policy and procedure practice web view · 2017-11-09chapter three: safety, ... incident...

Chapter three: Safety, quality Improvement and education

The following template policies and procedures are based on the requirements of the

RACGP Standards for General Practices (4th Edition)

TABLE OF CONTENTS

1 QUALITY IMPROVEMENT ACTIVITIES (CRITERION 3.1.1)...............................................11.1 Quality improvement.............................................................................................................11.2 Quality improvement tools and resources............................................................................11.3 Implementing quality improvement.......................................................................................21.4 Examples of quality improvement........................................................................................32 CLINICAL RISK MANAGEMENT SYSTEMS (CRITERION 3.1.2).........................................42.1 Definitions.............................................................................................................................42.2 Clinical risk management.....................................................................................................52.3 Defining mistakes and near misses......................................................................................72.4 Business continuity and information recovery plan..............................................................83 CLINICAL GOVERNANCE (CRITERION 3.1.3)....................................................................93.1 Definitions.............................................................................................................................93.2 Implementing clinical governance......................................................................................103.3 The Western Australian clinical governance system..........................................................123.4 Clinical leaders...................................................................................................................153.4.1 Role of clinical leaders.......................................................................................................154 PATIENT IDENTIFICATION (CRITERION 3.1.4)................................................................164.1 Patient identification...........................................................................................................164.2 Errors in patient identification.............................................................................................165 QUALIFICATIONS OF GENERAL PRACTITIONERS (CRITERION 3.2.1).........................175.1 General practice is a specialist discipline...........................................................................175.1.1 Where vocationally recognised general practitioners are unavailable...............................175.2 Professional and ethical obligations...................................................................................185.3 Continuing professional development requirements..........................................................185.3.1 Cardiopulmonary resuscitation skills..................................................................................185.3.2 Identifying training providers and resources – general practitioners..................................196 QUALIFICATIONS OF NURSING STAFF (CRITERION 3.2.2)...........................................206.1 Nurses in general practice..................................................................................................206.2 Scope of practice................................................................................................................206.3 Enrolled nurse supervision.................................................................................................206.4 Clinical tasks.......................................................................................................................216.5 Administrative tasks............................................................................................................226.6 Competency standards......................................................................................................226.7 Continuing professional development requirements..........................................................236.7.1 Identifying training providers and resources – practice nurses..........................................237 TRAINING OF ADMINISTRATIVE STAFF (CRITERION 3.2.3)..........................................247.1 Training relevant to the role................................................................................................247.2 Policies and procedures.....................................................................................................247.3 First aid and cardiopulmonary resuscitation skills..............................................................247.4 Assessment and training needs.........................................................................................257.4.1 Identifying training providers and resources – administrative staff.....................................25


1 QUALITY IMPROVEMENT ACTIVITIES (CRITERION 3.1.1)

Cross references with practice information (Criterion 1.2.1)Policy

Our practice will participate in quality improvement (QI) activities.

1.1 Quality improvement Our practice team recognise that QI is integral to the continuous development and expansion of our services to our patients.

Our practice seeks and responds to patients’ feedback on their experiences with our practice to support QI activities.

Our practice team will collect feedback, data and best practice recommendations from various sources. These may include:

Patients

Other health providers

The community

Local stakeholders

Our staff

Professional organisations

Practice data

1.2 Quality improvement tools and resourcesOur practice team will use QI tools, resources and organisations to improve our QI activities. These may include:

RACGP Oxygen: Intelligence in Practice http://www.racgp.org.au/yourracgp/racgp-oxygen/

The Clinical Health Improvement Portal (CHIP)

The PCS Clinical Audit Tool (CAT)

PEN Clinical Audit Tool http://www.pencs.com.au/

The Canning Data Extraction Tool http://www.canningtool.com.au/

The Improvement Foundation http://improve.org.au/

Institute for Healthcare Improvement http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

Information contained in this manual is current at February 2015

Policy and Procedure Practice Manual I [Type the company name] 1

http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

http://improve.org.au/

http://www.canningtool.com.au/

http://www.pencs.com.au/

http://www.racgp.org.au/yourracgp/racgp-oxygen/


1.3 Implementing quality improvement Our practice uses the Model for Improvement

Source: The Improvement Foundation


2 Policy and Procedure Practice Manual I [Type the company name]

THIN

KIN

G PA

RT

STEP 1. PLAN Describe the idea What, who, when, where Make predictions Define data to be

collectedSTEP 2. DO Carry out the plan Record data

STEP 4. ACT What next? Implement change or

try something new? What idea will you

test?STEP 3. STUDY Analyse data Compare data to

predictions Summarise and reflect

on lessons

DO

ING

PAR

T

PDSA CYCLE

By answering this question you will develop ideas for change

Question 3.What changes can we make that will result in an

improvement?

By answering this question you will develop measures for tracking your goal

Question 2.How will we know that a change is an improvement?

By answering this question, you will develop your goal

Question 1.What are we trying to accomplish?

IDENTIFY IDEAS

DEVELOP MEASURES

DEFINE YOUR GOAL


1.4 Examples of quality improvementOur practice team will come together on a regular basis to consider QI activities or special projects as a collaborative effort.

For example:

Review and update of practice policies and procedures, or a component of, such as:

Practice services, Chapter 13.2 - Clinical handover actions recommend a team planning session with doctors and staff to evaluate past handover systems and to ensure that they are effective, fail-safe and sustainable

Practice services, Chapter 14.2 - Essential follow up systems recommends a team planning session with doctors and staff to evaluate past follow up systems and to ensure that they are effective, fail-safe and sustainable

Audits of our clinical data for health risk assessments

Practice services, Chapter 9.3 - Health risk assessments for the national cervical screening, BreastScreen Australia and the national bowel cancer screening programs

Implementation of preventative care activities

Practice services, Chapter 9.2 - Preventative care for occupational and standard ‘flu vaccinations, mole scan checks and asthma awareness clinics

Carry out staff performance appraisals

Practice services, Chapter 1.3 - Performance reviews Patient satisfaction

Rights and needs of patients, Chapter 3 - Patient feedback and complaints Data cleansing

Archiving inactive or deceased patients

Removing sample patients

Merging or removing duplicate patients

Confirming patient identifiers such as correct name, address and date of birth every time a patient visits

Conducting Online Patient Verification (OPV) checks through Medicare Australia and Online Veterans Verification (OVV) through the Australian Government Department of Veterans’ Affairs

Maintaining recall lists

Updating medications

Actioning and clearing outstanding ‘actions’ or ‘requests’ in your practice software

Analysis of near misses or errors




2 CLINICAL RISK MANAGEMENT SYSTEMS (CRITERION 3.1.2)

Policy

Our practice has risk management systems to enhance the quality and safety of our patient care.

Our practice has documented and tested plans for business continuity and information recovery.

2.1 Definitions ‘Risk’ is defined as:

Anything that threatens your ability to meet an objective; and

The probability of a negative consequence.

‘Risk management’ is the act of:

Identifying potential risks;

Establishing the extent of the potential risks;

Planning the possible responses to the risk (if it occurs); and

The monitoring or evaluation of the risk management process for continuous improvement systems.

A general practice encounters potential risks on a daily basis. Developing and embedding risk management systems encourages corporate governance.

Our practice will plan for these risks on a level of possibility using a ‘risk matrix’ and putting in place risk management strategies or controls to avoid, monitor and plan for risk occurrences, and how to deal with the after effects of an incident or even a near-miss.

Our practice may face numerous types of risks, both in the health and safety of our staff, patients and the general public but also to the establishment of the business, such as financial risk, risk to assets, risk to reputation or legal risk.

Our practice will also put into place QI practises such as goals and measures to monitor improvement (or decline), change management and evaluation.

For more information on risk management:

Risk management – Principles and guidelines. International Organisation for Standardisation (ISO) 31000:2009

http://www.iso.org/iso/catalogue_detail?csnumber=43170



http://www.iso.org/iso/catalogue_detail?csnumber=43170


2.2 Clinical risk managementClinical risk management is the act of identifying perceived risks in medical practise, establishing the extent of the potential risk, planning the possible responses to the risk (if it occurs) and the monitoring or evaluation of the risk management process for continuous improvement systems.

Our practice has appointed (<Name/position of person with primary responsibility for clinical risk management systems>) with primary responsibility for clinical risk management systems. Specific areas of responsibility may be delegated to another nominated member of the practice team.

These particular responsibilities will be documented in the position description of (<Name/position of person with primary responsibility for clinical risk management systems>).

For example, the practice nurse is delegated responsibility to monitor, identify and report near misses and mistakes in the use of the practice autoclave. This responsibility is documented in the practice nurse position description. Training will be provided and competencies maintained and monitored for the nurse to be able to carry out this responsibility.

The following procedure will be carried out <insert regularity of risk management procedures eg annually>:

Identify the risk

A useful conduit to establish this is a team brainstorming activity. The team can work through the plan, use previous experiences or industry examples of past occurrences of threats, risks and hazards and work through the risk management process for each of these.

A risk should be delineated as:

The cause – eg error in patient identification.

The impact – eg patient results given to the wrong person, breach of privacy.

Quantify the risk

Now that the risks have been identified, how likely are they to occur?

If they do occur, how damaging will they be to patients or the practice?

Would the occurrence of the risk be solely negative or are there potential positive outcomes?




Risk Matrix – By using a risk matrix our practice can establish the probability and impact of perceived threats.

Sample risk matrix

Severity

Prob

abili

ty

Low Medium High

High Low risk High risk High risk

Medium Medium risk Low risk High risk

Low Medium risk Medium risk Low risk

Risk response

Once the risk has been quantified, the likelihood and impact estimated, the practice team can visit potential responses to the risk if it eventuates. A contingency plan should include a strategy and action items to address each risk. An identified risk can be:

Avoided.

Transferred.

Mitigated – what actions can be taken to lessen the risk? Implement policies and procedures for staff to use three approved identifiers when providing results over the phone.

Accepted – accept the risk. If the risk is late delivery of one type of vaccination due to a lack of stock but the local pharmacy has reserves which patients can access, the effort to manage the risk may not be necessary.

Monitoring and control

Potential risks should be monitored and continuously reviewed and even revised. Break up the risks into small steps that can be monitored and checked off as they are achieved.

Regular evaluation of the risks will identify if any incidents or near-misses occurred that should have been identified as a potential threat.

Tip: Use the Plan, Do, Study, Act cycle for QI

For more information please see:

Safety, quality improvement and education, Chapter 1 - Implementing quality improvement




2.3 Defining mistakes and near missesOur practice nurtures a culture of just and open communication to support the resolution of errors in clinical handover.

When errors or near-misses occur in clinical handover, every member of the practice team is encouraged to report the circumstance using de-identified data, so the event can be analysed and processes introduced to reduce the risk of a recurrence and harm occurring to other patients.

This practice will undergo an annual, structured risk assessment of computer and information security and will make improvements as identified and required.

This will include at a minimum, the review of:

Policies and procedures.

Assets register (hardware, software, data, [digital] certificates).

Network diagrams.

Threat analysis.

Possible data breach analysis.

Business continuity plan including contacts.

Training requirements of team members.

For more information see:

Practice services, Chapter 1 - 14.3.- Errors – in follow-up

Reference:

Risk management – Principles and guidelines. Standards Australia and Standards New Zealand. Third edition 2004. https://policy.deakin.edu.au/download.php?id=214&version=3&associated



https://policy.deakin.edu.au/download.php?id=214&version=3&associated


2.4 Business continuity and information recovery planOur practice business continuity and information recovery plan will enable continuous:

Clinical care whilst the clinical team cannot access electronic medical records.

Appointment scheduling.

Billing.

Business financial operations (payroll, Medicare claims).

Our practice business continuity and information recovery plan will: Identify critical practice functions.

Identify additional resources that will be required for continuity and recovery.

Document continuity and recovery processes, including alternative work procedures.

Emergency response actions.

Proceed through the three levels of response:

Emergency first response.

Continuity phase.

Recovery phase.

Our practice will provide education and resources to our staff to enable a full understanding of the practice business continuity and information recovery plan. New staff will be provided with a copy of the plan during induction and drill testing of the plan will occur annually.




3 CLINICAL GOVERNANCE (CRITERION 3.1.3)

Policy

Our practice has clear lines of accountability and responsibility for encouraging improvement in safety and quality of clinical care.

3.1 DefinitionsClinical governance is defined 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’.i

Good clinical governance will include elements of:

Examples of clinical governance activities may include practice audits such as:

Patient health summaries – does a random review show general practitioners are maintaining patient health summary information?

Instrument and equipment processing (processing reusable medical equipment).

Clinical effectiveness.

Adverse events and near misses.

Staff training, competencies, CPD requirements for professional organisations.

Patient and staff safety.



Clinical audits

Team mentoring and education –

basic and ongoing

CLINICAL GOVERNANCE

Clinical effectiveness –

evidence based practice

Risk management –

clinical and general

Open communication

Research and development


3.2 Implementing clinical governanceThe following section has been adapted from the Clinical Governance Standards for Western Australian Health Services, Office of Safety and Quality in Health Care Western Australian Department of Health1.

The Office of Safety and Quality in Health Care, recommends a clinical governance framework based on four pillars:

Consumer value: encourages general practices to involve their communities and stakeholders in maintaining and improving the performance of their general practice and in the planning for the organisation’s future.

Consumer liaison involves ongoing strategies which promote two way communications between consumers and general practices. Examples include informed consent, complaint management, patient satisfaction surveys and providing information about services to patients, their families and carers. The information obtained from these strategies supports informed decision making.

Consumer participation is the involvement of consumers in general practice planning, policy development and decision making. It ensures that general practices are confident they are providing accessible and equitable health care to their communities and that they are truly responsive to local priorities. Involve the local government authority, local allied health services, hospitals, consumer groups, Silver Chain etc in planning future extensions, medical equipment purchases and needs for the community.

Clinical performance and evaluation: aims to guarantee the progressive introduction, use, monitoring and evaluation of evidence-based clinical standards. The outcome is a culture where evaluation of organisational and clinical performance, including clinical audit, is commonplace and expected in every clinical service.

Clinical standards incorporate clinical guidelines, practice policies and procedures. For example, the Royal Australian College of General Practitioners (RACGP) issues the following; Standards for General Practices: 4th edition; Infection control standards; Computer and Information Security Standards; and Standards for general practices offering video consultations.

Clinical indicators are measures or benchmarks that enable general practices to compare themselves against similar health services, or against a previous similar time period. To facilitate system improvement, clinical indicators must be meaningful and reflect clinical practice standards.

Clinical audits are a method of evaluating and improving clinical practice. They can be defined as ‘the systematic measurement and evaluation of the efficiency and effectiveness of organisational systems and processes’. Clinical audits analyse the quality of clinical care outcomes, including the procedures used for diagnosis and treatment, the use of resources, and the adequacy of evaluation of clinical outcomes and patient quality of life.

1 Office of Safety and Quality in Health Care Western Australian Department of Health Clinical Governance Standards for Western Australian Health Services http://www.health.wa.gov.au/circularsnew/frameworks/Clinical_Governance,_Safety_and_Quality.pdf



http://www.health.wa.gov.au/circularsnew/frameworks/Clinical_Governance,_Safety_and_Quality.pdf



Clinical risk: concentrates on minimising clinical risk and improving overall clinical safety. This is achieved through the identification and reduction of potential risks and examination of adverse incidents or near-misses for causative and contributing factors and trends within and across the medical practice. To maximise learning opportunities lessons should be shared across the practice team.

Incident and adverse event reporting, monitoring and trend analysis incorporates activities such as learning from incidents or patterns of incidents, including near misses, management of adverse events, maintaining a risk register and monitoring medico-legal or possible medico-legal cases.

Sentinel event reporting, monitoring and clinical investigation defines the process for identification, reporting and investigating sentinel events (any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness).

Risk profile analysis: including the identification, investigation, analysis and evaluation of clinical risks and the selection of the most appropriate method of correcting, eliminating or reducing identifiable risks.

Professional development and management: supports the selection and recruitment of medical practitioners, nurses, administration and other practice staff, their ongoing professional development, maintenance of their professional standards and the control and monitoring of new and innovative procedures. These processes ensure the appointment and ongoing employment of appropriately skilled and experienced staff and the careful introduction of new policies and procedures.

Competency standards: the medical practice must be confident its staff have adequate skills and experience and are properly trained within their field, in order to undertake the responsibilities of their position within the practice. This includes the assessment of new medical practitioners by the practice principal or senior medical practitioners; the setting of competency standards for all staff and assessment of performance and regular assessment throughout their employment.

Continuing professional development (CPD): includes ongoing and regular education linked to the responsibilities and needs of all employed by the general practice.




3.3 The Western Australian clinical governance system Consumer (patient) value

Clinical performance and evaluation

Clinical risk Professional development and management

Expected outcomes

Enhanced practice understanding and responsiveness to consumer requirements

Enhanced patient and consumer knowledge and participation in practice delivery and management

Improved confidence for consumers

Improved patient outcomes

Development of agreed pathways for clinical practice

Improved adherence to evidence based clinical practises and reduced variation in clinical practise


Reduced health care costs through reduced adverse events

Improved monitoring and reporting of clinical incidents, near misses and adverse events

Improved investigation of clinical incidents, near misses and adverse events

Improved risk management processes

Reduced number and severity of adverse events

Improved professional development and skills training for all staff members

Improved performance management

Improved job satisfaction with staff

Suggested Key Performance Indicators (KPIs) for monitoring and reporting

Patient satisfaction reports

Consumer complaints and compliments data

Development and utilisation of procedure specific consent forms in health services

Utilisation and compliance with Open Disclosure policy and processes

Compliance against clinical standards

Clinical indicators for safety and quality

Implementation and compliance with evidence based clinical pathways and best-practice protocols

Clinical performance data

Clinical incidents and adverse events recorded

Potential and actual medico-legal claims

Complaints and freedom of information (FOI) requests

Decision support tools for monitoring high risk interventions

Clinical audit outcomes

Reports on activities and outcomes of QI committees

Staff satisfaction

Professional development and clinical skills training for staff

Processes for introduction of new policies and procedures

Systems for training staff in management




Consumer (patient) value



Standards and policies

Establish policies and procedures to improve patient knowledge and facilitate greater consumer participation and improvement in health service delivery and management, including: Practice

Mission Statement/ Goals/Aims

Complaint management policy

Consent policy and standardised procedure specific consent forms

Establish policies and procedures to audit, monitor, review and evaluate clinical practice performance and management standards, including: Improved

adherence to evidence-based clinical practises and reduced variation in clinical practise


Reduced health care costs through reduced adverse events

Develop and monitor policies and procedures to manage and implement changes for clinical risk, incident monitoring, clinical incidents and adverse events, including: Clinical risk

management policy

Clinical incident monitoring and reporting policy

Complaint management policy

Guidelines for clinical incident investigation

Establishment of a QI committee

Informed consent guidelines and procedure specific consent forms

Establish and review professional development and staff management policies, procedures and clinical audits, including: Staff orientation

guidelines Professional

development and clinical skills training for staff

Evidence based clinical practise guidelines

Performance management policies and competency assessment processes

Guidelines for introduction of new policies or procedures




Consumer (patient) value



Examples of information tools

Patient satisfaction survey

Consumer complaints and compliments

Data from review of use of consent forms

De-identified patient data including: Complaints

register Clinical

incident, adverse event and sentinel event reports

Medico-legal data


Clinical audit data

QI committee reports

Clinical risk register

Clinical incident, adverse event and sentinel event reports

Medico-legal data


Clinical audit data

De-identified QI committee reports

Staff satisfaction surveys

Staff retention data

Teaching and education

Performance, development and management databases

Clinical research and publications

Other health workforce information

References and more information:

Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998;317:61–5.

Office of Safety and Quality in Health Care Western Australian Department of Health. Western Australian Clinical Governance Guidelines. http://www.health.wa.gov.au/circularsnew/frameworks/Clinical_Governance,_Safety_and_Quality.pdf

Standards Australia (2004). Australia and New Zealand Standard on Risk Management AS/NZS 4360:2004.

Australian Commission on Safety and Quality in Healthcare. https://www.safetyandquality.gov.au/



https://www.safetyandquality.gov.au/




3.4 Clinical leadersOur practice’s clinical leaders are <name the clinical leader(s)>.

Our clinical leaders will be responsible for embedding safety and QI practises and sharing information about QI and patient safety within the greater practice team.

Our clinical leaders will ensure the ongoing development of an organisational culture of openness, safety and quality. This culture will reward and resource participation and leadership.

3.4.1 Role of clinical leadersOur clinical leaders will regularly review, revise and introduce strategies for:

Identifying and mitigating clinical risks for the practice, the staff and the patients.

Introducing systems and procedures to learn and share safety lessons to implement solutions to prevent harm through changes to practice processes.

Implementing strategies to decrease variability in care delivery and outcomes for patients.

Devising procedures to provide timely and equitable access to care.

Our clinical leaders will meet regularly (such as quarterly in March, June, September, and December) to manage systems such as:

Accurate registers of patients with specified chronic conditions.

Proactively identify those at risk or those that would benefit from special intervention.

Extract specified clinical data and collate that data to guide improvement in the practice.




4 PATIENT IDENTIFICATION (CRITERION 3.1.4)

Policy

Our patients are correctly identified at each encounter with our practice team.

4.1 Patient identificationOur team will ask a patient to identify their own name, date of birth and address rather than volunteering the information from current records, each time they make an appointment and attend our practice. This activity will ensure all contact details are kept up-to-date.

Our approved list of identifiers includes:

Name

Address

Date of birth

Gender

Patient record number where it exists

A Medicare number is not an approved identifier as more than one number may exist for a patient.

4.2 Errors in patient identificationOur practice nurtures a culture of just and open communication to support the resolution of errors in clinical handover.

When errors or near-misses occur in clinical handover, every member of the practice team is encouraged to report the circumstance using de-identified data, so the event can be analysed and processes introduced to reduce the risk of a recurrence and harm occurring to other patients.

For more information please see policies on:

Safety, quality improvement and education, Chapter 2 - Clinical risk management systems




5 QUALIFICATIONS OF GENERAL PRACTITIONERS (CRITERION 3.2.1)

Policy

All medical practitioners in our practice are appropriately qualified and trained, have current Australian registration and participate in CPD.

5.1 General practice is a specialist disciplineOur practice recognises that general practice in Australia is a specialist field. Our medical practitioners will have relevant experience and training in general practice and where possible, hold a Fellowship qualification with the Royal Australian College of General Practitioners (RACGP) or the Australian College of Rural and Remote Medicine (ACRRM).

We require our general practitioners to have a minimum of two years’ Australian equivalent working experience in general practice.

General practitioners will be required to undertake CPD activities, apply for and maintain Vocational Recognition with Medicare Australia in order to access the Group A1 schedule of fees.

5.1.1 Where vocationally recognised general practitioners are unavailableWhere recruitment efforts have failed to engage a specialist general practitioner, our practice will consider applications from non-Vocationally Recognised medical practitioners. In these circumstances, applicants will be required to:

Have a minimum of two years’ Australian equivalent working experience in general practice.

Meet all Australian Health Practitioner Registration Authority (AHPRA), Australian Medical Council (AMC) and College requirements for registration if overseas trained.

Actively work towards a vocational qualification in general practice (OTDs and Registrars).

Be a specialist in another relevant field.

Be a registrar in general practice training. This includes the programs coordinated by Western Australian General Practice Education and Training (WAGPET), Remote Vocational Training Scheme (RVTS) or ACRRM.

Participate in CPD activities, group learning sessions and accept training and mentoring from clinical supervisors.




5.2 Professional and ethical obligationsAll members of our clinical team will comply with the professional and ethical boundaries required by law, their boundaries of their knowledge, skills and competence and their associated professional organisations such as:

Australian Health Professional Regulation Authority (AHPRA)

Royal Australian College of General Practitioners (RACGP)

Australian College of Rural and Remote Medicine (ACRRM)

Australian Medical Council (AMC)

Australian Medical Association (AMA)

5.3 Continuing professional development requirementsClinical staff are required to meet the Medical Board of Australia CPD minimum criteria and professional body CPD (such as RACGP and ACRRM).

Evidence of the relevant (usually triennium) quality improvement (QI) and CPD certificate will be required for the staff file.

All medical practitioners will complete CPR in accordance with their College CPD recommendations.

5.3.1 Cardiopulmonary resuscitation skillsSelect the most appropriate option for your practice, or create your own procedure

<Option one>

All staff, clinical and non-clinical, are required to complete an annual refresher course in CPR.

<Option two>

All staff, clinical and non-clinical, are required to complete CPR training every three years.




5.3.2 Identifying training providers and resources – general practitioners Training and development activities may be provided either in house or through external providers. This practice regularly uses organisations such as the RACGP, ACRRM, Rural Health West, WAPHA, universities and other local/national accredited training providers.

If you locate a course, education session, workshop, meeting that you wish to attend, please bring details to the practice principal (clinical) who will authorise attendance and payment, in certain circumstances and where the budget allows. Time may be granted on full pay for certain meetings, education sessions and courses.

The practice principal will formally approve the education session in writing and place details on the clinical staff member’s CPD record which is stored in the personnel file.

The practice manager will liaise with the clinical staff member for application, fees, etc. When seeking time off to attend external sessions, staff workloads are considered to ensure practice coverage.

Applications must be made with as much advance notice as possible.




6 QUALIFICATIONS OF NURSING STAFF (CRITERION 3.2.2)

Policy

All members of our clinical team are appropriately qualified and trained, have relevant current Australian registration and participate in CPD.

6.1 Nurses in general practiceA practice nurse may be a registered nurse (RN) or an enrolled nurse (EN). The duties undertaken by a practice nurse are varied, dependent on a range of factors including the skills of the nurse and the location and demographics of the general practice.

The duties our practice nurse is expected to perform within the general practice environment will be listed in the position description.

See also:

Safety, quality improvement and education, Chapter 5.4 - Cardiopulmonary resuscitation skills

6.2 Scope of practiceNurses are legally bound by a framework of core professional standards that makes them accountable and responsible for their own actions within nursing practice.

All registered and enrolled nurses employed by our practice will work within their scope of practise and competency level as advised by the Nurses and Midwifery Board of Australia.

6.3 Enrolled nurse supervisionEnrolled nurses are appropriately qualified nurses who can perform a wide range of nursing activities. However, the enrolled nurse cannot practise independently and must be supervised by a registered nurse. Enrolled nurses practising independently are deemed to be working outside of their scope of practice.

Where an enrolled nurse is employed in our practice he/she will have in place clear pathways for professional supervision by the registered nurse.

A general practitioner cannot supervise an enrolled nurse.




6.4 Clinical tasksOur practice nurses are trained and expected to carry out:

ECGs.

Spirometry.

Audiometry.

Undertake ear syringing.

Engage in health promotion activities.

Administration of medication.

Monitoring of Schedule 8 drugs.

Wound management and dressings.

Provide assistance with minor surgical procedures.

Triaging of patients.

Administer immunisations when directed by the general practitioner.

Provide assistance with health assessments and chronic disease management activities.

Contribute to the multidisciplinary practice team.

As a guide, areas where the duties that may be undertaken by a registered nurse could vary from those that may be undertaken by an enrolled nurse are listed below:

Duty RN* EN*

Cannulation ▲ no

Conduct ECGs, spirometry and audiometry yes ▲

Ear syringing ▲ ▲

Give immunisation injections yes ▲

Give IV drugs yes no

Give oral medication yes ▲

Plastering ▲ ▲

Sign out, check, give or hold keys to schedule 8 drug cabinet yes no

Triage yes no

Venipuncture ▲ ▲

Wound management and dressing yes ▲

▲upon completion of appropriate coursework and deemed competent

**Refer to the Nursing and Midwifery Board of Australia for confirmation of nursing scope




6.5 Administrative tasksPractice nurses are also expected to:

Maintain treatment room stock.

Maintain infection control and cold chain procedures.

Carry out and coordinate equipment sterilisation and maintenance.

Maintain and assist in achieving accreditation compliance.

Manage practice recall systems and disease registers.

6.6 Competency standardsThe Nurses and Midwifery Board of Australia has developed a professional framework for nursing practice using a set of national standards and codes. The core standards are:

Codes of ethics for:

Midwives

Nurses

Codes of professional conduct for:

Midwives

Nurses

Professional practice guidelines for:

Nursing and midwifery – Advertising of regulated health services

Nursing and midwifery – Guidelines for mandatory notifications

Guidelines covering:

Competency standards

Decision making framework

Registration standards

Principles for the assessment of national competency standards

Professional boundaries

Re-entry to practise policy




6.7 Continuing professional development requirementsCPD is critical to the practice nurse role and to quality patient care. Professional development undertaken can include courses, supervised clinical practice, and reflective practice in conjunction with personal study, mentoring and networking activities.

Nursing staff are required to meet the Nurses and Midwifery Board of Australia CPD minimum criteria.

Evidence of the relevant quality improvement and CPD program (QI & CPD) certificate will be required for the staff file.

All nursing staff will complete CPR in accordance with their CPD recommendations.

6.7.1 Identifying training providers and resources – practice nursesTraining and development activities may be provided either in house or through external providers. This practice regularly uses organisations such as the RACGP, ACRRM, Rural Health West, WAPHA, universities and other local/national accredited training providers.

If you locate a course, education session, workshop, meeting that you wish to attend, please bring details to the practice principal (clinical) who will authorise attendance and payment, in certain circumstances and where the budget allows. Time may be granted on full pay for certain meetings, education sessions and courses.

The practice principal will formally approve the education session in writing and places details on the clinical staff member’s CPD record which is stored in the personnel file.

The practice manager will liaise with the clinical staff member for application, fees, etc. When seeking time off to attend external sessions, staff workloads are considered to ensure practice coverage.


Resources:

The following websites will provide further information on practice nurse employment, regulations, CPD and resources:

Australian Government Department of Health, A-Z index, nursing in general practice, enhanced primary care items http://www.health.gov.au/internet/main/publishing.nsf/content/a-z

Australian Nursing and Midwifery Accreditation Council https://www.anmac.org.au/

Australian Nursing and Midwifery Federation http://anmf.org.au/

Australian Primary Health Care Nurses Association https://www.apna.asn.au/

Western Australian Health Department http://ww2.health.wa.gov.au/Home

Nursing and Midwifery Board of Australia http://www.nursingmidwiferyboard.gov.au/

Royal College of Nursing Australia https://www.acn.edu.au/



https://www.acn.edu.au/

http://www.nursingmidwiferyboard.gov.au/

http://ww2.health.wa.gov.au/Home

https://www.apna.asn.au/

http://anmf.org.au/

https://www.anmac.org.au/

http://www.health.gov.au/internet/main/publishing.nsf/content/a-z


7 TRAINING OF ADMINISTRATIVE STAFF (CRITERION 3.2.3)

Policy

Our administrative staff regularly participate in training relevant to their role in the practice.

7.1 Training relevant to the roleThis practice has a policy of training all staff members, over time, to be competent in the performance of all their assigned duties. We will endeavour to provide each member of the practice team with opportunities for personal and professional development on a regular basis.

See also:

Safety, quality improvement and education, Chapter 5.4 - Cardiopulmonary resuscitation skills

7.2 Policies and proceduresOur practice team will be involved in regular training against the policies and procedures. Where there is an update or a new policy or procedure, staff will be included in a communication strategy to ensure all team members comply.

All staff members will complete a confidentiality and privacy agreement which includes internet and email usage. More information on this policy is found in:

Practice management, Chapter 4 - Confidentiality and Privacy Practice management, Chapter 1.6 - Staff Privacy and Confidentiality

7.3 First aid and cardiopulmonary resuscitation skillsAll administrative staff must have a current first aid certificate. It is the responsibility of individual staff members to ensure that this is renewed every three years or as recommended by the provider.

For other skills necessary for a staff member to possess but which may be used only infrequently, annual or biennial refresher training will be included in that staff member’s performance appraisal criteria.

Select the most appropriate option for your practice, or create your own procedure

<Option 1>

All staff, clinical and non-clinical, are required to complete an annual refresher course in CPR.

<Option 2>

All staff, clinical and non-clinical, are required to complete CPR training every three years.




7.4 Assessment and training needsTo assess the training needs of our staff we will develop a matrix for each person in the practice, based on their position description, of all the tasks and skills that they need to be competent in to successfully perform their job. Then a rating scale of ‘needs training’; ‘trained’ and ‘demonstrates competency’ will be applied for each person for each skill.

This practice also relies on a variety of inputs to identify staff training needs such as staff-identified needs and regular performance appraisals. All education sessions are recorded in each staff member’s professional development record. This is stored in the personnel file.

Consideration of the following competencies will be considered:

Medical terminology

Accounts

Medicare

Reception skills (telephone, filing, customer service, appointment book, confidentiality)

Medico legal implications

Triage

Occupational health and safety

Practice software systems

Other software systems (Word, Excel, Powerpoint)

Dealing with difficult patients

Resources:

The AMA WA provides extensive training options for medical receptionists http://www.amawa.com.au/amatraining/training-directory/medical-reception-course/

7.4.1 Identifying training providers and resources – administrative staffTraining and development activities may be provided either in house or through external providers. This practice regularly uses organisations such as the RACGP, Rural Health West, WAPHA, Australian Association of Practice Management, universities, other local/national accredited training providers, trade unions and the Australian Medical Association.

If staff locate a course, education session, workshop, meeting that they wish to attend, please bring the details to the practice manager who will authorise attendance and payment, in certain circumstances where the budget allows. Time may be granted on full pay for certain meetings, education sessions and courses.

The practice manager will formally approve the education session in writing and place details on the staff member’s CPD record which is stored in the personnel file.

The practice manager will liaise with the staff member for application, fees, etc in seeking time off to attend external sessions, staff workloads are considered to ensure practice coverage.




http://www.amawa.com.au/amatraining/training-directory/medical-reception-course/

policy and procedure practice web view · 2017-11-09chapter three: safety, ... incident...

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