff must complete a full induction program including Workplace Health and Safety (WH&S) as detailed on the Staff Induction Checklist as part of their orientation. It is essential that new staff understand the day-to-day operations of the practice including the occupational health and safety issues relevant to their role, the practice code of conduct, infection control policies and the processes by which the privacy of patient health information. It is useful for new staff to have an understanding of the local health and cultural environment in which the practice operates. Furthermore, staff and GPs in particular need to be aware of key public health regulations (such as reporting requirements for communicable diseases or mandatory reporting of child abuse) that will affect how they work. General practitioners need to be made aware of local health and community services including pathology, hospital and other services they are likely to refer to in the course of normal consulting. 15 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 The Staff Induction Checklist provides the general knowledge essential for any position within a medical practice. Job specific orientation and induction will also need to be undertaken and documented. As each stage of the induction program is completed with the new staff member and their induction supervisor sign the Staff Induction Checklist and the completed document is filed in the employee’s Staff Record file. This written record of induction is important to protect the practice against legal liability and injury claims in the future. New staff members are not permitted to work independently until competency in specific areas of induction such as infection control, confidentiality and WHS have been demonstrated and signed-off. Procedure The following overview and checklist can be customised to reflect the practice’s needs. Process Before the first day. First day First week Description Appoint a member of staff to be responsible for the new employee induction. Prepare Staff Induction Checklist and have copy of procedures manual & job description available to refer to. Make the new staff member feel welcome. Go through all items on the Staff Induction Checklist Prepare Staff Induction Checklist - Induction &Training Plan Sign the Staff Induction Checklist Part 1 - First Day to show all items have been completed File Staff Induction Checklist Part 1 - First Day and a copy of Part 2 - Induction &Training Plan in the new employee’s staff records file. Give a copy of all induction forms including Staff induction Checklist -Key policies and procedures to the employee. Make time each day to go through key policies, procedures and other training needs identified on the Induction &Training Plan Arrange induction and training with other staff members in areas such as reception systems, record-keeping, sterilisation/infection control & spills, doctor’s requirements, customer service and complaints, patient privacy, triage. Provide opportunities for the new staff member to ask questions, 16 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 First month After 3 months and make sure they receive plenty of feedback and encouragement. Tick off each item on the Induction &Training Plan as it is completed. Continue to provide the new employee with opportunities to ask questions as well as encouragement and support with regular informal meetings. Link the new staff member into local networks and professional organisations, such as those at the division. Continue Induction &Training Plan until all items are completed. Sign the Induction &Training Plan to show it has been completed. Give a copy to the employee and file the original in the employee’s Staff Records File. Review the induction and training plan and their performance. Provide recognition for the areas which they are performing well in and develop a new plan to resolve any remaining training needs or provide skills enhancement – Performance Review. All completed staff induction records are kept <<insert location of induction records>>. RACGP 4th edition Standards 4.1.1 2.6 Privacy (Customise as appropriate) Policy All patient information is private and confidentiality of patient information must be maintained at all times. The rights of every patient are to be respected. All information collected by this practice in providing a health service is deemed to be private and confidential. This practice complies with Federal and State privacy regulations including the Privacy Act 1998 and the Privacy Amendment (Private Sector) Act 2000, as well as the standards set out in the RACGP Handbook for the Management of Health Information in Private Medical Practice 1st Edition (2002). Under no circumstances are employees of this practice to discuss or in any way reveal patient conditions or documentation to unauthorised staff, colleagues, other patients, family or friends, whether at the practice or outside it, such as in the home or at social 17 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 occasions. This includes patient’s accounts, referral letters or other clinical documentation. General Practitioners and staff are aware of confidentiality requirements for all patient encounters and recognise that significant breaches of confidentiality may provide grounds for disciplinary action or dismissal. Every employee of this practice is aware of the privacy policy and has signed confidentiality agreement as part of their terms and conditions of employment. This confidentiality agreement continues to be binding on employees even after their employment has terminated. Procedure All employees of this practice are issued with the privacy policy and sign a confidentiality agreement as part of their terms and conditions of employment. The policies and procedures of the practice are further explained during the induction of new staff members, and the induction form is signed by the new employee as confirmation that they understand and accept their obligations in relation to patient privacy and the confidentiality of medical information. Copies of signed staff confidentiality agreements are kept <<insert location of confidentiality agreements>>. RACGP 4th edition Standards 4.2.1 & 4.2.2 2.7 Performance Review (Customise as appropriate) Policy Annual staff reviews are conducted to ensure continuing high levels of work performance and to assist in job enrichment. The review is part of a continuous process of feedback to individual staff on their work performance. It is extended to include performance improvement and career development. Performance reviews benefit the practice and its employees by: 18 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 ensuring all staff know what is expected of them and how their work is important to the practice. providing staff with formal recognition and appreciation for their work. providing an opportunity to review goals, celebrate achievements and set objectives for the future. helping staff to develop their skills and performance to achieve practice goals and further their own career. dealing with problems and resolving grievances – see also Grievance Procedure in 2.10 Equal Opportunity, Bullying and Harassment. A review involves identifying, evaluating and developing the work performance of staff so that Practice goals are more effectively achieved. At the same time the process benefits staff in terms of recognition, receiving feedback, catering for work needs and offering career guidance and support. The relevant position description forms the basis for evaluation and lines of accountability. The performance review document, including comments concerning current progress and future goals, is signed by both parties, with a copy retained by the staff member. The original is filed in the Staff Record File. Procedure A review is conducted 3 months after commencement of the position and at least annually thereafter. Depending on the staff member, reviews may occur more frequently as required. The employee to be reviewed is issued with a self-appraisal template and a copy of their current position description at least 1 week before their review meeting. Review meetings are conducted where both parties are able to discuss their views on the position and set goals for the next 12 months. A training plan and goal sheet is completed with a copy provided to the employee and a copy incorporated in the staff members records. Any amendments that need to be made to the position description are updated and a new copy filed in the staff record as well as being provided to the employee. RACGP 4th edition Standards 4.1.1. 19 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 2.8 Staff Code of Conduct (Customise as appropriate) Whilst this procedure is advised, there is no longer the requirement of three warnings. However, the employee must be given ‘a fair go’ and have an opportunity to improve within a reasonable time frame. Always document these issues. Policy We encourage an environment that fosters robust general practice teams. Our staff conduct themselves in a manner that promotes the attributes we believe are desirable characteristics of general practice team: a just, supportive, transparent, cohesive and collaborative culture, which is associated with improved patient outcomes and enhanced patient safety. defined goals, including an identifiable overall practice ‘mission’ and specific, measurable operational objectives that are shared by all team members. a ‘systems’ approach that includes the development of both clinical systems and administrative systems. division of labour, including the delegation of tasks and assignment of tasks among team members. effective training, both for the functions that people routinely perform and cross training to substitute for other roles in cases of absences or changed/increased work demands. excellent communication, including supportive interpersonal communication through well designed communication structures and processes. All staff are issued with an employee code of conduct when commencing employment. A copy of the code of conduct can be found <<insert location where code of conduct can be viewed>>. All breaches of the code will be investigated by the employee’s supervisor in a professional manner. Counselling and disciplinary action of employees will take place and be documented in <<insert method of documentation>> for any breaches of this code of conduct. Employees are aware that gross breaches of the code may result in dismissal from the business. 20 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 <<Insert person responsible>> is responsible for ensuring that all staff comply with the practice code of conduct and to deal with any breaches in a professional and fair manner. RACGP 4th edition Standards 4.1.1 2.9 Equal Opportunity, Bullying & Harassment (Customise as appropriate) Policy Our practice is committed to the principles of merit, fairness and respect for all people. This practice seeks to provide a working environment in which all employees are able to perform their duties without being subject to discrimination or inappropriate behaviour. Our practice complies with our legal obligations and has a range of policies and procedures to encourage Equal Opportunity and prevent discrimination, bullying and harassment. These include: a policy preventing bullying and harassment of any kind, including sexual harassment, in this workplace. a procedure to deal with the personal threat of violence a grievance procedure for complaints arising from breaches of these policies. For serious breaches the practice’s disciplinary procedures may be used, including termination of employment. All staff working at this practice have the responsibility to: treat all people in this workplace fairly and with respect. refrain from behaviour which could constitute harassment, bullying or discrimination report any incidents of harassment, bullying or discrimination to the designated complaints person maintain confidentiality if they are involved in complaints. Bullying and Harassment Policy There are a number of laws in Australia dealing with issues related to bullying and harassment including EEO legislation, OHS requirements, criminal law, defamation and common law provisions such as negligence. These laws all require the employer to take all reasonable steps to stop bullying and harassment in the workplace, including: 21 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 1) Policies and procedures to prevent bullying and harassment 2) Dealing with grievances in a fair, appropriate and timely manner. Bullying and harassment is defined as any unwelcome behaviour or communication which has no legitimate function in the workplace and intimidates, humiliates or offends another person. Any form of bullying or harassment is totally unacceptable in this practice. <<Insert Practice Name>> regards these actions and any similar behaviour as serious misconduct and any person who is found to be behaving in this manner may have their employment terminated. Any employee who is subjected to bullying, harassment or intimidation by a fellow employee, manager or supervisor should notify the designated complaints person. All complaints of harassment will be promptly and confidentially investigated using the practice’s grievance procedure. Any employee or manager who violates this policy will be subjected to disciplinary action, as described above. 2.10 Anti-discrimination policy This practice does not discriminate on the basis of: race (including colour, nationality and ethnic origin). family status including marital status and responsibilities as a carer. sexual orientation and lawful sexual activity. age. gender and gender identity. physical Features. political beliefs or activity. religious beliefs or activity. breastfeeding. impairment including physical, intellectual or psychiatric. pregnancy or potential pregnancy. political opinion or activity. criminal record. union membership or industrial activity. personal association with a person with any of the above characteristics. 22 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Grievance Procedure If you or any employee of this practice is exposed to any form of behaviour which constitutes discrimination, bullying or harassment, the following procedure must be adopted.Do not ignore harassment – ignoring the behaviour could be interpreted as consent. This procedure may also be used for handling of other workplace grievances such as complaints about working conditions, wages or work colleagues. Grievances undermine morale and affect teamwork and need to be dealt with promptly. 1) Inform the offender that the behaviour is offensive and unacceptable. 2) Seek assistance in having the behaviour stopped by reporting the incident to your designated complaints person 3) The investigator/designated complaints person will conduct a detailed investigation of the incident(s) to assist in the resolution of the grievance. Witness statements and evidence may be collected. For the investigation to be properly conducted confidentiality must be maintained, it must be impartial, the person reporting the incident must not be victimised or experience adverse repercussions and the complaint must be dealt with as quickly as possible. 4) Actions taken to resolve the grievance will depend on the circumstances and the results of the investigation. Generally the main aim will be to ensure the incident does not occur again. Possible solutions may include: an apology. an undertaking that the behaviour will cease. formal counselling of the alleged harasser, using the disciplinary procedure (2.7) disciplinary action, including termination for serious misconduct. training for groups of staff or the whole staff to raise awareness of EEO obligations. covering costs associated with the harassment, such as medical or psychology expenses. notifying the police. if the complaint cannot be substantiated when it is investigated it must still be taken seriously, including attempting to find a resolution of the mater with the employees involved. it may be appropriate to take action against a complainant who makes a serious allegation against a work colleague which is found to be false or frivolous after investigation. This could include termination of employment. 23 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 5) A record is kept of the complaint, its investigation and actions taken. 6) After action has been taken and the problem appears to have been resolved there is a need for occasional monitoring and follow-up to ensure that those involved are satisfied with the outcome, and the problem has not reoccurred or surfaced in a different form. 7) If the matter remains unresolved, the grievance provisions in the relevant awards or workplace agreements require that it be referred to an external party.This party may be specified in the award or agreement. Seek advice from your division or employer group. RACGP 4th edition Standards 4.1.1 24 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 3 Occupational Health & Safety (Customise as appropriate) Policy This practice is committed to preventing workplace injury and illness and ensuring a safe and secure working environment for doctors, staff, patients and all other visitors. We recognise that health and safety is an integral part of every activity we perform and as such we maintain current knowledge of our obligations under State/Territory and Federal WH&S legislation and we understand that non compliance with these legal requirements can result in being prosecuted and fined. It is a legal duty of every workplace to maintain standards to protect the health, safety and welfare of every person within the workplace. This includes staff, patients, visitors and anyone else who may enter the premises. As an employer we must provide a safe and healthy workplace for our workers and contractors. All our workers have a duty of care to ensure that they work in a manner that is not harmful to their own health and safety and the health and safety of others. Effective WHS regulation requires that WorkSafe provides clear, accessible advice and guidance about what constitutes compliance with the Act and Regulations. Procedure This practice has a designated elected health and safety representative (HSR). The name and telephone extension of our HSR is kept <<insert location>>. Information relating to WH&S issues is communicated to other staff via <<insert communication method>> and updated regularly by the HSR. We consult with employees on matters that may directly affect their health, safety or welfare and the HSR, is also involved in the consultation We have current workplace Injury Insurance. Our practice keeps a record of all workrelated injuries and illnesses. All near-misses are also recorded in the register. The register is located <<insert location>>. 25 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 All incidents which cause of could have caused serious injury or deaths are made known to Worksafe by contacting 13 23 60. Incidents or accidents are also investigated internally by the <<Practice Manager/ Supervisor/ Business Owner>>. Corrective action is then taken to prevent the incident occurring again and any changes are communicated to all staff. To support the safety health and wellbeing of our practice team we have policies and procedures in the following areas: tasks involving manual handling are identified and measures are taken to reduce or eliminate the risk of injury to doctors and staff as far as reasonably practical. incidents and all injuries involving all staff and patients and others that occur in the workplace are documented and managed professionally and ethically, according to relevant medical standards and guidelines. at induction and periodically all staff are instructed in safety and infection control protocols ensuring risks are known and precautions taken, including staff immunisation. we strive to work together to maintain a safe physical work environment and that supports the health and wellbeing of doctors, staff, patients and visitors. Including ensuring regular breaks, adequate staffing levels and a smoke free environment. we have a duty of care to safeguard the health of employees which also covers psychological as well as physical health. we strive to encourage consultation between management and staff on all matters pertaining to OH&S matters as obligated under the legislation. we endeavour to provide a working environment in which all doctors, staff, patients and visitors are not subject to unlawful discrimination, sexual harassment, violence or bullying. audits are undertaken to ascertain that all practice and office equipment is appropriate for its purpose. Records of maintenance, including electrical safety checks and calibration schedules are maintained. 26 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 records of updates and training provided to all staff in relevant equipment operation and maintenance, manual handling skills, and compliance with WH&S requirements are maintained. we strive to ensure the practice environment and facilities are adequate, and provide for the comfort, safety and security of doctors, staff, patients and visitors. we do not tolerate violence of any nature. non medical emergency procedures and fire safety precautions are clearly documented and designated members of the emergency team have a reference and a basis for their decisions and actions within that role. we have appointed one member of staff with primary responsibility for the development and consistent implementation of our infection control systems and procedures which includes environmental cleaning. Specific areas of responsibility may be delegated to nominated members of the practice team and these particular responsibilities should be documented in the relevant position descriptions. to minimise harm to our patients we have clear lines of accountability and responsibility for the delivery of safe and effective quality care. we have a requirement for two members of the staff to be present during the normal opening hours of the practice. Handling Hazardous Substances we implement arrangements for the safe use, handling, storage and transport of chemicals and hazardous substances. regular audits of products used by the practice are undertaken and hazardous substances are stored, handled and documented according to assessed risk. the practice endeavours to control risk associated with the use of hazardous substances which are stored in labelled containers. a register of hazardous substances is kept and maintained by the practice. (see hint above about this). staff members are instructed on how to handle hazardous substances appropriately and documentation and ongoing training is provided regarding this. regular risk assessment is undertaken by this practice in order to control risk associated with the use of hazardous substances. 27 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure Material Safety Data Sheets (MSDS) are kept for all chemicals stored on site. They are accessible to all staff and are kept <<insert location>>. MSDS detail the correct use, storage and action to take when exposure to chemicals occurs. MSDS sheets are available by contacting the supplier. A list of practice suppliers including their contact details is kept <<insert location>>. All chemicals are used in accordance with manufacturers instructions. It is the responsibility of <<insert person responsible>> to ensure that the MSDS sheets are available and updated when necessary. All containers of chemical agents are appropriately labelled. This is to ensure that the contents of containers can be readily identified and used correctly. For this reason, labels must be kept fixed to the container at all times and clearly understood. Specifically, it is recommended that a container with diluted cleaning agent state: name, type and purpose of chemical agent instructions on preparing and discarding the solution warnings and/or health and safety instructions. Containers of chemicals are stored in a cupboard out of the reach of children. If the cupboard is below the waist, a childproof lock should be fitted. Staff members who are required to handle chemicals are trained in their correct and safe use, and this includes the correct use of personal protective equipment (PPE). All chemicals and cleaning equipment are used for the purpose intended and in accordance with the manufacturers instructions and dilution ratios are strictly adhered to. 28 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Our practice has the listed chemical and cleaning products for the following uses: Product Use Storage location MSDS available RACGP 4th edition Standards 4.1.2 & 5.3.3 3.1 Manual Handling (Customise as appropriate) Policy Manual handling is any activity requiring the use of force exerted by a person to lift, push, pull, carry, or otherwise move or restrain any animate or inanimate object. It includes activities involving awkward posture and repetitive actions. Manual handling injuries account for nearly 50% of all Workcover claims. The objectives of the Occupational Health and Safety Manual Handling Regulations 1999, are to reduce the number and severity of musculoskeletal disorders associated with tasks involving manual handling. Under these regulations, this Practice aims to identify tasks involving hazardous manual handling and to undertake risk assessments. Risks to staff are thus reduced or eliminated as far as practicable. Procedure avoid tasks that involve: o twisting, bending or extensive reaching o repeated or prolonged stooped posture o lifting requiring extended reach o repetitive lifts from below mid thigh or using forceful movements 29 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 o prolonged bent neck posture when working on low flat bench o repetitive tasks for a prolonged time o using excessive force to push, pull or hold object reduce the size or weight of objects to be lifted or carried. prevent slips or falls by wearing appropriate footwear. ensure adequate lighting. clean area regularly; spills should be wiped up immediately. check equipment is in good working order and there is adequate space in which to work. weight limits: Seated – 4.5 kg. Standing – 16 to 20 kg. (For ideal conditions and with a compact load held close to the body and with a short carrying distance). Before doing any type of manual handling assess the situation ask the following questions: should two people be lifting this or am I able to lift this safely and without risk or injury? is my pathway clear of all objects? what distance am I going to be going? can I see clearly? can I split the load to make it lighter? size up the load – if in doubt seek assistance. Our practice has one or more height adjustable examination couch/s to assist in the care of patients with a disability, and to reduce the risk of staff injuring themselves when assisting patients on or off the examination couch. Where our practice facilities are inadequate for staff and visitors to safely assist patients with a disability we make alternative arrangements. e.g. Home visits. Staff Responsibility If you identify a task, piece of equipment, or work area that may be a risk, report it to the Practice Manager or the WH&S representative. A further detailed risk assessment will be conducted and if necessary, changes will be made to reduce the risk of injury with training for staff as needed. RACGP 4th edition Standards 5.1.1, 4.1.2, 5.1.3 30 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 3.2 Incidents and Injury and Adverse Patient Events (Customise as appropriate) Policy This practice has designated <<insert person responsible>> with primary responsibility for clinical risk management including the following up of incidents, injuries and adverse patient events and near misses. It is a legal requirement under the WH&S legislation and for insurance purposes, to report any injury sustained or thought to be sustained in the workplace, recognizing that good reporting also leads to effective prevention. Our practice encourages the identification, analysis and prevention of errors, failure or inadequate systems that can potentially be a risk to patient safety to assist with risk management strategies not to apportion blame. Incidents that should be reported (regardless of whether harm has occurred) to assist with making improvements to minimise the risk of recurrence, include: needle stick injury or mucous membrane exposure to blood or bodily fluids. Slip, trips or falls drug or vaccine incident (loss, misplacement or other). adverse patient outcome. failure or inadequate patient handover delayed treatment or follow up or unnecessary repeat of tests. Medication or prescribing errors. any deviations from standard clinical practice. Accidents or incidents may involve the following: staff (employed directly by this practice). non-staff (patients, visitors, contractors). events (e.g. theft, non-patient assault, gas leak, bomb hoax, security breach, medication error or patient complication following medical intervention, breakdown in clinical handover). 31 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Actual and potential risks are identified and actions are taken to increase the safety and improve quality care. The privacy of individuals involved is maintained. Every effort is made to document the risk reviews and improvements made to the practice as a result. Procedure Staff use the <<insert form/reporting method>> to report any slips, lapses or near misses in clinical care or deviations in patient care that might result in harm. The medical defence organisation is contacted for events that might give rise to a claim. Completed reports are: completed as soon as possible after incident occurs, preferably within 24 hours. Records are kept <<insert location>> Any additional medical or other certificates, reports, pathology or other documents related to the accident/incident are dealt with as soon as possible original documents are submitted. For injury occurring in the practice or course of work, WorkCover reporting protocols must also be followed. It is a legal requirement to report all injuries sustained in the workplace The doctor should refer patients to another practitioner if there is a possible conflict of interest, for example a staff WorkCover claim being managed by the employing practitioner. The staff member with designated responsibility in Risk Management conducts a thorough review of all the hazards relevant to the cause(s) of any injury that has occurred with a view to identifying appropriate controls. Risk minimization techniques are then developed and implemented to reduce the risk of reoccurrence. All documentation of the incident/event/near-miss is kept <<insert location>>. RACGP 4th edition Standards 3.1.2 32 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 3.3 Sharps Injury Management and Other Body Fluid Exposure (Customise as appropriate) Policy The employer is responsible to ensure that all staff: are familiar with the practice policy regarding management of blood and body fluid exposure. consider the blood and body substances of all patients as potential sources of infection. understand how to prevent exposure to blood and body fluids. have access to education and regular in service training in infection control matters. have documented their immunisation status and have been offered NHMRC recommended immunisations appropriate to their role. analyse any incidents and modify procedures as required to reduce the risk of recurrence. In our practice, we understand that the management of occupational exposure to blood or body fluids includes: rapid assessment of the staff member and the source patient. documentation of the incident. counselling for the staff member. timely administration of medications where appropriate. investigation of the incident to enable modification of procedures if required. Occupational exposure to needle stick injuries and body substances can be prevented by using standard precautions, wearing personal protective equipment (PPE) and implementing safe work processes. Procedure In the event of an occupational exposure, our practice will follow this procedure after occupational exposure: 1. Clean/decontaminate skin: wash with soap and water mouth/nose/eyes: rinse well with water or saline. 33 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 2. Notify the practice principal or GP on duty immediately The source: explain and reassure the source and offer pre test counselling. obtain consent to have the source patient’s blood tested for Hepatitis B, Hepatitis C and HIV the results should be available in 1-2 hrs if marked “urgent – needle stick” and received at an appropriate testing laboratory. take a history from the source – maintain the source patient’s confidentiality and do not interview them in front of relatives o unprotected sexual intercourse o sharing needles, tattoos, body piercing o sharing razor blades or toothbrushes o blood or body fluid exposure of mucous membranes or non intact skin. o blood transfusion before Feb 1990 (for HCV) o infection with HIV, HBV, HCV o if the source patient has a history of at - risk activities inform them about the window period in diagnosis. if any of the staff member’s blood went into the patient or onto instruments that were then used, the staff member also needs to be listed as a source. The Exposed person if the source is unknown the person needs to be tested and post exposure prophylaxis (PEP) needs to be considered obtain consent from the exposed person for urgent baseline testing for Hepatitis B, Hepatitis C and HIV to establish if the staff member has previously acquired an infection from other exposures. the exposed person’s confidentiality must be maintained especially if a staff member. the exposed person may elect to have these tests performed at a different facility or their own GP advise them to practice safe sex until their results and the source’s results and history have been reviewed give the exposed person the telephone number for the state/territory Health department communicable disease contact and other advisory services. 3. Treatment needs to be commenced if it is anticipated that the sources blood test results will not be available within 24hrs and the source patient could be HIV positive or in the window period. 34 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 if the HBV status of the exposed person is not known, and the sources HBV status will not be available within 24-48 hrs then give: o Hepatitis B immunoglobulin o Hepatitis B Vaccination 1st Dose o ADT (Adult Diphtheria and Tetanus) the exposed health care worker should be referred for immediate consultation with an infectious diseases specialist for consideration of PEP for HIV : o if the injury is classified as high risk, or o if the source patient has participated in at risk activities, or o If the source patient is positive for HIV or other significant blood borne infections. o If the source patient is unknown 4. DocumentExposure: We have appointed one member of staff with primary responsibility for the development and consistent implementation of our infection control systems and procedures. Report any exposure to this person or their delegated authority in addition to normal incident reporting protocols. Report should include: what procedure was being undertaken how the injury happened and the name of anyone that witnessed it the nature and extent of the injury exactly what you were injured with (specify gauge of the needle) the body substance involved how much blood or body fluid was the health professional exposed to. what personal protective equipment was being used? the full name and address of the source. If the source cannot be identified document “source patient not known”. RACGP 4th edition Standards 5.3.3 & 3.1.2 3.4 Staff Immunisation (Customise as appropriate) Policy We have appointed one member of staff with primary responsibility for the development and consistent implementation of our infection control systems and procedures which includes 35 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 staff immunisation. All practice staff are advised of the risks of infection and are encouraged to be immunised against vaccine-preventable diseases to prevent transmission of disease to and from practice staff and patients when commencing employment with the practice. Staff are also offered additional vaccinations where appropriate depending upon the likelihood of their contact with patients and/or blood supply substances. The practice will keep an extensive and up-to-date record of the immunisation history of each staff member. This will assist in identifying non immune staff to ensure they are excluded from contact with patients during disease outbreaks. Subject to informed consent, the immunisation status of staff is known and recorded including the documentation of any refusal. When a staff member has declared they’ve had a vaccination, evidence, such as immunology reports, must be kept in the staff record. Staff are able to refuse immunisation or to refuse to declare their immunisation status and this is recorded in their staff record. Procedure Upon commencement of employment, all staff are explained the risks and benefits of immunisation in relation to their position. All staff are offered appropriate immunisation if elected, according to the NHMRC recommended list for healthcare workers. Immunisation records are signed and dated by both the administering GP and staff member, These records are filed in the staff record and kept <<insert location>>. If staff members declare they have already been immunised, immunity testing must be carried out as this cannot be assumed. Additional immunisation may be recommended based on the results of this testing. Staff refusal to be immunised or refusal to disclose their immunisation status will be documented and kept in their staff record. RACGP 4th edition Standards 5.3.3 & 4.1.2 36 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 3.5 Smoke-Free Environment (Customise as appropriate) Policy As a prominent health care provider our aim is to promote the health and well being of all staff, patients and others whilst they are on our premises. Smoking is therefore not permitted in this practice and is discouraged on the premises or the surrounding environment. The use of illegal drugs and alcohol is prohibited on and around the site. No smoking signs are visible in the waiting room and/or reception area. Signs are not to be removed, except to replace worn or frayed items. 3.6 Staff Health and Wellbeing (including GPs) (Customise as appropriate) Policy This practice is committed to providing and maintaining a safe and healthy workplace for doctors, staff, patients and all other visitors. This includes psychological as well as physical health. Health and safety is an integral part of every activity we perform, and as such, the WH&S of GPs and practice staff is a priority of this practice, and is governed by WH&S legislation and regulations. This practice recognises that that breaks may reduce fatigue and support the health and wellbeing of both the General Practitioner and practice staff, as well as enhancing the quality of patient care. Our doctors and practice team can discuss concerns about violence in the practice and we have the right to discontinue care. To promote physical safety whilst at work, at least two staff members must be rostered at all times. Our home visits and after hours policy has also been developed with staff safety as an integral consideration. 37 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure Our practice implements the following strategies to protect the health and wellbeing of staff: workflow management strategies have been developed to deal with staff on unexpected leave or who may be on leave for an extended period. The strategies are known to all staff and are coordinated by <<insert the person responsible>>. Scheduling of regular breaks for both practice staff and members of the clinic team Enforcing a policy which does not allow team members to accrue a large amount of leave and encourage regular leave periods. Strategies to deal with violence which may occur in the practice including how to deal with difficult patients, reporting systems and opportunities for counselling and debriefing. Strategies to deal with non-medical emergencies including evacuation procedures and fire safety training for staff During normal opening hours, at least two staff members are rostered/present at work at all times. RACGP 4th edition Standards 4.1.2 3.7 Practice Facilities (Customise as appropriate) Policy The practice premises, including the facilities and equipment are safe and adequate to meet the needs of the staff and patients. The facilities at our practice make adequate provision for and encourage patient auditory and visual privacy. Facilities are well maintained and visibly clean with surfaces easilyible for cleaning. Every reasonable effort is made to make the environment safe and comfortable for staff and people who use the practice. 38 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Our waiting area/s are sufficient to accommodate the usual numbers of patients who would usually be waiting at any given time. Our practice has one or more height adjustable beds. The physical conditions in our practice support patient privacy and confidentiality. Procedure Upon inspection of the practice, the following features can be observed: Dedicated room for each clinical team member Consultation rooms are quiet, adequately lit, comfortable and feature an examination couch The waiting room has sufficient space to manage the usual practice patient load All equipment is safe and fit for purpose Sensitive information or materials are kept in a secure location accessible only by practice staff Hand washing facilities and toilets are readily available for both patients and staff and are kept clean At least one height-adjustable bed is available within the practice RACGP 4th edition Standards 5.1.1, 5.1.2, 5.2.1, 5.3.3 3.8 Security (Customise as appropriate) Policy Our practice ensures as much as possible that our facilities provide appropriate security for patients, staff and visitors. All practice staff are aware of, and are able to, implement protocols to ensure the safety and security of all persons within the practice. Procedure During normal opening hours, there are at least 2 members of staff present. 39 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 The practice has implemented the principles in the RACGP Guide General Practice- A Safe Place toolkit. All staff have been provided training in how to deal with difficult patients and the security protocols of the practice during their induction. The practice also makes available RACGP GP support programs. Security issues are discussed regularly at staff meetings and all violent incidents are discussed and assessed on a whole of practice level. <<Customise as appropriate>> Our practice has available a duress alarm system to notify all staff members if they are experiencing a violent encounter. It is the responsibility of the appointed Risk Management leader to ensure that these policies and procedures are implemented and adhered to. RACGP 4th edition Standards 5.1.1 & 4.1.2 3.9 Non Medical Emergencies (Customise as appropriate) Policy Non medical emergencies may occur that will require a quick, informed and effective staff response. Types of non-medical emergencies include: failure of electricity supply, telephone or water, fire or false fire alarm, property damage, break-in, abusive or threatening telephone calls or persons at the practice, leakage of toxic chemicals, bomb threats and letter bombs. We also have a business continuity plan for unexpected events such as natural disasters, national or local infection outbreaks or the sudden, unexpected absence of clinical staff or computer system failures. The practice has appointed a designated member of staff to have primary responsibility for our risk management systems. These may include clinical and non clinical risks and events. Specific areas of responsibility can be delegated to other nominated members of the practice team and these particular responsibilities are documented in the relevant position descriptions. 40 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure (Select the option most appropriate for your practice) Option 1 Our practice has <<a non-medical emergency manual /documented emergency policies>> which details the safety procedures to be undertaken during the specific emergency situations. The manual/policies are located <<insert location>> and all staff have been made aware of the manual during their orientation/induction. Designated members of the practice team have been appropriately trained in procedures for emergency situations and these roles are documented in their position descriptions. Our business continuity plan has been developed to deal with unexpected events such as natural disasters, power or business failures, or other unforeseen circumstances which may impact on normal business operation. The business continuity plan was last tested on <<insert date of test>>. RACGP 4th edition Standards 4.1.2, 3.1.2, 4.2.2 41 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 4 Infection Control 4.1 Principles of infection control (Customise as appropriate) Policy Because many infectious agents are present in health care settings, patients may be infected while receiving care, health care workers and others such as receptionists and cleaners may be infected during the course of their duties or when working and interacting with patients and other people. Potential infection risks to the practice team and our patients need to be reduced. Our practice has implemented systems that minimise the risk of health care associated infections including delegation of infection control and prevention responsibilities to a competent staff member. We have appointed one member of staff with primary responsibility for the development and consistent implementation of our infection control systems and procedures. Specific areas of responsibility may be delegated to nominated members of the practice team and these particular responsibilities should be documented in the relevant position descriptions (e.g.. infection control processes, sterilisation process, environmental cleaning, staff immunisation, staff education). Our practice has written polices relating to key infection control processes which are reviewed and updated regularly. All staff have an individual responsibility to identify any potential infection risks within the practice and to be familiar with and implement the relevant infection control procedures of our practice. New staff, including contracted staff and casuals, are familarised with our infection control policies that are appropriate to their duties as part of their induction to our workplace. Where appropriate, their competency is assessed and this assessment recorded or evidence of previous competency is obtained and recorded. Mechanisms are in place to ensure ongoing education and competency occur on a regular basis or when changes occur to our procedures. 42 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Our practice remains alert to changes to guidelines for infection control, and can implement them accordingly in a timely manner. We have a system for monitoring and obtaining information about national and local infection outbreaks, as well as about emerging new risks of cross infection and we have an effective mechanism for timely receiving and dissemination of any important communication or updates about emerging diseases or infection control measures to all relevant staff. Procedure We have a designated staff member <<insert staff members name>> who has responsibility for co coordinating and sustaining our infection control processes. This includes: continually modifying and improving our procedures and written policies in accordance with the most recent evidence and guidelines and adopting a risk management approach when implementing infection control measures. ensuring the timely dissemination of information concerning changes to infection control procedures or information about national and local infection control outbreaks. maintaining staff knowledge, education and competency in infection control activities and ensuring the consistent implementation of our infection control policies and procedures. ensuring the practice remains visibly clean and environmental cleaning processes are documented. appropriate delegation of infection control responsibilities and documentation of such delegation To ensure consistency of workplace practices our policy and procedure manual contains the following written infection control protocols: prevention of disease in the workplace by staff immunisation. blood and body fluid spills management. sharps injury management hand hygiene. a cleaning schedule for clinical and non clinical areas of the practice which describes the frequency of cleaning, products to use and person responsible. Where appropriate we have documented evidence of cleaning activity.(Refer to section 5). procedures for all aspects of the provision of sterile instruments whether by the use of disposables, or by onsite or offsite sterilisation. safe storage and stock rotation of sterile products. procedures for waste management including the safe storage and disposal of clinical waste and general waste. the appropriate use and application of standard and additional precautions. 43 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 access for patients and staff to Personal Protective Equipment (PPE) including evidence of education on the appropriate application, removal and disposal of PPE. triage of patients with potential communicable diseases. pathology testing done within the practice. ongoing education and training provided to each staff member and the mechanism for assessing staff competency in infection control procedures. RACGP 4th edition Standards 5.3.3 & 4.1.1 4.2 Blood and body fluid spills (Customise as appropriate) Policy Our practice has management systems for dealing with blood and body substance spills. blood and body fluids, including blood, vomit, urine, faeces, sputum and body tissue are treated as potentially infectious substances that can transmit disease should contact occur. doctors, nurses, other health professionals, practice staff and external contractors (e.g. cleaners) consistently use standard precautions to achieve a basic level of infection control regardless of the known or perceived infection status of the patient. any spillage needs to be treated promptly to reduce the potential for contact with other patients, staff or visitors. the designated infection control leader is responsible to ensure all staff are familiar with the practice’s policy and procedure for the management of blood and body fluid spills and staff receive adequate training on how to appropriately clean blood and body substance spills which is appropriate for the tasks they are expected to perform. staff are also familiar with the actions to take in the event of exposure to blood or body fluids while cleaning a spill. Our practice has a spills kit readily available consisting of a rigid walled container with a lid and contains: 1 small bucket (with water level marked) and pre-measured amount of detergent* (in a labelled container) to be made up when necessary. utility rubber gloves. face and eye protection: Goggles/safety glasses/face shield/mask. disposable or reusable impermeable/plastic apron/gown. 44 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 roll of paper towelling (that retains strength when wet). scrapers (2 pieces of firm cardboard or plastic). hazard/cleaning sign. biohazard bag. polymerising beads or other absorbent material. list of contents to assist restocking after use. copy of the instructions for cleaning spills. *The detergent used for general cleaning is satisfactory for treating most spills (Source: Infection control standards for office based practices, 4th Edition) Procedure As part of the induction process all staff are provided with information about our practice’s protocol for managing spills of blood and body. In our practice, the Spills Kit is located (*insert the location of the Spills Kit here). It is the responsibility of all staff members who use the spills kit to ensure all items are replaced after each use and the items are not expired. If additional or replacement stock is to be ordered, <<insert staff member responsible for ordering equipment>> is informed. Disposable items in the Spills Kit must be replaced after each use and reusable items cleaned according to protocol. The management of spills should be flexible enough to cope with different types of spills, taking into account the following factors: the nature of the spill the pathogens most likely to be involved in these different types of spills the size of the spill the type of surface the area involvedthe possibility of some material remaining on a surface where cleaning is difficult (e.g. between tiles) and of bare skin contact with that surface. Only staff with confirmed vaccination status and training are permitted to clean spills of blood or body fluid and perform other high risk activities such as instrument reprocessing. (Refer to Section 3 Staff Immunisation) Spot spill Practice procedure 45 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 In our practice, this procedure is followed when cleaning a spot spill: 1. don PPE as considered appropriate 2. quarantine area 3. use disposable paper to absorb the bulk of the blood and body fluid 4. wash the surface with warm water and a neutral detergent 5. dry thoroughly with a clean wipe 6. dispose of waste in the infectious waste container 7. if broken glass or any other sharp is involved it must be picked up with forceps and disposed of in a sharps container before cleaning and disinfection is attempted. Small or large spill Practice procedure In our practice, this procedure is followed when cleaning a small or large spill: 1. don PPE as considered appropriate 2. quarantine area 3. absorb the spill with paper towel and dispose of as clinical waste. 4. clean the surface with detergent and water. Where there is the possibility of some material remaining on a surface where cleaning is difficult (eg between tiles) and there is a possibility of bare skin contact with that surface, then a disinfectant may be used after the surface has been cleaned with detergent and water. The contaminated surfaces should be treated with a disinfectant (Sodium Hypochlorite solution - 1000 parts per million of available chlorine, usually achieved by a 1 in 50 dilution of 5% liquid bleach or (Milton - 1% sodium hypochlorite – used as 1:10) Granular chlorine: e.g., Det-Sol 5000 or Alcohol: e.g, Isopropyl 70%, ethyl alcohol 60%. Always read manufacturer’s instructions and precautions. (eg Sodium Hypochlorite is corrosive to metals and alcohol highly inflammable, hardens plastic and swells rubber) 5. leave the solution on the surface for a minimum of 10 minutes or as directed by the manufacturer. 6. clean the surface again to remove the sodium hypochlorite if used. 7. dry thoroughly. 46 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Carpet Practice procedure In our practice, this procedure is followed when cleaning a spill on carpet: 1. blot up as much of the spill as possible using disposable towels, and then clean with a detergent 2. arrange for the carpet to be cleaned with an industrial cleaner as soon as possible. RACGP 4th edition Standards 5.3.3 4.3 Hand washing and hand hygiene (Customise as appropriate) Policy Effective Hand hygiene has been proven to reduce the spread of infection. This minimises the risk of cross-contamination through physical contact with patients and co-workers as well as touching inanimate objects such as door handles and telephones. Gloves are not a substitute for hand cleaning. Fingernails are to be kept short and clean with jewellery kept to a minimum as these may harbour bacteria. Cuts and abrasions are covered with water resistant dressings. Nailbrushes are not used. The employer is responsible to ensure all staff members have been educated on effective hand hygiene and hand care. Staff must wash their hands: before and after examining and treating patients before and after and between performing any procedure before and after taking blood, before and after giving an injection after handling pathology specimens after handling any equipment that might have been soiled with blood or other body substance after routine use of gloves before and after eating before and after smoking after blowing your nose after going to the toilet when visibly soiled or perceived to be soiled 47 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Easy access to hand hygiene facilities is promoted with dedicated hand washing facilities (with hot and cold water, liquid soap and single use paper towel) readily available in every clinical management or treatment area. Hand disinfectants designed for use without water, such as alcohol based hand gel can be used in the following situations: emergency situations where there may be insufficient time and/or facilities e.g. in the doctors bags. when hand washing facilities are inadequate, e.g. reception areas, home visits. in all treatment and examination areas to encourage hand hygiene in addition to hand washing facilities. In patient and staff areas during flu season to encourage hand hygiene. Signage is displayed in areas where hand hygiene facilities exist to encourage proper hand washing techniques. Visible soil must be removed with detergent based wipes first. If significant direct physical contact with a patient or patient’s blood or body fluids is likely to occur this should ideally take place in an area where access to hand washing facilities is available. Hand Hygiene products need to be selected with consideration of the following factors: type of hand hygiene requires i.e. routine, aseptic (clinical), or surgical. the location of the product. compatibility of agents if multiple agents are used e.g. hand creams, ointments. care and protection of staff hands and sensitivities. There is no soap bars utilised in our practice. Where possible liquid hands wash dispensers with disposable cartridges, including a disposable dispensing nozzle, are used; where these are not available a pump pack is used. These are never topped up and are ideally discarded when empty. Should they need to be refilled, the container is washed and dried thoroughly prior. The nozzle is kept clean and free of dried soap. Appropriate facilities for drying hands are provided. Hot air dryers are not used in clinical areas. Single use towels (paper or cloth) are provided in shared locations and clinical areas. Disposable paper towel is used prior to aseptic procedures. Hand moisturiser is made available for staff use. 48 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure Routine hand cleaning for soiled hands The following procedure is followed for a routine hand wash: 1. wet hands thoroughly and lather vigorously using liquid soap. 2. wash for 10-15 seconds. 3. rinse thoroughly. 4. dry with paper towel or single use cloth towel. 5. use paper towel to turn taps off if not ‘hands free’. Hand Washing for aseptic (non-surgical or clinical) procedures The following procedure is followed for a non-surgical hand wash: 1. wash hands thoroughly using neutral liquid soap or an anti-microbial cleaner (e.g. 2% Chlorohexidine). 2. wash for 1 minute. 3. rinse thoroughly. 4. dry thoroughly with paper towel or single use cloth towel. 5. use paper towel to turn taps off if not ‘hands free’. Hand washing prior to surgical (invasive) procedures The following procedure is followed for a surgical hand wash: 1. Remove Jewellery 2. Wet hands and forearms 3. Wash hands, nails and forearms thoroughly with an antimicrobial cleaner i. (e.g. 4% chlorohexidine, 0.75% detergent based povidine or 1% aqueous povidine) 4. First wash 5 minutes and each subsequent wash 3 minutes 5. Rinse carefully keeping hands above the elbows 6. Do not touch taps (ask another staff member to do this if not ‘hands free’. 7. Dry thoroughly with sterile paper or cloth towels. Location hand washing facilities Patient toilets Liquid soap Paper towel/air dryer Equipped for routine hand washing yes Equipped for aseptic hand washing no Equipped for Surgical hand washing no 49 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Consulting rooms Treatment room Liquid Soap Antimicrobial cleaner (2% Chlorhexidine) Paper towel Liquid Soap Antimicrobial cleaner (4% Chlorhexidine) Paper towel Sterile towel yes yes no yes yes yes RACGP 4th edition Standards 5.3.3 4.4 Single Use Equipment <<Delete this section if your practice does not use disposable equipment>> (Customise as appropriate) Policy Equipment and medications labelled by the manufacturer as disposable or single patient use are not reprocessed (cleaned) or re-used in this practice. Single use packaging is the only acceptable presentation for dressings, suture materials, suture needles, hypodermic needles, syringes and scalpels. Single use vials should be used in preference to multi dose vials of injectable substances as multi dose vials present an infection hazard if incorrectly used. Items marked by the manufacturer as “single use” must never be reused under any circumstances. Some items may be reprocessed for use by the same patient if labelled “single patient use” and in this case the manufacturer’s instructions for reuse must be followed. These may include cleaning requirements and limitations to the number of times the item can be reprocessed. Single use items or equipment contaminated with blood or body fluid are considered clinical waste and are disposed of accordingly. 50 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Where possible saline solution and skin preps are purchased in single use sachets or containers. Larger containers, if used, are dated when opened and changed regularly. Procedure <<Select the Option that is most applicable to your practice>> Option 1: Our practice does not use reusable medical equipment. All instruments are disposable. It is the responsibility of all staff to ensure that soiled or contaminated disposable instruments are placed in the correct sharps disposables bins after each use. Appropriate PPE must be worn when using equipment. Option 2: Our practice uses a combination of single-use and reusable disposable equipment. All single-use equipment is disposed of in an appropriate manner directly after use in the correct sharps disposal bins. Reusable equipment is reprocessed according to the manufacturer’s instructions. Further instructions on equipment processing are located later in this section. It is the responsibility of all staff to ensure the equipment they are using is disposed of according to their classification and in accordance with practice policies and procedures. RACGP 4th edition Standards 5.3.3 4.5 Offsite Sterilisation <<Delete this section if your practice does not use offsite sterilisation services>> (Customise as appropriate) Policy Our practice uses an offsite sterilisation process to ensure that equipment is appropriately cleaned and sterile for use with patients. 51 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Our practice uses the services of <<insert service provider name>>. Validation of the sterilisation process occurs annually and copies of records are kept <<insert location of sterilisation records>>. The following documentation is maintained: a copy of the offsite facilities current accreditation certificate (e.g. accredited general practice or ACHS accredited hospital). our procedures for safe transport of instruments and equipment to and from the offsite facility. an agreement between our practice and the off site sterilisation facility stating who is responsible for washing and packaging items, transport, turnaround time, quoted prices and names of contact people for both organisations. evidence that the offsite facility correctly performs the sterilisation and validates it processes.e.g. validation documentation or certification provided annually. Our practice has appropriate policies and procedures to ensure preliminary cleaning of items, packaging and transportation arrangements including evidence of staff training and competency. Procedure It is the responsibility of <<insert the person’s name>> to co-ordinate the off site sterilisation arrangements. ensure that all instruments that require sterilisation are cleaned in accordance with the documented procedure. items are packaged and labelled prior to despatch to the facility in accordance with the documented procedure place all instruments in a plastic container labelled “contaminated” with a firmly fitting lid. If items are not cleaned prior, standard precautions must be adhered to when handling this container and contents. document all instruments leaving the practice. telephone to inform the offsite sterilisation service provider that a cycle of instrument sterilisation needs to be undertaken for our practice and to arrange a delivery and pickup time use a different plastic container “labelled sterilised items” to collect the items from the sterilisation facility on return of the instruments following sterilisation, check the packages for damage thoroughly before signing off. 52 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Packaging of Items for offsite sterilisation. Procedure Our practice ensures the packaging of items for sterilisation provides an effective barrier against sources of potential contamination in order to maintain sterility and to permit aseptic removal of the contents at point of use. A copy of the procedure for packaging items is located with the packaging materials so all staff can readily refer to these instructions. All staff follow this procedure when packaging instruments. 53 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Step 1 Visually check items have been cleaned and dried, and are in good working condition and free of rust or surface damage Step 2 If your workplace uses specific sets then group items according to your protocols. Step 3 Insert the items into the package considering the following principles Step 4 Ensure package is the appropriate size for required items. Open and unlock items with hinges or ratchets. Package in a manner that prevents damage to items or injury to end user and facilitates steam movement across the surface of items. Use tip protectors if necessary to prevent sharp instruments from perforating the packaging. Check each package has a class 1 indicator integrated on the packaging. (Steriliser indicator tape or a separate class 1 indicator must be used if absent on the packaging material.) Step 5 Select Option 1 Remove peel-off strip from pouch, and fold precisely along the marked line to seal the pouch Or Option 2: Cut packaging from roll and fold each end over twice. Apply sterilisation tape (usually has a class 1 indicator stripe) to seal over the fold extending it around the edge of the package. Step 6 Use a felt-tip, non-toxic, solvent-based marker pen to label the pack with Initials of the person packaging the item Date of sterilisation & load number (this may be added prior to loading the steriliser if not known). Contents of the package (if opaque packaging). Step 6 Inspect pack to ensure packaging material is intact. Step 7 Store item/s in a container with lid, cupboard or drawer, clearly marked as “unsterile items” until ready to load into the steriliser. 54 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 4.6 Onsite Sterilisation <<Delete this section if your practice does not sterilise equipment onsite>> (Customise as appropriate) Policy This practice is able to provide assurance that any items provided for procedures into normally sterile tissue, sterile cavities or the bloodstream are sterile. This practice understands that sterilisation is more than simply putting loads through a steriliser and the process of sterility assurance includes all aspects of equipment reprocessing, and staff education. Our practice has a supply of reusable instruments that are maintained in good working order and are free of rust and surface damage. The correct procedures must be followed to ensure that these instruments are cleaned and sterilised after each use. Our practice uses steam at high temperature under pressure for sterilising cleaned instruments. This is the most reliable and cost effective method of sterilisation and is recommended for use in general practice. Specific instructions on the packaging and use of the autoclave are kept <<insert the location>>. These instructions must include a comprehensive workflow schedule to ensure that there is no possible contamination of the clean areas where the sterile instruments are unloaded and stored. All items to be sterilised must be thoroughly cleaned first. Our practice documents each cycle in a sterilisation log. Our portable steam steriliser has a closed door drying cycle that must be used when processing wrapped articles so as to ensure that instrument packs are dry before unloading. Our practice validates our sterilisation process annually at the servicing of the steriliser. <<Insert name of staff member>> is responsible for correct operation and training staff on how to process instruments. All staff are aware of the processing time required and the maximum load limits as determined by the validation process 55 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Holding times for steam sterilisation All times are based on the assumption that the items to be sterilised are thoroughly clean. Temperatu re @ C Pressure Holding time for steam sterilisation (this includes safety factor) KPa psi 121C 103 15 15 minutes 126C 138 20 10 minutes 134C (wrapped items) 203 30 3 minutes Penetration time if applicable (as determined by technician) Total Sterilisation Time The “holding time” does not include: the time taken for heating the load to the desired temperature any large volumes of material or heavily wrapped/packaged items included in a given load, and time taken to allow the inside of the packs to achieve the desired temperature. This is the “Penetration time” and must be added to the holding time. STERILISATION TIME = PENETRATION TIME + HOLDING TIME. Packaging of items for sterilisation Policy Our practice ensures the packaging of items for sterilisation provides an effective barrier against sources of potential contamination in order to maintain sterility and to permit aseptic removal of the contents at point of use. A copy of the procedure for packaging items is located <<insert location of the procedure document>> so all staff can readily refer to these instructions. All staff follow this procedure when packaging instruments. Items that are being sterilised for disinfection but which do not need to be kept sterile for reuse can be processed unwrapped e.g. vaginal speculums 56 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 6 Step 7 Visually check items have been cleaned and dried, and are in good working condition and free of rust or surface damage If your workplace uses specific sets then group items according to your protocols. Insert the items into the package considering the following principles Ensure package is the appropriate size for required items open and unlock items with hinges or ratchets Package in a manner that prevents damage to items or injury to end user and facilitates steam movement across the surface of items use tip protectors if necessary to prevent sharp instruments from perforating the packaging Check each package has a class 1 indicator integrated on the packaging. (Steriliser indicator tape or a separate class 1 indicator must be used if absent on the packaging material.) Select Option 1. Remove peel-off strip from pouch, and fold precisely along the marked line to seal the pouch Or Option 2. Cut packaging from roll and fold each end over twice. Apply sterilisation tape (usually has a class 1 indicator stripe) to seal over the fold extending it around the edge of the package. Use a felt-tip, non-toxic, solvent-based marker pen to label the pack with initials of the person packaging the item date of sterilisation & load number (this may be added prior to loading the steriliser if not known) contents of the package (if opaque packaging). Inspect pack to ensure packaging material is intact. Store item/s in a container with lid, cupboard or drawer, clearly marked as “unsterile items” until ready to load into the steriliser. 4.7.1 Instrument and equipment processing area (Customise as appropriate) Policy 57 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 The RACGP Standards recommend a designated area should be used for processing all instruments and equipment for reuse to prevent possible contamination of processed items. A workflow pattern, systematically moving from dirty to clean, must be established within the designated area. All staff must understand and adhere to the designated work flow pattern. The workflow pattern must enable items to progress from the cleaning area to the steriliser packaging/unloading and sterile stock storage area without re-contamination. The equipment processing area needs to include: adequate bench space with surfaces made of a smooth, non-porus material without cracks or crevices to allow for cleaning good lighting bins for specific waste adequate storage space for materials and equipment. Specified cleaning equipment such as: 1. heavy duty utility gloves, plastic apron to protect clothing, protective eyewear and if items are grossly soiled, a mask or visor. 2. a non-corrosive, non-abrasive, free rinsing and mildly alkaline detergent in the original container or a clean, well labelled bottle. 3. cleaning brushes of a suitable size to effectively reach all parts of the item being cleaned. 4. low-linting towelling for drying the cleaned items. This area, including sinks and containers need to be cleaned daily. Procedure In our practice, our equipment processing area is located (*insert location here) and our facilities include: (Select from option 1, 2 or 3 depending on which best describes your practice equipment cleaning facilities. Delete other options and return italic text to normal) (Option 1). Dedicated double sink with adequate bench space either side for work to flow from dirty to clean area. A separate hand washing area is also available elsewhere in the room. 58 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 use the sink on the dirtiest side (according to the workflow pattern) to wash the dirty instruments with the plug inserted. This is the dirty sink. use the other sink to initially rinse the instruments and then for the final rinse. Do not insert the plug but rinse under running water. use the separate hand washing area for hand cleansing (Option 2). A double sink with adequate bench space either side for work to flow from dirty to clean area. This sink is also the only area available for hand washing. obtain and label a large plastic container to act as the dirty sink and place this on the dirtiest side (according to the workflow pattern) of the existing sink.Use this container to wash the dirty instruments in. use the sink directly adjacent to initially rinse the instruments and then for the final rinse. Do not insert the plug. use the second adjacent sink as a dedicated hand washing area. OR use sink can also be used for washing hands. However, it must be cleaned after washing the sink on the dirtiest side (according to the workflow pattern) to wash the dirty instruments with the plug inserted. This is the dirty sink. use the other sink to initially rinse the instruments and then for the final rinse. Do not insert the plug but rinse under running water. This is the clean sink. the clean instruments to render it suitable for hand washing. (Option 3). A single sink available to use for cleaning items, Separate hand washing facilities are available. obtain and label a large plastic container to act as the dirty sink and place this on the dirtiest side (according to the workflow pattern)of the existing sink .Use this container to wash the dirty instruments in. use the sink to initially rinse the instruments and then for the final rinse. Do not insert the plug. use the separate hand washing area for hand cleansing (Option 4). A single sink is available to use for cleaning items and washing hands. obtain and label a large plastic container to act as the dirty sink and place this on the dirtiest side (according to the workflow pattern)of the existing sink .Use this container to wash the dirty instruments in. 59 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 use the sink to initially rinse the instruments and then for the final rinse. Do not insert the plug the sink can also be used for washing hands. However, it must be cleaned after washing instruments to render it suitable for hand washing. Environmental Issues The area and equipment associated with instrument and equipment processing: is only cleaned or managed by appropriately trained Practice Staff. must remain in a clean and tidy manner throughout the day. is thoroughly cleaned at the end of the day. If a plastic utility container is used as the Dirty sink for washing the instruments this container must be treated with due care. The container is not touched with ungloved hands and it is thoroughly washed at the end of the day as part of the practice’s routine cleaning. This container is not to be used for any purpose other than instrument pre-cleaning RACGP 4th edition Standards 5.3.3 4.7.2 Cleaning reusable Instruments and equipment (Customise as appropriate) Policy A basic risk assessment is required to determine the appropriate level of processing required for specific instruments. The site/manner where an instrument will be used can assist in determining the risk of infection. This analysis determines the level of processing required to minimise the probability of infection to the patient. More information to assist with this risk assessment can be obtained from RACGP Infection Control Standards for Office Based Practices, 4th Edition (page 51). In our practice, we have a designated staff member responsible for sterilisation in our practice. It is part of their role to ensure all staff who are sterilizing instruments are adequately trained and competent in the procedure. 60 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 More information about aspects that require training and competency can be obtained from RACGP Infection Control Standards for Office Based Practices, 4th Edition (page 52). Thorough physical cleaning of items to remove blood and other debris is needed if effective disinfection or sterilisation is to be achieved. Preliminary cleaning must be done as soon as possible during or after use to prevent coagulation of blood and other proteins. Any delay will increase the bio-burden (through bacterial multiplication) and also increases the difficulty of removing adherent soil. The effectiveness of sterilisation is dependent on the bio-burden being as low as possible. Procedure In our practice, the designated leader for sterilisation is <<insert name of person responsible>>. All staff cleaning reusable items must: wear appropriate PPE. use equipment as specified. have received appropriate formal or in house training. be appropriately immunised. Our practice follows this procedure for all instruments and equipment that is going to be reused for patient care. This includes items that need to be: clean but are not required to be sterile for re-use e.g. kidney dishes, ear syringes. sterilised after use, but not used as sterile e.g. vaginal speculums. sterile for re-use e.g. surgical instruments. 61 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Step 1 Wash hands with liquid soap and dry thoroughly with paper or single use towel. Step 2 Put on personal protective equipment including goggles, plastic apron and heavy duty kitchen gloves. Step 3 During or immediately after use open instruments and, dry- or damp-wipe off gross soil. Rinse the item under gently running tepid water over the clean sink. Step 4 If unable to clean instruments immediately, open instruments and soak in a container with a lid in tepid water and detergent until they can be cleaned. Clean instruments as soon as possible as prolonged soaking damages instruments. Use fresh water and detergent Step 5 Prepare dirty sink/basin by filling with sufficient tepid water and the correct amount of detergent to cover the items being washed. Step 6 Thoroughly wash each instrument in the dirty sink/basin to remove all organic matter. Open and disassemble items to be cleaned. Keeping items under the waterline to minimise splashing and droplets, scrub items with a clean, firm-bristled nylon brush. Use a thin brush to push through lumens, holes or valves. Step 7 Rinse the washed instruments in gently running hot water over the clean sink/basin. Step 8 Inspect instruments to ensure they are clean. Look at hinges, handles and working surfaces. Step 9 Place each washed instrument on a clean lint free cloth or surface and repeat the above process until all instruments have been cleaned and rinsed. Step 10 Carefully discard dirty water down the sink. If using a container, aim to pour the dirty water directly into the plughole rinsing the sink afterwards with running water. Step 11 Wash cleaning brushes/cloths with detergent and tepid water after every use. Hang to dry. Can consider sterilising these in the last load of the day. Step 12 Wash the dirty and clean sink/basin by rinsing it with tepid water and detergent. Wipe down the sink/basin with a disposable towel. 62 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Step 13 Remove kitchen gloves and replace with non sterile disposable gloves...Carefully dry each instrument with a clean, lint free cloth. Do not allow to air dry. Step 14 Remove and Clean personal protective equipment by washing or wiping down and drying. Step 15 Wash hands with liquid soap and dry thoroughly with paper or single use towel. RACGP 4th edition Standards 5.3.3 63 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 4.7.3 Loading the steriliser (Customise as appropriate) Policy Correct loading of sterilisers is needed for successful sterilising to: allow efficient air removal permit total steam penetration of the load allow proper drainage of condensation and to prevent wet loads prevent damage to items in the load maximise efficient utilisation of steriliser when loading the steriliser, care needs to be taken that the steam can circulate effectively and that all surfaces are accessible and exposed to steam. never exceed the validated load <<insert location where details of the validated load can be found e.g. on the wall near the steriliser>> Step 1 Load items into the steriliser following these points: allow enough space between each item to allow air removal, steam penetration and drying to occur do not crush items together do not allow items to touch the floor, top or walls of the chamber Follow the pattern of loading described in the practice validation protocol when doing a full load. Step 2 Fill the chamber with or ensure reservoir has sufficient deionised/demineralised water as per the manufacturer’s instructions. Step 3 If the steriliser allows you to select different loads check that the appropriate load parameters are selected. Step 4 Monitor the sterilisation process by one of the following: automatic printout or computerised data logger download (records at a minimum of 60 second intervals). 64 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 use of a class 4, 5 or 6 chemical indicator with every cycle. Manually record time and temperature throughout the cycle at least every 30 seconds. Step 5 Close and secure chamber door as per manufacturer’s instructions. Step 6 Press “Start” button or relevant button to commence the cycle as per manufacturer’s instructions. Pro ced ure Our practice follows this process when loading the steriliser: 65 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 4.7.4 Unloading the steriliser (Customise as appropriate) Policy For packaged items, the period of time between their removal from a steriliser (any type) and their return to room temperature is recognised as being the most critical time with respect to assurance of sterility. Cooling generates a tiny flow of room air into the pack at flow rates demonstrated to breach porous packaging materials leading to their failure to provide a microbiological barrier. Correct cooling practice is needed to maintain sterility. When a sterile item is not cooled in the correct manner the article can have moisture build up, which can contaminate stock. The item must be reprocessed if the packaging is torn, punctured or wet. 66 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure Our practice follows this process when unloading the steriliser: Step 1 When cycle is complete, check printout, data logger, or Class 4, 5 or 6 chemical indicator to ensure the temperature has reached the parameters of at least 3 minutes at 134c and stayed above 134c for the specified period determined during penetration study. Note a minimum of 3 minutes at 134c is required for unwrapped goods. For wrapped, packed or pouched items, these measurements need to be confirmed by a technician, known as penetration time and time at temperature testing at validation. Step 2 Circle and sign these parameters on the printout and attach to the sterilisation log. Step 3 Open the steriliser door to its maximum to allow contents to cool. Step 4 Turn off electricity or as per manufacturer’s instructions. Step 5 Wash hands with liquid soap and dry thoroughly with paper or single use towel or put on clean, dry gloves. Use gloves specifically designed for removing hot sterilising racks from the chamber to prevent staff receiving burns. Step 6 Visually examine packages to ensure that: the load is dry the packages are intact The indicators have changed colour. Any items that are dropped on the floor, torn, wet or have broken or incomplete seals are contaminated and must be repackaged and reprocessed. Step 7 Take items from the sterilising chamber and place on a cooling rack on a clean field until cool (or allow items to cool inside the chamber once packages have been checked). Step 8 Record details in the sterilisation log. 67 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 4.7.5 Documentation of the Cycle (Customise as appropriate) Policy A sterilisation log is maintained which contains details of: date of cycle. steriliser Identification (only if more than 1 steriliser in the practice). load Number. contents of the load. identification of the person who prepared the load. class 1 Chemical indicator change. condition of the packs. (dry with seals and package integrity intact). evidence of the process such as a print out or class 4,5 or 6 Chemical Indicator or if a data download logger is used, sign off that it was viewed and is correct. signature of the person releasing the load. any comments or problems such as failed cycles and actions taken. Procedure the Loading section of the sterilisation log is completed and signed when the steriliser is loaded. the unloading section of the sterilisation log is completed and signed when the steriliser is unloaded. sterilisation log sheets are retained and filed <<insert the location for storage>> according to the procedures for medical records. Failed cycle In the event of a failed cycle: document failed cycle with a brief summary of the problem in the sterilistion log. notify appropriate staff members. do not use items from the steriliser until the error is rectified. refer to the troubleshooting guide on the operating instructions. replace the packaging and re-process the instruments. if fault occurs again contact the service technician for advice and record any actions in the Steriliser Maintenance Log Sheet. 68 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 4.7.6 Monitoring the Sterilisation Process (Customise as appropriate) Policy Monitoring is a programmed series of checks and challenges, repeated periodically, and carried out according to a documented protocol, which demonstrates that the process being studied is both reliable and repeatable. If the temperature or pressure of the steam inside the autoclave is above or below what it should be, the steam will not be able to condense and sterilisation will be unreliable. The efficiency of the sterilisation process should therefore be checked on a regular basis according to the manufacturer’s specifications or those documented in the current edition of AS/NZS 4815. Procedure 69 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Our practice follows these methods of monitoring:Test – Processed Method Class 1 chemical indicator Frequency A class 1 chemical indicator must be used for: every wrapped item (external), or every load, if unwrapped. Test – Time, temperature and pressure Method Frequency Time, temperature and pressure can be measured by using: a steriliser with a print out facility, or data logger/computer download, or manually recording of temperature and pressure throughout the cycle, or Class 4, 5 or 6 chemical indicator (time and temperature only). Every load Test – Calibration Method By a qualified service technician Frequency 6 – 12 monthly (or more frequently as per manufacturer’s instructions) Test – Validation Method See definition and process below Frequency 12 monthly and as required RACGP 4th edition Standards 5.3.3 4.7.7 Validation of the sterilisation processes (Customise as appropriate) Policy “Validation” is a documented procedure for obtaining, recording and interpreting results required to establish that the sterilisation protocols/procedures followed by our practice will consistently yield sterile instruments and equipment, as exactly the same procedure is followed for every part of each sterilisation process. “Sterilisation” is more than simply putting loads through a steriliser. Successful sterilisation to achieve and maintain sterility of equipment and instruments reliably and repeatedly is a process which begins with pre-cleaning of equipment after use, cleaning of the instruments, 70 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 drying, packaging, loading the chamber, the sterilisation cycle, unloading the chamber, monitoring of each cycle, recording cycle details and monitoring in the log book, storage and traceability of the sterilised equipment, detection of abnormalities in the process and corrective appropriate action, and daily, weekly and annual steriliser maintenance. Validation covers three activities, which are: installation qualification (‘commissioning’) operational qualification (‘commissioning’) performance qualification. The validation process must be carried out by our practice upon installation and annually in conjunction with a maintenance contractor. A qualified service technician must ensure that all gauges and process recording equipment fitted to the steriliser are calibrated using independent test equipment. The contractor must also document results of heat distributionstudies on an empty chamber and conduct a penetration test using our practice’s challenge pack. Validation of the sterilisation processes must be completed as soon as possible after the routine annual calibration and service, and immediately after any of the events listed below: commissioning a new steriliser (a service technician should install the steriliser according to manufacturer’s instructions and should then check the operation of the machine) significant changes are made to the existing steriliser, such as major repairs or recalibration, which could adversely affect the result of the sterilisation process changes to any part of the sterilisation process, such as changes to the contents, packing or packaging of the “challenge pack” or to loading details of the “challenge load”. If validation of the sterilisation process is successful then any load subsequently processed over the next twelve months can be treated as sterile. This is provided that: all the validated documented sterilisation procedures continue to be followed exactly the pack contents, packing, and packaging and chamber loading do not exceed the parameters of the validated packs/loading each cycle is monitored correctly and no changes are made to any part of the sterilisation process, which could adversely affect it. Procedure Our practice follows this procedure when conducting validation: 71 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Review and perform your infection control policies and procedures including: workflow issues cleaning of instruments pack contents, packing and packaging loading of the steriliser sterilisation cycle unloading the steriliser storage of sterile items maintenance of the steriliser. Check that the procedures were successful in terms of performance and reliability and sign-off each one using the validation methodology checklist. Attach the validation methodology checklist to the validation record. Select the hardest to sterilise items (challenge pack) in terms of product or pack density to create your challenge pack and record details on the validation record. At time of routine service, request the service person to: calibrate the machine conduct a heat distribution or “cold spots” study in an empty chamber (usually performed only on installation, or available from the manufacturer or otherwise determined by the sterilisation technician) obtain the penetration time using a thermocouple or data logger by choosing the hardest to sterilise items in terms of product or pack density to create your challenge pack undertake a time at temperature analysis to ensure the temperature is maintained throughout the entire sterilisation phase. provide servicing/testing documentation detailing the outcome. Where onsite technical support is not immediately available, please refer to the current edition of the AS/NZS 4815. Using the validation record template, record the following details: date of annual validation batch number and biological indicators cycle that is being used for validation temperature and time at which validation is being done attach your servicing/testing documentation to the validation record. Select the items that you will include in the load and record details on the validation record including the “challenge pack”. 72 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Step 7 Step 8 Step 9 Step 10 Step 11 Step 12 Step 13 Step 14 Label the biological indicators to reflect cycle as follows: 1st Cycle label one Indicator 1M (for the 1st Indicator placed in the 1st cycle challenge pack in the middle of the pack) and the other 1C (for the non packed Indicator placed on the tray nearest the coldest part of the steriliser chamber) 2nd Cycle label one Indicator 2M (for the 2nd Indicator placed in the 2nd cycle challenge pack in the middle of the pack) and the other 2C (for the non packed Indicator placed on the tray nearest the coldest part of the steriliser chamber) rd 3 Cycle label one Indicator 3M (for the 3rd Indicator placed in the 3rd cycle challenge pack in the middle of the pack) and the other 3C (for the non packed Indicator placed on the tray nearest the coldest part of the steriliser chamber) the 7th Indicator can be labelled Z. This indicator is never sterilised and is usually placed beside the steriliser whilst the three (3) consecutive cycles are being run. This 7th indicator will prove that the batch of indicators was active. Place the biological indicators inside the challenge pack and in the coldest spot of the chamber and outside of the steriliser. Record the location in the test indicator diagram on your validation record. Load the steriliser as documented above and draw or photograph details in the loading diagram on your validation record. Perform three consecutive, identical loads and cycles including the test indicators as marked. With each load, unpack and repack the challenge pack. All items for each load must be at room temperature. Send the biological indicators for testing/incubation to the pathology company or use an in-house incubator set at correct temperature for incubation. Document the findings and investigate any failures (a pass result is 100%). Any load run subsequently and which does not exceed the parameters of the validated load can be treated as a load not requiring biological test indicators. Attach this checklist to the validation record. RACGP 4th edition Standards 5.3.3 73 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 4.7.8 Maintenance of the steriliser (Customise as appropriate) Policy It is critical that the steriliser is maintained by practice staff and service personnel, in accordance with the steriliser manufacturer’s instructions and that routine servicing by suitably qualified person occurs at least annually. The maintenance procedures must be clearly documented, performed and recorded on an ongoing basis (daily, weekly and monthly) by practice staff and service technicians. The operating instructions are located <<insert location>>. Procedure Changing the water Deionised or distilled water is used and the water reservoir is checked prior to use and drained and refilled weekly Cleaning the steriliser Scale build up and corrosion in the chamber is regularly cleaned using a phosphoric acid or citric acid solution or paste. Outlet drains are visually checked to ensure they are free of debris and seals are visually checked for signs of wear and tear. 4.7.9 Servicing the steriliser A maintenance contract for servicing of the steriliser is established with <<insert name of organisation>>. The steriliser is serviced at least 12 monthly or more frequently if required. The servicing company details are: <<insert company name, contact person and telephone contact details>>. Validation of the sterilisation process Performed at least annually or more frequently if required. Usually this is following the service. Validation is undertaken, according to the validation protocol. Documentation 74 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 All maintenance and servicing is documented in the maintenance log. This includes maintenance performed by staff such as changing the water, cleaning and checking the door seal and outlet drain.Evidence of validation is documented and retained. The 3 validation cycles are recorded in the sterilisation log. Documentation relating to the maintenance and servicing of the sterilizer is kept <<insert location/s>>. 4.9 Storage of sterile items (Customise as appropriate) Policy All sterile items, including those processed in the practice facility and those procured from commercial suppliers, shall be stored and handled in a manner that maintains the sterility of the packs and prevents contamination from any source. Factors that influence shelf life are event-related (not time-related) and are dependent on storage and handling conditions. Procedure Instruments in our practice are stored: in a clean, dry and well ventilated area in an area free from draughts in an area where there is reduced chance of contamination from dust and water with dust covers should items be stored for a long period of time in a manner which allows stock rotation, e.g. place recently used items at the back and take from the front with the contents of the package clearly visible to reduce handling of instruments. Instruments and items used for procedures in other locations such as aged care facilities and home visits are transported to the facility in a separate rigid walled container with a lid labelled sterile items. Care is taken to maintain the sterility of these while transporting to the facility. In our practice, sterile equipment is kept <<insert location>>. RACGP 4thedition Standards 5.3.3 75 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 4.10 Management of waste (Customise as appropriate) Policy The RACGP Infection Control Standards for Office Based Practices outline policies and procedures to assist our practice to safely manage waste. We are also aware of any relevant local or State regulations that impact on our waste management. Our waste policies include: use of Standard precautions when handling waste correct segregation of waste into three streams: “Clinical”, “Related” and “General” storage of waste disposal of waste Effective and safe waste management is important for infection control and also to reduce the impact on the environment and reduce costs. All staff receive education regarding the management and handling of waste, appropriate to their role, including the safe use and disposal of sharps. These categories are defined as: clinical waste has the potential to cause sharps injury, infection or public offence and includes: discarded sharps, human tissues (but excluding hair, teeth, urine and faeces) and materials or solutions containing free flowing or expressible blood. It also includes related waste such as cytotoxic waste, pharmaceutical waste, chemical waste and radioactive waste general Waste is any waste that does not fall into the clinical or related category and may include office waste, kitchen waste, urine, faeces, teeth, hair, nails, sanitary napkins, tampons, disposable nappies, used tongue depressors, disposable vaginal specula, cervical cytology spatulas and plastic cytology brushes, nonhazardous pharmaceutical waste (e.g. out of date saline). NB: General waste contaminated with blood or body substances (though not to such an extent that it would be considered clinical waste, i.e. not contaminated with ‘expressible blood’) must be stored in out of reach or access to children. 76 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure All staff use appropriate PPE which always includes gloves as a minimum, when handling waste. Clinical waste is removed by trained staff. Waste, either general or clinical, is not compressed by hand. Clinical waste includes sharps disposal containers and designated biohazard bins. These are located in each area where clinical waste is generated. They are emptied <<insert frequency>>. Containers used for “non sharp” Clinical Waste in our practice: have a good sealing lid. hand free operation (e.g. wide open mouth, foot pedal or sensor operated) rigid walls should be lined with a plastic bag (preferably a yellow biohazard identified bag) have a biohazard sign affixed to the outside. are located away from the reach of children. While awaiting collection non sharp clinical waste is double bagged using a biohazard identified yellow bag and stored securely inside a locked yellow biohazard identified bin in an area that is separate from clean stores and with restricted access. Sharps are defined as anything that can penetrate the skin and some examples include: needles, scalpels, stitch cutters, glass ampoules, sharp plastic items, punch biopsy equipment, lancets, wire cytology brushes, razors, scissors and disposable surgical instruments. Containers used for disposal of “sharp” clinical waste: comply with Australian standards are placed out of reach of children cannot be knocked over are located so that the neck is clearly visible to health professionals when disposing of items have scalpel blade removers securely mounted to the walls are closed and replaced when the full indicator is reached. While awaiting collection sharps containers are never reopened and are stored with the other clinical waste for collection. Related waste cytotoxic products are disposed of into the sharps containers. 77 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 pharmaceutical waste is disposed of in accordance with the state/ regulations. Our practice uses the services of <<insert the name of the pharmacy or service>>. chemical waste such as formalin need to be disposed of according to state/territory and local government regulations and OH&S requirements. This practice has a service agreement, with <<insert name of company>>, who are contractors specifically licensed to dispose clinical waste through special burial or high temperature incineration. The bins are collected every <<insert frequency of clinical waste collection>>. <<Insert person’s name>> is delegated responsibility to ensure adequate stock levels of clinical waste containers are maintained and collection schedules are timely. Our practice considers recycling principles and the environmental impact when sorting general waste. General waste must not be accessible to children particularly when contaminated by blood or bodily fluids. The sensitivity of information should also be considered when disposing of paper-based materials. RACGP 4th edition Standards 5.3.3 4.11 Sharps Management (Customise as appropriate) Policy Our practice makes every attempt to minimise the risk of injury to both staff and patients, and prevent the possible transmission of disease by discarded sharps. Sharps represent the major cause of accidents involving potential exposure to blood-borne diseases. All sharp items contaminated with blood and body fluids are regarded as a source of potential infection. Safe handling and disposal of sharps is essential to protect the operator and others from injury and possible transmission of disease. Sharps may be defined as any object or device that could cause a penetrative injury. Consideration is given to the purchase and use of devices that significantly reduce the risk of sharps injury. The staff member who generates or uses a sharp is responsible for the safe use and disposal of that sharp. This responsibility cannot be delegated. 78 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 The employer is responsible to ensure all staff are familiar with the practice’s policy and procedure for the safe handling and disposal of sharps and staff are also familiar with the actions to take in the event of a sharps injury. Procedure Sharps disposal containers are placed in all areas where sharps are generated. Where possible they are located between hip and shoulder height. Sharps are placed into rigid-walled, puncture-resistant yellow containers that meet the relevant Australian Standard. Containers are not in a location accessible to children either when in use or when awaiting collection. The following principles are taken into consideration: the person using the sharp is legally responsible for its safe disposal. sharps must be disposed of immediately or at the end of the procedure whichever is most appropriate. sharps must be placed in a yellow puncture-resistant container bearing the black biohazard symbol (AS 4031). used sharps must not be carried about unnecessarily. injection trays must be used to transport the needle and syringe to and from the patient. needles and syringes must be disposed of as one unit. needles must not be recapped. needles must not be bent or broken prior to disposal. containers must not be overfilled as injuries can occur whilst trying to force the sharp into an overfilled container – close container securely when at the fill line. the lid must be sealed once the container is full. For push-on lids, use both hands and apply pressure only to the edges of the lid. sharps disposal units must be conveniently placed in all areas where sharps are generated and should be mounted on a wall or on a bench to prevent spillage. sharps containers must not be placed on the floor or in areas where unauthorised access or injury to children can occur. sharps containers must not be placed directly over other waste or linen receptacles assistance must be obtained when taking blood or giving injections to an uncooperative patient or to a child. For removal and disposal of the sharps container, refer to the instructions detailed under ‘Waste Disposal’ above. 79 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 This practice assumes an active role in reducing the opportunities for sharps injury by purchasing safe equipment whenever such an option is available without compromising the quality and safety of patient care. Examples include: self retracting single use lancets for blood glucose testing self retracting canula insertion devices and needleless. IV administration systems. vacuum blood collection tubes scalpel blade removal devices plastic ampoules Our induction process includes information about the safe disposal of sharps and actions to take in the event of a sharps injury. RACGP 4thedition Standards 5.3.3 4.12 Transmissible and Notifiable Diseases The following table outlines the required action to be taken by practice staff in the event of a suspected or confirmed case of the listed diseases. All staff has been given adequate training in how to respond to these cases. 80 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Disease Acute Bacterial Conjunctivitis Adenoviruses Amoebiasis Anthrax – cutaneous Anthrax - pulmonary Bronchiolitis Chickenpox Croup Cytomegalovirus (CMV) Ebola Enteroviruses Extended Spectrum Beta-Lactamase (ESBL) Giardiasis Hand, foot and mouth disease Hepatitis A Herpes simplex Haemophilus influenza type B (HIB) Impetigo Influenza Measles Methicillin Resistant Staphylococcus Aureus (MRSA) Meningitis Mumps Parvovirus B19 Pediculosis Pertussis Pinworm Respiratory Syncytial Virus (RSV) Rotaviruses Round worm Ring worm Rubella Salmonellosis Scabies Shigellosis Shingles Slapped cheek disease Staphylococcal infections Streptococcus Group A Sudden Acute Respiratory Distress Syndrome (SARS) Tuberculosis Vancomycin Resistant Enterococci (VRE) Varicella Viral haemorrhagic fevers Recommended Precautions Contact Droplet Contact Contact Airborne Contact and droplet Contact and airborne Droplet Contact Airborne Contact Contact Contact Contact Contact Contact and droplet Droplet Contact Contact and droplet Contact and airborne Contact Droplet Droplet Droplet Contact Droplet Contact Contact and droplet Contact Contact Contact Droplet Contact Contact Contact Contact and droplet Contact Contact Droplet Contact and airborne Airborne Contact Contact and airborne Airborne Reportable to State/Territory Health Departments Yes, if gonorrhoeal or chlamydial No No Yes Yes No No No No Yes No No Yes No Yes No Yes No Yes Yes No Yes Yes No No Yes No No No No No Yes Yes No Yes No No No No Yes Yes No No Yes 81 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 4.13 Standard Precautions (Customise as appropriate) Policy Standard precautions apply to work practices that assume that all blood and body substances, including respiratory droplet contamination, are potentially infectious. The NHMRC recommends the use of personal protective equipment including heavy duty protective gloves, gowns, plastic aprons, masks, eye protection or other protective barriers when cleaning, performing procedures, dealing with spills or handling waste Standard precautions are standard operating procedures that apply to the care and treatment of all patients, regardless of their perceived or confirmed infectious status. Standard precautions also apply to the handling of blood and other body fluids. Standard precautions are work practices that are used consistently to achieve a basic level of infection control in all health care settings and all situations. Standard precautions are designed to protect both patients and staff, and comprise the following measures: hand washing use of appropriate personal protective equipment (PPE) for example gloves, plastic aprons and eyewear use of aseptic technique to reduce patient exposure to microorganisms safe management of sharps, blood and body fluid spills, linen and clinical waste routine environmental cleaning effective reprocessing of reusable equipment and instruments evironmental controls such as design and maintenance Procedure All staff involved in patient care or who may have contact with blood or body fluids are required to understand and use standard precautions when they are likely to be in contact with: blood other body fluids, secretions or excretions, except sweat (e.g. urine, faeces) non intact skin mucous membranes 82 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 RACGP 4th edition Standards 5.3.3 4.14 Additional Precautions (Customise as appropriate) Policy Additional precautions are used for patients known or suspected to be infected with highly transmissible pathogens. Additional precautions are measures used in addition to standard precautions when extra barriers are required to prevent transmission of specific infectious diseases. Our staff are educated in how to triage and apply additional precautions for patients known or suspected to have a potential communicable disease. Additional precautions require: ‘isolation’ of the infectious source to prevent transmission of the infectious agent to susceptible people in the health care setting a means for alerting people entering an isolation area of the need to wear particular items to prevent disease transmission. There are three additional precaution categories based on routes of infection transmission in a health care environment. These are: contact precautions droplet precautions airborne precautions. Procedure Additional precautions are used for patients known or suspected to be infected with highly transmissible pathogens (e.g. influenza). In general practice the main goal is minimising exposure to other patients and staff. This may be achieved through: the use of PPE distancing techniques (one metre between patients in the waiting room, isolating the patient in a separate room or their car) 83 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 effective triage and appointment scheduling including putting these patients ahead of others hand hygiene encouraging cough etiquette and respiratory hygiene surface cleaning avoid touching your nose & mouth To help prevent the transmission of communicable diseases, our practice educates patients through posters and information leaflets on appropriate respiratory etiquette, hand hygiene and triaging influenza cases. RACGP 4th edition Standards 5.3.3. 4.15 Personal Protective Equipment (PPE) (Customise as appropriate) Policy Our practice has available Personal Protective Equipment (PPE) which includes heavy duty protective gloves, gowns, plastic aprons, masks (surgical & P2), eye protection; or other protective barriers in all cases where there is potential for contact with blood or body fluids such as when cleaning, performing procedures, dealing with spills or handling waste and when dealing with infectious diseases. Procedure All staff and patients have easy access to appropriate PPE. In areas where PPE is used there are posters providing education on the appropriate application, removal and disposal of PPE PPE is also used when handling chemicals such as cleaning products or Liquid Nitrogen. Our practice ensures that all staff receive education, at induction and on an ongoing basis, as to the appropriate use of various types of PPE, and where to access it. Staff training records are kept <<insert location>>. PPE includes: gloves (sterile, non sterile and standard rubber type). face masks including standard surgical and P2 masks. face and eye shields. 84 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 gowns (long and short sleeved). plastic aprons. All staff understand and are competent in: determining the appropriate use and selecting the correct type of PPE for the presenting situation. explaining the purpose of different PPE equipment. demonstrating the correct fitting and removal of PPE and the safe disposal of these items. PPE is located <<insert location>>. Maintenance and reordering of PPE is the responsibility of <<insert staff member name>>. 85 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 PPE Appropriate use Disposable gloves Disposable gloves should be used: Sterile gloves Heavy duty gloves Surgical Masks when handling blood and body substances or when contact with such is likely when handling equipment or surfaces contaminated with such substances during contact with non-intact skin during venipuncture – although needlestick injury may still occur, the presence of the glove layer could reduce the volume of any inoculum. Sterile gloves should be used: during any surgical procedure involving penetration of the skin or mucous membrane and/or other tissue when venipuncture is performed for the purpose of collecting blood for culture. Heavy duty gloves should be used: during general cleaning and disinfection during instrument processing during cleaning blood or body fluid and other substance spills. Surgical Masks can be used: during procedures or activities that might result in splashing and the generation of droplets of blood, body substances or bone fragments When there is a risk of droplet transmission of disease. To protect unimmunised staff and patients Worn by the patient to prevent the spread of disease (suspected or known) P2 or N95 Masks Worn by staff when there is a risk of airborne transmission of disease (suspected or known) Tuberculosis and pandemic influenza. (Particulate filter masks) Protective eyewear Protective eyewear should be used to prevent splashing or spraying of blood and body fluids into the wearers eyes such as during surgical procedures, venipuncture, or cleaning of spills, contaminated areas or instruments. Worn by staff when there is a risk of airborne/droplet transmission of 86 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 disease (suspected or known). Gowns and plastic aprons Gowns and plastic aprons should be used when there is a risk of contamination of wearer’s clothing or skin with blood and body substances such as during surgical procedures, venipuncture, or cleaning of spills, contaminated areas or instrument processing. Worn by staff when there is a risk of airborne/droplet transmission of disease (suspected or known). Sterile gowns Sterile gowns should be used during procedures that require a sterile field. All staff use appropriate PPE when undertaking any of the following procedures: any examinations requiring contact with mucous membranes. cleaning or dressing wounds, taking down bandages. cleaning up after procedures. preparing instruments and equipment for sterilisation. assisting with or performing procedures. cleaning of contaminated surfaces. cleaning spills of blood & body fluids. using chemicals. taking blood. handling all pathology specimens before they are bagged. controlling bleeding. RACGP 4th edition Standards 5.3.3 4.16 Laundry (Customise as appropriate) Policy All staff members at our practice have received education regarding the management of soiled linen, including when to change linen, the use of appropriate precautions during handling, the washing, drying and storage of linen. 87 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure Linen needs to be changed if: a patient requires the use of contact precautions, (e.g. known or suspected of having CAMRSA, scabies or lice) blood or body fluid has been spilt on the linen it is visibly soiled. before an operative procedure. When changing linen: staff use PPE and standard precautions as required care is taken to ensure sharps are not caught up in the linen Clean linen is located in a clean, dry dust free location away from dirty linen and items. In our practice, clean linen is stored <<insert location of clean linen>>. Option 1: (select if you purchase all disposable linen for your practice) This practice uses only disposable linen on all examination couches and patient treatment areas. Linen is changed regularly and, provided it does not contain expressible blood or body fluid, it is disposed of into the normal domestic rubbish. Any linen that is contaminated with expressible blood or body fluid is disposed of immediately into the clinical infectious waste bin. Option 2: (Select if your practice wash/launder and reuse your linen and delete Option 1 and 3) Used linen is stored in a covered, lined container which is located away from clean items in the (*insert location) before laundering. Any linen that is contaminated with blood or body fluids is collected in a plastic bag before being placed in the used linen receptacle and is rinsed in cold water with oxygenated stain removal at the earliest opportunity All linen is transported in a leak proof container. A separate clean, container or basket is used to return laundered linen to the practice. Linen is washed in a washing machine on a hot or cold cycle using activated oxygen based laundry detergent and dried in the dryer. Option 3:( Select if you use a laundering service to wash and reuse your linen and delete Option 1 and 2) The laundering is contracted out to a commercial laundry service. The laundering service used is <<insert name of the company you use>>. A copy of our agreement is available from <<insert location kept>>. 88 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 RACGP 4th edition Standards 5.3.3 4.17 Safe handling of pathology specimens (Customise as appropriate) Procedure The following process is followed when handling pathology specimens: label and name containers before use to avoid the need for extensive handling after the specimen has been collected. after collection of blood and body substances these should be placed in the appropriate specimen container, as specified by the testing laboratory. wipe the container clean to remove any visible soiling and check specimen is correctly identified. securely seal to prevent any leakage during transport. place the container upright in a waterproof bag or container. take care to avoid contamination of pathology slips by keeping them separate from the clinical specimens. for transport between institutions and interstate, pack the primary specimen, surrounded by sufficient material to absorb its contents, in a sealable inner container and provide a sealable outer container of waterproof, robust material. Label in accord with postal and other transport regulations. Keep cool if necessary. RACGP 4th edition Standards 5.3.3 4.18 Environmental Cleaning Service (Customise as appropriate) Policy All areas of our practice environment are visibly clean. Regular cleaning of work areas is necessary because dust, soil and microbes on surfaces can transmit infection. Cleaning of our practice clinical and non clinical areas must be regular and scrupulous. 89 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 We have a cleaning policy that sets out a schedule and responsibilities for cleaning all areas of the practice in accordance with the requirements outlines in the RACGP Infection control standards for office based practices (4th edition). We have appointed one member of staff with primary responsibility for the development and consistent implementation of our infection control systems and procedures which includes environmental cleaning. Specific areas of responsibility may be delegated to nominated members of the practice team and these particular responsibilities should be documented in the relevant position descriptions. The practice team member with delegated responsibility for environmental cleaning can describe the process for the routine cleaning of all areas of the practice and can provide documentation on the practice’s cleaning policy. A good neutral detergent can be used for most of the cleaning requirements in a health care setting, and this includes floors, walls, toilets and other surfaces. The use of disinfectants is discouraged because they are expensive, often toxic and require contact times to be effective. All work surfaces are made of smooth, non-porous material without cracks or crevices to allow for efficient cleaning. Any gross soiling or body substance spills must be cleaned as soon as possible. Sinks and wash basins must be either sealed to the wall or sufficiently far from the wall to allow cleaning of all surfaces. Damp dusting and wet mopping is used in the cleaning of the environment. Dry dusting and sweeping will disperse dust and bacteria into the air and then resettle. It is potentially hazardous and inefficient, and must be avoided in patient treatment or food preparation areas. All cleaning equipment is stored in a clean and dry condition, in an area not accessible to the public. Our practice has a cleaning schedule with procedures for cleaning clinical and non-clinical areas of our practice. All cleaning staff must receive training in WH&S issues appropriate to general practice and the immunisation status of all cleaning staff is documented. All staff involved in cleaning receives ongoing education in our infection control policies including Hand Hygiene and the correct use of Personal Protective Equipment (PPE) and Waste management. 90 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure <<Insert name>> has the delegated responsibility for the development and consistent implementation of our environmental cleaning processes. This includes education of staff and following up any issues with the quality of environmental cleaning. Our cleaning schedule below describes the frequency of cleaning, products to use and person responsible for cleaning specific clinical and non clinical areas of the practice. Where appropriate we have documented evidence of cleaning activity. Additional and specific cleaning may be required in areas where patients known or suspected to be infected with highly transmissible agents (e.g. influenza) have been. Option 1: (Select if your practice is cleaned by staff and contract cleaners then delete all other options) Practice staff and contract cleaners are responsible for cleaning the premises as specified in the documented cleaning register. Practice staff undertake daily cleaning and the contract cleaners provide general cleaning in all areas of the Practice on a <<insert frequency>> basis. An annual contract with <<insert contract cleaners name>> is negotiated and reviewed every <<insert review date>>. Evidence of cleaning and cleaning procedures is kept <<insert location>>. Option 2. (Select if all cleaning is performed by practice staff. Then delete all other options) Practice staff members are responsible for cleaning the premises. Documented cleaning procedures and evidence of cleaning are kept <<insert location>>. Option 3 (select if cleaning is only performed by a contracted cleaning service. Then delete all other options) An external cleaning service <<insert contract cleaners name>> is responsible for cleaning the premises as specified in the attached cleaning guide. This service is contracted to provide general cleaning in all areas of the Practice on a daily basis (Mon – Fri). An annual contract is negotiated and reviewed every <<insert review date>>. 91 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 The cleaning service operates after 5pm. Spills that occur during normal consulting hours are the responsibility of <<insert person’s name>>. Cleaning staff should adhere to the following principles when cleaning: don personal protective equipment (PPE) such as gloves and a waterproof apron make up water and detergent solution each day use clean dry cloths and mops wash and dry all surfaces promptly dispose of used cleaning solution in the dirty utility area, not in hand basins or clinical sinks wash and dry buckets, cloths, mops and PPE after use wash hands when each task is completed. Areas which are only cleaned/ managed by appropriately trained practice staff are: spillage of blood or body fluids medical instruments or items for re-use are cleaned according to the procedure for cleaning instruments and re-usable items. treatment room benches and trolleys consulting room benches containing medical equipment infectious waste and sharps containers All practice staff responsible for cleaning have been appropriately immunised as documented in their staff records. Should cleaning not conform to the expectations of staff it should be reported to the <<insert designated environmental cleaning person>>. The designated leader also conducts routine audits to ensure a high standard of cleaning. Audits are done every <<insert frequency>> or more frequently as required, using items as defined in the cleaning contract. Safety data sheets of cleaning solutions, disinfectants etc are kept on file in case of a medical emergency. RACGP 4thedition Standards 5.3.3 Routine Cleaning Guide Surface Treatment room benches and Method and cleaning agents to be used Wash with hot water and Frequency Nightly and more Cleaner Responsible Authorised 92 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 trolleys detergent. Dry thoroughly often if required practice staff Benches/drawers containing medical Items Wash with hot water and detergent. Dry thoroughly Weekly and more often if required Authorised practice staff Re-usable medical items and instruments Refer to procedure in Section 4 As required Authorised practice staff Benches and tables in kitchen Wash with hot water and detergent Nightly Sinks, hand basins and toilets Hot water & detergent. An abrasive cream cleanser may be a useful stain remover Daily Hard floors - Treatment Room Vacuum and wet mop with hot water and detergent Daily Hard floors - Other areas Vacuum and wet mop with hot water and detergent Daily - weekly depending on use Carpeted areas Vacuum Daily – weekly depending on use 6 –12 monthly Steam Cleaned Office desks, benches and furniture Damp mop with hot water and detergent / Vacuum Weekly Examination couches Hot water and detergent Daily Toys Dishwasher / Hot water and detergent Daily - Weekly depending on use Waiting Room furniture Hot water and detergent/ Vacuum Daily Curtains - Cubicle Machine hot wash 3 monthly Windows and window furnishings Dry clean / Vacuum Annually Walls and ceilings Hot water and detergent Annually Storerooms Hot water and detergent 3 monthly 93 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 5 Practice Management 5.1 Access & Parking (Customise as appropriate) Policy The GPs and staff recognise that access to the practice facilities is important to our patients. make all reasonable efforts to facilitate physical access to the premises and services offered. are committed to considering how best to meet the needs of our patients with physical disabilities or other special needs. Where possible wheelchair access, suitable parking and pictorial signage is provided to assist patients with a physical or intellectual disability. Where physical access is limited to the practice or where physically attending the practice could result in an adverse outcome for the patient the practice provides off site or home visits. Car parking facilities are available within a reasonable distance from the practice for staff, visitors and patients and where possible there are designated spots for disabled drivers. Sufficient signs are provided externally and internally to assist Staff, visitors and patients in accessing the practice facilities. Procedure This practice provides physical access to patients, visitors and staff via the main entrance. Our practice has a height adjustable examination couch located in <<insert location>> to assist in the care of patients with a disability, and to reduce the risk of patients injuring themselves when getting on or off the examination couch or staff when assisting patients. 94 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Doorways and walkways are to be kept free of clutter, boxes etc. to ensure a clear pathway for all persons and in an emergency Prominent signs at the front of the site: allow the public to easily locate the practice and the parking facilities from the street. display the practice name, address, hours open, telephone numbers (work & after hours). (Please select correct option) Option 1 Access for patients with disabilities. wheelchair access is provided to reception, toilets and consulting rooms. the practice has installed ramps and railings as required to assist patients with disabilities designated disabled parking is provided in close proximity to the entrance (list additional measures, ie. wheelchair lift for stairs) Option 2 As our practice has limited access to all facilities and services, home or other visits are available for patients with disabilities or that may be otherwise unable to access a practice service or facility. RACGP 4th edition Standards 5.1.3 & 5.1.1 5.2 Appointments (Customise as appropriate) Policy Our patient scheduling system is flexible enough to accommodate patients with urgent, non-urgent, complex and planned chronic care, and preventative needs. Our GPs and other members of the clinical team are consulted about the length and scheduling of appointments. Patients are encouraged to book longer appointments for multiple conditions, concerns or family members. Our standard consultation length aims to provide adequate time for GPs to facilitate high quality care. 95 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Patients can request to see their preferred doctor or member of the health team. If a patient is unable to see their preferred GP, they are advised about the availability of other clinical staff and offered an appointment to see them. The urgency of the patient’s condition is always assessed before booking an appointment with their preferred GP at a later time. Where possible information is provided in advance about the cost of healthcare and the potential for out of pocket expenses. If a patient presents at the practice with urgent medical needs, practice staff will respond with appropriate action in relation to the patient’s condition. The practice makes every effort to accommodate patients with urgent needs and all staff are trained in how to respond to medical emergencies. A triage guide is available at the reception area to assist non-clinical team members. Procedure (Please select the appropriate option) Option 1 Appointment Based Booking System In our practice, we use a pre-booked appointment system. A standard consultation is booked for <<insert standard booking length>>. Patients can and are encouraged to request longer consultations if necessary. We accommodate urgent medical cases by: (customise as appropriate) Leaving vacant appointments throughout the day Having a designated GP to deal with urgent cases Employing the assistance of a nurse for triage procedures All patients are asked at the time of requesting an appointment if the matter is urgent. In urgent medical situations, practice staff follow the triage guide located <<insert location of triage guide>>. All urgent medical situations are documented by practice staff in the patient file and include details of: The actions of practice staff The presentation state of the patient The names of any other staff or person involved in assisting with the emergency 96 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 To provide continuity of care, all patients are asked who their preferred GP is or check their record for previous appointments. If they are unable to see their regular GP on that day, they are offered alternative appointments or other GPs within the practice. If excessive wait times exist, practice staff make an effort to advise patients before attending for their appointment. Appointments made for patients required to attend a recall or periodic medical review appointments are flagged and it is imperative the no shows are contacted and another appointment re-scheduled. Option 2 Informal Appointment System Our practice uses an informal appointment system where patients are seen on a first come, first serve basis. When a patient requests an appointment, they are asked whether a longer consultation will be required. Standard consultation times are <<insert standard consultation time>>. We accommodate all medical emergencies as they are presented. Practice staff follow the triage guide located <<insert location of triage guide>>. All urgent medical situations are documented by practice staff in the patient file and include details of: The actions of practice staff The presentation state of the patient The names of any other staff or person involved in assisting with the emergency Patients are advised when presenting at the practice if there are excessive waiting times and are encouraged to come back at a later time. Patients are able to request their preferred GP or practice staff will check their appointment history in an attempt to maintain continuity of care. If the patients preferred GP is unavailable, the patient is offered an alternative GP (where possible). Appointments made for patients required to attend a recall or periodic medical review appointments are flagged and it is imperative that no shows are contacted and another appointment re-scheduled. 97 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure for making an appointment- Formal System (Delete if not applicable) Determine if the appointment is urgent. YES Refer to the triage guide. NO Determine if the patient is new or a regular patient of the practice. Regular Patient New Patient Provide the new patient with as much information about the practice as possible including any costs for treatment, arrangements for parking and request any specific documents or information to bring to their 1st visit. Identify the patient using 3 approved patient identifiers. Ask for the patient’s preferred GP, time and date for the appointment. If not available, offer alternative time, date or GP. Make a record of the patients appointment in the booking system under the allocated time slot. Make any relevant notes associated with the appointment, for example, worker’s compensation, etc. *NB: If the patient indicates that the appointment is for the follow up of results, highlight the appointment for the GP. Procedure for making an appointment- Informal System (Delete if not applicable) When a patient requests an appointment, determine the urgency of the appointment. If the appointment is urgent, follow the procedure in the triage manual. 98 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 If the appointment is not urgent, determine if the patient is a new patient or a regular patient of the practice. If the patient is new, ask them to complete a new patient form. Enter their details in the database and allocate them the next available timeslot. Since they are a new patient, it’s best to allocate a slightly longer appointment time to allow a proper medical history to be taken by the GP. If the patient is a regular of the practice, ask the patient to confirm at least 3 approved patient identifiers. Do not volunteer this information to the patient but ask them to state them. Log the patient in the appointment system. If there are excessive waiting times, inform the patient of their expected wait time and invite them to come back at a later time. Cancellations & Missed appointments Policy If appointments have been made for the follow up of test results, these are flagged in the appointment system. Patients who do no attend appointments are contacted, either by telephone or a letter sent via registered post, and reminded of their appointment. Missed appointments for the follow up of results are of crucial importance and are always followed up by practice staff. <<Delete if not applicable>> Patient who do no attend appointments and fail to provide the practice with sufficient notice will be charged a fee. Our policy for missed or cancelled appointments including any associated fees, are outline din our Practice Information Sheet and a sign displayed prominently in the waiting area. RACGP 4th edition Standards 1.1.1, 3.1.4, 1.5.1, 1.2.4, 2.1.3, 1.5.3 99 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 5.3 Home Visits (Customise as appropriate) Policy Doctors and other practice staff make visits to regular patients of our practice where it is safe and reasonable. These visits may be to patients in their homes, residential aged care facility, residential care facility, or hospital both within and outside normal opening hours, where such visits are deemed safe. All patients are made aware that home visits or a suitable care alternative, are available both within and outside normal opening hours via <<insert method used to notify patients>>. Regular patients who meet the eligibility criteria are offered home visits. For regular patients whose circumstances are deemed not safe and reasonable, e.g. the patient is located too far away for a home or other visit, the practice ensures that there is an alternate system of care that these patients can access. There are arrangements to exchange clinical details about patient care for doctors who perform home and other visits on behalf of the patient’s regular doctor and the care provided is documented in the patient’s medical records. Home and other visits are provided by appropriately qualified health professionals who have received information and advice about safety and security when conducting home visits. Any anticipated costs associated with home visits or alternative care systems are discussed with the patient. Procedure A patient can arrange for a home visit if the criteria below are met: regular patients of this practice live within a <<Insert km radius of the practice>>. where it is deemed by the GP to be safe and reasonable the patient has provided a phone number that you have called them back on 100 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 patient has the type of problem that necessitates a home visit such as: acute illness immobile elderly have no means of transport unable to access the practice facilities due to disability <<Insert your practice requirements here>> If the patient at the time of request indicates that the matter is urgent, refer to the triage protocol and list of urgent conditions for appropriate action. When in doubt, ask to put the caller on hold and refer to the patient’s doctor for advice. Our doctors home visit schedules are recorded in <<insert method of record>>. Patients can request home visits however the final decision rests with the treating GP. Practice staff are not to book home or other visits without consulting the GP. When another health professional is performing home or other visits on behalf of GP at our practice, arrangements are in place to ensure timely exchange of clinical information. All visits provided within or outside normal opening hours are documented in the patient’s medical records. If information is held about the patient in different records (for example, residential aged care facility) there must be a record made for every consultation in each system indicating where the clinical notes for the consultation are recorded to ensure patient health information is available when required. All staff undertaking home visits are given information and advice about protecting their safety. Where it is unsafe or unreasonable to provide a patient with care at home or in another location outside the practice, patients are advised of alternative arrangements. <<Insert the alternative system of care for patients of the practice>>. This advice is documented in the patient health record along with evidence of the subsequent care provided. RACGP 4th edition Standards 1.1.3, 1.7.1, 1.1.4, 1.2.4 101 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 5.4 Telephone (Customise as appropriate) Policy Our practice allows patients to obtain timely advice or information about their clinical care via the telephone. Staff members are mindful of confidentiality and respect the patient’s right to privacy. Patient names are not openly stated over the telephone within earshot of other patients or visitors. This practice prides itself on the high calibre of customer service we provide, especially in the area of patient security, confidentiality, and right to privacy, dignity and respect. It is important for patients telephoning our practice to have the urgency of their needs determined promptly. Staff should try to obtain adequate information from the patient to assess whether the call is an emergency before placing the call on hold. Staff members have been trained initially, and on an ongoing basis, to recognise urgent medical matters and the procedures for obtaining urgent medical attention. Reception staff members have been informed of when to put telephone calls through to the nursing and medical staff for clarification. Patient messages taken for subsequent follow-up by a doctor or other clinical staff are documented for their attention and action, or in their absence to the designated person who is responsible for that absent team members workload. Staff inserts the details of all calls and telephone conversations assessed to be significant in a telephone call log. The doctor needs to determine if advice can be given on the phone or if a face to face consultation is necessary, being mindful of clinical safety and patient confidentiality. Patients are advised if a fee will be incurred for phone advice. Non medical Staff does not give treatment or advice over the telephone. The release of test results over the phone by non-clinical staff is discouraged and can only be done under strict doctor instructions. Before results are given over the telephone, all patients are identified using 3 approved patient identifiers. <<Delete as appropriate>> <All practice staff are familiar with each GPs policy for returning telephone calls> OR <A copy of each doctors telephone policy preferences if kept (insert location)> OR <Our 102 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 practice uses a uniform telephone for all GPs. The practice policy for returning phone calls to patients is (insert policy)>. Staff do not give out details of patients who have consultations here nor any other identifying or accounts information, except as deemed necessary by government legislation or for health insurance funds. A comprehensive phone answering message is maintained and activated to advise patients of how to access medical care outside normal opening hours. This includes advising patients to call 000 if it is an emergency. << If available, the practice ‘on hold’ call message advises patients to call 000 in the event of an emergency>>. Staff are aware of alternative modes of communication that may be used by patients with a disability or special needs including the Translating and Interpreter Service (TIS) and the National Relay Service. Important or clinically significant communications with or about patients are noted in the patients health record. Procedure All telephone calls should be answered by a member if the practice team using an approved/accepted greeting. All calls are immediately assessed for their level of urgency by asking ‘is it urgent?’. Calls which are to be placed on hold are firstly asked if this is acceptable and sufficient time allowed for the caller to respond. If the call is urgent, the practice staff member will refer to the appropriate action from the triage guide or alert a member of the clinical care team immediately. Telephone calls from patients which are not urgent are directed according to the GPs telephone policy. Whenever messages are taken, they are recorded in <<insert location/method>> and include details of the patient name, time/date of the call, and nature of the call, any important facts and a return contact number. All messages must be returned within a timely fashion or by the end of the day. Sensitivity is paid to the privacy and security of patient health information and patient details are not mentioned within earshot of other patients. Patients are identified using 3 approved patient identifiers before any personal information is discussed. 103 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Alternative modes of communication are available for patients with specific needs, for example, TIS for patients with non-English speaking needs. RACGP 4thedition Standards 1.1.1, 1.1.2, 1.1.4, 1.2.3, 5.1.2, 4.2.2 5.5 Electronic Communication (Customise as appropriate) Policy Patients are able to obtain advice or information related to their care or appointment reminders by electronic means, where the doctor determines that a face-to-face consultation is unnecessary. Electronic communication includes: email, fax, and SMS. Practice staff and doctors determine how they communicate electronically with patients, both receiving and sending messages. All significant electronic contact with patients is recorded in the patient health records. Patients are advised through the Practice Information Sheet (PIS) of the practice policy on electronic communications including: Seeking permission or consent from patients The possibility for electronic communications and information to be compromised Notification of any costs involved The frequency of which emails are read by a member of practice staff When an email message is sent or received in the course of a person's duties, that message is a business communication and therefore constitutes an official record. Employees should be aware that electronic communications could, depending on the technology, be forwarded, intercepted, printed and stored by others. Electronic mail is the equivalent of a post card. In regards to this, health information given in electronic communications should be limited and discussed in more general terms. Patients should be advised that information may be compromised. Wherever possible, the practice should ensure secure encryption of emails is taking place. 104 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 The practice uses an email disclaimer notice on outgoing emails that are affiliated with the practice. The following disclaimer is used on all emails sent from this practice: <<Insert message here>>) (Delete if not applicable) The Practice Website Our practice has a website to communicate to patients important information about our practice. It is the responsibility of <<insert person responsible>> to update the practice website on a <<insert frequency>> basis. The practice website can be accessed using the following link <<insert link>> The website is continually monitored to ensure it is kept current and up to date. It contains the minimum information required on the practice information sheet. Any changes to the practice information sheet are also reflected on the website. If it contains any advertising the practice should include a disclaimer that the practice does not endorse any advertised services or products. Advertising must comply with the MBA Code of Conduct on advertising available at: http://goodmedicalpractice.org.au/. RACGP 4thedition Standards 1.1.2 & 1.2.1, 4.2.2 5.6 Medical Emergencies & Urgent Queries (Customise as appropriate) Policy This practice classifies patients seeking medical consultations, according to their priority of need. Our triage system ensures that clinical care is provided to patients with urgent medical problems as a priority. Patients telephoning the practice have the urgency of their needs determined promptly. Where possible, our phone on-hold message includes a recommendation to call 000 if the matter is an emergency. Staff members know and use the triage process, a copy of which is accessible at reception. 105 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Administrative staff and members of the clinical team have the skills and knowledge to assess the urgency of the need for care and can describe our procedures for dealing with urgent medical matters, including when the practice is fully booked. Our induction process includes an orientation to our triage system and staff members are given training in its effective use and are encouraged to regularly update CPR and other first aid skills. The doctors and staff provide appropriate care and privacy for patients and others in distress. We have provisions for doctors to be contacted after hours for life threatening or urgent matters and/or results. Procedure Staff members receive regular training and update’s in CPR, appropriate for their duties, at least every 3 years. All Staff members receive information at induction and on an ongoing basis about our triage guidelines and protocols for medical emergencies. Documentation of training is retained in the individual staff training record. Whenever patients contact the practice, their level of urgency for medical attention is assessed by practice staff in accordance with the practice triage procedure. A log book or computer entry is used to record all significant telephone conversations or actions including medical emergencies and urgent queries. The log records: the name and contact phone number of the patient/caller the date and time of the call the urgent or non urgent nature of the call important facts concerning the patient’s condition the advice or information received from the doctor details of any follow up appointments A triage flowchart and triage manual are located <<insert location>>. 106 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 RACGP 4th edition Standards 1.1.1 5.7 After Hours Service (Customise as appropriate) Policy This practice ensures reasonable arrangements for medical care, including the follow up of seriously abnormal and life threatening pathology results for our patients, both within and outside our normal opening hours. The arrangements for medical care outside normal opening hours, how to access this care and the possibility of out of pocket costs, is communicated clearly to patients of this practice. Feedback about the quality and timeliness of after hours care provided to our patients by a deputising service is also obtained. Patient satisfaction with our after hours service is regularly evaluated and improvements implemented if necessary. Our practice provides after hours care through <delete as appropriate>>: Our practice GPs provide their own care for patients outside normal opening hours either individually or through a roster. Formal arrangements for cooperative care outside the normal opening hours of our practice through a cooperatives of one or more local practices Formal arrangements exist with an accredited medical deputising service Formal arrangements exist with an appropriately accredited local hospital or an after hours facility. <<Remove if care is provided by practice GPs>> <<The practice has a formal written arrangement with this provider of after hour’s care that outlines how it receives information about any care provided to their patients, and how the GP providing the care can contact the practice for clarification or help regarding background information relating to that patient, especially in an emergency.>> Our patient health records contain reports or notes pertaining to consultations occurring outside the normal opening hours for care. Our practice has provisions enabling designated providers of after hours care or pathology providers to contact a patients doctor, or in that persons absence, the person who is caring for that absent team members patients. 107 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure Our normal opening hours are <<insert your opening hours here>>. Advice to our patients on how to access after hours care, including the potential for out of pocket expenses is available:<<delete those not applicable to your practice>> in the practice information brochure on a sign visible from outside the practice practice website Outside of normal hours the practice has a comprehensive message on the answering machine, call diversion or paging system via our main telephone number. This message includes recommending patients call 000 if the matter is an emergency. This is maintained for all incoming calls when this practice is closed. The patient feedback tool contains questions concerning adequate information being given to patients about after hour’s services. The results of patient feedback are evaluated and improvements implemented if required. In the event that the practice doctors need to be contacted, we have an agreement established with the following organisations: <<please list the organisations which you have arrangements with>> Contact details for the GPs or their nominated replacements have been provided to these organisations and it has been outlined in what situations they are to contact the GPs. Any correspondence or notification received about after hours care provided to a patient is documented in their medical record. RACGP 4thedition Standards 1.1.1, 1.1.4, 1.2.4, 1.5.2, 1.2.1, 1.7.1, 2.1.2 5.8 Practice Meetings (Customise as appropriate) Policy Regular discussions where all staff are encouraged to have input are important in building a high performing team. We aim to cultivate a just, open and supportive culture where 108 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 individual accountability and integrity is preserved, but there is a whole-of- team approach to the quality of patient care. (Select the most appropriate option) Option 1 Practice meetings are conducted on a <<insert frequency>> basis or more frequently as required to facilitate the exchange of practice news, other general administration and protocol issues, complaints and to discuss risk management issues arising out of the practice. Matters pertaining to clinical care may be discussed at these meeting if appropriate, or at the practices clinical meetings. Urgent daily notices or other general items are communicated to staff via <<insert method, for example staff noticeboard, staff memo or distribution email>>. Option 2 Due to the small nature of our practice, formal staff meetings or practice meetings do not take place. Instead our practice communicates important issues via informal discussions held on a daily basis during normal work hours. Important communications are detailed as a record in the ‘Communications Book’. Procedure Staff meetings It is important that all members of the practice team have the opportunity to discuss administrative issues with the practice directors and/or owners when necessary. All staff are expected to attend and contribute to the staff meeting. Staff meetings are held <<insert frequency>> and minutes are recorded. Items for the agenda may be submitted to the Practice Manager up to one week prior to the scheduled meeting. All meeting minutes are kept <<insert location>>. Administrative and WH&S practices are regularly reviewed at these meetings. Staff members are given the opportunity to discuss administrative matters with the doctor(s) and/or practice manager when necessary. Discussion and suggestions for improvements to patient safety, policies or procedures associated with risk management, is a standing item on our practice meeting agenda. 109 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Practice discussions about near misses or slips or lapses, with the intention of identifying what went wrong and how to reduce the likelihood of it happening again, are also included in practice and clinical meetings, where appropriate. The decisions made at staff meetings should be documented along with the person responsible for implementing the related action. <<Delete if not applicable>> The Communication Book is located <<insert location>> and all staff are able to access it to read or make important notes regarding practice issues. It is the responsibility of <<insert person responsible>> to ensure the communication book is completed when necessary and viewed by all staff on a regular basis. Clinical Meetings Good communication between members of the clinical team is important for ensuring a consistent approach to clinical care. Doctors and clinical staff, such as nurses and in house allied health, meet face to face at least quarterly, to discuss clinical matters. In between meetings, a communication book and emails are used to consider and communicate clinical issues. <<Insert person responsible for clinical improvement>> is responsible for leading the clinical improvement and is the chair of the meetings. Practice protocols, near misses or latest literature may be discussed. The meetings are recorded on the practice meeting schedule to ensure staff can arrange to attend. There is also a standing discussion item about clinical issues, support systems, new guidelines and evidence. This includes a review of patient information brochures used for preventative activities and to support management or treatment choices, to ensure they are of appropriate quality and all members of the team are giving consistent information. Clinical issues, updates, case studies and reports of Continuous Quality Improvement (CQI) activities, complaints and incident reviews are presented, discussed and action taken as required helping improve processes and patient outcomes. Drug representatives may from time to time arrange a lunch or breakfast meeting, providing a specialist to speak on a particular topic. RACGP 4th edition Standards 1.4.1, 3.1.2, 4.1.1 110 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 5.9 Patient Rights (Customise as appropriate) Policy All practice staff members respect the rights and needs of all patients. No patient is refused access to clinical assessment or medical treatment on the basis of gender, race, disability, Aboriginality, age, religion, ethnicity, beliefs, sexual preference or medical condition. Our practice has implemented provisions to assist all patients to access our services including <<provide an example, ie. Interpreter services>>. The practice identifies important/significant cultural groups within our practice including non-English speaking patients, religious groups and those of Aboriginal and Torres Strait Islander background. We endeavour to continue to develop any strategies required to meet their needs. Patients have the right to refuse any treatment, advice or procedure. Our doctors discuss all aspects of treatment and will offer alternatives should a patient seek another medical opinion. Comprehensive documentation of events when patients refuse treatment or advice, or seek an alternative clinical opinion, are made in the patient record. Contact should also be made to the treating GPs medical defence organisation. Patients are provided with sufficient information about the purpose, importance, benefits, risks and possible costs associated with proposed investigations, referrals or treatments to enable patients to make informed decisions about their health. Patients in Distress There may be times when patients present at the practice in a highly distressed state. These patients require close monitoring and should be afforded dignity when seeking help. When a patient presents at our practice in a distressed state, staff escort the patient to a spare room, usually the <<insert the room commonly left vacant or used for emergencies>>, alert the GP about the situation and continue to monitor the patient until they can be seen by a member of the clinical team. Patients are made comfortable by offering water or tissues. 111 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 RACGP 4th edition Standards 1.2.1, 1.2.2, 2.1.1, 1.5.2 5.10 Complaints (Customise as appropriate) Policy In our practice, customer satisfaction and patient experience is important to us. All patients have the right to complain if they feel the service they received did not meet their expectations. We have a complaints resolution process which all staff can describe, and we also make the contact details for the state or territory health complaints agencies readily available to patients if we are unable to resolve their concerns ourselves. All complaints are attempted to be resolved at a practice level. Only if a satisfactory outcome is not reached should the complaint be directed to the Health Care Complaints Commission (HCCC). Where possible patients and others are encouraged to raise any concerns directly with the practice team who are trained to handle and respond to complaints. We believe most complaints can be responded to and resolved at the time the patient or other people makes them known to us. Patients have the opportunity to remain anonymous if requested. Our practice complies with relevant privacy legislation when responding and handling complaints. All staff should be prepared to address complaints as they arise. Depending on the nature of the complaint and advice received from medical indemnity company, complaints are recorded and actioned within a central complaints register. A copy is placed in the patient’s medical record if the complaint is related to patient care. All clinical staff and the practice manger are aware of their professional and legal obligations regarding the mandatory reporting of unprofessional conduct. Contact is made with the GPs MDO and advice sought on the appropriate action in the event a complaint relates to clinical care. 112 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure Patients and others have opportunities to register their complaints either verbally to staff, in writing (letter) or via our suggestion box. Patients should feel free to complain anonymously if desired. All staff are aware of the complaints management process and are trained to respond appropriately. When receiving complaints staff should keep in mind the following in order to minimise further patient anxiety and hostility, possible leading to litigation: handle all complaints seriously, no matter how trivial they may seem. verbal complaints made in person should be addressed in a private area of the practice where possible. address the patient’s expectations regarding how they want the matter resolved. assure the patient that their complaint will be investigated and the matter not overlooked. offer the patients the opportunity to complete a formal complaint form. (They may accept or decline). All patients are made aware through <<customise as appropriate>> the Practice Information Sheet and signage in the practice waiting area, of their right to lodge a complaint and how they can make a complaint. Brochures with contact details for the HCCC are located in the waiting area and can be generated upon request by practice staff. The HCCC contact details are also available on the Practice Information Sheet. It is the responsibility of <<insert person responsible for complaints>> to collect, investigate and handle complaints. The practice takes the following steps to handle complaints: When a patient indicates they would like to make a complaint, ask if they would like to complete a form. If verbal, take the patient to a private area and document the details of their complaint. Be sure to ask the patient if they would like to remain anonymous or not. Notify the team member responsible for complaints handling and record the complaint in the register. 113 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 The person responsible for complaints handling should acknowledge receipt of the complaint either via telephone or a letter, to advise the patient of the work you will be conducting to investigate the complaint. If the complaint is of a clinical nature, contact the GPs MDO for advice and appropriate action. Investigate the complaint and work with the patient to achieve a mutually beneficial outcome. Discuss the complaint at a staff meeting or clinical meeting (if applicable). Notify the patient or the whole patient population, of the outcome or relevant changes to the practice as a result of the complaint. Record details of the investigation and outcome in the complaints register. If the matter cannot be resolved advise the patient about how to contact the Health Complaints commissioner. The National Privacy Commissioner is able to receive complaints concerning privacy issues. Complaints here will have a response within 28 days. National Privacy Commissioner Privacy hotline 1300 363 992. GPO Box 5218 Sydney NSW 2001 http://www.privacy.gov.au/complaints Members of the public may make a notification to Australian Health practitioner regulation agency (http://www.ahpra.gov.au/) (AHPRA) about the conduct, health or performance of a practitioner or the health of a student. Practitioners, employers and education providers are all mandated by law to report notifiable conduct relating to a registered practitioner or student to AHPRA. RACGP 4th edition Standards 2.1.2 & 4.1.1 114 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 5.11 Non English Speaking Patients (Customise as appropriate) Policy Our doctors and staff have a professional obligation to ensure they understand our patients and that the patients understand any verbal instructions or written information. Patients who do not speak the primary language of our clinical staff or who have a communication impairment, are offered the choice of using an interpreter service to assist with clinical consultations. Our practice does not encourage the use of family members or friends of patients to act as translators unless this is an expressed wish of the patient and he health problem is only minor. Our practice also accesses a number of translated health information to assist with patients who have difficulties reading or understanding English. Procedure All patients are asked when registering with our practice if they require the service of a translator or interpreter. These details are recorded on their medical record. Our practice advises patients of the availability of translating and interpreting services via: <<List all methods of notification>> When a patient arrives at our practice with a friend or family member, we ask if they consent to have them act as a translator and advise of alternative methods available. We advise the patient that it is practice policy not to have family and friends act as translators. In our practice, the following staff are bilingual: List staff and languages spoken Staff are only encouraged to translate for patients in emergency situations or with the patient’s expressed consent when dealing with minor health issues. 115 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Whenever a translator is used during clinical consultations, this should be documented in the patient health record. A copy of the TIS contact list is available <<insert location of contact details>>. It is the responsibility of <<insert person responsible>> to ensure this list is updated regularly and to ensure all client access codes are renewed before expiration. RACGP 4th edition Standards2.1.1, 1.2.3, 2.1.3 5.11.1 Culturally Appropriate Care (Customise as appropriate) Policy We aim to identify important and significant cultural groups within our practice and have implemented strategies to meet their needs. In order to improve health outcomes we: encourage and record when our patients choose to self-identify their Aboriginal or Torres Strait Islander origin or cultural background to practice staff. Encourage and record our patients ethnic and cultural background when patients choose to identify with practice staff Are able to access specific guidelines for the clinical care if patients who identify as Aboriginal or Torres Strait Islander Patients religious beliefs are respected to the best of our staffs ability. The practice has an anti-discrimination policy which all staff are aware of. Procedure Our practice routinely encourages identifying and recording the cultural background of our new and existing patients. Cultural background and ethnicity e.g. Aboriginal and Torres Strait Islander background, can be an important indication of clinical risk factors and can assist GPs and clinical staff in providing disease prevention and delivering culturally appropriate care. The standard indigenous status question asked is ‘Are you of Aboriginal or Torres Strait Islander origin?’ This question should be asked of all patients, irrespective of appearance, 116 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 country of birth or whether the staff know of the client or their family background. Our practice collects this information as part of our ‘new patient’ form. Where our software has the option to input Aboriginal and/or Torres Strait Islander status or cultural background/s we use the drop down options rather than free text to assist with extracting the information for accreditation purposes or preventative activities. To encourage Aboriginal or Torres Strait Islander origin patients to self identify we have <<insert any measures you have taken e.g. Self identification posters in the waiting room, Displaying the Aboriginal and Torres Strait Islander flags on brochures, or having the Koori Mail in your waiting room http://www.koorimail.com>>. <<Customise as appropriate>> Our practice staff and GPs have undertaken cultural awareness training to assist in the development of culturally appropriate services at our practice. Our practice also collects and records information on patient ethnicity and languages spoken to assist with delivering clinical care appropriately. RACGP 4thedition Standards 1.4.1, 1.7.1, 2.1.1 5.12 Directory of Local Health and Community Services (Customise as appropriate) Policy Our practice engages with a range of health, community and disability services to plan and facilitate optimal patient care to patients whose health needs require integration with other services. A readily accessible<<written or computerised>>directory of health and community services, utilised by patients within our area, including how to refer or contact these agencies, is maintained and updated regularly. It is the responsibility of <<insert person responsible>>to ensure this database is updated and maintained on a regular basis. GPs and other clinical staff are encouraged to advise the person responsible to maintain the database if new providers are to be included. 117 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Clinical staff are encouraged to co ordinate patient care across the general practice setting with other health services and to build good working relationships with these providers to facilitate collaborative care Procedure This directory is located (*Insert how to access your directory of services). The contact numbers in this list are checked and updated annually or more often if required, by <<insert person responsible>>. All new staff are made aware of how to access this list during their induction. The directory of local health and community services lists: local medical/diagnostic services. local hospitals and specialist consulting services. primary healthcare nurses. pharmacists. disability and community services. health Promotion and public health services and programs. relevant Government departments in the Region. local allied health services. community, social or self help groups in the area. culturally appropriate services for non English speaking background and Aboriginal and Torres Strait Islander patients. Where possible, a brief explanation about any fees applicable, contact numbers or names and procedures for interacting with these services is included on this list. RACGP 4th Edition Standards 1.6.1 5.13 Provision of Brochures, Leaflets and Pamphlets for Patients (Customise as appropriate) Policy There is a range of posters, leaflets and brochures available or on display in the waiting room, reception and/or consulting rooms. Where appropriate these are available in more than one language or in formats to assist patients with intellectual impairment. 118 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Leaflets, brochures and pamphlets can vary considerably in quality. The brochures used by this practice are carefully selected and screened by clinical staff to ensure they are culturally appropriate and contain current, evidence based information. The quality and accuracy of any Audio visual resources or internet sites recommended to patients or used to provide printed information to patients is also considered. The brochures, posters, leaflets and pamphlets available include information about health promotion, and illness prevention, specific diseases, medical procedures and privacy and patient rights. The doctors and clinical staff use written information during a consultation to: support diagnosis and management of conditions. for health promotion and illness prevention Brochures and educational materials are also available for patients to self select. Procedure All health promotion and educational materials are carefully reviewed by members of the clinical team to ensure they are consistent with the current best practice guidelines. Items are obtained from reputable sources and, where possible, items should be dated, contain the name of the source and referenced to supportive evidence. Our practice regularly obtains brochures from these organisations: List organisations which brochures are obtained from At least annually we conduct an audit of our brochures, leaflets and patient information sheets to ascertain if they are current and if better options are available. Brochures and leaflets are displayed in the waiting room or in the consultation rooms. It is the responsibility of <<insert the name of the person responsible>>to ensure that brochures are kept up to date, discarded when no longer current and new brochures incorporated when available. The provision of specific written material to support advice given in consultations is encouraged to help patients remember the key messages from the consultation and address individual patients’ needs. RACGP 4th Edition Standards 1.2.3, 1.3.1, 1.4.1, 1.2.2 119 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 5.14 Practice Information Sheet (Customise as appropriate) Policy The Practice Information Sheet (PIS) provides patients with adequate information about our practice to facilitate access to care. It is also a useful way to inform patients of current practice policies or changes to our services. We endeavour to ensure all patients, new and existing, are provided with the most up to date version to ensure the information they have is accurate. Our practice information sheet is made available at reception and is provided to all new patients when registering with the practice. If a patient is unable to read or understand our practice information sheet an alternative method is used to supply this information. These may include: verbally. larger font versions. through the National Relay Service or AUSLAN for patients who are deaf. through the translation and Interpreter service (TIS) for patients who speak languages other than English. getting our sheets translated into languages commonly used at our practice. <<Customise as appropriate>> Telephone messages, the on hold recording and our website is also used, where possible, to reinforce some of the information about our practice and our services Procedure The practice information sheet is kept at reception; it is available to all patients and handed to each new patient on their first visit. Where patients are unable to read or understand our written sheet we use other means to communicate the essential information. To maintain the accuracy of our information sheet it is reviewed regularly and updated as required. When this sheet is updated the date is inserted in the footer to denote the latest version. Reception staff are advised there has been a change and are encouraged to bring 120 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 this new version to the attention of our patients. It is the responsibility of <<insert person responsible>> to review and update the practice information sheet. The Practice information sheet contains at a minimum: practice address and phone numbers consulting hours and arrangements for care outside our normal opening hours, including a contact telephone number. our practice’s billing principles such as bulk billing, accounts settlement, approximate cost for treatment, potential out of pocket expenses. our practice’s communication policy including receiving and returning phone calls and electronic communication (e.g. SMS & email). our practices policies for the management of patient health information including that patients can obtain a copy of their health information and where additional posters or the full privacy policy can be obtained from the practice. the process for the follow up of results e.g. who will contact whom and by when. how to provide feedback or make a complaint to the practice (include the contact for the local state health complaints conciliation body and the name of the person responsible for feedback and complaints). Additional information on the practice information includes:<<customise as appropriate>> names and qualifications or special interests of doctors, nurses, allied health and other practice team members (subject to their consent). clinical and other services available. that they can request a summary of the policy on home, hospital, and nursing home visits. inform patients that longer consultations are available on request. encourage ways in which patients can give feedback (e.g. tell patients if you have a suggestion box). how patients are able to request their preferred doctor. inform patients about your reminder systems and the option of opting out of receiving reminders. information about how patients can assist by telling the practice if their personal information changes e.g. changed address or provide any court documentation to advise any child custody arrangements. where the practice has a website it should contain at a minimum, the information required in the practice information sheet. The website information should be accurate and updated regularly. 121 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 It is the responsibility of <<insert the person responsible>> to ensure copies of the practice information sheet are available at reception. RACGP 4thedition Standards 1.2.1, 1.2.3, 1.2.4 5.15 Office Supplies (Customise as appropriate) Policy Supplies of stationery, other office and Practice stores including prescription pads, letterhead, certificates etc. are accessible only to authorised persons. Practice office equipment and facilities are appropriate for its purpose and are safe to use. Regular audits are conducted to review the safety and security of practice equipment and stationery supplies. Facsimile, printers and other electronic communication devices in the practice are located in areas that are only accessible to the general practitioners and other authorised staff. Faxing is point to point and will therefore usually only be transmitted to one location Procedure It is the responsibility of <<insert person responsible>> to monitor the safety and security of practice equipment and office stationery supplies. Sensitive practice stationary such as prescription pads and letterheads are located <<insert location>> and are only accessible by authorised staff. Reports of broken practice equipment or low levels of office supplies are made to <<insert person responsible>> to rectify the situation. RACGP 3rd edition Standards 5.1.1 122 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 6 Privacy and Personal Health Information 6.1 Privacy and Security of Personal Health Information (Customise as appropriate) Policy This practice is bound by the Federal Privacy Act 1998 and National Privacy Principles, and also complies with the New South Wales Health Records and Information Act 2004. ‘Personal health information’ is a particular subset of personal information and can include any information collected to provide a health service. This information includes medical details, family information, name, address, employment and other demographic data, past medical and social history, current health issues and future medical care, Medicare number, accounts details and any health information such as a medical or personal opinion about a person’s health, disability or health status. All patient health information is considered private and confidential. Disclosure of patient health information is not conducted without the consent of patient’s and the GPs. Any information disclosed without consent will result in disciplinary action and possible dismissal of staff. All staff working within the practice have signed confidentiality agreements as conditions of their employment. Information security is discussed at staff induction and continued education occurs throughout employment. When patient health information is computerised, electronic measures have been taken to ensure the safety and security of this information. The person responsible for Information Technology/Information Management (IT/IM) is <<insert name of person responsible>> who is charged with the coordinating, implementing and monitoring these measures. Our practice complies with both state and federal privacy legislation relating to medical records. Our practice also complies with the National Privacy Principles. 123 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 For each patient we have an individual patient health record containing all clinical information held by our practice relating to that patient. The practice ensures the protection of all information contained therein. Our patient health records can be accessed by an appropriate team member when required. We also ensure information held about the patient in different records (e.g. at a residential aged care facility) is available when required. Procedure In our practice, patient health information is kept <<edit as appropriate>> using a paper-based filing system/ electronic filing system/ using a combination hybrid system. Paper-based records are stored <<insert location of paper-based file storage>>. In our practice, the following measures are taken to ensure the security and privacy of patient health information kept as paper records: files are stored in a locked cabinet/secure room/secure offsite location. files are stored in area where constant staff supervision can easily be afforded files are stored in an area that restricts public access files are placed out of view from the patient either face down or behind desks in high patient traffic areas For records stored electronically, the following procedures are in place to protect patient health information: all staff have individual logins and passwords staff have restricted levels of access to patient health information depending on their role computer screens are located in positions where patient view is obstructed or blocked screensavers and automated computer locks are activated during periods of inactivity appropriate firewalls and antivirus software is installed and updated regularly all information electronically communicated is done so using an encrypted network. Our practice policy has a documented privacy policy for the management of patient health information which is available to patients upon request and displayed within the waiting area or in the Practice Information Sheet. The policy outlines the following: 124 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 practice contact details what information is collected reason for the information to be collected how the security of information is maintained range of people who may access the information procedures for access, transfer and disclosure to a third party contact details if they believe there has been a privacy breach with their information The maintenance of privacy requires that any information regarding individual patients, including staff members who may be patients, may not be disclosed either verbally, in writing or in electronic form, except for strictly authorised use within the patient care context at the practice or as legally directed. Whenever sensitive documentation is discarded the practice uses an appropriate method of destruction including shredding or security bin. Electronic information is securely destroyed using appropriate electronic equipment and processes. Hybrid Record Systems Our practice uses a hybrid record keeping system for patient medical files. To ensure continuity of care and completeness of the medical record, we ensure that there is an record in each system indicating where the clinical consultation notes and reports are recorded. RACGP 4thedition Standards 4.2.1, 1.7.1, 1.2.1, 4.2.2 6.2 Computer Information Security (Customise as appropriate) Policy Our practice has systems in place to protect the privacy, security, quality and integrity of the data held electronically. Doctors and staff are trained in computer use and our security policies and procedures. Additional training and policy updates occur when necessary changes are made. 125 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 <<Insert staff member responsible for IT/IM>> has designated responsibility for overseeing the maintenance of computer security and our electronic systems and these responsibilities have been documented in their position description. All clinical staff have access to a computer to document clinical care. For medico legal reasons and accurate reporting, staff always log in under their own passwords to document care activities they have undertaken. Our practice ensures that all computers and servers used by the practice, comply with the RACGP computer security checklist and that: <<edit as appropriate>> computers are only accessible via individual password access to those in the practice team who have appropriate levels of authorisation. computers have screensavers or other automated privacy protection devices are enabled to prevent unauthorised access to computers. servers are backed up and checked at frequent intervals, consistent with a documented business continuity plan. back up information is stored in a secure off site environment. computers are protected by antivirus software that is installed and updated regularly computers connected to the internet are protected by appropriate hardware/software firewalls. we have a business continuity plan that has been developed, tested and documented. Electronic data transmission of patient health information from our practice is in a secure format. Our practice has the following information to support the computer security policy: current asset register documenting hardware and software including software licence keys logbooks/print-outs of maintenance, backup including test restoration, faults, virus scans folder with warranties, invoices/receipts, maintenance agreements Inappropriate use of the practices computer systems or breaches of practice computer security will be fully investigated and may be grounds for dismissal. This practice has a sound backup system and a contingency plan to protect practice information in the event of an adverse incident, such as a system crash or power failure. This plan encompasses all critical areas of the practice’s operations such as making appointments, billing patients and collecting patient health information. This plan is tested on a regular basis to ensure backup protocols work properly and that the practice can continue to operate in the event of a computer failure or power outage. 126 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure The person responsible for IT/IM has completed the RACGP Computer Security Checklist and Self-Assessment. A computer security manual has been specifically developed to assist with the computer security operations and is located <<insert location>>. Our disaster recovery folder stocked with items to enable the practice to operate in the event of a power failure is located <<Insert location>> and includes the following: torches paper prescription pads/ medical certificates etc appointment schedule printout and manual book letterhead consultation notes manual credit card/payment/Medicare processing equipment emergency numbers Add additional items as appropriate RACGP 4thedition Standards 4.2.1 & 4.2.2 6.3 Practice Privacy Policy (Customise as appropriate) Policy National Privacy Principle 5 requires our practice to have a document that clearly sets out its policies on the collection, handling and storage of patient health information. This document, commonly called the Privacy Policy, outlines how we handle personal information collected (including health information) and how we protect the security of this information. It must be made available to anyone who asks for it and patients are made aware of this. The collection statement informs patients about how their health information will be used including other organisations to which the practice usually discloses patient health information and any law that requires the particular information to be collected. Patient consent to the handling and sharing of patient health information should be provided at an early stage in the process of clinical care and patients should be made aware of the collection statement when giving consent to share health information. 127 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 In general, quality improvement or clinical audit activities for the purpose of seeking to improve the delivery of a particular treatment or service would be considered a directly related secondary purpose for information use or disclosure therefore specific consent for this use is not required. Procedure We inform our patients about our practice’s policies regarding the collection and management of their personal health information via: <<edit as appropriate>> a sign at reception. brochure/s in the waiting area. our patient information sheet. new patient forms – ‘Consent to share information’. verbally if appropriate. the practice website. A copy of our practice privacy policy is located <<insert location>> and is available to patients upon request. The practice features the following collection statement on each ‘New Patient’ registration form: <<edit as appropriate>> “<Insert Medical Practice Name> located at <insert practice address> collects your personal details and health information to ensure we deliver the best possible healthcare service. Patients are entitled to access their information at any stage by contacting the practice or their GP. Your health information may be disclosed to other organisations over the course of your treatment and these instances will be discussed with you if required. Failure to provide accurate and comprehensive information could negatively affect your healthcare. If you have any concerns regarding your privacy, please contact the practice. “ Prior to a patient signing consent to the release of their health information patients are made aware they can request a full copy of our privacy policy and collection statement. Patient consent for the transfer of health information to other providers or agencies is obtained via a signed transfer form, which is then incorporated into the patient medical record. Documents which contain patient health information sent to other health care providers, 128 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 such as referrals, are discussed with patients prior to their distribution. All requests for access to health information by patients are documented and incorporated into the medical record. <<Delete if not applicable>> All new patients signed registration form is scanned into their medical record/stored in their medical file. RACGP 4thedition standards 4.2.1 6.4 3rd Party Requests for Access to Medical Records/Health Information (Customise as appropriate) Policy Requests for 3rd Party access to the medical record should be initiated by either: receipt of correspondence from a solicitor or government agency by the patient completing a Patient Request for Personal Health Information Form Where a patient request form or and signed authorisation is not obtained the practice is not legally obliged to release. Where a patient does not provide consent for 3rd party access, the third party may seek access under relevant privacy laws. An organisation ‘holds’ health information if it is in their possession or control. If you have received reports or other health information from another organisation such as a medical specialist, you are required to provide access in the same manner as for the records you create. If the specialist has written ‘not to be disclosed to a third party’ or ‘confidential’ on their report, this has no legal effect in relation to requests for access under the Health Records Act 2001. You are also required to provide access to records which have been transferred to you from another health service provider. We only transfer or release patient information to a third party once the consent to share information has been signed and in specific cases, informed patient consent has may be sought. Where possible de identified information is sent 129 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Our practice team can describe the procedures for timely, authorised and secure transfer of patient health information in relation to valid requests. Procedure Patient consent for the transfer of health information to other providers or agencies is obtained on each individual occasion when a request is made. As a rule no patient information is to be released to a 3rd Party unless the request is made in writing and provides evidence of a signed authority to release the requested information, to either the patient directly or a third party. Where possible de identified data is released. Written requests should be noted in the patient's medical record. Requests should be forwarded to the patient’s GP for action. Requested records are to be reviewed by the treating medical practitioner or principal doctor prior to their release to a third party. Where a report or medical record is documented for release to a third party, the practice may specify a charge to be incurred by the patient or third party, to meet the cost of time spent preparing the report or photocopying the record. This fee should be disclosed to the patient or third party at the time of the request. The practice retains a record of all requests for access to medical information including transfers to other medical practitioners. A full patient record is never released unless specified for legal reasons, such as a subpoena. A patient health summary is usually sent to another health care provider and additional reports or results as required. Security of any health information requested is maintained when transferring requested records and electronic data transmission of patient health information from our practice is in a secure format. A courier service or traceable registered post service is used to send records to a third party. The practice’s medical defence organisation is always contacted for advice prior to the release of patient health information. RACGP 4thedition Standards 4.2.1 & 4.2.2 130 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 6.5 Request for Access to Personal Health Information (Customise as appropriate) Policy Patients at this practice have the right to access their personal health information (medical record) under the Commonwealth Privacy Amendment (Private Sector) Act 2000 and the NSW Health Records and Information Privacy Act 2004. The Act gives individuals a right of access to their personal health information held by any organisation in the private sector in New South Wales in accordance with Health Privacy Principle 6 (HPP 6). This principle obliges health service providers and other organisations that hold health information about a person to give them access to their health information on request, subject to certain exceptions and the payment of fees (if any). Public sector organisations continue to be subject to the Freedom of Information Act 1982. This practice complies with both laws and the National and Health Privacy Principles (NPPs & HPPs) adopted therein. Both Acts give individuals the right to know what information a private sector organisation holds about them, the right to access this information and to also make corrections if they consider data is incorrect. Reports from specialists and diagnostic results form part of a patient’s medicl record and therefore are provided under access regulations. Amendments to the Privacy Act 1998 apply to information collected after 21st December 2001, however they also apply to data collected prior to this date provided it is still in use and readily accessible. We respect an individual's privacy and allow access to information via personal viewing in a secure private area. The patient may take notes of the content of their record or may be given a photocopy of the requested information. A GP may explain the contents of the record to the patient if required. An administrative charge may be applied, at the GPs discretion, e.g. for photocopying record, X-rays and for staff time involved in processing request. 131 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure Our patients are advised of their right to access their personal information via <<insert method>>. Our privacy policy is available to patient upon request. Release of information is an issue between the patient and the doctor. Information will only be released according to privacy laws and at doctor's discretion. Requested records are reviewed by the medical practitioner prior to their release and written authorisation is obtained from the patient. When our patients request access to their medical record and related personal information held at this practice, we document each request and endeavour to assist patients in granting access where possible and according to the privacy legislation. Exemptions to access will be noted and each patient or legally nominated representative will have their identification checked prior to access being granted. A Request for Personal Health Information form is completed by the patient and a copy is incorporated into the patient health record. Request by another (not patient) An individual may authorise another person to be given access, if they have the right e.g. legal guardian, orif they have a signed authority. Under NPP 2 Use & Disclosure, a 'person responsible' for the patient, if that patient is incapable of giving or communicating consent, may apply for and be given access, for appropriate care and treatment or for compassionate reasons. Identity validation applies. The Privacy Act 1998 defines a 'person responsible' as a parent of the individual, a child or sibling of the individual, who is at least 18 years old, a spouse or de facto spouse, a relative (at least 18 years old) and a member of the household, a guardian or a person exercising an enduring power of attorney granted by the individual that can be exercised for that person's health, a person who has an intimate relationship with the individual or a person nominated by the individual in case of emergency. Each request for access is acknowledged and the specific needs for access are discussed between the GP and the patient. If a fee will be charged for granting access or preparing records, this will be discussed with the patient prior to access being granted. Fees are not excessive and aim to cover any administrative costs. Before the release of any health information, the GP will contact their MDO to assess whether data should be withheld. In cases where an access request or data is being 132 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 denied, it will be documented in writing and sent to the patient outlining reasons for this decision. Personal health information may be accessed in the following ways: view and inspect information view, inspect and talk through contents with the doctor take notes obtain a copy (can be photocopy or electronic printout from computer) listen to audio tape or view video information may be faxed to patient Before any access is granted, the identity of the patient should be confirmed using 3 approved patient identifiers. If access is granted to a guardian, their identity and authority must also be checked. If the patient is viewing the data, supervise each viewing so that patient is not disturbed and no data goes missing. If a copy is to be given to the patient ensure all pages are checked and this is noted in the request form. If the doctor is to explain the contents to a patient then ensure an appointment time is made. RACGP 4thedition Standards 4.2.1 6.6 Medical Records Administration Systems Select the appropriate option for the medical records at your practice, throughout this section Our practice uses paper based medical records for the storage or management of patient health information. Our practice uses <<Insert name of software>> for the storage or management of patient health information. 133 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Our practice uses a Hybrid system to manage Patient medical information. This system comprises of paper based records and computer records. <<Insert the name of the software you use and any cut-off dates for paper records>>. For all consultations, importance communications or correspondence related to a patient whose record is part of the hybrid system, a record is made in each system indicating where the consultation notes are recorded. Before entering, accessing or actioning anything from a patient health record on the practice system, practice staff correctly identify each patient using three approved patient identifiers. The approved identifiers include: Patient name (both first and surname) Date of birth Gender (as determined by the patient) Address Patient health record number (where one exists) All referral letters written by the practice also contain at least three approved identifiers. This policy also applies to all patient medical records accessed via telephone enquiries. Procedure At each encounter with a patient, whether in person or over the telephone, patients are asked to state their name, date of birth and address. Practice staff are cautious not to volunteer their information for confirmation to avoid errors. All patients regardless of how well known they are to practice staff are asked to state these details. All referral letters written by the GPs of our practice contain at least three approved identifiers. RACGP 4thedition Standards 3.1.4 & 1.7.1 134 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 6.7 Retention of Records and Archiving (Customise as appropriate) Policy Our practice refers to state and federal legislation regarding the length if time a medical record must be retained. For children, records must be kept until the child reaches the age of 25 years old. All other records must be kept for a minimum of 7 years from the last date of contact. Other records relating to restricted or controlled drugs, sterilisation and human resources are kept for the same period as medical records. Our practice conducts a regular process of culling and destroying patient health records on a <<insert frequency>> basis. Our practice also conducts a regular process of identifying and inactivating patient records. An inactive patient record is considered someone who has not visited the practice or accessed services at least three times in the past two years. All records are destroyed in a secure manner to protect the privacy of patients and advice is sought from the practice MDO before disposal. Procedure All inactive paper-based medical records are stored <<insert location>>. Electronic medical records are designated as inactive using the clinical desktop software. It is the responsibility of <<insert person responsible>> to conduct a regular culling process for patient medical records. All paper-based medical records no longer required to be kept are destroyed using a secure destruction method. Our practice uses <<insert method>> to securely destroy records. If this process is undertaken by an external organisation, the <<insert person responsible>> will obtain a certificate of destruction. 135 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 RACGP 4thedition Standards 1.7.1, 4.2.1, 4.2.2 6.8 Transfer of Medical Records (Customise as appropriate) Policy Transfer of medical records from this practice can occur in the following instances: for medico-legal reasons e.g. record is subpoenaed to court. when a patient asks for their medical record to be transferred to another practice where an individual medical record report is requested from another source. where the doctor is retiring and the practice is closing. Our practice team can describe the procedures for timely, authorised and secure transfer of patient health information to other providers and in relation to valid requests. Procedure In accordance with state and federal privacy regulations, a request to transfer medical records must be signed by the patient giving us authority to transfer their records. The request form should contain: the name of the receiving practitioner or practice. the name, address (both current and former if applicable) and date of birth the patient whose record is required. the reason for the request. When fulfilling a request, this practice may choose to either prepare a summary letter (manually or via clinical software) and include copies of relevant correspondence and results pertinent to the ongoing management of the patient. make a copy of the medical record and dispatch the copy to the new practice, retaining the original on site for a minimum of 7 years. The requesting clinic is advised if we intend to transfer a summary or a copy of the full medical record. All attempts are made to ensure that the format is preferred by the practitioner/practice. 136 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 If there is going to be any expenses related to the transfer, the requesting clinic and the patient, are advised prior to sending the medical records. Once payment of the fee has been received, staff process the request as soon as possible. Any charges must not exceed the prescribed maximum fee. The patients’ signed request letter/form and a notation when the record was transferred is made on the medical record retained by our practice. Details about the receiving practice, date and method of transfer are also documented. Electronic data transmission of patient health information from our practice is in a secure format. All reasonable steps are taken to protect the health information from loss and unauthorised disclosure during the transfer. This practice does not allow individuals to collect the file and take it to their new provider. RACGP 4thedition Standards 4.2.1, 4.2.2, 1.5.2 137 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 7 Clinical Management 7.1 Clinical Autonomy (Customise as appropriate) Policy Doctors in this Practice are free to make decisions that affect the management of their patients in accordance with accepted clinical judgement, best available evidence and adherence to valid clinical care guidelines. Doctors exercise full autonomy in determining: the appropriate clinical care of their patients. the health professionals including specialists, other general practitioners and para-medical practitioners to whom they refer. the pathology, diagnostic imaging or other investigations they order and the provider they use. how and when to schedule follow up appointments with individual patients. whether to accept new patients provided that this action is non-discriminatory and does not apply to emergencies. Feedback is sought from doctors and other staff concerning the use of practice equipment, appointment scheduling and other matters relating to professional autonomy. All members of the clinical team comply with their professional and ethical obligations and practice within the boundaries of their knowledge, skills and competence, and their role within the practice team. RACGP 4thedition Standards 1.4.2 138 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 7.2 Clinical Content of Medical Records (Customise as appropriate) Policy Each patient at our practice has their own individual patient health record containing all the health information held by our practice about that patient. Our practice can demonstrate that the following actions are being completed by staff: recording the emergency contact of all patients recording the Aboriginal and Torres Strait Islander status of patients who wish to self-identify recording other cultural backgrounds of patients recording the allergy status, including ‘no known allergies’, of all patients updating and monitoring the accuracy of patient health summaries recording the preventative health care status of patients wherever possible. The new patient and update patient details form attempt to capture this information to be incorporated into the patient record. An audit of patient health records can show that: at least 90% of active patients have an allergy status recorded at least 75% of active patients have an updated and current health summary Procedure In our practice, our record keeping system is paper-based/ fully electronic/ hybrid combination system. All staff members responsible for delivering clinical care have appropriate levels of access to make clinical notes. Clinical staff are required to document all important communications with patient in their designated health record. Documentation should also be sought from practitioners who provide care on behalf of the practice or care which takes place outside the practice premises. 139 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 At a minimum, consultation notes will include: Date of consultation Patient reason for consultation Relevant clinical findings Diagnosis Recommended management plan and, where appropriate, expected process of review Any medicines prescribed for the patient Complementary medicines used by the patient Any relevant preventative care undertaken Any referral to other healthcare providers or health services Any special advice or other instructions Who conducted the consultation At a minimum, patient health summaries will include: Adverse drug reactions Current medicines list Current health problems Relevant past health history Health risk factors (smoking, nutrition, alcohol and physical exercise) Immunisations Relevant family history Relevant social history including cultural background where clinically relevant All referral letters, correspondence and reports/results relating to patients will be incorporated into their medical record. Practice staff who contact the patient for following up care or results, must document in the patient health record all attempts to contact patients. If access is restricted to administrative staff, <<insert name of person responsible>> will transcribe this information at a later stage. Wherever possible, records must be legible and of a standard which will ensure continuity of patient care across clinicians. All patient records are accessible by clinical staff at the time of consultation. All staff are provided with training during their induction and on an ongoing basis on how to create and edit patient records. 140 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 RACGP 4th edition Standards 1.7.1, 1.7.2, 1.7.3, 1.1.3, 1.1.4, 1.5.1 7.3 Informed Consent (Customise as appropriate) Policy Our doctors, nurses and other healthcare workers inform their patients of the purpose, importance, benefits, risks and possible costs of proposed investigations referrals or treatments, including medications and medicine safety. We believe that patients need to receive sufficient information to allow them to make informed decisions about their care. When communicating to patients the risks, benefits, importance and purpose of proposed treatments or investigations, the following factors are taken into consideration: Language barriers including written material in languages other than English Patient’s ability to provide comprehensive understanding and informed consent Whether a third party is responsible for care In situations where patients are dependent on a third party for their ongoing care we endeavour to provide all appropriate information to the carer. Issues of personality, personal fears and expectations, beliefs and values are also considered. Our clinical staff utilise written material including diagrammatic representations to assist patients to understand the proposed treatments/investigations. In cases where this has occurred, records are made in the patient health file. Patients are advised of possible costs involved, including additional out of pocket costs, for procedures, investigations and treatments conducted on site prior to them being conducted. Patients are encouraged to seek alternative clinical opinions in the event they disagree with the proposed activities of our clinical staff. Refusal to undergo proposed treatment or expressed interest in seeking another clinical opinion are documented in the patient health record. 141 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure Clear communication is provided about the potential for out of pocket costs including any unexpected developments and the possible costs of additional treatments or procedures before proceeding. All advice relating to proposed clinical care of patients is provided by clinical staff who have adequate training to supply such information. Under no circumstances are administrative staff to offer clinical advice or answer any clinically based questions from patients. If deemed necessary, administrative staff may be asked to witness a patient’s consent to a procedure once explanations have been provided by the clinical team. Wherever possible, clinical staff utilise written material to support the explanation of the costs, risk, benefits, purpose and importance of proposed treatments, medications, investigations and procedures. In these situations, it is recorded in the patients medical record when written material is used. Patients who refuse or wish to seek further clinical opinion for treatment are free to do so. It is recorded in the patient health file when patient refuse treatment or indicate they plan to seek alternative opinions. In extreme cases, the treating clinicians MDO will also be contacted and advice sought. For children, all medical decisions will be made by parents until the GP has determined the child is of age to make their own medical decisions. Carers of patients will be included in the decision making process if the patient is deemed as being unable to make their own decisions. RACGP 4th edition Standards 1.2.2 & 1.2.4 7.4 Referral Protocols (Customise as appropriate) Policy Patients may require the services if additional care providers to external to the practice. 142 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Whenever referral letters are written, the costs, benefits, risks, importance and purpose of the referral is explained to the patient by the clinician. All referral documents are filed in the patients medical record. The practice has an up to date <<edit as appropriate: written or computerised>> directory of local allied health providers, community and social services and also local specialists to assist when choosing practitioners to facilitate optimal patient care. Clinicians are aware of their obligations to provide sufficient clinical handover to other health care providers when writing referrals and ensure that all information contained within referral documents is accurate and up to date. Patients are made aware that their health information is being disclosed in referral letters and documents. Procedure Our directory of local allied health providers, community and social services and also local specialists is available <<insert how to access this>>. It is the responsibility of <<insert name of person responsible>> to ensure database is updated and maintained. For referred services where costs are not known, the patients are advised of the potential for out of pocket expenses and encouraged or assisted to make their own enquiries. If the patient indicates that the costs pose a barrier to the suggested treatment or investigation alternatives may need to be discussed (e.g. referral to public services). Special care is taken to advise patients of the costs of consultations or procedures that do not attract a government subsidy. Letters of referral are <<edit as appropriate: paper or computer based>>. If referrals are to be sent electronically, the practice ensures that this is performed in a secure manner to maintain patient privacy. All referral letters are incorporated into the patient medical record either electronically or by manual scanning. In the case of an emergency or other unusual circumstance a telephone referral may be appropriate. All telephone referrals need to be documented in the patient’s health record. Referral letters should: be legible (preferably typed) on appropriate practice stationary. contain relevant history examination findings and current management 143 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 include any allergies, adverse drug reactions and a current accurate medications list. include the reason/purpose for the referral and expectation of the referral. identify the Doctor or clinical staff member making the referral. identify the setting from which the referral is being made if known, identify the healthcare provider to whom the referral is being made and the setting be dated. contain at least 3 of the approved patient identifiers e.g. name, date of birth and address. Clinically significant referrals are followed up. RACGP 4th edition Standards 1.2.4, 3.1.4, 1.5.2, 1.6.1, 5.3.1, 1.6.2 7.5 Clinical Handover (Customise as appropriate) Policy Clinical handover has been defined by the Australian Medical Association as ‘the transfer of professional responsibility and accountability for some or all aspects of a patient’s or a group of patients’ care to another person or professional group on a temporary or permanent basis’. Failure or inadequate handover of care is a major risk to patient safety and a common cause of serious adverse patient outcomes. It can lead to delayed treatment, delayed follow up of significant test results, unnecessary repeat of tests, medication errors and increased risk of medico legal action. Clinical handover communications can be face-to-face, written, via telephone and also by electronic means. All staff are informed about our policy on clinical handover to ensure standard processes are followed. Clinical handover of patient care occurs frequently in general practice both within the practice to other members of the clinical team, and to external care providers. 144 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 We have standard and documented processes for timely clinical handover with services that provide care outside normal opening hours. Procedure Clinical handover needs to occur whenever there is a change of care providers. Examples of clinical handover include: a GP covering for a fellow GP who is on leave or is unexpectedly absent. a GP covering for a part time colleague. a GP handing over care to another health professional such as a practice nurse, physiotherapist, podiatrist or psychologist. a GP referring a patient to a service outside the practice. a shared care arrangement (e.g. team care of a patient with mental health problems). When appropriate, the clinical handover is documented in the consultation notes (where possible). Written or verbal clinical handover between GPs occurs on a formal arranged basis when doctors cover for those working on a sessional basis or when a GP or other clinical staff member is away because of annual leave or illness. In addition to a formal handover, adequate clinical records, including a health summary and up to date medications list, enable the routine care of patients to continue. Practitioners relieving for another should read the patient’s preceding clinical records. Clinical handover to external health care providers usually occurs through the provision of referral documents. All referral letters contain sufficient information to facilitate optimal patient care. The practice should ensure that sufficient information is provided to the emergency department about the clinical condition of an inbound patient, to facilitate prompt and appropriate care. This may be directly to the ambulance service or to the hospital. Deputising services are responsible for handing the care of a patient back to the patient’s regular medical practitioner in a timely and appropriate manner. Our practice receives a notification the following business day whenever a patient of our practice uses the deputising service. This is incorporated into the patient file and adequately followed up. RACGP 4th edition Standards 1.5.2 & 5.3.1 145 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 7.6 Follow up of Tests, Results and Referrals (Customise as appropriate) Policy Our practice’s system for the follow up of tests, results and referrals has a strong focus on risk management. Our practice team can describe: how patients are advised of the process for follow up of results. the system by which pathology results, imaging reports, investigations reports and clinical correspondence received by our practice is reviewed by a GP, signed, acted upon in a timely manner and incorporated into the patient’s medical record. how we follow up and recall patients with clinically significant tests, results or correspondence. All test results, including pathology results, diagnostic imaging and investigation reports, and clinical correspondence received are reviewed, initialled (or electronic equivalent) and, where appropriate, acted upon in a timely manner. This is all incorporated into the patient health record. All test results, pathology, imaging and investigation reports received by the practice are reviewed, initialled and where appropriate, acted upon in a timely manner. The nature and extent of the practices responsibility for the follow up of tests and results will vary from case to case and will be determined by: the probability that the patient will be harmed if follow up does not occur. the likely seriousness of the harm. the burden of taking steps to avoid the risk of harm. In cases where patients have indicated they will not attend a recommended test or in circumstances where the likely harm of non-attendance is high, the patients are flagged in the reminder system by the treating GP. These patients should be followed up to ensure that recommended test are carried out or the situation documented in the patient health record. The need to recall patients should be considered in the overall context of the patient including their history and significance of the health issue. The treating GP or their 146 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 designated representative is the person who is responsible for making the decision on which patients to recall. When contacting patients for the follow up of results, our practice will attempt to contact the patient by telephone three times before sending a letter to their designated address. All attempts are documented in the patients medical record. Sometimes our doctors may need to be contacted outside normal working hours by the pathology service about a serious or life threatening result. We have provisions for doctors to be contacted after hours for life threatening or urgent results. Our patients (or their carers) are made aware of their obligations and responsibilities for their own healthcare. This includes being informed about how to obtain their results and the seriousness of not attending for ordered appointments/investigations and any recall or subsequent follow up. Where appropriate this advice may be documented in the patient’s medical records. In addition to an appreciation of the need for timeliness when following up and actioning referrals, tests and results, our staff members are also aware of the need for confidentiality and discretion with regard to referrals, diagnostic tests and results or correspondence. Procedure Write your practice procedure for the follow up and recall of test results. Please note the key points below when writing your procedure. Your practice procedure must outline how the practice: ensures timely action of follow up ensures that GPs initial all results before being filed. This includes the electronic equivalent ensure that results are incorporated into the patient record identifies the team members responsible for each step of the system manages non-response from patients ensure continuity if care for patients including how it is incorporated into the medical record ensures patient privacy when following up results RACGP 4th edition Standards 1.1.4 & 1.5.3 147 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 7.7 Reminder Systems for Preventative Care <<Delete if your practice does not have a Reminder System>> (Customise as appropriate) Policy We are working towards a systematic approach to the entry of patient data in the medical records to facilitate the search, extraction and utilisation of patient information for our prevention and screening activities. This includes comprehensive patient health summaries and documentation of preventative activities in the patient’s medical records. Consideration of patient’s individual circumstances is encouraged when providing information about health promotion and illness prevention for patients (and carers). Verbal and written information is provided to patients about health promotion and specific disease prevention. This is distinct from the education and information that is provided to patients to support a diagnosis and choice of treatment. Wherever possible, our practice coordinates with other health care services and state registers including: List all registries that the practice participates in We also maintain specific disease registers through our clinical desktop system as part of our commitment to chronic disease management. Patient permission is sought before placing their name on a proactive reminder system and this permission is recorded on the patient file. Details of how the patient can opt out of this system are also available to the patient via <<insert method of notifying patients, ie. Practice information sheet>>. Procedure Write your practice procedure for actioning the reminder system. Please note the key points below when writing your procedure. You may want to include the following: an outline of the roles of administrative and clinical staff, 148 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 how you select patients, how you search clinical data e.g. any data extraction tool used, how you ensure all staff are aware of preventative activities, samples of letters or the templates used list specific risk factors or diseases you target RACGP 4thedition Standards 1.3.1 7.8 3rd Party Observing or Clinically involved in the Consultation (Customise as appropriate) Policy Consent must always be obtained from patients prior to a 3rd Party Observing or being clinically involved in the consultation. This includes medical or nursing students, a person included at the doctor’s request, an interpreter or person to assist with communication, a chaperone, or someone accompanying the patient to the consultation at the patient’s request such as a carer or relative. In some circumstances the patient or the GP may feel more comfortable if there is a chaperone present during the consultation. For medico legal reasons it is recommended to consider offering a chaperone for unaccompanied children. Procedure Wherever possible, we ask the patient to consent to a 3rd Party being present during the consultation when making the appointment and confirm that this consent remains upon arrival for their appointment. Where prior consent was not obtained, the patient is asked to consent to the presence of a 3rd party before entering the consultation room. It is not acceptable to ask permission for a 3rd party to be present during the consultation in the consulting room as some patients may feel unable to refuse. Practice staff are mindful of the particular needs of people with intellectual disabilities who may not be able to provide consent. In such cases a legal guardian or advocate may need to be appointed to oversee the interests of the patient. 149 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Our practice uses signage or other written information to inform patients about the presence of medical or nursing students. RACGP 4th edition Standards 1.2.3 & 2.1.3 7.9 Practice Participation in Research Projects (Customise as appropriate) Policy Our practice <<does/does not>> participate in external research projects. Whenever any member of our practice team is conducting research involving our patients, we can demonstrate that the research has appropriate approval from an ethics committee. The research protocol, consent procedures and process for resolving problems is retained by the practice. When we collect patient health information for quality improvement audits or professional development activities, we only transfer de-identified patient health information to a third party. Whenever identifiable patient information must be transferred, we always seek patient consent prior to transmission and ensure the privacy of information is maintained. Procedure Research projects involving patient care: must have the explicit and documented written consent of the patient the patient must receive a written and oral explanation about the research and be able to withdraw consent at any time the project must be approved by a relevant human research ethics committee (HREC) established under the NH&MRC guidelines. privacy laws must be adhered to The practice should retain a record of the request for participation in any research project, including the research protocol, consent procedures and process for resolving problems should be retained by the practice. RACGP 4thedition Standards 4.2.1 150 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 7.10 Management of a Patient Refusing Treatment or Advice (Customise as appropriate) Policy This practice takes an active approach to ensure the best outcomes for patients at all times even if they choose to reject investigation and/or management advice. Our practice endeavors to help our patients understand the importance of medicines and treatment advice to help them make informed decisions about their health care. Our clinical team can demonstrate how we provide care for patients who refuse a specific treatment, advice or procedure. Procedure Staff and doctors are to respect the right of all patients to make investigation and treatment choices or to seek a further clinical opinion. Patients should be advised to notify their doctor or nurse if they plan to seek another clinical opinion. Patients should also be advised that if they choose to follow another healthcare providers management plan, to notify their doctor or nurse. An appropriate risk management strategy to be followed includes ensuring that: The patient has been provided with the full range of options available, including the risks and benefits of each to enable them to make an informed choice. The consequences of the choices made are explained including those of non-investigation and treatment. Documentation of the explanation and actions taken by the patient should be made in the patient medical record. RACGP 4thedition Standards 2.1.1 151 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 7.11 Refusal to Treat a Patient (Customise as appropriate) Policy The practice or individual clinical team members have the right to refuse to treat patients in defined circumstances. Our practice ensures arrangements are made for the timely transfer of the patients care to another member of the clinical team either within our practice or to another healthcare service. Procedure GPs or other clinical staff may refuse to treat patients for a number of reasons including: Threatening or violent patient behaviour Breakdown in the therapeutic relationship Patient healthcare needs are outside the scope of the practitioner Scaling back the practice patient load Any refusal to treat a patient is done for substantial reasons not based on discrimination. Patients in emergency situations will always be treated to the best of our ability. Emergency medical treatment is defined as treatment that is necessary to: save a patient’s life prevent serious damage to health prevent or alleviate significant pain or distress An appropriate risk management strategy to be followed in these circumstances includes ensuring that: the patient has been provided with reasons about why they cannot have ongoing treatment at this clinic. the patient has been provided with alternative possible treatment locations and written referrals, if appropriate. any complaints that may arise are dealt with according to the complaints procedure. full documentation of the actions taken above in the medical record is essential. Our practice will endeavor to assist such patients with ongoing care including referral to other health care providers and transfer of any medical history. 152 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 RACGP 4th edition Standards 2.1.1 7.12 Practice Equipment (Customise as appropriate) Policy Our practice has all the necessary equipment to provide comprehensive primary care and emergency resuscitation. The practice staff ensure that these are maintained, safe and in a serviceable condition at all times. The available equipment is sufficient for the procedures commonly performed within our practice and meets the needs of our patients. All equipment that requires calibration or is electrically or battery-powered, are maintained according to manufacturer’s instructions and are documented on a maintenance schedule. Members of the clinical team are consulted about the equipment and supplies the practice uses or purchases. Our practice has timely access to spirometry and electrocardiography via <<insert method of access, ie. internally or local diagnostic centre>>. Procedure The practice has the necessary medical equipment to ensure comprehensive primary care and resuscitation, including the following: auriscope blood Glucose monitoring equipment disposable syringes and needles equipment for resuscitation, equipment for maintaining an airway (including airways for children and adults), equipment to assist ventilation (including bag & mask), IV access, and emergency medicines examination Light eye examination equipment (e.g. fluorescein eye staining) gloves (sterile & non-sterile) height measurement device 153 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 at least one height adjustable patient examination couch measuring tape monofilament for sensation testing (10g Nylon) ophthalmoscope oxygen patella hammer peak flow meter or Spirometer scales spacer for inhaler specimen collection equipment sphygmomanometer (small, med and large cuffs) stethoscope surgical Masks thermometer torch tourniquet urine testing strips vaginal Specula visual acuity charts x Ray viewing facilities Our practice also has the following additional equipment based on the particular needs and interests of our clinical team: List any additional equipment, for example, a defibrillator. Relevant staff are trained in the care, use and maintenance of equipment and where appropriate to analyse and interpret any results. Liquid Nitrogen and oxygen are hazardous materials and are therefore stored securely and staff are trained in their safe use. The maintenance schedule for equipment is kept <<insert location>>. It is the responsibility of <<insert person’s name>> to schedule regular equipment maintenance and to document these in the schedule. RACGP 4thEdition Standards 1.4.2 & 5.2.1 154 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 7.13 Doctor’s Bag (Customise as appropriate) Policy All of our doctor’s have access to a fully equipped doctor’s bag for emergency care and routine off site visits. When not in use, the doctor’s bag is stored securely and checked on a regular basis. In some instances doctors may share a doctor’s bag or items may be kept in two smaller bags. Required items may be added to the bag prior to use to avoid doubling up on equipment. Where doctors’ bags are shared, the arrangements are reviewed on an ongoing basis to ensure that doctors have access to a bag when required. Additional bags are purchased if required. Sensible security measures are taken at all times and any relevant legislation or regulations relating to S8, S4 and drugs of dependence are adhered to. The doctors should consider the practice location, health needs of the community and the type of clinical conditions likely to be encountered when determining the contents and drugs to be kept in the doctor’s bag. Regular checks should be performed to stock the supplies and dispose of expired stock. Procedure When attending an off site consultation or emergency each doctor has a fully equipped doctor’s bag containing: auriscope disposable gloves equipment for maintaining an airway in both adults and children in date medicines for medical emergencies opthalmoscope practice stationary (including prescription pads and letterhead) sharps container sphygmomanometer stethescope syringes and needles in a range of sizes thermometer 155 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 tongue depressors torch It is the responsibility of <<insert person’s name>> to stock take and replenish items from the doctor’s bag on a <<insert frequency>> basis. Ideally, the doctor’s bag should be re-stocked after each use. The bag contents, including equipment and stock levels of drugs, are systematically checked. All drugs must be “in date” and the dangerous drug register accurate and completed. Any out of date items are discarded as per policy. When not in use the doctor’s bag is stored securely <<insert location>>. If stored with a doctor’s personal items, arrangements are made for the secure storage of the bag whilst the GP is on leave. RACGP 4thEdition Standards 5.2.2 7.14 Vaccine Storage (Customise as appropriate) Policy We ensure that all vaccines are acquired, stored, administered, supplied, and disposed of in accordance with the manufacturer’s directions and jurisdictional requirements. Vaccine storage requires constant maintenance of the 'cold chain' to ensure vaccine potency. The 'cold chain' refers to the system of transporting and storing vaccines within the safe temperature range of between 2ºC - 8ºC. We have a staff member with designated responsibility for ensuring our cold chain management processes comply with the current edition of the national vaccine storage guidelines and for conducting an annual audit of our vaccine storage procedures. This role is defined in their position description. We have documented protocols for the monitoring of vaccine storage including equipment maintenance and auditing procedures. 156 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure Tasks associated with maintaining the cold chain of vaccine storage may be delegated to other staff members, however <<Insert the name and position of the staff member>> has primary responsibility to: ensure our vaccine storage procedures comply with the “National Vaccine Storage Guidelines”. communicate these guidelines to staff and develop documentation of the procedures. provide adequate training to other staff appropriate for their role ensure there is a process for handing over the cold chain responsibility to another designated person when they are unavailable to perform their duties. conduct an annual self audit of our vaccine storage to ensure appropriate actions are taken if the temperature has been outside the recommended range. maintain the vaccine storage equipment and temperature recording thermometer. Please refer to the vaccine storage protocols located <<insert location>>. These protocols are reviewed by <<insert person responsible for vaccine storage>> on a <<insert frequency>> basis. RACGP 4thedition Standards 5.3.1 & 5.3.2 7.15 Medication Prescribing and Administration (Customise as appropriate) Policy Our clinical team ensures that at each patient encounter where medications are prescribed or discussed, patients are adequately informed about the purpose, importance, benefit and risks of their medicines. Patient’s ability to comprehend verbal and written material is taken into consideration and the use of translators is considered, where appropriate. As part of our clinical team’s ongoing professional development and commitment to contemporous medical practice, all clinical team members can demonstrate access to current medicines information and prescribing guidelines. Medications lists for each patient are updated by a member of the clinical team at every patient encounter. Patient allergies are also recorded in each patient file to minimise risk of negative drug interactions. 157 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Patient education is an important element whenever medications are prescribed. Written material such as consumer medicines information, are used to help patients understand their medication and this is documented in the patient health record. Procedure To reduce the risk of medication errors when prescribing or referring, all GPs and clinical staff take the following steps: update the patient medication list at each patient encounter including removing single-use medications Discuss the risks, benefits, importance and purpose of all prescribed medications Provide written materials to support verbal discussions with patients regarding medications Record patient allergies in the medical record and confirm at each prescribing encounter Where appropriate, provide patients with a copy of their medications list Enquire and record the complimentary medications status of all patients If required, use translators or translated material to assist patients to comprehend medication instructions and information These activities are recorded in the patient’s medical record whenever they are undertaken. Our clinical team currently has access to the following prescribing guidelines and resources: List all guidelines and resources currently available to clinical staff, ie. Australian Medicines Handbook. RACGP 4thedition Standards 5.3.1 158 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 7.16 Controlled Substances (Customise as appropriate) Policy Schedule 4 and Schedule 8 poisons (inc. doctor’s bag emergency drugs, professional samples and vaccines) are obtained on the authorisation of a medical practitioner(s). These drugs are the responsibility of the medical practitioner(s) and subject to regulatory controls. Nurses are not permitted to be in possession of S4 or S8 drugs. Only under written instructions from the general practitioner may they access the drugs and administer them under practitioner supervision. Only when the medical practitioner is present can nurses access the drug. S8 poisons must be stored in a locked facility, fixed to the floor or wall. Storage facilities for Schedule 8 poisons must remain locked at all times except when it is necessary to open it to carry out an essential operation such as medical treatment, stock checks and reordering. Keys & combinations must not be accessible to or known by unauthorised persons. Keys cannot be left on the premises over night. When required to be transported for use in other locations, S8 drugs must be stored in a locked receptacle (e.g. doctors Bag), in the doctors possession. If the receptacle is necessarily out of the doctor’s immediate possession it should be secured, out of sight, in a lockable facility (e.g. locked cupboard or locked vehicle) to prevent unauthorised access. Up to 6 divided doses of a S8 drug, for emergency use, may be stored in a locked facility that does not comply with legislative requirements. These doses must be kept in a central location or receptacle in a room that can be locked when a medical practitioner is not in attendance. Schedule 4 poisons including sample packs may be stored in a filing cabinet, cupboard or drawer, within the practice. If an authorized person (usually a medical practitioner) is present, the storage facility may remain unlocked at their discretion. This option requires the storage facility to be locked when the authorized person/s are not present. S4 drugs of dependence are either stored in the same manner as other S4 poisons or in the drug cabinet with S8 poisons again at the discretion of the authorised person. 159 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Schedule 4 vaccines that require refrigeration must be stored in either: a lockable refrigerator that is locked when an authorized person (usually a medical practitioner) is not present. or in a refrigerator secured within a lockable room that is locked when an authorized person is not present. Nurse Immunisers should familiarise themselves with legislative issues that are applicable to their situation. Records of all transactions including supply acquisition and disposal of S4 and S8 drugs, must be true and accurate and entered on the day that the action occurred. These records must be retained for a minimum period of 7 years and are kept in the same location as the drugs. Any alterations or cancellations of entries in the drug register must not be made. Any mistakes that require correction should be done as a footnote with initial and dates. Each brand name and strength of drugs kept must be detailed on a new page in the register. Stock checks are to be conducted every March and September, or within one month of assuming control of the practice. This should be recorded under the last entry and clearly labeled as “Balance in Hand”. Lost, stolen or destroyed drug register must be reported to the Pharmaceutical Services Branch. The destruction of S4 or S8 drugs must only be performed in the presence of a pharmacist to act as a witness. The destruction must be documented in the practice drug register and include the pharmacists name, professional registration number and date of destruction. Both parties must sign the entry. S4 and S8 labels will require: the name of the patient, the date of dispensing and if necessary an identifying code, the name , address and telephone number of the medical clinic or doctor providing supply including the name of the prescribing doctor directions for the correct use of the medicine directions for storage and expiry date (may be those on the packet if left uncovered). the brand and generic names of the drug including strength and form. the words “KEEP OUT OF THE REACH OF CHILDREN” ancillary labels as specified in the “Australian Pharmaceutical Formulary”. 160 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 When prescribing or supplying S4 and S8 medications the doctor takes all reasonable steps, given the time and circumstances that exist at the consultation to ensure a therapeutic need exists. Prescribing to maintain an addiction is not a therapeutic need and is illegal. RACGP 4thedition Standards 5.3.1 For information on jurisdictional requirements refer to the drugs and poisons branch of the relevant jurisdiction: New South Wales Pharmaceutical Services Branch NSW Health Telephone: 02 9879 3214 Fax: 02 9859 5165 7.17 Clinical References and Resources (Customise as appropriate) Policy Consistency and quality of care can be assisted by the use of current resources, access to clinical guidelines and communication between team members. This process is encouraged and facilitated by the practice clinical leader. This practice provides our clinical staff with access to a range of resources and materials for reference on clinical matters and items of interest for professional development. The references available contain information that is consistent with current practice guidelines or based on best available evidence. In the absence of well conducted trials or other higher order evidence the opinion of consensus panels of peers is acceptable. References and resources including practice guidelines should be accessible at the point of care. Wherever possible, all resources are dated and contain the name of the source. There is an organised system of access for all practice staff to journals, clinical guidelines and other reference material. The clinical references available and any new additions, deletions or updated versions is communicated to all staff and clinical team members to assist with consistency in the approach to diagnosis and management of patient care. Distribution occurs at either formal clinical meetings or electronic methods, and are documented in the <insert location, ie. communication book or notice board>>. 161 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure <<Insert the guidelines and references readily available at your practice and how or where they can be accessed>> At least annually we conduct an audit of our clinical resources and references to ascertain if they comply with current practices and are providing consistent management and information to patients across the practice team. It is the responsibility of <<insert person’s name>> as clinical leader to conduct this audit. It is a standing item at our clinical meetings to discuss any new clinical issues, resources or clinical practice guidelines. RACGP 4thedition Standards 1.3.1, 1.4.1, 5.3.1, 3.1.3, 3.1.2 7.18 Drug Storage and Disposal Please note: RACGP 4th Edition Standards state “Practices must comply with jurisdictional requirements on Schedule 4 and Schedule 8 medicines.” The requirements can vary in different states and Territories of Australia. Failure to comply with the legislation renders individuals and practice entities liable to prosecution. Compliance with legislation does not ensure compliance with other professional standards and other accreditation requirements which should also be observed. (Customise as appropriate) Policy Perishable medical supplies including vaccines, pharmaceutical and medical consumables are correctly stored, stock rotated and discarded if past expiry dates. Our practice has appointed a designated person to take primary responsibility for the proper storage and security of medicines, vaccines and other healthcare products. All medications in our practice are stored according to legislative requirements or in a manner that ensures the safety of our patients and staff. A list of all the locations where medical consumables are stored within the practice is located <<insert location>>. Perishable medical items are acquired through regular stock ordering and samples acquired from pharmaceutical company representatives. All stock orders are recorded <<insert location and method>>. Samples accepted from pharmaceutical representatives 162 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 are also entered in this log and can assist with the disposal and/or return of expired medications. Procedure <<Insert name and position title of the designated person>> maintains a log of areas to be checked containing perishable medical stock. All stock is checked on a <<insert frequency of checking>> basis. Items with expired ‘use by dates’ are to be withdrawn from active storage locations and disposed of immediately using appropriate methods. Any drugs which are subject to legislative regulation are disposed of according to strict instructions. All other expired medications and other consumables from our practice are disposed of via <<insert method, ie. Local pharmacist takes them>>. It is the responsibility of all staff who use or dispense medical consumables to check the expiry date prior to use. RACGP 4thedition Standards 5.3.1 163 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 8 Continuous Improvement 8.1 Risk Assessment & Management (Customise as appropriate) Policy This practice has multiple systems to regularly monitor, identify and report near misses and mistakes in both clinical care and general operation. The practice has appointed a designated member of staff (*insert name) to have primary responsibility for our risk management systems. These may include clinical and non clinical risks and events. Specific areas of responsibility can be delegated to other nominated members of the practice team and these particular responsibilities are documented in the relevant position descriptions. The aim of risk assessment and management is to: identify all strategic risks using a risk management process. ensure risk management becomes part of day to day management. co-ordinate the undertaking of regular formal risk assessments and reviews with staff involved. provide staff with education, policies and procedures necessary to manage risk. ensure employees are aware of risks and how to manage them. assign responsibility for overseeing the practice risk management systems to designated staff, and document this in their position description. document and regularly review our risk management systems. monitor risk profile and implement a continuous improvement approach to risk management. ensure successful implementation of changes and improvements made to our risk management systems. Our practice has a documented system for dealing with near misses and mistakes and we ensure that doctors, nurses and other staff involved in clinical care are educated in what to do and whom to notify when a slip, lapse or mistake occurs, or when there is an unanticipated adverse outcome. Any improvements that are implemented to prevent identified slips, lapses and mistakes or potential risks are documented and the practice team is informed. 164 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Our practice has protocols for Non Medical Emergencies which are kept <<insert location>>. All staff are given training about non-medical emergencies during orientation. Procedure Staff use the “Adverse Outcome Report” to report any slips, lapses or near misses in clinical care or deviations in patient care that might result in harm. The medical defence organisation is contacted for all events that may have an adverse outcome. All accidents or near misses are fully investigated by practice staff and the findings discussed at a staff meeting to prevent them occurring again. Staff use the ‘Accidents and Near Misses’ register to record all events within the practice when a non-clinical event occurs which causes harm or has the potential to cause harm. Where appropriate, the workplace insurance company is contacted for advice and recommended action. Some of the tools and strategies used in this practice to manage risk include: achievement of RACGP standards via the accreditation process regular staff and clinical meetings including effective communication with our staff. appropriate staff qualifications, induction and training. patient feedback obtained via surveys/Suggestion Box /logbook of complaints/ comments <<delete where appropriate>> documentation of sterilisation procedures including servicing, details of individual loads/cycles and staff training comprehensive medical records and back up of electronic data. documentation/ tracking of abnormal results. regular reviews of systems and procedures especially as a result of any analysis of reported near misses. logging/recording of telephone exchanges with patients ensuring correct identification of patients at each face to face, telephone and electronic encounter documented contingency plans for events that may disrupt care or stretch practice resources to the limit, including disasters and disease outbreaks. RACGP 4thedition Standards 3.1.2 & 4.1.2 165 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 8.2 Review of Policies & Procedures (Customise as appropriate) Policy Policies and procedures relating to the administration of this practice are formally reviewed on an annual basis or when changes occur requiring earlier review or revision (e.g. equipment changes). Policies and procedures are an important component of the practice quality improvement program, as well as forming the basis for staff induction and ongoing training. Our practice ensures that all policies and procedures comply with the RACGP Standards for General Practice. Procedure Each designated leader is responsible for conducting a review of the policies and procedures relevant to the following areas: Cleaning Complaints Management Infection Control Information Technology Quality Improvement Risk Management Systems Sterilisation Vaccine Management Discussion and suggestions for improvement to quality, patient safety or policies and procedure is a standing item on our practice meeting agenda. Staff may informally approach the Practice Principal or Manager with suggestions for new policies and procedures or with revisions to existing policies and procedures, at any time. The Practice Principal, in consultation with the Practice Manager and staff, approve all policies and procedures. Once approved, documentation is amended in this manual and elsewhere as necessary. 166 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Analysis of practice data may also inform any changes to services or other practice activities to improve the health outcomes of our patients. These quality improvement activities may necessitate a new or revised written protocol. Formal revision and final approval of all new and revised policies and procedures is presented at a staff meeting. To ensure all staff are aware of new policies and recent changes we have a distribution plan. RACGP 4thEdition Standards 3.1.1, 3.1.3, 4.1.1 8.3 Continuing Staff Education (Customise as appropriate) Policy The practice GP’s, nurses and other health care providers employed by this practice are: appropriately qualified, trained and competent. able to provide evidence of training qualifications and of appropriate current national registration. participate in continuing education relevant to their roles and can provide evidence of this. have undertaken training in CPR within the last 3 years. In the case of GPs, this training must be in accordance with the RACGP QI&CPD recommendations or at least to the same. Able to demonstrate they work within their scope of practice relevant to their role The administrative staff such as receptionists and practice managers, who do not provide clinical care: have undertaken training in CPR within the last 3 years. have undertaken training relevant to their role within the past 3 years. can describe or provide records of such training. Records of GP continuing professional development activities including CPD points and activity details are retained by individual GP’s and a copy must be given to the Practice Manager to retain for the practice records annually. The practice supports continuing professional development for all of the staff it employs. Details of activities & dates are recorded and should be retained by the Practice Manager. 167 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Copies of these records or an annual summary should be given to staff for their own personal records. All Doctors, Nurses and staff involved in clinical care practice within their legal scope of responsibilities. We encourage our staff to maintain their knowledge, skills and attitudes through membership to their professional specialty organisations. The practice has access to documented copies of relevant scope of practice guidelines. Both in house and external training programs are utilised. Staff should obtain a certificate of attendance or evidence of participation and completion for all training, even informal training sessions (e.g. provided by the General Practitioners or other staff in the practice). It is acknowledged that some crucial areas for staff training exist, depending on the staff member’s role and responsibilities. These training requirements are met according to the training schedule and documented in each staff member’s employment record. All staff are given adequate infection control training for their role. It is the responsibility of the designated infection control leader to ensure this training occurs. Education is not limited to professional technical skill updates but includes a variety of training and educational activities in areas of need as they arise. Staff are encouraged to identify any training needs they may have and seek to find training to meet these needs. Usually this occurs in consultation with their supervisor and this process should be documented. Staff training may include: education at formal institutions. educational seminars attended. online training. in service education given by company sales representatives or other staff. reading Journals, evidence based guidelines or researching information for the practice. New staff are supported with any training they may require to perform their role. This may be identified prior to commencement or during the induction phase. (Initial 3 months). Procedure The practice GP’s, nurses and other health care providers involved in clinical care must provide evidence of current registration each year. Further evidence on training relevant 168 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 to their roles including QI&CPD records or other professional development is kept by the practice. Copies of certificates and training records for clinical team members are kept <<insert location>>. This record also includes approved CPR training completed within the last 3 years. Administrative staff must also show evidence of relevant training for their role. Copies of training certificates are kept <<insert location>>. If training is provided internally or informally by other staff members, this is recorded on the training register located <<insert location>>. Administrative staff can also demonstrate triage and CPR training completed within the last 3 years. All employees of the practice have a completed training induction checklist located <<insert location>>. The practice team member with delegated responsibility for staff education on infection control documents in each individual staff training records how the induction program and additional ongoing training provided (as identified through discussion and competency assessment) covers infection control as relevant to each staff members role. Training and regular updates should include: hand hygiene standard precautions & Transmission based precautions including PPE use and the triage of patients with potential communicable diseases. dealing with blood and body fluid spills and managing exposure to blood or body fluids. principles of environmental cleaning and reprocessing of medical equipment. where to find information on other aspects of infection control in the practice. safe handling and disposal of clinical and general waste. RACGP 4thedition Standards 3.2.1, 3.2.2, 3.2.3, 5.3.3 169 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 8.4 Accreditation & Continuous Improvement (Customise as appropriate) Policy This practice is committed to attaining and where possible, exceeding the Standards for General Practice 4th Edition as defined by RACGP. The practice team is committed to encouraging quality improvement and identifying opportunities to make changes that will improve the clinical care of patients and activities to promote health in the overall practice population. The practice uses patient and practice data to identify opportunities for improvement and to monitor evidence of improvement occurring. Our practice can demonstrate improvements we have made in response to the analysis of patient and others feedback, including complaints, and where appropriate we provide information to patients about improvements made as a result of their input or feedback. Our practice undertakes quality review activities such as audits, routine data checks, accounts reviews and medical record reviews on regular basis. Any interesting findings or changes made as a result of reviews are discussed at practice or clinical meetings. Procedure Discussion and suggestions for improvement to quality and patient safety is a standing item on our practice meeting agenda. The designated staff member for quality improvement shares all information related to this topic with staff on a regular basis. Our practice regularly reviews practice data, policies and procedures to help facilitate quality improvement. Wherever possible, patient feedback and complaints are incorporated into quality improvement activities and we endeavour to notify patients through special bulletins whenever changes do occur as a result. The practice participates in a formal, peer-review process known as accreditation. Our practice accreditation expires on <<insert expiry date>>. Our practice endeavours to comply with all relevant legislation and guidelines relating to general practice. 170 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 RACGP 4thedition Standards 2.1.2, 3.1.1, 3.1.3 8.5 Patient Feedback (Customise as appropriate) Policy Our practice encourages patients and other people to give feedback, both positive and negative, as part of our partnership approach to healthcare, and we have processes in place for responding to feedback In order to respond to patient feedback and make improvements, practices need to identify the person in the practice with primary responsibility for examining issues raised by patients and facilitating improvements in the practice. In our practice, the designated staff member is <<insert name and role>>. Where possible patients are encouraged to raise any concerns directly with the practice team and attempts are made for a timely resolution of such concerns within the practice in accordance with our complaints resolution process. We seek structured /systematic patient experience feedback at least once every 3 years which meets the requirements outlines in the RACGP publication “Learning from our patients”. Feedback collected includes, but is not limited to, the following 6 categories that are considered critical to patient’s experiences within healthcare facilities. access and availability information provision privacy and confidentiality continuity of care communication skills of the clinical staff interpersonal skills of clinical staff The data collected is analysed and the findings, including any improvements made, are communicated back to our patients. As part of our Risk Management Activity, a log of incidents, including complaints, is maintained in an event log and the incident is noted on the patient’s history. All improvements made to the practice as a result of patient feedback are discussed at practice meetings and recorded in the minutes. 171 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure At any time patients may provide feedback or make a complaint. A notice is displayed in the waiting room and details are included in the practice information sheet to advise patients how to make a complaint to our practice. We also advise the contact information for the State/Territory health complaints agency and the commonwealth agency. Staff are trained to ensure patients of the practice feel confident that any feedback or complaints made at the practice will be handled appropriately. All staff are aware and can identify the staff member responsible for complaints handling. At least every 3 years we use a systematic method for collection patient experience feedback. We have purchased or downloaded a copy of the RACGP publication “Learning from our patients” <<insert where this is located>> and we meet the requirements outlined in this publication. We collect feedback using: <<delete those not applicable to your practice>> an RACGP approved questionnaire an individual practice specific questionnaire we have developed which has been approved by the RACGP a series of focus groups with patients which complies with the RACGP guidelines a series of interviews with patients which comply with the RACGP guidelines Data collected is analysed to identify potential opportunities for quality improvement. We communicate the findings of our feedback and any improvements made back to our patients using either a poster in the waiting room, newsletters, the website or individually as appropriate. Complaints and patient feedback are discussed at practice meetings to facilitate whole of practice improvement. RACGP 4th edition Standards 2.1.2 172 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 8.6 Continuity of Care (Customise as appropriate) Policy This practice aims to encourage patients to develop a positive relationship with their doctor and practice staff over time to enhance the provision of high quality comprehensive patient care including effective health promotion and strategies for the early detection of disease. Our practice has systems and procedures in place to help facilitate continuity of care for patients when visiting our practice including management and informational continuity. All staff are trained in how they can facilitate continuity of care. Our medical notes demonstrate relational, management and informational continuity of comprehensive care. In addition 50% of our active patient health records have entries extending back over two years. Our practice provides home visits for our patients and has an agreement with an after hours provider who provides communication back to the practice about the nature of any after hours care delivered. Procedure Our practice implements the following procedures or systems to facilitate continuity of care: Comprehensive medical records including an updated patient health summary Referral letters which contain a minimum of 3 approved patient identifiers, updated medication list and sufficient information for the ongoing management of the patient Regular clinical meetings where clinical practice guidelines are discussed and information shared about patient cases within the practice A formal clinical handover system to account for clinical staff member leave or unexpected absence A robust recall and reminder system for all important test results Patient are able to request their GP of choice when making an appointment and administrative staff working to try and ensure their GP is available. If cases where patients do not request their regular GP, the administrative staff attempt to book an appointment with the GP from their last visit. 173 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 All staff are able to describe how continuity of care in our practice is facilitated. RACGP 4thedition Standards 1.1.1, 1.4.1, 1.5.1, 1.5.2 8.7 Clinical Governance (Customise as appropriate) Policy The RACGP 4th Edition Standards describe Clinical governance as a ‘system through which organisations are responsible for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish’. We recognise that good clinical leadership is required to engage the entire practice team in a commitment to excellence by nurturing a culture of openness and mutual respect that allows just and open discussions about areas for improvement. We aim to develop an organisational culture where participation and leadership in safety and quality improvement are resourced, supported, recognised and rewarded and all staff feel accountable and involved in monitoring and improving care and services. To promote clear lines of accountability and responsibility for encouraging improvement in safety and quality of clinical care and the sharing of information about quality improvement and patient safety within the practice team we have appointed leaders who have designated areas of responsibility for safety and quality improvement systems within the practice. Our practice leaders oversee the delegation of tasks to others but retain accountability for quality and safety. Roles and responsibilities are specified in our position descriptions and all members of the practice team are aware of the designated leadership responsibilities of key staff. Our leaders promote compliance with the RACGP 4th Edition Standards for general practice and relevant jurisdictional legislation or accepted industry requirements. 174 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012 Procedure All members of our practice team can identify the staff members with primary or delegated responsibility for: Clinical Risk management systems including receiving and disseminating any important communication or updates (e.g. health alerts) and contingency plans Clinical leadership Quality improvement and risk management (non clinical) Clinical care Information management Human resources Feedback and complaints Occupational Health and Safety (Health and Safety representative) Electronic systems and computer security Proper storage and security of medicines Cold chain management Infection control within our practice. (e.g. sterilisation process, staff immunisation, staff education). Environmental cleaning, These responsibilities are noted in position descriptions. Our leaders can delegate specific areas of responsibility to other nominated members of the practice team and these particular responsibilities should be documented in position descriptions. RACGP 4thedition Standards 3.1.3, 5.3.1, 5.3.2, 5.3.3, 4.1.1, 4.2.2 175 Adapted by IWSML based on work produced by Dandenong Casey General Practice Association and published by QIP/AGPAL july 2012