Transcript IPMA Cork Compliance

Practice Management
Rochestown Park Hotel, Cork
Mary Toomey
Saturday, 5th November 2011
Agenda for Today
• Compliance & Inspections
– Employment Law
– Health and Safety
– HIQA
– Data Protection
Inspections into General Practices
• NERA
• Health and Safety Authority
• HIQA (in future)
National Employment Rights Authority
• Inspectors have right to
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To enter any premises at a reasonable time
To demand sight of records
To inspect records
To take copies of records
To interview and require information from any
relevant person
Best Practices,
Good Record Keeping
High-performing, happy
staff = good employment.
Having high performing
paperwork =
good employment law!
Records for NERA Inspection
1. Employer registration number with the
Revenue Commissioners
2. Full Name, Address and PPS Number for each
employee (full-time and part-time)
3. Terms of employment for each employee
4. Payroll details (Gross to Net, Rate per hour,
Overtime, Deductions, Shift and other Premiums
and Allowances, Commissions and Bonuses,
Service Charges, etc.)
Records for NERA inspection (2)
5. Copies of Payslips
6. Employees’ job classification
7. Dates of commencement and where relevant,
termination of employment
8. Hours of work for each employee (including
starting and finishing times, meal breaks and
rest periods). These may be in the form of Form
OWT1 (or in a form substantially similar).
Records for NERA inspection (3)
9. Register of employees under 18 years of age
10. Whether board and/or lodgings are
provided and relevant details
11. Holidays and Public Holiday entitlements
received by each employee
12. Any documentation necessary to
demonstrate compliance with employment
rights legislation (e.g. work permits)
ORGANISATION OF WORKING TIME ACT, 1997
AN ROINN FIONTAR TRADÁLA AGUS FOSTAÍOCHTA-DEPARTMENT OF ENTERPRISE, TRADE AND EMPLOYMENT
PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS
FIGURES
LETTER
EMPLOYER’S PAYE REGISTERED NUMBER
BUSINESS NAME OF EMPLOYER
_____________________________________________________________________________
BUSINESS ADDRESS
_____________________________________________________________________________
_____________________________________________________________________________
FIGURES
LETTERS
EMPLOYEE’S REVENUE AND SOCIAL
INSURANCE (RSI) NUMBER
SURNAME _____________________________
FIRST NAME _________________________________________________
* NUMBER OF HOURS WORKED BY EMPLOYEE PER DAY AND PER WEEK
WEEK COMMENCING :
AND ENDING:
WEEK COMMENCING:
AND ENDING:
WEEK COMMENCING:
AND ENDING:
WEEK COMMENCING:
AND ENDING:
MONDAY
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TUESDAY
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WEDNESDAY :
THURSDAY
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FRIDAY
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SATURDAY
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SUNDAY
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_____________________
MONDAY
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TUESDAY
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WEDNESDAY :
THURSDAY
:
FRIDAY
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SATURDAY
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SUNDAY
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_____________________
MONDAY
:
TUESDAY
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WEDNESDAY :
THURSDAY
:
FRIDAY
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SATURDAY
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SUNDAY
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_____________________
MONDAY
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TUESDAY
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WEDNESDAY :
THURSDAY
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FRIDAY
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SATURDAY
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SUNDAY
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_____________________
WEEKLY TOTAL
:
WEEKLY TOTAL :
WEEKLY TOTAL :
WEEKLY TOTAL :
I DECLARE THAT THE ABOVE INFORMATION IN RELATION TO DAILY AND WEEKLY HOURS WORKED IS CORRECT
SIGNATURE OF EMPLOYER: _____________________________________________________________________________________
SIGNATURE OF EMPLOYEE: _____________________________________________________________________________________
* NO. OF HOURS WORKED EXCLUDES MEAL BREAKS AND REST BREAKS
Essential Employment Law Checklist
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Contract (Terms & Conditions of Employment)
Grievance Procedure
Disciplinary Procedure
Annual Leave
Public Holidays
Records of Hours Worked and Breaks
Payslips showing gross to net
Any other relevant special documentation
Health & Safety Authority
• Primary focus is preventative and educational
• Inspection focus
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Safety Statement
Risk Assessments
Safety Representative
Awareness of all staff of their responsibilities
Accident Reporting
Safety, Health and Welfare at Work Act 2005
• Design, provide and maintain a safe place of
work including safe access and egress
• Provide safe equipment
• Prevent risks from the use of any article or
substance used at work
• Manage work activities so as to ensure the
safety, health and welfare of people at work
• Prevent improper behaviour or conduct which
could put people at risk
Safety, Health and Welfare at Work Act 2005
• Provide welfare facilities
• Provide suitable protective equipment /
clothing
• Provide appropriate training / information
• Appoint one or more competent persons to
specifically advise the employer in relation to
Health and Safety
• Ensure reportable accidents / dangerous
occurrences are reported to HSA.
Risk Assessments
Fire - Electricity - Manual Handling - Equipment
Needlesticks - Clinical Waste - Slips, Trips & Falls
Chemicals - Liquid Nitrogen - Ergonomics & VDUs
Compressed Air & Gases - Stress - Violence
Risk Assessment
Risk Assessment (Sample)
1
Area
Hazard / Consequence
Risk
Assessment
Control Measures
Entrance
Wheelchairs blocking
emergency door. This is a
fire hazard
Unacceptable
Remove
wheelchairs and
ensure they are
stowed safely in
suitable place
Action Person:
2
Reception
Nora the Practice Nurse
Poorly maintained
electrical equipment can
give rise to burns, fire and
electric shock.
Action Person:
Joe the Janitor
Completion Date: 6/10/2011
Unacceptable
1. Damaged /
worn leads to be
replaced
2. Ensure all
equipment is
tested in
accordance with
PAT Regs 1999
Completion Date: 8/10/2011
Safety Statement
• Describes the organisational and physical
arrangements for safety, including the
assignment of responsibilities to individuals
and a statement of co-operation required
from employees to maintain those standards
• Must refer to the specific hazards in the
workplace and indicate the risks associated
and the controls in place for each hazard
Essential Fire Safety For Your Practice
• Fire Register – record keeping
• Fire alarm system – tested weekly
(keep records)
• Fire extinguishers in place with
maintenance contract for annual
service (keep certificates)
• Emergency evacuation plan in place
• Appoint fire warden/s to ensure
evacuation of all people
• Ensure adequate signage
• Fire drills – every 6 months (keep records)
• Prohibit smoking in the building
• Regularly inspect electrical apparatus & replace / repair
Safety in GP Practices
• Oxygen cylinders
– Risk of fire or impact damage
– Should be stored upright and chained securely
– Should be kept in a place where the risk of being
damaged by bumping; and away from flammable
or combustible materials, direct flames, electrical
or heat sources
– Should be transported in an upright position
– Keep the MSDS sheet for any gas in your practice
Safety in GP Practices
• Liquid Nitrogen for Cryotherapy
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Lung damage or asphyxiation if inhaled
Skin / eye damage if splashed
Explosion risk if warmed
Keep a MSDS sheet for liquid nitrogen
Cold protection gloves, lab coat, closed shoes and
safety glasses should be worn, even for handling
small amounts
– Pour slowly & carefully to avoid spillage
Other Safety Concerns
in General Practice
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Sharps and needlestick injuries
Blood or body fluid spillage
Latex allergy / dermatitis
Slips, trips
Working at heights / falls
Manual handling
Ergonomics & VDUs
Stress
Violence
Essential Health & Safety Checklist
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Safety Statement
Risk Assessments
Log of Incidents / Accidents
Records of fire drills
Records of equipment tests
Records of maintenance of equipment
Records of improvements made
HIQA
• National Quality Standards for Residential Care
Settings for Older People in Ireland (Feb 2009)
• Report & Recommendations on Patient Referrals
from General Practice to Outpatient and Radiology
Services (March 2011)
• National Standard for Patient Referral Information
(March 2011)
• Standards for Health Information Governance
• National Standards for Safer Better Healthcare
Safer Better Healthcare Standards
8 “Themes”:
• Person Centred Care
• Leadership, Governance and Management
• Effective Care
• Safe Care
• Workforce
• Use of Resources
• Use of Information
• Promoting Better Health
What to Expect?
• Standards to be published (which are general &
apply to almost all areas of healthcare)
• Guidance documentation (to be issued specific
to different areas of healthcare)
• Licencing system - a license may be required to
deliver healthcare
• Monitoring - Unclear exactly how standards will
be monitored (inspection/report or self
reporting?)
Similarities to UK
• Care Quality Commission in the UK – licensing
legislation passed in 2010
• Out-of-hours providers to register by 2012
• Primary medical services required to register
by 2013
Lessons from Care of the Elderly
• Time & duration
• Methods employed: Observation, Record Check and
Interviews (patient, family, staff).
• Drilling down in specific areas
• Overview at end of visit with major issues identified
there and then
• Right to reply
• Report – agreed action plan
• Follow up visits
Focus of Inspections
in Care of the Elderly
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Statement of purpose and function
Clear accountable management structures
All relevant policies in place
Risk management (both policy and practice)
Complaint handling and resolution
Finances / accounts
Notification of incidents to HIQA in
accordance with regulations
How Best to Prepare?
• How can we demonstrate that we provide a quality,
safe service?
• Consider responsibilities and identify the lead person
or people in your Practice – both for clinical aspects
(Dr / Practice Nurse) and other people in charge
(Practice Manager). These people will need to
become very familiar with the standards once
published.
• Involve all staff through education / practice.
• Log and follow up patient complaints / comments.
How Best to Prepare - Clinical
• Structured approach to quality assurance
• Conduct any necessary clinical audits & keep the
records (BMA guidance, HIQA guidance once
published)
• Record how you improve your service
• Conduct analysis of any adverse events on a regular,
defined basis and keep a record of lessons learned
from this
• Involve staff and patients
How Best to Prepare - Governance
• Clear supervision structures
• Hold structured meetings and record minutes
• Have appropriate policies, procedures and guidance
documents in place
• Make sure these policies, procedures and guidance
documents actually reflect practice on the ground
• Ensure staff are trained in / familiar with policies,
procedures and guidelines
• Review documentation regularly
How Best to Prepare - Staff
• Have a policy on recruitment and induction
• Ensure you have CVs, references, background
checks, garda clearances, job descriptions all
on file
• Demonstrate that you have assessed staff
training needs
• Ensure staff receive all mandatory training
• Keep good records
The Eight Rules of Data Protection
1. Obtain and process information fairly
2. Keep it only for one or more specified, explicit
and lawful purposes
3. Use and disclose it only in ways compatible
with these purposes
4. Keep it safe and secure
The Eight Rules of Data Protection
5. Keep it accurate, complete and up-to-date
6. Ensure that it is adequate, relevant and not
excessive
7. Retain it for no longer than is necessary for
the purpose or purposes
8. Give a copy of his/her personal data to an
individual, on request
Data Protection Checklist
• Do you have appropriate security measures in
place both internally and externally to ensure
all access to data is appropriate?
• Do you have procedures in place to ensure
that data is kept up-to-date?
• Do you have a defined policy on retention
periods for all items of personal data?
• Do you have a data protection policy in place?
Data Protection Checklist
• Do you have procedures for handling access
requests from individuals?
• Are you clear on whether or not you should
be registered, and are you registered?
• Are your staff appropriately trained in data
protection?
Data Protection Requests
• Individuals can request if you have information
about them – reply must be provided within 21 days
• Individuals can request a copy of data kept - a fee of
up to €6.35 is payable
• Copies of the information held must be provided
within 40 days
• If information isn’t provided, the individual can
complain to the Data Protection Commissioner.
Marketing… Opt -In or Opt-Out?
• Opt in = you must have their consent
• Opt out = you must have offered an opt out
option which has not been availed of
Individual
Customer
Postal
Marketing
Text/Email
Marketing
Phone
Marketing
to
Landlines
Opt-Out
Opt-Out
(provided
similar
product or
service)
Opt-Out
Fax
Marketing
Phone
Marketing
to Mobile
Phones
Opt-Out
Opt-Out
Marketing… Opt-In or Opt-Out?
Individual
Customer
Individual
NonCustomer
Business
Contacts
(Customer &
NonCustomer)
5/11/11
Postal
Marketing
Text/Email
Marketing
Phone
Marketing
to Landlines
Opt-Out
Opt-0ut
(provided
similar
product or
service)
Opt-Out
Opt-In
Opt-In if on
NDD,
Opt-Out
otherwise
Opt-Out
Opt-In if on
NDD,
Opt-Out
otherwise
Opt-Out
Opt-out
Fax
Marketing
Phone
Marketing
to Mobile
Phones
Opt-Out
Opt-Out
Opt-In
Opt-In if on
NDD,
Opt-Out
otherwise
Opt-In
Opt-In
Thank You