Indicator Group 1

Respecting the needs and rights of patients

The practice demonstrates its commitment to respecting the needs and rights of its practice population

The practice has a written policy that describes how it provides services to patients

• The practice has a written policy regarding service hours, after hours service, types of service, etc. (see Indicator A.2.1 for information about practice services available to patients)
• The practice has clearly posted guidelines and policies about payment for uninsured services

The practice team is familiar with the Canada Health Act, Professional Codes of Ethics, Geneva Declaration and Four Principles of Family Medicine

• The practice understands and implements the elements of the Canada Health Act with respect to Universality and Portability, and ensures that patients are aware of their health insurance coverage. In the Canada Health Act there are specific instructions about Universality (eligibility for OHIP coverage, registration requirements, and other categories of individual coverage) and Portability (minimum waiting periods, coverage during absences in Canada and absences outside Canada )

The practice team is familiar with its contractual requirements (the model of practice of family medicine)

• The practice understands the model of family practice within which it works, and communicates its contractual obligation for the model of practice with the patients. Patients should know whether they have signed a contract or agreement. This would include Fee-For-Service, Health Service Organization, Family Health Team, Primary Care Network, Family Health Network, Family Health Group, Community Health Centre, Community Service Contract, Northern Group Funding Plan (see Glossary)

The patient has the right to have someone else in the room during an examination or consultation

• The patient is informed of the right to have a third party present during an examination or consultation
• When a patient is accompanied to the practice by a third person, it is important to ensure that the patients consents to the presence of that person in an examination or consultation
• The clinic room is furnished to accommodate family members
• Female staff are available to assist with examinations or consultations

The practice demonstrates its dedication to comprehensive care by providing the full basket of services as outlined in the PCCCAR Report

• All members of the practice are familiar with the practice’s dedication to provide the full basket of services as outlined in the PCCCAR Report
• If a practice limits its scope, there are arrangements with other providers and patients can be referred to these providers for these services, e.g. obstetrics, palliative care, hospital care, etc.

The practice complies with guidelines regarding new patients

• Newly registered patients are offered a consultation to ascertain details of their past medical and family histories, social factors including occupation, lifestyle, and measurements of risk factors
• Those findings are recorded in the medical records, and patients with significant medical conditions are reviewed

Further Information for Indicator A.1.1

CMA Code of Ethics 2004

Canada Health Act, Annual Report, 2005-2006

Health Card requirements

MOHLTC website: Questions and answers re OHIP eligibility

Accessibility for Ontarians with Disabilities

Ontario Association of the Deaf

Ontario Human Rights Commission - Policy and Guidelines on Disability and the Duty to Accommodate

Cultural competence: Essential measurement of quality for managed care organizations Annals of Internal Medicine.1996:124;10;919-921

OCP – Labelling Prescriptions for the Visually Challenged

The practice maintains the privacy of patient information in accordance with Bill 31

The practice team has had training to implement Bill 31- the Health Information Protection Act and the Quality of Care Information Protection Act

• All members of the practice team must be familiar with Bill 31 and have taken the necessary steps to ensure that they are abiding by the intent of the law

The practice has a designated contact person responsible for monitoring privacy issues

• Designated contact person
• Process is identified for collection, use and disclosure of personal health information

Patient consent is obtained and recorded for the disclosure of personal information and the release of notes to another party

• The purpose of this criterion is to determine that appropriate consent has been obtained
• Use the sample consent form in the Physician Privacy Toolkit to confirm that consent is recorded in the chart

The practice follows reasonable steps to ensure records are protected

• Records are protected against theft, loss and unauthorized access, copying, modification, use, disclosure and disposal

The practice has established and maintains appropriate information practices and informs its patients about these practices (see OMA toolkit http://www.oma.org/phealth/privacymain.htm)

• The practice posts a policy about how it has it has established and maintains appropriate information practices

The practice has a written statement and/or privacy policy

• There is a written policy made available to all patients on: the information practices; the contact person information; the access, correction, inquiry and complaints procedure
• There are procedures to: Identify when a use or disclosure of personal health information is beyond what is described in the written statement; Notify affected patients about such a use or disclosure make and keep notes of such a use or disclosure in or linked to the affected personal health record

The practice collects and stores patients’ personal information in compliance with the law

• The practice defines scopes of practice and job responsibilities for health care professionals and staff to identify who requires personal health information, what information they require, and for what purpose
• The practice is aware of who collects what personal health information (to limit duplication of collection); about the consent requirements for collection; about restricting the collection of personal health information to the purposes for which you have consent or which are permitted or required by law; and about restricting the collection of personal health informatio
• The practice regularly reviews collection practices to ensure compliance with the Act
• The practice is aware of how records are protected against theft, loss and unauthorized access, copying, modification, use, disclosure, retention and disposal

The practice takes reasonable steps to protect personal health information that is transferred to others

• The practice can describe and show what reasonable steps are taken to protect health information transferred to others

Members of the practice team who have access to medical records have signed a confidentiality agreement

• A practice log that records team members and others signed commitment to confidentiality of patient records
• The log should record: name, date employment commenced, signed agreement

Further Information for Indicator A.1.2

Ontario’s Bill 31 received third reading in the legislature on May 17, and will be proclaimed into law effective November 1, 2004. Bill 31 consists of two schedules - the Health Information Protection Act (HIPA), and the Quality of Care Information Protection Act (QCIPA)

Ontario Medical Association (OMA) provides guidance in the Physician Privacy Toolkit and a Physician Privacy Statement September 2004

CPSO – Medical Records

CPSO Policy on Confidentiality and Access to Patient Information

CMA PrivacyWizard(TM) - Create handouts for your patients, review and enhance office privacy practices and better understand your privacy obligations.

OHA’s Quality of Care Information Protection Act Toolkit

Canadian Consumer Information Gateway

College of Dietitians of Ontario – Privacy Code

College of Nurses of Ontario – Privacy Code

Canadian Pharmacists Association – Pharmacist’s Personal Information Privacy Code

Ontario College of Social Workers and Social Service Workers - Code of Ethics, Principle V: Confidentiality

The practice encourages patient suggestions and feedback into service planning

The practice encourages patient suggestions and feedback on services provided

• Information about encouragement and methods used to invite patient suggestions and feedback on services provided, e.g. suggestion boxes

Suggestions, feedback, follow-up changes and improvements are incorporated in the practice quality improvement process

• The practice documents all suggestions, feedback, follow-up changes and system improvements

Information about use of patient suggestions and feedback is communicated back to the practice team and patients

• How patient feedback is communicated back to the practice team is documented

The practice has carried out a patient satisfaction questionnaire within the last three years

• Results of patient questionnaire undertaken in the last three years are available

Further Information for Indicator A.1.3

Home Care (HAAC) Patient Satisfaction Questionnaire

General Practice Assessment Questionnaire UK

Improving Practice Questionnaire, UK

College of Physicians and Surgeons of Alberta PAR Patient Questionnaires

Practice Enhance Program Patient Questionnaire

Quality in Health Care Article Validation of a questionnaire measuring patient satisfaction with general practitioner services (see Appendix for Patient Satisfaction Questionnaire)

The practice respects patients rights to formally complain

The practice has a documented complaints protocol

• The practice should have a complaints policy and procedure in place
• The practice will declare any ongoing or outstanding formal complaints or litigation and any previous substantive complaints or litigation which were not settled in the practices or professionals favour

There is a designated practice complaints officer

• A complaints officer is assigned

Practice team members are familiar with the practice complaints protocol

• There is a training log regarding the complaints protocol

Complaints and their resolutions are incorporated in the practice quality improvement process

• The practice documents all complaints, their resolution, and any system improvements
• The practice describes how patients provided with appropriate and timely responses to formal complaints

Further Information for Indicator A.1.4

CPSO Complaints Process

College of Physicians and Surgeons of Alberta Physicians and the Complaints Process

Ontario College of Social Workers and Social Service Workers Complaints Process

Ontario College of Pharmacists Complaints Process (for patients)

BMJ Article

The practice honours its commitment to recognising the diversity of its patients

Patients are not discriminated against based on diversity

• No patients are turned away based on diversity
• The quality of care provided does not vary in quality because of personal characteristics such as gender, ethnicity, socio-economic status, etc.

The practice team is trained to provide services that are sensitive to diversity

• The training record demonstrate how the team identifies the range of cultural requirements and manages the relationships

The complaints officer or a designated person is responsible for monitoring and documenting discrimination

• Any complaints, including discrimination charges, and their resolutions are documented

The practice demonstrates evidence of linkages to diverse groups that make up the practice population

• A record of links to diverse groups
• Involvement in the range of activities (e.g. meetings, networks) that link the members of the practice team to different cultural groups (e.g. young, disabled, refugee, blind)
• Record of local resource people, including interpreters and translators, Memoranda of Understanding if they exists, evidence of active relationships, community engagement or relationship building working with other people and organisations to support diversity and patients with specific needs

Patients with disabilities are consulted about any particular needs they may have in order to meet obligations for full information

• The practice ensures that patients with disabilities are consulted about their ability to access services. Discuss what information or help is provided by the practice to those who need additional help (e.g. blind, hearing impaired, mental health problems)

Further Information for Indicator A.1.5

The SOGC has published a policy paper entitled A Guide for Health Professionals Working with Aboriginal Peoples

CMA Office for Public Health - Aboriginal Health

National Aboriginal Health Organization

Information Centre on Aboriginal Health

Special Health Issues for Newcomers to Ontario

A Report of the Canadian Task Force on Mental Health Issues Affecting Immigrants and Refugees 1988 - After the Door has been Opened: Mental Health Issues Affecting Immigrants and Refugees in Canada

Mandatory reporting occurs in accordance with legislation in the family practice

Providers have training in mandatory reporting

• The practice has a record of training in mandatory reporting
• The providers are familiar with the laws regarding mandatory reporting
• Where appropriate, there is a record of any mandatory reporting

Further Information for Indicator A.1.6

CPSO Mandatory Reporting Policy

Ontario College of Social Workers and Social Service Workers Mandatory Reports

Certain communicable diseases, conditions, or adverse reactions to immunizations: The Health Protection and Promotion Act requires that a physician who, while providing professional services to a person who is not a patient in or an outpatient of a hospital, forms the opinion that the person has or may have a reportable disease, or the person is or may be infected with an agent of a communicable disease shall, as soon as possible after forming the opinion, report this fact to the Medical Officer of Health of the health unit in which the professional services are provided. The actual diseases that constitute reportable and notifiable diseases are set out in the Acts regulations.The report must be made as soon as possible to the Medical Officer of Health at the local health unit.