Policy and Procedure Practice Manual · Web viewPractice Management, Chapter 11.2 - Professional...

Chapter four: Practice management

Information contained in this manual is current at February 2015

Policy and Procedure Practice Manual I [Type the company name] 1

The following template policies and procedures are based on the requirements of the

RACGP Standards for General Practices (4th Edition)

TABLE OF CONTENTS

1 HUMAN RESOURCE SYSTEM (CRITERION 4.1.1).......................................................11.1 Recruitment......................................................................................................................11.1.1 Selection...........................................................................................................................11.1.2 Appointment – all staff......................................................................................................21.1.3 Appointment – medical practitioners.................................................................................41.1.4 Appointment – practice nurses.........................................................................................41.1.5 Probationary period..........................................................................................................4

1.2 Performance reviews........................................................................................................51.2.1 Setting standards for performance...................................................................................51.2.2 Appraising against performance criteria...........................................................................61.2.3 Discussing appraisals with staff........................................................................................61.2.4 Counselling about performance short-falls.......................................................................61.2.5 Rewarding performance and salary reviews.....................................................................71.2.6 Setting new goals.............................................................................................................7

1.3 Position descriptions.........................................................................................................81.4 Employment contracts and independent contractors.......................................................91.5 Staff general appearance.................................................................................................91.6 Staff code of conduct......................................................................................................101.7 Staff privacy and confidentiality......................................................................................111.8 Personnel file..................................................................................................................111.9 National Employment Standards....................................................................................121.9.1 Maximum weekly hours..................................................................................................121.9.2 Flexible working arrangements.......................................................................................131.9.3 Parental leave.................................................................................................................141.9.4 Annual leave...................................................................................................................151.9.5 Personal/carer’s leave....................................................................................................151.9.6 Community service leave................................................................................................161.9.7 Compassionate leave.....................................................................................................161.9.8 Long service leave..........................................................................................................171.9.9 Public holidays................................................................................................................191.9.10 Notice of termination and redundancy pay.....................................................................201.9.11 Fair work information statement.....................................................................................22

1.10 Payment..........................................................................................................................221.11 Code of conduct..............................................................................................................231.11.1 Behaviour........................................................................................................................231.11.2 Equal opportunity and anti-discrimination.......................................................................251.11.3 Attendance and absence................................................................................................261.11.4 Use of practice resources...............................................................................................271.11.5 Ownership of information and materials.........................................................................271.11.6 Conflicts of interest.........................................................................................................281.11.7 Serious misconduct........................................................................................................29

1.11.8 Management of serious misconduct...............................................................................301.11.9 Internal grievance procedures........................................................................................30

1.12 Orientation of new staff members...................................................................................311.12.1 Orientation – all staff.......................................................................................................311.12.2 Orientation – medical staff..............................................................................................32

1.13 Internal communication...................................................................................................322 OCCUPATIONAL HEALTH AND SAFETY (CRITERION 4.1.2)....................................332.1 Occupational health and safety......................................................................................332.2 Safety during normal opening hours...............................................................................342.3 Physical resources..........................................................................................................342.4 Non-medical emergencies..............................................................................................352.4.1 Emergency handling procedures....................................................................................352.4.2 Fire protection.................................................................................................................362.4.3 Fire and emergency wardens.........................................................................................372.4.4 Emergency plan..............................................................................................................372.4.5 Location of fire extinguishers..........................................................................................382.4.6 Bomb threat....................................................................................................................382.4.7 Electricity/telephone/water supply failure........................................................................392.4.8 Gas leak..........................................................................................................................392.4.9 Flooding..........................................................................................................................392.4.10 Deranged or hostile person............................................................................................402.4.11 Hold-up or robbery..........................................................................................................402.4.12 Violence in the workplace...............................................................................................412.4.13 Workplace bullying..........................................................................................................42

2.5 Staff immunisation program............................................................................................432.5.1 Risk categorisation chart................................................................................................432.5.2 Recommended vaccinations for at risk staff...................................................................442.5.3 Other vaccinations..........................................................................................................442.5.4 Maintaining records........................................................................................................45

2.6 Incidents and injury.........................................................................................................462.6.1 Needlestick injury and exposure to blood or body fluids................................................472.6.2 Procedure following occupational exposure...................................................................482.6.3 Classification of exposures.............................................................................................50

2.7 Personal protective equipment.......................................................................................512.7.1 Type of personal protective equipment and appropriate use.........................................522.7.2 Gloves.............................................................................................................................522.7.3 Hand washing.................................................................................................................532.7.4 Hand Washing Techniques.............................................................................................53

2.8 Manual handling.............................................................................................................542.9 Smoking, drugs and alcohol...........................................................................................563 CONFIDENTIALITY AND PRIVACY OF HEALTH INFORMATION (CRITERION 4.2.1)573.1 Maintaining confidentiality...............................................................................................583.2 Administration of privacy legislation................................................................................59

3.3 Medical reports...............................................................................................................593.4 Computer privacy............................................................................................................603.5 Incoming mail..................................................................................................................603.5.1 Facsimile – maintaining privacy and confidentiality........................................................613.5.2 Medical students.............................................................................................................613.5.3 Insurance company and social welfare agency..............................................................613.5.4 Research and quality program........................................................................................613.5.5 Disease registers (for public health purposes)...............................................................623.5.6 Notifiable diseases..........................................................................................................623.5.7 Police and lawyers..........................................................................................................623.5.8 External employers.........................................................................................................623.5.9 Subpoena, court order, search warrant and coroner......................................................633.5.10 Relatives and friends......................................................................................................633.5.11 Consent in an emergency...............................................................................................63

3.6 Australian Privacy Principles..........................................................................................643.6.1 Consideration of personal information privacy...............................................................643.6.2 Collection of personal information..................................................................................643.6.3 Dealing with personal information...................................................................................653.6.4 Integrity of personal information.....................................................................................663.6.5 Access to, and correction of, personal information.........................................................67

4 INFORMATION SECURITY (CRITERION 4.2.2)...........................................................714.1 Computer and Information Security Standards..............................................................714.2 Allocation of responsibility..............................................................................................714.2.1 Responsibility based access...........................................................................................724.2.2 External systems administrator.......................................................................................734.2.3 Computer Security Coordinator......................................................................................744.2.4 Responsible officer.........................................................................................................75

4.3 Internet and email use....................................................................................................764.3.1 Email...............................................................................................................................764.3.2 Internet............................................................................................................................764.3.3 Password maintenance..................................................................................................77

4.4 Password management..................................................................................................774.5 Information back-up........................................................................................................784.5.1 Back-up frequency and access.......................................................................................784.5.2 Back-up reliability............................................................................................................784.5.3 Back-up media and rotation............................................................................................79

5 SUPPLIES AND ORDERING.........................................................................................805.1 Office Supplies................................................................................................................80


1 HUMAN RESOURCE SYSTEM (CRITERION 4.1.1)

Policy

Our practice supports effective human resource management.

1.1 RecruitmentOur practice recruitment strategy is to attract a wide range of suitable candidates for a vacancy.

Our practice will ensure that existing staff have the opportunity to apply for higher duty positions to advance their career. Both internal and external applicants will be subject to the same procedures established in the recruitment process. Every vacancy is considered individually, and the most efficient and effective recruitment methods are chosen.

In order to do this any, or all, of the following strategies are used:

Advertising within the practice. Recommendations from other practices, existing practice staff, family and friends. Advertising in the local community newspaper and/or a major metropolitan newspaper. Advertising in professional publications and/or online such as seek.com.au. Using an employment agency.

1.1.1 Selection

All recruitment and selection procedures are formally documented. These written guidelines provide a structure to ensure that the rights and responsibilities of all stakeholders are clearly understood. This formal documentation provides the checks and balances that guarantee our recruitment and selection procedures are based on the principles of equity and fairness.

Although recruitment and selection processes may vary for medical staff and administrative staff, the principles will remain the same. The following procedure is used to fill all vacancies in this practice:

All positions have written selection criteria, a position description, duty statement and contract. All applicants must address the position description and/or selection criteria when applying for

a position. The practice manager will review all applications. References will be checked for all positions. The practice manager and practice principal interview those applications that most closely

meet the selection criteria. This may be face to face or by telephone. If more than one applicant is deemed suitable, a second interview, or work trial, is arranged. Where qualifications or registration is mandatory these must be sighted. Conditions of employment and remuneration are outlined or negotiated. The applicant who most closely fulfils the requirements is offered the position, with a

probationary period of three months. Once the applicant has accepted the position the unsuccessful applicants will be notified in

writing. If there is more than one potential candidate, resumes may be retained for future positions.




1.1.2 Appointment – all staff

All members of our practice team have a current:

Position description; and Employment contract or independent contractor agreement.

It is the policy of this practice that all terms and conditions of employment, including job offers, are to be in writing. This is to ensure that the information is provided to all stakeholders in a clear and unambiguous manner, all parties understand and agree to comply with the terms and conditions of employment and the practice is prepared for the commencement of the new staff member and that they are able to start work without procedural delays.

As soon as practicable after the applicant has accepted the position, a letter of appointment, in duplicate, signed by the practice principal is sent to the applicant.

The letter will include:

Hourly wage rate, or annual salary, or details of other arrangements. Hours of work. Leave entitlements. Orientation arrangements. Payment details. Request to obtain a National Police Certificate (criminal record check). Starting date and arrangements. Superannuation arrangements. Performance review details. Probationary period to be completed.

Attachments to the letter may include:

Confidentiality agreement. Duty statement. Employment contract or independent contractor agreement. Fair Work Information Statement. Form for banking details. Personal particulars form (including emergency contacts). Position description. Tax file declaration. Working With Children Check application if required.

The applicant must sign both letters of appointment and retain one for their records.

The signed letter of appointment and the completed paperwork must be returned to the practice manager as soon as possible.


2 Policy and Procedure Practice Manual I [Type the company name]


See CHAPTER SIX: TEMPLATES, FORMS AND CHECKLISTS for templates including:

Personnel forms for completion – checklist Orientation checklist Position descriptions Letter of appointment Fair Work Information Statement Staff immunisation program information Reference checking questions Confidentiality agreement Personal particulars form Banking details form Tax File Number declaration Working With Children Check application (if required) National Police Certificate application




1.1.3 Appointment – medical practitioners

In addition to the standard appointment policy for all staff, medical practitioners will be required to:

Provide evidence of and maintain their own Medical Board of Australia registration. Provide evidence of and maintain their own Professional Liability Insurance. Provide evidence of compliance with professional college continuing professional development

requirements.

Medical practitioners will also be advised that they will be unable to commence work until all Medicare Provider Number arrangements and hospital clinical privileges are in place as required.

Forms for completion will include at a minimum:

Application for a Medicare provider number. ‘Pay group link’ the provider number to this practice. Application Rural Other Medical Practitioners Scheme (ROMPS) if non-vocationally registered

and eligible. Form adding an additional doctor for the Practice Incentives Program (PIP) and General

Practice Immunisation Incentive (GPII).

1.1.4 Appointment – practice nurses

In addition to the standard appointment policy for all staff, practice nurses will be required to:

Provide evidence of and maintain their Medical Board of Australia registration. Provide evidence of compliance with professional association continuing professional

development. Provide evidence of medical indemnity (where applicable).

1.1.5 Probationary period

All staff of this practice will be subject to a mandatory <<determined by the practice>> probationary period before ratification of their employment.




1.2 Performance reviewsPolicy

Annual staff reviews are conducted to ensure continuing high levels of work performance and to assist in job enrichment. The review is part of the ongoing evaluation of an individual staff member’s work performance. It is extended to include performance improvement and personal and career development.

A review involves identifying, evaluating and developing the work performance of staff so that practice goals are more effectively achieved At the same time the process benefits staff in terms of recognition, receiving feedback, catering for work needs and offering career guidance and support.

All staff members will have their performance reviewed every <<determined by the practice>>. The practice manager is responsible for reviewing the performance of administrative staff and nursing staff.

The practice principal is responsible for reviewing the performance of medical staff. Terms and considerations are also considered at the time of the performance review.

A formal review is conducted <<determined by the practice>> after commencement of position and <<determined by the practice>> thereafter. The review is informal with face to face discussion and conducted by the practice manager and principal.

The staff member will be notified of the scheduled review at least <<determined by the practice>> in advance, at which time a mutually convenient time can be arranged for the meeting.

At the review the staff member is given formal feedback concerning their performance. Note that this is not the only occasion for feedback, as it is expected that staff will continually be given information about their performance during the normal course of work.

Strategies and plans for achieving goals in the next <<determined by the practice>> are developed and documented by the reviewer and staff member together.

The performance review document, including the next year’s goals and comments concerning current progress is signed by both parties with a copy retained by the staff member. The original will be placed in the staff member’s personnel file.

1.2.1 Setting standards for performance

Standards for performance are set against the mission and objectives of the practice, the requirements of the position as outlined in the position description, the duties as outlined in the duty statement and the practice standards outlined in this manual. These performance standards are agreed to by both the practice and the staff member and form part of the letter of appointment or service agreement.




1.2.2 Appraising against performance criteria

It is the policy of this practice that the person undertaking the appraisal of a member of staff will objectively look at that staff member’s performance. There must be clear evidence available for the classification of performance given in each area of appraisal. Performance is judged under the following classification scheme:

Excellent Performance in this area consistently exceeds required standards over the entire appraisal period.

Satisfactory Performance in this area consistently meets required standards.

Marginal Performance in this area is sometimes satisfactory and sometimes unsatisfactory.

Unsatisfactory Performance in this area consistently falls below the standard required.

1.2.3 Discussing appraisals with staff

Performance appraisal interviews will be undertaken at a prearranged time. They will be thoroughly documented, undertaken in privacy and remain strictly confidential. Evidence and examples will be presented to the staff member to support any unsatisfactory or marginal classifications. Staff will be invited to give their opinion of their appraisal.

In the instance of dispute about performance classifications the staff member being appraised has the right to discuss their complaints with the practice principal.

1.2.4 Counselling about performance short-falls

In the case of areas of a staff member’s performance being found marginal or unsatisfactory the following procedure will be undertaken, either at the same time, or at an agreed upon date within seven days of the initial appraisal:

The causes for poor performance are to be explored and identified. A plan is to be put in place to rectify the problem. A time frame for showing improved performance is to be agreed upon. The areas are to be re-appraised at the end of the agreed period.




1.2.5 Rewarding performance and salary reviews

Satisfactory or excellent performance will be acknowledged both by praise of the staff member and, if feasible by provision of rewards. Such rewards may include:

An increase in remuneration. Paid time off. A broadening of responsibility. Provision of professional or personal development opportunities. A gift (eg paid dinner for staff member and partner or flowers).

1.2.6 Setting new goals

At the conclusion of each performance appraisal, new goals will be set for the next appraisal period. New goals may include:

Becoming competent in new tasks or duties. Looking for methods of improving the procedures or processes involved in current tasks. Improving performance from satisfactory to excellent on current tasks. Undertaking professional development. Progression towards a more senior role.




1.3 Position descriptionsPolicy

In this practice the practice manager is responsible for all recruitment of medical staff, nursing staff and administrative staff. It is the policy of this practice to analyse the position requirements before any recruitment activities take place. In order to do this, the following questions will be considered:

What are the most important routine tasks the person filling this vacancy will have to carry out? What other important tasks must be carried out on a periodic basis? What skills and experience are needed to perform these tasks? What knowledge and qualifications are needed to perform these tasks? What attitudes, beliefs and values are required to fulfil the requirements of the position? Are there any particular attributes that would be especially helpful in fulfilling the requirements

of the position? Are there going to be any additional tasks that may be added to the role in the future? If so, what additional skills will be needed to perform those tasks? Who will the position report to? Who is the position responsible for? Will the position be casual, part-time or full-time? What will be the remuneration for this position?

In this practice the above questions are answered in a structured format and used as the basis to create the following documents for every position:

Selection criteria Position description Duty statement Performance appraisal guidelines

All staff members of this practice have a specific job description that describes:

Overall aim and functions of the job Major duties/tasks Qualifications and work experience required Other personal attributes and skills required or desirable

Although this job description acts as a guide to the duties of the position, staff may also be required to complete other tasks that may not be listed on the job description. The position description is considered a living document and will be modified by the practice manager and/or practice principal as required.




1.4 Employment contracts and independent contractorsOur practice recognises that the state and national industrial relations systems each have different employment laws, awards and minimum conditions. Employment agreements are required to meet state or federal legislation and incorporate the benefits.

The Western Australian state system is regulated by the Industrial Relations Act and Minimum Condition of Employment Act and state awards apply.

The national system is regulated by the Fair Work Act and national employment standards apply.

Select the most appropriate option for your practice

Our practice is governed by the minimum conditions of the:

<Option 1>

Western Australian state system and the Industrial Relations Act and Minimum Condition of Employment Act.

<Option 2>

National Australian system and the Fair Work Act and the ten national employment standards apply.

1.5 Staff general appearanceSelect the most appropriate option for your practice, or create your own procedure

<Option 1>

All clinical, nursing and administrative staff are required to wear neat, tidy, clean and ironed clothing.

Personal hygiene is a priority and staff must be aware that excessive fragrance from deodorants and perfumes can be harmful to persons with allergies. Staff are to refrain from unnecessary use of these items for both staff and patient sensitivities.

Long hair is to be kept clean, neat and tidy. This may include tying it up. Cosmetics such as make-up, nail polish and personal jewellery are to be kept to a minimum.

<Option 2>

All clinical, nursing and administrative staff are required to wear the prescribed uniform whilst on duty. In cases where a uniform is not able to be worn staff are to wear neat clothing similar to the prescribed uniform (eg blue jumper, white skirt, blue shirt, white pants). Clothing must be ironed, clean and kept in good condition.




1.6 Staff code of conductOur staff are the most valuable resource of this practice. Patients are attracted and retained because they receive a high standard of care and service from well-trained medical and administrative staff. It is the policy of this practice to recruit and retain the best available team of people.

This is achieved by:

Attracting the highest standard of candidates for any vacant position.

Equitable and thorough selection of personnel.

Orientation and training in practice procedures.

Treating all members of staff with respect, fairness and honesty.

Providing a safe, healthy, rewarding and satisfying working environment.

Providing staff with the opportunity for personal and professional development.

Facilitating and inviting staff to participate in quality improvement practises, setting key performance indicators and suggestions for adaption of policies and procedures where necessary.

It is expected that each staff member act according to acceptable professional and social standards at all times. Each person will be treated with courtesy, dignity and respect and as an individual.

Inappropriate language, smoking and taking of illegal drugs will not be tolerated on practice premises and those who indulge in this behaviour will be subject to disciplinary action.

This practice notes that legislation is at times amended. Although the following sections outline procedures on industrial relation and workplace related matters, we note that we are compelled to check the relevant legislation prior to a decision being made.

For more information please see policies on:

Practice Management, Chapter 11.2 - Professional and ethical obligations




1.7 Staff privacy and confidentialityAll patient information is private. Confidentiality of patient information must be maintained at all times. This practice adheres to the Australian Privacy Principles.

For more information please see policies on:

Practice management, Chapter 4 - Confidentiality and Privacy

Patient information is not to be verbally discussed with or visually presented to staff members, families or other persons, whether in the practice or outside, eg in the home. Patient’s medical records are medico-legal documents and are not to be left in view of others. Our patient’s rights are to be respected and staff must ensure strict adherence to privacy of any visual documentation or verbal matters with staff, patients or others. This includes patient’s accounts, referral letters or other clinical documentation.

Each staff member will be required to sign a confidentiality agreement, which is binding under terms of employment. In accepting employment at this practice the confidentiality policy will be explained to the new employee by the practice manager or principal and a confidentiality agreement will be signed, and the original retained in staff personnel file. A copy will also be given to the staff member.

A breach of privacy guidelines will result in disciplinary action or immediate dismissal.

1.8 Personnel fileEach staff member has a confidential personnel file created when they commence employment.

Information regarding the employer and employee relationship is documented on the file including:

Position description. Employment contract. Confidentiality agreement. Immunisation history and/or conscientious objection form. Time sheets. Leave forms. Copies of annual performance appraisals. Evidence of medical board registration (for medical practitioners and nurses). Evidence of current professional indemnity (for medical practitioners). Evidence of police clearance, working with children check. Copy of driver’s license if required to drive the practice vehicle.

Staff are not permitted access to their personnel file, unless the employer decides otherwise, and in no circumstances is access given to another staff member’s personnel file.




1.9 National Employment Standards For the purposes of this document, we have referred to the National Employment Standards (NES) throughout the document. Users should be aware of industry specific awards, agreements, modern awards, enterprise agreements and award or agreement-based transitional instruments.

There are 10 minimum workplace entitlements in the NES:

1. A maximum standard working week of 38 hours for full-time employees, plus ‘reasonable’ additional hours.

2. A right to request flexible working arrangements.

3. Parental and adoption leave of 12 months (unpaid), with a right to request an additional 12 months.

4. Four weeks paid annual leave each year (pro rata).

5. Ten days paid personal/carer leave each year (pro rata), two days paid compassionate leave for each permissible occasion, and two days unpaid carer’s leave for each permissible occasion.

6. Community service leave for jury service or activities dealing with certain emergencies or natural disasters. This leave is unpaid except for jury service.

7. Long service leave.

8. Public holidays and the entitlement to be paid for ordinary hours on those days.

9. Notice of termination and redundancy pay.

10. The right for new employees to receive the Fair Work Information Statement.

More information can be found at http://www.fairwork.gov.au/leave/national-employment-standards/pages/default

1.9.1 Maximum weekly hours

The ordinary hours of work for our practice full-time employee staff are <determined by the practice>>.

Overtime

The practice manager must pre-approve all overtime. Note that overtime is not a common requirement of this practice, however at times staff may be asked to work a little later than the usual finish time. Overtime rates of pay are included in the employee contract.



http://www.fairwork.gov.au/leave/national-employment-standards/pages/default

http://www.fairwork.gov.au/leave/national-employment-standards/pages/default


1.9.2 Flexible working arrangements

Our practice provides flexible working arrangements on request. An employee may request a change in their working arrangements from the practice manager if they require flexibility because they:

Are the parent, or have responsibility for the care, of a child who is of school age or younger; Are a carer (within the meaning of the Carer Recognition Act 2010); Have a disability; Are 55 or older; Are experiencing violence from a member of their family; or Provide care or support to a member of their immediate family or household, who requires care

or support because they are experiencing violence from their family.

In addition to this:

Select the most appropriate option for your practice, or create your own procedure

<Option 1>

This practice has a flexible policy for staff to swap shifts, session or hours of work with each other as long as the person wanting to swap arranges for all required working hours to be covered by a suitably qualified and experienced person. Notification for such changes must be given to the practice manager at least two days in advance.

<Option 2>

This practice has a formal policy for swapping of shifts. All requests for such swaps must be given to the practice manager in writing seven days in advance. The practice manager will negotiate for someone to fill the timeslot. If no suitably qualified and experienced person is available to fill the requested timeslot no swapping of shift will be allowed.

<Option 3>

This practice has a flexible policy on roster changes. We believe that in the spirit of goodwill and teamwork all parties should be able to amend rosters. Due to unforeseen circumstances it is often necessary to change staff members’ rosters with very little notice. As long as sessions are covered with the appropriate staff, this practice has a flexible and fair approach to roster changes.

All questions regarding rosters or roster changes must be directed to the practice manager.




1.9.3 Parental leave

All employees are eligible for unpaid parental leave if they have completed at least 12 months of continuous service with the practice under the NES.

This includes casual employees, but only if:

They have been employed by the employer on a regular and systematic basis for a sequence of periods over at least 12 months; and

Had it not been for the birth (or expected birth) or adoption (or expected adoption) of a child, they would have a reasonable expectation of continuing employment by the employer on a regular and systematic basis.

Each eligible member of an employee couple may take a separate period of up to 12 months of unpaid parental leave. However, if only one person is taking leave, or if one member of an employee couple wishes to take more than 12 months leave, the employee may request a further period of up to 12 months, from their employer.

The leave must be associated with:

The birth of a child to the employee, the employee’s spouse, or the employee’s de facto partner; or

The placement of a child under 16 with the employee for adoption.

Employees wishing to take unpaid parental leave are required to:

Inform the practice manager of their intention to take unpaid parental leave by giving at least 10 weeks written notice (unless it is not possible to do so), and specify the intended start and end dates of the leave; and

Confirm the intended start and end dates at least four weeks before the intended start date or advise the employer of any changes to the intended start and end dates (unless it is not possible to do so).




1.9.4 Annual leave

Employees are entitled to four weeks paid leave per year unless otherwise stated in accordance with a Modern Award or Independent Contractor agreement. Applications for leave should be lodged no less than six weeks prior to the first day of leave. This will ensure where possible, the availability of staff and correct payment of salary and documentation of accrued entitlements. This data is kept and becomes part of the staff personnel record. Queries regarding leave will be referred to the practice manager.

Staff are advised not to book flights or accommodation until the leave is formally approved to avoid loss of deposits etc.

To apply for leave, staff will:

1. Review the staff leave calendar. 2. Consider other staff and work rosters when planning annual leave.3. Discuss details of annual leave with the practice manager prior to completion of the application

form.4. Complete and submit the annual leave application form to the practice manager no less than

six weeks prior to the first day of leave.5. Leave will not be considered approved until formal notice is given by the practice manager. 6. The practice manager will approve or decline the leave application within 14 business days of

the application.

Leave without pay

Requests can be made for leave dependent upon staffing levels. Consideration will be given to the reason for intended leave and staff’s employment record. Leave of this nature is granted on the understanding that it is ad-hoc and a special occurrence. Should repeated requests be made then a change to staff member’s terms of employment would be considered. Requests will be considered by the practice manager.

1.9.5 Personal/carer’s leave

Employees are entitled to ten days paid personal (sick)/carer’s leave and two days unpaid carer’s leave unless otherwise stated in accordance with a Modern Award or Independent Contractor agreement. This accrues pro rata on a weekly basis and is cumulative from year to year. It may be used in cases of personal illness or injury (sick/personal leave) or to supervise the convalescence of another person whose care is their responsibility (carer’s leave).

Where more than two days of consecutive personal days are required, a doctor’s certificate will be required.

To apply for personal/carer’s leave, staff will:

1. Ring the practice manager prior to commencement time if you are going to be late or absent for a work period due to your or your dependant’s ill health; and

2. Complete a leave form upon return to work and attach this with the doctor’s certificate (if supplied) to your timesheet.




1.9.6 Community service leave

Our employees, including casual employees and independent contractors, are entitled to be absent from work for the purpose of performing certain community service activities such as:

A ‘voluntary emergency management activity’. Jury service (including attendance for jury selection) that is required by or under a law of the

commonwealth, a state or a territory.

There is no set limit on the amount of community service leave an employee is entitled to, however there is no obligation for the practice to pay the employee for community service leave taken, except in the circumstances of jury duty where an employee (other than a casual) is entitled to ‘make-up pay’ for the first 10 days that the employee is absent for a period of jury service.

An employee is entitled to be absent from his or her employment:

For the time that the employee is engaged in the eligible community service activity, including reasonable travelling time associated with the activity, and reasonable rest time immediately following the activity.

If the absence is reasonable in all the circumstances (jury service is taken to always be reasonable).

An employee involved in community service leave must give the practice manager: Notice of the absence as soon practicable. The period or expected period of absence. A letter of confirmation from the community organisation satisfying that the employee is entitled

to the leave.

1.9.7 Compassionate leave

Employees are entitled to two days compassionate leave (unpaid for casuals) as needed unless otherwise in accordance with a Modern Award or Independent Contractor agreement.

This practice acknowledges the immediate need for staff to take special leave on certain occasions including family illness and death of an immediate family member. Immediate family includes: parents, husband, wife, child, grandparents, sister, brother, aunt and uncle. Leave outside of these conditions may also be considered and granted at the practice manager’s discretion. All requests for compassionate leave will be discussed directly with the practice manager.

Procedure

1. Ring the practice manager prior to commencement time if you are going to be late or absent for a work period due to unexpected compassionate leave.

2. Discuss expected period of absence as necessary with the practice manager.3. Complete a leave form upon return to work and place it with your timesheet.




1.9.8 Long service leave

Our practice will recognise the long-term commitment of our staff by paying out long service leave in accordance with the applicable legislation.

Long service leave obligations are outlined in the NES. At the time of writing this document (November 2014), the NES preserves long service leave entitlements in awards and agreements as they were at 31 December 2009. If an employee would not have had an entitlement under an award or agreement if they had been employed in the same circumstances on 31 December 2009, their entitlement to long service leave will generally come from the State or Territory long service leave legislation. This is intended to be temporary and will be replaced by a national long service leave standard in the future.

A Western Australian employee’s entitlement to long service leave is provided by the Long Service Leave Act 1958. Long service leave is generally 8.667 weeks of paid leave after 10 continuous years of service.

There are many rules and requirements for long service leave. Current information on these entitlements in Western Australia is available from the Government of Western Australia Department of Commerce.

Use the Department of Commerce long service leave calculation guide for calculating the long service leave entitlement for full-time, part-time and casual employees.

The salary and wages officer/practice manager will maintain a register/reports of wages paid and will record the continuous years of service by its employees.

Calculating long service leave

The calculation to determine how much long service leave owing is:

0.8667X (multiplied by)Completed years of service= (equals) Number of weeks of long service leave owed.

Calculation after 10 years

When terminating after 10 years of continuous service, an employee’s long service leave entitlement is calculated based on their completed years of service only.

Step 1

Calculate the number of weeks owed for whole years of service:

0.8667X (multiplied by)Completed years of service= (equals)

Weeks of long service leave owed




Calculation after 7 years but less than 10 years

An employee who has worked more than 7 years continuous service but less than 10 years is entitled to pro rata long service leave. An employee is paid out their long service leave according to the exact number of days they have been with their employer. A three-step calculation will need to be done:

Step 1

Calculate the number of weeks owed for whole years of service:

0.8667X (multiplied by)Completed years of service= (equals) Weeks of long service leave owed

Step 2

Calculate the additional weeks owed for service completed using the additional days (calendar) of service:

Days of service÷ (divided by) 365 X (multiplied by) 0.8667= (equals) Additional weeks of long service leave owed

Step 3

Add the total from Step 1 and Step 2 together to calculate the total amount of long service leave payable on termination:

Step 1 Total+ (plus)Step 2 Total= (equals) The total number of weeks of long service leave owed

Long service leave on termination

There are two different calculations for long service leave upon termination, which depend upon an employee’s length of service. When an employee has completed seven years of service but less than 10 years, the long service leave is calculated on a pro-rata basis for their entire period of employment, including years, months, weeks and days. Where an employee has completed 10 or more years of continuous employment, the amount of long service leave to be paid is calculated on the number of completed years of service.




Payment

As a general rule, the long service leave entitlement is paid at the ordinary rate of pay, and the normal weekly number of hours of work applicable at the time of taking the leave.

Ordinary pay does not include shift premiums, overtime, penalty rates and allowances. For example, if an employee normally works 45 hours per week and is paid 40 hours at the ordinary time rate of pay and 5 hours at the overtime rate of pay, the employee, while on long service leave, will be paid for 45 hours per week but all of those hours will be paid at the ordinary rate of pay.

Part-time and casual employment

For part-time and casual employees, the hours payable are calculated by averaging the number of hours worked during the qualifying period of employment. Please note: The above calculation formulas provided are based on the entitlement under the Long Service Leave Act 1958.

Useful links National Employment Standards. http://www.fairwork.gov.au/Employee-entitlements/national-

employment-standards Long Service Leave Act 1958.

http://www.slp.wa.gov.au/legislation/statutes.nsf/main_mrtitle_555_homepage.html Government of Western Australia Department of Commerce.

https://www.commerce.wa.gov.au/labour-relations Long service leave calculator.

http://www.commerce.wa.gov.au/sites/default/files/atoms/files/long_service_leave_calculation_0_0.pdf

1.9.9 Public holidays

Our practice recognises the following public holidays:

1 January (New Year’s Day) 26 January (Australia Day) Good Friday Easter Monday 25 April (Anzac Day) Western Australia Day Queen’s birthday holiday (the day on which it is celebrated in Western Australia) 25 December (Christmas Day) 26 December (Boxing Day) Any other day or part-day declared or prescribed by or under State law of Western Australia as

a public holiday.

Employees who are usually at work on a day which falls on a public holiday will be paid for their ordinary hours. Employees are not entitled to payment if they do not have ordinary hours of work on the public holiday.





https://www.commerce.wa.gov.au/labour-relations

http://www.slp.wa.gov.au/legislation/statutes.nsf/main_mrtitle_555_homepage.html

http://www.fairwork.gov.au/Employee-entitlements/national-employment-standards

http://www.fairwork.gov.au/Employee-entitlements/national-employment-standards


1.9.10 Notice of termination and redundancy pay

Termination – by employer

This practice will provide its employees with the minimum period of notice, or payment in lieu of notice, that the practice must give to an employee to terminate their contract.

A staff member’s employment may be terminated at any time by either party by the giving of notice, or by the payment of forfeiture of an equivalent amount of salary in lieu of notice.

In order to terminate the employment of an employee, this practice will provide the following notice:

Period of Continuous Service Period of Notice

Not more than 1 year 1 week

More than 1 year, but not more than 3 years 2 weeks

More than 3 years, but not more than 5 years 3 weeks

More than 5 years 4 weeks

Employees over 45 years old who have worked for the employer for at least 2 years will receive an extra 1 week notice.

This practice reserves the right to terminate the employment of a staff member immediately, without notice or payment in lieu of notice, if the employee:

Commits any serious or persistent breach of any of the provisions of their contract of employment.

Commits any serious misconduct or wilful neglect in the discharge of the employee’s duties or responsibilities.

Behaves in any manner which, in the opinion of the medical practice adversely affects the reputation or public image of the medical practice.

Is convicted of any serious criminal offence other than an offence which in the opinion of the employer does not affect the employee’s position.

In calculating any payment in lieu of notice, this practice notes that the minimum compensation payable to an employee will be at least the total of the amounts the practice would have been liable to pay the employee if the employee's employment had continued until the end of the required notice period.

The total must be worked out on the basis of:

The ordinary working hours to be worked by the employee; The amounts payable to the employee for the hours including, for example allowances,

loadings and penalties; and Any other amounts payable under the employee's employment contract.

Prior to the staff member leaving the practice, all equipment, keys, uniforms and documents belonging to the practice must be returned prior to final payment being made.




Termination – by employee

All staff members are required to give written notice as detailed in his or her letter of appointment or service agreement. As a standard, it is the policy of this practice that two weeks’ notice be supplied to the employer. The notice of termination by an employee is as follows:

Period of Continuous Service Period of Notice

Not more than 1 year 1 week

More than 1 year, but not more than 3 years 2 weeks

More than 3 years, but not more than 5 years 3 weeks

More than 5 years 4 weeks

If an employee fails to give notice the employer shall have the right to withhold monies due to the employee with a maximum amount equal to the ordinary time rate for the period of notice.

Redundancy

When an employee's job is made redundant, eligible employees will be given the appropriate notice period as well as paid the level of redundancy, also known as severance pay as legislated by the Australian Government Fair Work Ombudsman.

* There is a reduction in redundancy pay from 16 weeks to 12 weeks for employees with at least ten years continuous service. The reason for this is that the Australian government assumes the employee is also entitled to long service leave at this point (after ten years).

"Weeks’ Pay" means the ordinary time rate of pay for the employee concerned provided that the following amounts are excluded from the calculation of the ordinary time rate of pay: overtime, penalty rates, disability allowances, shift allowances, special rates, fares and travelling time allowances, bonuses and any other ancillary payments.

For more information see the Australian Government Fair Work Ombudsman website:

http://www.fairwork.gov.au/Ending-employment/Redundancy/redundancy-pay-and-entitlements#2045-2064-102-130



Employee’s period of continuous service with the employer on termination

Redundancy pay period

At least 1 year but less than 2 years 4 weeks

At least 2 years but less than 3 years 6 weeks








At least 10 years 12 weeks*




1.9.11 Fair work information statement

From 1 January 2010, all new employees will be provided with the Fair Work Information Statement as soon as possible after the commencement of employment. This Statement provides basic information on matters that will affect employment.

For further information, contact the Fair Work Infoline on 13 13 94 or visit www.fairwork.gov.au.

FAIR WORK INFORMATION STATEMENT

1.10 PaymentAll administrative and nursing staff members will be paid on a <<Weekly>> <<Fortnightly>> <<Monthly>> <<Quarterly>> basis. Payments will be made via electronic funds transfer. Payment will only be made if a signed and accurate timesheet has been submitted.

All medical staff members will be paid according to the agreement detailed in their individual letter of appointment or service agreement. This payment is contingent upon the receipt of the appropriate paperwork as detailed in individual letters of appointment or service agreements, such as a complete and accurate tax invoice.

Employees are required to submit their <<Weekly>> <<Fortnightly>> <<Monthly>> timesheet to the practice manager, no later than close of business on <specify deadline>. Applications for leave and doctors certificates should be attached to the timesheet.

Independent contractors (medical practitioners and allied health) will submit a <<Weekly>> <<Fortnightly>> <<Monthly>> <<Quarterly>> tax invoice addressed to the practice and submitted to the practice manager as per the Schedule of the independent contractor agreement.



http://www.fairwork.gov.au/


1.11 Code of conductPolicy

Our practice is committed to providing an environment of equal opportunity, free from discrimination for existing and prospective clients and staff members.

Our practice values diversity, respects human dignity, is equitable and tolerant and protects clients and employees from all forms of discrimination, harassment and victimisation. It allows clients and employees the freedom to express opinions and make decisions in a safe environment.

The insert practice name code of conduct is based on the principles of:

Equity and justice. Respect for people. Personal and professional responsibility.

1.11.1 Behaviour

All employees and contractors are expected to:

Observe the policies, procedures, practises, customs and priorities established by our practice leaders;

Obey all lawful directions of our practice leaders; Comply with any legislative and industrial requirements applicable; Devote their time, attention and skill to their work during normal business hours and at other

times as reasonably required to perform their duties; Respect the work responsibilities of other staff by not interrupting them unnecessarily,

particularly on non-work-related matters; Respond to communication/requests (verbally, written or electronic) from clients, stakeholders

and other staff members as promptly as possible; Attend appointments and meetings punctually or inform the other person/s of any delays; Clean up after themselves, especially in the staff room and kitchen and office areas open to the

public; Not accept a directorship or enter a partnership except where our practice leaders have given

prior approval; and Not work for reward for any person or business other than this practice, except where prior

approval has been given.

Positive behaviour and professional conduct is expected in the workplace. All staff members should act in a supportive manner that enhances our practices work ethic and behaviour and demonstrate the following attributes:

Respect

All staff are expected to be respectful, honest and courteous at all times. They must give accurate information and prompt attention and observe fairness and equity in their dealings with others.




Teamwork

All staff are expected to work together towards agreed work objectives and goals and communicate regularly with one another about progress. They are encouraged to look for ways to improve work methods and solve workplace problems. Good teamwork involves giving support and guidance to each other and recognising each other’s results and achievements. Taking undue credit for the ideas or work of others is not acceptable.




1.11.2 Equal opportunity and anti-discrimination

This practice abides by Industrial Relations Act 1999, Anti-Discrimination Act 1991 and Workplace Health and Safety Act 1995 where it is unlawful to discriminate on the basis of:

Age Disability Lawful sexual activity/sexual orientation Marital, parental or career status Physical features Political beliefs or activity Pregnancy Race Religious belief or activity Sex Personal association with a person who is identified by reference to any of the above attributes Or to harass another in areas of:

Education Employment

If a staff member considers that a breach of this policy has occurred either personally or to anyone at the practice, then the matter is to be reported to the practice manager or principal immediately. The matter will be treated confidentially and will not be disclosed to unauthorised personnel.

Applying the principles of equity and justice at our practice includes avoidance of the following behaviours:

Discrimination

Discrimination is any unfair treatment, generally where one person is treated differently from another in the same situation, on the basis of race, gender, disability and a variety of other grounds.

Harassment

Harassment is any form of behaviour that is not wanted, not asked for and that humiliates or offends someone. It denies respect for the rights of staff to fair treatment, can be harmful to organisational effectiveness and may also be unlawful.

Vilification

Vilification is any public act that is likely to incite hatred, serious contempt or severe ridicule of a person or group of people.

Victimisation

Victimisation occurs when someone is treated unfairly because they have made a complaint about discrimination or helped someone else make one.




Bullying

Bullying at work can be defined as repeated unreasonable or inappropriate behaviour directed towards an employee or group of workers that creates a risk to health and safety. Any behaviour that has the potential to harm or offend someone should be identified as a hazard and assessed for its risk to safety and health. It is important to differentiate between a person’s legitimate authority at work and bullying. All employers have a legal right to direct and control how work is done, and managers have a responsibility to monitor workflow and give feedback on performance.

See also:

Practice management: Chapter 2.4.13 - Workplace bullying

Inappropriate behaviour

Conflict between staff members may occasionally be manifested in behaviour described as intimidating and/or inappropriate.

The following list illustrates specific examples of inappropriate behaviour that is unacceptable:

Insults, slandering, name calling, crude language and put downs; Shouting, slamming doors, banging on the desk and violent/threatening behaviour; Undue loud noise such as shouting or talking too loudly, especially in the open areas; Invasion of personal space and privacy including entering someone’s office without knocking or

saying “excuse me”, interrupting someone when they are conversing on the phone or physically standing over someone;

Ignoring another person when they are speaking and directly excluding them from the conversation;

Using private information to “bully” another staff member or someone outside the organisation; Looking through another person’s office (for example - files, drawers, pigeon hole and

materials on desk top) without prior permission; and Demonstrating partiality to a particular group or subgroup of staff.

1.11.3 Attendance and absence

Staff should not be absent from work without the prior consent of the practice manager (except for illness, injury or other unavoidable reasons). The relevant leave form should be completed prior to the absence wherever possible or immediately after their return.

Staff who are absent from the office for any reason during normal business hours are expected to advise the practice manager and record their absence in the attendance file.




1.11.4 Use of practice resources

Staff are expected to use practice resources efficiently through recycling, energy saving and waste minimisation. All facilities and equipment are to be used carefully and honestly and secured against theft, misuse and waste.

The following guidelines apply to personal use by staff members of practice equipment:

Phones, fax machines and computers may occasionally be used for personal use, within reasonable limits;

Prior permission of the practice manager is to be obtained for minimal personal use of photocopiers and payment may be required;

Employees may use the practice mail system, provided they attach their own stamps to personal correspondence;

The internet must never be used to download or access any illegal software or pornographic, defamatory, offensive, share-trading or gambling-related material; and

Use of email for personal reasons is generally discouraged.

For more information please see:

Practice management, Chapter 4.2 – responsibility based access

1.11.5 Ownership of information and materials

Any original work, process, design or other material produced by employees in the course of their employment remains the property of this practice. This includes copyright in any material such as computer programs. In this context, ‘course of employment’ means that the practice equipment/facilities and time were used to generate the intellectual property and that the intellectual property generated is related to the person’s normal duties.

Ownership of all material created for the purpose of or in the course of employment rests with the practice and should not be used other than for the purposes of practice business. Any revenue generated from this material remains the property of the practice.




1.11.6 Conflicts of interest

Staff members should take suitable measures to avoid, or appropriately deal with, any situation in which they may have, or be seen to have, a conflict of interest.

A conflict of interest may be seen to arise if the performance of a person’s duties as a staff member could be prejudicially influenced by that person’s private, personal or financial interests.

Potential areas of conflict include:

Recruitment of staff, contractors or consultants; Reclassification, promotion or termination of employees; Proposals for projects or partnerships; Selection of suppliers; and Representing the practice at another forum.Examples of relationships that may cause conflicts of interest include family relationships; positive and negative emotional relationship and employment relationships where a perception of bias may reasonably be seen to exist.

The onus is on the individual staff member to declare the conflict of interest before it arises. Appropriate action can then be taken in consultation with management.

Our practice leaders rely upon the accuracy of information contained in the employment application, as well as the accuracy of other data presented throughout the hiring process and employment. Any misrepresentation, falsification, or material omission in any of this information may result in exclusion of the individual from further consideration for employment or, if the person has been hired, termination of employment.

The duty of fidelity is a key part of the employment relationship. This imposes a mutual duty of trust and confidence on our practice and its staff. As part of this duty, employees are required to be full, frank and open in disclosing to the practice manager any material fact which may impact on their ability to perform their work and comply with their obligations. In particular, this includes notifying the practice manager of any prior criminal convictions (other than those the law regards as spent or irrelevant) or criminal convictions sustained during employment. The practice leaders will treat this information discretely and in confidence but reserves the right to consider what impact (if any) this conviction may have on an employee’s work or the performance of their duties and the options available to the practice to deal with it.




1.11.7 Serious misconduct

Staff are expected to act in the best interests of the practice and our patients at all times. Any conduct detrimental to the interests of this practice, its relations with the public, its clients or suppliers, or damaging to its public image will be considered to be a breach of the practice code of conduct, which renders the employee liable to disciplinary action.

To ensure orderly operation and provide the best possible work environment, this practice expects staff to follow rules of conduct that will protect the interests and safety of all employees.

It is not possible to list all the forms of behaviour that are considered unacceptable in the workplace. The following are examples of infractions of rules of conduct that may result in disciplinary action, up to and including immediate termination of employment:

Theft or inappropriate removal or possession of employer property;

Falsification of records, including timekeeping records;

Fraud or misappropriation of funds;

Working under the influence of alcohol or illicit drugs;

Possession, distribution, sale, transfer or use of alcohol or illegal drugs in the workplace, while on duty, or while operating employer-owned vehicles or equipment;

Assault, fighting or threatening violence in the workplace;

Negligence or improper conduct leading to damage of employer-owned or customer-owned property;

Insubordination or other disrespectful conduct;

Violation of safety or health rules;

Smoking in prohibited areas;

Sexual harassment, bullying or discrimination;

Possession of dangerous or unauthorised materials, such as explosives or firearms in the workplace;

Excessive absenteeism or any absence without notice;

Unauthorised use of telephones, computers, software, photocopiers, mail system or other employer-owned equipment outside the limits specified in the code of conduct;

Unauthorised disclosure of business ‘secrets’ or confidential information;

Unsatisfactory performance or conduct;

Gross or wilful misconduct; or

Wilful or negligent damage to employer property.




1.11.8 Management of serious misconduct

Any breach of the insert practice name code of conduct, practice policies and procedures or acts of other unacceptable behaviour will not be tolerated.

As soon as the practice manager is made aware, the practice manager will advise the staff member that the behaviour or breach is unacceptable. The staff member will be given the opportunity to explain their behaviour and any exceptional circumstances that may have arisen that affected the situation, for example, potential breach of privacy in a life threatening situation.

The practice manager will record all communication in the staff member’s personnel file and decide whether to pursue disciplinary action.

Disciplinary action will take the form of:

First warning Verbal from practice manager/principal and recorded in staff personnel file.

Second warning If the problem continues then it is again discussed with the staff member and a written notification given to that person. Item recorded in staff personnel file.

Final warning If the problem persists, then both the practice manager and principal will see the staff member. A written warning is given to the staff member and placed on the personnel file.

The staff member will be terminated if the matter occurs again.

1.11.9 Internal grievance procedures

We recognise that from time to time staff may have grievances that need to be resolved to maintain a harmonious professional working environment. This practice aims to identify and resolve these issues with the staff concerned and for the benefit of the practice. The objective of this procedure is to resolve staff complaints about each other in a manner that is fair and constructive.

Where an employee believes that he/she has been subject to a breach in the Code of Conduct by another employee, they should take the following steps progressively until the issue is resolved:

1. Raise the issue directly and immediately where possible with the person allegedly breaking the code.

2. Ask for help and/or advice from another staff member or person.

3. Refer to the practice manager for further advice on handling the situation.

See also:

Practice management: Chapter 2.4.13 - Workplace bullying




1.12 Orientation of new staff membersOur practice has an induction system that orientates all new staff members to our practice team and to the practice specific systems, policies and procedures. This practice believes that effective and efficient orientation of new staff members benefits everyone.

The purpose of our orientation program for new staff members is to:

Welcome them to the practice.

Introduce them to the people working in the practice.

Help them to understand their responsibilities.

Outline the reporting relationships in the practice.

Familiarise them with the layout and whereabouts of resources in the practice.

Help them to get to know other staff members.

Introduce them to the culture of the practice (how we do things around here).

Give them the basic knowledge to start working in their appointed position effectively and in a healthy and safe manner.

1.12.1 Orientation – all staff

All new staff members will have a comprehensive, formal orientation, conducted by the practice manager. All new staff members will receive a copy of the policy and procedure manual.

The orientation program includes for all staff (as appropriate to position held):

A tour of the practice Opening procedures

Billing arrangements Pathology and other results

Closing procedures Pathology specimens

Consulting rooms Personnel administration

Dealing with patient enquiries Resources available

General administration Security

Greeting patients Staff room

How to use the computer Staff meeting schedule

How to use the telephone, fax and photocopier

Teamwork

Infection control Telephone procedures

Introduction to other staff members Treatment room

Introduction to the front desk Vaccines and the cold chain

Making appointments Who to go to for assistance

Message handling Workplace health and safety




1.12.2 Orientation – medical staff

All new medical staff and locums will receive a comprehensive, formal orientation, conducted by the practice manager and the practice principal. All new staff members receive a copy of the policy and procedure manual and are also provided with an overview of the key features of the manual by the practice manager.

In addition to the Orientation – all staff policy, the medical staff induction also includes:

Clinical handover.

System for follow up of test results.

Clinical meeting schedule.

Specialist contacts and referral database.

Doctor’s Bag - Use and storage.

1.13 Internal communicationFor this practice to function effectively, staff will be aware of the current status of issues and progress with all aspects of our service.

To this end the following methods of communication are used:

Staff meetings, held every <frequency of staff meetings>. Clinical meetings with doctors, held every <frequency of clinical meetings>. Memos, facsimile (fax) and email. Informal discussions. Staff notice board. Staff communication book. Policy and procedure manual.

To maintain and enhance communication, continuing education and professional development is encouraged for all staff. Staff report back via staff meetings. Staff are also required to read, understand and contribute to updates for policies and procedures as needed.

Minutes of staff/team meetings will be taken and will be available for review (Template Agenda and Template Minutes).

The staff notice board is updated regularly by the practice manager and all workshops, forums and other educational opportunities are placed there. Staff will read the notice board regularly.

The staff communication book is housed at reception. Urgent daily notices, handover notes and other general items for immediate attention are to be written here. All staff are required to read and initial for each work session attended.

For further information see:

Practice services, Chapter 10.5 - Consistent communication




2 OCCUPATIONAL HEALTH AND SAFETY (CRITERION 4.1.2)

Our practice implements strategies to ensure the occupational health and safety of our patients and members of the practice team.

2.1 Occupational health and safetyOur practice facilities are appropriate for a safe and effective environment for patients and the practice team.

This practice considers that the health and safety of staff members, patients and visitors is vital to the ultimate success of the practice.

All procedures and policies in this practice are in accordance with the Occupational Safety and Health Act 1984, Occupational Safety and Health Regulations 1996 and Commission for Occupational Safety and Health Codes of Practice. Our staff members are regularly trained in these standards, actions and preventative measures to avoid any workplace injury or illness. Under the Occupational Safety and Health Act 1984, everyone has a legal duty to uphold certain standards of health, safety and welfare. This includes employers, employees, contractors and visitors.

Staff are instructed in safety and infection control protocols ensuring risks are known and precautions taken, including vaccinations.

Doctors and staff work together to maintain a safe physical work environment. Knowledge and skills are updated for equipment, drug, vaccine use and storage together with mandatory government information requirements, eg material safety data sheets (MSDS), workplace health and safety (WH&S) posters for staff in the work environment.

Template forms, checklists and reports are accessed from the Western Australian Department of Commerce - WorkSafe. Please refer to Practice Contacts for contact details.

The <name of workplace health and safety officer> is the nominated workplace health and safety officer (WHSO) for resolution of health and safety issues. If a staff member has any concerns or queries, then they are to be directed to WHSO or the practice manager.

The WHSO conducts a formal risk assessment in the practice on an annual basis. Once the report is complete, adjustments to the work place are made and/or training is provided to ensure that the exposure to risk is minimised.

A sign explaining our practice approach to health and safety, together with the name and telephone extension of our WHSO is kept in an area frequently attended by staff (eg kitchen or noticeboard). Information relating to WH&S issues are posted on the notice board and updated regularly by the WHSO.

When hiring new staff the practice manager informs them, in writing, of the nature of their work and asks if they have any pre-existing injury that may be affected by the new job. New staff are also notified, in writing that failure to inform or hiding a pre-existing injury which might be affected by the nature of the proposed new job, could result in that injury not being eligible for future compensation claims.




2.2 Safety during normal opening hoursThis practice has a policy of promoting staff security by having appropriate procedures in place that will minimise risk to staff. There are to be a minimum of two people on the premises at the same time. A number of situations may threaten staff security. Procedures are outlined for some of the more serious situations. All staff are aware of and able to implement protocols, to ensure the safety and security of all persons within the practice.

During normal practice hours at least one other practice staff member or doctor is present in addition to at least one doctor on duty.

The premises are protected by a computerised alarm system that has motion detection sensors located at various points on the site.

A ‘panic’ button linked to security system/police station is located at reception.

The practice has a security firm that patrols the site after hours <name of firm> and <contact details>

All equipment on-site is engraved with the practice name and a security number. The practice maintains the security number register.

Contracts and warranties for medical, office and other equipment are maintained by the practice manager.

Staff are encouraged to be vigilant whilst on duty and act to ensure the continuing safety of all patients, visitors and other staff.

2.3 Physical resourcesThis practice has the following physical resources to enhance the safety and security of staff, patients and visitors. Staff have been trained in their use:

Good lighting outside and inside. Physically secure doors, windows, locks and grills. Security system. Fire extinguisher(s). Emergency button.




2.4 Non-medical emergenciesEmergencies may occur that will require a quick, informed and effective staff response. Procedures should be in place to ensure that all employees understand the action to be taken in the event of an injury, illness, fire or other emergency.

Types of non-medical emergencies include:

Fire or false fire alarm. Bomb threats. Failure of electricity supply. Property damage. Break-in. Abusive or threatening telephone calls or persons at the practice. Leakage of toxic chemicals. Letter bombs.

2.4.1 Emergency handling procedures

The following factors are addressed when this practice is developing new emergency handling procedures.

1. Evacuation proceduresProcedures for evacuation should ensure that all persons in the office (including those who cannot use stairs) can exit the premises.

2. Accounting for all personnelMeans by which all persons in the office are able to be accounted for in an emergency need to be developed. There should be pre-planned escape routes and a reporting area. Consider also the use of a visitors register.

3. Treatment of injuries and illnessesMeans by which cases of serious, traumatic injury or illness are able to receive earliest possible access to treatment need to be developed. Consider the ease of access for emergency services to all parts of the workplace.

4. Assign responsibilitiesResponsibility for various actions to be performed by different persons in an emergency situation should be determined and documented. Methods for informing all staff of 'who is responsible for what' should be developed.

5. Provision of equipment/materialsSuitable equipment and materials need to be available to minimise the outcome of a possible accident or emergency. Consider hazards in the office that may require specific types of first aid. Type and quantity of fire extinguishers must be adequate for the office.

6. TrainingAll employees need to be trained in accident and emergency procedures. Suitably trained first aid officers and fire wardens should be readily available.

7. Review processA periodic review process should be undertaken to ensure the accident/emergency procedures are able to meet changes in the environment. Regular emergency and evacuation drills and their evaluation will enable periodic review to take place.




2.4.2 Fire protection

This practice believes that the first step to fire safety is prevention. Fire prevention measures we have in place are:

Our practice has automatic fire detection systems in place, such as sprinklers and /or smoke detection alarms.

Passageways and exits are free and clear from storage and waste. Our practice avoids storing or stockpiling flammable materials such as waste paper, packaging

materials or waste where they could be accessed by the public, including areas immediately outside the business premises.

Cracked, frayed or broken electrical cords or plugs are marked faulty, discarded and replaced. There is plenty of air circulation space around heat producing equipment (eg steriliser,

photocopier, vaccine fridge and computers).Electrical leads and cords are pinched behind or under furniture wherever possible. They are never run across doors or walkways.

Power outlets and extension boards are not overloaded. If an appliance or item of equipment smells or gives off smoke, it is immediately turned off,

unplugged and not used until it has been checked by a qualified electrician. Escape stairs and exit doors are not locked or blocked. Where our business is near bush, the practice grounds are prepared and cleared to reduce the

risk of bushfire. Our building complies with the Building Code of Australia and meets the Fire and Emergency

Service Commissioner specifications. Our building is regularly inspected to check the fire safety equipment has been installed

correctly, is tested and functional. All machinery is serviced as recommended by manufacturers and is kept clean. If possible,

machinery including computers and photocopiers, are switched off when the business is unattended.

Our practice staff will secure all doors, windows or other access points when the business is unattended. Our practice has adequate outside lighting to deter trespassers.

Our practice has a written and practised fire escape plan that includes full staff lists and designated meeting points.




2.4.3 Fire and emergency wardens

Our practice has a designated fire and emergency warden(s). These are <Names of wardens>.

The fire and emergency warden(s) are trained for emergencies in the workplace and liaise with external emergency agencies such as the Western Australian Department of Fire and Emergency Services (DFES).

The role of the fire and emergency warden(s) is to ensure the safety of the building’s occupants in an emergency. During emergencies, instructions from fire and emergency warden(s) and DFES personnel override the normal management structure.

2.4.4 Emergency plan

In the event of a fire, our practice staff members are trained in the following emergency plan:

Alert

Sound the fire alarm, alert the fire and emergency warden(s) and other staff. Fire and emergency warden(s) to notify the emergency services no matter how small the fire. Ring 000 and ask for Fire, Police or Ambulance. Only attempt to fight a fire if it is small (no larger than a wastebasket) and only if you have the correct equipment and training to handle it.

Evacuate

All staff and visitors are to evacuate the building using the fire exits.

Check

Fire and emergency warden(s) will check all rooms, toilets, behind doors, storage areas etc.

Assembly

Fire and emergency warden(s) will direct staff and visitors to the emergency assembly area.

Head count

Fire and emergency warden(s) will conduct a head count of all staff, contractors and visitors (Note: fire and emergency warden(s) to collect visitors log on evacuation). Staff and visitors are not to return to the building under any circumstances until cleared by DFES.

Records

Save as many records as possible if it is safe to do so (such as the back-up tape).

Report

Report any people unaccounted for to the fire and emergency warden(s) and/or the fire emergency services.




2.4.5 Location of fire extinguishers

Instructions for use are also located on every fire extinguisher.

This practice has fire extinguishers and fire hoses available at:

<Location of Fire Extinguishers>

If a fire does occur, doctors are responsible for patients they are treating. They must take their doctor’s bags with them in case there are injuries. Reception staff are responsible for everyone in the waiting room and treatment room.

The meeting or assembly point for this practice is located at <location of emergency evacuation assembly point>

Fire wardens have been trained in the correct use of fire extinguishers:

P Pull the pin

A Aim at the base of the fire

S Squeeze the handle

S Sweep from side to side

2.4.6 Bomb threat

A bomb threat may be received via telephone, written or as a suspect object or it may be non-specific, for example merely, a statement that a device has been placed somewhere. All threats are to be regarded as genuine. Do not give details of the threat to the news media.

1. If threat is by telephone, attract attention of a second person who can contact the fire brigade, but DO NOT HANG UP PHONE - even after the caller has, as the telephone company may be able to trace origin of the call.

2. Record exact information from caller.

3. Ask specific questions as per suggested checklist in Section 10 Bomb Threat Checklist.

4. Do not interrupt caller, listen for background noise, and try to determine the gender, age and nationality of the caller.

5. If the threat is in the form of an object/package in unknown whereabouts, but on site then search in pairs.

6. Examine areas that are easily accessible to the public first.

7. Open doors and windows so, in case of explosion, pressure is dissipated and structural damage is minimised.

8. If an object is found – DO NOT TOUCH IT. Report the find and keep the area clear, and contact the police who will provide advice.

9. If bomb explodes treat the situation as a fire emergency and evacuate.




2.4.7 Electricity/telephone/water supply failure

1. Ring electricity/telephone/water supply company and report the failure.

2. Ensure patients and staff are reassured and comfortable.

3. Use mobile telephones and emergency torches as needed.

For more information see:

Physical factors, Chapter 7.1.12 - Refrigerator power failures

2.4.8 Gas leak

1. Evacuate the practice.

2. Open doors and windows to assist in diluting concentration.

3. Report to the gas company and await instructions.

2.4.9 Flooding

1. Turn off water at the meter/mains and check for burst pipes within the practice grounds.

2. To minimise risk of electrocution, turn off power to electrical equipment.

3. If water is dripping from light fittings also turn off power but only if it is safe to do so.

4. Beware of slipping hazard.

5. Inform the water company if the problem is from a burst water main beyond the practice.

6. Mop up area with towels, etc.

7. Ring the local council authority if the flooding is due to blocked street drains.




2.4.10 Deranged or hostile person

1. Speak quietly and rationally to the person, and do not appear threatening in any way.

2. Move as many people as possible away from the expected path of the offender.

3. If people cannot move away, then minimise exposure by moving behind furniture and walls.

4. Do not antagonise the offender.

5. Activate the silent alarm button to contact the security company or ask another staff member or bystander to contact the police. If the person is disturbed, either from intellectual or mental impairment or from drugs and/or alcohol, contact the ambulance service.

6. Follow Steps 1 to 4 until the police and/or ambulance arrive.

7. Preserve evidence which may be helpful to an investigation.

8. When the police and/or ambulance arrive, strictly follow their instructions.

9. Immediately after the incident, the practice manager or practice principal is to provide critical incident debriefing and counselling.

10. The practice manager is to organise an impromptu meeting where actions, processes and outcomes are reviewed to ensure that the situation has been handled effectively and whether or not any improvement can be made.

2.4.11 Hold-up or robbery

1. Follow the instructions of the offender and meet his/her demands quickly and completely.

2. Do not fight or attempt to disarm or follow the offender.

3. Be deliberate in your actions if asked to hand over property to the offender.

4. As far as is practicable ensure the safety of visitors/patients.

5. Observe the offender and note physical description and any identifying features. Note dress and mannerism, speech, type of weapon, clear details of offender’s demands.

6. Stay out of danger if not directly involved. Leave the area if safe to do so and raise the alarm.

7. Once the offender departs, notify the practice manager and lock all doors.

8. Immediately contact police and provide the following details:

Full name. Workplace address. Workplace phone number. Brief details of incident.

9. Preserve evidence which may be helpful to an investigation.

10. When the police arrive, strictly follow their instructions.

11. Immediately after the incident, the practice manager or practice principal is to provide critical incident debriefing and counselling.

12. The practice manager is to organise an impromptu practice meeting where actions, processes and outcomes are reviewed to ensure that the situation has been handled effectively and whether or not any improvement can be made.




2.4.12 Violence in the workplace

Violence is the unjust or unwarranted use of force and power. Many people in their workplaces are the victims of violence, including verbal abuse, threats, harassment, physical assault, serious bodily injury and death. Violence can occur in any occupation and in a variety of situations.

Violent situations at work can be categorised into:

Overview Description

Dissatisfaction with a service

One of the more widely recognised and more frequent violent situations that occurs in a broad range of occupations.

People with impaired judgement

Includes violence committed by those with a mental or intellectual impairment.

Violence by people in an extremely disturbing social situation includes violence committed under the stress of a marriage break-up or other domestic tensions.

Violence by people affected by drugs or alcohol which includes violence committed under the influence of mind-altering substances or because of the absence of a substance (withdrawal syndrome).

Violence motivated by gain

Includes acts of violence committed to improve the offender’s material situation, such as the gain of money, drugs or valuable goods.

Occupational violence Refers to violence occurring between any people in a particular workplace. May include bullying, intimidation, abuse of power, isolation, alienation of workers or simply poorly managed conflicts of opinion or personality.

This practice is aware of our legal responsibilities to provide our employees, contractors and visitors with a safe environment free from various forms of violence, for example, under the Anti-discrimination Act.

After a staff member has experienced violence in the workplace, either directly or as a witness, this practice will offer critical incident debriefing and counselling immediately after an event as this may help to prevent the development of post-traumatic stress disorder.

It is important that following occupational violence within the practice that actions, processes and outcomes are reviewed to ensure that the situation has been handled effectively and whether or not any improvement can be made.

For more information see:

Practice services, Chapter 1.2.7 – Subsequent action following an emergency or exceptional situation




2.4.13 Workplace bullying

Where an employee believes that he/she has been subject to workplace bullying, the staff member should:

Keep a diary of workplace bullying recording: Incidents, in as much detail as possible.

The names and addresses of people willing to support your claims.

Approach the alleged bully:

Tell the bully that you object to their bullying behaviour and ask them to stop the behaviour.

You could also ask someone else to approach the alleged bully on your behalf.

Report the alleged workplace bullying to your employer and provide them with details of the bullying incident diary and what steps you have taken to stop the problem.

Ask your employer or an outside organisation to provide advice, support and assistance in dealing with workplace bullying.

Seek mediation from your employer or with an outside organisation such as the Dispute Resolution Centre.

Undertake personal development courses to enable you to cope with the bullying while the problem is being resolved. Courses may cover improving communication skills, conflict resolution, stress management, self-confidence and self-esteem.

For more information, see:

Practice management, Chapter 1.11.9 - Internal grievance procedures




2.5 Staff immunisation programDoctors, other health professionals and practice staff will be offered immunisation appropriate to their duties. Determining what diseases staff should be vaccinated against will depend on the category of risk. To protect staff, this practice offers vaccination for the following diseases utilising the Risk Categorisation Chart below.

2.5.1 Risk categorisation chart

Category Description

Category A Direct contact with blood or body substances:

This category includes all persons who have physical contact with, or potential exposure to blood or body substances. Examples include medical practitioners, nurses, allied health practitioners, health care students; and cleaning staff responsible for decontamination and disposal of contaminated materials.

Category B Indirect contact with blood or body substances:

This category includes workers in patient areas who rarely have direct contact with blood or body substances. These employees may be exposed to infections spread by droplets, such as rubella, but are unlikely to be at risk from blood borne diseases. These persons may include medical receptionists.

Category C Laboratory staff:

Laboratories pose special risks because of the equipment used (such as centrifuges), and the possibility of exposure to high concentrations of micro-organisms generated by culture procedures. The major risk to laboratory staff occurs in the handling of blood and blood products.

This Category is not applicable to a standard general practice setting.

Category D Minimal patient contact:

In many health care establishments, clerical staff, gardening staff and numerous other occupational groups, have no greater exposure to infectious diseases than the general public. These employees do not need to be included in workplace vaccination programs or other programs aimed at protecting category A, B and C staff.




2.5.2 Recommended vaccinations for at risk staff

Risk Category of Staff Recommended Vaccinations

Category A, B and D Influenza

Category A and B Diphtheria/tetanus/pertussis

Category A and B Measles/mumps/rubella

Category A and B Chicken pox

Category A Hepatitis A

Category A Hepatitis B

2.5.3 Other vaccinations

Varicella

Varicella immunisation or serology to confirm immunity is recommended for doctors, other health professionals and staff with direct clinical contact in settings seeing paediatric cases.

Influenza

Influenza vaccination offered annually may be appropriate to prevent transmission of influenza to other staff and patients; and to reduce work time lost due to influenza.

Hepatitis A

In communities where Hepatitis A is endemic, such as in some Indigenous communities, Hepatitis A vaccination may be offered. Seroconversion can be assessed by testing a few months following vaccination.

Meningococcal C

Meningococcal C is no more prevalent among health professionals than the general population. Staff members in the ‘at risk’ age group (up to 19 years of age) should be vaccinated.




2.5.4 Maintaining records

Our practice will keep an up to date record of the immunisation status of our employees. Records will be recorded in the staff member’s personnel records and will include:

Advice given regarding the need for appropriate vaccination suitable for the type of practice and their duties.

The staff member’s response. Details of the vaccinations and serological results before present employment. Details of the vaccinations received subsequent to employment (date, type and antibody

response if appropriate). Any refusal of the health professional to be appropriately vaccinated or have antibody levels

assessed. Education given regarding infectious diseases and the use of standard and additional

precautions including the effective use of personal protective equipment. Any additional counselling.

The Royal Australian College of General Practitioners provides a template Staff Immunisation Record in the manual, Infection Control Standards for Office Based Practices 4th edition.

Procedure

This procedure should be followed with regard to staff immunisation at the time of orientation:

Ask new staff member for a history of vaccinations and natural disease exposure. Provide new staff member with a copy of the staff immunisation policy to read. After staff member has had the opportunity to review the staff immunisation policy, organise a

meeting between the principal doctor where he/she will explain the efficacy of the vaccine, risks associated by the administration of the vaccine, risks associated by not having the vaccine, and the cost of the vaccine (if the practice is not covering the cost), so that a fully informed decision can be made.

The new staff member is then required to sign the consent form for vaccination, serology, or refusal of vaccination as a conscientious objector.

If vaccination is given, the date, batch number and expiry date are recorded and stored in the staff member’s personnel file.

If a member of staff identifies a task, piece of equipment or work area that may be a risk, it is the responsibility of the staff member to report it to the WHSO or the practice manager. A further detailed risk assessment will be conducted and if necessary, changes will be made to reduce the risk of injury with training for staff as needed.

See: STAFF IMMUNISATION PROGRAM INFORMATION

Source:

Infection Control Standards for Office Based Practices 4th edition. Royal Australian College of General Practitioners. South Melbourne, Victoria. September 2006




2.6 Incidents and injuryIt is a legal requirement under the workplace health and safety legislation and for insurance purposes, to report all work injuries. It should be recognised that good reporting also leads to effective prevention.

All incidents, accidents and ‘near misses’ are to be reported on the practice incident report form. Forms are filed in a folder that is deemed the accident register. Please refer to INCIDENT REPORT FORM for a template.

Incidents may include:

Needlestick injury; Mucous membrane exposure to blood or bodily fluids; Slip or fall; Drug or vaccine incident (loss, misplacement); or Any injury sustained or thought to be sustained.

In order that appropriate follow up, counselling or other action, whether it be preventative or to ensure faster return to normal duties for a staff member, is undertaken, full documentation is needed by all staff concerned with the incident.

Accidents or incidents may involve the following:

Staff (employed directly by this practice). Non-Staff (patients, visitors, contractors). Events (occurrence that has caused an incident, eg theft, non-patient assault, gas leak, bomb

hoax, security breach, medication error).

After an incident, the following process should be adhered to:

1. Complete an incident form as soon as possible after incident occurs, preferably within 24 hours. This form should be given to the practice manager or practice principal.

2. If there are additional medical or other certificates or reports related to the accident/incident, give the original to the practice manager or practice principal.

3. Investigate the incident to enable modification of procedures if required.

4. Modify procedures and provide staff with full training.




2.6.1 Needlestick injury and exposure to blood or body fluids

This practice abides by standard precautions of Australian best practice, which is that the blood and bodily fluids of all people should be treated as potential sources of infection regardless of perceived risk. Human immunodeficiency virus (HIV), Hepatitis B (HBV) and Hepatitis C (HCV) may be transmitted by exposure to blood or other body fluids.

Standard precautions are applicable to:

Injury from a needle or sharp instrument that has been in contact with blood or other body substances.

Blood or other bodily fluid in the eyes/nose/mouth. Blood or other bodily fluid on non-intact skin.Management of an occupational exposure to blood or body fluid should include:

Rapid assessment of the health worker and the source patient. Full documentation of the incident to meet legal requirements. Counselling of the health care worker. Timely administration of medications where appropriate. Investigation of the incident to enable modification of procedures if required.

Occupational exposure to needle stick injuries and body substances can be prevented by practicing standard precautions, wearing personal protective equipment (PPE) and implementing safe work practices.

Any exposure of a staff member from a source positive, or likely to be positive for HIV, HBV or HCV will be referred immediately to an infectious disease physician or clinical immunologist for counselling, management and ongoing follow up.




2.6.2 Procedure following occupational exposure

1. Gently encourage bleeding if the exposure involves a cut or puncture, such as needlestick.

2. Clean and decontaminate:

Skin – Wash thoroughly with soap and running water. Eyes – Rinse well while they are open with running water or saline for at least 30 seconds. Mouth – Spit any blood or other body fluids out and rinse the mouth with water several

times.3. Apply an antiseptic and a clean dressing to a cut or puncture.

4. Complete an incident report form and give it to the principal of the practice as soon as possible.

5. State on the incident report form:

What you were doing. How the injury happened and the name of anyone that witnessed it. The nature and extent of the injury. Exactly what you were injured with (eg specify gauge of the needle). The body substance involved. How much blood or body fluid was on the sharp or splashed on you. What PPE (if any) you were using. The full name and address of the source of the sharp/blood or body fluid. If the source cannot be identified document ‘source patient not known’. If, after the injury, any of your blood went into the patient or onto instruments that were then

used.6. Provide the incident report as soon as possible to the principal of the practice.

7. Obtain consent to have the source patient’s blood tested for HBV, HCV and HIV.

8. The results should be available in 24 hours if marked ‘urgent-needlestick’.

9. Obtain informed written consent from the source patient. Most will agree if approached in a sensitive manner.

10. Maintain the source patient’s confidentiality and do not interview them in front of relatives.

11. Reassure the patient that he/she has not been exposed and the tests are part of a routine protocol which every health care facility follows after the occupational exposure of a health care worker.

12. Ask the source patient about 'at risk' activities, especially in the past six months. Such as:

Unprotected sexual intercourse. Sharing needles, or tattoos, or body piercing. Sharing razor blades or toothbrushes. Contact with another person’s blood or mucous membranes on their non-intact skin. Blood transfusion prior to February 1990.

13. If the source patient has a history of at-risk activities inform them about the window period in diagnosis.

14. Obtain informed written consent from the exposed staff member for baseline testing for HBV, HCV and HIV to establish if the health care worker has previously acquired an infection from other exposures. The staff member's results should be sent to their own general practitioner.

15. The staff member’s confidentiality must be maintained.




16. The staff member may elect to have these tests performed at a different facility or the results sent to their own general practitioner.

17. Advise them to practise safe-sex until their results and the patient’s results and history have been reviewed.

18. Advise the staff member to call the National Needlestick Hotline (NNH) on 1800 804 823. Please refer to Section Two Practice Contacts.

19. If the needle has been in the rubbish or on the floor, administer Adult Diphtheria and Tetanus (ADT), if necessary.

20. If the injured staff member’s HBV result will not be available within 25-48 hours, and if their HBV status in not documented, then give:

Hepatitis B Immunoglobulin, and Hepatitis B Vaccine (first dose) Chemoprophylaxis may be appropriate if, you anticipate that the source patient’s HIV

results will not be available within 24 hours, and if either: The source patient is likely to be positive or in the window period, or It was a high-risk injury from an unknown source. For advice about this point consult the NNH 1800 804 823.

21. If the injury is classified as a high risk, if the source patient has had at-risk activities or if the source patient has a positive blood test, the exposed staff member must be referred for immediate consultation with an infectious diseases specialist.

References:

Management of Occupational Exposure to Blood and Body Fluids in the Health Care Setting. Western Australian Department of Health Issued 20 December 2007. http://www.health.wa.gov.au/circularsnew/circular.cfm?Circ_ID=12334

Infection Control Standards for Office Based Practices 4th edition. Royal Australian College of General Practitioners. South Melbourne, Victoria. September 2006

Australian Immunisation Handbook 10th edition. Australian Government Department of Health. http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home



http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home

http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home

http://www.health.wa.gov.au/circularsnew/circular.cfm?Circ_ID=12334


2.6.3 Classification of exposures

Risk assessment of occupational exposure to blood or body fluids is conducted on the basis of the type of exposure and the amount of infectious material involved.

Risk Classification Table

Risk Description

Non-Exposure Intact skin visibly contaminated with blood or any bodily substance.

Doubtful Exposure 1. Intradermal (superficial) injury with a needle considered not to be contaminated with blood or body substance.

2. Superficial wound not associated with visible bleeding, caused by an instrument considered not to be contaminated with blood or body substance.

3. Prior wound or skin lesion contaminated with a body substance other than blood, eg urine.

4. Mucous membrane or conjunctival contact with a body fluid other than blood.

Possible Exposure 1. Intradermal (superficial) injury with a needle contaminated with blood or body substance.

2. A wound not associated with visible bleeding, produced by an instrument contaminated with blood or body substance.

3. Prior wound or skin lesion contaminated with blood or body substance.

4. Mucous membrane or conjunctival contact with blood or body substance.

Definite Exposure

(Moderate Risk)

1. Skin penetrating injury with a needle contaminated with blood or body substance.

2. Injection of blood/body substance < 1ml.3. Laceration or similar wound which caused bleeding, and is produced

by an instrument that is visibly contaminated with blood or bodily substance.

4. In laboratory settings, any direct inoculation with HIV tissue or material likely to contain HIV, HBV or HCV not included above.

Massive Exposure

(High Risk)

1. Transfusion of blood.2. Injection of large volume of blood/body substance (>1ml).3. Injection of a laboratory specimen containing high concentration of

virus

Source:

Management of Occupational Exposure to Blood and Body Fluids in the Health Care Setting. Western Australian Department of Health Issued 20 December 2007. http://www.health.wa.gov.au/circularsnew/attachments/1116.pdf



http://www.health.wa.gov.au/circularsnew/attachments/1116.pdf


2.7 Personal protective equipment Personal protective equipment (PPE) must be used in all cases where there is potential for a staff member to come into contact with blood or body fluids. PPE must also be used when handling chemicals such as cleaning products or dry ice for the intention of cryotherapy.

PPE includes:

Gloves Masks Face and eye shields Gowns and plastic aprons

PPE is located <Location of Personal Protective Equipment>. The maintenance of PPE is the responsibility of <Position responsible for maintenance of PPE>.

All staff must use appropriate PPE when undertaking any of the following procedures:

Any examinations requiring contact with mucous membranes. Cleaning or dressing wounds, removing or handling bandages. Cleaning up after procedures. Preparing instruments and equipment for sterilisation. Assisting with or performing procedures. Vigorous scrubbing or cleaning of contaminated surfaces. Using chemicals. Taking blood. Handling ALL pathology specimens before they are bagged. Controlling bleeding.




2.7.1 Type of personal protective equipment and appropriate use

PPE Appropriate useDisposable gloves Handling blood and body substances or when contact with such is

likely.

Handling equipment or surfaces contaminated with such substances.

Contact with non-intact skin.

Venipuncture – although needle stick injury may still occur, the presence of the glove layer could reduce the volume of any inoculum.

Sterile gloves Any surgical procedure involving penetration of the skin or mucous membrane and/or other tissue.

When venipuncture is performed for the purpose of collecting blood for culture.

General purpose gloves

General cleaning and disinfection.

During instrument processing.

Cleaning blood or body fluid and other substance spills.

Masks and protective eyewear

Worn during procedures that might result in splashing and the generation of droplets of blood, body substances or bone fragments.

Droplet and airborne precautions – assessing patients with infections transmitted by respiratory droplets


Gowns and plastic aprons

To prevent contamination of wearer’s clothing or skin with blood and body substances if there is a risk of splashing or spraying.


Sterile gowns Used for all aseptic procedures requiring a sterile field.

2.7.2 Gloves

Hands must be washed after removing gloves as pathogens on the skin can multiply rapidly inside the moist, warm environment created by the glove and because gloves may have undetectable tiny pinholes.

Disposable and Sterile Gloves

New gloves must be used for each patient. Gloves must be changed if going from a “dirty” site to a “cleaner” site on the same patient. Gloves must be changed if visibly torn or damaged. Gloves must not be washed or re-used.




General Purpose Gloves

General purpose utility gloves must be washed clean and stored dry ready for re-use. These gloves must be replaced if torn or showing signs of deterioration.




2.7.3 Hand washing

Hand washing before and after significant patient contact remains the single most important factor in the prevention of spread of infection.

It is the policy of this practice that hands are washed before and after:

Direct contact with a patient. Performing any procedure. Giving an injection. Taking blood. Handling pathology specimens. Donning gloves. Eating. Smoking. Blowing your nose. Going to the toilet.

Hands must also be washed as soon as they are visibly soiled. Soap dispensers and the pumps are disposed of after use or thermally disinfected prior to refilling.

2.7.4 Hand Washing Techniques

There are three hand washing procedures used in this practice depending on the risk category.

Routine Hand Wash

1. Wet hands thoroughly and lather vigorously using liquid soap.2. Wash for 10-15 seconds.3. Rinse under running water.4. Dry thoroughly with paper towel using a patting action.5. Do not touch taps with clean hands – use paper towel to turn taps off.

Hand Wash Prior to Aseptic (Non-Surgical) Procedures

1. Wash hands thoroughly using an anti-microbial soap.2. Wash for 1 minute.3. Rinse carefully under running water.4. Dry thoroughly with paper towel using a patting action.5. Do not touch taps with clean hands – use paper towel to turn taps off.

Hand Wash Prior to Invasive (Surgical) Procedures

1. Wash hands, nails and forearms thoroughly using an antiseptic hand wash.2. First wash 5 minutes and each subsequent wash 3 minutes.3. Rinse carefully under running water, keeping hands above the elbows.4. Do not touch taps.5. Dry thoroughly with sterile towels.




2.8 Manual handlingOur practice will provide:

A workplace where our employees, contractors and visitors are not exposed to hazards as far as practicable;

A safe system of work; and Information, instruction, training and supervision to workers so they can work in a safe manner.

Definitions

The Western Australian Department of Commerce – WorkSafe defines the following in the Code of Practice Manual Tasks:

Manual tasks

Refers to any activity or sequence of activities that requires a person to use their physical body (musculoskeletal system) to perform work including:

Manual handling (the use of force in lifting, lowering, pushing, pulling, carrying or otherwise moving,

Holding or restraining any person, animal or thing); Performing repetitive actions; Adopting awkward or sustained postures; and Using plant, tools or equipment that exposes workers to vibration.

Activity

Refers to the movements or postures adopted at any given time in order to perform a manual task.

Hazard

Means anything that may result in injury or harm to the health of a person.

Those manual tasks that have the potential to cause injury or disease are referred to in this code of practice as hazardous manual tasks.

Hazardous manual tasks

Include:

Manual tasks having any of the following characteristics: Forces exerted by the worker (eg lifting, lowering or carrying) or on the worker by an item,

person or animal (eg restraining a dog); Awkward postures (eg bending forwards, twisting or reaching); Sustained postures (eg prolonged sitting or standing); Repetitive movements (eg repeating an action frequently, without breaks); Vibration – whole-body (eg sitting in certain vehicles) and hand-arm (eg using certain

powered tools); Manual tasks involving the handling of a person or an animal; or Manual tasks involving the handling of unstable or unbalanced loads or loads difficult to grasp

or hold.




Musculoskeletal disorder

Means an injury or disease of the musculoskeletal system.

Risk

In relation to any injury or harm, means the probability of that injury or harm occurring.

It is the policy of this practice that all staff members are trained in correct manual handling procedures. The following methods are employed by this practice to reduce or eliminate the risks associated with manual handling:

Using mechanical handling equipment where possible. Varying the task or having rest periods where repetitive tasks are carried out for long periods. Using adjustable working heights for benches or platforms so the majority of tasks carried out

by standing workers are at waist height and within easy reach. Changing workplace layouts so twisting movements are kept to a minimum. Ensuring workers new to the work or returning from an extended absence are not required to

perform prolonged repetitive movements. Ensuring adequate training and supervision are available to workers.

The following procedures are to be used by all staff members:

1. Assess the item to be handled. Weight is not the only factor. Size and shape will also affect the degree of difficulty of the lift.

2. Decide if you can manage the lift alone or if help will be required. You are the only person who can decide this. Get help if required. If assistance is not available, wait until it is. If you are not sure if you can manage the lift alone, you must seek assistance. Manual handling is only to be done alone when the staff member is 100 percent certain it is within their capabilities.

3. Items of light to medium weight and a small, regular size must be lifted using the procedure known as ‘leg lift’. This involves moving to a squatting position, grasping the object and lifting it by straightening the legs. The ‘back lift’, involving stooping and lifting by straightening the bent back, is to be avoided at all times as this places undue strain on the body.

4. Never attempt to lift a patient without first seeking help. If a patient collapses while you are assisting them, guide them to the floor without bearing their weight.

5. If there are sufficient staff to enable the patient to be safely lifted, then this can be undertaken. Lifts must be carried out under direct medical supervision to prevent any further injury to the patient.

6. If there is insufficient assistance to lift the patient safely, leave the patient where they are.

7. Children may like to be picked up or carried. The guidelines for this activity are dictated by a combination of common sense and accepted practice. Do not lift a child in the course of your duties that you would not attempt to lift under other circumstances.

8. Prevent slips and falls by wearing appropriate footwear, ensuring that the workplace has adequate lighting, removing obstacles and cleaning areas regularly with spills wiped up immediately.

9. Check equipment is in good working order and there is adequate space in which to work.




2.9 Smoking, drugs and alcoholAs a primary health care provider, our aim is to promote the health and well-being of all staff, patients and others whilst they are on our premises and in our care. Smoking is therefore not permitted within the practice or the practice grounds. The use of illegal drugs and alcohol is prohibited on and around the site. Staff must not present for work if under the adverse effects of alcohol or illegal drugs.

Staff and visitors will be required to take ‘smoking breaks’ out of the practice grounds and will do so only in their own time such as before work and during meal breaks. Staff and practice visitors who smoke on breaks are required to make an effort to remove any nicotine odour on or about clothing and self, prior to returning to duty. No cigarette butts are to be disposed of in the practice gardens or surrounds.

No smoking signs are visible in the waiting and reception area. Signs are not to be removed, except to replace worn or frayed items. Brochures and posters for ‘QUIT’ and related no smoking, drug free strategies are to be placed in waiting room and visibly displayed to ensure our valued patients are aware of our commitment to better health strategies.

Stickers that comply with the ‘no smoking’ signage requirements are available free of charge from the Western Australian Department of Health. Order forms can be downloaded from the Western Australian Department of Health website www.health.wa.gov.au



http://www.health.wa.gov.au/


3 CONFIDENTIALITY AND PRIVACY OF HEALTH INFORMATION (CRITERION 4.2.1)

Policy

Our practice collects personal health information and safeguards its confidentiality and privacy in accordance with the Australian Privacy Principles

All staff are mindful of and respect the patient’s right to confidentiality and privacy. Patient details are not openly stated over the telephone within audible range of other patients or visitors. This practice prides itself on the high calibre of customer service we provide, especially in the area of patient security, confidentiality, and right to privacy, dignity and respect.

Staff do not give out details of patients who have consultations here nor any other identifying or accounts information, except as deemed necessary by government legislation.

This practice will ensure that reasonable steps are taken to implement practises, procedures and systems in compliance with the Australian Privacy Principles (effective March 2014).

The practice Privacy and Confidentiality Collection Statement (for patients) and the Privacy and Confidentiality Collection Statement (for staff) is made available at all times. Patients and staff are required to consent to the privacy and confidentiality statement.

A template is available in:

Templates, forms and checklists: Chapter 7.3 - Privacy and confidentiality collection statement

The maintenance of privacy requires that any information regarding individual patients, including staff members who may be patients, may not be disclosed either verbally, in writing, in electronic form, by copying either at the practice or outside it, during or outside work hours, except for strictly authorised use within the patient care context at the practice or as legally directed.

There are no degrees of privacy. All patient information must be considered private and confidential, even that which is seen or heard and therefore is not to be disclosed to family, friends or others without the patient’s approval or at the doctor’s discretion. Any information given to unauthorised personnel will result in disciplinary action and possible dismissal.

Each staff member is bound by his/her confidentiality agreement, which is signed upon commencement of employment at this practice.

All information received in the course of a consultation between a doctor and the patient is considered personal health information. This information includes medical information, family information, address, employment and other demographic and accounts data obtained via reception. Medical information can include past medical and social history, current health issues and future medical care. It includes the formal medical record whether written or electronic and information held or recorded on any other medium, for example letter, fax, or electronically.




Both medical and non-medical staff in this practice have a responsibility to maintain the privacy of personal health information and related financial information. The privacy of this information is every patient’s right. With this in mind, doctors are aware of the potential for breaches when:

Discussing results and information Speaking too loudly to patients Discussing results with other doctors Discussing results especially with relatives of adolescents and the frail

3.1 Maintaining confidentialityThe practice staff will ensure:

Items for the courier or pathology will be placed out of sight and behind the counter, not on top in public view;

That if a door to any office, consulting or treatment room is closed, they will knock and wait for a response prior to opening the door; and

It is the doctor’s responsibility to keep scripts, medications, medical records and related personal patient information secure, whilst they are not in attendance in their consulting room.

All staff must follow the listed guidelines to minimise the risk of potential breaches of confidentiality.

Waiting patient medical records are not left in an area accessible by the public.

Charts remain turned over at the front desk when not in use.

Speak softly at front desk.

Only minimal personal information is discussed in a public area.

Follow appropriate telephone procedures.

Close treatment and consulting room doors.

Use privacy screens or curtains.

Computer screens must not be able to be seen or be accessible to the public including couriers and visitors.

Computer screens displaying a previous patient’s data are closed before the next patient enters the consulting room.

Computer screens are locked when the doctor or staff leave the consulting or treatment room, or if the patient is left alone.

Strict guidelines are followed when releasing confidential details (phone, hard copy and electronically).




3.2 Administration of privacy legislationThe practice manager is our privacy officer who implements and monitors adherence to all privacy legislation in this practice.

The privacy officer acts as liaison for all privacy issues and patient requests for access to their personal health information. If staff have any queries concerning privacy law they are to refer to the privacy officer.

The practice manager attends information and training sessions with regard to privacy legislation laws and trains staff and implements new policy and procedures in the practice when deemed appropriate.

A privacy audit of policies and procedures is conducted regularly within the practice. Following this audit, changes to the policies and procedures will be made (if necessary) and training will be conducted accordingly. Please refer to PRIVACY AUDIT CHECKLIST for a suggested template.

3.3 Medical reportsThe practice will frequently receive a request through a third party insurer, solicitor, or other person desiring information about a particular patient.

In all cases, this information can only be given out with the written consent of the patient. Routinely, the request for such information will contain a patient’s signed consent. Once this has been received, it is to be recorded on the file and the report request passed on to the treating doctor or practice principal for consideration.

These requests cannot be charged to Medicare. Third party accounts will be charged according to the current AMA Schedule of Fees or as arranged privately with an insurer or patient.


<Option 1>

It is the policy of this practice that each request is dealt with on a case by case basis and any decisions relating to the provision of reports and fees charged are only to be made by the treating doctor or practice principal. It is also the policy of this practice that no reports are sent until the required fee has been paid.

<Option 2>

This practice has a standard set of charges for such reports. It is the policy of this practice that no reports are sent until the required fee has been paid.

On receipt of a request, ensure that a signed patient consent form is attached. Check that the consumer is a patient of this practice. Refer the request to the treating doctor or practice principal for approval. Reply to the request, indicating that the report has been completed and will be forwarded as

soon as the required fee has been received. Advise that it is the policy of this practice that no reports are sent until the required fee has

been paid.




3.4 Computer privacyIt is the policy of this practice that data held on the practice’s computer system is secured to prevent unauthorised access, exploitation and loss of data.

Staff members, temporary staff and contractors that require access to the practice’s systems are required to sign confidentiality agreements before commencing work. Please refer to CONFIDENTIALITY AGREEMENTS for suggested templates.

Electronically held data will be protected from exploitation by organisations that may sell the data for commercial purposes. Disks, electronic storage devices, universal serial bus (USB) flash drives, faxes and computer printouts are positioned or stored out of sight when not in use.

Computer equipment is located in physically secure areas within the practice or is secured by anti-theft and data loss protection devices (lockable cables, drive locks).

3.5 Incoming mailIn this practice, <person responsible for sorting mail> is responsible for sorting the mail.

It is vital that any and all mail relating to a patient is seen by the doctor. Patient information is never filed without having been seen and signed by the doctor. All mail is opened unless marked private or confidential.

Paper based incoming mail

1. Separate the mail based on advertising, personal and patient information.

2. Stamp generic mail with the date stamp, recording the date that the mail was opened.

3. Imprint results and reports with a stamp containing the following prompts:

Date received.

Date results reviewed by doctor.

Initials of doctor.

Follow up action to be taken by staff.

4. Do not file test results until the above information is completed.

5. Attach the results to the patient’s medical record.

6. Place the medical record with the attached results in the requesting doctors in tray (paper based filing) or place the results in the requesting doctors in tray (electronic based filing).

7. If the requesting doctor will not be in the practice in the next 24 hours, refer the results and file to another doctor for review.

8. Upon return of the file from the doctor, check the result for any actions that need to be carried out.

9. Actions for follow up or reminders to be sent are undertaken by the practice nurse (see recalls and reminders).

10. If all actions have been completed and recorded, file the results and the medical record.




Computerised incoming mail

1. Incoming results, letters and images are downloaded according to the service provider instructions.

2. The doctor is to review, electronically sign, date and record action on each piece of mail before marking as actioned.

3. Actions for follow up or reminders to be sent are undertaken by the practice nurse (see recalls and reminders).

3.5.1 Facsimile – maintaining privacy and confidentiality

Due to the medico-legal nature of our patient information, the following procedure is to be strictly adhered to:

When faxing patient information, the fax number and identification of the recipient must be confirmed before transmitting. Ask the person requesting the fax to ensure that someone authorised is standing by to receive the fax at that fax machine.

Record “Confidential” on the fax coversheet. Check the number dialled before pressing ‘SEND’. Keep transmission report produced by the fax as evidence that the fax was sent. Also confirm

the correct fax number on the report.

3.5.2 Medical students

Patients may not wish to have their personal health information used for education purposes. This practice respects its patient’s right to privacy and where possible will use de-identified data for case studies. We will always inform patients of impending medical students participating in practice activities and ask patients to consent to this.

3.5.3 Insurance company and social welfare agency

No information is to be given without express written consent from the patient. All enquires must be directed to the patient’s doctor. Release of information is an issue between the patient and the doctor.

3.5.4 Research and quality program

Where it is desired to publish material related to clinical work or for practice continuous quality improvement activities, the anonymity of patients is to be preserved. Research requests are to be approved by the practice principal.

The patient must consent to any specific data collection for research purposes. If the data is required by or in accordance with rules established for accreditation by RACGP or other diligent professional health agencies, then data will be de-identified where possible, with related obligations of confidentiality upon health professionals engaging in these activities.




3.5.5 Disease registers (for public health purposes)

For cervical screening, breast screen and other disease specific registers, consent is required from the patient to use their personal health information for this purpose. The patient is given the opportunity to decline inclusion in these types of registers.

3.5.6 Notifiable diseases

In Western Australia the Health Act 1911 is the principal piece of legislation that provides the mechanisms through which statutory or mandatory notification is affected. A number of other Acts and Regulations also stipulate the requirement for notification of medical events or conditions.

Notifications to the Western Australian Department of Health are specified under the following legislation:

Acts

Health Act 1911 Poisons Act 1964 Regulations

Regulations made under the Health Act 1911 Poisons Regulations 1965

It is the responsibility of the treating doctor or nominated person to notify the Western Australian Department of Health of any statutory medical notifications including communicable diseases.

For more information on current mandatory medical notifications, see http://ww2.health.wa.gov.au/~/media/Files/Corporate/general%20documents/Infectious%20diseases/PDF/Statewide%20ND%20rpts/2017-week-31-statewide-notifiable-disease-report.ashx

3.5.7 Police and lawyers

Police and lawyers must obtain a signed patient consent (or subpoena, court order or search warrant) for release of information. The request is directed to the doctor. Only when a signed patient request is obtained is the doctor legally obliged to release information.

3.5.8 External employers

If the patient has signed consent to release information for a pre-employment questionnaire or similar report then direct the request to the doctor who will respond with the required information. Otherwise no information is to be released. When in doubt always refer the request to the doctor. The patient may seek access to the Australian Privacy Principles.



http://ww2.health.wa.gov.au/~/media/Files/Corporate/general%20documents/Infectious%20diseases/PDF/Statewide%20ND%20rpts/2017-week-31-statewide-notifiable-disease-report.ashx




3.5.9 Subpoena, court order, search warrant and coroner

Information will be released if a subpoena, court order, search warrant or coroner’s request is received. If the doctor is concerned about confidentiality issues, he/she may decide to challenge it in court if sufficient evidence amounts to possible breach in confidentiality.

1. Inform the patient’s doctor and practice principal.

2. The doctor may wish to speak to his/her medical defence organisation for advice.

3. Retrieve the patient’s medical record (if paper-based).

4. Record the date of court case in the patient’s medical record.

5. Make a copy of the record.

6. Retain the copy on file and mark as duplicate on each page with reason for copy.

7. Sometimes a staff member is required to take the medical record to court. Telephone the relevant solicitor or clerk of courts and try to arrange a confidential courier to transport the record in, as an alternative.

8. Telephone closer to the day requested, if a staff member must take the record physically to court, to ensure the date is correct and the case is still on.

9. Return the record to the practice after the review by the court unless otherwise instructed by the court.

3.5.10 Relatives and friends

No information is to be released unless the patient has authorised another person to be given access if they have the legal right and a signed authority.

Separate records are advised for all family members but especially for children whose parents have separated and care must be taken that sensitive demographic information about either partner is not recorded on the demographic component of the record.

If a person contacts the practice to see if their family member or friend is or has been at the practice, advise the caller that it is the policy of this practice that this information is not provided.

If the caller pursues their query, advise them that a message will be left for the doctor and he or she will call them back as soon as convenient.

Administrative staff will not give treatment or advice over the telephone.

3.5.11 Consent in an emergency

Where immediate treatment is necessary to preserve a life or prevent serious injury, all attempts are made to gain the patient’s consent. This may not be successful in all cases prior to administering emergency care.




3.6 Australian Privacy PrinciplesIn compliance with the Privacy Amendment (Enhancing Privacy Protection) Act 2012, which amended the Privacy Act 1988, this practice has prepared this privacy policy utilising the text of the Australian Privacy Principles (APPs) to describe the ways and circumstances under which personal information is collected, stored, used and disclosed and also how complaints are handled by this practice.

3.6.1 Consideration of personal information privacy

Open and transparent management of personal information

This practice will manage personal information in an open and transparent way. This practice will have a clearly expressed and up to date APP privacy policy PRIVACY AND

CONFIDENTIALITY COLLECTION STATEMENT.

Anonymity and pseudonymity

This practice recognises the patient and client option of not identifying themselves, or of using a pseudonym.

3.6.2 Collection of personal information

Collection of solicited personal information

This practice will not solicit personal information from another agency, organisation, individual or small business unless where prior approval has been given by the patient.

This practice will only collect sensitive information about a person where the individual: Consents to the collection of the information; and The information is reasonably necessary for, or directly related to the healthcare and

management of the patient. This practice will collect personal information by lawful and fair means only. The practice will only collect personal information directly from a patient unless:

The patient consents to the collection of the information from someone other than themselves or legal guardian or carer; or

Under Australian law, or a court/tribunal order, the practice is required to collect the information from someone other than the patient or legal guardian or carer; or

It is unreasonable to do so eg in the case of an emergency.

Dealing with unsolicited personal information

If the practice receives unsolicited personal information about an individual, the practice will within a reasonable period after receiving the information, determine whether or not the practice could have collected the information under APP 3 (Collection of solicited personal information) if the practice had requested the information.

The practice may use or disclose the personal information for the purposes of making the determination.

If the practice determines that the practice could not have collected the personal information and the information is not contained in a Commonwealth record, the practice will, as soon as practicable but only if it is lawful and reasonable to do so, destroy the information or ensure that the information is de-identified.




Notification of the collection of personal information

Where possible, prior to collecting personal information about a patient, or as soon as practicable after collecting personal information, the practice will provide the patient with the PRIVACY AND CONFIDENTIALITY COLLECTION STATEMENT.

This includes: The identity and contact details of the practice. Collection and use statement. Practice privacy statement for patients.

If the practice collects personal information from someone other than the individual and the individual is not aware that the practice has collected the personal information, the practice will:

Advise the individual how they may access the personal information that is held by the practice and seek the correction of such information;

Advise the individual how they may complain about a breach of the APP , or a registered APP code (if any) that binds the practice, and how the practice will deal with such a complaint;

Advise the individual how the personal information will be used, including whether the practice is likely to disclose the personal information to overseas recipients; and

If the practice is likely to disclose the personal information to overseas recipients — the practice will advise the individual of the countries that are likely to be notified (where practicable).

3.6.3 Dealing with personal information

Use or disclosure of personal information

This practice will generally collect personal and sensitive information about our patients (individuals). This information will only be collected for the primary purpose of providing medical treatment and advice to the individual.

The practice will not use or disclose the information for another purpose (the secondary purpose) unless:

The individual has consented to the use or disclosure of the information; The individual would reasonably expect the practice to use or disclose the information for the

secondary purpose and the secondary purpose is: If the information is sensitive information — directly related to the primary purpose; or If the information is not sensitive information — related to the primary purpose; or The use or disclosure of the information is required or authorised by or under an Australian

law or a court/tribunal order; or A permitted general situation exists in relation to the use or disclosure of the information by

the practice; or The practice reasonably believes that the use or disclosure of the information is reasonably

necessary for one or more enforcement related activities conducted by, or on behalf of, an enforcement body.

Written note of disclosure

If the practice uses or discloses personal information in the above circumstances, the practice will make a written note of this in the patient health records.




Direct marketing

Where the practice holds personal information about an individual, the practice will not use or disclose this information for the purposes of direct marketing, unless where:

The practice collected the information from the individual; and The individual would reasonably expect the practice to use or disclose the information for that

purpose (for example, recalls and reminders); and The practice provides a simple means by which the individual may easily request not to receive

direct marketing communications from the practice; and The individual has not previously made such a request to the organisation.

Cross border disclosure of personal information

At all times, before the practice considers disclosing personal information about an individual to a third party located overseas, the practice will take all reasonable steps to ensure that the overseas recipient does not breach the APP, other than APP 1 (Open and transparent management of personal information) in relation to the information.

Exceptions to this apply where the practice reasonably believes that:

The recipient of the information is subject to a law, or binding scheme, that has the effect of protecting the information in a way that, overall, is at least substantially similar to the way in which the APP protect the information; or

There are mechanisms that the individual can access to take action to enforce that protection of the law or binding scheme; or

After being informed, the individual consents to the disclosure; or The disclosure is required or authorised under Australian law or a court/tribunal order.

Adoption, use or disclosure of government related identifiers

The practice will not adopt a government related identifier of an individual as its own identifier of the individual (such as a Medicare Card number).

The practice will not use or disclose a government related identifier of an individual unless: The use or disclosure of the identifier is reasonably necessary for the organisation to verify

the identity of the individual for the purposes of the organisation's activities or functions; or The use or disclosure of the identifier is reasonably necessary for the organisation to fulfil

its obligations to an agency or a state or territory authority; or The use or disclosure of the identifier is required or authorised by or under an Australian

law or a court/tribunal order; or The organisation reasonably believes that the use or disclosure of the identifier is

reasonably necessary for one or more enforcement related activities conducted by, or on behalf of, an enforcement body.

3.6.4 Integrity of personal information

Quality of personal information

The practice will take all reasonable steps to ensure that the personal information collected is accurate, up-to-date and complete.

The practice will take all reasonable steps to ensure that the personal information that the entity uses or discloses is, having regard to the purpose of the use or disclosure, accurate, up-to-date, complete and relevant.




Security of personal information

The practice will take all reasonable steps to ensure that the personal information collected is protected: From misuse, interference and loss; and From unauthorised access, modification or disclosure.

Where the practice holds personal information about an individual; and The practice no longer needs the information for any purpose for which the information may be

used or disclosed by the practice under the APP; and The information is not contained in a Commonwealth record; and The practice is not required by or under an Australian law, or a court/tribunal order, to retain the

information;The practice will take all reasonable steps to destroy the information or to ensure that the information is de-identified.

3.6.5 Access to, and correction of, personal information

Access to personal information

If a patient or guardian or representative (or the family of a deceased patient) requests access to a patient’s personal information, including medical records, the applicant will put the request in writing, with detailed information why the request is being made. The practice manager will review the request by:

Discussing the request with the patient’s doctor; and Discussing the request with the doctor’s medico-legal advice team.

Dealing with requests for access

The practice will then:

Respond to the request for access to the personal information, acknowledging the request; Advise the applicant of the practice policy for access to medical records; Advise the applicant of the outcome within a reasonable period (recommended 30 days) after

the request is made; and Give access to the information in the manner requested by the individual, if it is reasonable and

practicable to do so.




Exceptions to access

When considering the applicant’s request to view medical records, the doctor and/or practice manager will consider if access to the patient’s medical history:

Will pose a serious threat to the life, health or safety of any individual, or to public health or public safety; or

Will have an unreasonable impact on the privacy of other individuals; or Is a frivolous or vexatious request; or Relates to existing or anticipated legal proceedings between the practice/doctor and the

individual, and would not be accessible by the process of discovery in those proceedings; or Would reveal the intentions of the doctor/practice in relation to negotiations with the individual

in such a way as to prejudice those negotiations; or Would be unlawful; or Is required or authorised by or under an Australian law or a court/tribunal order; or Would be likely to prejudice one or more enforcement related activities conducted by, or on

behalf of, an enforcement body; or Would reveal evaluative information generated within the entity in connection with a

commercially sensitive decision-making process; or Could lead to the practice suspecting that unlawful activity, or misconduct of a serious nature,

that relates to the practice’s functions or activities has been, is being or may be engaged in; or Prejudice in the taking of appropriate action in relation to the matter;Then the request for access may be denied.

Other means of access

If the practice refuses to give access to the personal information; or Agrees to give access in the manner requested by the individual; Then the practice will take reasonable steps to give access in a way that meets the needs of the practice and the individual.

Access may also be given through the use of a mutually agreed intermediary.

Access charges

If the practice charges the individual for giving access to the personal information the charge will not be excessive and must not apply to the making of the request.

Refusal to give access

If the practice refuses to give access to the personal information or to give access in the manner requested by the individual, the practice will give the individual a written notice that sets out:

The reasons for the refusal except to the extent that, having regard to the grounds for the refusal, it would be unreasonable to do so; and

The mechanisms available to complain about the refusal; and Any other matter prescribed by the regulations.If the practice refuses to give access to the personal information, the reasons for the refusal may include an explanation for the commercially sensitive decision.




Correction of personal information

Where the practice holds personal information about an individual; and either:

The practice is satisfied that, having regard to a purpose for which the information is held, the information is inaccurate, out of date, incomplete, irrelevant or misleading; or

The individual requests the entity to correct the information;The practice will take reasonable steps to correct that information and will ensure that, having regard to the purpose for which it is held, the information is accurate, up to date, complete, relevant and not misleading.

Notification of correction to third parties

If the practice corrects personal information about an individual that the practice previously disclosed to another entity and the individual requests the practice to notify the other entity of the correction, the practice will take all reasonable steps to give that notification unless it is impracticable or unlawful to do so.

Refusal to correct information

Should the practice refuse to correct the personal information as requested by the individual, the practice will give the individual a written notice that sets out:

The reasons for the refusal except to the extent that it would be unreasonable to do so; and The mechanisms available to complain about the refusal; and Any other matter prescribed by the regulations.

Request to associate a statement

Should the practice refuse to correct the personal information as requested by the individual and the individual requests the practice to associate with the information a statement that the information is inaccurate, out-of-date, incomplete, irrelevant or misleading; the practice will take reasonable steps to make the statement apparent to users of the information.

Dealing with requests

If a request is made under subclause 13.1 (Correction) or 13.4 (Request to associate a statement), the practice will:

Respond to the request for information within a reasonable period (recommended 30 days) after the request is made; and

Not charge the individual for the making of the request, for correcting the personal information or for associating the statement with the personal information.




More information

The Office of the Australian Information Commissioner contains a fact sheet on the APPs which can be found at:

http://www.oaic.gov.au/privacy/privacy-resources/privacy-fact-sheets/other/privacy-fact-sheet- 17-australian-privacy-principles; or

http://www.oaic.gov.au/privacy/privacy-resources/privacy-guides/app-quick-reference-tool For the purposes of this policy, no distinction has been made between the handling of personal information and sensitive information (including health information); therefore all information will be referred to as “personal information” throughout this policy.

See PRIVACY AND CONFIDENTIALITY COLLECTION STATEMENT.



http://www.oaic.gov.au/privacy/privacy-resources/privacy-guides/app-quick-reference-tool

http://www.oaic.gov.au/privacy/privacy-resources/privacy-fact-sheets/other/privacy-fact-sheet-17-australian-privacy-principles

http://www.oaic.gov.au/privacy/privacy-resources/privacy-fact-sheets/other/privacy-fact-sheet-17-australian-privacy-principles


4 INFORMATION SECURITY (CRITERION 4.2.2)

Policy

Our practice has an effective information security system ensuring the security of our patient health information.

4.1 Computer and Information Security Standards Our policies and procedures are consistent with the Royal Australian College of General Practitioners (RACGP) Computer and Information Security Standards (CISS) and the APPs (2014).

The CISS provides templates for use in developing:

Asset register. Risk assessment. Data breach response and reporting. Access control. Business continuity and information recovery. Back-up rotation schedule. Network diagram.

View the current RACGP CISS and templates at: http://www.racgp.org.au/your-practice/e-health/protecting-information/ciss/

4.2 Allocation of responsibilityOur practice has designated practice team members for championing and managing computer and information security. These practice team members have their roles and responsibilities documented in their position descriptions.



http://www.racgp.org.au/your-practice/e-health/protecting-information/ciss/


4.2.1 Responsibility based access

All staff will be given responsibility based access determined by their roles and functionality required.

Access is as follows:

Systems administrator: This level of access is the highest and is only granted to IT/security trained and external service providers for the server, operating system and network maintenance functions, and software support. Remote access will be granted.

Practice manager and principal(s): This access includes administrative functionality on the financial, clinical and network systems used in the practice. Remote access will be granted.

Receptionist: This level of access is for patient administration such as appointments and billing. There is no access to clinical programs. Remote access will not be granted.

Clinical practice team members: This level of access is for use of the clinical programs. This access level may be further subdivided where delineation between the doctor, nursing and allied healthcare staff access is required. Remote access may be granted to perform after hours duties.

Guest clinical account: This level of access is for locums and agency nurses. Access is given to clinical records as required to perform duties, but no access to practice financials are available. This access level may be further subdivided where delineation between the doctor, nursing and allied healthcare staff access is required. Remote access may be granted to perform after hours duties.

Other staff, such as researchers, students, software vendors and other healthcare provider organisations: This level of access will vary depending on the activities the person is undertaking. Generally, remote access will not be granted.




4.2.2 External systems administrator

This practice has a regular external systems administrator (ESA) who is responsible for the maintenance and repair of our computer hardware and software systems.

The ESA is <name of external systems coordinator> and their contact details are listed in:

Our practice, Chapter 3 - Practice Contacts

All external service providers will have a written contract in place governing:

Privacy and confidentiality. Ownership of intellectual property. Remote access. Back-up and restoration procedures. Response times. Costs – routine, additional, after hours. Audit log. Secure disposal of information assets. Cloud services. Roles and responsibilities of the ESA and the practice Computer Security Coordinator (CSC). Regular assessment of practice threats, vulnerabilities, and controls assessments. Report and acting on any data breaches.




4.2.3 Computer Security Coordinator

The practice Computer Security Coordinator (CSC) is currently <name of computer security coordinator>

In this leadership role, the CSC will:

Have the skills required to undertake the duties and responsibilities required for the position. Where identified, the CSC will undergo additional external training in order to fulfil and maintain

the duties of the role. Liaise with external providers. Have medium to advanced knowledge of relevant computer operating systems (eg Windows)

and the relevant application software. Have demonstrated management skills to be able to develop practice computer security

policies. Raise awareness and provide training, back-up and support in computer and information

security governance on a day to day basis to the whole practice team. Foster a security culture within the practice team. Manage the risk assessment, creation and policy review; and the security management and

reporting functions. Ensure all practice security policies are being followed. Ensure that information transferred electronically is secure.




4.2.4 Responsible officer

The national Healthcare Identifiers Service (HI Service) uniquely identifies healthcare providers and individuals who seek healthcare. This practice is registered as a Healthcare Provider Organisation (HPI-O) under the HI Service. Our medical practitioners are registered with the Australian Health Practitioners Registration Authority (AHPRA) and have received and recorded their Individual Healthcare Provider Identifiers (IH-I)

<Option 1> Seed Organisation

This practice is recorded as the Seed Organisation (SO) and therefore controls the delivery of services by this solitary medical practice / primary practice (where there are multiple or satellite practices)

<Option 2> Network Organisation

This satellite practice / multiple positioned practice is recorded as a Network Organisation (NO) and is linked to the Seed Organisation <name and location of seed organisation>.

Our practice will have one Responsible Officer (RO) for the organisation. This is currently <<Name of RO>>.

Our practice will have one Organisation Maintenance Officer (OMO) per practice location. These/This is currently <<Name of OMO>>.

The connection is demonstrated below:



RO

OMO

OMO

Satellite Practice BNetwork

Satellite Practice ANetwork

SeedPrimary Medical

Practice

A Seed Organisation is any legal entity which provides or controls the delivery of healthcare services within Australia.

A Network Organisation is a Healthcare Provider Organisation that is linked to the Seed in an organisation hierarchy.

Responsible Officer (RO) One only per HPI-O For example, the practice principal

Organisation Maintenance Officer (OMO) One or more For example, the practice manager


4.3 Internet and email useOur practice has processes in place to ensure the appropriate and proper use of internet and email in accordance with the practice policies and procedures for managing information security.

4.3.1 Email

The use of email is recognised as a useful tool for communication purposes. Practice staff are permitted to use the practice email accounts to send and receive business related material such as education updates, stakeholder communication, submitting Medicare provider number applications, communicating with locums / staff where appropriate.

Practice staff will have access to a practice email account in the following levels:

Practice manager: Personalised use of a practice email account, for example [email protected]

Receptionists: Group access to a practice email account, for example [email protected]

Clinical practice team members: Medical practitioners, nurses, allied health practitioners will have personalised use of a practice email account, for example [email protected]

Guest clinical account: This level of access is for locums and agency nurses. Guests will not have a practice email account.

The use of a practice email account is for business communications only. Patient information will only be sent via e-mail if it is securely encrypted according to industry and best practice and the patient has consented to this mode of direct communication. Employees are reminded that the practice may become liable for the contents of any email message under certain circumstances. As such, the template email disclaimer will be inserted into the signature of all practice emails.

The use of personal email accounts during working hours is generally discouraged but may be used in personal/lunch/break times where this does not interfere with day to day operations. Large files such as video files and photographs should not be transmitted for personal communication.

4.3.2 Internet

The use of the internet as a legitimate business and research tool is both recognised and approved by <name of practice>. However, staff and management have a responsibility to ensure that there is no abuse of the resources for private purposes, that staff productivity is not compromised, that offensive material is not spread throughout the organisation and that the practice computer system is protected from the introduction of computer viruses.

The internet must never be used to download or access any illegal software or pornographic, defamatory, offensive, share-trading or gambling-related material.

Downloading of material via the internet slows access for other staff. The internet should not be used for downloading music, videos or radio programs, for making personal purchases or accessing interactive social websites, including Facebook, My Space, MSN and Twitter.



mailto:[email protected]




Configuration and protection

All downloads from the internet must be scanned for viruses. All sites accessed must comply with legal and ethical standards and the practice policies. Web browser security settings are not to be changed without authorisation of the practice

manager. The practice will have in place firewalls and intrusion detection systems as advised by technical

support providers.

4.3.3 Password maintenance

Each of our team members will have unique identification for all protected systems. Staff will not share passwords. Access will be by individual password only and passwords will be periodically changed <every XX days> (recommended every 90 days) and immediately if compromised.

Passwords will not be generic. Passwords will be private and not shared. Passwords cannot be re-used. Passwords will be made up of 6 – 8 characters with alpha, numeric and special characters. Our staff are strongly discouraged from using:

Dates of birth. Family or pet names. Dictionary words.

4.4 Password management Only the practice manager or system administrator can reset passwords. User identifications are archived or removed upon leaving the employment of the practice. Lock out will occur after three unsuccessful login attempts to an account.




4.5 Information back-upOur practice has a reliable information back-up system to support timely access to business and clinical information.

4.5.1 Back-up frequency and access


<<Option 1>>

Our practice has an automatic system for daily back-up. This system updates all data and programs and programs OR all data OR partial data (eg

clinical and practice management software, emails, user profiles, desktop settings, internet favourites and bookmarks).

Our server is also backed-up. Only authorised team members have access to the back-up.

<<Option 2>>

Our practice has a manual system for daily back-up. This system updates all data and programs OR all data OR partial data. Appropriate practice team members have access to the back-up.

<<Option 3>>

Our practice has a manual system for daily/weekly back-up. This system updates all data and programs OR all data OR partial data. Access to the back-up is open to all staff.

4.5.2 Back-up reliability


<<Option 1>>

Our back-up systems are routinely checked for reliability and outcome tracked. Our back-up is regularly manually restored.

<<Option 2>>

Our back-up systems are periodically checked for reliability. Our back-up is manually restored.

<<Option 3>>

Our back-up systems are checked for completion. Our back-up is manually restored ad hoc.




4.5.3 Back-up media and rotation


<<Option 1>>

Our back-up is stored on a second hard disk OR raid configuration OR solid state OR to another computer/laptop.

Our back-up media is rotated daily, weekly and monthly.

<<Option 2>>

Our back-up is stored on a CD/DVD. Our back-up media is rotated daily and weekly.

<<Option 3>>

Our back-up is stored on a Jaz/ZIP or tape (eg DAT/QIC) media. Our back-up is media is rotated daily.

Automated back-up

At the end of each day the last receptionist rostered on will: Insert back-up media for the day in the server. Ensure that all other computers have logged out of the server.

Next morning the first receptionist rostered on will: Check for any error messages on the server. Check that the files on the back-up media look correct (name, size and date).




5 SUPPLIES AND ORDERING

5.1 Office SuppliesSupplies of stationery, other office and practice stores can be obtained from our stationery storage cupboard, which is located at the <location of stationery supplies>. Supplies of printed letterhead, business cards and memos are also stored here.

It is the responsibility of the <person responsible for maintaining stationery supplies> to check stock on a <frequency of stationery check> basis and re-order when supplies are low. This position is also responsible for checking incoming goods.

<Option 1>

This practice has a list of office supplies which is located at <location of office supplies list> (SEE TEMPLATE OFFICE SUPPLIES LIST). When a staff member takes a supply of stationery, for example pens and post-it notes, they are required to tick off the item as having been removed from the cupboard.

<Option 2>

This practice has a list of office supplies which is located <location of office supplies list> (SEE TEMPLATE OFFICE SUPPLIES LIST). Staff are not required to mark which item they have taken, but are required to let the position responsible for monitoring and ordering office supplies know when there is only a small quantity of the item left.

<Option 3>

This practice does not keep a list of office supplies, however staff are required to let the person responsible for monitoring and ordering office supplies know when there is only a small quantity of the item left.

The practice’s stationery and printing provider contact details are listed in:

Our practice, Chapter 3 - Business and service provider contacts



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