status quo of quo vadis? - KCE

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118 Quality development in general practice in Belgium: status quo or quo vadis ? KCE Reports 76 CRITERION 1.4.2 CLINICAL AUTONOMY FOR GPS 1. our GP(s) are free to determine: • 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) (interview). 2. our GP(s) are consulted about: • the scheduling of appointments • the equipment and supplies that our practice uses (interview). 3. our practice has a written policy that confirms that our GP(s) can exercise autonomy in decisions that affect clinical care, within the parameters of evidence based medicine (document review). Standard 1.5 - Continuity of care CRITERION 1.5.1 CONTINUITY OF COMPREHENSIVE CARE 1. over 25% of our active patient health records include entries extending back over more than 2 years (health records review). 2. our practice has strategies or policies that encourage continuity of comprehensive care (interview, document review). CRITERION 1.5.2 CONTINUITY OF THE THERAPEUTIC RELATIONSHIP 1. our staff can describe how patients can request their preferred GP when making an appointment or attending our practice (interview) 2. A sample of patient health records indicates that patients generally see the same GP (health records review) 3. our practice has used patient feedback to establish whether patients of our practice are able to see the GP of their choice, if available (patient feedback). CRITERION 1.5.3 CONSISTENT APPROACH 1. our GP(s) and staff who provide clinical care can describe how they ensure consistency of diagnosis and management of common and serious conditions (within the parameters of evidence based care) within our practice (interview) 2. our practice has regular meetings to discuss clinical care (interview, document review). CRITERION 1.5.4 SYSTEM FOR FOLLOW UP OF TESTS AND RESULTS 1. our patient health records contain evidence that pathology results, imaging reports, investigation reports and clinical correspondence received by our practice have been: • reviewed by a GP • initialled, and • where appropriate, acted upon in a timely manner (health records review). 2. our GP(s) and staff can describe the system by which pathology results, imaging reports, investigation reports, and clinical correspondence received by our practice are: • reviewed
KCE Reports 76 Quality development in general practice in Belgium: status quo or quo vadis ? 119 • signed or initialled (or the electronic equivalent) • acted on in a timely manner, and • incorporated into the patient health record (interview). 3. our practice has a written policy describing the review and management of pathology results, imaging reports, investigation reports and clinical correspondence received by our practice (document review). 4. our GP(s) and staff can describe how patients are advised of the process for the follow up of results (interview). 5. our GP(s) and staff can describe the procedure for follow up and recall of patients with clinically significant tests and results (interview). 6. our practice has a system to recall patients with clinically significant tests and results (document review). 7. our practice has a written policy to follow up and recall patients with clinically significant tests and results (document review). Standard 1.6 - Coordination of care CRITERION 1.6.1 ENGAGING WITH OTHER SERVICES 1. our practice demonstrates how it engages with the following: • medical services such as diagnostic services, hospitals and specialist consultant services • allied health services • disability and community services, and • health promotion and public health services and programs (document review, interview). 2. There is evidence our practice refers patients to health, community or disability services (health records review). CRITERION 1.6.2 REFERRAL DOCUMENTS 1. our practice can demonstrate that referral letters are legible and where appropriate: • include the purpose of the referral • include relevant history, examination findings and current management • include a list of allergies and current medicines • are on appropriate practice stationery • are documented in patients’ health records (health records review).
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status quo of quo vadis? - KCE

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