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Standards for general practices (4th edition)

including Interpretive guide for Aboriginal and Torres Strait Islander health services

Standard 1.4 Diagnosis and management of health problems

In consultation with the patient, our practice provides care that is relevant and in broad agreement with best available evidence.

Criterion 1.4.1

Consistent evidence based practice

Our practice has a consistent approach for the diagnosis and management of conditions affecting patients in accordance with best available evidence.

Indicators

► A. Our clinical team uses current clinical guidelines relevant to general practice to assist in the diagnosis and management of our patients.

► B. Our clinical team can describe how we ensure consistency of diagnosis and management of our patients.

► C. Our clinical team can demonstrate how we communicate about clinical issues and support systems within our practice.

► D. Our clinical team can explain how we access and use specific clinical guidelines for patients who identify as Aboriginal or Torres Strait Islander.

Explanation

Key points

  • Consistency and quality of care can be assisted by the use of clinical guidelines
  • Consistency and quality of care can be assisted by communication between team members.

Best available evidence

Contemporary practice is based on best available evidence in the context of current Australian general practice. This criterion recognises that, in the absence of well conducted clinical trials or other higher order evidence, the opinion of consensus panels of peers is an accepted level of evidence and may be the best available evidence at that time.

Clinical practice guidelines provide important recommendations for clinical care and should be accessible at the point of care. Practices need to check that clinical practice guidelines are current.

Resources that support evidence based practice

General practitioners and clinical staff find it valuable, both for the treatment of patients and their own professional development, to have access to resources about a range of clinical issues. These may include paper based resources (eg. text books and peer reviewed journals) and electronic resources (eg. access via the internet or CD-ROM).

This criterion does not necessarily require access to the most recent editions of texts, materials or publications, nor does it require those resources to be in electronic format. However, resources need to contain information that is consistent with current practice and not recommended management that is no longer applicable.

Recommendations on clinical care are available from sources such as:

Patient identification

It is important to ensure the correct patient gets the correct procedure. A useful resource for GPs, especially those undertaking procedural work and minor surgery, is the Ensuring Correct Patient, Correct Site, Correct Procedure Protocol from the Australian Commission on Safety and Quality in Health Care, or an equivalent protocol that incorporates these five steps. This is a nationally agreed protocol for public hospitals; compliance with the protocol reduces the risk of error for GPs who perform procedures in public or private hospitals, or in their own practices.

Health inequalities

The Australian Institute of Health and Welfare (AIHW) report Australia’s Health 2010 (available at www.aihw.gov.au/publications/aus/ah10/ah10.pdf ) outlines some significant differences in key indicators of general health and wellbeing.

This information is important because it highlights the need for primary healthcare interventions tailored to specific groups within the Australian community.

The AIHW report explains that while the health of the Australian population improved markedly during the 20th century, health gains have not been equally shared across all sections of the population and today Australia is characterised by large morbidity and mortality inequalities between population subgroups. This includes homeless youth, children of single parent families, people with developmental disabilities, Aboriginal and Torres Strait Islander people, refugees and those from culturally and linguistically diverse populations.

For example, the AIHW identifies that Aboriginal and Torres Strait Islander people have a life expectancy that is significantly less than that of other Australian men and women.

The RACGP encourages and supports practices to accommodate the specific health needs of individuals who experience disadvantage. In particular, the RACGP has worked with the National Aboriginal Community Controlled Health Organisation to produce guidelines for the care of Aboriginal or Torres Strait Islander people.

A consistent approach is vital

Consistency in the approach to diagnosis and management of care across the various people who are involved in the clinical care of an individual patient (ie. the people involved do not work at ‘cross purposes’) is an important aspect of continuity of care. Patients value consistency in the quality of treatment they receive from a practice and expect that treatment and advice given by different GPs within the practice will not be in conflict. If the practice employs nurses or allied health professionals, patients expect that advice provided by these professionals will be consistent with the diagnosis and management approach of the treating GP. Providing consistency in diagnosis and management of health issues across a team of GPs, or a multidisciplinary general practice team, assists in ensuring that the practice provides continuity of care for patients (see Criterion 1.5.1 Continuity of comprehensive care and the therapeutic relationship).

This consistency is just as important in small or solo practices where the receptionist needs to have an approach (eg. to providing information) that is consistent with that of the GP, as it is in large practices with numerous clinical staff.

In addition to ensuring that clinical care is consistent with the best available evidence, it is important that there is continuity in the clinical care provided to the patient.

Management continuity involves having a consistent and coherent approach to the management of a health condition that is responsive to the patient’s changing needs and assists to ensure that the people providing services are not working at ‘cross purposes’. An example is ensuring that general practice nurses and GPs treating a patient with diabetes provide consistent advice to the patient about their treatment and care. Management continuity is particularly important for people with chronic or complex diseases. For example, it may involve having a plan for the patient’s care that is shared by the people providing the care.

Communication within the clinical team

Good communication between members of the clinical team is important for ensuring a consistent approach to clinical care. Face-to-face meetings of the clinical team are preferable but communication books and electronic notice boards can be useful to consider clinical issues.

Standard 1.4 Diagnosis and management of health problems

In consultation with the patient, our practice provides care that is relevant and in broad agreement with best available evidence.

Criterion 1.4.1

Consistent evidence-based practice

Our practice has a consistent approach for the diagnosis and management of conditions affecting patients in accordance with best available evidence.

In a nutshell

Your health service provides its staff with ready access to key clinical guidelines in order to enable a consistent clinical approach to the diagnosis and management of health conditions. The clinical guidelines need to be relevant to the community, up to date and based on the best available evidence. Good communication between your team members can support a consistent approach to diagnosis and management.

Key team members

  • Health service manager
  • Clinical staff

Key organisational functions

  • Clinical health management practices and protocols
  • Staff internal and professional communication policies
  • Clinical resources
  • Culturally safe and competent clinical practice
  • Quality and safe clinical practice

Indicators and what they mean

Table 1.8 explains each of the indicators for this criterion. Refer to Criterion 1.4.1 Consistent evidence based practice of the Standards for general practices for explanations of some of the concepts referred to in this criterion and a list of resources that support evidence-based practice.

Table 1.8 Criterion 1.4.1 Consistent evidence-based practice
IndicatorsWhat this means and handy hints

▶ A. Our clinical team uses current clinical guidelines relevant to general practice to assist in the diagnosis and management of our patients.

Your health service uses clinical guidelines for health conditions relevant to general practice, your community and your patient demographics – for example, Aboriginal and Torres Strait Islander or homeless youth. Where your health service operates in a culturally diverse context, you will need to ensure that the set of clinical guidelines you use accommodates the issues relevant to that diverse population’s health.

The clinical guidelines need to be current and based on the best available evidence. See Criterion 1.4.1 Consistent evidence based practice for a list of resources that support evidence-based practice.

It is important your clinicians are advised when particular clinical guidelines are updated by the independent body that developed them, and that the updated guidelines are easily accessible for clinical staff during their working day.

▶ B. Our clinical team can describe how we ensure consistency of diagnosis and management of our patients.

Your clinical staff understand the importance of consistency in diagnosis and healthcare management, and they work as a team to manage individual patients, where needed. Clinical staff can describe the systems in place to ensure management continuity. These systems can include:

  • the use of clinical guidelines, and culturally safe practices and resources
  • regular team or clinical staff meetings
  • other means of staff communication about health management, such as books and whiteboards.

Management consistency is especially important for patients with chronic diseases as it reduces confusion and misunderstanding in the management of their health conditions. Also, patients value consistency and quality in their healthcare. A consistent management approach enhances patient trust and this in turn encourages patients to work in partnership with their doctor and clinical staff to gain good health outcomes.

▶ C. Our clinical team can demonstrate how we communicate about clinical issues and support systems within our practice.

Your clinical staff need to have an effective way of communicating with each other about clinical healthcare and management, both generally and for each individual patient. This is demonstrated when your health service encourages staff to use systems and processes to discuss issues related to patient diagnosis and management. It could include measures to ensure that:

  • staff have easy access to paper-based and/or electronic resources (including clinical guidelines) that support consistent evidence-based practice
  • clinical staff are aware of and engage in culturally safe practices
  • there are regular face-to-face clinical staff meetings to discuss management and patient communication issues.

▶ D. Our clinical team can explain how we access and use specific clinical guidelines for patients who identify as Aboriginal or Torres Strait Islander.

Because of the particular health disadvantages experienced by Aboriginal and/or Torres Strait Islander peoples, your health service needs to use specific guidelines – for example, guidelines for the screening, prevention and management of major chronic conditions in the community. Clinical staff need to have easy access to these clinical guidelines.

With the development of decision-support tools clinical staff could use systems that make relevant sections and recommendations of these guidelines readily available for each consultation.

Case study

Below is a description of the ways in which an Aboriginal community controlled health service can ensure consistent, evidence-based care for its patients and community. Not all of these good practices are required by the Standards, but they illustrate the many practical and creative things that ACCHSs can do to ensure they deliver services of high safety and quality to their community.

The service’s staff have access to, and use, evidence-based resources and clinical guidelines in either electronic or printed format. These resources and guidelines include:

  • the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people (2nd edition)
  • the Central Australian Rural Practitioners Association Standard treatment manual (5th edition)
  • the Minymaku kutju tjukurpa women’s business manual (4th edition)
  • the Clinical procedures manual for remote and rural practice (2nd edition)
  • the Medicines book for Aboriginal health workers (2nd edition)
  • the Australian medicines handbook
  • the Guidelines for preventive activities in general practice (6th edition) (the RACGP red book)
  • Putting prevention into practice; guidelines for the implementation of prevention in the general practice setting (the RACGP green book)
  • Aboriginal primary healthcare: an evidence-based approach (2nd edition).

The health service regularly updates its electronic health record software to include the most recent medicines information, clinical guidelines, decision-support tools and health-assessment templates. For commonly used guidelines, it develops clinical protocols to help staff put them into practice.

When the service inducts new staff it gives them advice on where they will find resources and guidelines, and any other available communication methods – for example, clinical staff meetings. All staff are promptly informed about updates to clinical information and resources.

The part-time staff have established a communications book in which they leave messages for each other about patients who have had changes in treatment or who need to be followed up. They also use the communication book if there has been a major change in the service’s protocol or guidelines.

The service holds, and documents, regular clinical team meetings that include discussions on available new treatments as well as current processes that may improve how the service provides care to its patients. These meetings are also an opportunity for staff members to share their knowledge with others. If multiple staff members see the same patient, they talk together when necessary, to ensure they are on the same track.

‘Ensuring correct patient, correct site, correct procedure’ charts are located in all consulting and treatment rooms in the service, to remind staff to check they have the right patient before starting the consultation, doing any treatment or using a medical record.

The service has an outreach clinic located in a remote area and each Friday the remote area nurse holds ward rounds via telephone with the doctor who visits the clinic each month. They discuss any problems the nurse may have had during the week and review treatment options for patients.

Showing how you meet Criterion 1.4.1

Below are some of the ways in which an Aboriginal community controlled health service might choose to demonstrate how it meets the requirements of this criterion for accreditation against the Standards. Please use the following as examples only, because your service may choose other, better-suited, forms of evidence to show how it meets the criterion.

  • Make current clinical guidelines available in electronic and/or hard copy for staff to access.
  • Ensure and show that electronic health record software is regularly updated to the most recent version.
  • Keep records of clinical team meetings about the use of clinical guidelines.
  • Have regular clinical team meetings that are documented.
  • Ensure that when asked, staff members can show how they find and use resources and guidelines.
  • Keep a communication book, internal mail and/or email system to pass on important messages to other staff members.
  • Keep well-documented health records, treatment and care plans in patient health records.
  • Ensure that when asked, staff members can explain how they discuss the care of patients with other staff members, while ensuring patient confidentiality.
  • Ensure that when asked, staff members can show what evidence-based resources and guidelines they use regularly.
  • Ensure that when asked, staff members can explain what steps they take to help patients feel culturally secure in the service.
  • Ensure that when asked, clinical staff members can explain what specific clinical guidelines the service uses for patients who identify as Aboriginal or Torres Strait Islander, how they access them and how they use them to support evidence-based practice, including in the prevention and management of chronic diseases.
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