Criterion C3.2 – Accountability and responsibility

Why this is important

Roles and responsibilities

Having clear lines of accountability and responsibility is part of good governance. It encourages continuous improvement in safety and patient care.

When specific roles and responsibilities are agreed to and documented (eg in position descriptions):

• the practice can monitor each team member’s performance against their role’s requirements, and determine whether any support and training is required
• each team member knows who they are reporting to for each duty or responsibility
• each team member knows who is responsible for each aspect of the practice’s operations.

Performance monitoring

The objectives of performance monitoring are to assess the performance of an individual and to determine how the practice team would benefit from further training and development.

Induction program

An induction program must be a routine part of employment, so that all new practitioners and other practice team members understand:

• the principles and policies under which the practice operates
• the day-to-day operations of the practice
• workplace health and safety issues
• the processes for maintaining the privacy and confidentiality of patients’ health information
• the systems used to identify and manage emergency patients who come to, or contact, the practice.

Meeting this Criterion

Roles and responsibilities

For each role, you could create a position description that includes the title of the role and the responsibilities and duties of the person in that role. This can then form the basis of:

• recruiting for the role
• training and development
• setting lines of accountability
• monitoring performance • managing remuneration
• succession planning.

Each person could sign their position description to indicate that they understand their role and responsibilities. Position descriptions could be reviewed regularly (eg once a year) to keep them up to date and to make sure each person understands their role and responsibilities.

Your practice must also appoint one member of the team who has responsibility for risk management and one person who has responsibility for complaints resolution. The same person could be responsible for both areas. The responsibilities of each role must be documented, and members of the practice team must understand the responsibility of each role, and who holds each role. For example, risk management responsibilities of this role could include a coordinated process for managing and responding to cardiac emergencies, which involve all members of the practice team, and consider staffing.

Performance monitoring

One way that managers can monitor a team member’s performance is to have regular meetings where issues can be raised and addressed before they become a problem. This is particularly useful in smaller practices where informal processes generally work better than formal processes.

If you decide to introduce formal performance discussions (eg every six months), consult with your practice team to ensure that the process is practical and fair. Organisations that spend a substantial amount of time training the managers and practice team about the process are generally more successful at implementing effective performance discussions.

The performance monitoring system could cover:

• setting standards for performance
• assessing performance against the standards • providing and receiving feedback about performance
• agreeing on actions to further improve performance.

Whether you use formal or informal processes, managers need to document the performance discussions, agreed actions and ongoing development needs. Performance discussions provide the opportunity for a balanced conversation between a manager and the practice team member, and are therefore not meant to be disciplinary in nature. Practitioners in the practice team could choose to have performance discussions with each other, rather than with the practice manager or other practice staff members.

Induction program

The following information could be included in your induction program:

• An overview of the practice’s systems and processes
• The local health and cultural environment in which your practice operates (eg if the practice is located in an area that has a high level of illicit drug use, the practice team needs to understand the practice’s policy on the management of Schedule 8 medicine prescribing)
• Key public health regulations (such as reporting requirements for communicable diseases and child abuse)
• Local health and community services, including pathology, hospital, and other services to which the practice team is likely to refer

Meeting each Indicator

C3.2 A All members of our practice team understand their role in the practice.

You must:

You could:

• create position descriptions
• create an organisational chart
• maintain a practice policy document.

C3.2 B Our practice has performance discussions with each team member.

You must:

You could:

• implement a formalised performance monitoring process
• have regular catch-ups between managers and their practice team members
• establish development goals for members of the practice team.

C3.2 C Our practice inducts new members of the practice team and familiarises them with our systems and processes.

You must:

You could:

• keep an accurate and up-to-date employment file on each member of the practice team
• maintain a human resources policy and procedure manual • create templates and checklists for inducting new team members
• maintain a documented induction process.

C3.2 D Our practice has at least one team member who has the primary responsibility for leading risk management systems and processes.

You must:

You could:

• maintain a human resources policy and procedure manual
• create a position description/s that include the responsibility for risk management.

C3.2 E Our practice has at least one team member who coordinates the resolution of complaints.

You must:

You could:

• maintain a complaints register
• create a position description/s that include the responsibility for complaint resolution
• keep minutes or notes of practice meetings that show that patients’ complaints have been considered and discussed in those meetings.