Top Tips for Accreditation

October 2016

Magali De Castro Clinical Director, HotDoc

Top Tips for Accreditation

This session will cover:

• Steps involved in the Accreditation process

• How to navigate the RACGP Standards for General Practices

• Most common non-compliance areas

• Top resources to get your practice ready for accreditation

“[Accreditation] shows patients that your practice is serious about providing high quality,

safe and effective care”

- RACGP Standards for General Practice 4th Ed

What is Accreditation?

• Voluntary

• Over 80% of practices in Australia undertake Accreditation

• Ensure practice services are in line with best available evidence and peer-reviewed guidelines

• Assessed against the Royal Australian College of General Practitioners (RACGP) Standards 4th Ed

• 3-year cycle

Benefits of Accreditation

• Ensure policies and procedures are in line with best practice

• Protects your clinic, your staff and your patients

• Provides an opportunity for the practice to reflect on current systems and explore areas for quality improvement

• May serve as a prompt to review, update or upgrade equipment

• Professional recognition among peers

• Financial incentives: Practice Incentive Program (PIP) & Practice Nurse Incentive Program (PNIP)

The Process of Accreditation

1.  Practice registers for accreditation with either:

GPA or AGPAL

2. Allocated a key contact person (at GPA or AGPAL) to assist with accreditation questions and requirements

3. Practice completes a self-assessment questionnaire

4. Site visit is scheduled

Accreditation Survey Visit

• Interview practice staff • Review practice documentation • Audit patient health records

• The surveyors write a report of their findings to be reviewed by the accrediting body

• Accreditation is granted or request issued for the practice to supply additional evidence

Surveyors will:

RACGP Standards for General Practice 4th Ed

RACGP Standards (4th Ed)

Section 1: Practice services

Section 2: Rights and needs of patients

Section 3: Safety, quality improvement and education

Section 4: Practice management

Section 5: Physical factors of the practice

Navigating the Standards

The surveyor conducts a review of:

• Doctor bag (s)

• Schedule 8 Drug records and storage

• Medical records

• Doctors’ RACGP QA & CPD and AHPRA registrations

• Practice Information Sheet

• Practice collecting “emergency contact person” for patients

Key areas surveyors will always check

Criterion 1.7.2 Health summaries

At least 90% of active records have allergies recorded

At least 75% contain a current health summary including:

Adverse drug reactions

Current medicines list

Current health problems

Relevant past health history

Health risk factors

Immunisations

Relevant family and social history

A Closer Look…

Criterion 1.7.3 Consultation notes

Include consultations outside normal opening hours

Home or other visits

Telephone or electronic communications

Should include:

Date of consultation

Reason for visit

Clinical findings and diagnosis

Management and process of review

Medicines prescribed

Any preventive care or referral to other providers

Problems raised in previous consultations are followed up

A Closer Look…

Have ready on the day samples of:

• After-hours visits (undertaken by another service or by the practice)

• Home/institution visits

• Patient/doctor phone contact

Key areas surveyors will always check

All pathology results, imaging reports, investigation reports and clinical correspondence are:

• Reviewed by a GP

• Signed or electronic equivalent

• Acted upon in a timely manner

• Documented system to identify, follow up and recall patients with clinically significant results

Criterion 1.5.3 System for follow up of tests and results

The following documentation should be ready for review on the day:

• Current registrations: GPs and nurses. 3.2.2

• Current CPD activity statement for all doctors and nurses in the practice. 3.2.2

• Certificates of continuing education for the past 3 years for other staff 3.2.3

• CPR certificates for GPs, nurses and staff 3.2.2, 3.2.3

• Induction program for new GPs and staff (including infection control) 4.1.1

• Job descriptions/position statements for all staff 4.1.1

• Immunisation status of staff 4.1.1

Key areas surveyors will always check

The following documentation should be ready for review on the day:

• Agendas or minutes of staff and clinical meetings 4.1.1

• After-hours arrangements/rosters (where applicable)

• Contract for disposal of sharps, biohazards and confidential waste

• Vaccine fridge cold chain audit (eg Data logging or audit check list)

• Schedule of maintenance of key equipment

• Schedule for routine cleaning

Key areas surveyors will always check

• Patient records must have a current medicines list

• All medicines & consumables:

• Stored & handled as per manufacturer direction

• Within expiry date

Criterion 5.3.1 Safe and quality use of medicines

• Sterilising & machine calibration

• Pack and load process for steriliser

• Sterilising log book

• Hardest pack to sterilise and steriliser instruction manual

Key areas surveyors will always check

• Patient feedback approved by RACGP

• Computer security checklist provided by RACGP

• Disaster contingency/Business continuity plan

• List of improvements to the clinic in the last 3 years

• An improvement made to prevent a slip or mistake in clinical care from reoccurring

Key areas surveyors will always check

• Timely access to

• Spirometer

• ECG machine

• Maintain key equipment according to a documented schedule

Criterion 5.2.1 Practice equipment

Policy manual tagged with the following policies:

o Home visits

o Review of results and letters received by the practice

o Cold chain

o Infection control

o Handover of patients

o Practice feedback

o Adverse events

o Routine cleaning

o 3 patient identifiers

Key areas surveyors will always check

Criterion 3.1.4 Patient identification

• 3 patient identifiers

• Applied when making appointments, writing prescriptions, writing referrals, giving results or entering correspondence

Most common identifiers are:

• Patient name, date of birth and address

A Closer Look…

Criterion 5.3.3 Healthcare associated infections

• Describe the process for the routine cleaning of the practice

• Immunisation status of practice team members

• Staff should be offered immunisations, as appropriate to their duties

• Demonstrate how patients are educated in respiratory etiquette and hand hygiene

A Closer Look…

• Policy & Procedure Manual

• Triage Guide

• Staff Training Sheets

Top Resources for Accreditation

Thank you for participating!

Got a question? Email: md@hotdoc.com.au