Foundation Standard

As part of criteria 12.1 and 12.2 of the Foundation Standard, an audit is required for infection control and waste management. A simple audit checklist and audit tool has been developed that can be used for this purpose. 

Despite the increase in immunisation providers outside general practice since COVID-19, general practice continues to be the service that facilitates the majority of childhood immunisations. A good process that identifies roles and responsibilities, timing and method of inviting (recalling) whānau for immunisation can improve coverage for the practice, with the ultimate health gain of fewer vaccine-preventable illnesses in patients and whānau.

As part of Foundation Standard criteria 7.2, practices are required to have a documented process on how recalls are undertaken in general practice. The areas that need to be covered in the standard are outlined in this process. Pinnacle has put together a process for practices to use/amend that covers those areas (see the files section below). Your nurse leads and child immunisation improvement nurse are always available if you have any questions about immunisation or practice recall process nursing@pinnacle.health.nz

All practices in Aotearoa New Zealand need to meet Foundation Standard, a standard set by RNZCGP. Pinnacle has trained assessors and as part of Pinnacle membership we provide practices with free assessment. 

Pinnacle provide support in a variety of ways. Contact the practice systems support team, nurse leads or Michelle Bayley if you have any clinical questions. Join the monthly Zoom for updates on trends we are seeing during practice assessments and answers to any questions you might have. These are advertised through our newsletters and on the events page of our website.

We recommend that once practices have met the standard, they put in place a regular way of reviewing policies for the future and divide that up so that it doesn’t become the burden of one staff member.  

Key themes from practice assessments

• Training – due to COVID-19, this may have slipped from practice priorities. Most training is online and no longer needs repeating. Information around training requirements can be found on the RNZCGP website. Note for small practices <20 staff, ALL training certificates need to be uploaded.
• Policy updates – policies need updating regularly (at least three yearly and two yearly for your waste management). Ensure they include virtual clauses and changes as a result of the pandemic, such as ventilation and streaming of patients. Policies should reflect what you are actually doing in your practice. The RNZCGP has a good structure for a policy if you are ever starting from scratch.   Most practices will already have existing policies. When reviewing these, check the content is still correct (especially in respect to legislation) and it contains all information listed under the Foundation Standard indicator listed as required.
• Enrolment form – make sure the enrolment form you use is up to date. This includes enrolling with the Midlands Regional Health Network Charitable Trust.
• Phenol liquid is classified as a category 6.1A hazardous substance. This means if you are still holding this in practice, you require certified handling training (with an associated certificate). More information can be found on the RNZCGP website alongside how to purchase phenol swabs (which do not fall into that category). 
• There are two audits in the standard – medicines reconciliation and repeat prescribing. After completion it is important to write, and discuss at your next clinical governance meeting, a summary of findings. This can occur after the assessment, just note it.
• Standing orders. There are now less of these being used in practices due to the increase in community nurse prescribers. Ensure you follow all legal requirements, including ensuring the issuer (normally a GP) has confirmed annually the competency of each person working under the individual standing order.  You can find more information on our website, including a webinar. The nurse leads are always happy to help practices around standing orders. 

All practices must comply with the PHO enrolment requirements when enrolling patients. These are summarised on our website, including a useful video for practices presented by Te Whatu Ora. 

Through Foundation Standard assessments and discussions with Te Whatu Ora Health Payments Integrity Unit, the following points may be of interest.

• Enrolment form - ensure your enrolment form is up-to-date. Key areas of focus include: 
  • patients enrol with Midlands Health Trust not Pinnacle or MHN
  • there are certain criteria that have changed since the last enrolment form. In particular, the new question around gender, and the information around the national patient experience survey. Please ensure both of these are clearly displayed on your enrolment form if you are using your own form (not the Pinnacle one).
• Having a process to regularly audit your enrolment process can identify any gaps before you have an audit. Use the random 100 NHIs that are sent to you quarterly via your Healthlink folder for this purpose.
• Ensure you have a documented enrolment procedure and that all staff are aware of this. Information around what is required can be found on our website and in the guidance under the RNZCGP foundation standard criteria 2.2. 
• Ensure the date of enrolment on the enrolment form, and in your practice management system, match.
• Ensure ethnicity is recorded correctly.

Through the foundation standard assessment process a few gaps have been noted around the management of hazardous substances within practices.

Under section 13.2 practices are required to show evidence of:

• an inventory of all the hazardous substances at your workplace, including substance type, quantity and location and associated data safety sheets
• hazardous substances in your workplace are added to the hazards and risk register
• team members working with hazardous substances are trained to work safely with them
• team members managing highly hazardous substances (such as class 6.1A and 6.1B substances) have certified handling certificates or work directly under the supervision of a certified handler.

Consideration should also be given to eliminating the risk where it is reasonably practicable to do so. 

Where it is not reasonably practicable, then a plan on how to minimise the risk could include:

• substituting the substance for a less hazardous substance
• removing the mist, gas or vapour at the source of generation using local exhaust ventilation
• isolating the process that uses the substance in an enclosure
• using the substance only in well-ventilated areas
• prevention of harm through personal protective equipment (PPE).

Procedures in your Emergency Management Plan and/or your Health Emergency Policy are reviewed and updated on a regular basis with consideration being given to relevant legislation and practice standards.

Some further clarifications on the AS/NZS 3003:2018 and AS/NZS 2500:202 standards.  Practices that have portable RCDs need these to be 10mA which can still be purchased.  These are required for Medical electrical equipment that is fastened to the patient in a manner such that contact resistance is lowered and easy disconnection is not possible ie electrodes or transducers attached to the patient, and parts that are in electrical contact with conducting liquids which in turn enter the patient.  Examples of these types of electrical equipment include ECGs (plugged into direct current), diathermy, speculum with lighting (plugged into direct current).  Electirc beds in a consult room would not need a portable RCD, however in a treatment room where a patient may be having an ECG on an electric bed, and there is a possibility of static electricity or liquid on the bed, then a portable RCD would be safest. 

If a practices is new and/or has done alternations after 2018, they will need to be compliant with AS/NZS 3003:2018 and patient areas will need to have a body protected electrical area which includes socket outlet RCDs.

To meet this indicator (9.3), practices need:

• a documented medicine reconciliation policy and procedure in accordance with the Health Quality and Safety Commission Medical Reconciliation Standard 2012
• included in this policy is the requirement of an annual audit against the policy. 

Medicines reconciliation is about obtaining the most accurate list possible of patient medicines, allergies and adverse drug reactions by using two different sources of information. Sources of information could include a discharge summary, community pharmacy records, the patient or whānau, your practice management system. Reconciling medications reduces the risk of medication errors and confusion that may occur during patient transfer of care.  The RNZCGP have some good guidance around this based on the Health Quality and Safety Commission Medicine Reconciliation Standard. Most practices find that by starting with patients who have been discharged from hospital, it makes this a tangible group of patients to start the process with. Also we know that the interface between primary and secondary care is the area where most errors can occur so this is a good group of patients to use this process. 

Medicines reconciliation policy

The RNZCGP have a general policy that practices can use as a template.

Ensure you cover:

• purpose
• accountabilities and responsibilities
• process including:
  • timelines
  • collection and accurate identification of a patient’s current list of medications
  • comparing the information collected to a list of medicines recently available to the patient
  • identifying and resolving discrepancies
  • accurately recording and communicating the outcomes – this could include the patient, community pharmacy, the hospital
• education and training requirements:
  • include in the induction checklist
• audit process:
  • include the template you use as an appendix
  • include timeframes for auditing ie how often
• reporting
  • relevant learnings are reported to the clinical governance group (include timeframe). 

Medicines reconciliation audit

Every practice needs to audit regularly against their process in the policy.  The college have a good template that you can use on their site (medicines reconciliation paper form in the guidance).  This template on its own is not enough to meet the standard.  Ensure you include in the narrative the way you audited your patients.  Acknowledgement to Lakes Surgery for their example below. 

Methodology

• Reports were run in the practice’s PMS to identify inbox records for specialist letters and hospital discharge summaries.
  • Timeframe was records dated between the 1^stand 14^th of August 2022.
  • 42 discharge summaries were detected and 5 of these were selected at random (every 8^threcord).
  • 237 other scanned inbox records were detected and 10 of these were selected at random (every 23^rdrecord). If the random record was not a specialist letter the next record on the list was selected instead.
• A total of 15 records were looked at (5 discharge summaries and 10 specialist records) to check whether medicine reconciliations had been done.
• They were also checked to see if the reconciliation was completed within 1 week of being received.

Results

• All records that had medications had a reconciliation done.
• All reconciliations were completed within the 1 week time frame.

Discussion

• Discussion was held on Monday 29^thof August at the morning team huddle, 9am.
• Discussed who we can send medicine reconciliations to now that our clinical pharmacist has left. Agreed to send to Louise, nurse prescriber, who is able to do these reconciliations.
• Previous clinical pharmacist was provided by Pinnacle one day per week. Manager to check with Pinnacle around replacement clinical pharmacy

To meet this indicator (9.1), practices need:

• a documented repeat prescribing policy and procedure
• annual audits of repeat prescribing activity in accordance with the policy. 

Repeat prescribing policy

All practices are required to have a repeat prescribing policy. There is some good guidance on the RNZCGP website.

The documented policy for repeat prescribing needs to outline a reliable, safe and consistent approach to repeat prescribing. The policy needs to be clear on who generates, takes responsibility for, and the process for generating repeat prescriptions and the audit process. 

Considerations

• Roles and responsibilities within the practice. Note only authorised prescribers can prescribe – in practices this is normally general practitioner, nurse practitioner, pharmacist prescriber or delegated prescriber.   
• Regular assessment guidelines to ensure the prescription remains appropriate.
• A definition of what constitutes appropriate regular review - and is it different for different conditions.
• Any medications that cannot be prescribed without a consultation.
• Additional measures to optomise Māori access to repeat prescriptions and collection of medicines. 

New additions since last policy renewal 

• An e-prescribing process.
• Annual auditing process which differentiate Māori from non Māori.
• How audits will be discussed and actioned at clinical governance meetings. 

Annual audit

There is a requirement for the practice to audit against the process in the policy including a view on prescribing to Māori vs non Māori. Look at a previous day or week to audit of all the repeat prescriptions generated by the practice.  

The audit needs to reflect checks that show alignment with your policy. A good way to do this is to print out your policy and mark points you want to monitor. Depending on what is in your policy you could audit:

• how the request came into the practice (eg if your policy says it cannot come via email, ensuring this occurred)
• role of staff member who generated the repeat
• whether there is an indication for each medication
• time prescription is sent to pharmacy (if your policy stipulates a time period)
• is the patient being monitored for potential adverse effects.

Include in your evidence:

• your findings and reflections
• actions
• next review date
• date the audit is discussed at Clinical Governance meetings and any recommendations.

17 August 2022

Ngā Paerewa, the Health and Disability Services Standard has been updated. This relates to Foundation Standard indicator 14 of the 2020 standard.  

This may mean some significant changes to what your practice is currently doing, or a re-alignment to your current policies. 

The most significant ones, as a starter for you to be aware of, include the following. 

1. There must be a designated IPC lead.
2. Ventilation: good ventilation is not the only measure to reduce the risk of airborne particles being transmitted through ventilation systems, but is part of a comprehensive package of protective measures, such as physical distancing, mask wearing, and frequent hand washing. Good guidance around this is given by the RNZCGP.
3. Re-usable medical devices (RMDs): if a practice is reprocessing reusable medical and surgical instruments and equipment, RMDs, AS/NZS4815:2006 sets the standard for cleaning, disinfecting and sterilizing reusable medical and surgical instruments and equipment, and the maintenance of associated environments.
4. An increase depth on Health and disability services standards NZS 8134:2021 Ngā Paerewa, the Health and Disability Services Standard, section 5; Infection prevention and antimicrobial stewardship, replaces the previous standard (NZS:8134.3:2008). 

- It fosters continuous quality improvement (CQI) and is considered best practice for primary care. In order for the practice to document how team members are going to manage infection prevention and antimicrobial stewardship.

- Antimicrobial stewardship is about avoiding the unnecessary use of antimicrobials, for example, antibiotics, and making sure that whenever they are used, they are used with care to minimise the risk of antimicrobial resistance. Patients, doctors, nurses and pharmacists all play an important part in antimicrobial stewardship.  Note as primary care does not have a national antimicrobial stewardship programme, practices are exempt from 5.3, 5.4, 5.5.4 and 5.5.5. More information is found on the foundation standard page.

Enjoy a deep dive into the updated standards! They are very readable and practical. The nursing lead team is always available for kōrero on this subject.