RACGP Standards for General Practices

1 For General practices5th editionSTANDARDSA ccreditationStandards for General Practices , 5th edition DisclaimerThe information set out in this publication is current at the date of first publication and is intended for use as a guide of a General nature only and may or may not be relevant to particular patients or circumstances. Nor is this publication exhaustive of the subject matter. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular circumstances when so doing. Compliance with any recommendations cannot of itself guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional and the premises from which the health professional operates.

2 Accordingly, The Royal Australian College of General Practitioners Ltd ( RACGP ) and its employees and agents shall have no liability (including without limitation liability by reason of negligence) to any users of the information contained in this publication for any loss or damage (consequential or otherwise), cost or expense incurred or arising by reason of any person using or relying on the information contained in this publication and whether caused by reason of any error, negligent act, omission or misrepresentation in the citationThe Royal Australian College of General Practitioners. Standards for General Practices . 5th edn. East Melbourne, Vic: RACGP , Royal Australian College of General Practitioners Ltd 100 Wellington Parade East Melbourne, Victoria 3002 Tel 03 8699 0414 Fax 03 8699 0400 : 978-0-86906-470-2 (web) ISBN: 978-0-86906-473-3 (print)Published July 2017 The Royal Australian College of General Practitioners 2017 This resource is provided under licence by the RACGP , the terms of which are available at By using this resource you agree to its supply on these terms.

3 In summary, you may use this resource for a broad range of purposes providing you acknowledge the RACGP . However, the licence does not extend to any distribution or commercial use unless otherwise agreed. For further information or to discuss a commercial licence, please contact us on 1800 472 acknowledge the Traditional Custodians of the lands and seas on which we work and live, and pay our respects to Elders, past, present and for General practices5th editioniiiRACGP Standards for General Practices , 5th editionContentsIntroduction to the Standards for General Practices (5th edition ) 1 Development of this edition 1 Changes from the previous edition 1 Revised structure 1 Numbering of Criteria and Indicators 2 Indicators that focus on outcomes and patients 3 Fewer Indicators 3 Restructured explanatory notes 3 Use of could and must 3 Plain English 3 Reduced citation of federal, state or territory legislation 4 Evidence-based Standards 4 Accreditation 4 Practices that can be accredited 4 Voluntary accreditation 4 The accreditation cycle 4 The assessment process 5 Requirements for accreditation agencies and surveyors 6 Mandatory and aspirational Indicators 7 Demonstrating compliance 7 The Resource guide 7 Core module 9 Core Standard 1.

4 Communication and patient participation 10 Criterion Information about your practice 11 Criterion Telephone and electronic communications 13 Criterion Informed patient decisions 16 Criterion Interpreter and other communication services 19 Criterion Costs associated with care initiated by the practice 22 Core Standard 2: Rights and needs of patients 24 Criterion Respectful and culturally appropriate care 25 Criterion Presence of a third party during a consultation 30 Criterion Accessibility of services 32ivRACGP Standards for General Practices , 5th editionCore Standard 3: Practice governance and management 34 Criterion Business operation systems 35 Criterion Accountability and responsibility 39 Criterion Emergency response plan 43 Criterion Practice communication and teamwork 45 Criterion Work health and safety 48 Criterion Research 51 Core Standard 4: Health promotion and preventive activities 54 Criterion Health promotion and preventive care 55 Core Standard 5: Clinical management of health issues 57 Criterion Diagnosis and management of health issues 58 Criterion Clinical autonomy for practitioners 60 Criterion Clinical handover 61 Core Standard 6.

5 Information management 63 Criterion Patient identification 64 Criterion Patient health record systems 66 Criterion Confidentiality and privacy of health and other information 68 Criterion Information security 72 Core Standard 7: Content of patient health records 77 Criterion Content of patient health records 78 Core Standard 8: Education and training of non-clinical staff 83 Criterion Education and training of non-clinical staff 84 References 86 Quality Improvement module 87QI Standard 1: Quality improvement 88 Criterion Quality improvement activities 89 Criterion Patient feedback 92 Criterion Improving clinical care 95QI Standard 2: Clinical indicators 98 Criterion Health summaries 99 Criterion Safe and quality use of medicines 101vRACGP Standards for General Practices , 5th editionQI Standard 3: Clinical risk management 104 Criterion Managing clinical risks 105 Criterion Open disclosure 107 References 109 General Practice module 111GP Standard 1: Access to care 112 Criterion Responsive system for patient care 113 Criterion Home and other visits 117 Criterion Care outside of normal opening hours 119GP Standard 2.

6 Comprehensive care 122 Criterion Continuous and comprehensive care 123 Criterion Follow-up systems 126 Criterion Engaging with other services 132 Criterion Transfer of care and the patient practitioner relationship 135GP Standard 3: Qualifications of our clinical team 137 Criterion Qualifications, education and training of healthcare practitioners 138GP Standard 4: Reducing the risk of infection 142 Criterion Infection prevention and control, including sterilisation 143GP Standard 5: The medical practice 150 Criterion Practice facilities 151 Criterion Practice equipment 154 Criterion Doctor s bag 158GP Standard 6: Vaccine potency 161 Criterion Maintaining vaccine potency 162 References 166 Glossary 1671 RACGP Standards for General Practices , 5th editionIntroduction to the Standards for General Practices (5th edition )The Royal Australian College of General Practitioners ( RACGP ) has developed the Standards for General Practices (5th edition ) (the Standards ) with the purpose of protecting patients from harm by improving the quality and safety of health services.

7 The Standards also support General Practices in identifying and addressing any gaps in their systems and of this editionThe fifth edition of the Standards was developed over a three-year period in consultation with General practitioners (GPs), practice managers, nurses, consumers, technical experts, and many other stakeholders. The process included: targeted stakeholder workshops throughout Australia three rounds of public consultation three rounds of testing and from the previous editionRevised structureThe fourth edition of the Standards had five sections that accreditation surveyors used as the basis of their assessments of General Practices . The fifth edition of the Standards has three modules that collectively cover all of the areas in the fourth edition , but in a different structure. This modular structure allows the RACGP to update the modules separately, and to adapt the Standards for other healthcare settings such as correctional services and immigration detention centres.

8 For example, the first two modules (the Core module and the Quality Improvement module) are relevant for all healthcare settings, but the third module (the General Practice module) can be adapted to accommodate the specific needs of each healthcare setting. Figure 1 (on the following page) illustrates this modular approach and how it is different to previous editions. The RACGP s Standards for General Practices (5th edition ): A benchmark for quality care and risk management in Australian General Standards for General Practices , 5th editionCore moduleQuality Improvement moduleGeneral Practice moduleStandards for General Practices (5th edition )Core moduleQuality Improvement moduleOther settingsStandards for other settings (ie correctional services, immigration detention centres, etc)Section 2 Rights and needs of patientsSection 3 Safety, quality improvement and educationSection 4 Practice managementSection 5 Physical factorsSection 1 Practice servicesStandards for General Practices (4th edition )Figure 1.

9 Modular structure of the StandardsNumbering of Criteria and IndicatorsThe numbering system works as follows: The Standards in each module are numbered separately ( Standards 1 8 in the Core module, Standards 1 3 in the Quality Improvement module, and Standards 1 6 in the General Practice module). The Criteria for each Standard has a code indicating the module (C for Core, QI for Quality Improvement and GP for General Practice), followed by sequential numbering that indicates the Standard and Criterion. For example, is the first Criterion for the first Standard in the Core module; is the second Criterion for the first Standard in the Core module; is the second Criterion for the fourth Standard in the GP module). Table 1 demonstrates the different structure between the Standards fourth and fifth 1. Comparison between fourth and fifth edition structureNumbering in the Standards (4th edition )Numbering in the Standards (5th edition )Section 1: Practice servicesStandard : Access to careCriterion Scheduling care in opening hoursCore moduleStandard 1: Communication and patient participationCriterion Information about your practiceIndicatorsA.

10 Our practice can demonstrate that we have a flexible system for determining the order in which patients are seen, to accommodate patients needs for urgent care, non-urgent care, complex care, planned chronic disease management, preventive healthcare and longer Our patients can access up-to-date information about the a minimum, this information contains: our practice s address and telephone numbers our consulting hours and details of arrangements for care outside normal opening hours our practice s billing principles a list of our practitioners our practice s communication policy, including when and how we receive and return telephone calls and electronic communications our practice s policy for managing patient health information (or its principles and how full details can be obtained from the practice) the process we use to follow up on results how to provide feedback or make a complaint to the practice information about the range of services we provide3 RACGP Standards for General Practices , 5th editionIndicators that focus on outcomes and patientsThe Indicators in this edition have, where appropriate, been written with a focus on outcomes and patients, instead of on prescribed processes or what the practice example.