Personal tools
You are here: Home → Quality Indicators → Quality Indicators ONLINE
Navigation
 

Section A | Section B | Section C | Section D | Section E

Section B

Physical factors affecting the practice

|

Indicator Group 5

Practice’s physical facilities and safety

  • Indicator B.5.1: The practice waiting area is comfortable and sufficient to accommodate patients and their family members who wait for services
  • Indicator B.5.2: Examination areas for assessment and management ensure patient comfort, safety, and privacy
  • Indicator B.5.3: The practice has appropriate disinfection and sterilisation facilities available for infection control and follows appropriate infection control procedures
  • Indicator B.5.4: The practice safely disposes of sharps and biomedical waste
  • Indicator B.5.5: The practice has appropriate vaccine storage and maintains the Cold Chain in line with provincial guidelines
  • Indicator B.5.6: The practice ensures that only authorised people have access to prescription medications
  • Indicator B.5.7: The practice demonstrates a commitment to the Workplace Safety and Insurance Act 1997
  • Indicator B.5.8: Fire Risk is minimised by demonstrating a commitment to relevant legislation and Codes of Practice relating to fire safety, disasters or other emergencies
  • Indicator B.5.9: The practice demonstrates a commitment to an eco-efficient or Green Office
  • Indicator B.5.10: Office procedures are only performed after suitable training and in accordance with accepted guidelines
  • Indicator B.6.1: Medical equipment and resources are appropriate, available and maintained

Indicator B.5.1

The practice waiting area is comfortable and sufficient to accommodate patients and their family members who wait for services

Criteria B.5.1.1

The waiting area has adequate space, seating, heating, lighting and ventilation

  • The practice waiting room meets international standards – The NZMA Charter of General Practice states that a patient may expect services that are provided from a well designed, equipped and maintained premises. The recommendation is 4 seats per FTE doctor. The temperature, all year round should be conducive to comfort in the waiting room.

Criteria B.5.1.2 (Mandatory)

The waiting area meets the needs of children

  • The waiting area provides a children’s space
  • Toys should be clean and safe
  • It is important that children are not at risk – e.g. electric sockets without safety plugs, multi boxes for electricity within easy reach of children

Criteria B.5.1.3 (Mandatory)

The waiting area has current materials

  • Magazines are at a suitable height for disabled people
  • Reading materials and posters are current
  • Patients can access or be referred to computer terminals, videos, and audios

Indicator B.5.2

Examination areas for assessment and management ensure patient comfort, safety, and privacy

Criteria B.5.2.1

Examination couches are safe, accessible and visually private

  • Examination couches are a safe height or have portable steps available
  • The examination area is private

Criteria B.5.2.2 (Mandatory)

Each examination room is maintained at a comfortable temperature and has adequate lighting, including task lighting

  • The examination room is not too hot or cold and a comfortable temperature for patients that need to undress
  • The room should be light enough to observe the patient and task lighting should be available for examinations

Criteria B.5.2.3 (Mandatory)

ach examination room is free from excessive, external noise

  • The examination room is not affected by noise that interferes with the patient/doctor visit (traffic, radio, practice team conversations, etc.)

Criteria B.5.2.4 (Mandatory)

Patients are assured of auditory privacy during visits

  • The content of patient visits cannot be heard by people in the waiting room or other areas of the practice

Further Information for Indicator B.5.2

Indicator B.5.3

The practice has appropriate disinfection and sterilisation facilities available for infection control and follows appropriate infection control procedures

Criteria B.5.3.1 (Mandatory)

There is a policy and procedure for infection control

  • The practice has a policy and procedure for infection control
  • The practice has a policy for frequent hand washing
  • There is regular monitoring and review of infection control procedures
  • An audit trail is present
  • There is a person designated as the officer responsible for infection control and sterilisation procedures
  • Infection control is implemented according to recent guidelines (SARS, lessons learned re coordination, masks, isolation of respiratory cases, etc.)

Criteria B.5.3.2

There are facilities to ensure hand hygiene in all patient contact areas

  • There should be facilities for hand washing in all clinical management areas
  • Low and medium risk hand washing facilities include liquid soap and water, disposable paper towels or single use towels. Reusable cloth towels, if used at all, should not be used in treatment areas or toilets and changed frequently.
  • In high risk areas, sterile washing procedures with liquid soap and water are practiced
  • Where a hand basin is not available within the practice or for ‘off site’ visits, waterless hand scrubs or alcohol preparations are available for use

Criteria B.5.3.3 (Mandatory)

There are documented policies and procedures for cleaning, disinfection and sterilisation of equipment and facilities

  • There are policies and procedures for cleaning, disinfecting and sterilising equipment (routine cleaning of facilities, blood and body substance spills, instrument cleaning, methods of sterilisation, ‘off site’ instruments, low risk and single-use instruments/equipment and linen, disinfection, waste management and sterilisation procedures)
  • The practice describes the process of audit, review and action

Criteria B.5.3.4 (Mandatory)

The practice correctly uses appropriate chemical solutions, a steam steriliser or autoclave for sterilisation of non-disposable instruments and materials

  • The practice demonstrates the following: steriliser or autoclave for non disposable instruments and materials and type of sterilisation equipment used in the practice
  • The practice monitors, validates, maintains, and calibrates equipment
  • The practice describes how sterilisation of non disposal instruments occurs
  • If Gluteraldehyde is used, the WHIMiS information or MSDS (Material Safety Data Sheet) is available, and the area is well ventilated

Criteria B.5.3.5

Sterile or surgically clean instruments are stored in a manner that ensures maintenance of their sterility or surgical cleanliness

  • The practice stores sterile or surgically clean instruments, protected from dust and in a dry space, e.g. closed cupboard, sealed containers
  • There is a rotation system
  • Items that are required to be sterile at point of use are packaged

Criteria B..3.6 (Mandatory)

Appropriate members of the practice team are trained in cleaning disinfection and sterilisation of equipment

  • There is a practice training record
  • There are identified team members who are trained in disinfection and sterilisation

Indicator B.5.4

The practice safely disposes of sharps and biomedical waste

Criteria B.5.4.1

Biomedical waste (includes anatomical waste, blood, non-anatomical waste and other waste) is safely disposed of in accordance with local regulations

  • The practice has a plan for disposal of biomedical waste. It must identify and meet local council regulations.

Criteria B.5.4.2

The practice has appropriate leak proof containers/bags for safe disposal of biomedical waste

  • All waste must be collected and transported by a waste management company that is licensed to transport biomedical waste. This waste must be packaged and colour-coded according to agreement with your biomedical waste contractor.

Criteria B.5.4.3

Biomedical waste is stored and collected separately from other waste where required

  • Biomedical waste should be stored safely (closed cupboard or a sealed plastic container)

Criteria B.5.4.4

The practice has appropriate puncture-resistant sharps containers displaying a biohazard symbol, placed in all areas where sharps are used

  • Containers are in clinical areas where sharps are used
  • All sharps containers display a biohazard symbol

Criteria B.5.4.5 (Mandatory)

Sharps containers are kept out of reach of children

  • Children cannot reach sharps containers in the practice

Criteria B.5.4.6

The practice has a protocol/policy and procedures in case of an accidental needle-stab or other type of exposure

  • A protocol/policy and procedure is in place
  • There is documented evidence of application of protocol/policy and procedure in case of accidental needle-stab or other type of exposure

Indicator B.5.5

The practice has appropriate vaccine storage and maintains the Cold Chain in line with provincial guidelines

Criteria B.5.5.1

There is a designated vaccine refrigerator for the storage of vaccines

  • The practice has a designated vaccine fridge that does not contain food, drinks or specimens
  • The practice ensures all members of the team know about the rules for the vaccine fridge

Criteria B.5.5.2

A daily log is kept showing effective monitoring of the temperature within the refrigerator

  • The vaccine fridge log records the date, time, temperature and any action taken to correct abnormal readings daily
  • There is a procedure and person responsible for monitoring the daily log including electronic thermometer batteries and temperatures

Criteria B.5.5.3

A maximum/minimum thermometer is kept in the fridge at all times

  • There is a minimum/maximum thermometer, or electronic probe in the fridge

Criteria B.5.5.4 (Mandatory)

Vaccine expiry dates are current

  • The practice demonstrates that all vaccine dates in the practice are current (e.g. random sample of stocks, current only)
  • There is a system used to keep vaccines current (stock rotation, ordering, storage in the fridge)

Criteria B.5.5.5

National/provincial guidelines are used to preserve the Cold Chain during storage, offsite immunisation and transport

  • The practice describes the procedure used to preserve the Cold Chain during offsite immunisation and transporting vaccines

Indicator B.5.6

The practice ensures that only authorised people have access to prescription medications

Criteria B.5.6.1

Medications and pharmaceutical products are only accessible to authorised people

  • The practice takes precautions to ensure that medications and other pharmaceutical drugs and samples, such as analgesics, narcotics, psychotropic drugs or other potentially dangerous drugs, are not kept in the examining rooms
  • The practice has a method for communicating with the pharmacy when the practice uses samples for dispensing
  • The practice has a policy for ensuring security for medications and pharmaceutical drugs
  • The practice demonstrates that medications and pharmaceutical products are stored ‘out of sight’ not in open containers on bench/trolley tops or in high-traffic areas where they could be readily accessed by unauthorised people or children
  • Syringes and needles are stored safely so that they are not accessible to patients
  • The practice demonstrates that restricted drugs are stored in locked cupboards and are not able to be seen or accessible to patients, especially children

Criteria B.5.6.2

The practice has a method for communicating with the pharmacy when the practice uses samples for dispensing

  • The practice describes its method of communicating sample use with the local pharmacy

Criteria B.5.6.3

The practice safely disposes of outdated drugs

  • The practice describes its method of safely disposing outdated drugs

Criteria B.5.6.4

A log is maintained for restricted medications as required by regulations

  • There is a practice log that follows Federal Narcotics Control Agency specifications that when narcotics are given to a patient they be recorded both in the patient’s chart and in a separate log kept with the narcotics container. This documents the amount dispensed to whom and when, and makes internal abuse more difficult, especially in large offices. It is recommended that the narcotics be kept in a locked cupboard.
  • There is a regular narcotics count to verify inventory

Criteria B.5.6.5

Doctor’s bags are not accessible to unauthorised persons

  • Doctor’s bags should be locked in a cupboard or stored in a locked compartment in a vehicle or other clearly non-accessible place when in the office/car/house
  • There should be a locking device on the bag
  • There is a system used by the practice to ensure that doctor’s bags are not accessible to unauthorised people

Criteria B.5.6.6

Prescription pads are not accessible to unauthorised persons

  • There are no prescription pads left in the examining rooms where patients can access them

Indicator B.5.7

The practice demonstrates a commitment to the Workplace Safety and Insurance Act 1997

Criteria B.5.7.1

The practice team complies with Workplace Safety and Insurance Board (WSIB) policies and identifies and manages WSIB procedures

  • The practice has a WSIB Manual and a policy that describes how the practice meets health and safety legislation
  • The practice policy should include how the practice addresses natural emergencies, earthquakes, man-made emergencies such as injury, armed robbery, power failure, fire, hazard identification, notifying serious harm, principal and contractors, accident recording, training of employees
  • The team is aware of WSIB and how it works in the practice setting

Criteria B.5.7.2

WSIB accidents and incidents are recorded, investigated and followed up

  • There is a WSIB accident and incident register
  • A register of events, actions and training in WSIB issues is a legal requirement. This is to cover employers and employees.
  • Completed incident forms must be retained on file in the practice (Form 7)
  • The practice has a WSIB officer responsible for facilitating the recording of an event and taking action

Criteria B.5.7.3

The practice reviews WSIB procedures annually, making amendments, additions or alterations as necessary

  • There is a log of WSIB meetings
  • Minutes are taken at the meetings
  • The practice describes how the team are made aware of additions or alterations to WSIB procedures
  • The practice describes the process used to deal with WSIB issues and actions and how changes made as a result
  • The practice describes the communication pathway that shows all team members are involved

Criteria B.5.7.4

The practice can demonstrate WSIB in action

  • The practice describes how it implements ergonomic workstations, computer workstations, smoke free workplaces, biomedically safe workplaces, appropriate immunisation for the practice team
  • The practice describes how furniture in the practice permits the team to work comfortably and efficiently for the range of tasks that they carry out
  • There is a record of team members immunisations

Indicator B.5.8

Fire Risk is minimised by demonstrating a commitment to relevant legislation and Codes of Practice relating to fire safety, disasters or other emergencies

Criteria B.5.8.1

The practice has an identified fire warden

  • There is an appointed fire warden and deputy for the practice

Criteria B.5.8.2 (Mandatory)

There is an evacuation plan approved by the Ontario Fire Marshall with which all team members are familiar

  • Practice evacuation plan has been approved by the Ontario Fire Marshall

Criteria B.5.8.3

The practice has a Fire and Emergency Code of Practice

  • The practice should have a Fire and Emergency Code of Practice

Criteria B.5.8.4

The practice team is trained to evacuate the practice by participation in regular fire drills

  • Fire drill record
  • Fire drills must be held regularly

Criteria B.5.8.5

The practice undertakes a six-monthly audit of the evacuation procedures in line with the regulations

  • Audit
  • That there is a record of 6 monthly audits that have been undertaken by the practice. It should be in line with the practice Fire and Emergency Code of Practice.

Criteria B.5.8.6

The practice undertakes a regular audit of its fire protection equipment

  • There is a log of the regular audit of fire protection equipment (smoke alarms, CO alarms, fire extinguishers)

Indicator B.5.9

The practice demonstrates a commitment to an eco-efficient or Green Office

Criteria B.5.9.1

There is a plan describing eco-efficient policies and practices

  • The practice has reviewed its policies and practices with a view to greening wherever possible, and minimising the adverse environmental impact of the practice

Criteria B.5.9.2

There are sustainable purchasing and procurement policies

  • When orders are made, green products are favoured, wherever possible, such as in cleaning and paper products.
  • Staff have a knowledge of green products available

Criteria B.5.9.3

The practice is energy efficient

  • The practice has reviewed its energy use, and reduced wherever possible

Criteria B.5.9.4

Recycling of paper and other products, as available in the community, is practised

  • Paper recycling bins are present in all work areas where paper is generated
  • Other recycling that is available in the community is practised e.g., blue, grey and green boxes

Criteria B.5.9.5

There are no mercury thermometers or sphygmomanometers

  • They have been recycled with toxic waste
  • They have been replaced with digital thermometers and aneroid sphygmomanometers

Criteria B.5.9.6

The practice is accessible via public transport

  • The practice promotes active commuting, or the use of public transit whenever possible

Indicator B.5.10

Office procedures are only performed after suitable training and in accordance with accepted guidelines

Criteria B.5.10.1

There is a list of approved procedures performed in the practice and who may perform them

  • List of approved procedures

Criteria B.5.10.2

Practice staff is trained to perform the listed procedures

  • Provide training log

Criteria B.5.10.3

The practice has appropriate equipment and facilities for the procedures that are performed

  • The practice describes how it regularly reviews its equipment and facilities for the procedures that are performed

Criteria B.5.10.4

Patients who require procedures are routinely asked for consent

  • Patients are offered information and choice about all procedures to be performed
  • The information given and the patient’s consent to any such procedure are recorded

Criteria B.5.10.5

The practice keeps a record or log of their minor procedures

  • Date of procedure
  • Patient name
  • Procedure performed
  • Whether a specimen was sent for pathology
  • Date result received
  • Date patient was informed of result

Further Information for Indicator B.5.10

Indicator B.6.1

Medical equipment and resources are appropriate, available and maintained

Criteria B.6.1.1

Medical equipment and resources are available and maintained

  • Practice audit of medical equipment
  • Medical equipment is recorded as being checked, available and maintained

Criteria B.6.1.2

All essential basic equipment is available

  • Practice audit of medical equipment
  • The following equipment should be available and in good working order within the practice: Sphygmomanometer – calibrated within the last year, Stethoscope, Otoscope/Ophthalmoscope, Tendon hammer, Peak flow meter (both adult and paediatric), Tape measure, Weighing scales, Height measure, Snellen chart, Tuning fork, Urine testing sticks – check expiry dates, Vaginal speculae, Doppler, Fridge min/max thermometer

Criteria B.6.1.3

All essential emergency equipment is available and in good working order

  • The practice reports how it regularly audits medical equipment
  • The practice reports how all essential emergency equipment listed is available and in good working order

Criteria B.6.1.4

All essential emergency drugs are available in stock and/or in the doctor’s bag

  • The practice reports regular audits of essential emergency drugs
  • The practice demonstrates that all essential emergency drugs are available within the practice and/or doctor’s bags

Criteria B.6.1.5 (Mandatory)

There is a system for drug maintenance and checking expiry dates of drugs (including samples from drug companies)

  • The practice demonstrates the process for ensuring drugs in stock are current
  • The practice reports that there is a system to maintain the contents of the doctor’s bags

|

This site conforms to the following standards: