The Foundation programme represents a collection of legislative, regulatory and clinical requirements for all general practices in Aotearoa New Zealand. It represents a nationally consistent benchmark by which a practice can measure its current quality of care and progress toward health equity outcomes.
To meet PHO Service Agreement Amendment Protocol (PSAAP) requirements and qualify for capitation funding, practices will need to complete the College’s revamped Foundation programme.
This standalone programme provides a baseline standard expected of a general practice.
Pinnacle will provide assessors to assess you against the standard which will be at no cost to your practice. This is one of the membership benefits of Pinnacle. You are still welcome to find your own assessor through the College website, but fees associated with the assessment process will be at your own cost.
Are you preparing for your Foundation Assessment? Or keeping track of actions throughout the three-year certification period to remain on track? A few documents that may be useful have been developed.
There are four documents we've added to the files and links section below.
Any questions or suggestions for future content, please feel free to contact Lisa Zame, details below.
Practices that are due to be assessed in early 2025 will have received letters with potential dates for assessment. This ensures practices have ample time for planning as a team and can put processes in place early to meet the standard. Please ensure you have signed those letters and sent them back to quality.team@pinnacle.health.nz. Pinnacle supply the assessors free of charge so it is important that these assessments are booked as soon as possible.
The RNZCGP website has good information to support practices to meet the standard. In particular the quality programmes resources tab on the left hand side has some good resources on it.
The Pinnacle team are available to answer any questions you may have around the standard. Your first point of contact is Lisa Zame, the Foundation Standard Facilitator. The Pinnacle nursing team are available if you have any questions regarding criteria affecting nursing. Common areas that require nursing input are standing orders.
We have set up “walk-in” Foundation Standard online Teams hui, that occur on the first Wednesday of each month 12.30-1.30pm where practices can ask any questions of other practices or Pinnacle staff. Check the events section of our website to find the next date and for the reccuring Teams meeting link.
We will share trends occurring through the assessment process, as tips in our practice newsletters on a bi-monthly basis. We will ensure these are shared with practices through our website.
If you would like a Pinnacle staff member to meet with your team for an initial start-up meeting, please contact Lisa to arrange a time. It is important you have a representative from each area of your team at that meeting to help ease the load of one person trying to complete all areas of the standard.
It is important practices set up processes to ensure that when assessment date comes, it is not a big piece of work. Products such as GP Docs are useful to manage the process within the practice. If you do not have a product such as GP Docs, it is important as a team you are consistently using staff meetings and clinical governance meetings to update a few policies each month.
Any recent changes to legislation or requirements within the standard are captured on the RNZCGP changes within each criteria or under Foundation Standard recent updates.
Once the assessor has completed the Foundation Standard site visit, they inform the practice if any further actions or evidence is needed to meet the requirements. This time period is referred to as the ‘post assessment dialogue’ (PAD) phase.
The PAD phase should take between 2-6 weeks, and it is expected that all evidence is current when the assessment is submitted to the College. A longer PAD phase can cause timebound evidence to expire, creating additional work for both practices and assessors as they identify and refresh the expired pieces of evidence.
To improve efficiency and resolve this issue, the College introduced the subject in the August 2024 Quality Pānui, of implementing a PAD limit of 3 months, effective from 1 January 2025.
Since January, the College have observed that the number of assessments being submitted outside the PAD time frame has continued to increase.
From 1 June 2025 the College will be implementing the following process for all Foundation Standard assessments submitted that exceed the 3-month PAD limit:
If you have any questions, please contact Lisa Zame.
Esteem Healthcare Essential Sterilisation Workshop
Summary of content: Correct cleaning, processing and packaging of instruments to ensure sterility. See flyer here.
Cost: $350 + GST per practice (group learning onsite, 60-minute duration)
Acehub online education
Summary of content: How to clean reusable devices, how to inspect and seal packs, autoclave process for benchtop sterilisation machines, how to care for instruments, chemicals and detergents.
Cost: $65 + GST 2hrs on demand online learning. Acehub also have another module on removing biofilm and market both courses as a bundle for $75 + GST.
Equipment supplier training
Suppliers of autoclaves and autoclave equipment often provide education to practices on the equipment they have purchased e.g. Amtec, 3M, EBOS etc. Practices will be required to liaise directly with their suppliers to confirm availability of this.
The only two audits required as evidence for Foundation Standard are:
These audits ensure a practice’s policies and procedures are current and being adhered to.
After completion it is important to discuss findings at your next clinical governance meeting. This can occur after the assessment, just note it.
See the sample template for repeat prescribing audit and the sample template for medicines reconciliation audit.
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
Key themes from practice assessments
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.
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:
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:
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.
Worksafe has produced a practical guide on working safely with hazardous substances. This includes instructions for filling out inventories, a hazardous substances calculator and other resources. It is highly recommended that practices use this website to record their hazardous substances. This site will also help practices determine what substances in their practices are hazardous including those that don’t meet the threshold such as medical detergents, bleach and the mercury in a sphygmomanometer.
It is a legal requirement for team members handling hazardous substances to be able to manage these safely and have had training that is documented. Team members can do inhouse training using the data sheets. The RNZCGP has provided a data sheet training template to assist practices with this.
Liquid phenol kept in a bottle is considered a class 6.1 substance and requires certified handler training. Practices using phenol for toenail surgery can purchase phenol swabs which does not require certified handler training. Whitely Allcare supply phenol swabs but only supply these to pharmacies. RNZCGP are currently looking for a supplier directly to practices. In the interim, practices are advised to prescribe the swabs ensuring they are aware of which pharmacies in their area carry these.
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). Electric 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:
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.
The RNZCGP have a general policy that practices can use as a template.
Ensure you cover:
Every practice needs to audit regularly against their process in the policy (at least annually). The college have a good template that you can use on their site (medicines reconciliation process and audit MARCH 2025). 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
Results
Discussion
To meet this indicator (9.1), practices need:
All practices are required to have a repeat prescribing policy.
The documented policy for repeat prescribing needs to outline a reliable, safe and consistent approach to repeat prescribing.
Considerations
The purpose of auditing is to ensure that the repeat prescribing policy and procedure is being adhered to. By auditing the policy and then differentiating Māori from non-Māori, the practice can identify whether there are any inequities existing which might prompt an improvement initiative.
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:
Include in your evidence:
The college have a good template that you can adapt on their website (Sample template for repeat prescribing audit).
Your policies and procedures must align with infection control standards.
Key features of section 5 of the Ngā paerewa, the health and Disability Services Standard NZS8134:2021:
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.
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.
The nursing lead team is always available for kōrero on this subject.
Lisa Zame, Foundation Standard Facilitator
lisa.zame@pinnacle.health.nz
027 282 8843
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