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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 1.4.2

Clinical autonomy for general practitioners

Our practice ensures that all GPs in our practice can exercise autonomy in decisions that affect clinical care.

Explanation

Key points

  • General practitioners are free, within the parameters of evidence based care, to determine:
    • the appropriate clinical care of their patients
    • the specialists and other health professionals to whom they refer
    • the pathology, diagnostic imaging or other investigations they order and the provider they use
    • how and when to schedule follow up appointments with individual patients
    • whether to accept new patients (subject to Criterion 2.1.1 Respectful and culturally appropriate care).
  • Members of the clinical team are consulted about: 
    •  the length and scheduling of appointments 
    •  equipment and supplies the practice uses.

Clinical autonomy within evidence based care

The intent of this criterion is that GPs are free, within the parameters of evidence based care, to make decisions that affect the clinical care they provide, rather than having these decisions imposed upon them.

This criterion is not intended to conflict with Criterion 1.4.1 Consistent evidence based practice and does not preclude adherence to valid guidelines for clinical care of an individual patient based on clinical judgment and best available evidence.

Professional and ethical obligations

All members of the clinical team should comply with the professional and ethical obligations required by law and the relevant professional organisation and practice within the boundaries of their knowledge, skills and competence. While this criterion is about the clinical autonomy of GPs, it is recognised that other members of the clinical team also exercise clinical autonomy relevant to their knowledge, skills and competence and their role within the practice team.

AMA Code of Ethics (2004), Editorially Revised 2006

Section 3 of the AMA Code of Ethics (2004) outlines the importance of professional independence and argues that to provide high quality healthcare, doctors must safeguard clinical independence and professional integrity from increased demands from society, third parties, individual patients and governments. The AMA Code is available at www.ama.com.au/codeofethics.

Corporate entities

Some organisations have developed codes of practice to ensure general practice systems do not restrict the ability of GPs to provide good medical care. It is important that such codes respect the professional independence of GPs in relation to clinical decision making and allow for the clinical team to be consulted on issues such as the length and scheduling of appointments, preferred supplies and equipment and preferred service providers.

The AMA Code of conduct for corporations involved in the provision of management and administrative services in medical centres in Australia (November 2001) can be found at http://ama.com.au/node/3752.

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 1.4.2

Clinical autonomy for general practitioners

Our practice ensures that all GPs in our practice can exercise autonomy in decisions that affect clinical care.

In a nutshell

Your doctors are free to make decisions about clinical care, based on evidence. See Criterion 1.4.2 Clinical autonomy for general practitioners of the Standards for general practices for the kinds of decisions doctors are free to make within the boundaries of evidence-based practice.

All members of your healthcare team should also be able to make clinical judgements within the limits of their training, scope of practice and competency, and within the capacity of the service in which they are working. Clinical decisions need to be undertaken within a framework of evidence-based care, ethical obligations and culturally safe practice.

Key team members

  • All clinical staff

Key organisational functions

  • Human resources policy and procedures (qualifications and certifications)
  • Staff training and induction
  • Credentialing
  • Defining scope of practice
  • Clinical governance
  • Clinical risk-management systems

Indicators and what they mean

There are no indicators for this criterion. Clinical autonomy is important to protect the safety and quality of healthcare, and could be considered in relation to Criterion 1.4.1 Consistent evidence-based practice. Together, these criteria mean that GPs should be free to make decisions about patient care as long as they make ethical decisions, use good clinical judgement and draw on the best available evidence for each patient. This is also consistent with the basic principles of Aboriginal community controlled health services, such as integrated, holistic care and self-determination.

Some examples of evidence for this criterion include:

  • maintaining a policy ensuring clinical autonomy for general practitioners and other health professionals in the context of delivering evidence-based care, and according to their scope of practice, knowledge and skills, and consistent with their role in the team
  • ensuring GPs have autonomy with respect to:
    • overall clinical care of their patients
    • 
referrals to specialists and other health professionals
    • 
ordering of pathology, imaging or other investigations
    • scheduling of follow-up appointments
    • acceptance of new patients
    • 
duration and scheduling of appointments (in conjunction with other members of the healthcare team)
    • 
supplies and equipment used by the health service (in conjunction with other members of the healthcare team)
  • where a GP is not present all of the time, ensuring arrangements for the above are delegated to the practice nurse with clear and agreed guidelines in place
  • ensuring all healthcare staff use current clinical guidelines as relevant
  • providing evidence that health professionals adhere to their own professional obligations and codes of conduct or ethics
  • ensuring that when asked, clinical staff members can demonstrate how they determine when to recall patients for follow-up care and the length of appointment required
  • ensuring that when asked, clinical staff members can explain how they can make decisions about who they refer to, length and scheduling of appointments and when they recall patients
  • ensuring that a patient health file review or audit demonstrates a variety of specialist referrals by different doctors.

Case study

Below is a description of the ways in which an Aboriginal community controlled health service can ensure that its GPs (and other health professionals) are free to make decisions about clinical care, based on evidence. 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 health service has well-developed systems and processes in place to enable GPs and other members of the healthcare team to exercise discretion in making independent clinical judgements for their patients within the context of evidence-based care, and as appropriate to their role in the team. These systems and processes include:

  • 
a system for ensuring that all healthcare staff qualifications have been checked and are current (credentialing)
  • 
a system for ensuring that all healthcare staff have the skills and experience to do the job they have been given (defining scope of practice)
  • 
the consistent use of recommendations from agreed clinical guidelines as appropriate for the service’s patient population
  • 
awareness and understanding of relevant codes of professional conduct
  • 
the development of a service-specific code of practice that incorporates critical elements of all relevant external codes of conduct. This is the service’s key resource for identifying and communicating expectations regarding the healthcare team’s professional and ethical obligations for delivering safe, quality healthcare to the community.

There is a policy outlining the kinds of clinical decisions that can be made by different members of the healthcare team, and which decisions need to be referred to the senior clinician. This policy also emphasises that the board has decision-making powers in relation to a range of areas, but it must not interfere with the ability of the GPs and other health professionals to make the most appropriate clinical decisions for their patients.

Some decisions are made after discussion with the whole healthcare team. These decisions include:

  • duration and scheduling of appointments
  • 
supplies and equipment used by the health service.

There are regular clinical staff team meetings to share and discuss matters affecting autonomous decision-making as appropriate to each team member’s role. For the remote health centre, these meetings are held by teleconference.

In addition to oversight of longer-term care such as care plans, regular clinical supervision is undertaken with each member of the healthcare team. This is where GPs and nurses or health workers discuss clinical and other issues relating to their current patients and programs. For the remote health centre, these supervision sessions are held by teleconference.

All of the above discussions include consideration of how and when traditional medicines or other accepted forms of treatment can be administered alongside those covered by clinical guidelines.

GPs understand the importance of working within a multidisciplinary team, and they all participate fully in this process. They ensure that processes are in place for appropriate decision-making by other members of the healthcare team when they are not present, and that issues or concerns are followed up as soon as possible. When it is important that other team members understand their exercise of clinical autonomy, the GPs will explain their decision in a team meeting.

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