AGPAL Quality News – Spring 2020

ACCREDITATION NEWS FOR PRIMARY HEALTHCARE | SPRING 2020

THANK YOU FOR YOUR INCREDIBLE WORK AND EFFORT DURING COVID-19

In This Issue

Published by Australian General Practice Accreditation Limited

Infection control

Follow-up systems & recalls

Managing clinical risks

Find out if your practice is cleaning your ‘COVID-19 installed’ reception screens to meet the RACGP Standards for general practices 5th edition Criteria GP1.1 and GP4.1.

Tackled under RACGP Standards 5th edition Criterion GP2.2, are important for both the patient and general practice, as appropriate action must be taken for clinically significant results.

We outline the mandatory Indicators in the RACGP Standards 5th edition Criterion QI3.1, and how to identify, monitor and continuously improve on your practice's near misses.

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Education and Training

Cultural awareness training package

Face-to-face workshop

e-Learning modules

Participant workbooks

$8,000 for up to 40 participants

Support your staff to better understand their role in providing relevant, safe and appropriate care and services to Aboriginal and Torres Strait Islander patients and families by minimising discrimination through culturally effective and appropriate communication.

www.agpalqipeducation.com.au

HSQF and ISO certification made easy!

We’re committed to providing a collaborative certification process, with supportive staff and sector-experienced auditors who are carefully matched to each client to create a value-adding, culturally safe certification experience.

www.qipcertifications.com.au

ACCREDITATION NEWS FOR PRIMARY HEALTHCARE | SPRING 2020

Editorial team AGPAL Marketing and Communications PO Box 2058 Milton BC QLD 4064 1300 362 111 info@agpal.com.au www.agpal.com.au

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Thank you from the AGPAL Board Chair

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A word from the CEO

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What's happening in your world

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Cleaning your practice's 'sneeze screens'

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Hand sanitiser saviours

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Providing safe and inclusive services for LGBTIQA+ people

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Supporting the mental health of your staff

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Standards in Focus

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Follow up systems and recalls

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Managing clinical risks

Advertising contact 1300 362 111 marketingteam@ agpal.com.au

is published by Australian General Practice Accreditation Limited (AGPAL) This publication is partly funded by advertising revenue Print Post Approved 42402201212 ISSN 1448-0808

Sanitiser saviours

Standards in Focus

ABN 60 077 562 406

Disclaimer Opinion expressed in this publication is not the official opinion of any of the companies within the AGPAL Group of Companies unless expressly stated. None of the AGPAL Group of Companies accept any responsibility for the accuracy of any information contained in this publication, any statement in or omission from this publication, even where such inaccuracy, statement or omission is caused by negligence. Readers should rely on their own inquiries in making decisions touching their own interests.

7 Facebook group helps solve national shortage

Inclusivity

13 Follow up systems and recalls

Unless otherwise stated, products and services advertised or otherwise appearing in this publication are not endorsed by the AGPAL Group of Companies. It is the responsibility of the advertiser to ensure that advertisements comply with the Trade Practices Act 1974 as amended.

All advertisements are accepted for publication on the condition that the advertiser indemnifies AGPAL Group of Companies, the publisher and their respective servants and agents in respect of all actions, suits, claims, loss and/or damages resulting from anything published on behalf of the advertiser.

9 Providing safe and inclusive services

17 Managing clinical risks

BOARD

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Thank you Living through a pandemic and experiencing firsthand its myriad impacts has brought into sharp focus the role public health and healthcare workers play in our national security, and social and economic structures.

We acknowledge that despite ongoing challenges to effectively and equitably reduce infections and ensure our most vulnerable are adequately protected, compared to other countries, Australia’s response to controlling COVID-19 has been among the most successful in the world.

Our media outlets and government agencies continue to do an excellent job in explaining the importance of social distancing and other restrictions to help stop the spread of the virus.

We have seen, however, the rise of an unintended consequence – patients being unwilling to visit a GP either thinking they are doing the right thing per social distancing or being fearful of exposure to the virus.

General practice staff have become experts at mitigating pandemic-associated risks to provide safe, high-quality care during this time.

This includes effectively triaging patients who may present with COVID-19 while protecting other patients and colleagues from transmission.

We can thank general practice staff for striving to ensure the on-going treatment of patients’ dayto-day health issues – whether chronic or acute – and understanding and navigating ever-changing information, advice, evidence and government incentive programs.

The pivot to telehealth and other technologybased solutions combined with a broad and willing uptake by many patients has been nothing short of revolutionary and may well be viewed in the long term as a ‘silver lining’ of this pandemic.

General practices have also been on the frontline of ensuring vital vaccination and immunisation coverage is effectively maintained to ensure outbreaks of preventable disease do not take hold in any way, shape or form anywhere in Australia.

While infection control and prevention is always top of mind in clinical settings, once the World Health Organization announced COVID-19 a global pandemic in early March, the multi-sector demand for hand sanitiser and personal protective equipment (PPE) exploded – vastly

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outstripping supply. A particularly challenging problem for healthcare and those working on the frontline with potentially infected patients.

Across Australia, general practice staff including clinicians, practice managers, nurses, receptionists and administrators banded together to source and resolve shortages, as well as clarify and share indications for correct use.

We also know that during this time some general practices have faced worrying financial challenges due to a reduction in face-to-face consultation revenue combined with the additional costs of implementing new systems and process and PPE. Some practices have had to stand down nursing and support staff or take other cost-cutting measures without impacting high-quality, safe care. My hope is that these issues are short-lived; resolved through an organic shift back to a ‘new normal’ and an appropriate government response.

On a personal level – as humans living and working through this crisis – primary care doctors, nurses and their support teams are no different from other citizens in that exposure to global media, COVID-19 hot spots, lockdowns, border closures and other restrictions affects them and their loved ones in many and sometimes difficult ways.

Unfortunately, as a nation we continue to be at risk of COVID-19 infection. General practices will continue to be our first point of call to discuss concerns and reach a diagnosis, and receive treatment.

It is with all of the above and more in mind that I – on behalf of the AGPAL Group of Companies – join with people from all states and territories to express deep gratitude to each and every general practice staff member across Australia.

Whether you are a GP, nurse or other allied health clinician, support and/or administrative staff, or a general practice patient – please stay safe by continuing to adhere to government advice and look after yourselves and your families in the most holistic way possible.

Dr Richard Choong AGPAL Board Chair

CEO NOTES

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Welcome to your Spring 2020 edition of Quality News.

As we move through 2020, each month seems to roll into the next whereby time passes at a glacial pace while also whirling by in an indistinguishable blur.

On-site assessments will be based upon a risk-based approach and will only take place in settings where there is a low risk of transmission of COVID-19.

General practices have played a central role on the frontline of care during COVID-19, managing the everyday needs of patients while adapting to triaging, telehealth, new levels of infection control and prevention, and implementing risk management like never before.

All accredited practices that had a valid accreditation expiry date as at or after Wednesday 25 March 2020 are automatically eligible for a 12month extension to their certification expiry date.

I echo the sentiments Richard outlined on the previous page and extend my appreciation and admiration to all general practice staff for your hard work and dedication during this challenging year. Working in such demanding and taxing circumstances throughout what is now proving to be a new way of life is testament to your resilience and the dedication you have for your communities.

Now more than ever, it is important to ensure you take care of yourselves – both physically and mentally. While many patients are coming to your practice for care and advice, data indicates healthcare workers are less inclined to seek the same support services. The article on page 11 provides ideas and resources that may assist your staff to maintain good mental health.

Some community groups are at elevated risk of adverse health effects due to the ongoing pandemic, particularly the lesbian, gay, bisexual, transgender, intersex, queer/questioning, asexual, and many others such as non-binary and pansexual (LGBTIQA+). These communities are known to have health disparities that may negatively influence disease outcomes. Together with Rainbow Health Victoria, we have compiled some tips, to assist your practice in providing safe and inclusive services throughout COVID-19.

Due to the COVID-19 pandemic, the Australian Commission on Safety and Quality in Health Care (the Commission) suspended accreditation for general practices and healthcare organisations to reduce unnecessary risk to staff, patients and the community. Having undertaken a review and considerable planning, the Commission has recently advised accrediting agencies that general practice accreditation will recommence as of 26 October.

While accreditation assessments have been on hold, we know for most general practices continuous quality improvement has not been.

In this edition of Quality News, we continue to provide information to support you and your team on meeting the RACGP Standards for general practices 5th edition (the RACGP Standards) – particularly those that frequently appear within the top-10 common non-compliances.

Follow-ups and recalls, while always important, are very much currently so for practices providing COVID-19 testing. These are outlined extensively in the RACGP Standards under Criterion GP2.2 – Follow-up systems. On page 13, we have put together information on the importance of followups and recalls, and ways to ensure your practice sufficiently meets this criterion.

Due to COVID-19, there are new levels of clinical risk that can directly impact the health of your practice team and the day-to-day operations of your practice. We examine this topic on page 17 – the RACGP Standards Criterion QI3.1. Recent risk mitigation has been displayed by practices introducing 'sneeze screens' to protect practice staff. In support of the safety of your staff, on page 5 the infection control measures required to clean these ‘COVID-19 installed’ screens are outlined.

We are looking forward to once again working with you throughout your accreditation process and I would like to remind you that your AGPAL Team is here to support you in any way we can. If you have any questions or concerns, we would be pleased to help. We are just a phone call or email away on 1300 362 111 or info@agpal.com.au.

Dr Stephen Clark Chief Executive, AGPAL

SPRING 2020

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WHAT’S HAPPENING On-site assessments for accreditation to recommence

Vale Dr Harry Nespolon

The Commission has confirmed that on-site assessments against the RACGP Standards will recommence from 26 October for eligible practices that are at low risk of COVID-19 transmission.

Dr Nespolon was at the forefront of advocating for Australian GPs to ensure they had the resources and support necessary to care for their community.

AGPAL is pleased to advise that all accredited practices that had a valid accreditation expiry date as at/or after Wednesday 25 March 2020 are automatically eligible for a 12-month extension to their certification expiry date.

Sydney GP and RACGP President, Dr Harry Nespolon has sadly passed away from pancreatic cancer.

We extend our deepest condolences to his partner, daughters, friends, colleagues and patients.

As part of the Practice Incentives Program (PIP) and Workforce Incentive Programs (WIP), payments will automatically continue for accredited practice. Accredited practices are not required to contact Services Australia. https://bit.ly/QN20_NGPA

AMDS Program Guidelines changes The Australian Government Department of Health’s Approved Medical Deputising Service (AMDS) Program Guidelines have changed effective from 1 August 2020.

The most notable updates that impact how AGPAL approaches medical deputising service (MDS) accreditation relates to: Co-location – specificity has been included that an MDS must be a stand-alone entity that, in addition to not sharing resources, has a separate entrance and address to any other general or medical service, including allied health.

Transferring calls to another AMDS – the guidelines describe that the MDS is able to transfer calls to another AMDS if required, but notes the requirement to have a formal agreement if this is to occur.

In querying to the Department under what circumstances would it be reasonable to transfer a call to another provider, the Department responded by clarifying that while the Guidelines allow calls to be transferred to another service provider, a service provider cannot transfer the care of a patient.

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The Department further described that service providers are required to operate for the entirety of the Commonwealth-defined after-hours period.

They cannot defer this responsibility to another service provider as a means of reducing their operating hours, and that where a consultation booking is required, a doctor from the originating deputising service needs to attend to the patient.

o Immunisation schedule changes from 1 July 2020 Designed to improve protection against meningococcal and pneumococcal disease, changes to the National Immunisation Program (NIP) took effect from 1 July 2020.

Changes were made to the NIP meningococcal vaccination schedule, NIP pneumococcal vaccination schedule and NIP hepatitis A childhood vaccination schedule.

The changes were recommendations from the Australian Technical Advisory Group on Immunisation (ATAGI) and other clinical experts.

View these as well as ATAGI advice, NIP Schedules and Meningococcal B consumer resources: https://bit.ly/QN20_NIP

Draft ‘RACGP Standards for general practice residential aged care’ open for second consultation Gary Smith, AGPAL Director and Co-Surveyor, and Chair of Quality Innovation Performance Limited (QIP) has a wealth of experience from his 34+ years in general practice, and we are delighted to invite you to join us for our ‘Coffee with Gary’ webinar series.

Focusing on all things practice management, these webinars are open and engaging conversations, offering you an opportunity to table questions and concerns you have been wondering about, as there are likely many others who are experiencing similar situations or who may be able to share their solutions.

See more webinars and register below http://bit.ly/QN20_webinars

The RACGP has released a second draft of the Standards for general practice residential aged care (1st edition) for feedback from members and stakeholders.

This second consultation will include piloting the draft Standards, subject to the COVID-19 recovery phase, and we are pleased to announce that AGPAL has been selected by the RACGP as the preferred provider to conduct the pilot.

These Standards were developed specifically to improve patient care and address the barriers that general practitioners face when delivering such vital care in residential aged care facilities.

To ensure the Standards are fit-for-purpose, we encourage you to review the draft and provide your feedback to the RACGP. https://bit.ly/QN20_RACGP-ACD

Informed consent fact sheet

Join AGPAL as a Surveyor

The Australian Commission on Safety and Quality in Health Care has developed new guidance for clinicians on how to obtain informed consent in health care.

Are you a GP or practice manager with 2.5 days a year that you can spare to commit to AGPAL Surveying?

Ensuring informed consent is properly obtained is a legal, ethical and professional requirement on the part of all treating health professionals. It is integral to the right to information in the Australian Charter of Healthcare Rights.

Survey, mentor others and learn about the diversity of general practice. Create quality outcomes within Australian healthcare while enjoying flexible working. http://bit.ly/QN20_consent

http://bit.ly/QN20_consent SPRING 2020

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INFECTION CONTROL

Image courtesy of Your Health Griffith

Cleaning your practice's 'sneeze screens' What's required to clean the ‘COVID-19 installed’ screens?

It has been great to see general practices find inventive ways to protect staff. Reception area screens are now a standard sight in clinics throughout Australia with the likes of plastic manufacturing companies, practice managers, handypersons and DIY husbands and wives rolling up their sleeves to build and install these useful fixtures.

Now that these screens are well and truly a feature of general practice reception areas, it needs to be ensured that they are thoroughly and correctly cleaned to meet the RACGP Standards for general practices 5th edition.

Cleaning these screens falls under Criteria GP1.1 – Responsive system for patient care, and GP4.1 – Infection prevention and control, including sterilisation. Your infection control policy should cover the environmental cleaning of clinical and non-clinical areas of the practice.

Managing the risk of cross-infection in your practice must be minimised and practice team members need to know how to implement standard and transmission-based precautions, spills management and environmental cleaning.

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Per the Australian Guidelines for the Prevention and Control of Infection in Healthcare1, a two-step clean would be suitable to clean your screens2.

Your two-step clean should involve a physical clean using a detergent followed by disinfection with a Therapeutic Goods Administration (TGA)-listed hospital-grade disinfectant3 with specific claims, or a chlorine-based product such as sodium hypochlorite, where indicated for use.

Physical (mechanical or manual) cleaning is the most important step in cleaning. Per these guidelines, the sole reliance on a disinfectant, such as household-grade anti-bacterial spray, without physical cleaning, is not recommended as it will not sufficiently kill COVID-19.

Step one – physically clean the surfaces (both sides) with detergent.

Step two – clean with a TGA-listed, hospital-grade disinfectant with specific claims. Ensure you clean all areas of the screen, holders, brackets and attachments. Suitable disinfectants for use against COVID-19 in the Australian Register of Therapeutic Goods (ARTG) for legal supply in Australia have been outlined by the TGA. To kill germs, any disinfectant must: •

have enough time in contact with the surface to kill the germs (as per the manufacturer’s instructions)

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be used at the right concentration

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be applied to a clean, dry surface, and

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be effective against those particular germs.

The following lists are comprised of suitable physical, non-aerosol spray, disinfectant products that have been entered into the ARTG with specific claims against COVID-19 on the product label4 that comply with step two:

Disinfectants These disinfectants are to be used with disposable cloth/paper towels:

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S-7 XTRA – Concentrate and TRU-750ml

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SIQURA Hospital Grade Surface Disinfectant

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Spectrum

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Taskforce Commercial Grade Disinfectant

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Trigene - Advance and Sterigene Concentrates and Solutions

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Aeris Active & Evocide Extra Hospital Grade Disinfectant Cleaner

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AP439 Biosan II

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AP610 Percide

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Aussan L44 Concentrate

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Virex II – J-flex and J-Fill

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Clinell Universal Sanitising Spray

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Viraclean, and

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Clinicare Hospital Grade Disinfectant (liquid)

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Zoono Z-71 Germkiller.

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CounterFlu Hospital Grade Disinfectant

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Clorox - Total 360 and Fuzion Cleaner Disinfectant

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Ki-ose 350 Commercial Grade Disinfectant Cleaner

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Nanocyn Disinfectant & Sanitiser

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Netbiokem DSAM Commercial Grade Disinfectant Cleaner

Wipes •

Clinell – Low-Level Instrument and Universal Sanitising Wipes

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Clorox - Disinfecting Wipes, Germicidal Wipes

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Oxivir – Five 16, Tb and Tb Wipes

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Premier Disinfectant Wipes, and

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S-7 XTRA Wipes.

3.

Therapeutic Goods Administration. (2020). Disinfectants, sterilants and sanitary products. Retrieved 09 July 2020 from https://bit.ly/QN20_R3.

4.

Therapeutic Goods Administration. (2020). Disinfectants for use against COVID-19 in the ARTG for legal supply in Australia.

Retrieved 10 July 2020 from URL: www.tga.gov.au/node/904382.

5.

Safe Work Australia. (26 May 2020). Cleaning to prevent the spread of COVID-19. Retrieved 11 August 2020 from https://bit.ly/QN20_R4.

References 1.

2.

Australian Government National Health and Medical Research Council Australian Commission on Safety and Quality in Health Care. (May 2019). Australian Guidelines for the Prevention and Control of Infection in Healthcare. Retrieved 09 July 2020 from https://bit.ly/QN20_R1 Australian Government Department of Health. (10 March 2020). Environmental cleaning and disinfection principles for COVID-19 (Version 1). Retrieved 10 July 2020 from https://bit.ly/QN20_R2.

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SANITISER SAVIOURS

Hand sanitiser saviours How a Facebook group helped solve a national shortage

After having difficulty sourcing hand sanitiser for her practice, Anna Davidson, Practice Manager at Nelson Plaza Clinic in Nelson Bay, NSW, wondered how many others were facing similar issues. The desperate shortage of hand sanitiser meant some practices had already run out, and as product that was manufactured to the general practice required standard was in such short supply, Anna set a plan into motion.

This story started in mid-March with Anna’s posts in the ‘Practice Managers Network’ Facebook group, comprising 4500+ mostly Australian general practice staff. Just one month later, Anna – along with Riwka Hagen, who runs the Facebook group, and Matt Gilchrist, a frequent group collaborator – were the force behind more than 5000 units of 5L hand sanitiser bottles being distributed to practices across Australia during the first wave of the pandemic.

"The demand was overwhelming, from nurses, doctors, specialists – I had an oncologist email me desperate for hand sanitiser to maintain hygiene while treating patients with cancer," Anna told the ABC1.

Anna, Matt and Riwka worked tirelessly to establish and secure a pipeline for the manufacture and supply of hand sanitiser for health organisations in Australia.

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The group, now called Hand Sanitiser Project Australia, teamed up with Mera Chemicals and WaterTest Systems, together with Manildra Group, to supply and distribute the hand sanitiser.

It is estimated Mera Chemicals spent more than $650,000 to make the hundreds of thousands of litres of sanitiser for the Practice Managers Network.

The story was picked up by many media outlets, including Crikey and the ABC. Practice managers like Trish Cuthbert, from Granite Belt Medical Services in Stanthorpe, Queensland quoted that their surgery would have been one of many that may have had to close had it not been for the efforts of Anna, Riwka and Matt.

"If it wasn't for our three guardian angels, thousands of surgeries throughout Australia would have had no access to hand sanitiser‌" she said1.

The Crikey article questioned why improvisation was the latest medical skill general practice staff are having to learn, noting the now Acting Chief Medical Officer, Paul Kelly, praised the ingenuity of a GP who was improvising PPE with swimmers’ face masks and snorkels. Crikey noted that improvisation was on an industrial scale with the Hand Sanitiser Project Australia Team.

The AGPAL Team would like to thank Anna, Riwka and Matt for coming together in a time of need to organise the production and distribution of the much-needed hand sanitiser for general practices right around the country. Your dedication to the industry is incredible.

This hand sanitiser is now available for purchase by medical centres, specialists, allied health, aged care, pharmacy, hospitals, schools, child care centres, remote mining sites, transport organisations, vital industry and disadvantaged communities from: www.watertestsystems.com.au/ hand-sanitiser Not part of the Practice Managers Network Facebook group yet? Jump in at: www.facebook.com/groups/ PracticeManagersNetwork/

Did you know?

In response to the COVID-19 pandemic, on 28 March 2020, the Therapeutic Goods Administration (TGA) excluded specified hand sanitisers from TGA regulation, provided they only contain particular ingredients in specific quantities in the final formulation and comply with certain manufacturing, advertising and labelling conditions.

Under the Therapeutic Goods (Excluded Goods —Hand Sanitisers) Determination 2020, hand sanitiser products that meet the requirements specified in the Exclusion Determination are not subject to therapeutic goods legislation and do not need to be included in the Australian Register of Therapeutic Goods. However, these products will continue to be regulated as consumer goods under Australian Consumer Law.

Hand sanitiser produced for therapeutic use, suitable for medical and health services must contain at least 80% ethanol or 75% pharmacy grade isopropyl alcohol and neither can include colours, fragrances or emollients.

In response to feedback and concerns raised with the TGA by members of the public, businesses and industry representatives, the Exclusion Determination was amended on 6 May to clarify ingredient, labelling and presentation requirements.

Find out more at www.tga.gov.au/hand-sanitisersinformation-manufacturers-suppliersand-advertisers

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INCLUSIVITY

Providing safe and inclusive services

throughout COVID-19 and beyond Data has indicated that some people are at greater risk of more serious illness with COVID-19. Lesbian, gay, bisexual, transgender, intersex, queer/questioning, asexual, and many others such as non-binary and pansexual (LGBTIQA+) communities are known to have health disparities that might influence disease outcomes.

COVID-19 is understandably causing stress and uncertainty throughout all of our communities and workplaces. Studies indicate that due to experiences of inequality and devaluing of their identities and relationships, including experiences of homophobia, biphobia and transphobia many LGBTIQA+ communities experience poorer mental health and higher rates of suicide and self-harm, and could be at greater risk of experiencing anxiety, depression and feelings of isolation.

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These risks are significantly elevated due to COVID-19, and accessing available health support services is more important than ever for LGBTIQA+ communities. Barriers to accessing services – for example, expecting or experiencing discrimination – may be heightened at times of stress and upheaval.

LGBTIQA+ inclusivity within the RACGP Standards 5th edition Guidance for ensuring respectful and culturally appropriate care and managing potential risks is referenced throughout the RACGP Standards 5th edition. The Criterion and Indicators that may be useful to your practice to assist you in this include: •

•

Indicator C2.1 A Our practice, in providing patient healthcare, considers patients’ rights, beliefs, and their religious and cultural backgrounds. This can include developing and maintaining ways to ensure care that is safe, welcoming and appropriate for LGBTIQA+ clients and considering what specific needs LGBTIQA+ people might have.

Criterion GP2.3 – Engaging with other services. This may involve developing referral networks and working cooperatively with LGBTIQA+ specialist healthcare providers and services, as well as reaching out to these organisations for secondary consultation.

•

Criterion GP5.1 – Practice facilities, and Indicator GP5.1 C Our consultation spaces permit patient privacy and confidentiality. As not everyone lives with people who know about their gender, sexuality or intersex variation, or what services they are accessing.

•

Criterion C7.1 – Content of patient health records, outlines issues with patient data collection for the LGBTIQA+ patient demographic. Page 80 of the Standards outlines ways to improve the accuracy of responses when collecting information from patients.

To assist you and your team in meeting these indicators and to provide safe and inclusive services to LGBTIQA+ people – Rainbow Health Victoria has shared some key tips to provide safe and inclusive services and workplaces.

Resource Download Rainbow Health Victoria’s tip sheet from your AGPAL accreditation hub by heading to your Education & Resource Library and searching ‘LGBTIQA’ or visit http://bit.ly/QN20_RTTips

While these tips are specific to the LGBTIQA+ community, they can be used in a broader spectrum to ensure your diverse range of patients to feel safe.

If your organisation is serious about demonstrating a commitment to LGBTIQA+ inclusion, consider Rainbow Tick accreditation.

Rainbow Tick is a world first quality framework to help organisations show that they are safe, inclusive and affirming services and employers for the LGBTIQA+ community.

Looking for formal recognition of a commitment to LGBTIQA+ inclusivity?

Find out more about Rainbow Tick accreditation http://bit.ly/QN20_RT

Services can include the above listed Criterion and Indicators as part of their accreditation or can apply to do the Rainbow Tick as a stand-alone assessment subject to ongoing reassessment and quality improvement.

“Working towards and receiving the Rainbow Tick reinforced our team's commitment to providing the best possible service to our individual consumers and our dedication to being a welcoming culture to all. It is valued and embraced by our staff and consumers and attracts consumers and staff with similar values.”

– Sue Jones, The Melbourne Clinic (Rainbow Tick Accredited Organisation) Reference Carman M, Bourne A, Fairchild J. (2020). COVID-19: impacts for LGBTIQ communities and implications for services: A Research Briefing Paper by Rainbow Health Victoria. Retrieved 18 August 2020 from: http://bit.ly/QN20_LGBTI.

SPRING 2020

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STAFF SUPPORT

Supporting the mental health of your staff Supporting positive mental health and wellness in all workplaces is essential. Throughout the healthcare sector, providers treat or refer patients to specialists for mental health conditions daily. Yet, many of these professionals are also suffering, particularly so with the ongoing stress and uncertainty of the COVID-19 pandemic.

Some practice managers have recently taken it upon themselves to go the extra mile for their staff.

A flower for a colleague, a round of coffees for the team, implementing some ‘human’ initiatives such as ‘Fun Fridays’, healthy competitions like step challenges or seasonal parties with Secret Santa type gift exchanges can have a positive impact on practice team morale. If added onto your ‘usual’ calendar of celebrations (for birthdays, anniversaries, cultural or religious occasions, etc), initiatives that recognise our humanity can be the bridge from ho-hum to hi-hum!

‘We are all having to learn an enormous amount of new information to augment our practice, what we do, and move towards a new way of operating.

This could be long-term or short-term, we don’t know yet.’ – Di Hickey

For those looking for something more than these gestures, housed in your AGPAL accreditation hub, is a webinar recorded in June 2020 by AGPAL’s sister company Quality Innovation Performance Limited (QIP) titled ‘We are #inthistogether: supporting mental health in healthcare’.

This webinar, hosted by QIP with mental health expert Di Hickey, discusses approaches to support the creation of a mentally healthy workplace and identifies professional resources available to help those who may be suffering from mental health issues.

Resources There is a wealth of support online for mental health, but as part of QIP’s ‘We are #inthistogether’ webinar, a series of specific resources is outlined to assist in providing appropriate and thorough mental health support for healthcare organisations. Take a look at some of them: Queensland Mental Health Commission – COVID-19 and mental health https://bit.ly/QN20_MH1

Worksafe Queensland – Workplace psychological health considerations https://bit.ly/QN20_MH4

Safe Work Australia – Mental health: Tips for managing stress from COVID-19 https://bit.ly/QN20_MH2

Beyond Blue – Protecting your mental health and wellbeing as a healthcare worker https://bit.ly/QN20_MH5

Staying connected via the Australian Network on Disability (AND) – Staying connected – inclusive working from home practices and supporting mental health and wellbeing https://bit.ly/QN20_MH3

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STANDARDS IN

FOCUS

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Follow-up systems and recalls Tackled under RACGP Standards 5th edition, Criterion GP2.2 is important for both the patient and general practice, appropriate action must be taken for clinically significant results.

Follow-up systems are important for both the patient and general practice. Tackled under Criterion GP2.2 – Follow-up systems, clinically significant results must be communicated quickly and appropriately so appropriate action can be taken.

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Managing clinical risks We outline the mandatory Indicators in RACGP Standards 5th edition Criterion QI3.1, and how to identify, monitor and continuously improve on your practice's near misses.

STANDARDS

Follow-up systems and recalls Follow-up appointments, sometimes referred to as recalls, are important for both the patient and general practice. Clinically significant results must be communicated quickly and appropriately so appropriate action can be taken, reducing the likelihood of adverse patient outcomes that may lead to medico-legal issues for the practice.

In 2012, 'recalls' became the focus of a Victorian Supreme Court case (Grinham v Tabro Meats Pty Ltd and Victorian WorkCover Authority v Murray) which examined the ‘clinical and legal obligations of a doctor in relation to the follow up of a patient when they do not return for further testing or consultation despite being asked to do so’.

As a result of legal proceedings from this case, it was established that a general practitioner can potentially defend an allegation of a failure to recall a patient so long as there is sufficient evidence that reasonable attempts were made to recall and contact the patient.

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Follow-up and recall systems are outlined in the RACGP Standards 5th edition under GP Standard 2, Comprehensive care, which ensures practices provide comprehensive care to patients.

Criterion GP2.2 has four mandatory indicators and one aspirational indicator.

Key definitions As defined within the RACGP Standards for general practices 5th edition glossary of terms Clinical significance A way of referring to an assessment of: •

the probability that a patient will be harmed if they do not receive further medical advice, treatment or other diagnostics

•

the likely seriousness of the harm.

Follow up Activities that are the logical and responsible steps to take after taking earlier related actions, including: •

making a phone call to find out the status of tests and results that are expected but not yet been received, and

•

contacting a patient to discuss a report, test or results.

High-risk results Clinical test results that are seriously abnormal and life-threatening and need to be communicated in an appropriately timely manner.

Recall The process of requesting a patient to attend a consultation to receive further medical advice on matters of clinical significance.

Reminder A reminder occurs due to the patient being added to a recommended preventive activity list that is generated and actioned periodically. For example, cervical screen or immunisation in a reminder list.

Criterion GP2.2 – Follow-up systems The RACGP Standards 5th edition notes that 'the information gained from tests can affect the choices that a patient, the GP, and other clinicians make about the patient’s care. Clinically significant results need to be communicated quickly and appropriately so appropriate action can be taken, which can reduce the likelihood of an adverse patient outcome.

It is best practice to inform patients of clinically significant results face-to-face, so the patient can ask questions and receive advice from the GP. Using recalls and reminders to proactively contact patients about their care means that patients will be more likely to, for example, come back to the practice to discuss a test result or undergo a preventive activity, such as cancer screening. Failure to recall a patient may result in an adverse outcome and the responsible practitioner may face medico-legal action.'

GP2.2

A

GP2.2 A Pathology results, imaging reports, investigation reports, and clinical correspondence that our practice receives are reviewed; electronically notated, or, if on paper, signed or initialled; acted on where required; and incorporated into the patient health record.

To meet GP2.2 A, your practice must record details of a GP’s review of pathology results in the patient’s health record and have a process to review and manage results received by the practice.

To ensure this process is met, your practice could have a policy and/or documented procedures for reviewing and managing results.

GP2.2

B

GP2.2 B Our practice recalls patients who have clinically significant results.

Your practice must document in the patient’s health record each attempt to contact and recall patients about clinically significant results and have a process for recalling patients with clinically significant results.

Meeting this indicator could be done by having a recall policy that outlines recall responsibilities in relevant position descriptions, with a specific team member holding lead responsibility.

This indicator is one that benefits greatly from the practice having a clinical information software system, often referred to as ‘medical software’.

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STANDARDS

In the past few years, medical software providers have created a range of options to assist in the recall process. Many practices find these recall processes are quicker and more efficient than ever before – ensuring this key activity is well managed and giving practice staff more time to spend on other tasks. This system could assist in maintaining templates to trigger and send recalls.

This indicator echoes the ‘could’ items of GP2.2 B with the recall policy and procedure, responsibilities of the team for the recall process and utilising the medical software system for recalls.

Using medical software for recalls

While not mandatory, GP2.2D offers opportunities where your practice 'could' implement a range of options for patient reminders that support the A, B, C and E mandatory indicators. Take a look at page 130 of the Standards to see the range of options in how to initiate and manage reminders.

Follow the links below to see more about using recalls in your practices’ software: Best Practice – Recall appointments https://bit.ly/QN20_recallBP Clinic to Cloud – Patient recall https://bit.ly/QN20_recallC2C Genie Solutions – Recalls https://bit.ly/QN20_recallGS HealthEngine – Recalls Help Centre https://bit.ly/QN20_recallHE Helix – User Guide: Recalls https://bit.ly/QN20_recallHx HotDoc – Recalls (integrated with Medical Director, Best Practice and ZedMed) https://bit.ly/QN20_recallHD Medical Director – Clinical: Recalls https://bit.ly/QN20_recallMD Practice Hub –Using Recalls https://bit.ly/QN20_recallPH

GP2.2

C

Indicator GP2.2 C Our patients are advised of the practice’s process for follow-up tests and results.

This means that the practice must document in the patient’s health record what follow-up has occurred and what treatment, if any, was required and document conversations about test results in the patient’s notes. The practice team members must also be educated on this process so patients are aware of and told of the process to receive results.

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GP2.2D GP2.2D Our practice initiates and manages patient reminders.

GP2.2

E

GP2.2 E High-risk (seriously abnormal and lifethreatening) results identified outside normal opening hours are managed by our practice.

At times, general practices will receive high-risk results outside of normal practice areas depending on the severity of the results and issues. This indicator requires high-risk results identified outside normal opening hours to be managed by the practice.

Within Indicator GP2.2 E, your practice must give diagnostic services the contact details of the practitioner who ordered the investigation and have a process for managing high-risk results identified outside of normal opening hours.

To achieve compliance in this Indicator, your practice could have a dedicated team member who receives high-risk results outside of normal opening hours. Your practice should ensure all practice team members are educated about how anyone who provides diagnostic services or receives high-risk results outside of normal opening hours can contact the practice team member/s who have access to the patient’s health record.

Where a designated contact is appointed, it is important that your practice ensures their current contact details are provided.

The key is in your practice’s policy and procedure manual A well-rounded policy and procedure manual will assist your practice in meeting elements of mandatory Indicators GP2.2 A, B, C and E, and aspirational Indicator GP2.2 D. If your practice has utilised the AGPAL Policy and Procedure Manual Template resource, available within your AGPAL accreditation hub, your practice is likely already compliant with these indicators. Specifically, section ‘7.7 Follow up of tests, results and referrals’ of AGPAL’s Policy and Procedure Manual Template outlines the following key items for review by your practice: •

Sometimes our general practitioners may need to be contacted outside our practice’s normal opening hours by the pathology service about a serious or life-threatening result, and we have provisions for allowing this contact to occur (refer to Section 5.10 – After-hours service).

•

Where a patient indicates they do not intend to comply with a recommended test or referral, the patient is deemed to have refused medical treatment or advice and is managed in accordance with 'Section 7.12 – Management of a patient refusing treatment or advice'.

•

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 is documented in the patient’s health record.

•

In addition to an appreciation of the need for timeliness when following up and actioning referrals, tests and results, our practice team members are aware of the need for confidentiality and discretion with regard to referrals, diagnostic tests and results or correspondence.

Resources There is a suite of resources available to support you and your team in meeting Criterion GP2.2. Take a look at the webinars, and use the templates to get you on your way: AGPAL accreditation hub • P olicy and Procedure Manual Template (Section 5.2 Appointments and Section 7.7 - Follow up of tests, results and referrals), and • Recall letter template.

RACGP Guide to providing telephone and video consultations in general practice – specifically Section 2. Providing and documenting care http://bit.ly/QN20_recall2.1

RACGP eHealth - Guiding principles for clinical follow up systems in medical software (for 4th edition Standards) http://bit.ly/QN20_Recall1 RACGP webinar: Improving health record quality in general practice (27 June 2019) https://bit.ly/QN20_recall3 RACGP webinar: Technology in general practice (25 July 2019) https://bit.ly/QN20_recall4

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STANDARDS

Managing clinical risks Clinical risk management can be defined as actively identifying circumstances and opportunities that put patients at risk of harm and putting in place quality and safety systems and processes to control those risks.

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Clinical risk management includes identifying and understanding not only actual adverse events but also things like ‘near misses’ and mistakes, medico-legal risks, and failure of clinical equipment and/or communication process.

Clinical risk management focuses on understanding the probability of harm to a patient that potentially negatively affects the quality of their care.

The Western Australian Department of Health indicates that clinical risk management is about minimising risks and harm to patients through the following steps:

It is important to use systems to recognise and analyse near misses and adverse events to ensure you identify, implement, and test solutions to prevent them from happening again. If your practice doesn’t make improvements after identifying an incident that resulted in a near miss, patients may be exposed to avoidable future adverse events and the practice team may increase their risk of medico-legal action.

•

Identifying what can and does go wrong during care

•

Understanding the factors that influence this

•

Learning lessons from adverse events and poor outcomes

•

Ensuring action is taken to prevent a recurrence, and

•

Putting systems in place to reduce risks.

SPRING 2020

This is where clinical risk management and continuous quality improvements come into play.

What do your AGPAL Surveyors say?

What does clinical risk management look like in your practice? It may well be of such a second nature to you that you don’t even consider it to be part of a risk management process.

It can be anything from the day-to-day activities you and your team do to deliver care, actions taken to identify and reduce risk of harm to your patients, or continuous quality improvements made within your practice.

"The practice needs to have a system – and it can be simple – for monitoring, identifying and reporting a near miss or adverse event. Risk should be a standing discussion item at all practice meetings."

– AGPAL GP Surveyor, Dr Scott Phipps “Staff should show they know how to report a near miss or adverse event from the moment they are inducted into the practice. The practice should consider who reviews the near miss/adverse event reports and provides direction to change processes if there has been an issue.” he continued.

Mark Brommeyer, Senior Lecturer in Healthcare Management at Flinders University notes that “continuous quality improvement within practices

is important as healthcare and related needs are ever-changing, and therefore so should your practice in how it operates and provides care.”

“Quality improvement helps to identify opportunities to make changes to improve patient safety and care and can be achieved in a number of ways.

These include regular review of practice structure, systems and operations and the services provided” he continued.

"Quality improvement changes should be based on your own practice and the data you collect, be it patient feedback, team or staff feedback and suggestions and audits,” Mark finished.

Where to look for near misses While your practice may never have experienced an actual adverse event (an incident), it most certainly will have been exposed to near misses. A near miss can take many forms, with the same area or topic generating many pathways for clinical risks.

Near miss examples include a GP missing a diagnosis; a practice nurse administering incorrect vaccinations or out of date medications to patients; clinical staff failing to follow up on test results; an administrative delay in recalling a patient for results; or results not being marked as notified within recalls.

Every aspect of your practice should be scanned for near misses. Patient files can be a minefield for near misses – with anything from accessing the incorrect patient file for similarly named patients to a patient’s address not confirmed when calling an ambulance for them.

Medical devices are also a ‘hotspot’ area for risks with clinical staff potentially not knowing how to use devices correctly, the devices not being

properly cared for or maintained, or failing to undertake audits on treatment room stock, which may lead to malfunctions.

The RACGP’s 2014 publication, ‘Clinical risk management in general practice: A quality and safety improvement guide and educational resource for individual- or group-based learning’ is an excellent resource to help you identify and understand clinical risks and their solutions.

The guide gives several examples of near misses, pathways the clinical team could have gone, and the severity of outcomes-based upon those pathways. See page 20 for resources to help you achieve quality improvement and for information on where you can find the guide.

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STANDARDS

Clinical risk management within the 5th edition Most practitioners and practices already manage clinical risk daily. Many have informal and ad hoc methods aimed at preventing near misses and adverse events. Within the RACGP Standards, Criterion QI3.1 – Managing clinical risks, the following suggestions are offered to reduce near misses and adverse events: •

Establish a system so that practitioners talk to trusted peers and supervisors for advice

•

Use a formal process of discussing within the practice what went wrong and how to reduce the likelihood of it happening again

•

Use structured techniques to analyse the causes of near misses and adverse events to reduce the likelihood of recurrence

•

Establish a system so that members of the practice team know how and to whom to report a near miss or adverse event, and that they can do so without fear of recrimination

•

Keep copies of the practice’s risk or critical incident register

•

Implement a clinical governance framework to help achieve a balance of ‘find it’, ‘fix it’, and ‘confirm it’ function to improve the quality and safety of care •

Find it – use tools such as clinical audits and performance indicators to identify where quality improvement programs could improve care and patient health outcomes

•

Fix it – after identifying where improvements can be made, implement strategies to address the issue, and

•

Confirm it – measure the outcomes of the improvement using an effective evaluation process.

While these are suggested ways to reduce clinical risks, the two Indicators within Criterion QI3.1 that are mandatory and are ‘musts' for your practice are outlined on the following page.

Key definitions Adverse events – incidents that cause harm.

Near misses – incidents that had the potential to cause harm but did not.

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SPRING 2020

QI3.1 A Our practice monitors, identifies, and reports near misses and adverse events in clinical care.

Your practice must implement and maintain an incident or event register. This is important as patient safety incidents in clinical care occur in all health settings.

You could implement and maintain a clinical risk management policy, such as the one provided as part of AGPAL’s Policy and Procedure Manual Template, found in your AGPAL accreditation hub.

If you use systems to recognise and analyse near misses and adverse events, you can identify, implement, and test solutions to prevent them from happening again.

Alternatively, your practice team could conduct clinical audits and make changes to clinical care to reduce the risk of identified issues or keep a record of team meetings and planning meetings where risks are discussed.

QI3.1 B Our practice team makes improvements to our clinical risk management systems in order to prevent near misses and adverse events in clinical care.

You must record the actions taken in response to events recorded on the incident or event register. To show that you are doing this, your team could record revisions to policies and procedures that have been shown to reduce risk.

Access AGPAL’s clinical near miss and mistake register template to ensure your practice outlines the description of each near miss, the action to address it, action to prevent it, and an allocated person responsible for these actions.

Consistent use and application of a clinical risk management tool is important for patient care because: •

The same mistake can have different causes on different occasions.

•

The causes of near misses and mistakes are identified and processes are improved to reduce the likelihood of them occurring again.

•

Without improvements, patients may be exposed to an increased risk of adverse outcomes and the practice staff exposed to medico-legal action.

•

Practices must demonstrate how and why they have made changes to improve clinical care.

Resources AGPAL accreditation hub: • AGPAL clinical near miss and mistake register template • AGPAL Policy and Procedure Manual Template – section 3.2 Incidents and injury and adverse patient events, and

References 1.

Western Australian Department of Health (3 October 2019). Clinical risk management. Retrieved on 20 August 2020 from URL http://bit.ly/QN20_Risk1

2.

Royal Australian College of General Practitioners (August 2014). Clinical risk management in general practice guide.

Retrieved on 20 August 2020 from URL http://bit.ly/QN20_Risk2

• AGPAL webinar: Clinical Risk Management.

RACGP Clinical Risk Management in General Practice (2014) http://bit.ly/QN20_Risk2 SPRING 2020

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