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Standards for general practices (4th edition)

including Interpretive guide for Aboriginal and Torres Strait Islander health services

Standard 2.1 Collaborating with patients

Our practice respects the rights and needs of patients.

Criterion 2.1.1

Respectful and culturally appropriate care

Our practice provides respectful and culturally appropriate care for patients.

Indicators

► A. Our practice does not discriminate against or disadvantage patients in any aspect of access, examination or treatment.

► B. Our clinical team can demonstrate how we provide care for patients who refuse a specific treatment, advice or procedure.

► C. Our clinical team can describe what they do when a patient informs them that they intend to seek a further clinical opinion.

► D. Our practice team can describe what they do to transfer care, in a timely manner, to another GP in our practice or to another practice when a patient wants to leave the GP’s care.

► E. Our practice team can describe arrangements for informing a patient and transferring the care of a patient whom a GP within our practice no longer wishes to treat.

► F. Our practice team can describe how our practice provides privacy for patients and others in distress.

G. Our practice team can identify important/significant cultural groups within our practice and outline the strategies we have in place to meet their needs.

Explanation

Key points

  • Patients have the right to respectful care, which promotes their dignity, privacy and safety
  • The Federal Disability Discrimination Act (1992), as well as various state and territory Disability Services Acts and Equal Opportunity Acts, prohibit the discriminatory treatment of people based on their personal characteristics
  • Where patients indicate they wish to seek a second opinion, this should be documented in the patient’s health record
  • Where patients refuse advice, procedures or treatments, this should be recorded in the patient’s health record
  • Practices need a strategy which details the steps to be taken when GPs or the practice team no longer consider it appropriate to treat a particular patient, including how to assist the patient with ongoing care
  • Practices need a plan to respectfully manage patients in distress
  • Indicators C, D and E cross reference to Criterion 1.5.2 Clinical handover
  • Indicator G cross references to Criterion 1.7.1 Patient health records.

MBA Code of Conduct – a valuable resource

The Medical Board of Australia (MBA) has adopted a code of conduct that defines clear, nationally consistent standards of medical practice. The code is entitled Good Medical Practice: A Code of Conduct for Doctors in Australia. Section 3 of the Code of Conduct is on ‘working with patients’ and it contains helpful information and advice on the doctor-patient partnership, effective communication, culturally safe and sensitive practice, and informed consent. The MBA Code of Conduct is available at www.medicalboard.gov.au/Codes-and-Guidelines.aspx.

Patients’ rights

This criterion requires that both GPs and other members of the practice team deal with all patients in a respectful, polite and professional manner. Where a carer plays an ongoing role in the day-to-day care of a patient, it is generally advisable to include the carer in the doctor-patient relationship with the permission of the patient (if the patient is competent to give such consent).

Practices need to be aware that the Federal Disability Discrimination Act (1992), as well as the various state and territory Disability Services Acts and Equal Opportunity Acts, prohibit the discriminatory treatment of people based on their personal characteristics (such as gender or religion).

Further information is provided by the Australian Human Rights Commission at www.hreoc.gov.au. This website has guides to the relevant legislation and links to state and territory agencies with similar responsibilities.

The Australian Commission on Safety and Quality in Health Care has produced an Australian Charter of Healthcare Rights available in several languages at www.health.gov.au/internet/safety/publishing.nsf/content/priorityprogram-01.

Mutual respect for successful collaboration

Patients have the right to respectful care that promotes their dignity, privacy and safety. Patients have a corresponding responsibility to give respect and consideration to their GPs and other practice staff. All members of the practice team need to have appropriate interpersonal skills to work with patients and others in the practice. Much of the success of a practice depends on the positive, friendly, attentive, empathetic and helpful behaviour of staff at the reception desk.

The ideal patient-doctor partnership is a collaboration based on mutual respect and a mutual responsibility for the health of the patient. The GP’s duty of care is to explain the benefits and potential harm of specific medical treatments and to clearly and unambiguously explain the consequences of not adhering to a recommended management plan.

General practitioners have a responsibility to ensure that when taking a history from a patient and developing subsequent management plans, they themselves fully understand the discussion that takes place and that, in turn, the patient fully understands the proposed management and treatment. This may be facilitated by the use of translating services. It is of the utmost importance that GPs ensure there is clear and effective communication between both parties in the doctor-patient relationship so that GPs can effectively manage their patients’ healthcare.

Second opinions

Patients have the right to seek further clinical opinion from other healthcare providers. Practices are encouraged to document in the patient’s health record any indication that a patient intends to seek a further clinical opinion. Patients need to be encouraged to notify their GP when they are choosing to follow another healthcare provider’s management advice. This allows the GP the opportunity to reinforce any potential risks of this decision.

Where patients do seek further clinical opinion, an appropriate risk management strategy for practices includes documenting this decision in the patient’s health record. In addition, the GP is encouraged to document in the patient’s health record an explanation of the actions taken when a patient seeks a further clinical opinion, including referral to other care providers if arranged.

Refusal of treatment or advice

If a GP is aware that a patient has refused advice, procedures or treatments, an appropriate risk management strategy for practices needs to include recording of such refusals in the patient’s health record, including referrals to other care providers and an explanation of the action taken.

Patient requests for transfer of care

When a patient requests to be transferred to the care of another GP in another practice, a copy of patient health information needs to be transferred to the other practice in a timely manner to help facilitate care of the patient. Practice staff need to comply with the requirements of the state or territory legislation governing the transfer of patient health information.

GP requests for transfer of care

There may be patients whom a GP no longer considers it appropriate to treat (eg. when a patient has behaved in a threatening or violent manner, or where there has been some other cause for a significant breakdown in the therapeutic relationship). General practitioners have the right to discontinue treatment of a patient, especially when the GP thinks they can no longer give the patient optimal care. In such circumstances it is advisable for the practice to document a process to be followed by practice staff if the patient makes any subsequent contact with the practice. In rural and remote areas it may be difficult for the practice to uphold a decision to discontinue the treatment of a patient. The College reminds GPs that irrespective of a decision to discontinue the treatment of a patient, there is still a professional and ethical obligation to provide emergency care. Section 2 of the MBA Code of Conduct provides helpful advice on these areas (available at www.medicalboard.gov.au/Codes-and-Guidelines.aspx).

Dealing with patients who are distressed

A patient in distress may feel more comfortable in a private area than in a public waiting area. Practices, even those with limited facilities, need to attempt to provide privacy for such patients (eg. by allowing them to sit in an unused room, staff room or other area). This does not mean that a practice needs to have a room permanently set aside for such patients, but that a practice needs to have a plan that can be implemented as the need arises to ensure the patient is treated respectfully.

Managing health inequalities

The RACGP supports the choice of general practices to favour or specifically ‘target’ people and communities with high needs for comprehensive primary care, where choices need to be made about the allocation of limited resources.

One way of addressing the health inequalities of some individuals, families and communities is by providing targeted, culturally appropriate care to these patients. In these cases, the RACGP believes the general practice is still providing initial, continuing, comprehensive and coordinated medical care to individuals, families and communities, despite targeting a specific patient group.

For these practices it is important that the practice has clear systems to deal with requests for care by patients outside the target population. Examples of specific patient groups with high needs for comprehensive primary care include refugees, asylum seekers, prisoners, people of indigenous background or people from other cultural backgrounds associated with known health risk factors.

Respectful patient health records

Demonstrating respect for patients extends beyond the face-to-face interaction between the practice staff and the patient to the recording of patient health information. Making or recording derogatory, prejudiced, prejudicial, or irrelevant statements about patients has serious consequences for treatment, compensation and other legal matters and may contravene antidiscrimination legislation. Such remarks are also prone to misinterpretation when records are used by other GPs and can result in differential treatment for such patients.

Cultural awareness education

For information on the RACGP cultural awareness and cultural safety project see http://www.racgp.org.au/yourracgp/faculties/aboriginal/guides/cultural-awareness/.

Reconciliation Australia provides information about organisations that offer cultural awareness training available at www.reconciliation.org.au/home/reconciliation-action-plans/rap-community/cultural-awareness-training-register).

The Cultural Dictionary, a project of the Migrant Resource Centre Canberra & Queanbeyan Inc, aims to increase cultural understanding for service providers and is available at www.dhcs.act.gov.au/__data/assets/pdf_file/0017/5282/Cultural_Dictionary.pdf).

Standard 2.1 Collaborating with patients

Our practice respects the rights and needs of patients.

Criterion 2.1.1

Respectful and culturally appropriate care

Our practice provides respectful and culturally appropriate care for patients.

In a nutshell

This criterion is about providing healthcare that is culturally appropriate, and is respectful of your patients’ right to be treated with dignity, privacy and safety, and their right to accept or reject recommended treatment options or clinicians. It is also about observing obligations under the Federal Discrimination Act 1992, as well as relevant state and territory disability services Acts and equal opportunities Acts that prohibit discriminatory treatment of people based on their personal characteristics.

Aboriginal and Torres Strait Islander peoples have long experienced poor health consequences as a result of racially discriminatory policies. A growing body of current evidence suggests that discrimination and racism are linked to adverse health conditions amongst Indigenous people.  Aboriginal community controlled health services are well positioned to ensure respectful and culturally appropriate care for all the communities they serve. 

Key team members

  • All health service staff

Key organisational functions

  • Codes of conduct of various professional bodies
  • Patient rights policy
  • Cessation of patient care protocols
  • Patient records policy and processes
  • Anti-discrimination policy
  • Cultural safety policy and processes

Indicators and what they mean

Table 2.1 explains each of the indicators for this criterion. Refer to Criterion 2.1.1 Respectful and culturally appropriate care of the Standards for general practices for more information and explanations of some of the concepts referred to in this criterion. 

Table 2.1 Criterion 2.1.1 Respectful and culturally appropriate care
IndicatorWhat this means and handy hints
▶ A. Our practice does not discriminate against or disadvantage patients in any aspect of access, examination or treatment. Your health service does not discriminate against, or disadvantage, patients. To be sure this happens on a day-to-day basis, your service is advised to have an anti-discrimination policy that sets out expectations of employees regarding non-discriminatory behaviour towards patients. This includes everyone who is able to influence the patient experience, including part-time, contract, locum and volunteer staff.

It is important that the policy is reinforced with the requisite training or information sessions, and appropriate performance management processes regarding patients’ rights to access, examination and treatment free from all forms of discrimination. The policy needs to be reinforced with a complaints mechanism.
▶ B. Our clinical team can demonstrate how we provide care for patients who refuse a specific treatment, advice or procedure. Your health service is advised to have a policy (for example, a patient rights and responsibilities policy) that acknowledges patients’ right to accept or reject specific treatment, advice or procedures in the context of ongoing care. It could provide guidelines for responding to, and recording, instances when a patient refuses a specific treatment, advice or procedure. The information to be recorded could include:
  • details of the refusal
  • the specific treatment, advice or procedure being refused
  • referrals to other care providers
  • an explanation of the action taken.
▶ C. Our clinical team can describe what they do when a patient informs them that they intend to seek a further clinical opinion. Your clinical team know what to do when a patient informs them that they intend to seek a second opinion. When this occurs, information could be recorded, such as:
  • the patient’s desire to seek a second opinion
  • referrals to other care providers (where given)
  • an explanation of the action taken (where occurred).
Clinical staff could encourage patients to notify your health service when they intend to follow another healthcare provider’s management advice. This will allow your clinical staff an opportunity to discuss potential risks (if any) of this decision.
▶ D. Our practice team can describe what they do to transfer care, in a timely manner, to another GP in our practice or to another practice when a patient wants to leave the GP’s care. Your clinical team acknowledges a patient’s right to be transferred to the care of another GP, or a GP in another service, and can initiate a timely and appropriate transfer of patient health records to another health service, where a transfer of care is requested by a patient. Protocols could be in place to provide for:
  • the relevant copies of health records to be transferred (in compliance with requirements of state or territory legislation governing transfer of health records)
  • the transfer of records in a timely manner
  • the security of information being transferred.
▶ E. Our practice team can describe arrangements for informing a patient and transferring the care of a patient whom a GP within our practice no longer wishes to treat. It is suggested your health service has a policy on cessation of patient care to cover instances where GPs may consider it no longer appropriate that they treat a patient. These instances could include when a patient behaves in threatening or violent manner or where there has been a significant breakdown of the health professional–patient relationship. Note: while this criterion refers to GPs and doctors, other healthcare professionals should be included because they can face similar issues.

The policy could provide guidelines to assist the treating GP/other clinician if they wish to stop treating the patient. These guidelines could include:
  • an emphasis on the timely transfer of patient health records to another health service
  • a process for staff to follow if the patient makes subsequent contact with the health service, including which staff member would be responsible for contact (for example, the health service manager)
  • a statement that the service’s professional and ethical obligation to provide emergency care could mean that a doctor may be required to provide care to discontinued patients in medical emergencies.
Although doctors have a right to discontinue treatment, this does not override their professional and ethical obligation to provide emergency care. It is recognised that in rural and remote locations, it may be difficult for your health service to uphold a doctor’s decisions to discontinue treatment of a patient. Refer to Section 2 of the MBA code of conduct (details in the Other information for Standard 2.1 section) for helpful advice on these areas.
▶ F. Our practice team can describe how our practice provides privacy for patients and others in distress. Distressed people need to be made comfortable in a private area rather than in a public area. There is no obligation to have a dedicated room for these situations, but your health service is advised to have a plan in place for when these situations occur.

A protocol on dealing with distressed people could include:
  • details of the staff member (preferably one with clinical experience) who should be contacted when a distressed person presents at your health service
  • the room that can be used (for example, the nearest available consulting room)
  • what actions the attending staff member needs to take (for example, provide a general wellbeing check, or to stay with the person until a doctor is available)
  • advice to document the situation in the patient health records, or in an incident report for a person who is not a patient, where the distress involves significant risk.
G. Our practice team can identify important/significant cultural groups within our practice and outline the strategies we have in place to meet their needs. ACCHSs need to be culturally competent and safe for all patients. It is important that your health service is aware of the different communities whose members visit it, and that it has in place cultural safety policies, protocols and processes across the whole of the health service. This includes the availability of cultural safety training in relation to all these communities. This training should be extended to all clinicians, including visiting specialists and locum GPs.

Cultural safety practices need to be in place not only during clinic consultations but during interactions at reception and elsewhere. Cultural safety should inform all aspects of your health service’s delivery, including preventive health programs, public health education campaigns and all policies and protocols that impact on patient care. Your staff need to be trained and have knowledge of, skills in, and commitment to, cultural safety practices.

Updated cultural awareness and safety resources need to be easily available and accessible for all staff. Appropriate staff – including human resources employees, cultural mentors, cultural liaison officers, Aboriginal health workers, cultural brokers and/or cultural educators – may also provide ongoing advice.

Case study

Below is a description of the ways in which an Aboriginal community controlled health service can ensure respectful and culturally appropriate care for its clients 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 health service takes the rights of patients very seriously. This is not just because of its legal requirements but also because of its understanding that trust between healthcare providers and their patients is a fundamental prerequisite for safe and quality healthcare. This is reinforced at every point of contact patients (and their carers, if relevant) have with service staff, including reception and administrative staff.

Effective communication is regarded as a vital means of promoting patient rights, and service staff use effective communication strategies to ensure there is good understanding on both sides.

The rights of patients are respected even when the GP may disagree with a decision a patient has made. This includes when a patient decides to seek a further opinion; to refuse to follow advice, procedures or treatments; or to be transferred to another GP or a GP in another service. The GP will try to communicate clearly what they believe the consequences of such decisions may be, but they will also encourage patients to explain the reasons for their decision, and will listen to them. The GP will try to work with patients to help them reach a decision that is best for their overall healthcare and wellbeing.

If there is a trusting relationship, patients may be more likely to tell GPs something that they may otherwise not disclose. This means GPs can actually help with a problem they didn’t know about before – for example, that the medication they prescribed was too expensive. If they cannot help, GPs still show respect for things that patients consider to be important, such as the use of traditional medicine or traditional healers.

If any patient still wants to seek a second opinion, refuses treatment or advice, or requests a transfer of care, the service assists them to do this, and this is clearly documented in their health record.

The concept of culturally safe care outlined in the service’s policy and procedure manual extends not just to its Aboriginal and/or Torres Strait Islander patients – the majority of its patient population – but to the relatively small number of patients from other cultures who also use the service. Cultural safety training is provided for all staff (including part-time, visiting and locum staff), and issues about culturally appropriate behaviours are openly discussed. The service’s staff induction includes directions on the polite, friendly and culturally safe way in which it expects its patients to be treated both in person and on the telephone.

The policy and procedure manual documents that staff members do not use rude or insulting language in the content of a patient’s health records. Contents of health records are to be factual and clear to prevent other staff members from misinterpreting treatment plans or the patient history.

Aboriginal heath workers are actively used as part of the clinical team, health promotion and program development and delivery. They also act as cultural mentors to non-Indigenous staff.

Gender-appropriate staff members are used where possible and appropriate, for consultations or as a chaperone.

The physical layout of the health service allows for separate entry and waiting areas for male and female patients (if patients choose to utilise them). A transport service is provided to assist patients who are geographically isolated or financially disadvantaged to access the service.

The health service has a distressed persons protocol, which describes what actions its staff should take in relation to a person who is upset. This includes which staff member(s) need to be contacted, especially in the case of a patient with mental health issues, and the designated room for use for distressed people. The protocol also distinguishes between those people who are in physical distress or injured and those who are emotionally distressed and require privacy.

Showing how you meet Criterion 2.1.1

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.

  • Maintain a cultural safety policy.
  • Maintain a patient rights policy.
  • Maintain cessation of patient-care protocols.
  • Maintain patient records policies and processes.
  • Maintain an anti-discrimination policy.
  • Show that you provide a transport service for patients unable to access the service.
  • Maintain separate entry and waiting rooms for men and women, if culturally appropriate.
  • Show that you provide gender-appropriate staff members to act as chaperones.
  • Maintain a policy and procedure manual.
  • Show that cultural safety is covered in staff member interviews.
  • Keep documentation in patient’s notes.
  • Provide referrals to other healthcare providers.
  • Provide a room to ensure privacy for distressed patients.
  • Provide cultural safety training for staff members; document it in the staff training log.
  • Keep reports of community consultation processes.
  • Record patient feedback, including complaints.

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