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					                     REPORT


 IDENTIFYING THE CARER PROJECT 2010
   GENERAL PRACTICE ENGAGEMENT




              FOR
THE COMMONWEALTH DEPARTMENT OF
       HEALTH AND AGEING




                   30 June, 2010




Project Manager                    Project Officer
Ms Janne McMahon                   Mrs Judy Hardy
    1. INTRODUCTION

In 2007 and 2009 the Australian Government funded the Private Mental
Health Consumer Carer Network (Australia), (hereafter the Network) to
undertake two projects titled Identifying the Carer, which examined issues
associated with identification of carers as a precursor to the future
development of a burden of care measure for carers.

Further to the Identifying the Carer Project Brief dated 14 October, 2009 the
Network requested that the Australian Government’s Department of Health
and Ageing consider an additional brief Project to enable further work to be
undertaken around the identification of carers within the General Practice
setting.

1.1`Role of GPs in the identification of carers

GPs play a critical role in the identification of all carers including those who
care for a person with a mental illness. Many carers become unwell
themselves as a result of their caring role.

The Royal Australian College of General Practitioners (RACGP) is currently
reviewing standards for practice accreditation. Final submissions are required
by 30 June 2010. The Network believes this process provides an ideal
opportunity for the issues associated with identification and support of carers
to be considered by this review. The evidence base for this was discovered
during the literature search for the recently completed ‘Carers Identified’
report. The literature also identified protocols for ‘Carer friendly’ practice within
the GP settings. Minor modification of the Better Outcomes ATAPS and Better
Access Programs could also significantly impact on the identification of carers
by GPs.

The Network felt it was crucial that the opportunity to have input into the
review of the RACGP Standards for General Practices (4th Edition)


   2. SUMMARY OF ACTIVITIES
The Network Project Officer met with the Project Director, Review of GP
Standards in Melbourne. At that meeting the following information was
provided by the Network Project Officer.

       Background to, and outcomes, of the two projects undertaken by the
        Network in relation to identification of carers.

       Information regarding the size of the caring population and the
        importance of recognising and engaging with carers in the general
        practice setting.

       The importance of recognising that carers present in two manners in
        GP practice.


Identifying the Carer - GP Engagement Project Report 2010              Page 2 of 123
            o  As patients themselves – which may, or may not be related to
              their caring activities; and
            o As a third party accompanying the identified patient.

        It appears that the primary focus to date within the GP Standards has
        been on the carer as a third party. GPs generally know which of their
        patients are carers themselves however they have not, in general,
        recognised them as a group whose caring activities place them at
        significant risk to their health status. Nor have they recognised them as
        a specific target group for promotion and prevention activities.

       The existence of Carer Recognition Legislation in most States and
        Territories and the development of National Legislation currently being
        considered by the Australian Government. The development of a carer
        specific (no7) in the revised National Standards for Mental Health
        Services developed for application in public and private services,
        including office based practice.


The following information was provided by the Project Director, Review
of GP standards, Ms Leanne Rich:

       The review process has received no submissions at that time
        specifically relating to mental health.

       The Project Director was aware of the fact that the National Standards
        for Mental Health Services had been reviewed from her own networks
        but no activity has occurred that has brought them to the attention of
        the current review of GP Standards.

       The National Standards for Mental Health Services (hereafter NSMHS)
        are considered by the RACGP to be too specific in their focus for the
        current review.

       The RAGCP Standards for General Practices (hereafter RACGP
        Standards) are developed by the RACGP with expert advice and are
        trialled in the field however the accreditation process is conducted by
        either of 2 separate accreditation agencies, AGPAL or GPA.
        Accreditation is currently a voluntary system and historically there have
        been no interim reviews between 3 year accreditation cycles. This has
        been recognised as an issue and is being addressed.

       The RACGP Standards are placing increased emphasis on consumer
        participation in the delivery of services. There are several standards
        that provide opportunities for GPs to also focus on carers.

       The usual process for introducing a new concept/material into the
        RACGP Standards is to initially flag the issue by way of provision of
        examples in the explanatory text that accompanies each indicator.
        Specific separate resources, including fact sheets are then developed


Identifying the Carer - GP Engagement Project Report 2010          Page 3 of 123
        around these new concepts and included on the constantly updated
        web site. It has been the experience of the RACGP that where new
        concepts are introduced by way of examples in one version of
        standards there is likelihood of greater acceptance of this concept as a
        specific standard with specific indicators in the next revision of the
        Standards, ie a developmental approach.

       Expansion of existing negotiations with the Medical Software agents
        could be expanded to include modifications to enable the carer status
        of people to be recorded. If this occurs it would facilitate the
        identification a person’s carer status in new patient records, health
        records and referral letters that are populated by the health summary
        record.

       The RACGP would be keen to work with DoHA to develop specific
        resources for GPs to assist them to understand the complexities that
        accompany carers as third parties where the patient has a mental
        illness. They would also welcome assistance with the development or
        modification of existing documents/information sheets to act as
        resources for GPs to assist them to understand the critical role that
        carers play and the impact that this has on their health leading them to
        become patients themselves. This would require some financial
        assistance. The information brochure developed as part of the ‘Carers
        Identified’ Project for Families and other carers was seen as ideal for
        modification as a tool for GPs.

       The RACGP would welcome a submission from the Network. A copy of
        the most recent edition was provided for the Network Project Officer to
        examine in detail and to make suggested changes by way of specific
        wording and provision of examples of situations where GPs could
        review the manner in which they deliver services.

    3. ACTIONS UNDERTAKEN

       Development of a submission to the Review of RACGP Standards for
        General Practices (4th Edition). During the development stages of the
        submission it was sent for consultation with the members of the
        Reference Group for the ‘Carers Identified’ project, 2010 and to the
        members of the Private Mental Health Consumer Carer Network
        (Australia) for comment. Their comments have been included in the
        final version.

       Development of a summary of available literature to provide an
        evidence base for the role GPs play in identification of ‘general’
        carers, including mental health carers.

       Developed a summary of the 2010 report ‘Carers Identified’ as it
        related to GP practice, including the relevant recommendations.




Identifying the Carer - GP Engagement Project Report 2010          Page 4 of 123
       Track changes were made to the latest version of the 4th Revision of
        the GP Standards (99 pages) to encompass the Networks suggestions
        for prompts and examples to assist GPs to deliver more carer focused
        services.

The Network made the following recommendation:
    Introduce and expand new concepts by providing examples in the
     explanatory text that accompanies each indicator;

       Develop specific separate resources, including fact sheets, around
        these new concepts; and

       Include newly developed resources on the RAGCP website on a
        progressive basis.

It is anticipated this approach could, in turn, lead to a likelihood of
greater acceptance of these concepts as requiring specific indicators in
the next revision of the Standards, ie a developmental approach.

The Network also expressed a willingness to work with the RACGP on
the development or modification of existing resources to suit the
specific needs of GPs.




Identifying the Carer - GP Engagement Project Report 2010      Page 5 of 123
   Submission to the Royal Australian College of General
                      Practitioners

               Revision of the RACGP Standards for
                  General Practices (4th Edition)

Introduction
The Private Mental Health Consumer Carer Network (Australia) welcomes the
opportunity to comment on the 4th revision of the RACGP Standards.

The Network has been funded by the Australian Government, Department of
Health and Ageing to undertake two projects over the last three years related
to mental health carers. The report of the 2007 project ‘Identifying the Carer’
is       available        on        the        DoHA          website         at
http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-pubs-i-
carer

In 2009 DoHA funded a further project with the following deliverables:
     Development of national policies and protocols for identification of
      carers; and
     Development of an information brochure for carers of people with a
      mental illness.

The report of this project, ‘Carers Identified’ is currently being considered by
the appropriate committees of the National Mental Health Standing
Committee and the Private Mental Health Alliance.

Extensive international literature searches and national consultations were
components of both projects. Both highlighted the crucial role that GPs play in
the identification and support of all carers, including those that care for people
with a mental illness. Many carers become unwell themselves as a result of
the burden of undertaking their caring role. With the carer’s first point of
contact usually being a GP, it is considered crucial that GPs have in place
standards, protocols and resources to assist them to identify and support
carers.

Carers – who are they?
There are nearly 2.6 million people in Australia who are carers. They provide
unpaid care and support to people who have a disability, mental illness,
chronic condition, terminal illness or who are frail. These people may not call
themselves ‘carers’; they are partners, parents, siblings, relatives, other family
members and/or friends.



Identifying the Carer - GP Engagement Project Report 2010           Page 6 of 123
Carers come from diverse socio-economic and cultural backgrounds. They
may be any age. They may be working &/or studying, as well as providing
care. In most cases, caring is a demanding role that requires mental and
physical energy, commitment and dedication.

The Rural Health Education Foundation suggests that carers in outer regional
and remote areas experience higher rates of disability or a long-term health
condition themselves, and are more likely to experience financial hardship
than carers in major cities. They also note that Indigenous people in rural and
remote Australia are more likely to be carers than non-Indigenous people in
these areas. This was based on research undertaken by Carers Australia in
2009 published in The Tyranny of Distance.

Caring for a person with a mental illness has particular challenges. The
episodic nature of mental illness, the stigma still associated with it, the
symptoms of the illness, and the struggle to obtain appropriate treatment and
care for a family member or friend. Some, or all of this, can contribute to a
carer feeling overwhelmed. Carers need strategies to manage these
challenges. Their efforts can predispose carers to mental illness themselves.

In 2007, carers were found to have the lowest wellbeing of any large group
recorded by the Australian Unity Wellbeing Index in The Wellbeing of
Australians: Carer Health and Wellbeing.

It is likely that a GP will be the first point of call for the majority of these
people.

Carers present at two levels in the general practice setting:
    As patients themselves – which may, or may not be related to
      their caring activities; and
    As a third party accompanying the patient.

The current revision of the GP Standards is placing increased emphasis on
patient participation in the delivery of services. This move towards a
partnership approach to service delivery is crucial as it will empower patients
to take more responsibility for their own care and to relieve the burden on
GPs.

The partnership also needs to include carers who play an ongoing role in the
day to day care of many patients with acute, chronic and long term conditions.

During consultations undertaken by the Network it was reported to us that
‘privacy and confidentiality’ were terms that were often used across all
healthcare sectors as a reason for not engaging with carers. This position can
no longer be justified.

The Australian Law Reform Commission undertook a review of privacy law in
2008 and recognized that disclosure of information to ‘a person responsible
for an individual’ can occur within current privacy law. The need for legislative
reform in this area to clarify this issue was also recognized by the 2009 House


Identifying the Carer - GP Engagement Project Report 2010          Page 7 of 123
of Representatives Inquiry into Better Support for Carers. Recommendation
14 of that report called for investigation of whether privacy and mental health
legislation ‘adequately allows carers to be involved in the treatment of the
individuals for whom they care’.The majority of States and Territories also
now have Carer Recognition Legislation in place that mandates carers rights
to information and support. National Carer Recognition Legislation has also
been drafted and is currently being considered by the Australian Government.
The recently revised National Standards for Mental Health Services(2009)
that have been developed for application across public and private settings,
including office based practice, now include a specific standard (no7) related
to the identification and support of carers.

Work by Zinn (2003) and S v City (2002) suggested that clinicians might now
run the risk of litigation as a consequence of depriving carers of information
and limiting channels of communication.

Carers Australia, in their 2010 budget submission to the Australian
Government, acknowledge that general practitioners, mental health
professionals in public and private sectors, and other key primary and acute
health care providers need skills, knowledge and an inclusive attitude to build
partnerships with carers. This will require an ongoing education strategy
through undergraduate, postgraduate and continuing education programs.
The development of Standard 7 in the revised National Standards for Mental
Health Services, together with State and National Carer Recognition
Legislation provides a framework for this to occur. The revision of the RACGP
Standards for General Practices (4th Edition) further provides an opportunity
to introduce change in this area.

The concept of confidentiality is often a concern to clinicians. One effective
way of raising the profile of the needs of carers that has been reported, has
been to involve carers directly in the teaching and training process i.e. to ‘tell
their story’ of their own experience. Carers are usually very willing to do this,
and clinicians repeatedly report that the open disclosure has a major impact
on how they develop strategies to engage families following training in family
interventions.

One main component of the model is information sharing between the patient
and the family members during on-going training programs .

During this process, information about the service and the particular difficulty
the patient identifies is discussed. With this approach both the patient and the
carer have control over what information is divulged to each other and to the
GP. The evidence base for this work maintains that, by encouraging greater
effective communication between people who significantly influence each
other, improved outcomes for both parties are dramatic. Service satisfaction
through a positive experience is well known to enhance future relationships
between patients, carers and clinicians.


In the GP area carers are not only third parties. They frequently become
primary patients themselves; patients who need to be recognised as at


Identifying the Carer - GP Engagement Project Report 2010           Page 8 of 123
particular risk for negative changes in their health status as a result of their
caring activities.

Ensuring GP practice is set up in a manner that actively encourages the
identification of people who are carers will have long term benefits for
individual patients, carers and GPs themselves.

The literature reports that patients, family or other carers and clinicians
working together collaboratively, provide an excellent opportunity for
incentive–based learning. Staff start to find that they are ‘thanked‘ by families,
rather than having to cope with families that are angry, frustrated, and
therefore seen as difficult and ‘dysfunctional.’ Less staff burn–out, less
absenteeism, and fewer resignations have also been reported. Inclusion of
the family and other carers is much more satisfying in that they are now view
each other as ‘allies’, rather than ‘enemies.’ Clinicians also find that issues
such as confidentiality disappear when carers become part of the treatment
and care team. Cost effectiveness of these interventions has been reported in
several cases, including in Australia (Mihalopoulos, 2004).

Family Interventions are a proven way of helping families stay together.
Rather than focussing treatment solely on the patient, new ways of thinking
and acting must incorporate the patient’s social network, most particularly his
or her family and friends. This is undoubtedly in the patient’s best interests for
optimum recovery.

Recommendations

    1. Introduce and expand new concepts by providing examples in the
       explanatory text that accompanies each indicator.

    2. Develop specific separate resources, including fact sheets,
       around these new concepts.

    3. Include newly developed resources on the RAGCP website on a
       progressive basis.

This approach could, in turn, lead to a likelihood of greater acceptance
of these concepts as requiring specific indicators in the next revision of
the Standards, ie a developmental approach.

The following documents are attached for consideration by the National
Expert Committee.

Attachment 1
Evidence base from Literature Search – GP contributions to the Identification
of the Carer Project and support of carers.

Attachment 2
Summary of relevant recommendations from the Network’s 2010 Report
‘Carers Identified’



Identifying the Carer - GP Engagement Project Report 2010           Page 9 of 123
Attachment 3
Suggested track changes to the Draft RACGP Standards for General
Practices (4th Edition).

The Network would be pleased to work with the RACGP on the
development or modification of existing resources to suit the specific
needs of GPs.

Yours faithfully,




Ms. Janne McMahon OAM
Independent Chair
28 June, 2010




Identifying the Carer - GP Engagement Project Report 2010   Page 10 of 123
Attachment 1

GP contribution to identification and support of carers.

The evidence base from the literature

GP practice in Australia is significantly different than that delivered by the
NHS in the UK. However, a search of the literature identified some ‘good
practice’ protocols that have been implemented, albeit in a rather ad hoc
manner it the UK.

The UK National Strategy for Carers (1999) identified the NHS as being the
most important point of contact for adult carers and it specified some key roles
for primary care staff. They recognised that the most important point of
contact for young carers was within education, however, acknowledged that
primary care staff working with families/parents offers obvious opportunities
for identifying young carers. The strategy highlighted the primary care roles
as being ideal for identifying patients who are carers or who have a carer;
checking carers’ physical and emotional health; informing carers of their rights
to an assessment and other support services; sign-posting and referring
carers to other sources of support and developing carer friendly practice
based services.

Greenwich Primary Care Trust (PCT) is an example of practice committed to
trying to address what they consider to be their responsibilities to carers and
have worked with the Greenwich Carers Centre to identify how to best support
carers using their services. There are a large number of research documents
citing primary care as being the one most obvious care sector for providing,
identifying and supporting carers. Hospital Discharge is also mentioned as an
important area on which to focus but that is not being addressed within this
piece of work.

Why Primary Care providers are so important

‘Patients who are carers’ often notice that caring for somebody has an impact
on their own health. Many suffer stress and depression due to the strains of
their caring role and some often suffer physical strain due to wrongly moving
or handling the person they are caring for.

There have been a number of Carers in Primary Care projects across the UK
and feedback from ‘patients who are carers’ show that many thousands of
carers have benefited from being connected to sources of help at times when
they needed it most. Professionals involved in the projects state that their


Identifying the Carer - GP Engagement Project Report 2010         Page 11 of 123
own awareness of the needs of ‘patients who are carers’ has been raised and
has enabled them to make some simple but significant changes to the way
they offer their services. This in the end benefited everybody.

National and local research in the UK shows that ‘patients who are carers’
need certain things from their GP practice.
    That the practice has an awareness of the needs of ‘patients who are
      carers’.
    That practices are pro-active at identifying ‘patients who are carers’ so
      as to inform them of the support available.
    That practices have a way of recording information about them so as to
      assist them when required and also to use the statistical information to
      inform future service delivery.
    That practices are able to provide relevant and timely information and
      advice to ‘patients who are carers’.
    That practices are able to refer ‘patients who are carers’ to other
      appropriate providers.
    That practices are able to offer carer friendly support services to
      ‘patients who are carers’.

Identification of ‘patients who are carers’
The strategic framework for identifying carers within the NHS hinges on some
new opportunities around supporting carers found in the new GP contracts.
Practices are able to claim a small number of points for having systems in
place to identify carers and a mechanism for the referral of carers to social
services for an assessment. Unfortunately, the contract only mentions
referrals to social services and does not give any recognition to the way in
which primary care itself may/should respond to carers’ needs. The new
contract does however provide for the inclusion of ‘enhanced services’ (that
may be determined locally) and this presents even wider opportunities to
include support to carers.

The following mechanisms were developed in order for a practice to identify
patients who are carers:
      Identifying Carers
          Have a named member of staff responsible for maintaining the practice’s
            procedure for identification of carers. A carer specialist or champion
          Examine existing database – ‘trawling of records’
          Utilise normal practice appointment consultations
          Practice Leaflet
          Use of health events, campaigns
          Utilise patients personal health checks
          Ordering or collecting of repeat prescriptions
          Global messages on prescriptions
          Hospital discharge
          Electronic and paper notice boards, leaflets
          New Patient questionnaires




Recording information about ‘patients who are carers’



Identifying the Carer - GP Engagement Project Report 2010                 Page 12 of 123
The Care Quality Commission assesses the performance of Primary Care
Trusts through a scoring framework and there is a requirement for them to
assess the support provided to carers via primary care. Careful recording of
the number of carers known to practices serves to provide statistical
information and also enables the practice to direct resources where needed in
future. Extensive national and local research shows that caring can have a
negative impact on the health of ‘patients who are carers’. In a recent study
carried out by the Princess Royal Trust for Carers 42% of ‘patients who are
carers’ reported that they themselves had a long term illness or disability and,
67% reported that their own health needs had been adversely affected as a
result of their caring role. Information stored about individual ‘patients who
are carers’ will therefore help the practice to have a better understanding of:

           the health needs of ‘patients who are carers’ and whether their
            physical health needs will be exacibated by their caring role.

           the ability of ‘patients who are carers’ to utilise local health services.

           the health promotion needs of ‘patients who are carers’ for both
            themselves and the person they are caring for.

A number of different ways for a practice to record the information within the
practice was subsequently developed:

     Recording Information
         Have a named member of staff responsible for maintaining the practice’s
           procedure for carer records
         Record in normal patient record-keeping system as well as any individually
           decided carer register etc.
         Obtain carers consent to be fully registered with practice as carer (REED code
           918A) – patients that have a carer can be recorded as REED code 918F
         Records should be easily available to health professionals using record
         Record any agreement by the person being cared for that the carer can have
           clinical information about them
         Cross reference records belonging to patient and carer (if using same practice)
         Paper records should be marked (tagged) to show patient is a carer
         Records should be easily changeable if situations change for the caring
           relationship




Providing information and advice to ‘patients who are carers’
In all national and local studies in the UK ‘patients who are carers’ cite
information and advice as being the one biggest area of need in their caring
role. Information needs can vary considerably depending on the relationship
between the ‘patient who is a carer’ and the person they are caring for and,
the level and type of illness/disability. However, there are a number of
information and advice issues that are generic to all ‘patients who are carers’
and all of these appear to be easily supported. One of the most basic is
information about the illness/disability of the person they are caring for and



Identifying the Carer - GP Engagement Project Report 2010                  Page 13 of 123
advice on how to help the person being cared for manage their
illness/disability.

A number of different ways in which a practice can provide basic information
and advice to patients who are carers were identified:




     Informing Carers
      Have a named member of staff responsible for maintaining the practice’s procedure
        for providing information and advice to patients who are carers
      All practice staff to receive Carer Awareness training so as to enable them to detect
        potential information/advice needs in patients who are carers
      All practice staff to have access to a regularly maintained recognised list of possible
        carer support needs and potential provider agencies
      All practice staff to remain aware that ‘patients who are carers’ need some
        information on the illness/disability of the person they are caring for in order to
        care for them properly.




Referring ‘patients who are carers’ to other providers
There are a number of agencies able to support many of the
information/advice needs of ‘patients that are carers’ in the local Not For Profit
(Voluntary) Sector in the UK. These agencies range from dedicated carer
support services through disability/illness focused groups to individual
community groups.

Unlike Australia, carers in the UK are entitled to have an assessment of their
own needs in relation to their caring role. This is the responsibility of social
services. This therefore was identified as the most obvious choice when
referring a ‘patient who is a carer’ for an in-depth understanding of their
needs. This ‘carer’s assessment’ is the gateway to a whole range of social,
educational, leisure and health service provision for ‘patients who are carers’.

A number of different ways in which a practice can refer identified carers to
other relevant providers was identified:

     Referring Carers to others
         Have a named member of staff responsible for maintaining the practice’s
            procedure of referring carers
         Utilise local carers information packs system
         All practice staff to have access to a regularly maintained recognised list of
            carers support needs and provider agency
         Referral to recognised carers organisation
         Request written details from the provider agency of any support/services
            given to the carer following referral
         Record outcomes of referrals onto patients notes




Offering practical support to help ‘patients who are carers’



Identifying the Carer - GP Engagement Project Report 2010                     Page 14 of 123
Extensive national and local research in the UK shows that there are a
number of historic primary care work practices that actually hinder ‘patients
who are carers’ in their caring role. The national census shows that 32% of
‘patients who are carers’ care for more than 20 hours per week and 21% care
for more than 50 hours per week. This level of care giving has an obvious
knock on effect on the amount of time a ‘patient who is a carer’ has to spend
on their own needs. Equally changing behaviour patterns or support needs of
the person being cared for makes it difficult for a ‘patient who is a carer’ to
pre-book appointments as there is no guarantee that they will be able to leave
the person being cared for when an appointment has been made or they may
have to arrange for alternative care for the person they are caring for so that
they can keep their appointment. There may also be a limit on the time the
‘patient who is a carer’ can be away from the caring situation, or if they have
had to bring the person they are caring for with them to the surgery long
waiting times can also be very distressful.

In order to address these issues a number of different ways in which a
practice can practically support ‘patients who are carers’ were identified:

     Offering Practical help
      Have a named member of staff who specialises in carers and who attends the
        local Primary Care Carers Forum on behalf of the practice.
      Carer specialist or champion.
      Make usual services more carer friendly
      Appointment systems
      More specialised waiting areas
      Repeat prescription procedures
      Home visits
      Implementation of New services just for patients that are carers
      Well carer health checks
      Well carer clinics
      Practice based carers’ support group
      Practice based young carers support sessions
      Specific training sessions for patients that are carers re their role in caring for
        another person’s health needs



It was also acknowledged that to offer an immediate fully comprehensive
support service to carers via GP surgeries could be untenable. In light of this,
protocols were developed so that implementation could be introduced in 3
phases. Some surgeries felt that they could implement the services contained
in all 3 phases now whereas others may only be able to introduce systems
one phase at a time.

It was however envisaged that services in all three phases could be
introduced by March 2008. However, anecdotal information indicates that the
uptake has been much slower and very patchy. This requires further in depth
examination.

An outline of the three phases is supplied for information.



Identifying the Carer - GP Engagement Project Report 2010                   Page 15 of 123
Preparation work

Before a practice can start properly supporting ‘patients who are carers’ a
number of different structures/systems have to be put into place. The amount
and type of preparation will depend on which ‘phase’ of the Protocol is to be
addressed:

 Phase 1

        Inform all practice staff that you are becoming a Carer Aware GP
         surgery
        Select a member of staff to be the practice’s Carers Specialist or
         Carers Champion
        Identify the correct computerised path/code for recording ‘patients
         who are carers’
         on the practices record system and inform all staff of the process
        Identify a method for marking all paper records to highlight ‘patients
         who are carers’
        Identify a system for GPs/Nurses etc. to refer ‘patients who are
         carers’ back to reception for re-referral (internal or external)
        Compile a statement to include in the practice’s Practice leaflet and
         New Patient resource to inform the public of how you support ‘patients
         who are carers’ and what services they can expect to receive from
         you
        Obtain from GCC all FREE ‘carer as patients’ leaflets, cards,
         templates etc.

 Phase 2 – all of Phase 1 plus:-
    Develop a series of questions for use in your new patients health
      check to identify whether they are a ‘patient who is a carer’ or whether
      they have a carer
    Identify a system for informing other practices about their patients
      who have one of your patients as their carer (‘Patient who is a carer’
      GP referral form)
    Photocopy enough copies of all designed ‘patients who are carers’
      documentation and distribute accordingly

 Phase 3 – all of Phase 2 plus:-
     Implement a ‘Well Carer Health Check’ and designate staff to provide
       this at the surgery
 Book all staff onto the GCC Carers Awareness Training Programme for
 Primary Care (this can be provided in house or at the Carers Centre)




Identifying the Carer - GP Engagement Project Report 2010         Page 16 of 123
Attachment 2
Findings from the Private Mental Health Consumer Carer Network
(Australia) National Project – Carers Identified, prepared for DoHA, May
2010.

This project focussed on the process of identification of carers of people with
a mental illness. The differences that such carers experience were
acknowledged however many of the findings relate to general carers and are
relevant to general practice.

Summary of Relevant Findings

    All participants were of the view that identification and engagement of
    carers is crucial in any recovery based approach to care. This position is
    substantiated by the literature. They also agreed that change in clinical
    practice will only occur if it is mandated by legislation, well grounded in
    policy and protocols, compliance is audited on a regular basis and
    incentives are associated with positive changes in practice.

    Research that recognises that carers play a critical role in the process of
    recovery and relapse prevention is continuing to be largely ignored by both
    public and private specialist mental health services.

    The professional judgement of clinicians is recognised, however no single
    clinician or carer can meet all the needs of all patients. A partnership and
    recovery approach to care will improve patient outcomes and decrease the
    burden on services and carers.

    The ideal process for identification of carers where they are a third party is
    by the patient. These discussions together with the degree of involvement
    should be negotiated, documented and regularly reviewed. The
    experience of staff currently working in a carer inclusive manner is that if
    approached in this manner then the majority of patients recognise and
    welcome the involvement of their support network.

    Some carers who self identify are not necessarily the best people to be
    involved in the ongoing care and recovery of patients, either because of
    their past history with the patient, or their own particular needs. However,
    these carers continue to have rights and mechanisms need to be
    developed to ensure their needs are met.

    Some patients will, from time–to–time, because of the nature of their
    illness, refuse to identify or to involve carers. All professional interactions



Identifying the Carer - GP Engagement Project Report 2010            Page 17 of 123
    with them and written information provided to them needs to reinforce the
    importance of their support network being actively involved in their care.

   Patient refusal to identify carers does not lesson the burden on carers. It
    may in some cases increase the burden of care leading them to become
    patients themselves.

    Patient refusal to identify carers and privacy legislation is NOT a basis for
    preventing clinical staff across a range of settings from having a working
    relationship with the family/carer. Carers still have a right to give
    information to clinical staff to assist in assessment, treatment and ongoing
    care.

    Identification is not a one–off process. Service providers at all levels, on
    the basis of existing policies, Carer Recognition Legislation, mental health
    legislation and National Standards for Mental Health Services have a
    responsibility to identify and support carers. Cultural and organisational
    change, policies, protocols, education and support will be necessary to
    encourage changes in clinical practice.

   Policies and protocols to identify carers are essential and will vary
    according to service setting. General Practice was identified as an
    opportunity and one of the most important “trigger points” for identification
    and engagement with carers to occur.

2   Primary care: General practitioner (GP) practices

The primary focus of the policies and protocols developed was to assist in the
identification of carers of people with a mental illness. However information
obtained from the literature search and the consultations highlighted the clear
role that GPs play in the initial identification of all carers, including those who
care for a person with a mental illness. Including mental health within a
framework of general health, may also be less stigmatising, thus potentially
leading to earlier engagement

Waiting rooms provide ideal locations for posters and pamphlets that assist
people to self identify and to take responsibility for seeking further information.
The information should be presented in the most appropriate format for the
target audience. In Indigenous communities pictorial representations of the
information has had some success. In other areas electronic communication
may be the best medium.

The following content is suggested for a poster appropriate for display in
general practice settings that would:

       Assist people to identify they are a carer;

       Acknowledge they are entitled to recognition and support;

       Provide a simple avenue through the free post or internet option to
        seek further information and support; and



Identifying the Carer - GP Engagement Project Report 2010            Page 18 of 123
       Provide opportunities for discussion with the GP practice.

Because these posters are not specific to mental health they avoid the stigma
that some people who care for a person with a mental illness can feel.

Posters such as these could also be suitable for use in settings such as
CentreLink offices, Emergency Departments, schools, libraries etc. The
content could also form the basis for media ads.




Identifying the Carer - GP Engagement Project Report 2010            Page 19 of 123
  EXAMPLE FOR ILLUSTRATIVE PURPOSES ONLY




  LOGO


Do you provide support or assistance to
       someone who lives with
                            mental illness
                            substance abuse
                            physical illness, or
                            a disability


        This means that you are a
                ‘carer’
                     It also means that you may be
                      entitled to help and support
  Example only – taken from: The Princess Royal Trust – UK
            FREE Information Packs are available use this service.
  More targeted posters could also be developed for fromin specialist mental
  health settings.
    Complete the attached form and free post to CARERS AUSTRALIA
                  Information can also one – not from
  Insert possible mental health specificbe obtainedsure about this. I think
  we should stay with the generic at this stage
                          www.carersaustralia.com.au

  need for graphic design

Service details




  Identifying the Carer - GP Engagement Project Report 2010    Page 20 of 123
Do you provide support or assistance to someone who lives with

                               mental illness
                               substance abuse
                               physical illness, or
                               a disability
   This means you are a ‘carer’.
    It also means that you may be entitled to help and support.

        For a FREE information pack explaining what help is available please fill in this form, fold along
        the dotted line, moisten along gummed edge, press edges together and free post today.

           Your name…………………………………………………………………………………………
 fold                                                                                                              fold
           Your address ……………………………………………………………………………………...

           ………………………………………………………………………………………………………

           Postcode………………………………………….Tel No…………………………..……………..

           Being a carer can affect your health. This is why it is a good idea to let your GP practice know
           that you are a carer too. If you would like us to provide you with additional information or support,
           please tick the box below and sign.


           Please send me information on support services that may be available           (tick box)


           Would you like us to contact you to discuss your needs                         (tick box)




        Tear off forms could be attached to the posters such as illustrated above that
        would enable requests for additional information or contact to be sent via a
        free post option to the local office of Carers Australia who are well placed to
        receive and respond to enquiries. Opportunities also exist for GP practice staff
        to be specific points of contact for people who identify through this
        mechanism.




        Identifying the Carer - GP Engagement Project Report 2010                              Page 21 of 123
In terms of carers of people with a mental illness the Fourth National Mental
Health Plan, 2009 states:

        Primary care plays a central role in the treatment and care of those
        experiencing mental health problems and mental illness. General
        Practitioners (GPs) are often the first point of entry to the care system.
        GPs are the route of access to psychologists and other appropriately
        trained professionals providing services through the Better Outcomes
        in Mental Health Care and Better Access to Psychiatrists,
        Psychologists and General Practitioners through the Medicare
        Benefits Schedule initiatives and the Mental Health Nurse Incentive
        Program. Their training, attitudes and knowledge of the service system
        positively influence peoples’ experiences of care and treatment
        outcomes.

GPs are particularly well placed to identify carers. Families concerned about
the early warning signs and symptoms of mental health problems or mental
illness are likely to see their GP as the first point of contact for information and
assistance with a family member. This provides an ideal opportunity for early
intervention and better support for carers.

Minimal modification of the Australian Government Initiatives to include carer
identification could provide a significant impetus to identification within the
primary care sector.

Examples of activities that were suggested for consideration in general
practice include the following.

(i)     The Practice Notice board

Each practice could ensure that it displays in its general waiting/reception
area at least:

                   one prominent poster that:

                        –   asks adults to identify themselves as a Carer; and

                        –   offers information on the support available.

                   one prominent poster that:

                        –   asks adult patients who have a young person helping
                            them at home to identify themselves; and

                        –   offers information on the support available.

Those surgeries with an electronic means of sharing information with patients
in waiting areas could run a routine message that assists people to self
identify as carers, the support available and who to contact in the practice.
Consideration could be given to presentation of this information in pictorial
form in Indigenous Medical Centres.




Identifying the Carer - GP Engagement Project Report 2010                Page 22 of 123
(ii)    Carer Registration Vouchers

Each practice could ensure that it has Carer Registration ‘Vouchers’ available
to the general public in its waiting/reception areas. These vouchers could be
developed on a national basis and obtained from the Divisions of General
Practice at no charge. ‘Patients who are carers’ reading these vouchers could
then be directed to complete a voucher and return it to the receptionist at their
GP practice so as to receive a Carers Information Pack. They could also be
offered a FREE ‘well carer health check’ at a time convenient to all parties.
The Medicare Benefits Schedule reforms aimed at increasing the uptake in
general practice of prevention item numbers could be modified to encompass
identified carers. The practice could also be responsible for forwarding details
for information packs to the appropriate Carers Australia Office.

(iii)   Practice Leaflet and New Patient Registration Form

Each practice could ensure that there are relevant questions in Practice
Leaflet and New Patient Registration Forms that would lead people to self
identify as having a role in caring for someone else, or having someone who
provides care to them. The documents should be worded in a manner so as
to ensure it attracts the maximum number of ‘patients who are carers’ as is
possible.

This could also be reinforced via the inclusion of a field in the demographic
area of the electronic record system for identification of people who are
providing care to another person. This will require changes to Zedmed, the
clinical software currently used by GPs.

(iv)    Consultations and home visits

All consultations provide an opportunity for the GP/Practice Nurse to enquire
as to whether or not the person they are seeing as the patient is (as well as
being unwell) caring for somebody or being cared for by somebody.
Consultations should also be used to establish whether there are children
within the family taking an active caring role for a sick or disabled parent or
sibling.

(v)     Existing records and other known information

Many receptionists, nurses, practice managers and GPs will already be aware
of adult and child ‘patients who are carers’, or patients who have a carer. This
information should not be wasted. Each practice could set aside dedicated
time when all staff are asked to prepare a list of all patients known to them
that are either ‘patients who are carers’ or patients who have a carer. Those
patients identified as ‘patients who are carers’, could be sent a Carers
Registration Voucher inviting them to apply for Carers Information Packs and,
a FREE ‘well carer health check’. Those patients identified as having a carer
should also be sent a Carers Registration Voucher with a covering letter
asking them to pass the voucher to their carer. The practice could be
responsible for providing the packs or forwarding details for information packs
to the local Carers Australia office.


Identifying the Carer - GP Engagement Project Report 2010          Page 23 of 123
(vi)     Medicare Cheques for Doctors and Prescription Folders

Medicare Australia could assist with the identification of carers via the
placement of messages on all benefit cheques issued that need to be paid to
GPs. These messages could encourage people to speak with their GP if they
provide care or support to another person.

This could occur in association with National Carers Week.

Each practice could also ensure that it works on a regular basis with local
pharmacies to encourage carers to identify themselves to their GP practice by
placing stickers on the folders that are used for repeat prescriptions. Stickers
could be developed nationally and obtained free of charge from Divisions of
GPs.

This could also coincide with National Carers Week celebrated annually in
Australia.

(vii)    Influenza vaccination and Screening Programmes

Regular influenza vaccination, mammogram and other routine screening
programs could also provide opportunities for identification of carers through a
short list of appropriately worded questions.

3      REFERRAL TO SPECIALIST MH CARE

With patient and carer consent, the referral letter to specialist mental heath
care provider could identify carers and the role they play in caring for the
person with a mental illness. This could also include contact details and a
request for continued involvement by the mental health service with the
identified carers. This would be facilitated by the addition of a ‘carer’ field to
referral letter templates in GP electronic data bases.

4 INCENTIVES

The Private Mental Health Consumer Carer Network(Australia) understands
that incentives are frequently required in order to encourage change in clinical
practice. We believe that inclusion of information related to carers in the
revision of the RACGP Standards would be one such incentive. Negotiations
could also occur with accreditation bodies to have them consider the
allocation of accreditation points to practices that demonstrate they have
implemented ‘carer friendly practices’.

These activities could be further supported by planned changes outlined in the
Fourth National Mental Health Plan (2009-2014) for partnerships with other
government areas of responsibility.

The following recommendations were made in the 2010 report Carers
Identified on the basis of the research and discussion during
consultations.



Identifying the Carer - GP Engagement Project Report 2010           Page 24 of 123
5       SUGGESTED NATIONAL PROTOCOLS FOR IDENTIFICATION OF
        CARERS IN PRIMARY CARE SETTINGS

It is recommended that:
The following protocols to identify carers are discussed with the Royal
Australian College of General Practitioners for consideration during the
revision of the RACGP Standards for General Practices (4th Edition)

        Provision of general information encouraging self–identification
         on electronic and paper notice boards including posters and
         leaflets.

        New Patient Forms to identify carers.

        Utilise normal practice appointment consultations.

        Practice newsletters to feature articles regarding carers.

        Utilise patients personal health checks to identify if they
         undertake care for another person.

        Have a named member of staff responsible for maintaining the
         practice’s procedure for identification of carers – a carer
         specialist or champion.

Suggestions for potential modifications to existing processes associated with
the manner in which GPs currently treat patients being cared for as part of the
chronic disease program have also been identified and require further
development for consideration by the appropriate section of the Royal
Australian College of General Practitioners.




Identifying the Carer - GP Engagement Project Report 2010         Page 25 of 123
ATTACHMENT 3




      RACGP Standards for general
              practices

                   DRAFT 4th edition FOR
                     CONSULTATION
THIS DRAFT IS RELEASED FOR CONSULTATION PURPOSES ONLY. IT IS NOT PURPORTED BY THE RACGP TO
REPRESENT THE FINAL 4TH EDITION OF THE STANDARDS.

THE DRAFT IS SUBJECT TO CHANGE IN RESPONSE TO FEEDBACK FROM THE GENERAL PRACTICE PROFESSION AND
STAKEHOLDERS; AND FINAL SIGN OFF BY RACGP COUNCIL.




Prepared by The Royal Australian College of General Practitioners National Expert Committee on Standards for General
Practices.


The Royal Australian College of General Practitioners
College House
1 Palmerston Crescent
South Melbourne, Victoria 3205
Australia

Tel 03 8699 0414
Fax 03 8699 0400
www.racgp.org.au




Identifying the Carer - GP Engagement Project Report 2010                                            Page 26 of 123
  CHANGES IN DRAFT RACGP STANDARDS FOR GENERAL PRACTICES 4TH
                            EDITION

The RACGP’s National Expert Committee on Standards for General Practice has
completed the Draft 4th Edition Standards for General Practices and these will soon
be trialled by the accreditation providers with practices which agree to participate.
Practices who choose to participate in the trial of the Draft Standards will not be
granted accreditation against the RACGP Standards for General Practices 4th edition
as the trial will not be conducted against all Criteria but the practice will benefit
significantly, not only from gathering an insight as to what the 4th edition Standards
will eventually contain but they will also be able to provide feedback to the NECSGP
to make changes to the final Standards where there is strong disagreement with the
content of the Draft Standards.

General Principles: The RACGP Standards for General Practices 3rd edition has
been well accepted by the general practice profession and internationally as
providing the basis for an accreditation process that is a leader not only in Australia
when compared with other health care disciplines but also internationally amongst
other general/family practice organisations. Nevertheless, the NECSGP has
undertaken a review to update all the Standards, Criteria and Indicators. While the
format of the Standards document is not markedly different, there are significant
amendments made in response not only to the changes that have occurred in
contemporary Australian general practice and those that are anticipated but also to
reflect the changes in society and patient needs and expectations. Examples of this
are the use of the terms, “Practice team” and “Clinical team” throughout the
document and an increase consciousness of the need for GPs and staff to work in a
safe environment. In general, the Committee has decided not to change greatly the
format of the document, so that the individual Standards, Criteria and Indicators are
generally in a similar location to those in the 3rd. edition RACGP Standards. The
committee has also been conscious of the demands preparing for accreditation
surveys make upon practices in documenting or being able to demonstrate to
accreditation surveyors how they meet the Standards. The NECSGP has
endeavoured to reduce the number of Indicators in the survey process and the
overall number of Indicators in this document has been reduced – 4 less criteria and
39 less indicators.

Cost is another factor that has been considered. The Committee has considered the
great diversity in the size and location of practices in Australia and is conscious that
the additional work involved in accreditation is disproportionately large for solo and
remote practices. As
 always, the words contained in the preface to the Standards “any formal assessment
process against the RACGP Standards needs to be based on common sense and
needs not seek to penalise or exclude practices on the basis of technicalities,” should
be remembered when practices are accredited.

In developing and writing the Draft Standards, the NECSGP has followed the
following general principles.

In the RACGP Standards for General Practices 3rd edition, the document has
prescribed how the accreditation process will determine whether a practice has met
an Indicator, e.g. by health records review, interview, document review etc. The
providers of accreditation in Australia consider this method should change, so that
these descriptors should be deleted and the process changed so that the relevant
general practice teams will need to “demonstrate” how they meet an Indicator. This
is not expected to be an easy option for practices and obviously the method of


Identifying the Carer - GP Engagement Project Report 2010                Page 27 of 123
demonstrating compliance with an Indicator may not change at all, e.g. meeting an
Indicator specifically relating to quality of medical records can only be achieved by
medical record review by a general practitioner(s) undertaking a review of a random
sample of the practice’s patient health records.

The Australian Commission for Quality and Safety in Health Care has developed
Draft National Safety and Quality Healthcare Standards (NSQH Standards) at the
request of COAG Health Ministers and it is expected that these initial Standards will
be finalised soon and implemented eventually to ensure the compliance of all health
care services. As the name suggests, these Standards relate to improvements in
the quality of patient care and improved patient safety. The areas covered by the
initial NSQH Draft Standards relate to Governance for Safety and Quality in Health
Service Organisations, Healthcare Associated Infections, Medication Safety, Patient
Identification and Procedure Matching, and Clinical Handover. The NECSGP has
noted the content of NSQH Standards and while realising that the RACGP Standards
for General Practices 3rd ed. already can demonstrate that most of NSQH Standards
are met by accredited general practices, there are areas in the RACGP Standards for
General Practices Draft 4th ed Standards where changes have been made to address
additional areas that were not explicitly covered. It is not expected that practices who
are accredited against the RACGP Standards will need to undergo accreditation
against the NSQH Standards with the possible exception of those practices that
undertake invasive procedures under sedation or general anaesthesia on site (the
Commission considering these to be high risk areas).

In Australia and internationally, there is evidence of increased involvement of
practices with their patients in providing “patient centred” care and the Draft RACGP
Standards reflect this. Accreditation providers in Australia have provided feedback
that the patient feedback processes included in the RACGP Standards for General
Practices 3rd ed did not provide valid and reliable feedback of an adequate quality,
so this is an area in the Draft 4th ed. Standards where significant changes have been
made. The Explanatory Notes included at Criterion 2.1.2 in the RACGP Standards
for General Practices Draft 4th ed. provide details of these feedback changes from
those of the 3rd ed Standards.

The NSQH Draft Standards also includes, in its Standards relating to Clinical
Governance, the requirement to obtain patient feedback and that they are used to
measure and improve the performance of the health service provider.

There are areas in general practice where practices and individual practice members
have to comply with Commonwealth and State law. Examples of these are to
maintain current registration requirements such as medical indemnity insurance, non-
discriminatory care for people with disabilities and to comply with management of
Dangerous Drugs (S8s) and Schedule 4 drugs. The Committee has not included all
of these in the Draft Standards as general practices and individuals working in them
are presumed to comply with these requirements.

e-Health: Electronic communications and data transfer is a rapidly changing process
in our society and these changes affect the process for the acquisition, storage and
transmission of personal health information and information to facilitate best-
evidence care. The maintenance of the confidentiality and the security of patient’s
medical; information is included in the Draft 4th ed Standards in accord with the
National Privacy Principles as well as the RACGP’s Handbook For The Management
Of Health Information In Private Medical Practice There have been major changes
foreshadowed in these areas and the RACGP has been assisted in the development



Identifying the Carer - GP Engagement Project Report 2010                Page 28 of 123
of the relevant sections of these Draft Standards by the contribution from members of
NEHTA and from the RACGP’s e-Health Standards Subcommittee.

This edition of the Standards has been developed by the National Expert Committee
for Standards in General Practice appointed by the Council of the RACGP. These
Standards are standards for general practice written by active members of the
general practice community or are patients of general practices. Members of the
group are general practitioners, some with accreditation surveying experience with
both of the present general practice accreditation bodies, a representative of the
Consumers Health Forum, the Practice Managers Association and the Australian
Practice Nurses Association as well as administrative staff from the RACGP. The
Standards were written after extensive consultations with the general practice
profession.

As has always been the case, when the RACGP Standards are used as the basis of
the accreditation process, practices are expected to meet the Standards at all times,
not just on the day of the accreditation survey. This is important for the safe and
effective care of patients.

During the life of the 4th ed. Standards, while significant changes are anticipated to
take place in general practice and its processes, obviously the Committee has not
been able to include these definitively. Some are foreshadowed in the explanations
following each Criterion. Perhaps the most significant changes in the RACGP’s Draft
4th ed. Standards from its 3rd ed Standards will be found in Standards 3 and 4.




Identifying the Carer - GP Engagement Project Report 2010               Page 29 of 123
CONTENTS
SECTION ONE: PRACTICE SERVICES
Standard 1.1 ACCESS TO CARE
Criterion 1.1.1 Scheduling care in opening hours
Criterion 1.1.2 Telephone and electronic communications
Criterion 1.1.3 Home and other visits
Criterion 1.1.4 Care outside normal opening hours
Standard 1.2 INFORMATION ABOUT THE PRACTICE
Criterion 1.2.1 Practice information
Criterion 1.2.2 Informed patient decisions
Criterion 1.2.3 Interpreter services
Criterion 1.2.4 Costs associated with care initiated by the practice
Standard 1.3 HEALTH PROMOTION AND PREVENTION OF DISEASE
Criterion 1.3.1 Health promotion and preventive care
Standard 1.4 DIAGNOSIS AND MANAGEMENT OF HEALTH PROBLEMS
Criterion 1.4.1 Consistent evidence based practice
Criterion 1.4.2 Clinical autonomy for general practitioners
Standard 1.5 CONTINUITY OF CARE
Criterion 1.5.1 Continuity of comprehensive care and the therapeutic relationship
Criterion 1.5.2 Clinical handover NEW
Criterion 1.5.3 System for follow up of tests and results
Standard 1.6 COORDINATION OF CARE
Criterion 1.6.1 Engaging with other services
Criterion 1.6.2 Referral documents
Standard 1.7 CONTENT OF PATIENT HEALTH RECORDS
Criterion 1.7.1 Patient health records
Criterion 1.7.2 Health summaries
Criterion 1.7.3 Consultation notes
SECTION TWO: RIGHTS AND NEEDS OF PATIENTS
Standard 2.1 COLLABORATING WITH PATIENTS
Criterion 2.1.1 Respectful and culturally appropriate care
Criterion 2.1.2 Patient centered feedback
Criterion 2.1.3 Presence of a third party
SECTION THREE: SAFETY, QUALITY IMPROVEMENT AND EDUCATION
(clinical governance)
Standard 3.1 SAFETY AND QUALITY
Criterion 3.1.1 Quality improvement activities


Identifying the Carer - GP Engagement Project Report 2010              Page 30 of 123
Criterion 3.1.2 Clinical risk management systems
Criterion 3.1.3 Clinical leadership NEW
Criterion 3.1.4 Patient Identification NEW
Standard 3.2 EDUCATION AND TRAINING
Criterion 3.2.1 General practitioner qualifications
Criterion 3.2.2 Clinical staff qualifications (staff other than GPs and nurses)
Criterion 3.2.3 Training of staff who have nonclinical roles
SECTION FOUR: PRACTICE MANAGEMENT
Standard 4.1 PRACTICE SYSTEMS
Criterion 4.1.1 Human resource system
Criterion 4.1.2 Occupational health and safety
Standard 4.2 MANAGEMENT OF HEALTH INFORMATION
Criterion 4.2.1 Confidentiality and privacy of health information
Criterion 4.2.2 Information security
SECTION FIVE: PHYSICAL FACTORS
Standard 5.1 FACILITIES AND ACCESS
Criterion 5.1.1 Practice facilities
Criterion 5.1.2 Physical conditions conducive to confidentiality and privacy
Criterion 5.1.3 Physical access
Standard 5.2 EQUIPMENT FOR COMPREHENSIVE CARE
Criterion 5.2.1 Practice equipment
Criterion 5.2.2 Doctor’s bag
Standard 5.3 CLINICAL SUPPORT PROCESSES
Criterion 5.3.1 Safe and quality use of medicines NEW
Criterion 5.3.2 Vaccine potency
Criterion 5.3.3 Health care associated infections
GLOSSARY OF TERMS
REFERENCES
APPENDIX A. HISTORY OF STANDARDS DEVELOPMENT
APPENDIX B. HISTORY OF ACCREDITATION




Identifying the Carer - GP Engagement Project Report 2010                  Page 31 of 123
1 SECTION ONE
2 PRACTICE SERVICES
3 STANDARD 1.1 ACCESS TO CARE
Our practice provides timely care and advice.

4 STANDARD 1.2 INFORMATION ABOUT THE PRACTICE
Our practice provides sufficient information to enable our patients to make informed decisions regarding
their care.


5 STANDARD 1.3 HEALTH PROMOTION AND PREVENTION
                          OF DISEASE
5.1    Our practice provides health promotion and illness prevention services
       that are based on patient need and best available evidence.

6 STANDARD 1.4 DIAGNOSIS AND MANAGEMENT OF
                          HEALTH PROBLEMS
In consultation with the patient, our practice provides care that is relevant and in broad agreement with
best available evidence.
6.1
7 STANDARD 1.5 CONTINUITY OF CARE
7.1    Our practice provides continuity of care for its patients.
7.2
8 STANDARD 1.6 COORDINATION OF CARE
Our practice engages with a range of relevant health and community services to improve patient care.
8.1
9 STANDARD 1.7 CONTENT OF PATIENT HEALTH
  RECORDS
Our patient health records contain sufficient information to identify the patient and to document
reason(s) for visit, relevant examination, assessment, management, progress and outcomes.




Identifying the Carer - GP Engagement Project Report 2010                                Page 32 of 123
9.1       ►STANDARD 1.1
9.2
9.3       CRITERION 1.1.1 Scheduling care in opening hours

Our practice has a flexible system that enables us to accommodate patients’ needs for life
threatening, urgent, nonurgent, complex, planned chronic care, and preventive health needs.-

Indicators
►A. Our practice can demonstrate that we have a flexible appointment system that
     accommodates patients’ needs for urgent, complex, planned chronic disease
     management, preventive health and longer consultations.
►B. Our practice can demonstrate how we identify, prioritise and respond to life
   threatening and urgent medical matters (triage).
After Hours Practice

►C. Our service obtains feedback from practices for whom we deputise, about the quality
   and timeliness of our care for their patients.

Explanation

In a nutshell

          Practice staff need to be able to quickly and accurately identify patients needs for urgent,
           nonurgent, complex planned chronic care and preventive health needs
          Administrative staff require ‘triage’ training
          Practices need a responsive appointment system
          Practices need procedures for administrative and clinical staff outlining:
              o identifying patients with urgent medical matters
              o seeking urgent medical assistance when required
              o managing patients who have urgent medical needs when the practice is
                   operating at full capacity
              o the system for documenting triage responses by administrative staff.

The needs of patients vary widely and practices need to have flexible systems that can
accommodate urgent, nonurgent, complex, planned chronic care and preventive health needs
during normal opening hours.

There are times when patients need urgent access to primary medical care and practices need to
have systems that anticipate this need (eg. the appointment system could include reserving unbooked
appointment times for patients with urgent medical needs). Patients also value the opportunity to see
a general practitioner within a reasonable time for nonurgent and preventive health matters.

When patients contact general practices by telephone, often the reason for contact is to make
an appointment. It is necessary for administrative staff receiving incoming calls to assess the
urgency of the need for care, ie. ‘triage’ patients. For this reason, administrative staff should
have training in triage to identify patients in need of urgent care.

Administrative staff who have the responsibility of answering incoming telephone calls should
give the caller the opportunity to answer when they ask the patient, ‘Is the matter urgent or
may I put you on hold?’, so that patients with urgent needs are able to convey this information.

As it is common that administrative staff do not have access to patient health records, the
practice needs to have a method for documenting triage responses by administrative staff.

The practice team need to be able to describe the practice’s policy and procedures for identifying
patients with urgent medical matters and the procedures for seeking urgent medical assistance from a
clinical staff member. The practice team also need to be able to describe how the practice deals with
patients who have urgent medical needs when the practice is operating at full capacity (eg. when it is



Identifying the Carer - GP Engagement Project Report 2010                       Page 33 of 123
fully booked).

Actual length of individual consultations will vary according to clinical need. There is a body of
evidence suggesting that longer consultation times are associated with better health outcomes and
improved patient satisfaction. Much of the benefit is thought to arise from the improved
communication between doctors and their patients that occur in longer consultations. Research also
suggests that preventive care, effective record keeping, patient satisfaction and patient participation in
the consultation can be compromised when consultations are too short. Data from Bettering the
Evaluation and Care of Health (BEACH) show average consultation times in Australian general
practice are around 14 minutes.

The practice system needs to include consultations of appropriate length for patients with more
complex matters. Longer consultations may be required if the patient has complex medical needs or if
the patient’s carer or a translator is present. Patients need to be encouraged to ask for a longer
consultation if they think it is necessary. Staff need to have the skills and knowledge to assist in
determining the most appropriate length and timing of consultations at the time of booking. Although it
is difficult to predict how much time will be needed for a particular consultation, this criterion requires
that practices have systems that predict and endeavour to meet this need.

Thus, key indicators for whether consultation times are long enough are not only the duration, but
other factors such as the adequacy of patient health records. Whether a practice meets this criterion
may need to be seen in the context of other indicators in the practice. Assessment of this criterion
needs to take into account the specific circumstances of the practice.

Practices that do not have a formal appointment system can meet this criterion if there is adequate
communication to patients on anticipated waiting times and if the practice prioritises patients
according to urgency of need.

Gaining data from Medicare Australia may be one useful way to demonstrate that the practice meets
this criterion.




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9.4       STANDARD 1.1
9.5
9.6       CRITERION 1.1.2 Telephone and electronic communications

To ensure safe and effective care, patients of our practice can communicate to clinical staff
via telephone or electronic (or other) means. All communications using these methods occur
when a member of our clinical staff determines that it is clinically safe.

Indicators
►A. Our practice team can demonstrate how we receive and return telephone and (if
   applicable) electronic messages from patients.
►B. For important communications, there is evidence of practice/patient telephone
   or electronic advice and information in our patient health records.
C. Our practice’s ‘on hold’ message (if we have one) provides advice to call 000 in
    case of an emergency.

Explanation

In a nutshell

          If the practice has an ‘on hold’ telephone message, it should include a message to ‘phone 000
           if you have an emergency’
          Practices can communicate with their patients using electronic means
          Practices need to communicate to patients their practice policy on the use of electronic
           methods of communication, including limitations of use
          Practices need a communications policy.

While patients appreciate the ability to have access to a member of the clinical team by
telephone or electronic means to discuss their care, the clinical team need to consider the
quality of care they can provide to patients via telephone or electronic means and whether this
care might be compromised. It is acknowledged that practices can judge the appropriateness
of individual communications and that full consultations cannot usually be conducted by
telephone or electronic means. Many practices provide the results of investigations by
telephone to their patients; the person responsible for giving the result should ensure that the
recipient of the advice is correctly identified (using the ‘three point patient identifier process’)
so that patient confidentiality is not compromised. General practitioners may wish to obtain
advice from their medical defence organisation about the appropriateness of providing advice
by telephone or electronic means.


Some practices choose to communicate with patients using electronic means, such as email or SMS,
although this is not required to meet this criterion. Communication with patients via electronic means
needs to be conducted with appropriate regard to the privacy and confidentiality of the patient’s health
information (as per Criterion 4.2.1 and 4.2.2).

Practices need to have processes for ensuring that telephone and electronic messages from patients
are recorded and given to the person for whom they are intended, or in that person's absence, to the
person who is caring for that absent team member's patients.

If the practice decides to provide patients with access to the practice by email, it is important
that patients are aware of the risk of compromise to the confidentiality of their privacy when
communicating by email without encryption. Similarly, information provided by the practice by
email should be of a general nature when privacy is not assured. Information provided by fax
may be even less secure when other people may have access to the fax machine.

Reception staff need to know which telephone calls should be transferred to GPs or to other staff who
provide clinical care. Except in urgent situations, these need not interrupt consultations with other
patients. General practitioners need to be prepared to make time available in each session to take or



Identifying the Carer - GP Engagement Project Report 2010                       Page 35 of 123
return telephone calls. General practitioners and staff involved in clinical care need to make a record
of all important contacts in the patient’s health record. It is also important that staff are aware of
individual GP’s policies on receiving telephone calls during consultations, ideally a uniform system
within the practice.

Peer reviewers need to take a common sense approach to the interpretation of the meaning of
important communications.

Some practices may choose to charge a fee for telephone or electronic communication. A frequent
complaint from consumers is that they are frequently unaware of the cost involved when they
telephone for advice after hours. Whenever a fee is charged, patients should be aware of this and
information about the costs of telephone/electronic consultations must be readily available to patients
as outlined in Criterion 1.2.4.

General practitioners and practice staff need to be aware of alternative modes of communication used
by their patients, including those with a disability. Examples include the National Relay Service (NRS)
for patients who are deaf and the Translation and Interpreter Service (TIS) for non-English speaking
background patients. For further information about the NRS see www.relayservice.com.au; for TIS
see www.immi.gov.au/living-in-australia/help-with-english/help_with_translating/




Identifying the Carer - GP Engagement Project Report 2010                       Page 36 of 123
 9.7       STANDARD 1.1
 9.8
 9.9       CRITERION 1.1.3 Home and other visits

 Regular patients of our practice are able to obtain visits (where such visits are safe and
 reasonable) in their home, residential aged care facility, residential care facility or hospital,
 both within and outside normal opening hours.

Indicators
  ►A. There is evidence that patients of our practice access home and other visits both
      within and outside normal opening hours.
 ►B. Our practice team can demonstrate our practice’s process on home and other
    visits, both within and outside normal opening hours, and the situations in which a
    visit is appropriate.
 ►C. Our practice has a written policy on home and other visits, both within and
    outside normal opening hours.

 Explanation

 In a nutshell

           Home and other visits need to be available to regular patients of the practice
           Practices need a home and other visits policy specifying:
               o geographic area for home and other visits
               o types of problems that necessitate a home visit
               o an alternative to a home visit if a home or other visit is not available.

 Home and other visits (such as in residential aged care facilities, residential care facilities or
 hospitals) need to be available to regular patients of the practice where such visits are safe
 and reasonable. Visits may be performed by, or on behalf of, the practice.

 There needs to be a direct continuing relationship between the practice GP(s) and those doctors who
 perform the home and other visits on their behalf. This includes arrangements to exchange clinical
 details about patient care.

 General practitioners and practice staff need to be able to describe the conditions under which a
 home or other visit is deemed appropriate. Examples include deciding upon a reasonable distance
 within which visits are provided and the types of problems that necessitate such visits. What is ‘safe
 and reasonable’ has not been defined here, as it is a decision that each practice needs to make in
 their local context (eg. with regard to location, patient population). What is safe and reasonable should
 be considered by the practice in light of what their peers (or practices in the same area) would agree
 was safe and reasonable.

 Information that may assist in determining what is safe and reasonable is available from the
 Australian Medical Association (AMA) Position statement, ‘Personal safety and privacy for doctors’
 (available at www.ama.com.au) and the RACGP publications: Keeping the doctor alive: A self care
 guidebook for medical practitioners and General practice – a safe place (both available at
 www.racgp.org.au).

 Documentary evidence that the practice provides care outside the practice may include appointment
 schedules and Medicare data. Such documentary evidence may be stored at the practice or at an
 external facility (eg. a residential aged care facility progress notes).

 The RACGP does accept that there will be individual circumstances where home or other visits will be
 neither safe nor reasonable. In these circumstances the practice must be able to clearly document the
 alternate system of care that these patients can access. There must be documentary evidence that
 this system provides care for the practice’s patients who require such services and ought to take into
 account the approach of similar practices in the area.



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Practices need to consider how to provide continuity of care to patients who can no longer attend the
practice due to disability. Patients value an ongoing relationship with their GP, even when their needs
change.

Home and other visits need to be performed by recognised GPs (either Fellows of the RACGP or
vocationally recognised). In some areas it may not be possible to recruit recognised GPs. In such
circumstances, doctors who provide home visits, and who are not recognised GPs, need to be
appropriately trained and qualified to meet the needs of the practice community. Doctors who are not
recognised GPs need to have been assessed for entry to general practice and be supervised,
mentored and supported in their education to the national standards of the RACGP (as outlined in
Criterion 3.2.1).

The following actions have been proposed as means of enhancing the safety of after hours medical
practitioners:
     patients must have a telephone number on which the after hours care service can call
         back
     the after hours care service needs to be informed when the medical practitioner arrives
         at, and departs from, each call
     a medical practitioner is not sent to a patient/caller requesting pain relief unless a pain
         management plan is in place
     police are requested to attend patients threatening suicide, and a medical practitioner
         is not sent
     a medical practitioner is not sent to premises where evidence of a threatening or
         abusive person(s) is present. Police are requested to assist in these instances
     callers are asked to restrain dogs, to turn on an outside light at night, and provide
         guidance on identifying the residence in the absence of a house number (eg. nearest
         intersection)
     patients are asked to provide their date of birth, and the name of their regular
         GP/general practice. Where these details or a contact telephone number are not
         provided, consideration is given to referring the patient to hospital or calling an
         ambulance (as appropriate)
     services are mindful of situations where a medical practitioner has attended a patient
         for a longer period than seems necessary.

Adapted from the National Association of Medical Deputising Services


After Hours Practice

Medical deputising services (MDS) must provide home visits.

For after hours care services that make home and/or other visits, Indicator A is not applicable.

This criterion and indicators are not applicable for after hours care services that only provide
consultations within a clinic (ie. make no home and/or other visits).




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9.10 STANDARD 1.1
9.11
9.12 CRITERION 1.1.4 Care outside normal opening hours

Our practice ensures safe and reasonable arrangements for medical care for patients outside
our normal opening hours.

Indicators
►A. There is evidence of one (or a combination) of the following for our patients:
       our practice’s GP(s) provide(s) their own care for patients outside normal
          opening hours of the practice, either individually or through a roster, or
       formal arrangements for cooperative care outside the normal opening hours
          of our practice exist through a cooperative of one or more local practices, or
       formal arrangements exist with an accredited MDS, or
       formal arrangements exist with an appropriately accredited local hospital or
          an after hours facility, in the circumstances where we do not use an
          accredited MDS or cooperative.
►B. Patient health records contain reports or notes of consultations occurring outside
    normal opening hours by, or on behalf of, our practice.
►C. A message on our practice’s telephone answering machine, call diversion system
   or paging system, and a sign visible from outside our practice, provides
   information to patients on how to obtain care outside our practice’s normal
   opening hours.
►D. Our practice team can demonstrate how we provide medical care outside our
   normal opening hours.
After Hours Practice

►E. Our service can demonstrate that:
             we provide timely reporting of the care provided back to the patient’s
              nominated general practice/GP
             there is a defined means of access for the deputising practitioner(s) to
              patient health information and to the practice(s) whose patients are seen, in
              exceptional circumstances, including the contact details of the general
              practices and their normal opening hours
             care is provided by appropriately qualified health professionals.

Explanation

In a nutshell

           Practices need to have a documented arrangement for the care of their patients outside
            normal opening hours
           Practices need a formal agreement with the alternate provider
           Alternate providers and pathology providers need a manner of contacting the practice for
            urgent matters when the practice is closed
           Practices need to communicate their arrangements with their patients and their carers
            where appropriate.

Sometimes patients of the practice require provision of medical care outside normal
opening hours. Practices are required to make, and be able to demonstrate, reasonable
arrangements for access to primary medical care services for their regular patients at these
times. Some practices use their own GPs to provide care or use a local cooperative of GPs,
a MDS or, where a MDS is not available, have an agreement with a local hospital. Some
practices use a combination of all these arrangements.




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It may be necessary for practices to consider the quality and sustainability of the potential options
and to make judgments about which option will provide the highest quality of care while
maintaining the safety of patients and GPs. In these circumstances, GPs may want to discuss
those trade-offs with peer surveyors.

Regardless of the arrangements used to provide care outside normal opening hours, documentary
evidence of the system the practice uses to provide such care needs to be available. If the practice
uses other GPs to provide care (such as a MDS or cooperative), the practice needs to have
evidence of how and when it receives information about any care provided to their patients outside
normal opening hours, and also how the GPs providing that care can contact the practice in an
emergency or in the case of exceptional circumstances. Regular patients of the practice who seek
care outside normal opening hours of the practice may be better known to the practice than to the
service providing care on behalf of the practice, with the practice being more likely to have
accurate information about the patient’s current care. It may be of substantial benefit if the doctor
providing care is able to contact a GP within the practice for clarification or help regarding
background information relating to that patient and who carers for them(especially in an
emergency situation).

The successful follow up of abnormal life threatening results outside normal opening hours of the
practice relies on general practices having robust and reliable systems for contact. Failures in
these processes in pathology follow up have been the subject of criticism and recommendations
for improvement in recent coroner inquests where patients have been harmed through the lack of
robust ways in which to convey urgent information.

General practices need to have after hours arrangements in place to allow abnormal and life
threatening results identified by pathology to be conveyed to a medical practitioner, who will
ensure that an informed appropriate medical decision is made and acted on promptly.

If the general practice uses another service (ie. a cooperative, MDS or hospital) then the general
practice must have a defined, reliable means of access for the deputising practitioner to patient
health information and to the practice in exceptional circumstances. This places an obligation on
the general practice to establish this means of contact (eg. a contact telephone number for one or
more of the practice doctors). It also places an obligation on deputising services to contact the
general practice in exceptional circumstances.

General practices need to clarify what is expected of the deputising doctors in cases of urgent and
life threatening results being communicated to the deputising doctor in lieu of the GPs in the
general practice and vice versa. Ideally this will be outlined in a formal agreement between the
general practice and the after hours care provider.

General practice care outside normal opening hours needs to be performed by recognised GPs
(either Fellows of the RACGP or vocationally recognised). In some areas it may not be possible to
recruit recognised GPs. In such circumstances, doctors who provide general practice care outside
normal opening hours, and who are not recognised GPs, need to be appropriately trained and
qualified to meet the needs of the practice community. Doctors performing general practice care
who are not recognised GPs need to have been assessed for entry to general practice and be
supervised, mentored and supported in their education to the national standards of the RACGP (as
outlined in Criterion 3.2.1).

When the practice’s GPs themselves cannot safely or reasonably deliver care outside normal
opening hours, the practice must be able to clearly document the alternative system of care that is
available for their patients at these times. Assessment of this criterion needs to take into account
the approach of similar practices in the area. It is necessary that the care be appropriate to the
needs of the patient; that it be timely and reliable; and that what is claimed to be available is
actually provided. What is ‘safe and reasonable’ has not been defined here as it is a decision that
each practice needs to make in their local context (eg. with regard to location, patient population).
What is safe and reasonable should be considered by the practice in light of what their peers (or
practices in the same area) would agree was safe and reasonable.

Arrangements for medical care outside normal opening hours needs to be communicated clearly to



Identifying the Carer - GP Engagement Project Report 2010                         Page 40 of 123
patients of the practice.

It is the obligation of general practices who have arrangements with after hours care services to
describe their preferred arrangements for the management of patients who live beyond the
boundaries of the after hours service(s) to that service(s).

The environment of general practice is dynamic and GPs are referred to the RACGP ‘Primary
medical care outside normal general practice opening hours’ position statement (available at
www.racgp.org.au).

The Australian Competition and Consumer Commission (ACCC) has developed an information kit
for the medical profession (available at www.accc.gov.au/content/index.phtml/itemId/575092). This
may be of assistance to GPs who want to ensure that their arrangements comply with the Trade
Practices Act, ie. are not anticompetitive as defined within the Trade Practices Act.




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 9.13 STANDARD 1.2
 9.14
 9.15 CRITERION 1.2.1 Practice information

 Our practice provides patients with adequate information about our practice to facilitate
 access to care.

Indicators
  ►A. Our practice information sheet is available to patients and is accurate and
  contains at a minimum:
          our practice address and telephone numbers
          our consulting hours and arrangements for care outside our practice’s
           normal opening hours, including a contact telephone number
        billing principles and representative consultation costs for care within our
           practice
        our practice’s communication policy, including receiving and returning
           telephone calls and electronic communication
        our practice’s policy for the management of patient health information (or its
           principles and how full details can be obtained from the practice)
        the process for the follow up of results
        how to provide feedback or make a complaint to the practice (including
           contact details of the local state or territory health complaints conciliation
           body).
 ►B. Our practice team can demonstrate how we communicate essential information to
 patients who are unable to understand our practice information sheet.
 ►C. If our practice has a website, the information is accurate, and contains at a
    minimum, the information included in our practice information sheet and meets the
    advertising requirements of the AMC Code of Conduct.

 Explanation

 In a nutshell

 Providing written information about the practice is useful to patients and their carers as it
 provides an opportunity to inform them about the range of services provided by the practice,
 such as:
     how to obtain medical care within and outside normal opening hours
     billing principles, such as bulk billing, accounts settlement, representative or
        approximate costs for treatment
     communication policies, including clarifying the use of electronic means (eg. SMS,
        email)
     patient health information management policy (eg. how to obtain a copy of the health
        information kept by the practice)
     process for follow up of results (eg. who will contact whom and by when)
     how to provide feedback and complaints to the practice (eg. contact number for the
        person responsible for dealing with feedback and complaints).

 A photocopied, typed or electronically generated information sheet is acceptable. The
 information on the practice information sheet is very important to all patients and the practice
 needs to find alternative ways to provide or discuss this information with patients who are
 unable to read or understand the practice information sheet. Where a practice serves defined
 ethnic communities, it is appropriate to make written information available in the most
 common languages used by the practice population.

 Information services provided by the practice (eg. health promotion information or ‘tailor made’ health
 information magazines) may contain local advertising. The practice should consider whether they
 should include a disclaimer that the inclusion of these advertisements is not an endorsement by the



 Identifying the Carer - GP Engagement Project Report 2010                       Page 42 of 123
practice of these services. The practice information sheet needs to comply with the AMC Code of
Conduct on advertising (available at http://goodmedicalpractice.org.au/).

Where a practice has a website, it needs to ensure that the information is maintained regularly to
reflect changes in the practice. Information needs to be accurate and contain, at a minimum, the
information included in it’s practice information sheet. It also needs to meet the advertising
requirements of the AMC Code of Conduct.




Identifying the Carer - GP Engagement Project Report 2010                      Page 43 of 123
9.16 STANDARD 1.2
9.17
CRITERION 1.2.2 Informed patient decisions

Our practice gives patients sufficient information about the purpose, importance, benefits and
risks associated with proposed investigations, referrals or treatments to enable patients to
make informed decisions about their health.

Indicators
►A. Our clinical team can demonstrate how we provide information to our patients
    about the purpose, importance, benefits, and risks of proposed investigations,
    referrals or treatments.
►B. Our clinical team can describe how we use leaflets, brochures, written or
   electronic information to support our explanation of the diagnosis and
   management of conditions when appropriate.
►C. Our clinical team can describe how they provide information (printed or
   otherwise) about medicines and medicine safety to patients.
Explanation

In a nutshell

       Patients learn in different ways
       Practices need to provide information to patients to support their learning about their condition
        and proposed management
       Information needs to be provided in formats that are easy for patients to understand.

It is important that patients have sufficient information to make appropriate decisions about
their own health care. Information about the purpose, importance, benefits and risks of
proposed investigations, referrals or treatments need to be tailored to the individual patient’s
needs. This information needs to be delivered in appropriate language – avoid jargon or
complicated terms – and where necessary include clear diagrams and written information.
Consideration also needs to be given to the patient’s physical, visual and/or cognitive
capacities, which may impact on their ability to understand the information, make decisions or
provide consent. Consideration needs to be given to the way information is communicated in
relation to potentially sensitive investigations or tests (eg. sexually transmissible infections,
blood borne viruses, fetal abnormality screening, pregnancy tests). If working cross culturally,
special care is needed to ensure that there is a shared understanding between the GP and the
patient about the information provided.

The Australian Council for Quality and Safety in Health Care encourages patients to actively discuss
with their health care provider the purpose, importance, benefits and risks associated with their care.
The publication ‘Ten tips for safer health care’ is available at
www.health.gov.au/internet/safety/publishing.nsf/Content/10-tips and provides further detail. Practices
may find it useful to refer patients to this information to help create an understanding of shared
responsibility between the patient and the practice.

The provision of information about medicines and medicine safety (including Consumer Medicines
Information [CMI]) may assist patients to make informed decisions about their medicines. Consumer
Medicines Information provides an online version of leaflets produced by pharmaceutical companies
and is available to the general public at www.racgp.org.au/medicines/.

Should a patient decide not to follow the advice of the GP after receiving sufficient information to
make an informed decision about their care, their refusal and their awareness of its implications, as
discussed with the GP, should be documented in the patient health record (Criterion 2.1.1).




Identifying the Carer - GP Engagement Project Report 2010                       Page 44 of 123
 9.18 STANDARD 1.2
 9.19
 9.20 CRITERION 1.2.3 Interpreter services

 Our practice provides for the communication needs of patients who are not proficient in the
 primary language of our clinical team.

 Indicators
►A. Our clinical team can describe how they communicate with patients who do not
speak the primary language of our staff.
►B. Our practice has a list of contact numbers for interpreter services and is registered
with the Translating and Interpreter Service.
 9.21
 Explanation

 In a nutshell

        GPs have a professional obligation to understand their patients’ problems
        Patients have a right to understand the information provided by GPs and their
         recommendations
        Practices need to know how to access interpreter services.

 The Australian Government provides free telephone interpreting services for GPs:
      The Translating and Interpreting Service (TIS)
      Doctors Priority Line
      Onsite interpreting service (subject to interpreter availability.
 Information on these services is available at www.immi.gov.au/tis or by calling 131 450.

        A free AUSLAN service for patients who are deaf is available at www.nabs.org.au.

 Use of patients’ relatives and friends as interpreters is common. This is acceptable if it is an
 expressed wish of the patient and the problem is minor. However, further consideration should be
 given to the following:
      whether friends and relatives will put their own interpretation into the translated
         communication
      the use of friends and relatives in sensitive clinical situations or where serious decisions have
         to be made may be hazardous
      children as interpreters is not encouraged.

 Qualified medical interpreters should be the interpretation medium of choice.




 Identifying the Carer - GP Engagement Project Report 2010                       Page 45 of 123
9.22 STANDARD 1.2
9.23
9.24 CRITERION 1.2.4 Costs associated with care initiated by the practice


Our practice informs patients of the potential for out-of-pocket expenses for health care
provided within our practice and for referred services.

Explanation

In a nutshell

       It is valuable for patients to know in advance the costs associated with the health care
        services provided by the practice
       Cost can be a barrier to care
       Patients need to know in advance whether additional costs to those of the consultation
        will occur
       Patients should be informed of consultations that do not attract a government subsidy.


It is valuable for patients to know in advance whether the health care services they may require from
the practice will attract additional costs to those of the consultation so that they can make an informed
decision about their own health care. Patients are often unaware of these costs until after they receive
the required treatment, investigation or procedure. While it is often not practical to stop in the middle
of a procedure and inform patients that it will cost more than originally thought, effort to inform
patients of the cost of additional treatments or procedures before proceeding is needed. In these
situations, clear communication about unexpected developments can assist the patient to understand
the need for additional costs.

Costs can include:
    brief, standard and longer consultations
    additional costs for late or missed appointments
    costs for nursing consultations
    costs for home/other visits or care outside the practice’s normal opening hours
    costs related to bulk billing status.
   

Special care must be taken to advise patients of the costs of consultations that do not attract a
government subsidy (eg. cost of telephone and electronic consultations, and diving or commercial
driving license medical examinations).




Identifying the Carer - GP Engagement Project Report 2010                       Page 46 of 123
9.25 STANDARD 1.3
9.26
CRITERION 1.3.1 Health promotion and preventive care

Our practice provides health promotion, illness prevention and preventive care, and a
reminder system based on patient need and best available evidence.

Explanation

In a nutshell

           Practices need a systematic approach to health promotion, preventive care
            and early detection and intervention
           Practices are encouraged to provide patients (and carers) with information
            about health promotion and illness prevention
           Practices should have a range of written information available for patients
            to take home
           Practices need to have a systematic process for providing preventive care
            to patients
           Practices need access to up-to-date resources for both patients and clinical
            staff

General practices are the gateway to health care for most of the Australian population and are
therefore well placed to play a key role in health promotion, illness prevention and preventive
care. General practices also have the potential to coordinate with other health professionals
and key agencies to achieve health promotion and preventive care objectives. The holistic
approach to care that general practices provide allows for each patient’s individual
circumstances to be considered when providing health promotion, preventive care, early
detection and intervention.

Health promotion is distinct from the education and information that GPs use to
support their diagnosis and choice of treatment. Such prevention, education and
health promotion may be delivered by GPs, general practice nurses, or other allied
health professionals, and reinforced through the use of written materials and
resources.

It is useful for patients to self select information on a range of health issues that may affect or
interest them. The provision of written material is recommended as patients remember only
3–4 key messages from a consultation. This criterion refers to the many health pamphlets and
brochures available from sources such as health departments, nongovernment organisations,
health promotion programs, local community organisations, and support and self help groups.
Some educational materials are also produced in audio-visual format, which may complement
the written material provided by the practice. Practices are encouraged to be selective about
the leaflets, brochures and pamphlets they make available, as these may vary considerably in
quality and reliability. The use of the internet as a source of health information is becoming
more common. Practices need to consider the quality of the information available on internet
sites before recommending them to patients. Practices are encouraged to use the checklist in
the current edition of the RACGP publication Putting prevention into practice: guidelines for
the implementation of prevention in the general practice setting (the ‘green book’, available at
www.racgp.org.au/greenbook) to help determine whether patient education materials,
including those on the internet, are of sufficient and high quality (eg. HealthInsite at
www.healthinsite.gov.au).

This criterion also requires practices to have a systematic process for providing preventive
care to patients. This may be through the use of formal preventive activities such as patient
prevention surveys, or the use of disease registers and recall and reminder systems. It may
also be through the use of patient presentations at the practice as an opportunity to provide
health promotion and illness prevention activities additional to those relating to the specific
reason for the patient’s visit. Preventive activities need to be based on the best available



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evidence. Reminder systems need to operate in such a way as to protect the privacy and
confidentiality of patient health information. Practices also need to consider their responsibility
to their patients if the practice ceases using a reminder system.

General practices might also collect information routinely and transfer it to a health summary.
A completed health summary makes a useful statement of the patient’s main health issues.
This contributes to better continuity of care within the practice and when patients seek care in
other settings.

Some information may also be transferred to national registers (eg. immunisation data) or
state and territory based systems (eg. cervical screening or familial cancer registries) in order
to improve care. Practices might also use data collected in the practice’s clinical software or
paper based systems (eg. smoking status, diabetes register) to improve the targeting and use
of prevention activities (eg. smoking cessation, weight management). They may use collected
information transferred from private pathology providers (eg. diabetes screening, cervical
screening). This is not only a quality improvement activity (Criterion 3.1.1) but it also provides
a check that the practice is identifying all relevant patients for their health promotion and
preventive care activities.

Further information regarding health promotion and preventive activities in general practice is
available in the current editions of the RACGP Guidelines for preventive activities in general
practice (the ‘red book’, available at www.racgp.org.au/guidelines/redbook), the RACGP
Putting prevention into practice: guidelines for the implementation of prevention in the general
practice setting (the ‘green book’, available at www.racgp.org.au/greenbook) and RACGP
Smoking, Nutrition, Alcohol and Physical Activity (SNAP) framework for general practice
(available at www.racgp.org.au/guidelines/snap).

There are other useful resources on lifestyle related risk factors, for example:

           Australia: The Healthiest Country by 2020 Technical Report 1 – Obesity in Australia:
            a need for urgent action, Section 4.7, pp 42-45
           Australia: The Healthiest Country by 2020 Technical Report 2 - Tobacco Control in
            Australia: making smoking history (including addendum for October 2008 to June
            2009), Sections 3.3–3.5 pp 33-45
           Australia: The Healthiest Country by 2020 Technical Report 3 - Preventing alcohol-
            related harm in Australia: a window of opportunity (including addendum for October
            2008 to June 2009), Section 45, pp 28-30.
All reports are available at www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/national-preventative-health-strategy-1lp



After Hours Practice


The RACGP acknowledges that the provision of information by after hours care services
about health promotion and illness is likely to be opportunistic.




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9.27 STANDARD 1.4
9.28
CRITERION 1.4.1 Consistent evidence based practice

A consistent approach is adopted within our practice to the diagnosis and management of
common and serious conditions of individual patients consistent with best available evidence.

Indicators
►A. Our clinical team uses current clinical guidelines relevant to general practice to
   assist in the diagnosis and management of care of our patients.
►B. Our clinical team can explain how we can access guidelines for specific clinical
   care of patients who self identify as Aboriginal or Torres Strait Islander.
►C. Our clinical team can describe how we ensure consistency of diagnosis and
   management of common and serious conditions (within the parameters of
   evidence based care) within our practice.
►D. Our clinical team can demonstrate how we communicate about clinical issues and
   support systems. For example:
            regular clinical team meetings
            use of a communication book
            electronic notice board.

Explanation

In a nutshell

       Consistency of care can be assisted by the use of guidelines
       Consistency of care can also be assisted by communication between team members.

Contemporary practice is based on best available evidence in the context of current Australian
general practice. This criterion recognises that, in the absence of well conducted clinical trials or other
higher order evidence, the opinion of consensus panels of peers is an accepted level of evidence and
may be the best available evidence at that time.

Clinical practice guidelines must be up-to-date and may include recommendations from sources such
as:
     Australian Medicines Handbook (www.amh.net.au/)
     Australian Prescriber (www.australianprescriber.com)
     Central Australian Rural Practitioners Association (CARPA) treatment and reference manuals
         www.carpa.org.au)
     Cochrane database (www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME
     The Australian Council for Safety and Quality in Health Care ‘5 step correct patient, correct
         site, correct procedure’ (www.safetyandquality.org/5stpcorectpatnt.pdf)
     Diabetes Australia (www.diabetesaustralia.com.au/home/index.htm)
     National Aboriginal Community Controlled Health Organisation (NACCHO) National guide to
         a preventative health assessment in Aboriginal and Torres Strait Islander People
     National Asthma Council (www.nationalasthma.org.au/)
     National Health and Medical Research Council (www7.health.gov.au/nhmrc/)
     National Heart Foundation (www.heartfoundation.com.au/)
     National Prescribing Service (www.nps.org.au/)
     RACGP Smoking, Nutrition, Alcohol and Physical Activity (SNAP) framework for general
         practice
     RACGP Guidelines for preventive activities in general practice (‘red book’)
     RACGP Putting prevention into practice: guidelines for the implementation of prevention in
         the general practice setting (‘green book’)
     RACGP Medical care of older persons in residential aged care facilities (‘silver book’)



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       Rational Assessment of Drugs and Research (RADAR)
       Therapeutic Guidelines (www.tg.com.au/home/index.html).

It may be important for GPs, especially those undertaking procedural work and minor surgery, to use
the ‘Correct patient, correct site, correct procedure’ protocol from the Australian Council for Safety
and Quality in Health Care, or an equivalent protocol that incorporates these five steps. This is a
nationally agreed protocol for public hospitals; compliance with the protocol reduces the risk of error
for GPs who perform procedures in public or private hospitals, or in their own practices.

The health of the Australian population improved markedly during the 20th century. Health gains
however, have not been equally shared across all sections of the population, and today Australia is
characterised by large morbidity and mortality inequalities between population subgroups (eg.
homeless youth, children of single parent families, people with developmental disabilities, refugees,
and those from culturally and linguistically diverse [CALD] populations). In particular, Aboriginal and
Torres Strait Islander people have a life expectancy that is 20 years less than that of non-Aboriginal
people, and a death rate in the 35–44 years age group that is five times greater. Aboriginal and
Torres Strait Islander children in the 0–14 years age group are 2.7 times more likely to die than non-
Aboriginal children in the equivalent age group and the infant mortality rate is three times greater.
Aboriginal and Torres Strait Islander women are twice as likely to have a low birth weight baby than
are non-Aboriginal women. (A brief summary of details provided by the AIHW Australia’s Health
Report 2004 is available from www.aihw.gov.au/publications/index.cfm/title/10014). It is important
therefore, that practices make available clinical guidelines to assist GPs and others providing clinical
care in the diagnosis, treatment and management of these patients.

General practitioners and clinical staff find it valuable – both for the treatment of patients and their
own professional development – to have access to resources about a range of clinical issues. These
may include paper based resources (eg. text books and peer reviewed journals) and electronic
resources (eg. access via the internet or CD-ROM). These resources may relate to clinical matters but
might not be limited to what the profession would consider to be references on ‘evidence based
practice’.

This criterion does not require access to the most recent editions of texts, materials or publications,
nor does it require those resources to be in electronic format. However, resources need to contain
information that is consistent with current practice and not recommended management that is no
longer applicable.

Complementary and alternative medicines are often used by patients. Practices are referred to the
RACGP Position statement on complementary medicines in Australia, the AMA Position statement on
complementary medicine, and the Medical Council of New Zealand’s Statement on complementary
and alternative medicines.

Consistency in the approach to diagnosis and management of care across the various people who
are involved in the clinical care of an individual patient (ie. the people involved do not work at ‘cross
purposes’) is an important aspect of continuity of care. Patients value consistency in the quality of
treatment they receive from a practice and expect that treatment and advice given by different GPs
within the practice will not be in conflict. If the practice employs nurses or allied health professionals,
patients expect that advice provided by these professionals is consistent with the diagnosis and
management approach of the treating GP. Providing consistency in diagnosis and management of
health issues across a team of GPs or a multidisciplinary general practice team assists in ensuring
that the practice provides continuity of care for patients (Criterion 1.5.1).

This consistency is just as important in small or solo practices where the receptionist needs to have
an approach (eg. to providing information) that is consistent with that of the GP, as it is in large
practices with numerous clinical staff.

In addition to ensuring that clinical care is consistent with the best available evidence. It is important
that there is continuity in the clinical care provided to the patient. Management continuity involves
having a consistent and coherent approach to the management of a health condition that is
responsive to the patient’s changing needs, and assists to ensure that the people providing services
are not working at ‘cross purposes’. An example is ensuring that general practice nurses and GPs



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treating a patient with diabetes provide consistent advice to the patient about their treatment and care.
Management continuity is particularly important for people with chronic or complex diseases. For
example, it may involve having a plan for the patient’s care that is shared by the people providing the
care.

Another way of ensuring that the members of the practice team who are providing clinical care to
patients adopt a consistent approach (within the parameters of evidence based practice) is through
the discussion of clinical issues in a meeting.

After Hours Practice

The function of an after hours care service is to assist GPs/general practices provide both continuity of
care and continuous access to care for their patients. An after hours care service needs to play an
integral role in the care of patients by the general practice team, assisting to achieve a consistent
approach to care for patients. This consistency is achieved primarily by effective communication between
the after hours care service, the patient and the patient’s usual GP/general practice.




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9.29 STANDARD 1.4
9.30
9.31 CRITERION 1.4.2 Clinical autonomy for general practitioners

Our practice ensures that all GPs in our practice can exercise autonomy in decisions that
affect clinical care.

Explanation

In a nutshell

General practitioners are free to determine:
          the specialists and other health professionals 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 (subject to Criterion 2.1.1).

Our practice team is consulted about:
          the scheduling of appointments
          the equipment and supplies that our practice uses.

The intent of this criterion is that GPs are free – within the parameters of evidence based care – to
make decisions that affect the clinical care they provide, rather than having these decisions imposed
upon them. The AMC Code of Conduct (available at http://goodmedicalpractice.org.au/) indicates that
in order to provide high quality health care, clinical independence and professional integrity must be
safeguarded from increased demands from society, third parties, individual patients and governments.
This means that the practice discusses with the GPs their individual preferences for the systems the
practice uses to provide clinical care (including investigation options, appointment scheduling, patient
load and equipment), rather than forcing GPs to use practice systems that impact on their ability to
provide care as an individual practitioner.

Some organisations have developed codes of practice so that practice systems do not restrict the
abilities of GPs to provide medical care. For example, there is a code of conduct for corporations
involved in the provision of management and administrative services in medical centres in Australia,
which emphasises the importance of GPs having professional independence and not being compelled
to use certain providers or services.

This criterion is not intended to conflict with Criterion 1.4.1, and does not preclude adherence to valid
guidelines for clinical care of an individual patient based on clinical judgment and best available
evidence.




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9.32 STANDARD 1.5
9.33
9.34 CRITERION 1.5.1 Continuity of comprehensive care and the therapeutic
      relationship
9.35
Our practice provides continuity of comprehensive care to patients.

Indicators
►A. Our staff can describe how patients can request their preferred GP when making
   an appointment or attending our practice.
►B. Our practice team can describe how we encourage continuity of comprehensive
   care.

Explanation

In a nutshell

There are a number of types of continuity:
       the sense of affiliation between the patient and their doctor (‘my doctor’ or ‘my
          patient’), sometimes called ‘relational continuity’
       consistency of care by the various people involved in a patient’s care (ie. not
          working at ‘cross purposes’), sometimes called ‘management continuity’, and
       continuity of information across health care events, particularly through
          documentation, handover and review of notes from previous consultations,
          sometimes called ‘informational continuity’.

By definition, general practices provide ‘initial, continuing, comprehensive and coordinated medical
care’ (see ‘What is general practice’ at www.racgp.org.au/whatisgeneralpractice) and it is important
that patients have the opportunity to develop an ongoing relationship with the practice, GPs and staff
members. One way to demonstrate continuity of care is through patient health records that show
patients attending the practice over time. Research by the RACGP during the revision of these
Standards demonstrated that the vast majority of practices (except those recently established) can
demonstrate this.

Continuity is the degree to which a series of discrete health care events is experienced by the patient
as coherent and connected, and consistent with the patient’s medical needs and personal context.
Continuity of care is distinguished from other attributes of care by two core elements, care over time
and the focus on individual patients. This criterion focuses on those two elements: the attendance of
individual patients, over time, at the general practice.

Relational continuity is a sustained relationship between a single practitioner and a patient (or
sometimes more than one practitioner and a patient) that extends beyond individual consultations or
episodes of illness. This can be described as a sense of affiliation between a patient and their doctor
(‘my doctor’ or ‘my patient’). It is often viewed as the basis for continuity of care.

It is acknowledged that some practices do not have formal, written appointment schedules by which
patients are booked to see their GP. However, such practices need to be able to demonstrate that
they have a ‘system’ or a ‘rationale’ for determining how patients may see the GP of their choice, if
requested.

Many practices now employ general practice nurses or allied health professionals as part of the
practice team. The principles in this criterion relating to the patient’s right to see their preferred GP
also apply to appointments with general practice nurses or allied health professionals.

After Hours Practice

The therapeutic relationship between the patient and the GP who usually provides their continuing



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comprehensive health care needs to be encouraged. Indicator A is not applicable. Indicator B is
applicable to after hours care services.




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9.36 STANDARD 1.5
9.37
CRITERION 1.5.2 Clinical handover NEW

Our practice has an effective handover system that ensures safe and continuing health care
delivery for patients.

Indicator
►A. Our practice team can demonstrate how we ensure an accurate and timely
   handover of patient care.

Explanation

In a nutshell

           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
           Clinical handover communications can be face-to-face, written, via telephone and
            also by electronic means
           Failure or inadequate transfer of care is a major risk to patient safety and a common
            cause of serious adverse patient outcomes. Inadequate handover can also lead to
            wasted resources, delayed treatment, delayed follow up of significant test results,
            unnecessary repeat of tests, medication errors and increased risk of medicolegal
            action
           Practices, including MDS, should have standard processes for clinical handover
           Practices should encourage reporting of near misses and breakdowns in clinical
            handover procedures and make improvements to minimise the risk of recurrence.

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’.

Clinical handover of patient’s(s’) care outside the practice occurs in many ways. It includes (but not an
exclusive list): referral for an investigation, referral to an ancillary health care provider, referral to a
specialist and referral to a hospital, as an outpatient or as an in-patient. Criterion 1.6.2 states that
referral letters include sufficient information to facilitate optimal patient care including details of ‘the
purpose of the referral’. As an example, clarifying rather than assuming, who will manage the
responsibility for follow up of investigations when referring a woman with a breast lump to a breast
physician or surgeon.

Many practices hand over care of all their patients to a medical deputising service or other provider
outside the normal opening hours of the practice. It is prudent to notify the deputising care provider of
patients that you anticipate may need care, eg. a patient with terminal illness. Deputising services
need to have a defined means of timely contact with a GP or GPs of the practice when they are
deputising, should they need to access more detailed health information about a patient. Deputising
services also have a responsibility to appropriately hand over care back to the patient’s practitioner in
a timely manner when care is provided by the deputising service.

Pathology services sometimes need to contact a practice doctor after the practice is closed
concerning a serious result, eg. an unexpected result suggesting a patient has acute leukaemia. It is
the responsibility of the practice to provide the pathology service(s) they use with after hours contact
details so that patients can be managed promptly and appropriately.

Clinical handover between GPs is perhaps more common in recent years when so many GPs work on
a sessional basis at a practice and may be absent for more than 1 day at a time on a regular basis.
Other events when handover is important are when a GP or other clinical staff member is away
because of annual or illness. Practices should have a defined method to cover the hand over of care
of patients who have been under the care of the absent clinical team member. Many have a ‘buddy’
system when there is a reciprocal arrangement when one doctor follows up results and



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correspondence or continues the care of the absent doctor of patients whose condition has raised
concern, in a timely manner. If a practitioner has a ‘buddy’ system to hand over care, this should be a
formal rather than an informal arrangement. Adequate clinical records will enable another doctor to
safely and effectively continue the routine care of patients in a safe and effective manner.
Practitioners should routinely read the patient’s preceding clinical records for the past few
consultations.

There are occasions when the need for a handover process is more critical, such as a patient having
a test that is anticipated to be abnormal and may need to be followed up when the referring GP is not
on duty; or the review of a child with undifferentiated abdominal pain later in the day to ensure he/she
does not have a surgical condition such as acute appendicitis. While most practices do this well,
these are occasions of greater risk of harm when failure of adequate handover occurs.

Whenever clinical handovers occur, whether external or internal, practices should ensure patients are
aware of who will take over their care in the absence of their regular doctor. Patients need to be
involved in the decision, particularly when they consult with more than one GP in the practice or a
specialist or other care provider.

When errors in patient handover occur, every member of the practice team is encouraged to report
them so that the event can be analysed and processes introduced to reduce the risk of a recurrence
and harm occurring to other patients (see Criterion 3.1.2).

When a standard process for clinical handover is used, the safety of patient care will improve, as
critical information is more likely to be transferred and acted on. It is prudent to keep a record of the
handover process and document that the patient has shared in decision making and has been
informed.

    1. ACSQHC OSSIE guide to clinical handover. Available at
       www.health.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-05_OssieGuide.
    2. Wong MC, Yee KC, Turner P. (2008). Clinical handover literature review, eHealth Services
       Research Group. University of Tasmania Australia. Available at
       www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram‐05.
    3. Australian Medical Association (2006). Safe handover: Safe patients. Guidance on clinical
       handover for clinicians and managers. Available at www.ama.com.au/web.nsf/doc/WEEN-
       6XFDKN.




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STANDARD 1.5
9.38
9.39 CRITERION 1.5.3 System for follow up of tests and results

Our practice has a system for the follow up and review of tests and results.

Indicators
►A. Our patient health records contain evidence that all pathology results, imaging
    reports, investigation reports and clinical correspondence received by or
    performed in our practice have been:
      reviewed by a GP
      signed or initialled or electronic equivalent, and
      where appropriate, acted upon in a timely manner.
►B. Our practice team can describe the system by which pathology results, imaging
   reports, investigation reports, and clinical correspondence received by our
   practice are:
      reviewed
      signed or initialled (or the electronic equivalent)
      acted on in a timely manner
      incorporated into the patient health record.
►C. Our practice has a written policy describing the review and management of
   pathology results, imaging reports, investigation reports and clinical
   correspondence received by our practice.
►D. Our practice team can describe how patients are advised of the process for the
   follow up of results.
►E. Our practice team can describe how we follow up and recall patients with clinically
   significant tests and results.
►F. Our practice has a documented system to recall patients with clinically significant
   results.


Explanation

In a nutshell

‘Follow up’ can have several meanings.
     Following up the information: following up on tests and results that are
        expected to be, but have not yet been, received by the practice
     Following up the patient: chasing or tracing the patient to discuss the report,
        test or results after they have been received by the practice and reviewed, or if
        the patient did not attend as expected.

The practice needs a system aimed to ensure that:
    all received test results and clinical correspondence (eg. reports from other health
       care providers) relating to a patient’s clinical care are reviewed
    clinically significant tests and results are followed up
    patients are made aware who is responsible for communicating with whom about
       results, and when this is to occur.

Overall, the following factors are important in determining if something is clinically significant
and therefore requires follow up:
    the probability that the patient will be harmed if adequate follow up does not occur
    the likely seriousness of the harm
    the burden of taking steps to avoid the risk of harm.




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This criterion focuses on the systems that general practices need to use to follow up tests and
results. The information gained from tests and results can have considerable impact on the
choices patients and GPs make in patient care.

The GPs’ and practice’s responsibilities reflect the recognition that the patient-doctor
relationship is a special one based on trust. It is also characterised by the GP having special
knowledge and skills that the patient generally does not have. While practices are not
expected to follow up every test ordered – nor to contact patients with the results of every test
or investigation undertaken – there may be considerable risk in not following up clinically
significant tests and results.

During the review of the Standards for general practices (2nd edition), members of the
profession expressed concern about the way in which the RACGP would reflect the
profession’s standards in the area of follow up. Some felt the courts had inappropriately
shifted patient responsibilities to GPs. Others commented that the decisions of the courts
were less important to them than the emotional consequences of missing clinically significant
results. In response, the RACGP commissioned a legal opinion on the issue and considered
that opinion and the views of the profession when preparing this edition of the Standards. The
RACGP decided to provide lengthy detail in this explanation to assist in clarifying the issues
for practices.

General practitioners are not legally responsible for everything that goes wrong, others (for
example, the patient or a third party provider such as a pathology company) may be legally
responsible instead of (or together with) the GP.

The system needs to be designed in a way that anticipates that individual cases will require
different levels of follow up depending on the clinical significance of the case.

The nature and extent of responsibility for following up tests and results will depend on what
is reasonable in all of the circumstances. Overall, the following factors are important in
determining if something is clinically significant and therefore requires follow up:

       the probability that the patient will be harmed if adequate follow up does not occur
       the likely seriousness of the harm
       the burden of taking steps to avoid the risk of harm.

The clinical significance of a test or result needs to be considered in the overall context of the
patient’s history and presenting problems. Clinically significant results do not necessarily only
mean ‘abnormal’ results. For example, a normal mammogram in a woman with a breast lump,
or a normal electrocardiogram in a patient with chest pain, does not preclude the need for
further consultation, investigation and management. ‘Clinically significant’ is a judgment made
by the GP that something is clinically important for that particular patient in the context of that
patient’s health care. The judgment may be that an abnormal result is clinically important and
requires further action. On the other hand, the result may be normal but may still require
further action.

The practice needs to have in place some process or system for following up – even if it is as
basic as a simple diary entry, or logbook containing ‘worrying’ or ‘high risk’ cases – so that
where there is a concern about the significance of the test or result, a reminder occurs.
General practitioners do not necessarily need to supervise such a system directly, but it
needs to operate consistently where it is needed (although the GPs will be the ones who
identify the ‘worrying’ cases).

The practice needs to be able to identify unexpected significant results when they are
received, particularly if the significance of such results was not raised in the consultation. In
these circumstances practices need to alert the patient, who may not anticipate or understand
the significance of the result.

Problems in follow up can be avoided or minimised through interventions at earlier points in
patient care. The relationship between doctor and patient is a special one, based on trust and



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communication. While the patient is the ultimate decision maker, it is important for the patient
to be well informed in order to make such decisions. Decisions need to be based on
information that the GP has a duty to provide. The GP needs to convey the information to the
patient in a way that helps the patient to understand it. A patient who makes a decision based
on insufficient information is not making an informed decision. Once properly informed,
however, there can be legally effective informed consent, and there can also be legally
effective informed refusal.

Patients also have responsibility in their own health care; this includes the seeking of results.
It is important to have follow up systems in the practice that are meaningful for patients; that
create a shared understanding of what is going to happen; that define who is responsible for
follow up; and that encourage patients to discuss how they can help manage their own health.
These systems might include outlining the practice’s policy for follow up in the patient
information sheet, placing a notice in the waiting area, and having the GPs and clinical staff
routinely describe the practice’s system for follow up to patients when requests for pathology
or imagining tests are made. The standards for ensuring that patients have the information
they need to make informed decisions are covered in Criterion 1.2.2.

At an early stage in the patient’s care, the practice needs to focus on the reinforcement of the
respective rights and responsibilities of the patient and members of the general practice team
in following up tests and results. Developing this understanding with patients reinforces for
patients that they should actively engage with the GP, and that part of this requires them to
think about the way they help manage their own health. Brief but accurate documentation of
the discussion and outcome of such discussions is important. Documentation of relevant
clinical information is also required so that the information provides a trigger to the GP, or to
others who may view, and rely on, the records later. The standards for maintaining patient
health records are covered in Criteria 1.7.1, 1.7.2 and 1.7.3.

Reliance on patient memory or motivation alone does not reduce the need for an effective
follow up system in the practice. Patients may not follow the recommendations for tests
provided by the practice because of their particular circumstances, fear, ignorance,
personality, expectations, beliefs, cultural background or a range of other factors. The
practice needs to have systems to identify and respond to situations where a particular patient
is unlikely to, or may not either understand or comply with, their responsibilities to go through
with a test or to follow up the results with the practice. General practitioners in the practice
need to reflect on which patients, tests and results justify a suspicion or concern. The practice
needs to have a system that will allow GPs to take action to address their concerns. These
concerns could be based on suspicion that the information from a test is likely to be clinically
significant, or that the patient might not have the test performed.

In rare cases where a patient indicates they do not intend to comply with the recommendation
for a test, the practice needs to ensure that the patient has received sufficient information with
which to make an informed decision and to understand the consequences of their actions (or
inactions). This discussion between the GP and patient needs to be recorded
comprehensively in the patient health record (Criterion 1.2.2).

In cases where a GP suspects that the results will be clinically significant, the practice needs
to create additional safeguards to ensure that potentially clinically significant information does
not get ‘lost in the system’. One approach is by obtaining a clearly expressed agreement from
the patient (which is documented by the GP) that the patient is responsible for having the
recommended tests performed and/or getting the results. However, this alone might not be
sufficient for follow up in all circumstances. The practice needs to have a system that protects
against the failure of both the GP and the patient remembering to follow up on tests or results.
These systems need to allow for more intensive follow up action if required by the
circumstances.

Review and action on results or reports needs to be completed in a timely manner. The speed
with which results/reports are acted on, and the degree of effort taken to contact the patient to
discuss the results, will depend on the GP’s judgment of the clinical significance of the
result/report, and the context, duration and longevity of the clinical relationship. If the practice



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needs to initiate follow up contact with a patient, it needs to do so in a reasonable manner.
The number and types of attempts will take into account all of the circumstances. Depending
on the likely harm to the patient, three telephone calls at different times of the day and follow
up by mail to the address in the patient’s health record may be needed. These attempts at
follow up need to be documented in the patient’s health record.

A close analysis of how and when things go wrong in the follow up of patients with clinically
significant tests or results often shows that it is a problem, or several problems, with the
practice system including:

       the quality and content of discussions with the patient
       the recording of those discussions
       the recording of the clinical encounter.

It is therefore useful for practices to understand that protecting patients and GPs from errors
involves a series of safeguards and devising, implementing and monitoring systems in the
practice.

The RACGP recognises that information technology can be a useful tool in follow up, however
current clinical information systems have limitations and may not provide sufficient safeguards
to be relied on in all cases. The RACGP has requested that medical record software
companies focus on the development of reliable systems for the follow up of tests and results
as a high priority.

After Hours Practice


After hours care services need to have a system to ensure that all received results and
clinical correspondence relating to a patient’s clinical care are reviewed and that clinically
significant tests and results are followed up by the medical practitioner who ordered the test.




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9.40 STANDARD 1.6
9.41
9.42 CRITERION 1.6.1 Engaging with other services

Our practice engages with a range of health, community and disability services to plan and
facilitate optimal patient care.


Indicators
A. ►Our practice team can demonstrate how we plan and coordinate comprehensive
    care by our interaction with:
         medical services such as diagnostic services, hospitals and specialist
            consultant services
         primary health care nurses
         allied health services
         pharmacy
         disability and community services
         health promotion and public health services and programs.

After Hours Practice

9.43 ►B. Our service seeks feedback about the quality and responsiveness of our
    service from the practices whose patients we see.


Explanation

In a nutshell

Engaging other medical services (eg. diagnostic services, hospitals and consultants), allied
health, social, disability, and community services can assist the practice to provide optimum
care to patients whose health needs require integration with other services (besides the
general practice). For example, patients requiring rehabilitation, mental health services or
aged care services can benefit from the practice taking an active role in engaging other
services to assist in their care.

Practices are encouraged to integrate patient care across the general practice setting into other
health care, allied health care and social, disability and community services. The practice needs to
have readily accessible written or electronic information about local health, disability and community
services and how to engage with them to plan and facilitate patient care.

Practices may also need to be aware of different referral arrangements for public and private
providers.

After Hours Practice

After hours care services may, where clinically appropriate, coordinate referrals through the patient’s
usual GP/general practice.




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9.44 STANDARD 1.6
9.45
9.46 CRITERION 1.6.2 Referral documents

Our referral documents to other health care providers contain sufficient information to
facilitate optimal patient care.

Indicator
►A. Our practice can demonstrate that referral letters are legible and unless
    inappropriate:
       include the purpose of the referral
       include the relevant history, examination findings and current management
       include a list of allergies and current medicines
       are on appropriate practice stationery
       the patient is identified using at least three approved patient identifiers
       the doctor making the referral is appropriately identified
       the health care setting, from which the referral has been made, is
        appropriately identified
       if the referral is transmitted electronically then it is done in a secure manner.

Explanation

In a nutshell

Practices need to ensure enough information is provided on referrals to ensure that:
    the correct patient is referred
    the person to whom the patient is referred receives sufficient relevant information to
       manage the patient
    patient confidentiality is preserved.

Referral documents are a key tool in integrating the care of patients with external health care
providers and therefore need to be legible (preferably typed) and contain sufficient information to
allow the other health care provider to provide care to the patient. Most of the information needed for
a referral may be found in the patient’s health summary; many practices routinely incorporate a copy
of the patient health summary into a referral letter or attach the summary as a separate document.
Patients need to be aware that their patient health information is being disclosed in these referral
documents (eg. inclusion of sensitive material such as a previous termination of pregnancy or STI
would be unlikely to be of clinical relevance to a local physiotherapist, but would be important in an
obstetric or gynaecological referral. Practices may consider whether patients should be given the
opportunity to read the content of the letter before it is forwarded to another care provider. Referrals
forwarded by email should be encrypted unless the patient has provided informed consent to do
otherwise.

In the case of an emergency or other unusual circumstance, a telephone referral may be appropriate.
A telephone referral needs to be documented in the patient’s health record.

For both medicolegal and clinical reasons, practices need to keep copies of important (nonroutine)
referral letters, ie. new referrals or those for serious conditions, in the patient’s health record. While
the significance of individual letters is at the discretion of the GP, practices in which no referral letters
have been retained would have difficulty meeting this criterion.

It is anticipated that new legislation presently before Parliament (2010) may result in the
establishment of Individual Healthcare Provider Identifiers and Location identifiers.

Identification of the doctor and health care location may involve the use of the Individual Healthcare
Identifiers: (anticipated new Bill in late 2010). All three entities need to be accurately identified in a
referral letter: patient, doctor and location of referral.




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Correct identification of patients is crucial to ensure the right patient receives the right treatment. This
issue is covered in more detail in Criterion 3.1.4

Approved patient identifiers include name, address, date of birth, and gender.

After Hours Practice

Where practical, after hours care services are encouraged to forward a copy of any referral letter (s)
to the patient’s regular GP/general practice.




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9.47 STANDARD 1.7
9.48
9.49 CRITERION 1.7.1 Patient health records

For each patient we have an individual patient health record containing all clinical information
held by our practice relating to that patient.

Indicators

►A. There is evidence that each patient has a legible individual patient health record
   containing all clinical information held by our practice relating to that patient.
►B. Where our practice has an active hybrid medical record system, for each
   consultation/interaction, our practice can demonstrate that there is a record
   made in each system indicating where the clinical notes are recorded.
►C. Our active patient health records include identification, contact and demographic
   information (where appropriate) including:
        the patient’s full name
        date of birth
        gender
        contact details.
►D. Our practice can demonstrate how we routinely record the following information
   in our active patient health records:
          self identified Aboriginal and Torres Strait Islander status
          the person that the patient wishes to be contacted in an emergency.
►E. Our practice can demonstrate that we are working toward recording the self
identified cultural background of our patients.

Explanation

In a nutshell

       Practices need to ensure information held in different records of the same patient
        are available when needed
       Practices need to routinely record self identified Aboriginal and Torres Strait
        Islander status and the person that the patient wishes to be contacted in an
        emergency
       Practices need to be working toward recording self identified cultural
        background.

Practices need to have an effective system whereby a patient’s health information is stored in
a dedicated patient health record. Health records need to include: the patient’s contact and
other demographic information, medical history, consultation notes (including care outside
normal opening hours of the practice and home visits), letters received from hospitals or
consultants, other clinical correspondence, investigations or referrals, and results. Besides
clinical information, the patient health record may also contain other relevant information
pertaining to the patient such as any WorkCover, insurance information or relevant legal
reports.

There are risks associated with hybrid records, where some information is recorded on
computer eg scripts, and some information on paper notes. When the patient notes are stored
in two areas it is possible for important issues to be overlooked, particularly if another doctor
sees the patient. To make this less of a problem, a note in each system improves the
continuity of these hybrid systems.




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If health information about a patient is kept in two sites (as in the case of hybrid records or
records held in a residential aged care facility), practices need to ensure they have a system
in place to ensure all the information is available and accessible when needed.

The information required from each patient might be collected by practice staff having new
patients complete a generic form or by interviewing patients in a private environment before
consultation. Practices should also have a system whereby patient information is updated
regularly so that it remains current and accurate.

It is critical that patient health records are legible so that another practitioner could take over
the care of the patient if necessary. Not only does written information need to be legible (able
to be read and understood), if the practice scans documents such as external reports, the
scanning needs to be undertaken in a way that reproduces the legibility of the original
document.

The RACGP recognises that improving the health of Aboriginal and Torres Strait Islander
people is one of Australia’s highest health priorities. A recent summary of Aboriginal health
highlights that the majority of Aboriginal Australians have a lower life expectancy than non-
Aboriginal Australians, and are more likely to suffer from cardiovascular disease, respiratory
disease, injuries, renal failure, noninsulin dependent diabetes mellitus, lung cancer, cervical
cancer and liver cancers, and preventable communicable diseases. It is valuable to
encourage patients to self identify as Aboriginal or Torres Strait Islander, if appropriate. Some
patients may provide this information without being asked, but others may not. It is important
not to assume that a person is or is not an Aboriginal or Torres Strait Islander. The nationally
accepted question to ask is: ‘Are you of Aboriginal or Torres Strait Islander origin?’ This exact
form of words may not be appropriate in all clinical settings and useful guidance can be found
in the Commonwealth Department of Health and Ageing, Aboriginal and Torres Strait Islander
Adult Health Check Medicare item supplementary and reference materials for health
practitioners.

Practices need to be routinely recording self identified Aboriginal or Torres Strait Islander
status in order to assist in appropriately tailoring care to patients. Aboriginal and Torres Strait
Islander self identification refers to the process by which patients are encouraged to identify
themselves as being of Aboriginal or Torres Strait Islander origin. When this information is
reported and recorded in health information systems the resulting data item is known as the
patient’s ‘self identified Aboriginal and Torres Strait Islander status’. This important task in
general practice is supported by the National Aboriginal Community Controlled Health
Organisation (NACCHO). Current evidence, such as the BEACH study, suggests that there is
substantial under identification of Aboriginal and Torres Strait Islander people, despite the
importance of tailoring health care to their specific and different needs. An example of this is
the different ages when influenza and pneumococcal vaccines are indicated.

Other cultural groups also have higher risk of developing certain diseases or conditions that
impact on their treatment. Thus, practices need to be working toward recording self identified
cultural background.

Practices also need to routinely record the person the patient would like contacted in an
emergency.

Ease of storage may be assisted by culling outdated test results that no longer have clinical
relevance (in line with relevant state and territory legislation regarding the retention of patient
health information). In these circumstances, the practice needs to have a system for the
timely identification of information that is no longer relevant. General practices may want to
consult their GPs’ medical defence organisations when determining the practice’s policy
regarding culling results.




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9.50 STANDARD 1.7
9.51
9.52 CRITERION 1.7.2 Health summaries

Our practice incorporates health summaries into active patient health records.

Indicators
►A. Our practice can demonstrate that at least 90% of our active patient health records
    contain a record of allergies.
►B. Our practice can demonstrate that at least 75% of our active patient health records
   contain a health summary. A satisfactory summary includes, where appropriate:
        adverse reaction to medicines
        current medicines list
        current health problems
        relevant past health history
        health risk factors (eg. SNAP)
        immunisations
        relevant family history
        relevant social history.
C. Working toward recording preventive care status.
D. Our practice team uses and has documented standardised clinical terminology
    (such as coding) that enables data collection for review of clinical practices.

Explanation

In a nutshell

       Health summaries assist in providing ongoing care, both within the practice and on referral to
        other health care providers
       Useful health summaries need to be kept up-to-date
       Practices need to routinely record known allergies in the health record.

A vital component of a quality health record is a health summary. The RACGP encourages
practices to aim for all active records to contain an up-to-date health summary. A good health
summary assists the patient’s own GP, other GPs in the practice, locums, registrars, and
students to rapidly obtain an overview of all components of the patient’s care. Health
summaries reduce the risk of inappropriate management including medicine interactions and
side effects (particularly when allergies are recorded). Health summaries provide the social
and family overview vital to whole patient care. A health summary will assist with health
promotion by highlighting lifestyle problems and risk factors (eg. smoking, alcohol, nutrition,
physical activity status). It also helps disease prevention by tracking immunisation and other
preventive measures.

A good health summary should also include a summary of the patient's preventive care status, ie. a
listing of the preventive activities that are indicated for the patient based on his or her age, gender and
health history, showing when each of those activities was last performed, the result, finding or action
on that occasion, and when that preventive activity was or is due to be performed next. The RACGP
‘red book’ and SNAP guide provide useful guidelines on preventive health activities (available at
www.racgp.org.au/guidelines).

While it is important to record all allergies in the health record, it is particularly important to record
allergies to medicines as this facilitates safer prescribing (especially when computer based) and
reduces the likelihood of adverse patient outcomes. It is important also to record ‘no known allergies’,
but not to have this as an assumption in the absence of recorded data.

The recording of recent important events covers a wide range of social events of importance to the
patient, which may include changes in accommodation, family structure (birth of children, separation
or divorce, death of family members), and employment. Recent important events can alter patient



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preferences, values and the context of care.

Where a practice does not meet the 75% level in one or more of the elements of a health summary
(eg. risk factors), the practice needs to describe how it is attempting to improve the completeness of
the health summary in regards to that element. Where a practice knows they have a deficit in the
recording of any information, it needs to have a plan of how to improve this.

This criterion applies to active patient health records only. An ‘active health record’ is a record of a
patient who has attended the practice three or more times in the past 2 years. Practices with high
numbers of recurrent, transient patients (eg. resort areas) will need to identify health records of
regular patients for review, if undertaking an external peer review.

The RACGP appreciates that family and social history especially should only be recorded in a health
summary where it assists patient care and does not impair patients’ rights to privacy and, as such, not
all health summaries will include all the items listed in Indicator B.




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9.53 STANDARD 1.7
9.54
9.55 CRITERION 1.7.3 Consultation notes

Each of our patient health records contains sufficient information about each consultation to
allow another member of our clinical team to safely and effectively carry on the management
of the patient.

Indicators
►A. Our patient health records document consultations, including consultations
    outside normal opening hours, home or other visits, telephone or electronic
    consultations where clinically significant, comprising:
          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 (including name, strength,
           directions for use/dose frequency, number of repeats, and date medicine
           started/ceased/changed)
        complementary medicines used by the patient
        any relevant preventive care undertaken
        documentation of any referral to other health care providers or health
           services
        any special advice or other instructions
        identification of who conducted the consultation, eg. by initial in the notes,
           or audit trail in electronic record.
►B. Our patient health records show evidence that problems raised in previous
consultations are followed up.


9.55.1.1.1.1 Explanation


In a nutshell

           The quality of the patient health information should be legible and understandable
            by another GP or clinical staff member to facilitate safe and effective care.
           Complementary medicine consumption by patients should be documented to
            minimise drug interactions
           Patient’s medical records should be updated as soon as practicable at or after
            consultations and visits. The records should identify the person in the clinical
            team making the entry.

A consultation in general practice is the entry point to the health care system for most Australians. A
consultation is an interaction between the practice and the patient related to the patient’s health
issues. A consultation may be with a GP, nurse or other staff member who provides clinical care
within the practice.

The quality of patient health information needs to be such that another GP or clinical staff member
could read and understand the terminology and abbreviations used, and from the information
provided, be equipped to manage the care of the patient. Documentation of all the items in Indicator A
will not be required for every individual consultation (eg. consultations for repeat prescriptions).

Ideally, information about the consultation needs to be entered into the patient health record as soon
as is practical at the time of the consultation, or as soon as information (eg. results) becomes
available.




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Many people now take complementary medicines. There is a danger of interactions, such as St
John’s wort and SSRIs, therefore complementary medicines prescribed in the practice need to be
documented in the same manner as other medicines.

As part of risk assessment, practices are encouraged to routinely record patient’s height, weight and
blood pressure at intervals of their choosing. This is useful in children to assess normal growth or
failure to thrive and also to document weight loss and gain over a period of time in all age groups as
this may be an indicator of disease.

As part of the continuing care that GPs provide, information concerning patients is gathered over
more than one consultation. It is important there is a connecting process so that information about
clinically significant, separate events in a patient’s life, and in the care provided, are not overlooked
but are recorded and managed in a way that makes this information readily accessible. Regularly
updated health summaries are one method of managing this information. Clinically significant
information may include the patient’s health needs and goals, medical condition(s), preferences and
values. All this contributes to care that is responsive to patient needs.

Medical defence organisations have identified lapses in following up on problems and issues raised
previously by patients as a considerable risk. This can occur when patients are not seen by their
usual GP, although it can also occur when a GP is busy or distracted. Thus, for high quality patient
care, it is useful for general practices to have systems that reduce the risk of such lapses.


10




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     SECTION TWO
11   RIGHTS AND NEEDS OF PATIENTS

12   STANDARD 2.1 COLLABORATING WITH PATIENTS

Our practice provides timely care and advice.




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12.1 STANDARD 2.1
12.2
12.3 CRITERION 2.1.1 Respectful and culturally appropriate care

Our practice respects the rights and needs of patients and health care providers.

Indicators
►A. Our practice does not disadvantage patients in any aspect of access, examination
or treatment.
►B. Our clinical team can demonstrate how we provide care for patients who refuse a
specific treatment, advice or procedure.
►C. Our clinical team can describe what they do when a patient informs them that they
intend to seek a further clinical opinion.
►D. Our practice team can describe what they do to transfer care, in a timely manner,
to another GP in our practice or to another practice when a patient wants to leave the
GP’s care.
►E. Our practice team can describe arrangements for informing the patient and
managing the transfer of care of a patient whom a GP within our practice no longer
wishes to treat.
►F. Our practice team can describe how our practice provides privacy for patients and
others in distress.
G. Our practice team can identify important/significant cultural groups within our
practice, and outline the strategies we have in place to meet their needs.



Explanation

In a nutshell

Patients have the right to respectful care, which promotes their dignity, privacy and safety

               The Federal Disability Discrimination Act 1992,30 as well as various state and
                territory Disability Services Acts and Equal Opportunity Acts, prohibit the
                discriminatory treatment of people based on their personal characteristics
               Practices need a risk management strategy to manage patients who intend
                seeking a second opinion, which includes documenting this decision in the
                patient’s health record
               Practices need an appropriate risk management strategy for when patients
                refuse advice, procedures or treatments, including recording of such refusals
                in the patient’s health record
               Practices need a risk management strategy which details the steps when the
                GP(s) or practice team no longer consider it appropriate to treat a particular
                patient, including how to assist the patient with ongoing care
               Practices need to have a plan to respectfully manage patients in distress that
                can be implemented as the need arises.

Patients have the right to respectful care that promotes their dignity, privacy and safety. Patients have
a corresponding responsibility to give respect and consideration to their GPs, practice staff and other
patients. The GPs and staff need to have appropriate interpersonal skills to work with patients and
others in the practice. Much of the success of a practice depends on the positive, friendly, attentive,
empathetic and helpful behaviour of staff at the reception desk. This criterion requires that both GPs
and staff deal with patients in a respectful, polite and friendly manner.

Demonstrating respect for patients extends beyond the face-to-face interaction between the practice
staff and the patient to the recording of patient’s health information. Making or recording derogatory,
prejudiced, prejudicial, or irrelevant statements about patients has serious consequences for



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treatment, compensation and other legal matters, and may contravene anti-discrimination legislation.
Such remarks are also prone to misinterpretation when records are used by other GPs and will result
in differential treatment for such patients. Practices need to be aware that the Federal Disability
Discrimination Act 1992, as well as the various state and territory Disability Services Acts and Equal
Opportunity Acts, prohibit the discriminatory treatment of people based on their personal
characteristics (such as gender or religion). Further information is provided by the Australian Human
Rights Commission at www.hreoc.gov.au/. Their website has guides to the relevant legislation and
links to state and territory agencies with similar responsibilities. The Australian Committee on Safety
and Quality in Healthcare has produced an Australian Charter of Healthcare Rights (available at
www.health.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-01).

The ideal patient-doctor partnership is a collaboration based on mutual respect and a mutual
responsibility for the health of the patient. The GP’s duty of care is to explain the benefits and
potential harm of specific medical treatments and to clearly and unambiguously explain the
consequences of not adhering to a recommended management plan. Patients have the right to seek
further clinical opinion from other health care providers. Practices are encouraged to document in the
patient’s health record any indication by the patient that they intend to seek a further clinical opinion.
Patients need to be encouraged to notify their GP when they are choosing to follow another health
care provider’s management advice. This allows the GP the opportunity to reinforce any potential
risks of this decision. Where patients do seek further clinical opinion, an appropriate risk management
strategy for practices includes documenting this decision in the patient’s health record. In addition, the
GP is encouraged to document in the patient’s health record an explanation of the actions taken when
a patient seeks a further clinical opinion, including referral to other care providers if arranged.

Where patients refuse advice, procedures or treatments, an appropriate risk management strategy for
practices needs to include recording of such refusals in the patient’s health record, including referrals
to other care providers, if arranged. General practitioners are encouraged to document in the patient
health record an explanation of the action taken.

When a patient requests to be transferred to the care of another GP (in another practice), a copy of
patient health information needs to be transferred to the other practice in a timely manner to help
facilitate care of the patient. Practice staff need to comply with the requirements of the state or
territory legislation governing the transfer of patient health information. A useful publication is the
Guide to Privacy in the Private Healthcare Sector 2005 (available at www.privacy.gov.au-publications-
hg_01.pdf.url). Where the practice produces a summary for transfer to another practice, it is useful to
keep a copy of the summary in the patient’s health record. It is recommended that a copy of the
patient health information be transferred and that the practice retain the original health information.

There may be patients whom a GP(s) no longer considers it appropriate to treat (for example, when a
patient has behaved in a threatening or violent manner or where there has been some other cause for
a significant breakdown in the therapeutic relationship). The GP has the right to discontinue treatment
of that patient, especially when the GP thinks they can no longer give the patient their best care.
Concerns about violence in general practice continue to be raised by the profession, especially
following the deaths of several GPs, and assaults and threats to general practice staff. In order to deal
with these uncommon but distressing situations, the practice is encouraged to have a risk
management strategy which details the steps taken to protect doctors and staff of the practice and to
assist patients with ongoing care, including referral to other health care providers. Some states and
territories have specific legislation governing the cessation of treatment (such as when a practice
closes down) and practices need to be aware of their obligations. The RACGP has published a useful
tool to assist practices to deal with these distressing situations, General practice: a safe place
(available at www.racgp.org.au/gpsafeplace).

A patient in distress may feel more comfortable in a private area than in a public waiting area.
Practices, even those with limited facilities, need to attempt to provide privacy for such patients (eg.
by allowing them to sit in an unused room, staff room or other area). This does not mean that a
practice needs to have a room permanently set aside for such patients, but needs to have a plan that
can be implemented as the need arises to ensure the patient is treated respectfully.

The RACGP supports the choice of general practices to favour or specifically ‘target’ people and
communities with high needs for comprehensive primary care, where choices need to be made about



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the allocation of limited resources. This is one way of addressing the health inequalities of some
individuals, families and communities by providing culturally appropriate care to these patients. In
these cases, the RACGP believes the general practice is still providing initial, continuing,
comprehensive and coordinated medical care to individuals, families and communities, despite
targeting a specific patient group. For these practices it remains important that the practice has clear
systems to deal with requests for care by patients outside the target population.




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12.4 STANDARD 2.1
12.5
12.6 CRITERION 2.1.2 Patient centred feedback

Our practice provides opportunities for, and responds to, patient feedback.

Indicators
►A. Our practice has a process for receiving and responding to feedback and complaints
   from patients and other people, and its practice team members are able to describe
   this process.
►B. Our practice has a complaints resolution process and makes contact information
   for the state/territory health complaints agency readily available to patients if we are
   unable to resolve their concerns/complaints.
►C. Our practice actively seeks patient feedback about our practice and undertakes
   patient feedback survey (with processes and content approved by the RACGP) of
   patients of the practice.
►D. Our practice can demonstrate improvements we have made in response to patient
   feedback.
E. Our practice provides information to patients about the practice improvements
    made as a result of their input.

Explanation

In a nutshell

This criterion requires that practices have two ways of gaining patient feedback:
     an ongoing mechanism to gain feedback from patients, eg suggestion box, complaints
        management system
     systematic approach to gaining structured feedback from patients on a t3 yearly basis.
        This is commonly achieved through the provision of a written questionnaire to patients
        of the practice, but sometimes it is also done through using focus group discussions
        or interviews with patients.

Internationally, and in Australia, there is growing emphasis on the robust and meaningful collection of
information about patient experiences in both primary and tertiary care settings. In Australia there are
a range of patient ‘charters’ or ‘principles’ of patient centred care and consumer involvement. These
relate to the provision of health care that involves, engages and prioritises the role of the
consumer/patient in their care – sometimes referred to as a ‘partnership approach’ to health care.
Critical to this type of health care, although only one element of it, is a process for patients to provide
feedback (both positive and negative) to the individual clinicians and the practice team about their
care.

Discussing consumer feedback and concerns openly helps people within the general practice to
understand strengths in their practice, potential problems, and how to improve. It is helpful to know
what patients think about a practice and what they are likely to tell other people. The more feedback a
practice receives – whether complaints, compliments or suggestions – the better it will be able to
provide care. Systematic ways of measuring ‘consumer satisfaction’ are an integral part of most
business and profitability planning in other sectors (such as finance or law) and assists organisations
to tailor their services to the needs of their clients/consumers; the same approach can be used to
assess and improve the quality of care provided by general practices. Patients need to be assured
that their care will not be jeopardised by providing feedback or by making a complaint. Practices can
encourage feedback by letting patients know that their feedback and complaints are welcome, because
they enable continuous improvement of this practice

Unique information about the quality of care provided by a general practice and individual clinicians
can be gained from patients. Patients determine their views on quality and safety in a practice in
many ways, depending on their past experiences, needs, circumstances, individual values and



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preferences, expectations and resources. The question of whether patients can ‘judge’ quality of the
care arises because patients do not have access to the same information about technical aspects of
care that their health care clinicians do. However, there is strong evidence that patients are capable of
evaluating different aspects of quality of care. Patients’ evaluations of aspects of a consultation (such
as trust, interpersonal and communication skills of the doctor) are associated with their evaluation of
access and continuity of care.

Key safety and quality issues that patients might provide feedback on, relate to access to care in the
practice (such as scheduling care, telephone or electronic advice or home visits), informed decision
making (the type and quality of clinical and financial information provided to them), care provided by
individual clinicians, the way in which their rights are respected (having a third party present in the
consultation, privacy provisions, the way complaints are handled) and general satisfaction with the
care and facilities provided by the practice.

This criterion requires that practices have two ways of gaining patient feedback. First, the practice
needs to have an ongoing mechanism to gain feedback from patients (such as a ‘suggestion box’ at
reception) that allows timely consideration on any comments, suggestions or complaints from patients
or other people and allows the practice to address these issues as they arise and make any
improvement necessary. Where possible, patients and practices should be encouraged to raise any
concerns directly with the practice, and attempts made to resolve the concerns within the practice.
The Australian Council for Safety and Quality in Health Care (ACSQHC) publication, ‘Better practice
guidelines on complaints management for healthcare services’, provides guidance on the importance
value of effective complaints management in the Australian health care setting.

The second requirement for this criterion is that the practice is required to have a systematic
approach to gaining structured feedback from patients on a 3 yearly basis. This is commonly achieved
through the provision of a written questionnaire to patients of the practice, but sometimes is also done
through using focus group discussions or interviews with patients. Internationally and across all health
care sectors, it is recognised that whatever method is used to gain feedback, it should be a method
that has been demonstrated to be ‘valid and reliable. More technical definitions of what is ‘valid and
reliable’ are available in the RACGP ‘Engaging patients guide’, however in essence, it means that the
method used to gain patient feedback (such as a questionnaire) has been proven to measure what it
intends to measure (validity) and that it would give the same results if you gave it twice to the same
group of patients (reliability). A valid and reliable questionnaire is one that has been demonstrated to
be evidence based. Practices can be confident that the results really do reflect patient’s experiences
in their practice and decisions they make based on these results are more likely to be meaningful for
both the practice and patients.

The use of evidence based methods of gaining patient feedback is increasingly becoming the
minimum expectation both in Australia and internationally for seeking information from patients about
their experiences. The Draft National Safety and Quality Health Care Standards require health
services to implement ‘well designed, valid and reliable patient experience feedback mechanisms’
and use these to evaluate the performance of the health service. It is recognised that there are limited
patient questionnaires available in Australia that have been demonstrated to be valid and reliable. It is
even more difficult to demonstrate validity and reliability for nonquestionnaire methods of gaining
patient feedback (such as focus groups or interviews). In order to ensure that practices are provided
with the opportunity to use well designed, valid and reliable methods of gaining patient feedback,
practices are required to use a RACGP endorsed method (such as a questionnaire) to gain feedback
from patients. Further advice about what types of patient feedback methods are considered credible
and evidence based (valid and reliable) are available from the RACGP ‘Engaging patients guide’.

Gaining feedback from patients (whether it be on an ongoing basis in the practice or via a more
systematic way such as a questionnaire) is not a ‘quick and simple’ exercise for any general practice
– nor is it intended to be a ‘tick box’ activity to meet these Standards. Important information about a
practice and its clinicians can be gained from patients – this is information from the point of view of
the patient that a practice cannot ever ‘know’ unless they ask patients directly. Practices are required
to demonstrate that they have considered carefully the results of patient feedback and have acted on
these results by making an improvement in a key quality and safety issue raised by patients (such as
access, communication, privacy). Depending on what feedback patients give, practices might take the
opportunity to use this information for a rapid PDSA cycle, including making changes to the practice



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and then ‘checking’ with patients (perhaps through re-surveying or running a group discussion) that
the improvements have addressed the issue.

The RACGP has heard from patients that they value knowing how their feedback has led to
improvements. An example of how changes can be communicated back to patients is through the
practice newsletter (if the practice has one).

After Hours Practice

For after hours care services, Indicator A includes responding to feedback from the practices for
which they deputise.




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12.7 STANDARD 2.1
12.8
12.9 CRITERION 2.1.3 Presence of a third party

12.10 The presence of a third party observing or being involved in the clinical care during a
      consultation occurs only with the consent of the patient before the consultation.
12.11
Indicator
►A. Our practice team can demonstrate how we inform patients and obtain their prior
   consent for the presence of a third party during consultations.

Explanation

In a nutshell

       Patients are entitled to provide consent for the presence of a third party before the
        consultation commencing
       Third parties can be interpreters, carers, relatives, medical or nursing students on placement,
        general practice registrars.

In some circumstances, the patient or GP may feel more comfortable if there is a third party
present during an examination. Appropriate consent needs to be obtained from the patient
where the doctor requests the presence of a third party. The RACGP has a position statement
on the use of chaperones available at www.racgp.org.au/policy/Chaperones_in_gp.pdf.

Where a patient is accompanied to the practice by a third person (such as a family member or
carer), it is also important to ensure that the patient consents to the presence of that person in
their consultation. Practice staff need to be 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 have been appointed to oversee the interests of the patient. More information
on                guardianship               can             be              found              at
www.hreoc.gov.au/disability_rights/hr_disab/areas/Appendices.htm#app1.

Exposure to general practice is important for the recruitment and training of our future GPs. Young
doctors are more likely to enter general practice if they have exposure to general practice in their
university education. The general practice term is the most important part of vocational training, and
most general practice registrars report that the experience is valuable. Hence, education and training
are among the reasons for a third party to observe or to be involved during the consultation. The
permission of the patient must be obtained before the consultation if undergraduate students, general
practice nurses or other doctors or health professionals are to be involved in the consultation, whether
through direct observation, interview or examination.

Ideally, permission needs to be sought when the patient makes an appointment, or failing that, when
they arrive at reception. It is not acceptable to ask permission in the consulting room, as some
patients may feel ‘ambushed’ and unable to refuse.




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13 SECTION THREE
14 SAFETY, QUALITY IMPROVEMENT AND EDUCATION
(CLINICAL GOVERNANCE)

15   STANDARD 3.1 SAFETY AND QUALITY
Our practice is committed to quality improvement.

Standard 3.2 EDUCATION AND TRAINING
Our practice supports and encourages quality improvement and risk management through
education and training.




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15.1 STANDARD 3.1
15.2
CRITERION 3.1.1 Quality improvement activities

Our practice supports quality improvement activities.

Indicators
►A. Our practice team can describe an aspect(s) of our practice we have improved in
   the past 3 years.
►B. Our practice uses relevant patient and practice data for quality improvement, eg.
   scheduling, access, hypertension, diabetes, lipid management, smoking.
►C. Whenever any member of our team is conducting research involving our patients
   we can demonstrate that the research has current approval from an appropriate
   ethics committee.



Explanation

In a nutshell

       Practices need to engage in quality improvement activities to make changes that will
        increase quality and safety for patients:
            o practice structures, systems and processes
       Decisions on service changes are based on practice data
       Achieving improvements requires the collaborative effort of the practice team.

It is very important that standards for general practices encourage quality improvement and
incorporate systems of continuous improvement. Practices that engage in quality improvement
activities review the practice’s structures, systems and processes to discover opportunities to make
changes that will increase quality and safety for patients. It is critical that the practice also has a plan
for carrying out any improvements it has identified as being necessary. Quality improvement activities
can vary from activities designed to improve the day-to-day operations of the practice (eg. improving
patient health record keeping, changing the way patient complaints are handled, or altering systems
in response to ‘near misses’), to those specifically designed to improve the health of the entire
practice population (eg. improving rates of immunisation, improving care of patients with diabetes, or
altering the systems used to identify risk factors for illnesses that are particularly prevalent in the
practice’s local community). Quality improvement in general practice is not restricted to clinical areas
and may include improvements made in response to feedback from patients (Criterion 2.1.2) or other
nonclinical aspects. One of the most effective quality improvement activities is formal accreditation
using these Standards; peers can provide extremely useful ideas about how a practice can improve in
a range of areas.

Quality improvement activities are underpinned by effective information management techniques that
allow practices to analyse their practice data and make decisions for service changes based on the
data collected. Innovative use of information technology can assist practices in performing quality
improvement activities to improve the health of their practice population. Ideally, practices need to
investigate their own practice data for quality improvement purposes. Where such data is not easily
accessible (eg. in noncomputerised practices), national recall and reminder registers (eg. the
Australian Childhood Immunisation Register) can provide practice specific data for practices to use in
quality improvement activities.

Engaging in quality improvement activities is an opportunity for the practice’s GPs and other staff
members to come together as a team to consider quality improvement. Quality improvement can
relate to many areas of a practice and achieving improvements may require the collaborative effort of
the practice team as a whole.

A description of quality improvement tools and guides for use, eg. PDSA cycles, is available at



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www.racgp.org.au/qacpd/20082010triennium/gpforms.

The January/February 2007 issue of Australian Family Physician discussed the theory of quality
improvement in general practice and included an examination of the RACGP Quality Framework
(available at www.racgp.org.au/afp/200701).

The RACGP has developed several tools to assist practices in using their practice data for quality
improvement:
     ‘Oxygen: Intelligence in practice’ will improve the way that patient information can be used to
       better inform decisions in both clinical and business settings, and continues the range of
       initiatives developed by the RACGP over many years to enhance the quality of care provided
       by Australian GPs (available at www.racgp.org.au/oxygen).

The RACGP has also produced many guidelines to assist practices and teams to provide evidence
based patient care, eg. the ’red book’, ‘green book’, ‘silver book’, and diabetes guidelines (available at
www.racgp.org.au/publications/guidelines).




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 15.3 STANDARD 3.1
 15.4
 CRITERION 3.1.2 Clinical risk management systems

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

 Indicators
►A. Our practice team can demonstrate the procedures for managing:
             processes for regularly monitoring, identifying and reporting near misses
              and mistakes in clinical care
             unjustified variations in practice that may result in patient harm.
►B. Our practice has documented systems for dealing with near misses and mistakes.
►C. Our practice team can describe improvements made to our systems to prevent near
misses and mistakes in clinical care.
►D. Our practice monitors improvements to ensure successful implementation of
changes made to our clinical risk management systems.
►E. Our practice has a continuity plan of action for the practice in case of adverse and
unexpected events (eg. natural disasters, pandemic, sudden unexpected deaths,
computer crashes).

 Explanation

 In a nutshell

             Near misses and mistakes in clinical care that might harm patients can occur in all
              general practices
             Practices need systems to examine near misses and mistakes to identify the
              source of the problem and solutions
             Solutions need testing and review to ensure they work effectively
             Practices need to have a plan for business continuity for unusual but potentially
              disruptive events.

 Near misses and mistakes in clinical care that might harm patients can occur in all general practices.
 One review suggests that the frequency with which a GP will be involved in an incident in which an
 error occurred will be 5-80 times per 100 000 consultations. The evidence about the frequency of
 slips, lapses and mistakes varies, and the better constructed studies suggest even higher rates of
 occurrence.

 Most GPs and practices already manage clinical risk on a daily basis. Many have informal and ad hoc
 methods of trying to prevent near misses and mistakes. Some GPs talk to other trusted peers or
 supervisors. Other practices have a more formal process that includes practice discussions about
 what went wrong and how to reduce the likelihood of it happening again, or using structured
 techniques to analyse the causes of the error and reduce the likelihood of its recurrence. Practice
 team members need to be confident that they are able to discuss problems in a blame free
 environment.

 The same mistake can have different causes on different occasions. Part of the quality improvement
 process is having a consistent clinical risk management system so that the causes of near misses
 and mistakes are identified and processes improved to reduce the likelihood of them occurring again.

 If the practice does not make improvements after identifying a near miss or mistake, then patients
 may be exposed to an increased risk of adverse outcomes, and the GPs and practice staff to an
 increased risk of medicolegal action. An example of this situation is where a clinically significant test
 result is not communicated to the patient or adequately followed up; the practice knows about this,



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and yet makes no attempt to prevent a recurrence. Another example might be when an important
detail in a previous consultation is not considered/read by the GP at that patient’s next consultation,
resulting in a problem being overlooked; the practice becomes aware of this, and yet does not act to
prevent it happening again. This second example is more likely with the use of certain electronic
based record systems that do not show the previous consultation record when a patient’s record is
opened.

The vast majority of near misses and mistakes do not lead to patient harm as they are ‘near misses’
that are caught before any harm occurs. An example of this is when the GP prescribes a medicine for
a patient who then tells the GP that they are allergic to that medicine. Another is when a GP notices
that the general practice nurse has prepared an incorrect vaccine before the vaccination takes place
and replaces it with the correct vaccine. These ‘near misses’ can provide opportunities for quality
improvement.

The practice needs to have a process in place where the practice team – including nursing and other
staff involved in clinical care – know how to (and whom to) notify when a near miss or mistake occurs,
or when there is an unanticipated adverse outcome. A recent study suggests that staff members who
are able to hold discussions about difficult subjects such as disrespect, micro-management,
competence and error are likely to be involved with better patient health outcomes, remain longer in
their positions, and be more satisfied with their work. Practices will have different systems in place to
identify and reduce clinical risk. It is important however, for practices to be able to demonstrate how
and why they have made changes to improve clinical care.

The RACGP recommends that GPs notify their medical defence organisation of all events or
circumstances that they perceive might give rise to a claim.

Practices need to have contingency plans for unusual events that may disrupt patient care, eg.
disasters leading to destruction of premises or records; or disease outbreaks overstretching practice
capacity. The RACGP has prepared the ‘Pandemic flu kit’, which outlines disaster management
(available at www.racgp.org.au/pandemicresources).

The RACGP has developed a useful resource to assist practices to analyse the cause of near misses
and to help prevent future incidences. Using near misses to improve the quality of care for your
patients is available at www.racgp.org.au/publications/orders.




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 15.5 STANDARD 3.1
 15.6
 CRITERION 3.1.3 Clinical leadership NEW

 16   OUR PRACTICE HAS CLEAR LINES OF ACCOUNTABILITY AND RESPONSIBILITY FOR CREATING AN
      ENVIRONMENT OF EXCELLENCE IN SAFETY AND QUALITY OF CLINICAL CARE.
 17
 18   INDICATORS
►A. Our practice has leader(s) who have designated areas of responsibility for safety
and quality improvement.
►B. Our practice has strategies that facilitate sharing information about quality
improvement and patient safety.


 Explanation

 In a nutshell

            Clinical leadership is a key element of clinical governance to ensure a systematic
             approach to accountability for the delivery of safe and effective quality care
            It takes leadership to build an empowered and participative team that delivers high
             quality and safe care to patients.

 Clinical governance is 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’.

 Adapted from: Scally and Donaldson. A first class service: Quality in the New NHS. BMJ 1998;Vol
 317.

 The appointment of a clinical leader will ensure:
         The ongoing development of an organisational culture wherein participation and
            leadership in safety and quality improvement are resourced, supported, recognised and
            rewarded
         The ability to hold accountable all staff involved in monitoring and improving care and
            services
         A multidisciplinary team approach developed to endorse and promote a climate of safety
            and quality that does not blame, but rather seeks to solve problems.

 In small practices one person may fulfil this role.

 Poor performance and poor practice can too often thrive behind closed doors. Implementing a clinical
 governance framework will assist in finding the balance of 'find it', 'fix it' and 'confirm it' functions in
 relation to improving the quality and safety of care
 .
           ‘Find it’: practices can use tools such as clinical audits and performance indicators to
               identify where quality improvement programs could impact on the quality of care delivered
               and improve patient health outcomes
           ‘Fix it’: once the gaps in quality care have been identified, practices can implement
               strategies (eg. re-design of clinical services and the development of policies and
               procedures) to address the issue
           ‘Confirm it’: confirmation of the improvement can be measured through an effective
               evaluation process (eg. systematic re-audit of targeted indicators).

 Through the clinical leader a general practice can develop a systematic organisational approach to
 monitoring, managing and improving safety. This will include clear delineation of, and support for,
 corresponding staff accountability and responsibility. This approach will ensure practices have:




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            a team based approach to care, in which each team member will be aware of their roles
             and responsibilities for improving the patient’s clinical outcomes
            an accurate record of each patients’ health histories
            supports to assist clinicians in providing evidence based care
            mechanisms to identify and mitigate clinical risk both for the practice, the staff and the
             patients
            systems and procedures to learn and share safety lessons and to implement solutions to
             prevent harm through changes to practice processes
            strategies to decrease variability in care delivery and outcomes for patients
            procedures to provide timely and equitable access to care
            accurate registers of patients with specified chronic conditions
            systems to manage patients with chronic conditions systematically and to proactively
             identify those at special risk, or who would benefit from increased intervention
            the capacity to extract specified clinical data, and to collate that data to guide
             improvement in the practice
            involvement and communication with patients and the public to communicate openly with
             and listen to patients.


18.1
18.2




 18.3 STANDARD 3.1
 18.4
 CRITERION 3.1.4 Patient Identification NEW
19
 Our patients are correctly identified at each encounter with our practice team.
20
 21 INDICATOR
►A. Our practice has a patient identification matching system using three approved
patient identifiers and the practice team can describe how it is applied.


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Explanation
In a nutshell

                Correct patient identification is vital for patient safety and the maintenance of
                 patient confidentiality
                Use at least three approved identifiers for each patient encounter or activity
                 such as making appointments, writing prescriptions, writing referrals to other
                 providers, giving results, entering results or correspondence into records
                Don’t assume you have the correct patient record when treating familiar
                 patients
                Unique patient identifiers are being developed which will replace the need for
                 the three approved patient identifiers.

Identifying patients consistently and correctly are key elements in reducing the risk of adverse events
and enhancing patient safety, as well as being essential in maintaining patient confidentiality.

Approved patient identifiers are those items of information accepted for use in patient identification
and include:

                patient name (family and given names)
                date of birth
                gender (as identified by the patient themselves)
                address.

A Medicare number is not an approved identifier.

Studies have confirmed that an adequate level of correct patient identification can be achieved by
using at least three approved patient identifiers each time identification is made, whether the practice
has computer or paper based records. This minimises the risks of misidentification of patients and
mismatches when they are undergoing procedures or clinical tests. Studies undertaken in the USA
using databases of medical records have demonstrated that the risk of false positive matching falls
from a 2 in 3 chance, using last name only, to a 1 in 3500 chance when first and last names, postcode
and date of birth are used.

When asking for the patient identifier information, it is recommended that the staff member ask the
patient to state their name, date of birth and address rather than volunteering the information from the
record the staff member has open.

Errors have occurred when obliging patients have misheard and have agreed inappropriately that the
information is true when only asked to confirm details stated to them.

When a patient is very familiar to the practice team member, it may appear almost nonsensical to
check their identity, but most practices have patients with identical names and it is not uncommon for
mismatching of the patient with their record to occur; some practices overcome this by asking the
patient if they can check their address and other particulars when they attend.

Telephone and electronic identification

It is important to ensure correct patient identification when a patient telephones for a test result to
maintain patient confidentiality and safety. Practice staff should be aware of the practice policy in the
use of text responses for mobile telephones and emails. It is difficult in this case to identify the caller
as well as who will be reading the message.

Correct patient identification is also at risk of failure when patients ask for a repeat of their
medications without attending the practice, as identity checking is more difficult when the patient is
not physically present. Where practices provide this service and have a request form, this form should
include the recommended patient identifiers.




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Referral documents to another health care provider, such as a specialist, pathology or imaging
service or hospital, should also document three of the approved patient identifiers of the patient being
referred:
         return reports and results can then be easily identified and filed
         administration staff should be trained to also include and check the three approved
            identifiers on all patient correspondence
         checking the name only is not sufficient identification.

The National E-Health Transition Authority is developing a system of unique patient identifiers for
patients, as well as individual health care providers and organisations.

           This system will facilitate the accurate and secure transfer of patient health information
            between the different areas that provide care to an individual patient, subject to that
            patient’s consent
           This unique patient identifier, if the system is introduced, may mean that the provision by
            patients of their three approved identifiers may become redundant
           With the introduction of unique patient health identifiers, the ability to collect patient data
            and utilise this in practice quality improvement processes will be enhanced.

If errors in patient identification do occur, every member of the practice team is encouraged to report
them so that the event can be analysed and processes introduced to reduce the risk of a recurrence
and harm occurring to other patients (see Criterion 3.1.2).

1. Makeham MAB et al. Patient safety events reported in general practice: a taxonomy. Quality and
Safety in Health Care 2008;17:53-7.
2. Makeham MAB, Bridges-Webb C, Kidd MR. Lessons from the TAPS Study: Errors relating to
medical records. Australian Family Physician 2008;37:243-4.
3. Standards Australia. Australian Standard AS5017 – 2006 Health Care Client Identification. Sydney:
Standards Australia, 2006.
4. Hillestad R, et al. Identity crisis: An examination of the costs and benefits of a unique patient
identifier for the U.S. Health Care System. 2008 Available at
www.rand.org.pubs/monographs/MG753/.
5. Australian Commission on Safety and Quality in Healthcare. Draft National Safety and Quality
Healthcare Standards. Nov. 2009, p 48.




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STANDARD 3.2
21.1
22 CRITERION 3.2.1 GENERAL PRACTITIONER QUALIFICATIONS
22.1
All GPs in our practice are appropriately qualified and trained, have current registration, and
participate in continuing professional development.

Indicators

►A. All of our doctors can provide evidence of appropriate current national medical
registration.
►B. Our practice demonstrates that all our doctors are recognised GPs, with the
exception of:
            registrars enrolled in a recognised general practice training program
            other specialists practising within their specialty, or
            trainees undertaking a placement to gain experience in general practice as
             part of another specialist training program, or
            where recruitment of recognised GPs has been unsuccessful, our practice
             demonstrates that doctors have the qualifications and training necessary to
             meet the needs of patients.
►C. Our practice can provide:
            evidence of satisfactory participation in the RACGP QA&CPD Program by
             all our GPs, or
            evidence that our doctors participate in quality improvement and
             continuing professional development to at least the same standard as the
             RACGP QA&CPD Program.
►D. Our GP(s) have undertaken training in CPR in accordance with RACGP QA&CPD
   recommendations.

Explanation

In a nutshell

            GPs must be suitably trained, qualified and maintaining their knowledge
            For practices unable to recruit vocationally recognised GPs, other doctors can be
             recruited provided they have the qualifications and training to meet the needs of
             patients.

General practice is a distinct discipline in medicine and requires specific training. Doctors in general
practices need to be appropriately trained and qualified in the discipline of general practice, and be
either vocationally recognised or have Fellowship of the RACGP (FRACGP). The RACGP defines a
GP as a registered medical practitioner who is qualified and competent for general practice in
Australia, has the skills and experience to provide whole person, comprehensive, coordinated and
continuing medical care, and who maintains professional competence for general practice (through
continuing professional development).

In some areas it may be impossible to recruit recognised GPs. In such circumstances, practice
doctors who are not recognised GPs need to be appropriately trained and qualified to meet the needs
of the practice community. Doctors who have not yet met the equivalent of the FRACGP need to be
assessed for entry to general practice and be supervised, mentored and supported in their education
to the national standards of the RACGP. Adequate professional and personal support for doctors
entering general practice is critically important.

Doctors working in general practices who are not participating in RACGP QA&CPD activities



Identifying the Carer - GP Engagement Project Report 2010                         Page 87 of 123
need to demonstrate recent and continuing participation in activities equivalent to Group 1
activities of the RACGP QA&CPD Program. The RACGP QA&CPD Program is based on adult
learning principles (ie. knowledge is more likely to be gained when the adult undertaking the
learning recognises a need to know, goes looking for the knowledge, and reviews what has
been learnt) and requires GPs to undertake two Group 1 activities in each triennium (eg. small
group learning or clinical audits). Further information about the RACGP QA&CPD Program is
available at www.racgp.org.au/QACPD.

There is also a fact sheet available that explains in detail the educational requirements for
various subgroups, eg. GPs undertaking postgraduate studies, taking extended leave, starting
in general practice (available at www.racgp.org.au/standards/factsheets).

The RACGP recognises that cardiopulmonary resuscitation (CPR) skills in particular are used
infrequently, and thus may diminish. The RACGP QACPD Program now states the requirements for
CPR training:
         CPR courses must be consistent with the Australian Resuscitation Council (ARC)
             guidelines
         CPR courses must be a minimum of 1 hour in duration
         Trainers must have a current CPR instructor’s certificate that complies with ARC
             guidelines.




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22.2 STANDARD 3.2
22.3
CRITERION 3.2.2 Clinical staff qualifications (clinical staff, other than GPs, including nurses
and allied health professionals)

All our staff involved in clinical care are appropriately trained and skilled for their role in our
practice.

Indicators
►A. All our nurses and allied health professionals have:
               current national registration
               appropriate credentialing and competence
               work within their current scope of practice
               actively participate in continuing professional development relevant to their
                position in accordance with their professional organisation’s requirements.
    ►B. Our other staff members involved in clinical care have appropriate training,
    qualifications and competency, and participate in continuing education relevant to
    their role, eg. cold chain management.
    ►C. Our clinical staff have undertaken training in CPR in accordance with their
    relevant professional body’s recommendations, or at a minimum every 3 years.

Explanation

In a nutshell

               Health professionals need to ensure that they work within their scope of practice and
                competencies, and meet the requirements of the National Registration Board
               Other staff involved in clinical care need to be appropriately trained and competent to
                perform delegated duties
               CPR training needs to be at the minimum of every 3 years.

Practices are increasingly employing clinical staff in addition to GPs. This may include general
practice nursing staff, medical students, allied health professionals or other staff members
who provide clinical care. Health professionals are responsible for maintaining their own
professional standards.

For information regarding employment and professional standards of practice nurses, refer to
the following:

               The Royal College of Nursing Australia has produced, in conjunction with the
                RACGP, a ‘Nursing in general practice kit’ (available at
                www.rcna.org.au/Default.aspx?SiteSearchID=360&ID=/results). It covers the
                specifics of employment of practice nurses, supervisory requirements for enrolled
                nurses, and position descriptions
               The Australian Nursing and Midwifery Council has produced a suite of competency
                standards for the registered nurse, midwife, nurse practitioner and enrolled nurse
                (available at www.anmc.org.au/)
               The Australian Practice Nurse Association has produced a number of resources
                specific to nursing in general practice, such as the ‘Practicalities of supervision of
                enrolled nurses’. For further information email admin@apna.asn.au or telephone
                1300 303 184 (freecall).

Nonmedical staff may also be involved in clinical care in the practice. The RACGP Position
statement       on       delegation       of         tasks       is        available      at
www.racgp.org.au/policy/GPs_and_their_teams.pdf. The principles of task delegation include:



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       respect and support for the patient-doctor relationship
       clearly defined roles that are aligned with licensing requirements, competency,
        education and training of the individual in that role
       practice systems that enable the provision of safeguards against error and harm
       mechanisms for ensuring provision of relevant patient information including the
        meeting of the ethical and legal requirements of the patient consent process
       availability of effective medical indemnity insurance
       availability of resources
       acceptability to the people – health care provides, patients and the broader community of the
        approach.

Training may be gained through participation in external courses or ‘on the job’ training at the
practice. This criterion relates to staff employed by the practice rather than co-located
independent practitioners (who are not employed directly by the practice).

The RACGP recognises that CPR skills in particular are used infrequently, and thus may diminish.
CPR updates must be performed in accordance with the requirements of professional bodies, or at a
minimum every 3 years.




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22.4 STANDARD 3.2
22.5
CRITERION 3.2.3 Training of staff who have nonclinical roles
22.6
     Our administrative staff participate in training.

Indicators
►A. Our administrative staff can demonstrate and provide evidence of training relevant
to their role in the practice, eg. triage.
►B. Our administrative staff have CPR training at a minimum every 3 years.

Explanation

In a nutshell

               Administrative staff play a vital role in the provision of quality general practice care
               Administrative staff require training appropriate to their role in the practice
               Administrative staff are required to have CPR training at least once every 3 years.

Administrative staff (such as receptionists and practice managers who do not provide clinical
care) need training to be successful in their roles. This may include formal training (eg. a
computer course, training in the use of software programs, training in first aid, practice
management, medical terminology, medical practice reception, cross cultural training) or ‘on
the job’ training provided by the GPs or other staff in the practice (eg. learning how to use the
patient health records system, making appointments, recognising urgent situations when
patients present in reception, confidentiality requirements, familiarisation with the practice
policy and procedures manual, how to recognise a medical emergency).

The    RACGP      has     written   a   receptionist  training   package   (available  at
www.racgp.org.au/gplearning). Other courses that may be useful can be found through the
Australian Association of Practice Managers at www.aapm.org.au/html/s01_home/home.asp.

As administrative staff may present during a medical emergency, they need to be trained to provide
CPR to assist the clinical team. It is also desirable that administrative staff are trained in first aid. CPR
training, at a minimum of every 3 years is essential.




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23   SECTION FOUR
24   PRACTICE MANAGEMENT


25   STANDARD 4.1 PRACTICE SYSTEMS
Our practice demonstrates effective human resource management processes.

Standard 4.2 MANAGEMENT OF HEALTH INFORMATION
Our practice has an effective system for managing patient information.




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25.1 STANDARD 4.1
25.2
CRITERION 4.1.1 Human resource system

Our practice has documented management processes that ensure that all members of our
practice team are aware of their roles and rights, responsibilities and accountabilities.
25.3
Indicators
►A. All members of our practice team have position descriptions and can describe
their role in the practice.
►B. Our practice has an induction system that orientates new GPs and staff to the
practice’s specific systems.
►C. Our practice team can identify the person/s responsible for leading our practice’s
quality improvements and risk management processes.
►D. Our practice team can identify the person/s who coordinate the seeking of
administrative feedback, and the investigation and resolution of administrative and/or
other complaints.
►E. Our practice team are able to discuss administrative matters with the principal
GP(s) or practice directors or owners(s), when necessary.
►F. Our practice has a system to monitor staff members’ progress against their
position descriptions.
►G. Our practice can show evidence of regular practice discussions that encourage
involvement and input from all staff, eg. staff meetings, with documentation of:
               actions and outcomes
               the person(s) responsible for implementing decisions.


Explanation

In a nutshell

               Practice team members need clarity regarding their role and responsibilities in
                the practice
               Practice team members need to know who is responsible for various aspects of
                the practice’s operations
               Practices need a system of assisting new members to learn their role, ie.
                induction and monitoring of progress in their new role
               Practice discussions regarding administrative matters assist with ensuring
                consistency.

Research from both general practice and other industries supports the importance of attention to
human resources. For example, research in Australia and the USA confirms that teamwork is
important to the quality of care. The research literature identifies teamwork as an important success
factor in a number of safety initiatives across different industries. The alignment of role, competence
and (where required) licensing, was also identified by the authors of a study of high performing clinical
teams as a common element.

As a result, GPs and staff need to have position descriptions that outline their roles, responsibilities
and conditions of employment. A position description establishes the role of the employee within the
organisation, documents the parameters of the responsibilities and duties associated with that
position, and forms the basis for evaluation and lines of accountability. Recruitment, training and
development, performance evaluation, remuneration management and succession planning can all be
based on the measure of an individual against their position description.

It is important for the practice to have an induction program for new GPs (including registrars and



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locums) and staff. New GPs and staff need to understand the day-to-day operations of the practice
including the occupational health and safety issues (eg. infection control policies) relevant to their
roles, as well as the processes by which the privacy and confidentiality of patient health information is
maintained within the practice. It is useful for new staff to have an understanding of the local health
and cultural environment in which the practice works. For example, if the practice is located in an area
with a high level of problems caused by illicit drug use, it is useful for new staff to understand the
practice’s policy concerning management of Schedule 8 medicine prescribing. 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 the existence of local health and community services
(including pathology, hospital and other services they are likely to refer to in the course of normal
consulting). An induction program that covers these issues, as well as the specific operational
processes of the practice, is essential to assist new staff and GPs to perform their roles.

Practices that have not employed new staff in the past 3 years are not required to have an induction
program already developed. However, these practices need to be able to describe what they plan to
do when employing a new staff member.

It is important that the practice team has identified leaders in areas such as clinical, information
management, complaints/feedback and human resources. In the clinical area, leadership might
include convening a practice meeting to review the quality of care provided, or the mentoring of new
GPs. It might mean instigating a plan to monitor the management of patients on particular treatments
(eg. warfarin) with a view to improving the way the practice manages these patients. In order to
respond to patient feedback and make improvements, practices need to identify the person in the
practice who will be responsible for examining issues raised by patients and facilitating improvements
in the practice. It is possible a single individual within the practice may assume all these leadership
responsibilities (eg. a principal GP or the practice manager). In some practices however leadership
will be undertaken by different members of the practice team.

It is important that the GP(s) and staff have the opportunity to discuss administrative issues with the
practice directors and/or owners when necessary. When the practice is owned by a person or body
other than the practising GP(s), then GPs and staff need to have defined methods of discussing
practice administrative matters with the owner(s). This criterion does not require a formal staff meeting
(although this is desirable, particularly in larger practices).

Further information about human resource issues relating to general practice can be obtained from
the Australian Association of Practice Managers publication, ‘The guide: AAPM business manual for
health care’ (available for purchase from www.aapm.org.au), a range of resources from the AMA
(www.ama.com.au), the RACGP publication, ‘The RACGP employment kit: tips in negotiating an
employment contract in general practice’, and the Australian Competition and Consumer
Commission’s ‘Guide for general practitioners to the authorisation granted by the ACCC to The Royal
Australian College of General Practitioners’.




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25.4 STANDARD 4.1
25.5
CRITERION 4.1.2 Occupational health and safety
25.6
Our practice implements strategies to ensure the occupational health and safety of our GP(s)
and staff.

Indicators
►A. At least two members of the practice team are present during normal opening
hours.
►B. Our practice team can describe how our practice supports their safety, health and
   wellbeing.

Explanation

In a nutshell

            Safety of practice teams is an occupational health and safety requirement
            Design and set up of general practices has an impact on staff safety.

The occupational health and safety of GPs and practice staff is governed by occupational health and
safety (OH&S) state/territory and federal legislation, which may vary from state-to-state. Practices
need to consider how they ensure the practice is a safe working environment for GPs and staff.

A GP cannot be both a receptionist and a medical practitioner at the same time. During normal
practice hours, practices need to be staffed by at least one additional person who is trained to take
telephone calls, make appointments, assess the urgency of requests for appointments and assist with
medical emergencies and CPR.

This need not apply to surgery consultations conducted outside normal practice opening
hours. Normal practice hours are the hours the practice advertises as being its regular hours
of opening for routine consultations during which patients can see a GP.

It is recognised that some practices conduct nonroutine ‘emergency surgeries’ outside of normal
consulting hours (eg. at weekends and on public holidays) for patients needing urgent care. It is also
recognised that in providing such care it may not be economical or feasible to employ an additional
person to be present at these times. While the RACGP would not wish to discourage the provision of
such care, practices are encouraged to employ an additional person at these times. Appropriate
staffing assists in providing security and safety for patients, staff and GPs.

The RACGP has produced several useful resources to assist practices in ensuring and maintaining a
safe working environment:
        ‘Rebirth of a clinic’ describes building and layout designs for safety. Available at
            www.racgp.org.au/publications
        General practice - a safe place: Tips and tools, addresses research into violence in
            general practice and provides strategies to combat violence. Available at
            www.racgp.org.au/gpsafeplace
        Keeping the doctor alive: a self-care guidebook for medical practitioners provides
            strategies to deal with stress in the workplace. Available at
            www.racgp.org.au/peersupport.

The RACGP also provides counselling for GPs facing crises in their professional or personal lives.
Available at
www.racgp.org.au/Content/NavigationMenu/educationandtraining/RACGPMentalHealth1/MentalHealt
hReviewnewsletterMHR/200812MHRnewsletter.pdf.

Other organisations providing resources include:



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           Australian Association of Practice Managers (www.aapm.org.au)
           AMA Position statement ‘Personal safety and privacy for doctors’ (www.ama.com.au)
           General Practice Registrars Australia (www.gpra.com.au)
           Local divisions of general practice (www.adgp.com.au)
           NSW Rural Doctors Network (www.nswrdn.com.au)
           State and territory Doctors Health Advisory (www.doctorshealth.org.au).

Practices can support the health and wellbeing of GPs and staff in many ways. For example,
scheduling regular breaks in consulting time may reduce fatigue and support the health and wellbeing
of the GP, as well as enhancing the quality of patient care. Fatigue and related factors (sometimes
called ‘human factors’) are associated with increased risks of harm to patients. Practices can also
make information available to their GPs and staff about support services in their state or territory.
Another strategy is to have a plan for how to re-allocate workflow (patient appointments) if a GP is
unexpectedly absent from the practice. Providing support for GPs and staff is important in all areas of
Australia, but perhaps more important in areas of workforce need where GPs face additional pressure
and workload.

After Hours Practice

Indicator A is only applicable to after hours care services that provide clinic based services.




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25.7 STANDARD 4.2
25.8
CRITERION 4.2.1 Confidentiality and privacy of health information

Our practice collects and safeguards the confidentiality and privacy of personal health
information in accordance with national privacy principles.


Indicators
►A. Our practice team can describe how they ensure the confidentiality of patient
health records.
►B. Our practice team can demonstrate how patient health records can be accessed
by an appropriate team member when required.
►C. Our practice team can describe the processes we use to provide patients with
access to their health information.
►D. Our practice team can demonstrate how patients are informed about our
practice’s policy regarding management of their personal health information.
►E. Our practice team can describe the procedures for transferring relevant patient
health information to another service provider.
►F. Our practice team can demonstrate how we facilitate the timely transfer of patient
health information in relation to valid requests.
►G. When we collect identifiable patient health information for QA&CPD activities, we
   only transfer to a third party once informed consent has been obtained.
►H. When we collect de-identifiable patient health information for QA&CPD activities,
   we only transfer it to a third party if we have approval to do so from a recognised
   medical college’s QA&CPD process.
25.9
Explanation

In a nutshell

       Privacy of health information is a legislated requirement
       Patients need to be informed of the practice’s health information privacy policy
       The practice needs to have a documented policy for the management of patient
        health information in the practice.

The Federal Privacy Act 2001 states that a patient’s ‘personal health information’ includes a
person’s name, address, account details, Medicare number and any health information
(including medical or personal opinion) about the person. Sometimes, details about a
person’s medical history or other contextual information can identify them, even if no name is
attached to that information. This is still ‘personal health information’ (more information is
available from www.privacy.gov.au). The RACGP Handbook for the management of health
information in private medical practice describes minimum safeguards and procedures that
need to be followed by general practices in order to meet appropriate legal and ethical
standards concerning the privacy and security of patient records (www.racgp.org.au).
Practices are encouraged to become familiar with relevant federal and state/territory privacy
legislation as this will also impact on the way in which practices manage patient health
information (www.privacy.gov.au). The practice needs to have a documented policy for the
management of patient health information in the practice. This policy needs to outline: the
practice’s procedures for informing new patients about privacy arrangements (including how
patients are informed about the use of their information for quality assurance, research and
professional development); the range of people (eg. GPs, general practice nurses, general
practice registrars and students) who may have access to their patient health records and the
scope of that access; the procedures for patients to gain access to their health information;
the way the practice gains patient consent before disclosing their personal health information



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to third parties; the process of providing health information to another medical practice should
patients request that; the ways the practice maintains the security of information held at the
practice; the way the practice addresses complaints about privacy related matters; and the
policy for the retention of patient health records.

Patient consent is often provided at an early stage in the process of clinical care. As a result,
practices need to ensure that patients develop a shared expectation about the use of the data
in a number of different circumstances. This includes the degree of access that GPs in group
practices may have and the likelihood of the use of individual patient information during
quality improvement activities within the practice.

Research is an important component of general practice activity in Australia. Practices are
encouraged to participate in research both within their own practice and through reputable
external bodies. The RACGP Handbook for the management of health information in private
medical practice provides advice about privacy related issues for practices seeking to be
involved in research activities. Many hospitals, universities and professional organisations
involved in research will have a human research ethics committee (HREC) to review research
proposals. Further information about HRECs and research can be found in the National
Health and Medical Research Council (NHMRC) ‘National statement on ethical conduct in
research involving humans’ (available at www.nhmrc.gov.au). Research activities that require
HREC approval are distinct from audits undertaken by a practice as part of a quality
improvement activity (eg. as part of a QA&CPD program). For example, a practice wishing to
determine how many of its pregnant patients are given advice on smoking cessation, or how
many patients with heart failure are prescribed ACE inhibitors and beta blockers, may
complete an audit on their practice data. This type of intra-practice audit does not require
HREC approval. Practices involved in research need to give consideration to how ‘identifiable’
their patient information will be. There is a difference between identifiable patient information
(by which a patient can be individually identified), de-identified patient information (which
cannot be traced back to the individual patient) and potentially identifiable information (which
can possibly be traced back to that patient).

Consideration of privacy and confidentiality of patient information for research purposes is
particularly important when practices are considering involving themselves in commercial
market research activities.

Privacy, confidentiality and security of patient health information is equally important for
practices that have paper based, hybrid paper/electronic, and solely electronic based systems
of information management. Each system will pose different challenges to privacy and
information security, with hybrid systems having distinct vulnerability to errors in information
management.




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25.10 STANDARD 4.2
25.11
25.12 CRITERION 4.2.2 Information security
Our practice ensures the security of our patient health information.

Indicators
►A. Our practice team can demonstrate that the personal health information of
    patients of our practice is neither stored nor left visible in areas where
    members of the public have unrestricted access or where constant staff
    supervision is not easily provided.
►B. Our practice ensures that our practice computers and servers comply with the
RACGP computer security checklist, and that:
         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 enabled
         servers are backed up and checked at frequent intervals, consistent with
            a documented practice continuity plan
         back up information is stored in a secure offsite 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.
►C. If our practice uses computers to store personal health information, we have
   a practice continuity plan that has been developed, tested and is documented.
►D. Our practice has a designated person(s) who is/are responsible for the
   practice electronic systems and the name and contact details of that
   person(s) are documented.
►E. Our communication devices are accessible only to authorised staff.
►F. Electronic data transmission of patient health information from our practice
   is in a secure format.
►G. Our practice has an appropriate method of destruction of health record
   systems before disposal (eg. shredding of paper records, removal and
   destruction of hard drives).


Explanation

In a nutshell

Computer security is an important issue in the running of a practice, and for patient
care. There are three key areas that need to be considered, when assessing the
security of a general practice:
     availability – the data should be available when you want it. If a fully
        computerised system is inoperable during normal clinic hours, there needs to
        be a suitable business contingency plan
     integrity – the data should remain intact
     access – only designated people should have access to sensitive patient
        clinical and financial information.
Improving computer security in general practice is about change management. This is one of
the key reasons why it is important that there is a recognised member of the practice team
who takes responsibility for computer security issues.
     They need to know who and when to call for expert advice.
     They also need to see that staff and GPs are aware of computer and data storage
        device security issues.




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       They need to ensure that security protocols are followed, and that appropriate
        practice training takes place.

In recognition of the many areas of concern in information security, reference is made to the
RACGP Handbook for the management of health information in private medical practice
(revised 2010 edn) and the RACGP Computer security guidelines (available at
www.racgp.org.au/guidelines). These documents provide information and explanations on the
safeguards and procedures that need to be followed by general practices in order to meet
appropriate legal and ethical standards concerning security of patient health information.

It is likely that practices will have different levels of access to patient health information for
different staff members. For example, receptionists may not have access to patient health
information. The type of staff authorised to access patient health information needs to be
documented in the practice policy and procedures manual. General practitioners and staff
need to ensure that their passwords are not given to other members of the practice team and
they need to appreciate why this is important.

The practice must also ensure that both active and inactive patient health information/records
are kept and stored securely. An inactive patient health record is generally considered to be a
record of a patient who has not attended the practice for more than 2 years. It is
recommended that inactive patient health records are retained by the practice indefinitely or
as stipulated by the relevant national, state or territory legislation. General practices may want
to consult their GPs’ medical defence organisations when deciding on the practice's policy
with respect to the retention of records. Hardware and software system changes and
developments may prevent older versions of medical software from running correctly on
newer systems and provision needs to be made for this eventuality, which may include
retaining older systems for this eventuality.

General practitioners and staff need to ensure the confidentiality and security of patient health
information and other sensitive practice materials and equipment. The presence of an
additional person in the practice (besides the GP(s) on duty) will increase security and safety
for patients, GPs and staff, and reduces the risk of unauthorised access to patient health
information.

When a practice uses computers to store patient health information, the practice needs to
have a documented plan (a ‘business continuity’ plan) in the case of an emergency (eg.
power failure) in order to protect and save the information stored in the computers. This plan
needs to consider all critical areas of practice function such as making appointments, billing
patients and providing adequate clinical care. Once a plan has been formulated, it needs to
be tested regularly and documented. All practice team members need to be familiar with their
appropriate actions for their role within the practice.

Consideration needs to be given to the increasing portability of computer based systems.
These need to be managed in an equally secure manner as the main practice network.
Furthermore, being potentially more accessible to nonpractice team members, their physical
security needs to be taken into account, eg. laptop computers, personal digital assistants
(PDAs) and mobile telephones carried by GPs when travelling between different locations of
health care provision.

Review of the RACGP security guidelines should be undertaken when equipment is to be
made redundant by the practice in order that patient clinical and financial information is not
transferred inadvertently. Deleting the records is insufficient to clear data from a computer
system.




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26   SECTION FIVE
27   PHYSICAL FACTORS

28   STANDARD 5.1 FACILITIES AND ACCESS
Our practice provides a safe and effective working environment for our practice team and
patients.
29
30 STANDARD 5.2 EQUIPMENT FOR COMPREHENSIVE CARE
Our practice provides medical equipment and resources that are well maintained and
appropriate for comprehensive patient care and resuscitation.

31   STANDARD 5.3 CLINICAL SUPPORT PROCESSES
Our practice has processes in place that support safety and the quality of clinical care.




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 31.1 STANDARD 5.1
 31.2
 31.3 CRITERION 5.1.1 Practice facilities

 Our practice facilities are appropriate for a safe and effective working environment for
 patients, staff and GPs.

Indicators
 ►A. Our practice has at least one dedicated consulting/examination room for every
    clinician working in our practice at any time.
 ►B. Each of our consultation rooms (which may include an attached examination
    room/area):
          is free from excessive extraneous noise
          has adequate lighting
          has an examination couch
          is maintained at a comfortable ambient temperature
          ensures patient privacy is maintained when the patient needs to undress
           for a clinical examination, eg. the use of adequate curtains or screens, and
           gowns or sheets.
 ►C. Our practice has a waiting area sufficient to accommodate the usual number of
    patients and other people who would be waiting at any time.
 D. Our practice waiting area caters for the specific needs of children.
 ►E. Our practice has toilets and hand cleaning facilities readily available for use by
    both patients and staff.
 ►F. Prescription pads, letterhead, administrative records and other official documents
    stored in our practice are accessible only to authorised persons.
 ►G. Our practice and office equipment is appropriate to its purpose.
 ►H. Our practice has a height adjustable bed.



 31.3.1 Explanation

 In a nutshell

        Practice facilities need to be safe for GPs, staff and patients
        The dignity of the patient and visual privacy needs to be assured (eg. by the use of
         curtains, screens, drapes, gowns)
        Practices need to have a height adjustable bed.

 Health and safety refers not just to requirements within consultation areas but also to other aspects of
 the practice. The security of the practice facilities (and the staff) is an important issue and practices
 are advised to consider what action will be taken in the event of a security breach.

 The RACGP publication ‘Rebirth of a clinic’, is useful to assist practices with the design and layout of
 practice facilities which are fit for purpose and address the security needs of practice staff. (Available
 through the RACGP publications department or at www.racgp.org.au/publications.)

 While this criterion discusses consultation ‘rooms’, it is acknowledged that some practices may have
 ‘areas’ rather than rooms in which to treat patients. These consultation areas need to be appropriate
 for the health and safety of GPs, staff and patients.

 Consultation room temperature needs to be such that a patient undressed for an examination remains
 comfortable.

 The dignity of the patient and visual privacy can be afforded to patients during clinical



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examination by the use of a gown or sheet and an adequate curtain or screen positioned in
such a way as to maximise the privacy of the patient. This includes situations in which there is
a door opening to an area to which the public may have access, and also when patients are
required to undress/dress in the presence of the GP or general practice nurse.

Toilets should be located within the practice. Toilets not within the practice itself need to be adjacent
to, or within close proximity. Toilets need to be easily accessible and well signposted. Separate staff
and patient toilets are desirable. Washbasins need to be situated in close proximity to the toilets to
minimise the possible spread of contamination. Washbasins need to be easily accessible to GPs, staff
and patients.

Consumer representatives have informed the RACGP that ‘access’ to the general practice facilities
and services is of substantial importance to patients. The practice can facilitate access by having a
telecommunications system that adequately meets the needs of its patients. These
telecommunication needs may change over time, and practices are advised to monitor the need for
telephone and facsimile lines as well as staffing resources, and make adjustments according to need.
It is advised that the practice have at least one dedicated line for telephone calls and one line for
facsimile communication. It is imperative that a telephone line be available to summon assistance in
an emergency. A single, constantly ringing telephone line does not provide this flexibility. Practices
also need to have the capacity for electronic communication (eg. email or facsimile).

The RACGP has been involved in an ongoing discussion with the disability sector and the Australian
Human Rights Commission (AHRC) with respect to improving access to high quality general practice
for people with a disability. The RACGP continues to endeavour to ensure that affordable height
adjustable beds are available in the market.

Consumers, representing 30% of submissions received by the RACGP in the review of the revised 3rd
edition of the Standards, strongly advocated for access to height adjustable beds in general practices.
Height adjustable beds assist in provision of examination where a person has limited mobility for any
reason.

Height adjustable beds may assist general practice teams as follows:
     Reduce risks associated with all patients (people with physical disability, people who are
        older, people with limited range of movement)
     Reduce the risk of misdiagnosis or non-detection of serious medical conditions
     Reduce the occupational health and safety issues for health practitioners (injury from
        assisting patients onto tables)
     Reduce risks associated with legal responsibility (ensure equal access for people with
        disability to the same range and quality of medical care as others)

The Australian Human Rights Commission (AHRC), in its submission to the review of the revised 3rd
edition, highlighted the obligation of general practices to provide equal access and treatment. The
AHRC has expressed concern that general practices may not be complying with the Disability
Discrimination Act if they cannot provide effective access to height adjustable beds for people with a
disability when required. People with disability are concerned that the issue be addressed in general
practice, where most of their care occurs (despite being aware that the problem also arises in
consultant specialists’ rooms and other health services). The AHRC and the RACGP have become
aware of distressing examples described by patients and carers of inadequate physical examinations
of people with limitations on movement (eg. examined on the floor; leaning over the doctor’s desk;
laying back in the wheelchair, no examination performed; referrals to emergency departments). For
examples refer to submissions on the revised 3rd edition at www.racgp.org.au/standards/fourthedition
and “Report on Access to Adjustable Height Examination Tables by People with Disability at General
Practitioners” http://www.pdcnsw.org.au/images/stories/documents/ahet-report.pdf

The RACGP is aware of the cost to practices and continues to advocate for infrastructure support for
general practices to the Department of Health and Ageing (see RACGP Submission to the Minister for
Health and Ageing: Federal Budget 2010–2011 at www.racgp.org.au/reports).

The disability sector has had experts review height adjustable beds available on the market to ensure
they meet the needs of people with disabilities. Simple, functional specifications for appropriate beds



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are available at www.racgp.org.au/standards/513.

After Hours Practice

For after hours care services that only provide visit based care, Indicators A, B, C, D, E, F,G, and H
are not applicable. However, these services need to refer to, and meet, the infection control criterion
in these standards (Criterion 5.3.4).

While Indicator E is not applicable, services will need to ensure that effective hand cleaning (eg. with
alcohol based hand rub) can occur when patients are seen outside the general practice.




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31.4 STANDARD 5.1
31.5
31.6 CRITERION 5.1.2 Physical conditions conducive to confidentiality and privacy

The physical conditions in our practice encourage patient privacy and confidentiality.

Indicators
►A. The physical facilities of our practice support patient confidentiality and privacy.
►B. Visual and auditory privacy of consultations and treatments is ensured.

Explanation

In a nutshell

       Visual privacy refers to ensuring patient records cannot be seen by an inappropriate
        person
       Auditory privacy refers to ensuring personal information cannot be overhead by an
        inappropriate person.

It is important that patients have confidence that their health information is being treated respectfully
and with consideration to their privacy and confidentiality. Privacy and confidentiality of patient
information needs to be considered at all times, including during telephone conversations between
staff and patients. The physical arrangements of the practice need to be considered in providing
privacy and confidentiality to patients.

The layout of reception and waiting areas can also assist in encouraging patient privacy and
confidentiality, especially when patients are discussing personal issues with practice staff.

Where possible, consultations need to be private and not able to be ‘overheard’ by others. Auditory
privacy within the practice can be enhanced by the use of background music to mask conversations
between staff members and between staff and patients. The privacy of patients may also be ensured
by the use of a curtain or screen, and gown or sheet when the patient needs to undress for a clinical
examination or procedure (Criterion 5.1.1).

Practices have a responsibility to protect the privacy and confidentiality of patients and this may be
achieved through the physical set up of the practice and through processes that protect their health
information (Criteria 4.2.1 and 4.2.2).

After Hours Practice

There is a range of circumstances in which patient confidentiality may be compromised when after
hours care services are being provided. Patient privacy is as relevant in an environment outside a
general practice (eg. patients’ homes, residential aged care settings) as within. It is important that
measures are taken to keep patient health information private when examining patients in their home
or aged care facility, in an operations facility, or when triaging.




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31.7 STANDARD 5.1
31.8
31.9 CRITERION 5.1.3 Physical access
31.10
Our practice provides appropriate physical access to our premises and services including
access for people with disabilities and special needs.

Indicators
►A. There is wheelchair access to our practice and its facilities, or
if physical access is limited, our practice provides home or other visits to patients
    with disabilities.
►B. Our GP(s) and staff can describe how they facilitate access to our practice for
    patients with disabilities and special needs.

Explanation

In a nutshell

       General practitioners and staff need to consider the ways in which they can help
        facilitate access to the practice and its services for patients
       Practices need to think about how they can maintain relationships and provide access
        to their facilities and services for with people with disabilities and special needs.

Consumer representatives have informed the RACGP that ‘access’ to general practice facilities
and services is of high importance to patients. Practices need to make all reasonable efforts to
facilitate physical access to their premises and services.

When considering what is ‘reasonable’, practices need to consider the needs of patients with
restriction of movement that prevents safe access to the practice. For example, it is useful to make
wheelchair access available for disabled patients (ie. to access reception, waiting areas, consultation
and examination areas, toilets) and the practice can usefully be equipped with ramps, railings, and
accessible toilets to assist patients with disabilities. Patients with a disability need to be able to park
their vehicles within a reasonable distance to allow them to access the practice.

It is recommended that practices refer to the Australian standards regarding access to buildings for
people with disabilities to help inform appropriate design for practices being built or undergoing
renovations. These standards can be accessed through Standards Australia at
www.standards.com.au.

The practice may take a range of steps to assist patients with a disability, such as having signage that
is pictorial in nature rather than text (for patients with an intellectual disability); accessible pathways
from the door to reception and to consultation rooms that are wide enough for patients in wheelchairs;
and a unisex wheelchair accessible toilet for patients with disabilities.

For patients who are no longer able to access the general practice premises, ie. where transfer to the
practice could result in adverse effects to the patient, the practice needs to provide home or other
visits. People who could be affected in this manner include those receiving end stage palliative care,
people with severe motor dysfunction (eg. quadriplegia, motor neurone disease), and residents of
nursing homes.

For more information relating to the Federal Disability Discrimination Act 1992 and legislation
regarding the right to access general practices, the website www.hreoc.gov.au is recommended.

After Hours Practice

This criterion and indicators are not applicable for after hours care services that provide visit only
care.




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 31.11 STANDARD 5.2
 31.12
 31.13 CRITERION 5.2.1 Practice equipment

 Our practice has access to the medical equipment necessary to ensure comprehensive
 primary care and resuscitation.

Indicators
  ►A. Our practice has equipment for comprehensive primary care and resuscitation is
  available within our practice, including:
           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 and mask), IV access, and emergency medicines
           examination light
           eye examination equipment (eg. fluorescein staining)
           gloves (sterile and nonsterile)
           height measurement device
           measuring tape
           monofilament for sensation testing
           ophthalmoscope
           oxygen
           patella hammer
           peak flow meter
           scales
           spacer for inhaler
           specimen collection equipment
           visual acuity charts
           urine testing strips
           sphygmomanometer (with small, medium and large cuffs)
           stethoscope
           thermometer
           torch
           tourniquet
           vaginal specula
           X-ray viewing facilities
           surgical masks
           spirometer
           ECG.
  B. Our practice has a pulse oximeter.
 ►C. Our practice can demonstrate that the equipment we use is sufficient for the
    procedures we commonly perform.
 ►D. Our practice can demonstrate how we maintain our key equipment, according to
    the documented schedule.



 Explanation




 Identifying the Carer - GP Engagement Project Report 2010                  Page 107 of 123
In a nutshell

       Practices need to have the necessary equipment for comprehensive primary care and
        resuscitation
       Equipment that requires calibration or that is electrically or battery operated requires
        regular servicing.

Practices need to have the necessary equipment for comprehensive primary care and resuscitation.
To meet this criterion, equipment must be present and in working order. It needs to be noted that
there is a large range of equipment that practices may need in order to provide services. Additional
equipment to which a practice has access will depend on the nature of the practice, the interests and
requirements of the GP(s), and any procedures that the practice performs.

Equipment that requires calibration or that is electrically or battery powered (eg. electrocardiographs,
spirometers, autoclaves, vaccine refrigerators, scales, defibrillators) needs to be serviced on a regular
basis to ensure that it is maintained in good working order. (There are articles relating to calibration
and maintenance available at www/racgp.org.au/standards/521.)

Liquid nitrogen and oxygen are hazardous materials that require secure storage.

There is evidence, both internationally and in Australia, to suggest that immediate defibrillation
significantly improves the chance of survival after cardiac arrest. Although cardiac arrest in the
general practice setting is a rare event, the difference in outcomes between early defibrillation and it
not being done for a few minutes, is very significant (10% increase in mortality for each minute from
the time of the arrest). Practices are encouraged to consider the clinical need for a defibrillator in their
practice.

After Hours Practice

After hours care services need to be able to demonstrate how the minimum equipment requirements
outlined in this criterion would be accessed, when needed.




Identifying the Carer - GP Engagement Project Report 2010                          Page 108 of 123
 31.14 STANDARD 5.2
 31.15
 31.16 CRITERION 5.2.2 Doctor’s bag

 Our practice ensures that each GP has access to a doctor’s bag.

 Indicator
►A. Each of our GP(s) has access to a fully equipped doctor’s bag for emergency care
as well as for routine visits which, when in use, contains:
             auriscope
             disposable gloves
             equipment for maintaining an airway in both adults and children
             in-date medicines for medical emergencies
             ophthalmoscope
             practice stationery (including prescription pads and letterhead)
             sharps container
             sphygmomanometer
             stethoscope
             syringes and needles in a range of sizes
             thermometer
             torch

 Explanation

 In a nutshell

        The doctor’s bag is required to have the equipment in the doctor’s bag when in use
        The types of emergency drugs depends on the practice location and the type of clinical
         conditions likely to be encountered
        Doctor’s bags need to be stored securely.

 General practitioners are not required to maintain two sets of equipment, but rather can place the
 necessary items in the bag when attending an off-site consultation or emergency. More than one GP
 in the practice may share the use of a doctor’s bag. It is acceptable for items of equipment to be kept
 in more than one bag so that they collectively include all the items listed in Indicator B. Large
 practices need to consider whether more than one doctor’s bag is needed to ensure that GPs have
 access to a doctor’s bag when required.

 It would be useful for practices to consider what medicines they use in their doctor’s bags.
 Consideration needs to be given to the practice location, the type of clinical conditions likely to be
 encountered, the shelf life (or date of expiry) and climatic vulnerability of the various medicines, and
 the cost and size of the doctor’s bag.

 The doctor’s bag is required to have the required equipment and suggested medications (see below)
 when in use. However, at times the doctor’s bag may be required at very short notice, therefore it
 needs to be stocked with most emergency equipment except the more expensive items such as
 ophthalmoscopes and perishables.

 Most drugs required are available through the doctor’s bag order form available at
 www.pbs.gov.au/html/healthpro/browseby/explanatory-notes?ref=section1-prescribingmedicines.
 Medicines available through Doctor’s Bag can be viewed at
 www.pbs.gov.au/html/healthpro/browseby/doctorsbag.

 The article by Andrew Baird, ‘Drugs for the doctor’s bag’, sums up the drugs needed and their
 emergency use and dosages. (Available at www.australianprescriber.com/magazine/30/6/143/6/.)
 These include:



 Identifying the Carer - GP Engagement Project Report 2010                         Page 109 of 123
       adrenaline
       aspirin
       atropine sulphate
       benztropine mesylate
       benzylpenicillin
       chlorpromazine or haloperidol
       diazepam injection
       diazepam tablets
       ergotamine maleate
       frusemide
       glucose 50% and or glucagon
       glyceryl trinitrate spray or tablets
       hydrocortisone sodium succinate
       metoclopramide hydrochloride
       morphine sulphate or appropriate analgesic agent
       naloxone hydrochloride
       prednisone
       promethazine hydrochloride
       salbutamol aerosol.

The RACGP has produced a fact sheet on the doctor’s bag and is available at
www.racgp.org.au/standards/522.

Paediatric emergency drugs and dosages can be found in the Royal Children’s Hospital
Pharmacopaecia, available at www.rch.org.au/pharmacy/dev/index.cfm?doc_id=11341.

In larger practices each doctor may not have their own bag but do need access to one.

DOCTOR’S BAGS MUST BE KEPT SECURE, AS PER STATE AND TERRITORY LEGISLATION.




Identifying the Carer - GP Engagement Project Report 2010                     Page 110 of 123
31.17 STANDARD 5.3
31.18
CRITERION 5.3.1 Safe and quality use of medicine NEW

Our clinical team prescribes, dispenses and administers appropriate medicines safely to
informed patients.

Indicators
►A. Our clinical team can provide evidence that our patients are informed about their
   medication options, benefits and risks, and patient responsibilities.
►B. Our clinical team can demonstrate how we review our prescribing habits to
   support best practice treatment.
►C. Our clinical team can demonstrate how we ensure patients and other health
   providers to whom we refer, receive an accurate, current medication list.
►D. Our clinical team can demonstrate the process we have to ensure that medicines
   or medical consumables we use are acquired, stored appropriately, and are not
   used or provided to patients after their expiry dates, and are disposed of safely.


Explanation

In a nutshell

       Patients need a shared understanding of the need for medicines, to assist them to
        comply with a recommended treatment plan
       GPs can use clinical guidelines to enable best practice prescribing.

Quality use of medicines (QUM) means ‘selecting management options wisely, choosing suitable
medicines if a medicine is considered necessary and using medicines safely and effectively’. QUM is
one of four central objectives of Australia’s National Medicines Policy. The policy also advocates a
partnership approach to QUM and recognises that governments, health care professionals and
providers, consumers and/or their carers and others have accepted a shared responsibility in this
endeavour.
Evidence from research into medication safety shows suboptimal use of medicines and significant
patient harm frequently results from the discontinuity that occurs when consumers/patients move
between different health care settings and health care providers. For example:
       on admission to hospital, up to one in two patients arrived with incomplete medicine lists,
        resulting in a medicines not being administered during their hospital stay
       on discharge of patients from hospital GPs often face difficulties relating to the receipt of
        discharge summaries
       to a lesser degree GPs sometimes experience delays receiving reports following referral to
        other specialists.

General practitioners need to regularly review the list of their patients’ current medications to ensure
these are up-to-date and do not lead to errors when prescribing, referring patients to other specialists,
and on admission to hospital. Single use medications, including antibiotics, should be removed from
patients’ records when their use is no longer required.

Clinical teams need to be aware of their patients’ use of complementary medicines and the potential
for side effects and drug interactions with conventional medicines. This should be noted on letters of
referral and admission to hospital.

Particular care needs to be taken with sound alike or look alike medicines, particularly when using
‘drop down’ boxes in electronic prescribing programs. There is evidence that inadvertent errors in
prescribing can be reduced with the use of ‘Tall man lettering’. (The RACGP is investigating the
possibility of incorporating Tall man lettering into existing prescribing software.)



Identifying the Carer - GP Engagement Project Report 2010                        Page 111 of 123
In the community, as many as 10.4% of patients report experiencing an adverse drug event within the
previous 6 months of presentation to their GP, and 23.2% of these were considered preventable. In
high risk patients up to 25% report experiencing an adverse drug event in the previous 3 months. Risk
factors for adverse medication events or medication errors in the community are patient age (older
patients being at most risk), serious health conditions, multiple medicines use, use of high risk
medicines, and transfer of care from community to hospital (refer to articles below).

To promote safe use of medicines, vaccines and other health care products, practices need to ensure
that they do not keep perishable materials beyond their expiry dates. This is also relevant for
perishable sample medicines or other health products that need to be stored, used and provided to
patients before their expiry dates. It is also important to ensure that medicines, vaccines and other
health care products are stored appropriately, including being secured where appropriate.

The use of Therapeutic Guidelines, such as ‘Antibiotic’ is now considered normal practice.
Therapeutic Guidelines are available at www.tg.org.au/index.php?sectionid=97.

The Australian Pharmaceutical Advisory Council (APAC) has a number of useful guides for GPs to
assist practices achieve continuity in medication management. These include:
     Guiding principles to achieve continuity in medication management in the community
         (www.health.gov.au/internet/main/publishing.nsf/Content/apac-publications-guiding)
     Guidelines for medication management in residential aged care facilities
         (www.health.gov.au/internet/main/publishing.nsf/Content/nmp-pdf-resguide-cnt.htm).

There are other important and useful tools that guide safe medication management in general
practice, such as the National Prescribing Service (NPS) Indicators of quality prescribing in Australian
general practice (February 2006). The NPS indicators implement QUM principles, and is a useful tool
to describe and assess practice processes and prescribing habits. They can be viewed at
www.nps.org.au/health_professionals/tools/quality_prescribing_indicators_in_australian_general_prac
tice.

State and territory legislation covers the acquisition, use, storage and disposal of medicines within
general practice. It is the individual practice’s responsibility to ensure compliance with these legal
requirements. The RACGP has produced fact sheets for guidance on jurisdictional requirements for
the use of Schedule 8 medicines. It also provides contact details for all state and territory drugs and
poisons units. Available at www.racgp.org.au/standards/factsheets.

Other resources

Miller G, Britt H, Valenti L. Adverse drug events in general practice patients in Australia. Medical
Journal of Australia 2006;184(7):321-4.
Sorensen L, et al. Medication reviews in the community: results of a randomized, controlled effectives
         trial. British Journal of Clinical Pharmacology 2004;58(6):648-64.
Easton K, Morgan T, Williamson M. Medication safety in the community: A review of the literature.
Sydney: National Prescribing Service, 2008.




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31.19 STANDARD 5.3
31.20
31.21 CRITERION 5.3.2 Vaccine potency
31.22
Our practice has appropriate processes that maintain the potency of vaccines.

Indicators
►A. Our practice team can identify the person(s) with the responsibility for cold chain
   management (defined in the job description of the appointed staff member/s).
►B. The person/s responsible for cold chain management in our practice can describe
   the process used for cold chain management, which accords with the current
   published edition of the National Vaccine Storage Guidelines.
►C. Our practice can demonstrate how we review our processes to ensure potency of
   our vaccine stock:
            ordering protocols
            maintenance of equipment
            annual audit of our vaccine storage procedures
            continuum of management of cold chain, including handover process
            assessment of the accuracy of our vaccine refrigerator/s thermometer.

Explanation

In a nutshell
     The success of any vaccination program depends on the potency of vaccines when
        they are administered to patients
     A cold chain management system for the transportation and storing of vaccines aims
        to keep vaccines within the safe temperature range of +2 to +8 degress celsius
     Self auditing is important because it forms part of a routine quality assurance and risk
        management process.

Vaccines are delicate biological products, and if not stored appropriately, become ineffective. The
essential references for appropriate clinical practice for this criterion are the current edition of the
National Vaccine Storage Guidelines ‘Strive for 5’ and the current edition of the NHMRC Australian
Immunisation Handbook, which outline the requirements of general practices and other immunisation
providers in relation to cold chain management. These references are available online at
www.immunise.health.gov.au

For practices to be confident that the potency of vaccines is maintained, they must:


       monitor and record the maximum and minimum temperature of refrigerators in which vaccines
        are stored at least once daily, before any vaccines are used
       have a reliable refrigerator, capable of maintaining a stable temperature, and of adequate size
        for the practice’s storage needs and frequency of vaccine ordering
       develop routine processes to maintain the cold chain, which are clearly documented. This
        may include identification, through a risk analysis, of potential situations of risk to vaccine
        potency and documentation of appropriate management strategies
       ensure that all people handling vaccines receive ongoing education (supported by the
        practice) that is appropriate for the responsibility in performing their role
       know what action to take if the temperature of the refrigerator has been outside the
        recommended range of +2ºC and +8ºC

It is recommended that vaccines are stored in a purpose built vaccine refrigerator. If your practice is
using a domestic refrigerator, certain modifications are necessary to reduce the risk of adverse
vaccine storage events. This may include use of a combination of the following:



Identifying the Carer - GP Engagement Project Report 2010                        Page 113 of 123
       using a thermometer probe placed in the vicinity of stored vaccines to monitor the maximum
        and minimum refrigerator temperature
       storage of vaccines in their original packaging in a set of sliding plastic drawers or enclosed
        plastic containers to increase insulation
       placing bottles of salt water or unfrozen ice packs/gel packs in unused areas (eg. refrigerator
        door or identified colder areas of the refrigerator) to help stabilise the temperature.
       use of temperature ‘data loggers’ that can be placed in various vaccine storage areas to
        measure temperatures and keep a record of the results over a period of time.


Note that cyclic defrost and bar refrigerators are not recommended because they produce wide
fluctuations in internal temperatures.

A member of the practice team needs to be nominated who will ensure best practice and consistency
with ordering, storage, and compliance with cold chain management guidelines. The role and
responsibilities need to be clearly articulated within a job description and include the opportunity for
appropriate ongoing education to provide the necessary skills. There needs to be a handover process
when the responsible person is unavailable to perform their duty.

Routine self auditing gives practices the confidence that potent vaccines are being administered. An
example of a self audit is contained in the appendix of the National Vaccine Storage Guidelines ‘Strive
for 5’.

Data loggers can be used in audits to verify cold chain efficacy and to enable a quality control check
of the vaccine refrigerator temperature. They are small, electronic devices that continuously measure
temperatures and keep a record of the results over a period of time. They require computer software
to download the readings. Data loggers may be inbuilt in some vaccine refrigerators, or external data
loggers may be purchased. (Data logging services are provided by some state/territory immunisation
programs and some local divisions of the General Practice Network.)

Data loggers are useful in determining and recording:

       the accuracy of the refrigerator thermometer
       temperature fluctuations within the refrigerator, and how long the refrigerator stayed at this
        temperature
       potential cooler or warmer areas within the refrigerator – areas which may not be suitable for
        vaccine storage.




Identifying the Carer - GP Engagement Project Report 2010                       Page 114 of 123
31.23 STANDARD 5.3
31.24
31.25 CRITERION 5.3.3 Health care associated infections

Our practice can demonstrate the principles and procedures necessary to prevent the
transmission of infectious diseases through immunisation and infection control.


Indicators
►A. Our practice team can identify the person/s in the practice with the responsibility
for the coordination of infection control processes (defined in the job description of
the appointed staff member/s).
►B. The person/s responsible for coordinating the infection control processes within
our practice (and other relevant practice staff) can describe in detail how sterile
procedures are undertaken, including where relevant:
           provision of an adequate range of sterile reprocessed or disposable
            equipment
         procedures for having instruments sterilised off-site, including
            documentary evidence of assurance of a validated process
         procedures for on-site sterilisation of equipment, including monitoring the
            integrity of the whole sterilisation process, validation and steriliser
            maintenance
         safe storage and stock rotation of sterile products.
►C. Our practice team members can demonstrate how risks of potential cross
infection within our practice are managed including procedures for:
          hand hygiene
          the use of personal protective equipment
          utilisation of triage policy
          safe storage and disposal of clinical waste including sharps
          managing blood and body fluid spills.
►D. Our practice is visibly clean and our practice team can demonstrate the process
for the routine environmental cleaning of all areas of the practice and provide
documentation outlining the process for those responsible for cleaning.
►E. Our practice has a written practice specific policy that outlines our practice’s
infection control plan, procedures and staff education and assessment of competency.
►F. The induction of new staff to our practice ensures they are familiar with standard
precautions against infection
►G. Subject to their informed consent:
            the natural immunity to vaccine preventable diseases or immunisation
             status of our practice team is known
            staff members are offered NHMRC recommended immunisations, as
             appropriate to their duties
            their post-immunisation immunity is assessed and documented.
►H. Our practice team can demonstrate how patients are educated in respiratory
   etiquette, hand hygiene and isolation techniques to prevent the transmission of
   communicable diseases.



Explanation


In a nutshell




Identifying the Carer - GP Engagement Project Report 2010                   Page 115 of 123
       The practice needs a written infection control policy
       All practice staff need to be offered immunisation appropriate to their role in the
        practice, in accordance with occupational health and safety obligations
       The practice team needs to have a staff member who has the responsibility as infection
        control coordinator
       The coordinator and practice team members need access to, and support for, ongoing
        education to support effective infection control practice.


The practice requires a written and well understood practice policy that utilises and applies evidence
based practice by reference to, and in accordance with, the current edition of the RACGP Infection
control standards for office based practices. Additional resources include:
     Strive for 5
     National Hand Hygiene: 5 moments of hand hygiene
     Australian Immunisation Handbook
     Department of Health and Ageing, Infection control guidelines for the prevention of
         transmission of infectious disease in the health care setting.
         The written practice policy needs to include:
     immunisation for staff working within the practice in accordance with recommendations in the
         current Australian Immunisation Handbook
     cold chain management
     vaccine handling including multidose vials
     sharps injury management
     blood and body fluid spills management
     hand hygiene: environmental cleaning of both clinical and nonclinical areas of the practice
     the performance of aseptic and sterile procedures (includes the provision of sterile
         instruments whether by the use of disposables, and/or by on site or off site sterilisation and
         storage of re-processable instruments. If sterilisation is performed on site the policy also
         needs to include the procedure of instrument re-processing and the validation process; and if
         off site, appropriate and safe transport
     waste management, including the safe storage and disposal of clinical waste and sharps
     the appropriate use and application of standard and transmission based precautions
     access for patients and staff to personal protective equipment (PPE) and evidence of
         education to appropriate application, removal and disposal of PPE
     the prevention of disease in the workplace by documented serology and the provision of
         disease preventable immunisations for staff.


Practices need to provide evidence of:
    the ongoing education and training in infection control provided to each staff member
    cold chain monitoring
    monitoring of the sterilisation process and sterilisation equipment maintenance if applicable
        (practices performing on site sterilisation)
    annual validation records if applicable (practices performing on or off site sterilisation)
    staff immunisation records.

In terms of the re-processing of reusable equipment, the Infection control standards for office based
practices recommends sterilisation as the preferred process for the reprocessing of all re-usable
instruments and equipment (noncritical, semicritical and critical) that can withstand this process
regardless of their intended use.

Where the practice uses off site sterilisation facilities, the practice needs to be able to document and
describe the procedures for safe transport of instruments to and from the practice, and demonstrate
that the off site facility correctly performs the sterilisation and validates its processes.

In relation to waste management within the practice, the Infection control standards for office based
practices defines three categories of waste produced by health care facilities and outlines the
appropriate disposal mechanism for each.



Identifying the Carer - GP Engagement Project Report 2010                        Page 116 of 123
1. Clinical waste: includes discarded sharps, laboratory and associated waste directly involved in
   specimen processing, human tissue (excluding hair, teeth, urine and faeces), materials or
   solutions containing free flowing or expressible blood
2. Related waste: includes cytotoxic waste, pharmaceutical waste, chemical waste and radio-active
   waste
3. General waste: includes all waste materials that do not fall into the clinical or related waste
   categories. General waste contaminated with blood or body substances (though not to such an
   extent that it would be considered clinical waste, ie. not contaminated with expressible blood),
   may be disposed of through the general waste process of the practice but must not be accessible
   to children. Gauze that has blood on it (but which cannot be expressed) used disposable vaginal
   spatula, cervical spatula and brushes, and tongue depressors are likely to be the most common
   terms in this category.

Disposal of clinical waste can be achieved:
     for most clinical waste: into a safely located yellow, leak proof container displaying a
       biohazard symbol
     for sharps: into a safely located yellow, leak proof and puncture resistant container displaying
       a biohazard symbol (eg. mounted on a wall or on a bench) in all areas where sharps are
       generated.

Disposal of general waste can be achieved by:
     a small bin lined with plastic mounted on the wall or on a bench. It can then be disposed of
       through the general waste stream
     the usual waste paper bin under the desk can then be used for waste not contaminated by
       blood or body fluids.

Contaminated general waste and clinical waste must not be accessible to children.


Potential infection risks to the practice team and patients need to be reduced. In this context, it is
important for all staff to be familiar with infection control procedures within the practice, including the
use of standard and additional precautions, spills management, and environmental cleaning. The
practice needs to ensure that all staff are offered appropriate immunisations based on the current
edition of the Australian Immunisation Handbook and the refusal or receipt of these vaccines, or
natural immunity to the disease, be recorded in the personnel folder of each staff member.

The practice needs to ensure that all staff are offered appropriate immunisations and these recorded
in the personnel folder of each staff member.

All practice staff require education as to the use, and have easy access to, appropriate PPE (eg. face
masks, gloves, gowns, eye protective wear). Staff need to have a clear understanding as to the
purpose of this equipment, and how to apply, remove and dispose of it appropriately.

Standard precautions apply to work practices that assume that all blood and body substances,
including respiratory droplet contamination, are potentially infectious.

The RACGP Infection control standards for office based practices recommends the use of hand
hygiene; PPE, 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.

Transmission based precautions are used for patients known or suspected to be infected with highly
transmissible pathogens (eg. influenza). In general practice this may be achieved by minimising
exposure to other patients and staff through:
     the use of PPE (eg. masks)
     distancing techniques (one metre between patients in the waiting room, isolating the patient in
        a separate room)
     effective triage and appointment scheduling, and
     hand hygiene.



Identifying the Carer - GP Engagement Project Report 2010                           Page 117 of 123
 RACGP STANDARDS for general pract ices 3rd edition 77
It is important that practices remain alert to changes to guidelines for infection control, and be in a
position to implement them accordingly. General practices should also have systems for monitoring
and obtaining information about national and local infection outbreaks and public health alerts, such
as pandemic influenza, measles and pertussis outbreaks.

Useful resources
    www.racgp.org.au/infectioncontrol
    www.racgp.org.au/pandemicresources.

To order a copy of the Infection control standards for office based practices contact RACGP Publications
on 03 8699 0414, or order from the website at www.racgp.org.au/publications.




Identifying the Carer - GP Engagement Project Report 2010                        Page 118 of 123
GLOSSARY OF TERMS
32

Aboriginal and Torres Strait Islander self identification: Patients identifying as being of
Aboriginal or Torres Strait Islander origin

Access: The ability of patients to approach and obtain services from the general practice

Accreditation: A formal process to ensure delivery of safe, high quality health care based on
assessment against the RACGP Standards for general practices

Active patient: A patient who has attended the practice/service three or more times in the
past 2 years

Active patient health record: Refers to records of patients seen within the past 2 years

Administrative staff: Staff employed by the practice who provide clerical or administrative
services and who do not perform any clinical tasks with patients

Adverse event: An incident in which unintended harm resulted to a person receiving health
care

After hours services: Services that provide care outside the normal opening hours of
general practices, whether or not they deputise for other general practices, and whether or
not they provide clinic or visit based care

Allied health professional: Health professionals who work alongside doctors and nurses to
provide optimum health care for all Australians (eg. physiotherapists, dieticians, podiatrists)

Anti-virus software: Software (computer program) that protects the computer or network
from virus programs that can corrupt software and impede its functioning

Appointment system: The system a practice uses to assign consultations between patients
and GPs or other staff members who provide clinical care

CALD: People from culturally and linguistically diverse backgrounds

Care outside normal opening hours: Clinical care that is provided to patients of the general
practice when the practice is normally closed. Each practice will have different opening and
closing hours

Carers: Refers to people who have the responsibility of caring for other people

Clinic based care: Care that is provided when patients attend a general practice, in contrast
to when they are visited at home

Clinical management area: Areas in the practice where clinical care is delivered

Clinical risk management system: A system or process the practice has put in place that is
directed toward the effective management of potential opportunities for error and adverse
effects

Clinically significant: A judgment made by a clinician that something is clinically important
for that particular patient in the context of that patient’s health care. The judgment may be that
something is abnormal and therefore clinically important for that particular patient, or it could
be something that is normal, but is clinically important for that particular patient

Clinical team: The part of the practice team that has qualifications related to health and
performs clinical functions




Identifying the Carer - GP Engagement Project Report 2010                         Page 119 of 123
Complaint: An expression of dissatisfaction or concern with an aspect of the general
practice. Complaints may be expressed verbally or in writing and may be made through a
formal complaints process, consumer surveys or focus groups

Confidentiality: The discretion in keeping information secret

Consumer Medicines Information: Written information produced by pharmaceutical
companies for the general public relating to their medicines

Continuity of care: The degree to which a series of discrete health care events is
experienced by the patient as coherent and connected and consistent with the patient’s
medical needs and personal context. Three aspects of continuity have been defined in the
literature:
      informational continuity is the flow of information across health care
         events/consultations, particularly through documentation, handover and review of
         notes from previous consultations
      management continuity is the consistency of care by the various people involved in a
         patient’s care
      relational continuity is the sense of affiliation between the patient and their doctor

Co-operative (as in after hours): GPs from different practices working together to provide
care to patients outside normal opening hours of their practices

Disability: Any type of impairment of body structure or function, activity limitation and/or
restriction of participation in society

Disaster recovery plan: A documented plan of the actions the practice needs to take to
retain and restore patient health information in the event of a ‘disaster’ (normally a power
failure or other such event)

Discrimination: Providing differential treatment or consideration based on characteristics of
the patient. Discrimination can be positive (providing differential treatment to enhance care to
the patient) or negative (providing differential treatment to the detriment of the patient’s care)

Early detection and intervention: The detection of early stages of disease and the prompt
and effective intervention to prevent disease progression

Electronic communication: The transfer of information (not necessarily patient health
information) within or outside the practice through email, internet communications, SMS or
facsimiles

Encryption: A process to convert text into cipher text (meaningless data) as a way to protect
the contents of electronic communication and guarantee its authenticity

Enhanced Primary Care: Relates to a government program to assist people with chronic
illness, and other people who need a range of services to support them in the community

Error: A generic term to encompass all those occasions in which a planned sequence of
mental or physical activities fails to achieve its intended outcome, and when these failures
cannot be attributed to the intervention of some chance agency

Fellowship of the RACGP (FRACGP): Fellowship of the RACGP is granted to GPs who
have demonstrated that they have reached the standard required for unsupervised general
practice in Australia

Firewall: Any of a number of security schemes that prevent unauthorised users from gaining
access to the practice’s computer network

Full backup: A copy of all files residing in a computer or server hard drive. The files are
marked as having been ‘backed up’



Identifying the Carer - GP Engagement Project Report 2010                         Page 120 of 123
Gender: Refers to the socially constructed roles, behaviours, activities, and attributes that a
given society considers appropriate for men and women. By way of contrast, ‘sex’ refers to
the biological and physiological characteristics that define men and women

General practice: A health care setting that provides initial, continuing, comprehensive and
coordinated medical care for individuals, families and communities

General practice registrar: A registered medical practitioner who is enrolled in a general
practice training program approved by the RACGP to achieve Fellowship of the RACGP

General practitioner: A registered medical practitioner who is qualified and competent for
general practice anywhere in Australia; has the skills and experience to provide whole person
comprehensive and coordinated and continuing medical care and; maintains professional
competence for general practice

Hardware: The physical components of a computer (monitor, hard drive)

Health promotion: Preventive health activities that reduce the likelihood of disease occurring

Home visits: A general practice consultation conducted in the private home of the patient

Human research ethics committee: A committee that reviews applications from people or
investigators/institutions undertaking research projects. The committee needs to be
constituted according to National Health and Medical Research Council requirements

Human resources: Relating to the field of personnel recruitment, training and management

Induction program: A form of training provided to new staff members or GPs to introduce
them to the practice systems, processes and structures

Informed consent: Consent by a patient (either written or verbal) to the proposed
investigations, treatments or investigations or participation in research after achieving an
understanding of the relevant purpose, importance, benefits, and associated risks

Interpreter service: A service that provides trained language translation either face-to-face or
by telephone

Medical deputising services: Services that arrange for or facilitate the provision of medical
services to patients of GPs (principals) by other medical practitioners (deputising doctors)
during the absence of, and at the request of, the GPs

Near miss: An incident that did not cause harm but could have

Need: Where these Standards use the phrase ‘a practice needs...’, the RACGP’s position is
that what ‘needs’ to be done in any situation is determined by what is reasonable in all the
circumstances. In interpreting the Standards, care must be taken to be sensitive to the often
highly variable circumstances of any particular situation

Network: A collection of connected computers used for information sharing and electronic
communication

Normal opening hours: The advertised opening hours of the general practice

Other visit: A general practice consultation conducted in a facility other than the general
practice (eg. residential aged care facility)

Outcomes indicators: Indicators that relate to the effects of care on patients and
communities




Identifying the Carer - GP Engagement Project Report 2010                        Page 121 of 123
Outside normal opening hours: The hours not covered by normal opening hours

Patient health information: A patient’s health information includes their name, address,
account details, Medicare number and any health information (including opinion) about the
person. Sometimes, details about a person’s medical history or other contextual information
can identify them, even if no name is attached to that information

Patient health record: The place (either computerised or hard copy) where an individual
patient’s personal health information is stored

Physical facilities: The building and equipment used to provide clinical care to patients

Policy and procedures manual: A resource document containing written practice
information about the practice’s policies and procedures

Position description: A document describing an employee’s role, responsibilities and
conditions of employment

Practice information sheet: A photocopied, typed or electronically generated information
sheet which includes essential information for patients about services provided by the practice
and methods of access to those services

Practice team: Teams of staff who provide care within the practice, eg. GPs, receptionists,
practice managers, general practice nurses, allied health professionals

Privacy of health information: The protection of personal and health information to prevent
unauthorised access, use and dissemination

Process indicators: Indicators that relate to what is done in giving and receiving care

Public key infrastructure: PKI is a secure method of transmitting information electronically
to provide authentication and confidentiality. PKI is used to transfer information between GPs
and specialists, and hospitals, GPs and divisions. The Health Insurance Commission (HIC) is
using PKI for all new electronic data interchange (EDI) and e-business solutions, known as
HIC Online

QA&CPD: Quality assurance and continuing professional development – educational
activities that lead to quality improvement in clinical care as endorsed by the RACGP

Referral: To send on or direct a patient to another practitioner

Relevant family history: Information about the patient’s family history that the GP considers
to be important for the purposes of providing clinical care to the patient

Relevant social history: Information about the patient’s social history (including employment,
accommodation, family structure) that the GP considers important for the purposes of
providing clinical care to the patient

Risk management: The culture, processes and structures that are directed toward the
effective management of potential opportunities for adverse events

Safe and reasonable: A decision that each practice needs to make in light of factors affecting
their practice (eg. location, patient population) in providing clinical care. What is safe and
reasonable needs to be considered by the practice in light of what their peers (or practices in
the same area) would agree was safe and reasonable

Safety: The degree to which potential risk and unintended results are avoided or minimised




Identifying the Carer - GP Engagement Project Report 2010                      Page 122 of 123
Screensavers: A software program that displays constantly changing images or dims the
brightness of a display screen to protect the screen from having an image etched onto its
surface, or being read

Self identified cultural background: Patients identifying as being of a particular ethnic or
cultural background or heritage

Server: A computer in a network that provides services to the users connected to the network
(eg. printing, accessing files)

Software: Computer programs that perform specific functions (eg. word processing or
management of information)

Staff involved in clinical care: Staff employed by the practice who perform any clinical tasks
with patients

Structure indicators: Indicators that relate to material resources, facilities, equipment and
the range of services provided at the general practice

System: An organised and coordinated method or procedure

Timely: An appropriate length of time

Urgent: A health need, compelling immediate action or attention




Identifying the Carer - GP Engagement Project Report 2010                       Page 123 of 123

				
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