Appendix A

DOCUMENTATION REQUIRED PRIOR TO ASSESSMENT

For Aiming for Excellence Standard (A4E) 2011-2014

Attach all evidence, policies and documents into QA2QI, the online tool. This will allow the assessors to access the information in preparation for the CORNERSTONE assessment.

For evidence that is an annual or more regular process, these should be loaded for each year (with the specific date in the description)

Please Note: ensure all data is available to the assessors no less than ten working days prior to the date of the assessment.

In exceptional circumstances, if it is not possible to attach one or more of the documents please email, or notify Assessor that this will be available to view on the day of assessment.

This is the minimum requirement.

Please do not duplicate evidence, it is not required. Please read carefully the Criteria and make sure the attached evidence applies.

NOTE – Do not include any identifiable patient information.

Indicators / Documentation / Evidence
3 / Policy: Complaints policy
Complaint form
Complaints register / Upload to QA2QI
Upload to QA2QI
Have available for Assessor to view on the day
4 / Informed consent- example of the form/s used to document informed consent from a patient or legally designated representative when agreeing to a treatment or procedure / Upload to QA2QI
Note: Assessor will want to see evidence in notes so GPs / PNs to list note some NHIs where informed consents are scanned in and documentation is evident in the daily record.
Same applies to support person present re documentation in notes.
5 / Maori Health Plan / Upload to QA2QI
7 / Patient information on how to access 24 hour medical care ( brochure, front door sign, flyer, newsletter, website / Upload to QA2QI
9 / Patient Satisfaction Survey results
For new Patient Experience Survey – PES / Upload to QA2QI
Need to show Assessor on the day

Revised March 2017

Indicators / Documentation / Evidence
10.1 / Strategic Plan / Upload to QA2QI or have available for Assessor to view on the day
10.2 / Quality Plan / Upload to QA2QI
10.4 / Quality improvement activity / Load into QA2QI. If you have this documented e.g. in a PDSA
13.3
13.4 / Policy –Security of electronic patient information /Back up and retrieval system / Upload to QA2QI
16.1 / Policy & procedures: Infection control
Aligned to AS/NZS 4815:2006
(refer to page 32 of A4E) / Upload to QA2QI
16.4 / Calibration and validation- sterilizer / Upload to QA2QI
17 / Cold Chain Management – copy of current Cold Chain Accreditation certificate / Upload to QA2QI
18.1 / Medical equipment – audit of servicing of equipment / Copy of latest servicing of equipment
Upload to QA2QI
18.5` / Report: Annual emergency (medical) drill / Upload to QA2QI
Copy of drill report
18.8/18.9 / Procedure: Documented procedure for checking and maintenance of equipment & medications and supplies / Upload to QA2QI
Copy of documented procedure ( not just copies of checklist) but a documented procedure of what happens in the practice
19.1 / Letter: Fire Evacuation Scheme / Upload to QA2QI
Copy of letter from Fire Service- scheme approval
19.2. / Evacuation drill ( fire drills) / Upload to QA2QI
Required 6 monthly – load with dates showing 6 monthly.
19.3 / Emergency Response Plan / Upload to QA2QI
Copy of front page to show evidence of update and currency of plan ( if using the web based tool)
Have available on the day the full plan.
19.4 / Business Continuity Plan / Upload to QA2QI
Copy of front page to show evidence of update and currency of plan ( if using the web based tool)
Have available on the day the full plan
20.3 / Health & Safety review
( in line with the Health and Safety at Work Act 2015) / Upload to QA2QI – practice policy and/or manual
Show evidence of what has occurred for review.
Have available for Assessor on the day.
( current Hazard/risk register, audits, checks, current register of accidents/ incidents)
Indicators / Documentation / Evidence
21.1 / Forms: Registration and enrolment form
Medical questionnaire (if applicable)
A documented process to cover 21.1 – 21.4. / Upload to QA2QI
22 / Audit: Medical records notes audit
Report: Patient records – record review
All clinical staff, long term locums and regular part-time clinical staff
Use current (Jan 2017) medical record audit template- 10 records each. / Upload to QA2QI - Practice wide collated report- as per a PDSA format or quality improvement action plan
Do not load individual clinician audits onto QA2QI
23.3 / Procedure: Triaging urgent medical needs / Upload to QA2QI
Documented triage system
24.1 / Policy: Patient test results, imaging reports and investigations, clinical correspondence tracking and management / Upload to QA2QI
25.2 / Policy: Repeat Prescribing / Upload to QA2QI
25.4 / Audit: Repeat prescribing / Upload to QA2QI
Load copy of audit and report
25.5 / Audit of non-collected prescription / Upload to QA2QI
28/ 30/ 34 / Screening and Recall, Immunisation/ Disease prevention / Have available on the day, latest report on health targets ( IPIF)
33 / Policy: Incident Management policy
Incident reporting form
Incident register / Upload to QA2QI
Upload to QA2QI
Have available for Assessor to view on the day
35.1 / Teamwork survey / Upload to QA2QI
Have available for Assessor to view on the day- what and how this has been discussed with the team.
35.2 / Team meetings / Upload to QA2QI
Copy of a couple of recent meetings
Have available for Assessor to view on the day
35.4 / Orientation Manual / Upload to QA2QI
35.5 / Practice Resource / Upload to QA2QI

Human Resources and Training Records

Indicators / Documentation / Evidence
34.1 / Annual Practicing Certificates – GPs and nurses / Can be loaded on QA2QI or see individual records on the day of the assessment visit
36.1 / Signed employment agreements including terms & conditions / See individual records on the day of the assessment visit
36.2 / Position descriptions / See individual records on the day of the assessment visit
36.3 / Confidentiality agreements / Can be loaded on QA2QI or see individual records on the day of the assessment visit
36.4 / Indemnity insurance / Can be loaded on QA2QI or see individual records on the day of the assessment visit
36.6 / Performance review for all team / See individual records on the day of the assessment visit
Training Records
1.3
2.2
5.2
6.1
16.2
17.4
17.5
23.1
23.3
34.3 / Code of Health & Disability Services Consumers’ Rights 1996
Health Information Privacy Code 1994
Principles of the Treaty of Waitangi
Cultural competence and cultural safety
Infection control & disinfection & sterilisation
Cold chain training ( included in vaccinator updates)
Authorised vaccinator ( letter of approval from Medical Officer of Health)
Non clinical staff – identify and respond to urgent medical conditions
Current CPR certificates – for all members who may be required to administer CPR
Record of continuing professional development / Training records/ certificates can be loaded on QA2QI or see individual records for the practice teams on the day of the assessment visit, as applicable

Revised March 2017