The following template policies and procedures
are based on the requirements of the
RACGP Standards for General Practices (4th Edition)

TABLE OF CONTENTS

1quality improvement activities (criterion 3.1.1)

1.1Quality improvement

1.2Quality improvement tools and resources

1.3Implementing quality improvement

1.4Examples of quality improvement

2clinical risk management systems (criterion 3.1.2)

2.1Definitions

2.2Clinical risk management

2.3Defining mistakes and near misses

2.4Business continuity and information recovery plan

3Clinical governance (Criterion 3.1.3)

3.1Definitions

3.2Implementing clinical governance

3.3The Western Australian clinical governance system

3.4Clinical leaders

3.4.1Role of clinical leaders

4Patient Identification (Criterion 3.1.4)

4.1Patient identification

4.2Errors in patient identification

5qualifications of general practitioners (Criterion 3.2.1)

5.1General practice is a specialist discipline

5.1.1Where vocationally recognised general practitioners are unavailable

5.2Professional and ethical obligations

5.3Continuing professional development requirements

5.3.1Cardiopulmonary resuscitation skills

5.3.2Identifying training providers and resources – general practitioners

6qualifications of nURSING staff (Criterion 3.2.2)

6.1Nurses in general practice

6.2Scope of practice

6.3Enrolled nurse supervision

6.4Clinical tasks

6.5Administrative tasks

6.6Competency standards

6.7Continuing professional development requirements

6.7.1Identifying training providers and resources – practice nurses

7Training of administrative staff (Criterion 3.2.3)

7.1Training relevant to the role

7.2Policies and procedures

7.3First aid and cardiopulmonary resuscitation skills

7.4Assessment and training needs

7.4.1Identifying training providers and resources – administrative staff

Chapter three: Safety, quality Improvement and education

1quality 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.

1.1Quality improvement

Our practice team recognise that QIis 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

1.2Quality improvement tools and resources

Our practice team will use QI tools, resources and organisations to improve our QI activities. These may include:

  • RACGP Oxygen: Intelligence in Practice
  • The Clinical Health Improvement Portal (CHIP)
  • The PCS Clinical Audit Tool (CAT)
  • PEN Clinical Audit Tool
  • The Canning Data Extraction Tool
  • The Improvement Foundation
  • Institute for Healthcare Improvement

1.3Implementing quality improvement

Our practice uses the Model for Improvement

Source: The Improvement Foundation

1.4Examples of quality improvement

Our 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 actionsrecommend 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

2clinical 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.

2.1Definitions

‘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.

Ourpractice 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 goalsand 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

2.2Clinical risk management

Clinical 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 egannually>:

  • 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 – egerror in patient identification.
  • The impact – egpatient 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
Probability / 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

2.3Defining mistakes and near misses

Our practice nurtures a culture of just andopen 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 toreport the circumstance using de-identified data, so the event can be analysed and processes introducedto 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.

2.4Business continuity and information recovery plan

Our 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.

3Clinical 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.

3.1Definitions

Clinical 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.

3.2Implementing clinical governance

The 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 Health[1].

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 liaisoninvolves 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 standardsincorporate 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 comparethemselves 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.
  • 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.

3.3The 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
  • Improved patient outcomes
  • 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 / Clinical performance and evaluation / Clinical risk / Professional development and management
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
  • Improved patient outcomes
  • 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 / Clinical performance and evaluation / Clinical risk / Professional development and management
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
  • Consumer complaints and compliments data
  • Clinical audit data
  • QI committee reports
/
  • Clinical risk register
  • Clinical incident, adverse event and sentinel event reports
  • Medico-legal data
  • Consumer complaints and compliments 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: