Criterion C3.1 – Business operation systems

        1. Criterion C3.1 – Business operation systems

Indicator


C3.1 A Our practice plans and sets goals aimed at improving our services.

C3.1 B Our practice evaluates its progress towards achieving its goals.

C3.1 C Our practice has a business risk management system that identifies, monitors, and mitigates risks in the practice.

C3.1 D Our practice has a complaints resolution process.

Why this is important

Planning, setting and evaluating goals

A business needs to operate successfully to create an environment where quality clinical care can be delivered. To operate a business successfully, strategic thinking and business planning is as important as financial budgeting and reporting. A documented business plan (that is linked to your strategy and includes how it will be implemented) is an effective way of measuring your progress, and increases the likelihood of achieving your practice’s objectives.

Having a plan helps to get the team working together towards a common goal. It also gives the team the ability to evaluate progress and helps the practice achieve consistency and quality in its operations, and to conduct continuous quality improvement.

It is the responsibility of your practice to define its governance structures relative to its own requirements, as governance arrangements and structure will vary depending on the size and complexity of each practice. In smaller practices, there may be a merging of governance and management responsibilities. Other practices may be part of a wider corporate group and have either public or private shareholders, and others still may be government bodies or not-forprofit community-based organisations. A clear understanding of ownership and governance arrangements will help you develop appropriate policy and performance frameworks.

Business risk management

Managing safety and risk is part of quality assurance, and therefore is a significant part of practice management. Clinical risks need to be managed, but so too do business risks, because if the business fails, the practice will not be able to provide clinical care. A risk management process helps you to consistently identify, document and manage business risks.

You could schedule regular risk management meetings and/or include risk management as a standing agenda item for team meetings so that identified risks are regularly reviewed, updated and minimised.

More information on emergency planning and preparation is located at Criterion C3.3 – Emergency response plan.

Managing complaints

Patient complaints are a valuable source of information. Open discussions about patients’ needs and their concerns about the quality of care will help your practice understand potential problems and identify how you can improve your services.14

Meeting this Criterion

Planning, setting and evaluating goals

You could develop a strategic plan that documents your practice’s direction and objectives. The strategic plan could include:

  • the practice’s mission, vision, ethics (or code of behaviour) and values
  • how you plan to make efficient use of resources, including the level of staffing and skill mix required
  • environmental factors
  • financial factors
  • human resource management, including effective recruitment, selection, appointment, management, retention, separation, and support systems.

If you have a smaller practice (eg with fewer than 10 practice staff), you could have an action plan that sets out your goals and progress, instead of a strategic plan.

You can evaluate the practice’s progress against its strategy and goals in a number of ways. For example:

  • including it as an agenda item in team meetings
  • scheduling strategy planning and evaluation meetings at defined intervals
  • reviewing the practice’s patient population data and outcomes
  • seeking patient feedback
  • holding a team planning meeting.

Business risk management

You could develop a business risk management strategy that identifies, analyses and evaluates risks and explains how you have managed them.

Risks that might be identified in your practice’s business risk management strategy include:

  • poor record keeping
  • IT system failures
  • inadequate systems for updating patients’ contact details and following up test results
  • lack of documentation of the consent process
  • workplace health and safety incidents as a result of equipment that is not maintained in accordance with the manufacturer’s recommendations
  • inadequate number of practice staff working during busy times
  • conflicts of interest
  • workforce planning
  • unexpected sick leave
  • emergencies (eg environmental disasters)
  • updates to or breaches of the IT security system.

Mitigating business risk enables your practice to operate successfully, allowing you to focus on providing quality patient care.

A risk register is a good way of identifying and recording potential risks so that you can take action to reduce the likelihood of the risk occurring and the severity of the impact if the risk becomes a reality.

The risk register could also include a risk matrix to help you define the level of each identified risk (eg low, moderate, high, extreme), based on a combination of the:

  • likelihood of an event
  • severity of its impact if it was to occur.

If you fail to keep your risk register up to date, your risk mitigation strategies may not be adequate and new risks may not be identified. This can potentially have adverse impacts on the practice’s operations and the quality of healthcare the practice provides.

You could schedule regular risk management meetings and/or include risk management as a standing agenda item for team meetings so that identified risks are regularly reviewed, updated and minimised.

Managing complaints

You must have a receptive attitude to patient feedback and complaints. If you receive a patient complaint, try to resolve the issue within the practice team. If the practice team cannot resolve the complaint, contact your medical defence organisation for advice on resolving a complaint before any further action is taken.

Develop a system to record, review and manage complaints, and include how you will advise patients of the progress and outcome of their complaint. Consider displaying notices that state that the practice will always try to resolve complaints directly.

Read Section 3 of the Medical Board of Australia’s Good medical practice: A code of conduct for doctors in Australia, which contains advice about managing complaints at the practice level (available at www.medicalboard.gov.au/Codes-Guidelines-Policies.aspx).

You can take basic actions such as:

  • acknowledging the patient’s right to complain
  • working with the patient to resolve the issue, where possible
  • providing a prompt, open and constructive response, including an explanation and, if appropriate, an apology
  • ensuring the complaint does not adversely affect the patient’s care (in some cases, it may be advisable to refer the patient to another practitioner or to another practice)
  • complying with laws, policies and procedures relating to complaints.

If the matter cannot be resolved, the patient can contact their state’s health complaints commissioner for advice and possible mediation. Practices could ensure patients have access to information about the processes for making a complaint in their state or territory.

During the complaint process, consider the patient’s cultural and/or language needs, particularly if the matter cannot be resolved between the patient and the practice. It may be that the patient could benefit from an interpreter service or a legal representative.

Meeting each Indicator

C3.1 A Our practice plans and sets goals aimed at improving our services.

You must:

  • plan and set business goals.

You could:

  • write a statement of the practice’s ethics and values
  • maintain a business strategy
  • maintain an action plan.

C3.1 B Our practice evaluates its progress towards achieving its goals.

You could:

  • write a statement of the practice’s ethics and values
  • maintain a business strategy
  • maintain an action plan.

C3.1 C Our practice has a business risk management system that identifies, monitors, and mitigates risks in the practice.

You must:

  • maintain a documented risk management process
  • develop procedures to mitigate risks.

You could:

  • maintain a risk register
  • maintain a log of risks if you are a small practice
  • keep a record of meetings where risks have been identified and actions agreed on to manage those risks.

C3.1 D Our practice has a complaints resolution process.

You must:

  • maintain a complaints resolution process.

You could:

  • keep a log or ledger of complaints
  • place a suggestion box in the waiting room and regularly review suggestions
  • establish and follow a process for dealing with suggestions and complaints.