mat health clinic (c) · mat health clinic 201 9 10 2.2 staff recruitment policy effective...

MAT Health Clinic 2019

1

MAT Health Clinic Strathpine

Quality Management Policy &

Procedure Manual

260-264 Medical Road Strathpine 4500

Ph: 07 3889 0000

Fax: 07 3889 1234


2

Table of Contents

1 Introduction ........................................................................................................................ 5

1.1 Mission Statement ....................................................................................................... 5

1.2 Practice background .................................................................................................... 5

1.3 Practice profile ............................................................................................................. 5

1.4 Practice team ................................................................................................................ 6

1.5 Practice services .......................................................................................................... 7

1.6 Practice hours .............................................................................................................. 7

1.7 Practice consultation fees ............................................................................................ 8

Human Resources ....................................................................................................................... 8

2.1 Awards & Entitlements ................................................................................................ 8

2.2 Staff Recruitment ....................................................................................................... 10

2.3 Position Descriptions ................................................................................................. 11

2.4 Staff Employment Records ........................................................................................ 12

2.5 Staff Induction ........................................................................................................... 13

2.6 Privacy ....................................................................................................................... 19

2.7 Performance Review .................................................................................................. 21

2.8 Staff Code of Conduct ............................................................................................... 23

2.9 Equal Opportunity, Bullying & Harassment .............................................................. 24

2.10 Anti-discrimination policy ..................................................................................... 25

3 Occupational Health & Safety .......................................................................................... 27

3.1 Manual Handling ....................................................................................................... 30

3.2 Incidents and Injury and Adverse Patient Events ...................................................... 32

3.3 Sharps Injury Management and Other Body Fluid Exposure.................................... 33

3.4 Staff Immunisation .................................................................................................... 36

3.5 Smoke-Free Environment .......................................................................................... 37

3.6 Staff Health and Well Being (including GP's) ........................................................... 37

3.7 Practice Facilities ....................................................................................................... 39

3.8 Security ...................................................................................................................... 39

3.9 Non Medical Emergencies ......................................................................................... 40

4 Infection Control ................................................................................................................... 42

4.1 Principles of infection control ................................................................................... 42

4.2 Blood and body fluid spills ........................................................................................ 44

4.3 Hand washing and hand hygiene ............................................................................... 46

4.4 Single Use Equipment ............................................................................................... 49

4.5 Onsite Sterilisation .................................................................................................... 50

4.7.1 Instrument and equipment processing area ........................................................ 53


3

4.7.2 Cleaning reusable Instruments and equipment ................................................... 55

4.7.3 Loading the steriliser ............................................................................................... 59

.......................................................................................................................................... 60

4.7.4 Unloading the steriliser ........................................................................................... 61

4.7.5 Documentation of the Cycle .................................................................................... 63

4.7.6 Monitoring the Sterilisation Process ....................................................................... 64

4.7.7 Validation of the sterilisation processes ............................................................ 65

4.7.8 Maintenance of the steriliser ............................................................................. 69

4.7.9 Servicing the steriliser ........................................................................................ 69

4.9 Storage of sterile items .............................................................................................. 70

4.10 Management of waste ............................................................................................ 70

4.11 Sharps Management ............................................................................................. 74

4.12 Transmissible and Notifiable Diseases ................................................................. 76

4.13 Standard Precautions .............................................................................................. 77

4.14 Additional Precautions ................................................................................................. 78

4.15 Personal Protective Equipment (PPE) ................................................................... 79

4.16 Laundry .................................................................................................................. 83

4.17 Safe handling of pathology specimens ................................................................ 84

4.18 Environmental Cleaning Service ........................................................................... 84

5 Practice Management ....................................................................................................... 89

5.1 Access & Parking ...................................................................................................... 89

5.2 Appointments............................................................................................................. 90

5.3 Home Visits ............................................................................................................... 94

5.4 Telephone ................................................................................................................... 96

5.5 Electronic Communication ........................................................................................ 98

5.6 Medical Emergencies & Urgent Queries ................................................................... 99

5.7 After Hours Service ................................................................................................. 101

5.8 Practice Meetings .................................................................................................... 102

5.9 Patient Rights ........................................................................................................... 104

5.10 Complaints ........................................................................................................... 105

5.11 Non English Speaking Patients................................................................................ 108

5.11.1 Culturally Appropriate Care ................................................................................ 109

5.12 Directory of Local Health and Community Services ........................................... 110

5.13 Provision of Brochures, Leaflets and Pamphlets for Patients .............................. 111

5.14 Practice Information Sheet ................................................................................... 113

5.15 Office Supplies ..................................................................................................... 114

6 Privacy and Personal Health Information ...................................................................... 116

6.1 Privacy and Security of Personal Health Information ............................................. 116


4

6.2 Computer Information Security ............................................................................... 118

6.3 Practice Privacy Policy ............................................................................................ 119

6.4 3rd Party Requests for Access to Medical Records/Health Information .................. 121

6.5 Request for Access to Personal Health Information ................................................ 124

6.6 Medical Records Administration Systems ............................................................... 126

6.7 Retention of Records and Archiving ....................................................................... 128

6.8 Transfer of Medical Records ................................................................................... 129

7 Clinical Management ..................................................................................................... 131

7.1 Clinical Autonomy ................................................................................................... 131

7.2 Clinical Content of Medical Records ...................................................................... 132

7.3 Informed Consent .................................................................................................... 133

7.4 Referral Protocols ................................................................................................... 135

7.5 Clinical Handover .................................................................................................... 136

7.6 Follow up of Tests, Results and Referrals ............................................................... 139

7.7 Reminder Systems for Preventative Care ................................................................ 141

7.8 3rd Party Observing or Clinically involved in the Consultation ............................. 142

7.9 Practice Participation in Research Projects ............................................................. 143

7.10 Management of a Patient Refusing Treatment or Advice .................................... 143

7.11 Refusal to Treat a Patient ......................................................................................... 145

7.12 Practice Equipment .............................................................................................. 146

7.13 Doctor’s Bag ........................................................................................................ 148

7.14 Vaccine Storage ................................................................................................... 149

7.15 Medication Prescribing and Administration ............................................................... 151

7.16 Controlled Substances .......................................................................................... 153

7.17 Clinical References and Resources ............................................................................ 155

7.18 Drug Storage and Disposal ................................................................................. 156

8 Continuous Improvement .................................................................................................... 157

8.1 Risk Assessment & Management ................................................................................. 157

8.2 Review of Policies & Procedures ............................................................................ 159

8.3 Continuing Staff Education .......................................................................................... 160

8.4 Accreditation & Continuous Improvement ............................................................. 163

8.5 Patient Feedback ...................................................................................................... 164

8.6 Continuity of Care ................................................................................................... 166

8.7 Clinical Governance ................................................................................................ 167


5

1 Introduction

1.1 Mission Statement

Our mission is to provide the highest standard of patient care whilst incorporating a

holistic approach toward diagnosis and management of illness.

We are committed to promoting health, well-being and disease prevention to all

patients. We do not discriminate in the provision of excellent care and aim to treat all

patients with dignity and respect.

1.2 Practice background

1.3 Practice profile

Name of practice MAT Health Clinic Strathpine

Street address 260 – 264 Medical Road Strathpine 4500

Postal address 260-264 Gympie Road Strathpine

In hours phone number 07 3889 0000

After hours phone number 1300 111 000

Fax number 07 3889 1234

Email address [email protected]

Web address www.mathealthclinic.com.au

http://www.mathealthclinic.com.au/


6

1.4 Practice team

Director

Practice Principal Martin Evans

Medical

General Practitioner Dr Philippa Clarke

General Practitioner Dr Gary Peters

General Practitioner Dr Wayne Cooper

General Practitioner/Skin

Cancer Specialist

Dr Ken Willis

Dermatology and skin checks Dr Li Wei

Allied health

Psychologist Jeanette Zali

Physiotherapist Ellie Torsello

Nursing

Practice Nurse Lyn Mason

Yvonne Robinson

Administrative

Practice Manager Katrina Peters

Lead Receptionist Jordan Sparks

Receptionist Krystal Spendy

Administrator TBC


7

1.5 Practice services

In addition to general medical consultations, our practice offers the following services:

Women’s/Men’s Health Pre-Employment Medicals

Occupational Medicine WorkCover Consultations

Paediatrics/Immunisations Enhanced Primary Care

Pathology Skin Checks

Antenatal Care Podiatry

Driving Medicals Spirometry Testing

Dietician Vaccinations/Immunisations

Health Checks Psychology/Mental Health Counselling

Clinical Nutritionist Insurance Medicals

There is a range of posters, leaflets, and brochures about health issues relevant to the

community available for all of our patients in:

The waiting room.

The consultation rooms.

The treatment room.

1.6 Practice hours

Monday to Friday 8.00am – 5.00pm

Nursing Home and

Home visits

Dr Phillip Clarke visits patients at Ella Cara Aged Care

Community on pre-arranged days. All other home visits are

provided by our After Hours Deputising Service.

After Hours During our non operational hours, this practice has a formal

arrangement with an After Hours Medical Deputising Service

(National Home Doctor Service)The After Hours Medical

Deputising Service is able to make contact with the patients

doctor if necessary to ensure measures are implemented to

facilitate continuity of care.

A summary of care provided to patients of this practice who

are attended to by the MDS is sent to the treating doctors

within 24 hours of attendance.


8

1.7 Practice consultation fees

This practice bills to

Patient (payments can be made by cash, card or cheque)

Medicare (bulk bill, pensioners and concession card holders only)

DVA

WorkCover

Private fees apply to some services that are unable to be Bulk Billed.

An up-to-date copy of our schedule of fees is located:

At reception

In the practice information sheet.

Further Information about informing patients of the cost of care can be found in Practice Fees

Human Resources

Research from both general practice and other industries supports the importance of attention

to human resources. Good human resource management supports good clinical care (RACGP

4th Edition Standards 2010).

2.1 Awards & Entitlements

Policy

Refer to MAT Health Clinic Corporate Manual

This practice complies with all its legal obligations under the Fair Work Act 2009 with

regard to employees. These include:

provision of rates of pay, leave and other entitlements as set out in the relevant

award or workplace agreement;

a safe and healthy workplace;

equal opportunity and freedom from discrimination and harassment


9

protection of employee and patient privacy; and

maintenance of appropriate staff records

compliance with the National Employment Standards

Additionally, this practice follows established procedures and policies for employment

and management of staff, including:

Clear communication of expectations and standards, using position descriptions and

job specifications as well as staff codes for conduct and presentation.

Recruitment procedures which are fair, thorough and facilitate selection of the best

candidate.

A formal induction procedure for all staff, to familiarise them with important

practice procedures relating to patient care, occupational health and safety,

emergencies, confidentiality and conduct.

Regular feedback and opportunities for development through performance review.

Procedure

In our practice, all staff members have a signed employment contract which complies

with their relevant Modern award and the National Employment Standards (NES).

Records of staff contracts can be found with the practice manager and the administration

office.

The Modern awards used by this practice to employ staff are as follow:

Health Professionals and Support Services Award 2010

Nurses Award 2010

Medical Practitioners Award 2010

Our practice has obtained advice to ensure that all employee contracts comply with the

relevant legislation.

RACGP 4th edition Standards 4.1.1.


10

2.2 Staff Recruitment

Policy

Effective selection and management of staff is critical to the success of this practice. Our

ability to care for patients and operate a successful medical practice depends upon attracting,

developing and retaining the right people.

Before the recruitment process begins, our practice analyses the position requirements by

asking the following questions:

What are the most important tasks this position will be carrying out?

Are there any additional tasks that they could be doing?

What knowledge, skills, qualifications are required to perform the role?

Are there any particular attributes which are necessary for the role?

Who will the position report to and who is responsible for this supervision?

Will the position be full-time or part-time and how will it be remunerated?

Can these tasks not already be performed by current staff?

Once these questions have been answered, the information is used to develop the following

documents:

Position description

Job vacancy advertisement

Performance appraisal outline

Selection criteria

Procedure

The recruitment process of our practice is thorough and conducted in a way that is fair and

complies with relevant legislation.

Once a suitable candidate has been selected, the applicant is notified in writing and supplied

with copies of:

The employment contracts

Position description

Confidentiality agreement


11

Personal details form

Tax file declaration form

Super Choice form

Banking details form

Current immunisation status declaration form

Information about recommended vaccinations

It is the responsibility of the practice manager to coordinate and carry out all the practice

recruitment functions. When required, this person will consult other relevant members of the

practice.

2.3 Position Descriptions

Policy

General practitioners and other staff need documented position descriptions that outline and

define their current roles, responsibilities and conditions of employment.

Position descriptions are signed by employees to indicate that roles and responsibilities are

acknowledged and understood.

Included within our position descriptions are any designated areas of responsibility. All

members of the practice team are able to identify the person(s) who have designated

responsibility in the following areas:

Cleaning

Complaints management

Quality Improvement

Infection Control

Information technology

Risk management systems

Sterilisation

Vaccine management

Procedure

The position description outlines:

Key selection criteria, skills, qualifications, etc. required for the role

Duties, responsibilities and hazards associated with the position

Remuneration and entitlements

Timetable for annual performance reviews


12

Position descriptions are reviewed regularly during performance appraisals or on a needs

basis whenever a member of the team leaves the practice.

RACGP 4th edition Standards 4.1.1, 5.3.2, 5.3.3, 4.2.2

2.4 Staff Employment Records

Policy

A range of information must be made and kept for each employee as prescribed by the Fair

Work Act 2009 and Fair Work Regulations 2009. Our practice understands that penalties apply

to employers who fail to comply with the record-keeping requirements of the Fair Work Act

2009.

Therefore we maintain staff employment records which comply with all legal and

statutory obligations.

The following information is kept as part of the mandatory employment records of all

staff working in this practice:

Details of the employer including ABN, employee commencement date and basis

of employment (ie. Full-time, part-time.)

Pay records including the rate of pay, gross and net amounts, and details of

financial incentives

Hours of work including any overtime

Leave records

Superannuation contribution records

Individual flexibility arrangements (if applicable)

Guarantee of annual earnings record (if applicable)

Termination records

Transfer of business records

All clinical staff including GP's must be able to provide evidence of appropriate national

registration and evidence of satisfactory participations in prescribed professional

development activities in accordance with their relevant vocation.

All staff must have undertaken CPR training in accordance with the Australian

Resuscitation Council very 3 years.

Procedure

Our employee records are:

in a form that is readily accessible to a Fair Work Inspector


13

legible and in English (preferably in plain, simple English)

kept for seven years

not altered unless for the purposes of correcting an error

not false or misleading to the employer’s knowledge.

private and confidential. Generally, no one can access them other than the employee,

their employer, and relevant payroll staff.

made available at the request of an employee or former employee(copy only).

Evidence of staff qualifications are kept as part of the staff employment records. Copies

of national registration and current CPR training can be found in the employee file.

RACGP 4th edition Standards 3.2.1, 3.2.2 & 3.2.3 & 4.1.1.

2.5 Staff Induction

Policy

Practices need a system for assisting new members of the practice team to learn their role.

This includes new GP's, registrars and locums, and other new staff.

Our practice has an induction program for all new General Practitioners and practice staff

which includes ongoing monitoring of progress in their new role by the company’s operations

manager with the site practice manager. To ensure staff and patient safety, new members of

the general practice team must be able to demonstrate knowledge of the key procedures in the

Policy and Procedure Manual and key operating systems relevant to their role within the

practice by the end of the induction period. Where appropriate, we have provided other

contractors using rooms in the facility with an overview of relevant practice systems.

Staff are also expected to familiarise themselves with the Policy and Procedure Manual and

use it as a resource in the course of their employment.

All new staff must complete a full induction program including Workplace Health and Safety

(WH&S) as detailed on the Staff Induction Checklist as part of their orientation.

It is essential that new staff understand the day-to-day operations of the practice including the

occupational health and safety issues relevant to their role, the practice code of conduct,

infection control policies and the processes by which the privacy of patient health

information.

It is useful for new staff to have an understanding of the local health and cultural environment

in which the practice operates. Furthermore, staff and GP's in particular need to be aware of

key public health regulations (such as reporting requirements for communicable diseases or


14

mandatory reporting of child abuse) that will affect how they work. General practitioners need

to be made aware of local health and community services including pathology, hospital and

other services they are likely to refer to in the course of normal consulting.

The Staff Induction Checklist provides the general knowledge essential for any position

within a medical practice. Job specific orientation and induction will also need to be

undertaken and documented.

As each stage of the induction program is completed with the new staff member and their

induction supervisor sign the Staff Induction Checklist and the completed document is filed in

the employee’s Staff Record file. This written record of induction is important to protect the

practice against legal liability and injury claims in the future.

New staff members are not permitted to work independently until competency in specific

areas of induction such as infection control, confidentiality and WH&S have been

demonstrated and signed-off.


15

Procedure

The following overview and checklist for MAT Health Clinic Medical and Skin Centres.

Staff Induction Checklist About MAT Health Clinic Performed Staff

initials

PM

Initials

Date

Brief MAT Health Clinic history

Location of head office

Roles and responsibilities of head office staff

Location and brief outline of other MAT Health

Clinic practices

Welcome to our practice Performe

d

Staff

initial

s

PM

initials

Date

An introduction to other staff members

A tour of our practice including bathroom

facilities and tea room

Collection of employment documentation

Policy and procedure manual

Practice history

Practice profile eg. GP’s, special interests, patient

demographics

Services provided by the practice

Practice operating hours

Practice opening and closing procedures

Provide keys to the new staff member

Practice Administration Performed Staff

initials

PM

initials

Date

An introduction to the front desk

How to handle incoming and outgoing

correspondence

The location and procedure for ordering

stationary and other office supplies

The process and staff member responsible for

distributing faxes

Details about the practice consultation fees

Information about billing arrangements

The arrangements for home and other visits

The arrangements for care outside of normal

opening hours

Telephone Procedures Performed Staff

initials

PM

initials

Date

How to place callers on hold


16

When to transfer telephone calls to GP's and

other clinical staff

Information about each GP's policy on receiving

and returning patient phone calls

The importance of not interrupting patient

consultations unless an ‘urgent situation’

A definition of an ‘urgent situation’

How to take and deliver messages

Appointment Management Performed Staff

initials

PM

initials

Date

Information about the appointment system

How to determine the urgency of patient health

care needs

How to accommodate patients with urgent, non-

urgent, complex, planned chronic care and

preventative health care needs

How to determine the most appropriate length

and time of consultation at the point of booking

The types of appointments available at our

practice

How to offer patients the opportunity to request

their preferred GP and other clinical staff

How to book appointments

How to handle patients who attend for their

scheduled appointment

The importance of informing patients of waiting

times

The process for handing non-attendance and

cancelled appointments

How to identify and care for patients in distress

Triage and Medical Emergencies Performed Staff

initials

PM

initials

Date

How to handle a medical emergency – on the

phone or in person and with or without a GP in

attendance

How to determine the urgency of patient health

care needs

Patient Management

Performed Staff

initials

PM

initials

Date

The importance of respecting patients rights

The importance of treating patients with courtesy

and respect

How to handle patient requests for repeat

prescriptions and referrals

How to handle incoming and outgoing pathology

How to handle difficult or angry patients

Information about each GP's policy on receiving

and returning patient emails


17

How to access services to help communicate with

patients who speak a language other than that of

the GP's and/or those with a disability

Information about local health, disability and

community services

How to provide important information to patients

Patient Health Records and Confidentiality Performed Staff

initials

PM

initials

Date

The importance of privacy, confidentiality and

security of patient health information – including

verbal, written and electronic information

The process for handling results, reports and

clinical correspondence

Information about the practice recall and

reminder system

The practice policy on retention of records and

archiving

The process for transferring patient health

records

The practice security policy for prescription pads

and computer generated prescription paper,

letterhead, medical certificates, medications,

patient health records and related patient health

information including accounts

Computer Administration Performed Staff

initials

PM

initials

Date

Information about privacy, confidentiality and

security issues

Allocation the appropriate passwords and

permissions

How to lock the computer and activate screen-

savers

Our email policy (if applicable)

Our website policy (if applicable)

Computer security procedures – firewall, disaster

recovery procedures

How to scan documents and digital images

Procedures for anti-virus management

Procedures for backing-up electronic information

Procedures for transferring patient health

information

Human Resource Management Performed Staff

initials

PM

initials

Date

Staff code of conduct

Staff requirements for continuing professional

development


18

Our practice policy on equal opportunity and

sexual harassment

The frequency and procedure for staff meetings

What to do in the event of an incident or injury

Our practice policy on lifting heavy objects

Our practice policy on smoking, drugs and

alcohol in our practice

How to handle violent situations in the workplace

Ways to maintain staff health and wellbeing

How to handle non-medical emergencies – fire,

bomb threats

Infection Control Performed Staff

initials

PM

initials

Date

Information about the principles of infection

control

The management of sharps injury

The management of blood and body fluid spills

Information about hand washing and hand

hygiene

Information about the practice cleaning schedule

How to ensure instruments are sterile at point of

use

Our procedure for cleaning and sterilising

instruments

Our procedure for safe storage and disposal of

clinical waste

Our procedure for handing, sorting, laundering

and storing linen

Information about implementing standard and

additional precautions

Information about how to prevent disease in the

workplace by serology and immunisations

Requesting current immunisation status of all

staff and immunisation appropriate to their duties

arranged if consented

Our procedure on handling and using chemicals

Our procedure for safe handling of pathology

specimens

Treatment Room Performed Staff

initials

PM

initials

Date

The process for using and maintaining practice

equipment

The process for storing, ordering, documenting

and disposing of controlled and restricted drugs

The process for storing, documenting and

disposing of schedule 4 drugs and pharmaceutical

samples

The process for checking, rotating and

resupplying perishable medical supplies


19

Cold-Chain Management Performed Staff

initials

PM

initials

Date

The process for receiving and transporting

vaccines

Information about the importance of managing

the cold-chain

How to manage the cold-chain

The name of the staff member responsible for

managing the cold-chain

The actions to take in the event of a cold-chain

breach

Continuous Quality Improvement Performed Staff

initials

PM

initials

Date

Information about practice accreditation and what

that means


patient feedback


investigation and resolution of complaints


leading clinical improvements

Nurse Specific Training Performed Staff

initials

PM

initials

Date

Recording the minimum/maximum temperatures

Recall procedure

Practice Incentives – managing the patients and

paperwork

I ________________________ have received sufficient training in all the topics listed above

for my training here at MAT Health Clinic __________________. I acknowledge and

understand the content of the items above and I agree to abide by the processed outlined in the

MAT Health Clinic Policy and Procedure Manual.

Employee Signature:________________________ Date: ____/____/_____

Practice Manager/Managers Signature:______________ Date:____/____/_____

All completed staff induction records are kept in individual staff file.

RACGP 4th edition Standards 4.1.1

2.6 Privacy


20

Policy

All patient information is private and confidentiality of patient information must be

maintained at all times. The rights of every patient are to be respected. All information

collected by this practice in providing a health service is deemed to be private and

confidential.

This practice complies with Federal and State privacy regulations including the Privacy

Act 1998 and the Privacy Amendment (Private Sector) Act 2000, as well as the standards

set out in the RACGP Handbook for the Management of Health Information in Private

Medical Practice 1st Edition (2002).

Under no circumstances are employees of this practice to discuss or in any way reveal

patient conditions or documentation to unauthorised staff, colleagues, other patients,

family or friends, whether at the practice or outside it, such as in the home or at social

occasions. This includes patient’s accounts, referral letters or other clinical

documentation.

General Practitioners and staff are aware of confidentiality requirements for all patient

encounters and recognise that significant breaches of confidentiality may provide grounds

for disciplinary action or dismissal.

Every employee of this practice is aware of the privacy policy and has signed

confidentiality agreement as part of their terms and conditions of employment. This

confidentiality agreement continues to be binding on employees even after their

employment has terminated.

Procedure

All employees of this practice are issued with the privacy policy and sign a

confidentiality agreement as part of their terms and conditions of employment. The

policies and procedures of the practice are further explained during the induction of new

staff members, and the induction form is signed by the new employee as confirmation

that they understand and accept their obligations in relation to patient privacy and the

confidentiality of medical information.

Copies of signed staff confidentiality agreements are kept in the employee file.

RACGP 4th edition Standards 4.2.1 & 4.2.2


21

2.7 Performance Review

Policy

Annual staff reviews are conducted to ensure continuing high levels of work performance and

to assist in job enrichment. The review is part of a continuous process of feedback to

individual staff on their work performance. It is extended to include performance

improvement and career development.

Performance reviews benefit the practice and its employees by:

ensuring all staff know what is expected of them and how their work is important to the

practice.

providing staff with formal recognition and appreciation for their work.

providing an opportunity to review goals, celebrate achievements and set objectives for

the future.

helping staff to develop their skills and performance to achieve practice goals and

further their own career.

dealing with problems and resolving grievances – see also Grievance Procedure in 2.10

Equal Opportunity, Bullying and Harassment.

A review involves identifying, evaluating and developing the work performance of staff so

that Practice goals are more effectively achieved. At the same time the process benefits staff

in terms of recognition, receiving feedback, catering for work needs and offering career

guidance and support.

The relevant position description forms the basis for evaluation and lines of accountability.

The performance review document, including comments concerning current progress and

future goals, is signed by both parties, with a copy retained by the staff member. The original

is filed in the Staff Record File.

Procedure

A review is conducted 3 months after commencement of the position and at least annually

thereafter. Depending on the staff member, reviews may occur more frequently as required.

The employee to be reviewed is issued with a self-appraisal template and a copy of their

current position description at least 1 week before their review meeting.

Review meetings are conducted where both parties are able to discuss their views on the

position and set goals for the next 12 months. A training plan and goal sheet is completed with

a copy provided to the employee and a copy incorporated in the staff members records. Any


22

amendments that need to be made to the position description are updated and a new copy filed

in the staff record as well as being provided to the employee.



23

2.8 Staff Code of Conduct

Policy

We encourage an environment that fosters robust general practice teams.

Our staff conduct themselves in a manner that promotes the attributes we believe are desirable

characteristics of general practice team:

a just, supportive, transparent, cohesive and collaborative culture, which is associated

with improved patient outcomes and enhanced patient safety.

defined goals, including an identifiable overall practice ‘mission’ and specific,

measurable operational objectives that are shared by all team members.

a ‘systems’ approach that includes the development of both clinical systems and

administrative systems.

division of labour, including the delegation of tasks and assignment of tasks among

team members.

effective training, both for the functions that people routinely perform and cross

training to substitute for other roles in cases of absences or changed/increased work

demands.

excellent communication, including supportive interpersonal communication through

well designed communication structures and processes.

All staff are issued with an employee code of conduct when commencing employment.

A copy of the code of conduct can be found in the employee file and head office.

All breaches of the code will be investigated by the employee’s supervisor in a professional

manner.

Counselling and disciplinary action of employees will take place and be documented in the

employee file for any breaches of this code of conduct. Employees are aware that gross

breaches of the code may result in dismissal from the business.

The practice manager is responsible for ensuring that all staff comply with the practice code

of conduct and to deal with any breaches in a professional and fair manner.


.


24

2.9 Equal Opportunity, Bullying & Harassment

Policy

Our practice is committed to the principles of merit, fairness and respect for all people. This

practice seeks to provide a working environment in which all employees are able to perform

their duties without being subject to discrimination or inappropriate behaviour. Our practice

complies with our legal obligations and has a range of policies and procedures to encourage

Equal Opportunity and prevent discrimination, bullying and harassment. These include:

a policy preventing bullying and harassment of any kind, including sexual

harassment, in this workplace.

a procedure to deal with the personal threat of violence

a grievance procedure for complaints arising from breaches of these policies. For

serious breaches the practice’s disciplinary procedures may be used, including

termination of employment.

All staff working at this practice have the responsibility to:

treat all people in this workplace fairly and with respect.

refrain from behaviour which could constitute harassment, bullying or

discrimination

report any incidents of harassment, bullying or discrimination to the designated

complaints person

maintain confidentiality if they are involved in complaints.

Bullying and Harassment Policy

There are a number of laws in Australia dealing with issues related to bullying and harassment

including EEO legislation, OHS requirements, criminal law, defamation and common law

provisions such as negligence. These laws all require the employer to take all reasonable

steps to stop bullying and harassment in the workplace, including:

1) Policies and procedures to prevent bullying and harassment

2) Dealing with grievances in a fair, appropriate and timely manner.

Bullying and harassment is defined as any unwelcome behaviour or communication which

has no legitimate function in the workplace and intimidates, humiliates or offends another

person. Any form of bullying or harassment is totally unacceptable in this practice.

The employer regards these actions and any similar behaviour as serious misconduct and any

person who is found to be behaving in this manner may have their employment terminated.


25

Any employee who is subjected to bullying, harassment or intimidation by a fellow employee,

manager or supervisor should notify the designated complaints person. All complaints of

harassment will be promptly and confidentially investigated using the practice’s grievance

procedure. Any employee or manager who violates this policy will be subjected to

disciplinary action, as described above.

2.10 Anti-discrimination policy

This practice does not discriminate on the basis of:

race (including colour, nationality and ethnic origin).

family status including marital status and responsibilities as a carer.

sexual orientation and lawful sexual activity.

age.

gender and gender identity.

physical Features.

political beliefs or activity.

religious beliefs or activity.

breastfeeding.

impairment including physical, intellectual or psychiatric.

pregnancy or potential pregnancy.

political opinion or activity.

criminal record.

union membership or industrial activity.

personal association with a person with any of the above characteristics.

Grievance Procedure

If you or any employee of this practice is exposed to any form of behaviour which constitutes

discrimination, bullying or harassment, the following procedure must be adopted. Do not

ignore harassment – ignoring the behaviour could be interpreted as consent.

This procedure may also be used for handling of other workplace grievances such as

complaints about working conditions, wages or work colleagues. Grievances undermine

morale and affect teamwork and need to be dealt with promptly.

1) Inform the offender that the behaviour is offensive and unacceptable.

2) Seek assistance in having the behaviour stopped by reporting the incident to your

designated complaints person


26

3) The investigator/designated complaints person will conduct a detailed investigation of

the incident(s) to assist in the resolution of the grievance. Witness statements and

evidence may be collected. For the investigation to be properly conducted

confidentiality must be maintained, it must be impartial, the person reporting the

incident must not be victimised or experience adverse repercussions and the complaint

must be dealt with as quickly as possible.

4) Actions taken to resolve the grievance will depend on the circumstances and the results

of the investigation. Generally the main aim will be to ensure the incident does not

occur again. Possible solutions may include:

an apology.

an undertaking that the behaviour will cease.

formal counselling of the alleged harasser, using the disciplinary procedure (2.7)

disciplinary action, including termination for serious misconduct.

training for groups of staff or the whole staff to raise awareness of EEO

obligations.

covering costs associated with the harassment, such as medical or psychology

expenses.

notifying the police.

if the complaint cannot be substantiated when it is investigated it must still be

taken seriously, including attempting to find a resolution of the mater with the

employees involved.

it may be appropriate to take action against a complainant who makes a serious

allegation against a work colleague which is found to be false or frivolous after

investigation. This could include termination of employment.

1) A record is kept of the complaint, its investigation and actions taken.

2) After action has been taken and the problem appears to have been resolved there is a

need for occasional monitoring and follow-up to ensure that those involved are satisfied

with the outcome, and the problem has not reoccurred or surfaced in a different form.

3) If the matter remains unresolved, the grievance provisions in the relevant awards or

workplace agreements require that it be referred to an external party. This party may be

specified in the award or agreement. Seek advice from your division or employer

group.



27

3 Occupational Health & Safety

Policy

This practice is committed to preventing workplace injury and illness and ensuring a safe

and secure working environment for doctors, staff, patients and all other visitors.

We recognise that health and safety is an integral part of every activity we perform and as

such we maintain current knowledge of our obligations under State/Territory and Federal

WH&S legislation and we understand that non compliance with these legal requirements can

result in being prosecuted and fined.

It is a legal duty of every workplace to maintain standards to protect the health, safety

and welfare of every person within the workplace. This includes staff, patients, visitors

and anyone else who may enter the premises.

As an employer we must provide a safe and healthy workplace for our workers and

contractors.

All our workers have a duty of care to ensure that they work in a manner that is not

harmful to their own health and safety and the health and safety of others.

Effective WHS regulation requires that WorkSafe provides clear, accessible advice and

guidance about what constitutes compliance with the Act and Regulations.

Procedure

This practice has a designated elected health and safety representative (HSR). The name and

telephone extension of our HSR is kept in head office. Information relating to WH&S issues

is communicated to other staff via the practice manager and updated regularly by the HSR.

We consult with employees on matters that may directly affect their health, safety or welfare

and the HSR, is also involved in the consultation

We have current workplace Injury Insurance. Our practice keeps a record of all work-

related injuries and illnesses. All near-misses are also recorded in the register. The register is

located with the operations manager in head office.

All incidents which cause of could have caused serious injury or deaths are made known to

Worksafe by contacting 13 23 60.


28

Incidents or accidents are also investigated internally by the Practice Manager and the

Operations Manager. Corrective action is then taken to prevent the incident occurring again

and any changes are communicated to all staff.

To support the safety health and well-being of our practice team we have policies and

procedures in the following areas:

tasks involving manual handling are identified and measures are taken to reduce or

eliminate the risk of injury to doctors and staff as far as reasonably practical.

incidents and all injuries involving all staff and patients and others that occur in the

workplace are documented and managed professionally and ethically, according to

relevant medical standards and guidelines.

at induction and periodically all staff are instructed in safety and infection control

protocols ensuring risks are known and precautions taken, including staff

immunisation.

we strive to work together to maintain a safe physical work environment and that

supports the health and well being of doctors, staff, patients and visitors. Including

ensuring regular breaks, adequate staffing levels and a smoke free environment.

we have a duty of care to safeguard the health of employees which also covers

psychological as well as physical health.

we strive to encourage consultation between management and staff on all matters

pertaining to OH&S matters as obligated under the legislation.

we endeavour to provide a working environment in which all doctors, staff, patients

and visitors are not subject to unlawful discrimination, sexual harassment, violence

or bullying.

audits are undertaken to ascertain that all practice and office equipment is

appropriate for its purpose. Records of maintenance, including electrical safety

checks and calibration schedules are maintained.

records of updates and training provided to all staff in relevant equipment operation

and maintenance, manual handling skills, and compliance with WH&S

requirements are maintained.

we strive to ensure the practice environment and facilities are adequate, and provide

for the comfort, safety and security of doctors, staff, patients and visitors.


29

we do not tolerate violence of any nature.

non medical emergency procedures and fire safety precautions are clearly

documented and designated members of the emergency team have a reference and a

basis for their decisions and actions within that role.

we have appointed one member of staff with primary responsibility for the

development and consistent implementation of our infection control systems and

procedures which includes environmental cleaning. Specific areas of responsibility

may be delegated to nominated members of the practice team and these particular

responsibilities should be documented in the relevant position descriptions.

to minimise harm to our patients we have clear lines of accountability and

responsibility for the delivery of safe and effective quality care.

we have a requirement for two members of the staff to be present during the normal

opening hours of the practice.

Handling Hazardous Substances

we implement arrangements for the safe use, handling, storage and transport of

chemicals and hazardous substances.

regular audits of products used by the practice are undertaken and hazardous

substances are stored, handled and documented according to assessed risk.

the practice endeavours to control risk associated with the use of hazardous

substances which are stored in labelled containers.

a register of hazardous substances is kept and maintained by the practice. (see hint

above about this).

staff members are instructed on how to handle hazardous substances appropriately

and documentation and ongoing training is provided regarding this.

regular risk assessment is undertaken by this practice in order to control risk

associated with the use of hazardous substances.

Procedure

Material Safety Data Sheets (MSDS) are kept for all chemicals stored on site. They are

accessible to all staff and are kept in the treatment room and with the practice manager.

MSDS detail the correct use, storage and action to take when exposure to chemicals

occurs.

MSDS sheets are available by contacting the supplier. A list of practice suppliers

including their contact details is kept in the nurse office. All chemicals are used in

accordance with manufacturer’s instructions.


30

It is the responsibility of the practice manager to ensure that the MSDS sheets are

available and updated when necessary.

All containers of chemical agents are appropriately labelled. This is to ensure that the contents

of containers can be readily identified and used correctly. For this reason, labels must be kept

fixed to the container at all times and clearly understood.

Specifically, it is recommended that a container with diluted cleaning agent state:

name, type and purpose of chemical agent

instructions on preparing and discarding the solution

warnings and/or health and safety instructions.

Containers of chemicals are stored in a cupboard out of the reach of children. If the cupboard

is below the waist, a childproof lock should be fitted.

Staff members who are required to handle chemicals are trained in their correct and safe use,

and this includes the correct use of personal protective equipment (PPE).

All chemicals and cleaning equipment are used for the purpose intended and in accordance

with the manufacturers instructions and dilution ratios are strictly adhered to.

Our practice has the listed chemical and cleaning, please see the registered nurse for an up to

date list.


3.1 Manual Handling

Policy

Manual handling is any activity requiring the use of force exerted by a person to lift,

push, pull, carry, or otherwise move or restrain any animate or inanimate object. It

includes activities involving awkward posture and repetitive actions. Manual handling

injuries account for nearly 50% of all Workcover claims. The objectives of the

Occupational Health and Safety Manual Handling Regulations 1999, are to reduce the


31

number and severity of musculoskeletal disorders associated with tasks involving manual

handling.

Under these regulations, this Practice aims to identify tasks involving hazardous manual

handling and to undertake risk assessments. Risks to staff are thus reduced or eliminated

as far as practicable.

Procedure

avoid tasks that involve:

o twisting, bending or extensive reaching

o repeated or prolonged stooped posture

o lifting requiring extended reach

o repetitive lifts from below mid thigh or using forceful movements

o prolonged bent neck posture when working on low flat bench

o repetitive tasks for a prolonged time

o using excessive force to push, pull or hold object

reduce the size or weight of objects to be lifted or carried.

prevent slips or falls by wearing appropriate footwear.

ensure adequate lighting.

clean area regularly; spills should be wiped up immediately.

check equipment is in good working order and there is adequate space in which to

work.

weight limits: Seated – 4.5 kg. Standing – 16 to 20 kg. (For ideal conditions and

with a compact load held close to the body and with a short carrying distance).

Before doing any type of manual handling assess the situation ask the following

questions:

should two people be lifting this or am I able to lift this safely and without risk or

injury?

is my pathway clear of all objects?

what distance am I going to be going?

can I see clearly?

can I split the load to make it lighter?

size up the load – if in doubt seek assistance.

Our practice has one or more height adjustable examination couch/s to assist in the care

of patients with a disability, and to reduce the risk of staff injuring themselves when

assisting patients on or off the examination couch. Where our practice facilities are

inadequate for staff and visitors to safely assist patients with a disability we make

alternative arrangements. e.g. Home visits.

Staff Responsibility


32

If you identify a task, piece of equipment, or work area that may be a risk, report it to the

Practice Manager or the WH&S representative. A further detailed risk assessment will be

conducted and if necessary, changes will be made to reduce the risk of injury with

training for staff as needed.

RACGP 4th edition Standards 5.1.1, 4.1.2, 5.1.3

3.2 Incidents and Injury and Adverse Patient Events

Policy

This practice has designated the practice manager with primary responsibility for clinical risk

management including the following up of incidents, injuries and adverse patient events and

near misses.

It is a legal requirement under the WH&S legislation and for insurance purposes, to

report any injury sustained or thought to be sustained in the workplace, recognizing that

good reporting also leads to effective prevention.

Our practice encourages the identification, analysis and prevention of errors, failure or

inadequate systems that can potentially be a risk to patient safety to assist with risk

management strategies not to apportion blame.

Incidents that should be reported (regardless of whether harm has occurred) to assist with

making improvements to minimise the risk of recurrence, include:

needle stick injury or mucous membrane exposure to blood or bodily fluids.

Slip, trips or falls

drug or vaccine incident (loss, misplacement or other).

adverse patient outcome.

failure or inadequate patient handover

delayed treatment or follow up or unnecessary repeat of tests.

Medication or prescribing errors.

Any deviations from standard clinical practice.

Accidents or incidents may involve the following:

staff (employed directly by this practice).

non-staff (patients, visitors, contractors). events (e.g. theft, non-patient assault, gas leak, bomb hoax, security breach,

medication error or patient complication following medical intervention, breakdown

in clinical handover).


33

Actual and potential risks are identified and actions are taken to increase the safety and

improve quality care. The privacy of individuals involved is maintained. Every effort is

made to document the risk reviews and improvements made to the practice as a result.

Procedure

Staff use the injury and incident form to report any slips, lapses or near misses in clinical care

or deviations in patient care that might result in harm. The medical defense organisation is

contacted for events that might give rise to a claim.

Completed reports are: Completed as soon as possible after incident occurs, preferably within 24 hours. Records are kept in the staff file.

Any additional medical or other certificates, reports, pathology or other documents

related to the accident/incident are dealt with as soon as possible original documents are

submitted.

For injury occurring in the practice or course of work, WorkCover reporting protocols

must also be followed. It is a legal requirement to report all injuries sustained in the

workplace

The doctor should refer patients to another practitioner if there is a possible conflict of

interest, for example a staff WorkCover claim being managed by the employing

practitioner.

The staff member with designated responsibility in Risk Management conducts a

thorough review of all the hazards relevant to the cause(s) of any injury that has occurred

with a view to identifying appropriate controls.

Risk minimization techniques are then developed and implemented to reduce the risk of re-

occurrence. All documentation of the incident/event/near-miss is kept with the practice

manager.


3.3 Sharps Injury Management and Other Body Fluid Exposure


34

Policy

The employer is responsible to ensure that all staff:

are familiar with the practice policy regarding management of blood and body fluid

exposure.

consider the blood and body substances of all patients as potential sources of infection.

understand how to prevent exposure to blood and body fluids.

have access to education and regular in service training in infection control matters.

have documented their immunisation status and have been offered NHMRC

recommended immunisations appropriate to their role.

analyse any incidents and modify procedures as required to reduce the risk of

recurrence.

In our practice, we understand that the management of occupational exposure to blood or

body fluids includes:

rapid assessment of the staff member and the source patient.

documentation of the incident.

counselling for the staff member.

timely administration of medications where appropriate.

investigation of the incident to enable modification of procedures if required.

Occupational exposure to needle stick injuries and body substances can be prevented by using

standard precautions, wearing personal protective equipment (PPE) and implementing safe

work processes.

Procedure

In the event of an occupational exposure, our practice will follow this procedure after

occupational exposure:

1. Clean/decontaminate

skin: wash with soap and water

mouth/nose/eyes: rinse well with water or saline.

1. Notify the practice principal or GP on duty immediately

The source:

explain and reassure the source and offer pre test counselling.

obtain consent to have the source patient’s blood tested for Hepatitis B, Hepatitis C

and HIV


35

the results should be available in 1-2 hrs if marked “urgent – needle stick” and

received at an appropriate testing laboratory.

take a history from the source – maintain the source patient’s confidentiality and do

not interview them in front of relatives

o unprotected sexual intercourse

o sharing needles, tattoos, body piercing

o sharing razor blades or toothbrushes

o blood or body fluid exposure of mucous membranes or non intact skin.

o blood transfusion before Feb 1990 (for HCV)

o infection with HIV, HBV, HCV

o if the source patient has a history of at – risk activities inform them about the

window period in diagnosis.

if any of the staff member’s blood went into the patient or onto instruments that were

then used, the staff member also needs to be listed as a source.

The Exposed person

if the source is unknown the person needs to be tested and post exposure prophylaxis

(PEP) needs to be considered

obtain consent from the exposed person for urgent baseline testing for Hepatitis B,

Hepatitis C and HIV to establish if the staff member has previously acquired an

infection from other exposures.

the exposed person’s confidentiality must be maintained especially if a staff member.

the exposed person may elect to have these tests performed at a different facility or

their own GP

advise them to practice safe sex until their results and the source’s results and history

have been reviewed

give the exposed person the telephone number for the state/territory Health

department communicable disease contact and other advisory services.

1. Treatment

needs to be commenced if it is anticipated that the sources blood test results will not

be available within 24hrs and the source patient could be HIV positive or in the

window period.

if the HBV status of the exposed person is not known, and the sources HBV status

will not be available within 24-48 hrs then give:

o Hepatitis B immunoglobulin

o Hepatitis B Vaccination 1st Dose

o ADT (Adult Diphtheria and Tetanus)

the exposed health care worker should be referred for immediate consultation with

an infectious diseases specialist for consideration of PEP for HIV:

o if the injury is classified as high risk, or

o if the source patient has participated in at risk activities, or


36

o If the source patient is positive for HIV or other significant blood borne

infections.

o If the source patient is unknown

1. Document Exposure:

We have appointed one member of staff with primary responsibility for the development

and consistent implementation of our infection control systems and procedures. Report

any exposure to this person or their delegated authority in addition to normal incident

reporting protocols. Report should include:

what procedure was being undertaken

how the injury happened and the name of anyone that witnessed it

the nature and extent of the injury

exactly what you were injured with (specify gauge of the needle)

the body substance involved

how much blood or body fluid was the health professional exposed to.

what personal protective equipment was being used?

the full name and address of the source. If the source cannot be identified document

“source patient not known”.


3.4 Staff Immunisation

Policy

We have appointed one member of staff with primary responsibility for the development and

consistent implementation of our infection control systems and procedures which includes

staff immunisation.

All practice staff are advised of the risks of infection and are encouraged to be

immunised against vaccine-preventable diseases to prevent transmission of disease to and

from practice staff and patients when commencing employment with the practice. Staff

are also offered additional vaccinations where appropriate depending upon the likelihood

of their contact with patients and/or blood supply substances.

The practice will keep an extensive and up-to-date record of the immunisation history of

each staff member. This will assist in identifying non immune staff to ensure they are

excluded from contact with patients during disease outbreaks.

Subject to informed consent, the immunisation status of staff is known and recorded

including the documentation of any refusal. When a staff member has declared they’ve


37

had a vaccination, evidence, such as immunology reports, must be kept in the staff

record.

Staff are able to refuse immunisation or to refuse to declare their immunisation status and

this is recorded in their staff record.

Procedure

Upon commencement of employment, all staff are explained the risks and benefits of

immunisation in relation to their position. All staff are offered appropriate immunisation

if elected, according to the NHMRC recommended list for healthcare workers.

Immunisation records are signed and dated by both the administering GP and staff

member. These records are filed in the staff record and kept in the staff personnel file.

If staff members declare they have already been immunised, immunity testing must be

carried out as this cannot be assumed. Additional immunisation may be recommended

based on the results of this testing.

Staff refusal to be immunised or refusal to disclose their immunisation status will be

documented and kept in their staff record.


3.5 Smoke-Free Environment

Policy

As a prominent health care provider our aim is to promote the health and well being of all

staff, patients and others whilst they are on our premises.

Smoking is therefore not permitted in this practice and is discouraged on the premises or

the surrounding environment. The use of illegal drugs and alcohol is prohibited on and

around the site.

No smoking signs are visible in the waiting room and/or reception area. Signs are not to

be removed, except to replace worn or frayed items.

3.6 Staff Health and Well Being (including GP's)

Policy


38

This practice is committed to providing and maintaining a safe and healthy workplace for

doctors, staff, patients and all other visitors. This includes psychological as well as

physical health.

Health and safety is an integral part of every activity we perform, and as such, the WH&S

of GP's and practice staff is a priority of this practice, and is governed by WH&S

legislation and regulations.

This practice recognises that that breaks may reduce fatigue and support the health and

wellbeing of both the General Practitioner and practice staff, as well as enhancing the

quality of patient care.

Our doctors and practice team can discuss concerns about violence in the practice and we

have the right to discontinue care.

To promote physical safety whilst at work, at least two staff members must be rostered at

all times. Our home visits and after hours policy has also been developed with staff safety

as an integral consideration.

Procedure

Our practice implements the following strategies to protect the health and wellbeing of staff:

Work flow management strategies have been developed to deal with staff on

unexpected leave or who may be on leave for an extended period. The strategies are known to

all staff and are coordinated by the practice manager.

Scheduling of regular breaks for both practice staff and members of the clinic team

Enforcing a policy which does not allow team members to accrue a large amount of

leave and encourage regular leave periods.

Strategies to deal with violence which may occur in the practice including how to deal

with difficult patients, reporting systems and opportunities for counselling and debriefing.

Strategies to deal with non-medical emergencies including evacuation procedures and

fire safety training for staff

During normal opening hours, at least two staff members are rostered/present at work

at all times.



39

3.7 Practice Facilities

Policy

The practice premises, including the facilities and equipment are safe and adequate to

meet the needs of the staff and patients.

The facilities at our practice make adequate provision for and encourage patient auditory

and visual privacy.

Facilities are well maintained and visibly clean with surfaces accessible for cleaning.

Every reasonable effort is made to make the environment safe and comfortable for staff

and people who use the practice.

Our waiting areas are sufficient to accommodate the usual numbers of patients who

would usually be waiting at any given time.

Our practice has one or more height adjustable beds. The physical conditions in our

practice support patient privacy and confidentiality.

Procedure

Upon inspection of the practice, the following features can be observed:

Dedicated room for each clinical team member

Consultation rooms are quiet, adequately lit, comfortable and feature an

examination couch

The waiting room has sufficient space to manage the usual practice patient load

All equipment is safe and fit for purpose

Sensitive information or materials are kept in a secure location accessible only by

practice staff

Hand washing facilities and toilets are readily available for both patients and staff

and are kept clean

At least one height-adjustable bed is available within the practice


3.8 Security

Policy


40

Our practice ensures as much as possible that our facilities provide appropriate security

for patients, staff and visitors. All practice staff are aware of, and are able to, implement

protocols to ensure the safety and security of all persons within the practice.

Procedure

During normal opening hours, there are at least 2 members of staff present.

The practice has implemented the principles in the RACGP Guide General Practice- A

Safe Place toolkit. All staff have been provided training in how to deal with difficult

patients and the security protocols of the practice during their induction.

The practice also makes available RACGP GP support programs. Security issues are

discussed regularly at staff meetings and all violent incidents are discussed and assessed

on a whole of practice level.

Our practice has available a duress alarm system to notify all staff members if they are

experiencing a violent encounter.

It is the responsibility of the appointed Risk Management leader to ensure that these

policies and procedures are implemented and adhered to.


3.9 Non Medical Emergencies

Policy

Non medical emergencies may occur that will require a quick, informed and effective

staff response.

Types of non-medical emergencies include: failure of electricity supply, telephone or

water, fire or false fire alarm, property damage, break-in, abusive or threatening

telephone calls or persons at the practice, leakage of toxic chemicals, bomb threats and

letter bombs.

We also have a business continuity plan for unexpected events such as natural disasters,

national or local infection outbreaks or the sudden, unexpected absence of clinical staff or

computer system failures.


41

The practice has appointed a designated member of staff to have primary responsibility for

our risk management systems. These may include clinical and non clinical risks and events.

Specific areas of responsibility can be delegated to other nominated members of the practice

team and these particular responsibilities are documented in the relevant position descriptions.

Procedure

Our practice has a triage list which details the safety procedures to be undertaken during the

specific emergency situations.

The manual/policies are located on the staff desktop and all staff have been made aware of the

manual during their orientation/induction. Designated members of the practice team have

been appropriately trained in procedures for emergency situations and these roles are

documented in their position descriptions.

Our business continuity plan has been developed to deal with unexpected events such as

natural disasters, power or business failures, or other unforeseen circumstances which may

impact on normal business operation.



42

4 Infection Control

4.1 Principles of infection control

Policy

Because many infectious agents are present in health care settings, patients may be infected

while receiving care, health care workers and others such as receptionists and cleaners may be

infected during the course of their duties or when working and interacting with patients and

other people. Potential infection risks to the practice team and our patients need to be reduced.

Our practice has implemented systems that minimise the risk of health care associated

infections including delegation of infection control and prevention responsibilities to a

competent staff member.

We have designated the nursing staff with primary responsibility for the development and

consistent implementation of our infection control systems and procedures.

Specific areas of responsibility may be delegated to nominated members of the practice team

and these particular responsibilities should be documented in the relevant position

descriptions (e.g.. infection control processes, sterilisation process, environmental cleaning,

staff immunisation, staff education).

Our practice has written polices relating to key infection control processes which are reviewed

and updated regularly.

All staff have an individual responsibility to identify any potential infection risks within the

practice and to be familiar with and implement the relevant infection control procedures of

our practice.

New staff, including contracted staff and casuals, are familiarised with our infection control

policies that are appropriate to their duties as part of their induction to our workplace. Where

appropriate, their competency is assessed and this assessment recorded or evidence of

previous competency is obtained and recorded. Mechanisms are in place to ensure ongoing

education and competency occur on a regular basis or when changes occur to our procedures.

Our practice remains alert to changes to guidelines for infection control, and can implement

them accordingly in a timely manner. We have a system for monitoring and obtaining

information about national and local infection outbreaks, as well as about emerging new risks

of cross infection and we have an effective mechanism for timely receiving and dissemination


43

of any important communication or updates about emerging diseases or infection control

measures to all relevant staff.

Procedure

We have designated the nursing staff who are responsible for co coordinating and sustaining

our infection control processes. This includes: continually modifying and improving our procedures and written policies in accordance

with the most recent evidence and guidelines and adopting a risk management approach

when implementing infection control measures.

ensuring the timely dissemination of information concerning changes to infection

control procedures or information about national and local infection control outbreaks.

maintaining staff knowledge, education and competency in infection control activities

and ensuring the consistent implementation of our infection control policies and

procedures.

ensuring the practice remains visibly clean and environmental cleaning processes are

documented.

appropriate delegation of infection control responsibilities and documentation of such

delegation

To ensure consistency of workplace practices our policy and procedure manual contains the

following written infection control protocols:

prevention of disease in the workplace by staff immunisation.

blood and body fluid spills management.

sharps injury management

hand hygiene.

a cleaning schedule for clinical and non clinical areas of the practice which describes

the

frequency of cleaning, products to use and person responsible. Where appropriate we

have documented evidence of cleaning activity.(Refer to section 5).

procedures for all aspects of the provision of sterile instruments whether by the use of

disposables, or by onsite or offsite sterilisation.

safe storage and stock rotation of sterile products.

procedures for waste management including the safe storage and disposal of clinical

waste and general waste.

the appropriate use and application of standard and additional precautions.

access for patients and staff to Personal Protective Equipment (PPE) including

evidence of education on the appropriate

application, removal and disposal of PPE.

triage of patients with potential communicable diseases.

pathology testing done within the practice.


44

ongoing education and training provided to each staff member and the mechanism for

assessing staff competency in infection control procedures.


4.2 Blood and body fluid spills

Policy

Our practice has management systems for dealing with blood and body substance spills.

blood and body fluids, including blood, vomit, urine, faeces, sputum and body tissue are

treated as potentially infectious substances that can transmit disease should contact

occur.

doctors, nurses, other health professionals, practice staff and external contractors (e.g.

cleaners) consistently use standard precautions to achieve a basic level of infection

control regardless of the known or perceived infection status of the patient.

any spillage needs to be treated promptly to reduce the potential for contact with other

patients, staff or visitors.

the designated infection control leader is responsible to ensure all staff are familiar with

the practice’s policy and procedure for the management of blood and body fluid spills

and staff receive adequate training on how to appropriately clean blood and body

substance spills which is appropriate for the tasks they are expected to perform.

staff are also familiar with the actions to take in the event of exposure to blood or body

fluids while cleaning a spill.

Our practice has a spills kit readily available consisting of a rigid walled container with a lid

and contains:

1 small bucket (with water level marked) and pre-measured amount of detergent* (in a

labeled container) to be made up when necessary.

utility rubber gloves.

face and eye protection: Goggles/safety glasses/face shield/mask.

disposable or reusable impermeable/plastic apron/gown.

roll of paper toweling (that retains strength when wet).

scrapers (2 pieces of firm cardboard or plastic).

hazard/cleaning sign.

biohazard bag.

polymerising beads or other absorbent material.

list of contents to assist restocking after use.

copy of the instructions for cleaning spills.

*The detergent used for general cleaning is satisfactory for treating most spills


45

(Source: Infection control standards for office based practices, 4th Edition)

Procedure

As part of the induction process all staff are provided with information about our practice’s

protocol for managing spills of blood and body.

In our practice, the Spills Kit is located in the treatment room.

It is the responsibility of all staff members who use the spills kit to ensure all items are

replaced after each use and the items are not expired. If additional or replacement stock is to

be ordered, both Practice manager and Practice Nurse is informed. Disposable items in the

Spills Kit must be replaced after each use and reusable items cleaned according to protocol.

The management of spills should be flexible enough to cope with different types of spills,

taking into account the following factors:

the nature of the spill

the pathogens most likely to be involved in these different types of spills

the size of the spill

the type of surface

the area involved the possibility of some material remaining on a surface where cleaning

is difficult (e.g. between tiles) and of bare skin contact with that surface.

Only staff with confirmed vaccination status and training are permitted to clean spills of blood

or body fluid and perform other high risk activities such as instrument reprocessing. (Refer to

Section 3 Staff Immunisation)

Spot spill

Practice procedure

In our practice, this procedure is followed when cleaning a spot spill:

1. don PPE as considered appropriate

2. quarantine area

3. use disposable paper to absorb the bulk of the blood and body fluid

4. wash the surface with warm water and a neutral detergent

5. dry thoroughly with a clean wipe

6. dispose of waste in the infectious waste container

7. if broken glass or any other sharp is involved it must be picked up with forceps and

disposed of in a sharps container before cleaning and disinfection is attempted.


46

Small or large spill

Practice procedure

In our practice, this procedure is followed when cleaning a small or large spill:

1. don PPE as considered appropriate

2. quarantine area

3. absorb the spill with paper towel and dispose of as clinical waste.

4. clean the surface with detergent and water. Where there is the possibility of some material

remaining on a surface where cleaning is difficult (eg between tiles) and there is a possibility

of bare skin contact with that surface, then a disinfectant may be used after the surface has

been cleaned with detergent and water. The contaminated surfaces should be treated with a

disinfectant (Sodium Hypochlorite solution - 1000 parts per million of available chlorine,

usually achieved by a 1 in 50 dilution of 5% liquid bleach or (Milton - 1% sodium

hypochlorite – used as 1:10) Granular chlorine: e.g., Det-Sol 5000 or Alcohol: e.g, Isopropyl

70%, ethyl alcohol 60%. Always read manufacturer’s instructions and precautions. (eg

Sodium Hypochlorite is corrosive to metals and alcohol highly inflammable, hardens plastic

and swells rubber)

5. leave the solution on the surface for a minimum of 10 minutes or as directed by the

manufacturer.

6. clean the surface again to remove the sodium hypochlorite if used.

7. dry thoroughly.

Carpet

Practice procedure

In our practice, this procedure is followed when cleaning a spill on carpet:

1. blot up as much of the spill as possible using disposable towels, and then clean with a

detergent

2. arrange for the carpet to be cleaned with an industrial cleaner as soon as possible.


4.3 Hand washing and hand hygiene

Policy


47

Effective Hand hygiene has been proven to reduce the spread of infection. This minimises the

risk of cross-contamination through physical contact with patients and co-workers as well as

touching inanimate objects such as door handles and telephones.

Gloves are not a substitute for hand cleaning. Fingernails are to be kept short and clean with

jewellery kept to a minimum as these may harbour bacteria. Cuts and abrasions are covered

with water resistant dressings. Nail brushes are not used.

The employer is responsible to ensure all staff members have been educated on effective hand

hygiene and hand care.

Staff must wash their hands:

before and after examining and treating

patients

after routine use of gloves

before and after and between performing

any procedure

before and after eating

before and after taking blood, before and after smoking

before and after giving an injection after blowing your nose

after handling pathology specimens after going to the toilet

after handling any equipment that might

have been soiled with blood or other

body substance

when visibly soiled or perceived

to be soiled

Easy access to hand hygiene facilities is promoted with dedicated hand washing facilities

(with hot and cold water, liquid soap and single use paper towel) readily available in every

clinical management or treatment area.

Hand disinfectants designed for use without water, such as alcohol based hand gel can be used

in the following situations:

emergency situations where there may be insufficient time and/or facilities e.g. in

the doctors bags.

when hand washing facilities are inadequate, e.g. reception areas, home visits.

in all treatment and examination areas to encourage hand hygiene in addition to

hand washing facilities.

In patient and staff areas during flu season to encourage hand hygiene.

Signage is displayed in areas where hand hygiene facilities exist to encourage proper hand

washing techniques.


48

Visible soil must be removed with detergent based wipes first. If significant direct physical

contact with a patient or patient’s blood or body fluids is likely to occur this should ideally

take place in an area where access to hand washing facilities is available.

Hand Hygiene products need to be selected with consideration of the following factors:

type of hand hygiene requires i.e. routine, aseptic (clinical), or surgical.

the location of the product.

compatibility of agents if multiple agents are used e.g. hand creams, ointments.

care and protection of staff hands and sensitivities.

There is no soap bars utilised in our practice. Where possible liquid hands wash dispensers

with disposable cartridges, including a disposable dispensing nozzle, are used; where these

are not available a pump pack is used. These are never topped up and are ideally discarded

when empty. Should they need to be refilled, the container is washed and dried thoroughly

prior. The nozzle is kept clean and free of dried soap.

Appropriate facilities for drying hands are provided. Hot air dryers are not used in clinical

areas. Single use towels (paper or cloth) are provided in shared locations and clinical areas.

Disposable paper towel is used prior to aseptic procedures. Hand moisturiser is made

available for staff use.

Procedure

Routine hand cleaning for soiled hands

The following procedure is followed for a routine hand wash:

1. wet hands thoroughly and lather vigorously using liquid soap.

2. wash for 10-15 seconds.

3. rinse thoroughly.

4. dry with paper towel or single use cloth towel.

5. use paper towel to turn taps off if not ‘hands free’.

Hand Washing for aseptic (non-surgical or clinical) procedures

The following procedure is followed for a non-surgical hand wash:

1. wash hands thoroughly using neutral liquid soap or an anti-microbial cleaner (e.g. 2%

Chlorohexidine).

2. wash for 1 minute.

3. rinse thoroughly.

4. dry thoroughly with paper towel or single use cloth towel.

5. use paper towel to turn taps off if not ‘hands free’.

Hand washing prior to surgical (invasive) procedures


49

The following procedure is followed for a surgical hand wash:

1. Remove Jewellery

2. Wet hands and forearms

3. Wash hands, nails and forearms thoroughly with an antimicrobial cleaner

i. (e.g. 4% chlorhexidine, 0.75% detergent based povidine or 1% aqueous povidine)

4. First wash 5 minutes and each subsequent wash 3 minutes

5. Rinse carefully keeping hands above the elbows

6. Do not touch taps (ask another staff member to do this if not ‘hands free’.

7. Dry thoroughly with sterile paper or cloth towels.

Location hand washing

facilities

Equipped for

routine hand

washing

Equipped for

aseptic hand

washing

Equipped for

Surgical hand

washing

Patient toilets

Liquid soap

Paper towel

yes no no

Consulting rooms Liquid Soap

Antimicrobial

cleaner (2%

Chlorhexidine)

Paper towel

yes yes no

Treatment room Liquid Soap

Antimicrobial

cleaner (4%

Chlorhexidine)

Paper towel

Sterile towel

yes yes yes


4.4 Single Use Equipment

Policy

Equipment and medications labeled by the manufacturer as disposable or single patient use

are not reprocessed (cleaned) or re-used in this practice.

Single use packaging is the only acceptable presentation for dressings, suture materials, suture

needles, hypodermic needles, syringes and scalpels.


50

Single use vials should be used in preference to multi dose vials of injectable substances as

multi dose vials present an infection hazard if incorrectly used.

Items marked by the manufacturer as “single use” must never be reused under any

circumstances. Some items may be reprocessed for use by the same patient if labelled “single

patient use” and in this case the manufacturer’s instructions for reuse must be followed. These

may include cleaning requirements and limitations to the number of times the item can be

reprocessed.

Single use items or equipment contaminated with blood or body fluid are considered clinical

waste and are disposed of accordingly.

Where possible saline solution and skin preps are purchased in single use sachets or

containers. Larger containers, if used, are dated when opened and changed regularly.

Procedure

Our practice uses a combination of single-use and reusable disposable equipment.

All single-use equipment is disposed of in an appropriate manner directly after use in the

correct sharps disposal bins.

Reusable equipment is reprocessed according to the manufacturer’s instructions. Further

instructions on equipment processing are located later in this section.

It is the responsibility of all staff to ensure the equipment they are using is disposed of

according to their classification and in accordance with practice policies and procedures.


4.5 Onsite Sterilisation

Policy

This practice is able to provide assurance that any items provided for procedures into

normally sterile tissue, sterile cavities or the bloodstream are sterile.

This practice understands that sterilisation is more than simply putting loads through a

steriliser and the process of sterility assurance includes all aspects of equipment reprocessing,

and staff education.

Our practice has a supply of reusable instruments that are maintained in good working order

and are free of rust and surface damage. The correct procedures must be followed to ensure


51

that these instruments are cleaned and sterilised after each use. Our practice uses steam at

high temperature under pressure for sterilising cleaned instruments. This is the most reliable

and cost effective method of sterilisation and is recommended for use in general practice.

Specific instructions on the packaging and use of the autoclave are kept in the treatment room.

These instructions must include a comprehensive workflow schedule to ensure that there is no

possible contamination of the clean areas where the sterile instruments are unloaded and

stored.

All items to be sterilised must be thoroughly cleaned first. Our practice documents each cycle

in a sterilisation log.

Our portable steam steriliser has a closed door drying cycle that must be used when

processing wrapped articles so as to ensure that instrument packs are dry before unloading.

Our practice validates our sterilisation process annually at the servicing of the steriliser.

The nursing staff are responsible for correct operation and training staff on how to process

instruments.

All staff are aware of the processing time required and the maximum load limits as

determined by the validation process

Holding times for steam sterilisation

All times are based on the assumption that the items to be sterilised are thoroughly clean.

Temperatu

re @ C

Pressure Holding time for

steam

sterilisation (this

includes safety

factor)

Penetration

time if

applicable (as

determined by

technician)

Total

Sterilisation

Time KPa psi

121C 103 15 15 minutes

126C 138 20 10 minutes

134C

(wrapped

items)

203 30 3 minutes

The “holding time” does not include:

the time taken for heating the load to the desired temperature


52

any large volumes of material or heavily wrapped/packaged items

included in a given load, and

time taken to allow the inside of the packs to achieve the desired

temperature.

This is the “Penetration time” and must be added to the holding time.

STERILISATION TIME = PENETRATION TIME + HOLDING TIME.

Packaging of items for sterilisation

Policy

Our practice ensures the packaging of items for sterilisation provides an effective barrier

against sources of potential contamination in order to maintain sterility and to permit aseptic

removal of the contents at point of use.

A copy of the procedure for packaging items is located in the treatment room so all staff can

readily refer to these instructions. All staff follow this procedure when packaging instruments.

Items that are being sterilised for disinfection but which do not need to be kept sterile for

reuse can be processed unwrapped e.g. vaginal speculums


53

Procedure

Step 1 Visually check items have been cleaned and dried, and are in good working

condition and free of rust or surface damage

Step 2 If your workplace uses specific sets then group items according to your

protocols.

Step 3 Insert the items into the package considering the following principles

Ensure package is the appropriate size for required items

open and unlock items with hinges or ratchets

Package in a manner that prevents damage to items or injury to end user

and facilitates steam movement across the surface of items

use tip protectors if necessary to prevent sharp instruments from perforating

the packaging

Step 4 Check each package has a class 1 indicator integrated on the packaging.

(Steriliser indicator tape or a separate class 1 indicator must be used if absent on

the packaging material.)

Step 5 Select

Option 1. Remove peel-off strip from pouch, and fold precisely along the

marked line to seal the pouch

Or Option 2.

Cut packaging from roll and fold each end over twice. Apply sterilisation tape

(usually has a class 1 indicator stripe) to seal over the fold extending it around

the edge of the package.

Step 6 Use a felt-tip, non-toxic, solvent-based marker pen to label the pack with

initials of the person packaging the item

date of sterilisation & load number

(this may be added prior to loading the steriliser if not known)

contents of the package (if opaque packaging).

Step 6 Inspect pack to ensure packaging material is intact.

Step 7 Store item/s in a container with lid, cupboard or drawer, clearly marked as

“unsterile items” until ready to load into the steriliser.

4.7.1 Instrument and equipment processing area

Policy

The RACGP Standards recommend a designated area should be used for processing all

instruments and equipment for reuse to prevent possible contamination of processed items.


54

A workflow pattern, systematically moving from dirty to clean, must be established within the

designated area. All staff must understand and adhere to the designated work flow pattern.

The workflow pattern must enable items to progress from the cleaning area to the steriliser

packaging/unloading and sterile stock storage area without re-contamination.

The equipment processing area needs to include:

adequate bench space with surfaces made of a smooth, non-porus material without

cracks or crevices to allow for cleaning

good lighting

bins for specific waste

adequate storage space for materials and equipment.

Specified cleaning equipment such as:

1. heavy duty utility gloves, plastic apron to protect clothing, protective eyewear and if

items are grossly soiled, a mask or visor.

2. a non-corrosive, non-abrasive, free rinsing and mildly alkaline detergent in the original

container or a clean, well labeled bottle.

3. cleaning brushes of a suitable size to effectively reach all parts of the item being

cleaned.

4. low-linting toweling for drying the cleaned items.

This area, including sinks and containers need to be cleaned daily.

Procedure

In our practice, our equipment processing area is located in the treatment room and our

facilities include:

Dedicated double sink with adequate bench space either side for work to flow from dirty to

clean area. A separate hand washing area is also available elsewhere in the room.

use the sink on the dirtiest side (according to the workflow pattern) to wash the dirty

instruments with the plug inserted. This is the dirty sink.

use the other sink to initially rinse the instruments and then for the final rinse. Do not

insert the plug but rinse under running water.

use the separate hand washing area for hand cleansing

Environmental Issues

The area and equipment associated with instrument and equipment processing:


55

is only cleaned or managed by appropriately trained Practice Staff.

must remain in a clean and tidy manner throughout the day.

is thoroughly cleaned at the end of the day.

If a plastic utility container is used as the Dirty sink for washing the instruments this container

must be treated with due care. The container is not touched with ungloved hands and it is

thoroughly washed at the end of the day as part of the practice’s routine cleaning. This

container is not to be used for any purpose other than instrument pre-cleaning


4.7.2 Cleaning reusable Instruments and equipment

Policy

A basic risk assessment is required to determine the appropriate level of processing required

for specific instruments. The site/manner where an instrument will be used can assist in

determining the risk of infection. This analysis determines the level of processing required to

minimise the probability of infection to the patient.

More information to assist with this risk assessment can be obtained from RACGP Infection

Control Standards for Office Based Practices, 4th Edition (page 51).

In our practice, we have a designated staff member responsible for sterilisation in our

practice. It is part of their role to ensure all staff who are sterilizing instruments are adequately

trained and competent in the procedure.

More information about aspects that require training and competency can be obtained from

RACGP Infection Control Standards for Office Based Practices, 4th Edition (page 52).

Thorough physical cleaning of items to remove blood and other debris is needed if effective

disinfection or sterilisation is to be achieved. Preliminary cleaning must be done as soon as

possible during or after use to prevent coagulation of blood and other proteins.

Any delay will increase the bio-burden (through bacterial multiplication) and also increases

the difficulty of removing adherent soil. The effectiveness of sterilisation is dependent on the

bio-burden being as low as possible.

Procedure

http://www.racgp.org.au/folder.asp?id=1229








56

In our practice, the designated leader for sterilisation is the practice nurses.

All staff cleaning reusable items must:

wear appropriate PPE.

use equipment as specified.

have received appropriate formal or in house training.

be appropriately immunised.

Our practice follows this procedure for all instruments and equipment that is going to be

reused for patient care. This includes items that need to be:

clean but are not required to be sterile for re-use e.g. kidney dishes, ear syringes.

sterilised after use, but not used as sterile e.g. vaginal speculums.

sterile for re-use e.g. surgical instruments.


57

Step 1 Wash hands with liquid soap and dry thoroughly with paper or single use

towel.

Step 2 Put on personal protective equipment including goggles, plastic apron and

heavy duty kitchen gloves.

Step 3 During or immediately after use open instruments and, dry- or damp-wipe

off gross soil. Rinse the item under gently running tepid water over the

clean sink.

Step 4 If unable to clean instruments immediately, open instruments and soak in a

container with a lid in tepid water and detergent until they can be cleaned.

Clean instruments as soon as possible as prolonged soaking damages

instruments. Use fresh water and detergent

Step 5 Prepare dirty sink/basin by filling with sufficient tepid water and the

correct amount of detergent to cover the items being washed.

Step 6 Thoroughly wash each instrument in the dirty sink/basin to remove all

organic matter. Open and disassemble items to be cleaned. Keeping items

under the waterline to minimise splashing and droplets, scrub items with a

clean, firm-bristled nylon brush. Use a thin brush to push through lumens,

holes or valves.

Step 7 Rinse the washed instruments in gently running hot water over the clean

sink/basin.

Step 8 Inspect instruments to ensure they are clean. Look at hinges, handles and

working surfaces.

Step 9 Place each washed instrument on a clean lint free cloth or surface and

repeat the above process until all instruments have been cleaned and

rinsed.

Step 10 Carefully discard dirty water down the sink. If using a container, aim to

pour the dirty water directly into the plughole rinsing the sink afterward

with running water.

Step 11 Wash cleaning brushes/cloths with detergent and tepid water after every

use. Hang to dry. Can consider sterilising these in the last load of the day.

Step 12 Wash the dirty and clean sink/basin by rinsing it with tepid water and

detergent. Wipe down the sink/basin with a disposable towel.


58

Step 13 Remove kitchen gloves and replace with non sterile disposable

gloves...Carefully dry each instrument with a clean, lint free cloth. Do not

allow to air dry.

Step 14 Remove and Clean personal protective equipment by washing or wiping

down and drying.


towel.



59

4.7.3 Loading the steriliser

Policy

Correct loading of sterilisers is needed for successful sterilising to:

allow efficient air removal

permit total steam penetration of the load

allow proper drainage of condensation and to prevent wet loads

prevent damage to items in the load

maximise efficient utilisation of steriliser

when loading the steriliser, care needs to be taken that the steam can circulate effectively

and that all surfaces are accessible and exposed to steam.

never exceed the validated load, information regarding this is located beside the

steriliser.

Procedure

Our practice follows this process when loading the steriliser:


60

Step 1 Loa items into the steriliser following these points:

allow enough space between each item to allow air removal, steam

penetration and drying to occur

do not crush items together

do not allow items to touch the floor, top or walls of the chamber

Follow the pattern of loading described in the practice validation

protocol when doing a full load.

Step 2 Fill the chamber with or ensure reservoir has sufficient deionised/de-

mineralised water as per the manufacturer’s instructions.

Step 3 If the steriliser allows you to select different loads check that the

appropriate load parameters are selected.

Step 4 Monitor the sterilisation process by one of the following:

automatic printout or computerised data logger download

(records at a minimum of 60 second intervals).

use of a class 4, 5 or 6 chemical indicator with every cycle.

Manually record time and temperature throughout the cycle at least

every 30 seconds.

Step 5 Close and secure chamber door as per manufacturer’s instructions.

Step 6 Press “Start” button or relevant button to commence the cycle as per

manufacturer’s instructions.


61

4.7.4 Unloading the steriliser

Policy

For packaged items, the period of time between their removal from a steriliser (any type) and

their return to room temperature is recognised as being the most critical time with respect to

assurance of sterility.

Cooling generates a tiny flow of room air into the pack at flow rates demonstrated to breach

porous packaging materials leading to their failure to provide a microbiological barrier.

Correct cooling practice is needed to maintain sterility. When a sterile item is not cooled in

the correct manner the article can have moisture build up, which can contaminate stock. The

item must be reprocessed if the packaging is torn, punctured or wet.


62

Procedure

Our practice follows this process when unloading the steriliser:

Step 1 When cycle is complete, check printout, data logger, or Class 4, 5 or 6

chemical indicator to ensure the temperature has reached the parameters

of at least 3 minutes at 134c and stayed above 134c for the specified

period determined during penetration study.

Note a minimum of 3 minutes at 134c is required for unwrapped goods.

For wrapped, packed or pouched items, these measurements need to be

confirmed by a technician, known as penetration time and time at

temperature testing at validation.

Step 2 Circle and sign these parameters on the printout and attach to the

sterilisation log.

Step 3 Open the steriliser door to its maximum to allow contents to cool.

Step 4 Turn off electricity or as per manufacturer’s instructions.


towel or put on clean, dry gloves. Use gloves specifically designed for

removing hot sterilising racks from the chamber to prevent staff

receiving burns.

Step 6 Visually examine packages to ensure that:

the load is dry

the packages are intact

The indicators have changed colour.

Any items that are dropped on the floor, torn, wet or have broken or

incomplete seals are contaminated and must be repackaged and

reprocessed.

Step 7 Take items from the sterilising chamber and place on a cooling rack on a

clean field until cool (or allow items to cool inside the chamber once

packages have been checked).

Step 8 Record details in the sterilisation log.


63

4.7.5 Documentation of the Cycle

Policy

A sterilisation log is maintained which contains details of:

date of cycle.

steriliser Identification (only if more than 1 steriliser in the practice).

load Number.

contents of the load.

identification of the person who prepared the load.

class 1 Chemical indicator change.

condition of the packs. (dry with seals and package integrity intact).

evidence of the process such as a print out or class 4,5 or 6 Chemical Indicator or

if a data download logger is used, sign off that it was viewed and is correct.

signature of the person releasing the load.

any comments or problems such as failed cycles and actions taken.

Procedure

the Loading section of the sterilisation log is completed and signed when the steriliser

is loaded.

the unloading section of the sterilisation log is completed and signed when the

steriliser is unloaded.

sterilisation log sheets are retained and filed in the treatment room according to the

procedures for medical records.

Failed cycle

In the event of a failed cycle:

document failed cycle with a brief summary of the problem in the sterilistion log.

notify appropriate staff members.

do not use items from the steriliser until the error is rectified.

refer to the troubleshooting guide on the operating instructions.

replace the packaging and re-process the instruments.

if fault occurs again contact the service technician for advice and record any

actions in the Steriliser Maintenance Log Sheet.


64

4.7.6 Monitoring the Sterilisation Process

Policy

Monitoring is a programmed series of checks and challenges, repeated periodically, and

carried out according to a documented protocol, which demonstrates that the process being

studied is both reliable and repeatable.

If the temperature or pressure of the steam inside the autoclave is above or below what it

should be, the steam will not be able to condense and sterilisation will be unreliable. The

efficiency of the sterilisation process should therefore be checked on a regular basis

according to the manufacturer’s specifications or those documented in the current edition of

AS/NZS 4815.

Procedure

Our practice follows these methods of monitoring:Test – Processed

Method Class 1 chemical indicator

Frequency A class 1 chemical indicator must be used for:

every wrapped item (external), or

every load, if unwrapped.

Test – Time, temperature and pressure

Method Time, temperature and pressure can be measured by using:

a steriliser with a print out facility, or

data logger/computer download, or

manually recording of temperature and pressure throughout the

cycle, or

Class 4, 5 or 6 chemical indicator (time and temperature only).

Frequency Every load

Test – Calibration

Method By a qualified service technician

Frequency 6 – 12 monthly (or more frequently as per manufacturer’s

instructions)

Test – Validation

Method See definition and process below

Frequency 12 monthly and as required



65

4.7.7 Validation of the sterilisation processes

Policy

“Validation” is a documented procedure for obtaining, recording and interpreting results

required to establish that the sterilisation protocols/procedures followed by our practice will

consistently yield sterile instruments and equipment, as exactly the same procedure is

followed for every part of each sterilisation process.

“Sterilisation” is more than simply putting loads through a steriliser. Successful sterilisation

to achieve and maintain sterility of equipment and instruments reliably and repeatedly is a

process which begins with pre-cleaning of equipment after use, cleaning of the instruments,

drying, packaging, loading the chamber, the sterilisation cycle, unloading the chamber,

monitoring of each cycle, recording cycle details and monitoring in the log book, storage and

traceability of the sterilised equipment, detection of abnormalities in the process and

corrective appropriate action, and daily, weekly and annual steriliser maintenance.

Validation covers three activities, which are:

installation qualification (‘commissioning’)

operational qualification (‘commissioning’)

performance qualification.

The validation process must be carried out by our practice upon installation and annually in

conjunction with a maintenance contractor. A qualified service technician must ensure that all

gauges and process recording equipment fitted to the steriliser are calibrated using

independent test equipment. The contractor must also document results of heat distribution

studies on an empty chamber and conduct a penetration test using our practice’s challenge

pack.

Validation of the sterilisation processes must be completed as soon as possible after the

routine annual calibration and service, and immediately after any of the events listed below:

commissioning a new steriliser (a service technician should install the steriliser

according to manufacturer’s instructions and should then check the operation of the

machine)

significant changes are made to the existing steriliser, such as major repairs or re-

calibration, which could adversely affect the result of the sterilisation process

changes to any part of the sterilisation process, such as changes to the contents, packing

or packaging of the “challenge pack” or to loading details of the “challenge load”.

If validation of the sterilisation process is successful then any load subsequently processed

over the next twelve months can be treated as sterile. This is provided that:


66

all the validated documented sterilisation procedures continue to be followed exactly

the pack contents, packing, and packaging and chamber loading do not exceed the

parameters of the validated packs/loading

each cycle is monitored correctly and no changes are made to any part of the

sterilisation process, which could adversely affect it.

Procedure

Our practice follows this procedure when conducting validation:


67

Step 1 Review and perform your infection control policies and procedures

including:

workflow issues

cleaning of instruments

pack contents, packing and packaging

loading of the steriliser

sterilisation cycle

unloading the steriliser

storage of sterile items

maintenance of the steriliser.

Step 2 Check that the procedures were successful in terms of performance and

reliability and sign-off each one using the validation methodology

checklist. Attach the validation methodology checklist to the validation

record.

Step 3 Select the hardest to sterilise items (challenge pack) in terms of product or

pack density to create your challenge pack and record details on the

validation record.

Step 4 At time of routine service, request the service person to:

calibrate the machine

conduct a heat distribution or “cold spots” study in an empty chamber

(usually performed only on installation, or available from the

manufacturer or otherwise determined by the sterilisation technician)

obtain the penetration time using a thermocouple or data logger by

choosing the hardest to sterilise items in terms of product or pack density

to create your challenge pack

undertake a time at temperature analysis to ensure the temperature

is maintained throughout the entire sterilisation phase.

provide servicing/testing documentation detailing the outcome.

Where onsite technical support is not immediately available, please refer

to the current edition of the AS/NZS 4815.

Step 5 Using the validation record template, record the following details:

date of annual validation

batch number and biological indicators

cycle that is being used for validation

temperature and time at which validation is being done

attach your servicing/testing documentation to the validation

record.

Step 6 Select the items that you will include in the load and record details on the

validation record including the “challenge pack”.


68

Step 7 Label the biological indicators to reflect cycle as follows:

1st Cycle label one Indicator 1M (for the 1st Indicator placed in the 1st

cycle challenge pack in the middle of the pack) and the other 1C (for

the non packed Indicator placed on the tray nearest the coldest part of

the steriliser chamber)

2nd Cycle label one Indicator 2M (for the 2nd Indicator placed in the 2nd




3rd Cycle label one Indicator 3M (for the 3rd Indicator placed in the 3rd




the 7th Indicator can be labelled Z. This indicator is never sterilised and is

usually placed beside the steriliser whilst the three (3) consecutive

cycles are being run. This 7th indicator will prove that the batch of

indicators was active.

Step 8 Place the biological indicators inside the challenge pack and in the coldest

spot of the chamber and outside of the steriliser. Record the location in the

test indicator diagram on your validation record.

Step 9 Load the steriliser as documented above and draw or photograph details in

the loading diagram on your validation record.

Step 10 Perform three consecutive, identical loads and cycles including the test

indicators as marked. With each load, unpack and repack the challenge

pack. All items for each load must be at room temperature.

Step 11 Send the biological indicators for testing/incubation to the pathology

company or use an in-house incubator set at correct temperature for

incubation.

Step 12 Document the findings and investigate any failures (a pass result is 100%).

Step 13 Any load run subsequently and which does not exceed the parameters of

the validated load can be treated as a load not requiring biological test

indicators.

Step 14 Attach this checklist to the validation record.



69

4.7.8 Maintenance of the steriliser

Policy

It is critical that the steriliser is maintained by practice staff and service personnel, in

accordance with the steriliser manufacturer’s instructions and that routine servicing by

suitably qualified person occurs at least annually.

The maintenance procedures must be clearly documented, performed and recorded on an

ongoing basis (daily, weekly and monthly) by practice staff and service technicians. The

operating instructions are located in the treatment room.

Procedure

Changing the water

Deionised or distilled water is used and the water reservoir is checked prior to use and

drained and refilled weekly

Cleaning the steriliser

Scale build up and corrosion in the chamber is regularly cleaned using a phosphoric acid

or citric acid solution or paste. Outlet drains are visually checked to ensure they are free

of debris and seals are visually checked for signs of wear and tear.

4.7.9 Servicing the steriliser

A maintenance contract for servicing of the steriliser is established with Able Service.

The steriliser is serviced at least 12 monthly or more frequently if required.

The servicing company details are:

SESS Quality Product Superior Service

PH 07 3000 1077

Validation of the sterilisation process

Performed at least annually or more frequently if required. Usually this is following the

service. Validation is undertaken, according to the validation protocol.

Documentation

All maintenance and servicing is documented in the maintenance log. This includes

maintenance performed by staff such as changing the water, cleaning and checking the door

seal and outlet drain. Evidence of validation is documented and retained. The 3 validation


70

cycles are recorded in the sterilisation log. Documentation relating to the maintenance and

servicing of the sterilizer is kept in the treatment room.

4.9 Storage of sterile items

Policy

All sterile items, including those processed in the practice facility and those procured from

commercial suppliers, shall be stored and handled in a manner that maintains the sterility of

the packs and prevents contamination from any source.

Factors that influence shelf life are event-related (not time-related) and are dependent on

storage and handling conditions.

Procedure

Instruments in our practice are stored:

in a clean, dry and well ventilated area

in an area free from draughts

in an area where there is reduced chance of contamination from dust and water

with dust covers should items be stored for a long period of time

in a manner which allows stock rotation, e.g. place recently used items at the back and

take from the front

with the contents of the package clearly visible to reduce handling of instruments.

Instruments and items used for procedures in other locations such as aged care facilities and

home visits are transported to the facility in a separate rigid walled container with a lid

labelled sterile items. Care is taken to maintain the sterility of these while transporting to the

facility.

In our practice, sterile equipment is kept in the treatment room.

RACGP 4thedition Standards 5.3.3

4.10 Management of waste

Policy

The RACGP Infection Control Standards for Office Based Practices outline policies and

procedures to assist our practice to safely manage waste. We are also aware of any relevant

local or State regulations that impact on our waste management.


71

Our waste policies include:

use of Standard precautions when handling waste

correct segregation of waste into three streams: “Clinical”, “Related” and “General”

storage of waste

disposal of waste

Effective and safe waste management is important for infection control and also to reduce the

impact on the environment and reduce costs.

All staff receive education regarding the management and handling of waste, appropriate to

their role, including the safe use and disposal of sharps.

These categories are defined as:

clinical waste has the potential to cause sharps injury, infection or public offence and

includes: discarded sharps, human tissues (but excluding hair, teeth, urine and faeces)

and materials or solutions containing free flowing or expressible blood. It also

includes related waste such as cytotoxic waste, pharmaceutical waste, chemical waste

and radioactive waste

general Waste is any waste that does not fall into the clinical or related category and

may include office waste, kitchen waste, urine, faeces, teeth, hair, nails, sanitary

napkins, tampons, disposable nappies, used tongue depressors, disposable vaginal

specula, cervical cytology spatulas and plastic cytology brushes, nonhazardous

pharmaceutical waste (e.g. out of date saline).

NB: General waste contaminated with blood or body substances (though not to such an

extent that it would be considered clinical waste, i.e. not contaminated with

‘expressible blood’) must be stored in out of reach or access to children.

Procedure

All staff use appropriate PPE which always includes gloves as a minimum, when handling

waste. Clinical waste is removed by trained staff. Waste, either general or clinical, is not

compressed by hand.

Clinical waste includes sharps disposal containers and designated biohazard bins. These are

located in each area where clinical waste is generated. They are emptied on a fortnightly

basis.

Containers used for “non sharp” Clinical Waste in our practice:

Have a good sealing lid.


72

Hand free operation (e.g. wide open mouth, foot pedal or sensor operated)

Rigid walls

Should be lined with a plastic bag (preferably a yellow biohazard identified bag)

Have a biohazard sign affixed to the outside.

Are located away from the reach of children.

While awaiting collection non sharp clinical waste is double bagged using a biohazard

identified yellow bag and stored securely inside a locked yellow biohazard identified bin in an

area that is separate from clean stores and with restricted access.

Sharps are defined as anything that can penetrate the skin and some examples include:

needles, scalpels, stitch cutters, glass ampoules, sharp plastic items, punch biopsy equipment,

lancets, wire cytology brushes, razors, scissors and disposable surgical instruments.

Containers used for disposal of “sharp” clinical waste:

Comply with Australian standards

Are placed out of reach of children

Cannot be knocked over

Are located so that the neck is clearly visible to health professionals when disposing of

items

Have scalpel blade removers securely mounted to the walls

Are closed and replaced when the full indicator is reached.

While awaiting collection sharps containers are never reopened and are stored with the other

clinical waste for collection.

Related waste

Cytotoxic products are disposed of into the sharps containers.

Pharmaceutical waste is disposed of in accordance with the state/ regulations. Our

practice uses the services of Chemmart Pharmacy Pullenvale.

Chemical waste such as formalin need to be disposed of according to state/territory

and local government regulations and OH&S requirements.

This practice has a service agreement, with Ace Waste who are contractors specifically

licensed to dispose clinical waste through special burial or high temperature incineration. The

practice nurse is delegated responsibility to ensure adequate stock levels of clinical waste

containers are maintained and collection schedules are timely.

Our practice considers recycling principles and the environmental impact when sorting

general waste. General waste must not be accessible to children particularly when

contaminated by blood or bodily fluids.


73

The sensitivity of information should also be considered when disposing of paper-based

materials.



74

4.11 Sharps Management

Policy

Our practice makes every attempt to minimise the risk of injury to both staff and patients, and

prevent the possible transmission of disease by discarded sharps.

Sharps represent the major cause of accidents involving potential exposure to blood-borne

diseases. All sharp items contaminated with blood and body fluids are regarded as a source of

potential infection. Safe handling and disposal of sharps is essential to protect the operator

and others from injury and possible transmission of disease. Sharps may be defined as any

object or device that could cause a penetrative injury.

Consideration is given to the purchase and use of devices that significantly reduce the risk of

sharps injury.

The staff member who generates or uses a sharp is responsible for the safe use and disposal of

that sharp. This responsibility cannot be delegated.

The employer is responsible to ensure all staff are familiar with the practice’s policy and

procedure for the safe handling and disposal of sharps and staff are also familiar with the

actions to take in the event of a sharps injury.

Procedure

Sharps disposal containers are placed in all areas where sharps are generated. Where possible

they are located between hip and shoulder height. Sharps are placed into rigid-walled,

puncture-resistant yellow containers that meet the relevant Australian Standard. Containers

are not in a location accessible to children either when in use or when awaiting collection.

The following principles are taken into consideration:

The person using the sharp is legally responsible for its safe disposal.

Sharps must be disposed of immediately or at the end of the procedure whichever is

most appropriate.

Sharps must be placed in a yellow puncture-resistant container bearing the black

biohazard symbol (AS 4031).

Used sharps must not be carried about unnecessarily.

Injection trays must be used to transport the needle and syringe to and from the

patient.

Needles and syringes must be disposed of as one unit.

Needles must not be recapped.

Needles must not be bent or broken prior to disposal.


75

Containers must not be overfilled as injuries can occur whilst trying to force the sharp

into an overfilled container – close container securely when at the fill line.

The lid must be sealed once the container is full. For push-on lids, use both hands and

apply pressure only to the edges of the lid.

Sharps disposal units must be conveniently placed in all areas where sharps are

generated and should be mounted on a wall or on a bench to prevent spillage.

Sharps containers must not be placed on the floor or in areas where unauthorised

access or injury to children can occur.

Sharps containers must not be placed directly over other waste or linen receptacles

Assistance must be obtained when taking blood or giving injections to an

uncooperative patient or to a child.

For removal and disposal of the sharps container, refer to the instructions detailed under

‘Waste Disposal’ above.

This practice assumes an active role in reducing the opportunities for sharps injury by

purchasing safe equipment whenever such an option is available without compromising the

quality and safety of patient care. Examples include:

Self-retracting single use lancets for blood glucose testing

Self-retracting cannula insertion devices and needleless. IV administration systems.

Vacuum blood collection tubes

Scalpel blade removal devices

Plastic ampoules

Our induction process includes information about the safe disposal of sharps and actions to

take in the event of a sharps injury.



76

4.12 Transmissible and Notifiable Diseases

The following table outlines the required action to be taken by practice staff in the event of a

suspected or confirmed case of the listed diseases. All staff has been given adequate training

in how to respond to these cases.

Disease Recommended

Precautions

Reportable to State/Territory

Health Departments Acute Bacterial Conjunctivitis

Adenoviruses

Amoebiasis

Anthrax – cutaneous

Anthrax - pulmonary

Bronchiolitis

Chickenpox

Croup

Cytomegalovirus (CMV)

Ebola

Enteroviruses

Extended Spectrum Beta-Lactamase (ESBL)

Giardiasis

Hand, foot and mouth disease

Hepatitis A

Herpes simplex

Haemophilus influenza type B (HIB)

Impetigo

Influenza

Measles

Methicillin Resistant Staphylococcus Aureus (MRSA)

Meningitis

Mumps

Parvovirus B19

Pediculosis

Pertussis

Pinworm

Respiratory Syncytial Virus (RSV)

Rotaviruses

Round worm

Ring worm

Rubella

Salmonellosis

Scabies

Shigellosis

Shingles

Slapped cheek disease

Staphylococcal infections

Streptococcus Group A

Sudden Acute Respiratory Distress Syndrome (SARS)

Tuberculosis

Vancomycin Resistant Enterococci (VRE)

Varicella

Viral haemorrhagic fevers

Contact

Droplet

Contact

Contact

Airborne

Contact and droplet

Contact and airborne

Droplet

Contact

Airborne

Contact

Contact

Contact

Contact

Contact

Contact and droplet

Droplet

Contact

Contact and droplet


Contact

Droplet

Droplet

Droplet

Contact

Droplet

Contact

Contact and droplet

Contact

Contact

Contact

Droplet

Contact

Contact

Contact

Contact and droplet

Contact

Contact

Droplet


Airborne

Contact


Airborne

Yes, if gonorrhoeal or chlamydial

No

No

Yes

Yes

No

No

No

No

Yes

No

No

Yes

No

Yes

No

Yes

No

Yes

Yes

No

Yes

Yes

No

No

Yes

No

No

No

No

No

Yes

Yes

No

Yes

No

No

No

No

Yes

Yes

No

No

Yes


77

4.13 Standard Precautions

Policy

Standard precautions apply to work practices that assume that all blood and body substances,

including respiratory droplet contamination, are potentially infectious.

The NHMRC recommends the use of personal protective equipment including heavy duty

protective gloves, gowns, plastic aprons, masks, eye protection or other protective barriers

when cleaning, performing procedures, dealing with spills or handling waste

Standard precautions are standard operating procedures that apply to the care and treatment of

all patients, regardless of their perceived or confirmed infectious status. Standard precautions

also apply to the handling of blood and other body fluids.

Standard precautions are work practices that are used consistently to achieve a basic level of

infection control in all health care settings and all situations.

Standard precautions are designed to protect both patients and staff, and comprise the

following measures:

hand washing

use of appropriate personal protective equipment (PPE) for example gloves, plastic

aprons and eye wear

use of aseptic technique to reduce patient exposure to micro organisms

safe management of sharps, blood and body fluid spills, linen and clinical waste

routine environmental cleaning

effective reprocessing of reusable equipment and instruments

environmental controls such as design and maintenance

Procedure

All staff involved in patient care or who may have contact with blood or body fluids are

required to understand and use standard precautions when they are likely to be in contact

with:

blood

other body fluids, secretions or excretions, except sweat (e.g. urine, faeces)

non intact skin

mucous membranes



78

4.14 Additional Precautions

Policy

Additional precautions are used for patients known or suspected to be infected with highly

transmissible pathogens. Additional precautions are measures used in addition to standard

precautions when extra barriers are required to prevent transmission of specific infectious

diseases.

Our staff are educated in how to triage and apply additional precautions for patients known or

suspected to have a potential communicable disease.

Additional precautions require: ‘isolation’ of the infectious source to prevent transmission of the infectious agent to

susceptible people in the health care setting

a means for alerting people entering an isolation area of the need to wear particular

items to prevent disease transmission.

There are three additional precaution categories based on routes of infection transmission in a

health care environment. These are: contact precautions

droplet precautions

airborne precautions.

Procedure

Additional precautions are used for patients known or suspected to be infected with highly

transmissible pathogens (e.g. influenza).

In general practice the main goal is minimising exposure to other patients and staff. This may

be achieved through:

the use of PPE

distancing techniques (one meter between patients in the waiting room, isolating the

patient in a separate room or their car)

effective triage and appointment scheduling including putting these patients ahead of

others

hand hygiene

encouraging cough etiquette and respiratory hygiene

surface cleaning

avoid touching your nose & mouth


79

To help prevent the transmission of communicable diseases, our practice educates patients

through posters and information leaflets on appropriate respiratory etiquette, hand hygiene

and triaging influenza cases.


4.15 Personal Protective Equipment (PPE)

Policy

Our practice has available Personal Protective Equipment (PPE) which includes heavy duty

protective gloves, gowns, plastic aprons, masks (surgical & P2), eye protection; or other

protective barriers in all cases where there is potential for contact with blood or body fluids

such as when cleaning, performing procedures, dealing with spills or handling waste and

when dealing with infectious diseases.

Procedure

All staff and patients have easy access to appropriate PPE. In areas where PPE is used there

are posters providing education on the appropriate application, removal and disposal of PPE

PPE is also used when handling chemicals such as cleaning products or Liquid Nitrogen.

Our practice ensures that all staff receive education, at induction and on an ongoing basis, as

to the appropriate use of various types of PPE, and where to access it. Staff training records

are kept in each staff members file.

PPE includes:

Gloves (sterile, non-sterile and standard rubber type).

Face masks including standard surgical and P2 masks.

Face and eye shields.

Gowns (long and short sleeved).

Plastic aprons.

All staff understand and are competent in:

Determining the appropriate use and selecting the correct type of PPE for the presenting

situation.

Explaining the purpose of different PPE equipment.

Demonstrating the correct fitting and removal of PPE and the safe disposal of these items.


80

PPE is located in the treatment room. Maintenance and reordering of PPE is the responsibility

of the practice nurse.


81

PPE Appropriate use

Disposable gloves Disposable gloves should be used:

When handling blood and body substances or when contact with such is

likely

When handling equipment or surfaces contaminated with such

substances

During contact with non-intact skin

During venepuncture – although needle stick injury may still occur, the

presence of the glove layer could reduce the volume of any inoculum.

Sterile gloves Sterile gloves should be used:

During any surgical procedure involving penetration of the skin or

mucous membrane and/or other tissue

When venepuncture is performed for the purpose of collecting blood for

culture.

Heavy duty gloves Heavy duty gloves should be used:

During general cleaning and disinfection

During instrument processing

During cleaning blood or body fluid and other substance spills.

Surgical Masks Surgical Masks can be used:

During procedures or activities that might result in splashing and the

generation of droplets of blood, body substances or bone fragments

When there is a risk of droplet transmission of disease.

To protect unimmunised staff and patients

Worn by the patient to prevent the spread of disease (suspected or

known)

P2 or N95 Masks

(Particulate filter

masks)

Worn by staff when there is a risk of airborne transmission of disease

(suspected or known) Tuberculosis and pandemic influenza.

Protective

eyewear

Protective eyewear should be used to prevent splashing or spraying of blood

and body fluids into the wearers eyes such as during surgical procedures,

venipuncture, or cleaning of spills, contaminated areas or instruments.

Worn by staff when there is a risk of airborne/droplet transmission of disease

(suspected or known).

Gowns and plastic

aprons

Gowns and plastic aprons should be used when there is a risk of

contamination of wearer’s clothing or skin with blood and body substances

such as during surgical procedures, venipuncture, or cleaning of spills,

contaminated areas or instrument processing.

Worn by staff when there is a risk of airborne/droplet transmission of disease

(suspected or known).

Sterile gowns Sterile gowns should be used during procedures that require a sterile field.


82

All staff use appropriate PPE when undertaking any of the following procedures:

any examinations requiring contact with mucous membranes.

cleaning or dressing wounds, taking down bandages.

cleaning up after procedures.

preparing instruments and equipment for sterilisation.

assisting with or performing procedures.

cleaning of contaminated surfaces.

cleaning spills of blood & body fluids.

using chemicals.

taking blood.

handling all pathology specimens before they are bagged.

controlling bleeding.



83

4.16 Laundry

Policy

All staff members at our practice have received education regarding the management of soiled

linen, including when to change linen, the use of appropriate precautions during handling, the

washing, drying and storage of linen. At MAT Health Clinic Strathpine we use disposable bed

liners, pillow cases, and blueys.

Procedure

Linen needs to be changed if:

a patient requires the use of contact precautions, (e.g. known or suspected of having

CAMRSA, scabies or lice)

blood or body fluid has been spilt on the linen

it is visibly soiled.

before an operative procedure.

When changing linen:

staff use PPE and standard precautions as required

care is taken to ensure sharps are not caught up in the linen

Clean linen is located in a clean, dry dust free location away from dirty linen and items. In our

practice, clean linen is stored in the nursing room cupboard.



84

4.17 Safe handling of pathology specimens

Procedure

The following process is followed when handling pathology specimens:

label and name containers before use to avoid the need for extensive handling

after the specimen has been collected.

after collection of blood and body substances these should be placed in the

appropriate specimen container, as specified by the testing laboratory.

wipe the container clean to remove any visible soiling and check specimen is

correctly identified.

securely seal to prevent any leakage during transport.

place the container upright in a waterproof bag or container.

take care to avoid contamination of pathology slips by keeping them separate

from the clinical specimens.

for transport between institutions and interstate, pack the primary specimen,

surrounded by sufficient material to absorb its contents, in a sealed inner

container and provide a sealed outer container of waterproof, robust material.

Label in accord with postal and other transport regulations. Keep cool if

necessary.


4.18 Environmental Cleaning Service

Policy

All areas of our practice environment are visibly clean.

Regular cleaning of work areas is necessary because dust, soil and microbes on surfaces can

transmit infection. Cleaning of our practice clinical and non clinical areas must be regular and

scrupulous.

We have a cleaning policy that sets out a schedule and responsibilities for cleaning all areas of

the practice in accordance with the requirements outlines in the RACGP Infection control

standards for office based practices (4th edition).

We have appointed one member of staff with primary responsibility for the development and

consistent implementation of our infection control systems and procedures which includes

environmental cleaning.


85

Specific areas of responsibility may be delegated to nominated members of the practice

team and these particular responsibilities should be documented in the relevant position

descriptions. The practice team member with delegated responsibility for environmental

cleaning can describe the process for the routine cleaning of all areas of the practice and

can provide documentation on the practice’s cleaning policy.

A good neutral detergent can be used for most of the cleaning requirements in a health care

setting, and this includes floors, walls, toilets and other surfaces. The use of disinfectants is

discouraged because they are expensive, often toxic and require contact times to be effective.

All work surfaces are made of smooth, non-porous material without cracks or crevices to

allow for efficient cleaning. Any gross soiling or body substance spills must be cleaned as

soon as possible. Sinks and wash basins must be either sealed to the wall or sufficiently far

from the wall to allow cleaning of all surfaces.

Damp dusting and wet mopping is used in the cleaning of the environment. Dry dusting and

sweeping will disperse dust and bacteria into the air and then resettle. It is potentially

hazardous and inefficient, and must be avoided in patient treatment or food preparation areas.

All cleaning equipment is stored in a clean and dry condition, in an area not accessible to the

public.

Our practice has a cleaning schedule with procedures for cleaning clinical and non-clinical

areas of our practice.

All cleaning staff must receive training in WH&S issues appropriate to general practice and

the immunisation status of all cleaning staff is documented.

All staff involved in cleaning receives ongoing education in our infection control policies

including Hand Hygiene and the correct use of Personal Protective Equipment (PPE) and

Waste management.

Procedure

The practice manager has the delegated responsibility for the development and consistent

implementation of our environmental cleaning processes. This includes education of staff

and following up any issues with the quality of environmental cleaning.

Our cleaning schedule below describes the frequency of cleaning, products to use and

person responsible for cleaning specific clinical and non clinical areas of the practice.

Where appropriate we have documented evidence of cleaning activity.


86

Additional and specific cleaning may be required in areas where patients known or

suspected to be infected with highly transmissible agents (e.g. influenza) have been.

Practice staff and contract cleaners are responsible for cleaning the premises as specified

in the documented cleaning register.

Practice staff undertake daily cleaning and the contract cleaners provide general cleaning

in all areas of the Practice on a daily basis.

An annual contract with Omega Enterprises is negotiated and reviewed every year.

Cleaning staff should adhere to the following principles when cleaning:

don personal protective equipment (PPE) such as gloves and a waterproof

apron

make up water and detergent solution each day

use clean dry cloths and mops

wash and dry all surfaces

promptly dispose of used cleaning solution in the dirty utility area, not in hand basins

or clinical sinks

wash and dry buckets, cloths, mops and PPE after use

wash hands when each task is completed.

Areas which are only cleaned/ managed by appropriately trained practice staff are:

spillage of blood or body fluids

medical instruments or items for re-use are cleaned according to the procedure for

cleaning instruments and re-usable items.

treatment room benches and trolleys

consulting room benches containing medical equipment

infectious waste and sharps containers

Should cleaning not conform to the expectations of staff it should be reported to the

practice manager.

Safety data sheets of cleaning solutions, disinfectants etc are kept on file in case of a

medical emergency.



87

Routine Cleaning Guide

Surface Method and cleaning

agents to be used

Frequency Cleaner

Responsible

Treatment room benches and

trolleys

Wash with hot water and

detergent. Dry thoroughly

Nightly and more

often if required

Authorised

practice staff

Benches/drawers containing

medical Items

Wash with hot water and

detergent. Dry thoroughly

Weekly and more

often if required

Authorised

practice staff

Re-usable medical items and

instruments

Refer to procedure in

Section 4

As required Authorised

practice staff

Benches and tables in kitchen Wash with hot water and

detergent

Daily Authorised

practice staff

Sinks, hand basins and toilets Hot water & detergent.

An abrasive cream cleanser

may be a useful stain

remover

Daily Authorised

practice staff

Hard floors - Treatment

Room

Vacuum and wet mop with

hot water and detergent

Daily

Authorised

practice staff

Hard floors - Other areas Vacuum and wet mop with

hot water and detergent

Daily - weekly

depending on use

Authorised

practice staff

Carpeted areas Vacuum

Steam Cleaned

Daily – weekly

depending on use

6 –12 monthly

Authorised

practice staff

Office desks, benches and

furniture

Damp mop with hot water

and detergent / Vacuum

Weekly Authorised

practice staff

Examination couches Hot water and detergent

Daily Authorised

practice staff

Toys Dishwasher / Hot water and

detergent

Daily - Weekly

depending on use

Authorised

practice staff

Waiting Room furniture Hot water and detergent/

Vacuum

Daily Authorised

practice staff

Curtains - Cubicle Machine hot wash

3 monthly Authorised

practice staff

Windows and window

furnishings

Dry clean / Vacuum

Annually Authorised

practice staff

Walls and ceilings Hot water and detergent

Annually Authorised

practice staff

Storerooms Hot water and detergent 3 monthly Authorised

practice staff


88


89

5 Practice Management

5.1 Access & Parking

Policy

The GP's and staff

recognise that access to the practice facilities is important to our patients.

make all reasonable efforts to facilitate physical access to the premises and

services offered.

are committed to considering how best to meet the needs of our patients with

physical disabilities or other special needs.

Where possible wheelchair access, suitable parking and pictorial signage is provided to

assist patients with a physical or intellectual disability.

Where physical access is limited to the practice or where physically attending the practice

could result in an adverse outcome for the patient the practice provides off site or home

visits.

Car parking facilities are available within a reasonable distance from the practice for

staff, visitors and patients and where possible there are designated spots for disabled

drivers.

Sufficient signs are provided externally and internally to assist Staff, visitors and patients

in accessing the practice facilities.

Procedure

This practice provides physical access to patients, visitors and staff via the main entrance.

Our practice has a height adjustable examination couch located in the treatment room and

the minor operations room to assist in the care of patients with a disability, and to reduce

the risk of patients injuring themselves when getting on or off the examination couch or

staff when assisting patients.

Doorways and walkways are to be kept free of clutter, boxes etc. to ensure a clear

pathway for all persons and in an emergency

Prominent signs at the front of the site:


90

allow the public to easily locate the practice and the parking facilities from the

street.

display the practice name, address, hours open, telephone numbers (work & after

hours).

Access for patients with disabilities.

wheelchair access is provided to reception, toilets and consulting rooms.

designated disabled parking is provided in close proximity to the entrance

the practice is located within a shopping centre, we are located on ground level.


5.2 Appointments

Policy

Our patient scheduling system is flexible enough to accommodate patients with urgent,

non-urgent, complex and planned chronic care, and preventative needs.

The individual preference, of our General Practitioners or other health care providers

such as our nurses, is accommodated and members of the clinical team are consulted

about the length and scheduling of appointments.

Patients can request to see their preferred doctor or member of the health team.

The length of clinical consultations will vary according to individual patients needs. Our

aim is to provide enough time for adequate communication between patients and their

doctors to facilitate preventative care, effective record keeping and patient satisfaction.

Patients are encouraged to ask for a longer appointment if they think it is necessary.

Our practice endeavours to accommodate patients with urgent medical matters even when

fully booked.

Staff members are trained to have the skills and knowledge to assist patients in

determining the most appropriate length and timing of consultations and to recognise and

act accordingly for patients with urgent medical matters.

Where possible information is provided in advance about the cost of healthcare and the

potential for out of pocket expenses.


91

We endeavour to respect patients cultural background and where possible meet their

needs including providing privacy for patients and others in distress.

Procedure

Each doctor or other health care providers such as nurses and allied health has specific

times allocated to his/her consulting sessions with documented needs for interval times,

short & long consultations, diagnostic tests, procedures etc.

Generally not more than 6 appointments are made for any 1 hour period and normally

there will not be any appointments scheduled for less than 10 minutes.

One appointment is required for each family member requesting to be seen.

If a third party is to be present during an examination, whether requested by the doctor or

accompanying the patient, consent from the patient will be obtained prior to the

consultation.

Patients are able to request their preferred doctor when making an appointment, and staff

will endeavour to ensure that patients generally see the same doctor. If patients are

unable to obtain an appointment with the doctor of their choice they are advised of the

availability of other doctors at this time. A patient can expect to see their doctor, or an

alternative as approved, within 2 working days.

Our Practice Information Brochure outlines the types of consultations that may require a

longer consultation and the costs. Patients can readily request a longer time when making

an appointment.

Our staff have the skills and knowledge to assist in determining the most appropriate

length and timing of appointments. Should a longer consultation be requested or

determined by information received from the patient, then our staff will endeavour to

allocate the appropriate time for a longer consultation.

Patients generally wait less than 30 minutes and patients are advised of any delays when

a doctor is running late. Wherever possible scheduled patients are called at home to

advise of a delay.

As a priority staff members are vigilant of the need to detect and place urgent callers or

walk in patients for immediate or earlier attention by a doctor. Patients are routinely

asked if the matter is urgent before being put on hold. Our practice accommodates urgent

patients even if we are fully booked.


92

Cancellations and ‘no-shows’ are monitored and marked accordingly in the Appointments

Book/Diary and these patients are followed up as appropriate. Attempts to contact

patients that fail to attend appointments are documented in the patient file.

Appointments made for patients required to attend a recall or periodic medical review

appointments are flagged and it is imperative the no shows are contacted and another

appointment re-scheduled.

Procedure (making an appointment)

Obtain patient’s name and correctly identify the patient using 3 approved identifiers Approved patient identifiers are those items of information accepted for use in patient identifi-

cation and include:

patient name (family and given names)

date of birth

gender (as identified by the patient themselves)

address

patient record number where it exists.

A Medicare number is not an approved identifier.

determine the urgency of the appointment and if the patient requests an urgent ap-

pointment refer.

determine the length of the appointment required. Does the patient have complex

medical or communication needs or multiple health matters they want to discuss?

advise of any potential for additional or out of pocket costs associated with

longer, urgent or missed consultations.

patient new? Inform of Practice location, parking, costs & payment methods. Ob-

tain contact phone number, address and other demographics. Ask to bring list of

current medications and child health record if applicable.

is doctor requested available at time requested? Give nearest available time; is this

to be a long consult?

if doctor not available, ask if another doctor would be suitable or another time slot

or date?

give suggested time and alternatives if needed.

write patient surname, given name in agreed timeslot for chosen doctor.

reconfirm patient name, time and doctor.

Note: appointments made for a periodic review (e.g. blood pressure check) or medical

recall (e.g. abnormal pathology result) are denoted as such so follow up procedures can

be instigated if the patient does not attend.

Cancellations & Missed appointments


93

Patients who continue to fail to attend routine appointments are sent letters informing

them of missed appointments and on the 3rd appointment missed they will receive a fee.

Computerised appointment book

Patients that miss appointments are phoned to remind them. If the patient cannot attend

the same day use computer program instructions to delete appointments to track

cancellations for medico legal purposes.

Patients that fail to attend a recall or periodic medical review appointment

For significant appointments a follow up letter is sent if the patient could not be contacted

by the phone call. If the appointment is flagged as ‘recall’ it is imperative every attempt is

made to contact these patients and such attempts are documented in the medical record

and also in the recall book if applicable.

persist in telephoning the patient over a few days at different times and, should

the patient not respond then send a letter asking that the patient ring the Practice.

If no response from the patient to the first letter, then send it again using regis-

tered mail.

Patients in distress

We respectfully manage patients and others in distress by providing privacy.


94

5.3 Home Visits

Policy

Doctors can make visits to regular patients of our practice where it is safe and reasonable.

These visits may be to patients in their homes, residential aged care facility, residential care

facility, or hospital both within and outside normal opening hours, where such visits are

deemed safe.

All patients are made aware that home visits or a suitable care alternative, are available both

within and outside normal opening hours via their treating doctor.

Regular patients who meet the eligibility criteria are offered home visits.

For regular patients whose circumstances are deemed not safe and reasonable, e.g. the patient

is located too far away for a home or other visit, the practice ensures that there is an alternate

system of care that these patients can access.

There are arrangements to exchange clinical details about patient care for doctors who

perform home and other visits on behalf of the patient’s regular doctor and the care provided

is documented in the patient’s medical records.

Home and other visits are provided by appropriately qualified health professionals who

have received information and advice about safety and security when conducting home

visits.

Any anticipated costs associated with home visits or alternative care systems are discussed

with the patient.

Procedure

A patient can arrange for a home visit if the criteria below are met:

where it is deemed by the GP to be safe and reasonable

the patient has provided a phone number that you have called them back on

patient has the type of problem that necessitates a home visit such as:

acute illness

immobile

elderly

have no means of transport


95

unable to access the practice facilities due to disability

If the patient at the time of request indicates that the matter is urgent, refer to the triage

protocol and list of urgent conditions for appropriate action. When in doubt, ask to put the

caller on hold and refer to the patient’s doctor for advice.

Our doctors home visit schedules are recorded in our appointment system.

Patients can request home visits however the final decision rests with the treating GP. Practice

staff are not to book home or other visits without consulting the GP.

When another health professional is performing home or other visits on behalf of GP at our

practice, arrangements are in place to ensure timely exchange of clinical information.

All visits provided within or outside normal opening hours are documented in the patient’s

medical records. If information is held about the patient in different records (for example,

residential aged care facility) there must be a record made for every consultation in each

system indicating where the clinical notes for the consultation are recorded to ensure patient

health information is available when required.

All staff undertaking home visits are given information and advice about protecting their

safety.

Where it is unsafe or unreasonable to provide a patient with care at home or in another

location outside the practice, patients are advised of alternative arrangements. Attend the

nearest emergency department or call for an ambulance. This advice is documented in the

patient health record along with evidence of the subsequent care provided.



96

5.4 Telephone

Policy

Our practice allows patients to obtain timely advice or information about their clinical

care via the telephone.

Staff members are mindful of confidentiality and respect the patient’s right to privacy.

Patient names are not openly stated over the telephone within earshot of other patients or

visitors. This practice prides itself on the high calibre of customer service we provide,

especially in the area of patient security, confidentiality, and right to privacy, dignity and

respect.

It is important for patients telephoning our practice to have the urgency of their needs

determined promptly. Staff should try to obtain adequate information from the patient to

assess whether the call is an emergency before placing the call on hold. Staff members

have been trained initially, and on an ongoing basis, to recognise urgent medical matters

and the procedures for obtaining urgent medical attention. Reception staff members have

been informed of when to put telephone calls through to the nursing and medical staff for

clarification.

Patient messages taken for subsequent follow-up by a doctor or other clinical staff are

documented for their attention and action, or in their absence to the designated person

who is responsible for that absent team member’s workload. Staff inserts the details of all

calls and telephone conversations assessed to be significant in a telephone call log.

The doctor needs to determine if advice can be given on the phone or if a face to face

consultation is necessary, being mindful of clinical safety and patient confidentiality.

Patients are advised if a fee will be incurred for phone advice. Non-medical Staff do not

give treatment or advice over the telephone. The release of test results over the phone by

non-clinical staff is discouraged and can only be done under strict doctor instructions.

Before results are given over the telephone, all patients are identified using 3 approved

patient identifiers.

All practice staff are familiar with each GP's policy for returning telephone calls. The

practice policy for returning phone calls to patients via the nurse or reception as requested

by the GP.

Staff do not give out details of patients who have consultations here nor any other

identifying or accounts information, except as deemed necessary by government

legislation or for health insurance funds.


97

A comprehensive phone answering message is maintained and activated to advise

patients of how to access medical care outside normal opening hours. This includes

advising patients to call 000 if it is an emergency.

Staff are aware of alternative modes of communication that may be used by patients with

a disability or special needs including the Translating and Interpreter Service (TIS) and

the National Relay Service.

Important or clinically significant communications with or about patients are noted in the

patient’s health record.

Procedure

All telephone calls should be answered by a member if the practice team using an

approved/accepted greeting.

All calls are immediately assessed for their level of urgency by asking ‘is it urgent?. Calls

which are to be placed on hold are firstly asked if this is acceptable and sufficient time

allowed for the caller to respond.

If the call is urgent, the practice staff member will refer to the appropriate action from the

triage guide or alert a member of the clinical care team immediately.

Telephone calls from patients which are not urgent are directed according to the GP's

telephone policy. Whenever messages are taken, they are recorded in a messaging system

and include details of the patient name, time/date of the call, and nature of the call, any

important facts and a return contact number. All messages must be returned within a

timely fashion or by the end of the day.

Sensitivity is paid to the privacy and security of patient health information and patient

details are not mentioned within earshot of other patients. Patients are identified using 3

approved patient identifiers before any personal information is discussed.

Alternative modes of communication are available for patients with specific needs, for

example, TIS for patients with non-English speaking needs.

RACGP 4thedition Standards 1.1.1, 1.1.2, 1.1.4, 1.2.3, 5.1.2, 4.2.2


98

5.5 Electronic Communication

Policy

Patients are able to obtain advice or information related to their care or appointment

reminders by electronic means, where the doctor determines that a face-to-face

consultation is unnecessary. Electronic communication includes: email, fax, and SMS.

Practice staff and doctors determine how they communicate electronically with patients,

both receiving and sending messages. All significant electronic contact with patients is

recorded in the patient health records.

Patients are advised through the Practice Information Sheet (PIS) of the practice policy

on electronic communications including:

Seeking permission or consent from patients

The possibility for electronic communications and information to be

compromised

Notification of any costs involved

The frequency of which emails are read by a member of practice staff

When an email message is sent or received in the course of a person's duties, that message is a

business communication and therefore constitutes an official record.

Employees should be aware that electronic communications could, depending on the

technology, be forwarded, intercepted, printed and stored by others. Electronic mail is the

equivalent of a post card. In regards to this, health information given in electronic

communications should be limited and discussed in more general terms. Patients should be

advised that information may be compromised.

Wherever possible, the practice should ensure secure encryption of emails is taking place.

The practice uses an email disclaimer notice on outgoing emails that are affiliated with the

practice. The following disclaimer is used on all emails sent from this practice:

This email and any files transmitted with it are confidential and intended solely for the use of

the individual or entity to whom they are addressed. If you are not the named addressee you

should not disseminate, distribute or copy this email. Please notify the sender immediately by

email if you have received this email by mistake and delete this email from your system. If you

are not the intended recipient you are notified that disclosing, copying or distributing or

taking any action in relation to the contents of this information is strictly prohibited.


99

The Practice Website

Our practice has a website to communicate to patients important information about our

practice.

It is the responsibility of the practice manager or operations manager to update the practice

website on a monthly basis.

The practice website can be accessed using the following link www.meplus.com.au

The website is continually monitored to ensure it is kept current and up to date. It contains

the minimum information required on the practice information sheet. Any changes to the

practice information sheet are also reflected on the website.

If it contains any advertising the practice should include a disclaimer that the practice

does not endorse any advertised services or products. Advertising must comply with the

MBA Code of Conduct on advertising available at: http://goodmedicalpractice.org.au/.

RACGP 4thedition Standards 1.1.2 & 1.2.1, 4.2.2

5.6 Medical Emergencies & Urgent Queries

Policy

This practice classifies patients seeking medical consultations, according to their priority

of need. Our triage system ensures that clinical care is provided to patients with urgent

medical problems as a priority.

Patients telephoning the practice have the urgency of their needs determined promptly.

Where possible, our phone on-hold message includes a recommendation to call 000 if the

matter is an emergency. Staff members know and use the triage process, a copy of which

is accessible at reception.

Administrative staff and members of the clinical team have the skills and knowledge to

assess the urgency of the need for care and can describe our procedures for dealing with

urgent medical matters, including when the practice is fully booked.

Our induction process includes an orientation to our triage system and staff members are

given training in its effective use and are encouraged to regularly update CPR and other

first aid skills.

http://www.lutwychemedicalcentre.com.au/

http://goodmedicalpractice.org.au/


100

The doctors and staff provide appropriate care and privacy for patients and others in

distress.

We have provisions for doctors to be contacted after hours for life threatening or urgent

matters and/or results.

Procedure

Staff members receive regular training and update’s in CPR, appropriate for their duties,

at least every 3 years.

All Staff members receive information at induction and on an ongoing basis about our

triage guidelines and protocols for medical emergencies. Documentation of training is

retained in the individual staff training record.

Whenever patients contact the practice, their level of urgency for medical attention is

assessed by practice staff in accordance with the practice triage procedure.

A log book or computer entry is used to record all significant telephone conversations or

actions including medical emergencies and urgent queries.

The log records:

the name and contact phone number of the patient/caller

the date and time of the call

the urgent or non-urgent nature of the call

important facts concerning the patient’s condition

the advice or information received from the doctor

details of any follow up appointments

A triage flowchart and triage manual are located at the reception desk and in the reception

folder on the computer.



101

5.7 After Hours Service

Policy

This practice ensures reasonable arrangements for medical care, including the follow up

of seriously abnormal and life threatening pathology results for our patients, both within

and outside our normal opening hours.

The arrangements for medical care outside normal opening hours, how to access this

care and the possibility of out of pocket costs, is communicated clearly to patients of this

practice. Feedback about the quality and timeliness of after hours care provided to our

patients by a deputising service is also obtained. Patient satisfaction with our after hours

service is regularly evaluated and improvements implemented if necessary.

Our practice provides after hours care through national home doctors service.

Formal arrangements for cooperative care outside the normal opening hours of

our practice through a cooperatives of one or more local practices

Formal arrangements exist with an accredited medical deputising service

Formal arrangements exist with an appropriately accredited local hospital or an

after hours facility.

The practice has a formal written arrangement with this provider of after hour’s care that

outlines how it receives information about any care provided to their patients, and how

the GP providing the care can contact the practice for clarification or help regarding

background information relating to that patient, especially in an emergency.

Our patient health records contain reports or notes pertaining to consultations occurring

outside the normal opening hours for care.

Our practice has provisions enabling designated providers of after hours care or

pathology providers to contact a patients doctor, or in that persons absence, the person

who is caring for that absent team members patients.

Procedure

Our normal opening hours are:

Monday to Friday 8.00am to 5.00pm

Advice to our patients on how to access after hours care, including the potential for out of

pocket expenses is available:

in the practice information brochure


102

on a sign visible from outside the practice

practice website

all staff members

Outside of normal hours the practice has a comprehensive message on the answering

machine, call diversion or paging system via our main telephone number. This message

includes recommending patients call 000 if the matter is an emergency. This is

maintained for all incoming calls when this practice is closed.

The patient feedback tool contains questions concerning adequate information being

given to patients about after hour’s services. The results of patient feedback are

evaluated and improvements implemented if required.

In the event that the practice doctors need to be contacted, we have an agreement

established with the following organisations:

National Home Doctor Service

Contact details for the GP's or their nominated replacements have been provided to these

organisations and it has been outlined in what situations they are to contact the GP's.

Any correspondence or notification received about after hours care provided to a patient

is documented in their medical record.

RACGP 4thedition Standards 1.1.1, 1.1.4, 1.2.4, 1.5.2, 1.2.1, 1.7.1, 2.1.2

5.8 Practice Meetings

Policy

Regular discussions where all staff are encouraged to have input are important in building a

high performing team. We aim to cultivate a just, open and supportive culture where

individual accountability and integrity is preserved, but there is a whole-of- team approach to

the quality of patient care.

Practice meetings are conducted on a three monthly basis or more frequently as required

to facilitate the exchange of practice news, other general administration and protocol

issues, complaints and to discuss risk management issues arising out of the practice.

Matters pertaining to clinical care may be discussed at these meeting if appropriate, or at

the practices clinical meetings.

Urgent daily notices or other general items are communicated to staff via the messaging

system or verbally.


103

Procedure

Staff meetings

It is important that all members of the practice team have the opportunity to discuss

administrative issues with the practice directors and/or owners when necessary. All staff are

expected to attend and contribute to the staff meeting.

Staff meetings are held three monthly and minutes are recorded. Items for the agenda

may be submitted to the Practice Manager up to one week prior to the scheduled meeting.

All meeting minutes are kept with the practice manager.

Administrative and WH&S practices are regularly reviewed at these meetings. Staff

members are given the opportunity to discuss administrative matters with the doctor(s)

and/or practice manager when necessary.

Discussion and suggestions for improvements to patient safety, policies or procedures

associated with risk management, is a standing item on our practice meeting agenda.

Practice discussions about near misses or slips or lapses, with the intention of identifying

what went wrong and how to reduce the likelihood of it happening again, are also

included in practice and clinical meetings, where appropriate.

The decisions made at staff meetings should be documented along with the person responsible

for implementing the related action.

The Communication Book is located at reception and all staff are able to access it to read or

make important notes regarding practice issues.

It is the responsibility of the practice manager to ensure the communication book is completed

when necessary and viewed by all staff on a regular basis.

Clinical Meetings

Good communication between members of the clinical team is important for ensuring a

consistent approach to clinical care. Doctors and clinical staff, such as nurses and in

house allied health, meet face to face at least quarterly, to discuss clinical matters. In

between meetings, a communication book and emails are used to consider and

communicate clinical issues.


104

The practice manager is responsible for leading the clinical improvement and is the chair of

the meetings. Practice protocols, near misses or latest literature may be discussed. The

meetings are recorded on the practice meeting schedule to ensure staff can arrange to attend.

There is also a standing discussion item about clinical issues, support systems, new

guidelines and evidence. This includes a review of patient information brochures used for

preventative activities and to support management or treatment choices, to ensure they

are of appropriate quality and all members of the team are giving consistent information.

Clinical issues, updates, case studies and reports of Continuous Quality Improvement (CQI)

activities, complaints and incident reviews are presented, discussed and action taken as

required helping improve processes and patient outcomes.

Drug representatives may from time to time arrange a lunch or breakfast meeting, providing a

specialist to speak on a particular topic.


5.9 Patient Rights

Policy

All practice staff members respect the rights and needs of all patients.

No patient is refused access to clinical assessment or medical treatment on the basis of

gender, race, disability, Aboriginality, age, religion, ethnicity, beliefs, sexual preference or

medical condition. Our practice has implemented provisions to assist all patients to

access our services including for example an interpreter service.

The practice identifies important/significant cultural groups within our practice including

non-English speaking patients, religious groups and those of Aboriginal and Torres Strait

Islander background. We endeavour to continue to develop any strategies required to

meet their needs.

Patients have the right to refuse any treatment, advice or procedure. Our doctors discuss

all aspects of treatment and will offer alternatives should a patient seek another medical

opinion. Comprehensive documentation of events when patients refuse treatment or

advice, or seek an alternative clinical opinion, are made in the patient record. Contact

should also be made to the treating GP's medical defence organisation.


105

Patients are provided with sufficient information about the purpose, importance, benefits,

risks and possible costs associated with proposed investigations, referrals or treatments to

enable patients to make informed decisions about their health.

Patients in Distress

There may be times when patients present at the practice in a highly distressed state.

These patients require close monitoring and should be afforded dignity when seeking

help.

When a patient presents at our practice in a distressed state, staff escort the patient to a

spare room, usually a free consultation room or in the nurse room, alert the GP about the

situation and continue to monitor the patient until they can be seen by a member of the

clinical team. Patients are made comfortable by offering water or tissues.


5.10 Complaints

Policy

In our practice, customer satisfaction and patient experience is important to us. All patients

have the right to complain if they feel the service they received did not meet their

expectations.

We have a complaints resolution process which all staff can describe, and we also make

the contact details for the state or territory health complaints agencies readily available to

patients if we are unable to resolve their concerns ourselves. All complaints are attempted

to be resolved at a practice level. Only if a satisfactory outcome is not reached should the

complaint be directed to the Office of the Health Ombudsman.

Where possible patients and others are encouraged to raise any concerns directly with the

practice team who are trained to handle and respond to complaints. We believe most

complaints can be responded to and resolved at the time the patient or other people makes

them known to us.

Patients have the opportunity to remain anonymous if requested. Our practice complies

with relevant privacy legislation when responding and handling complaints.

All staff should be prepared to address complaints as they arise. Depending on the nature

of the complaint and advice received from medical indemnity company, complaints are


106

recorded and actioned within a central complaint’s register. A copy is placed in the

patient’s medical record if the complaint is related to patient care.

All clinical staff and the practice manager are aware of their professional and legal

obligations regarding the mandatory reporting of unprofessional conduct. Contact is

made with the GP's MDO and advice sought on the appropriate action in the event a

complaint relates to clinical care.

Procedure

Patients and others have opportunities to register their complaints either verbally to staff,

in writing (letter or email) or via our suggestion box. Patients should feel free to

complain anonymously if desired.

All staff are aware of the complaints management process and are trained to respond

appropriately.

When receiving complaints staff should keep in mind the following in order to minimise

further patient anxiety and hostility, possible leading to litigation:

handle all complaints seriously, no matter how trivial they may seem.

verbal complaints made in person should be addressed in a private area of the

practice where possible.

email or letters of complaint should be acknowledged within the first 24 hours.

address the patient’s expectations regarding how they want the matter resolved.

assure the patient that their complaint will be investigated and the matter not

overlooked.

offer the patients the opportunity to complete a formal complaint form. (They

may accept or decline).

All patients are made aware through the Practice Information Sheet and signage in the

practice waiting area, of their right to lodge a complaint and how they can make a

complaint. Brochures with contact details for the Office of the Health Ombudsman are

located in the waiting area and can be generated upon request by practice staff. The

Office of the Health Ombudsman contact details are also available on the Practice

Information Sheet.

It is the responsibility of the practice manager to collect, investigate and handle

complaints. The practice takes the following steps to handle complaints:

When a patient indicates they would like to make a complaint, ask if they would

like to complete a form.


107

If verbal, take the patient to a private area and document the details of their

complaint. Be sure to ask the patient if they would like to remain anonymous or

not.

Notify the team member responsible for complaints handling and record the

complaint in the register.

The person responsible for complaints handling should acknowledge receipt of

the complaint either via telephone, letter or email, to advise the patient of the

work you will be conducting to investigate the complaint.

If the complaint is of a clinical nature, contact the GPs MDO for advice and

appropriate action.

Investigate the complaint and work with the patient to achieve a mutually

beneficial outcome.

Discuss the complaint at a staff meeting or clinical meeting (if applicable).

Notify the patient or the whole patient population, of the outcome or relevant

changes to the practice as a result of the complaint.

Record details of the investigation and outcome in the complaints register.

If the matter cannot be resolved advise the patient about how to contact the Health

Complaints commissioner.

The National Privacy Commissioner is able to receive complaints concerning privacy

issues. Complaints here will have a response within 28 days.

National Privacy Commissioner

Privacy hotline 1300 363 000.

GPO Box 0021

Sydney NSW 2001

http://www.privacy.gov.au/complaints

Members of the public may make a notification to Australian Health practitioner regulation

agency (http://www.ahpra.gov.au/) (AHPRA) about the conduct, health or performance of a

practitioner or the health of a student. Practitioners, employers and education providers are all

mandated by law to report notifiable conduct relating to a registered practitioner or student to

AHPRA.


http://www.privacy.gov.au/complaints

http://www.ahpra.gov.au/

http://www.ahpra.gov.au/Notifications-and-Outcomes/Conduct-Health-and-Performance.aspx

http://www.ahpra.gov.au/Notifications-and-Outcomes/Conduct-Health-and-Performance/Health.aspx

http://www.ahpra.gov.au/Ancillary/Glossary.aspx#N


108

5.11 Non English Speaking Patients

Policy

Our doctors and staff have a professional obligation to ensure they understand our

patients and that the patients understand any verbal instructions or written information.

Patients who do not speak the primary language of our clinical staff or who have a

communication impairment, are offered the choice of using an interpreter service to assist

with clinical consultations. Our practice does not encourage the use of family members or

friends of patients to act as translators unless this is an expressed wish of the patient and

the health problem is only minor.

Our practice also accesses a number of translated health information to assist with

patients who have difficulties reading or understanding English.

Procedure

All patients are asked when registering with our practice if they require the service of a

translator or interpreter. These details are recorded on their medical record.

When a patient arrives at our practice with a friend or family member, we ask if they

consent to have them act as a translator and advise of alternative methods available. We

advise the patient that it is practice policy not to have family and friends act as

translators.

Staff are only encouraged to translate for patients in emergency situations or with the

patient’s expressed consent when dealing with minor health issues.

Whenever a translator is used during clinical consultations, this should be documented in

the patient health record.

A copy of the TIS contact list is available at reception. It is the responsibility of the

practice manager to ensure this list is updated regularly and to ensure all client access

codes are renewed before expiration.

RACGP 4th edition Standards2.1.1, 1.2.3, 2.1.3


109

5.11.1 Culturally Appropriate Care

Policy

We aim to identify important and significant cultural groups within our practice and have

implemented strategies to meet their needs.

In order to improve health outcomes we:

encourage and record when our patients choose to self-identify their Aboriginal or

Torres Strait Islander origin or cultural background to practice staff.

Encourage and record our patients ethnic and cultural background when patients

choose to identify with practice staff

Are able to access specific guidelines for the clinical care if patients who identify as

Aboriginal or Torres Strait Islander

Patient’s religious beliefs are respected to the best of our staffs ability. The practice has an

anti-discrimination policy which all staff are aware of.

Procedure

Our practice routinely encourages identifying and recording the cultural background of

our new and existing patients. Cultural background and ethnicity e.g. Aboriginal and

Torres Strait Islander background, can be an important indication of clinical risk factors

and can assist GP's and clinical staff in providing disease prevention and delivering

culturally appropriate care.

The standard indigenous status question asked is ‘Are you of Aboriginal or Torres Strait

Islander origin?’ This question should be asked of all patients, irrespective of appearance,

country of birth or whether the staff know of the client or their family background. Our

practice collects this information as part of our ‘new patient’ form.

Where our software has the option to input Aboriginal and/or Torres Strait Islander status or

cultural background/s we use the drop down options rather than free text to assist with

extracting the information for accreditation purposes or preventative activities.

Our practice staff and GP's have undertaken cultural awareness training to assist in the

development of culturally appropriate services at our practice. Our practice also collects and

records information on patient ethnicity and languages spoken to assist with delivering

clinical care appropriately.

RACGP 4thedition Standards 1.4.1, 1.7.1, 2.1.1


110

5.12 Directory of Local Health and Community Services

Policy

Our practice engages with a range of health, community and disability services to plan

and facilitate optimal patient care to patients whose health needs require integration with

other services.

A readily accessible written and computerised directory of health and community

services, utilised by patients within our area, including how to refer or contact these

agencies, is maintained and updated regularly. It is the responsibility of the practice

manager to ensure this database is updated and maintained on a regular basis.

GP's and other clinical staff are encouraged to advise the person responsible to maintain

the database if new providers are to be included.

Clinical staff are encouraged to co ordinate patient care across the general practice setting

with other health services and to build good working relationships with these providers to

facilitate collaborative care

Procedure

This directory is located in our practice software – Medical Director. The contact numbers in this list are checked and updated annually or more often if

required, by receptionists and practice manager. All new staff are made aware of how to

access this list during their induction.

The directory of local health and community services lists:

local medical/diagnostic services.

local hospitals and specialist consulting services.

primary healthcare nurses.

pharmacists.

disability and community services.

health Promotion and public health services and programs.

relevant Government departments in the Region.

local allied health services.

community, social or self-help groups in the area.

culturally appropriate services for non-English speaking background and

Aboriginal and Torres Strait Islander patients.


111

Where possible, a brief explanation about any fees applicable, contact numbers or names

and procedures for interacting with these services is included on this list.

RACGP 4th Edition Standards 1.6.1

5.13 Provision of Brochures, Leaflets and Pamphlets for Patients

Policy

There is a range of posters, leaflets and brochures available or on display in the waiting

room, reception and/or consulting rooms. Where appropriate these are available in more

than one language or in formats to assist patients with intellectual impairment.

Leaflets, brochures and pamphlets can vary considerably in quality. The brochures used

by this practice are carefully selected and screened by clinical staff to ensure they are

culturally appropriate and contain current, evidence based information.

The quality and accuracy of any Audio visual resources or internet sites recommended to

patients or used to provide printed information to patients is also considered.

The brochures, posters, leaflets and pamphlets available include information about health

promotion, and illness prevention, specific diseases, medical procedures and privacy and

patient rights.

The doctors and clinical staff use written information during a consultation to:

support diagnosis and management of conditions.

for health promotion and illness prevention

Brochures and educational materials are also available for patients to self select.

Procedure

All health promotion and educational materials are carefully reviewed by members of the

clinical team to ensure they are consistent with the current best practice guidelines. Items

are obtained from reputable sources and, where possible, items should be dated, contain

the name of the source and referenced to supportive evidence.

Our practice regularly obtains brochures from these organisations:

Vaccination dates matter


112

At least annually we conduct an audit of our brochures, leaflets and patient information

sheets to ascertain if they are current and if better options are available.

Brochures and leaflets are displayed in the waiting room or in the consultation rooms as

well as via the medical television.

It is the responsibility of the practice manager to ensure that brochures are kept up to

date, discarded when no longer current and new brochures incorporated when available.

The provision of specific written material to support advice given in consultations is

encouraged to help patients remember the key messages from the consultation and

address individual patients’ needs.

RACGP 4th Edition Standards 1.2.3, 1.3.1, 1.4.1, 1.2.2


113

5.14 Practice Information Sheet

Policy

The Practice Information Sheet (PIS) provides patients with adequate information about

our practice to facilitate access to care. It is also a useful way to inform patients of current

practice policies or changes to our services. We endeavour to ensure all patients, new and

existing, are provided with the most up to date version to ensure the information they

have is accurate.

Our practice information sheet is made available at reception and is provided to all new

patients when registering with the practice.

If a patient is unable to read or understand our practice information sheet an alternative

method is used to supply this information. These may include:

verbally.

larger font versions (on request)

through the National Relay Service or AUSLAN for patients who are deaf.

through the translation and Interpreter service (TIS) for patients who speak

languages other than English.

Telephone messages, the on hold recording and our website is also used, where possible,

to reinforce some of the information about our practice and our services

Procedure

The practice information sheet is kept at reception; it is available to all patients and

handed to each new patient on their first visit.

Where patients are unable to read or understand our written sheet we use other means to

communicate the essential information.

To maintain the accuracy of our information sheet it is reviewed regularly and updated as

required. When this sheet is updated the date is inserted in the footer to denote the latest

version. Reception staff are advised there has been a change and are encouraged to bring

this new version to the attention of our patients. It is the responsibility of the practice

manager to review and update the practice information sheet.

The Practice information sheet contains at a minimum:

practice address and phone numbers


114

consulting hours and arrangements for care outside our normal opening hours,

including a contact telephone number.

our practice’s billing principles such as bulk billing, accounts settlement,

approximate cost for treatment, potential out of pocket expenses.

our practice’s communication policy including receiving and returning phone

calls and electronic communication (e.g. SMS & email).

our practices policies for the management of patient health information including

that patients can obtain a copy of their health information and where additional

posters or the full privacy policy can be obtained from the practice.

the process for the follow up of results e.g. who will contact whom and by when.

how to provide feedback or make a complaint to the practice (include the contact

for the local state health complaints conciliation body and the name of the person

responsible for feedback and complaints).

Additional information on the practice information includes:

names and qualifications or special interests of doctors, nurses, allied health and

other practice team members (subject to their consent).

clinical and other services available.

that they can request a summary of the policy on home, hospital, and nursing

home visits.

inform patients that longer consultations are available on request.

encourage ways in which patients can give feedback (e.g. tell patients if you have

a suggestion box).

how patients are able to request their preferred doctor.

inform patients about your reminder systems and the option of opting out of

receiving reminders.

information about how patients can assist by telling the practice if their personal

information changes e.g. changed address or provide any court documentation to

advise any child custody arrangements.

where the practice has a website it should contain at a minimum, the information

required in the practice information sheet. The website information should be

accurate and updated regularly.

It is the responsibility of the practice manager to ensure copies of the practice information

sheet are available at reception.


5.15 Office Supplies


115

Policy

Supplies of stationery, other office and Practice stores including prescription pads,

letterhead, certificates etc. are accessible only to authorised persons.

Practice office equipment and facilities are appropriate for its purpose and are safe to use.

Regular audits are conducted to review the safety and security of practice equipment and

stationery supplies.

Facsimile, printers and other electronic communication devices in the practice are located

in areas that are only accessible to the general practitioners and other authorised staff.

Faxing is point to point and will therefore usually only be transmitted to one location

Procedure

It is the responsibility of the practice manager to monitor the safety and security of

practice equipment and office stationery supplies.

Sensitive practice stationary such as prescription pads and letterheads are located in a

locked cupboard and are only accessible by authorised staff.

Reports of broken practice equipment or low levels of office supplies are made to the

practice manager to rectify the situation.

RACGP 3rd edition Standards 5.1.1


116

6 Privacy and Personal Health Information

6.1 Privacy and Security of Personal Health Information

Policy

This practice is bound by the Federal Privacy Act 1998 and National Privacy Principles,

and also complies with the New South Wales Health Records and Information Act 2004.

‘Personal health information’ is a particular subset of personal information and can include

any information collected to provide a health service.

This information includes medical details, family information, name, address, employment

and other demographic data, past medical and social history, current health issues and future

medical care, Medicare number, accounts details and any health information such as a

medical or personal opinion about a person’s health, disability or health status.

All patient health information is considered private and confidential. Disclosure of

patient health information is not conducted without the consent of patient’s and the GP's.

Any information disclosed without consent will result in disciplinary action and possible

dismissal of staff.

All staff working within the practice have signed confidentiality agreements as

conditions of their employment. Information security is discussed at staff induction and

continued education occurs throughout employment.

When patient health information is computerised, electronic measures have been taken to

ensure the safety and security of this information. The person responsible for Information

Technology/Information Management (IT/IM) is Ramtech who is charged with the

coordinating, implementing and monitoring these measures.

Our practice complies with both state and federal privacy legislation relating to medical

records. Our practice also complies with the National Privacy Principles.

For each patient we have an individual patient health record containing all clinical

information held by our practice relating to that patient. The practice ensures the protection of

all information contained therein. Our patient health records can be accessed by an

appropriate team member when required. We also ensure information held about the patient in

different records (e.g. at a residential aged care facility) is available when required.


117

Procedure

In our practice, patient health information is kept using an electronic filing system/ using

a combination hybrid system.

For records stored electronically, the following procedures are in place to protect patient

health information:

all staff have individual logins and passwords

staff have restricted levels of access to patient health information depending on

their role

computer screens are located in positions where patient view is obstructed or

blocked

screensavers and automated computer locks are activated during periods of

inactivity

appropriate firewalls and antivirus software is installed and updated regularly

all information electronically communicated is done so using an encrypted

network.

Our practice policy has a documented privacy policy for the management of patient health

information which is available to patients upon request and displayed within the waiting area

or in the Practice Information Sheet. The policy outlines the following:

practice contact details

what information is collected

reason for the information to be collected

how the security of information is maintained

range of people who may access the information

procedures for access, transfer and disclosure to a third party

contact details if they believe there has been a privacy breach with their information

The maintenance of privacy requires that any information regarding individual patients,

including staff members who may be patients, may not be disclosed either verbally, in

writing or in electronic form, except for strictly authorised use within the patient care

context at the practice or as legally directed.

Whenever sensitive documentation is discarded the practice uses an appropriate method of

destruction including shredding or security bin. Electronic information is securely destroyed

using appropriate electronic equipment and processes.


118

Hybrid Record Systems

Our practice uses a hybrid record keeping system for patient medical files. To ensure

continuity of care and completeness of the medical record, we ensure that there is a record in

each system indicating where the clinical consultation notes and reports are recorded.

RACGP 4thedition Standards 4.2.1, 1.7.1, 1.2.1, 4.2.2

6.2 Computer Information Security

Policy

Our practice has systems in place to protect the privacy, security, quality and integrity of the

data held electronically. Doctors and staff are trained in computer use and our security

policies and procedures. Additional training and policy updates occur when necessary changes

are made.

Ramtech has designated responsibility for overseeing the maintenance of computer security

and our electronic systems and these responsibilities have been documented in their position

description.

All clinical staff have access to a computer to document clinical care. For medico legal

reasons and accurate reporting, staff always log in under their own passwords to document

care activities they have undertaken.

Our practice ensures that all computers and servers used by the practice, comply with the

RACGP computer security checklist and that:

computers are only accessible via individual password access to those in the practice

team who have appropriate levels of authorisation.

computers have screensavers or other automated privacy protection devices are

enabled to prevent unauthorised access to computers.

servers are backed up and checked at frequent intervals, consistent with a documented

business continuity plan.

back up information is stored in a secure off site environment.

computers are protected by antivirus software that is installed and updated regularly

computers connected to the internet are protected by appropriate hardware/software

firewalls.

we have a business continuity plan that has been developed, tested and documented.

Electronic data transmission of patient health information from our practice is in a secure

format.


119

Our practice has the following information to support the computer security policy:

current asset register documenting hardware and software including software licence

keys

logbooks/print-outs of maintenance, backup including test restoration, faults, virus

scans

folder with warranties, invoices/receipts, maintenance agreements

Inappropriate use of the practices computer systems or breaches of practice computer security

will be fully investigated and may be grounds for dismissal.

This practice has a sound backup system and a contingency plan to protect practice

information in the event of an adverse incident, such as a system crash or power failure. This

plan encompasses all critical areas of the practice’s operations such as making appointments,

billing patients and collecting patient health information. This plan is tested on a regular basis

to ensure backup protocols work properly and that the practice can continue to operate in the

event of a computer failure or power outage.

Procedure

The person responsible for IT/IM has completed the RACGP Computer Security

Checklist and Self-Assessment. A computer security manual has been specifically

developed to assist with the computer security operations and is located with Ramtech.

Our disaster recovery folder stocked with items to enable the practice to operate in the event

of a power failure is located in the practice manager office and includes the following:

torches

paper prescription pads/medical certificates, etc

appointment schedule printout and manual book

letterhead

consultation notes

manual credit card/payment/Medicare processing equipment

emergency numbers

RACGP 4thedition Standards 4.2.1 & 4.2.2

6.3 Practice Privacy Policy

Policy


120

National Privacy Principle 5 requires our practice to have a document that clearly sets out its

policies on the collection, handling and storage of patient health information.

This document, commonly called the Privacy Policy, outlines how we handle personal

information collected (including health information) and how we protect the security of this

information. It must be made available to anyone who asks for it and patients are made aware

of this.

The collection statement informs patients about how their health information will be used

including other organisations to which the practice usually discloses patient health

information and any law that requires the particular information to be collected. Patient

consent to the handling and sharing of patient health information should be provided at an

early stage in the process of clinical care and patients should be made aware of the collection

statement when giving consent to share health information.

In general, quality improvement or clinical audit activities for the purpose of seeking to

improve the delivery of a particular treatment or service would be considered a directly

related secondary purpose for information use or disclosure therefore specific consent for this

use is not required.

Procedure

We inform our patients about our practice’s policies regarding the collection and management

of their personal health information via:

A sign at reception.

Brochure/s in the waiting area.

Our patient information sheet.

New patient forms – ‘Consent to share information’.

Verbally if appropriate.

The practice website.

A copy of our practice privacy policy is located at reception and is available to patients upon

request.

The practice features the following collection statement on each ‘New Patient’

registration form:

MAT Health Clinic Strathpine located at 130 – 134 Gympie Road, Strathpine, QLD, 4500

collects your personal details and health information to ensure we deliver the best

possible healthcare service. Patients are entitled to access their information at any stage

by contacting the practice or their GP. Your health information may be disclosed to other

organisations over the course of your treatment and these instances will be discussed with


121

you if required. Failure to provide accurate and comprehensive information could

negatively affect your healthcare. If you have any concerns regarding your privacy,

please contact the practice.

Prior to a patient signing consent to the release of their health information patients are

made aware they can request a full copy of our privacy policy and collection statement.

Patient consent for the transfer of health information to other providers or agencies is

obtained via a signed transfer form, which is then incorporated into the patient medical

record.

Documents which contain patient health information sent to other health care providers,

such as referrals, are discussed with patients prior to their distribution. All requests for

access to health information by patients are documented and incorporated into the

medical record.

All new patients signed registration form is scanned into their medical record/stored in

their medical file.

RACGP 4thedition standards 4.2.1

6.4 3rd Party Requests for Access to Medical Records/Health

Information

Policy

Requests for 3rd Party access to the medical record should be initiated by either: receipt of correspondence from a solicitor or government agency

by the patient completing a Patient Request for Personal Health Information

Form

Where a patient request form or and signed authorisation is not obtained the practice is

not legally obliged to release.

Where a patient does not provide consent for 3rd party access, the third party may seek

access under relevant privacy laws.

An organisation ‘holds’ health information if it is in their possession or control. If you have

received reports or other health information from another organisation such as a medical

specialist, you are required to provide access in the same manner as for the records you

create. If the specialist has written ‘not to be disclosed to a third party’ or ‘confidential’ on

their report, this has no legal effect in relation to requests for access under the Health Records


122

Act 2001. You are also required to provide access to records which have been transferred to

you from another health service provider.

We only transfer or release patient information to a third party once the consent to share

information has been signed and in specific cases, informed patient consent has may be

sought. Where possible de identified information is sent

Our practice team can describe the procedures for timely, authorised and secure transfer of

patient health information in relation to valid requests.

Procedure

Patient consent for the transfer of health information to other providers or agencies is

obtained on each individual occasion when a request is made.

As a rule no patient information is to be released to a 3rd Party unless the request is made

in writing and provides evidence of a signed authority to release the requested

information, to either the patient directly or a third party. Where possible de identified

data is released.

Written requests should be noted in the patient's medical record. Requests should be

forwarded to the patient’s GP for action.

Requested records are to be reviewed by the treating medical practitioner or principal doctor

prior to their release to a third party. Where a report or medical record is documented for

release to a third party, the practice may specify a charge to be incurred by the patient or third

party, to meet the cost of time spent preparing the report or photocopying the record. This fee

should be disclosed to the patient or third party at the time of the request.

The practice retains a record of all requests for access to medical information including

transfers to other medical practitioners.

A full patient record is never released unless specified for legal reasons, such as a subpoena. A

patient health summary is usually sent to another health care provider and additional reports

or results as required.

Security of any health information requested is maintained when transferring requested

records and electronic data transmission of patient health information from our practice is

in a secure format. A courier service or traceable registered post service is used to send

records to a third party.

The practice’s medical defence organisation is always contacted for advice prior to the

release of patient health information.


123



124

6.5 Request for Access to Personal Health Information

Policy

Patients at this practice have the right to access their personal health information (medical

record) under the Commonwealth Privacy Amendment (Private Sector) Act 2000 and the

Information Privacy Act 2009. The Act gives individuals a right of access to their personal

health information held by any organisation in the private sector in accordance with National

Privacy Principle 6 (NPP 6). This principle obliges health service providers and other

organisations that hold health information about a person to give them access to their health

information on request, subject to certain exceptions and the payment of fees (if any).

Public sector organisations continue to be subject to the Freedom of Information Act 1982.

This practice complies with both laws and the National and Health Privacy Principles (NPPs

& HPPs) adopted therein. Both Acts give individuals the right to know what information a

private sector organisation holds about them, the right to access this information and to also

make corrections if they consider data is incorrect.

Reports from specialists and diagnostic results form part of a patient’s medical record and

therefore are provided under access regulations.

Amendments to the Privacy Act 1998 apply to information collected after 21st December

2001, however they also apply to data collected prior to this date provided it is still in use

and readily accessible.

We respect an individual's privacy and allow access to information via personal viewing

in a secure private area. The patient may take notes of the content of their record or may

be given a photocopy of the requested information. A GP may explain the contents of the

record to the patient if required. An administrative charge may be applied, at the GPs

discretion, e.g. for photocopying record, X-rays and for staff time involved in processing

request.

Procedure

Our patients are advised of their right to access their personal information via our privacy

policy. Our privacy policy is available to patient upon request.

Release of information is an issue between the patient and the doctor. Information will

only be released according to privacy laws and at doctor's discretion. Requested records


125

are reviewed by the medical practitioner prior to their release and written authorisation is

obtained from the patient.

When our patients request access to their medical record and related personal information

held at this practice, we document each request and endeavour to assist patients in

granting access where possible and according to the privacy legislation. Exemptions to

access will be noted and each patient or legally nominated representative will have their

identification checked prior to access being granted.

A Request for Personal Health Information form is completed by the patient and a copy

is incorporated into the patient health record.

Request by another (not patient)

An individual may authorise another person to be given access, if they have the right e.g.

legal guardian, or if they have a signed authority. Under NPP 2 Use & Disclosure, a

'person responsible' for the patient, if that patient is incapable of giving or communicating

consent, may apply for and be given access, for appropriate care and treatment or for

compassionate reasons. Identity validation applies.

The Privacy Act 1998 defines a 'person responsible' as a parent of the individual, a child

or sibling of the individual, who is at least 18 years old, a spouse or de facto spouse, a

relative (at least 18 years old) and a member of the household, a guardian or a person

exercising an enduring power of attorney granted by the individual that can be exercised

for that person's health, a person who has an intimate relationship with the individual or a

person nominated by the individual in case of emergency.

Each request for access is acknowledged and the specific needs for access are discussed

between the GP and the patient. If a fee will be charged for granting access or preparing

records, this will be discussed with the patient prior to access being granted. Fees are not

excessive and aim to cover any administrative costs.

Before the release of any health information, the GP will contact their MDO to assess

whether data should be withheld. In cases where an access request or data is being

denied, it will be documented in writing and sent to the patient outlining reasons for this

decision.

Personal health information may be accessed in the following ways:

view and inspect information

view, inspect and talk through contents with the doctor

take notes

obtain a copy (can be photocopy or electronic printout from computer)


126

listen to audio tape or view video

information may be faxed to patient

Before any access is granted, the identity of the patient should be confirmed using 3

approved patient identifiers. If access is granted to a guardian, their identity and authority

must also be checked.

If the patient is viewing the data, supervise each viewing so that patient is not disturbed

and no data goes missing.

If a copy is to be given to the patient ensure all pages are checked and this is noted in the

request form.

If the doctor is to explain the contents to a patient then ensure an appointment time is

made.


6.6 Medical Records Administration Systems

Our practice uses a Hybrid system to manage Patient medical information. This system

comprises of paper based records and computer records via Medical Director.

For all consultations, important communications or correspondence related to a patient

whose record is part of the hybrid system, a record is made in each system indicating

where the consultation notes are recorded.

Before entering, accessing or actioning anything from a patient health record on the

practice system, practice staff correctly identify each patient using three approved patient

identifiers. The approved identifiers include:

Patient name (both first and surname)

Date of birth

Gender (as determined by the patient)

Address

Patient health record number (where one exists)

All referral letters written by the practice also contain at least three approved identifiers.

This policy also applies to all patient medical records accessed via telephone enquiries.


127

Procedure

At each encounter with a patient, whether in person or over the telephone, patients are

asked to state their name, date of birth and address.

Practice staff are cautious not to volunteer their information for confirmation to avoid

errors. All patients regardless of how well known they are to practice staff are asked to

state these details.

All referral letters written by the GP's of our practice contain at least three approved

identifiers.



128

6.7 Retention of Records and Archiving

Policy

Our practice refers to state and federal legislation regarding the length of time a medical

record must be retained.

For children, records must be kept until the child reaches the age of 25 years old. All

other records must be kept for a minimum of 7 years from the last date of contact.

Other records relating to restricted or controlled drugs, sterilisation and human resources

are kept for the same period as medical records.

Our practice conducts a regular process of culling patient health records on a yearly basis.

Our practice also conducts a regular process of identifying and inactivating patient

records.

An inactive patient record is considered someone who has not visited the practice or

accessed services at least three times in the past two years.

All records are destroyed in a secure manner to protect the privacy of patients and advice

is sought from the practice MDO before disposal.

Procedure

All inactive paper-based medical records are stored in the practice manager office.

Electronic medical records are designated as inactive using the clinical desktop software.

It is the responsibility of the practice manager to conduct a regular culling process for

patient medical records.

All paper-based medical records no longer required to be kept are destroyed using a

secure destruction method. Our practice uses Grace Shredding to securely destroy

records.

If this process is undertaken by an external organisation, the practice manager will obtain

a certificate of destruction.



129

6.8 Transfer of Medical Records

Policy

Transfer of medical records from this practice can occur in the following instances:

for medico-legal reasons e.g. record is subpoenaed to court.

when a patient asks for their medical record to be transferred to another practice

where an individual medical record report is requested from another source.

where the doctor is retiring and the practice is closing.

Our practice team can describe the procedures for timely, authorised and secure transfer of

patient health information to other providers and in relation to valid requests.

Procedure

In accordance with state and federal privacy regulations, a request to transfer medical

records must be signed by the patient giving us authority to transfer their records.

The request form should contain:

the name of the receiving practitioner or practice.

the name, address (both current and former if applicable) and date of birth the

patient whose record is required.

the reason for the request.

When fulfilling a request, this practice may choose to either

prepare a summary letter (manually or via clinical software) and include copies of

relevant correspondence and results pertinent to the ongoing management of the

patient.

make a copy of the medical record and dispatch the copy to the new practice,

retaining the original on site for a minimum of 7 years.

The requesting clinic is advised if we intend to transfer a summary or a copy of the full

medical record. All attempts are made to ensure that the format is preferred by the

practitioner/practice.

If there is going to be any expenses related to the transfer, the requesting clinic and the

patient, are advised prior to sending the medical records. Once payment of the fee has

been received, staff then process the request as soon as possible.

Any charges must not exceed the prescribed maximum fee.


130

The patients’ signed request letter/form and a notation when the record was transferred is

made on the medical record retained by our practice. Details about the receiving practice,

date and method of transfer are also documented.

Electronic data transmission of patient health information from our practice is in a secure

format.

All reasonable steps are taken to protect the health information from loss and

unauthorised disclosure during the transfer.

This practice does not allow individuals to collect the file and take it to their new

provider.



131

7 Clinical Management

7.1 Clinical Autonomy

Policy

Doctors in this Practice are free to make decisions that affect the management of their

patients in accordance with accepted clinical judgement, best available evidence and

adherence to valid clinical care guidelines.

Doctors exercise full autonomy in determining:

the appropriate clinical care of their patients.

the health professionals including specialists, other general practitioners and

para-medical practitioners to whom they refer.

the pathology, diagnostic imaging or other investigations they order and the

provider they use.

how and when to schedule follow up appointments with individual patients.

whether to accept new patients provided that this action is non-discriminatory and

does not apply to emergencies.

Feedback is sought from doctors and other staff concerning the use of practice

equipment, appointment scheduling and other matters relating to professional autonomy.

All members of the clinical team comply with their professional and ethical obligations

and practice within the boundaries of their knowledge, skills and competence, and their

role within the practice team.



132

7.2 Clinical Content of Medical Records

Policy

Each patient at our practice has their own individual patient health record containing all

the health information held by our practice about that patient.

Our practice can demonstrate that the following actions are being completed by staff:

recording the emergency contact of all patients

recording the Aboriginal and Torres Strait Islander status of patients who wish to

self-identify

recording other cultural backgrounds of patients

recording the allergy status, including ‘no known allergies’, of all patients

updating and monitoring the accuracy of patient health summaries

recording the preventative health care status of patients wherever possible.

The new patient and update patient details form attempt to capture this information to be

incorporated into the patient record.

Procedure

In our practice, our record keeping system is fully electronic/ hybrid combination system.

All staff members responsible for delivering clinical care have appropriate levels of

access to make clinical notes. Clinical staff are required to document all important

communications with patient in their designated health record. Documentation should

also be sought from practitioners who provide care on behalf of the practice or care

which takes place outside the practice premises.

At a minimum, consultation notes will include:

Date of consultation

Patient reason for consultation

Relevant clinical findings

Diagnosis

Recommended management plan and, where appropriate, expected process of

review

Any medicines prescribed for the patient

Complementary medicines used by the patient


133

Any relevant preventative care undertaken

Any referral to other healthcare providers or health services

Any special advice or other instructions

Who conducted the consultation

At a minimum, patient health summaries will include:

Adverse drug reactions

Current medicines list

Current health problems

Relevant past health history

Health risk factors (smoking, nutrition, alcohol and physical exercise)

Immunisations

Relevant family history

Relevant social history including cultural background where clinically relevant

All referral letters, correspondence and reports/results relating to patients will be

incorporated into their medical record.

Practice staff who contact the patient for following up care or results, must document in

the patient health record all attempts to contact patients.

Wherever possible, records must be legible and of a standard which will ensure

continuity of patient care across clinicians. All patient records are accessible by clinical

staff at the time of consultation.

All staff are provided with training during their induction and on an ongoing basis on

how to create and edit patient records.

RACGP 4th edition Standards 1.7.1, 1.7.2, 1.7.3, 1.1.3, 1.1.4, 1.5.1

7.3 Informed Consent

Policy

Our doctors, nurses and other healthcare workers inform their patients of the purpose,

importance, benefits, risks and possible costs of proposed investigations referrals or

treatments, including medications and medicine safety. We believe that patients need to

receive sufficient information to allow them to make informed decisions about their care.


134

When communicating to patients the risks, benefits, importance and purpose of proposed

treatments or investigations, the following factors are taken into consideration:

Language barriers including written material in languages other than English

Patient’s ability to provide comprehensive understanding and informed consent

Whether a third party is responsible for care

In situations where patients are dependent on a third party for their ongoing care we

endeavour to provide all appropriate information to the carer.

Issues of personality, personal fears and expectations, beliefs and values are also

considered.

Our clinical staff utilise written material including diagrammatic representations to assist

patients to understand the proposed treatments/investigations. In cases where this has

occurred, records are made in the patient health file.

Patients are advised of possible costs involved, including additional out of pocket costs,

for procedures, investigations and treatments conducted on site prior to them being

conducted.

Patients are encouraged to seek alternative clinical opinions in the event they disagree

with the proposed activities of our clinical staff. Refusal to undergo proposed treatment

or expressed interest in seeking another clinical opinion are documented in the patient

health record.

Procedure

Clear communication is provided about the potential for out of pocket costs including any

unexpected developments and the possible costs of additional treatments or procedures

before proceeding.

All advice relating to proposed clinical care of patients is provided by clinical staff who

have adequate training to supply such information. Under no circumstances are

administrative staff to offer clinical advice or answer any clinically based questions from

patients. If deemed necessary, administrative staff may be asked to witness a patient’s

consent to a procedure once explanations have been provided by the clinical team.

Wherever possible, clinical staff utilise written material to support the explanation of the

costs, risk, benefits, purpose and importance of proposed treatments, medications,

investigations and procedures. In these situations, it is recorded in the patients medical

record when written material is used.


135

Patients who refuse or wish to seek further clinical opinion for treatment are free to do so.

It is recorded in the patient health file when patient refuse treatment or indicate they plan

to seek alternative opinions. In extreme cases, the treating clinicians MDO will also be

contacted and advice sought.

For children, all medical decisions will be made by parents until the GP has determined

the child is of age to make their own medical decisions. Carers of patients will be

included in the decision making process if the patient is deemed as being unable to make

their own decisions.


7.4 Referral Protocols

Policy

Patients may require the services of additional care providers external to the practice.

Whenever referral letters are written, the costs, benefits, risks, importance and purpose of

the referral is explained to the patient by the clinician. All referral documents are filed in

the patient’s medical record.

The practice has an up to date computerised directory of local allied health providers,

community and social services and also local specialists to assist when choosing

practitioners to facilitate optimal patient care.

Clinicians are aware of their obligations to provide sufficient clinical handover to other

health care providers when writing referrals and ensure that all information contained

within referral documents is accurate and up to date.

Patients are made aware that their health information is being disclosed in referral letters

and documents.

Procedure

Our directory of local allied health providers, community and social services and also

local specialists is available via Medical Director. It is the responsibility of the practice

manager to ensure database is updated and maintained.

For referred services where costs are not known, the patients are advised of the potential

for out of pocket expenses and encouraged or assisted to make their own enquiries. If the


136

patient indicates that the costs pose a barrier to the suggested treatment or investigation

alternatives may need to be discussed (e.g. referral to public services).

Special care is taken to advise patients of the costs of consultations or procedures that do

not attract a government subsidy.

Letters of referral are computer based. If referrals are to be sent electronically, the

practice ensures that this is performed in a secure manner to maintain patient privacy. All

referral letters are incorporated into the patient medical record either electronically or by

manual scanning.

In the case of an emergency or other unusual circumstance a telephone referral may be

appropriate. All telephone referrals need to be documented in the patient’s health record.

Referral letters should:

be legible (preferably typed) on appropriate practice stationary.

contain relevant history examination findings and current management

include any allergies, adverse drug reactions and a current accurate medications

list.

include the reason/purpose for the referral and expectation of the referral.

identify the Doctor or clinical staff member making the referral.

identify the setting from which the referral is being made

if known, identify the healthcare provider to whom the referral is being made and

the setting

be dated.

contain at least 3 of the approved patient identifiers e.g. name, date of birth and

address.

Clinically significant referrals are followed up.

RACGP 4th edition Standards 1.2.4, 3.1.4, 1.5.2, 1.6.1, 5.3.1, 1.6.2

7.5 Clinical Handover

Policy

Clinical handover has been defined by the Australian Medical Association as ‘the transfer

of professional responsibility and accountability for some or all aspects of a patient’s or a

group of patients’ care to another person or professional group on a temporary or

permanent basis’.


137

Failure or inadequate handover of care is a major risk to patient safety and a common

cause of serious adverse patient outcomes. It can lead to delayed treatment, delayed

follow up of significant test results, unnecessary repeat of tests, medication errors and

increased risk of medico legal action.

Clinical handover communications can be face-to-face, written, via telephone and also by

electronic means.

All staff are informed about our policy on clinical handover to ensure standard processes

are followed.

Clinical handover of patient care occurs frequently in general practice both within the practice

to other members of the clinical team, and to external care providers.

We have standard and documented processes for timely clinical handover with services

that provide care outside normal opening hours.

Procedure

Clinical handover needs to occur whenever there is a change of care providers. Examples of

clinical handover include:

a GP covering for a fellow GP who is on leave or is unexpectedly absent.

a GP covering for a part time colleague.

a GP handing over care to another health professional such as a practice nurse,

physiotherapist, podiatrist or psychologist.

a GP referring a patient to a service outside the practice.

a shared care arrangement (e.g. team care of a patient with mental health problems).

When appropriate, the clinical handover is documented in the consultation notes (where

possible).

Written or verbal clinical handover between GP's occurs on a formal arranged basis when

doctors cover for those working on a sessional basis or when a GP or other clinical staff

member is away because of annual leave or illness. In addition to a formal handover,

adequate clinical records, including a health summary and up to date medications list,

enable the routine care of patients to continue. Practitioners relieving for another should

read the patient’s preceding clinical records.

Clinical handover to external health care providers usually occurs through the provision of

referral documents. All referral letters contain sufficient information to facilitate optimal

patient care.


138

The practice should ensure that sufficient information is provided to the emergency

department about the clinical condition of an inbound patient, to facilitate prompt and

appropriate care. This may be directly to the ambulance service or to the hospital.

Deputising services are responsible for handing the care of a patient back to the patient’s

regular medical practitioner in a timely and appropriate manner. Our practice receives a

notification the following business day whenever a patient of our practice uses the

deputising service. This is incorporated into the patient file and adequately followed up.



139

7.6 Follow up of Tests, Results and Referrals

Policy

Our practice’s system for the follow up of tests, results and referrals has a strong focus on

risk management.

Our practice team can describe:

how patients are advised of the process for follow up of results.

the system by which pathology results, imaging reports, investigations reports

and clinical correspondence received by our practice is reviewed by a GP, signed,

acted upon in a timely manner and incorporated into the patient’s medical record.

how we follow up and recall patients with clinically significant tests, results or

correspondence.

All test results, including pathology results, diagnostic imaging and investigation reports,

and clinical correspondence received are reviewed, initialled (or electronic equivalent)

and, where appropriate, acted upon in a timely manner. This is all incorporated into the

patient health record.

All test results, pathology, imaging and investigation reports received by the practice are

reviewed, initialled and where appropriate, acted upon in a timely manner.

The nature and extent of the practices responsibility for the follow up of tests and results

will vary from case to case and will be determined by:

the probability that the patient will be harmed if follow up does not occur.

the likely seriousness of the harm.

the burden of taking steps to avoid the risk of harm.

In cases where patients have indicated they will not attend a recommended test or in

circumstances where the likely harm of non-attendance is high, the patients are flagged in

the reminder system by the treating GP. These patients should be followed up to ensure

that recommended test are carried out or the situation documented in the patient health

record.

The need to recall patients should be considered in the overall context of the patient

including their history and significance of the health issue. The treating GP or their

designated representative is the person who is responsible for making the decision on

which patients to recall.


140

When contacting patients for the follow up of results, our practice will attempt to contact

the patient by telephone three times before sending a letter to their designated address.

All attempts are documented in the patient’s medical record.

Sometimes our doctors may need to be contacted outside normal working hours by the

pathology service about a serious or life threatening result. We have provisions for

doctors to be contacted after hours for life threatening or urgent results.

Our patients (or their carers) are made aware of their obligations and responsibilities for

their own healthcare. This includes being informed about how to obtain their results and

the seriousness of not attending for ordered appointments/investigations and any recall or

subsequent follow up. Where appropriate this advice may be documented in the patient’s

medical records.

In addition to an appreciation of the need for timeliness when following up and actioning

referrals, tests and results, our staff members are also aware of the need for

confidentiality and discretion with regard to referrals, diagnostic tests and results or

correspondence.

Procedure

Please see the practice manual in Share drive

Your practice procedure must outline how the practice:

ensures timely action of follow up

ensures that GPs initial all results before being filed. This includes the electronic

equivalent

ensure that results are incorporated into the patient record

identifies the team members responsible for each step of the system

manages non-response from patients

ensure continuity if care for patients including how it is incorporated into the

medical record

ensures patient privacy when following up results



141

7.7 Reminder Systems for Preventative Care

Policy

We are working towards a systematic approach to the entry of patient data in the medical

records to facilitate the search, extraction and utilisation of patient information for our

prevention and screening activities. This includes comprehensive patient health

summaries and documentation of preventative activities in the patient’s medical records.

Consideration of patient’s individual circumstances is encouraged when providing

information about health promotion and illness prevention for patients (and carers).

Verbal and written information is provided to patients about health promotion and

specific disease prevention. This is distinct from the education and information that is

provided to patients to support a diagnosis and choice of treatment.

Wherever possible, our practice coordinates with other health care services and state

registers including:

List all registries that the practice participates in

We also maintain specific disease registers through our clinical desktop system as part of

our commitment to chronic disease management.

Patient permission is sought before placing their name on a proactive reminder system

and this permission is recorded on the patient file. Details of how the patient can opt out

of this system are also available to the patient via the new patient registration form.

Procedure

Please see the practice manual in Share drive

You may want to include the following:

an outline of the roles of administrative and clinical staff,

how you select patients,

how you search clinical data e.g. any data extraction tool used,

how you ensure all staff are aware of preventative activities,

samples of letters or the templates used

list specific risk factors or diseases you target



142

7.8 3rd Party Observing or Clinically involved in the

Consultation

Policy

Consent must always be obtained from patients prior to a 3rd Party Observing or being

clinically involved in the consultation.

This includes medical or nursing students, a person included at the doctor’s request, an

interpreter or person to assist with communication, a chaperone, or someone accompanying

the patient to the consultation at the patient’s request such as a carer or relative.

In some circumstances the patient or the GP may feel more comfortable if there is a chaperone

present during the consultation. For medico legal reasons it is recommended to consider

offering a chaperone for unaccompanied children.

Procedure

Wherever possible, we ask the patient to consent to a 3rd Party being present during the

consultation when making the appointment and confirm that this consent remains upon arrival

for their appointment.

Where prior consent was not obtained, the patient is asked to consent to the presence of a 3rd

party before entering the consultation room. It is not acceptable to ask permission for a 3rd

party to be present during the consultation in the consulting room as some patients may feel

unable to refuse.

Practice staff are mindful of the particular needs of people with intellectual disabilities

who may not be able to provide consent. In such cases a legal guardian or advocate may

need to be appointed to oversee the interests of the patient.

Our practice uses signage or other written information to inform patients about the

presence of medical or nursing students.



143

7.9 Practice Participation in Research Projects

Policy

Our practice does participate in external research projects.

Whenever any member of our practice team is conducting research involving our

patients, we can demonstrate that the research has appropriate approval from an ethics

committee. The research protocol, consent procedures and process for resolving problems

is retained by the practice.

When we collect patient health information for quality improvement audits or professional

development activities, we only transfer de-identified patient health information to a third

party. Whenever identifiable patient information must be transferred, we always seek patient

consent prior to transmission and ensure the privacy of information is maintained.

Procedure

Research projects involving patient care:

must have the explicit and documented written consent of the patient

the patient must receive a written and oral explanation about the research and be able

to withdraw consent at any time

the project must be approved by a relevant human research ethics committee (HREC)

established under the NH&MRC guidelines.

privacy laws must be adhered to

The practice should retain a record of the request for participation in any research project,

including the research protocol, consent procedures and process for resolving problems

should be retained by the practice.


7.10 Management of a Patient Refusing Treatment or Advice

Policy


144

This practice takes an active approach to ensure the best outcomes for patients at all times

even if they choose to reject investigation and/or management advice.

Our practice endeavors to help our patients understand the importance of medicines and

treatment advice to help them make informed decisions about their health care.

Our clinical team can demonstrate how we provide care for patients who refuse a specific

treatment, advice or procedure.

Procedure

Staff and doctors are to respect the right of all patients to make investigation and treatment

choices or to seek a further clinical opinion.

Patients should be advised to notify their doctor or nurse if they plan to seek another clinical

opinion. Patients should also be advised that if they choose to follow another healthcare

providers management plan, to notify their doctor or nurse.

An appropriate risk management strategy to be followed includes ensuring that:

The patient has been provided with the full range of options available, including the

risks and benefits of each to enable them to make an informed choice.

The consequences of the choices made are explained including those of

non-investigation and treatment.

Documentation of the explanation and actions taken by the patient should be made in

the patient medical record.



145

7.11 Refusal to Treat a Patient

Policy

The practice or individual clinical team members have the right to refuse to treat patients in

defined circumstances. Our practice ensures arrangements are made for the timely transfer of

the patients care to another member of the clinical team either within our practice or to

another healthcare service.

Procedure

GP's or other clinical staff may refuse to treat patients for a number of reasons including:

Threatening or violent patient behaviour

Breakdown in the therapeutic relationship

Patient healthcare needs are outside the scope of the practitioner

Scaling back the practice patient load

Any refusal to treat a patient is done for substantial reasons not based on discrimination.

Patients in emergency situations will always be treated to the best of our ability. Emergency

medical treatment is defined as treatment that is necessary to:

save a patient’s life

prevent serious damage to health

prevent or alleviate significant pain or distress

An appropriate risk management strategy to be followed in these circumstances includes

ensuring that:

the patient has been provided with reasons about why they cannot have ongoing

treatment at this clinic.

the patient has been provided with alternative possible treatment locations and written

referrals, if appropriate.

any complaints that may arise are dealt with according to the complaint’s procedure.

full documentation of the actions taken above in the medical record is essential.

Our practice will endeavor to assist such patients with ongoing care including referral to other

health care providers and transfer of any medical history.



146

7.12 Practice Equipment

Policy

Our practice has all the necessary equipment to provide comprehensive primary care and

emergency resuscitation. The practice staff ensure that these are maintained, safe and in a

serviceable condition at all times.

The available equipment is sufficient for the procedures commonly performed within our

practice and meets the needs of our patients.

All equipment that requires calibration or is electrically or battery-powered, are maintained

according to manufacturer’s instructions and are documented on a maintenance schedule.

Members of the clinical team are consulted about the equipment and supplies the practice uses

or purchases.

Our practice has timely access to spirometry and electrocardiography via our internal

equipment.

Procedure

The practice has the necessary medical equipment to ensure comprehensive primary care and

resuscitation, including the following:

Auriscope

blood Glucose monitoring equipment

disposable syringes and needles

equipment for resuscitation, equipment for maintaining an airway (including airways

for children and adults), equipment to assist ventilation (including bag & mask), IV access,

and emergency medicines

examination Light

eye examination equipment (e.g. fluorescein eye staining)

gloves (sterile & non-sterile)

height measurement device

at least one height adjustable patient examination couch

measuring tape

monofilament for sensation testing (10g Nylon)

ophthalmoscope

oxygen

patella hammer

peak flow meter or Spirometer

scales


147

spacer for inhaler

specimen collection equipment

sphygmomanometer (small, med and large cuffs)

stethoscope

surgical Masks

thermometer

torch

tourniquet

urine testing strips

vaginal Speculum

visual acuity charts

x Ray viewing facilities

Our practice also has the following additional equipment based on the particular needs and

interests of our clinical team:

Defibrillator

Relevant staff are trained in the care, use and maintenance of equipment and where

appropriate to analyse and interpret any results.

Liquid Nitrogen and oxygen are hazardous materials and are therefore stored securely and

staff are trained in their safe use.

The maintenance schedule for equipment is kept in the treatment room. It is the responsibility

of the practice nurse to schedule regular equipment maintenance and to document these in the

schedule.

RACGP 4thEdition Standards 1.4.2 & 5.2.1


148

7.13 Doctor’s Bag

Policy

All of our doctor’s have access to a fully equipped doctor’s bag for emergency care and

routine off site visits. When not in use, the doctor’s bag is stored securely and checked on

a regular basis.

In some instances doctors may share a doctor’s bag or items may be kept in two smaller

bags. Required items may be added to the bag prior to use to avoid doubling up on

equipment. Where doctors’ bags are shared, the arrangements are reviewed on an ongoing

basis to ensure that doctors have access to a bag when required. Additional bags are

purchased if required.

Sensible security measures are taken at all times and any relevant legislation or

regulations relating to S8, S4 and drugs of dependence are adhered to.

The doctors should consider the practice location, health needs of the community and the

type of clinical conditions likely to be encountered when determining the contents and

drugs to be kept in the doctor’s bag. Regular checks should be performed to stock the

supplies and dispose of expired stock.

Procedure

When attending an off site consultation or emergency each doctor has a fully equipped

doctor’s bag containing:

auriscope

disposable gloves

equipment for maintaining an airway in both adults and children

in date medicines for medical emergencies

opthalmoscope

practice stationary (including prescription pads and letterhead)

sharps container

sphygmomanometer

stethescope

syringes and needles in a range of sizes

thermometer

tongue depressors

torch


149

It is the responsibility of the practice nurse to stock take and replenish items from the

doctor’s bag on quarterly basis. Ideally, the doctor’s bag should be re-stocked after each

use.

The bag contents, including equipment and stock levels of drugs, are systematically

checked. All drugs must be “in date” and the dangerous drug register accurate and

completed. Any out of date items are discarded as per policy.

When not in use the doctor’s bag is stored securely in the treatment room or with the

individual doctor. If stored with a doctor’s personal items, arrangements are made for the

secure storage of the bag whilst the GP is on leave.

RACGP 4thEdition Standards 5.2.2

7.14 Vaccine Storage

Policy

We ensure that all vaccines are acquired, stored, administered, supplied, and disposed of in

accordance with the manufacturer’s directions and jurisdictional requirements.

Vaccine storage requires constant maintenance of the 'cold chain' to ensure vaccine potency.

The 'cold chain' refers to the system of transporting and storing vaccines within the safe

temperature range of between 2ºC – 8ºC.

Vaccines are subject to regular stock rotation and checks for expiry dates.

The fridge used for vaccine storage is maintained in accordance with our equipment schedule

We have a staff member with designated responsibility for ensuring our cold chain

management processes comply with the current edition of the national vaccine storage

guidelines (Strive for 5, 2nd edition 2013) and for conducting an annual audit of our vaccine

storage procedures. This role is defined in their position description.

Procedure

Tasks associated with maintaining the cold chain of vaccine storage may be delegated to other

staff members, however Stephen Taylor has primary responsibility to: ensure our vaccine storage procedures comply with the “National Vaccine Storage

Guidelines”.

communicate these guidelines to staff and develop documentation of the procedures.

provide adequate training to other staff appropriate for their role


150

ensure there is a process for handing over the cold chain responsibility to another

designated person when they are unavailable to perform their duties.

conduct an annual self audit of our vaccine storage (Using the self audit tool in the

National Vaccine Storage Guidelines; Strive for 5 appendix)

to ensure appropriate actions are taken if the temperature has been outside the

recommended range.

maintain the vaccine storage equipment and temperature recording thermometer.

Maintenance of cold chain within the practice

The vaccine storage guidelines as outlined in “National Vaccine Storage Guidelines-

Strive for 5, 2nd ed 2013 should be adhered to.

Refrigerator door openings should be kept to a minimum.

Stephen Taylor is the person designated with the responsibility for overseeing all

vaccine procedures.(Checking refrigerator, ordering stock, and receiving stock) and assisting

with implementation and evaluation of protocols.

Nursing staff are responsible for counting vaccine stock, checking expiry dates and

rotating stock on a weekly basis to ensure those with earlier expiry dates are used first.

Each nursing staff member is responsible for accounting for stock control as they

administer vaccines

Education and update information should be available to all staff handling the

vaccines

Food should NOT be stored in the same refrigerator as vaccines

Vaccines should be kept in their boxes

Do Not over stock fridge

Record the fridge temperature twice daily on relevant chart

Maintenance of cold chain away from practice

Advise patient purchasing their vaccines from a pharmacy to make prior arrangements

to collect their vaccines immediately before their appointment and insulate them to prevent

warming. Most pharmacy’s supply an insulated disposable bag for transport.

Emergency management of vaccines

Refer to information provided in the National Vaccine Storage Guidelines Strive for 5

2nd ed 2013 ( How to manage a power failure and off site immunization procedures for

transportation of vaccines)

Procedures for Temperatures NOT within 2 degrees C to 8 degrees C If the fridge temperature falls below 2 degrees C or above 8 degrees C for

more than 20 minutes notify nursing staff member on duty. This person should immediately:-


151

For government funded vaccines , contact the Department of health on 1800

882 000 or download cold chain breach forms from the DH website For privately purchased vaccines , contact vaccine manufacturers. Advise all staff that the vaccines from the fridge are unavailable for use

pending advice from DH and place a sign on the fridge to this effect. DO NOT DISCARD VACCINES . Implement any action directed from the Department of Health.


7.15 Medication Prescribing and Administration

Policy

Our clinical team ensures that at each patient encounter where medications are prescribed

or discussed, patients are adequately informed about the purpose, importance, benefit and

risks of their medicines. Patient’s ability to comprehend verbal and written material is

taken into consideration and the use of translators is considered, where appropriate.

As part of our clinical team’s ongoing professional development and commitment to

contemporise medical practice, all clinical team members can demonstrate access to

current medicines information and prescribing guidelines.

Medications lists for each patient are updated by a member of the clinical team at every

patient encounter. Patient allergies are also recorded in each patient file to minimise risk

of negative drug interactions.

Patient education is an important element whenever medications are prescribed. Written

material such as consumer medicines information, are used to help patients understand

their medication and this is documented in the patient health record.

Procedure

To reduce the risk of medication errors when prescribing or referring, all GP's and

clinical staff take the following steps:

update the patient medication list at each patient encounter including removing

single-use medications

Discuss the risks, benefits, importance and purpose of all prescribed medications

Provide written materials to support verbal discussions with patients regarding

medications


152

Record patient allergies in the medical record and confirm at each prescribing

encounter

Where appropriate, provide patients with a copy of their medications list

Enquire and record the complimentary medications status of all patients

If required, use translators or translated material to assist patients to comprehend

medication instructions and information

These activities are recorded in the patient’s medical record whenever they are

undertaken.

Our clinical team currently has access to the following prescribing guidelines and

resources:

MIMS online

Australian Therapeutic Guidelines

NPS MedicineWise

Australian Medicines Handbook



153

7.16 Controlled Substances

Policy

Schedule 4 and Schedule 8 poisons (inc. doctor’s bag emergency drugs, professional samples

and vaccines) are obtained on the authorisation of a medical practitioner(s). These drugs are

the responsibility of the medical practitioner(s) and subject to regulatory controls.

Nurses are not permitted to be in possession of S4 or S8 drugs. Only under written

instructions from the general practitioner may they access the drugs and administer them

under practitioner supervision. Only when the medical practitioner is present can nurses

access the drug.

S8 poisons must be stored in a locked facility, fixed to the floor or wall. Storage facilities

for Schedule 8 poisons must remain locked at all times except when it is necessary to

open it to carry out an essential operation such as medical treatment, stock checks and

reordering. Keys & combinations must not be accessible to or known by unauthorised

persons. Keys cannot be left on the premises over night.

When required to be transported for use in other locations, S8 drugs must be stored in a

locked receptacle (e.g. doctors Bag), in the doctors possession. If the receptacle is

necessarily out of the doctor’s immediate possession it should be secured, out of sight, in

a lockable facility (e.g. locked cupboard or locked vehicle) to prevent unauthorised

access.

Up to 6 divided doses of a S8 drug, for emergency use, may be stored in a locked facility

that does not comply with legislative requirements. These doses must be kept in a central

location or receptacle in a room that can be locked when a medical practitioner is not in

attendance.

Schedule 4 poisons including sample packs may be stored in a filing cabinet, cupboard or

drawer, within the practice. If an authorized person (usually a medical practitioner) is present,

the storage facility may remain unlocked at their discretion. This option requires the storage

facility to be locked when the authorized person/s are not present.

S4 drugs of dependence are either stored in the same manner as other S4 poisons or in the

drug cabinet with S8 poisons again at the discretion of the authorised person.

Schedule 4 vaccines that require refrigeration must be stored in either:

a lockable refrigerator that is locked when an authorized person (usually a

medical practitioner) is not present.


154

or in a refrigerator secured within a lockable room that is locked when an

authorized person is not present.

Nurse Immunisers should familiarise themselves with legislative issues that are applicable to

their situation.

Records of all transactions including supply acquisition and disposal of S4 and S8 drugs, must

be true and accurate and entered on the day that the action occurred. These records must be

retained for a minimum period of 7 years and are kept in the same location as the drugs.

Any alterations or cancellations of entries in the drug register must not be made. Any

mistakes that require correction should be done as a footnote with initial and dates. Each

brand name and strength of drugs kept must be detailed on a new page in the register.

Stock checks are to be conducted every March and September, or within one month of

assuming control of the practice. This should be recorded under the last entry and clearly

labeled as “Balance in Hand”. Lost, stolen or destroyed drug register must be reported to the

Pharmaceutical Services Branch.

The destruction of S4 or S8 drugs must only be performed in the presence of a pharmacist to

act as a witness. The destruction must be documented in the practice drug register and

include the pharmacists name, professional registration number and date of destruction. Both

parties must sign the entry.

S4 and S8 labels will require:

the name of the patient,

the date of dispensing and if necessary an identifying code,

the name , address and telephone number of the medical clinic or doctor providing

supply including the name of the prescribing doctor

directions for the correct use of the medicine

directions for storage and expiry date (may be those on the packet if left uncovered).

the brand and generic names of the drug including strength and form.

the words “KEEP OUT OF THE REACH OF CHILDREN”

ancillary labels as specified in the “Australian Pharmaceutical Formulary”.

When prescribing or supplying S4 and S8 medications the doctor takes all reasonable steps,

given the time and circumstances that exist at the consultation to ensure a therapeutic need

exists. Prescribing to maintain an addiction is not a therapeutic need and is illegal.


For information on jurisdictional requirements refer to the drugs and poisons branch of the

relevant jurisdiction:


155

New South Wales

Pharmaceutical Services Branch NSW Health

Telephone: 02 9879 3200 Fax: 02 9859 5000

7.17 Clinical References and Resources

Policy

Consistency and quality of care can be assisted by the use of current resources, access to

clinical guidelines and communication between team members. This process is encouraged

and facilitated by the practice clinical leader.

This practice provides our clinical staff with access to a range of resources and materials for

reference on clinical matters and items of interest for professional development.

The references available contain information that is consistent with current practice guidelines

or based on best available evidence. In the absence of well conducted trials or other higher

order evidence the opinion of consensus panels of peers is acceptable. References and

resources including practice guidelines should be accessible at the point of care. Wherever

possible, all resources are dated and contain the name of the source.

There is an organised system of access for all practice staff to journals, clinical guidelines and

other reference material. The clinical references available and any new additions, deletions or

updated versions is communicated to all staff and clinical team members to assist with

consistency in the approach to diagnosis and management of patient care. Distribution occurs

at either formal clinical meetings or electronic methods or individual handouts.

Procedure

RACGP 4th edition standards Mims online

Current Immunisation Handbook

At least annually we conduct an audit of our clinical resources and references to ascertain

if they comply with current practices and are providing consistent management and

information to patients across the practice team. It is the individual responsibility of the

doctors.

RACGP 4thedition Standards 1.3.1, 1.4.1, 5.3.1, 3.1.3, 3.1.2


156

7.18 Drug Storage and Disposal

Please note: RACGP 4th Edition Standards state “Practices must comply with

jurisdictional requirements on Schedule 4 and Schedule 8 medicines.” The requirements

can vary in different states and Territories of Australia. Failure to comply with the

legislation renders individuals and practice entities liable to prosecution. Compliance

with legislation does not ensure compliance with other professional standards and other

accreditation requirements which should also be observed.

Policy

Perishable medical supplies including vaccines, pharmaceutical and medical consumables

are correctly stored, stock rotated and discarded if past expiry dates.

Our practice has appointed a designated person to take primary responsibility for the

proper storage and security of medicines, vaccines and other healthcare products. All

medications in our practice are stored according to legislative requirements or in a

manner that ensures the safety of our patients and staff.

Perishable medical items are acquired through regular stock ordering and samples

acquired from pharmaceutical company representatives. All stock orders are recorded on

the Medsurg website and via email of stock order. Sample medications are labelled according to RACGP 4TH Edition guidelines prior to

placement in locked drug sample cupboard, medications are dispensed by General

Practitioners only and label is completed prior to being dispensed.

Procedure

All stock is checked on a weekly basis. Items with expired ‘use by dates’ are to be

withdrawn from active storage locations and disposed of immediately using appropriate

methods.

Any drugs which are subject to legislative regulation are disposed of according to strict

instructions. All other expired medications and other consumables from our practice are

disposed of via Ace Waste Clincal Waste Bin

It is the responsibility of all staff who use or dispense medical consumables to check the

expiry date prior to use.



157

8 Continuous Improvement

8.1 Risk Assessment & Management

Policy

This practice has multiple systems to regularly monitor, identify and report near misses and

mistakes in both clinical care and general operation.

The practice has appointed the practice manager to have primary responsibility for our risk

management systems. These may include clinical and non clinical risks and events. Specific

areas of responsibility can be delegated to other nominated members of the practice team and

these particular responsibilities are documented in the relevant position descriptions.

The aim of risk assessment and management is to:

identify all strategic risks using a risk management process.

ensure risk management becomes part of day to day management.

co-ordinate the undertaking of regular formal risk assessments and reviews with staff

involved.

provide staff with education, policies and procedures necessary to manage risk.

ensure employees are aware of risks and how to manage them.

assign responsibility for overseeing the practice risk management systems to

designated staff, and document this in their position description.

document and regularly review our risk management systems.

monitor risk profile and implement a continuous improvement approach to risk

management.

ensure successful implementation of changes and improvements made to our risk

management systems.

Our practice has a documented system for dealing with near misses and mistakes and we

ensure that doctors, nurses and other staff involved in clinical care are educated in what to do

and whom to notify when a slip, lapse or mistake occurs, or when there is an unanticipated

adverse outcome. Any improvements that are implemented to prevent identified slips, lapses

and mistakes or potential risks are documented and the practice team is informed.

All staff are given training about non-medical emergencies during orientation.

Procedure


158

Staff use the ‘near miss and adverse events register’ to report any slips, lapses or near misses

in clinical care or deviations in patient care that might result in harm. The medical defence

organisation is contacted for all events that may have an adverse outcome.

All accidents or near misses are fully investigated by practice staff and the findings discussed

at a staff meeting to prevent them occurring again. Staff use the ‘near miss and adverse events

register’ to record all events within the practice when a non-clinical event occurs which

causes harm or has the potential to cause harm. Where appropriate, the workplace insurance

company is contacted for advice and recommended action.

Some of the tools and strategies used in this practice to manage risk include:

achievement of RACGP standards via the accreditation process

regular staff and clinical meetings including effective communication with our staff.

appropriate staff qualifications, induction and training.

patient feedback obtained via surveys/Suggestion Box /logbook of complaints/

comments

documentation of sterilisation procedures including servicing, details of individual

loads/cycles and staff training

comprehensive medical records and back up of electronic data.

documentation/ tracking of abnormal results.

regular reviews of systems and procedures especially as a result of any analysis of

reported near misses.

logging/recording of telephone exchanges with patients

ensuring correct identification of patients at each face to face, telephone and electronic

encounter

documented contingency plans for events that may disrupt care or stretch practice

resources to the limit, including disasters and disease outbreaks.



159

8.2 Review of Policies & Procedures

Policy

Policies and procedures relating to the administration of this practice are formally

reviewed on an annual basis or when changes occur requiring earlier review or revision

(e.g. equipment changes).

Policies and procedures are an important component of the practice quality improvement

program, as well as forming the basis for staff induction and ongoing training. Our

practice ensures that all policies and procedures comply with the RACGP Standards for

General Practice.

Procedure

Each designated leader is responsible for conducting a review of the policies and

procedures relevant to the following areas:

Cleaning

Complaints Management

Infection Control

Information Technology

Quality Improvement

Risk Management Systems

Sterilisation

Vaccine Management

Discussion and suggestions for improvement to quality, patient safety or policies and

procedure is a standing item on our practice meeting agenda. Staff may informally

approach the Practice Principal or Manager with suggestions for new policies and

procedures or with revisions to existing policies and procedures, at any time.

The Practice Principal, in consultation with the Practice Manager and staff, approve all

policies and procedures. Once approved, documentation is amended in this manual and

elsewhere as necessary.

Analysis of practice data may also inform any changes to services or other practice

activities to improve the health outcomes of our patients. These quality improvement

activities may necessitate a new or revised written protocol.


160

Formal revision and final approval of all new and revised policies and procedures is

presented at a staff meeting. To ensure all staff are aware of new policies and recent

changes we have a distribution plan.

RACGP 4thEdition Standards 3.1.1, 3.1.3, 4.1.1

8.3 Continuing Staff Education

Policy

The practice GP’s, nurses and other health care providers employed by this practice are:

appropriately qualified, trained and competent.

able to provide evidence of training qualifications and of appropriate current

national registration.

participate in continuing education relevant to their roles and can provide

evidence of this.

have undertaken training in CPR within the last 3 years. In the case of GP's, this

training must be in accordance with the RACGP QI&CPD recommendations or

at least to the same.

Able to demonstrate they work within their scope of practice relevant to their role

The administrative staff such as receptionists and practice managers, who do not provide

clinical care:

have undertaken training in CPR within the last 3 years.

have undertaken training relevant to their role within the past 3 years.

can describe or provide records of such training.

Records of GP continuing professional development activities including CPD points and

activity details are retained by individual GP’s and a copy must be given to the Practice

Manager to retain for the practice records annually.

The practice supports continuing professional development for all of the staff it employs.

Details of activities & dates are recorded and should be retained by the Practice Manager.

Copies of these records or an annual summary should be given to staff for their own

personal records.

All Doctors, Nurses and staff involved in clinical care practice within their legal scope of

responsibilities. We encourage our staff to maintain their knowledge, skills and attitudes

through membership to their professional specialty organisations. The practice has access

to documented copies of relevant scope of practice guidelines.


161

Both in house and external training programs are utilised. Staff should obtain a certificate

of attendance or evidence of participation and completion for all training, even informal

training sessions (e.g. provided by the General Practitioners or other staff in the practice).

It is acknowledged that some crucial areas for staff training exist, depending on the staff

member’s role and responsibilities. These training requirements are met according to the

training schedule and documented in each staff member’s employment record. All staff are

given adequate infection control training for their role. It is the responsibility of the

designated infection control leader to ensure this training occurs.

Education is not limited to professional technical skill updates but includes a variety of

training and educational activities in areas of need as they arise.

Staff are encouraged to identify any training needs they may have and seek to find

training to meet these needs. Usually this occurs in consultation with their supervisor and

this process should be documented.

Staff training may include:

education at formal institutions.

educational seminars attended.

online training.

in service education given by company sales representatives or other staff.

reading Journals, evidence based guidelines or researching information for the

practice.

New staff are supported with any training they may require to perform their role. This

may be identified prior to commencement or during the induction phase. (Initial 3

months).

Procedure

The practice GP’s, nurses and other health care providers involved in clinical care must

provide evidence of current registration each year. Further evidence on training relevant

to their roles including QI&CPD records or other professional development is kept by the

practice.

Copies of certificates and training records for clinical team members are kept in each

staff members file. This record also includes approved CPR training completed within the

last 3 years.

Administrative staff must also show evidence of relevant training for their role. Copies of

training certificates are kept in the employee file. Administrative staff can also demonstrate

triage and CPR training completed within the last 3 years.


162

All employees of the practice have a completed training induction checklist located in the

employee file.

The practice team member with delegated responsibility for staff education on infection

control documents in each individual staff training records how the induction program and

additional ongoing training provided (as identified through discussion and competency

assessment) covers infection control as relevant to each staff members role. Training and

regular updates should include:

hand hygiene

standard precautions & Transmission based precautions including PPE use and the

triage of patients with potential communicable diseases.

dealing with blood and body fluid spills and managing exposure to blood or body

fluids.

principles of environmental cleaning and reprocessing of medical equipment.

where to find information on other aspects of infection control in the practice.

safe handling and disposal of clinical and general waste.



163

8.4 Accreditation & Continuous Improvement

Policy

This practice is committed to attaining and where possible, exceeding the Standards for

General Practice 4th Edition as defined by RACGP.

The practice team is committed to encouraging quality improvement and identifying

opportunities to make changes that will improve the clinical care of patients and activities to

promote health in the overall practice population.

The practice uses patient and practice data to identify opportunities for improvement and to

monitor evidence of improvement occurring.

Our practice can demonstrate improvements we have made in response to the analysis of

patient and others feedback, including complaints, and where appropriate we provide

information to patients about improvements made as a result of their input or feedback.

Our practice undertakes quality review activities such as audits, routine data checks, accounts

reviews and medical record reviews on regular basis. Any interesting findings or changes

made as a result of reviews are discussed at practice or clinical meetings.

Procedure

Discussion and suggestions for improvement to quality and patient safety is a standing

item on our practice meeting agenda. The designated staff member for quality

improvement shares all information related to this topic with staff on a regular basis.

Our practice regularly reviews practice data, policies and procedures to help facilitate quality

improvement. Wherever possible, patient feedback and complaints are incorporated into

quality improvement activities and we endeavor to notify patients through special bulletins

whenever changes do occur as a result.

The practice participates in a formal, peer-review process known as accreditation. Our

practice endeavors to comply with all relevant legislation and guidelines relating to general

practice.



164

8.5 Patient Feedback

Policy

Our practice encourages patients and other people to give feedback, both positive and

negative, as part of our partnership approach to healthcare, and we have processes in place for

responding to feedback

In order to respond to patient feedback and make improvements, practices need to identify the

person in the practice with primary responsibility for examining issues raised by patients and

facilitating improvements in the practice. In our practice, the designated staff member is the

practice manager.

Where possible patients are encouraged to raise any concerns directly with the practice team

and attempts are made for a timely resolution of such concerns within the practice in

accordance with our complaints resolution process.

We seek structured /systematic patient experience feedback at least once every 3 years which

meets the requirements outlines in the RACGP publication “Learning from our patients”.

Feedback collected includes, but is not limited to, the following 6 categories that are

considered critical to patient’s experiences within healthcare facilities.

access and availability

information provision

privacy and confidentiality

continuity of care

communication skills of the clinical staff

interpersonal skills of clinical staff

The data collected is analysed and the findings, including any improvements made, are

communicated back to our patients.

As part of our Risk Management Activity, a log of incidents, including complaints, is

maintained in an event log and the incident is noted on the patient’s history. All improvements

made to the practice as a result of patient feedback are discussed at practice meetings and

recorded in the minutes.

Procedure

At any time patients may provide feedback or make a complaint.


165

A notice is displayed in the waiting room and details are included in the practice information

sheet to advise patients how to make a complaint to our practice. We also advise the contact

information for the State/Territory health complaints agency and the commonwealth agency.

Staff are trained to ensure patients of the practice feel confident that any feedback or

complaints made at the practice will be handled appropriately. All staff are aware and can

identify the staff member responsible for complaints handling.

At least every 3 years we use a systematic method for collection patient experience

feedback.

We collect feedback using:

CFEP Surveys

Data collected is analysed to identify potential opportunities for quality improvement.

We communicate the findings of our feedback and any improvements made back to our

patients using either a poster in the waiting room, newsletters, the website or individually as

appropriate.

Complaints and patient feedback are discussed at practice meetings to facilitate whole of

practice improvement.



166

8.6 Continuity of Care

Policy

This practice aims to encourage patients to develop a positive relationship with their doctor

and practice staff over time to enhance the provision of high quality comprehensive patient

care including effective health promotion and strategies for the early detection of disease.

Our practice has systems and procedures in place to help facilitate continuity of care for

patients when visiting our practice including management and informational continuity. All

staff are trained in how they can facilitate continuity of care.

Our medical notes demonstrate relational, management and informational continuity of

comprehensive care.

Our practice provides home visits for our patients and has an agreement with an after hours

provider who provides communication back to the practice about the nature of any after hours

care delivered.

Procedure

Our practice implements the following procedures or systems to facilitate continuity of care:

Comprehensive medical records including an updated patient health summary

Referral letters which contain a minimum of 3 approved patient identifiers, updated

medication list and sufficient information for the ongoing management of the patient

Regular clinical meetings where clinical practice guidelines are discussed and

information shared about patient cases within the practice

A formal clinical handover system to account for clinical staff member leave or

unexpected absence

A robust recall and reminder system for all important test results

Patients are able to request their GP of choice when making an appointment and

administrative staff working to try and ensure their GP is available.

If cases where patients do not request their regular GP, the administrative staff attempt

to book an appointment with the GP from their last visit.

All staff are able to describe how continuity of care in our practice is facilitated.



167

8.7 Clinical Governance

Policy

The RACGP 4th Edition Standards describe Clinical governance as a ‘system through which

organisations are responsible for continuously improving the quality of their services and

safeguarding high standards of care by creating an environment in which excellence in

clinical care will flourish’.

We recognise that good clinical leadership is required to engage the entire practice team in a

commitment to excellence by nurturing a culture of openness and mutual respect that allows

just and open discussions about areas for improvement.

We aim to develop an organisational culture where participation and leadership in safety and

quality improvement are resourced, supported, recognised and rewarded and all staff feel

accountable and involved in monitoring and improving care and services.

To promote clear lines of accountability and responsibility for encouraging improvement in

safety and quality of clinical care and the sharing of information about quality improvement

and patient safety within the practice team we have appointed leaders who have designated

areas of responsibility for safety and quality improvement systems within the practice.

Our practice leaders oversee the delegation of tasks to others but retain accountability for

quality and safety. Roles and responsibilities are specified in our position descriptions and all

members of the practice team are aware of the designated leadership responsibilities of key

staff.

Our leaders promote compliance with the RACGP 4th Edition Standards for general practice

and relevant jurisdictional legislation or accepted industry requirements.

Procedure

All members of our practice team can identify the staff members with primary or delegated

responsibility for:

Clinical Risk management systems including receiving and disseminating any

important communication or updates (e.g. health alerts) and contingency plans

Clinical leadership

Quality improvement and risk management (non clinical)

Clinical care

Information management

Human resources

Feedback and complaints

Occupational Health and Safety (Health and Safety representative)


168

Electronic systems and computer security

Proper storage and security of medicines

Cold chain management

Infection control within our practice. (e.g. sterilisation process, staff immunisation, staff

education).

Environmental cleaning,

These responsibilities are noted in position descriptions. Our leaders can delegate specific

areas of responsibility to other nominated members of the practice team and these particular

responsibilities should be documented in position descriptions.

RACGP 4thedition Standards 3.1.3, 5.3.1, 5.3.2, 5.3.3, 4.1.1, 4.2.2