Application form for the approval of accrediting … · Web viewApplication form for the approval...

TRIM: D17-17818

May 2017

Application form for the approval of accrediting agencies assessing general practice

Note: Applicants should read the Guide to the approval process for accrediting agencies assessing general practice before completing this application form.

Official ACSQHC use only

Date received: Applicant number:

Notes:

Application form for the approval of accrediting agencies assessing general practice, May 2017 2Australian Commission on Safety and Quality in Health Care

Part A: Application instructionsApplicants should read the Guide to the approval process for accrediting agencies assessing general practice before completing this form.

By ticking a box you are answering in the positive or are agreeing to a statement of question. Please leave the box empty if you choose to answer ‘no’ or feel the question is not applicable.

Applicants are advised that incomplete documentation may lead to a delay in the assessment of their application as outlined in section 5 of the Guide to the approval process for accrediting agencies assessing general practice.

Submitting Applications:Applications should be submitted no later than close of business Friday 27 October 2017.

Applications must be submitted in hard copy and electronically.

One hard copy application with original signatures and copies of supporting documentation plus a USB with electronic copies are to be sent to:

General Practice Accrediting Agency Approval Assessment ProcessAustralian Commission on Safety and Quality in Health CareLevel 5, 255 Elizabeth StSydney NSW 2000

An electronic copy with supporting documentation should also be emailed to: [email protected]

Applicants should ensure that supporting documentation is collated and labelled in a way that makes it clear which section of the application it relates to.

Applicants are advised that incomplete documentation may lead to a delay in the assessment of their application as outlined in Part B of this application form to ensure you have completed all necessary steps of the application prior to submission.


mailto:[email protected]

Part B: Application ChecklistOn completion of the application form please check that you have:

☐ Read the Guide to the approval process for accrediting agencies assessing general practice

☐ Completed each question in all sections of this application form

☐ Collated and labelled all the necessary supporting documentation

☐ Signed the Declaration of Compliance

☐ Dispatched one original, signed copy of the application form with supporting documents plus USB with electronic copy of all documents to:

General Practice Accrediting Agency Approval Assessment ProcessAustralian Commission on Safety and Quality in Health CareLevel 5, 255 Elizabeth StSydney NSW 2000

☐ Provided an electronic copy of the completed application form and any supporting documentation via the [email protected].

Intention to seek interview with the PanelSection 5 of the Guide to the approval process for accrediting agencies assessing general practice outlines the process of assessment of applications. Applicants may request to meet with the General Practice Accrediting Agency Approval Assessment Panel (the Panel) to present information or address an issue that has arisen as part of the application process.

Please indicate below if you are requesting an interview with the Panel to discuss your application.

☐ Yes, we would like an interview with the Panel to discuss this application.

If you have indicated Yes, the person nominated as the ‘Contact Officer’ in this application will be contacted by an officer of the Commission to make arrangements for an interview.

Accrediting agencies can elect to attend the interview in person or via teleconference.

Note: The Panel may request an interview with any applicant to address queries in relation to their application even if the applicant does not requested an interview with the Panel.


mailto:[email protected]

Part C: Organisational informationApplicant details Required information

Name of business or company applying for approval

ABN

Name of organisation, if different from company business name

AddressStreet, suburb, state & post code

Postal address

Website

Person authorised to submit this application Required information

Name

Position/title

Phone number

Mobile number

Email address

Contact person for this application Required information

Name

Position/title

Phone number

Mobile number

Email address

Supporting documentation☐ Certification of registration enclosed

☐ Other supporting documentation, please list:


Part D: Accreditation statusPlease provide details of the international accreditation award/s your organisation holds.

☐ISQua against the Organisation Standards Required information (if applicable)

Date accreditation awarded

Date accreditation expires

Details of any conditions or restrictions on the awarding of your organisation’s accreditation

☐JASANZ to the healthcare management systems Required information (if applicable)




☐Other (please provide details):Required information (if applicable)




Supporting documentation☐ Copy of relevant accreditation awards enclosed



Part E: Assessment products offered to general practicesPlease provide details for each safety and quality assessment product offered to general practices that relate to the standard/s. Also provide copies of any communication or promotional material provided to general practices.

Product name .

Length of cycle assessment

Key processes in assessment cycle Timing

Format of assessment (onsite/desktop/short notice)

Other information

Self-assessment

Mid-cycle or periodic assessment

Organisation-wide assessment

Product name .




Other information

Self-assessment




Product name .




Other information

Self-assessment



Product name .




Other information

Self-assessment




Part F: Organisational processesQuality assuranceDescribe the quality assurance process undertaken during the accreditation process. This process is to be described briefly. It is not sufficient for this application to refer to an internal policy or procedure.

Assessment of general practices in rural, regional and remote areasDescribe how assessment services will be provided and tailored to general practices in metropolitan, rural, regional and remote areas. This process is to be described briefly. It is not sufficient for this application to refer to an internal policy or procedure.

Release of informationList the relevant causes in your contract terms and conditions related to the release of information, to the Commission and other bodies:

a) for routine reporting on assessment outcomes

b) when significant patient risk is identified

Schedule of assessmentsFor accrediting agencies applying for approval for the first time

Number and type of general practice assessments scheduled

Number and type of general practice with assessment to be scheduled

.

Please attach a schedule of assessments, including the organisation name, date and type of assessment (mid cycle / organisation wide) for each of the relevant programs:


Supporting documentation☐ Quality assurance policies and/or procedures

☐ Schedule of planned accreditation (Note: For first time applicants only)

☐ Release of information clauses

☐ Metropolitan, rural, regional and remote assessment policy, procedure and/or protocol



Part G: Assessor workforceWorkforce sizeNumber of assessors usually available to assess general practices

No. of assessors

.

Selection CriteriaDescribe the selection criteria used when recruiting assessors (including the skills, experience and qualifications sought specifically for healthcare accreditation assessments). This process is to be described briefly. It is not sufficient for this application to refer to an internal policy or procedure.

Performance managementDescribe the process for assessing and maintaining skills and competencies (including the management of performance). This process is to be described briefly. It is not sufficient for this application to refer to an internal policy or procedure.

Inter-assessor variationDescribe the process in place to reduce inter-assessor variation. This process is to be described briefly. It is not sufficient for this application to refer to an internal policy or procedure.

Training activitiesList the type and frequency of assessor training activities undertaken by your organisation, (e.g. workshops, webinars, access to e-learning packages) and provide your agency’s schedule of training events.

Description Frequency/availability Date of last activity

.


Supporting documentation☐ Assessor selection criteria and recruitment processes

☐ Assessor performance management policy and procedures

☐ Schedule of training events for the next 12-month period



Part H: Appeals processesAppeals processOutline your agency’s appeals process available to general practices and provide a copy of policy, procedure and/or protocol documentation. This process is to be described briefly. It is not sufficient for this application to refer to an internal policy or procedure.

Complaints processOutline your agency’s complaints process available to general practices and provide a copy of policy, procedure and/or protocol documentation. This process is to be described briefly. It is not sufficient for this application to refer to an internal policy or procedure

Supporting documentation☐ Appeals policy, procedure and/or protocol documentation

☐ Complaints policy, procedure and/or protocol documentation



Part I: Declaration of complianceDECLARATION OF COMPLIANCE TO ASSESS GENERAL PRACTICES TO THE

RACGP STANDARDS FOR GENERAL PRACTICES

I, (name), authorised on behalf of (organisation applying for approval), certify that the information provided in this application is correct. I acknowledge that it is an offence under Section 137 of the Criminal Code Act 1995 to provide false or misleading information or documents to the Commonwealth.

I, declare this organisation (named above) will meet the conditions of approval set out below by the Australian Commission on Safety and Quality in Health Care to assess general practices to the RACGP Standards for general practices.

Conditions of approval to assess general practices to the RACGP Standards for general practices

International accreditationAn approved accrediting agency will hold and maintain accreditation with an internationally recognised body, either:

a) Joint Accreditation Scheme of Australia and New Zealand (JASANZ) to JASANZ HCSMS Scheme

(Part 1) Requirements for bodies providing audit and certification of Health Care Service Management Systems

and

(Part 3) Additional requirements for bodies assessing the conformity of general practices under the Practice Incentives Programme.

b) International Society for Quality in Healthcare (ISQua) to the Governance Standards, or

c) Other international accrediting body which may be recognised by the Commission from time to time.

Assessment products offeredAn approved accrediting agency will:

offer accreditation program/s that consist of:- an assessment of the RACGP Standards for general practices in their entirety, at

least once per accreditation cycle- a cycle of assessment that is not more than three years

conduct onsite assessment of the RACGP Standards for general practices, unless approval is sought and granted by the delegate

conduct onsite assessments in a manner that is consistent with the needs of the service and relevant to support quality improvement

include standard contractual terms and conditions for each assessment product relating to the assessment of the RACGP Standards for general practices

have a quality assurance process in place for the accreditation process.


Complaints and appeals processAn approved accrediting agency will:

have a comprehensive complaints and appeals process in place include within their complaints and appeals process mechanisms to escalate issues

to the relevant state or territory health care complaints body or the Commission.

Assessor workforceAn approved accrediting agency will:

maintain a rigorous process for the selection, training, support and performance management of assessors

provide the assessor workforce with necessary tools and information to effectively perform their role

allocates at least two assessors on each assessment, one of which must be a General Practitioner (GP), in accordance with the Medical Board of Australia’s requirements, with a minimum of five-year experience as a vocationally registered GP

ensure assessors have and maintain their relevant experience of the general practice sector

provide general practices with information on the skills and experience of assessor teams prior to onsite assessments and seek feedback on their suitability

ensure processes are in place to declare and manager assessor conflicts of interest to maintain impartiality.

Recruitment, training and performance management of assessorsAn approved accrediting agency will:

ensure all assessors recruited and/or contracted to their organisation:- maintain their knowledge, skills, and experience with the general practice sector

to understand and assess general practices to the RACGP Standards for general practices

- participate in not less than 2 assessment processes annually, to maintain their accreditation skills and knowledge

- participate at least annually in the performance development and management processes of the accrediting agency.

exclude assessors who do not meet the recruitment requirements set out above from participating in accreditation processes

report to the Commission on recruitment and performance of assessors, as outlined below

implement a training program on the RACGP Standards for general practices for their assessor workforce that:- is held at least annually- requires all assessors to attend annually- ensures mechanisms are in place to access alternative training and training

materials if an assessor does not participate in the scheduled annual training program

- monitors and reports to the Commission on participation of assessors in training- ensures representatives from the Commission and the General Practice

Accreditation Coordinating Committee are invited to present during all training on the RACGP Standards for general practices


exclude assessors from participating in accreditation processes if they have not participated in training on the RACGP Standards for general practices for more than 12 months

invite representatives from the Commission and the General Practice Accreditation Coordinating Committee to participate in assessor workforce training

make available the RACGP resources to the assessor workforce whenever training is held.

Assessment of general practicesAn approved accrediting agencies will:

assess general practices to the current edition of the RACGP Standards for general practices

use the RACGP Standards for general practices without modification assess each indicator of the RACGP Standards for general practices use the rating scale specified by the General Practice Accreditation Coordinating

Committee to assess each indicator of the RACGP Standards for general practices seek agreement from the General Practice Accreditation Coordinating Committee,

convened by the Commission to make any changes to an approved accreditation program that uses the RACGP Standards for general practices, including changes to the timing of events, length of cycle, and type of assessment or assessment requirements

not use the RACGP Standards for general practices to assess general practices in any accreditation program outside of Australia.

comply with the requirements of the National General Practice Accreditation Scheme to be eligible to assess general practices to the RACGP Standards for general practices.

Reporting to general practicesAn approved accrediting agency will:

notify general practices immediately or as soon as practical if a significant risk of patient harm is identified during an assessment and require an action plan be developed by the general practice within two business days.

notify the general practice in writing within five business days of the overall outcome of the initial assessment and detail on all not met actions

provide general practices with a final report on accreditation within 30 business days of the final assessment including any not met actions

Reporting to the Commission and the General Practice Accreditation Coordinating Committee

An approved accrediting agency will: notify the Commission and the relevant state or territory health care complaints

body within 2 business days of a significant risk identified during assessment, including submission of an action plan developed by the general practice to mitigate the risk

notify the Commission within two business days of general practices commencing or ceasing their membership during an assessment or before an accreditation award is determined

routinely submit to the Commission, and the General Practice Accreditation Coordinating Committee, accreditation outcome data on or before the 10th of each month, for assessment of general practices completed during the previous month


when requested by the Commission, provide data on indicators determined not applicable by the accrediting agency

notify the Commission and the General Practice Accreditation Coordinating Committee of practices that do not meet the standards and do not obtain accreditation

report annually to the Commission each assessor’s name and number of assessments completed in the previous calendar year

provide the Commission with data annually on the training of assessors carried out in the previous calendar year by the accrediting agency, the name of each assessor that attended the training and name of each assessor that has not participated in training.

Data reporting requirementsAn approved accrediting agency will:

include in all member/client contracts with general practices conditions that outline and enable the submission of demographic and accreditation outcome data to the Commission and the General Practice Accreditation Coordinating committee.

submit on-time, complete, accurate accreditation outcomes data, free of charge and in the agreed format, to the Commission. These requirements include:- routine assessment data which is to be submitted by the tenth day of each

month, where the tenth day falls on a weekend, the data should be submitted the working day before

- routine assessment data will include all assessments that have been awarded accreditation by the submission date and assessment that have been finalised but not awarded accreditation

- the general practice assessment schedule, which is to be submitted annually and updated quarterly

- transmission of data electronically. submit the following data items to the Commission for each general practice:

- practice name or unique identifier- practice network (if relevant)- practice service type or model of delivery- number of location of practice sites- practice location / rurality rating- practice workforce –

o GP full time equivalent and headcounto practice nurse full time equivalent and headcounto other clinical or allied health staff full time equivalent and/or headcounto other non-clinical staff - full time equivalent and/or head count

- date of assessment- assessment type (for example assessment of all standards or follow up

assessment)- date accreditation expires- accreditation status- indicators / criteria not met at assessment and brief rationale for rating


publish the name and location of members/clients that successfully complete accreditation to the RACGP Standards for general practices on the accrediting agency’s web site.

Accrediting agencies that hold a Declaration of a Quality Assurance Activity are still required to submit accreditation outcomes data however this information will be de-identified. Items C to K should be provided with a unique identifier for each practice.

Additional data requirements, such as safety and quality information, may be introduced at a later date by the General Practice Accreditation Coordinating Committee following consultation with accrediting agencies and the general practice sector.

Award requirementsAn approved accrediting agency will:

issue accreditation awards to general practices meeting the requirements of the RACGP Standards for general practices, and include the following:- name of the general practice- period of accreditation (date awarded and expiry date)- description of the practice(s) covered by the award- accredited to the RACGP Standards for general practices

publish the name and location of members/clients that successfully complete accreditation to the RACGP Standards for general practices on the accrediting agency’s web site.

Participation and collaboration with the CommissionAn approved accrediting agency will:

comply with requirements set out in Advisories issued and amended by the Commission or the RACGP, on behalf of the General Practice Accreditation Coordinating Committee, from time to time

nominate a representative for the Commission’s General Practice Accrediting Agencies Working Group

ensure the representative participates actively on the General Practice Accrediting Agencies Working Group and works cooperatively on issues to improve nationally consistent interpretation and assessment of the RACGP Standards for general practices

meet annually with the Commission to discuss the accrediting agency’s performance and strategies for improvement and to take action to implement agreed strategies within agreed timeframes

direct their assessor workforce to work collaboratively with representatives from the Commission, the RACGP and the General Practice Accreditation Coordinating Committee, when required

agree to allow the Commission and/or members of the General Practice Accreditation Coordinating Committee to participate in an onsite assessment as an observer when requested, where there is prior agreement from the general practice

advise the Commission if the fee structure for members/clients is based on a community rating, where fees are equally distributed across clients regardless of factors that impact their serviceability, or is quoted individually based on actual costs. It would be intended that for general practices in rural and remote locations were not disadvantaged.


Use of the RACGP resourcesAn approved accrediting agency will:

ensure assessors reference or use resources from the RACGP related to the Standards for general practices, where appropriate

acknowledge the RACGP’s intellectual property when using RACGP’s resources and tools.

☐ I am authorised by the submitting accrediting agency to make this declaration.

Signature:

Name:

Position/title:

Date:


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