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Clinic Audits

Introduction

Urgent Care Standard

In the accreditation process, Clinics are audited against a written standard.

RNZCUC developed the latest standard, the urgent care standard (UCS), in 2015. The UCS addresses many areas that are fundamental to good urgent care, and RNZCUC recommends that Clinics undertake accreditation.

The UCS is internationally recognised, and JAS-ANZ approval is pending.

How does a Clinic become accredited?
The first step in seeking accreditation is to engage an approved auditor, who will advise the Clinic on preparation for audit and obtaining a copy of the Standard. Once the Clinic is prepared, the auditor will assess wide-ranging aspects of the Clinic including the Clinic building and fit-out, systems, and compliance with legislation.

Clinics must be reaccredited every three years.

Who are the auditors?
The auditing team comprises one of the two professional auditors listed below and a RNZCUC fellow.

1) DAA Group Limited

Contact: Janice McEwan
551 Springs Road, Prebbleton 7604
Phone: 03 329 6477
Fax:     03 329 6577
Mobile: 029 2347500
Email:  janice.mcewan@daagroup.co.nz
Website:  http://www.daagroup.co.nz

 Contact: Cathy Cummings
PO Box 5088, Lambton Quay, Wellington 6145
Phone: 04 499 0367
Fax:     04 499 0368
Mobile: 021 470 332
Email:  cathy.cummings@daagroup.co.nz
Website:  http://www.daagroup.co.nz

2) Health Audit NZ Ltd

Contact: Majid Zahoor
PO Box 217235 Botany Junction, Auckland 2164
Phone: 0800 4 AUDIT (0800 428 348)  Or 09 274 3525
Email: manager@hanz.kiwi
Website: http://www.hanz.kiwi


Can RNZCUC help?
Compliance with the UCS can appear daunting. RNZCUC strove to make the UCS practical and useful, though the need to comply with legislation and current quality-assurance industry practices has led to some requirements the purpose of which is not immediately obvious.

Clinics seeking accreditation may contact RNZCUC for assistance.

PARTICULAR REQUIREMENTS - RNZCUC policy and interpretation of the UCS

RNZCUC has policies around interpretation of some key areas of the UCS.

The UCS refers to these as 'particular requirements'.

RNZCUC may vary, clarify or expand on these requirements. Any variations are listed below.

1) Hours
Generally a facility will be required to be open until 8pm 7 days (8am - 8pm in the weekends).
RNZCUC policy around exemptions to this criterion is as follows:

I. Rural areas / small provincial towns
RNZCUC will consider these facilities case-by-case, recognising their staffing difficulties.

II. Urban areas

A. Standard operating hours
To operate at reduced hours, a facility must conduct an analysis and show the Community's needs are met despite the closure.
An example of an analysis acceptable to RNZCUC would be statistics of patient attendance for twelve months showing attendance of fewer than two patients per hour in the hours leading up to the proposed closure time.

B. Christmas day

A facility may close provided it enters a formal arrangement with another facility that will open for the Standard hours and is less than a twenty minute drive away. The closing facility must take reasonable measures to advertise the closure to its patients in advance and with signage on the day. 'Reasonable measures' could include, a month in advance, notifying patients of the closure by email, public notice, signs on external windows, in the waiting room and at reception, and by telephone answer message.

C. Other public days holidays (including Easter Friday, Sunday and Monday)

To operate at reduced hours, a facility must conduct an analysis and show the Community's needs are met despite the closure.
An example of an analysis acceptable to RNZCUC would be statistics of patient attendance for twelve months showing attendance of fewer than two patients per hour in the hours leading up to the proposed closure time for  a reasonable (in RNZCUC's judgement) number of instances of the holiday in question (from previous years), again showing attendance of fewer than two patients per hour.

RNZCUC may take into account other information, such as patient attendance data from other urgent care facilities and EDs in the area.

- It not enough on its own to have an agreement with another facility to cover some of these hours.

- It is not enough to survey the facility's patients asking if they are satisfied with the facility's hours.

2) Medical Director
The Medical director must be a FRNZCUC or hold written dispensation from RNZCUC to serve as medical director.

RNZCUC has previously given such dispensation to urgent care trainees who are making satisfactory progress towards Fellowship, to GPs with the University of Auckland's PGDipCEM who are doing urgent care CME, and emergency medicine Fellows.

All applications are considered with regard to precedent, and to the College's general principle of 'raising the bar' over time.

 In July 2016, RNZCUC adopted the following policy with regard to dispensations to serve as medical director, for clinic audit purposes.

The policy takes effect from October 1st 2016.

-    The applicant must in good standing with RNZCUC and the MCNZ, such that in the opinion of RNZCUC the applicant is not unsuitable for the post, in terms of providing safe patient care personally and overseeing safe patient care by the facility. Aspects considered should include: disciplinary proceedings, professional conduct, training programme performance and progress.

Dispensations may, at RNZCUC's diecretion, be given to:
-    RNZCUC Advanced Trainees who aremaking satisfactory progress towards urgent care Fellowship.
-    MCNZ-CHS Fellows of Emergency Medicine who are making satisfactory progress towards urgent care Fellowship.
-    Fellows of RNZCGP with Diploma in Community Emergency Medicine who are making satisfactory progress towards urgent care Fellowship.

Basic RNZCUC trainees will be given dispensation only in exceptional circumstances; e.g. for provincial towns or semi-rural environments with difficulty finding staff, and will be case by case, with careful assessment of whether the appointment is likely to improve standards of patient care.

In all cases, dispensations are subject to review or revocation by RNZCUC at any time, and basic trainees holding such dispensations are to be closely assessed and monitored, including:
a) Full executive approval required
b) BoC assessment, with Education Committee support, including clinical notes audit pass prior to dispensation
c) Evidence, to the satisfaction of the Board of Censors, of commitment to early Fellowship including in particular enrolment in and completion of the following as soon as practicable:
i) UCPEX
ii)  Practical skills weekend, resusc courses, trauma and communications courses
iii) Accreditation requirements and CPD kept up to date
d) Any additional supervision and review (including practice visits) stipulated by the Board of Censors
e) Review at BoC discretion
f) Revocation of the dispensation at Executive Committee discretion

Additional notes

Triage

Section 3.2.1 - Besides the ACEM triage scale,  the College has also approved an 'ABC' urgent care system developed by a College Fellow.

Briefly, the system classifies patients as 'A' - see immediately; 'B' - see next, and 'C' - see in order of arrival.

Clinics may submit other triage systems for consideration.

2.4.7 Guidance on service provider assessment of the competence of medical staff

Section 2.4.7 includes:

1) The service provider shall maintain a system to identify, plan, facilitate and record the training needs of the organization and of individual personnel and

2) Training of personnel, to the extent and as determined necessary through competency assessment, shall be undertaken.

Notes

1) Service providers’ medical directors commonly check the clinical notes of new doctors. Some check all notes of all doctors.

RNZCUC strongly supports this practice.

2) Instilling and assessing competence is primarily the job of medical schools and Colleges. Service providers however have the opportunity to provide additional checks and safeguards, in the interests of safe patient care.

3) Vacancies can arise at short notice and doctors may be difficult to find at times.

An example of an acceptable competency assessment system could include the following:

1) The service provider sends a pre-employment self-assessment questionnaire to new doctors, covering (in the case of a doctor) the medical personnel skills listed.

2) Medical director review of doctors’ clinical notes.

The MD initially checks all notes of new doctors, scaling back over a period of weeks to months as he / she feels comfortable with the quality of care apparent from the notes, and with regard to the doctor’s experience and qualifications (e.g. Fellowship, advanced trainee or basic trainee in UC, EM or GP, DipCEM-holder, general registrant), with particular care in the case of general registrants.

3) The service provider has a documented system that addresses any deficiencies, including medical director review of the questionnaire and discussion of deficiencies with the new doctor.

To take the example of a doctor who has a deficiency in the use of a slit lamp, this could include one or more of the following:

a) Encouraging and assisting the doctor to get training in slit lamp use, e.g. from the doctor’s College

b) The service provider clinic itself providing training in slit lamp use.

c) Rostering the doctor with someone who can use a slit lamp.

d) Being satisfied that the doctor’s usual practice is at least safe, e.g. that he / she refers all cases that need a slit lamp examination to an eye service.

Training to become a Clinic auditor

DAA Group and HANZ offer courses - contact details above.

Facility audit subcommittee

RNZCUC has a facility audit subcommittee, responsible for all aspects of the UCS and its application, including updating particular requirements, revision of the UCS providing RNZCUC Fellows to attend audits as technical experts, and signoff of audits.

Conflict of interest

 In accordance with RNZCUC's conflict of interest policy, audit subcommittee members will declare conflicts of interest in advance and absent themselves from discussion and voting on audits where such conflict exists.

Variation of particular requirements

RNZCUC's facility audit subcommittee will review particular requirements annually, or earlier if needed, for example, because of a change in legislation, or feedback from the auditing bodies or accredited clinics.

The subcommittee will circulate proposed variations of particular requirements to the auditing bodies and interested parties for comment. After one month, the subcommittee will consider all comments, and make changes it deems necessary,

RNZCUC will then publish the change on its website, along with the date from which the change takes effect, and will promptly notify interested parties, including clinics that are accredited or seeking accreditation and clinic auditors.

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